RESPIRATORY SYSTEM  Larynx

 Trachea
Normal Value of Atmospheric  Bronchi
Pressure (PA)  Lungs
 760 mm Hg
 14.7 psi (pounds per square inch) Important Concepts!!!
 Hilus
Important Concepts!!! o Hilar Mass
 Principle of air flow is from areas  Pleurisy
of higher pressure to areas of o Pleural Effusion
lower pressure
 Intrapulmonic Space
 For exchange of gases to occur, o Space inside the lung
NORMALLY (N), there must be a
 Intrathoracic Space
pressure gradient of PLUS AND
o Space between the lungs
MINUS SIX
(+/-) 6 mm Hg and the bony thorax
 Pressure must be positive (+) (or  Normal Respiratory Rate
greater outside) to enter the lung o Twelve (12) cycles per
minute
RESPIRATORY INSPIRATION EXPIRATION o Also known as Eupnea
MECHANISM
Respiratory  Tachypnea
Muscles o Respiratory Rate above
1. Diaphragm Lowers and Rises and the normal rate
contracts relaxes  Bradypnea
2.Pectoral Contracts Relaxes o Respiratory Rate below
Muscle the normal rate
3. Intercostal Moves inward Moves outward  Apnea
Muscles and contracts and contracts
o Absence of Respiration jor
Lung Size Increases Decreases absence of breathing
Thorax Size Increases Decreases
Intrapulmonic Decreases Increases
Pressure (less than (greater than Types of Respiration
atmospheric atmospheric
pressure) pressure)
Reference is the cell
Intrathoracic Decreases (less Increases  Internal or Cellular Respiration
Pressure than (greater than
atmospheric atmospheric  External Respiration
pressure) pressure)
Important Concepts!!!
Important Concepts!!!  Hyperpnea
Upper Respiratory Tract o Deep Breathing
Composed of:  Hypopnea
 Nose o Shallow Breathing
 Pharynx  Kussmaul’s Breathing
 Associated Structures o Deep, rapid breaths
Factors Affecting the Rate and Depth
of Respiration
Lower Respiratory Tract:
Composed of:

1
Neurological  Determination of Lung function
 Medulla o PCO2
 Center of Respiration  Hypoxic Drive
 Pons o Stimulant is CO2
 Affects the rhythm  Hyperventilation
 Expansion of the lungs o Prone to Alkalosis
 Herring Brewer o Patient gets a lot of O2
 Prevents over distension of the o Decreases amount of CO2
lungs o Therefore, breathe inside
a bag
Clinical o Do paper bag breathing
Arterial Blood Gas o Do cupped hand breathing
 Artery  Respiratory Acidosis
o Complete presence of o Do pursed lip breathing
oxygen and carbon dioxide o You want to retain positive
 Parameters: (+) pressure on the lung
o pH o Takes effect on CO2
 7.35 to 7.45 utilization
o pHCO3 o To remove CO2
 22 to 26 meq / Liter  Expiration is prolonged (longer
o PCO2 than inspiration) by pursed lip
 35 to 45 mm Hg breathing
o PO2
 80 to 100 mm Hg ASSESSMENT TO RULE OUT
(for adults) RESPIRATORY DISORDER
 40 to 60 mm Hg (for
infants) 1. Cough
 If increased or
greater than 60% in Important Concept!!!
infants, it leads to Three (3) types of cough medications:
RETROLENTAL  Antitussives
FIBROPLASIA o Suppresses the cough
reflex
Important Concepts!!!  Expectorant
 Acidosis or alkalosis is detected o Clears the airway
by the pH
Control:  Mucolytic
Respiratory / metabolic o Lyses, breaks down,
 Bicarbonate liquefies the phlegm
o Buffer / neutralizer
o Must be > 26 meq / L to Types of Cough
counteract acidosis
 Kidney 1.1) Non-productive Cough
o Base factor  With presence of phlegm
 With copious amounts of phlegm

2
  Phlegm is retained and is not • Vomiting of
expelled from the body bright red
 Medication is a MUCOLYTIC blood
o It lyses, breaks down and o Yellow Green
liquefies the phlegm  Signifies infection
o Greenish
1.2) Productive Cough  Depends on type of
 With presence of phlegm infecting microbe
 With copious amounts of phlegm o Rusty
 Phlegm is being expelled from  Brown
the body  Blood is brownish
 Medication is an due to
EXPECTORANT extravasation
o To clear airway  Pneumonia
 Due to blood (old
1.3) Dry Cough blood)
 No phlegm  Viral or bacterial
 Cough needs to be suppressed  With consolidation
 Medication is an ANTITUSSIVE (hardening or
o With sedating effect “naninigas”)
 Important Concept! o Two Types of
o No antitussive is given Consolidation
when there is phlegm  Lobar
o Suppression of cough will • Occurs at the
not allow the phlegm to be lobes
expelled from the body  Bronchial
• Occurs in the
2. Sputum and Phlegm bronchi
• Occurs in
2.1 Color bronchopneu-
Important Concepts!!! monia
 Saliva  More common
o Normal color is clear
 Phlegm Interjected Concept!
o Red  Pulmonary Tuberculosis
 With blood o Bacterial
 Hemoptysis o Mode of Transmission
• Spitting of  Droplet nuclei
blood o Route
 Hematamesis  Airborne
• Upper GI o It is appropriate to wear
bleeding MASK
o It is inappropriate to wear
GOWN

3
 o With CAVITIES Important Interjected Concepts!
Signs of Inflammation
Other Interjected Concepts!  Rubor
 Black and tarry stool o Redness
o Indicates dead blood  Calor
 Melena indicates upper GI o Heat
bleeding  Tumor
o Swelling
2.2) Viscosity and Tenacity  Dolor
 Mucin o Pain
o Makes saliva slippery  Functiolaesa
 Phlegm o Loss of Function
o Irritated saliva
o Thick and tenacious saliva Viscosity and Tenacity of Sputum
 Hypermucous Production (continued. . .)
o Leads to phlegm
2.2.1) Frothy Sputum
Important Interjected Concepts!!!  Air is present but is due to
 Rhinitis PULMONARY EDEMA
o Nasal cavity inflammation  Pneumothorax
 Colds o Air at intrapleural space
o Viral in nature
 Coryza 2.2.2) Stringy and Thready (thinner)
o Viral in nature Sputum
 Glossitis  Due to BRONCHIAL ASTHMA
o Inflammation of the tongue  “Masyadong malagkit”
 Glottitis  Caused by allergen
o Inflammation of the glottis o Dust
 Tracheitis o Pollen
o Inflammation of the o All dust particles
trachea
 Bronchiolitis Interjected Concept
o Inflammation of the  Clear and stretchy vaginal mucus
bronchioles or discharge indicates fertility
 Pneumonitis
3. Assess for Cyanosis
o Inflammation of the alveoli
 Bluish color due to lack of oxygen
 Gastritis
o Inflammation of the
3.1) Central Cyanosis
stomach
 Bluish coloration of the:
 Stomatitis
 Face
o Inflammation of the oral
 Chest
cavity

4
3.2) Peripheral Cyanosis • Suction
 Bluish coloration of the
extremities 4. Abnormal Breath Sounds
 Also called Adventitious Breath
3.3) Differential Cyanosis Sounds
 Acrocyanosis
 Use Apgar scoring 4.1) Rales
o Within one (1) minute Two (2) types:
o After five (5) minutes  Fine Rales
 APGAR also stands for:  Coarse Rales
o A for Appearance
o P for Pulse 4.1.1) Fine Rales
 Heart Rate  Sound similar to when you rub
determines if the your hair
baby is alive  Also called Friction Rub
o G for Grimace
 To rule out 4.1.2) Coarse Rales
neurological  Sound similar to crumpling of
problems or paper
problems with the
nervous system 4.2) Ronchi
 Important Concept!!  Sound similar to bubbling water
• In newborns,
eyeblinking before 4.3) Wheezing
crying is Normal  Musical sound
 Whistling sound
• If there is NO  Occurs more on or during
BLINKING, this expiratory phase
indicates A SIGN
OF MYASTHENIA Important Concept!
GRAVIS of the  Abnormal breath sounds are due
newborn to:
• This indicates that o Obstruction
there is NO o Phlegm
INNERVA-TION
o A for Activity 5. Abnormal Respiration
 Muscle Tonicity  Pattern of breathing or sequence
o R for Respiration of breathing
 Changes in
respiration requires 5.1) Biot’s Respiration
immediate  Initially NORMAL
intervention and  Followed by APNEA
action  Then NORMAL
 First thing to do to  Then APNEA
newborn:

