ACKNOWLEDGEMENTS

In the words of Dr. Myles Munroe, all that we know is a sum total of what we have
learned from all who have taught us, both directly and indirectly. I am forever indebted
to the countless outstanding men and women who, by their commitment and
dedication to becoming the best they could be, have inspired me to do the same.
I am ever mindful of the unparalleled love, prayer, support, and patience of my
precious best friend, Christabel, and am deeply thankful for her understanding,
inspiration, and faithfulness in reminding me that she is my number one support team.

DEDICATION

I am proud to dedicate this book to my beautiful best friend Christabel. For your
steadfastness and love. This pamphlet is dedicated to all those courageous students
who have ever dared to step out of the dominant culture of resignation and mediocrity
and endeavor to create the life of their dreams. I honor and salute you!
INTRODUCTION

This pamphlet is aimed at helping students to understand topics and how to answer
them in a test and exam according to NMCZ standard. I wish you all the best as you
utilize this material; I assure you that you will be helped marvelously. If you have no
one that believes in you, I want you to know that I am you number one fan. I believe in
you so much. See you at the top…!

Your friend Cletus.

IN EACH OF THE FOLLOWING QUESTIONS, ENCIRCLE THE LETTER
CORRESPONDING WITH THE MOST APPROPRIATE ANSWER, ONE (1)
MARK EACH
1. The causative agent for streptococcal pharyngitis is
(a) Bacteria
(b) Virus
(c) Fungus
(d) Protozoa
2. The following are signs of laryngitis EXCEPT:
(a) Productive cough
(b) Sore throat
(c) Aphonia
(d) Hoarseness
3. Signs and symptoms of pulmonary tuberculosis include all of the following
EXCEPT:
(a) Productive cough
(b) Cyanosis
(c) Enlarged lymph nodes
(d) Night sweat
4. Pott‘s disease is
(a) Tuberculosis of the bone
(b) Tuberculosis adenitis
(c) A tuberculosis inflammation of the bodies of the vertebrae
(d) Tuberculosis of the abdomen
5. The best drug you can administer to a patient with angina pectoris is:
(a) Digoxin
(b) Glyceryl trinitrate
(c) Aldomet
(d) Tolbutamide
6. By what route are the sulphonamides most frequently administered?
(a) Per oral
(b) Per rectum
 (c) Intra-muscular
(d) Intra-venuos
7. An anti-microbial drug that is contra-indicated in pregnancy is:
(a) Penicillin
(b) Sodium sulfasoxideine
(c) Streptomycin
(d) Tetracycline
8. Paralysis of the arm and leg on one side of the body is known as:
(a) Paraplegia
(b) Paraparesis
(c) Hemiplegia
(d) Monoplegia
9. Carbimazole is a drug that is used to treat:
a) Cushing‘s syndrome
b) Thyrotoxicosis
c) Trypanosomiasis
d) Epilepsy
10. A code of good manners of behaviour commonly called courtesy in hospital is
called:
(a) Ethics
(b) Etiquette
(c) Professional code of conduct
(d) Laws

11. Qualities of a good nurse include the following EXCEPT:

(a) Loyalty
(b) Observant
(c) Control of emotion
(d) Change of attitude
12. Inflammation of the tongue is known as:
 (a) Parotitis
(b) Stomatitis
(c) Aerophagy
(d) Glossitis
13. The step ladder fashion fever seen in typhoid is a characteristic of stage:
(a) 1
(b) 2
(c) 3
(d) None of the above
14. Entamoeba histolytica is the cause of:
(a) Bacillary dysentery
(b) Cholera
(c) Amoebic dysentery
(d) Chron‘s disease
15. Malabsorption syndrome may cause deficiency in:
(a) Vitamin B 12
(b) Vitamin A
(c) Vitamin C
(d) Vitamin D

16. Which of the following ARE NOT present in a new born circulation
(a) Inferior vena cava
(b) Pulmonary artery
(c) Hypogastric arteries
(d) Abdominal aorta
17. The first drug of choice in the treatment of schistosomiasis is:
a) Praziquantel
b) Pyrantel pamoate
c) Pyrazinamide
d) Protamine sulphate
18. The cause of ascites in liver cirrhosis is:
a) Liver congestion with blood stasis
 b) Accumulation of toxic substances
c) Abnormal proliferation of hepatocytes
d) Splenomegaly
19. Which of the following substances are filtered out of the blood by the kidneys?
a) Diuretics
b) Chyle
c) Nitrogenous waste
d) Carbondioxide
20. Agents that promote secretion of urine are called:
a) Diuretics
b) Antidiuretics
c) Uremics
d) Diaphoresis
21. Habitual drug and alcohol consumption by persons is often called:
a) Substance abuse
b) Alcoholism
c) Intoxication
d) Burnout
22. People with personality disorders are often called:
(a) Manic
(b) Psychosis
(c) Neurotic
(d) Psychopaths
23. The three phases that are commonly used to consider how to assist people to live
healthier lives include:
(a) Health promotion, health education and IEC
(b) Health promotion, service delivery and IEC
(c) Health promotion, IEC and community diagnosis
(d) Health promotion, service delivery and community diagnosis
24. The bone of the leg are:
(a) Radius and ulna
(b) Ulna and tibia
(c) Tibia and fibula
(d) Fibula and radius
25. The heart wall is thickest in the:
(a) Right ventricle
(b) Left ventricle
(c) Left atrium
(d) Right atrium
26. The functions of the large intestines is:
(a) The absorption of food
(b) Absorption of nutrient
(c) Absorption of water
(d) Digestion of food
27. The life span of red blood cells is believed to be approximately:
(a) 120 days
(b) 220 days
(c) 140 days
(d) 130 days
28. The following are the three kinds of cells in the nervous system EXCEPT:
(a) Neurons
(b) Schwann cells
(c) Neuroglia
(d) Stomatic cells
29. The largest muscle in the leg is the:
(a) Obicularis
(b) Sartorius
(c) Gluteus
(d) Gastrocnemius
30. The mechanical process of inspiration and expiration is termed as
(a) Mechanism of breathing
(b) Mechanism of inspiration
(c) Mechanism of expiration
(d) Mechanism of the alveoli
31. Which of the following is NOT TRUE about surfactant:
(a) Increases surface tension
 (b) Increases pulmonary compliance
(c) Reduces tendency for alveoli to collapse
(d) Reduces surface tension
32. Which of the following would indicate an increased risk of deep vein thrombosis:
(a) Anaemia
(b) Hypertension
(c) Obesity
(d) Vitamin K deficiency
33. A patient who is dyspnoeic is nursed in which of the following position?
(a) Prone
(b) Semi prone
(c) Dorsal
(d) Orthopnoeic
34. Repeat HIV testing is recommended while PrEP is taken and that should be done:
a) Every 6 months
b) Every 3 months
c) At the end of PrEP
d) Every 4 weeks
35. A prolonged gasping inspiration followed by very short usually inefficient
expiration, associated with CNS disorders is called:
a) Cheyenne stroke
b) Kussmaul respiration
c) Biot‘s
d) Apneustic
36. Control of tuberculosis (TB) includes all of the following EXCEPT:
(a) Treat all new cases promptly
(b) Isolate all TB patients
(c) Educate public on spread of TB
(d) Medication compliance
37. In a typical attack of bronchial asthma:
(a) The onset is gradual and insidious
(b) There are spasms of the muscle walls of the bronchioles
 (c) The attack is always precipitated by emotional disturbance
(d) Inspiration is more difficult than expiration and produces wheezing
38. The pulmonary function test is used to__________
a) Diagnose abnormal lung tissue
b) Demonstrate abnormal pulmonary blood flow
c) Evaluate how patient breathes
d) Measure obstructions to pulmonary function
39. The condition that occurs when alveolar ventilation is inadequate to meet the
body‘s demand or to eliminate sufficient carbondioxide is called:
a) Hyperventilation
b) Hypoventilation
c) Hypoxia
d) Apnoea
40. Rheumatic heart disease is:
(a) Delayed response to an infection by group A-beta haemolytic
streptococcus
(b) A collagen disease
(c) A disease of negroes
(d) Rapid response to an infection by group B-beta haemolytic staphylococcus
41. A cardiac glycoside commonly used to improve the construction of myocardium
is:
(a) Lomotil
(b) Digoxin
(c) Frusemide
(d) Quinidine
42. Which one of the following organisms causes dysentery?
(a) Giardia lamblia
(b) Trichomonas horminis
(c) Shigella
(d) Brucella arbutus
43. The disease characterized by substernal chest pain and a suffocating feeling is:
a) Anaemia
 b) Angioma
c) Aneurism
d) Angina
44. The medical term used for genital warts is
a) Condylomata acuminate
b) Genital Herpes
c) Vaginitis
d) Syphilis
45. The structures of the mediastinum are:
(a) Heart and lungs
(b) Lungs and great vessels
(c) Diaphragm and heart
(d) Heart and great vessels
46. Which of the following is most likely to be a source of tape worm infestation:
a) Chicken
b) Lamb
c) Beef
d) Duck
47. Which of the following is NOT a complication of Mumps?
a) Epididymo-orchitis
b) Meningitis
c) Pericarditis
d) Pneumonia
48. A condition in which there is an increased number of red blood cells in the blood
is called:
a) Polycythaemia
b) Leukaemia
c) Anaemia
d) Hemophilia
49. A localized dilation of a cerebral artery that results from a weakness in the arterial
wall is called:
a) Cerebral aneurism
 b) Myelomeningocele
c) Stroke
d) Haematoma
50. A sudden impairment of cerebral circulation in one or more of the blood vessels
supplying the brain is called:
a) Brain thrombosis
b) Cerebral vascular accident
c) Cerebral haemorrhage
d) Subdural haemorrhage

MATCHING ITEMS – MATCH THE ITEMS IN COLUMN I WITH ITEM IN

COLUMN II. ITEMS IN COLUMN II SHOULD BE USED ONCE ONLY
Match the following enzymes in column I with their actions in column II.
Column I Column II
51.......C..... Amylase A. Emulsification of fats
52.......G...... Pepsin B. Convert fats to fatty acids and glycerol
53.......E.... Surcease C. Convert polysaccharides to disaccharides
54........B..... Lipase D. Curdles milk
E. Converts disaccharides to monosaccharides
F. Protects the stomach mucosa from the
digestive action of pepsin
G. Converts proteins to peptones
Match the following drugs in column I with their meaning in column II.
Responses in column I should be used only once
Column I Column II
55. ---D---Digoxin A. Antineoplastic
56---E---Amiloride hydrochloride B. Centrally acting sympatholytic
57---B---Methyldopa C. Glycerol suppositories
58---C---Senna D. Cardiac glycosides
59----G--Frusemide E. Potassium sparing diuretic
F. Anabolic steroid
 G. Loop diuretic
H. Aminoglycoside

Match the minerals in column I with their functions in column II

Column I Column II
60.....C... Calcium A. Helps maintain the normal acid base balance
61......B.. Iodine B. Essential to normal growth and development of the
thyroid gland
62.....G... Flourine C. Aids in the clotting of blood
63....E.... Iron D. Specific function in man is not known
E. Used to manufacture new red blood cells
F. Is necessary for the proper healing of tissue
G. Prevents tooth decay
Match the following cranial nerves in column I to the organs they supply in column II
Column I Column II
64......C..... Oculomotor A. Mouth
65......A..... Trigeminal B. Neck
66......F..... Vagus C. Eye
67.......D.... Glossopharyngeal D. Tongue
E. Nose
F. Heart
G. Head
Match the type of Reflex in column I with how it is elicited in column II
COLUMN I COLUMN II
68.......H..... Kernig A. Flexing chin on chest
69......F...... Hoffmann B. Stroking tibial surface
70......A...... Brudzinski C. Brisk dorsiflexion of foot with flexed knee
71.......G..... Gordon D. Stroking below lateral malleolus
E. Stroking lateral sole foot
F. Flickering middle finger down
G. Squeezing calf muscle
 H. Straightening le with thigh muscle flexed

SECTION C: COMPLETION
COMPLETE THE FOLLOWING SENTENCES USING ONE, TWO OR
THREE WORDS ONLY.
72. The causative organism of gonorrhoea is---Neisseria gonorrhoeae------------
73. The potential space between the two layers of pleura is called the---pleural
cavity---
74. The data that is obtained by the nurse through observation, physical
examination and diagnostic tests is called--- objective data ------
75. Which condition mimics signs and symptoms of congestive cardiac failure----
-----------COPD or pneumonia
76. Collection of fluid in the pleural space is referred to as---pleural effusion-----
77. The single most important investigation in every patient suspected of a chest
disorder is---chest X-ray-
78. The recommended drug for treatment of gonorrhoea when using syndromic
management is---- ciprofloxacin --
79. The causative organism for chancroid is --- Haemophilus ducreyi -------------
-
80. The haematological disorder in which there is inadequate circulating platelets
is called----thrombocytopenia ----------
81. Examination of the chest using a stethoscope is termed----auscultation--------
82. A form of tuberculosis that is characterized by a wide dissemination of tiny
lesions throughout the human body is called— miliary TB --------
83. Hansen‘s disease is the other name for---leprosy------------
84. The process of converting glucose to glycogen is known as---glycogenolysis
-
85. Cryptococcal meningitis is caused by a fungus called—Cryptococcus
neoformans-
86. A protozoa infection caused by trichomonas vaginalis is called—
Trichomoniasis
 87. The current confirmatory test for HIV in Zambia is—SD Bio line-------
88. The causative organism for syphilis is called----Treponema pallidum-------
89. Other than transmission through sex, blood and blood products and organ
transplant, syphilis can be transmitted by----mother to child (trans placental)
90. Inflammation of the tongue is called---glossitis---------------------
91. The term that refers to a set of symptoms and signs which occur together and
constitute the manifestation of some special condition is called---syndrome----
92. If untreated, Filariasis involving the eyes can cause a type of blindness called-
----onchocerciasis----
93. -----Liver cirrhosis---is a chronic liver disease characterized by diffuse
inflammation and fibrosis resulting in drastic structural changes and significant
loss of function.
94. The primary site of tuberculosis infection in the lungs is known as the—
Ghon focus--
95. The body of a tapeworm is made of successive segments called-- ploglottids-
----
96. -----Sporozoite ----is the sexual phase in the life cycle of malaria parasite
taking place in the mosquito.
97. What name is given the fixed ARVs dose combinations of Emtricitabine,
Tenofovir and Efevirenz (FTC/TDF/EFV)?--------Atripla---------------
98. Laryngo tracheal bronchitis is called---croup-------
99. Spoon shaped brittle nails in Iron deficiency anaemia is called---koilonychia
--
100. The superficial skin infection that usually causes scaring is—folliculitis --

PART A
Encircle the most appropriate response
1. ____________ occurs when the HIV infected individual tests positive to HIV
antibody test
(a) Incubation period
(b) window period
 (c) Sero conversion
(d) Infectious period
2. The HIV enzyme that incorporates the viral RNA into the host genome DNA is
known as:
(a) Reverse transcriptase
(b) Integrase
(c) Protease
(d) fusion
3. Which of the following anti retroviral drugs belongs to NNRTIs?
(a) Efavirenz
(b) Emitricitabine
(c) Lopinavir
(d) Abacavir
4. The following ARVs are NRTIs EXCEPT;
(a) Emitricitabine
(b) Lamivudine
(c) Tenofovir
(d) Atazanavir
5. Renal toxicity is associated with
(a) Abacavir
(b) Niverapine
(c) Tenofovir
(d) Retonivir
6. The recommended approach to management of sexually transsmitted infections
is_______approach.
(a) Clinical
(b) Syndromic
(c) Aetiological
(d) Bacteriogical
7. The STI syndromes include the following EXCEPT;
(a) Lymphogranuloma venereum
(b) Scrotal swelling
(c) Inguinal swelling/bubo
(d) Urethral discharge
8. A patient with genital ulcer syndrome is given acyclovir. Which STI is targeted?
(a)Gonorrhea
(b) Syphilis
(c)Herpes Simplex
(d) Chancroid
9. Heart palpitations in anaemia results from _______
(a) Tachycardia
(b) Dizziness
(c)unconsciousness
(d) Headache
10. Thrombocytes are involved in_______
(a) blood clotting
(b) blood formation
(c)blood destruction
(d) blood production
11. The following are Clinical manifestations of thrombocytopenia EXCEPT;
(a) Ecchymosis
(b) Petechiae
(c)Aplastic anaemia
(d) Prolonged bleeding
12. Which of the following diseases is precipitated by upper respiratory tract
infections?
(a)Gastro enteritis
(b) Osteomyelitis
(c)Rheumatic heart disease
(d) Diabetes mellitus
13. The right sided heart failure accounts for the following EXCEPT;
(a)Distended jugular veins
(b) Ascitis
(c)Pedal oedema
(d) Pulmonary oedema
14. Broncho dilators include:
(a)Digoxin
(b) Aminophyline
(c)Acetaminophen
(d) Predinisolone
15. Which of the following is caused by fungi?
(a)Shingles
(b) Pneumocystis jirovecii Pneumonia
(c)Cryptosporidiosis
(d) Toxoplasmosis
16. Amphotericin B and fluconazole are best treatment for ___
(a) Crypyococcal meningitis
(b) Pneumocystis carinii pneumonia
 (c)Oral Hairy Leucoplakia
(d) Kaposi‘s Sarcoma
17. The commonest cause of hypothyroidism is___
(a)Iodine deficiency
(b) Auto immune diseases
(c)Thyroid tumour
(d) Infections
18. Which of the following diseases produces inflammatory nodules
(granulomas) in the skin and nerves over time just like tuberculosis?
(a)Rabies
(b) Epilepsy
(c)Glomerulonephritis
(d) Leprosy
19. Leprosy is mainly transmitted through____________
(a)Sexual contact
(b) Droplet inhalation
(c)Faecal – oral
(d) Direct contact
20. Thyrotoxicosis refers to _____________
(a)Elevated thyroid function/activity
(b) Increased levels of thyroid hormone in the blood
(c)Overproduction of parathormone
(d) Under secretion of thyroid hormone
21. Hyperthyroidism refers to……..
(a)Elevated thyroid function/activity
(b) Increased levels of thyroid hormone in the blood
(c)Overproduction of parathormone
(d) Under secretion of thyroid hormone
22. The primary indication of hyperparathyroidism is ______________
(a) Increased blood calcium levels
(b) Muscle weakness
(c) kidney stones
(d) Abdominal pain
23. The recommended diet for patient with hypothyroidism include;
(a) Increasing the intake of calcium-rich foods
(b) Reducing the intake of calcium-rich foods
(c) Increasing the intake of Soda drinks
(d) Reducing fluid intake
24. BPH is an example of ______________ cause of renal failure.
 (a) Pre renal
(b) Post renal
(c) Renal
(d) Intra renal
25. Antropophilic dermatophytes are those
_______________________________
(a) Whose transmission is from animal to man
(b) Whose transmission is from the soil to man
(c) Whose transmission is from man to man
(d) Whose transmission is from the environment to man

26. Antropophilic dermatophytes are usually ___________________________

(a)Acute, intense and inflammatory
(b) Chronic, non-inflammatory and mild
(c)Moderate inflammatory
(d) All of the above
27. Superficial scaly infection producing hypo- and hyperpigmention is typical of
_________________

(a)Tinea pedis
(b) Pityrasis
(c)Ascariasis
(d) Myasis

28. Infestation of the body with larval stages of a non bitting fly is
called_________
(a)Tinea pedis
(b) Pityrasis
(c)Ascariasis
(d) Myasis

29. Helminthiasis is caused

by_______________________

(a)Ancylostoma duodenale and Necator americanus

(b) Ascaris lumbricoides
(c)Tricuiris trichiura
(d) Enterobius vermicularis

30. Inflammation of the skin, clinically characterized by polymorphous lesions is

called_____________________

(a) Dermatitis
(b) Dermatophyte
(c)Myasis
(d) Tinea

31. Niclosamide is the drug of choice in the treatment of

_____________________
 (a)Hook worm
(b) Whipworm
(c)Tapeworm
(d) Round worm
32. ______________________ is a disease of the nervous system which affects
the skin and the nerves.
(a)Myasis
(b) Pityrasis
(c)Leprosy
(d) Neuritis

33. A patient with low resistance comes to the clinic with the following
characteristics: a wide dissemination of the bacilli involving the nerves, nose,
testes, pharynx and the trachea, and has multiple small symmetrically distributed
lesions. This patient can be said to have what type of leprosy?
(a)Tuberculoid
(b) Borderline
(c)Indeterminate
(d) Lepromatous

34. Shingles is the other name for _________________________

(a) Chicken pox
(b) Varicella zoster
(c)Herpes zoster
(d) Moluscumcontagiosum

35. Post herpetic neuralgia is common in which one of the following conditions?
(a) Chicken pox
(b) Varicella zoster
(c) Herpes zoster
(d) Moluscumcontagiosum

36. Which one of the following parasites is sexually transmitted?

(a) Myasis larva
(b) Pubic pediculosis
(c) Taeniasis
(d) Ascariasis
37. Which one of the following can gain access to the human system by both skin
penetration and ingestion via the oral cavity?
(a) Whip worm
(b) Pin worm
(c) Pork tape worm
(d) Ankylostoma duodonale

38. Which one of the following is acquired through ingestion and inhalation of its
eggs?
(a) Whip worm
(b) Pin worm
(c) Pork tape worm
(d) Ankylostoma duodonale
39. After mating, the male of one of the following worms usually die and are
passed in stool.
(a) Whip worm
(b) Pin worm
(c) Pork tape worm
(d) Ankylostomaduodonale

40. A viral disease of the nervous system that is usually transmitted to man by a
bite of an infected animal such as fox or a cat is called
_________________________
(a) Encephalitis
(b) Brucellosis
(c) Rabies
(d) Poliomyelitis
41. Post-herpetic neuralgia may be treated with a low dose
of____________________
(a) Paracetamol
(b) Carbamazepine
(c) Fluconazole
(d) Itraconazole

42. Leprosy is classified as either paucibacillary or multibacillary. The treatment

of multibacillary leprosy usually lasts______________________
(a) 4 months
(b) 6 months
(c) 8 months
(d) 12 months

43. All of the following are characteristics of diabetes mellitus type I EXCEPT
(a) There is inadequate insulin production
(b) There is no insulin production
(c) Sudden onset of symptoms
(d) Complete cure of the disease

44. The following are forms of insulin EXCEPT

(a) Intramediate acting insulin
(b) Short acting insulin
(c) Intermediate acting
(d) Long acting

45. TB treatment failure and treatment after default fall under which category of
TB treatment
(a) Category I
(b) Category II
(c) All of the above
(d) None of the above

46. All of the following are upper respiratory tract infections EXCEPT
 (a) Rhinitis
(b) Bronchitis
(c) Pharyngitis
(d) Laryngitis

47. The direct inspection and examination of the larynx, trachea, and bronchial
tree using a flexible fiber optic tube is called__________________________
(a) Laryngoscopy
(b) Bronchoscopy
(c) Laryngoscope
(d) Bronchoscope

48. Which one of the following drugs is used for the treatment of both Tb and
leprosy?
(a) Ethambutol
(b) Rifampicin
(c) Pyrazinamide
(d) Doxorubicin

49. Trichuris trichiura is nicknamed as whip worms

because______________________
(a) They are whip shaped
(b) They are used as whips
(c) They whip other worms
(d) They cause whips in man

MATCHING QUESTIONS
MATCH THE ITERMS IN COLUMN I WITH THEIR APPROPRIATE
DEFINITION IN COLUMN II
COLUMN I COLUMN II
50. Infectivity __E_ A. ability of the infected person to develop clinical
disease
51. Pathogenecity _A_ B. having a disease that can be
spread to others
52. Virulence __F__ C. ability of exposed person to
become infected with the disease
53. Infectious _B___ D. inhibit the multiplication and growth of bacteria
54. Bacteriostatic _D___ E. ability of a person with clinical disease to develop

severe illness or Death

F. ability to produce harmful viruses
G. ability to produce more bacteria
MATCH THE ITERMS IN COLUMN I WITH THEIR APPROPRIATE
DESCRIPTION IN COLUMN II
COLUMN I COLUMN II
55. Predisposing factors _B_A. factors which aggravate
an already existing disease
56. Enabling factors __C_ B. attribute which increase
the chances of an individual to develop a disease.
57. Precipitating factors_A__C. factors which assist in the development of the
disease
58. Reinforcing factors_F__ D. any condition preceding disease or illness
59. Risk factors _E__ E. factors which create a state of susceptibility so
that the host becomes vulnerable to the agent
F factors which are associated with immediate exposure
to the disease agent
MATCH THE TERMS IN COLUMN I WITH THEIR EXPLANATIONS IN
COLUMN II
COLUMN I COLUMN II
60. Macule_B___ A. Erosion that heals without
leaving a scar
61. Papule__C__ B. Flat, erythematous, purpuric,
pigmented lesion
62. Vesicle__G__ C. Elevated, palpable, circumscribed solid
lesion
63. Pustule__H__ D. Deep loss of skin surface that leaves a scar
64. Crust__F__ E. Thin flake of epidermis that detaches from the skin
F. Dried residue of serum, pus or blood on the skin surface

G. Elevation of the skin containing serous fluid H. Elevation of

the skin containing pus

MATCH THE ITEMS IN COLUMN I WITH THOSE COLUMN II

COLUMN I COLUMN II
65. Tinea capitis__C__ A. Feet
66. Tinea barbae__E__ B. Trunk
67. Tinea inguinalis_G__ C. Scalp
68. Tinea manuum__F_ D. Face
69. Tinea pedis__A__ E. Beard
F. Hand

G. Cruris

FILL IN THE BLANK SPACES WITH APPROPRIATE WORD/S

70. The third stage in the clinical progression of acute renal failure is termed
____diuresis______stage/phase
71. In renal failure, urea is excreted in sweat and crystallizes on the skin to form
______________________
72. In renal failure, the bitter metallic test in the mouth is due to accumulation of
__________________in the mouth
73. BUN is an investigation done to determine levels of urea in blood. The letters BUN
stand for_____blood____ _____urea___ _nitrogen___
74. _Thrombocytopenia_____ is a hematological disorder in which there are inadequate
circulating platelets
75. A form of tuberculosis that is characterized by a wide dissemination of tiny lesions
throughout the human body is known as ______Miliary TB
76. Hansen's disease is the other name for _____________Leprosy
77. The primary site of tuberculosis infection in the lungs is known as the ___Ghon
Focus__________
78. All new tuberculosis patients are under treatment category____1______
79. The irreversible widening (dilation) of the portion of the bronchi resulting from
damage to bronchial wall is called______Bronchioecstasis
80. A ______Goniometer________is used to determine the degree of flexion or
extension of the joint
81. ____Lithotomy_________ position is suitable for examination of the rectum and
vagina
82. Which theory postulates that every human disease is caused by a microbe specific to
the disease? ______Koch’s Desease theory_
83. During assessment, ___________Objective__________data is obtained through
observations and physical examination
84. Chancroid is caused by the organism called ______Haemopilus Ducreyi
85. _________Leprosy____________ is a disease that results in severe skin sores, nerve
damage, and gradual muscle weakness
86. The two commonest forms of filariasis are_________Lymphatic____ and
Subcutaneous_____
87. ____________________________
88. ________________Mosqiutoes________ is the most wide spread of all human
parasites
89. The pulmonary phase of_____________________________ worm infestation is
Called____________________________
90. The body of the tapeworm is made of successive segments
called_________Proglottids________
91. The body of tape worm is called_________________________________
92. The nearly mature Schistosoma worms pair, with the longer female worm residing in
the __________________________________ of the shorter male.
93. _____Sporogony___________ is the sexual phase in the life cycle taking place in the
mosquito.
94. If untreated filariasis involving the eyes can cause a type of blindness
called____Onchocercasis (River blindness____
95. The drug treatment of choice for filariasis
is_________Diethylcarbamazine_________
96. _Liver Cirrhosis__________is a chronic liver disease characterized by diffuse
inflammation and fibrosis resulting in drastic structural changes and significant loss of
function
97. Individuals infected by filarial worms may be described as either microfilaraemic or
amicrofilaraemic. The term ―microfilaraemic‖ mean that_______Direct Observation of
filarial in peripheral blood__.
98. ____Dermatology____________________ is a branch of medicine corned with the
study of skin diseases.
TUBERCULOSIS

 TB is a chronic infection disease which primarily affects the lungs but may also
affect bones, meninges ,kidneys lymph nodes and the abdomen and is caused by
an organism called mycobacterium tuberculosis and is characterized by
consolidation granulosis and fibrosis of the affected tissue
 It is a chronic infectious pulmonary disease caused by mycobacterium tubercle
usually characterized by cough for more than three weeks, night sweats, fever
especially at night, weight loss and dyspnea

ETIOLOGY

 Mycobacterium tuberculosis (commonly affects humans)

 Mycobacterium bovis (in animals though may affect humans)
 Mycobacterium Avium (rare)

TYPES OF TUBERCULOSIS

Pulmonary Tuberculosis (PTB): This is a chronic infectious disease of the

respiratory tract which is characterized by formation of granulomas in the lungs.

Extra Pulmonary tuberculosis: This tuberculosis which occurs anywhere in the body
but outside the lungs e.g. TB spine, TB abdomen, TB meningitis.

Milliary tuberculosis: This is tuberculosis in which there is widespread dissemination

of TB throughout the body from a primary focus or later stages of tuberculosis

RISK/ PREDISPOSING FACTORS

 Poor housing; small houses with poor ventilation play a major role in TB
transmission.
 Poor nutritional status; undernourished are predisposed to TB as resistance to
infection is reduced.
 Overcrowding in places like markets, schools, and these make it easier to
contract TB.
 Age; reduced immunity in the young and old make them prone to TB
  Smoking; the smoke destroys the lung resulting in parenchymal dysfunction
leading to diseases like TB.
 Alcoholism; alcohol reduces the immunity of an individual making him or her
prone to TB
 Drugs; patients who take immuno-suppressive drugs like steroids (e.g.
prednisolone) are prone to TB due to reduced immunity.
 Immuno suppression caused by diseases like HIV/AIDS, cancer, age the
youngest and oldest being at risk.

 Occupation; health workers are at risk of contracting TB due to their nature of

work. Those who work in industries; e.g. mining industry

MODE OF SPREAD

 Air borne

PATHOPHYSIOLOGY

When a person inhales the infectious agent it goes to the alveoli where it will start
multiplying. Later the organism may be carried via the lymphatic to the nearby lymph
node like the hilar nodes. The presence of the bacteria will provoke an immune
reaction causing inflammation in the lung. Neutrophils and other macrophages will
migrate to the area and engulf the bacteria without necessarily bringing about total
destruction of the bacteria.

The neutrophils, macrophages will interact with the T lymphocyte resulting in

development of cellular immunity. The macrophages will surround the bacterial and
then change into giant multinucleated cell and epithelioid cell this results in the
formation of the tubercle. The central part of the tubercle will undergo necrosis
resulting in the formation of the necrotic cheese like substance called caseation
necrosis. This cheese like substance may be coughed up as purulent sputum leaving a
cavity or become calcified after healing. This is called a primary lesion of ghon‘s
focus. This may be seen on x ray as patches. The se primary lesion contain tubercle
bacilli lying dormant but may be reactivated later when the immunity goes down
causing what is called post primary TB or secondary T.B

SIGNS AND SYMPTOMS

 Productive cough for more than three weeks due to irritation of the respiratory
tract by the bacilli causing the inflammatory process
 Fever at night due to infection and activity of the bacilli at night.
 Chest pains due to irritation of the sensory neurons by the inflammatory process
 Hemoptysis due to rupture of the blood vessels in the lung
 Malaise and fatigue due to tissue hypoxia
 Dyspnea due to destruction of the lung tissue by the inflammatory process
 Night sweats due to fever at night
 Enlargement of the lymph nodes of the neck axilla or groin
 Weight loss due to anorexia
 Anorexia due to G.I.T. involvement
 Headache due to cerebral hypoxia and toxins produced during the inflammatory
reaction
 Abdominal distention due to ascites
MEDICAL MANAGEMENT

AIMS

 To isolate the causative organism

 To treat the infection
 To relieve signs and symptoms
 To prevent complications

INVESTIGATIONS AND DIAGNOSIS

History-Taking

 I will do history taking which will reveal a patient coming in contact with an
infected person.
 I will do history taking which will reveal night sweat
 I will do history taking which will reveal a patient being a smoker.

Physical-Examination

 I will do physical examination which will show swollen lymphnodes on palpation.

  I will do physical examination which will reveal difficulties in breathing on
inspection.

Laboratory Tests

 Sputum analysis – for Acid Alcohol Fast Bacilli (AAFB). 3 samples need to be
examined to diagnose TB. i.e. 1st sport on contact. 2nd early morning on following
day and 3rd same day when bringing the 2nd sample.

 Chest X-ray - shows presences of cavities in the lungs.

 Full blood count (FBC) - shows white cell count and ESR raised

 Gastric lavage in children– when examined for AAFB reveals causative organism.

TREATMENT

CLASSIFICATION OF TB

a. New: No previous treatment or treatment for less than one month.

b. Relapse: previously treated and declared cured.
c. Treatment after default: Started on retreatment regime having failed previous
treatment
d. Treatment after default: Returning to treatment with positive smear.

The only effective treatment of TB is adequate chemotherapy which means

appropriate Fixed Dose Combination drugs given in correct doses, tken daily by the
patient under supervision for a stipulated duration.

Advantages

 Prevention of resistance
 Simplification of treatment

Drugs
New patients with presumed drug. Susceptible pulmonary tuberculosis should have 6
months of TB treatment. This consists of 2 months intensive and 4 months
continuation

Intensive Phase (2 months)

It is designed for rapid killing of actively growing bacilli and killing of semi dormant
bacili.

Continuation Phase (4 months)

Elimination of bacili that are still multiplying and reduces the risk of failure and
relapse.

In the first phase, drugs given include;

Rifampicin 150mg (R)

Action: Bacteriocidal with high potency

Side effects:

 Nausea and vomiting

 Diarrhea
 Red orange discoloration of body fluids.

Isoniazid 75mg (H)

Action: Bacteriocidal with high potency

Side effects

 Peripheral neuropathy
 Optic neuritis
 Vertigo
 Steven Johnson syndrome
Pyrazinamide 400mg (z)

Action: Bacteriocidal with low potency

Side Effects

 Rash
 Hepatotoxicity
 Arthralgia
 Jaundice

Ethambutol 275mg (E)

Action: Bacteriostatic with low potency

Side effects

 Optic neuritis
 Red, green color blindness
 Peripheral neuritis

First phase drugs given are:RHZE for 2 months

Second phase drugs given are: RH for 4 months

Note:

TB meningitis and TB of the spine may be treated for 12 months.

TB treatment for patients previously treated should have a drug susceptibility test to
find out if they have any drug resistance. If not then the standard first line treatment of
two months. 2RHZE/4RH. If there is resistance, then Multi drug Resistance TB regime
should be prescribed.
Standard longer regime for RR/MDR TB (Rifampicin resistant/multi drug resistant)
TB patients lasts for 20 months.

Intensive phase for 8 months where the patient receives drugs like;

 Kanamycin
 Levofloxacin
 Ethionamide
 Cycloserine
 Pyrazinamide

In the 12 months, the patient receives the same drugs except kanamycin. MDR TB
occurs when there is resistance to both rifampicin and isoniazide.

Causes of MDR TB

 Prolonged shortage of drugs

 Use of anti-TB drugs of unproven quality
 Incorrect management of individual cases by clinicians
 Poor adherence
 Suboptimal dosage/doses
 Poor drug absorption.

EDUCATION MESSAGE
 Duration of treatment
 Adherence or importance of compliance
 How to deal with situations such as travel and loss of tablets
 Possible side effects
 Importance of having a balanced diet
 Avoidance of smoking and alcohol during and after treatment.
 Cough hygiene (elbow technique, disinfect tissue)
QUESTIONS ON TUBERCULOSIS

1. Mr. Friday Kabaso, a male aged 46 is admitted to your ward with a history of
chest pain and coughing for 4 weeks. A provisional diagnosis of pulmonary
tuberculosis is made (PTB) while waiting for the results.
a. State 5 signs and symptoms of PTB other than the one mentioned in the question
stem. 15%
b. Draw a well labeled diagram of the respiratory system 15%
c. Explain how sputum should be collected and sent for examination 5%
d. Using the nursing care plan, identify 5 nursing problems that Mr. Kabaso will
present with and show how you are going to manage them 50%
e. Explain 5 goals of antiretroviral therapy (ART) 20%

2. A 30-year-old Mr. Sikanyika is presented to the emergency room with complaints of

persistent diarrhoea in the last 6 weeks, fever, weight loss, cough with blood stained
sputum and difficulty with breathing. He has been unable to do his normal daily work
in the last 6 weeks because of his symptoms. On examination, he was wasted, pale and
dehydrated. Three sputum examinations for acid-fast bacilli were positive. He has
never suffered from tuberculosis before. Mr. Sikanyika is scheduled to start TB
treatment immediately and ART 2 weeks after initiation of anti TB drugs

A) i. What WHO Stage of HIV is Mr. Sikanyika? 2%

ii. Indicate the tuberculosis treatment category for this patient 2%

iii. Mention three (3) characteristics of mycobacterium tuberculosis 6%

iv. State the difference between incubation period and window period 4%
B) i. Mention three (3) ARV drugs currently in use as recommended First Line
regime in Zambia (2 NRTIs and 1 NNRTI) 6%

ii. State Five (5) general principles of ART 15%

C) Describe the management this patient will require under the following:
i. Tuberculosis treatment
 (a) Intensive/initial phase 7%
(b) Continuation phase 3%
ii. Nursing care under the following needs;
(a) Maintaining patentAirway 5%
(b) Improving Nutritional Status 5%
(c) Improving patient knowledge 5%
(d) Promoting activity tolerance and rest 5%
D) Outline six (7) points you would include in your IEC on the prevention and
control of spread of HIV infection to the youths in your local community
35%

LIVER CIRRHOSIS
Liver Cirrhosis is a very serious degenerative disease that happens when healthy cells
in the liver are damaged and replaced by scar tissue, usually as a result of alcohol
abuse or chronic hepatitis. As liver cells give way to tough scar tissue, the organ loses
its ability to function properly. Severe damage can actually lead to liver failure and
even death. It's important to understand some of the functions of the liver.

FUNCTIONS OF THE LIVER

 Production of bile salts
 To store glycogen (from excess glucose)
 Detoxification of substances such as drugs and alcohol
 Production of fibrinogen and prothrombin necessary for clotting
 To synthesize vitamins A,D,E and K
 Production of certain immunoglobulins that are part of the immune system
LIVER CIRRHOSIS
DEFINITION
  This is a chronic progressive disease of the liver in which there is extensive
damage to the liver parenchyma cells which later heal by fibrosis impeding the
vascular flow leading to liver failure functioning
 It is a chronic progressive disease of the liver characterized by diffuse destruction
and regeneration of hepatic parenchymal cells.

TYPES OF LIVER CIRRHOSIS

 Laennec's Cirrhosis (Alcoholic, Nutritional or Portal Cirrhosis): This come
from excessive alcohol intake leading to fat accumulation in liver cells resulting
into wide spread scar formation throughout the liver.
 Post-necrotic Cirrhosis: This is a complication of viral, liver toxins or hepatitis
leading to broad bands of scar tissue within the liver.
 Billiary Cirrhosis: This type is associated with chronic biliary obstruction and
infection leading to diffuse fibrosis of the liver
 Cardiac Cirrhosis: This comes as a result of protracted venous congestion in the
liver caused by right ventricular failure which eventually cause cellular necrosis
due to poor cellular nutrition, hypoxia and inadequate blood flow and scar tissue
forms on healing causing malfunctioning of the liver.
CAUSES/PREDISPOSING FACTORS
 Excessive alcohol intake
 Hepatitis
 Blockage of the bile ducts
 Schistosomiasis
 Primary sclerosing cholangitis
 Cystic fibrosis
PATHOPHYSIOLOGY
Liver Cirrhosis is a very serious degenerative disease that happens when healthy cells
in the liver are damaged and replaced by scar tissue, usually as a result of alcohol
abuse or chronic hepatitis. As liver cells give way to tough scar tissue, the organ loses
its ability to function properly. Severe damage can actually lead to liver failure and
even death.
SIGNS AND SYMPTOMS
 Flatulence due to disturbed metabolism
 Dyspepsis due to disturbed carbohydrate and fat metabolism
 Diarrhoea and constipation due to disturbed metabolism of food
  Pain and heavy feeling in the right upper quadrant as a result of swelling and
stretching of the liver capsule, spasms of the biliary ducts and vascular spasms
 Palmer erythema: red areas on the palms of the hands
 Ascites due to portal hypertension and changes in osmotic pressure in the liver
blood vessels
 Anaemia due to gastro intestinal bleeding, haemolysis secondary to hypersplenism
or nutritional deficiencies of folic acid and vitamin B12
 Jaundice due to changes in the liver functions and compression of bile ducts by
connective tissue overgrowth. And also due to decreased ability of the liver to
conjugate and excrete bilirubin
 Pallor due to inadequate red blood cell production and survival and also poor diet
and bleeding may be responsible.
 Spider angiomas due to small dilated blood vessels with bright red center and
spider-like branches commonly seen on the nose, cheeks, upper trunk, neck and
shoulder
COMPLICATIONS
 Hepatic coma (encephalopathy) due to ammonia entering the systemic circulation
due to failure of the liver to carry out diminution function.
 Portal hypertension
 Oesophageal varices
 Ascitis
 Bleeding tendencies due to reduced fibrinogen
 Heartfailure
 Renal failure
 Cancer of the liver
MANAGEMENT
AIMS
 To prevent infection
 To prevent further liver damage
 To prevent complications

HISTORY TAKING
 I will do history taking which will reveal a history of hepatitis
 I will do history taking which will reveal the patient being an alcoholic
PHYSICAL EXAMINATION
  I will do physical examination which will reveal hepatomegaly on palpation
 I will do physical examination which will reveal jaundice on inspection
LABORATORY TESTS
 Liver biopsy to detect destruction and fibrosis of hepatic tissue
 Ultrasonography imagine to rule out biliary obstruction
 Blood for LFT to reveal diminished liver function
TREATMENT
There is no specific treatment. Treatment is based on the presenting symptoms.
Bed rest
Diuretics to relieve ascites
Restrict all nephrotoxic drugs e.g methyldopa

Furosemide 40- 120mg per oral once daily

Side Effects
 Hypokalemia
 Dehydration
Nursing considering:
 To be given with slow k to prevent hypokalemia

Propranolol 20mg 8 hourly

Action: beta blocker lowers pressure in the portal vein
 It's also used to prevent bleeding and rebreeding from varices in patients with liver
cirrhosis

If infection is present antibiotics are given e.g cefotaxine 2g 6 hourly and

metronidazole 500 mg 8 hourly IV
Lactulose 30 mg can be given to eliminate ammonia from the blood into the bowel.

NURSING MANAGEMENT
AIMS
  To maintain adequate nutritional status
 To give psychological care
 To promote rest

AEPROPHENEMA

QUESTION ON LIVER CIRRHOSIS

Mr. Mpundu Kalande, a 52 year old business man, married with 6 children is
admitted to male medical ward with history of excessive alcohol intake. He is
diagnosed to have liver cirrhosis.

a. i. Define liver cirrhosis {5%}

ii. Explain the five types of liver cirrhosis {15%}
b. discuss the management of Mr. Kalande during his stay in hospital {50%}
c. Explain any four complications of liver cirrhosis {20%}
d. State five effects of alcohol abuse {10%}

NEPHROTIC SYNDROME
DEFINITION
 A renal disorder that is due to damage to the renal glomeruli resulting in heavy
proteinuria, low plasma protein, hyperlipidemia and generalized edema.
 This is a collection of symptoms caused by many diseases that affect the kidneys,
resulting in severe prolonged loss of proteins into urine, decreased blood levels of
proteins (especially albumin) , retention of excess salt and water in the body and
increased levels of fats (lipids) in the blood.
 This is a collection of symptoms characterized by proteinuria, hypoproteinemia,
oedema and hyperlipidemia.
CAUSES
1. PRIMARY CAUSES (AUTOIMMUNE DISORDERS)
Minimal change disease: This is a common cause of nephrotic syndrome in children.
Nephrons appear normal with optical microscope as lesions ar only seen with
electronic microscope.
Focal Segmental Glomerulosclerosis: Common cause of glomerulo nephritis in
adults characterized by tissue scarring in the glomeruli. Focal means some of the
glomeruli have scars while intact. Segmental means only parts of the glomerulus suffer
damage.
Membraneous Glomerulonephritis: Antibodies are produced against certain proteins
located in the kidneys filtering system causing increased leaking in the kidney.
2. SECONDARY CAUSES (EXISTING CONDITIONS/DISEASE)

Congestive cardiac failure: leads to renal hypoperfusion leading to renal ischemia.

Anemia: leads to renal hypoperfusion
Renal artery thrombosis: leads to renal hypoperfusion
Hypertension: leads to rupture of blood vessels in the kidneys.
Diabetes melittus: causes diabetic nephropathy
Lupus erythromatous

PATHOPHYSIOLOGY

The initial pathophysiological change is damage to the cells in the basement of the
glomerula. This damage leads to increased glomerula membrane permeability to
proteins resulting in proteinuria. This results in low plasma proteins or
hypoalbuminemia which causes a reduction in oncotic pressure. The resultant
decreased oncotic pressure leads to oedema. Fluid loss from vascular system causes
reduced circulatory volume (hypovolemia) contributing to reduced cardiac output
which leads to decreased renal blood flow causing reduction in glomerula filtration
rate leading to renal ischemia. The decreased blood flow to the kidneys triggers the
activation of renin angiotensin aldesterone system which stimulated sodium and fluid
retention leading to fluid overload causing further oedema.

SIGNS AND SYMPTOMS

  Proteinuria due to damage to the glomeruli
 Hypoalbuminemia due to secondary proteinuria
 Hyperlipidemia due to hepatic synthesis of lipoproteins
 Oedema due to fluid retention
 Haematuria due to damage to the renal glomeruli
 Hepatomegally due fluid retention
 Weight gain
MEDICAL MANAGEMENT
AIMS
 To relieve pulmonary congestion
 To relieve signs and symptoms
 To prevent complications

INVESTIGATIONS
HISTORY TAKING
 I will do history taking which will reveal haematuria
 I will do history taking which will reveal difficulties in breathing
PHYSICAL EXAMINATION
 I will do physical examination which will show hepatomegaly on palpation
 I will do physical examination which will reveal oedema on palpation

LABORATORY TESTS
 Urinalysis will show proteinuria
 Blood for protein analysis will show hypoalbuminemia.

TREATMENT
DRUGS
Frusemide 20-30mg
Action: inhibits sodium and fluid retention in the ascending loop of Henle.
Side Effects: polyuria, hypotension
Captopril 12.5mg- 25mg 12 hourly
Action: Inhibits the conversion of angiotensin I to angiotensin II by inhibiting ACE
Side effects: tachycardia, angina pectoris, hypotension, dizziness

Prednisolone 0.14mg/kg
Action: reduces vascular permeability
Side effects: increased appetite, insomnia, fluid retention
Antibiotics for prophylaxis such as benzypenicilin 1.4-2mu qid.

NURSING PROBLEMS

 Impaired gaseous exchange related to pulmonary oedema evidenced by

difficulties in breathing
 Fluid volume excess related to fluid retention evidenced by oedema
 Altered nutrition related to restriction of food and proteinuria evidenced by pale
skin, poor hair texture
 Risk of infection related to long hospital stay or lowered immunity.
 Risk of pressure sore formation related to oedema

QUESTIONS ON NEPHROTIC SYNDROME

Mukela Mangolwa a 2 year old boy has been admitted to your medical ward
with a diagnosis of Nephrotic syndrome.

a) (i) Define Nephrotic syndrome. 5%

(ii) State five signs and symptoms of Nephrotic syndrome. 10%
b) Discuss the Pathophysiology of Nephrotic syndrome. 15%

c) Describe the management of Mukela in the first 72 hours of admission. 50%

ASTHMA
DEFINITION
It has been defined in several ways. Some of which include;
 It is a chronic inflammatory disorder of the airway that is characterized by
narrowing of the air passage due to a wide variety of stimuli.
 It is an intermittent reversible obstructive airway disease characterized by hyper
responsiveness of the tracheal bronchial-tree to various stimuli leading to
narrowing of the airway resulting in dyspnea, cough, wheezing e.t.c
 It is a chronic inflammatory condition of the upper respiratory tract characterized
by severe dyspnea and wheezing resulting in reversible narrowing of the air-
passage due to bronchospasms.
TYPES
Asthma may be intrinsic or extrinsic.
Intrinsic is also known as non-atopic or non- allergic. Extrinsic is also known as a
topic or allergic.
INTRINSIC ASTHMA
This is the type of asthma that is not usually associated with any allergies and accounts
for about 10% of asthma cases and is more common in adults.
EXTRINSIC ASTHMA
This is the commonest type of asthma and accounts for about 90% of asthma cases.
80% of all cases have documented history of allergies to a wide range of allergies and
it is very common in children.
PREDISPOSING FACTORS
 Infections (RTI): Act as antigen which triggers immunal reaction.
 Certain drugs such as acetylsalicylic acid causes the production of leukotrien
which cause bronchospasms
 Dust, pollen, spices, smoke
 Emotional stress e.g anger can bring about change in the breathing pattern leading
to triggering of asthma attack
 Hereditary
PATHOPHYSIOLOGY
When an allergen is inhaled and absorbed in the bronchial mucosa, it stimulates a
group of T-helper cells to produce cytokines such as interleukin-4 (,IL-4). Interleukin-
4 causes the production of IgE which in turn allows degranulation of mast cells and
release of histamines and other inflammatory mediators. These inflammatory
mediators trigger bronchospasms, swelling of the mucus membrane and excessive
mucus production, which eventually lead to wheezing and difficulties in breathing.
SIGNS AND SYMPTOMS
 Wheezing: due to bronchospasms
 Cough: due to irritation of the respiratory tract
 Difficulties in breathing: Due to excessive accumulation of mucus or
bronchospasms or narrowing of the respiratory tract
 Tachycardia: due to tissue hypoperfusion
 Tachypnea: due to tissue hypoxia
 Cyanosis: due to hypoxia
 Confusion: due to hypoxia

MEDICAL MANAGEMENT
AIMS
 To restore normal respiratory pattern
 To relieve signs and symptoms
 To improve oxygenation
 To prevent complications

INVESTIGATIONS
HISTORY TAKING
 I will do history taking which will reveal history of asthma in the family
PHYSICAL EXAMINATION
 I will do physical examination which will confirm difficulties in breathing on
inspection
 I will do physical examination which will reveal wheezing on inspection
SPECIAL TESTS/RADIOLOGICAL INVESTIGATIONS
 Bronchoscopy to reveal bronchospasms
 Arterial Gas analysis which will show elevated reduced oxygen
TREATMENT
DRUGS
Salbutamol 4mg 8 hourly
Action: Acts as a selectively adrenergic beta 2 receptor to cause bronchodilatation and
vasodilation
Side Effects
 Insomnia
 Weakness
 Heart palpitations
 Tachycardia
 Nausea and vomiting
 Tremors
Aminophylline 100mg -300 mg in slow IV
Action: Relaxes bronchiosmooth muscles causing bronchodilatation and increasing
vital capacity
Side Effects
 Headache
 Insomnia
 Dizziness
 Nausea and vomiting
 Tachycardia
Hydrocortisone 100-200mg IV stat
Action: Anti-inflammatory
Side Effects
 Weight gain
 Euphoria
 Nausea and vomiting
 Headache

Oxygen 3-8l via a nasal mask or cannula

QUESTION ON ASTHMA
Mr. George Zulu aged 30 years is admitted to male Medical Ward in an
Asthmatic attack.

a. Define Asthma 5%
b. (i) State five (5) signs and symptoms which Mr. Zulu may present with 15%
(ii) Explain the path physiology of an asthmatic attack 15%
c. Discuss the management of Mr. Zulu while in the hospital 50%
d. State five (5) points you would include in your information, Education and
Communication (IEC) to Mr. Zulu on the prevention of Asthmatic attacks. 15%

SCHISTOSOMIASIS
DEFINITIONS
• Schistosomiasis is a parasitic infection of the urinary tract or intestine caused by
schistosoma characterised by passage of blood in urine or bloody stool.
• A chronic parasitic disease of the large bowel or the urinary bladder caused by the
genus schistosomia characterized by haematuria, frequent micturition and
Katayama fever
• It is group of chronic disorders caused by small, parasitic blood flukes
characterized by inflammation of the intestines, bladder, liver, and other organs.

CAUSATIVE ORGANISM
• The causative organism is schistosoma.
TYPES OF SPECIES
There are five main species of schistosoma that cause disease in man. Each causes a
different clinical presentation of the disease.
These are:
 Schistosoma mansoni (intestinal)
 Schistosoma haematobium (urinary)
 Schistosoma japonicum (Asian intestinal )
 Schistosoma intercalatum (intestinal)
  Schistosoma mekongi

Mode of Spread
• Man becomes infected when the skin comes in contact with water infested with
cercaria or through ingestion of infested water.
Incubation Period
• 4-6 weeks

LIFE CYCLE

Eggs of the schistosomes are passed by the definitive host in urine (S. Haematobium)
or faeces (S. Mansoni). It contains a fully embryonated miracidium. Upon reaching
fresh water, the miracidium hatches within a few minutes partly as a result of osmosis
or its own movements. The miracidium swims actively by the means of its ciliated
epidermis for 8-12 hours, searching for a snail host. The miracidium enters the snail.
Miracidium infect fresh water snails by penetrating the snails‘ [Link] miracidium
transforms into sporocysts within an hour of penetration.
Sporocysts begin to divide producing thousands of new parasites called cercariae
which are the larvae capable of infecting mammals. Cercariae are highly motile and
penetration of the human skin occurs after the cercaria attaches to the skin. A cercaria
can penetrate the skin of the definitive host within a few minutes. It sheds its tail and
in the tissues becomes a schistosomulum.
The schistosomulum travels to the lungs where it undergoes further developmental
changes after which it migrates to the liver (8-10 days) where growth takes place.
During this period, the parasite feeds on RBCs from the liver. Mature worms migrate
to the bladder, ureters and kidneys through the vesicle plexus ([Link]). The
mesenteric veins (S. Mansoni) where they begin to lay eggs and later eggs are passed
out in human excreta. Some eggs migrate through the bowel or bladder tissue and are
shed in feces or urine. While other eggs are swept into the portal blood and lodge in
other tissue sites. Eggs shed into urine or feces may reach maturity in freshwater and
complete their life cycle by infecting susceptible snails.

PATHOPHYSIOLOGY
Adult worms release eggs in the venules. Eggs become lodged in the intestinal wall
and cause an immune system reaction called a granulomatous reaction. This will lead
to erosion of some blood vessels, either in the bladder or intestine causing bleeding
and pus. There will be tissue proliferation and repair resulting in fibrosis. This immune
response can lead to obstruction of the colon and blood loss. The infected individual
may have what appears to be a potbelly. Eggs can also become lodged in the liver,
leading to portal hypertension, splenomegaly, and the buildup of fluid in the abdomen.
Life-threatening dilations or swollen areas in the esophagus or gastrointestinal tract
that can tear and bleed profusely (esophageal varices) can also develop. In severe
cases, constriction of the urethra may occur with consequent hydronephrosis. In
females, the pelvic organs are also affected. In general, organs liable to be affected are
the liver, kidneys, intestines, ureters, lungs and the bladder.
SIGNS AND SYMPTOMS
 Itching at the point of penetration for 1-2 days.
 Urinary as allergic reaction to ova deposition
 Fever due to parasites in the blood.
 Headache
 Cough as the larvae migrates through the lungs.
 Haematuria
 Frequency in maturation
 Pain in the iliac fossa which radiates to the loin .
 Hypertension due to hydronephrosis.
 Heamospermia due to seminal vesicle involvement
 Papilomata of the vulva and lesions on the cervix .
 Malaise
 Frequent blood stained stool .
 Abdominal pains
 Hepatospleenomegaly
 Severe haematemesis (fatal) from oesophageal varices
 Jaundice
 Epilepsy , blindness , blindness due to deposition of ova on the CNS.

QUESTIONS ON SCHISTOSOMIASIS
Teddy, a 15 year old school boy who comes from Lukanga swamps, has been
diagnosed with Schistosomiasis. {Bilharzia}.This problem is endemic in the area
where he stays and most families depend on the nearby infested river for their
living.

a. What type of disease is Schistosomiasis infection {5marks}

b. Mention five types {5} of Schistosomiasis which infect the human body and the
areas mainly affected {10Marks}
c. With the aid of a well labeled diagram, describe the life cycle of schistosoma
haematobium {30 marks}
d. Discus the medical management you would give to your patient indicating the
drug/s of choice, the dosage, side effects and Nursing implications. {25 marks}
e. Draw up a comprehensive teaching plan {IEC} that you would give to School
children living alongside a river bank infested with Schistosomiasis. {40 marks}

2. Mubema, a 16 year old from a shanty compound comes to your health center
with history of passing blood in urine. A provisional diagnosis of Schistosomiasis
is made.
a. (i) Mention three (3) main species of the disease 3%
(ii) With the aid of a diagram, describe the life cycle of Schistosomiasis. 30%
b. Outline three (3) investigations done to confirm the diagnosis. 12%
c. Name three (3) drugs that can be used in the management of the Mubema, stating
the dose, three (3) side effects and two (2) nursing implications. 30%
d. Explain five points that you would include in your IEC to this community.