5
  Pattern is NANA – normal,  5. Malaise
apnea, normal, apnea, etc. o Weakness
 6. Easy Fatigability
5.2) Cheyne Stokes o Management
 Initially NORMAL o Provide bed rest
 Followed by HYPERPNEA (deep  7. General Debilitation
breathing) o Loss of function
 Then APNEA o Patient wants to move but
 Pattern is NHA – normal, is unable to do so
hyperpnea, apnea o Debilitation
 Apathetic
5.3) Kussmaul’s Respiration (schizophrenic)
 Hyperpnic with tachypnea  8. Irritability
 “Malalim na, mabilis pa”
 Asthmatic and labored breathing Interjected Concept!!!
 Correct technique in cleaning the
Common Signs and Symptoms of patient is from A CLEANER
Respiratory Diseases AREA to a DIRTIER AREA to
avoid conveying infection
 1. Dyspnea
 Also called Difficulty of Breathing Chronic Signs and Symptoms of
o Management Respiratory Diseases
 Positioning
• High-  Overdeveloped strap muscles
Fowler’s  Elevated sternum and shoulder
 Barrel chest or Pigeon Breast
 Interjected Concept!! o No elastic recoil
In reverse trendelenberg, only the o Common in emphysema
head part is elevated  Stridor
 This is indicated for arterial o Noisy Respiration
occlusion  Clubbing of Fingers
o Caused by hypoxia of the
 2. Cough joints
 3. Anorexia  Chest Retraction
o Loss of appetite
o Management Interjected Concept!
 Provide small  The urinary bladder is considered
frequent feedings full when it contains a volume of
 Patient chooses his about 450 to 500 ml
own food  You cannot stop the urge to void
 Nurse assists in the at this level of fullness of the
selection of the food urinary bladder
 Good oral hygiene
triggers appetite General Management Techniques:
 4. Weight Loss  To minimize weakness

6
 o Provide bed rest reverse isolation
 For dyspnea because they are
o Proper positioning prone to infection
 Provide good nutrition  AIDS patients are
o Proper and balanced on reverse isolation
nutrition because they are
 Environmental Sanitation immunocompro-
mised
 Oxygenation
o If patient is dyspneic and
not relieved by positioning
o Nasal Cannula or nasal
o Strict Isolation
prongs
 Patient is being
o Nasal flow
isolated because he
 Low flow can readily spread
 One (1) to three (3) the disease
liters per minute  The people around
 Average of two (2) the patient are
liters per minute being protected
 High flow is at six  Example:
(6) liters per minute  PTB patients are
 Coupette subjected to strict
o A plastic bubble isolation
 Isolette  Mycobacterium
o An incubator tuberculosis is
 Nasal Catheter transmitted through
 Tip should be placed posterior to droplet and is
the uvula airborne
 Medication
Important Concepts!!! o A dependent function
If the respiratory disease in an infectious o Antibiotics are
disorder, management would include administered
the following: o For allergens
 Isolation  Antihistamines are
o Reverse Isolation given
 Patient is being o Bronchospasm
isolated because he  Bronchodilators
could easily be o Cough
infected by
 Cough medication
diseases
 The patient himself RESPIRATORY DISORDERS
is being protected
 Example: PULMONARY TUBERCULOSIS
 Burn patients are  Causative agent is
subjected to Mycobacterium tuberculosis

7
  Acid-fast bacillus
 Temperature Stage No. 3 – FAR ADVANCED
o Coated with wax  With cavitary
o Melt this with temperature  Whole or entire lungs are
(an additional factor) affected
 Mode of transmission is droplet /  Pneumonectomy or removal of
airborne the entire lungs is performed
 Position patient at the
Stages of Pulmonary Tuberculosis AFFECTED SIDE
 Mediastinal Shift is a common
Stage No. 1 – MINIMAL complication
INFILTRATION  Turning on an hourly basis is also
 No cavitaries but with lesion performed
 Primary complex in children
 With chemotherapy or multi-drug Diagnostic Tests for Pulmonary
therapy Tuberculosis
 Urine becomes BRICK ORANGE
o Due to Rifampicin Chest X-ray
o A normal and expected  To show where the lesion is
side effect of Rifampicin located
use
Sputum Examination
Interjected Concepts!!!  Culture and Sensitivity
 In cancer, chemotherapy causes  To identify the bacteria
the following:  To know what antibiotic will be
o Alopecia used to combat the invading
 Loss of hair microorganism
o Keratin  The doctor and the medical
 Protein in the hair technician would perform this
o Collagen
White Blood Cell (WBC) and
 Protein in the
Erythrocyte Sedimentation Rate
internal organs
(ESR) Test
o DNA and RNA proliferation
 Increased WBC levels indicate:
is blocked
o Bacterial infection
o Koch’s infection
Stage No. 2 – MODERATELY
ADVANCED
Mantoux Test or Tubercullin Test
 With cavitary
 Utilizes PPD (Purified Protein
 One-half of lung is affected
Derivative)
 Lobectomy or removal of one
 Route is Intradermal
lobe is performed
 Result is read after forty-eight
 Initially, position the patient at the
(48) to seventy-two (72) hours
UNAFFECTED SIDE
 Positive Reading if:
 Then, turn patient on an hourly
basis

8
 o 10 mm induration or  For patients with dyspnea, place
diameter of the wheal in high-Fowler’s position
(hardness or “pantal” but  Provide good and proper nutrition
not the erythema)  Increase Fluid Intake
o 5 mm induration for HIV  Medication
positive patients o Triple Chemotherapy
o Rifampicin
Important Concepts!  Brick orange urine
 A positive result or a positive o Isoniazid (INH)
Mantoux Test does not mean that
 Peripheral neuritis
a person has PTB
 Provide Vitamin B6
 It only means that the person had
or pyridoxine
been exposed to the invading
o Pyrazinamide (PZA)
bacteria
 Gout formation
 Then, it is advised that the other
tests would be performed  Uric acid crystals
 The most credible test is the
Important Concepts!!!
SPUTUM TEST (also for
pneumonia)  In PTB, there is an onset of low-
grade fever
 You will know the microorganism
 In Pneumonia, there is an onset
 You will know the drug to be used
of high-grade fever
Signs and Symptoms of PTB
Short-Course Chemotherapy
 Six (6) months
 Fever
o Low grade fever (onset) in  Prolonged
o More than one year
the afternoon
o Patient’s resistance is low  Use Ethambutol
at this time o Side effect is OPTICAL
o Virulence also increases NEURITIS
o If PTB is advanced, fever  Use Streptomycin
does not manifest as low o Side effect is on the 8th
grade cranial nerve
 Excessive Sweating o Therefore, this is
o Hyperhidrosis OTOTOXIC
 Dehydration
CHRONIC OBSTRUCTIVE
o Management is to
PULMONARY DISEASES
increase oral fluid intake
Mnemonic is ABBE
 Anorexia
 Asthma
 Weight Loss
 Bronchitis
 Easy Fatigability
 Bronchiectasis
o With scarring or nodules
Management of PTB patients
called SARCOID
 Bed Rest
 Positioning

9
 o With numerous sarcoids Nursing Interventions for COPD
called SARCOIDOSIS patients:
 May lead to:  Assess the following:
o Lung cancer o Breathing pattern
o Emphysema o Breath sounds
o Secretions
Important Concept on COPDs!!!  Promote mobilization of
All COPDs are characterized by: secretions through:
 Presence of phlegm o Mucolytic agents
 Obstruction by phlegm o For productive cough, use
expectorants
Signs and Symptoms of COPD o Increased humidification of
 Productive Cough moistening
 Exertional Dyspnea o Fluid intake of 1.5 to 2.0
o In asthmatic liters per day
 Pink Cyanosis  Saliva is not part of
o Due to compensatory daily fluid loss
mechanism o Suctioning
 Blue bloaters o Chest Physiotherapy
o Cyanosis o Positioning to allow
o Hyperventilate maximum breathing
o Reddish during attack - o Teach the patient to use
hyperemia pursed lip breathing
o Increases altitude and  Administer low flow oxygen
decreased PO2 results into  Monitor therapeutic and side
hyperemia effects of the medications used
 Wheezing  Bed rest
o Expiratory  Encourage Range of Motion
 Barrel Chest exercises
o Common in emphysema  Assist with activities of daily living
 Anorexia (ADL) as needed
 Followed by weight loss, body  Assess for signs of infection
malaise, etc.  Provide proper caloric
 Respiratory infection requirement: Increase protein
 Fatigue intake
 Cor Pulmonale  Provide health teachings:
o Right Ventricular o Avoidance of smoking,
Hypertrophy due to irritants, infection
increased vascular o Avoidance of extreme
resistance or temperatures
vasoconstriction o Proper nutrition and
 Results into a BOOT-SHAPED hydration
HEART o Use measures to conserve
energy

10
 o Equivalent to about fifty
Important Concepts!!! (50) to seventy (70) ml
 For Orthopnea  Tidal Volume is about 500 to 700
o Do the Orthopnic position ml per respiration
o Fowler’s Position and lean  Cardiac Output
forward o 5 – 7 liters per minute
o Lung is most expanded in  Stroke Volume
this position o 50 – 70 ml per beat
o Lung is most open in this  Tidal Volume
position o 500 – 700 ml per
o Lungs expand but they do respiration
not thicken
 Atelectasis Important Concepts!!!
o Lung collapse Approximate Distribution of Oxygen
o Overdistended lung in the Body
collapse Brain 15% of oxygen in
 Emphysema the circulating
o Bursting of alveoli blood
o Bleeding occurs Heart 5% of oxygen in
o If there is pus, it is called the circulating
EMPYEMA blood
 Pyothorax GI and Liver 25% of oxygen in
o Presence of pus in the the circulating
pleural space blood
Renal System 25% of oxygen in
Important Concepts!!! the circulating
blood
 The heart is located at the center
of the chest Extremities 30% of oxygen in
(upper and the circulating
 The apex of the heart is
lower) blood
positioned to the left of the chest
 Right Atrium is larger than the
Important Concepts!!!
other chambers
Decreased level of consciousness
 The Left Ventricle has the highest
 Caused by peripheral hypoxia
pressure among the four
 Syncope
chambers of the heart
o Fainting
 This serves as the main pump of
the heart  Tachycardia
o Early sign of decreased
 Cardiac Output
o Five (5) to seven (7) liters level of consciousness
o Average is six (6) liters  Bradycardia
o Late sign of decreased
 Stroke Volume
level of consciousness
o Amount or volume of blood
released through the heart
Interjected Concepts!!!
in one beat
 Angina Pectoris

11
 o Stabbing pain
o Unifocal pain
 Myocardial Infarction
o Crushing pain
o Excruciating pain
o Radiating to the left
 Due to the fact that
the output is at the
left
 Coarctation of the
aorta
Other Important Concepts!!!
 Pulse Deficit
o The difference between
the APICAL and the
BRACHIAL PULSE
o Normally, the difference
between these values is
ZERO
o Difference signifies the
presence of an
OCCLUSION
 Pulse Rate resembles the Heart
Rate
 Pulse Pressure
o Systolic-Diastolic
o Normal is 40 mm Hg
o Artery is 40 mm Hg
o Vein is 10 mm Hg
o Artery has pulse
 Tricuspid Valve is located
between the Right Atrium and the
Right Ventricle
Important Concept!!!
Cor Pulmonale
 Also called Right Ventricular
Hypertropy
 Pulmonary artery constriction
leads to decreased blood flow to
the lungs for oxygenation
 Blood is, therefore, retained at
the Right Ventricle
12
 A sphincter can be opened by
increased pressure
 A valve cannot be opened by
increased pressure
 Therefore, there is an INCREASE
IN THE SIZE OF THE RIGHT
VENTRICLE
 Cor Pulmonale results into a
BOOT-SHAPED HEART
Suctioning
 OB-gyne
o The first thing to do to the
newborn in the Philippine
setting is to SUCTION
THE BABY
 CGFNS
o The first thing to do to the
newborn is to WRAP THE
BABY to prevent
hypothermia
Situation:
 Newborn has mucus on mouth
and nose.
Question:
 Which do you suction first?
Answer
 The mouth!
Rationale:
 There is more mucus in the
mouth from the GI tract.
 This gives rise to greater risk for
aspiration
 Then place the patient on lateral
trendelenberg
Important Concept!!
Infants are obligate nose breathers
Important Concepts!!!
 After a month, if the infant has a
respiratory disorder
o Suction the NOSE FIRST
  In adults, the nose is cleaner
 Therefore, the proper sequence Signs and Symptoms of Infection
of suctioning is from cleaner to Mnemonic is SHIRP
dirtier (nose then mouth)  S is for:
o Swelling
Interjected Concepts!!!  H is for:
Wash the breast of a woman with o Heat
lukewarm water  I is for:
o Impaired Motor Function
Important Concepts!!!  R is for:
 For patient with increased o Redness
Intracranial pressure and mucus
 P is for:
at both the nose and the mouth…
o Pain
o Do suctioning only at the
mouth
Important Concepts!!!
o Do not suction at the nose
 If infection is present, there is
o This would cause the
ALWAYS INFLAMMATION
patient to sneeze
 But not all inflammation is
 Sneezing further increases accompanied by infection
intracranial pressure
 Increase protein in diet for tissue
repair
Chest Physiotherapy (CPT)
 Increase protein in diet for repair
 Done on the chest in a gentle
of lung tissue
manner
 Extreme temperature is a
 If the patient is female, do it at
triggering factor for asthma but is
the upper part of the chest
not an allergen
 Composed of:
o Tapping PNEUMONIA
 Using one hand  Viral and bacterial
 With greater force  With consolidation
o Clapping  With fever
 Using both hands  High-grade at onset
o Cupping  During an attack of pain, position
 Using one hand the patient ON THE AFFECTED
 Position SIDE
o Semi-Fowler’s Position  Management
Important Concepts! o Turn patient
 Back tapping, back clapping and  Turning promotes
back cupping is not part of CPT circulation
 Low-flow oxygenation is used in  Without circulation,
COPDs to maintain hypoxic drive one cannot remove
o CO2 stimulates breathing the consolidation of
 Use pursed lip breathing for phlegm
acidosis to maintain positive (+) o Cough-up
pressure as expiration is longer

13
 Priority intervention
First thing to do CT Scan
Increases CAT Scan
circulation to  For axial skeleton
remove
consolidated Sputum Examination
phlegm  Cytologic examination of the
o Deep Breathing sputum

LUNG CANCER Bronchoscopy

 Biopsy is needed to confirm this  Direct visualization of the trachea
disease and the bronchus
 Real cause is unknown,  If with biopsy, it is called
idiopathic FIBEROPTIC BRONCHOSCOPY
 Smoking only decreases cellular  Pre-procedure
resistance o Anesthesia is given
o Xylocaine applied
Predisposing Factors in Lung Cancer  Post-procedure
 Familial o NPO until gag reflex
o Genetic / hereditary returns
 Cigarette smoking  Without the presence of the gag
o Second hand smoke reflex, there is a risk for
o Filtered cigarettes lessens aspiration
contamination
 Exposure to occupational Signs and Symptoms of Lung Cancer
carcinogens  Persistent Coughing and
o Asbestos Expectoration
 Asbestos in lungs in o Phlegm
increasing o Irritation due to the
quantities causes presence of tumor
lung cancer o This is the CLASSIC SIGN
o Silicosis and SYMPTOM of lung
 Silicon oxide in cancer
lungs  Dyspnea
 Dysphagia
o Talcosis  Hoarseness of voice
 Cement in the lungs o Vocal cords are
o Bronchiectasis compressed by the tumor
 Nodules are sarcoid  Anorexia
 Benign or malignant
Important Interjected Concepts!!!
Diagnostic Tests for Lung Cancer  Pediculosis
o Presence of lice
Chest X-ray  PTB is characterized by:
 To know where the tumor is o Bacterial causation

14
 o Cavitaries in the lungs o The water level at the
o Low-grade fever (onset) bottle ASCENDS
with chills  Upon EXPIRATION
 Lightening o The water at the tube
o Fetus if floating above ASCENDS
pelvis o The water level at the
 Descent bottle DESCENDS
o Also considered as  Avoid milking and kinking the
STATION tube
o Fetus is no longer floating o These are not routinely
above pelvis but is at the done
level of the ischial spine  Negative pressure is suction
 Crowning pressure
o Fetus is at about +3 or +4  Clamping of the tube is NOT
relative to level of the DONE
ischial spine
Indicators for Chest Tube Removal
Chest Tube  Absence of distress
 Thoracostomy Tube  Absence of fluctuation
 Purposes: o This means that the lung is
o Primary Purpose already re-expanded
 For re-expansion of  Normal breath sounds in the area
the lung  Fully expanded lung on X-ray is
o Secondary Purpose the most determinant indicator
 To maintain o This means that the
negative pressure primary purpose has been
in the lung through served
drainage
Important Concepts!!!
Important Concepts!  When pulling out the Chest Tube
 All chest surgeries require chest o Ask the patient to EXPIRE
tubes o Thorax should be airtight
 In pneumonectomy, no lungs are o Petroleum gauze is
left needed before pulling out
 All bottles should be placed the tube
below the chest level  If Valsalva is included in the
 Bubbling must be intermittent choices in the board examination,
 If bubbling is continuous, there IS CHOOSE VALSALVA
A LEAKAGE
 Fluctuations in water level is Interjected Concept!!!
normal  In the removal of the Foley
 Upon INSPIRATION Catheter,
o The water at the tube o Ask the patient to
DESCENDS INSPIRE
 This allows the patient to relax

15
 o Applied to the rectum
GENITOURINARY TRACT o For diagnostic purposes:
 Barium Enema
Important Concepts! • White and
 The female labia majora is milky
homologous to the male scrotum o For cleansing purposes
 The female clitoris is homologous  Base enema
to the male glans penis  Soap enema
 Both these structures have a
special type of blood vessel Important Concepts!!!
containing erectiles  Upper GI Series
 The meatus is the area where the o Barium Swallow
urine is passed out
 Lower GI Series
 The female urethra is the avenue o Barium Enema
for passage of urine while the
 Skene’s Gland in Females
male urethra is the avenue for the
o Found at the sides of the
passage of both urine and sperm
urinary meatus
 The females have a vaginal
o For lubrication purposes
opening a canal serving as the
receptacle for the penis o Homologous to the
 Both sexes have a rectum and an Cowper’s gland in males
anus  Bartholin’s Gland
o Found at the sides of the
Catheterization vaginal opening
 Done to prevent urinary retention o Also for lubrication
and bladder distention purposes
 Smegma
Important Concepts!!! o This is the cheesy white
 The urinary bladder is paralyzed substance found around
by anesthesia the clitoris
 Vaginal Opening  Radical Perineal Prostatectomy
o Speculum o This is a procedure done
 For pap smear to males
 For dilatation and o Therefore, males also
curettage have a perineum
 Vaginal Douche  Fourchette
o For Vaginitis o Site of episiotomy
o This is an acidic solution o Site of episiorraphy
o Contains lactic acid or  On the mons pubis
acetic acid o APOCRINE GLANDS are
o Normal pH of the vagina is present
4.5 to 5.5  Sweat glands
o Acidic environment aids to  Present at puberty
prevent possible infection o When young, these are
 Enema ECCRINE GLANDS