ANAEMIA

DEFINITIONS:

 It is a reduction of oxygen carrying capacity of blood as a result of fewer

circulating erythrocytes in blood.
 It is a reduction in the number of circulating red blood cells or in their content of
hemoglobin or both.
 It is a Blood disorder where there is reduced haemoglobin for the age and sex of
an individual which may be due to excessive destruction of RBCs, inadequate
production of RBCs, or loss of blood. (Kumar & Clark 2005)
  Is a reduction in either the number of RBCs, the amount of hemoglobin or the
hematocrit (Ignatavicius D and Workman M. L,2006)
 Anaemia is a reduction in the oxygen carrying capacity of the blood caused by
decrease in red blood cell production, or reduction in haemoglobin count of blood
or a combination of both (Myles, 2003).
 Anaemia is a state in which the blood haemoglobin level is below the normal
range for the patient‘s age and sex (CBoH, 2002)
 It is a reduction of oxygen carrying capacity of blood as a result of fewer
circulating erythrocytes in blood.
 It is a reduction in the number of circulating red blood cells or in their content of
hemoglobin or both usually characterized by pallor, tachycardia and malaise.

CLASSIFICATION

Anaemia may be classified in two ways ie. According to:

 Cause or
 According appearance of the RBC.

CLASSIFICATION ACCORDING TO CAUSES

 Haemorrhagic anaemia (Anaemia due to blood loss)

 Haemolytic anaemia (Anaemia due to excessive destruction of RBCs)
 Aplastic anaemia (Anaemia due to bone marrow aplasia)
 Blood forming element deficiency anaemia. (e.g. Iron anaemia, folic acid and
vitamin B12 deficiency anaemia) NOTE some times this may be considered
under aplastic anaemia.

CLASSIFICATION ACCORDING TO APPEARANCE OF THE RBCS

 Macrocytic hyperchromic anaemia: Cell appears larger than normal and

appears red usually seen in folic acid or vitamin B deficiency anemia
 Microcytic hypocromic anaemia: The cells appear smaller than normal and
they appear pale. Usually due to iron deficiency
  Normocytic normocromic: The cells are normal in size and colour. Seen an
acute blood loss.

SPECIFIC TYPES OF ANAEMIA AND THERE CAUSES

Blood Forming Element Deficient Anaemia: The cause of this type of anaemia
includes the shortage of the element like iron, vitamin B12 and folic acid in the body.
The sub types under this include;

 Iron Deficiency Anaemia: There always an increased demand for iron which is
not always met. This can be due to inadequate dietary intake of iron or impairment
in the absorption of iron in the GIT. The bone marrow needs iron to make
hemoglobin. Without adequate iron, the body can't produce enough hemoglobin
for red blood cells resulting in iron deficiency anemia. One way your body gets
needed iron is when blood cells die — the iron in them is recycled and used to
produce new blood cells. So, if you lose blood, you lose iron. Women with heavy
periods who lose a lot of blood each month during menstruation are at risk of iron
deficiency anemia. Slow, chronic blood loss from a source within the body such
as an ulcer, a colon polyp or even colon cancer can lead to iron loss and iron
deficiency anemia
 Vitamin B12 Deficiency Anaemia (Pernicious Anaemia): People who have an
intestinal disorder that affects the absorption of nutrients are prone to this type of
anemia. Some people are unable to absorb vitamin B-12 for a variety of reasons
and develop vitamin B-12 deficiency anemia, which is sometimes called
pernicious anemia. Vitamin deficiency aneamias fall into a group of aneamias
called megaloblastic aneamias, in which the bone marrow produces large,
abnormal red blood cells.
 Folic Acid Deficiency Anaemia: This is also a type of megaloblastic leukaemia.
Folic acid is not stored in the body therefore; the body‘s needs must constantly be
met through dietary intake. Deficiency of folic acid causes a form of
megaloblastic anaemia identical to that seen in vitamin B12 deficiency, but not
associated with neurological damage
  Aplastic (Hypo Plastic) Anaemia: results from bone marrow failure in which
there is reduced number of erythrocyte. This is a life-threatening anemia caused
by a decrease in the bone marrow's ability to produce all three types of blood cells
i.e. .red blood cells, white blood cells and platelets. Many times, the cause of
aplastic anemia is unknown, but it's believed to often be an autoimmune disease.
Some factors that can be responsible for this type of anemia include chemotherapy
and radiation therapy. Some drugs like chloramphenicol, may also depress the
bone marrow causing aplastic anaemia.
 Haemolytic Anaemia: It occurs when circulating red blood cells are destroyed or
are removed prematurely from the circulation because the cells are abnormal or
the spleen is overactive. This is a type of anaemia caused by destruction of red
blood cells. The cause include; sickle cell anaemia, infections like malaria, blood
transfusion incompatibility, toxic drugs and poisons e.g. lead poison and snake
venom
 Haemorrhagic Anaemia: This anaemia due to sudden blood loss from a blood
vessel. E.g. Following trauma, surgery, child birth, chronic epistaxis,
schistosomiasis, menorrhagia, anti-inflammatory drugs or anti-coagulant
medications. This may cause haemorrhage.

PREDISPOSING FACTORS

 Dietary insufficiency: A diet which is low in iron, vitamin C and protein. This
can be due to poverty or poor eating habits, customs and poor preparation of food
will eventually lead to anaemia.
 Infections like Malaria may cause haemolytic anaemia
 Worm infestation: Some worms release toxins that suppress the normal function
of the bone marrow. Worms such as hook worms and wipe worms use up the
nutrients from the diet for its own growth, hence deprive the host of the essential
nutrients.
 Medication or drugs: substances such as anti-epileptic agents, anti-coagulants
and some oral antibiotics
  Malabsorption: caused by conditions such as coeliac disease.
 Inherited disorders: such as thalassaemia or sickle cell disease.
 Autoimmune disorders : such as autoimmune haemolytic anaemia, where the
immune cells attack the red blood cells and decrease their life span.
 Periods of rapid growth or high energy requirements: such as puberty or
pregnancy.

 Blood loss : due to trauma, surgery, cancer, peptic ulcer, heavy menstruation,
bowel cancer or frequent blood donations.

 Chronic diseases such as rheumatoid arthritis and tuberculosis.

 Hormone disorders such as hypothyroidism.

 Bone marrow disorders - such as cancer, infection or certain medications

PATHOPHYSIOLOGY

Red Blood Cells are produced at the same rate of their destruction. This ensures that
the level remain within normal range. The average life span of an erythrocyte is 120
days after which they are destroyed. When the rate of production is exceeded by the
rate of destruction a deficit results giving rise to anaemia. Low Hb means reduced
oxygen carrying capacity of blood. This will lead to the use of the compensatory
mechanism to meet the body demand for oxygen. The compensatory mechanisms
include; Tachycardia, in order to meet the body demand for oxygen. This mechanism
leads to cardiomegally due to hypertrophy of cardiac muscles. This will eventually
make the heart less efficient giving rise to various symptoms.

GENERAL SIGNS AND SYMPTOMS OF ANAEMIA

 Pallor due to low Hb

 Heart palpitations due to tachycardia and myocardial hypoxia
 Dizziness due to cerebral hypoxia
 Easy fatigability due to tissue hypoxia
 Dyspnea on exertion due to cardio pulmonary involvement
  Fainting spells due to cerebral hypoxia

 Headache due to cerebral hypoxia

 Feeble rapid pulse due to reduced blood volume and due to hypoxia

 Bleeding tendencies due to lack of clotting factors

 Susceptibility to infection due to accompanying leukocytopaenia

 Cyanosis due to tissue hypoxia

 Difficulties to concentrate due to cerebral hypoxia.

 Cracked or reddened tongue

 Strange food cravings due to deficiencies

MEDICAL MANAGEMENT

AIMS

 To relieve signs and symptoms

 To prevent complications

INVESTIGATIONS

History Taking

 I will do history taking which will reveal history of anaemia in family

 I will do history taking which will reveal patient having chronic illnesses such as
peptic ulcers and regular medications.

Physical Examination

 I will do physical examination which will show pallor on inspection.

Laboratory Tests
  Blood tests including Full blood count to detect blood iron levels and
haemoglobin levels will be lower than normal. Males (normal) 14- 17g/dl
Females 12 – 16g/dl
 Gastroscopy or colonoscopy to rule out ulcers and cancers respectively
 Bone marrow biopsy to rule out bone marrow aplasia
 Faecal occult to rule out chronic blood loss

TREATMENT

Is according to cause:

In Iron deficiency anaemia, give;

 Iron Sulphate tablets 200mg [Link] gluconate.

 Inferon injection in severe cases: 2mls bd x 5 days.
 Give foods rich in Iron to correct the condition.

In pernicious anaemia give

 Vitamin B12 IM 2mls BD, 2 times a week, maintenance of 1mg for life.
 Deficiency of Folic Acid give Folic acid 5mg od (orally).

In Aplastic anaemia.

 Put patient on whole blood transfusion.

 Treat cause eg if it drugs, withdraw or reduce dose or duration, treat underlying
infection. Give patient antibiotics to control infection eg penicillin.

For headache panadol can be given 1000mg tds for 3/7

COMPLICATIONS.

 Congestive cardiac failure – due to increased workload of the heart to pump more
blood in order to meet the metabolic needs of the body.
 Ischaemia – leading to Angina Pectoris.
 Intercurrent infections.
 Paralysis due to deficient oxygen supply to the nerves.
  Cardiomegally
 Heart failure
 Renal failure
 Hepatomegally

PREVENTION

 Anaemia caused by dietary deficiency can be prevented by making sure that

certain food groups are consumed on a regular basis, including dairy foods, lean
meats, nuts and legumes, fresh fruits and vegetables
 Vegetarians who prefer not to eat any dairy foods (vegans) should consider taking
vitamin and mineral supplements regularly.

 Iron and folic acid supplementation during pregnancy: This will help to
prevent anaemia during pregnancy.

 Prompt and adequate management of infections like malaria: To prevent

malaria.

 Avoiding of unprescribed drugs: This will help prevent anaemia that may be
caused by some drugs like chloramphenicol,

 Regular deworming. To prevent worm infestation such as hook worm which

may cause anaemia.

 Child spacing: should be practiced in order to enable the body recover and
replace its iron stores before another pregnancy.

 Encourage pregnant women to attend antenatal and post natal clinic: This
will help prevent ante and post partum haemorrhage, thereby preventing anemia.

NURSING CARE

AIMS

 To eliminate the cause.

  To increase the oxygen carrying capacity of blood.
 To reduce the demand for oxygen.
 Alleviate discomfort.
 Prevent complications.
 Prevent acquisition of infection

ENVIRONMENT

I will nurse the patient in a general ward, however reverse barrier nursing will be used
to prevent nosocomial infection. I will nurse the patient in a warm room because the
patient has cold intolerance in order to promote patients comfort. I will nurse the
patient in a well ventilated room by opening nearby windows to promote air
circulation and prevent respiratory tract infections. I will provide oxygen apparatus for
use when in time of dyspnea. I will nurse the patient in a well lit room for easy
observation. I will include the bed blocks on the room for elevating the foot end of the
bed incase of shock..

POSITION

I will nurse the patient in a propped up position to relieve dyspnea. In case of shock, I
will elevate the foot end of the bed to promote blood supply to the brain. As the
condition improves I will allow the patient to adopt any position of comfort

REST AND ACTIVITY

I will encourage the patient to be on bed rest in the acute phase in order to reduce the
demand for oxygen. In severe cases of anaemia, I will put the patient on complete bed
rest until HB is raised to prevent hypoxia. I will plan my nursing care in such a way
that periods of rest are allowed in order to conserve patients energy. I will provide a
quiet environment to promote rest. I will nurse the patient in a quiet room to promote
rest. I will play the radio at low volume if there is any on the ward to promote rest. I
will do related procedures in blocks to promote rest I will administer prescribed
analgesics to relieve headache there by promote rest

OBSERVATIONS

I will do vital sign and BP to act as the base line data in order to know if the condition
is improving or deteriorating. I will observe for cyanosis if improving or getting worse
and give oxygen therapy when necessary. I will observe Dyspnea if present will prop
up the patient to promote lung expansion and there by relieve dyspnea. I will observe
the pressure area to detect on set of pressure sore development. I will observe the
patient‘s facial expressions to detect pain and administer prescribed analgesics like
panadol. I will observe the feeding pattern of my patient and take measures like giving
small frequent meals to promote appetite. I will observe the respirations to detect
tachypnea and report accordingly

PSYCHOLOGICAL CARE

I will explain the disease process in order to raise the knowledge levels and thereby
alley anxiety. I will encourage the patient to ask question and I will answer
accordingly those I cant answer I will refer to the physician. I will explain all
procedures to my patient in order to allay anxiety. I will involve a successfully
managed case to come and talk to my patient in order to allow the patient ask pressing
question and get answer this will improve the patients out look on his condition. I will
involve the loved ones in his care in order for him not to feel neglected. I will provide
diversional therapy in order to shift the patient‘s mind from the hospital routine and his
condition. I will involve him in planning his own care in order for him not to feel left
out. I will explain to him that as the health care team we are doing everything possible
to ensure that he get better in order to promote co-operation.

ELIMINATION

I will provide a lot of fluids and roughage to prevent constipation. I will prove copious
fluids in order to promote renal wash out and there by prevent renal problems. I will
offer a bed pan if he is confined to bed to ensure bowel movement
HYGIENE

I will encourage the patient to take plunge baths in order to remove dead epithelium
and promote comfort

I will do hair care to promote self esteem and also prevent pediculosis. I will do nail
care to prevent auto infection and bruising self which can lead to bleeding. I will do
mouth care with a soft brush to prevent halitosis and causing bleeding because patient
has bleeding tendancies. I will change any soiled linen and clothes to promote comfort

NUTRITION

I will provide energy giving foods like nshima to provide the energy needed for the
metabolic processes. I will provide protein foods like fish and beans to promote
replacement of worn out tissues. I will provide vegetables and fruits to raise the
immunity and promote skin and mucous membrane. I will provide a lot of oral fluids
to prevent dehydration due to excessive sweating and promote bringing up of phlegm.
I will serve small frequent meals to promote appetite. I will provide Iron rich food
such as liver, meat, green leafy vegetables to promote blood formation. I will allow
visitors to bring food preferred by the patient in order to promote appetite. I will
encourage the patient to do regular mouth washes in order to promote appetite.

MEDICATION

I will administer prescribed analgesic like panadol at the right time to promote rest. I
will give prescribed antibiotics like X-pen to promote quick recovery. I will ensure
that I offer my patient iron and folic acid to promote blood formation. I will ensure
that the drugs are swallowed in my presence to promote recovery. I will ensure that I
sign for the drug to prevent over dosing the patient. I will give the drug at the right
time and frequencies to ensure required plasma level are maintained thereby
promoting recovery

ADVISE ON DISCHARGE

I will educate the patient about his condition in order to create awareness and prevent
recurrence of the condition. I will explain the need for taking the medication in order
to promote compliance and recovery. I will educate the patient about the sign and
symptoms of the condition for early diagnosis and treatment thereby preventing
complications. I will talk to the patient about the need to take a balanced diet using
locally available foods in order to boost the immunity and blood formation. I will
educate the patient about the need keep the review dates so that his progress is
monitored to ensure full recovery. I will advise the patient to ensure that he is
dewormed at least twice a year in order worm infestation thereby prevent anaemia. I
will advise my patient to have malaria promptly treated to avoid haemolysis which can
lead anaemia

SICKLE CELL DISEASE

Definition Of Sickle Cell Disease (Sickle Cell Anaemia)

 It is a severe, chronic, hereditary haemolytic disorder due to the homozygous

presence of haemoglobin S, usually characterized be pallor and recurrent crises.

 This is an inherited blood disorder characterized by breakdown of red blood cells

leading to anemia and blockage of blood vessels.

TYPES OF HAEMOGLOBIN

 Adult Haemoglobin (HbA): Denoted be the letter A. Composed of 2 alpha and 2

beta chains
 Fetal haemoglobin (HbF): Denoted by the letter F Composed of 2 alpha and 2
gamma chains

Other abnormal Hb include: C,D etc

GENOTYPES OF PARENTS AND CHANCE OF PASSING DISEASE OR

TRAIT TO OFF SPRINGS

• Parent 1 Parent 2 Normal Trait Dx

• AS------------ AA 50% 50% 0%

 • AS------------- AS 25% 50% 25%

• SS-------------SS 0% 0% 100%

TYPES OF SICKLE CELL DISORDER

There are basically three, i.e.:

• Sickle cell disease (sickle cell Anaemia): There is homozygous inheritance of Hb

S (Hb SS). It is symptomatic.

• Sickle cell trait: There is heterozygous inheritance of Hb S (Hb SA). It is

asymptomatic.

• Sickle cell syndromes: Associated with presence of Hb S (Hb SC sickle cell Hb

C)

NOTE: Please concentrate on Sickle cell Disease

Red blood cells, normal

Red blood cells, sickle cell

PATHOPHYSIOLOGY:

The Hb A consists of 4 molecules of haem folded in 1 molecule of globulin. Each

globulin molecule consist of 2 alpha and 2 beta chain. The amino acid sequence on the
beta chain is altered in at least 40% of the total haemoglobin in sickle cell disease. The
amino acid glutamine is replaced by the amino acid valine changing the properties of
the Hb. When the HbS is subjected to low oxygen tension the abnormal beta chain
contracts and piles together within the red blood cell. This distorts the shape of the red
blood cell. These cells assume a sickle shape, become rigid clump together and form
masses of RBCs. The masses block the blood flow. This leads to sickling of RBCs
with more obstruction of blood vessels and ischemia of the affected tissues. Repeated
episodes of ischemia leads to progressive damage from infarction. Usually the cell
return their normal shape after the low oxygen conditions are removed and proper
oxygenation occurs. Although the cell may appear normal at least some of the Hb
remains twisted decreasing the flexibility of the cell. The repeated sickling of the cell
lead to permanent distortion of the cell structure adopting a characteristic crescent
(sickled) shape due to cell membrane damage. The cell becomes more fragile and
easily haemolysed. The life span reduces from 120 to less than 30 days. The sickle
shaped cell increase the viscosity of blood thereby increasing the chances of infarction
causing further sickling of cells. The reduced life span of the RBC causes haemolytic
anaemia. The patient also experiences periodic episodes of cellular sickling called
crises, characterized by high fever, general body pains,etc.

SIGNS AND SYMPTOMS OF SICKLE CELL DISEASE

 Attacks of abdominal pain due to tissue ischaemia

 Bone pain due to ischaemia
 Breathlessness cardio pulmonary involvement
 Delayed growth and puberty because energy demands of the bone marrow for
red blood cell production compete with the demands of a growing body.
 Fatigue due to tissue hypoxia
 Fever due the inflammatory reaction caused by tissue infarction
 Jaundice due to increased levels of bilirubin as a result of increased haemolysis
 Paleness due low Hb
 Rapid heart rate as a compensetory mechanism to hypoxia
 Susceptibility to infections due to low immunity
 Ulcers on the lower legs (in adolescents and adults) due to ischaemia
 Bloody urine (hematuria) due to renal damage following repeated tissue
infarction
 Chest pain due to pulmonary infarction or cardiac ischaemia
 Restlessness especially during crises due to pain

 Painful erection (priapism; this occurs in 10 - 40% of men with the disease) due
to blood beign trapped by occluded blood vessel.

 Poor eyesight/blindness due to impaired blood supply to the retina

 Cyanosis due to hypoxia

TYPES OF CRISES

There are basically four types namely;

• Haemolytic crisis

• Thrombo embolitic crisis/ vaso occlusive crisis

 • Splenic sequestration crisis

• Aplastic crisis

HAEMOLYTIC CRISIS

There is massive destruction of red blood cells because of reduced supply of oxygen
and nutrients caused by infection, stress and some drugs e.g. methyldopa which will
lead to occlusion of small blood vessles . This is characterised by severe jaundice

The HbS is very fragile and easily haemolysed. Severe haemolysis leads to low
oxygen carrying capacity. This will lead to low oxygen tension there by precipitating a
crisis

THROMBO EMBOLITIC CRISIS/ VASO OCCLUSIVE CRISEIS

This is the common type in which small blood vessels are occluded by the sickled
shaped cells causing distal ischemia and infarction, leading to severe pain especially in
the legs, feet, lungs, heart with swelling in the joints.

The Hb SS because of the changes in the structure tends to increase the viscosity of
blood. This causes obstruction of the blood vessel due to thrombosis. This later leads
to low oxygen tension in the area distal to the point of occlusion there by causing a
crisis. This may lead to ulcer formation and stroke

SPLENIC SEQUESTRATION CRISIS

This is the type of crisis in which large amount of blood is pooled to the spleen and
liver causing spleenomegally and hepatomegaly resulting into circulatory collapse.

APLASTIC CRISIS

This is a type where the bone marrow ceases to produce red blood cells characterized
by severe anaemia which lead to dyspnea, lethargy and opportunistic infection. This is
the leading cause of death in sickle cell patients. The result is low oxygen tension due
to inadequate red blood cells. This will cause a crisis
PREDISPOSING FACTORS TO A CRISIS

 Infection due increase metabolic rate there is high demand of oxygen.

 Respiratory acidosis due to increased carbon-dioxide circulating in the blood
interfering with oxygen intake.
 Extreme fatigue which cause oxygen and nutrient demand for basal metabolism
 Emotional Stress
 Exposure to coldness because it increase oxygen demands
 Strenuous activities because it increases demand for oxygen and energy
 Dehydration – due to viscosity of blood reduces oxygen supply.
 Sometimes crisis occurs spontaneously with no apparent precipitating factor

MEDICAL MANAGEMENT

AIMS

• To treat the cause.

• To resuscitate the patient

• To relieve pain

• To initiate blood dilution

• To prevent infection

• To help replace the destroyed blood

DIAGNOSIS

History Taking

 I will do history taking which may reveal history of sickle cell in the family

Physical Examination

 I will do physical examination which will jaundice on inspection

Laboratory Tests

 Full blood count will show low HB and RBC count

  Sickling test will show sickling of cell
 Haemoglobin electrophoresis will confirm the diagnosis

TREATMENT

• Oxygen therapy to relieve hypoxaemia e.g. 5l/minute

1. Antibiotics
 Antibiotics e.g. e.g. crystapen penicillin 50000 mega qid for 5/7
 Septrin 10 mg per kg body weight orally 12 hourly 5/7 if infection is present.

Side Effect:

 Abdominal upset
 Renal stones

Nursing Implication:

Advise intake of oral fluids

2. Analgesia

Diclifenac 25-50 mg tds im

This is used for pain in vaso-occlusive crisis and fever if present. Narcotic analgesics
like pethidine 50-100mg bd

3. Folic acid 5-10 mg od for 14/7

4. Blood transfusion with packed cell may be give

• Non steroidal anti inflammatory drugs such as aspirin 600mg tds for 3/7

• Iv fluid with normal saline to relieve dehydration e.g. 1000ml /24hours

• Hydroxurea used to reduce number of episodes

COMPLICATIONS

 Cardiomyopathies
 Renal failure
  Retinopathy
 Growth, retardation
 Stroke or brain injury
 Splenomegaly
 Priapism
 Gallstones
 Stroke or brain injury
 Splenomegaly
 Leg ulcer

NURSING CARE

AIMS

 To relieve pain
 To prevent complications
 To promote comfort
 To offer IEC to the patient and mother about the condition
 To relieve anxiety

ENVIRONMENT

I will nurse the patient in a general ward, however reverse barrier nursing will be used
to prevent nosocomial infection. I will nurse the patient in a warm room because the
patient has cold intolerance in order to promote patients comfort. I will nurse the
patient in a well ventilated room by opening nearby windows to promote air
circulation and prevent respiratory tract infections. I will provide oxygen apparatus for
use when in time of dyspnea. I will nurse the patient in a well lit room for easy
observation. I will include the bed blocks on the room for elevating the foot end of the
bed incase of shock..

PAIN RELIEF
I will do warm compresses on the painful areas to relieve pain. I will provide a bed
cradle to relieve the weight of the linen their by prevent pain due to pressure. I will
offer prescribed analgesics to for pain relief and comfort.

POSITION

I will nurse the patient in a propped up position to relieve dyspnea. In case of shock, I
will elevate the foot end of the bed to promote blood supply to the brain. As the
condition improves I will allow the patient to adopt any position of comfort

PSYCHOLOGICAL CARE

I will involve a successfully managed case to come and talk to my patient in order to
allow the patient ask pressing question and get answer this will improve the patients
out look on his condition. I will explain to him that as the health care team we are
doing everything possible to ensure that he get better in order to promote co-operation.
I will explain the disease process in order to raise the knowledge levels and thereby
alley anxiety. I will encourage the patient to ask question and I will answer
accordingly those I cant answer I will refer to the physician. I will explain all
procedures to my patient in order to allay anxiety. I will involve a successfully
managed case to come and talk to my patient in order to allow the patient ask pressing
question and get answer this will improve the patients out look on his condition. I will
involve the loved ones in his care in order for him not to feel neglected. I will provide
diversional therapy in order to shift the patient‘s mind from the hospital routine and his
condition. I will involve him in planning his own care in order for him not to feel left
out. I will explain to him that as the health care team we are doing everything possible
to ensure that he get better in order to promote co-operation.

REST AND ACTIVITY

I will encourage the patient to be on bed rest in the acute phase in order to reduce the
demand for oxygen. In severe cases of anaemia, I will put the patient on complete bed
rest until HB is raised to prevent hypoxia. I will plan my nursing care in such a way
that periods of rest are allowed in order to conserve patient‘s energy. I will provide a
quiet environment to promote rest. I will nurse the patient in a quiet room to promote
rest. I will play the radio at low volume if there is any on the ward to promote rest. I
will do related procedures in blocks to promote rest I will administer prescribed
analgesics to relieve headache there by promote rest. I will plan my nursing care in
such a way that periods of rest are allowed in order to conserve patient‘s energy.

OBSERVATIONS

I will do vital sign and BP to act as the base line data in order to know if the condition
is improving or deteriorating. I will observe for cyanosis if improving or getting
worse and give oxygen therapy when necessary. I will observe dyspnea if present will
prop up the patient to promote lung expansion and there by relieve dyspnea. I will
observe the pressure area to detect on set of pressure sore development, I will observe
the IV fluids to prevent fluid over load. I will observe the feeding pattern of my patient
and take measures like giving small frequent meals to promote appetite. If on blood
transfusion, I will observe the transfusion to detect transfusion reaction

HYGIENE

I will encourage the patient to take plunge baths in order to remove dead epithelium
and promote comfort

I will do hair care to promote self esteem and also prevent pediculosis. I will do nail
care to prevent auto infection and bruising self which can lead to bleeding. I will do
mouth care with a soft brush to prevent halitosis and causing bleeding because patient
has bleeding tendancies. I will change any soiled linen and clothes to promote comfort

NUTRITION

I will provide energy giving foods like nshima to provide the energy needed for the
metabolic processes. I will provide protein foods like fish and beans to promote
replacement of worn out tissues. I will provide vegetables and fruits to raise the
immunity and promote skin and mucous membrane. I will provide a lot of oral fluids
to prevent dehydration due to excessive sweating and promote bringing up of phlegm.
I will serve small frequent meals to promote appetite. I will provide Iron rich food
such as liver, meat, green leafy vegetables to promote blood formation. I will allow
visitors to bring food preferred by the patient in order to promote appetite. I will
encourage the patient to do regular mouth washes in order to promote appetite.

ELIMINATION

I will provide a lot of fluids and roughage to prevent constipation. I will prove copious
fluids in order to promote renal wash out and there by prevent renal problems. I will
offer a bed pan if he is confined to bed to ensure bowel movement

MEDICATION

I will administer prescribed analgesic like pethidine or morphine at the right time to
promote rest. I will give prescribed antibiotics like X-pen to promote quick recovery. I
will ensure that I offer my patient folic acid and folic acid to promote blood formation.
I will ensure that the drugs are swallowed in my presence to promote recovery. I will
ensure that I sign for the drug to prevent over dosing the patient. I will give the drug at
the right time and frequency to ensure required plasma level are maintained thereby
promoting recovery

HEALTH EDUCATION

I will educate the patient about his condition in order to create awareness and prevent
recurrence of the condition. I will explain the need for taking the medication in order
to promote compliance and recovery. I will educate the patient about the predisposing
factors in order to prevent crises. I will talk to the patient about the need to take a
balanced diet using locally available foods in order to boost the immunity and blood
formation. I will educate the patient about the need keep the review dates so that his
progress is monitored to ensure full recovery. I will advise the patient to ensure that he
is dewormed at least twice a year in order . I will advise my patient to have malaria
promptly treated to avoid haemolysis which can lead anaemia
 NURSING CARE PLAN FOR SICKLE CELL

Date Problem Nursing Objective/goal Nursing Evaluation

Diagnosis implementation

Pain in Chest and To relieve the I will do warm Patient has a relief
the limbs limb pains patient of the compresses on the of chest and limb
and chest related to chest and limb painful areas to pains and rested
vasoocclusion pains there by relieve pain. comfortably within
manifested by resting I will provide a bed 2 hours.
restlessness comfortably cradle to relieve the
and within 1- 2 weight of the linen
verbalization hours. their by prevent pain
by the patient due to pressure.

I will offer
prescribed analgesics
to for pain relief and
comfort

Risk of Risk of To protect the - I will support the The patient has been
falling falling related patient from patient when prevented from
to dizziness falling [Link] prevent falling
and him from falling
restlessness
- I will advise the
evidenced by patient to call for
verbalization
assistance when she
by the patient wants to walk to
and
bathroom or just
staggering make a move
when
 attempting to
walk

Anxiety Anxiety To allay the  -I will explain The patient‘s

related to anxiety of the the disease anxiety has been
little patient thereby process in order allayed, evidenced
knowledge promoting rest to raise the by patient resting
about and sleep knowledge and not asking
prognosis of within 4hours. levels and questions.
disease and thereby alley
fear of death anxiety
manifested by  I will encourage
lack of sleep the patient to
and ask question and
restlessness. I will answer
accordingly
those I cant
answer I will
refer to the
physician
 I will explain all
procedures to
my patient in
order to allay
anxiety
 I will involve a
successfully
managed case to
come and talk to
my patient in
 order to allow
the patient ask
pressing
question and get
answer this will
improve the
patients out
look on his
condition
 I will explain to
him that as the
health care team
we are doing
everything
possible to
ensure that he
get better in
order to promote
co-operation.

Insomnia Insomnia To promote -I will explain the Patient is able to

(disturbed related to sleep by condition to the sleep following the
sleep) anxiety and allaying client to allay interventions
pain anxiety of the anxiety.
evidenced by patient
-I will give
exhaustion prescribed drugs
 and such as Pethidine
verbalization 50mg 6 hourly to
by the patient relieve pain

-I will provide and

maintain a quite
environment to
promote rest.

Oedema Oedema due To reduce the -I will monitor fluid By the 4th day the
(puffiness to fluid over oedema within intake and out put to puffiness has
of the load and fluid 5 days prevent overload. reduced
face) retention -I will advise the
manifested by
patient to sit up in
the puffiness bed and walk about
of the face.
to improve
circulation hence
preventing
circulatory stasis and
fluid retention.

QUESTIONS ON ANAEMIA AND SICKLE CELL

Mrs. Mutumwa aged 26, a known sickle cell patient is admitted to female medical
ward in a sickle cell crisis

a. Define sickle cell disease. 2 marks

b. State any four (4) precipitating factors of sickle cell crisis. 8marks
c. Explain the pathophysiology of sickle cell crisis 20 marks
 d. Identify five (5) problems that Mrs Mutumwa may have and using a nursing care
plan, discuss how you would manage the identified problems.
50 marks
e. State five (5) points that you would include in your Information, Education and
Communication (IEC) to Mrs. Mutumwa on the prevention of sickle cell crisis.
15 marks

PEPTIC ULCERS

DEFINITION.

 Peptic Ulcer is an erosion of the mucosa and deeper structures of the upper GIT
and is due to action of gastric juices containing pepsin and acid.
 Peptic ulcer is erosion in the mucosa of the GIT where it is exposed to the erosion
effect of gastric acid and pepsin.
 Is a break in continuity of epithelial surface of the gastric mucosa as a result,
exposes the mucosa to acid-pepsin secretion.
 Is the ulceration or erosion of the mucous membrane of the stomach and the
proximal part of the duodenum by the digestive action of hydrochloric acid and
pepsin.

NB: peptic ulcer is therefore associated with imbalance between acid and mucosal
pepsin secretion and mucosal resistance.

CLASSIFICATIONS

According to duration

• Acute – characterized by superficial erosion & minimal inflammation. They are

of short duration and resolve quickly especially if the cause is known and
removed.
• Chronic – These are of long duration eroding through muscular wall with the
formation of the fibrous tissue. It is present continuously for many months or
intermittently throughout the person‘s age.

BY REGION/LOCATION
1) Duodenum (called duodenal ulcer): in the duodenum
2) Esophagus (called esophageal ulcer): affects lower part of oesophagus
3) Stomach (called gastric ulcer): along lower curvature of the stomach.
CAUSES/PREDISPOSING FACTORS

The exact cause is idiopathic. The following are the predisposing factors.

• Age; disease of adult and rare in children.

• Occupation; worrying ones, stressful, tension and anxiety.

• Hereditary; occur in families.

• Blood group O; more susceptible.

• Emotions; emotionally tense, unable to express hostility & repress strong needs.

• Smoking – inhibits secretion of bicarbonates and also causes rapid transit of

gastric acid to the duodenum

• Poor eating habits; hurriedly & irregularly.

• Drugs; e.g. Salicylates, indomethacin.

• Tumours; like gastrosinomas-Zollinger Ellison syndrome which produces

excessive gastrin hormone.

• Bacterial Infection; like helicobacter pylori interfere with normal defences against
stomach acid, or give a toxin that contribute to ulcer formation.
 • Highly seasoned foods

DEFFERNCES BETWEEN GASTRIC AND DUODENAL ULCER

FACTORS DUODENAL GASTRIC
ULCER ULCER
AGE Young Old and middle
adulthood age
EMOTIONAL Yes No
STRESS
SEX Mainly male Both male and
female
ACID increased Normal to low
SECRETION
PAIN Occurs 2-4 Occurs 1-2
hours after hours after
eating eating
RELIEF Relieved by Not relieved by
food food
LOCATION Found in the Found in the
duodenum stomach
PERFORATION Likely to Unlikely to
perforate perforate

PATHOPHYSIOLOGY.

 Ulceration occurs due to decrease in resistance of the Gastric mucosa to pepsin

and acid injury.

 Normally, Hydrochloric acid is secreted but ulcerations do not occur due to the
following reasons:
  The mucosa secretes sufficient mucous to dilute the secretion of acid and provides
a protective coating against acid action.

 The peptic ulcer may develop when the secretory output of Hydrochloric acid is
more than pepsin or when there is more Hydrochloric acid than pepsin.

 The usual cause of peptic ulceration is hyersecretion of HCL than the defense
secretion of the mucous and neutralization of the duodenal juices.

 There should be a balance failure to which ulcers develop.

SIGNS AND SYMPTOMS.

 Abdominal pain, classically epigastric strongly correlated to mealtimes. In

case of duodenal ulcers the pain appears about three hours after taking a meal;
 Bloating and abdominal fullness;
 Water brash (rush of saliva after an episode of regurgitation to dilute the acid
in esophagus - although this is more associated with gastro esophageal reflux
disease);
 Nausea, and vomiting;
 Loss of appetite and weight loss;
 Hematemesis (vomiting of blood); this can occur due to bleeding directly
from a gastric ulcer, or from damage to the esophagus from severe/continuing
vomiting.
 Melena (tarry, foul-smelling feces due to oxidized iron from hemoglobin);

MEDICAL MANAGEMENT

Aims
 To relieve signs and symptoms
 To promote recovery
  To prevent complications

INVESTIGATIONS

History Taking

 I will do history taking which will reveal patient being a smoker

 I will do history taking which will reveal the patient experiencing pain after eating

Physical Examination

 I will do physical examination which will reveal patient being anemic on

inspection

Laboratory Investigations

 I will escort my patient for endoscopy which will confirm the presence of an ulcer
and the affected site of the ulcer.
 I will escort the patient for barium swallow which will indicate the exact site of
the ulcer
 I will collect blood for full blood count

Treatment

Eradication therapy

 Current recommendations are that all patients with duodenal ulcers and gastric
ulcers should have H. pylori eradication therapy (triple therapy) for 14 days using
a proton pump inhibitor, and a combination of two antibiotics i.e. Omeprazole
20mg twice daily, clarithromycin 500mg, tinidazole 500mg bd
Omeprazole

Dose: 20mg orally 12 hourly daily for 4 to 8 weeks

Mechanism of Action: inhibits the activity of the acid pump and binds to
hydrogen-potassium adenosine triphosphatase to block the formation of gastric
acid.

Side effects:
Headache,

Dizziness,

Diarrhea,

Abdominal pain,

Nausea and vomiting,

Constipation, ,

Nursing Implications:

 Caution patient not to perform hazardous activities if dizziness occurs;

 Tell patient to swallow capsules whole and not to open or crush them.

Clarithromycin

Dose: 500mg orally 8 hourly

Mechanism of Action: blocks protein synthesis

Side effects:

 Headache,
 Diarrhea,
 Nausea,
 Abdominal pain or discomfort

Nursing Implications:

 use cautiously in patients with hepatic or renal impairment;

 obtain urine specimen for culture and sensitivity tests before first dose.
 Begin therapy pending results; monitor patient for super infection.

Tinidazole

Dose: 500mg orally 12 hourly

Side effects,

headache,
 ataxia, syncope,

abdominal cramps,

nausea and vomiting,

anorexia,

seizures

Nursing Implications:

 Instruct patient to take drug with food;

 Tell patient to avoid alcohol while taking the drug and for at least 48 hrs after
completing therapy;
 Tell patient that he will experience metallic taste and dark or red-brown urine

Other Drugs

1. Anti-acids such as magnesium hydroxide with aluminum hydroxide 50 – 80 mcq

1hr and 3 hrs. after meals and at bed time
2. Histamine receptor antagonists such as Ranitidine 150mg PO twice daily or
300mg PO at bedtime. Ranitidine reduce gastric secretion for short term therapy
up to 8 weeks.
3. Mucosal Barrier Fortifiers such as sucralfate 1g PO qid or 2g BD 1hr before and
2hrs after meals, and at bed time; do not give within 30min of giving antacids or
other drugs
4. Anticholinergic drugs such as propantheline, to inhibit the vagus nerve effect on
the parietal cells and to reduce gastrin production and excessive gastric activity in
duodenal ulcers (anticholinergics are contraindicated in gastric ulcers)
COMPLICATIONS
• GIT Bleeding /Heamorrhage
• Perforation
• Pyloric stenosis
• Peritonitis.
• Carcinoma development.
 • Recurrent ulceration.
NURSING MANAGEMENT OF A PATIENT WITH PEPTIC ULCERS

AIMS

1. To relieve symptoms
2. To promote healing of the ulcer
3. To prevent complication and recurrence
ENVIRONMENT:

I will nurse the patient in a room/environment that is quiet to promote rest and
relaxation which will aid in the healing process. I will provide all the accessories
needed by the patient such as bed side lockers, and cardiac table for patient use. and I
will nurses the patient in a room that has good lighting for easy observation. I will
nurse the patient in a well ventilated room by opening nearby windows for free
circulation of air and prevent upper respiratory tract infections.

PSYCHOLOGICAL SUPPORT

I will explain the condition in simple terms and possible cause and be calm and
confident in order to alley anxiety. I will encourage the patient to ask questions and
express his concerns and I will answer him accordingly and questions I don‘t have
answer to, I will refer the patient to the doctor so he can clear his concerns and allay
anxiety. I will give appropriate diversional therapy such as providing a newspaper if
there is any on the ward to divert the mind of the patient off the condition. I will
encourage visitation by significant others and involve the family members in his care
so that the patient does not feel abandoned. Usually the patient will be distressed so I
reassure him that we will do everything possible to relieve him of their condition.

PAIN RELIEF AND REST

I assess if patient is in pain and provide necessary measures to relieve pain and
promote rest. I will do related procedures at in block in order to avoid disturbing the
patient. I will give appropriate diversional therapy such as providing a newspaper if
there is any on the ward to divert the mind of the patient off the condition. I limit
visitation since sometimes they can be distressing in order to promote rest.

NUTRITION

I will offer regular meals, but small in amount and easily digestable to promote
appetite. I will advice the patient to avoid very hot, cold and highly seasoned food as
they stimulate secretion of hydrochloric acid. I will advice the patient to avoid foods
such as coke, raw fruits, tea coffee, alcohol and salads. I will ask the patient to identify
the food that precipitate discomfort for him so that they should be omitted from his
diet. I will encourage the patient to be taking light foods such as soups, milk, rice,
juices that are rich in proteins to promote healing and carbohydrates for energy.

HYGIENE

If patient is on frequent milk diet, I will encourage him to rinse his mouth quickly as
milk favors the growth of micro-organisms. I will advice the patient to use a mild
antiseptic or water to clean the mouth to prevent halitosis and infections. I will change
soiled linen to prevent infections, and also so that the patient is comfortable. I will
encourage the patient to do nail care to avoid accumulation of microbes in the nails.

OBSERVATIONS

I will do observations of vital signs i.e temperature , pulse respirations and blood
pressure initially to serve as baseline data and consequently to monitor on patients
condition. I observe patients response to treatment to assess progress. I will assess
patient‘s response to drugs to note for any reactions. I will monitor the patient for signs
of bleeding through fecal occult blood, vomiting so that appropriate measures can be
taken. I will monitor the patient‘s hemoglobin levels to rule out anemia.

I.E.C/ADVICE

I advise patient to avoid extremely hot or cold food and fluids, to chew thoroughly,
and to eat in a leisurely fashion to reduce pain. I will administer medications properly
and teach patient dose and duration of each medication. I will advise patient to modify
lifestyle to include health practices that will prevent recurrences of ulcer pain. I will
teach on stress management especially at work e.g. taking leaves, work delegation

After going through the notes try and see if you can answer the question below;

G.N.C QUESTION

1) Mr. Bitato a 40 year old businesss man is admitted to your ward with history of
severe abdominal pains and blood stained vomitus for two days. After investigation a
diagnosis of peptic ulcer disease is made.

a) i. Define peptic ulcer [5marks]

ii. Draw a well labelled diagram of the sites of peptic ulcer disease [151 marks]

iii. State any other five (5) signs and symptoms of peptic ulcer disease [15 marks]

b) Describe the management of Mr Bitato till discharge under the following headings;

i. Medical management [15 marks]

ii. Nursing management [35 marks]

c) State five (5) points that you would include in your information, education and
communication (IEC) to Mr Bitato on discharge. [20 marks]

d) State any five (5) Aetiology/predisposing factors to peptic ulcer disease [15marks]

CHOLERA

DEFINITION

 This is an acute infection of the GIT caused by vibrio cholera characterized by

diarrhea, projectile vomiting and severe dehydration.
  Cholera is an acute infectious disease caused by vibrio cholerae characterized by
copious rice water diarrhoea, vomiting, muscle cramps, severe dehydration and
vascular collapses.

 This is an acute infection of the GIT caused by vibrio cholerae characterized by

rice watery stool, vomiting and severe dehydration. Cholera is very infectious

 Is an infection of the small intestine that causes a large amount of watery

diarrhoea and caused by the bacterium Vibrio cholerae.

CAUSES

• Cholera is caused by the bacterium Vibrio cholerae. Transmission is primarily

due to the faecal contamination of food and water due to poor sanitation. This
bacterium can, however, live naturally in aquatic environments.

• The bacteria releases a toxin that causes increased release of water in the
intestines, which produces severe diarrhoea.

INCUBATION PERIOD

• Is 4 to 48 hours.

MODE OF TRANSMISION

 Feacal -oral (contaminated water or food)

 Greetings (Hand shakes)

 Flies act as vectors

PATHOPHYSIOLOGY

When the Vibrio Cholerae is ingested remain in the gut, it does not penetrate the
mucosa lining to enter into the blood stream. It adheres to the mucosa of the small
intestines by both outer membrane protein and flagella adhesions and it starts to
multiply. They then start secreting toxins known as enterotoxins. The toxins
stimulates the epithelial cells to secrete fluid which are passed in the stool. Because of
toxins patient will be vomiting, and due to loss of water and electrolytes, there will be
dehydration Immunity to both cholera toxin and bacterial follows natural infection

SIGNS AND SYMPTOMS

 Very rapid onset of severe vomiting and diarrhoea (rice water type) >3 times a
day.

 Severe de-hydration- Due to rapid loss of fluids up to 20 liters daily.

 low pulse, undetectable blood pressure,

 Rapid weight loss

 Sunken eyes, wrinkled hands and feet due to dehydration as a result of loss of
fluids.

 Slow recovery of shape after depression of skin

 Anuria (No urine output).

 Muscle cramps due to loss of potassium

 Shock occurs as a result of collapse of the circulatory system.

COMPLICATIONS OF CHOLERA

Dehydration – this is caused by excessive vomiting and diarrhea leading to loss of

electrolytes and fluids

Hypovolaemic Shock – this is due to reduction in the circulatory volume caused by

loss of body fluids.

Renal failure - Due to reduced circulatory volume which will lead to reduced blood
supply to the kidneys

Hyponatremia - this is low sodium in blood due to excessive loss of sodium in

diarrhea
Hypokalaemia – this is low potassium in blood due to excessive loss of potassium
through diarrhea and vomiting

Cardiac failure - this may be due to reduction in the circulatory volume due to loss of
body fluids were the heart over works to try and meet the body‘s demands for nutrients
and oxygen/blood. In addition, it can also be due to hypokalemia since the heart
requires potassium to contract and pump blood to different parts of the body.

MEDICAL MANAGEMENT

AIMS

 To eliminate the causative organism

 To restore normal hydration status, this should take no more than 4 hours.
 To maintain the nutritional status of the patient
 To prevent complications

INVESTIGATIONS

History Taking

 I will do history taking which will confirm the patient having travelled to an
endemic area.

Physical Examination

 I will do physical examination on inspection will reveal, severe dehydration.

 I will do physical examination which will confirm an impalpable pulse on
palpation at the wrist.

Laboratory Tests

 I will collect stool for microscopy which will detect the typical cholera vibrio.

THERAPY/TREATMENT

FLUIDS
NOTE

I will rehydrate depending on severity

Plan A. There is NO dehydration

Plan B. There is SOME dehydration

Plan C. There is SEVERE dehydration.

Plan A. There Is No Dehydration

 I will give ORS solution after each stool . Children less than 2 years old: 50–100
ml (1/4–1/2 cup) ORS.

Plan B. There Is Some Dehydration

The patient is losing a lot of fluids because of diarrhoea and vomiting. The lack of
water in his body results in:

 Sunken eyes
 Absence of tears
 Dry mouth and tongue
 The patient is thirsty and drinks eagerly
 The skin pinch goes back slowly

I will give oral Rehydration Salt in the amount recommended.

I will start intravenous infusion of fluids such as Ringer‘s Lactate or normal saline
immediately.

Plan C. There Is Severe Dehydration

In severe dehydration, I will give 30mls per kg body weight in the first 30 minutes
rapid I.V. then 70mls per kg body weight in the next 2½ hours.

The aim is to restore normal hydration and acid-base balance within 2-3 hours. I will
continue rehydrating the patient at a slower rate until the pulse and BP return to
normal
  When the patient can drink orally, I will give 5mls/kg body weight/hour
(250mls/hr).
 I will monitor vital signs every 30 minutes. If signs of circulatory overload are
detected, I will slow down the rate of flow.
 I will Monitor urine output every hour (normal is 30-40mls/hr). If less patient has
acute renal failure.
 I will give ORS as soon as the patient can drink.
 I will maintain the patient on fluid by equal amount from stool losses. In this case
oral rehydration is given as required.

DRUGS

 Chloramphenicol

Dose: 250-500mg 6 hourly for 5/7 max. 1g

 Tetracycline

Dose: 250-500mg 6 hourly for 5/7 which is the drug of choice and diarrhoea
should subside within 48 hours

 Doxycycline

Dose: 200mg stat, then 100mg 24 hourly for 1 week

Other drugs

 Erythromycin 500mg PO qid for 5 days

 Ciprofloxacin 250-500mg PO daily for 5 days

 Septrine 960mg BD for 5/7

 Amoxil 500mg for 5/7

 Glucose can be added to the IVFs being given if there are signs of hypoglycemia

 Mild sedatives like Phenobarbitone 30mg 6 hourly to allay the pt‘s anxiety

 Paracetamol 500mg-1g TID for 5/7 or mild analgesics like codeine for abdominal
pain/cramps
NURSING CARE

AIMS

 To promote recovery
 To prevent spread of cholera
 To promote nutritional status
 To improve fluid volume
 To alley anxiety

ENVIRONMENT

I will nurse patient in cholera centre and in cholera bed, in an isolated place and use
barrier nursing to prevent spread of infection. The place shall have good lighting for
easy view and well ventilated by opening near by to allow fresh air. I will provide the
drip stands for hanging on fluids and an observation tray. I will provide a bucket for
the patient to use for vomiting and this should consist of a disinfectant in it. The room
should be clean to prevent patient from being nauseated which can trigger vomiting
since this patient may present with nausea and vomiting.

PSYCHOLOGICAL CARE

I will explain the condition to the patient and his/her relatives in simple terms and this
should include possible causes, disease process, treatment and why certain things are
not allowed like why no visitors are not allowed to alley anxiety and gain
coorperation. I will reassure patient that the disease can be controlled if he complies to
treatment and preventive measures to allay anxiety. I will encourage patient to ask
questions if at all he has any and answer them as truthfully as I can to alley anxiety and
gain trust. I will explain all procedures done on patient to alley anxiety and gain his
cooperation. I will involve patient in the plan of their care to avoid dependency .

NUTRITION AND FLUIDS

I will provide nutritious balanced meals containing proteins and vitamins to promote
healing. I will offer food rich in carbohydrates to provide energy. Since patient may
have anorexia and vomiting, I will serve food in small frequent amounts to promote
appetite and prevent vomiting. Avoid spiced foods for this may worsen the condition.
I will give fluids either orally or intravenously to prevent dehydration and also to flush
out toxins. I will remove stool and vomitus from environment to promote appetite.

POSITION

I will nurse patient on a special bed with a hole around the buttock area with a bucket
under to receive stool. I will position the patient in such a way that the buttocks are
over the bucket to allow for free flow of stool in it. But whatever position, the airway
should be maintained.

HYGIEN

If condition is bad and patient is unable to bath herself, I will offer a bed bath to
promote hygiene, comfort and blood circulation. Whenever the bucket is full of stool, I
will properly dispose off by burying it or burning and same applies to the vomitus. I
will encourage frequent hand washing with disinfectant to prevent infection. I will
wash hands before and after attending to the patient to prevent infection

OBSERVATION

I will observe all isolation measures and restrict even visitors to not visit the patient to
prevent spread of the disease. I will observe the intake of fluids and output of urine
closely so as to monitor progress of the patient and know how much fluids are needed
to replace. I will check and change soiled beddings and clothing and open nearby
windows in the room to promote ventilation and eliminate the odour of the vomitus
which may contribute to the patient‘s discomfort and may cause repetitive vomiting.

HEALTH EDUCATION /PREVENTION

I will educate the patient and relatives on modes of transmission for the disease and
how it enters the body and how they can protect themselves from such roots. I will
warn them not to be buying food from unhygienic places and that of proper washing
and keeping of food as this predisposes them to getting cholera. I will encourage the
community to be using their toilets and also that they should be washing their hands
after using the toilet to prevent cholera. I will encourage them to be clean, thoroughly
wash food before eating and that storage of food should be properly, be properly
maintained and left over be kept properly or be thrown away to prevent infection. I
will advice them to have a good habit of washing the hands before eating any food and
proper washing of fruits before eating them to prevent infection. I will advise them to
be boiling water before drinking to kill bacteria.

QUESTIONS ON CHOLERA

1. Mrs. Susan Chalwe of Chipulukusu compound aged 32 is brought to your health

centre with history of severe diarrhea. After investigations a diagnosis of cholera
is made.
a) Define cholera (5%)
b) Discuss Mrs. Chalwe‘s management in the first 24 hours of hospitalization.
(20%)

EPILEPSY

Definition

 Epilepsy is a neurological disorder characterised by recurrent seizures with or

without loss of consciousness due to an abnormal electrical discharge in the brain.
 Epilepsy is a group of chronic paroxysmal neurologic disorder characterized by
abnormal, uncontrolled, electrical discharge from the neurons of the cerebral
cortex in response to a stimulus.
 It is a CNS disorder characterized by recurrent attacks of seizures due to an
abnormal electrical discharge by the cerebral cortex with or without loss of
consciousness.

CAUSE OF EPILEPSY

 Idiopathic (Unknown)

However, risk factors associated with onset of Epilepsy exists

RISK FACTORS TO EPILEPSY

 Congenital defects like Cerebral Palsy

 Hydrocephalus
 Head injury of any sort
 Subarachnoid haemorrhage
 Cerebral Vascular Accident (CVA)
 Intracranial tumour
 Meningitis
 Exposure to toxins
 Cerebral Hypoxia
 Birth complications like Asphyxia and RDS
 Birth Injuries
 Metabolic and endocrine disorders like hypoglycaemia and hyperglycaemia

CLASSIFICATION OF EPILEPSY

PRIMARY EPILEPSY

Its cause remains known. But it has a tendency to run in families. It is hereditary. It
usually starts early in life

SECONDARY EPILEPSY

It develops later in life. These are due to existing structural or physiological defects
following cerebral cranial injury or disease. It does not run in families

NEURAL TRANSMISSION

The process of normal neuronal firing takes place as a communication

between neurons through electrical impulses. Such information is passed
from neuron to neuron via the axons, which act like the cable or wires in your house
PHASES/STAGES OF EPILEPTIC SEIZURES

AURAL (WARNING) STAGE

 May take serious forms in different people

 Some may experience numbness or tingling sensation in any part of the body.
 Patient may have strange taste or smell.
 May be very brief that may not give room for the patient to prepare oneself

TONIC STAGE

 Patient loses consciousness

 Falls to the ground
 May produce an epileptic cry.
 All the muscles become stiff/rigid
 The jaws close

 Pupils dilate

 Head turned on one side

 Breathing ceases which may lead to cyanosis

 It lasts for 20-30 seconds

CLONIC STAGE
  Lasts for 30 seconds or longer.
 Violent jerking or convulsive movements of the body and limbs.
 The jaws open and close
 The tongue may be bitten during this time
 Frothing at the mouth
 Sweating due to muscular spasms
 Incontinence of urine and stool
 Breathing re-established

COMA (POSTICTAL) STAGE

 Patient relaxes for few minutes

 Goes into deep sleep
 Wakes up later and fails to explain what had happened.
 May go into fugue/automatism

 In this state patient may perform actions which he/she fail to account for because
of unconsciousness.

 Patient may go into status epilepticus if not recovering from the first thirty
minutes of seizures.
CLASSIFICATION OF EPILEPTIC SEIZURES

Epileptic seizures are classified in two according to their severity;

1. Partial (Focal) Seizures

2. Generalised Seizures
 1. PARTIAL (FOCAL) SEIZURES

These are further classified into four (4) categories;

 Simple Partial (Jacksonian) Seizures

 Complex Partial (Temporal Lobe) Seizure
 Complex Partial Generalised Tonic-clonic
 Absence Seizures (Petitmal)

ABSENCE SEIZURES (PETITMAL)

 Starts in early childhood and ceases in adolescence or develops into a Grandmal in

some patients
 In this condition, there is brief loss of consciousness.
 Sudden brief loss of attention and awareness

 May drop whatever he/she holding due to loss of power in limbs

 May experience blackout and suddenly falls down

 There is no post-ictal period

COMPLEX PARTIAL GENERALISED TONIC-CLONIC

 Here the consciousness is impaired

  May progress from complex partial and then go Tonic-Clonic.
 The post-ictal is always present in this type
 The duration is very brief and consciousness is not lost or impaired.
 Speech is arrested or patient becomes mute.
 Patient may experience visual sensations such as seeing light
 Patient is able to remember events afterwards
 Patient may interact with others.

SIMPLE PARTIAL (JACKSONIAN) SEIZURES

 This type does not impair the patient‘s consciousness.

 These are localized twitching of the extremities, usually around the face, hand,
lower limbs, or eyes.

 Loss of motor activity

 Patient stares blankly in the sky with eyes rolling upwards

 Patient may stop whatever he/she has been doing

COMPLEX PARTIAL (TEMPORAL LOBE) SEIZURE

 Consciousness is impaired
 Condition may begin as Simple Partial seizures and progress to complex partial
seizures.
 There is automatic behavior such as, lip smacking, chewing, or picking at clothes.
 There may be post – ictal state
2. GENERALISED SEIZURES???

Generalised seizures are further grouped into three (3) categories;

1. Atonic Seizures

2. Myoclonic Seizures

3. Toni-Clonic Seizures

ATONIC SEIZURES
  There is impairment of consciousness for the first few seconds
 Brief loss of muscle tone which may cause the patient to fall
 Drop something from the hand -―Drop Attack‖.
 No post – ictal period

MYOCLONIC SEIZURES

 Impaired consciousness for only few seconds or not at all

 Brief jerking of muscle group may occur and cause patient to fall
 No post-ictal period

TONIC-CLONIC (GRAND MAL)

 Here the seizures occur in well defined stages

 There is loss of consciousness
 There is post-ictal period

COMPLICATIONS OF EPILEPSY

 Status Epilepticus: the more severe form of Epilepsy which is characterised by

repetitive attacks with longer duration due to severe brain damage
 Mental Retardation: severe damage to the brain leads to poor IQ and poor
performance at school
 Accident related injuries: this happens during and attack
 Psychosis: this is due to brain damage as a result of brain hypoxia during fits as
well as brain shaky syndrome
 Dementia: this is due to brain damage

HOW DO WE MANAGE EPILEPSY

DIAGNOSIS OF EPILEPSY

 History: will reveal previous epileptic attacks of familiar predisposition.