16
 o Stones in the urinary tract
KIDNEYS  Stones in the Biliary Tract
 Paired, comes in the same size o Cholelithiasis
 Position  Stones in the gall
o Right kidney is lower due bladder
to the anatomical position o Choledocholitihasis
of the liver  Stones in the bile duct
o Fat anchors the kidney to
maintain it at the BREAST CANCER
retroperitoneal area  Idiopathic
 Left breast
Important Concepts!!! o Commonly first to develop
 Glomerular Filtration Rate (GFR) tumor
 Normal Value o Less active tissue is tumor
o 125 ml per minute prone
 Normal Urine Production  Heart is an involuntary organ
o 0.5 to 1.0 ml per minute o Heart is active
o 24 ml reabsorbed by the o Thus, there is no cancer of
kidney the heart
 Micturition Reflex
o 250 – 450 ml Predisposing Factors in Breast
o 125 ml can still be Cancer
contained  Familial
 Hydronephrosis o Genetic
o Drowning of the kidney in  Hormones
urine o Estrogen
 Nephrotosis o Extremes of estrogen
o Falling of the kidneys  Positive estrogen
o When fat is lost receptor tumor
o Kidney falls  Negative estrogen
o Ureter kinks receptor tumor
 Nephrosclerosis  In menopause,
o Hardening of the Kidney there is higher
 Arteriosclerosis negative estrogen
o Hardening of the arteries receptor tumor
 Early Menarche
Important Terminologies!!! (first menstruation)
 Nephrolithiasis • Positive
o Stones in the kidney estrogen
 Ureterolithiasis receptor
o Stones in the ureter tumor
o Nulliparity
 Cystolithiasis
o Stones in the bladder  Unable to give birth
due to inability to
 Urolithiasis
become pregnant

17
  Reproductive age is o Therefore, it can
from 15 to 45 metastasize
o Also due to failure to o Commonly located at:
breast feed  Upper outer
o Andropause is male quadrant near the
menopause axial (tail of
o Radiation Spence)
 Breast tumor  Below the nipple
 Breast gland tumor o This results to
 Adenocarcinoma ELEVATION when the
o Obesity tumor is SHALLOWLY
 20% and above LOCATED
ideal weight o This may also result to
o Multiple Pregnancy RETRACTION when the
 Presence of more tumor is DEEPLY
than one (1) fetus LOCATED
 Uniovular  Usually painless INITIALLY
o Pain is present at VERY
• One (1)
zygote LATE STAGE
• Monozygotic  With discharge that may be clear
twins or bloody
• Same sex  Skin Dimpling
 Biovular  Skin Elevation
• Two (2) egg  Lymphadenopathy on affected
cells arm
• Two (2)
Important Concept!
zygotes
 For non-lactating women with
• Dizygotic
breast discharge:
twins or
o No cancer yet
fraternal
twins o Have check-up
• May be of
different Diagnostic Test for Breast Cancer
sexes  Biopsy
o Isograft o Excisional Biopsy
 Graft from identical  Tumor is removed
twin
Signs and Symptoms of Breast
Cancer o Incisional Biopsy
 Cyst  Only a portion is
o Movable removed
 Breast Tumor o Needle Biopsy
o Fixed  Done through
o Non-encapsulated aspiration

18
Management of Breast Cancer o Lift up affected arm
 Medical management o If lying down, put a pillow
 Surgical management at the back
o Lumpectomy o If patient is already
 Surgical removal of menopause, BSE could be
non-cancerous done anytime
mass
 Wedge resection Interjected Concepts!!!
o Mastectomy  In thyroidectomy, check the nape
 Removal of the  In obtaining urine specimen:
breast o Get this early in the
o Radical Mastectomy morning
 Removal of the o First void is discarded
breast and other o Midstream void is
tissues collected as specimen
o Simple Mastectomy  Parasympathetic Nervous
 Breast alone is System
removed o Increases smooth muscle
 Fat alone activity of glands
o Salivation during sleep
Important Concepts!!!  Atropine Sulfate
 Post-mastectomy o Used to decrease
o Elevate affected arm secretions
above chest or heart level  With anti-cholinergic effect
o Use pillows to elevate arm
 Hemovac URINARY TRACT
o Suction Kidneys
 Check the back for bleeding  Most aggressive
 Protect affected arm
o Prevent overuse for first Functions of the Kidney:
two months  Homeostatic Functions
o Overuse of affected arm is o Fluid and Electrolyte
contraindicated Balance
 No exercise that is strenuous o Acid-Base Balance
 No exposure to sunlight o Hemoconcentration
 Breast Self Examination (BSE)  Through filtration
o Done one (1) week after  Secretory Functions
menstruation o Urine
o Because estrogen is o Renin
elevated o Erythropoietin
o Use one hand  Excretory Functions
o Three fingers o Water
o Outer to inner o Electrolytes
o Anytime of the day o Metabolic Wastes

19
 o Urea Abnormal Constituents of Urine
o Purines converted into uric  Normal urine has hormones
acid  Glucosuria
o Creatinine o Presence of glucose in
 Metabolic waste Diabetes mellitus patients
from muscles  Diabetes insipidus patients have
 Reaction to tissue decreased levels of Anti-diuretic
damage Hormone or ADH
 Very credible o This leads to the two (2)
measure of kidney Ps
function  Polyuria
o Presence of damaged  Polydipsia
tissues and cells results to  Diabetes mellitus patients have
increase in Creatinine problems with insulin
levels o This leads to the three (3)
o In Brain Damage Ps
 Creatinine released  Polyuria
is creatinine kinase  Polydipsia
or BB  Polyphagia
o In Heart Damage
 Creatinine released Types of Diabetes Mellitus
is MB
o In damage of other Type 1 Diabetes mellitus
muscles  Insulin Dependent Diabetes
 Creatinine released Mellitus
is MM  Juvenile onset
o Blood Urea Nitrogen  More controlled diet is necessary
 Affected by protein  More severe type of diabetes
diet  Pancreas could not produce
 Vitamin D Synthesis insulin
o Vitamin D comes from  Insulin is administered to the
food patient
o Raw vitamin D  Fats and proteins are utilized by
o Goes to the kidney and the the body in a process called
skin gluconeogenesis
o Must be exposed to  Utilization of fats results in the
ultraviolet radiation to be formation of ketones
converted to its active form  This leads to DIABETIC
o Deficiency of Vitamin D KETOACIDOSIS
results into weak bones  Blood becomes more viscous
 Ricketts in children  There is less plasma due to
 Osteomalacia in dehydration secondary to
adults polyuria

Type 2 Diabetes mellitus

20
  Adult onset
 Non-ketotic diabetes
 Management:
o Diet
o Exercise
o Oral hypoglycemics
Type 3 Diabetes mellitus
 Gestational Diabetes
Type 4 Diabetes mellitus
 Secondary DM
 Caused by disease
Important Interjected Concepts!!!
 In polycythemia vera
o There is also increase
blood viscosity
o However, there is no
decrease in blood volume
(this occurs in DM)
 Hematuria
o Blood in the urine
o This is ABNORMAL
 Pyuria
o Pus in the urine
o This is ABNORMAL
 Proteinuria
o Presence of protein in the
urine
o This is ABNORMAL
 Blood contains the following:
o Albumin
o Globulin
o Fibrinogen
 Albuminuria
o Presence of albumin in the
urine
o Results into decreased
albumin in the blood
o This brings about
DECREASED OSMOTIC
COLLOID PRESSURE
o This leads to EDEMA
21
o To compensate for
Albumin loss, lipid levels
increase in the blood
o This results to
HYPERLIPIDEMIA
o Hyperlipidemia contributes
to both:
 Atherosclerosis
• Deposition of
fat at the blood
vessel
 Arteriosclerosis
• Hardening of
the blood
vessels
 Hypertension
o Increased pressure
o Decreased perfusion
 Thirty percent (30%) of oxygen
goes to the extremities
SEIZURE DISORDERS
 Epilepsy
 Convulsions
Types of Seizures
 Petit mal seizures
o Short-term seizures
 Grand mal seizures
o Involves the whole body
o With aura
o Lasts for one (1) to two (2)
minutes
 Myoclonic Seizures
o Involves the upper
extremities
 Akinetic Seizures
o Patient collapses
o Drop attack
 Jacksonian Seizures
o Partial seizures
o Patient can still walk
 Psychomotor Seizures
o Decorticated
 o Decerebrated
Types of Convulsions
 Tonic
o Sustained
o Prolonged
 Clonic
o “kabilaan”
 Tonic-Clonic
o “kabilaan at matagalan”
 Epiliptiform
o Can recover quickly
Important Concepts!!!
 Epilepsy is more serious than
convulsions
 Fainting always occurs with
epilepsy
 In epilepsy, EEG is needed
URINARY TRACT INFECTION (UTI)
 Urethra is affected
 Females are commonly affected
o Due to the proximity of the
anus to the urinary meatus
 E. coli
o Normally present in the
colon
o Normal flora in the colon
o Comes out even during
flatus
Management of UTI
 Increase fluid intake
 Collect sterile urine specimen
o First void is discarded
o Midstream void is
collected
o For urine culture and
sensitivity test
 Provide warm SITZ BATH
o In the hospital, warm water
is used to submerge
22
patient up to below the
level of the umbilicus
o Also called HIP BATH
 “Suob”
o Warm compress
Medications for UTI
 Antibiotics are given
Important Concepts!!!
 Nystatin is given
 In cases of fungal infection
related to antibiotic therapy
 Oral Thrush
 Management
o Padded tongue depressor
 Swab
ACUTE GLOMERULONEPHRITIS
(AGN)
 Causative organism
 Group A Beta-hemolytic
Streptococcus (GABHS)
 Assess to rule out
Upper Respiratory Tract
Infections
 Tonsillitis
 6x or chronic type
 Suggestive of tonsillectomy
 Both are indication or
complication of Acute
Glomerulonephritis and
Rheumatic Heart Disease
 Anasarca
o More prominent in lower
extremities
o Prevent complications
Management of Lower Extremity
Edema
 Modified trendelenberg
 Elevate
Types of Edema
 Bipedal Edema
o Feet Edema
  Sacral Edema o Seizures gives rise to
 Ascites convulsions
 Carpal Edema  Edema
 Facial Edema o Results into decreased
 Periorbital Edema blood volume
o Decreased blood volume
Important Concepts!!! translates to hypovolemia
 Right-sided Congestive Heart  Oliguria
Failure o Scanty urine
o Systemic effects  Hematuria
o Compromises the kidney o Blood in the urine
o Brought about by
Important Concepts in Acute perforations in the kidney
Glomerulonephritis caused by GABHS
 This would bring about  Blood Urea Nitrogen Clearance
perforations in the glomeruli and o The manner in which the
damage the permeability of the kidney can clear Blood
glomerular wall Urea Nitrogen
 Assess for Albuminuria o This decreases in AGN
 Hypoalbuminemia or Albuminuria  Blood Urea Nitrogen (BUN)
o Gives rise to decreased o Increases due to the
COLLOID OSMOTIC presence of oliguria
PRESSURE o Normal Value
o Decreased colloid osmotic  10 – 20 mg / dl
pressure gives rise to o Other sources say it is:
EDEMA  5 – 25 mg / dl
 Heart  8 – 25 mg / dl
o Left-Sided Congestive o Lowest BUN value in
Heart Failure Females is 4 – 8 mg / dl
 Affects the o Therefore, always assess
Pulmonary for BUN
Circulation
 AGN onset with Hypertension
o Right-Sided Congestive
Heart Failure NEPHROTIC SYNDROME
 Affects the  A cluster of diseases
Systemic
 End point of a variety of diseases
Circulation
damaging the permeability of the
 Kidney glomerular wall
o Anasarca or full-body
 Therefore, there is POLYURIA
edema
 During the onset, there is. . .
 Increase in Lipids o HYPOTENSION
o Hyperlipidemia
 During the latter stage, there
o Gives rise to Hypertension
is. . .
o Hypertension gives rise to o HYPERTENSION
seizures

23
  When the Important Concepts!!!
glomerular wall  To decrease lipid levels in
becomes perforated hyperlipidimia
and the o Use LIPOSTAT
permeability is  Prevents lipid
damaged proliferation
 Hyperlipidemia
Proteinuria o Increased lipid levels in
▼▼▼ blood
Edema o Results into scarring of
▼▼▼ blood vessels
Hyperlipidemia o Blood accumulates in
▼▼▼
scarred areas
Hypertension
o Thrombus formation or
blood clots occur in the
scarred areas of the blood
vessel walls
o Thrombus detaches from
Management of Edema
the blood vessel wall and
Use diuretics is carried by the blood.
Thrombus is now called an
1. Chlorothiazide Group embolus
 Example:
Important Terminologies!!!
o Diuril
 Thrombosis
o Presence of plenty of
2. Loop Diuretics
thrombi
 Stops reabsorption of water at
the loop of Henle  Venous Thrombosis
o Presence of plenty of
 Example:
o Lasix thrombi in the veins
 Thrombophlebitis
3. Potassium-sparing Diuretics o Inflammation of the veins
 For patients with heart condition  Arteritis
 Allows sodium out and lets o Inflammation of the
potassium get in arteries
 Example:
o Spironolactone Interjected Concepts!!!
 Angio signifies arteries
4. Osmotic Diuretics  Thromboangitiis obliterans
 For the brain o Buerger’s Disease
 I.V. route for quick effect o Brought about by smoking
 Example: o Nicotine causes
o Mannitol vasoconstriction
o Lower extremities usually
affected

24
 Raynaud’s Disease o Normal is 26 to 32
o Affects mostly females seconds
o Upper extremity affectation  This is without
 Avascularity heparin
o Peripheral Vascular o In the presence of heparin
Diseases  PTT increases to
 Raynaud’s Disease one and one-half to
 Buerger’s Disease two times its normal
 Gangrene value (1.5x to 2.0x
• Massive normal value)
blood vessel  Approximately sixty-
death four seconds (64
• Amputation secs.)
is needed in  PTT Range of 60 –
gangrene 70 seconds
 All thrombi are blood clots indicates that
o Therefore, all thrombi are patient is properly
heparinized
blood
o Thromboplastin is clotting
 But not all emboli are blood
factor number three
o Other types of emboli are:
 Warfarin
 Air emboli
o Antidote is Vitamin K
 Fat emboli
 Prothrombin Time (PT)
 Anticoagulants
o Related to warfarin
o Heparin
o Normal is 11 to 12
 Provides quicker
seconds
anti-coagulant
o Other sources say that
effect
normal PT is 9.5 to 11.3
 Effect manifested in seconds
hours or in one (1) o This is in the absence of
hour
warfarin
o Warfarin
o In the presence of
 Provides slower warfarin, PT is lengthened
anti-coagulant or increased to 1.5x to
effect 2.0x its normal value
 Effect manifested in  Effect of warfarin is manifested in
two (2) to three (3) two (2) to three (3) days
days
 Heparin NEPHROLITHIASIS
o Protamine Sulfate  Renal Calculi
 Antidote of heparin  Two Types
 Partial Thromboplastin Time o Acid Stone
(PTT) o Alkali Stone
o Related to heparin

25
Acid Stone  Extracorporeal Shock Wave
 Uric Acid Stone Lithotripsy (ESWL)
 Vitamin C o External
o No incision
Alkali Stone o Increase fluid intake to
 Calcium oxalate remove stones which have
o Magnesium been rendered smaller in
o Phosphate size by the procedure
o Ammonium
 Vitamin D Lithotomy
 Removal of stones
Predisposing Factors in o Nephrolithotomy
Nephrolithiasis  Removal of stones
 Diet rich in the following: in the kidney
o Vitamin C o Cystolithotomy
o Vitamin D  Removal of stones
o Calcium in the urinary
 Immobility bladder
o Blood stasis o Ureterolithotomy
 Frequent Urinary Tract Infections  Removal of stones
o Scanty urine that does not in the ureter
irritate  Urolithotomy
o Removal of stones in the
Signs and Symptoms of urinary tract
Nephrolithiasis
 Pain RENAL FAILURE
o Flank pain Two (2) Types
o In person with Cystitis  Acute Renal Failure
 There is a drip  Chronic Renal Failure
 Oliguria
Acute Renal Failure
 Hydronephrosis
Characterized by:
 Hematuria
 Onset of sudden loss of
 High-grade fever with chills
glomerular function
 Potassium intoxication
Management of Nephrolithiasis
 Metabolic acidosis
 Increase oral fluid intake

Lithotripsy
Chronic Renal Failure
 Intraurethral Lithotripsy
Characterized by:
o No incision
 Onset of gradual loss of
 Percutaneous Lithotripsy glomerular function
o With small incision
 Potassium intoxication
o With suction
 Metabolic acidosis
o Basket type

26
  Protein contributes
Important Concepts in Renal Failure to nitrogenous
 Potassium goes out wastes
 This gives rise to potassium  Decreased sodium
intoxication o Presence of sodium
 Sodium gets in promotes edema
 H+ goes out when sodium comes  Bed rest
in  Prevent infection
o This makes the blood  Skin Care
acidic o Dry skin
o This produces a decrease  Due to edema and
in bicarbonate (HCO3-) hypovolemia
levels, giving rise to o Cracked skin
Metabolic Acidosis o Injured skin
o Uremic frost occurs
Signs and Symptoms of Renal Failure
 Urea on skin
 Lethargy
 “Parang amag”
o Due to cerebral hypoxia
 Use dilute vinegar
 Edema solution
o In the form of anasarca
 Weigh the patient
 Decreased blood volume o There is increase in weight
o Hypovolemia due to edema
o Hypotension
o Dizziness Pharmacological Management of
o No pain Renal Failure
 Hypertension  Diuretics
o Occipital Headache
o Problems with blood Medical Management of Renal Failure
passageway  Dialysis
o They become more o Peritoneal Dialysis
constricted  Infection or
o Dizziness then sets in peritonitis is a
 Pale common
o Decreased blood supply complication
 Ascites  Hemodialysis
 Abdominal Pain o Hemorrhage is a common
 Anorexia complication
 Weight Loss  Renal Transplant
 Body malaise o Alternative surgical
management
Management of Renal Failure
 Dietary Interjected Concepts!!!
o Decreased protein or low Levels of Consciousness
protein diet  Alert