 Physical examination: previous scars of burns/injuries due to previous attacks or
patient may have a seizure in the presence of the examiner
 Electro encephalogram (EEG): will show increased electrical activity
  Computed Tomographic Scan (CT scan): may show spinal or cerebral lesion.
 Lumbar puncture (LP): to rule out meningitis and any other infection of CNS.
 Magnetic Resonance Imaging (MRI): to rule structural lesion
 Skull X- RAY: will show spinal or skull fracture or tumors
 Glucose test: to rue out hyperglycaemia or Hypoglycaemia

TREATMENT OF EPILEPSY

a. Barbiturates
 Phenobarbitone 60 – 180mg as per prescription.
 Phenobarbitone 200mg – 400mg as per prescription. In children give 5.8mg/kg
body weight.
b. Hydantoins
 Phenytoin Sodium (Epanutin) 150 – 300mg as per prescription
 In children, give 3-4mg/kg body weight.
 Give carbamazepine 100 – 300mg as per prescription

 In status epilepticus give IV Diazepam 10mg – 30mg.

 Give Dextrose 5%-10% IV 1 litre in 24 hours for energy.

 Offer any supportive treatment when necessary, like Paracetamol

NURSING CARE

AIMS OF CARE

 To prevent injury
 To establish and maintain a patent airway
 To offer psychological care
 To promote hygiene

NURSING CARE DURING AN EPLEPTIC ATTACK (CONVULSIONS)

EMERGENCY MANAGEMENT

Emergency management during an attack has three (3) pillars (Aims):

 1. Safety and prevention of injury

2. Establishment and maintenance of airway

3. Monitoring and observation

PREVENTION OF INJURY

A seizure cannot be stopped once it has started. It is self-limiting and no immediate

treatment will shorten it. Proper reasoning is required during the fit so as to save life.
Therefore, the following measures should be instituted;

I will ensure total privacy during the attack. I will nurse the patient in a safe
environment, with no obstacles to prevent injuries. I will nurse the patient in a low bed
with rails or possibly on a floor bed to prevent injuries from falls. I will pad side rails
of the bed to prevent injury. If the patient is up and has not already fallen, I will place
him in semi prone position and provide a folded blanket or towel under the head to
prevent injury during clonic phase. I will ensure the airway is clear and maintain it
clear throughout the seizure. I will insert Padded spatula between teeth to prevent teeth
clenching. I will not restrain the jerking limbs forcefully to avoid fractures or
dislocations. I will, ensure patient lies flat on the lateral side to avoid chocking with
secretions. I will not place a heater near his bed to avoid burns or electric fan or lamp.
I will stay with the patient for safety to make observations and record the events. I will
provide a fit chart to monitor the frequency of seizures. I will observe and record the
time the seizure start and end on the fit chart for continuity of care. I will observe the
time of initiation, duration and source of the seizure for continuity of care. I will keep
assuring the family throughout the period to alley anxiety and gain their cooperation

MAINTAINING A PATENT AIRWAY

I will not attempt to insert anything between clenched teeth for fear of risk of pushing
tongue unto the oropharynx which may cause airway obstruction and injury to the
teeth and soft tissue. I will loosen restrictive clothing at the neck to maintain patent
airway. I will wipe out any froth (saliva) from the mouth to avoid accumulation which
may block the airway. I will suction if necessary to paten airway. I will turn the patient
on the side to promote drainage of secretions and prevent aspiration as soon as the
clonic stage begins to subside. I will ensure that the unit has free air circulation by
opening nearby windows. I will not overcrowd the patient by limiting the number of
people if i need assistance to promote free air circulation.

OBSERVATIONS

The following observations should be made;

 The mode of onset-did the patient indicate an aura?

 Was there a cry?
 In what part of the body did the initial phase start?
 Did the head and eyes deviate to one side?

 Are the seizure movements localised or generalized?

 Are the seizure movements localised or generalized?

 If generalized are they symmetrical or asymmetrical?

 Is the patient cyanosed

 Are the teeth clenched and is there frothing at the mouth

 Is there incontinence of urine and faeces.

 How long did the seizure last?

SUBSEQUENT NURSING CARE

PSYCHOLOGICAL CARE

Initially, patients are often sad, depressed and feel embarrassed after an episode. I will
assess the psychic status of the patient for baseline. I will let the patient express their
anger, fears, worries and concerns and attend to them. I will give an explanation of the
event to make the patient understand what happened to him and diffuse self blame by
giving adequate information. I will assure them that they can still lead a normal life to
alley anxiety and lack of self esteem. I will incorporate the patient and relatives in care
to instil a sense of self esteem in the patient. I will involve the ccupational therapist to
allay any anxieties about loss of a job. I will allow friends, family and church to offer
support to promote selfesteem

MAINTENANCE OF HYGIENE

I will remove and change any soiled linen and clothing to promote self esteem and
prevent infection. I will dispose off any stool or urine to prevent odour smell in the
room, promote self-esteem and prevent infections. I will advise the patient to clean the
mouth or use mouth wash to prevent halitosis ad promote appetite. I will encourage the
patient to take a shower or bath to promote blood circulation, promote self esteem and
prevent infection. I will involve the caretaker for continuum of care at home.

REST AND ACTIVITY

I will encourage the patient to rest as seizures usually leave patient exulted,. I will
nurse the patient in a noise free environment for rest. I will restrict visitations to
promote rest. I will do procedures in block to promote rest

PATIENT/FAMILY EDUCATION

I will provide adequate information about prescribed anticonvulsant to promote

adherence to drugs.. I will alert the client and family to the potential side-effects and
advise them to get in touch with the doctor if they occur for quick interventions and
prevention of complications. I will emphasize on treatment compliance to promote
healing. I will encourage the patient to honour review and appointments date to
monitor progress. I will discourage the patient from being around water bodies,
climbing heights, driving and operating heavy machines to prevent putting their lives
at risk as seizures happen suddenly. I will teach significant other about first aid
measures during an attack, like prevention of injury to prevent injuries

QUESTION ON EPILEPSY

1. Chembe is an epileptic patient, married with two (2) children has been brought to
the ward following a grandmal seizure two days ago. The patient had generalized
movement of the body and confusion ensued thereafter. Since then, the patient
 just stares blankly in the environment, withdrawn and has hallucinations and
illusions. Patient is also neglecting himself and not eating.
a. Define epilepsy 5%
b. Outline 5 types of epileptic seizures 20%
c. Describe the management of chembe 50%
d. Explain (5) five points you would include in your Information, Education and
Communication to the community on epilepsy.
25%

MENINGITIS

Definition
Meningitis is an acute inflammation of the meninges (protective membranes covering
the brain and spinal cord) which can be caused by bacteria, viruses, fungi and is
mainly manifests with fever, headache and disturbed neural functions.

ETIOLOGY OF MENINGITIS

Meningitis can have various etiological factors. The most common causes of
Meningitis are;

 Bacteria

 Viruses

 Fungi

 Direct injury to the brain (skull or meninges)

HOW IS MENINGITIS TRANSMITTED

Meningitis can be transmitted via;

 Air borne through droplets

 Contact with oral secretions or faeces from infected individuals (via kissing).
 Direct contamination (from a penetrating skull wound or skull fracture)
  Haematogenous (via the blood stream) from existing infections like Pneumonia,
endocarditic, rotten tooth Otitis media

HOW IS MENINGITIS CLASSIFIED

Meningitis classified according to etiology of the infection

BACTETIAL MENINGITIS

Bacterial (Septic) Meningitis is the most common form of Meningitis. This

Meningitis is caused by bacteria. It requires extensive treatment to clear the infection.
Bacterial meningitis treated by using antibiotics

COMMON CAUSES OF BACTERIAL MENINGITIS ARE;

 Haemophilus influenza

 Neisseria Meningitidis (the most common cause)

 Streptococcus Pneumoniae

 Staphylococcus aureus

 Escherichia Coli

VIRAL MENINGITIS

The disease is self-limiting. It does not require extensive treatment. Common causes of
Viral Meningitis are;

 Enteroviruses

 Mumps virus

 Human Immunodeficiency Virus

 Polio virus

FUNGAL MENINGITIS

This type of Meningitis is caused by Fungi. Treatment is usually with antifungals. This
is opportunistic in nature and usually affects individuals with lowered immunity
secondary to HIV/AIDS, Malnutrition and Cancer patients. This is a presumptive
diagnosis for HIV infection. This fungal infection is opportunist as it thrives due to
immuno suppression, especially in HIV/AIDS patients. Most common is
Cryptococcus (Cryptococcal Meningitidis). Other causes of Fungal Meningitis are;

 Histoplasma

 Blastomyces

 Coccidioides

 Candida albican

sPATHOPHYSIOLOGY OF MENINGITIS

The brain and spinal cord are protected by meninges. The causative organism reaches
the meninges via direct contact or through haematogenous spread. The hallmark of the
disease is as a result of an attack by the causative organism which leads to local or
generalised meningeal inflammation. Infection in the subarachnoid space multiplies
and causes an inflammatory reaction of the pia and arachnoid meninges. If the
infection is not treated early, multiplication of organisms shall be extensive leading
generalised meningeal inflammation . As a result of intensive inflammation, Purulent
exudate is produced and infection spread quickly through the CSF that circulates
around the brain and spinal cord. Bacteria and exudates can create vascular congestion,
plugging the arachnoid villa.
This obstruction of CSF flow and decreased reabsorption of CSF can lead to increased
intracranial pressure, brain herniation and death can occur. In severe cases, brain
abscess can occur due to intensive inflammation and exudation.

As a result of increased intracranial pressure, the patient will manifest clinical signs
and symptoms of neurological deficiencies like; severe headache, dizziness and in
most severe cases; confusion, convulsion, lethargy, and coma can be observed.

SIGNS AND SYMPTOMS

 Headache: due to increased intracranial pressure arising from inflammatory

responses
 Confusion and disorientation: due to cerebral damage arising from meningeal
inflammation
 Fever: secondary to infection and inflammatory responses of the meninges

 Lethargy and convulsions: due to cerebral oedema, brain herniation and

inflammation

 Coma: due to extensive cerebral oedema and brain herniation

 Vomiting: due to cerebral involvement (vomiting center) and meningeal

inflammation

 Photophobia and irritability: this is as a result of cerebral oedema

(inflammation)

 Brudzinski’s sign: inability to flex (bend) the leg to 90 degrees which is as a

result of increased intracranial pressure

 Kernig’s sign: inability to extend (straighten) the leg when the hip is flexed to 90
degrees which arises from meningeal inflammation and increased intracranial
pressure.

 Nuchal rigidity (stiff neck): the inability to flex the neck forward as the neck
muscles and spinal cord becomes stiff due to inflammatory processes
DIAGNOSIS OF MENINGITIS

History taking: the onset of symptoms and history or presence of bacterial infection
like Otitis media, pneumonia or human immunodeficiency virus.

Physical assessment: will real positive Brudzinski‘s signs, Positive kerning‘s signs
and nuchal (neck) rigidity.

Blood culture: to reveal the causative organism

Lumbar puncture: CSF analysis and gram stain/culture will reveal causative
organism

Sputum, urine and other body secretions: for microscopy, culture and sensitivity:
will reveal the causative organism

CSF Chemistry in Viral Meningitis, CSF remains clear while in Bacterial

Meningitis, the CSF appears cloudy and CSF will show low glucose level, high
protein and high white cell count

Computerized tomography Scan (CT Scan): will reveal meningeal inflammation to

confirm the diagnosis
Magnetic Resonance Imaging (MRI) of the head; will reveal meningeal
inflammation, brain herniation and exudation

TREATMENT

Treatment of Meningitis is based on the cause of an infection

Bacterial meningitis

Parenteral antibiotics should be used

The antibiotic must penetrate the blood-brain barrier into the CSF.

 Penicillin G or

 Ampicillin or

 Cloxacillin

 Chloramphenical or

 Gentamycin or

 Kanamycin or

 Cephalosporine; Cefalexine

Viral meningitis

 It is self-limiting however, there is a need to put the patient on antibiotic treatment

to prevent bacterial invasion which would otherwise thrive in viral infection.

Fungal meningitis

 Amphotericin-B or

 Ketoconazole or

 Fluconazole

SUPPORTIVE TREATMENT INCLUDES

 Glucocorticosteroids: Dexamethasone or Hydrocortisone to reduce meningeal

inflammation and cerebral oedema.
  Osmotic diuretic: Mannitol to reduce cerebral oedema.

 Diazepam: to control seizures, if present.

 Analgesics: Paracetamol for headache and to control fever.

 Limitation of fluid to about 1500ml to keep patient under hydrated and reduce
cerebral oedema and effects of inappropriate ant diuretic hormone secretion.

MANAGEMENT OF MENINGITIS

Nursing Care Plan

NURSING DIAGNOSIS

Actual Problems-

NURSING DIAGNOSIS #1

Pain (headache) related to meningeal inflammation and increased intracranial

pressure as evidenced by patient verbalizing.

NURSING DIAGNOSIS #2

Activity intolerance (self care deficit) related to disease progression and pain
evidenced by failure of the patient to perform activities of daily living.

NURSING DIAGNOSIS #3

NURSING DIAGNOSIS #5

Ineffective coping related to inadequate knowledge about the prognosis of the disease
as evidenced by patient being irritable, aggressive, crying, and self isolation

Anxiety related to disease progression and hospitalization as evidenced by patient

being restless and asking too many questions.
NURSING DIAGNOSIS #6

Altered nutrition less than body requirement related to reduced oral intake
evidenced by patient weakness and weight loss

NURSING DIAGNOSIS #7

Altered thermoregulation related to impairment of the regulation center in the brain

evidenced by high temperature readings of above 37C

NURSING PROBLEMS

Potential Problems

NURSING DIAGNOSIS #1

Risk of (nosocomial) infection related to (prolonged) hospitalization

NURSING DIAGNOSIS
#2

Risk of injury related to convulsions, weakness and dizziness

NURSING DIAGNOSIS #3

Risk of decubitus ulcers related to prolonged confinement to bed and inactivity

NURSING MANAGEMENT

Aims

 To prevent spread of infection

 To prevent pressure sore formation/reduce possibility of occurrence of
complications.
 To maintain good nutrition status.
  To offer psychological care to both patient and relatives
 To promote recovery

ENVIRONMENT

I will isolate the patient (as advised) for meningococcal infections only until the
pathogen can no longer be cultured from naso-pharynx to prevent spread. I will nurse
the patient to be nursed in a quite and less stimulating environment for rest. I will
nurse the patient in a room with a dim light to prevent photophobia. I will provide sun
shields may be used to promote comfort from photophobia. I will restrict visitors as
necessary to reduce noise. I will nurse the patient in a room with resuscitative
equipment available and in working condition for use when need arises.

OBSERVATION

I will observe measure and record the input fluids and output of urine to rule out renal
function. If the patient is unconscious I will insert an indwelling catheter to monitor
for urine output for renal function. I will weigh the patient on alternate days to monitor
the nutritional status. I will do physical assessment of Brudzinski‘s, Kerning‘s signs
and neck rigidity to be done to monitor recovery. I will monitor vital signs every 4 to 6
hours and gradually reduced as the patient‘s condition improves to monitor progress. I
will observe the level of consciousness and the mental status to monitor recovery. I
will monitor the feeding pattern to ensure adequate nutrition.

PREVENTION OF INJURY/REST

I will nurse the patient in padded railed bed or floor bed to prevent falls and injury. I
will never leave the patient alone for a long period of time to prevent falls. I will
support the patient in a position of comfort. I will ensure the head of the bed is
elevated at 30 degrees to promote venous return and reduce intracranial pressure. I will
keep the neck in alignment during position changes. I will provide gentle passive range
of motion and massage to the neck and shoulder joints and muscles to help relieve
stiffness. If the patient is afebrile, I will apply moist heat to the neck and back to
promote muscle relaxation and reduce pain and promote rest. I will apply ice bag to
the head or cool cloth to the eyes to help diminish the headache and promote rest. I
will loosen constricting bed clothing and avoid restraining the patient unnecessarily.

NUTRITION & FLUIDS

I will assess the feeding pattern to draw up the schedule for feeding and prevent
malnutrition. If the patient is unconscious, I will insert NGT for feeding. I will prevent
constipation, by giving stool softeners and laxatives to avoid intracranial pressure. I
will record intake of fluids and output of urine and chart accordingly to prevent
overload I will give Intravenous fluids in limited amounts to maintain a balanced
electrolyte status and prevent further intracranial pressure

PSYCHOLOGICAL CARE

I will explain the disease process to the patient and significant others to alley anxiety.
I will assess for the psychic of the patient for baseline. I will explain specific
respiratory precautions to prevent spread of infection to others. I will explain the
treatment and investigations to gain cooperation. I will give full details about the
condition to increase patient‘s knowledge. I will Involve the patient and relatives in
care to promote cooperation and prevent patient from feeling abandoned. When the
infection is less infectious, I will allow friends, family and church to visit and offer
support

ACTIVITY & HYGIENE

If the patient is unconscious, I will assist with activities of daily living such as oral
care to prevent infection and promote comfort. When the patient stabilizes, I will assist
in performing of activities of daily living like assisted bed bath to prevent infection,
promote blood circulation and comfort. I will do catheter toilet if patient is on
indwelling catheter to prevent infection.

HEALTH EDUCATION
I will teach transmission and preventive measures to the patient and significant to
prevent spread. I will advice the patient to avoid overcrowding areas especially in
meningococcal meningitis. I will counsel the patient on completion of medication so
as to avoid resistance. I will encourage the patient to get vaccinated for example
against meningococcal vaccine in epidemic period and Haemophilus Influenza
vaccine. I will advice the patient to honour review dates and appointment dates to
monitor progress of healing

COMPLICATIONS OF MENINGITIS

 Hydrocephalus: due to blockage of CSF flow

 Diabetes Insipidus: as a result of impairment of ADH hormone production and
secretion
 Impairment of hearing: due to damage to auditory nerves and hearing centre of
the brain
 Brain abscess: arising from cerebral necrosis

 Mental retardation: as a result of brain damage, specifically the cerebrum

 Encephalitis: due to extensive inflammation of the brain

 Multi organ failure: due to impairment of the brain which controls all the
physiology of other organs

 Paralysis: due to cerebral damage leading to damage to the cerebellum which

controls muscle coordination.

 Epilepsy: which arises from permanent damage to the brain

 Cortical blindness: this is due to damage to the vision center of the brain

QUESTIONS ON MENINGITIS

NMCZ 2020 JUNE

1 Mrs. Bwali female aged 37 is admitted to female medical ward at Monze mission
hospital with a diagnosis of bacterial meningitis.
a. Define meningitis. 5%
 b. Draw a well labeled diagram of the brain showing showing the meninges and
the flow of cerebral spinal fluid (csf). 20%
c. State 5 signs and symptoms that Mrs Bwali may present with on Admission.
15%
d. Identify 5 nursing problems that Mrs Bwali may have and using a nursing
care plan, discuss how you would manage them.
50%
e. Mention 5 five points that you would include in your information, education
and communication to Mrs. Bwali and her family on discharge.
10%

1. Mr. Peter Mumba 32 years old is admitted to male medical ward with a diagnosis
of meningitis.
a) Define meningitis (5%)
b) List five (5) signs and symptoms of meningitis (5%)
c) Explain the Nursing Management of Mr. Mumba while in hospital (15%)

RENAL FAILURE

FUNCTIONS OF KIDNEYS

Some of the functions of kidneys are;

Functions of the kidneys include the following:

 Regulation of blood ionic composition. The kidneys help regulate the blood
levels of several ions, most importantly sodium ions (Na_), potassium ions (K_),
calcium ions (Ca2_), chloride ions (Cl_), and phosphate ions (HPO4.
 Regulation of blood pH. The kidneys excrete a variable amount of hydrogen ions
(H_) into the urine and conserve bicarbonate ions (HCO3), which are an important
buffer of H_ in the blood. Both of these activities help regulate blood pH.
  Regulation of blood volume. The kidneys adjust blood volume by conserving or
eliminating water in the urine. An increase in blood volume increases blood
pressure; a decrease in blood volume decreases blood pressure.
 Regulation of blood pressure. The kidneys also help regulate blood pressure by
secreting the enzyme renin, which activates the renin–angiotensin–aldosterone
pathway. Increased renin causes an increase in blood pressure.
 Maintenance of blood osmolarity. By separately regulating loss of water and
loss of solutes in the urine, the kidneys maintain a relatively constant blood
osmolarity close to 300 milliosmoles per liter (mOsm/liter).*
 Production of hormones. The kidneys produce two hormones. Calcitriol, the
active form of vitamin D, helps regulate calcium homeostasis, and erythropoietin
stimulates the production of red blood cells.
 Regulation of blood glucose level. Like the liver, the kidneys can use the amino
acid glutamine in gluconeogenesis, the synthesis of new glucose molecules. They
can then release glucose into the blood to help maintain a normal blood glucose
level.
 Excretion of wastes and foreign substances. By forming urine, the kidneys help
excrete wastes—substances that have no useful function in the body. Some wastes
excreted in urine result from metabolic reactions in the body. These include
ammonia and urea from the deamination of amino acids; bilirubin.

DEFINITION
Renal failure is a clinical syndrome in which the kidneys are unable to remove/excrete
excess fluids (water) and waste products (urea) from the body resulting into fluid
overload and increased uraemia

RENAL FAILURE CAN BE CLASSIFIED AS BEING ACUTE OR CHRONIC

ACUTE RENAL FAILURE

 DEFINITION
Acute Renal failure is a clinical syndrome of abrupt/sudden onset of diminished
 kidney function (remove/excrete excess fluids and waste products) resulting into
fluid overload, reduced urine output and increased uraemia.
 Acute renal failure (ARF) refers to the abrupt loss of kidney function over a
period of hours to a few days, with a fall in Glomerular Filtration Rate (GFR)
accompanied by a rise in serum creatinine and urea nitrogen.

CHRONIC RENAL FAILURE

Chronic Renal Failure is a gradual, progressive and irreversible loss of kidney function
resulting into marked fluid overload, reduced urine output and increased uraemia.

CAUSES OF ACUTE RENAL FAILURE

Causes of renal failure can be classified according to factors which;

 Interrupt blood flow to the kidneys,

 Factors (pathology) which occur inside the kidneys
 Factors which cause urine obstruction or urine flow

CAUSES OF ACUTE RENAL FAILURE CAN BE CLASSIFIED AS;

1. Pre-renal causes

2. Intra-renal/renal causes

3. Post-renal causes

1. PRE-RENAL CAUSES OF ACUTE RENAL FAILURE

These factors interfere with renal perfusion. The kidney depends on an adequate
delivery of blood to be filtered by the glomeruli. Therefore, a reduced renal blood flow
obviously decreases the Glomerular filtration rate (GFR. Circulatory volume depletion
shift due to;

a. Diarrhoea
b. Excessive vomiting
c. Haemorrhage
d. Severe burns
e. Excessive use of diuretics
 f. Volume shift attributed to;
 Oedema
 Vasodilatation
g. Decreased cardiac output

h. Increased vascular resistance

i. Vascular obstruction

2. INTRA-RENAL CAUSES OF ACUTE RENAL FAILURE

Refers to parenchymal changes from disease or nephrotoxic substances. These factors

occur inside the kidneys, regardless of whether there is adequate renal blood supply.
These factors are;

 Acute tubular necrosis

 Trauma to the kidneys
 Certain genetic conditions
 Infectious diseases
 Metabolic disorders
 Glomerulonephritis
 Vascular lesions
3. POST-RENAL CAUSES OF ACUTE RENAL FAILURE

These factors interfere with urine flow;

 Prostatic hypertrophy
 Renal calculi
 Blood clot in the urinary tract
 Urethral strictures
 Pregnancy
 Urethral tumours
PHASES OF ACUTE RENAL FAILURE

There is a cascade (phases) of events which leads to acute renal failure as follows;

 Non-oliguric phase
 Oliguric phase
 Diuretic phases
 Recovery phase

NON-OLIGURIC PHASE

This is the first phase of acute renal failure. In this phase a patient may have a
glomerular filtration rate of as less as 1L/day and this need to be recognized as a
possible sign of ARF. The urine is dilute and nearly osmolar, indicating that not all
nephrons have stopped filtering. Hypertension and tachypnea as signs of fluid overload
are frequently found. It is recommended that the condition should be managed during
this stage to prevent it from worsening. If the condition is not corrected, the patient
will go into Oliguric phase. In this phase, urine production drastically falls below
400ml/day. Clinical manifestations are increased BUN and Creatinine. This will lead
to increased toxaemia which will be manifested by headache, confusion and
disorientation. Severe headache is also prominent in this phase due to toxaemia. Fluids
are usually restricted to prevent worsening the condition (cardiac overload) and
diuretics can be indicated to reduce cardiac overload

DIURETIC PHASE

This acts as a compensatory phase in which the kidneys tries to remove excess water
and toxins from the blood. During the diuretic phase the damaged kidneys try to heal
but scarring and damage occurs. In this phase, urine output increases. The large
amount of fluids (4 to 5 L/day) and electrolytes are lost. The patient may experience
signs of dehydration; increased thirsty, poor skin turgor, dry mouth and mucus
membrane. During this stage, intravenous and oral fluids are recommended to prevent
dehydration.

RECOVERY PHASE

This is the last phase and may last up to 12 months. In some cases most patients are
left with some residual renal dysfunction. Kidney may return to normal functioning
state or there may be some residual renal insufficiency. Kidney damage may remain
permanent due to fibrous which may occur following initial injury. One-third of clients
may recover successfully without complications

SIGNS & SYMPTOMS OF ACUTE RENAL FAILURE

 Oliguria: due to reduced Glomerular Filtration Rate (GFR)

 Muscle weakness and pain: due to acidosis, nerve cells are damaged which will
lead to muscle twitching, ache and weakness
 Dysarrhythmias (absence of cardiac activity): related to acidosis which will
eventually lead to cardiac involvement
 Pruritus: attributed to the excessive circulation of urea in blood causing irritation
(Uraemia)
 Pulmonary oedema (fluid accumulation in the lungs): as a result of circulatory
fluid over leading to seepage of fluids in the alveoli
 Hypertension: due to fluid overload in circulation related to reduced GFR
 Metabolic acidosis: this occurs when there is excessive accumulation of waste
products in the circulation
 Kussmal respirations: this is a shallow and deep breathing in response to
acidosis and accumulation of alveoli fluids
 Altered mental state: which may accompany confusion and disorientation due to
accumulation of toxins in blood (toxaemia) which will affect (intoxicate) the brain
cells
 Seizures, convulsions and coma: a medical emergency in which the patient
remains in coma for a long period of time due to severe acidosis leading to
cerebral involvement
COMPLICATIONS OF ACUTE RENAL FAILURE

 Permanent kidney damage (Chronic renal failure): this results from excessive
renal damage which will eventually lead to fibrosis and in turn impairing kidney
function
 Toxaemia: This complication will arise as a result of increased build up of toxins
in the blood leading to other organs of the body being affected
 Brain Abscess: This is a fatal condition which arises from toxaemia in which
brain cells die due to effects of toxins in the blood
 Fluid and electrolyte imbalance: due to reduced/diminished GFR, more fluids
and electrolytes will accumulate in the body which will lead to vascular shift
 Heart disease: Due to excess potassium levels (hyperkalaemia) in the
cardiovascular, the cardiac muscles will be affected leading to cardiac arrhythmias
and eventually shuts down
 Hypertension: This will be attributed to excess fluid build up in the
cardiovascular leading to fluid congestion
 Pulmonary oedema: Due to accumulation of fluids in the cardiovascular, this
will lead to seepage of fluids in the alveoli leading to pulmonary congestion which
will be manifested by kussmal respirations
 Hyperkalaemia: Due to reduced GFR, potassium levels will rise causing further
cardiac complications
 Anaemia: This can be due to haematuria and/or impairment in the formation of
blood platelets which may lead to bleeding tendencies
 Encephalitis: Inflammation of brain cells will be as a result of toxaemia and will
be manifested as headache, confusion and disorientation.
 Seizures and convulsions: This a serious and fatal manifestation of encephalitis
due to cerebral involvement by toxins
 Coma: This is another serious and fatal complication of ARF in which there is
disturbance in the conscious level of a patient which may last for many days or
even years and is a sign of severe brain damage
MANAGEMENT OF ACUTE RENAL FAILURE

MEDICAL MANAGEMENT

The goal of treatment is anchored on the three pillars:

Aims

 To Elimination of the precipitating factors

 To maintain homeostatic balance
 To prevent complications until the kidneys are able to resume function.

Acute renal failure (ARF) is primarily diagnosed by blood and urine tests. However,
other tests like Biopsies and Imaging studies can be carried out, as supportive
investigations to detect possible underlying cause (pathology).

History Taking

 I will do history taking which will reveal oliguria on onset of signs and symptoms
as well as exposure to risk factors.
 I will do history taking which will reveal muscle weakness and pain

Physical Examination

 I will do physical examination which will reveal oedema and reduced urine
output on inspection.

Laboratory Tests

 Serum creatinine (SCr) test: to rule out kidney failure.

 Blood Urea Nitrogen (BUN): Measures the amount of a waste product in the
blood called urea nitrogen. Urea nitrogen is produced when the liver breaks
down protein and its excreted in the urine. High BUN levels in blood is
indicative of Acute Renal Failure and may also suggest the underlying cause of
the kidney failure.
  Serum potassium test: This test is used to determine whether there is
excess potassium in the blood (a condition known
as hyperkalemia). Hyperkalemia is a characteristic of ARF and, if left untreated,
can lead to severe and potentially life-threatening dysarrhythmia.
 Urinalysis Is a lab analysis of the chemical and physical composition of urine.
It can be used to detect whether there is excess protein in the urine (proteinuria)
and blood in the urine (haematuria) which is considered a key feature of ARF
due to kidney damage.
 Ultrasound It is the preferred method of imaging testing and can be used to
measure the size and appearance of the kidneys, detect tumors or kidney
damage, and locate blockages in the urine or blood flow. It can also be used to
assess clots, narrowing, or ruptures in the arteries and veins of the kidneys.
 Computed tomography (CT) : It is a type of X-ray technique that produces
cross-sectional images of an organ. CT scans can be useful in detecting cancer,
lesions, abscesses, obstructions and the accumulation of fluid around the
kidneys. They are standardly used in obese people in whom an ultrasound may
not provide a clear enough picture.
 Renal biopsy: This cytological examination explores possible detection of
cancer to be the underlying pathology of ARF.

TREATMENT OF ACUTE RENAL FAILURE

 Restrict fluids, especially during Oliguric phase

 During diuretic phase, replace lost fluids plus an additional of 400ml/24hrs.
 Diuretics: In oliguric ARF for fluid removal; Furosemide or Mannitol

Note: Medications that are handled primarily by the kidneys, like methyldopa will
require dosage modifications or frequency to prevent medication toxicity causing
further damage to the kidneys.

 Antihypertensive: to control blood pressure. Aldoment or Atenolol

  Sodium bicarbonate to control acidosis
 Intravenous calcium to reverse the cardiac effects of life-threatening
hyperkalaemia.
 Vitamins B and C to replace losses if patient is on dialysis
 Packed cells for active bleeding or if anaemia is poorly tolerated

 Diet: Increase carbohydrates, reduce proteins, reduce Potassium and reduce

sodium in-takes, however, because of loss of K⁺ during the diuretic phase, K⁺ may
need to be increased during that time.

 Dialysis may be done to remove toxins

NURSING DIAGNOSIS FOR ACUTE RENAL FAILURE

Nursing Diagnosis #1

Fluid volume excess related to reduced glomerular filtration as evidenced by

breathlessness and oedema

Nursing Diagnosis #2

Activity intolerance (Self care deficit) related to fluid volume excess and uraemia as
evidenced by patient being confined to bed, looking unkempt and failure of the patient
to tolerate activities of daily living

Nursing Diagnosis #3

Ineffective copying (anxiety) related to disease process (oedema, headache) as

evidenced by patient being restless, sweating and asking many questions

Nursing Diagnosis #4
Impaired tissue perfusion related to pulmonary oedema (accumulation of alveoli
fluids) and acidosis evidenced by kussmal respirations (deep shallow breaths)

Nursing Diagnosis #5

Altered nutrition less than body requirement related to anorexia and disease
progression evidenced by loss of body weight

Nursing Diagnosis #6

Altered nutrition less than body requirement related to anorexia and disease
progression evidenced by loss of body weigh

Nursing Diagnosis #7

Headache related to toxaemia and renal cell necrosis as evidenced by patient showing
a gloomy face and verbalization

Nursing Diagnosis #8

Risk of nosocomial infection related to reduced immunity and hospitalisation

Nursing Diagnosis #9

Risk of impaired skin integrity related to accumulation of fluids (Oedema) and

inactivity (be confirmed to bed)

Nursing Diagnosis #10

Risk of injury related to weakness, headache, dizziness and confusion

PATIENT AND FAMILY TEACHING

 Teach the patient about the cause of renal failure and problems with recurrent
failure.
 Identification of preventable environmental or health factors contributing to the
illness, such as hypertension and nephrotoxic drugs is taught.
 Teach patient about medication regimen, including name of medication, dosage
reason for taking and side effects.
 Teach patient about prescribed dietary regimen
 Explain the risk of hypokalemia and to report symptoms (muscle weakness,
anorexia, nausea and vomiting, lethargy).
 Teach about signs and symptoms of returning renal failure (decreased urine
output, without decreased fluid intake
 Teach about signs and symptoms of condition; methods to avoid infection.
 Emphasize the need for on-going follow-up care.
 Give information about options for future; explanation of transplantation of
kidney and dialysis if these are a possibility.

Questions on Acute Renal Failure

1 Mrs. Anita Moonga 39 years old has been admitted to your ward with a
provisional acute renal failure.
A. Draw a well labeled diagram with the cross section of the kidney.
15%
B. Explain the process of urine formation.
15%
C. Outline five functions of the kidney
20%
 D. Discuss in detail the management of Mrs. Moonga throughout hospitalization
under the following headings:
ii. Medical management 15%
iii. Nursing care 35%
2. Mr. Nooya Kabuswe, a 39 years old man has been admitted to your ward with a
provisional diagnosis of acute renal failure.
A. Explain the process of urine formation. 20%
B. Draw a well labeled diagram of the nephron 15%
C. Explain the three (3) main causes of renal failure. 15%
D. Discuss the management of Mr. Kabuswe throughout his hospitalization
45%
E. State (5) five complications of acute renal failure. 15%

HYPERTENTION

DEFINATIONS

• It is a condition in which there is sustained elevation of arterior blood pressure i.e.

systolic of over 140 and diastolic above 90mmHg.

• A condition where there is consistent elevation of the systolic blood pressure

above 140mmHg and a diastolic blood pressure above 90mmHg

• Sustained high blood pressure is known as hypertension. BP of 140/90, at least 2

readings on separate occasions is known as hypertension

• A systolic blood pressure greater than 140 mm Hg and a diastolic pressure greater
than 90 mm Hg based on the average of two or more accurate blood pressure
measurements taken during two or more contacts with a health care provider

CLASSIFICATIONS

It has been classified into two (2), i.e.

 Primary hypertension (Essential hypertension)

  Secondary hypertension

PRIMARY HYPERTENSION

Primary hypertension is also known as essential or idiopathic hypertension. There are

characteristics associated with primary hypertension as follows:

 Typically appears between the ages of 30 and 50 years.

 Affects 90% to 95% of all hypertensive cases

 Has a poorer prognosis and is considered to be the most significant cause of

coronary artery disease

Primary hypertension is further subdivided into:

 Benign HTN which can be present for a long time without causing serious
problems
 Malignant HTN which is of sudden onset and produces severe symptoms making
survival to a few months or up to 2 years if not properly managed

SECONDARY HYPERTENSION

Secondary hypertension is that type of hypertension which results from other diseases.
Usually the cause is known and accounts for 5% to 10% of the hypertensive
population. It may result from the following conditions:

 Diseases of the cardiovascular system-coarctation of the aorta- lead to elevation of

the blood pressure due to narrowing of the aorta at the point of stenosis.
 Diseases of the renal system -glomerulonephritis, pyelonephritis, and congenital
cystic disease.
 Diseases of the endocrine system-Cushing‘s syndrome(causes retention of water
hence elevating the BP)
 Hyperthyroidism and phaechromocytoma-which causes excessive adrenaline
secretion and
 Adrenaline causes constriction of blood vessels causing hypertension
 Secondary to pregnancy
  Secondary to certain drugs e.g. estrogen containing contraceptive pills-leads to
release of renin which causes excessive secretion of adrenaline and adrenaline
causes constriction of blood vessels causing hypertension.

 Adrenal gland tumor

 Anxiety and stress

 Arteriosclerosis

 Birth control pills

 Endocrine disorders e.g. Cushing syndrome

 Diabetes mellitus

PREDISPOSING FACTORS

 Heredity (Runs in families)

 Obesity (Fat deposits on blood vessel walls)

 Anxiety (catecholamine release)

 Excessive salt intake (water retention)

 Alcohol

 Smoking (Catecholamine release/ Vasoconstriction)

 Stress (Catecholamine release)

 Excessive fat intake

 Sedentary life-style

 Oral contraceptive pills

PATHOPHYSIOLOGY OF HYPERTENSION

Maintenance of a normal blood pressure is dependent on the balance between the

cardiac output and peripheral vascular resistance. Most patients with essential
hypertension have a normal cardiac output but a raised peripheral resistance.
Peripheral resistance is determined not by large arteries or the capillaries but by small
arterioles, the walls of which contain smooth muscle cells. Contraction of smooth
muscle cells is thought to be related to a rise in intracellular calcium concentration,
which may explain the vasodilatory effect of drugs that block the calcium channels.
Prolonged smooth muscle constriction is thought to induce structural changes with
thickening of the arteriolar vessel walls possibly mediated by angiotensin, leading to
an irreversible rise in peripheral resistance, which also increases the blood pressure.

Renin-angiotensin system

Renin is secreted from the juxtaglomerular apparatus of the kidney in response to

glomerular under perfusion or a reduced salt intake. Renin is responsible for
converting renin substrate (angiotensinogen) to angiotensin I, a physiologically
inactive substance which is rapidly converted to angiotensin II in the lungs by
angiotensin converting enzyme (ACE). Angiotensin II is a potent vasoconstrictor and
thus causes a rise in blood pressure. In addition it stimulates the release of aldosterone
from the zona glomerulosa of the adrenal gland, which results in a further rise in blood
pressure related to sodium and water retention. Inappropriate secretion of renin may
therefore increase the blood pressure

Hypertension results in damage to blood vessels in vital organs. It produces medial

hyperplasia (thickening of the arterioles). As blood vessel wall thicken and perfusion
decreases, body organs are damaged. These changes can result in complications such
as myocardial infarction, stroke, renal failure and peripheral vascular disease.

CLINICAL FEATURES

 Mostly asymptomatic and discovered on routine exams, or when complication

occurs

 Some people with uncomplicated hypertension, however, may experience

symptoms such as

 Headache due to cerebral hypoxia.

  Dizziness due to cerebral hypoxia.

 Shortness of breath due to impaired gaseous exchange.

 Blurred vision due to rupture of blood vessel supplying the retina.

 Confusion due to reduced oxygen supply to brain

 Chest pain due to anginal pain as a result myocardial ischaemia

 Ear noise or buzzing due to ear involvement

 Palpitation due to over work of the heart

 Nose bleed due to rapture of blood vessel in the nose

 Tiredness due to impaired tissue perfusion

COMPLICATIONS

 Hypertensive encephaloparthy

 Congestive heart failure

 Kidney damage

 Stroke

 Blindness

 Brain damage

MEDICAL MANAGEMENT

Aims

 To relieve signs and symptoms

 To prevent complications

DIAGNOSIS

History Taking

 I will do history taking which will reveal hypertension in the family

Physical Examination
  Blood pressure will be high e.g. 150/100

Laboratory Tests

 Renal function test to rule out renal disease

 Aortography to rule out Coarctation

 Renal angiography to r/o stenosis

 Urinalysis can be done to r/o renal disorder

TREATMENT

a. Beta Blockers
 Propranol
 Dose: 80mg b.d
 Action: reduce cardiac output, decrease renin secretion from the kidney.
 Side effects: Bradycardia, hypotension, heart failure, bronchospasm and
peripheral vasoconstriction
b. Diuretics
 Hydrochlorothiazide
 Dose: 25 to 100mg o.d
 Action: increases excretion of water, sodium, potassium and chloride by blocking
the reabsorption of sodium and chloride
 Side effects: headache, dizziness, parasthesia, dehydration, abdominal pains and
dermatitis
c. Calcium channel blockers
 Nifedipine
 Dose: retard-20mg b.d
 Action: block movement of extracellular calcium into cells, causing
vasodilatation and decreased system vascular resistance.
 Side effects: headache, flushing, dizziness, tachycardia, palpitations and
lethargy
d. Angiotensin Converting Enzyme(ACE) inhibitors
  Captopril
 Dose: 12.5 mg b.d
 Action: inhibit the conversion of angiotensin I to angiotensin II
 Side effects: tachycardia, hypotension, loss of taste, hyperkalemia and cough.
e. Adrenergic Inhibitors
 Methyldopa
 Dose: 500mg tds
 Action: reduces sympathetic outflow from the CNS,produces vasodilatation,
decreases SVR and BP.
 Side effects: dry mouth, impotence, nausea, dizziness, restlessness and
depression

NURSING MANAGEMENT

AIMS

 To reduce the BP
 To educate the patient about his condition
 To prevent complications like stroke
 To promote quick recovery

ENVIRONMENT

I will nurse the patient in a stress free environment to promote rest and prevent further
elevation of the BP. I will nurse the patient in the acute bay for close observation. I
will nurse the patient in a room with BP checking apparatus for close monitoring of
patients‘ BP

REST AND ACTIVITY

I will nurse the patient in a quiet room to promote rest. I will play the radio at low
volume to promote rest. I will answer all phone calls promptly to prevent disturbing
the patient there by promote rest. I will do related procedures in blocks to promote
rest. I will administer prescribed analgesics to relieve headache there by promote rest.
I will ensure that squeaking trolleys a oiled to prevent noise and there by promote rest
OBSERVATIONS

I will do vital sign and BP to act as the base line data in order to know if the condition
is improving or deteriorating. I will observe dyspnea if present will prop up the patient
to promote lung expansion and there by relieve dyspnea. I will do regular BP checks to
monitor patient‘s response to treatment

PSYCHOLOGICAL CARE

I will explain the disease process in order to raise the knowledge levels and thereby
alley anxiety. I will encourage the patient to ask question and I will answer
accordingly those I cant answer I will refer to the physician. I will explain all
procedures to my patient in order to allay anxiety

ELIMINATION

I will offer a bed pan if he is confined to bed to ensure bowel movement.

NUTRITION

I will offer a salt free diet to prevent further elevation of the BP. I will advise my
patient to eat more fruits, vegetables, and fiber to boost the immunity and prevent
constipation.

MEDICATION

I will administer prescribed analgesia like paracetamol to relieve headache. I will give
prescribed antihypatensive in order to promote recovery. I will ensure that the drugs
are swallowed in my presence to promote recovery.

HYGIENE

I will encourage the patient to take plunge baths in order to remove dead epithelium
and promote comfort. I will do hair care to promote self esteem and also prevent
pediculosis. I will do nail care to prevent auto infection and bruising self which can
lead to bleeding

HEALTH EDUCATION/IEC

I will advise my patient to lose weight if he/she is overweight as excess weight adds to
strain on the heart. In some cases, weight loss may be the only treatment needed. I
will encourage the patient to exercise regularly to help burn fats. I will counsel the
patient to eat a healthy diet such as less fat and sodium to prevent water retention. I
will encourage him to eat more fruits, vegetables, and fiber to promote immune system
and prevent constipation. I will encourage my patient to avoid smoking as smoking
predisposes him to hypertension. If my patient has diabetes, I will advise him to keep
his blood sugar under control to prevent complications

QUESTIONS ON HYPERTENSION

1. Chikuni Hatembo 50years old with four(4) children and principal at a college is
admitted to a medical ward with a provisional diagnosis of secondary hypertension

a. Briefly explain the pathogenesis of hypertension (15%)

b. State five(5) signs and symptoms which Mr Hatembo is likely to present with
on admission (15%)
c. Discuss in detail the nursing management of Mr Hatembo from admission till
discharge. 50%
d. State four(4) complications of hypertension 20%

2. Mrs. Mulozi Kalyalya from Dundumwezi, 44years old married with six (6)
children is a Director of Programmes at a private school. She is admitted to a
medical ward with a provisional diagnosis of secondary hypertension.

a. i. Define hypertension 5%
ii. List five (5) signs and symptoms of hypertension 10%
b. Explain two (2) classifications of hypertension 10%
c. Describe the management of Mrs. Kalyalya from admission till discharge 50%
d. Explain five (5) complications Mrs. Kalyalya may develop.

ASTHMA

DEFINITIONS

 Asthma is a chronic and recurrent condition of the upper respiratory system which
is caused by hyper-responsiveness of the bronchial tree resulting in mucosal
swelling, bronchospasms and increased secretion of mucus.
 Asthma is a respiratory disorder characterized by recurrent attack of dyspnea
,wheezing and coughing due to an hyperactive airway resulting in mucosal
swelling, broncho spasms and increased secretion of mucus

CLASSIFICATION OF ASTHMA

Asthma is classified according to aetiology into two (2) categories;

1. Intrinsic Asthma

2. Extrinsic Asthma (the most common)

INTRINSIC ASTHMA

This type is not usually associated with any allergies. It accounts for about 10% of all
the Asthma cases. It usually start later in life, usually after the age of 30. In many cases
it follows any other infections like chronic bronchitis. Emotions, such as anger and
happiness can trigger the attack. This type has no genetic predisposition

EXTRINSIC ASTHMA

This is the commonest type. It accounts for about 90% of all cases. 80% of all cases
have are attributed to allergies to a wide range of allergens. It occurs in individuals
who have already formed IgE antibodies to common allergies. The condition usually
starts in childhood. Sufferers usually suffer from other allergic conditions like allergic
rhinitis, and eczema. Extreme coldness can also trigger an attack. It has a tendency to
run in families. It usually go into remission at puberty but 75% of case reappear later
in life.

ALLERGIES TO EXTRISIC ASTHMA

Some of the allergies may include;

 Pollen
 Fur
 Insects
 Perfumes and other ordours
 Animals
 foods

PATHOPHYSIOLOGY OF AN ASTHMATIC ATTACK

The pathology of an Asthmatic attack is anchored on three physiological changes;

1. Hyperresponsiveness of the bronchial tree

2. Bronchial oedema (leading to bronchial constriction)

3. Hypersecretion of mucous (mucus plugging)

Exposure to an allergy for the first time will trigger the production of Immuno globulin
E (IgE) in large amounts. Further exposure to this allergen will lead to an antigen
antibody reaction, with the release of histamine from the mast cell. This will lead to
inflammation of the broncho mucosa which narrows the airway causing difficulties in
breathing. The inflammatory process also leads to increased secretion of mucous
which further impairs airflow contributing to dyspnea. The inflammatory process plus
the histamines will trigger broncho spasms further impairing air flow. The obstruction
air flow causes mismatched alveolar ventilation causing Dyspnea and trapping air in
the lungs.

In order to expel air from the lung expirations are forced and accessory muscles of
respiration are brought into action. As air is forced through the constricted bronchiole,
the wheezing sound is heard. Cough reflexes will be as a way of clearing the mucus
and paten the airway

CLINICAL MANIFESTATIONS OF ASTHMA

  Dyspnea due to impaired ventilation as a result of bronchial constriction and
mucus plugging
 Wheezing (usually on expiration) as a result of forceful expiration through
constricted airway a fluid filled airway
 Coughing with or without sputum as an attempt to clear the air way of the
secretions and irritants
 Chest tightness due to pressure build up and inflammatory responses
 Cyanosis due to reduced tissue perfusion (hypoxia) as a result of bronchial
constriction
 Use of accessory muscles for breathing as a compensatory mechanism for
constricted bronchial tree
 Profuse sweating due to increased metabolic rate (forceful respirations) and
anxiety
 Weakness due to reduced tissue perfusion as a result of bronchial constriction
 Tachycardia as the heart attempt to compensate/reverse the acidosis.
 Nasal fairing due to forceful respirations as a result of bronchial oedema

MANAGEMENT

MEDICAL MANAGEMENT

AIMS

 To reduce/stop the bronchial oedema

 To promote and maintain a patent airway
 To reduce the pain
 To clear the mucus

Prevent/reduce subsequent attacks

DIAGNOSIS OF ASTHMA

NOTE: Asthma is usually diagnosed clinically

History Taking

 I will do history taking which will confirm patient being allergic to perfumes or
odours. ( onset of symptoms, history of any allergies, history of the same
condition in the family, history of URTIs, wheezing and history of previous
attacks.)

Physical Examination

 Physical examination will reveal the presentation of the case such as wheezing
and breathing patterns

Supportive diagnosis

 Spirometry will show reduced lung function

 Arterial blood gas analysis will show elevated PaCo2 and low oxygen
 Chest X ray to rule out chest infection it will also show an over distended lung
 Blood culture to detect if an infection triggered the attack

TREATMENT

Broncho dilators

 Salbutamol (Ventolin); 2-4mg 8 hourly, until symptoms subsides, then reduce the
frequency for mentainance (Intravenously)
 Aminophylline; 100mg-300mg 8 hourly (may be given by nebulizer or Inhaler)

Anti inflammatory

 Hydrocortisone 50-100mg STAT (Intravenously)

Analgesic

 Paracetamol 10mg/kg 8 hourly for 3 days (Orally)

Supportive treatment

 Oxygen therapy 4-5l

If its due to bacterial infection;

 Amoxicillin 500mg 8 hourly for 5-7 days (Orally)

 Give warm fluids to loosen the bronchial secretions

AIMS OF CARE

 To restore and maintain normal breathing

 To prevent injuries
 To prevent/correct acidosis
 Prevent complications, like acidosis
 To offer psychological care
 To give health education
 To reduce occurrence of further attacks
 To promote quick recovery

MANNAGEMENT DURING AN ATTACK

AIRWAY AND BREATHING

I will call for help immediately. I will quickly do a thorough assessment of breathing
to assess the severity. I will ensure that there is no airway obstruction to maintain
patent airway. I will ensure that the unit is clean/free from irritants to prevent
triggering of the attack. I will ensure that the unit is warm and well ventilated by
opening nearby windows to promote airway circulation. I will prop-up the client if in a
chair or if patient is in bed, I will use a back rest to promote full lung expansion. I will
remove any tight clothing, bendings on and around the neck and remove any tight
clothing from the chest to promote breathing. Where necessary, I will suction the
secretions, with caution to make the airway patent. In severe cases, intubation and
mechanical ventilation can be done for patency of airway.

SUBSQUENT CARE

ENVIRONMENT/ADMISSION
I will nurse the patient in the acute bay for close observation until the condition
improves. I will open nearby windows to promote ventilation in the room to prevent
other respiratory tract infections. I will provide a chair and bed with back rest for
ensuring of proper position. I will nurse the patient in a well lit room for easy
observation. I will nurse the patient in a clean room free from irritants like dust and
odours to prevent reccurence, I will nurse the patient in a unit with resuscitative
equipment, like drip stand and oxygen giving apparatus for use in emergency

AIRWAY AND BREATHING

I will assess the breathing patterns of the patient for baseline. I will nursed the patient
in propped up position to promote lung expansion and relieve dyspnea. As the
condition improves I will let the patient adopt any position of comfort to promote rest.
I will remove any tight clothing on the patient and around the chest and neck to
prevent airway obstruction. In acute phase, I will change patient‘s position two hourly
to prevent development of pressure sores. I will administer bronchodilators as
prescribed to paten airway. I will teach the patient on breathing exercises, like deep
breathes to promote full lung expansion. I will provide a chair or a bed with a back rest
to help patient assume a prop-up position to enable full lung expansion.

MONITORING FOR PROGRESS/OBSERVATION

I will do vital sign such as blood, pressure, respirations, to act as the base line data in
order to know if the condition is improving or deteriorating. I will observe for
wheezing, nasal fairing and use of accessory muscles in breathing to know if the
condition is improving or deteriorating. I will monitor for psychic state of the patient
in order to give appropriate health education. I will observe for cyanosis to monitor
improvement and give oxygen therapy when necessary. I will observe for Dyspnea, if
present prop up the patient to promote lung expansion and relieve dyspnea. I will
observe the patient‘s facial expressions to detect pain and administer prescribed
analgesics like paracetamol. I will observe the feeding pattern of my patient and take
measures like giving small frequent meals to promote appetite. I will observe the
sputum for color, amount and consistency to detect hemoptysis and report the
physician

PSYCHOLOGICAL CARE

I will assess the knowledge of the patient on the condition for baseline. In simple and
clear terms, I will explain the disease process in order to raise the knowledge levels
and thereby alley anxiety. I will encourage the patient to ask questions and answer
accordingly, to raise the knowledge levels and thereby alley anxiety. I will explain all
procedures to the patient and relatives to alley anxiety and promote cooperation. I will
involve the loved ones and patient in his care in order for the patient and relatives not
to feel neglected. I will provide diversional therapy in order to shift the patient‘s mind
from the hospital routine and his condition. I will involve him in planning of his own
care in order for him not to feel left out. I will assure the patient and relatives of the
care being given to instill hope of recovery.

MEDICATION

I will aadminister prescribed analgesic like paracetamol at the right time to alleviate
pain and promote rest. I will administer prescribed bronchodilators like Aminophylline
to promote quick recovery. I will ensure that the drugs are swallowed in my presence
to promote recovery.

NUTRITION AND FLUIDS

I will provide locally available energy giving foods, like Nshima to provide the energy
needed for the metabolic processes. I will provide protein rich foods like fish and
beans to promote replacement of worn out tissues. I will give vegetables and fruits to
boost the immunity. I will provide a lot of oral fluids to prevent dehydration due to
excessive sweating. I will serve small frequent meals to promote appetite. I will advise
the patient to regular mouth washes in order to promote appetite.

REST AND SLEEP

I will nurse the patient in a quiet unit for patient‘s rest. I will play the radio if there is
any available in the ward, at low volume to promote rest. I will do related procedures
in blocks to promote rest. I will administer prescribed analgesics to relieve pain and
promote rest

EXERCISES

I will encourage the patient to do deep breathing exercises in order to promote lung
expansion. I will encourage early ambulation as soon the patient‘s condition improves
in order to prevent deep vein thrombosis and other complications of immobility. I will
advise the patient to avoid strenuous exercises which can cause an attack

HEALTH EDUCATION

I will advise the patient to thoroughly dust the room to prevent triggering factors like
dust mites. I will advise the patient to identify allergens in order to prevent frequent
attacks. I will educate the patient‘s significant about first aid measures during an attack
for intervention and prevention of complications. I will educate the patient on the
importance of regular hospital reviews to monitor progress of recovery. I will advise
the patient to continue with the prescribed treatment on order to achieve full recovery.
I will educate the patient on the management of stressors to prevent attacks. I will
advise the patient to avoid over crowded places in order to prevent respiratory tract
infections which can predispose to an asthmatic attack. I will advise my patient to
avoid smoking in order to prevent attacks. I will advise the patient to always keep
warm in order to prevent frequency of attacks.

COMPLICATIONS OF ASTHMA

 Respiratory acidosis as a result of insufficient gas exchange which leads to blood

having increased carbon dioxide
 Respiratory collapse as a result of failure of the lungs to facilitate normal
oxygenation
  Secondary bacterial infections due to accumulation of mucus in the lungs and
bronchioles which is a culture media for bacterial growth
 Pneumothorax because of increased airway pressure or as a result of mechanical
ventilation leading to rupture of alveoli resulting to collection of air in the pleural
cavity
 Emphysema as a result of permanent damage to the inner walls of the lungs' air
sacs (alveoli) thereby reducing the surface area available for gas exchange
 Status asthmaticus is a more aggressive type of Asthma with frequent attacks
and responds poorly to treatment
 Heart failure the cardiac output is increased during an attack in order for the
heart to compensate the metabolic demand of the body which will eventually lead
to caseation of cardiac activities

QUESTIONS ON ASTHMA

Mr Gideon Bwalya, a 26 year old university student in the school of humanities has
a history of bronchial asthma and is admitted to your ward with status asthmaticus.
He is supposed to write his final examination in a weeks time.

A. Draw a well labeled diagram of the respiratory tree. 15%

B. Describe the pathophysiology of asthma 15%
C. Identify (5) five nursing problems that Mr. Bwalya will present with and
using a nursing care plan, describe the care you would give to address the
identified problems. 50%
D. Discuss (5) five points you will include in your Information. Education and
Communication to Mr. Bwalya on prevention of asthmatic attack.
20%

LIVER CIRRHOSIS
Cirrhosis is a serious degenerative disease that occurs when healthy cells in
the liver are damaged and replaced by scar tissue, usually as a result of alcohol
abuse or chronic hepatitis. As liver cells give way to tough scar tissue, the organ loses
its ability to function properly. Severe damage can lead to liver failure and possibly
death.

FUNCTIONS OF THE LIVER

 Synthesis of plasma proteins e.g. Albumin.

 To store glycogen (from excess glucose)
 Synthesis of vitamins A,D,E and K
 Diminution- Removal of amino group from amino acid and converted to amonia.
 Production of bile salts.
 Detoxification of substances such as drugs and alcohol.
 Production of fibrinogen and prothrombin necessary for clotting
 Production of certain immunoglobulins which are part of the immune system.

LIVER CIRRHOSIS

DEFINITION
 It is a chronic progressive disease of the liver in which there is an extensive
damage to the liver parenchyma cells which later heal by fibrosis impeding the
vascular flow leading to liver failure functioning.
 It is a chronic progressive disease of the liver characterised by diffuse destruction
and regeneration of hepatic parenchymal cells
 Cirrhosis is a complication of liver disease that involves loss of liver cells and
irreversible scarring of the liver (Dennis L, 2016).
 It is a diffuse process characterized by fibrosis and the conversion of normal liver
architecture into structurally abnormal nodules.
TYPES OF LIVER CIRRHOSIS
1. Laennec’s cirrhosis (alcoholic, nutritional or portal cirrhosis)
 Stems from excessive alcohol intake leading to fat accumulation in liver cells
resulting to wide spread scar formation through out the liver.
2. Post-necrotic cirrhosis
 A complication of viral, liver toxins or hepatitis leading to broad bands of scar
tissue within the liver.
3. Biliary cirrhosis
 Associated with chronic biliary obstruction and infection leading to diffuse
fibrosis of the liver.
4. Cardiac cirrhosis
 Associated with protracted venous congestion in the liver caused by right
ventricular failure.
 This cause cellular necrosis due to poor cellular nutrition, hypoxia and inadequate
blood flow and scar tissue forms on healing resulting to malfunctioning of the
liver.
CAUSES/PREDISPOSES
 Excessive Alcohol intake
Toxins, including alcohol, are broken down by the liver. However, if the amount of
alcohol is too high, the liver will be overworked, and liver cells can eventually become
damaged. Heavy drinking needs to be sustained for at least 10 years for cirrhosis to
develop.
 Hepatitis
Hepatitis C, a blood-borne infection, can damage the liver and eventually lead to
cirrhosis. Cirrhosis can also be caused by hepatitis B and D.
 Non-alcoholic steatohepatitis (NASH)
NASH, in its early stages, begins with the accumulation of too much fat in the liver.
The fat causes inflammation and scarring, resulting in possible cirrhosis later on.
NASH is more likely to occur in people who are obese, diabetes patients, those with
high fat levels in the blood, and people with high blood pressure.
  Blockage of the bile ducts
Some conditions and diseases, such as cancer of the bile ducts, or cancer of the
pancreas, can block the bile ducts, increasing the risk of cirrhosis.
Other diseases and conditions that can contribute to cirrhosis include:
 cystic fibrosis
 primary sclerosing cholangitis, or hardening and scarring of the bile ducts
 schistosomiasis, a parasite commonly found in some developing countries.

PATHOPHYSIOLOGY
Cirrhosis of the liver is a chronic disease that causes cell destruction and fibrosis
(scarring) of hepatic tissues. Fibrosis alters normal liver structure and vasculature,
impairing blood and lymph flow and resulting in hepatic insufficiency and
hypertension in the portal vein.
In this disease the lobes of the liver are covered with fibrous tissue, the parenchyma
degenerates and the lobes are infiltrated with fat. Gluconeogenesis, detoxification of
drugs and alcohol, bilirubin metabolism, vitamin absorption, GI function, hormonal
metabolism and other functions of the liver deteriorate. Blood flow through the liver is
obstructed, causing back pressure and leading to portal hypertension and oesophageal
varices. sUnless the cause of the disease is removed, hepatic coma, GI haemorrhage
and kidney failure may occur.s

CLINICAL FEATURES
 Dyspepsia - Disturbed carbohydrate and fat metabolism.
 Flatulence - Due to disturbed metabolism.
 Vomiting and nausea - Due to reduced carbohydrate blood contents, muscle
wasting and general debilitation.
 Anorexia - Due to reduced carbohydrate blood contents, muscle wasting and
general debilitation.
 Diarrhoea or constipation - Disturbed metabolism of food.
  Pain and heavy feeling in the right upper quadrant or epigastrium which is as a
result of swelling and stretching of the liver capsule, spasms of the biliary ducts
and vascular spasms.
 Spider Angiomas - these are small dilated blood vessels with a bright red centre
and spiderlike branches commonly seen on the nose, cheeks, upper trunk, neck
and shoulder.
 Palmar Erythema - red areas on the palms of the hands.
 These are due to elevation in circulating oestrogen because the liver cannot
metabolise hormone.
 Ascites due to portal hypertension and change in osmotic pressure in the liver
blood vessels.
 The changes in the formation and absorption of hepatic lymph also leads to
ascites.
 Alterations in the metabolism of salt and water by the kidneys equally cause
ascites.
 Pruritis as a result of elevated bilirubin. Hence, itching may lead to thickening
and darkening of the skin.
 Anaemia as a result of gastrointestinal bleeding, haemolysis secondary to
hypersplenism or nutritional deficiencies of folic acid and Vit. B12.
 Testicular atrophy/Impotence/Loss of libido - due to inability of liver to
metabolise oestrogen.
 Jaundice due to changes in the liver functions and compression of bile ducts by
connective tissue overgrowth.
 Also it is due to decreased ability of the liver to conjugate and excrete bilirubin.
 Pallor which is due to inadequate red blood cell production and survival, although
poor diet and bleeding are also responsible.

COMPLICATIONS
  Hepatic encephalopathy(coma): Due to ammonia entering systemic circulation
due to failure of the liver for diminution affecting the brain.
 Portal hypertension: Obstruction to normal flow of blood through the portal
system results in portal hypertension.
 Oesophageal varices: A complex of tortuous veins at the lower end of the
oesophagus enlarged and swollen as a result of portal hypertension.
 Ascitis: Due to accumulation of fluids in peritoneal cavity due to portal
permeability.
 Bleeding tendencies: Due to reduced fibrinogen.
 Testicular atrophy & gynaecomastia: Due to increased conversion of androgens
to estrogens increase levels in blood.
 Renal failure:
 Heart failure:
 Cancer of the liver:
MANAGEMENT
AIMS
 To prevent infection
 To prevent further liver damage
 To maintain nutritional status
 To prevent complications such as portal hypertension
History Taking
 I will do history taking which will reveal risk factors (such as alcoholism) that
warrant screening for conditions such as hepatitis.
Physiscal Examination:
 I will do physical examination which on palpation will confirm hepatomegally.
 I will do physical examination which on inspection will reveal, jaundice, pallar
Investigations to confirm the Diagnosis:
 Liver Biopsy: Detects destruction and fibrosis of hepatic tissue.
  Liver scan: (Computed Tomography - CT) - this demonstrate liver size, shape
and to some extent function as the isotopes used are selectively extracted by the
liver.
 Ultra-sonographic Imaging: for biliary obstruction.
 Blood for: - LFT, Blood urea nitrogen, Decreased fibrinogen levels, serum,
albumin and platelets, Prothrombin time prolonged.
TREATMENT
The management of the patient with liver cirrhosis is usually based on the presenting
symptoms;
There is no specific treatment except for symptomatic:
 Bed rest
 Diuretics to relieve ascites. E.g. Frusemide 80 - 160 mg
 Restrict all nephrotoxic drugs such as methyldopa
Furosemide (Lasix) 40mg PO max 120mg/24hrs can reduce or eliminate the edema
and ascites in most patients.
 Side Effects: hypokalaemia, hyponatremia dehydration.
 Drug to be given with slow K to prevent hypokalaemia
Nursing implications: monitor the function of the kidneys by measuring blood levels
of blood urea nitrogen (BUN) and creatinine to determine if too much diuretic is being
use.
Propranolol (Inderal), a beta blocker, is effective in lowering pressure in the portal
vein and is used to prevent initial bleeding and re-bleeding from varices in patients
with cirrhosis.
 Dose: 20mg t.d.s PO
 Antibiotic if peritonitis is present. Cefotaxime 2g/ 6hrly + metronidazole
500mg/8hrly iv.
 Vitamin B, C, D, K supplements
 Daily weight check, aim for 0.5kg daily weight los
Lactulose(Cholac)-used to eliminate the ammonia from the blood into the bowel. Tap
water enemas may also be ordered to help the body eliminate the ammonia.
  Dose: 30-45mls t.i.d until stools are soft.
Neomycin to rid the GIT of normal flora thereby reduce ammonia production.
 4-12g PO q.i.d for 5days

NURSING MANAGEMENT
AIMS:
 To promote rest to reduce liver metabolic demands.
 To improve nutritional stats
 To give psychological care
 To provide skin care
 To reduce any risk of injury
 To give I.E.C
 To reduce Ascitis
 To prevent further damage to the liver
 To maintain adequate nutritional level
 To prevent patient from developing complications
 To prevent and control bleeding
 To control clinical manifestations.
USE AEPROPHENEMA

QUESTION ON LIVER CIRRHOSIS

Mr. Ilukena, a known cross border truck driver, is admitted to male medical ward with
a diagnosis of stage e2 liver cirrhosis
A. Define liver cirrhosis 5%
B. Mention (5) five causes of liver cirrhosis 10%
C. Describe (3) three types of liver cirrhosis 15%
D. Outline the management of Mr. Ilukena under the following headings
i. Medical management 15%
ii. Nursing management 35%
 E. Mention (5) points you would include in you Information, Education and
Communication to Mr. Ilukena and family on discharge.

TUBERCULOSIS
1. Mr. Musengo, a habitual cigarette smoker has been brought to your Male Medical
Ward with complaints of chest tightness and history of loss of appetite. A confirmatory
diagnosis of Pulmonary Tuberculosis is made.
a. Define Pulmonary Tuberculosis [5 marks]
b. List six (6) characteristics of a Tubercle Bacillus [6 marks]
c. State five (5) risk factors to developing Tuberculosis [10 marks]
d. Discuss the management of Mr. Musengo until discharge, under the following
headings;
i. Five (5) specific investigation you will carry out on Mr. Musengo to confirm the
diagnosis [15 marks]
ii. Nursing care to Mr. Musengo until discharge [40 marks]
e. As a Registered Nurse, outline clearly, six (6) prevention and control
measures of Tuberculosis in the community. [24 marks]

CEREBRAL VASCULAR ACCIDENT (STROKE)

DEFINITIONS
 Cerebral Vascular Accident is a sudden onset of neurological deficiencies arising
from impairment of cerebral blood flow which can be due to blockage or rapture
of an artery in the brain causing bleeding into the subarachnoid space.
 Cerebral Vascular Accident (CVA) is a sudden disruption in cerebral circulation
due to ischeamia or haemorrhage that result in both motor and sensory deficit.

ETIOLOGY OF STROKE
The etiology of Cerebral Vascular Accident is mainly anchored on disruption of
cerebral blood flow which gives rise to various motor and sensory neurological
deficiencies. The etiology of Cerebral Vascular Accident is classified into three (3)
categories;
1. Cerebral thrombosis (Ischaemic Stroke)
2. Cerebral embolism (Ischaemic Stroke)
3. Cerebral haemorrhage

CEREBRAL THROMBOSIS (ISCHAEMIC STROKE)

This is also called ischaemic stroke. It is the most common cause of CVA. The onset
of a stroke due to thrombosis may be gradual and usually occurs when the person is at
rest. It is common in middle-aged and elderly people. Conditions that lead to stasis of
blood flow in the brain may cause cerebral thrombosis are;
 Most often associated with atherosclerosis; the lumen of the blood vessel is
narrowed, impeding the flow of blood.
 The circulatory stasis leads to thrombus formation, occlusion of the vessel and
ischemia of an area of brain tissue.

Narrowing of the vessel and ensuing thrombosis may be due to outside pressure by a
space occupying lesion. An inadequate delivery of blood to the brain, secondary to
cardiac insufficiency, shock or reduce intravascular volume may also cause stasis and
subsequent thrombosis

CEREBRAL EMBOLISM (ISCHAEMIC STROKE)

This is the second leading cause of Cerebral Vascular Accident. This is seen more
frequently in younger persons. Symptoms occur suddenly and at any time of the day.
An emboli may be a blood clot, a clump of fat or tumour cells, or bacteria, or air which
has been carried by the circulation from another area of the body. Blood clots which
form an emboli may originate in the heart as a result of cardiac disease or in the
saphenous or femoral veins due to circulatory stasis. A fat emboli often follows a
fracture. An infected embolus may be associated with bacterial endocarditis. An
embolism formed of tumour cells may arise from a malignant neoplasm
CEREBRAL HAEMORAGE (HAEMORRHAGIC STROKE)
The onset is sudden and is of sudden onset and is usually associated with physical
activity or emotional stress. . Cerebral haemorrhage results in blood escaping from a
ruptured artery which can be due to aneurism . Haemorrhage may either be
intracerebral or subarachnoid. The predisposing factors/diseases are hypertension and
diabetes mellitus

RISK FACTORS TO STROKE

 Advanced age: those more than 50 years of age are at risk related to hardening of
blood vessels and loss of elasticity which leads to rupture
 People suffering hypertension: usually suffer from haemorrhagic stroke due to
increased intracranial pressure
 Cardiac diseases: especially coronary artery disorders which can lead to
ischaemic stroke
 Cardiac arrhythmia: is associated with stasis of blood which increase chances of
blood clots
 Diabetes mellitus: related to deposition of sugar on the endothelial lining of the
capillaries leading to arterial hardening and subsequently rupture.
 Those with history of CVA: are at higher risk of suffering a second episode
 Cigarette smoking: nicotine, a content of cigarette makes blood viscous, blood
easily clots and blocks arteries
  Diet: diet rich in fats predisposes one to atherosclerosis
 Women on long term hormonal contraceptives: hormones oestrogen and
progestin increase levels of clotting factors this leads to formation of thrombus
 History of arteriosclerosis: this can lead to haemorrhagic stroke secondary to
rupture of hardened blood vessels
 Lack of physical exercises: sedatary life styles leads to accumulation of fats
(Atherosclerosis)which can cause ischaemic stroke
 Obesity: obesity is associated with high chances of developing ischaemic or
haemorrhagic strokes due to fat deposition in the blood vessels (Atherosclerosis)

PATHOPHYSIOLOGY OF CEREBRAL VASCULAR ACCIDENT

The human brain requires blood supply for survival and to successfully perform its
cerebral functions. CVA comes as a result of disruption in the cerebral blood supply.
This disruption can occur as a result of;
 Blood vessel blockage
 Blood vessel rupture
In ischaemic stroke, cerebral blood flow is interrupted by blockage of cerebral artery.
In Transient Ischaemic Stroke (TIS), symptoms maybe of a gradual onset and may
resolve within 24 hours when the arterial blockage is relieved. In haemorrhagic stroke,
there is an increased intracranial pressure which can be either due to pre-existing
hypertension or narrowing of the cerebral artery by an atheroma. The clinical
manifestation is sudden with a poor prognosis. Clinical manifestation of Cerebral
Vascular Accident usually occurs suddenly. Cerebral hypoxia will result into many
cerebral deficiencies;
 Speech incapacities
 Unconsciousness
 Incontinence of urine and bowels
 Visual disturbance
 Paralysis
CLINICAL PICTURE OF CVA
Premonitory symptoms
 Persistent headache
 Dizziness
 Fleeting loss of consciousness or ‗black out‘
 Brief confusion and disorientation
 Blurring of vision in one or both eyes
 Stumbling of speech or ‗thickness‘ of the tongue
 Transient local sensory or motor deficits
 Loss of body posture/balance

Loss of consciousness
 The period of unconsciousness may vary from hours to days which may follow
coma
 Coma lasting longer than 24 to 36 hours presents a grave prognosis.
 A few patients experience only a clouding of consciousness and confusion.

Convulsive movements
 Immediate onset may be accompanied by convulsive movements which may be
local or general

Headache and vomiting

 If patient is conscious, he may complain of a severe headache due to increased
intracranial pressure.
 Vomiting may occur with the initial onset and may be recurring in the conscious
patient.

Motor and sensory deficits

 Hemiplegia is one of the most common effects.
  If conscious, the patient may experience dysphagia indicating paralysis of the
swallowing muscles.
 There may be some loss of sensation in some parts.
 The mouth shifts to one side
 Motor and sensory deficits in the limbs occur on the side of the body opposite to
the lesions

Speech defect
 There may be complete or partial loss of speech.
 Patient may not only be unable to communicate verbally but may manifest some
impairment in comprehension of either verbal or written communication.

Eye changes
 The eyes as well as the head tend to turn to the side of the lesion in the early stage;
later, the deviation may be reversed and the head and eyes are probably turned to
the side of the paralysis.
 The pupils may be uneven or constricted to ‗pin point size, the corneal and
papillary reflexes may be absent.
 On examination, the fundus may reveal papilledema due to increased intracranial
pressure.
 The conscious patient may indicate impaired vision, and there may be defective
movement of one or both eyes.

COMPLICATIONS OF STROKE
 Recurrence of subsequent stroke due to pre-existing risk factors
 Infection such as Encephalitis and Brain Abscess secondary to accumulation of
blood which may be a source of infection
 Permanent brain damage resulting into permanent brain damage manifesting
into hemiplegia
  Sensory impairment due to cerebral damage which may manifest in loss of
sensation like taste and sight
 Permanent motor deficits like failure to ambulate
 Visual impairment secondary to brain damage leading to blindness
 Permanent speech loss due to motor deficiencies
 Aspiration due to absence of cough reflexes which will lead into Aspiration
Pneumonia

MEDICAL MANAGEMENT OF STROKE

AIMS
 To identify the cause of stroke
 To mitigate the impact of stroke
 To correct the deformity
 To rehabilitate the client

DIAGNOSIS OF STROKE
Diagnosis is primarily based on;
 Observation of the clinical features, patient‘s history including known or observed
risk factors.
 Onset of symptoms
 History of hypertension, Heart diseases, first episodes of stroke
 Computed Tomography: scan may determine the location and type of CVA or
confirm the pathology, e.g. tumour
 Lumbar puncture: will reveal bloody cerebrospinal fluid with an accompanying
rise in pressure in cases of haemorrhage
 ECG: to exclude or confirm any cardiac causes, e.g. myocardial infarction and
atrial fibrillation
 Cerebral angiography: to detect arterial plague formation, occlusion, or stenosis,
and can locate arterial aneurysms.
  Carotid ultrasound: This test uses sound waves to create images of the blood
vessels in your neck.
 This test can help in determining if there is abnormal blood flow toward your
brain.
 Magnetic Resonance Imaging: an MRI can provide a more detailed picture of
the brain compared to CT scan.
 It is more sensitive than a CT scan in being able to detect a stroke.
 Echocardiogram: This imaging technique uses sound waves to create a picture of
your heart.
 It can help find the source of blood clots.
 Electrocardiogram: ECG is an electrical tracing of your heart.
 This will help to determine if an abnormal heart rhythm is the cause of a stroke.

TREATMENT FOR STROKE

Medical management commonly includes
 Physical rehabilitation
 Dietary modification
 Drug regimes

Drugs
 Anticonvulsants such as phenytoin or Phenobarbitone to treat or prevent seizures.
These may be crushed and given via nasal gastric tube.
 Stool softeners, such as senakot and enema to prevent straining as a result of
constipation, which may increase Increased Intracranial pressure
 Diet; low sodium, increased potassium tube feeding or total parenteral nutrition
 Intubation and mechanical ventilation may be required
 IV fluids of dextrose 2.5percent in ½ normal saline
 Corticosteroids such as Dexamethasone to minimise associated cerebral oedema.
 Analgesics such as codeine to relieve headache.
  Anticoagulants such as Heparin be used in cases of cerebral embolism to dissolve
the clot.
 Oxygen therapy given via mask nasal cannula.
 Endotracheal intubation can be performed for ventilation
 Antihypertensives such as nifedipine or moduretic.
 Mannitol to reduce cerebral oedema

NURSING CARE FOR STROKE

AIMS OF MANAGEMENT
 To prevent further brain damage or stroke
 To reduce risk factors
 To give supportive care
 To help patient regain functional independence

ADMISSION/ENVIRONMENT
In the intensive phase, I will nurse the patient in the intensive care unit or in the acute
bay, close to the nurse‘s station for close observations. I will nurse the patient in a
room with facilities for emergency care such as suction machine, oxygen supply, and
cardiac monitor for use when need arises. I will provide a tray containing a
thermometer, a sphygmomanometer, a second hand watch, a touch with batteries and
an air way by the bed side to be used for vital signs and neurological observations. I
will nurse the patient in a warm enough room to prevent chilling the patient. I will
cover the patient with warm linen to prevent hypothermia. I will nurse the patient in a
clean room by dump dusting to prevent nosocomial infection. I will nurse the patient
in a quiet room and also restrict visitations to promote rest.
AIRWAY, BREATHING & POSITION
While unconscious, I will place the patient in a semi-prone position to promote full
lung expansion. I will put the patient in lateral position to facilitate free drainage of
secretion. I will introduce a pharyngeal airway to permit unobstructed breathing. I will
suction off oral secretions to clear airway and facilitate breathing. I will administer
oxygen therapy by nasal catheter or mask to improve tissue perfusion. I will maintain
good alignment of the patient‘s head to avoid compression of the neck vessels for
example flexion may interfere with cerebral venous drainage, causing cerebral
congestion, bleeding from the lesion and increased intracranial pressure. I will remove
all tight clothing, especially around the neck and chest to facilitate full lung expansion
OBSERVATION
In the initial acute stage, I will monitor and record vital signs quarter and half hourly
to monitor prognosis. An abnormal elevation of the blood pressure, a decrease in the
pulse and slow or Cheyne-Stokes respirations may indicate increasing intracranial
pressure. I will check the size of both pupils and their reaction to light at 2 hourly for
changes, and the level of consciousness is noted. I will monitor the breathing patterns
to monitor progress of the condition as snoring may indicate airway obstruction. I will
inspect for oral airway patency and suction appropriately to promote adequate tissue
perfusion. I will ensure that all the resuscitative equipment are in good working
condition to respond to emergency. I will monitor levels of consciousness using a
Glasgow Coma scale to monitor prognosis. I will monitor intake and out output of
fluids and chart appropriately to monitor nutrition and prevent overload. I will monitor
the elimination patterns to rule out constipation and monitor bowel function. If patient
is unconscious, I will atheterise the patient and monitor urine output to rule out renal
failure.

NUTRITION AND FLUIDS

During the first 24 to 48 hours, I will administer fluids intravenously to prevent
dehydration. I will control the rate of flow and volume carefully to avoid increase of
intravascular volume and blood pressure. If coma is prolonged, or the patient has
considerable dysphagia, I will introduce nasogastric feeding to provide sufficient
nutrients. I will accurately record the patient‘s fluid intake and output in the acute
phase to avoid fluid volume overload. When consciousness is regained, I will test the
swallowing reflex before giving any fluids orally to ascertain whether the patient is
able to take food orally. If the patient can swallow, I will give a soft diet and
progressively increase to a full, balanced diet as soon as tolerated to prevent
malnutrition. I will encourage the patient to feed himself as soon as possible to
establish independence. If one side of the face is paralyzed, I will place food in the
opposite side of the mouth to make swallowing easier. I will give mouth care
following the meal to remove retained food particles from the weak side to prevent
aspiration and formation of sores.
SKIN CARE
I will provide an air mattress or sheep skin to protect pressure areas. I will do pressure
area care to stimulate circulation. While confined to bed, I will turn the patient every 2
hours to prevent the formation pressure sores.
PSYCHOLOGICAL CARE
I will assess the psychological state of the patient for baseline. I will allow patient, if
possible and relatives to ventilate their fears by asking questions and answer
accordingly, but never give false hopes to increase knowledge levels. I will explain the
causes of urine and bowel incontinence if present and other signs and symptoms to
allay anxiety. I will involve the patient, if possible and relatives in the management of
patient to promote independence. Using simple and clear language, I will explain the
disease process to both patient and relatives to allay anxiety. I will explain the need for
the procedures being done on the patient to both patient and relatives to gain trust and
cooperation. I will allow family, friends and clergy to visit patient for social and
spiritual support.
ELIMINATION
During the acute phase, I will insert an indwelling catheter to prevent skin irritation by
involuntary voiding and to measure urinary output accurately and to monitor renal
function. When catheter is removed, I will place the patient on the bedpan or toilet at
frequent, regular intervals, to gradually decrease the patient‘s discouragement. Lack
of activity may lead to constipation therefore, I will give prescribed laxatives
constipation develops
REHABILITATION
I will involve a physiotherapist to rehabilitate the patient as early as possible to prevent
permanent disabilities. I will empower the patient‘s family by giving full information
about the condition to create awareness. I will do passive exercises on the patient
whenever attending to him to ensue good body alignment and prevent the development
of muscle atrophy, contractures and reduced range of motion due to immobility. I will
involve the physiotherapy department so that they start appropriate exercises which
will benefit the patient to prevent further disability. I will encourage the patient to
develop interests and worthwhile hobbies and to gradually assume responsibility for
some household chores within his physical and intellectual capacity.
HOME-BASED REHABILITATION
I will intensify home based care, especially after discharge to ensure that the patient is
coping effectively. During home based care visit, I will monitor the patient for
treatment compliance, coping mechanisms, dietary modification and avoidance of risk
factors to prevent recurrence. I will involve the physiotherapy to teach on how to use
crutches for mobility. I will link the patient to community social groups for help. I will
link the patient to other line ministries like social welfare, world vision, for financial
support.
QUESTION ON STROKE

2. Mr. Dumbo, a 65 year old peasant farmer is rushed to your health facility in
unconsciousness state. Further history reveals that for the past 3 days now, Mr. Dumbo
has been experiencing severe headache and altered levels of consciousness with
episodes of confusion and disorientation. A confirmatory diagnosis of Cerebral
Vascular Accident (Stroke) is arrived at.
a. Define Cerebral Vascular Accident [5 marks]
b. Explain three (3) types of stroke [15 marks]
c. With the aid of a clear diagram of the cross section of the brain, show the flow of
the Cerebral Spinal Fluids (CSF) [20 marks]
d. Identify five (5) nursing problems which Mr. Dumbo is likely to experience during
hospitalization and using a nursing care plan, discuss how you would manage them [50
marks]
e. List five (5) rehabilitative measures of Mr. Dumbo [10 marks]

SECTION D: ESSAY QUESTIONS

ANSWER TWO QUESTIONS ONLY. QUESTION ONE (1) IS COMPULSORY

1. Mr. Paddy Bwalya, a 50 years old man from chiwempala township is

admitted in male medical ward with the diagnosis of Hepatic coma
a) i. Define hepatic coma 5%

This is loss of the brain function following failure of the liver to excrete excess toxins
from the blood and is characterized by fever and coma

ii. Draw a well labelled diagram of the liver 20%

b)Outline two (2) signs and symptoms that Mr. Paddy may present with,
in each of the following stage:
I. Prodrome stage 5%
Insomnia
Short attention span
II. Comatose stage 5%
Headache, confusion, coma
 c) Describe the management of Mr. Bwalya from the time of admission
until discharge from the hospital under the following headings:
I. Medical management 15%
Investigations:
 History taking will reveal risks such as prolonged and excessive alcohol
intake.
 Physical examination will reveal signs and symptoms like jaundice, ascites,
and pain when palpating the liver.
 Liver function tests will show raised enzyme levels signaling stress of the
liver
 Complete blood count will show raised leukocyte levels. RBCs and clotting
factors may be reduced.
 MRI/CT scan will reveal changes in the contour and size of the liver.

TREATMENT

 Give oxygen therapy in breathing difficulties

 Antibiotics: Gentamycin and benzylpenicillin IV to treat the infection.
 Lactulose 30 mLs orally, daily or twice daily to enable the liver to rest
 Blood transfusion in cases of severe anaemia
 Diet: Give vegetable proteins instead of animal protein, administered via
nasogastric tube. Reduce fat intake
 Increase carbohydrate intake
 Give intravenous analgesics e.g. diclofenac 75mg BD to relieve pain

NURSING CARE 35%

Aims:

 To prevent brain damage.

 To reduce risk factors
 To give supportive care
 To help the patient regain functional independence
ENVIRONMENT

I will nurse the patient in the intensive care unit or acute bay close to the nurse‘s
station for close observation. I will nurse the patient in a unit with facilities for
emergency care such as; suction machine, oxygen supply, and cardiac monitor. here
should also be a tray containing; a thermometer, sphygmomanometer, a second hand
watch, a touch with batteries and airway should be left by the bedside for vital signs
and neurological assessments.

POSITION

While unconscious, I will place the patient in the semi-prone or lateral position to
facilitate breathing and prevent aspiration of mucus and vomitus. I will introduce a
pharyngeal airway to permit unobstructed breathing. I will maintain good alignment of
the head to avoid compression of the neck vessels. I will place side rails on the bed to
prevent the patient from falling from the bed due to disorientation.

OBSERVATIONS

In the initial stages, I will monitor vital signs and record half hourly to detect any
deviation from normal. A progressive rise in temperature to levels of hyperpyrexia is
an unfavorable sign indicating an interference with the body temperature regulating
center and loss of regulating reflex. I will monitor The signs of both pupils and their
reaction to light and checked at 2 hourly intervals for changes and levels of
consciousness.

FLUIDS & NUTRITION

During the first 24 to 48 hours, I will administer fluids intravenously to prevent

dehydration. I will carefully control the rate of flow and volume to avoid increase in
intravascular volume and blood [Link] coma is prolonged or the patient has
considerable dysphagia, I will introduce nasogastric feeding to provide sufficient
nutrients. Accurate record of the patient‘s fluid intake and output in the acute phase is
important. When consciousness is regained, I will test the swallowing reflex before
giving any fluids orally to ascertain whether the patient can swallow. If the patient can
swallow, I will give a light meal progressively increase to a full balanced diet as soon
as tolerated to prevent malnutrition. I will encourage the patient to feed himself as
soon as possible to establish independence. If one side of the face is paralyzed, I will
place food on the opposite side of the mouth to make swallowing easier. I will give
mouth care following the meal to remove retained food particles from the weak side to
prevent aspiration and formation of sores.

HYGIENE SKIN CARE

During the acute stage, I will give mouth care every 2 – 3 hours with a mild antiseptic
mouth wash to prevent accumulation of secretions and prevent infection such as
parotitis. I will bath the patient daily in bed to promote comfort and blood circulation.
I will apply petroleum jelly or lotion to prevent skin excoliation.

PSYCHOLOGICAL CARE

I will clearly give an explanation of what happened to him and what is going to be
done for him when the patient gains consciousness to alley anxiety and gain his
cooperation. I will allow the family members to visit him when he gains consciousness
so that he does not feel abandoned. I will take time to converse with the patient as a
normal person, thus assure him that I am interested in him and his health

ELIMINATION:

During the acute phase, I will insert an indwelling catheter to avoid possibility of
urethral and bladder irritation and development of infection. When the catheter is
removed, I will place the patient on a bedpan or toilet at frequent, regular intervals to
wean him from use of catheter.

ADVISE/IEC

 Avoid excess alcohol intake

 Avoid and reduce excess fat intake
 Maintain a good weight
 Advise patient to get vaccinated against hepatitis
 Advise prompt treatment of liver diseases
d. State five (5) points that could be included in the information, Education and
communication to Mr. Bwalya. 15%

 Avoid excess alcohol intake

 Avoid and reduce excess fat intake
 Maintain a good weight
 Advise patient to get vaccinated against hepatitis
 Advise prompt treatment of liver diseases.

2. Mrs. Mwale aged 25 years is admitted to a female medical ward with

symptoms of anemia. The examining physician gives a provisional
diagnosis of hookworm infestation.
a. Name two (2) species of hookworm. (4%)
i. Ankylostoma duodende
ii. Nector Americanus
b. State five (5) signs and symptoms of hookworm infestation.
 Ground itch at the site of entry of the infective larva.
 Weakness due to anemia and vomiting.
 Fever due to anemia.
 Coughing due to irritation as the worms are ascending the bronchial
tree.
 Asthmatic wheezing due to block of the airway.
 Craving for soil (pica) due to iron deficiency.
 Diarrhea due to irritation of the mucosa of the small intestine.
 Puffiness of the face due to low protein. Vomiting due to irritation as
the worms come up from the lungs to the esophagus.
 Palpitations due to anemia.
 Malena (blood in stool).
 Hypoproteanaemia due to protein sucking by the worms.
  Iron deficiency anemia due to sucking of blood by the worms
15%
c. With the aid of the diagram, describe the life cycle of hookworm.
30%

Man is the natural host of both worms. The adult worm live in the intestines and are
passed in the faeces. The eggs hatch in about 2-7 days in the faeces which has been left
lying in shady warm sandy oil. The actively motile larvae are produced which reach
the surface and infect man by penetrating the skin, usually on the feet. By the 3rd day
after penetration the larvae reach the lungs and escape eventually reaching the trachea.
The larvae are coughed up and swallowed and finally attached themselves to the
mucosa of the upper part of the small intestine 3-4 days after the infection. The adults
absorb blood from the intestinal tissues. The amount of blood loss from the host
depends on the number of worms.

Mention three (3) drugs used in the treatment of hookworm indicating it’s
Generic name, Brand name, Drug dosage, Frequency, Drug – action, Two (2) side
effects and One Nursing Implication.
33%

f. Mebendazole ( vermox) 2%

Mechanism of Action: Binding to tubulin, preventing its polymerization into

cytoskeletal microtubules
 (ii) Dosage: 100 mg BD x 3/7 3 days 2%

(iii) Side effects: 2% for any 2

 Abdominal pain
 Diarrhoea
 Iviticania
 Rash
 Erythema
iii. Nursing Implications 2%
 Ensure that drug is taken at the right time
 Educate patient that the drug can be chewed or swallowed with a small meal.
 Monitor side effects
 Not to be given to hypertensive patients
g. Pyrantel: ( combantrine) - 2%

Action; Paralyses worms and dislodges them from the GIT

Dosage: 5mg/KgBWT (Max:lg) given as a single dose - 2%

Side effects: 2%

 Anonexia
 Diarrhoea
 Headache
 Dizziness
Nursing Implication – 2%

 Weigh the patient & give right dose

 Monitor side effect.
h. LEVAMISOLE ( imidazothiazole)
Dose: 50mg every 8 hours for 3 days

Side Effects: Oral ulcerations, fever, and flu like signs

Nursing Implication: Store in a tightly closed light resistance container at room
temperature

d. Mention three (3) advantages and disadvantages of syndromic

management of STI 18%

ADVANTAGES

1. It focuses on common curable STIs such as: syphilis, gonorrhoea, chlamydia,

chancroid, Trichomoniasis and candidiasis.
2. It‘s appropriate for primary health care settings because it treats people who may
have more than one STI with the most effective drugs available.
3. It‗s able to treat multiple infections because usually, 6 out of every 10 STI patients
have two or more different infections at the same time.
4. It puts emphasis on rapid treatment thereby reliving patient‘s symptoms, helps
improve services so that patients will get effective treatment and will be more
comfortable using the service again.
5. It is easy for non-specialized health care workers to use flow charts to make a
diagnosis and treat patients.
6. Health care providers can use information given by a patient to help assess the
level of risk, help make a diagnosis and as a starting point for patient education
7. It lowers the risk of complications as the patient is treated as a whole.
8. It reduces transmission of etiological agents
9. It reduces the probability of incorrect clinical diagnosis
10. In many cases, referral is not needed
11. It improves accuracy especially when supplemented with simple laboratory
test such as RPR and minima clinical signs (WHO, 2005; Soliman, 2006)

DISADVANTAGES

1. The syndromic approach does not use a service provider‘s clinical skills and
experience like the clinical approach does.
 2. The approach does not seem scientific enough as the algorithms (flow charts)
used in syndromic management are based on epidemiological studies conducted
throughout the industrialized and developing world.
3. If a client is not cured of symptoms by the initial treatment, the client is less
likely to return for treatment to the clinic for additional treatment or may even
seek self-inappropriate alternatives or self-treatment.
4. Clients who become asymptomatic or are not treated for other potential causes
of the syndrome immediately may continue to spread the infection to partners.
5. The syndromic approach wastes money because a lot of drugs are used in
treating clients for infections they may not have.

SEVERE MALARIA

a. Define Malaria 5%
This is a protozoan infection of red blood cells transmitted by the bite of a blood
feeding Female anopheles mosquito that leaves plasmodia.

b. With the aid of a well labelled diagram describe the life cycle of plasmodium in
man and female anopholes 20%
Draw a well labelled diagram of the life cycle of plasmodium both in man and
mosquito and ONLY describe the life cycle in man.

LIFE CYCLE OF PLASMODIUM

ZYGOTE FORMED OOKINETE IN

STOMACH

GAMETOCYTES
TAKEN UP OOCYST

IN
 ANOPHELINE
MOSQUITO
SPOROCOITES IN
BLOOD MEAL SALIVARY GLANDS

GAMETOCYTES
FORMED
IN BLOOD MEAL

MAN
MEROZOITES
IN BLOOD

Sporozoites
in blood

MEROZOITES
MEROZOITES IN IN LIVER
RED BLOOD CELLS
CELLS

(SCHIZOGONY

c. Discuss the management until discharge 50%

Objectives
i. To prevent infection
ii. To promote quick recovery
iii. To prevent complications such as anaemia
iv. To promote comfort

Investigations

i. Blood slide for malaria parasites every other day

ii. Blood for hemoglobin estimation
iii. Blood for random blood sugar to rule out hypoglycemia
Medical Treatment

i. Quinine
- Dose: 20mg/kg bwt stat, then 10mg/kg body weight 8 hrly x 3 doses. After three
(3) doses, continue with tab quinine 600 mg tds x 5-7/7
- Side effects: Tinnitus, headache, hot and flush skin, nausea visual disturbances,
confusion etc.
- Nursing implications: Give the drug with 5% dextrose to prevent hypoglycemia.
Explain to the patient about the side effects so that he may anticipate the side
effects hence not taken by surprise.
ii. Paracetamol
- Dose: 500mg – 1000mg tds x 3/7
- Side effects: Liver damage
- Nursing complication: It should not be used for a long period of time.

iii. Ferrous sulphate

- Dose: 200 mg tds x 14/7 to provide the iron, an essential component for
haemoglobin formation
- Side effects: Nausea epigastic para, vomiting, constipate dark stool.
- Nursing Implications: Observe for GIT upset and discontinue the drug if severe.
Give drug with food or juice but not with milk or acids.

iv. Folic acid:

- Dose: 5mg od x 14/7 to promote RBC maturation.

Nursing Care
Environment
- Admit the patient in the acute bay for easy observation
- Ensure that the environment is well ventilated and clean to prevent cross infection
- Ensure that the environment has all the required resuscitative equipment in case
she goes into coma.
Position

- Allow him to adopt the position he is comfortable with to promote comfort and
rest.
- If he is on come ensure a two (2) hourly turning schedule is followed to prevent the
development of pressure sores.

Observation

- Check vital signs observations on admission to cut as base time data in the
management of the patient.
- Thereafter, check vital signs 4 hourly to monitor the progress of the condition.
- If the temperature is high, this usually should be the case remove extra linen, open
bear by windows and administer the prescribed analgesic.
- Check the blood slide every other day to help you monitor the progress in the
management of the patient.
- Observe how the patient is feeding, so that you may intervene appropriately to
improve and maintain good improve and vomiting observe the patient for signs
have and maintain good nutritional status.
- If the patient has diarrhea and vomiting observe the patient for signs of dehydration
and intervene appropriately.
- Observe the side effects of some drugs like quinine. If they are worse report to the
physician and reduce the dose. Also encourage patient to be taking a lot of juice
and water to minimize some of the side effects like renal failure and hypoglycemia.
- Observe the general psychological aspect of the patient to help you intervene
appropriately.

Psychological Care

- Allow the patient and significant others to ventilate their concerns so that you
many act appropriately.
- Be gentle and confident as you are caring for this patient so that he also has
confidence in you that you are going to help him.
- Explain each and every procedure you are doing on her so that you can gain
cooperation in her care.
- Explain to the patient and significant others that the healthcare team are doing
everything possible to help his recovery.
- Explain to her that the side effects he may be experiencing will stop as soon as he
finishes the treatment.
- Allow the significant others to be the bed side to promote the sense of safety.

Control of fevers

- Check the patient‘s temperature 4 hourly to help you know how to improve
appropriately.
- If the temperature is high remove extra linen to promote air circulation and
preparation to reduce high temperature.
- Open near by windows to promote air circulate
- Provide an electrical fan to promote air circulation
- Do tepid sponging to help out the patient
- Give the prescribed antipyretics e.g. paracetamol.

Nutrition

- In the acute phase when the patient is vomiting and has diarrhea the patient
should be given iv fluids to improve and maintain the nutritional status.
- As soon as the patient stops vomiting light diet such as porridge with groundnuts
to provide the nutritional status.
- Allow the patient to decide what fluids and food he wants to promote dietary
intake.
- Serve meals in small frequent amounts following patient‘s reference.
- Keep the environment clean and free from bad dour to avoid the patient losing
appetite.
- Do oral care before and after meals to stimulate the taste bands and remove food
particles and to prevent halitosis which may lead to anorexia.

Rest and comfort

 - Do nursing procedures in block of times to allow the patient to have adequate
time to rest.
- Remove noise on the ward to avoid disturbing the patients.

Hygiene

- Do daily bed making to promote rest and comfort

- Change linen when ever soiled or necessary.
- Assist the patient to have a daily big bath to promote blood circulation

Exercises

- Assist the patient to do both passive and active exercises to promote blood
circulate and maintain good body muscle tone.
- If patient is unable to work change position every 2-4 hours to prevent bed sores.

d. Explain five (5) points you would include in the IEC to

workers and superiors to promote occupational health 20%
i. During night duty shifts workers should put on long clothes that can cover
both upper and lower limbs
ii. The workers should be provided with mosquito repellants to apply on the
their faces and hands during night shifts.
iii. Advise the superiors to ensure that the premises where the workers are free of
tall grass and water detches are covered to reduce breeding of mosquitoes.
iv. Advise the employers to ensure that sick workers are given early referral to
health centres to prevent complicated or severe malaria cares.
v. Advise the employers to give workers adequate time to recover so that the
prescribed drugs are taken as ordered.
vi. Discourage workers sharing prescribed drugs
vii. Encourage workers to take their family members to the hospital when ever
they start presenting signs of malaria
viii. Promote and encourage presumptive treatment of malaria
 ix. Encourage use of window protectors to prevent entry of mosquitoes
x. Early closure of doors and windows at home.

SECTION A: GENERAL MEDICINE AND MEDICAL NURSING.

Answer TWO (2) QUESTIONS ONLY from this section.
1. Mr. Jeremia Jere an employee for Konkola Coppermine Plc is admitted to your
medical ward with history of dry cough and chest pains. On examination, a
diagnosis of lobar pneumonia is made.
a. State five (5) other signs and symptoms of lobar pneumonia other than the ones
mentioned above 15%
b. Mention five (5) causes of pneumonia 10%
c. Describe the management of Mr. Jere while in hospital till discharge 50%
d. Explain five (5) complications of pneumonia. 25%

2. Mrs. Mulozi Kalyalya from Dundumwezi, 44years old married with six (6)
children is a Director of Programmes at a private school. She is admitted to a
medical ward with a provisional diagnosis of secondary hypertension.

a. i. Define hypertension 5%
ii. List five (5) signs and symptoms of hypertension 10%
b. Explain two (2) classifications of hypertension 10%
c. Describe the management of Mrs. Kalyalya from admission till discharge 50%
d. Explain five (5) complications Mrs. Kalyalya may develop. 25%

3. Mrs. Alaidah Njovu aged 37 years; a housewife has been brought to your ward
with a complaint of haematemesis. A provisional diagnosis of peptic ulcer disease
has been made.

a. Define peptic ulcers 5%

b. Explain five (5) signs and symptoms of peptic ulcers apart from the one mentioned
above 20%
c. Describe the management you would give Mrs. Njovu during hospitalization 50%
d. Explain five (5) complications Mrs. Njovu may develop due to peptic ulcers 25%

SECTION B – TROPICAL DISEASES

Answer ONLY ONE (1) QUESTION from this section

4. Sililo Matalilo has been brought to your ward and after investigations a
diagnosis of typhoid fever is made.
a. Define typhoid fever. 5%
b. State five (5) specific signs and symptoms of typhoid fever. 20%
c. Describe the management of Sililo from admission till discharge. 50%
d. Discuss five (5) points you would include in your Information, Education and
Communication (IEC) to Sililo and family on prevention of typhoid 25%

5. Mr. Nalumino Mate a 48 year old man from Lwaano Valley is admitted to your
ward with history of headache and vomiting. He is confirmed to have malaria.
a. Draw the lifecycle of malaria. 15%
b. State five (5) signs and symptoms of malaria 15%
c. Describe the management of Mr. Mate during hospitalization 50%
d. Outline five (5) control measures that the community in Lwangwa should take to
prevent malaria 20%

MARKING KEY FOR MEDICINE AND MEDICAL NURSING

MARKING KEY FOR QUESTION ONE (1): PNEUMONIA

1. Mr. Jeremia Jere a miner at from Konkola Coppermine Plc is admitted to your
medical ward with history a of dry cough and chest pains. On examination, a
diagnosis of lobar pneumonia is made.
a. State five (5) other signs and symptoms of lobar pneumonia other than those
mentioned above 15%
 b. Mention five (5) causes of pneumonia 10%
c. Describe the management of Mr. Jere while in hospital till discharge 50%
d. Explain five (5) complications of pneumonia. 25%

a. State five (5) other signs and symptoms of lobar pneumonia. (15%)
i. Nasal flaring due to poor ventilation and labored breathing
ii. Dyspnea due to poor ventilation as a result of inflammation in the lung
iii. Cyanosis due to hypoxia
iv. Chest pains (stabbing in nature) due to inflammation in the lung and pleura
v. Fever due to the presence of the infection and infection
vi. Intercostals retraction due to impaired ventilation
vii. Haemoptysis due to rapture of blood vessels
viii. Nausea and vomiting due to gastrointestinal tract involvement and disturbance
ix. Headache due to cerebral hypoxia resulting from inadequate air intake
x. General body malaise due to tissue hypoxia
xi. Anorexia due to the inflammatory process general effects of the infection process
xii. Joint or muscle pains due to tissue hypoxia

b. Mention five (5) causes of pneumonia (10%)

 Chronic bronchitis
 Viral infections such as measles which affects the respiratory tract and also reduces
the immunity
 Inhalation of foreign material into the respiratory tract which later descends into the
lower respiratory tract causing pneumonia
 Obstruction of the respiratory tract by growths e.g. cancer which leads to retention
of fluids and secretions in the lung tissue this fluid eventually becomes infected
 Prolonged to cold which irritate the respiratory tract and reduces the ability of cilia
to expel the foreign bodies including micro organisms. This raises the risk of micro
organisms invading the respiratory tract
c. Describe the management of Mr. Jere while in hospital till discharge. (50%)
Aims; 2%
 To relieve dyspnoea
 To promote quick recovery
 To prevent septicemia

INVESTIGATIONS at least 5 for 5%

- History from the patient may reveal stabbing chest pain made worse by deep
breathing or cough
- On auscultation there will be reduced air entry and crackling sound (rales) in the
affected lung.
- On percussion there will be dullness on the affected side due to consolidation of the
underlying lung
- Sputum for microscopy culture and sensitivity will demonstrate the causative agent
and the specific drug to be used.
- White blood cell count will show elevated leukocyte count.
- Blood culture can show the causative agent if bactraemia is present
- Computerized tomography will show pneumonia even where chest X ray can not
- Chest X ray will show areas of opacity( seen as white patches)

TREATMENT 10% for route, dose, frequency, s/e, nursing/implications

 Bacterial infection give antibiotics e.g. Crystalline penicillin
 Analgesics and antipyretics like panadol
 Oxygen therapy to counteract hypoxia
 If the infection was fungal anti fungal have to be used e.g. Fluconazole 100mg bd 7-
14 days
 Broncho dilators e.g. ventolin 2-4mg tid

NURSING CARE 35%

Environment
 Patient will be nursed in a well ventilated room to prevent other respiratory tract
infection
 Patient will be nursed in a well lit room for easy observation and for orientation to
time and place
 Patient will be nursed in a general ward but reverse barrier nursing will be used to
prevent acquisition of nosocomial infections
 Will include the oxygen giving apparatus for use because patient is dyspnic
 I will include the drip stand in the room for IV when need arises

Position
 Patient will be nursed in fowlers position to promote lung expansion and relieve
dyspnea
 I will change the patient‘s position two hourly to prevent development of pressure
sores
 As the condition improves I will let the patient adopt any position of comfort to
promote rest

Rest
 I will nurse the patient in a quiet room to promote rest
 I will play the radio at low volume to promote rest
 I will answer all phone calls promptly to prevent disturbing the patient there by
promote rest
 I will do related procedures in blocks to promote rest
 I will administer prescribed analgesics in order to promote rest
 I will ensure that squeaking trolleys a oiled to prevent noise and there by promote
rest

Observations
 I will do vital sign and BP to act as the base line data in order to know if the
condition is improving or deteriorating
 I will observe for cyanosis if improving or getting worse and give oxygen therapy
when necessary
 I will observe for dyspnoea if present will prop up the patient to promote lung
expansion and there by relieve dyspnoea
 I will observe the pressure area to detect on set of pressure sore development
 I will observe the sputum for colour amount and consistency to detect Haemoptysis
and report the physician
 I will observe the patient‘s facial expressions to detect pain and administer
prescribed analgesics like paracetamol and observe the action and side effects
 I will observe the feeding pattern of my patient and take measures like giving small
frequent meals to promote appetite
 I will observe the respirations to detect tachycardia and report accordingly

Psychological care
 I will explain the disease process in order to raise the knowledge levels and thereby
alley anxiety
 I will encourage the patient to ask question and I will answer accordingly those I
cannot answer I will refer to the physician
 I will explain all procedures to my patient in order to allay anxiety
 I will involve a successfully managed case to come and talk to my patient in order to
allow the patient ask pressing question and get answer this will improve the patients
outlook on his condition
 I will involve the loved ones in his care in order for him not to feel neglected.
 I will provide diversional therapy in order to shift the patient‘s mind from the
hospital routine and his condition
 I will involve him in planning his own care in order for him not to feel left out
 I will explain to him that as the health care team we are doing everything possible to
ensure that he get better in order to promote co-operation.
Hygiene
 I will encourage the patient to take plunge baths in order to remove dead epithelium
and promote comfort
 I will do hair care to promote self esteem and also prevent pediculosis
 I will do nail care to prevent auto infection
 I will do mouth care to prevent halitosis
 Any soiled linen and clothes will be changed to promote comfort

Elimination
 I will provide a lot of fluids and roughage to prevent constipation
 I will prove copious fluids in order to promote renal wash out and there by prevent
renal problems
 I will offer a bed pan if he is confined to bed to ensure bowel movement

Nutrition
 I will provide energy giving foods like nshima to provide the energy needed for the
metabolic processes
 I will provide protein foods like fish and beans to promote replacement of worn out
tissues
 Vegetables and fruits will be provided to raise the immunity and promote skin and
mucous membrane integrity
 I will provide a lot of oral fluids to prevent dehydration due to excessive sweating
and promote bringing up of phlegm
 I will serve small frequent meals to promote appetite
 I will allow visitors to bring food preferred by the patient in order to promote
appetite
 I will do regular mouth washes in order to promote appetite

Exercises
 If my patient is confined to bed i will do passive exercises like limb movement and
massage in order to prevent muscle atrophy and promote blood circulation
 I will encourage the patient to do deep breathing exercises in order to promote lung
expansion
 I will encourage early ambulation as soon as the condition permits in order to
prevent deep vein thrombosis and other complications of immobility
Medication
 I will administer prescribed analgesic like paracetamol at the right time to promote
rest
 I will give prescribed antibiotics like X-pen to promote quick recovery
 I will ensure that the drugs are swallowed in my presence to promote recovery.

[Link].
 I will educate the patient about his condition in order to create awareness and
prevent recurrence of the condition
 I will explain the need for taking the medication in order to promote compliance
 I will educate the patient about the sign and symptoms of the condition for early
diagnosis and treatment thereby preventing complications
 I will talk to the patient about the need to take a balanced diet using locally available
foods in order to boost the immunity
 I will educate the patient about the need to keep the review dates so that his progress
is monitored to ensure full recovery
 I will advise the patient to avoid smocking to prevent continued irritation of the air
way thereby preventing recurrence of the condition.
 I will advise my patient to keep warm in order to prevent asthmatic attacks

d. Explain five (5) complications of pneumonia 25%

 Bronchiectasis
 Empyema
 Septicaemia
 Empyema
 Pleural effusion
MARKING KEY FOR QUESTION TWO (2): HYPERTENSION

2. Mrs. Mulozi Kalyalya from Dundumwezi, 44years old married with six (6)
children is a Director of Programmes at a private school. She is admitted to a
medical ward with a provisional diagnosis of secondary hypertension.

a. i. Define hypertension 5%
ii. List five (5) signs and symptoms of hypertension 10%
b. Explain two (2) classifications of hypertension 10%
c. Describe the management of Mrs. Kalyalya from admission till discharge 50%
d. Explain five (5) complications Mrs. Kalyalya may develop. 25%
a. i. Definition of hypertension (5%)
 It is a condition in which there is sustained elevation of arterial blood pressure i.e.
systolic of over 140mmHg and diastolic above 90mmHg.
 A condition where there is consistent elevation of the systolic blood pressure above
140mmHg and a diastolic blood pressure above 90mmHg

ii) List five (5) signs and symptoms of hypertension (10%)

• headache
• dizziness
• shortness of breath
• Confusion
• Ear noise or buzzing
• Palpitation
• Nosebleed
• Tiredness
• Blurred vision
• Chest pain

b. Explain two (2) classifications of hypertension (10%)

 Primary hypertension
Primary or essential hypertension affects 90-95% of cases therefore the commonest
usually with an idiopathic or unknown cause. It has a tendency to run in families. This
type of hypertension is further subdivided into:
• Benign hypertension; which can be present for a long time without causing serious
problems
• Malignant hypertension; is of sudden onset and produces severe symptoms making
survival to a few months or up to 2 years if not properly managed
 Secondary hypertension
Secondary hypertension accounts for 5-10% of people with hypertension. This means
that the hypertension in these individuals is secondary to (caused by) a specific
disorder of a particular organ or blood vessel, such as the kidney, adrenal gland, aortic
artery, etc.

c. Describe the management of Mrs. Kalyalya from admission till discharge

(50%)
Aims; 2%
• To reduce the blood pressure
• To educate the patient about his condition
• To prevent complications like stroke
• To promote quick recovery

INVESTIGATIONS (5% for at least 5)

• History will reveal HTN in the family
• Blood pressure will be high e.g. 150/100
• Renal function to rule out renal disease
• Aortography to rule out coarctation of the aorta
• Renal angiography to rule out stenosis
• Urinalysis can be done to rule out renal disorder
•
TREATMENT (At least 5 drugs for route, dose, frequency, 2 side effects, 2
nursing implications) 10%
• Alpha blockers e.g. Methydopa 250-500mg 8hourly for 5days
• Angiotensin-converting enzyme (ACE) inhibitors e.g. Enalapril
• Beta-blockers e.g. propranolol 20-40mg 8hourly for 5days
• Calcium channel blockers; Nifedipine 20mg 12hourly for 5days
• Diuretics Lasix (Furosemide) 30-60mg 8hourly 5days (with KCl 600mg)
• Vasodilators e.g. Hydralazin 20mg 12 hourly for 3days
• Analgesics for pain e.g. paracetamol 1g 8 hourly 3days

NURSING CARE (35%)

Aims

Environment
d. The patient will be nursed in a stress free environment to promote rest and prevent
further elevation of the BP
e. Patient will be nursed at the acute bay for close observation.
f. Room should have BP checking apparatus for close monitoring of patients BP

Rest
 I will nurse the patient in a quiet room to promote rest
 I will play the radio at low volume to promote rest
 I will answer all phone calls promptly to prevent disturbing the patient there by
promote rest
 I will do related procedures in blocks to promote rest
 I will administer prescribed analgesics to relieve headache there by promote rest
 I will ensure that squeaking trolleys a oiled to prevent noise and there by promote
rest
Observations
• I will do vital sign and BP to act as the base line data in order to know if the
condition is improving or deteriorating
• I will observe dyspnoea if present will prop up the patient to promote lung
expansion and there by relieve dyspnoea
• I will do regular blood pressure checks to monitor patient‘s response to treatment
Psychological care
• I will explain the disease process in order to raise the knowledge levels and thereby
alley anxiety
• I will encourage the patient to ask question and I will answer accordingly those I
can‘t answer I will refer to the physician
• I will explain all procedures to my patient in order to allay anxiety

Elimination
• I will offer a bed pan if he is confined to bed to ensure bowel movement

Exercises
• In the acute phase I will restrict patient‘s activity to promote recovery
• As condition improves mild exercises will be encouraged

Nutrition
• I will offer a salt free diet to prevent further elevation of the BP
• I will advise my patient to eat more fruits, vegetables, and fiber to boost the
immunity and prevent constipation

Medication
• I will administer prescribed analgesic like paracetamol to relieve headache
• I will give prescribed antihypertensive in order to promote recovery
• I will ensure that the drugs are swallowed in my presence to promote recovery.
Hygiene
• I will encourage the patient to take plunge baths in order to remove dead epithelium
and promote comfort
• I will do hair care to promote self esteem and also prevent pediculosis
• I will do nail care to prevent auto infection and bruising self which can lead to
bleeding
I.E.C.
• I will advise my patient to lose weight if he/she is overweight. Excess weight adds to
strain on the heart. In some cases, weight loss may be the only treatment needed.
• Exercise regularly.
• Eat a healthy diet; with less fat and sodium. Foods with baking soda all contain
sodium. Eat more fruits, vegetables, and fibre.
• I will encourage my patient to avoid smoking.
• If my patient has diabetes, I will advise him to keep his blood sugar under control

d. Explain five (5) complications Mrs. Kalyalya may develop. (25%)

1. Aortic dissection
2. Blood vessel damage (arteriosclerosis)
3. Hypertensive encephaloparthy
4. Congestive heart failure
5. Kidney damage
6. Hypertensive heart disease
7. Stroke
8. Vision loss

MARKING KEY FOR QUESTION THREE (3): PEPTIC ULCER

3. Mrs. Alaidah Njovu aged 37 years; a housewife has been brought to your ward
with a complaint of haematemesis. A provisional diagnosis of peptic ulcer disease
has been made.

a. Define peptic ulcers 5%

b. Explain five (5) signs and symptoms of peptic ulcers apart from the one mentioned
above 20%
c. Describe the management you would give Mrs. Njlovu during hospitalization 50%
d. Explain five (5) complications Mrs. Njovu may develop due to peptic ulcers 25%

a. Definition of peptic ulcers (5%)

 ‗A peptic ulcer is an ulceration involving the mucosa and deeper structures of the
upper gastro-intestinal tract and is due in part to action of the gastric juice, (Brunner
L.S. 1975).