27
 o Awake, aware o Digestive juice is the
 Obtunded person saliva, which contains
o Awake but not aware enzyme for carbohydrate
o ‘tulala” digestion:
 Lethargy  Amylase
 Stupor  Ptyalin
o Asleep  Stomach
o Response to painful stimuli o Partial digestion occurs
at sternum and sole of feet here
 Coma o Digestive juice in the
o Deep Coma stomach:
o Cannot be revived o Gastric Juice
o Respirator sustains life  Hydrochloric Acid
 Euthanasia or mercy killing  Pepsin
o Food remains in the
GASTROINTESTINAL SYSTEM stomach for about two (2)
to four (4) hours
Oxygen distribution to the different o If food is fatty or has much
body organs: protein content, food
Brain 15% of oxygen in remains in the stomach for
the circulating about three (3) to four (4)
blood hours
Heart 5% of oxygen in o Stomach is curved to the
the circulating left
blood  Cardiac Sphincter
GI and Liver 25% of oxygen in • Upper
the circulating sphincter
blood • Prevents
Renal System 25% of oxygen in backflow of
the circulating food to the
blood esophagus
Extremities 30% of oxygen in  Pyloric Sphincter
(upper and the circulating • Lower
lower) blood sphincter
• Prevents
Important Concepts!!! backflow of
 Small Intestine food from the
o Final digestion occurs in small
this organ intestine
o Digested products are  Small Intestine
absorbed by the villi o Digestive Juice:
 Mouth  Bile
o Preliminary digestion  Pancreatic Juice
occurs here • Pancreatic
o Initial digestion Amylase

28
 • Pancreatic o Main source of anti-bodies
Lipase  Lymph nodes
• Pancreatic o Also filters blood
Trypsin o Destroys microorganisms
• Induces
sleep Important Concepts!!!
• Tryptophan  Large Intestine
in milk o No digestion occurs here
• Warm milk o Water absorption
for vaso- o Electrolyte absorption
dilation  Diarrhea or Dehydration
• Increases o Causes electrolyte
trypsin levels imbalance
• Induces  Vomiting
sleep o Sodium (Na+) is the
 Proteases electrolyte that is most
 Liver abundantly lost in vomiting
o Produces bile  Diarrhea
o Bile passes through the o Sodium (Na+) is the
hepatic duct electrolyte that is most
o Bile is stored in the gall abundantly lost in diarrhea
bladder  Gastrointestinal Tract
 Gall bladder o Extracellular
o Storage of bile o Sodium is more abundant
o Bile passes through the  Blood
common bile duct o Extracellular
o Bile passes through the o Sodium is more abundant
Sphincter of Oddi going to
the duodenum Important Concept!!!
 After food is absorbed in the  Question:
Small Intestine, the absorbed o Which electrolyte loss is of
products are carried by the blood greater concern?
into the liver for storage
 Answer:
o Potassium (K+)
Organs Filtering the Blood
 Rationale
 Kidney
o Heart suffers from
o Filters out metabolic
arrhythmia or absence of
wastes
rhythm during increased or
 Liver
decreased levels of
o Filters out toxins
potassium
 Spleen o Hypokalemia
o Filters out resistant
 Decreased levels of
microorganisms potassium
o Red Blood Cells (old
RBCs are phagocytosed

29
  Decreased  Appendix
contraction o Living cell
 Flaccid o Composed of fecalith
o Hyperkalemia matter
 Increased levels of o Immunologic
potassium  Contains anti-
 Increased bodies
contraction  But this is still under
 Spastic study
 Dysrhythmia
o Irregular heart rhythms Interjected Concept!
 Arrhythmias  Nail beds and hair roots are alive,
o Lub-lub-dub just like the appendix, which is
o Lub-dub-dub composed of living cells
 Initially, vomiting results into
metabolic alkalosis Common Gastrointestinal Disorders
o Hydrochloric acid is being (these are manifestations only and
are not considered as diseases)
expelled through the
mouth  Anorexia
 Initially, diarrhea results into  Nausea
metabolic acidosis o Urge to vomit
o Base (in the form of bitter,  Vomiting
biting bile) is being  Diarrhea
eliminated through the  Constipation
anus
 Bile Interjected Concept!
o Emulsifies fat  The epiglottis, a flap-like structure
o Gives color to the stool and the glottis, an opening, are
o Normal color of the stool both part of the respiratory
system
 Yellowish brown
o Transitional color of the
Oral Cavity Disorder
stool
 Gingivitis
 Golden Yellow
o Stool of infants
PEPTIC ULCER
 From greenish to Also called Gastric Ulcer
yellow Two (2) major causes:
o Adult Stool  Extrinsic Factor
 Golden Brown  Intrinsic Factor
o Abnormal color of the
Stool Extrinsic Factor
 Gray colored Stool  Microbial invasion
 Acholic Stool o Virus
 Anus o Bacteria
o End of the colon

30
Intrinsic Factor  Example is PREDNISONE
 Integrity of Gastric Mucosa
 Mucosa 4. Irregular Eating Pattern
o Secretes gastric mucous
o If gastric mucosa is Interjected Concept!
destroyed, acidity causes  Number of times to chew before
ulceration swallowing solid food is:
o Therefore, decreased o Five (5) to ten (10) or
integrity of gastric mucosa o Six (6) to nine (9)
causes ulceration
 Frank hyperacidity Assessment (to Rule Out Gastric
Ulcer)
PREDISPOSING FACTORS in PEPTIC
ULCER 1. Pain
 Mid-upper abdomen
1. Emotional Stress o Epigastric region
 Constriction of blood vessels  May start a couple of hours when
 Reaction is to produce more acid stomach is empty and after
 Results to hyperacidity eating
 Relieved by eating and by an
Interjected Concept! antacid Antacid relieves
 Ulcer due to severe burns is hyperacidity only
called CURLING ULCER  Occurs at night
 Also due to stress brought about o Due to parasympathetic
by burns activity
o This occurs whether
2. Excessive Smoking patient had taken meals or
 Nicotine causes constriction not
 Decreased blood flow brings 2. Dietary Pattern
about ischemia
2.1) Types of Foods
3. Ingestion of Steroids (anti-  Ensure nutritious meals
inflammatory drugs) o To promote healing
 Steroid releases Histamine
Hydrogen (H+) 2.2) Avoid the following foods:
o This reacts with chloride
(Cl-) ion  Spicy Foods
 Chloride ion is the most abundant o Have vasodilating effect
anion outside the cell but are irritating
o H+ + Cl- -----► HCl  Greasy and Fatty Foods
o Therefore, STEROIDS are o These are hard to digest
GASTRIC IRRITANTS  Gas-forming Foods
 Nursing Responsibility o Most common in foods rich
o Give with meals or after in carbohydrates
meals

31
 o Sweet potato, yam, ube,
hard-boiled eggs
o Can increase pressure
inside
2.3) Avoid prolonged use of milk and
cream
 Patients with ulcer can consume
some milk but PROLONGED
USE IS DISCOURAGED
 Lactic acid is produced as a by-
product of milk digestion
o This results into LACTIC
ACIDOSIS
 Also contraindicated in Ulcerative
Colitis patients
o There is lactose
intolerance due to the
absence of lactulase
2.4) Avoid Alcohol
 Alcohol promotes release of
Gastrin
 Alcohol triggers pancreatitis
(similar to drugs)
2.5) Avoid beverages causing
vasoconstriction
 Tea
o Green Tea contains the
least amount of caffeine
among the different types
of tea
 Cola
o With caffeine
o Contains citric acid
o Also avoid all other types
of soda with the same
color as soda (i.e. root
beer, sarsa parilla)
 Coffee
 Caffeine
2.6) Avoid Snacks at Bedtime
32
 Common in cold weather
countries
 Increases acid levels
 Increases pain, which attacks at
night
2.7) Provide Iron for Healing
 Heme is iron
 Heme + globulin ---►
Hemoglobin
 Hemoglobin carries oxygen
 Increased oxygenation coupled
with increased blood flow and
venous return enhances healing
 Iron is present in the following
foods:
o Green leafy vegetables
o Liver
o Egg yolk
3. Observe for Complications
3.1) Hemorrhage
 Coffee ground emesis
o Old blood
 Melena
o Black tarry stool
o Sign of Upper GI bleeding
 Hematamesis
o Vomiting of blood
 Hematochezia
o Fresh blood in the stool
o Sign of Lower GI bleeding
Interjected Concepts!!!
 Spicy foods do not cause
hemorrhoids
o Rather, it makes
hemorrhoids more severe
o Spicy foods trigger more
dilation
 Pregnancy and increased
pressure causes hemorrhoids
3.2) Perforation
  To decrease GI
3.3) Pyloric Obstruction motility
o Increased heart rate
Implementation: o Indicated for Bradycardia
What to do during Ulcer? o A chronotropic drug

1. Medications 1.4) Histamine

 H2-receptor Antagonist
1.1) Antacids o Taken per orem
 Basic
 Cimetidine
 Given one (1) hour after meal o Tagamet
 Mg(OH)2
 Ranitidine
o Milk of magnesia
o Zantac
o Side effect is diarrhea
 Coats chloride to
 Al(OH)2 prevent the
o Amphojel formation of
o Side effect is constipation hydrochloric acid
o Absorbs water and
phosphate 2. Reduce Stressful Situations
 NaHCO3  Non-specific
 CaCO3
 MgAl(OH) 3. Promote Rest
o Maalox
o Simeco 4. Provide Health Teachings
o Mylanta  Dietary therapy
o No diarrhea
o No constipation 5. Provide Dietary Control