 ―A peptic ulcer is a mucosal break, 3mm or greater in size with depth that can
involve the stomach or the duodenum, (Luckmann, J. 1997)

 ―A peptic ulcer is an excavation formed in the mucosal wall of the stomach, pylorus,
duodenum, or oesophagus. Peptic ulcer is named according to its location, e.g.
gastric ulcers, duodenal peptic ulcer, etc. (Billings, 1982).

b. Explain five (5) signs and symptoms of peptic ulcer disease (20%)
 Epigastric pain (the most common symptom)

 Gnawing or burning
 Occurs 1-3 hours after meals
 Relieved by food or antacids
 Might occur at night when the stomach is empty and gastric secretions at peak
 Might radiate to back (consider penetration)

 Nausea and excessive salivation maybe present.

 Vomiting, which might be related to partial or complete gastric outlet obstruction
 Dyspepsia, including belching, bloating, distension, fatty food intolerance
 Heartburn
 Chest discomfort
 Anorexia, weight loss
 Haematemesis or melaena resulting from gastrointestinal bleeding from eroded
small blood vessels in the wall of the gastrointestinal tract.
 Dyspeptic symptoms that might suggest peptic are not specific because only 20-25%
of patients with symptoms suggestive of peptic ulceration are found on investigation
to have a peptic ulcer.

c. Describe the management you would give Mrs. Njovu during hospitalization
(50%)

Aims; 2%
Investigations 5% for at least any five of the following;
 History taking should involve assessment for abdominal pain; determine its location,
timing and severity of pain along with associated symptoms and precipitating
factors.
 Examine and palpate the abdomen carefully for pain, which is usually present in the
upper epigastrium, left of the midline of the abdomen.
 Endoscopy to visualize and identify inflammatory changes, ulcers and lesions. The
duodenal mucosa is visualized.
 Special radiology (Barium meal) is done to visualize the ulcer, after patient has
taken barium sulphate.
 Stool examination to detect presence of blood (occult or fresh) in stool which may
be a sign of bleeding from the gut.
 Gastroscopy and duodenoscopy to observe the mucosa. Biopsy may be done for
gastric ulcers to diagnose benign status.
 Upper gastrointestinal series roentgenograms to demonstrate ulceration.
 Exfoliative cystology (examination of the secretions and cells that are brushed or
scraped from the mucous membranes). (Billings D.M. et al. 1982)

TREATMENT 10% for at least 5 drugs

ANTIACIDS
Aluminum and magnesium hydroxide (Maalox,
Mylanta) -- Neutralizes gastric acidity, resulting in
increase in stomach and duodenal bulb pH. Aluminum
Drug Name
ions inhibit smooth muscle contraction, thus inhibiting
gastric emptying. Magnesium and aluminum antacid
mixtures are used to avoid bowel function changes.

Adult Dose 2-4 teaspoon Orally, 6 hourly OR whenever necessary

Paediatric Dose 0.5 mL/kg Orally 6 hourly OR whenever necessary

Contraindications Documented hypersensitivity

Both drugs reduce efficacy of fluoroquinolones,

corticosteroids, benzodiazepines, and phenothiazines;
Interactions
Aluminum and magnesium potentiate effects of valproic
acid, sulfonylureas, quinidine, and levodopa

Pregnancy Safety for use during pregnancy has not been established.

Use aluminium containing antacids with caution in

Nursing Implications patients who have recently suffered a massive upper GI
haemorrhage
H2-RECEPTOR ANTAGONISTS

These drugs inhibit the action of histamine on the parietal cell, which inhibits acid
secretion. The 4 drugs in this class are all equally effective and are available over the
counter in half prescription strength for heartburn treatment. Although the IV
administration of H2 blockers may be used to treat acute complications (e.g. GI
bleeding), the benefits are yet to be proven.

Cimetidine (Tagamet) -- Inhibits histamine at H2

receptors of the gastric parietal cells, resulting in reduced
Drug Name
gastric acid secretion, gastric volume, and hydrogen ion
concentrations.

150mg Orally 6 hourly, not exceeding 600mg/day

Adult Dose
50 mg/dose, IV/IM, 6 – 8hrly; not exceeding 400 mg/day

Not established but suggested dose: 20-40mg/kg/day

Pediatric Dose
Orally/IV/IM in divided doses

Documented hypersensitivity, Confusion, jaundice,

dizziness, peripheral neuropathy, impotence (reversible),
Contraindications
thrombocytopenia.
Side Effects

Can increase blood levels of theophylline, warfarin,

Interactions tricyclic antidepressants, phenytoin, quinidine,
propranolol, and metronidazole.

Pregnancy Usually safe but benefits must outweigh the risks.

Elderly patients may experience confusional states; may

cause impotence and gynecomastia in young males; may
Nursing Implications
increase levels of many drugs; adjust dose or discontinue
treatment if changes in renal function occur
 Ranitidine (Zantac) -Competitively inhibits histamine at
the H2 receptors of gastric parietal cells, resulting in
Drug Name
reduced gastric acid secretion, gastric volume, and
reduced hydrogen concentrations.

150mg Orally 12 hourly or 300mg Orally 6 hourly; not

Adult Dose
exceeding 300 mg/day; 50mg/dose IM/IV, 6 – 8 hourly

<12 years: Not established

>12 years: 1.25-2.5 mg/kg/dose Orally 12hourly; not
Pediatric Dose exceeding 300mg/day
0.75-1.5 mg/kg/dose IV/IM, 6 – 8hrly; not exceeding
400mg/day

Contraindications Documented hypersensitivity, vertigo, malaise, blurred

and Side Effects vision, jaundice, leucopsenia.

May decrease effects of ketoconazole and itraconazole;

Interactions may alter serum levels of ferrous sulfate, diazepam, non-
depolarizing muscle relaxants, and oxaprozin

Pregnancy Usually safe but benefits must outweigh the risks.

Caution in renal or liver impairment; if changes in renal

Precautions function occur during therapy, consider adjusting dose or
discontinuing treatment

PROTON PUMP INHIBITORS

These drugs bind to the proton pump of parietal cell, inhibiting secretion of hydrogen
ions into gastric lumen. Proton pump inhibitors relieve pain and heal peptic ulcers
more rapidly than hydrogen antagonists do. Drugs in this class are equally effective.
They all decrease serum concentrations of drugs that require gastric acidity for
absorption, such as ketoconazole or itraconazole.

Omeprazole (Prilosec) -- Decreases gastric acid

secretion by inhibiting the parietal cell H+/K+ ATP pump.
Drug Name Used for up to 4 wk to treat and relieve symptoms of
active duodenal ulcers. Physicians may prescribe for up
to 8 wk to treat all grades of erosive esophagitis.

Adult Dose 20 mg PO QID, for 4-8 weeks

Paediatric Dose Not established

Contraindications Documented hypersensitivity

May decrease effects of itraconazole and ketoconazole;

Interactions
may increase toxicity of warfarin, digoxin, and phenytoin

Pregnancy Safety for use during pregnancy has not been established.

Precautions Bioavailability may be increased in elderly patients

Drug Category: Gastrointestinal Agents. These are effective in the treatment of

peptic ulcers and in preventing relapse. Their mechanism of action is not clear.
Multiple doses are required, and they are not as effective as the other options.

Sucralfate (Carafate). This drug binds with positively

charged proteins in exudates and forms a viscous
Drug Name adhesive substance that protects the GI lining against
pepsin, peptic acid, and bile salts. Used for short-term
management of ulcers.

Adult Dose 1g Orally 6 hourly

Paediatric Dose Not established; suggested dose: 40-80mg/kg/day in

 divided doses 6hrly.

Contraindications Documented hypersensitivity

May decrease effects of ketoconazole, ciprofloxacin,

Interactions tetracycline, phenytoin, warfarin, quinidine, theophylline,
and norfloxacin

Pregnancy Usually safe but benefits must outweigh the risks.

Caution in renal failure and impaired excretion of

Precautions
absorbed aluminium

Drug Category: Analgesia. Analgesia like Paracetamol may be prescribed for pain
relief. Dosage, 500 – 1000mg Orally 8 hourly (Lopez et al, 1996).

NURSING MANAGEMENT 35%

Aims;
1. To relieve of pain
2. To reduce anxiety
3. To maintain nutrition requirements
4. To provide knowledge about disease and management.
5. To prevent complications

Environment
The patient should be nursed in a quiet environment and clean environment to promote
rest.
Pain relief
Administer prescribed antiacids such as aluminium hydroxide and magnesium
hydroxide to relieve pain and promote comfort.
The patient is educated to avoid foods and beverages that are irritating to the gastric
mucosa.
The patient is educated on the use of medication to relieve chronic gastritis such as
anti-acids.
Observations
Vital signs; temperature, pulse rate, respiration and blood pressure, are checked
4hourly to rule out any other infection and or any abnormalities which should be
reported to the doctor.

Psychological care
- Explain disease process according to patients understanding
- Explain diagnostic tests and drugs given
- Interact with patient in relaxed manner
- Encourage friends and family to participation in patient care
Nutrition
- Assess nutrition status.
- Discuss diet plan
- Explain bland diet – less fat, spice
- Avoid extremes of temperature.
- Avoid over stimulation from consumption of meat extracts, alcohol, coffee and other
caffeinated beverages, diets rich in cream and milk
- Eating 3 regular meals daily

Life style modification

- Advise the patient to stop smoking if he does
- Stopping drinking
Patient education
- Teach on factors aggravating the condition.
- Teach on drugs being administered and their side effects
- Teach on importance of continuing taking medications
- Teach on what to avoid in terms of food and medications
- Encourage the patient to honour follow up medical checkups.
Teach on signs of complications
Haemorrhage
- Cool skin
- Confusion
- Increase heart rate
- Blood in stool
- Low blood pressure fast pulse rule
- Severe abdominal pain
- Rigid tender abdomen
- Vomiting
- Elevated temperature
Medication
- Administer ordered drugs
- Observe their side effects
- Carry out nursing measures according to implications.
Hygiene
- Oral Care
- Assisted baths

d. Explain five (5) complications Mrs. Njovu may develop due to peptic ulcers
(25%)
1. Haemorrhage – Haemorrhage may be minimal manifested by melaena or massive
manifested by haematemesis.
2. Perforation – this is usually a surgical emergency. When perforation occurs,
gastro duodenal contents escape through the anterior wall of the stomach into the
peritoneal cavity, resulting in chemical

3. Peritonitis – usually resulting from perforation of the ulcer leading to leakage of

gastrointestinal contents into the peritoneum.

4. Intestinal obstruction – Long standing ulcer disease causes scaring because of

repeated ulcerations and healing. Scaring at the pylorus frequently causes pyloric
 obstruction, manifested most often by pain at night, when the stomach cannot be
emptied by peristalsis. This can also lead to vomiting (Black and Hawks, 2009).

5. Malignancy - due to regeneration of epithelium caused by chronic ulceration. (Mac

Sween and Whaley, 2001) require treatments especially for treatment of large and
small bowel.

6. Intractable peptic ulcers – This means a type of peptic ulcers that no longer
respond to any form of medical treatment.

MARKING KEY FOR QUESTION FOUR (4): TYPHOID FEVER

4. Sililo Matalilo has been brought to your ward and after investigations a
diagnosis of typhoid fever is made.

a. Define typhoid fever. 5%

b. State five (5) specific signs and symptoms of typhoid fever. 20%
c. Describe the management of Sililo from admission till discharge. 50%
d. Discuss five (5) points you would include in your Information, Education and
Communication (IEC) to Sililo and family on prevention of typhoid 25%

a. Definition of Typhoid Fever (5%)

It is a diarrhoea infectious disease caused by the bacterium salmonella typhi
characterised by pea soup stool, rose spots and stair case fever.

b. State five (5) specific signs and symptoms of typhoid fever (20%)
i. Stair case fever
ii. Pea soup diarrhoea
iii. Rose spots
iv. Bradycardia
v. Typhoid state confusion (delirium)
 c. Describe the management of Sililo from admission till discharge (50%)
Medical management 15%
Investigations 5%
i. History taking of the signs and symptoms from the patient
ii. Full blood count - Blood which will initially show leucocytosis, but later
iii. Leucopenia, neutropenia, normacytic anaemia and mild proteinuria and elevated
iv. Transaminases.
v. Blood culture to isolate organisms from blood or bone marrow.
vi. Stool or urine or to isolate organisms and identify the specific treatment.
vii. Widal test – to reveal salmonella antigen.

Medical treatment
- Patients should be managed under strict enteric precautions, with attention to
adequate hand washing and safe disposal of faeces and urine.
- Antibiotic therapy is essential and should begin empirically if the clinical suspicion
of an enteric fever is strong.

Recommended Antibiotics Include:-

1. CIPROFLOXACIN ORAL
Adults: 500 mg 12hourly for 14days

Children: 10mg/kg body weight 12 hourly for 14 days

OR
Coiprofloxacin IV in severe cases

Adults: 200 mg 12 hourly

Children: 10mg/kg body weight 12 hourly

OR
2. CERFTRIAXONE IV
Adults: 1-2g daily x 7days
 OR
3. CHLORAMPHENICAL ORAL/IV
Dose: 500 mg 6 hourly daily for 5days

S/E: Bone marrow toxicity, Aplastic Anaemia

OR
4. AMPICILLIN ORAL/IV
500mg 6 hourly for 5dys

OR

5. AMOXYCILLIN 400 mg 8 hourly Orally for 5days

OR

6. COTRIMOXAZOLE
OR

7. AZITHROMYCIN
And

8. CORTICOSTEROID THERAPHY
- Dexamethasone (initially 3mg/kg, then followed by 8 doses of 1mg/kg 6 hourly)

NURSING CARE 35%

Aims;
1. To allay anxiety
2. To relieve pain
3. To eliminate the causative organism
4. To prevent complications
5. To prevent cross infection

Environment
- Patient must be nursed in a clean environment, and in isolation to prevent the spread
of the disease.
- There should be no bed pan or urinal lying around in patient‘s room. Used bedpans
and urinals must be disinfected and emptied immediately after use.
- Room must be mopped and dump dusted with a disinfectant, and there must be
nothing in the room – that would attract flies e.g. left over foods or any colour or
effective smell.
- Visitors must be restricted or prevent from entering this environment for fear of
contracting the infection.
- If possible, the environment must have running water and soap for washing hands.
- The room must be well ventilated to allow free air movement.

Psychological care:
- Explain the condition to patient and his relatives ie, its cause, predisposing factors,
mode of transmission, treatment and complications if the case is not well managed.
- Explain that the disease is curable, but the most important thing is to adhere to
treatment and observe personal hygiene.
- Explain to patient friends and his relatives why patients has been quarantined, tell
them about the nature of the disease and why it is important for him to be
quarantined
- Explain every procedure that is done on him to allay anxiety and gain his
cooperation.
- Allow patient and his relatives to ask questions and answer them politely.

Observations
- Observe the patient for fever which a common symptom in this condition. Observe
the patient especially the 1st two-three days of starting treatment to see if patient is
responding to treatment.
- Observe the pulse rate 4-6 hourly, if blood pressure is low, it may be an indication of
intestinal bleeding. If blood pressure is low commence a drip of IV fluids especially
normal saline and inform the doctor.
- Observe the patient for abdominal pains and signs of shock and take precautions to
prevent it or manage it.
- Observe for nasal bleeding which is common in these patients.
- Observe for general condition of patient in case he may be going into a stupor or
coma.

Nutrition:
- Frequent feeds are needed because of gastro-intestinal bleeding or other gastro-
intestinal disruption.
- Sometimes parenteral feeds are recommended and given until the patient can digest
food.
- Avoid hard foods as they may irritate the mucosa lining of the intestinal lumen,
preferably give fluid diet.
- Avoid spicy foods because they will worsen the abdominal pains due to irritants
contained in the species.
- Give high protein and vitamin diet when the patient is stable to help in repair of
damaged body cells.
- Serve meals in small amounts to stimulate the appetite since the patient has loss of
appetite, and observe as he eats in case he has developed a sore throat. If he has sore
throat give frequent sips of milk to sooth the throat.

Elimination:
- Observe the patient‘s elimination patterns and the consistence of the waste matter
because the patient may constipation or sometimes diarrhoea. Record the
observations.
- Observe the urination pattern and encourage him to be voiding not to avoid urinating
for fear of pain on urination.
- Observe the colour and smell of urine in case of infection and treat accordingly.

Hygiene:
- All health personnel and relatives attending to this patient must strictly observe
hygiene. Every time after attending to this patient, they must always remember to
wash their hands and even before they leave the patient‘s room.
- The patient himself should be taught that he must always wash hands after visiting
the toilet and before eating anything to void infection.
- Fruits must be washed before eating them to prevent infection
- Left over foods must always be well covered and be re-boiled before eating it.
- Drinking water must always be treated either by boiling or chlorinating it and kept in
a clean container with a tightly closed lid.
- Relatives and friends must not be allowed to sit on patient‘s bed, and must wash
their hands before leaving patient‘s room.
- Gloves must always be warm when attending to this patient.
- Patient must have daily baths to promote blood circulation and self esteem.
- If patient has long finger nails, the nurse must see to it that they are cut short to
prevent labouring of micro organism.
- Linen must be changed frequently especially when soiled, then disinfected and sent
to the laundry separated with a label.
- Patient must have oral toilet or mouth washes to prevent halitosis which may
promote appetite.

Medication:
- Give prescribed antibiotics and observe for effects of the drug(s) the action, side
effects and general condition of the patient if responding to treatment or not.
- Give the right drug, at the right time to the right patient and the right dose by the
right route.
- Ensure the patient and make sure he has swallowed the drug if given orally.
d. Outline five (5) points you would include in your Information, Education and
Communication (IEC) on prevention of typhoid fever (25%)

- Explain the cause and predisposing factors of typhoid fever.

- Talk about preventive measures – hand washing before eating and after use of the
toilet, covering left over foods and re-boiling it before eating, washing fruits before
eating them.
- Proper disposal of human faeces and urine.
- Proper disposal of human faeces and urine, covering pit latrines etc.
- Boil drinking water
- Keep surroundings clean and dry to keep flies away which may spread infection
- Proper handling of soiled linen – handle with gloves and sluice it separately and
disinfect before washing it, and this linen to be kept and washed separately from
other linen.
- Educate patient and family on restriction of visitors into the environment
- Educate patient and family on other risk factors like over use of anti-acids, this
should be avoided.
- Educate them on causes, signs and symptoms, complications and how to prevent the
disease e.g. by observing hand washing after toilet and before eating. (6% for each
point with good explanation)

MARKING KEY FOR QUESTION FIVE (5): MALARIA

5. Mr. Nalumino Mate a 48 year old man from Lwaano Valley is admitted to your
ward with history of headache and vomiting. He is confirmed to have malaria.
a. Draw the lifecycle of malaria. 15%
b. State five (5) signs and symptoms of malaria 15%
c. Describe the management of Mr. Mate during hospitalization 50%
d. Outline five (5) control measures that the community in Lwaano should take to
prevent malaria 20%
a. Draw the lifecycle of malaria. (15%)

[Link] five (5) Clinical features of malaria 15%

- Paroxysms of chills
- Sudden attack of fever 37.7 – 40.60 c
- Headache as a result of parasitaemia
- Nausea and vomiting
- Temperature may be below normal
- Sweating
- Diarrhoea may develop
- Joint pains
- General body malaise
- Jaundice in the mucous membranes
- Splenomegally in chronic cases of malaria as complication
c. Describe the management of Mr. Mate during hospitalization (50%)

Aims; 2%

1. To promote quick recovery

2. To promote comfort
3. To prevent complications

INVESTIGATIONS 5% for at least five investigations

• History from the patient of sudden onset of fever, vomiting, joint pains etc.
• Clinical picture such as fever, nausea vomiting and general body weakness
• Blood slide for malaria parasite which will be positive
• FBC count will show low haemoglobin, leukocytosis and high ESR
• Lumbar puncture to rule out meningitis
• Blood Glucose estimation for patients with altered consciousness

i. Anti Malarial drugs 10%

- Quinine. Loading dose 1200mg intravenously in 500mls 5% dextrose followed by
600mg in 500mls as maintenance dose 8 hourly x 3days then orally 300-600mg, 8
hourly x 4days.
OR
*If patient is not vomiting and able to swallow give: Quinine, dose 600mg 8 hourly
orally for 7days.

Indication: It is indicated in falciparum Malaria

Side Effects: Tinnitus, headache, hot and flush skin, nausea, visual disturbances,
confusion, hypersensitivity reaction including thrombocytopenia, and renal failure,
also hypoglycaemia.
Nursing Implications: Give the drug with 5% IV or after a meal orally to avoid
hypoglycaemia. Observe for side effects and if severe discontinue drug. Explain same
of the effects to the patient so that they can report when they occur.

i. ANALGESICS:
Paracetamol 1000mg orally for 3days

Action: Analgesic that blocks pain receptors and relieves fever

Nursing implications: Give drug as ordered, don‘t give overdose, and observe
patient‘s response to treatment.

Side Effects: In overdose there‘s liver damage

ii. IRONS AND MINERALS:

(a) Ferrous sulphate; 200mg, orally 12 hourly for 7days

Action: Provides iron, an essential component for haemoglobin formation.

Side Effects: Nausea, epigastric pain, anorexia and vomiting, constipation or

diarrhoea, dark stool.

Nursing Implications: Observe for gastrointestinal upset and discontinue the drug if
severe, give drug with food or juice but not with milk or acids.

(b) Folic Acid may also be given 5mg orally once daily for 7days
Indication: Vitamin supplement to prevent anaemia.

NURSING CARE 35%

Admission
- Admit patient in acute bay if condition is serious for easy observations.
- Bed should be well made with clean linen
- Assess needs and problems for immediate interventions
- Check temperature and BP for baseline data.

Control of fever
- Remove extra linen to promote air circulation and evaporation to reduce high
temperature
- Open nearby windows to promote air circulation, or provide a fan if possible.
- Sponging may be done with care, do not chill the patient
- Check temperature after carrying out there measures
- Give prescribed antipyretics such as paracetamol 1g tablets for 3days orally.

Rest
- Promote adequate rest by avoiding noise on the ward to avoid irritating the patient.
- Encourage patient to be taking a lot of water to wash out waste products through
urine and sweat from the blood which may irritate the brain cells
- Administer prescribed analgesics at specified times like paracetamol 1g orally, 8
hourly for 3/7.

Observations
- Observe the general condition of the patient and ask how the patient is feeling.
- Check temperature, if high it‘s a sign of parasitaemia, blood pressure and pulse rate-
if abnormal like fast pulse rate and low BP. may indicate shock, take appropriate
measures.
- Find out whether patient has diarrhoea or vomiting, if has diarrhoea, give oral or iv
fluids to rehydrate him.
- Observe patient whether is taking adequate food and fluids to ensure that he doesn‘t
go into hypoglycaemia.
- Observe side effects of some drugs like quinine. If they are worse report to the
physician and reduce dose. Encourage patient to be taking a lot of juice or water to
minimize some of the side effects like renal failure and hypoglycaemia.

Nutrition
- Allow patients to decide what fluids and food he wants. Serve meals in small
frequent amounts, follow patients preference
- If patient vomits continuously, IV fluids may be given; 5% Dextrose I litre to run in
8 to 17 hours as supportive therapy
- Monitor intake of fluids and output using fluid balance chart.
- Environment should be kept clean, avoid bad odour
- Do oral care before and after meals to stimulate the taste buds and remove food
particles and to prevent halitosis which may lead to anorexia

Psychological care
- Allow the patient to ventilate his concerns and allow him to ask questions and attend
to them in a calm manner to allay anxiety.
- Be gentle and provide required answers to the client for assistance if unable to
address certain concerns.
- Explain all the procedures carried out to assist him, i.e. treatment he is receiving.
- You allow visiting relatives during visiting hour to give moral and social support.
- Give respect to the patient, address him by name, your gestures should be good or
have positive attitude. These will allay anxiety, patient feel loved and accepted. It
will also enhance co-operation and active involvement in his care.

Hygiene
- Keep the ward clean
- Charge linen whenever soiled or necessary
- Assist patient with hair wash and bathing at least once a day. Do oral care before
and after meals.
- Relatives should be involved if its patient‘s preference especially when bathing.
These will promote blood circulation, comfort and prevent other infections that may
develop as a result of dirty.

Exercises
- These will promote blood circulation and maintain good body muscle tone
- Encourage patient to flex and extend his limbs, and also to do deep breathing
exercises at least twice per day to facilitate full lung expansion for good oxygen
perfusion and ventilation.
- Encourage patient to move up and about in the ward when he is strong.
- If patient is unable to walk, change positions every 2-4hrs to prevent bed sores
- Exercises are also important because they prevent hypostatic pneumonia.

I.E.C.
- Explain when and how to take a drug on discharge
- Give written information as a reminder
- Drugs should not be shared
- Avoid drug resistance by completing therapy
- Patient to come for review on appointed date for follow up care.
- Avoid taking un prescribed drugs. These may lead to resistance or death.
- Family members /wife to be included in the health education so that they support the
patient.
[Link] five (5) control measures that the community in Lwaano should take to
prevent malaria (20%)
- Sleeping under insecticide treated bed nets to prevent mosquito bites
- Indoor Residual Spraying in homes using recommended chemicals to prevent
harbouring of mosquitoes
- Use of mosquito repellents at night to prevent mosquito bites
- Use of mosquito coils in homes at night to repel mosquitoes
- Burying ditches to prevent water stagnation that create suitable environments for
breeding of mosquitoes.
- Cutting and clearing nearby bushes to avoid settling of mosquitoes in nearby areas
to homesteads
- Early identification, diagnosis and treatment of suspected malaria cases
SINUSITIS

Martin Musonda, a 19 years grade 12 pupil at Anoya Zulu High School is admitted to
your Medical Ward with a diagnosis of severe smusitis.

(a) (i) Define Sinusitis 5%

(ii) Mention the four (4) main sinusis 8%

(b) State six (6) signs and symptoms of sinusitis 12%

(c) Discuss the management of Musonda till discharge 50%

(d) Explain five (5) complications which Musonda may develop if

Management is not effective 25%

ANSWERS:

(a) (i) Definition:

It is the inflammatory condition of the paranasal sinuses.

(ii) The main sinusies:

- Frontal sinusies
- Ethmoidal sinusies
- Sphenoida sinuse
- Maxillory sinusies

(b) Six (6) signs and symptoms

- Pain over the affected sinus
- Purulent Nasal drainage
- Nasal obstruction and congestion
- Low grade fever
- Malaise
- Nasal stuffiness and headache
 - Non productive cough
- Sore throat

(c) Management till discharge

(i) Investigations
- X-ray of the sinus or
- Computed tomography, to confirm the diagnosis. It may show fluid in
the sinus or thickened mucous membrane.
- Nasal endoscopy, used to examine the sinuses and obtain drainage for
culture.
- Clinical manifestations.

(ii) Medical treatment (Drugs)

- Effective treatment depends on the type of sinusitis.

(a) Antibiotics.
Amoxycillin, 250 mg, every 8 hours for 5 days. Orally.

Action: Bacteriastatic and bacteriodel.

Side effects: Nausea, diarrhea, rashes, leucopenia and

thrombocytopanice in prolonged use.

Nursing Intervention: Avoid it in a patient with history of allergy,

renal impairement and leucarmia. Observe for side effects or

Ampicillin 250 mg, orally, 6 hourly for 5-7 days.

(b) Analgesics: Panadol, 1000mg, 3 times daily for 3 days.

Indication: To relieve mild to moderate pain and pynexia.
 Side effects: Liver damage on prolonged use.

Nursing Action: Do not give it to a patient with inpaired kidney or

liver function.

Ibuprofen: Dose 400mg, orally, 8 hourly, for 3 days.

Indication: Fever and in moderate pain

Side effects: GIT irritation and brouchosposis.

(c) Antihistamines: These may be given if allergy is suspected.

Chlorpheniramine, 2 mg, orally, 6 hours,

Indication: Symptomatic relief of allergy.

Side effects: Exfoliation dematits and tinnitus may develop.

OR

Bomethazine Hydrochloride 20 mg orally/IM

(d) Corticosteroids:
These may be given to relieve inflammation and as anti-allergic drugs.

Prednisolone 20 mg, once per day, for 7 days orally.

Side effects: In prolonged use may sappress immunity.

Nursing consideration: Should be given after breakfast.

OR

Dexamethasone 20 mg initial dose IM.

NURSING CARE:

Nursing Diagnosis:

1. Pain related to signs obstruction, inflammation or infection.

 2. Altered nutrition, less than body requirements related to decreased
appetite and inadequate food intake.
3. Knowledge deficiency on the condition and self care as manifested by
anxiety.
4. Risk for infection related by impaired mucosal integrity.
5. Some throat as manifested by difficulties with swallowing.
6. Need for Health Education.

PAIN, RELATED TO OBSTRUCTION AND INFLAMMATION OF SINUSIS:

- The aim is to relieve pain and promote drainage of secretions.

Interventions

- Encourage the patient to be taking a lot of fluids to liquefy secretions.

- Steam inhalation and Nasal sprays or humidifier can be used to promote

secretion drainage.

- The patient should be encouraged to maintain semi fowler‘s position to promote

sinus drainage.

- Administer prescribed analgestics such as paracetamol 1g orally, 3 times per day

for 3 days, to relieve pain.

- Administer prescribed antibiotics to get ride of infection ie Amoxyccillin 500 mg,

6 hourly for 5 days.

ALTERED NUTRITION:

- Encourage frequent oral hygiene to enhance taste of food and remove

foul odour.
 - Provide nutritious, attractive foods to stimulate appetite
- Keep the environmental free of bad odour
- Give chance to the patient to choose the type of foods he wants.

KNOWLEDGE DEFICITY ON THE CONDITION AND SELF CARE:

- Explain to the patient the condition that is inflammation of sinus

characterized by pain and mucous discharge. It can be treated used
appropriate drugs depending on the course. This is done to increase
patient‘s knowledge of self care.
- Answer questions completely about self care responsibilities
- Instruct the patient to follow interventions
- If allergy is the course, follow instructions regarding environmental
control, drug therapy and prevention of sinus infection.
- Instruct the patient to take prescribed drugs
- Observe side effects of drugs such as nausea and vomiting. If they are
severe you may change the drug.
- Report signs of infection to the physician so that appropriate intervention
is instituded
NEED TO PROVIDE BASIC NURSING INTERVENTIONS:

- Offer a bath to the patient on daily basis or when ever necessary

- Provide psychological care to the patient to relieve anxiety. This can be
done by explain all the procedures and by maintaining good patient and
nurse relationship.
- Observe the elimination pattern to detect abnormalities related to urinary
out put and GIT.
- Allow friends from school to see him and provide books for reading.
NEED FOR HEALTH EDUCATION FOR CONTINUED SELF CARE AT
HOME:
 - The patient should avoid smoking or other irritants which can irritant
nasal passages.
- Should avoid factors which can predispose to exacerbations, such as
swimming and diving.
- Should take prescribed drugs. Instructions should be written.
- Should maintain good hygiene especial of the nasal cavity and proper
handling of discharges to avoid re-infection.

QUESTION: PULMONARY TUBERCULOSIS

a) Define Pulmonary Tuberculosis [5 marks]
Pulmonary Tuberculosis is a chronic granulomatous infection of the lungs caused by
Mycobacterium tuberculosis which is spread through droplets and is characterised by
fever, night sweats and cough
OR
Pulmonary Tuberculosis is a chronic granulomatous infection of the lungs which is
caused by Mycobacterium tuberculosis an alcohol Acid Fast Bacillus which is spread
through droplets and manifests into lung opacities, fever, night sweats and weight loss.
b) List six (6) characteristics of a Tubercle Bacillus [6 marks]
Some of the characteristics are;
 It is an Alcohol Acid Fast (AAF)
 It is a gram positive microorganism
 It is a non–spore-forming
 It is non-motile
 It multiplies slowly (18-24 hours)
 It is aerobic microorganism
 It is facultative
 It is rods-shaped
c) State five (5) risk factors to developing Tuberculosis [10 marks]
1. Poor housing, staying in small houses with poor ventilation are attributed to TB
transmission.
2. Poor nutritional status (malnutrition) is linked to poor immunity leading to reduced
immunity to TB infection
3. Overcrowding in places like markets, schools and churches make it easier to
contract TB infections
4. Age is attributed to reduced immunity in the young and old make them prone to TB
5. Immuno suppression caused by diseases like HIV/AIDS, cancer, age the youngest
and oldest being at risk.
6. Smoking destroys the lung resulting in parenchymal dysfunction leading to
disturbed lung architecture and making them susceptible to diseases like TB.
7. Prolonged drug (Steroids, Cytotoxic drugs and Chloramphenicol) use leads to
immuno-suppression putting an individual prone to TB
8. Prolonged drug (Steroids, Cytotoxic drugs and Chloramphenicol) use leads to
immuno-suppression putting an individual prone to TB
9. Chronic conditions like Cancers, Renal, Cardiac diseases lowers one‘s immunity
making someone prone to TB
10. Drinking unpasteurised milk leading to ingestion of Mycobacterium Bovis
d) Discuss the management of Mr. Musengo until discharge, under the following
headings;
i. Five (5) specific investigation you will carry out on Mr. Musengo to confirm the
diagnosis [15 marks]
1. History taking of onset and risk factors
2. Physical examination will reveal cough, lymphadenopathy, weight loss, lung
opacities, and breathlessness.
3. Gene xpert is the recommended primary investigation for the diagnosis of TB, it is a
confirmatory investigation tool for PTB diagnosis.
4. Mantoux test will reveal the exposure to Mycobacterium tuberculosis
5. Chest X-ray will reveal lung opacities
6. Sputum for microscopy, culture and sensitivity to reveal the pathology
7. Throat swab for microscopy, culture and sensitivity to confirm the diagnosis
8. Gastric lavage/aspiration for microscopy, culture and sensitivity
9. MRI and CT scan will reveal the lung opacities
10. Biopsy to rule out lung carcinoma
ii. Specific nursing care you will give Mr. Musengo [40 marks]
1. Admission/Environment 4 marks
2. Infection Prevention 5 marks
3. Airway and breathing 5 marks
4. Psychological care 5 marks
5. Observation 5 marks
6. Nutrition and fluids 5 marks
7. Health Education 5 marks
8. Rest and activity 3 marks
9. Medication 2 marks
10. Hygiene 1 mark
e) As a Registered Nurse, outline clearly, six (6) prevention and control measures of
Tuberculosis in the community [24 marks]
1. Massive community sensitisation on risk factors, causes, manifestation, treatment
and prevention of TB
2. Disease surveillance in the community
3. Contact tracing for all positive TB cases
4. Community to report promptly all suspected TB cases
5. Training and revamping TB treatment supporters in the community
6. Improving housing by providing ventilation
7. Avoiding overcrowded places
8. Health workers like nurses and laboratory personnel to use adequate PPE when
handling sputum samples and when attending to patients
9. Regular/routine screening for TB for early detection of an infection
10. Proper treatment/management of underlying chronic pathologies like HIV/AIDS,
cancers, DM and renal conditions
11. A BCG vaccination will prevent TB or reduce its aggressiveness
12. Prompt treatment is extremely important in preventing the spread of Tuberculosis
from those who have active TB disease to those who have never been infected with
TB.
13. Drug adherence to reduce the spread
14. Isolated of all positive TB cases
15. Covering of the mouth when coughing or sneezing
16. Proper disposal of used tissue or paper foil
17. Avoid drinking unpasteurised milk
QUESTION 2: CEREBRAL VASCULAR ACCIDENT (STROKE)
a) Define Cerebral Vascular Accident [5 marks]
Cerebral Vascular Accident (CVA) is a sudden disruption in cerebral circulation due to
ischaemia or haemorrhage that result in both motor and sensory deficit.
OR
Cerebral Vascular Accident is a sudden onset of neurological deficiencies arising from
impairment of cerebral blood flow which can be due to formation of a blood clot that
blocks an artery or rapture of an artery in the brain causing bleeding into the
subarachnoid space
b) Explain three (3) types of stroke [15 marks]
1. CEREBRAL THROMBOSIS (ISCHAEMIC STROKE)
-This is also called ischaemic stroke
-This is the most common cause of CVA.
-The onset of a stroke due to thrombosis may be gradual and usually occurs when the
person is at rest.
-It is common in middle-aged and elderly people.
-Conditions that lead to stasis of blood flow in the brain may cause cerebral
thrombosis are;
-Most often associated with atherosclerosis; the lumen of the blood vessel is narrowed,
impeding the flow of blood.
-The circulatory stasis leads to thrombus formation, occlusion of the vessel and
ischemia of an area of brain tissue.
-Narrowing of the vessel and ensuing thrombosis may be due to outside pressure by a
space occupying lesion
-An inadequate delivery of blood to the brain, secondary to cardiac insufficiency,
shock or reduce intravascular volume may also cause stasis and subsequent thrombosis
2. CEREBRAL EMBOLISM (ISCHAEMIC STROKE)
-This is the second leading cause of Cerebral Vascular Accident
-This is seen more frequently in younger persons
-Symptoms occur suddenly and at any time of the day.
-An emboli may be a blood clot, a clump of fat or tumour cells, or bacteria, or air
which has been carried by the circulation from another area of the body.
-Blood clots which form emboli may originate in the heart as a result of cardiac
disease or in the saphenous or femoral veins due to circulatory stasis.
-A fat emboli often follows a fracture
-An infected embolus may be associated with bacterial endocarditis
-An embolism formed of tumour cells may arise from a malignant neoplasm
3. CEREBRAL HAEMORAGE (HAEMORRHAGIC STROKE)
-The onset is sudden and is of sudden onset and is usually associated with physical
activity or emotional stress.
-Cerebral haemorrhage results in blood escaping from a ruptured artery which can be
due to aneurism
-Haemorrhage may either be intracerebral or subarachnoid.
-The predisposing factors/diseases are hypertension and diabetes mellitus.
e) Identify five (5) nursing problems which Mr. Dumbo is likely to experience
during hospitalization and using a nursing care plan, discuss how you would
manage them [50 marks]
NURSING PROBLES AND NURSING DIAGNOSES
1. Ineffective airway clearance related to unconsciousness and absence of cough
reflexes evidenced by snoring and difficulty breathing (shallow respirations)
2. Headache related to increased intraocular pressure evidenced by verbalization
3. Altered nutrition less than body‘s requirement related to reduced oral intake
(secondary to paralysis of oral muscles) evidenced by general body weakness
4. Self-care deficit related to muscle weakness/paralysis evidenced by patient looking
unkempt and failing to perform activities of daily living
5. Anxiety related to having little knowledge about the condition and prognosis
evidenced by the patient asking many questions and being moody
6. Ineffective coping related to inadequate knowledge about the condition and its
manifestations evidenced by self-isolation and moody
7. Risk of decubitus ulcers related to hospitalisation and being confined to bed
8. Risk of nosocomial infection related to (prolonged) hospitalisation
9. Risk of injury related to convulsions, weakness, dizziness and muscle weakness
10. Risk of impaired skin integrity related to being confined to bed, urine and faecal
incontinence
e) List five (5) rehabilitative measures of Mr. Dumbo [10 marks]
1. Speech rehabilitation
2. Occupational rehabilitation
3. Mobility rehabilitation
4. Community linkages
5. Family centered care
6. Economic linkage to social clubs and co-operatives

MOCK EXAM

PART A

IN EACH OF THE FOLLOWING QUESTIONS, ENCIRCLE THE LETTER

CORRESPONDING WITH THE MOST APPROPRIATE ANSWER, ONE (1)
MARK EACH

1. The causative agent for streptococcal pharyngitis is

(a) Bacteria

(b) Virus
 (c) Fungus

(d) Protozoa

2. The following are signs of laryngitis EXCEPT:

(a) Productive cough

(b) Sore throat

(c) Aphonia

(d) Hoarseness

3. Signs and symptoms of pulmonary tuberculosis include all of the following

EXCEPT:

(a) Productive cough

(b) Cyanosis

(c) Enlarged lymph nodes

(d) Night sweat

4. Pott‘s disease is

(a) Tuberculosis of the bone

(b) Tuberculosis adenitis

(c) A tuberculosis inflammation of the bodies of the vertebrae

(d) Tuberculosis of the abdomen

5. The best drug you can administer to a patient with angina pectoris is:

(a) Digoxin

(b) Glyceryl trinitrate

(c) Aldomet

(d) Tolbutamide

6. By what route are the sulphonamides most frequently administered?

 (a) Per oral

(b) Per rectum

(c) Intra-muscular

(d) Intra-venuos

7. An anti-microbial drug that is contra-indicated in pregnancy is:

(a) Penicillin

(b) Sodium sulfasoxideine

(c) Streptomycin

(d) Tetracycline

8. Paralysis of the arm and leg on one side of the body is known as:

(a) Paraplegia

(b) Paraparesis

(c) Hemiplegia

(d) Monoplegia

9. Carbimazole is a drug that is used to treat:

a) Cushing‘s syndrome

b) Thyrotoxicosis

c) Trypanosomiasis

d) Epilepsy

10. A code of good manners of behaviour commonly called courtesy in hospital is

called:

(a) Ethics

(b) Etiquette

(c) Professional code of conduct

 (d) Laws

11. Qualities of a good nurse include the following EXCEPT:

(a) Loyalty

(b) Observant

(c) Control of emotion

(d) Change of attitude

12. Inflammation of the tongue is known as:

(a) Parotitis

(b) Stomatitis

(c) Aerophagy

(d) Glossitis

13. The step ladder fashion fever seen in typhoid is a characteristic of stage:

(a) 1

(b) 2

(c) 3

(d) None of the above

14. Entamoeba histolytica is the cause of:

(a) Bacillary dysentery

(b) Cholera

(c) Amoebic dysentery

(d) Chron‘s disease

15. Malabsorption syndrome may cause deficiency in:

(a) Vitamin B 12

(b) Vitamin A
 (c) Vitamin C

(d) Vitamin D

16. Which of the following ARE NOT present in a new born circulation

(a) Inferior vena cava

(b) Pulmonary artery

(c) Hypogastric arteries

(d) Abdominal aorta

17. The first drug of choice in the treatment of schistosomiasis is:

e) Praziquantel
f) Pyrantel pamoate
g) Pyrazinamide
h) Protamine sulphate

18. The cause of ascites in liver cirrhosis is:

a) Liver congestion with blood stasis

b) Accumulation of toxic substances

c) Abnormal proliferation of hepatocytes

d) Splenomegaly

19. Which of the following substances are filtered out of the blood by the kidneys?

a) Diuretics

b) Chyle

c) Nitrogenous waste

d) Carbondioxide

20. Agents that promote secretion of urine are called:

e) Diuretics
 f) Antidiuretics
g) Uremics
h) Diaphoresis

21. Habitual drug and alcohol consumption by persons is often called:

e) Substance abuse
f) Alcoholism
g) Intoxication
h) Burnout

22. People with personality disorders are often called:

(a) Manic

(b) Psychosis

(c) Neurotic

(d) Psychopaths

23. The three phases that are commonly used to consider how to assist people to live
healthier lives include:

(a) Health promotion, health education and IEC

(b) Health promotion, service delivery and IEC

(c) Health promotion, IEC and community diagnosis

(d) Health promotion, service delivery and community diagnosis

24. The bone of the leg are:

(a) Radius and ulna

(b) Ulna and tibia

(c) Tibia and fibula

(d) Fibula and radius

25. The heart wall is thickest in the:

 (a) Right ventricle

(b) Left ventricle

(c) Left atrium

(d) Right atrium

26. The functions of the large intestines is:

(a) The absorption of food

(b) Absorption of nutrient

(c) Absorption of water

(d) Digestion of food

27. The life span of red blood cells is believed to be approximately:

(a) 120 days

(b) 220 days

(c) 140 days

(d) 130 days

28. The following are the three kinds of cells in the nervous system EXCEPT:

(a) Neurons

(b) Schwann cells

(c) Neuroglia

(d) Stomatic cells

29. The largest muscle in the leg is the:

(a) Obicularis

(b) Sartorius

(c) Gluteus

(d) Gastrocnemius
30. The mechanical process of inspiration and expiration is termed as

(a) Mechanism of breathing

(b) Mechanism of inspiration

(c) Mechanism of expiration

(d) Mechanism of the alveoli

31. Which of the following is NOT TRUE about surfactant:

(a) Increases surface tension

(b) Increases pulmonary compliance

(c) Reduces tendency for alveoli to collapse

(d) Reduces surface tension

32. Which of the following would indicate an increased risk of deep vein thrombosis:

(a) Anaemia

(b) Hypertension

(c) Obesity

(d) Vitamin K deficiency

33. A patient who is dyspnoeic is nursed in which of the following position?

(a) Prone

(b) Semi prone

(c) Dorsal

(d) Orthopnoeic

34. Repeat HIV testing is recommended while PrEP is taken and that should be done:

a) Every 6 months

b) Every 3 months

c) At the end of PrEP

 d) Every 4 weeks

35. A prolonged gasping inspiration followed by very short usually inefficient

expiration, associated with CNS disorders is called:

a) Cheyenne stroke

b) Kussmaul respiration

c) Biot‘s

d) Apneustic

36. Control of tuberculosis (TB) includes all of the following EXCEPT:

(a) Treat all new cases promptly

(b) Isolate all TB patients

(c) Educate public on spread of TB

(d) Medication compliance

37. In a typical attack of bronchial asthma:

(a) The onset is gradual and insidious

(b) There are spasms of the muscle walls of the bronchioles

(c) The attack is always precipitated by emotional disturbance

(d) Inspiration is more difficult than expiration and produces wheezing

38. The pulmonary function test is used to__________

a) Diagnose abnormal lung tissue

b) Demonstrate abnormal pulmonary blood flow

c) Evaluate how patient breathes

d) Measure obstructions to pulmonary function

39. The condition that occurs when alveolar ventilation is inadequate to meet the
body‘s demand or to eliminate sufficient carbondioxide is called:
 a) Hyperventilation

b) Hypoventilation

c) Hypoxia

d) Apnoea

40. Rheumatic heart disease is:

(a) Delayed response to an infection by group A-beta haemolytic

streptococcus

(b) A collagen disease

(c) A disease of negroes

(d) Rapid response to an infection by group B-beta haemolytic staphylococcus

41. A cardiac glycoside commonly used to improve the construction of myocardium

is:

(a) Lomotil

(b) Digoxin

(c) Frusemide

(d) Quinidine

42. Which one of the following organisms causes dysentery?

(a) Giardia lamblia

(b) Trichomonas horminis

(c) Shigella

(d) Brucella arbutus

43. The disease characterized by substernal chest pain and a suffocating feeling is:

a) Anaemia

b) Angioma
 c) Aneurism

d) Angina

44. The medical term used for genital warts is

a) Condylomata acuminate

b) Genital Herpes

c) Vaginitis

d) Syphilis

45. The structures of the mediastinum are:

(a) Heart and lungs

(b) Lungs and great vessels

(c) Diaphragm and heart

(d) Heart and great vessels

46. Which of the following is most likely to be a source of tape worm infestation:

a) Chicken

b) Lamb

c) Beef

d) Duck

47. Which of the following is NOT a complication of Mumps?

a) Epididymo-orchitis

b) Meningitis

c) Pericarditis

d) Pneumonia
48. A condition in which there is an increased number of red blood cells in the blood
is called:

a) Polycythaemia

b) Leukaemia

c) Anaemia

d) Hemophilia

49. A localized dilation of a cerebral artery that results from a weakness in the arterial
wall is called:

a) Cerebral aneurism

b) Myelomeningocele

c) Stroke

d) Haematoma

50. A sudden impairment of cerebral circulation in one or more of the blood vessels
supplying the brain is called:

a) Brain thrombosis

b) Cerebral vascular accident

c) Cerebral haemorrhage

d) Subdural haemorrhage

MATCHING ITEMS – MATCH THE ITEMS IN COLUMN I WITH ITEM IN

COLUMN II. ITEMS IN COLUMN II SHOULD BE USED ONCE ONLY

Match the following enzymes in column I with their actions in column II.

Column I Column II

51.......C..... Amylase A. Emulsification of fats

52.......G...... Pepsin B. Convert fats to fatty acids and glycerol

53.......E.... Surcease C. Convert polysaccharides to disaccharides

54........B..... Lipase D. Curdles milk

E. Converts disaccharides to monosaccharides

F. Protects the stomach mucosa from the

digestive action of pepsin

G. Converts proteins to peptones

Match the following drugs in column I with their meaning in column II.
Responses in column I should be used only once

Column I Column II

55. --D---Digoxin A. Antineoplastic

56---E---Amiloride hydrochloride B. Centrally acting sympatholytic
57-- B---Methyldopa C. Glycerol suppositories
58--C---Senna D. Cardiac glycosides
59--G--Frusemide E. Potassium sparing diuretic
F. Anabolic steroid
G. Loop diuretic
H. Aminoglycoside

Match the minerals in column I with their functions in column II

Column I Column II

60.....C... Calcium A. Helps maintain the normal acid base balance

61......B.. Iodine B. Essential to normal growth and development of the

thyroid gland

62.....G... Flourine C. Aids in the clotting of blood

63....E.... Iron D. Specific function in man is not known

E. Used to manufacture new red blood cells

 F. Is necessary for the proper healing of tissue

G. Prevents tooth decay

Match the following cranial nerves in column I to the organs they supply in column II

Column I Column II

64......C..... Oculomotor A. Mouth

65......A..... Trigeminal B. Neck

66......F..... Vagus C. Eye

67.......D.... Glossopharyngeal D. Tongue

E. Nose

F. Heart

G. Head

Match the type of Reflex in column I with how it is elicited in column II

COLUMN I COLUMN II

68.......H..... Kernig A. Flexing chin on chest

69......F...... Hoffmann B. Stroking tibial surface

70......A...... Brudzinski C. Brisk dorsiflexion of foot with flexed knee

71.......G..... Gordon D. Stroking below lateral malleolus

E. Stroking lateral sole foot

F. Flickering middle finger down

G. Squeezing calf muscle

H. Straightening le with thigh muscle flexed

SECTION C: COMPLETION

COMPLETE THE FOLLOWING SENTENCES USING ONE, TWO OR

THREE WORDS ONLY.
72. The causative organism of gonorrhoea is---Neisseria gonorrhoeae------------
73. The potential space between the two layers of pleura is called the---pleural
cavity---
74. The data that is obtained by the nurse through observation, physical
examination and diagnostic tests is called--- objective data ------
75. Which condition mimics signs and symptoms of congestive cardiac failure----
-----------COPD or pneumonia
76. Collection of fluid in the pleural space is referred to as---pleural effusion-----
77. The single most important investigation in every patient suspected of a chest
disorder is---chest X-ray-
78. The recommended drug for treatment of gonorrhoea when using syndromic
management is---- ciprofloxacin --
79. The causative organism for chancroid is --- Haemophilus ducreyi -------------
-
80. The haematological disorder in which there is inadequate circulating platelets
is called----thrombocytopenia ----------
81. Examination of the chest using a stethoscope is termed----auscultation--------
82. A form of tuberculosis that is characterized by a wide dissemination of tiny
lesions throughout the human body is called— miliary TB --------
83. Hansen‘s disease is the other name for---leprosy------------
84. The process of converting glucose to glycogen is known as---glycogenolysis
-
85. Cryptococcal meningitis is caused by a fungus called—Cryptococcus
neoformans-
86. A protozoa infection caused by trichomonas vaginalis is called—
Trichomoniasis
87. The current confirmatory test for HIV in Zambia is—SD Bio line---
88. The causative organism for syphilis is called----Treponema pallidum-------
89. Other than transmission through sex, blood and blood products and organ
transplant, syphilis can be transmitted by----mother to child (trans placental)
90. Inflammation of the tongue is called---glossitis---------------------
91. The term that refers to a set of symptoms and signs which occur together and
constitute the manifestation of some special condition is called---syndrome----
92. If untreated, Filariasis involving the eyes can cause a type of blindness called-
----onchocerciasis----
93. -----Liver cirrhosis---is a chronic liver disease characterized by diffuse
inflammation and fibrosis resulting in drastic structural changes and significant
loss of function.
94. The primary site of tuberculosis infection in the lungs is known as the—
Ghon focus--
95. The body of a tapeworm is made of successive segments called-- ploglottids-
----
96. -----Sporozoite ----is the sexual phase in the life cycle of malaria parasite
taking place in the mosquito.
97. What name is given the fixed ARVs dose combinations of Emtricitabine,
Tenofovir and Efevirenz (FTC/TDF/EFV)?--------Atripla---------------
98. Laryngo tracheal bronchitis is called---croup-------
99. Spoon shaped brittle nails in Iron deficiency anaemia is called---koilonychia
--
100. The superficial skin infection that usually causes scaring is—folliculitis --
NURSING CARE PLANS

NURSING CARE PROCESS FOR CHRONIC ILL PATIENT

PROBL NURSING OBJECT INTERVESION EXPECTED

EM DIAGNOSIS IVE OUT COME
Anxiety Anxiety which - To  Assess emotional  Patient will
is related to alley state. demonstrat
change in anxiety  Make time to listen to e
health status, through patient. appropriat
role function out the  Encourage free e range of
and course of expression of feeling and
interventions the hopeless desires to lessened
patterns which disease. die. fears.
are evidenced  Involve significant  Patient will
with others in the verbalize
apprehension, discussion. acceptance
restlessness  Identify the possible of situation.
and insomnia concerns.  Patient will
 Introduce a friend participate
who has a similar in the
condition and is routine and
living positively. special
events as
capable.
Ineffecti Ineffective To  Assess the family  The family
ve compromised counsel coping situation of will
compro family coping the the family. identify or
mised related to family to  Encourage verbalize
family temporarily understa significant others to resources
coping family nd and participate at level of to deal with
disorganizatio accept desire and capability situation.
n and family the with limits of safety.  Famil
changes, patient’s  Include in social y will
patient conditio events e.g. intera
providing little n celebrations. ct
support to dependi  Accept choice of with
significant ng on significant others the
others evident the regarding choice of patien
by significant disease involvement in the t and
others or care. staff.
withdrawing illness.  Family will
from patient, verbalize
significant knowledge
others and
describes understand
significant pre ing of the
occupied with situation.
personal
reactions e.g.
fear, grief,
guilt and
anxiety.

Sleep Sleep patterns To  Assess the sleeping  The patient

pattern disturbance stabilize patterns or habits. will report
disturba which may be the  Explain to patient improveme
nce related to sleeping about ward routine nt in sleep
illness, patterns. and procedures. patters.
psychological  Provide comfortable  Patient will
stress, bedding and some of verbalize
inactivity patient’s possession. sense of
environmental  Match with well being
changes and somebody with and sense
facility similar sleep patterns of feeling
routines and nocturnal needs rested.
evident by in a room.
report of not  Encourage physical
falling asleep, activity during the
not feeling well day.
rested.  Promote bed night
And comfort resumes e.g.
interrupted warm bath and
sleep massage.
awakening
earlier than
desired.
Self care Patient not To  Assess level of deficit  Patient will
deficit able to bath encoura in care. perform
e.g. not self may be ge  Involve patient in self care
being related to loss patient formulation of care activities
able to of mobility to to level of ability. within level
bath general perform  Encourage self care. of ability.
oneself. debilitation, own care  Provide and promote  Patient will
depression activities privacy during use
possibly within bathing or showing. resources
evidenced by level of effectively.
 in ability to activities
manage .
activities daily
living and
unkempt
appearance.
Inadequ Inadequate To  Assess cause of  Patient will
ate nutritional in restore weight loss. maintain
nutritio take which good  Check patient’s state normal
nal in way be related nutrition of dental health weight or
take to impaired al status periodically progress
dentition including fit and toward
cognitive condition. weight goal
limitation,  Monitor caloric and be free
depression, intake as indicated. from signs
inability to  Provide small of
feed self frequent feeding as malnutritio
effectively indicated. n.
evidenced by  Serve hot food hot  Patient
replaced or and cold food cold. demonstrat
observed  Promote a pleasant es feeding
dysfunctional environment for patterns or
eating pattern, eating and keep behavior to
Poor muscle patient company. maintain
tone, under appropriat
 Encourage patient to
weight which is e weight.
feed self according to
not ideal for condition.
height and
frame.
Risk for Risk for To  Assess reason and  Patient will
constipa constipation maintain cause for establish
tion which may be normal constipation. normal
related to in patterns  Rule out medical bowel
adequate fluid of bowel causes e.g. bowel function.
and nutritional function obstruction, cancer  Patient will
intake, poor as soon or hemorrhoids. demonstrat
muscle tone, as  Institute e change in
change in level possible. individualized life style
of actives, program of as
medication exercise or rest, diet necessitate
side effects and and bowel training. d by
lack of privacy  Provide adequate contributin
evidenced by fluid about 3 liters in g factors.
patient 24 hours.
complaining of
abdominal
fullness and
passing of hard
stool.
Impaire Impaired To  Assess functional  Patient will
d physical restore ability and reason for verbalize
physical mobility physical impairment. willingness
mobility related to moveme  Plan activities such to and
decreased nt as visits or adequate participate
strength and through rest as necessary. in desired
endurance to out  Encourage activities.
pain or illness. participation in self  Demonstrat
discomfort care. e
evidenced by  Provide techniques
impaired environmental of behavior
 coordination, change to meet visual that enable
limited range deficiencies. continuatio
of movement  Obtain supporting n of
and reluctance shoes and non activities.
to attempt skidding slippers.  Patient will
movement.  Assist with maintain,
ambulation if increase
indicated. strength
 Show patient ways to and
move safely. function of
 Involve a affected
physiotherapist body parts.

NURSING CARE PLAN FOR MENINGITIS

PROBL NURSI OBJECT NURSING RATION EXPECT

EM NG IVE INTERVENTION ALE ED

IDENTI DIAGN OUTCO

FIED OSIS ME

Convulsi  Con  Clien  I will give  To  Client

ons vulsion t will muscle relaxants like relax the has the
s have the Valium as muscles. fits
related fits prescribed.  To controlle
to controlle  I will give reduce the d and
abnorm d thereby antihypertensive blood injuries
 al prevent drugs as prescribed pressure. prevente
dischar injury to maintain the blood  To d for 30
ge of within an pressure within prevent minutes
electric hour of acceptable ranges injury to within an
al an  I secured the the hour of
impulse attack. tongue with a padded tongue. an attack.
across spatula to prevent  To
the tongue biting. prevent
brain  I will nurse the falls that
evidenc patient in a railed may cause
ed by bed. trauma.
violent  I will avoid  For
muscle stretching the patient monitorin
movem during the g the fit to
ents. convulsion and the act as a
relatives advised not guidance
to. for
 I will draw up the interventi
fit chart and recorded on.
the frequency and
duration.
Risk of  Ris  Clien  I will turn the  To  Client
developi k of t will patient 2 hourly. allow free has
ng develop have  I will involve the lung hypostati
hypostati ing hypostati physiotherapist for expansion c
c hyposta c chest exercises. . pneumon
pneumon tic pneumon  I will ensure that  To ia
ia pneumo ia the nasal gastric tube prevent prevente
nia prevente was in situ when feeds d, on
related d within feeding. entering auscultati
 to one  I will encourage the on no
immobi week of client to cough when respirator creps
lity & hospitali she gained y tract. sound
weakne zation consciousness.  To heard
ss  From time to clear up and there
time I elevated the the throat. was good
head part of the bed  To air entry
about 45 degrees as promote for one
the condition lung week of
allowed. expansion hospitaliz
. ation.

PROBL NURSI OBJECTI NURSING RATION EXPECT

EM NG VE INTERVENTION ALE ED
DIAGN OUTCO
IDENTI
FIED OSIS ME

Risk of  Ris  Client  I will do catheter  To  Client

developi k of will have toilet daily using prevent has
ng develop infection aseptic techniques. ascendin infection
infection ing prevented  I will do g of prevente
infectio during intravenous site care infection d during
n hospitaliza with special in the hospitali
 related tion attention at the urinary zation
to evidenced cannular site. tract. evidence
invasiv by stable  I will do oral  To d by
e vital signs care as well as nasal avoid stable
procedu e.g. care to prevent systemic vital
res temperatur cracking of the infection. signs e.g.
e of 36.0 membranes that  To temperat
degrees may be an entry site clean the ure of
celcious. of germs. membran 36.0
 I will change es and degrees
bed linen whenever avoid celcious.
soiled. cracking.
 I gave the client
daily bed baths.
Inability Inability Client will  I will insert a  To  Client
to to have her nasal-gastric tube assist has her
maintain maintain nutritional for feeding. patient nutrition
own own status  I will feed the receive al status
nutrition nutrition maintained patient two hourly the feeds. maintain
al status al status and with nutritious semi  For ed
related thereby solid foods and record evidence
to prevent fluids. purposes d by
weaknes hypoglyce  I will maintain and normal
s mia the feed chart and ensuring blood
evidence evidenced recorded after each that glucose
d by by weight feed. patient is levels of
signs & gain of 2kg  I will do daily being 80-
sympto for one weights fed. 120mg/dl
ms of week.  I will do blood  To & weight
hypogly determin gain of
 cemia & glucose tests using e weight. 2kg for
weight multisticks.  To one
loss. check week.
blood
glucose
levels.

Risk of Risk of Client will  I will draw up a  To  Client

developi developi have turning chart and be relieve has
ng ng pressure turning my client pressure pressure
pressure pressure sores every two hours and on sores
sores. sores developme record. pressure develop
related nt  I will do points. ment
to prevented pressure area care  To prevente
immobil evidenced using and apply promote d
ity by intact Vaseline/barrier good evidence
skin within cream on pressure blood d by
one week. points. supply on intact
 I will ensure that pressure skin for
the bed linen were points. week.
dry and clean by
removing any
cramps.
6
PROBL NURSI OBJECT NURSING RATION EXPECT
EM NG IVE INTERVENTION ALE ED
DIAGN OUTCO
IDENTI
FIED OSIS ME

Fever Fever To reduce  The nearby  To  Patient

related fever window was opened. promote no longer
to  Extra bed linen loss of feverish.
was removed. heat by Temperat
 Tepid sponging evaporati ure
was done. on. falling
 Antipyretic drug  To act gradually
was given as on the .
prescribed. heat
 Checked regulatin
temperature hourly g centre
and record the thus
findings. reduce
the
temperat
ure.
 To
help
monitor
temperat
 ure and
avoid
over
cooling
patient.
Severe To relief  Allowed patient  To  Pain
pain on pain and to assume a prevent relief no
affected promote comfortable position. addition longer
knee comfort  I put a soft pillow pressure complain
underneath the on the ing of
affected knee. knee. severe
 Cold compress  To pain.
on the affected knee relief
was applied. pressure.
 Analgesia as  To
prescribed was reduce
given. blood
flow to
the area
by
constricti
ng the
blood
vessels.
 To
block the
pain
receptors.
Restlessn To  Nursed patient in  To  Patient
promote a quite environment allow was able
ess rest  Relieved the pain patient to rest.
by carrying the rest.
measures as  To
prescribed. avoid
 Reduced fever by unnecess
carrying the ary
prescribed nursing disturban
measures. ces.
 All nursing
procedures carried
out collectively to
promote rest.
 Administered
sedatives as
prescribed.

13

PROBL NURSIN OBJECTI NURSING RATIONA EXPECT

EM G VE INTERVENTION LE ED
DIAGN OUTCO
OSIS ME

Risk of To prevent  I encouraged  To  Patient

developi developme patient to do active promote no
ng knee nt of knee exercises. limb longer at
stiffness. stiffness.  I involved the mobilizati risk of
physiotherapist to on developi
carry out passive ng
exercises. complica
 I encouraged tion. She
movements. was able
 I encouraged to use
frequent change of the limb.
position.
Knowled To  Assessed  To  Patient
ge deficit increase understanding of gain was able
regardin knowledge the condition. cooperatio to ask
g about  Explained the n. question
condition condition condition in simple  For s about
and and terms. clarificatio the
treatment related  Advised about n conditio
treatment. the treatment n.
involved e.g.  Verbaliz
mobilization of the es plans
knee. and
 Provided oral worries.
and written
information about
the knee and its
function.
 Nursing care plans for Diabetes Mellitus

No Nursi Outc Nursing Intervention/Rationale Evaluation

ng ome
Diag
nosis
1 Imbalanced Nutrit  Assess current timing and content of meals. Maintains ideal
Nutrition: ion  Advise patient on the importance of an individualized body weight with
More than balan meal plan in meeting weight-loss goals. Reducing body mass index
Body ce intake of carbohydrates may benefit some patients; less than 25
Requirement betwe however, fad diets or diet plans that stress one food
s related to en group and eliminate another are generally not
intake in needs recommended.
excess of and  Discuss the goals of dietary therapy for the patient.
activity intak Setting a goal of a 10% (of patient‘s actual body
expenditures e weight) weight loss over several months is usually
achievable and effective in reducing blood sugar and
other metabolic parameters.
 Assist patient to identify problems that may have an
impact on dietary adherence and possible solutions to
these problems. Emphasize that lifestyle changes
should be maintainable for life.
 Explain the importance of exercise in
maintaining/reducing body weight.
o Caloric expenditure for energy in exercise
o Carryover of enhanced metabolic rate and
efficient food utilization
  Assist patient to establish goals for weekly weight loss
and incentives to assist in achieving them.
 Strategize with patient to address the potential social
pitfalls of weight reduction.

2 Fear related Fear  Assist patient to reduce fear of injection by Demonstrates self-
to insulin less or encouraging verbalization of fears regarding insulin injection of insulin
injection discre injection, conveying a sense of empathy, and with minimal fear
ase identifying supportive coping techniques.
 Demonstrate and explain thoroughly the procedure for
insulin self-injection
 Help patient to master technique by taking a step-by-
step approach.
o Allow patient time to handle insulin and syringe
to become familiar with the equipment.
o Teach self-injection first to alleviate fear of pain
from injection.
o Instruct patient in filling syringe when he or she
expresses confidence in self-injection procedure.
 Review dosage and time of injections in relation to
meals, activity, and bedtime based on patient‘s
individualized insulin regimen.

3 Risk for Injury  Closely monitor blood glucose levels to detect Hypoglycemia
Injury is not hypoglycemia. identified and
(hypoglyc appea  Instruct patient in the importance of accuracy in treated
emia) rs insulin preparation and meal timing to avoid appropriately
related to hypoglycemia.
effects of  Assess patient for the signs and symptoms of
insulin, hypoglycemia.
inability to o Adrenergic (early symptoms) sweating, tremor,
eat pallor, tachycardia, palpitations, nervousness
from the release of adrenalin when blood glucose
falls rapidly
o Neurologic (later symptoms) light-headedness,
headache, confusion, irritability, slurred speech,
lack of coordination, staggering gait from
depression of central nervous system as glucose
level progressively falls
 Treat hypoglycemia promptly with 15 to 20 g of fast-
acting carbohydrates.

 Encourage patient to carry a portable treatment for

hypoglycemia at all times.
 Assess patient for cognitive or physical impairments
that may interfere with ability to accurately administer
insulin.

Between-meal snacks as well as extra food taken before

exercise should be encouraged to prevent hypoglycemia.

Encourage patients to wear an identification bracelet or

card that may assist in prompt treatment in a hypoglycemic
emergency.

Encourage patient to carry a portable treatment for

hypoglycemia at all times.

Assess patient for cognitive or physical impairments that

may interfere with ability to accurately administer insulin.

Between-meal snacks as well as extra food taken before

exercise should be encouraged to prevent hypoglycemia.

Encourage patients to wear an identification bracelet or

 card that may assist in prompt treatment in a hypoglycemic
emergency.
4 Activity Norm Advise patient to assess blood glucose level before and Exercises daily
Intoleranc al after strenuous exercise.
e related to Activi
Instruct patient to plan exercises on a regular basis each
poor ty is
day.
glucose appea
control rs Encourage patient to eat a carbohydrate snack before
exercising to avoid hypoglycemia.

Advise patient that prolonged strenuous exercise may

require increased food at bedtime to avoid nocturnal
hypoglycemia.

Instruct patient to avoid exercise whenever blood glucose

levels exceed 250 mg/day and urine ketones are present.
Patient should contact health care provider if levels remain
elevated.

Counsel patient to inject insulin into the abdominal site on

days when arms or legs are exercised.
5 Deficient Know Assess level of knowledge of disease and ability to care Verbalizes
Knowledg ledge for self appropriate use and
e related to is action of oral
Assess adherence to diet therapy, monitoring procedures,
use of oral suffici hypoglycemic
medication treatment, and exercise regimen
hypoglyce ent agents
mic agents Assess for signs of hyperglycemia: polyuria, polydipsia,
polyphagia, weight loss, fatigue, blurred vision

Assess for signs of hypoglycemia: sweating, tremor,

nervousness, tachycardia, light-headedness, confusion

Perform thorough skin and extremity assessment for

 peripheral neuropathy or peripheral vascular disease and
any injury to the feet or lower extremities

Assess for trends in blood glucose and other laboratory

results

Make sure that appropriate insulin dosage is given at the

right time and in relation to meals and exercise

Make sure patient has adequate knowledge of diet,

exercise, and medication treatment

Immediately report to health care provider any signs of

skin or soft tissue infection (redness, swelling, warmth,
tenderness, drainage)

Get help immediately for signs of hypoglycemia that do

not respond to usual glucose replacement

Get help immediately for patient presenting with signs of

either ketoacidosis (nausea and vomiting, Kussmaul
respirations, fruity breath odor, hypotension, and altered
level of consciousness) or hyperosmolar hyperglycemic
nonketotic syndrome (nausea and vomiting, hypothermia,
muscle weakness, seizures, stupor, coma).
6 Risk for Impai Assess feet and legs for skin temperature, sensation, soft No skin breakdown
Impaired red tissue injuries, corns, calluses,dryness, hammer toe or
Skin Skin bunion deformation, hair distribution, pulses, deep tendon
Integrity Integr reflexes.
related to ity is
Maintain skin integrity by protecting feet from breakdown.
decreased not
sensation appea o Use heel protectors, special mattresses, foot

and ring cradles for patients on bed rest.

 circulation o Avoid applying drying agents to skin (eg,
to lower alcohol).
extremities o Apply skin moisturizers to maintain suppleness
and prevent cracking and fissures.

Instruct patient in foot care guidelines

Advise the patient who smokes to stop smoking or reduce

if possible, to reduce vasoconstriction and enhance
peripheral blood flow. Help patient to establish behavior
modification techniques to eliminate smoking in the
hospital and to continue them at home for smoking-
cessation program.
7 Ineffective Effect Discuss with the patient the perceived effect of diabetes on Verbalizes initial
Coping ive lifestyle, finances, family life, occupation. strategies for
related to copin coping with
Explore previous coping strategies and skills that have had
chronic g diabetes
positive effects.
disease
and Encourage patient and family participation in diabetes self-

complex care regimen to foster confidence.

self-care  Identify available support groups to assist in lifestyle

regimen adaptation.
 Assist family in providing emotional support.

Nursing Care Plans for AIDS (HIV Positive)

Acquired immunodeficiency syndrome (AIDS) is a serious secondary
immunodeficiency disorder caused by the retrovirus, human immunodeficiency virus
(HIV). Both diseases are characterized by the progressive destruction of cell-mediated
(T-cell) immunity with subsequent effects on humoral (B-cell) immunity because of
the pivotal role of the CD4+helper T cells in immune reactions. Immunodeficiency
makes the patient susceptible to opportunistic infections, unusual cancers, and other
abnormalities.
AIDS results from the infection of HIV which has two forms: HIV-1 and HIV-2. Both
forms have the same model of transmission and similar opportunistic infections
associated with AIDS, but studies indicate that HIV-2 develops more slowly and
presents with milder symptoms than HIV-1. Transmission occurs through contact with
infected blood or body fluids and is associated with identifiable high-risk behaviors.
Persons with HIV/AIDS have been found to fall into five general categories: (1)
homosexual or bisexual men, (2) injection drug users, (3) recipients of infected blood
or blood products, (4) heterosexual partners of a person with HIV infection, and (5)
children born to an infected mother. The rate of infection is most rapidly increasing
among minority women and is increasingly a disease of persons of color.
Nursing Care Plans
There is no cure yet for either HIV or AIDS. However, significant advances have been
made to help patients control signs and symptoms and impair disease progression.
In this post, are 13 AIDS/HIV Positive Nursing Care Plans (NCP):
1. Imbalanced Nutrition: Less Than Body Requirements

Imbalanced Nutrition: Less Than Body Requirements: Intake of nutrients

insufficient to meet metabolic needs.
May be related to

 - Inability or altered ability to ingest, digest and/or metabolize nutrients:

nausea/vomiting, hyperactive gag reflex, intestinal disturbances, GI tract
infections, fatigue
  - Increased metabolic rate/nutritional needs (fever/infection)

Possibly evidenced by

 - Weight loss, decreased subcutaneous fat/muscle mass (wasting)

 - Lack of interest in food, aversion to eating, altered taste sensation
 - Abdominal cramping, hyperactive bowel sounds, diarrhea
 - Sore, inflamed buccal cavity
 - Abnormal laboratory results: vitamin/mineral and protein deficiencies,
electrolyte imbalances

Desired Outcomes

 - Maintain weight or display weight gain toward desired goal.

 - Demonstrate positive nitrogen balance, be free of signs of malnutrition, and
display improved energy level.

Nursing Interventions Rationale

Lesions of the mouth, throat, and

esophagus (often caused by
candidiasis, herpes simplex, hairy
leukoplakia, Kaposi‘s sarcoma other
Assess patient‘s ability to chew, taste,
cancers) and metallic or other taste
and swallow.
changes caused by medications may
cause dysphagia, limiting patient‘s
ability to ingest food and reducing
desire to eat.

Hypermotility of intestinal tract is

common and is associated with
Auscultate bowel sounds. vomiting and diarrhea, which may
affect choice of diet/route. Lactose
intolerance and malabsorption (with
 Nursing Interventions Rationale

CMV, MAC, cryptosporidiosis)

contribute to diarrhea and may
necessitate change in diet or
supplemental formula.

Indicator of nutritional adequacy of

Weigh as indicated. Evaluate weight
intake. Because of depressed
in terms of premorbid weight.
immunity, some blood tests normally
Compare serial weights and
used for testing nutritional status are
anthropometric measurements.
not useful.

Medications used can have side effects

affecting nutrition. ZDV can cause
altered taste, nausea and vomiting;
Bactrim can cause anorexia, glucose
Note drug side effects. intolerance and glossitis; Pentam can
cause altered taste and smell; Protease
inhibitors can cause elevated lipids,
blood sugar increase due to insulin
resistance.

Plan diet with patient and include SO,

Including patient in planning gives
suggesting foods from home if
sense of control of environment and
appropriate. Provide small, frequent
may enhance intake. Fulfilling
meals and snacks of nutritionally
cravings for noninstitutional food may
dense foods and non acidic foods and
also improve intake. In this population,
beverages, with choice of foods
foods with a higher fat content may be
palatable to patient. Encourage high-
recommended as tolerated to enhance
calorie and nutritious foods, some of
taste and oral intake.
which may be considered appetite
 Nursing Interventions Rationale

stimulants. Note time of day when

appetite is best, and try to serve larger
meal at that time.

Limit food(s) that induce nausea

and/or vomiting or are poorly
Pain in the mouth or fear of irritating
tolerated by patient because of mouth
oral lesions may cause patient to be
sores or dysphagia. Avoid serving
reluctant to eat. These measures may
very hot liquids and foods. Serve
be helpful in increasing food intake.
foods that are easy to swallow like
eggs, ice cream, cooked vegetables.

Schedule medications between meals

(if tolerated) and limit fluid intake Gastric fullness diminishes appetite
with meals, unless fluid has and food intake.
nutritional value.

Encourage as much physical activity May improve appetite and general

as possible. feelings of well-being.

Reduces discomfort associated with

Provide frequent mouth care,
nausea and vomiting, oral lesions,
observing secretion precautions.
mucosal dryness, and halitosis. Clean
Avoid alcohol-containing
mouth may enhance appetite and
mouthwashes.
provide comfort.

Minimizes fatigue; increases energy

Provide rest period before meals.
available for work of eating and
Avoid stressful procedures close to
reduces chances of nausea or vomiting
mealtime.
food.

Remove existing noxious Reduces stimulus of the vomiting

 Nursing Interventions Rationale

environmental stimuli or conditions center in the medulla.

that aggravate gag reflex.

Facilitates swallowing and reduces risk

Encourage patient to sit up for meals
of aspiration.

Identifies need for supplements or

Record ongoing caloric intake.
alternative feeding methods.

Maintain NPO status when May be needed to reduce nausea and

appropriate. vomiting.

May be needed to reduce vomiting or

to administer tube feedings.
Esophageal irritation from existing
Insert or maintain nasogastric (NG)
infection (Candida, herpes, or KS) may
tube as indicated.
provide site for secondary infections
and trauma; therefore, NG tube should
be used with caution.

Administer medications as indicated:

 Antiemetics: prochlorperazine
Reduces incidence of nausea and
(Compazine), promethazine
vomiting, possibly enhancing oral
(Phenergan), trimethobenzamide
intake.
(Tigan)

Given with meals (swish and hold in

 - Sucralfate (Carafate)
mouth) to relieve mouth pain, enhance
suspension; mixture of Maalox,
intake. Mixture may be swallowed for
diphenhydramine (Benadryl),
presence of pharyngeal or esophageal
and lidocaine (Xylocaine);
lesions.
 Nursing Interventions Rationale

Corrects vitamin deficiencies resulting

from decreased food intake and/or
disorders of digestion and absorption
 - Vitamin supplements in the GI system. Avoid megadoses
and suggested supplemental level is
two times the recommended daily
allowance (RDA).
Marinol (an antiemetic)
and Megace (an antineoplastic) act as
 Appetite stimulants: dronabinol appetite stimulants in the presence of
(Marinol), megestrol (Megace), AIDS. Oxandrin is currently being
oxandrolone (Oxandrin) studied in clinical trials to boost
appetite and improve muscle mass and
strength.
Reduces elevated levels of tumor
necrosis factor (TNF) present in
 TNF-alpha inhibitors: chronic illness contributing to wasting
thalidomide; or cachexia. Studies reveal a mean
weight gain of 10% over 28 wk of
therapy.
Inhibit GI motility subsequently
 Antidiarrheals: diphenoxylate decreasing diarrhea. Imodium or
(Lomotil), loperamide Sandostatin are effective treatments for
(Imodium), octreotide secretory diarrhea (secretion of water
(Sandostatin); and electrolytes by intestinal
epithelium).
 Antibiotic May be given to treat and prevent
therapy: ketoconazole (Nizoral), infections involving the GI tract.
 Nursing Interventions Rationale

fluconazole (Diflucan).

2. Fatigue

Fatigue: An overwhelming, sustained sense of exhaustion and decreased capacity for

physical and mental work at usual level.
May be related to

 - Decreased metabolic energy production, increased energy requirements

 (hypermetabolic state)
 - Overwhelming psychological/emotional demands
 - Altered body chemistry: side effects of medication, chemotherapy

Possibly evidenced by

 - Unremitting/overwhelming lack of energy, inability to maintain usual routines,

decreased performance, impaired ability to concentrate, lethargy/listlessness
 - Disinterest in surroundings

Desired Outcomes

 - Report improved sense of energy.

 - Perform ADLs, with assistance as necessary.
 - Participate in desired activities at level of ability

Nursing Interventions Rationale

Multiple factors can aggravate fatigue,

Assess sleep patterns and note including sleep deprivation, emotional
changes in thought processes and distress, side effects of drugs and
behavior. chemotherapies, and developing CNS
disease.
 Nursing Interventions Rationale

Planning allows patient to be active

Recommend scheduling activities
during times when energy level is
for periods when patient has most
higher, which may restore a feeling of
energy. Plan care to allow for rest
well-being and a sense of control.
periods. Involve patient and SO in
Frequent rest periods are needed to
schedule planning.
restore or conserve energy.

Provides for a sense of control and

Establish realistic activity goals feelings of accomplishment. Prevents
with patient. discouragement from fatigue of
overactivity.

Encourage patient to do whatever May conserve strength, increase

possible: self-care, sit in chair, short stamina, and enable patient to become
walks. Increase activity level as more active without undue fatigue and
indicated. discouragement.

Identify energy conservation

techniques: sitting, breaking ADLs Weakness may make ADLs almost
into manageable segments. Keep impossible for patient to complete.
travel ways clear of furniture. Protects patient from injury during
Provide or assist with ambulation activities.
and self-care needs as appropriate.

Tolerance varies greatly, depending on

the stage of the disease process,
Monitor physiological response to
nutrition state, fluid balance, and
activity: changes in BP, respiratory
number or type of opportunistic
rate, or heart rate.
diseases that patient has been subject
to.
 Nursing Interventions Rationale

Adequate intake or utilization of

nutrients is necessary to meet
increased energy needs for activity.
Encourage nutritional intake.
Continuous stimulation of the immune
system by HIV infection contributes to
a hypermetabolic state.

Programmed daily exercises and

Refer to physical and/or activities help patient maintain and
occupational therapy. increase strength and muscle tone,
enhance sense of well-being.

Provides assistance in areas of

Refer to community resources individual need as ability to care for
self becomes more difficult.

Presence of anemia or hypoxemia

Provide supplemental O2 as
reduces oxygen available for cellular
indicated.
uptake and contributes to fatigue.

3. Acute/Chronic Pain

Acute Pain: Unpleasant sensory and emotional experience arising from actual or
potential tissue damage or described in terms of such damage; sudden or slow onset of
any intensity from mild to severe with anticipated or predictable end and a duration of
<6 months.
Nursing Diagnosis

 - Acute Pain
 - Chronic Pain

May be related to
  - Tissue inflammation/destruction: infections, internal/external cutaneous lesions,
rectal excoriation, malignancies, necrosis
 - Peripheral neuropathies, myalgias, and arthralgias
 - Abdominal cramping

Possibly evidenced by

 - Reports of pain
 - Self-focusing; narrowed focus, guarding behaviors
 - Alteration in muscle tone; muscle cramping, ataxia, muscle weakness,
paresthesias, paralysis
 - Autonomic responses; restlessness

Desired Outcomes

 - Report pain relieved/controlled.

 - Demonstrate relaxed posture/facial expression.
 - Be able to sleep/rest appropriately.

Nursing Interventions Rationale

Indicates need for or effectiveness of

Assess pain reports, noting
interventions and may signal
location, intensity (0–10 scale),
development or resolution of
frequency, and time of onset. Note
complications. Chronic pain does not
nonverbal cues like restlessness,
produce autonomic changes; however,
tachycardia, grimacing.
acute and chronic pain can coexist.

Instruct and encourage patient to Efficacy of comfort measures and

report pain as it develops rather medications is improved with timely
than waiting until level is severe. intervention.

Encourage verbalization of Can reduce anxiety and fear and

feelings. thereby reduce perception of intensity
 Nursing Interventions Rationale

of pain.

Provide diversional activities:

Refocuses attention; may enhance
provide reading materials, light
coping abilities.
exercising, visiting, etc.

Perform palliative measures:

Promotes relaxation and decreases
repositioning, massage, ROM of
muscle tension.
affected joints.

Promotes relaxation and feeling of

well-being. May decrease the need for
Instruct and encourage use of narcotic analgesics (CNS depressants)
visualization, guided imagery, when a neuro/motor degenerative
progressive relaxation, deep- process is already involved. May not
breathing techniques, meditation, be successful in presence of dementia,
and mindfulness. even when dementia is minor.
Mindfulness is the skill of staying in
the here and now.

Oral ulcerations and lesions may cause

Provide oral care.
severe discomfort.

Apply warm or moist packs to

These injections are known to cause
pentamidine injection and IV sites
pain and sterile abscesses
for 20 min after administration.

Administer analgesics and/or Provides relief of pain and discomfort;

antipyretics, narcotic analgesics. reduces fever. PCA or around-the-
Use patient-controlled analgesia clock medication keeps the blood level
(PCA) or provide around-the-clock of analgesia stable, preventing cyclic
analgesia with rescue doses prn. undermedication or overmedication.
 Nursing Interventions Rationale

Drugs such as Ativan may be used to

potentiate effects of analgesics.

4. Impaired Skin Integrity

Impaired Skin Integrity: Altered epidermis and/or dermis.

Risk factors may include

 - Decreased level of activity/immobility, altered sensation, skeletal prominence,

changes in skin turgor
 - Malnutrition, altered metabolic state

May be related to (actual)

 - Immunologic deficit: AIDS-related dermatitis; viral, bacterial, and fungal

infections (e.g., herpes, Pseudomonas, Candida); opportunistic disease processes
(e.g., KS)
 - Excretions/secretions

Possibly evidenced by

 - Skin lesions; ulcerations; decubitus ulcer formation

Desired Outcomes

 - Be free of/display improvement in wound/lesion healing.

 - Demonstrate behaviors/techniques to prevent skin breakdown/promote healing.

Nursing Interventions Rationale

Assess skin daily. Note color,

Establishes comparative baseline
turgor, circulation, and sensation.
providing opportunity for timely
Describe and measure lesions and
intervention.
observe changes. Take photographs
 Nursing Interventions Rationale

if necessary.

Maintaining clean, dry skin provides a

barrier to infection. Patting skin dry
instead of rubbing reduces risk of
Maintain and instruct in good skin
dermal trauma to dry and fragile skin.
hygiene: wash thoroughly, pat dry
Massaging increases circulation to the
carefully, and gently massage with
skin and promotes comfort. Isolation
lotion or appropriate cream.
precautions are required when
extensive or open cutaneous lesions
are present.

Reposition frequently. Use turn

sheet as needed. Encourage periodic Reduces stress on pressure points,
weight shifts. Protect bony improves blood flow to tissues, and
prominences with pillows, heel and promotes healing.
elbow pads, sheepskin.

Skin friction caused by wet or

Maintain clean, dry, wrinkle-free wrinkled or rough sheets leads to
linen, preferably soft cotton fabric. irritation of fragile skin and increases
risk for infection.

Decreases pressure on skin from

Encourage ambulation as tolerated.
prolonged bedrest.

Cleanse perianal area by removing

Prevents maceration caused by
stool with water and mineral oil or
diarrhea and keeps perianal lesions
commercial product. Avoid use of
dry. Use of toilet paper may abrade
toilet paper if vesicles are present.
lesions.
Apply protective creams: zinc
 Nursing Interventions Rationale

oxide, A & D ointment.

Long and rough nails increase risk of

File nails regularly.
dermal damage.

Cover open pressure ulcers with

sterile dressings or protective May reduce bacterial contamination,
barrier: Tegaderm, DuoDerm, as promote healing.
indicated.

Provide foam, flotation, alternate Reduces pressure on skin, tissue, and

pressure mattress or bed. lesions, decreasing tissue ischemia.

Obtain cultures of open skin Identifies pathogens and appropriate

lesions. treatment choices.

Used in treatment of skin lesions. Use

of agents such as Prederm spray can
Apply and administer medications stimulate circulation, enhancing
as indicated. healing process. When multidose
ointments are used, care must be taken
to avoid cross-contamination.

Cover ulcerated KS lesions with

wet-to-wet dressings or antibiotic Protects ulcerated areas from
ointment and nonstick dressing, as contamination and promotes healing
indicated.

Refer to physical therapy for regular Promotes improved muscle tone and
exercise and activity program. skin health.

5. Impaired Oral Mucous Membrane

Impaired Oral Mucous Membrane: Disruptions of the lips and soft tissues of the
oral cavity
May be related to

 - Immunologic deficit and presence of lesion-causing pathogens, e.g., Candida,

herpes, KS
 - Dehydration, malnutrition
 - Ineffective oral hygiene
 - Side effects of drugs, chemotherapy

Possibly evidenced by

 - Open ulcerated lesions, vesicles

 - Oral pain/discomfort
 - Stomatitis; leukoplakia, gingivitis, carious teeth

Desired Outcomes

 - Display intact mucous membranes, which are pink, moist, and free of
inflammation/ulcerations.
 - Demonstrate techniques to restore/maintain integrity of oral mucosa.

Nursing Interventions Rationale

Assess mucous membranes and Edema, open lesions, and crusting on

document all oral lesions. Note oral mucous membranes and throat
reports of pain, swelling, difficulty may cause pain and difficulty with
with chewing and swallowing. chewing and swallowing.

Provide oral care daily and after

Alleviates discomfort, prevents acid
food intake, using soft toothbrush,
formation associated with retained food
non abrasive toothpaste, non
particles, and promotes feeling of well-
alcohol mouthwash, floss, and lip
being.
moisturizer.
 Nursing Interventions Rationale

Rinse oral mucosal lesions with Reduces spread of lesions and

saline and dilute hydrogen peroxide encrustations from candidiasis, and
or baking soda solutions. promotes comfort.

Suggest use of sugarless gum and Stimulates flow of saliva to neutralize

candy. acids and protect mucous membranes.

Abrasive foods may open healing

Plan diet to avoid salty, spicy,
lesions. Open lesions are painful and
abrasive, and acidic foods or
aggravated by salt, spice, acidic foods
beverages. Check for temperature
or beverages. Extreme cold or heat can
tolerance of foods. Offer cool or
cause pain to sensitive mucous
cold smooth foods.
membranes.

Encourage oral intake of at least Maintains hydration and prevents

2500 mL/day. drying of oral cavity.

Encourage patient to refrain from Smoke is drying and irritating to

smoking. mucous membranes.

Obtain culture specimens of Reveals causative agents and identifies

lesions. appropriate therapies.

Administer medications, as indicated:

Specific drug choice depends on

 - nystatin (Mycostatin),
particular infecting organism(s) like
ketoconazole (Nizoral).
Candida.
 - TNF-alpha inhibitor, e.g., Effective in treatment of oral lesions
thalidomide. due to recurrent stomatitis.

Refer for dental consultation, if May require additional therapy to

appropriate. prevent dental losses.
6. Disturbed Thought Process

Disturbed Thought Process: A state in which individual experiences a disruption in

cognitive operations and activities.
May be related to

 - Hypoxemia, CNS infection by HIV, brain malignancies, and/or disseminated

systemic opportunistic infection, cerebrovascular accident (CVA)/hemorrhage;
vasculitis
 - Alteration of drug metabolism/excretion, accumulation of toxic elements; renal
failure, severe electrolyte imbalance, hepatic insufficiency

Possibly evidenced by

 - Altered attention span; distractibility

 - Memory deficit
 - Disorientation; cognitive dissonance; delusional thinking
 - Sleep disturbances
 - Impaired ability to make decisions/problem-solve; inability to follow complex
commands/mental tasks, loss of impulse control

Desired Outcomes

 - Maintain usual reality orientation and optimal cognitive functioning.

Nursing Interventions Rationale

Establishes functional level at time of

Assess mental and neurological
admission and provides baseline for
status using appropriate tools.
future comparison.

Consider effects of emotional May contribute to reduced alertness,

distress. Assess for anxiety, grief, confusion, withdrawal, and
anger. hypoactivity, requiring further
 Nursing Interventions Rationale

evaluation and intervention.

Actions and interactions of various

medications, prolonged drug half-life
and/or altered excretion rates result in
cumulative effects, potentiating risk of
Monitor medication regimen and
toxic reactions. Some drugs may have
usage.
adverse side effects: haloperidol
(Haldol) can seriously impair motor
function in patients with AIDS
dementia complex.

Changes may occur for numerous

Investigate changes in personality,
reasons, including development or
response to stimuli, orientation and
exacerbation of opportunistic diseases
level of consciousness; or
or CNS infection. Early detection and
development of headache, nuchal
treatment of CNS infection may limit
rigidity, vomiting, fever, seizure
permanent impairment of cognitive
activity.
ability.

Maintain a pleasant environment Providing normal environmental

with appropriate auditory, visual, stimuli can help in maintaining some
and cognitive stimuli. sense of reality orientation.

Provide cues for reorientation. Put

radio, television, calendars, clocks, Frequent reorientation to place and
room with an outside view if time may be necessary, especially
necessary. Use patient‘s name. during fever and/or acute CNS
Identify yourself. Maintain involvement. Sense of continuity may
consistent personnel and structured reduce associated anxiety.
schedules as appropriate.
 Nursing Interventions Rationale

Discuss use of datebooks, lists,

These techniques help patient manage
other devices to keep track of
problems of forgetfulness.
activities.

Encourage family and SO to Familiar contacts are often helpful in

socialize and provide reorientation maintaining reality orientation,
with current news, family events. especially if patient is hallucinating.

Encourage patient to do as much as

Can help maintain mental abilities for
possible: dress and groom daily, see
longer period.
friends, and so forth.

Bizarre behavior and/or deterioration

of abilities may be very frightening for
SO and makes management of care or
Provide support for SO. Encourage
dealing with situation difficult. SO
discussion of concerns and fears
may feel a loss of control as stress,
anxiety, burnout, and anticipatory
grieving impair coping abilities.

Can reduce anxiety and fear of

Provide information about care on
unknown. Can enhance patient‘s
an ongoing basis. Answer questions
understanding and involvement and
simply and honestly. Repeat
cooperation in treatment when
explanations as needed.
possible.

Reduce provocative and noxious If patient is prone to agitation, violent

stimuli. Maintain bed rest in quiet, behavior, or seizures, reducing
darkened room if indicated. external stimuli may be helpful.

Promotes sleep, reducing cognitive

Decrease noise, especially at night.
symptoms and effects of sleep
 Nursing Interventions Rationale

deprivation.

Maintain safe environment: excess

furniture out of the way, call bell
within patient‘s reach, bed in low
Provides sense of security and stability
position and rails up; restriction of
in an otherwise confusing situation.
smoking (unless monitored by
caregiver/SO), seizure precautions,
soft restraints if indicated.

Discuss causes or future

Obtaining information that ZDV has
expectations and treatment if
been shown to improve cognition can
dementia is diagnosed. Use concrete
provide hope and control for losses.
terms.

Administer medications as indicated:

 - ZDV (Retrovir) and other Shown to improve neurological and

antiretrovirals alone or in mental functioning for undetermined
combination period of time.

Cautious use may help with problems

 Antipsychotics: haloperidol
of sleeplessness, emotional lability,
(Haldol), and/or antianxiety
hallucinations, suspiciousness, and
agents: lorazepam (Ativan).
agitation.
May help patient gain control in
Refer to counseling as indicated. presence of thought disturbances or
psychotic symptomatology.

7. Anxiety/Fear
Anxiety: Vague uneasy feeling of discomfort or dread accompanied by an autonomic
response.
Fear: Response to perceived threat that is consciously recognized as a danger.
May be related to

 - Threat to self-concept, threat of death, change in health/socioeconomic status,

role functioning
 - Interpersonal transmission and contagion
 - Separation from support system
 - Fear of transmission of the disease to family/loved ones

Possibly evidenced by

 - Increased tension, apprehension, feelings of helplessness/hopelessness

 - Expressed concern regarding changes in life
 - Fear of unspecific consequences
 - Somatic complaints, insomnia; sympathetic stimulation, restlessness

Desired Outcomes

 - Verbalize awareness of feelings and healthy ways to deal with them.

 - Display appropriate range of feelings and lessened fear/anxiety.
 - Demonstrate problem-solving skills.
 - Use resources effectively.

Nursing Interventions Rationale

Provides reassurance and opportunity

Assure patient of confidentiality
for patient to problem-solve solutions
within limits of situation.
to anticipated situations.

Maintain frequent contact with Provides assurance that patient is not

patient. Talk with and touch patient. alone or rejected; conveys respect for
Limit use of isolation clothing and and acceptance of the person, fostering
 Nursing Interventions Rationale

masks. trust.

Provide accurate, consistent

Can reduce anxiety and enable patient
information regarding prognosis.
to make decisions and choices based
Avoid arguing about patient‘s
on realities.
perceptions of the situation.

Patient may use defense mechanism of

denial and continue to hope that
diagnosis is inaccurate. Feelings of
Be alert to signs of withdrawal,
guilt and spiritual distress may cause
anger, or inappropriate remarks as
patient to become withdrawn and
these can be signs of indenial or
believe that suicide is a viable
depression. Determine presence of
alternative. Although patient may be
suicidal ideation and assess
too ―sick‖ to have enough energy to
potential on a scale of 1–10.
implement thoughts, ideation must be
taken seriously and appropriate
intervention initiated.

Provide open environment in which Helps patient feel accepted in present

patient feels safe to discuss feelings condition without feeling judged, and
or to refrain from talking. promotes sense of dignity and control.

Permit expressions of anger, fear,

despair without confrontation. Give
Acceptance of feelings allows patient
information that feelings are normal
to begin to deal with situation.
and are to be appropriately
expressed.

Recognize and support the stage Choice of interventions as dictated by

patient and/or family is at in the stage of grief, coping behaviors
 Nursing Interventions Rationale

grieving process.

Explain procedures, providing

opportunity for questions and Accurate information allows patient to
honest answers. Arrange for deal more effectively with the reality
someone to stay with patient during of the situation, thereby reducing
anxiety-producing procedures and anxiety and fear of the known.
consultations.

Identify and encourage patient Reduces feelings of isolation. If family

interaction with support systems. support systems are not available,
Encourage verbalization and outside sources may be needed
interaction with family/SO. immediately

Allows for better interpersonal

Provide reliable and consistent
interaction and reduction of anxiety
information and support for SO.
and fear.

Ensures a support system for patient,

and allows SO the chance to
Include SO as indicated when participate in patient‘s life. If patient,
major decisions are to be made. family, and SO are in conflict,
separate care consultations and
visiting times may be needed.

May assist patient or SO to plan

Discuss Advance Directives, end-
realistically for terminal stages and
of-life desires or needs. Review
death. Many individuals do not
specific wishes and explain various
understand medical terminology or
options clearly.
options,

Refer to psychiatric counseling May require further assistance in

 Nursing Interventions Rationale

(psychiatric clinical nurse dealing with diagnosis or prognosis,

specialist, psychiatrist, social especially when suicidal thoughts are
worker). present.

Provides opportunity for addressing

Provide contact with other
spiritual concerns. May help relieve
resources as indicated: Spiritual
anxiety regarding end-of-life care and
advisor or hospice staff
support for patient/SO.

8. Social Isolation

Social Isolation: Aloneness experienced by the individual and perceived as imposed

by others and as a negative or threatening state.
May be related to

 - Altered state of wellness, changes in physical appearance, alterations in mental

status
 - Perceptions of unacceptable social or sexual behavior/values
 - Inadequate personal resources/support systems
 - Physical isolation

Possibly evidenced by

 - Expressed feeling of aloneness imposed by others, feelings of rejection

 - Absence of supportive SO: partners, family, acquaintances/friends

Desired Outcomes

 - Identify supportive individual(s).

 - Use resources for assistance.
 - Participate in activities/programs at level of ability/desire.

Nursing Interventions Rationale

 Nursing Interventions Rationale

Isolation may be partly self-imposed

Ascertain patient‘s perception of
because patient fears
situation.
rejection/reaction of others.

Spend time talking with patient Patient may experience physical

during and between care activities. isolation as a result of current medical
Be supportive, allowing for status and some degree of social
verbalization. Treat with dignity isolation secondary to diagnosis of
and regard for patient‘s feelings. AIDS.

Reduces patient‘s sense of physical

Limit or avoid use of mask, gown, isolation and provides positive social
and gloves when possible and when contact, which may enhance self-
talking to patient. esteem and decrease negative
behaviors.

When patient has assistance from SO,

feelings of loneliness and rejection are
Identify support systems available diminished. Patient may not receive
to patient, including presence of usual or needed support for coping
and/or relationship with immediate with life-threatening illness and
and extended family. associated grief because of fear and
lack of understanding (AIDS
hysteria).

Gloves, gowns, mask are not routinely

required with a diagnosis of AIDS
Explain isolation precautions and except when contact with secretions
procedures to patient and SO. or excretions is expected. Misuse of
these barriers enhances feelings of
emotional and physical isolation.
 Nursing Interventions Rationale

When precautions are necessary,

explanations help patient understand
reasons for procedures and provide
feeling of inclusion in what is
happening.

Encourage open visitation (as able),

Participation with others can foster a
telephone contacts, and social
feeling of belonging.
activities within tolerated level.

Helps reestablish a feeling of

Encourage active role of contact participation in a social relationship.
with SO. May lessen likelihood of suicide
attempts.

Develop a plan of action with

Having a plan promotes a sense of
patient: Look at available resources;
control over own life and gives patient
support healthy behaviors. Help
something to look forward to and
patient problem-solve solution to
actions to accomplish.
short-term or imposed isolation.

Indicators of despair and suicidal

Be alert to verbal or nonverbal cues:
ideation are often present; when these
withdrawal, statements of despair,
cues are acknowledged by the
sense of aloneness. Ask patient if
caregiver, patient is usually willing to
thoughts of suicide are being
talk about thoughts of suicide and
entertained.
sense of isolation and hopelessness.

9. Powerlessness

Powerlessness: The lived experience of lack of control over a situation, including a

perception that one‘s actions do not significantly affect an outcome.
May be related to

 - Confirmed diagnosis of a potentially terminal disease, incomplete grieving

process
 - Social ramifications of AIDS; alteration in body image/desired lifestyle;
advancing CNS involvement

Possibly evidenced by

 - Feelings of loss of control over own life

 - Depression over physical deterioration that occurs despite patient compliance
with regimen
 - Anger, apathy, withdrawal, passivity
 - Dependence on others for care/decision making, resulting in resentment, anger,
guilt

Desired Outcomes

 - Acknowledge feelings and healthy ways to deal with them.

 - Verbalize some sense of control over present situation.
 - Make choices related to care and be involved in self-care.

Nursing Interventions Rationale

Patients with AIDS are usually aware

of the current literature and prognosis
unless newly diagnosed.
Identify factors that contribute to
Powerlessness is most prevalent in a
patient‘s feelings of powerlessness:
patient newly diagnosed with HIV and
diagnosis of a terminal illness, lack
when dying with AIDS. Fear of AIDS
of support systems, lack of
(by the general population and the
knowledge about present situation.
patient‘s family/SO) is the most
profound cause of patient‘s isolation.
For some homosexual patients, this
 Nursing Interventions Rationale

may be the first time that the family

has been made aware that patient lives
an alternative lifestyle.

Assess degree of feelings of

Determines the status of the individual
helplessness: verbal or nonverbal
patient and allows for appropriate
expressions indicating lack of
intervention when patient is
control, flat affect, lack of
immobilized by depressed feelings.
communication.

Encourage active role in planning

activities, establishing realistic and
May enhance feelings of control and
attainable daily goals. Encourage
self-worth and sense of personal
patient control and responsibility as
responsibility.
much as possible. Identify things
that patient can and cannot control.

Many factors associated with the

treatments used in this debilitating and
Encourage Living Will and durable
often fatal disease process place
medical power of attorney
patient at the mercy of medical
documents, with specific and
personnel and other unknown people
precise instructions regarding
who may be making decisions for and
acceptable and unacceptable
about patient without regard for
procedures to prolong life.
patient‘s wishes, increasing loss of
independence.

The individual can gain a sense of

Discuss desires and assist with completion and value to his or her life
planning for funeral as appropriate. when he or she decides to be involved
in planning this final ceremony. This
 Nursing Interventions Rationale

provides an opportunity to include

things that are of importance to the
person.

10. Deficient Knowledge

Deficient Knowledge: Absence or deficiency of cognitive information related to

specific topic.
May be related to

 - Lack of exposure/recall; information misinterpretation

 - Cognitive limitation
 - Unfamiliarity with information resources

Possibly evidenced by

 - Questions/request for information; statement of misconception

 - Inaccurate follow-through of instructions, development of preventable
complications

Desired Outcomes

 - Verbalize understanding of condition/disease process and potential

complications.
 - Identify relationship of signs/symptoms to the disease process and correlate
symptoms with causative factors.
 - Verbalize understanding of therapeutic needs.
 - Correctly perform necessary procedures and explain reasons for actions.
 - Initiate necessary lifestyle changes and participate in treatment regimen.

Nursing Interventions Rationale

Review disease process and future Provides knowledge base from which
 Nursing Interventions Rationale

expectations. patient can make informed choices.

Determine level of independence or

dependence and physical condition. Helps plan amount of care and
Note extent of care and support symptom management required and
available from family and SO and need for additional resources.
need for other caregivers.

Corrects myths and misconceptions;

Review modes of transmission of promotes safety for patient and others.
disease, especially if newly Accurate epidemiological data are
diagnosed. important in targeting prevention
interventions.

Instruct patient and caregivers

concerning infection control, using
good handwashing techniques for
everyone (patient, family,
caregivers); using gloves when
handling bedpans, dressings or
soiled linens; wearing mask if Reduces risk of transmission of
patient has productive cough; diseases; promotes wellness in
placing soiled or wet linens in presence of reduced ability of immune
plastic bag and separating from system to control level of flora.
family laundry, washing with
detergent and hot water; cleaning
surfaces with bleach and water
solution of 1:10 ratio, disinfecting
toilet bowl and bedpan with full-
strength bleach; preparing patient‘s
 Nursing Interventions Rationale

food in clean area; washing dishes

and utensils in hot soapy water (can
be washed with the family dishes).

Stress necessity of daily skin care,

including inspecting skin folds, Healthy skin provides barrier to
pressure points, and perineum, and infection. Measures to prevent skin
of providing adequate cleansing disruption and associated
and protective measures: ointments, complications are critical.
padding.

The oral mucosa can quickly exhibit

Ascertain that patient or SO can
severe, progressive complications.
perform necessary oral and dental
Studies indicate that 65% of AIDS
care. Review procedures as
patients have some oral symptoms.
indicated. Encourage regular dental
Therefore, prevention and early
care.
intervention are critical.

Review dietary needs (high-protein

Promotes adequate nutrition necessary
and high-calorie) and ways to
for healing and support of immune
improve intake when anorexia,
system; enhances feeling of well-
diarrhea, weakness, depression
being.
interfere with intake.

Enhances cooperation with or

Discuss medication regimen,
increases probability of success with
interactions, and side effects
therapeutic regimen.

Provide information about

Provides patient with increased sense
symptom management that
of control, reduces risk of
complements medical regimen;
embarrassment, and promotes comfort.
with intermittent diarrhea, take
 Nursing Interventions Rationale

diphenoxylate (Lomotil) before

going to social event.

Helps manage fatigue; enhances

Stress importance of adequate rest.
coping abilities and energy level.

Encourage activity and exercise at Stimulates release of endorphins in the

level that patient can tolerate. brain, enhancing sense of well-being.

Provides opportunity for altering

Stress necessity of continued
regimen to meet individual and
healthcare and follow-up.
changing needs.

Smoking increases risk of respiratory

Recommend cessation of smoking. infections and can further impair
immune system.

Identify signs and symptoms

requiring medical evaluation:
Early recognition of developing
persistent fever and night sweats,
complications and timely interventions
swollen glands, continued weight
may prevent progression to life-
loss, diarrhea, skin blotches and
threatening situation.
lesions, headache, chest pain and
dyspnea.

Identify community resources:

hospice and residential care centers, Facilitates transfer from acute care
visiting nurse, home care services, setting for recovery/independence or
Meals on Wheels, peer group end-of-life care.
support.

11. Risk for Injury

Risk for Injury: Vulnerable for injury as a result of environmental conditions
interacting with the individual‘s adaptive and defensive resources, which may
compromise health.
Risk factors may include

 - Abnormal blood profile: decreased vitamin K absorption, alteration in hepatic

function, presence of autoimmune antiplatelet antibodies, malignancies (KS),
and/or circulating endotoxins (sepsis)

Desired Outcomes

 - Display homeostasis as evidenced by absence of bleeding.

Nursing Interventions Rationale

Protects patient from procedure-

Avoid injections, rectal related causes of bleeding: insertion of
temperatures and rectal tubes. thermometers, rectal tubes can damage
Administer rectal suppositories with or tear rectal mucosa. Some
caution. medications need to be given via
suppository, so caution is advised.

Maintain a safe environment. Keep

all necessary objects and call bell Reduces accidental injury, which
within patient‘s reach and place bed could result in bleeding.
in low position.

Reduces possibility of injury, although

Maintain bed rest or chair rest when activity needs to be maintained. May
platelets are below 10,000 or as need to discontinue or reduce dosage
individually appropriate. Assess of a drug. Patient can have a
medication regimen. surprisingly low platelet count without
bleeding.

Hematest body fluids: urine, stool, Prompt detection of bleeding or

 Nursing Interventions Rationale

vomitus, for occult blood. initiation of therapy may prevent

critical hemorrhage.

Observe for or report epistaxis, Spontaneous bleeding may indicate

hemoptysis, hematuria, non development of DIC or immune
menstrual vaginal bleeding, or thrombocytopenia, necessitating
oozing from lesions or body orifices further evaluation and prompt
and/or IV insertion sites. intervention.

Monitor for changes in vital signs

Presence of bleeding and hemorrhage
and skin color: BP, pulse,
may lead to circulatory failure and
respirations, skin pallor and
shock.
discoloration.

Evaluate change in level of

May reflect cerebral bleeding.
consciousness.

Detects alterations in clotting

capability; identifies therapy needs.
Review laboratory studies: PT,
Many individuals (up to 80%) display
aPTT, clotting time, platelets,
platelet count below 50,000 and may
Hb/Hct.
be asymptomatic, necessitating regular
monitoring.

Transfusions may be required in the

Administer blood products as
event of persistent or massive
indicated.
spontaneous bleeding.

These medications reduce platelet

Avoid use of aspirin products and
aggregation, impairing and prolonging
NSAIDs, especially in presence of
the coagulation process, and may
gastric lesions.
cause further gastric irritation,
 Nursing Interventions Rationale

increasing risk of bleeding.

12. Risk for Deficient Fluid Volume

Risk for Deficient Fluid Volume: At risk of decreased intravascular, interstitial, and
intracellular fluid.
Risk factors may include

 - Excessive losses: copious diarrhea, profuse sweating, vomiting

 - Hypermetabolic state, fever
 - Restricted intake: nausea, anorexia; lethargy

Desired outcomes

 - Maintain hydration as evidenced by moist mucous membranes, good skin turgor,

stable vital signs, individually adequate urinary output.

Nursing Interventions Rationale

Monitor vital signs, including CVP

if available. Note hypotension, Indicators of circulating fluid volume.
including postural changes.

Around 97%, fever is one of the most

Note temperature elevation and
frequent symptoms experienced by
duration of febrile episode.
patients with HIV infections.
Administer tepid sponge baths as
Increased metabolic demands and
indicated. Keep clothing and linens
associated excessive diaphoresis result
dry. Maintain comfortable
in increased insensible fluid losses
environmental temperature.
and dehydration.

Assess skin turgor, mucous

Indirect indicators of fluid status.
membranes, and thirst.
 Nursing Interventions Rationale

Increased specific gravity and

Measure urinary output and specific decreasing urinary output reflects
gravity. Measure and estimate altered renal perfusion and circulating
amount of diarrheal loss. Note volume. Monitoring fluid balance is
insensible losses. difficult in the presence of excessive
GI and insensible losses.

Although weight loss may reflect

muscle wasting, sudden fluctuations
reflect state of hydration. Fluid losses
Weigh as indicated.
associated with diarrhea can quickly
create a crisis and become life-
threatening.

Maintains fluid balance, reduces

Monitor oral intake and encourage
thirst, and keeps mucous membranes
fluids of at least 2500 mL/day.
moist.

Make fluids easily accessible to

Enhances intake. Certain fluids may
patient; use fluids that are tolerable
be too painful to consume (acidic
to patient and that replace needed
juices) because of mouth lesions.
electrolytes

May help reduce diarrhea. Use of

Eliminate foods potentiating lactose-free products helps control
diarrhea diarrhea in the lactose-intolerant
patient.

Antibiotic therapies disrupt normal

Encourage use of live culture yogurt
bowel flora balance, leading to
or OTC Lactobacillus acidophilus
diarrhea. Must be taken 2 hr before or
(lactaid).
after antibiotic to prevent inactivation
 Nursing Interventions Rationale

of live culture.

May be necessary to support or

Administer fluids and electrolytes
augment circulating volume,
via feeding tube and IV, as
especially if oral intake is inadequate,
appropriate.
nausea and vomiting persists.

Alerts to possible electrolyte

Monitor laboratory studies as disturbances and determines
indicated: Serum or urine replacement [Link] renal
electrolytes; BUN/Cr; Stool perfusion and function. Bowel flora
specimen collection. changes can occur with multiple or
single antibiotic therapy.

May be necessary when other

Maintain hypothermia blanket if
measures fail to reduce excessive
used.
fever/insensible fluid losses.

13. Risk for Infection

Risk for Infection: At increased risk for being invaded by pathogenic organisms.
Risk factors may include

 - Inadequate primary defenses: broken skin, traumatized tissue, stasis of body

fluids
 - Depression of the immune system, chronic disease, malnutrition; use of
antimicrobial agents
 - Environmental exposure, invasive techniques

Possibly evidenced by

 - Not applicable. A risk diagnosis is not evidenced by signs and symptoms, as the
problem has not occurred and nursing interventions are directed at prevention.
Desired Outcomes:

 - Achieve timely healing of wounds/lesions.

 - Be afebrile and free of purulent drainage/secretions and other signs of infectious
conditions.
 - Identify/participate in behaviors to reduce risk of infection.

Nursing Interventions Rationale

Multiple medication regimen is difficult to

maintain over a long period of time.
Assess patient knowledge and ability to
Patients may adjust medication regimen
maintain opportunistic infection
based on side effects experienced,
prophylactic regimen.
contributing to inadequate prophylaxis,
active disease, and resistance.

Wash hands before and after all care

contacts. Instruct patient and SO to wash Reduces risk of cross-contamination.
hands as indicated.

Provide a clean, well-ventilated Reduces number of pathogens presented to

environment. Screen visitors and staff for the immune system and reduces possibility
signs of infection and maintain isolation of patient contracting a nosocomial
precautions as indicated. infection.

Discuss extent and rationale for isolation

Promotes cooperation with regimen and
precautions and maintenance of personal
may lessen feelings of isolation.
hygiene.

Provides information for baseline data;

frequent temperature elevations and onset
Monitor vital signs, including temperature. of new fever indicates that the body is
responding to a new infectious process or
that medications are not effectively
 Nursing Interventions Rationale

controlling incurable infections.

Respiratory congestion or distress may

indicate developing PCP; however, TB is
Assess respiratory rate and depth; note dry
on the rise and other fungal, viral, and
spasmodic cough on deep inspiration,
bacterial infections may occur that
changes in characteristics of sputum, and
compromise the respiratory system. CMV
presence of wheezes or rhonchi. Initiate
and PCP can reside together in the lungs
respiratory isolation when etiology of
and, if treatment is not effective for PCP,
productive cough is unknown.
the addition of CMV therapy may be
effective.

Neurological abnormalities are common

and may be related to HIV or secondary
infections. Symptoms may vary from
Investigate reports of headache, stiff neck, subtle changes in mood and sensorium
altered vision. Note changes in mentation (personality changes or depression) to
and behavior. Monitor for nuchal rigidity hallucinations, memory loss, severe
and seizure activity. dementias, seizures, and loss of vision.
CNS infections (encephalitis is the most
common) may be caused by protozoal and
helminthic organisms or fungus.

Oral candidiasis, KS, herpes, CMV, and

Examine skin and oral mucous membranes cryptococcosis are common opportunistic
for white patches or lesions. diseases affecting the cutaneous
membranes.

Clean patient‘s nails frequently. File, Reduces risk of transmission of pathogens

rather than cut, and avoid trimming through breaks in skin. Fungal infections
cuticles. along the nail plate are common.
 Nursing Interventions Rationale

Esophagitis may occur secondary to oral

Monitor reports of heartburn, dysphagia, candidiasis, CMV, or herpes.
retrosternal pain on swallowing, increased Cryptosporidiosis is a parasitic infection
abdominal cramping, profuse diarrhea. responsible for watery diarrhea (often
more than 15L/day).