1.2) Sucralfate and Carafate 6. Observe for Complications

 Given one (1) hour antecebum
7. Provide Moral Support
 Protective agent
o Coats the lining of the
Interjected Concepts!!!
stomach
 Inotropic Drugs
 Again, give before eating
o Increases cardiac
contractility
1.3) Anti-cholinergic
o Examples are:
 Anti-parasympathetic drugs
 Dopamine
 Atropine Sulfate
o Anti-diarrheal  Dobutamine
 Digoxin
 To decrease the
motility of the bowel  Beta-Adrenergic Blockers
(diarrhea) o Decreases heart rate in
o Anti-emetic tachycardic patients

Surgery for Ulcer

33
  Anastomosis is done
Vagotomy
 Cutting of the vagus nerve Important Concept!
(pneumogastric nerve)  -plasty means repair or
 Innervates the upper region of reinforcement
the respiratory tract (increased
intracranial pressure during GI
suctioning Post-operative Complications
 Indicated for hypersecretion of
acid 1. Hypovolemic Shock
o Do vagotomy  Decrease in blood volume
o Complication is diarrhea
o No more acids are present 2. Hematamesis
for digestion
3. Pulmonary Complications
2. Gastroenterostomy or Pyloroplasty  Atelectasis
 Decreases stimulation of Gastrin o First complication
 Formation in the antral region o Lung collapse
 Stomach and Small intestine are o Loss of function of the
anastomosed lungs
 Shortening of the pylorus o Anesthesia may cause
 Reinforcement of the pylorus atelectasis
 Bariatic surgery  Bronchitis
o Indicated for obese o Infection
patients o This may occur around
three (3) days post-
3. Partial Gastrectomy operatively
 Complication is hemorrhage  Pneumonia
 Increased pressure leads to
hematamesis 4. Fluid and Electrolyte Imbalance
 Two types:
o Billroth I 5. Dumping Syndrome
o Billroth II  Recline patient or place patient in
recumbent position after meals
3.1) Billroth I or
Gastroduodenostomy 6. Hemorrhage
 Removal of the pylorus
7. Diarrhea
 High abdominal incision results to
 Due to vagotomy
pulmonary complications
 Anastomosis is done
8. Vitamin B12 deficiency
 Due to malabsorption syndrome
3.2) Billroth II or Gastrojejunostomy
 Vitamin B12 is cyanocobalamin
 Two structures are removed:
o Pylorus  This is for RBC maturation
o Duodenum

34
  There is no absorption of Vitamin • Position
B12 patient at
o A GIT problem affected side
o An intrinsic problem for prevention
of bleeding
9. Anemia • Apply
 Absence of Vitamin B12 results to pressure
pernicious anemia  Sternum
 Decreased levels of RBC if there  Scapula
is a GIT problem with intrinsic  Flat bones contain Red Bone
factor Marrow
 Ischial Tuberosity
Interjected Concepts! o “inuupuan”
 If GIT is functional and Vitamin o “nangingitim”
B12 is lacking  Ischial Spine
o Extrinsic Problem o Reference for fetal
o Megaloblastic Anemia descent
o Vitamin B12 and Vitamin B9  If Bone Marrow does not produce
needed for maturation RBC
 Decrease in Iron o The resulting RBC
o Iron deficiency anemia deficiency is called
 Decrease in food APLASTIC ANEMIA
o Nutritional anemia  In SICKLE CELL ANEMIA
o An Extrinsic problem o RBCs have decreased
 Yellow Bone Marrow oxygen-carrying capacity
o Indirect Red Blood Cell  In whatever type of anemia, a
formation blood loss of five-hundred
 Red Bone Marrow milliliters (500 ml) and above
o Direct Red Blood Cell REQUIRES BLOOD
formation TRANSFUSION
 Bone Marrow Extraction
o Pelvic Bone BLOOD TYPING AND CROSS
MATCHING
 This has less
complications
o Sternum and Scapula  Blood Type O
o The universal DONOR
 Has pulmonary
complications  Blood Type AB
o The universal RECIPIENT
 In Bone Marrow Extraction
o Consider the following
Consider the following figure:
bones in the following
order:  In cross matching, arrow
indicates which blood type could
 Pelvis
be a donor to which blood type
• Posterior
 No counter flow is observed
Iliac Crest

35
 o Meaning blood type,  All blood types can receive blood
where arrow points, from other individuals with the
cannot be a donor to the same blood type
blood type where the
arrow begins
 No crossing of vertical or
horizontal lines is allowed (except ERYTHROBLASTOSIS FETALIS
when there is an arrow indicating
source can donate blood to Important Concepts!!!
where arrow is pointing)  Blood type is in the Red Blood
o Meaning, that blood types Cell
connected by lines without  The liver and the spleen of the
arrows cannot donate to child is responsible for the RBC
each other. of the child
 Types of Placental Separation
Type O o Duncan side
 Dull side
 Side is tearing off
 Bloody separation
Type A Type B
 Revealed placental
expulsion
 Durky
Type AB o Schultz side
 Center is tearing off
Therefore, from the figure above  Shiny side
 Type O individuals could  Concealed
o Donate blood to type A placental expulsion
individuals  When placenta separates either:
o Donate blood to type B o At birth
individuals o During birth
o Donate blood to type AB o Abortion
individuals o Still Birth
 Type A individuals could  Blood from the
o Donate blood to type AB infant may flow to
individuals the mother
 Type B individuals could  Direction of flow upon placental
o Donate blood to type AB breakage is from the newborn to
individuals the mother
 Type O individuals could not o If the mother is type AB
receive blood from any of the (universal acceptor) there
other blood groups in no incompatibility
 Type A individuals cannot receive o If the mother is type O
blood from type B individuals (universal donor) there is
 Type B individuals cannot receive high-risk for incompatibility
blood from type A individuals

36
  Therefore, always check if the
placenta is intact
o The placental breakage
during separation causes
incompatibility
 If the mother is Rh- and the
newborn is Rh+, upon placental
separation there is flow of fetal
blood to the mother.
o The mother will then
develop antibodies for Rh+
o This situation would give
rise to problems with the
subsequent fetuses which
are also Rh+
 Second child or
fetus with Rh+
blood will have
increased risk for
fatality due to
hemolysis as
mother has
antibodies for Rh+
 Third child or fetus
with Rh+ blood will
have even greater
risk for fatality, also
due to hemolysis,
again, as mother
has antibodies for
Rh+
 Preventive measure would be the
administration of RHOGAM within
seventy-two (72) hours after
delivery or abortion or still birth.
 If antibody is inactive, this
indicates that RHOGAM IS
EFFECTIVE
 If antibody is active, and it causes
hemolysis and fatality to the
second or third child, then
RHOGAM IS INEFFECTIVE
CHRON’S DISEASE
 Regional Enteritis
37
Volvolus
 Intertwining of the bowels
 Common in pediatric patients
Intussusception
 Telescoping of the bowel
 Part or segment of the intestine
goes into another segment
Colitis
 Inflammation of the Large
Intestine
Ulcerative Colitis
 Occurs at right side or at
ASCENDING COLON
 Classical sign is DIARRHEA
 Reabsorption of water is a normal
function of the large intestine
o If the large intestine is
inflammed, it cannot
reabsorb water
o This gives rise to diarrhea
 Milk cannot be administered to
Ulcerative Colitis patient
o There is lactose
intolerance
o LACTAMASE cannot be
produced (lactobacilli)
o If the large intestine is
impaired, lactamase
cannot be synthesized
Diverticulum
 Out-pouching of the membrane in
the sigmoid area
Diverticulosis
 Exists when multiple diverticula
are present without inflammation
or symptoms
Diverticulitis
 Occurs when food and bacteria
are retained in a diverticulum
  This produces infection and o Presence of pain indicates
inflammation that can impede positive for McBurney’s
drainage and lead to perforation sign.
or abscess formation  Analgesics are not given
 With left side pain o They mask the symptoms
 At side of sigmoid of pain

Hemorrhoids ACCESSORY ORGANS OF THE

 Protrusion of rectal vein at the GASTROINTESTINAL TRACT
rectum
LIVER CIRRHOSIS
Varicosity  Degenerative
 A ballooning of the vein  Necrotic
 Hepatocytes are no longer
Aneurysm functional
 A ballooning of the artery
Important Interjected Concepts
INTESTINAL HERNIA  Viral infections are self-limiting
 There are five (5) types of
1. Inguinal Hernia (“bituka”) hepatitis:
 Part of intestine goes to the male o Hepatitis A
scrotum  Infectious hepatitis
2. Femoral Hernia  Oral – Fecal route
 Herniation along the femoral o Hepatitis B
head  Serum hepatitis
 Blood
3. Umbilical Hernia
 Death through
hepatitis B is
4. Incisional Hernia
quicker than death
 After appendectomy
through AIDS
 Evisceration is an example of
 Death through
incisional hernia
hepatitis B may only
APPENDICITIS
be months away
 Characterized by the presence of o Hepatitis C
pain at the right lower region
o Hepatitis D
 Rebound Tenderness is present
o Hepatitis E
 Palpate at the left side
 McBurney’s Point Liver Cirrhosis (continued)
 McBurney’s Sign  A chronic progressive
o To rule out appendicitis degenerative disease of he liver
o Do Rovsing’s Test with structural changes
o Pinch at the left side of the  Scarring is the biological or
abdomen structural change
o There will be pain at the
right side of the abdomen