Inspect wounds and site of invasive

Early identification and treatment of
devices, noting signs of local inflammation
secondary infection may prevent sepsis.
and infection.

Wear gloves and gowns during direct

contact with secretions and excretions or
any time there is a break in skin of Use of masks, gowns, and gloves is
caregiver‘s hands. Wear mask and required for direct contact with body
protective eyewear to protect nose, mouth, fluids, e.g., sputum, blood/blood products,
and eyes from secretions during semen, vaginal secretions.
procedures (suctioning) or when
splattering of blood may occur.

Prevents accidental inoculation of

caregivers. Use of needle cutters and
Dispose of needles and sharps in rigid, recapping is not to be practiced. Accidental
puncture-resistant containers. needlesticks should be reported
immediately, with follow-up evaluations
done per protocol.

Label blood bags, body fluid containers, Prevents cross-contamination and alerts
soiled dressings and linens, and package appropriate personnel and departments to
appropriately for disposal per isolation exercise specific hazardous materials
protocol. procedures.

Clean up spills of body fluids and/or blood Kills HIV and controls other
 Nursing Interventions Rationale

with bleach solution (1:10); add bleach to microorganisms on surfaces.

laundry.

14. Other Possible Nursing Care Plans

Other nursing diagnoses you can use for HIV/AIDS:

 Hopelessness—related to nature of condition and poor prognosis.

 Interrupted family process—may be related to the nature of AIDS condition,
role disturbance, and uncertain future.
 Chronic Sorrow—related to loss of body function and its effects on lifestyle.
 Risk for Caregiver Role Strain—may be related to multiple needs of ill person
and chronicity of the disease.

The following are associated with AIDS dementia:

 Impaired Environmental Interpretation Syndrome—may be related to

dementia, depression, possible evidenced by consistent disorientation, inability to
follow simple directions or instructions, loss of social functioning from memory
decline.
 Ineffective Protection—may be related to chronic disease affecting immune and
neurological systems, inadequate nutrition, drug therapies, possibly evidenced by
deficient immunity, impaired healing, neurosensory alterations, maladaptive stress
response, fatigue, anorexia or disorientation.

References and Sources : [Link]

 Nursing Care Plans

5 Leukemia Nursing Care Plans

Leukemia is a malignant proliferation of white blood cell precursors in bone

marrow or lymph tissue and their accumulation in peripheral blood, bone marrow,
and body tissues. The blood‘s cellular components originate primarily in the
marrow of bones such as the sternum, iliac crest, and cranium. All blood cells
begin as immature cells (blasts or stem cells) that differentiate and mature into
RBCs, platelets, and various types of WBCs. In leukemia, many immature or
ineffective WBCs crowd out the developing normal cells. As the normal cells are
replaced by leukemic cells, anemia, neutropenia, and thrombocytopenia occur.
Nursing Care Plans
The care plan for patients with leukemia should be emphasized on comfort,
minimize the adverse effects of chemotherapy, promote preservation of veins,
manage complications, and provide teaching and psychological support.
Here are five (5) nursing care plans (NCP) for leukemia:
1. Risk for Infection

Risk for Infection: At increased risk for being invaded by pathogenic organisms.
Risk factors may include

o - Inadequate secondary defenses: alterations in mature WBCs (low

granulocyte and abnormal lymphocyte count), increased number of immature
lymphocytes; immunosuppression, bone marrow suppression (effects of
therapy/transplant)
o - Inadequate primary defenses (stasis of body fluids, traumatized tissue)
 o - Invasive procedures
o - Malnutrition; chronic disease

Possibly evidenced by

o Not applicable. A risk diagnosis is not evidenced by signs and symptoms, as

the problem has not occurred and nursing interventions are directed at
prevention.

Desired Outcomes

o - Identify actions to prevent/reduce risk of infection.

o - Demonstrate techniques, lifestyle changes to promote safe environment,
achieve timely healing.

Nursing Interventions Rationale

Place in a private room. Limit

visitors as indicated. Prohibit live
plants or flowers. Restrict fresh
To protect the patient from potential
fruits and make sure they are
sources of pathogens or infection.
properly washed or peeled.
Bone marrow suppression,
Coordinate patient care so that
neutropenia, and chemotherapy places
leukemic patient doesn‘t come in
the patient at high risk for infection.
contact with staff who also care for
patients with infections or
infectious diseases.

Require good hand washing

Prevents cross-contamination and
protocol for all personnel and
reduces risk of infection.
visitors.

Closely monitor temperature. Note Although fever may accompany some

correlation between temperature forms of chemotherapy, progressive
elevations and chemotherapy hyperthermia occurs in some types of
 Nursing Interventions Rationale

treatments. Observe for fever infections, and fever (unrelated to

associated with tachycardia, drugs or blood products) occurs in
hypotension, subtle mental changes. most leukemia patients. Septicemia
may occur without fever.

Helps reduce fever, which contributes

Prevent chilling. Force fluids,
to fluid imbalance, discomfort, and
administer tepid sponge bath.
CNS complications.

Prevents stasis of respiratory

Encourage frequent turning and
secretions, reducing risk of atelectasis
deep breathing.
or pneumonia.

Auscultate breath sounds, noting

crackles, rhonchi. Inspect secretions
for changes in characteristics:
Early intervention is essential to
increased sputum production or
prevent sepsis in immuno-suppressed
change in sputum color. Observe
person.
urine for signs of infection: cloudy,
foul-smelling, or presence of
urgency or burning with voids.

Handle patient gently. Keep linens Prevents sheet burn and skin
dry and wrinkle-free. excoriation.

Inspect skin for tender,

May indicate local infection. Open
erythematous areas; open wounds.
wounds may not produce pus because
Cleanse skin with antibacterial
of insufficient number of granulocytes.
solutions.

Inspect oral mucous membranes. The oral cavity is an excellent medium

Provide good oral hygiene. Use a for growth of organisms and is
 Nursing Interventions Rationale

soft toothbrush, sponge, or swabs susceptible to ulceration and bleeding.

for frequent mouth care.

Avoid using indwelling urinary These can provide an avenue for

catheters and giving I.M. injections. infection.

Provide thorough skin care by

keeping the patient‘s skin and
perianal area clean, apply mild
lotion or creams to keep the skin Additional measures to avoid infection.
from drying or cracking.
Thoroughly clean skin before all
invasive skin procedures.

Change IV tubing according to your

facility‘s policy. Use strict sterile
technique and a metal scalp vein
needles (metal butterfly needle) IV sites can harbor infection.
when starting IV. If the patient Additional measure to avoid infection.
receives total parenteral nutrition,
give scrupulous subclavian catheter
care.

Promote good perianal hygiene.

Promotes cleanliness, reducing risk of
Examine perianal area at least daily
perianal abscess; enhances circulation
during acute illness. Provide sitz
and healing. Perianal abscess can
baths, using Betadine or Hibiclens
contribute to septicemia and death in
if indicated. Avoid rectal
immune compromised patients.
temperatures, use of suppositories.

Coordinate procedures and tests to Conserves energy for healing, cellular

 Nursing Interventions Rationale

allow for uninterrupted rest periods. regeneration.

Promotes healing and prevents

Encourage increased intake of
dehydration. Constipation potentiates
foods high in protein and fluids
retention of toxins and risk of rectal
with adequate fiber.
irritation or tissue injury.

Break in skin could provide an entry

for pathogenic or potentially lethal
organisms. Use of central venous lines
(tunneled catheter or implanted port)
Limit invasive procedures
can effectively reduce need for
(venipuncture and injections) as
frequent invasive procedures and risk
possible.
of infection. Myelo suppression may
be cumulative in nature, especially
when multiple drug therapy (including
steroids) is prescribed.

Monitor laboratory studies:

Decreased numbers of normal or

o - CBC, noting whether WBC mature WBCs can result from the
count falls or sudden changes disease process or chemotherapy,
occur in neutrophils; compromising the immune response
and increasing risk of infection.
Verifies presence of infections;
o - Gram‘s stain cultures and
identifies specific organisms and
sensitivity.
appropriate therapy.
Indicator of development or resolution
o - Review serial chest x-rays.
of respiratory complications.
Prepare for and assist with Leukemia is usually treated with a
 Nursing Interventions Rationale

leukemia-specific treatments such combination of these agents, each

as chemotherapy, radiation, and/or requiring specific safety precautions
bone marrow transplant. for patient and care providers.

Administer medications as indicated:

May be given prophylactically or to

o - antibiotics
treat specific infection.
Restores WBCs destroyed by
o Colony-stimulating
chemotherapy and reduces risk of
factors: sargramostim
severe infection and death in certain
(Leukine)
types of leukemia.
Avoid use of aspirin-containing Aspirin can cause gastric bleeding and
antipyretics. further decrease platelet count.

Provide nutritious diet, high in

Proper nutrition enhances immune
protein and calories, avoiding raw
system. Minimizes potential sources of
fruits, vegetables, or uncooked
bacterial contamination.
meats.

2. Risk for Infection

Risk for Infection: At increased risk for being invaded by pathogenic organisms.
Risk factors may include

o - Inadequate secondary defenses: alterations in mature WBCs (low

granulocyte and abnormal lymphocyte count), increased number of immature
lymphocytes; immunosuppression, bone marrow suppression (effects of
therapy/transplant)
o - Inadequate primary defenses (stasis of body fluids, traumatized tissue)
o - Invasive procedures
o - Malnutrition; chronic disease
Possibly evidenced by

o Not applicable. A risk diagnosis is not evidenced by signs and symptoms, as

the problem has not occurred and nursing interventions are directed at
prevention.

Desired Outcomes

o - Identify actions to prevent/reduce risk of infection.

o - Demonstrate techniques, lifestyle changes to promote safe environment,
achieve timely healing.

Nursing Interventions Rationale

Place in a private room. Limit

visitors as indicated. Prohibit live
plants or flowers. Restrict fresh
To protect the patient from potential
fruits and make sure they are
sources of pathogens or infection.
properly washed or peeled.
Bone marrow suppression,
Coordinate patient care so that
neutropenia, and chemotherapy places
leukemic patient doesn‘t come in
the patient at high risk for infection.
contact with staff who also care for
patients with infections or
infectious diseases.

Require good hand washing

Prevents cross-contamination and
protocol for all personnel and
reduces risk of infection.
visitors.

Closely monitor temperature. Note Although fever may accompany some

correlation between temperature forms of chemotherapy, progressive
elevations and chemotherapy hyperthermia occurs in some types of
treatments. Observe for fever infections, and fever (unrelated to
associated with tachycardia, drugs or blood products) occurs in
 Nursing Interventions Rationale

hypotension, subtle mental changes. most leukemia patients. Septicemia

may occur without fever.

Helps reduce fever, which contributes

Prevent chilling. Force fluids,
to fluid imbalance, discomfort, and
administer tepid sponge bath.
CNS complications.

Prevents stasis of respiratory

Encourage frequent turning and
secretions, reducing risk of atelectasis
deep breathing.
or pneumonia.

Auscultate breath sounds, noting

crackles, rhonchi. Inspect secretions
for changes in characteristics:
Early intervention is essential to
increased sputum production or
prevent sepsis in immuno-suppressed
change in sputum color. Observe
person.
urine for signs of infection: cloudy,
foul-smelling, or presence of
urgency or burning with voids.

Handle patient gently. Keep linens Prevents sheet burn and skin
dry and wrinkle-free. excoriation.

Inspect skin for tender,

May indicate local infection. Open
erythematous areas; open wounds.
wounds may not produce pus because
Cleanse skin with antibacterial
of insufficient number of granulocytes.
solutions.

Inspect oral mucous membranes.

The oral cavity is an excellent medium
Provide good oral hygiene. Use a
for growth of organisms and is
soft toothbrush, sponge, or swabs
susceptible to ulceration and bleeding.
for frequent mouth care.
 Nursing Interventions Rationale

Avoid using indwelling urinary These can provide an avenue for

catheters and giving I.M. injections. infection.

Provide thorough skin care by

keeping the patient‘s skin and
perianal area clean, apply mild
lotion or creams to keep the skin Additional measures to avoid infection.
from drying or cracking.
Thoroughly clean skin before all
invasive skin procedures.

Change IV tubing according to your

facility‘s policy. Use strict sterile
technique and a metal scalp vein
needles (metal butterfly needle) IV sites can harbor infection.
when starting IV. If the patient Additional measure to avoid infection.
receives total parenteral nutrition,
give scrupulous subclavian catheter
care.

Promote good perianal hygiene.

Promotes cleanliness, reducing risk of
Examine perianal area at least daily
perianal abscess; enhances circulation
during acute illness. Provide sitz
and healing. Perianal abscess can
baths, using Betadine or Hibiclens
contribute to septicemia and death in
if indicated. Avoid rectal
immune compromised patients.
temperatures, use of suppositories.

Coordinate procedures and tests to Conserves energy for healing, cellular

allow for uninterrupted rest periods. regeneration.

Encourage increased intake of Promotes healing and prevents

foods high in protein and fluids dehydration. Constipation potentiates
 Nursing Interventions Rationale

with adequate fiber. retention of toxins and risk of rectal

irritation or tissue injury.

Break in skin could provide an entry

for pathogenic or potentially lethal
organisms. Use of central venous lines
(tunneled catheter or implanted port)
Limit invasive procedures
can effectively reduce need for
(venipuncture and injections) as
frequent invasive procedures and risk
possible.
of infection. Myelo suppression may
be cumulative in nature, especially
when multiple drug therapy (including
steroids) is prescribed.

Monitor laboratory studies:

Decreased numbers of normal or

o - CBC, noting whether WBC mature WBCs can result from the
count falls or sudden changes disease process or chemotherapy,
occur in neutrophils; compromising the immune response
and increasing risk of infection.
Verifies presence of infections;
o - Gram‘s stain cultures and
identifies specific organisms and
sensitivity.
appropriate therapy.
Indicator of development or resolution
o - Review serial chest x-rays.
of respiratory complications.
Prepare for and assist with Leukemia is usually treated with a
leukemia-specific treatments such combination of these agents, each
as chemotherapy, radiation, and/or requiring specific safety precautions
bone marrow transplant. for patient and care providers.
 Nursing Interventions Rationale

Administer medications as indicated:

May be given prophylactically or to

o - antibiotics
treat specific infection.
Restores WBCs destroyed by
o Colony-stimulating
chemotherapy and reduces risk of
factors: sargramostim
severe infection and death in certain
(Leukine)
types of leukemia.
Avoid use of aspirin-containing Aspirin can cause gastric bleeding and
antipyretics. further decrease platelet count.

Provide nutritious diet, high in

Proper nutrition enhances immune
protein and calories, avoiding raw
system. Minimizes potential sources of
fruits, vegetables, or uncooked
bacterial contamination.
meats.

3. Acute Pain

Acute Pain: Unpleasant sensory and emotional experience arising from actual or
potential tissue damage or described in terms of such damage; sudden or slow
onset of any intensity from mild to severe with anticipated or predictable end and
a duration of <6 months.
May be related to

o - Physical agents, e.g., enlarged organs/lymph nodes, bone marrow packed

with leukemic cells
o - Chemical agents, e.g., antileukemic treatments
o - Psychological manifestations, e.g., anxiety, fear

Possibly evidenced by

o - Reports of pain (bone, nerve, headaches, and so forth)

 o - Guarding/distraction behaviors, facial grimacing, alteration in muscle tone
o - Autonomic responses

Desired Outcomes

o - Report pain is relieved/controlled.

o - Appear relaxed and able to sleep/rest appropriately.
o - Demonstrate behaviors to manage pain.

Nursing Interventions Rationale

Investigate reports of pain. Note Helpful in assessing need for

changes in degree (use scale of 0– intervention; may indicate developing
10) and site. complications.

Monitor vital signs, note nonverbal May be useful in evaluating verbal

cues, e.g., muscle tension, comments and effectiveness of
restlessness. interventions.

Provide quiet environment and

reduce stressful stimuli. Limit or Promotes rest and enhances coping
reduce noise, lighting, constant abilities.
interruptions.

Place in position of comfort and

May decrease associated bone or joint
support joints, extremities with
discomfort.
pillows or padding.

Reposition periodically and assist Improves tissue circulation and joint

with gentle ROM exercises. mobility.

Provide comfort measures

(massage, cool packs) and Minimizes need for or enhances effects
psychological support, of medication.
encouragement, or presence.
 Nursing Interventions Rationale

Successful management of pain

requires patient involvement. Use of
effective techniques provides positive
Review patient‘s own comfort
reinforcement, promotes sense of
measures.
control, and prepares patient for
interventions to be used after
discharge.

Using own learned perceptions or

Evaluate and support patient‘s
behaviors to manage pain can help
coping mechanisms.
patient cope more effectively.

Encourage use of stress

management techniques. Teach Facilitates relaxation, augments
relaxation and deep-breathing pharmacological therapy, and enhances
exercises, guided imagery, coping abilities.
visualization.

Assist with and provide diversional Helps with pain management by

activities, relaxation techniques. redirecting attention.

Rapid turnover and destruction of

leukemic cells during chemotherapy
Monitor uric acid level as can elevate uric acid, causing swollen
appropriate. painful joints in some patients.
Massive infiltration of WBCs into
joints can also result in intense pain.

Administer medications as indicated:

o - Analgesics: acetaminophen Given for mild pain not relieved by

(Tylenol) comfort measures. Avoid aspirin-
 Nursing Interventions Rationale

containing products because they may

potentiate hemorrhage.
Used around-the-clock, rather than prn,
when pain is severe. Use of patient-
controlled analgesia (PCA) is
o - Opioids: codeine, morphine,
beneficial in preventing peaks and
hydromorphone (Dilaudid)
valleys associated with intermittent
drug administration and increases
patient‘s sense of control.
o - Antianxiety agents: diazepam May be given to enhance the action of
(Valium), lorazepam (Ativan). analgesics or opioids.

4. Activity Intolerance

Activity Intolerance: Insufficient physiologic or physiological energy to endure

or complete required or desired activity.
May be related to

o - Generalized weakness; reduced energy stores, increased metabolic rate from

massive production of leukocytes
o - Imbalance between oxygen supply and demand (anemia/hypoxia)
o - Therapeutic restrictions (isolation/bedrest); effect of drug therapy

Possibly evidenced by

o - Verbal report of fatigue or weakness

o - Exertional discomfort or dyspnea
o - Abnormal HR or BP response

Desired Outcomes

o - Report a measurable increase in activity tolerance.

 o - Participate in ADLs to level of ability.
o - Demonstrate a decrease in physiological signs of intolerance; e.g., pulse,
respiration, and BP remain within patient‘s normal range.

Nursing Interventions Rationale

Effects of leukemia, anemia, and

Evaluate reports of fatigue, noting chemotherapy may be cumulative
inability to participate in activities (especially during acute and active
or ADLs. treatment phase), necessitating
assistance.

Encourage patient to keep a diary

of daily routines and energy levels, Helps patient prioritize activities and
noting activities that increase arrange them around fatigue pattern.
fatigue.

Provide quiet environment and

Restores energy needed for activity
uninterrupted rest periods.
and cellular regeneration and/or tissue
Encourage rest periods before
healing.
meals.

Implement energy-saving
techniques (sitting, rather than
Maximizes available energy for self-
standing, use of shower chair).
care tasks.
Assist with ambulation and other
activities as indicated.

Schedule meals around

chemotherapy. Give oral hygiene May enhance intake by reducing
before meals and administer nausea.
antimetics as indicated.

Recommend small, nutritious, high- Smaller meals require less energy for
 Nursing Interventions Rationale

protein meals and snacks digestion than larger meals. Increased

throughout the day. intake provides fuel for energy.

Maximizes oxygen available for

Provide supplemental oxygen. cellular uptake, improving tolerance of
activity.

5. Deficient Knowledge

Deficient Knowledge: Absence or deficiency of cognitive information related to

specific topic.
May be related to

o - Lack of exposure to resources

o - Information misinterpretation/lack of recall

Possibly evidenced by

o - Verbalization of problem/request for information

o - Statement of misconception

Desired Outcomes

o - Verbalize understanding of condition/disease process and potential

complications.
o - Verbalize understanding of therapeutic needs.
o - Initiate necessary lifestyle changes.
o - Participate in treatment regimen.

Nursing Interventions Rationale

Treatments can include various

Review pathology of specific form
antineoplastic drugs, transfusions,
of leukemia and various treatment
peripheral progenitor (stem) cell
 Nursing Interventions Rationale

options. transplant or bone marrow transplant.

Provide psychological support by

establishing a trusting relationship
Diagnosis of cancer can be
to promote communication. Allow
devastating to the family. Providing
the patient and family to discuss or
avenues for verbalization can help
verbalize their anger and
promote understand and cooperation
depression. Let the family
throughout the course of care.
participate in patient care as much
as possible.

6. Other Possible Nursing Care Plans

Nursing diagnoses you can use to develop your own care plan for leukemia:

o Risk for Infection—inadequate secondary defenses: alterations in mature

WBCs (low granulocyte and abnormal lymphocyte count), increased number
of immature lymphocytes; immunosuppression, bone marrow suppression
(effects of therapy/ transplant).
o Ineffective Role Performance –health-alterations, change in physical
capacity.
o Ineffective Therapeutic Regimen Management—complexity of therapeutic
regimen, decisional conflicts, economic difficulties, excessive demands made
on individual or family, perceived benefits, powerlessness.
o Interrupted Family Processes—situational crisis (illness,
disabling/expensive treatments).

References and Sources : [Link]

 Nursing Care Plans

8 Liver Cirrhosis Nursing Care Plans

Liver cirrhosis, also known as hepatic cirrhosis, is a chronic hepatic disease

characterized by diffuse destruction and fibrotic regeneration of hepatic cells. As
necrotic tissues yields to fibrosis, the diseases alters the liver structure and normal
vasculature, impairs blood and lymph flow, and ultimately causing hepatic
insufficiency. Causes include malnutrition, inflammation (bacterial or viral), and
poisons (e.g., alcohol, carbon tetrachloride, acetaminophen). Cirrhosis is the fourth
leading cause of death in the United States among people ages 35 to 55 and represents
a serious threat to long-term health.
These are the clinical types of cirrhosis:

o - Laennec‘s cirrhosis is the most common type and occurs 30% to 50% of cirrhotic
patients. Up to 90% of whom have a history of alcoholism. Liver damage results from
malnutrition, especially of dietary protein, and chronic alcohol ingestion. Fibrous
tissue forms in portal areas and around central veins.
o - Biliary cirrhosis occurs in 15% to 20% of patients, and results from injury or
prolonged obstruction.
o - Postnecrotic cirrhosis stems from various types of hepatitis.
o - Pigment cirrhosis results from disorders such as hemochromatosis.
o - Idiopathic cirrhosis, has no known cause.
o - Noncirrhotic fibrosis may results from schistosomiasis or congenital hepatic fibrosis
or may be idiopathic.
 Nursing Care Plans
Nursing care planning for patients with liver cirrhosis includes promoting rest,
providing adequate nutrition, skin care, reducing risk for injury, and monitoring and
managing complications.
Here are 8 liver cirrhosis nursing care plans (NCP):
1. Imbalanced Nutrition: Less Than Body Requirements

Imbalanced Nutrition: Less Than Body Requirements: Intake of nutrients

insufficient to meet metabolic needs.
May be related to

o - Inadequate diet; inability to process/digest nutrients

o - Anorexia, nausea/vomiting, indigestion, early satiety (ascites)
o - Abnormal bowel function

Possibly evidenced by

o - Weight loss
o - Changes in bowel sounds and function
o - Poor muscle tone/wasting
o - Imbalances in nutritional studies

Desired Outcomes

o - Demonstrate progressive weight gain toward goal with patient-appropriate

normalization of laboratory values.
o - Experience no further signs of malnutrition.

Nursing Interventions Rationale

Measure dietary intake by calorie Provides important information about

count. intake, needs and deficiencies.

Weigh as indicated. Compare It may be difficult to use weight as a

 Nursing Interventions Rationale

changes in fluid status, recent direct indicator of nutritional status in

weight history, skinfold view of edema and/or ascites.
measurements. Skinfold measurements are useful in
assessing changes in muscle mass and
subcutaneous fat reserves.

Encourage patient to eat; explain

reasons for the types of diet. Feed Improved nutrition and diet is vital to
patient if tiring easily, or have SO recovery. Patient may eat better if
assist patient. Include patient in family is involved and preferred foods
meal planning to consider his/her are included as much as possible.
preferences in food choices.

Patient may pick at food or eat only a

Encourage patient to eat all meals few bites because of loss of interest in
including supplementary feedings. food or because of nausea,
generalized weakness, malaise.

Poor tolerance to larger meals may be

Give small, frequent meals. due to increased intra-abdominal
pressure and ascites (if present).

Salt substitutes enhance the flavor of

Provide salt substitutes, if allowed; food and aid in increasing appetite;
avoid those containing ammonium. ammonia potentiates risk of
encephalopathy.

Aids in reducing gastric irritation

Restrict intake of caffeine, gas-
and/or diarrhea and abdominal
producing or spicy and excessively
discomfort that may impair oral
hot or cold foods.
intake.
 Nursing Interventions Rationale

Suggest soft foods, avoiding Hemorrhage from esophageal varices

roughage if indicated. may occur in advanced cirrhosis.

Patient is prone to sore and/or

Encourage frequent mouth care,
bleeding gums and bad taste in
especially before meals.
mouth, which contributes to anorexia.

Conserving energy reduces metabolic

Promote undisturbed rest periods,
demands on the liver and promotes
especially before meals.
cellular regeneration.

Recommend cessation of smoking. Reduces excessive gastric stimulation

Provide teaching on the possible and risk of irritation and may lead to
negative effects of smoking. bleeding.

Glucose may be decreased because of

impaired gluconeogenesis, depleted
glycogen stores, or inadequate intake.
Protein may be low because of
Monitor laboratory studies: serum
impaired metabolism, decreased
glucose, prealbumin and albumin,
hepatic synthesis, or loss into
total protein, ammonia.
peritoneal cavity (ascites). Elevation
of ammonia level may require
restriction of protein intake to prevent
serious complications.

Initially, GI rest may be required in

Maintain NPO status when acutely ill patients to reduce demands
indicated. on the liver and production of
ammonia and urea in the GI tract.

Refer to dietitian to provide diet High-calorie foods are desired

 Nursing Interventions Rationale

high in calories and simple inasmuch as patient intake is usually

carbohydrates, low in fat, and limited. Carbohydrates supply readily
moderate to high in protein; limit available energy. Fats are poorly
sodium and fluid as necessary. absorbed because of liver dysfunction
Provide liquid supplements as and may contribute to abdominal
indicated. discomfort. Proteins are needed to
improve serum protein levels to
reduce edema and to promote liver
cell regeneration. Note: Protein and
foods high in ammonia (gelatin) are
restricted if ammonia level is elevated
or if patient has clinical signs of
hepatic encephalopathy. In addition,
these individuals may tolerate
vegetable protein better than meat
protein.

May be required to supplement diet or

to provide nutrients when patient is
Provide tube feedings, TPN, lipids
too nauseated or anorexic to eat or
if indicated.
when esophageal varices interfere
with oral intake.

2. Excess Fluid Volume

Excess Fluid Volume: Increased isotonic fluid retention

May be related to

o - Compromised regulatory mechanism (e.g., syndrome of inappropriate antidiuretic

hormone [SIADH], decreased plasma proteins, malnutrition)
o - Excess sodium/fluid intake

Possibly evidenced by

o - Edema, anasarca, weight gain

o - Intake greater than output, oliguria, changes in urine specific gravity
o - Dyspnea, adventitious breath sounds, pleural effusion
o - BP changes, altered CVP
o - JVD, positive hepatojugular reflex
o - Altered electrolyte levels
o - Change in mental status

Desired Outcomes

o - Demonstrate stabilized fluid volume, with balanced I&O, stable weight, vital signs
within patient‘s normal range, and absence of edema.

Nursing Interventions Rationale

To assess circulating volume status,

developing or resolution of fluid shifts,
and response to therapeutic regimen.
Positive balance/weight gain often
Measure I&O, weigh daily, and
reflects continuing fluid retention.
note gain of more than 0.5 kg/day.
Note: Decreased circulating volume
(fluid shifts) may directly affect renal
function and urine output, resulting in
hepatorenal syndrome.

BP elevations are usually associated

Monitor BP (and CVP if available). with fluid volume excess but may not
Note JVD and abdominal vein occur because of fluid shifts out of the
distension. vascular space. Distension of external
jugular and abdominal veins is
 Nursing Interventions Rationale

associated with vascular congestion.

Assess respiratory status, noting

Indicative of pulmonary congestion.
increased respiratory rate, dyspnea.

Auscultate lungs, noting diminished Increasing pulmonary congestion may

breath sounds and developing result in consolidation, impaired gas
adventitious sounds. exchange, and complications.

Monitor for cardiac dysrhythmias. May be caused by HF, decreased

Auscultate heart sounds, noting coronary arterial perfusion, and
development of S3/S4gallop rhythm. electrolyte imbalance.

Fluids shift into tissues as a result of

sodium and water retention, decreased
Assess degree of peripheral edema.
albumin, and increased antidiuretic
hormone (ADH).

Reflects accumulation of fluid (ascites)

resulting from loss of plasma
proteins/fluid into peritoneal space.
Measure abdominal girth. Note: Excessive fluid accumulation
can reduce circulating volume,
creating a deficit (signs of
dehydration).

Encourage bedrest when ascites is May promote recumbency induced

present. diuresis.

Provide frequent mouth care;

Decreases sensation of thirst.
occasional ice chips (if NPO).

Monitor serum albumin and Decreased serum albumin affects

electrolytes (particularly potassium plasma colloid osmotic pressure,
 Nursing Interventions Rationale

and sodium). resulting in edema formation. Reduced

renal blood flow accompanied by
elevated ADH and aldosterone levels
and the use of diuretics (to reduce total
body water) may cause various
electrolyte shifts/imbalances.

Vascular congestion, pulmonary

Monitor serial chest x-rays. edema, and pleural effusions
frequently occur.

Sodium may be restricted to minimize

Restrict sodium and fluids as fluid retention in extravascular spaces.
indicated. Fluid restriction may be necessary to
correct dilutional hyponatremia.

Albumin may be used to increase the

colloid osmotic pressure in the
Administer salt-free
vascular compartment (pulling fluid
albumin/plasma expanders as
into vascular space), thereby
indicated.
increasing effective circulating volume
and decreasing formation of ascites.

Administer medications as indicated:

Used with caution to control edema

and ascites, block effect of
aldosterone, and increase water
o Diuretics: spironolactone
excretion while sparing potassium
(Aldactone), furosemide (Lasix)
when conservative therapy with
bedrest and sodium restriction does not
alleviate problem.
 Nursing Interventions Rationale

Serum and cellular potassium are

o - Potassium usually depleted because of liver
disease and urinary losses.
Given to increase cardiac
Positive inotropic drugs and arterial output/improve renal blood flow and
vasodilators. function, thereby reducing excess
fluid.

3. Risk for Impaired Skin Integrity

Risk for Impaired Skin Integrity: At risk for altered epidermis and/or dermis.
Risk factors may include

o - Altered circulation/metabolic state

o - Accumulation of bile salts in skin
o - Poor skin turgor, skeletal prominence, presence of edema, ascites

Desired Outcomes

o - Maintain skin integrity.

o - Identify individual risk factors and demonstrate behaviors/techniques to prevent skin
breakdown.

Nursing Interventions Rationale

Inspect pressure points and skin

Edematous tissues are more prone to
surfaces closely and routinely.
breakdown and to the formation of
Gently massage bony prominences
decubitus. Ascites may stretch the
or areas of continued stress. Use of
skin to the point of tearing in severe
emollient lotions and limiting use of
cirrhosis.
soap for bathing may help.
 Nursing Interventions Rationale

Repositioning reduces pressure on

Encourage and assist patient with
edematous tissues to improve
reposition on a regular schedule.
circulation. Exercises enhance
Assist with active and passive ROM
circulation and improve and/or
exercises as appropriate.
maintain joint mobility.

Recommend elevating lower Enhances venous return and reduces

extremities. edema formation in extremities.

Keep linens dry and free of Moisture aggravates pruritus and

wrinkles. increases risk of skin breakdown.

Prevents patient from inadvertently

Suggest clipping fingernails short;
injuring the skin, especially while
provide mittens/gloves if indicated.
sleeping.

Provide perineal care following Prevents skin excoriation breakdown

urination and bowel movement. from bile salts.

Use alternating pressure mattress, Reduces dermal pressure, increases

egg-crate mattress, waterbed, circulation, and diminishes risk of
sheepskins, as indicated. tissue ischemia.

Use calamine lotion and provide

baking soda baths. Administer
May be soothing and can provide
medications (as indicated) such as
relief of itching associated with
cholestyramine (Questran),
jaundice, bile salts in skin.
hydroxyzine (Atarax),
diphenhydramine (Benadryl).

4. Ineffective Breathing Pattern

 Ineffective Breathing Pattern: Inspiration and/or expiration that does not provide
adequate ventilation
Risk factors may include

o - Intra-abdominal fluid collection (ascites)

o - Decreased lung expansion, accumulated secretions
o - Decreased energy, fatigue

Desired Outcomes

o - Maintain effective respiratory pattern; be free of dyspnea and cyanosis, with ABGs
and vital capacity within acceptable range.

Nursing Interventions Rationale

Rapid shallow respiration or presence

Monitor respiratory rate, depth, and of dyspnea may appear because of
effort. hypoxia and/or fluid accumulation in
the abdomen.

May indicate developing

complications. Presence of
Auscultate breath sounds, noting adventitious breath sounds may reflect
crackles, wheezes, rhonchi. accumulation of fluids or secretions.
Absent or diminished sounds suggests
atelectasis.

Changes in mentation may reflect

Investigate changes in level of
hypoxemia and respiratory failure,
consciousness.
which often accompany hepatic coma.

Facilitates breathing by reducing

Keep head of bed elevated. Position
pressure on the diaphragm, and
on sides.
minimizes risk of aspiration of
 Nursing Interventions Rationale

secretions.

Encourage frequent repositioning

Aids in lung expansion and mobilizing
and deep-breathing exercises and
secretions.
coughing exercises.

Monitor temperature. Note presence

of chills, increased coughing, Indicative of onset of infection,
changes in color and character of especially pneumonia.
sputum.

Monitor serial ABGs, pulse

Reveals changes in respiratory status,
oximetry, vital capacity
developing pulmonary complications.
measurements, chest x-rays.

To treat or prevent hypoxia and if

Provide supplemental O2 as respirations and oxygenation is
indicated. inadequate, mechanical ventilation
may be required.

Demonstrate and assist with

Reduces incidence of atelectasis,
respiratory adjuncts: incentive
enhances mobilization of secretions.
spirometer.

Prepare for/assist with acute care procedures:

Occasionally done to remove ascites

fluid to relieve abdominal pressure
o - Paracentesis
when respiratory embarrassment is not
corrected by other measures.
Surgical implant of a catheter to return
o - Peritoneovenous shunt accumulated fluid in the abdominal
cavity to systemic circulation via the
 Nursing Interventions Rationale

vena cava; provides long-term relief of

ascites and improvement in respiratory
function.
5. Risk for Injury

Risk for Injury: Vulnerable for injury as a result of environmental conditions

interacting with the individual‘s adaptive and defensive resources, which may
compromise health.
Risk factors may include

o - Abnormal blood profile; altered clotting factors (decreased production of

prothrombin, fibrinogen, and factors VIII, IX, and X; impaired vitamin K absorption;
and release of thromboplastin)
o - Portal hypertension, development of esophageal varices

Desired Outcomes

o - Maintain homeostasis with absence of bleeding

o - Demonstrate behaviors to reduce risk of bleeding.

Nursing Interventions Rationale

Closely assess for signs and The esophagus and rectum are the
symptoms of GI bleeding: check all most usual sources of bleeding because
secretions for frank or occult blood. of their mucosal fragility and
Observe color and consistency of alterations in hemostasis associated
stools, NG drainage, or vomitus. with cirrhosis.

Observe for presence of petechiae, Subacute disseminated intravascular

ecchymosis, bleeding from one or coagulation (DIC) may develop
more sites. secondary to altered clotting factors.
 Nursing Interventions Rationale

An increased pulse with decreased BP

Monitor pulse, BP (and CVP if and CVP can indicate loss of
available). circulating blood volume, requiring
further evaluation.

Changes may indicate decreased

Note changes in mentation and
cerebral perfusion secondary to
LOC.
hypovolemia, hypoxemia.

Avoid rectal temperature; be gentle Rectal and esophageal vessels are most
with GI tube insertions. vulnerable to rupture.

Encourage use of soft toothbrush,

In the presence of clotting factor
electric razor, avoiding straining for
disturbances, minimal trauma can
stool, vigorous nose blowing, and
cause mucosal bleeding.
so forth.

Use small needles for injections.

Apply pressure to small bleeding Minimizes damage to tissues, reducing
and venipuncture sites for longer risk of bleeding and hematoma.
than usual.

Advice to avoid aspiring-containing Prolongs coagulation, potentiating risk

products. of hemorrhage.

Monitor Hb/Hct and clotting Indicators of anemia, active bleeding,

factors. or impending complications.

Administer medications as indicated

Promotes prothrombin synthesis and

o - Supplemental vitamins: vitamin coagulation if liver is functional.
K, D, and C. Vitamin C deficiencies increase
susceptibility of GI system to irritation
 Nursing Interventions Rationale

and/or bleeding.
Prevents straining for stool with
resultant increase in intra-abdominal
o - Stool softeners
pressure and risk of vascular rupture
and hemorrhage.
In presence of acute bleeding,
Provide gastric lavage with room
evacuation of blood from GI tract
temperature and cool saline solution
reduces ammonia production and risk
or water as indicated.
of hepatic encephalopathy.

Temporarily controls bleeding of

esophageal varices when control by
Assist with insertion and
other means (e.g., lavage) and
maintenance of GI tube.
hemodynamic stability cannot be
achieved.

May be needed to control active

Prepare for surgical procedures:
hemorrhage or to decrease portal and
direct ligation (banding) or varices,
collateral blood vessel pressure to
esophagogastric resection,
minimize risk of recurrence of
splenorenal-portacaval anastomosis.
bleeding

6. Risk for Acute Confusion

Risk factors may include

o - Alcohol abuse
o - Inability of liver to detoxify certain enzymes/drugs

Desired Outcomes

o - Maintain usual level of mentation/reality orientation.

o - Initiate behaviors/lifestyle changes to prevent or minimize recurrence of problem.

Nursing Interventions Rationale

Observe for signs and symptoms of

behavioral change and mentation: Ongoing assessment of behavior and
lethargy, confusion, drowsiness, mental status is important because of
slurring of speech, and irritability. fluctuating nature of impending
Around patient at intervals as hepatic coma.
indicated.

Review current medication Adverse drug reactions or interactions

regimen. Note adverse drug (e.g., cimetidine plus antacids) may
reactions and effects of medication potentiate and/or exacerbate
to the patient. confusion.

Difficulty falling or staying asleep

Evaluate sleep and rest schedule. leads to sleep deprivation, resulting in
diminished cognition and lethargy.

Note development and/or presence Suggests elevating serum ammonia

of asterixis, fetor hepaticus, seizure levels; increased risk of progression to
activity. encephalopathy.

Consult with SO about patient‘s Provides baseline for comparison of

usual behavior and mentation. current status.

Have patient write name

periodically and keep this record for
Easy test of neurological status and
comparison. Report deterioration of
muscle coordination.
ability. Have patient do simple
arithmetic computations.

Reorient to time, place, person as Assists in maintaining reality

needed. orientation, reducing confusion and
 Nursing Interventions Rationale

anxiety.

Maintain a pleasant, quiet

Reduces excessive stimulation and
environment and approach in a
sensory overload, promotes relaxation,
slow, calm manner. Encourage
and may enhance coping.
uninterrupted rest periods.

Familiarity provides reassurance, aids

Provide continuity of care. If
in reducing anxiety, and provides a
possible, assign same nurse over a
more accurate documentation of
period of time.
subtle changes.

Reduce provocative stimuli,

confrontation. Refrain from forcing Avoids triggering agitated, violent
activities. Assess potential for responses; promotes patient safety.
violent behavior.

Patient/SO may be reassured that

Discuss current situation, future intellectual (as well as emotional)
expectation. function may improve as liver
involvement resolves.

Reduces metabolic demands on liver,

Maintain bedrest, assist with self- prevents fatigue, and promotes
care activities. healing, lowering risk of ammonia
buildup.

Identify and provide safety needs.

Reduces risk of injury when
Supervise during smoking, put bed
confusion, seizures, or violent
in low position, raise side rails and
behavior occurs.
pad if necessary.

Investigate temperature elevations. Infection may precipitate hepatic

 Nursing Interventions Rationale

Monitor for signs of infection. encephalopathy caused by tissue

catabolism and release of nitrogen.

Certain drugs are toxic to the liver,

Recommend avoidance of narcotics
whereas other drugs may not be
or sedatives, anti anxiety agents,
metabolized because of cirrhosis,
and limiting or restricting use of
causing cumulative effects that affect
medications metabolized by the
mentation, mask signs of developing
liver.
encephalopathy, or precipitate coma.

Ammonia (product of the breakdown

of protein in the GI tract) is
responsible for mental changes in
hepatic encephalopathy. Dietary
Eliminate or restrict protein in diet. changes may result in constipation,
Provide glucose supplements, which also increases bacterial action
adequate hydration. and formation of ammonia. Glucose
provides a source of energy, reducing
need for protein catabolism. Note:
Vegetable protein may be better
tolerated than meat protein.

May be used to reduce serum

Assist with procedures as indicated:
ammonia levels if encephalopathy
dialysis, plasmapheresis, or
develops and other measures are not
extracorporeal liver perfusion.
successful.

7. Disturbed Body Image

Disturbed Body Image: Confusion in mental picture of one‘s physical self.

 Situational Low Self-Esteem: Development of a negative perception of self-worth in
response to current situation.
May be related to

o - Biophysical changes/altered physical appearance

o - Uncertainty of prognosis, changes in role function
o - Personal vulnerability
o - Self-destructive behavior (alcohol-induced disease)

Possibly evidenced by

o - Verbalization of change/restriction in lifestyle

o - Fear of rejection or reaction by others
o - Negative feelings about body/abilities
o - Feelings of helplessness, hopelessness, or powerlessness

Desired Outcomes

o - Verbalize understanding of changes and acceptance of self in the present situation.

o - Identify feelings and methods for coping with negative perception of self.

Nursing Interventions Rationale

Discuss situation and encourage Patient is very sensitive to body

verbalization of fears and concerns. changes and may also experience
Explain relationship between nature feelings of guilt when cause is related
of disease and symptoms. to alcohol or other drug use.

Caregivers sometimes allow

Support and encourage patient; judgmental feelings to affect the care
provide care with a positive, of patient and need to make every
friendly attitude. effort to help patient feel valued as a
person.

Encourage family/SO to verbalize Family members may feel guilty about

 Nursing Interventions Rationale

feelings, visit freely and participate patient‘s condition and may be fearful
in care. of impending death. They need
nonjudgmental emotional support and
free access to patient. Participation in
care helps them feel useful and
promotes trust between staff, patient,
and SO.

Assist patient/SO to cope with Patient may present unattractive

change in appearance; suggest appearance as a result of jaundice,
clothing that does not emphasize ascites, ecchymotic areas. Providing
altered appearance (color of clothes, support can enhance self-esteem and
etc). promote patient sense of control.

Refer to support services. Increased vulnerability and concerns

Counselors, psychiatric resources, associated with this illness may
social service, clery and alcohol require services of additional
treatment program may help. professional resources.

8. Deficient Knowledge

Deficient Knowledge: Absence or deficiency of cognitive information related to

specific topic
May be related to

o - Lack of exposure/recall; information misinterpretation

o - Unfamiliarity with information resources

Possibly evidenced by

o - Questions; request for information, statement of misconception

o - Inaccurate follow-through of instructions/development of preventable complications
 Desired Outcomes

o - Verbalize understanding of disease process/prognosis, potential complications.

o - Correlate symptoms with causative factors.
o - Identify/initiate necessary lifestyle changes and participate in care.

Nursing Interventions Rationale

Review disease process and Provides knowledge base from which

prognosis and future expectations. patient can make informed choices.

Patients with cirrhosis needs close

Refer to dietitian or nutritionist. observation and sound nutritional
counseling.

Stress importance of avoiding

alcohol. Give information about
Alcohol is the leading cause in the
community services available to
development of cirrhosis.
aid in alcohol rehabilitation if
indicated.

Some drugs are hepatotoxic

Inform patient of altered effects of
(especially narcotics, sedatives, and
medications with cirrhosis and the
hypnotics). In addition, the damaged
importance of using only drugs
liver has a decreased ability to
prescribed or cleared by a
metabolize all drugs, potentiating
healthcare provider who is familiar
cumulative effect and/or aggravation
with patient‘s history.
of bleeding tendencies.

Insertion of a Denver shunt requires

Review procedure for maintaining patient to periodically pump the
function of peritoneovenous shunt chamber to maintain patency of the
when present. device. Patients with a LeVeen shunt
may wear an abdominal binder and/or
 Nursing Interventions Rationale

engage in a Valsalva maneuver to

maintain shunt function.

Because of length of recovery,

potential for relapses, and slow
Assist patient identifying support
convalescence, support systems are
person(s).
extremely important in maintaining
behavior modifications.

Proper dietary maintenance and

Emphasize the importance of good avoidance of foods high in sodium
nutrition. Recommend avoidance and protein aid in remission of
of high-protein/salty foods, onions, symptoms and help prevent ammonia
and strong cheeses. Provide written buildup and further liver damage.
dietary instructions. Written instructions are helpful for
patient to refer to at home.

Chronic nature of disease has

potential for life-threatening
Stress necessity of follow-up care
complications. Provides opportunity
and adherence to therapeutic
for evaluation of effectiveness of
regimen.
regimen, including patency of shunt
if used.

Minimizes ascites and edema

Discuss sodium and salt substitute formation. Overuse of substitutes
restrictions and necessity of may result in other electrolyte
reading labels on food and OTC imbalances. Food, OTC and/or
drugs. personal care products (antacids,
some mouthwashes) may contain
 Nursing Interventions Rationale

sodium or alcohol.

Adequate rest decreases metabolic

Encourage scheduling activities demands on the body and increases
with adequate rest periods. energy available for tissue
regeneration.

Promote diversional activities that Prevents boredom and minimizes

are enjoyable to patient. anxiety and depression.

Decreased resistance, altered

nutritional status, and immune
Recommend avoidance of persons
response (leukopenia may occur with
with infections, especially URI.
splenomegaly) potentiate risk of
infection.

Identify environmental dangers:

Can precipitate recurrence.
exposure to hepatitis.

Instruct patient/SO of signs and

symptoms that warrant notification
Prompt reporting of symptoms
of health care provider: increased
reduces risk of further hepatic
abdominal girth; rapid weight
damage and provides opportunity to
loss/gain; increased peripheral
treat complications before they
edema; increased dyspnea, fever;
become life-threatening.
blood in stool or urine; excess
bleeding of any kind; jaundice.

Instruct SO to notify health care Changes (reflecting deterioration)

providers of any confusion, may be more apparent to SO,
untidiness, night wandering, although insidious changes may be
 Nursing Interventions Rationale

tremors, or personality change. noted by others with less frequent

contact with patient.

9. Other Possible Nursing Care Plans

Other possible nursing diagnoses you can use to develop another care plan for liver
cirrhosis:

o Fatigue — decreased metabolic energy production, states of discomfort, altered body

chemistry (e.g., changes in liver function, effect on target organs, alcohol withdrawal).
o Imbalanced Nutrition: less than body requirements — inadequate diet; inability to
process/digest nutrients; anorexia, nausea/vomiting, indigestion, early satiety (ascites);
abnormal bowel function.
o Risk for ineffective management — perceived benefit, social support deficit,
economic difficulties.
o Family Processes, dysfunctional: alcoholism — abuse of alcohol, resistance to
treatment, inadequate coping/lack of problem-solving skills, addictive
personality/codependency.
o Risk for caregiver role strain — addiction or codependency, family dysfunction
before caregiving situation, presence of situational stressors, such as economic
vulnerability, hospitalization, changes in employment.

References and Sources : [Link]

 Nursing Care Plans

5 Nephrotic Syndrome Nursing Care Plans

Nephrotic syndrome is an alteration of kidney function caused by increased

glomerular basement membrane permeability to plasma protein (albumin). Altered
glomerular permeability result in characteristic symptoms of gross proteinuria,
generalized edema (anasarca), hypoalbuminemia, oliguria, and increased serum lipid
level (hyperlipidemia).
Nephrotic syndrome is classified either by etiology or the histologic changes in the
glomerulus. Nephrotic syndrome is further classified into three forms: primary
minimal change nephrotic syndrome (MCNS), secondary nephrotic syndrome, and
congenital nephrotic syndrome. The most common type of nephrotic syndrome is
MCNS (idiopathic type) and it accounts for 80% of cases of nephrotic syndrome.
MCNS can occur at any age but usually, the age of onset is during the preschool years.
MCNS is also seen more in male children than in female children. Secondary
nephrotic syndrome is often associated with secondary renal involvement from
systemic diseases. Congenital nephrotic syndrome (CNS) is caused by a rare
autosomal recessive gene which is localized on the long arm of chromosome 19.
Currently, CNS has a better prognosis due to early management of protein deficiency,
nutritional support, continuous cycling peritoneal dialysis (CCPD), and renal
transplantation. The prognosis for MCNS is usually good, but relapses are common,
and most children respond to treatment.
Nursing Care Plans
Nursing care planning for a client with nephrotic syndrome include relief from edema,
enhance nutritional status, conserve energy, supply sufficient information about the
 disease, importance of strict compliance with the medication and nutritional therapy,
and absence of infection or prevention of a relapse.
Here are five (5) nursing care plans (NCP) for Nephrotic Syndrome:
1. Excess Fluid Volume

Excess Fluid Volume: Increased isotonic fluid retention.

May be related to

o - Decreased kidney function

o - Fluid accumulation

Possibly evidenced by

o - Pitting edema
o - Periorbital and facial puffiness in morning and dependent in the evening
o - Abdominal ascites,
o - Scrotal or labial edema
o - Edema of mucous membranes of intestines
o - Anasarca
o - Slow weight gain
o - Decreased urine output
o - Altered electrolytes, sp. gr., BP, R

Desired Outcomes

o - Child‘s edema will be decreased.

o - Child will achieve ideal body weight without excess fluids.

Nursing Interventions Rationale

Daily body weight is a good

Weigh child daily; Utilize same
indicator of hydration status. A
weighing scale every day.
weight gain of more than 0.5 kg/day
 suggests fluid retention.

Strictly monitor and record intake Accurate measurement determines

and output. fluid balance.

Determine potential sources of Identification of other sources of

excess fluid (e.g., food, medications excess fluid aids in the therapeutic
used) regimen.

Amount of allowed fluid intake is

Advised to limit fluid intake as determined based on child‘s weight,
ordered. urine output and response to
treatment.

Corticosteroid therapy continues

until the urine is protein free and
Administer corticosteroid (e.g.,
continues to be normal for 10 days to
prednisone) as prescribed.
2 weeks. A therapeutic response
usually occurs in 1 to 3 weeks.

Instruct parents to provide frequent Oral hygiene reduces dryness of

oral hygiene. mouth and mucous membranes.

Teach parents on how to do

Collecting and examining urine for
dipstick urine testing and urine
protein shows the gravity of protein
collection and instruct to keep a
loss.
record of results.

Knowing the disease condition

Teach parents regarding kidney
enables the parents to follow through
function and disease condition.
with the therapeutic regimen.

2. Imbalanced Nutrition: Less Than Body Requirements

 Imbalanced Nutrition: Less Than Body Requirements: Intake of nutrients
insufficient to meet metabolic needs.
May be related to

o - inability to ingest and digest foods and absorb nutrients

Possibly evidenced by

o - Anorexia
o - Weight loss
o - Edema of intestinal tract affecting absorption
o - Rejection of low salt diet
o - Loss of protein [negative nitrogen balance]

Desired Outcomes

o - Client will consume a nutritionally balanced diet.

Nursing Interventions Rationale

Monitor client‘s weight daily

(using the same scale with the child Parents need to weigh children to
in the same clothing at the same monitor fluid and nutritional status.
time of the day).

Assess child‘s nutritional daily

Dietary patterns are considered in
patterns including food preference,
planning meals.
caloric intake, and diet history.

A high potassium diet maintains

therapeutic serum potassium level,
Encourage high potassium, low-fat,
especially if the child is receiving a
low sodium diet with moderate
potassium-wasting diuretic; A low-
amounts of protein.
sodium diet helps prevent or decrease
fluid retention; Protein intake is
 needed to compensate for protein
loss.

Provide comfortable and delightful Reduces unpleasant factors that add

environment during meal times. to appetite loss.

Consider six small nutrient-dense

Eating small, frequent meals
meals instead of three larger meals
diminishes the feeling of fullness and
daily to reduce the feeling of
reduces the stimulus to vomit.
fullness.

Schedule medications in such a Taking of medications before meals

way that they are not administered may produce a feeling of fullness that
immediately prior meals. contributes to anorexia.

Refer to a dietitian for a A dietician determines the client‘s

comprehensive nutrition daily requirements of specific
assessment and methods for nutrients to promote sufficient
nutritional support. nutritional intake.

3. Fatigue

Fatigue: An overwhelming, sustained sense of exhaustion and decreased capacity for

physical and mental work at usual level.
May be related to

o - Discomfort

Possibly evidenced by

o - Easily fatigued with any activity

o - Extreme edema
o - Lethargy

Desired Outcomes
o - Child will alternate activity with rest periods.

Nursing Interventions Rationale

Reveals information regarding

Assess extent of fatigue, weakness,
fatigue and tendency of lying in the
degree of edema and difficult
prone position and not moving or
movement or activity in bed.
changing position.

Enhances endurance while avoids

Plan activities with consideration fatigue; disease condition, steroid
and observe for changes in behavior therapy, and inactivity result in
following an activity. mood swings and irritability in the
child.

Reinforce bed rest during the most Prevents energy expenditure when
acute stage. edema is severe.

Provide chosen play activities as

Provides stimulation and activity
tolerated and modify the schedule to
within tolerance level as edema is
allow for rest periods and after
relieved.
activity.

Allow for quiet play accompanied

by an open activity and encourage Promotes independence and control
the child to establish own limits of situations.
when feasible.

Advise child to rest during times of Decreases fatigue and conserves

exhaustion. energy.

Inform parents and child that

complete participation in activities Promotes a return to active life for
will be permitted as the disease is the child.
resolved.
 4. Deficient Knowledge

Deficient Knowledge: Absence or deficiency of cognitive information related to

specific topic.
May be related to

o - Lack of exposure to information about the disease

Possibly evidenced by

o - Expressed need for information about the disease, drug administration, follow-up
care and procedures
o - Anxiety associated with relapse of disease

Desired Outcomes

o - Parents verbalize understanding of cause and treatment for illness.

Nursing Interventions Rationale

Assess knowledge of disease, signs

and symptoms of relapse, dietary
and activity aspects of care, Provides information about
medication administration and side education needs for follow-up care.
effects, monitoring urine and vital
signs.

Assess anxiety level and need for

Anxiety will hinder the ability to
assistance in the care of the ailing
learn.
child and possible relapse.

Educate parents and child about the

Teaching supplies required
cause of the child‘s illness and
information about the condition and
expected treatments. Encourage
management.
questions and allow time for
discussion.

Promotes safety measure to avoid

Notify parents that immunizations
complications in an
may be delayed.
immunocompromised child.

Educate about the administration of

medications including reversible
side effects of steroid and Promotes compliance of proper
immunosuppressive when medication administration and what
discontinued abruptly; that they can be expected from drug therapy.
must be stopped gradually to avoid
complication.

Educate parents and child possiblity Avoids the risk of infection that may
for relapse to prevent infection. precipitate a relapse.

Demonstrate and allow for parents

to return demonstrate urine testing
by dipstick for albumin, monitor for
edema, taking daily weights and Facilitates monitoring of possible
blood pressure, and to immediately relapse of disease.
notify physician on changes of
increased weight or presence of
albumin in urine.

Offer parents and child with praise

Positive reinforcement improves
and encouragement as they acquire
willingness to learn new skills.
skills.

Reinforce physician instructions

Promotes a return to usual patterns
about sodium restriction, activity
of living.
progression, and pacing.
 Provide information about the
disease, its causes, need for frequent Promotes understanding of disease
hospitalizations if the disease process and importance of
becomes prolonged or is a relapsing compliance with therapy to prevent
type with remissions and exacerbation.
exacerbations.

5. Risk For Infection

Risk for Infection: At increased risk for being invaded by pathogenic organisms.
May be related to

o - Inadequate secondary defenses

Possibly evidenced by

o [not applicable]

Desired Outcomes

o - Child‘s temperature will remain <99° F.

o - Child‘s breath sounds will be clear bilaterally.
o - Child‘s urine will be clear without foul odor.

Nursing Interventions Rationale

Assess for an increase in

temperature, respiratory changes Indicates presence of infectious
(dyspnea, productive cough with process as a result from steroid and
yellow sputum), urinary changes immunosuppressant therapy
(cloudy, foul-smelling urine), skin administered to improve body
changes (tenderness, redness, defenses and lessen relapse rate.
swelling).

Maintain and teach medical aseptic Promotes preventive measures

 techniques and handwashing when against infection.
providing care.

Maintain warmth for the child,

Avoids chilling and susceptibility to
regulate room environmental
upper respiratory infection.
temperature and humidity.

Provide private room or share room

Protects the child from transmission
with children who are free from
of microorganism.
infections.

Prevents or treats infection

Administer antibiotic therapy as
depending on the result of culture
ordered.
and sensitivities.

Advise parents and child to avoid

Provides an understanding of
exposure to persons with existing
susceptibility to infections.
infections.

Advise parents to immediately

Allows for prompt medical
notify the physician of sign or
intervention to avoid relapse.
symptom of infection.

References and Sources : [Link]

HEART FAILURE (CCF)

Possible Problems

1. Ineffective breathing
2. Anxiety
3. Altered nutrition
4. Risk of impaired skin integrity
5. Fluid volume excess

NURSING CARE PLAN

PROBLE NURSING OBJECTIV INTERVENTION EVALUATIO
M DIAGNOSI E S N
S
Ineffective Ineffective To promote - Elevate the Patient‘s
breathing breathing normal patient‘s head to breathing
related to breathing promote adequate pattern
pulmonary within 30 lung expansion. improved
congestion minutes of - Give oxygen by within 30
evidenced by hospitalizatio mask to improve minutes
difficulties in n the oxygen levels in evidenced by
breathing the body. normal
/restlessness Ensure a clear breathing rate of
airway by 18 breaths per
positioning patients minute
head to one side for
easy drainage of
secretions if
unconscious
-Monitor patient‘s
respiration rate
depth and quality in
order to detect any
further deviation or
improvement so as
 to take appropriate
action.
Anxiety Anxiety To allay -Explain the Patient‘s
related to the anxiety condition to the anxiety reduced
condition and within 2 client and the within 2 hours
lack of hours prognosis to raise of
knowledge hospitalisatio awareness. hospitalization
about the n -Explain to the evidenced by
prognosis client about calmness
evidenced by treatment
patient availability to gain
asking too cooperation.
many Provide a calm
question environment to
promote rest by
reducing noise
levels.
Explain all the
procedures and
equipment being
used on him to allay
anxiety.

Fluid fluid volume To reduce - Restrict salt intake Excess fluid

volume excess excess fluids diet to prevent reduced within
excess related to within 2 days increased sodium 2 days
decreased of retention of 60- 100 evidenced by
cardiac out hospitalisatio mmol / day. reduction in
put as n - Restrict fluid weight and
evidenced by intake to prevent edema
 oedema and further increase in
weight gain fluid volume.
- Administer
prescribed diuretics
e.g. lasix to
promote elimination
of excess fluids
Check patient‘s
weight daily to
monitor
effectiveness of
therapy
Risk for Risk of To maintain - Assist patient to -Patients skin
impaired impaired skin intact skin change position remained intact
skin integrity throughout frequently to reduce throughout
integrity related to hospitalisatio pressure on hospitalisation
decreased n prominent areas for
tissue a long time.
perfusion and - Assist patient in
inactivity bathing and
lubricating the skin
to promote skin
integrity.
-Provide protective
devices such as an
airing or pillow to
relieve pressure on
pressure points
- Asses the
integrity of the skin
 for signs of pressure
sore formation to
intervene promptly.
- Allow / help
patient to move in
and out of bed and
provide a chair for
sitting out of bed.
Altered Altered To improve - Provide frequent Patient‘s
nutrition nutrition less nutritional meals according nutritional
than body status within to patient‘s status improved
requirements 1 week of preference. evidenced by
related to hospitalisatio - Assist or normal hair
anorexia and n and after encourage patient to texture.
food discharge perform mouth
restriction washes to promote
evidenced by appetite.
change of - Assist the patient
hair texture. in feeding since he
is weak.
- Remove things in
the environment
which will disturb
the client‘s appetite
example bed pans.
- Give patient drugs
for appetite
example muilt-
vitamin as
prescribed.
 Involve family
member in patient
care for continuity
of care

Nursing Care Plans

8 Liver Cirrhosis Nursing Care Plans

Liver cirrhosis, also known as hepatic cirrhosis, is a chronic hepatic disease

characterized by diffuse destruction and fibrotic regeneration of hepatic cells. As
necrotic tissues yields to fibrosis, the diseases alters the liver structure and normal
vasculature, impairs blood and lymph flow, and ultimately causing hepatic
insufficiency. Causes include malnutrition, inflammation (bacterial or viral), and
poisons (e.g., alcohol, carbon tetrachloride, acetaminophen). Cirrhosis is the fourth
leading cause of death in the United States among people ages 35 to 55 and represents
a serious threat to long-term health.
These are the clinical types of cirrhosis:

o - Laennec‘s cirrhosis is the most common type and occurs 30% to 50% of cirrhotic
patients. Up to 90% of whom have a history of alcoholism. Liver damage results from
malnutrition, especially of dietary protein, and chronic alcohol ingestion. Fibrous
tissue forms in portal areas and around central veins.
o - Biliary cirrhosis occurs in 15% to 20% of patients, and results from injury or
prolonged obstruction.
o - Postnecrotic cirrhosis stems from various types of hepatitis.
o - Pigment cirrhosis results from disorders such as hemochromatosis.
o - Idiopathic cirrhosis, has no known cause.
o - Noncirrhotic fibrosis may results from schistosomiasis or congenital hepatic fibrosis
or may be idiopathic.

Nursing Care Plans

Nursing care planning for patients with liver cirrhosis includes promoting rest,
providing adequate nutrition, skin care, reducing risk for injury, and monitoring and
managing complications.
Here are 8 liver cirrhosis nursing care plans (NCP):
1. Imbalanced Nutrition: Less Than Body Requirements

Imbalanced Nutrition: Less Than Body Requirements: Intake of nutrients

insufficient to meet metabolic needs.
May be related to

o - Inadequate diet; inability to process/digest nutrients

o - Anorexia, nausea/vomiting, indigestion, early satiety (ascites)
o - Abnormal bowel function

Possibly evidenced by

o - Weight loss
o - Changes in bowel sounds and function
o - Poor muscle tone/wasting
o - Imbalances in nutritional studies

Desired Outcomes

o - Demonstrate progressive weight gain toward goal with patient-appropriate

normalization of laboratory values.
o - Experience no further signs of malnutrition.

Nursing Interventions Rationale

 Nursing Interventions Rationale

Measure dietary intake by calorie Provides important information about

count. intake, needs and deficiencies.

It may be difficult to use weight as a

Weigh as indicated. Compare direct indicator of nutritional status in
changes in fluid status, recent view of edema and/or ascites.
weight history, skinfold Skinfold measurements are useful in
measurements. assessing changes in muscle mass and
subcutaneous fat reserves.

Encourage patient to eat; explain

reasons for the types of diet. Feed Improved nutrition and diet is vital to
patient if tiring easily, or have SO recovery. Patient may eat better if
assist patient. Include patient in family is involved and preferred foods
meal planning to consider his/her are included as much as possible.
preferences in food choices.

Patient may pick at food or eat only a

Encourage patient to eat all meals few bites because of loss of interest in
including supplementary feedings. food or because of nausea,
generalized weakness, malaise.

Poor tolerance to larger meals may be

Give small, frequent meals. due to increased intra-abdominal
pressure and ascites (if present).

Salt substitutes enhance the flavor of

Provide salt substitutes, if allowed; food and aid in increasing appetite;
avoid those containing ammonium. ammonia potentiates risk of
encephalopathy.

Restrict intake of caffeine, gas- Aids in reducing gastric irritation

 Nursing Interventions Rationale

producing or spicy and excessively and/or diarrhea and abdominal

hot or cold foods. discomfort that may impair oral
intake.

Suggest soft foods, avoiding Hemorrhage from esophageal varices

roughage if indicated. may occur in advanced cirrhosis.

Patient is prone to sore and/or

Encourage frequent mouth care,
bleeding gums and bad taste in
especially before meals.
mouth, which contributes to anorexia.

Conserving energy reduces metabolic

Promote undisturbed rest periods,
demands on the liver and promotes
especially before meals.
cellular regeneration.

Recommend cessation of smoking. Reduces excessive gastric stimulation

Provide teaching on the possible and risk of irritation and may lead to
negative effects of smoking. bleeding.

Glucose may be decreased because of

impaired gluconeogenesis, depleted
glycogen stores, or inadequate intake.
Protein may be low because of
Monitor laboratory studies: serum
impaired metabolism, decreased
glucose, prealbumin and albumin,
hepatic synthesis, or loss into
total protein, ammonia.
peritoneal cavity (ascites). Elevation
of ammonia level may require
restriction of protein intake to prevent
serious complications.

Maintain NPO status when Initially, GI rest may be required in

indicated. acutely ill patients to reduce demands
 Nursing Interventions Rationale

on the liver and production of

ammonia and urea in the GI tract.

High-calorie foods are desired

inasmuch as patient intake is usually
limited. Carbohydrates supply readily
available energy. Fats are poorly
absorbed because of liver dysfunction
Refer to dietitian to provide diet and may contribute to abdominal
high in calories and simple discomfort. Proteins are needed to
carbohydrates, low in fat, and improve serum protein levels to
moderate to high in protein; limit reduce edema and to promote liver
sodium and fluid as necessary. cell regeneration. Note: Protein and
Provide liquid supplements as foods high in ammonia (gelatin) are
indicated. restricted if ammonia level is elevated
or if patient has clinical signs of
hepatic encephalopathy. In addition,
these individuals may tolerate
vegetable protein better than meat
protein.

May be required to supplement diet or

to provide nutrients when patient is
Provide tube feedings, TPN, lipids
too nauseated or anorexic to eat or
if indicated.
when esophageal varices interfere
with oral intake.

2. Excess Fluid Volume

Excess Fluid Volume: Increased isotonic fluid retention

 May be related to

o - Compromised regulatory mechanism (e.g., syndrome of inappropriate antidiuretic

hormone [SIADH], decreased plasma proteins, malnutrition)
o - Excess sodium/fluid intake

Possibly evidenced by

o - Edema, anasarca, weight gain

o - Intake greater than output, oliguria, changes in urine specific gravity
o - Dyspnea, adventitious breath sounds, pleural effusion
o - BP changes, altered CVP
o - JVD, positive hepatojugular reflex
o - Altered electrolyte levels
o - Change in mental status

Desired Outcomes

o - Demonstrate stabilized fluid volume, with balanced I&O, stable weight, vital signs
within patient‘s normal range, and absence of edema.

Nursing Interventions Rationale

To assess circulating volume status,

developing or resolution of fluid shifts,
and response to therapeutic regimen.
Positive balance/weight gain often
Measure I&O, weigh daily, and
reflects continuing fluid retention.
note gain of more than 0.5 kg/day.
Note: Decreased circulating volume
(fluid shifts) may directly affect renal
function and urine output, resulting in
hepatorenal syndrome.

Monitor BP (and CVP if available). BP elevations are usually associated

Note JVD and abdominal vein with fluid volume excess but may not
 Nursing Interventions Rationale

distension. occur because of fluid shifts out of the

vascular space. Distension of external
jugular and abdominal veins is
associated with vascular congestion.

Assess respiratory status, noting

Indicative of pulmonary congestion.
increased respiratory rate, dyspnea.

Auscultate lungs, noting diminished Increasing pulmonary congestion may

breath sounds and developing result in consolidation, impaired gas
adventitious sounds. exchange, and complications.

Monitor for cardiac dysrhythmias. May be caused by HF, decreased

Auscultate heart sounds, noting coronary arterial perfusion, and
development of S3/S4gallop rhythm. electrolyte imbalance.

Fluids shift into tissues as a result of

sodium and water retention, decreased
Assess degree of peripheral edema.
albumin, and increased antidiuretic
hormone (ADH).

Reflects accumulation of fluid (ascites)

resulting from loss of plasma
proteins/fluid into peritoneal space.
Measure abdominal girth. Note: Excessive fluid accumulation
can reduce circulating volume,
creating a deficit (signs of
dehydration).

Encourage bedrest when ascites is May promote recumbency induced

present. diuresis.

Provide frequent mouth care; Decreases sensation of thirst.

 Nursing Interventions Rationale

occasional ice chips (if NPO).

Decreased serum albumin affects

plasma colloid osmotic pressure,
resulting in edema formation. Reduced
Monitor serum albumin and
renal blood flow accompanied by
electrolytes (particularly potassium
elevated ADH and aldosterone levels
and sodium).
and the use of diuretics (to reduce total
body water) may cause various
electrolyte shifts/imbalances.

Vascular congestion, pulmonary

Monitor serial chest x-rays. edema, and pleural effusions
frequently occur.

Sodium may be restricted to minimize

Restrict sodium and fluids as fluid retention in extravascular spaces.
indicated. Fluid restriction may be necessary to
correct dilutional hyponatremia.

Albumin may be used to increase the

colloid osmotic pressure in the
Administer salt-free
vascular compartment (pulling fluid
albumin/plasma expanders as
into vascular space), thereby
indicated.
increasing effective circulating volume
and decreasing formation of ascites.

Administer medications as indicated:

Used with caution to control edema

o Diuretics: spironolactone
and ascites, block effect of
(Aldactone), furosemide (Lasix)
aldosterone, and increase water
 Nursing Interventions Rationale

excretion while sparing potassium

when conservative therapy with
bedrest and sodium restriction does not
alleviate problem.
Serum and cellular potassium are
o - Potassium usually depleted because of liver
disease and urinary losses.
Given to increase cardiac
Positive inotropic drugs and arterial output/improve renal blood flow and
vasodilators. function, thereby reducing excess
fluid.

3. Risk for Impaired Skin Integrity

Risk for Impaired Skin Integrity: At risk for altered epidermis and/or dermis.
Risk factors may include

o - Altered circulation/metabolic state

o - Accumulation of bile salts in skin
o - Poor skin turgor, skeletal prominence, presence of edema, ascites

Desired Outcomes

o - Maintain skin integrity.

o - Identify individual risk factors and demonstrate behaviors/techniques to prevent skin
breakdown.

Nursing Interventions Rationale

Inspect pressure points and skin Edematous tissues are more prone to
surfaces closely and routinely. breakdown and to the formation of
Gently massage bony prominences decubitus. Ascites may stretch the
 Nursing Interventions Rationale

or areas of continued stress. Use of skin to the point of tearing in severe

emollient lotions and limiting use of cirrhosis.
soap for bathing may help.

Repositioning reduces pressure on

Encourage and assist patient with
edematous tissues to improve
reposition on a regular schedule.
circulation. Exercises enhance
Assist with active and passive ROM
circulation and improve and/or
exercises as appropriate.
maintain joint mobility.

Recommend elevating lower Enhances venous return and reduces

extremities. edema formation in extremities.

Keep linens dry and free of Moisture aggravates pruritus and

wrinkles. increases risk of skin breakdown.

Prevents patient from inadvertently

Suggest clipping fingernails short;
injuring the skin, especially while
provide mittens/gloves if indicated.
sleeping.

Provide perineal care following Prevents skin excoriation breakdown

urination and bowel movement. from bile salts.

Use alternating pressure mattress, Reduces dermal pressure, increases

egg-crate mattress, waterbed, circulation, and diminishes risk of
sheepskins, as indicated. tissue ischemia.

Use calamine lotion and provide

baking soda baths. Administer
May be soothing and can provide
medications (as indicated) such as
relief of itching associated with
cholestyramine (Questran),
jaundice, bile salts in skin.
hydroxyzine (Atarax),
diphenhydramine (Benadryl).
 4. Ineffective Breathing Pattern

Ineffective Breathing Pattern: Inspiration and/or expiration that does not provide
adequate ventilation
Risk factors may include

o - Intra-abdominal fluid collection (ascites)

o - Decreased lung expansion, accumulated secretions
o - Decreased energy, fatigue

Desired Outcomes

o - Maintain effective respiratory pattern; be free of dyspnea and cyanosis, with ABGs
and vital capacity within acceptable range.

Nursing Interventions Rationale

Rapid shallow respiration or presence

Monitor respiratory rate, depth, and of dyspnea may appear because of
effort. hypoxia and/or fluid accumulation in
the abdomen.

May indicate developing

complications. Presence of
Auscultate breath sounds, noting adventitious breath sounds may reflect
crackles, wheezes, rhonchi. accumulation of fluids or secretions.
Absent or diminished sounds suggests
atelectasis.

Changes in mentation may reflect

Investigate changes in level of
hypoxemia and respiratory failure,
consciousness.
which often accompany hepatic coma.

Keep head of bed elevated. Position Facilitates breathing by reducing

 Nursing Interventions Rationale

on sides. pressure on the diaphragm, and

minimizes risk of aspiration of
secretions.

Encourage frequent repositioning

Aids in lung expansion and mobilizing
and deep-breathing exercises and
secretions.
coughing exercises.

Monitor temperature. Note presence

of chills, increased coughing, Indicative of onset of infection,
changes in color and character of especially pneumonia.
sputum.

Monitor serial ABGs, pulse

Reveals changes in respiratory status,
oximetry, vital capacity
developing pulmonary complications.
measurements, chest x-rays.

To treat or prevent hypoxia and if

Provide supplemental O2 as respirations and oxygenation is
indicated. inadequate, mechanical ventilation
may be required.

Demonstrate and assist with

Reduces incidence of atelectasis,
respiratory adjuncts: incentive
enhances mobilization of secretions.
spirometer.

Prepare for/assist with acute care procedures:

Occasionally done to remove ascites

fluid to relieve abdominal pressure
o - Paracentesis
when respiratory embarrassment is not
corrected by other measures.
 Nursing Interventions Rationale

Surgical implant of a catheter to return

accumulated fluid in the abdominal
cavity to systemic circulation via the
o - Peritoneovenous shunt
vena cava; provides long-term relief of
ascites and improvement in respiratory
function.
5. Risk for Injury

Risk for Injury: Vulnerable for injury as a result of environmental conditions

interacting with the individual‘s adaptive and defensive resources, which may
compromise health.
Risk factors may include

o - Abnormal blood profile; altered clotting factors (decreased production of

prothrombin, fibrinogen, and factors VIII, IX, and X; impaired vitamin K absorption;
and release of thromboplastin)
o - Portal hypertension, development of esophageal varices

Desired Outcomes

o - Maintain homeostasis with absence of bleeding

o - Demonstrate behaviors to reduce risk of bleeding.

Nursing Interventions Rationale

Closely assess for signs and The esophagus and rectum are the
symptoms of GI bleeding: check all most usual sources of bleeding because
secretions for frank or occult blood. of their mucosal fragility and
Observe color and consistency of alterations in hemostasis associated
stools, NG drainage, or vomitus. with cirrhosis.

Observe for presence of petechiae, Subacute disseminated intravascular

 Nursing Interventions Rationale

ecchymosis, bleeding from one or coagulation (DIC) may develop

more sites. secondary to altered clotting factors.

An increased pulse with decreased BP

Monitor pulse, BP (and CVP if and CVP can indicate loss of
available). circulating blood volume, requiring
further evaluation.

Changes may indicate decreased

Note changes in mentation and
cerebral perfusion secondary to
LOC.
hypovolemia, hypoxemia.

Avoid rectal temperature; be gentle Rectal and esophageal vessels are most
with GI tube insertions. vulnerable to rupture.

Encourage use of soft toothbrush,

In the presence of clotting factor
electric razor, avoiding straining for
disturbances, minimal trauma can
stool, vigorous nose blowing, and
cause mucosal bleeding.
so forth.

Use small needles for injections.

Apply pressure to small bleeding Minimizes damage to tissues, reducing
and venipuncture sites for longer risk of bleeding and hematoma.
than usual.

Advice to avoid aspiring-containing Prolongs coagulation, potentiating risk

products. of hemorrhage.

Monitor Hb/Hct and clotting Indicators of anemia, active bleeding,

factors. or impending complications.

Administer medications as indicated

o - Supplemental vitamins: vitamin Promotes prothrombin synthesis and

 Nursing Interventions Rationale

K, D, and C. coagulation if liver is functional.

Vitamin C deficiencies increase
susceptibility of GI system to irritation
and/or bleeding.
Prevents straining for stool with
resultant increase in intra-abdominal
o - Stool softeners
pressure and risk of vascular rupture
and hemorrhage.
In presence of acute bleeding,
Provide gastric lavage with room
evacuation of blood from GI tract
temperature and cool saline solution
reduces ammonia production and risk
or water as indicated.
of hepatic encephalopathy.

Temporarily controls bleeding of

esophageal varices when control by
Assist with insertion and
other means (e.g., lavage) and
maintenance of GI tube.
hemodynamic stability cannot be
achieved.

May be needed to control active

Prepare for surgical procedures:
hemorrhage or to decrease portal and
direct ligation (banding) or varices,
collateral blood vessel pressure to
esophagogastric resection,
minimize risk of recurrence of
splenorenal-portacaval anastomosis.
bleeding

6. Risk for Acute Confusion

Risk factors may include

o - Alcohol abuse
o - Inability of liver to detoxify certain enzymes/drugs
 Desired Outcomes

o - Maintain usual level of mentation/reality orientation.

o - Initiate behaviors/lifestyle changes to prevent or minimize recurrence of problem.

Nursing Interventions Rationale

Observe for signs and symptoms of

behavioral change and mentation: Ongoing assessment of behavior and
lethargy, confusion, drowsiness, mental status is important because of
slurring of speech, and irritability. fluctuating nature of impending
Around patient at intervals as hepatic coma.
indicated.

Review current medication Adverse drug reactions or interactions

regimen. Note adverse drug (e.g., cimetidine plus antacids) may
reactions and effects of medication potentiate and/or exacerbate
to the patient. confusion.

Difficulty falling or staying asleep

Evaluate sleep and rest schedule. leads to sleep deprivation, resulting in
diminished cognition and lethargy.

Note development and/or presence Suggests elevating serum ammonia

of asterixis, fetor hepaticus, seizure levels; increased risk of progression to
activity. encephalopathy.

Consult with SO about patient‘s Provides baseline for comparison of

usual behavior and mentation. current status.

Have patient write name

periodically and keep this record for
Easy test of neurological status and
comparison. Report deterioration of
muscle coordination.
ability. Have patient do simple
arithmetic computations.
 Nursing Interventions Rationale

Assists in maintaining reality

Reorient to time, place, person as
orientation, reducing confusion and
needed.
anxiety.

Maintain a pleasant, quiet

Reduces excessive stimulation and
environment and approach in a
sensory overload, promotes relaxation,
slow, calm manner. Encourage
and may enhance coping.
uninterrupted rest periods.

Familiarity provides reassurance, aids

Provide continuity of care. If
in reducing anxiety, and provides a
possible, assign same nurse over a
more accurate documentation of
period of time.
subtle changes.

Reduce provocative stimuli,

confrontation. Refrain from forcing Avoids triggering agitated, violent
activities. Assess potential for responses; promotes patient safety.
violent behavior.

Patient/SO may be reassured that

Discuss current situation, future intellectual (as well as emotional)
expectation. function may improve as liver
involvement resolves.

Reduces metabolic demands on liver,

Maintain bedrest, assist with self- prevents fatigue, and promotes
care activities. healing, lowering risk of ammonia
buildup.

Identify and provide safety needs. Reduces risk of injury when

Supervise during smoking, put bed confusion, seizures, or violent
in low position, raise side rails and behavior occurs.
 Nursing Interventions Rationale

pad if necessary.

Infection may precipitate hepatic

Investigate temperature elevations.
encephalopathy caused by tissue
Monitor for signs of infection.
catabolism and release of nitrogen.

Certain drugs are toxic to the liver,

Recommend avoidance of narcotics
whereas other drugs may not be
or sedatives, anti anxiety agents,
metabolized because of cirrhosis,
and limiting or restricting use of
causing cumulative effects that affect
medications metabolized by the
mentation, mask signs of developing
liver.
encephalopathy, or precipitate coma.

Ammonia (product of the breakdown

of protein in the GI tract) is
responsible for mental changes in
hepatic encephalopathy. Dietary
Eliminate or restrict protein in diet. changes may result in constipation,
Provide glucose supplements, which also increases bacterial action
adequate hydration. and formation of ammonia. Glucose
provides a source of energy, reducing
need for protein catabolism. Note:
Vegetable protein may be better
tolerated than meat protein.

May be used to reduce serum

Assist with procedures as indicated:
ammonia levels if encephalopathy
dialysis, plasmapheresis, or
develops and other measures are not
extracorporeal liver perfusion.
successful.

7. Disturbed Body Image

 Disturbed Body Image: Confusion in mental picture of one‘s physical self.
Situational Low Self-Esteem: Development of a negative perception of self-worth in
response to current situation.
May be related to

o - Biophysical changes/altered physical appearance

o - Uncertainty of prognosis, changes in role function
o - Personal vulnerability
o - Self-destructive behavior (alcohol-induced disease)

Possibly evidenced by

o - Verbalization of change/restriction in lifestyle

o - Fear of rejection or reaction by others
o - Negative feelings about body/abilities
o - Feelings of helplessness, hopelessness, or powerlessness

Desired Outcomes

o - Verbalize understanding of changes and acceptance of self in the present situation.

o - Identify feelings and methods for coping with negative perception of self.

Nursing Interventions Rationale

Discuss situation and encourage Patient is very sensitive to body

verbalization of fears and concerns. changes and may also experience
Explain relationship between nature feelings of guilt when cause is related
of disease and symptoms. to alcohol or other drug use.

Caregivers sometimes allow

Support and encourage patient; judgmental feelings to affect the care
provide care with a positive, of patient and need to make every
friendly attitude. effort to help patient feel valued as a
person.
 Nursing Interventions Rationale

Family members may feel guilty about

patient‘s condition and may be fearful
of impending death. They need
Encourage family/SO to verbalize
nonjudgmental emotional support and
feelings, visit freely and participate
free access to patient. Participation in
in care.
care helps them feel useful and
promotes trust between staff, patient,
and SO.

Assist patient/SO to cope with Patient may present unattractive

change in appearance; suggest appearance as a result of jaundice,
clothing that does not emphasize ascites, ecchymotic areas. Providing
altered appearance (color of clothes, support can enhance self-esteem and
etc). promote patient sense of control.

Refer to support services. Increased vulnerability and concerns

Counselors, psychiatric resources, associated with this illness may
social service, clery and alcohol require services of additional
treatment program may help. professional resources.

8. Deficient Knowledge

Deficient Knowledge: Absence or deficiency of cognitive information related to

specific topic
May be related to

o - Lack of exposure/recall; information misinterpretation

o - Unfamiliarity with information resources

Possibly evidenced by

o - Questions; request for information, statement of misconception

o - Inaccurate follow-through of instructions/development of preventable complications

Desired Outcomes

o - Verbalize understanding of disease process/prognosis, potential complications.

o - Correlate symptoms with causative factors.
o - Identify/initiate necessary lifestyle changes and participate in care.

Nursing Interventions Rationale

Review disease process and Provides knowledge base from which

prognosis and future expectations. patient can make informed choices.

Patients with cirrhosis needs close

Refer to dietitian or nutritionist. observation and sound nutritional
counseling.

Stress importance of avoiding

alcohol. Give information about
Alcohol is the leading cause in the
community services available to
development of cirrhosis.
aid in alcohol rehabilitation if
indicated.

Some drugs are hepatotoxic

Inform patient of altered effects of
(especially narcotics, sedatives, and
medications with cirrhosis and the
hypnotics). In addition, the damaged
importance of using only drugs
liver has a decreased ability to
prescribed or cleared by a
metabolize all drugs, potentiating
healthcare provider who is familiar
cumulative effect and/or aggravation
with patient‘s history.
of bleeding tendencies.

Insertion of a Denver shunt requires

Review procedure for maintaining
patient to periodically pump the
function of peritoneovenous shunt
chamber to maintain patency of the
when present.
device. Patients with a LeVeen shunt
 Nursing Interventions Rationale

may wear an abdominal binder and/or

engage in a Valsalva maneuver to
maintain shunt function.

Because of length of recovery,

potential for relapses, and slow
Assist patient identifying support
convalescence, support systems are
person(s).
extremely important in maintaining
behavior modifications.

Proper dietary maintenance and

Emphasize the importance of good avoidance of foods high in sodium
nutrition. Recommend avoidance and protein aid in remission of
of high-protein/salty foods, onions, symptoms and help prevent ammonia
and strong cheeses. Provide written buildup and further liver damage.
dietary instructions. Written instructions are helpful for
patient to refer to at home.

Chronic nature of disease has

potential for life-threatening
Stress necessity of follow-up care
complications. Provides opportunity
and adherence to therapeutic
for evaluation of effectiveness of
regimen.
regimen, including patency of shunt
if used.

Minimizes ascites and edema

Discuss sodium and salt substitute formation. Overuse of substitutes
restrictions and necessity of may result in other electrolyte
reading labels on food and OTC imbalances. Food, OTC and/or
drugs. personal care products (antacids,
some mouthwashes) may contain
 Nursing Interventions Rationale

sodium or alcohol.

Adequate rest decreases metabolic

Encourage scheduling activities demands on the body and increases
with adequate rest periods. energy available for tissue
regeneration.

Promote diversional activities that Prevents boredom and minimizes

are enjoyable to patient. anxiety and depression.

Decreased resistance, altered

nutritional status, and immune
Recommend avoidance of persons
response (leukopenia may occur with
with infections, especially URI.
splenomegaly) potentiate risk of
infection.

Identify environmental dangers:

Can precipitate recurrence.
exposure to hepatitis.

Instruct patient/SO of signs and

symptoms that warrant notification
Prompt reporting of symptoms
of health care provider: increased
reduces risk of further hepatic
abdominal girth; rapid weight
damage and provides opportunity to
loss/gain; increased peripheral
treat complications before they
edema; increased dyspnea, fever;
become life-threatening.
blood in stool or urine; excess
bleeding of any kind; jaundice.

Instruct SO to notify health care Changes (reflecting deterioration)

providers of any confusion, may be more apparent to SO,
untidiness, night wandering, although insidious changes may be
 Nursing Interventions Rationale

tremors, or personality change. noted by others with less frequent

contact with patient.

9. Other Possible Nursing Care Plans

Other possible nursing diagnoses you can use to develop another care plan for liver
cirrhosis:

o Fatigue — decreased metabolic energy production, states of discomfort, altered body

chemistry (e.g., changes in liver function, effect on target organs, alcohol withdrawal).
o Imbalanced Nutrition: less than body requirements — inadequate diet; inability to
process/digest nutrients; anorexia, nausea/vomiting, indigestion, early satiety (ascites);
abnormal bowel function.
o Risk for ineffective management — perceived benefit, social support deficit,
economic difficulties.
o Family Processes, dysfunctional: alcoholism — abuse of alcohol, resistance to
treatment, inadequate coping/lack of problem-solving skills, addictive
personality/codependency.
o Risk for caregiver role strain — addiction or codependency, family dysfunction
before caregiving situation, presence of situational stressors, such as economic
vulnerability, hospitalization, changes in employment.

References and Sources : [Link]

PROBL NURSIN OBJECTIVE/ INTERVENTION OUTCOM
EM G GOAL E
DIAGNO
SIS

Epigastri The patient -Promote Bedrest in a quite The

[Link]
c Pain will be environment, minimizing patient
tric Pain
related relieved of on visitors. has
to Pain
within -Allow the patient to experience
irritated an hour d relief of
maintain his own preferred
mucosa, evidenced by comfortable position pain
ulceratio resting within an
-Provide food regularly to
n and calmly and hour and
relieve the ulcers (especially
muscle verbalization is resting
duodenal ulcers)
spasms during within the
evidence hospitalisatio -Provide diversional period of
d by n therapy so as to divert the hospitalisa
restless patient’s mind from the tion.
and pain
verbaliza -Instruct the patient to
tion increase the intake of water
so as to neutralize the
acidity in the stomach

-Instruct patient to eat

slowly and chew small
pieces of food

-Advice the patient to avoid

foods and beverages that
irritate the stomach lining,
 these also stimulate acid
secretion.

-Advice the patient to avoid

cold and hot foods and
fluids, to chew food
thoroughly, and to eat in
leisurely way so as to avoid
irritation of the mucosa
-Administer the prescribed
drugs for relief of pain

[Link] Gastroin The patient -Observe and report signs -The

Intestina testinal will stop of gastro intestinal bleeding, patient
l tract bleeding including the amount, has
Hemorr hemorrh within 30 consistency and colour of stopped
hage age minutes of the meleana and bleeding
related admission Hematemesis within 30
to evidenced by minutes of
-Check the vital signs
extensio reduced admission
hourly if bleeding is active
n of meleana and evidenced
and report to the doctor if
ulcers hamatenesis. by
deteriorating
into the reduced
submuco meleana
-Apply ice packs over the
sal layer and
abdomen to constrict the
evidence Hemateme
vessels
d by sis
-Educate the patient to keep
maleana
observing their own stool so
and
as to detect any bleeding
 Hemate -Advice the patient to be
mesis taking ice cubes
- Insert the naso gastric tube
to remove any clots from the
stomach

3. Anxiety The patient -Encourage the patient to The

Anxiety related will be express his concerns and patient
to fear of relieved of fear and ask questions. has shown
coping anxiety -Be calm and reassure the a happy
with the during the patient that everything facial
disease, period of possible is being done to help grimace, is
death, hospitalisatio them. resting/sle
and n -Explain reasons for adhering eping and
change to treatment schedule, participati
of including diet and stopping to ng in his
lifestyle smoke self care.
manifest -Explain the condition of the
ed by patient to alley anxiety
restlessn -Provide a supportive
ess and environment by allowing the
lack of family to participant in the
sleep care
-Encourage the patient to
participant in his own care
-Teach the patient the stress
reducing techniques such as
meditation, reading and
imaginary
4. Risk Risk of The patient -Close observations of the The
of complica will be free client, that is check for the patient is
complic tions from the pulse indicative of bleeding free from
ations related complication if thready, check for the complicati
to s related to temperature which may be ons
gastroint peptic ulcer subnormal related to
estinal disease -Encourage the patient to peptic
hemorrh adhere to treatment including ulcer
age and the prescribed diet disease
infection -Advice the patient to be
to the observant of the stool and
ulcer vomitus so as to detect any
bleeding.
-Continue with stress
reduction techniques
-Encourage the patient to
adhere to prescribed diet and
medication
-When there is excessive
bleeding, insert a nasogastric
tube to assist determine the
rate of bleeding and to
facilitate gastric lavage
-Advice the client to notify
physician if black tarry stool
or Hematemesis is noted

The client
5. Knowled The patient -Assess client’s level of
is
Knowle ge deficit will be knowledge by asking them participatin
dge about knowledgeab what they know about the g in the
deficit the le about his disease teaching
about disease condition -Teach the client according to sessions by
the process, during the their level of understanding. asking and
disease treatmen period of answering
-Teach the patient on the
t regime hospitalisatio questions
importance of diet
and n correctly
adherence; avoid bed time
complica and is
snacking because it
tions responsible
increases night time acid
manifest for his care
secretion, eat slowly and
ed by during the
chew foods thoroughly,
ignoranc period of
avoid spicy and fried foods
e and hospitalisat
as they stimulate acid
anxiety ion .
secretion, eat between meals
if this helps relieve the pain
and take a lot of water to
neutralize the acid.
-Advice the patient to avoid
the over the counter drugs
and avoid NSAIDS, aspirin
and brufen.
-Advice the patient to keep
antacids available for use as
needed and teach on the side
effects of the prescribed
drugs.
-Teach the patient on stress
reduction by participating in
 recreation and hobbies that
promote relaxation, Change
of lifestyle that is reconsider
the occupation if stressful
-Let the patient explain what
they have learnt

NURSING CARE PLAN FOR A PATIENT WITH DIARRHOEA

Problem Nursing Objective/Goal Nursing Evaluation

Identified Diagnosis intervention
1 Body Fluid Fluid volume To rehydrate 1. Administer Patient rehydrated
Volume deficit related the patient oral within 4 hours
deficit to fluid loss within rehydration evidenced by
secondary to four(04) hours solution (ORS increased skin
diarrhoea of admission freely as much elasticity, absence
evidenced by as the patient of sunken eyes and
loss of skin can tolerate to moist tongue.
turgor, sunken replace the lost
eyes and dry fluids and
tongue electrolytes.
2. Administer
intravenous
(IV) fluids as
prescribed for
 severe
dehydration to
replace lost
fluids and
electrolytes.
3. If the
patient is
severely
dehydrated,
assess
effectiveness of
rehydration
quarter-hourly
by checking
the skin turgor.
4. Put up and
maintain a
fluid balance
chart to
monitor the
fluid intake and
output.
2 Altered Altered To maintain 1. Give small 1. Nutritional
nutrition nutrition nutrition frequent meals status restored
related to throughout which can be during
nutrient loss hospitalisation retained hospitalisation
due to 2. Insert a evidenced by
vomiting and Nasogastric weight gain and
diarrhoea tube if patient tolerance of feeds.
evidenced by is unable to
 weight loss feed orally and
in cases of
severe
vomiting.
3. Weigh the
patient daily to
monitor weight
gain.

Problem Nursing Objective/Goal Nursing Evaluation

Identified Diagnosis intervention
3 Risk of Risk of cross To prevent the 1. If it is a case Other patients,
spreading the infection spread of of contagious staff and relatives
infection to related to infection to diarrhoea, not infected by the
others contamination other patients, isolate the disease
of hands, bed staff and patient.
linen and relatives 2. Educate
utensils during the caretaker
hospitalisation and the patient
on the
importance of
hand washing
under running
water with
soap after
touching body
secretions and
before eating.
3. Change and
 decontaminate
soiled linen
with 0.5%
chlorine, as
soon as it is
soiled and
replace it with
clean linen to
make the
patient
comfortable.
Also label the
linen as
infectious
when sending
it to the
laundry.
4. Administer
prescribed
antibiotics to
eliminate the
causative
organism.

NURSING CARE PLAN FOR A PATIENT WITH DIARRHOEA CONTINUED

Problem Nursing Objective/Goal Nursing Evaluation

Identified Diagnosis intervention
4 Anxiety Anxiety To allay 1. Explain in Patient appears
related to the anxiety simple terms calm and relaxed
patient‘s throughout the the disease
condition illness process, such
evidenced by as the cause,
restlessness signs and
and symptoms,
verbalisation treatment,
complications
and the
possible
prognosis of
the disease
2. Do nursing
care in blocks
to give the
patient enough
time to rest
3. Restrict
visits to
visiting hours
4. Listen to the
patient‘s fears
and concerns
and be there for
them during
periods of
extreme stress.
5. whenever
possible,
 include the
patient in the
care, decisions,
and also
include the
family in all
phases of the
patient‘s care

Neurological Care Plans

4 Seizure Disorder Nursing Care Plans

Seizures are physical findings or changes in behavior caused by uncontrolled

electrical firing or discharges from the nerve cells of the cerebral cortex and are
characterized by sudden, brief attacks of altered consciousness, motor activity and
sensory phenomena. The term ―seizure‖ is often used interchangeably with
―convulsion.‖
Seizures can be caused by head injuries, brain tumors, lead poisoning,
maldevelopment of the brain, genetic and infectious illnesses, and fevers. Sensory
symptoms arise from the parietal lobe; motor symptoms arise from the frontal lobe.
Nursing Care Plans
Treatment of seizure disorder consists of anticonvulsant therapy to reduce the number
of future seizures. The nurse should monitor the patient for signs of toxicity:
nystagmus, ataxia, lethargy, dizziness, slurred speech, nausea and vomiting. It is also
the duty of the nurse to provide support to the family and answering questions and
correcting misconceptions that surround it.
Here are four (4) seizure disorder nursing care plans:
1. Risk for Trauma or Suffocation

Risk for Trauma: The state in which an individual is at risk of accidental tissue injury
(e.g., wound, burns, fracture).
Risk factors may include

 - Weakness, balancing difficulties; reduced muscle, hand or eye coordination

 - Poor vision
 - Reduced sensation
 - Cognitive limitations or altered consciousness
 - Loss of large or small muscle coordination
 - Emotional difficulties

Possibly evidenced by

 Not applicable. A risk diagnosis is not evidenced by signs and symptoms, as the
problem has not occurred and nursing interventions are directed at prevention.

Desired Outcomes

 - Verbalize understanding of factors that contribute to the possibility of trauma

and or suffocation and take steps to correct the situation.
 - Identify actions or measures to take when seizure activity occurs.
 - Identify and correct potential risk factors in the environment.
 - Demonstrate behaviors, lifestyle changes to reduce risk factors and protect self
from injury.
 - Modify environment as indicated to enhance safety.
 - Maintain treatment regimen to control or eliminate seizure activity.
 - Recognize the need for assistance to prevent accidents or injuries.
 Nursing Interventions Rationale

Determine factors related to Influences scope and intensity of

individual situation, as listed in interventions to manage threat to
Risk Factors, and extent of risk. safety.

Note client‘s age, gender,

Affects client‘s ability to protect self
developmental age, decision-
and others, and influences choice of
making ability, level of cognition or
interventions and teaching.
competence.

Alcohol, various drugs, and other

stimuli (loss of sleep, flashing lights,
Ascertain knowledge of various
prolonged television viewing) may
stimuli that may precipitate seizure
increase brain activity, thereby
activity.
increasing the potential for seizure
activity.

Review diagnostic studies or Such may result in or exacerbate

laboratory tests for impairments and conditions, such as confusion, tetany,
imbalances. pathological fractures, etc.

Enables patient to protect self from

Explore and expound seizure injury and recognize changes that
warning signs (if appropriate) and require notification of physician and
usual seizure pattern. Teach SO to further intervention. Knowing what
determine and familiarize warning to do when seizure occurs can
signs and how to care for patient prevent injury or complications and
during and after seizure attack. decreases SO‘s feelings of
helplessness.

Use and pad side rails with bed in Prevents or minimizes injury when
lowest position, or place bed up seizures (frequent or generalized)
against wall and pad floor if rails occur while patient is in bed. Note:
 Nursing Interventions Rationale

not available or appropriate. Most individuals seize in place and if

in the middle of the bed, individual is
unlikely to fall out of bed.

May cause burns if cigarette is

Educate patient not to smoke except
accidentally dropped during aura or
while supervised.
seizure activity.

Use of helmet may provide added

Evaluate need for or provide
protection for individuals who suffer
protective headgear.
recurrent or severe seizures.

Avoid using thermometers that can Reduces risk of patient biting and
cause breakage. Use tympanic breaking glass thermometer or
thermometer when necessary to suffering injury if sudden seizure
take temperature. activity should occur.

Patient may feel restless or need to

ambulate or even defecate during
aural phase, thereby inadvertently
Uphold strict bedrest if prodromal
removing self from safe environment
signs or aura experienced. Explain
and easy observation. Understanding
necessity for these actions.
importance of providing for own
safety needs may enhance patient
cooperation.

Do not leave the patient during and

Promotes safety measures.
after seizure.

Turn head to side and suction Helps maintain airway patency and
airway as indicated. Insert plastic reduces risk of oral trauma but
bite block only if jaw relaxed. should not be ―forced‖ or inserted
 Nursing Interventions Rationale

when teeth are clenched because

dental and soft-tissue damage may
result. Note: Wooden tongue blades
should not be used because they may
splinter and break in patient‘s mouth.

Supporting the extremities lessens

the risk of physical injury when
Support head, place on soft area, or patient lacks voluntary muscle
assist to floor if out of bed. Do not control. Note: If attempt is made to
attempt to restrain. restrain patient during seizure, erratic
movements may increase, and patient
may injure self or others.

Note pre seizure activity, presence

of aura or unusual behavior, type of
seizure activity (location or
duration of motor activity, loss of
consciousness, incontinence, eye
activity, respiratory impairment or Helps localize the cerebral area of
cyanosis), and frequency or involvement.
[Link] whether patient
fell, expressed vocalizations,
drooled, or had automatisms (lip-
smacking, chewing, picking at
clothes).

Provide neurological or vital sign Documents postictal state and time or

check after seizure (level of completeness of recovery to normal
consciousness, orientation, ability state. May identify additional safety
 Nursing Interventions Rationale

to comply with simple commands, concerns to be addressed.

ability to speak; memory of
incident; weakness or motor
deficits; blood pressure (BP), pulse
and respiratory rate).

Patient may be confused, disoriented,

Reorient patient following seizure and possibly amnesic after the
activity. seizure and need help to regain
control and alleviate anxiety.

May display behavior (of motor or

psychic origin) that seems
Allow postictal ―automatic‖
inappropriate or irrelevant for time
behavior without interfering while
and place. Attempts to control or
providing environmental protection.
prevent activity may result in patient
becoming aggressive or combative.

May be result of repetitive muscle

contractions or symptom of injury
Investigate reports of pain.
incurred, requiring further evaluation
or intervention.

This is a life-threatening emergency

that if left untreated could cause
metabolic acidosis, hyperthermia,
Detect status epilepticus (one tonic-
hypoglycemia, arrhythmias, hypoxia,
clonic seizure after another in rapid
increased intracranial pressure,
succession).
airway obstruction, and respiratory
arrest. Immediate intervention is
required to control seizure activity
 Nursing Interventions Rationale

and prevent permanent injury or

death. Note: Although absence
seizures may become static, they are
not usually life-threatening.

Specific drug therapy depends on

Carry out medications as seizure type, with some patients
indicated: requiring polytherapy or frequent
medication adjustments.

AEDs raise the seizure threshold by

stabilizing nerve cell membranes,
reducing the excitability of the
neurons, or through direct action on
 Antiepileptic drugs the limbic system, thalamus, and
(AEDs): phenytoin (Dilantin), hypothalamus. Goal is optimal
primidone (Mysoline), suppression of seizure activity with
carbamazepine (Tegretol), lowest possible dose of drug and
clonazepam (Klonopin), with fewest side effects. Cerebyx
valproic acid (Depakene), reaches therapeutic levels within 24
divalproex (Depakote), hr and can be used for nonemergent
acetazolamide (Diamox), loading while waiting for other
ethotoin (Peganone), agents to become effective. Note:
methsuximide (Celotin), Some patients require polytherapy or
fosphenytoin (Cerebyx); frequent medication adjustments to
control seizure activity. This
increases the risk of adverse
reactions and problems with
adherence.
 - Topiramate (Topamax), Adjunctive therapy for partial
 Nursing Interventions Rationale

ethosuximide (Zarontin), seizures or an alternative for patients

lamotrigine (Lamictal), when seizures are not adequately
gabapentin (Neurontin) controlled by other drugs.

Potentiates and enhances effects of

 - Phenobarbital (Luminal) AEDs and allows for lower dosage to
reduce side effects.
Used to abort status seizure activity
because it is shorter acting than
 - Lorazepam (Ativan)
Valium and less likely to prolong
post seizure sedation.
May be used alone (or in
combination with phenobarbital) to
suppress status seizure activity.
 - Diazepam (Valium, Diastat
Diastat, a gel, may be administered
rectal gel)
rectally, even in the home setting, to
reduce frequency of seizures and
need for additional medical care.
May be given to restore metabolic
 - Glucose, thiamine balance if seizure is induced by
hypoglycemia or alcohol.
Standard therapeutic level may not
Monitor and document AED drug
be optimal for individual patient if
levels, corresponding side effects,
untoward side effects develop or
and frequency of seizure activity.
seizures are not controlled.

Monitor CBC, electrolytes, glucose Identifies factors that aggravate or

levels. decrease seizure threshold.

Prepare for surgery or electrode Vagal nerve stimulator, magnetic

 Nursing Interventions Rationale

implantation as indicated. beam therapy, or other surgical

intervention (temporal lobectomy)
may be done for intractable seizures
or well-localized epileptogenic
lesions when patient is disabled and
at high risk for serious injury.
Success has been reported with
gamma ray radio surgery for the
treatment of multiple seizure activity
that has otherwise been difficult to
control.

2. Risk for Ineffective Airway Clearance

Risk for Ineffective Airway Clearance: At risk for the inability to clear secretions or
obstructions from the respiratory tract to maintain a clear airway.
Risk factors may include

 - Neuromuscular impairment
 - Tracheobronchial obstruction
 - Perceptual or cognitive impairment

Possibly evidenced by

 Not applicable. A risk diagnosis is not evidenced by signs and symptoms, as the
problem has not occurred and nursing interventions are directed at prevention.

Desired Outcomes

 - Maintain effective respiratory pattern with airway patent or aspiration prevented.

Nursing Interventions Rationale

 Nursing Interventions Rationale

Ensure patient to empty mouth of

dentures or foreign objects if aura
Lessens risk of aspiration or foreign
occurs and to avoid chewing gum
bodies lodging in pharynx.
and sucking lozenges if seizures
occur without warning.

Maintain in lying position, flat Helps in drainage of secretions;

surface; turn head to side during prevents tongue from obstructing
seizure activity. airway.

Loosen clothing from neck or chest

Aids in breathing or chest expansion.
and abdominal areas.

If inserted before jaw is tightened,

these devices may prevent biting of
tongue and facilitate suctioning or
Provide and insert plastic airway or
respiratory support if required.
soft roll as indicated and only if jaw
Airway adjunct may be indicated
is relaxed.
after cessation of seizure activity if
patient is unconscious and unable to
maintain safe position of tongue.

Reduces risk of aspiration or

asphyxiation. Note: Risk of
Suction as needed.
aspiration is low unless individual
has eaten within the last 40 min.

May lessen cerebral hypoxia

Supervise supplemental oxygen or resulting from decreased circulation
bag ventilation as needed or oxygenation secondary to vascular
postictally. spasm during seizure. Note: Artificial
ventilation during general seizure
 Nursing Interventions Rationale

activity is of limited or no benefit

because it is not possible to move air
in or out of lungs during sustained
contraction of respiratory
musculature. As seizure abates,
respiratory function will return unless
a secondary problem exists (foreign
body or aspiration).

Presence of prolonged apnea

Get ready for or assist with
postictally may need ventilatory
intubation, if indicated.
support.

3. Low Self-Esteem

Situational Low Self-Esteem: Development of a negative perception of self-worth in

response to current situation.
May be related to

 - Stigma associated with condition

 - Perception of being out of control
 - Social role changes
 - Feelings of abandonment
 - Inconsistent behavior

Possibly evidenced by

 - Verbalization about changed lifestyle

 - Fear of rejection; negative feelings about body
 - Change in self-perception of role
 - Change in usual patterns of responsibility
 - Lack of follow-through or nonparticipation in therapy
  - Expressions of helplessness or uselessness
 - Evaluation of self as unable to deal with situations or events

Desired Outcomes

 - Identify feelings and methods for coping with negative perception of self.
 - Verbalize increased sense of self-esteem in relation to diagnosis.
 - Verbalize realistic perception and acceptance of self in changed role or lifestyle.
 - Express positive self-appraisal
 - Demonstrate behaviors to restore positive self-esteem.
 - Participate in treatment regimen or activities to correct factors that precipitated
crisis.

Nursing Interventions Rationale

Determine individual situation Verbalization of concerns about

related to low self-esteem in the future implications can help patient
present circumstances. begin to accept or deal with situation.

Reactions vary among individuals,

Explore feelings about diagnosis,
and previous knowledge or
perception of threat to self.
experience with this condition affects
Encourage expression of feelings.
acceptance of therapeutic regimen.

Provides opportunity to problem-

solve response, and provides measure
of control over situation.
Analyze possible or anticipated
Concealment is destructive to self-
public reaction to condition.
esteem (potentiates denial), blocking
Encourage patient to refrain from
progress in dealing with problem,
concealing problem.
and may actually increase risk of
injury or negative response when
seizure does occur.
 Nursing Interventions Rationale

Concentrating on positive aspects can

help alleviate feelings of guilt and
Discuss with patient current and
self- consciousness and help patient
past successes and strengths.
begin to accept manageability of
condition.

Participation in as many experiences

Refrain from over protecting the as possible can lessen depression
patient; encourage activities, about limitations. Observation and
providing supervision and supervision may need to be provided
monitoring when indicated. for such activities as gymnastics,
climbing, and water sports.

Contradictory or unfavorable
Know the attitudes or capabilities of expectations from SO may affect
SO. Help individual realize that his patient‘s sense of competency and
or her feelings are normal; self-esteem and interfere with
however, guilt and blame are not support received from SO, limiting
helpful. potential for optimal management
and personal growth.

Tension and anxiety among

caregivers is contagious and can be
Elaborate the positive effect of staff
conveyed to the patient, increasing or
and SO remaining calm during
multiplying individual‘s own
seizure activity.
negative perceptions of situation or
self.

Refer patient and SO to support Provides opportunity to gain

group (Epilepsy Foundation of information, support, and ideas for
America, National Association of dealing with problems from others
 Nursing Interventions Rationale

Epilepsy Centers, and Delta who share similar experiences. Note:

Society‘s National Service Dog Some service dogs have ability to
Center). sense or predict seizure activity,
allowing patient to institute safety
measures, increasing independence
and personal sense of control.

Seizures have a profound effect on

personal self-esteem, and patient or
SO may feel guilt over perceived
Talk over and explain referral for
limitations and public stigma.
psychotherapy with patient and SO.
Counseling can help overcome
feelings of inferiority and self-
consciousness.

4. Deficient Knowledge

Deficient Knowledge: Absence or deficiency of cognitive information related to

specific topic.
May be related to

 - Lack of exposure, unfamiliarity with resources

 - Information misinterpretation
 - Lack of recall; cognitive limitation

Possibly evidenced by

 - Questions, statement of concerns

 - Increased frequency or lack of control of seizure activity
 - Lack of follow-through of drug regimen

Desired Outcomes
  - Verbalize understanding of disorder and various stimuli that may increase
potentiate seizure activity.
 - Participate in learning process.
 - Exhibit increased interest or assume responsibility for own learning by
beginning to look for information and ask questions.
 - Adhere to prescribed drug regimen.
 - Identify relationship of signs and symptoms to the disease process and correlate
symptoms with causative factors.
 - Initiate necessary lifestyle or behavior changes as indicated.

Nursing Interventions Rationale

Ascertain level of knowledge,

To assess readiness to learn
including anticipatory needs.

Individual may not be physically,

Determine client‘s ability or
emotionally, or mentally capable at
readiness and barriers to learning.
this time.

Review pathology and prognosis of

condition and lifelong need for Provides opportunity to clarify or
treatments as indicated. Discuss dispel misconceptions and present
patient‘s particular trigger factors condition as something that is
(flashing lights, hyperventilation, manageable within a normal
loud noises,video games, TV lifestyle.
viewing).

Alterations in hormonal levels that

Review possible effects of occur during menstruation and
hormonal changes. pregnancy may increase risk of
seizures.

Discuss significance of maintaining Regularity and moderation in

good general health, (adequate diet, activities may aid in reducing or
 Nursing Interventions Rationale

rest, moderate exercise, and controlling precipitating factors,

avoidance of exhaustion, alcohol, enhancing sense of general well-
caffeine, and stimulant drugs). being, and strengthening coping
ability and self-esteem. Note: Too
little sleep or too much alcohol can
precipitate seizure activity in some
people.

Know and instill the importance of

Lessens risk of oral infections and
good oral hygiene and regular
gingival hyperplasia.
dental care.

Identify necessity and promote

acceptance of actual limitations;
Lessens risk of injury to self or
discuss safety measures regarding
others, especially if seizures occur
driving, using mechanical
without warning.
equipment, climbing ladders,
swimming, and hobbies.

Although legal and civil rights of

persons with epilepsy have improved
Review local laws and restrictions
during the past decade, restrictions
pertaining to persons with epilepsy
still exist in some states pertaining to
and seizure disorder. Encourage
obtaining a driver‘s license,
awareness but not necessarily
sterilization, workers‘ compensation,
acceptance of these policies.
and required reportability to state
agencies.

Review medication regimen, Lack of cooperation with medication

necessity of taking drugs as regimen is a leading cause of seizure
ordered, and not discontinuing breakthrough. Patient needs to know
 Nursing Interventions Rationale

therapy without physician risks of status epilepticus resulting

supervision. Include directions for from abrupt withdrawal of
missed dose. anticonvulsants. Depending on the
drug dose and frequency, patient
may be instructed to take missed
dose if remembered within a
predetermined time frame.

Recommend taking drugs with May reduce incidence of gastric

meals, if appropriate. irritation, nausea and vomiting.

Discuss nuisance and adverse side May indicate need for change in
effects of particular drugs dosage or choice of drug therapy.
(drowsiness, fatigue, lethargy, Promotes involvement and
hyperactivity, sleep disturbances, participation in decision-making
gingival hypertrophy, visual process and awareness of potential
disturbances, nausea and vomiting, long-term effects of drug therapy,
rashes, syncope and ataxia, birth and provides opportunity to
defects, aplastic anemia). minimize or prevent complications.

Knowledge of anticonvulsant use

reduces risk of prescribing drugs that
may interact, thus altering seizure
Provide information about potential threshold or therapeutic effect. For
drug interactions and necessity of example, phenytoin (Dilantin)
notifying other healthcare providers potentiates anticoagulant effect of
of drug regimen. warfarin (Coumadin), whereas
isoniazid (INH) and chloramphenicol
(Chloromycetin) increase the effect
of phenytoin (Dilantin), and some
 Nursing Interventions Rationale

antibiotics (erythromycin) can cause

elevation of serum level of
carbamazepine (Tegretol), possibly
to toxic levels.

Useful in controlling serial or cluster

Familiarize proper use of diazepam seizures. Can be administered in any
rectal gel (Diastat) with patient, SO setting and is effective usually within
and caregiver as appropriate. 15 min. May reduce dependence on
emergency department visits.

Encourage patient to wear

Expedites treatment and diagnosis in
identification tag or bracelet stating
emergency situations.
the presence of a seizure disorder.

Stress need for routine follow-up

care and laboratory testing as Therapeutic needs may change and
indicated (CBC should be or serious drug side effects
monitored biannually and in (agranulocytosis or toxicity) may
presence of sore throat or fever, develop.
signs of other infection).

5. Other Possible Nursing Care Plans

Here are other nursing care plans you can make:

 Injury, risk for—weakness, balancing difficulties, cognitive limitations or altered

consciousness, loss of large or small muscle coordination.
 Self-Esteem (specify)—stigma associated with condition, perception of being out
of control, personal vulnerability, negative evaluation of self or capabilities.
  Therapeutic Regimen: ineffective management—social support deficits, perceived
benefit (versus side effects of medication), perceived susceptibility (possible long
periods of remission).

References and Sources : [Link]