38
Types of Liver Cirrhosis o Used to constrict blood
vessels
1. Laennec’s Cirrhosis o If vessels are not
 This is the original liver cirrhosis reinforced, portal vein will
 Portal, nutritional or alcoholic explode
cirrhosis  Backflow of pressure is toward
the Gastrointestinal Tract / GI
2. Post-necrotic Cirrhosis syndrome composed of:
 Post-hepatitis or toxin induced o Esophageal Varices
hepatitis o Hemorrhoids
 Viruses excrete toxins; after the  Caput Medusae
death of liver cells

Pathophysiology of Liver Cirrhosis

3. Biliary Cirrhosis Toxic Effect on Liver

 Related to prolonged biliary ▼
obstructive jaundice due to ▼Common causes
infection ▼are alcohol, drugs
 Jaundice is yellowish ▼or nutrition; with
discoloration due to bilirubin ▼incidence in men
 May involve any of the following: ▼▼▼▼
o Bile duct Liver Cells are Damaged
o Biliary duct and biliary ▼▼▼▼
stones Tissue Scarring and Fibrosis
o Cholelithiasis ▼▼▼▼
o Choledocholithiasis Distortion of Normal Liver Structure
▼▼▼▼
4. Cardiac Cirrhosis Interferes with blood flow through the
liver
 Related to long-standing
▼▼▼▼
Congestive Heart Failure
Portal Hypertension
 Right-Sided CHF
(Enlargement of umbilical, esophageal,
 With Primary and Secondary and rectal veins resulting to liver
Hypertension due to arterial dysfunction)
system constraint ▼▼▼▼
Insufficient removal of metabolic wastes
Scar ▼▼▼▼
 Structural change Fluid retention in peritoneal cavity
 Decreased blood flow to the liver ▼▼▼▼
 Most blood stays in the portal Hepatic encephalopathy
vein ▼▼▼▼
 Portal hypertension occurs Coma
 Portal veins are dilated
 This is localized Types of Jaundice
 Vasopressin or Pitressin  Physiologic Type

39
  Pathologic Type  Decreased levels of
protein in blood
Physiologic Jaundice results to
 Immature body part or organ decreased colloid
 Occurs in infants only osmotic pressure
 Immature liver of the infant  This would lead to
o Lacks enzymes Edema or ascites
o Glucoronyl Transferase is o Cirrhosis is a term used for
lacking the liver only
o Conjugation of bilirubin is  Infarction is a term used for the
not facilitated heart and the brain
 Jaundice occurs after twenty-four  Cerebral Infarction
hours o Brain infarction
 Yellowish skin is exhibited within  Myocardial Infarction
seven (7) to ten (10) days o Heart infarction
 Patient is most yellowish at
around third (3rd) to fourth (4th) Adult Jaundice
day  It is always PATHOLOGIC
 Always get the middle!!!
Types of Adult Jaundice
Pathologic Jaundice
 Jaundice within twenty-four (24) 1. Hepatocellular Jaundice
hours  Hepatocytes die
 Erythroblastosis fetalis
2. Hemolytic Jaundice
Interjected Concepts!!!  RBCs are hemolyzed
 Liver  Increased bilirubin escapes
o The biochemist of the 3. Obstructive Jaundice
body  Biliary problems
o The biochemist of all the  Gall stones
body functions
o Filters toxins Important Concepts!!!
 If this is not  Increased bilirubin in blood
facilitated, the o Unconjugated
toxins will stay in  Indirect bilirubin
the blood  Also known as b1
 Toxins will get to  Normal value is
the brain and would twice that of b2
lead to  Normal value is 0.8
encephalopathy, mg / dl
hepatic coma and o Conjugated
brain coma  Direct bilirubin
 Alters protein  Also known as b2
synthesis  Normal value is
about half of b1

40
  Normal value is 0.4 o Prone to bleed at umbilical
mg / dl cord
o Total Bilirubin o Immature liver cannot
 Represents the produce prothrombin
cumulative value of o Therefore, give Vitamin K
Unconjugated (b1) o Administer via I.M. route
and Conjugated (b2) o Site is at vastus lateralis
bilirubin  Never inject at the
 Normal value is 1.2 buttocks
mg / dl  Sciatic nerve may
 This is a gauge be damaged and
used to determine if this will cause
there is jaundice irreversible
 At birth, if Total paralysis
Bilirubin level is 2.0, o Allow the child to walk first
then there is before administering
physiologic jaundice injections at the buttocks

Signs and Symptoms of Liver 3. Edema of the Extremities, Ascites,

Cirrhosis Hematamesis

1. Anorexia, dyspepsia, indigestion, 4. Caput medusae

change in bowel habits, flatulence,  Prominent abdominal wall veins
constipation, fatigue  Big ones
 Anorexia
o Gives rise to weight loss 5. Anemia, Esophageal varices,
and body weakness Emaciation
 Dyspepsia  Anemia
o Inability of the stomach to o Pernicious anemia
produce pepsin for o GI is affected
digestion  Esophageal Varices
o The absence of pepsin o Use Sengstaken-
gives rise to indigestion Blakemore tube
 Flatulence  Emaciation
o “Kabag” leads to flatus o Excessive or severe
formation weight loss or cachexia
o Due to increased pressure
(blood flows back to the 6. Altered Hair Distribution, Spider
GIT) nevi, Angiomas
 Altered Hair Distribution
2. Hepatomegaly, Splenomegaly and o Decreased keratin
Jaundice synthesis by the liver
 Increased PT or prothrombin time o This affects the skin, the
 Newborn hair and the nails

41
 o Deceased collagen o 100 – 150 grams per day
synthesis by the liver  Low sodium diet
affects the structure of the o 0.5 to 1.0 gram per day
internal organs
 Deficiency in 2. Bed rest
collagen leads to
Systemic Lupus 3. Maintain clean and dry skin
Erythematosus
4. Assess level of pain and prevent
Important Interjected Concepts!!! bleeding
 In order for adults to fart, place
them in NICHE’S POSITION 5. Maintain Fluid Balance
o If not, use a rectal tube  1.0 to 1.5 liters per day
and a basin of water
 In infants, COLIC is equivalent to 6. Monitor for signs of mental
flatulence deterioration
 Prone position is best  Allow the client to demonstrate
 “Hagod sa likod nagburp – signature daily
pataas”  Avoid tranquilizers and sedatives
 Thoracentesis o These drugs mask the
 If air is to be removed, insert signs of mental
trocar at the level of the second deterioration
(2nd) or third (3rd) intercostal o Cardiovascular and
space neuromuscular drugs are
 If fluid (i.e. water) is to be all hepatotoxic
removed, insert trocar at the level o Liver cannot detoxify these
of the sixth (6th) to eighth (8th) drugs
intercostal space  Administer lactulose if ordered
o Duphalac is an ammonia
Implementation in Liver Cirrhosis detoxicant
o Also a laxative for easy
1. Provide adequate nutritional intake passage of stools
 High Calorie diet  Stool softeners soften the stool
o 3,000 calories per day
 Carbohydrates Important Interjected Concepts!!!
o 300 – 400 grams per day  Mesentery
 Proteins o Membrane that suspends
o If pre-coma an organ
 70 – 100 grams per  Omentum
day o Organ to organ
o If comatose suspension
 Totally eliminate  Collagen
proteins from the o Internal protein or protein
diet of internal organs
 Fats  Desquamation

42
 o “tuklap ang balat”
 Infant with Desquamation
o Due to environmental
adaptation to external
environment
Important Concepts!!!
 Liver Flap
o Flapping Tremors
o Asterixis
 Sign of impending
hepatic coma
 Due to
accumulation of
ammonia in the
bloodstream
 Hyperthyroid Person has FINE
TREMORS
 Protein is metabolized to
ammonia
 Ammonia is converted by the
liver to urea
 Urea is removed by the kidneys
 Therefore, the liver and the
kidney are both blood filters
 Renal Failure
o Characterized by:
o Increased levels of Blood
Urea Nitrogen
o Decreased levels of Blood
Urea Nitrogen Clearance
o Decreased protein or
controlled protein diet
o Decreased intake of
sodium due to the
presence of edema
 Liver Cirrhosis
o Characterized by:
o Controlled protein intake
o Controlled fat intake (as
bile is not produced)
o Decreased intake of
sodium due to the
presence of edema
43
Important Concepts in the
Management of Renal Failure and
Liver Cirrhosis
 In Renal Failure
o Bed rest is needed
o Skin is Dry
o Skin is whitish due to the
presence of UREMIC
FROST
o Therefore, apply vinegar
 In Liver Cirrhosis
o Bed rest is needed
o Skin is dry due to edema
and dehydration
o Urticaria is present
o Rashes are present
Implementation in Liver Cirrhosis
(continued. . .)
7. Assist client to comply with
prescribed bed therapy
8. Maintain normal respiratory
function
9. Encourage patient to express
feelings
Sengstaken-Blakemore Tube
 This tube is inserted at the nose
 It has three (3) lumens
o First lumen
For nasogastric suction
 Suction to prevent
vomiting
o Second lumen
 For inflation of
esophageal balloon
o Third lumen
 To inflate the
gastric balloon
 Complication
o Congestion in the lung
 o Keep scissors ready Furosemide
o If respiratory depression or  Lasix
arrest occurs: o A diuretic
 Cut the tube
 Deflate the balloon Spironolactone
 Remove the  Aldactone
Sengstaken-  Diuretic
Blakemore Tube  Aldosterone antagonist
 Potassium sparing
Interjected Concepts!!!  Retains potassium but not
 Striae Gravidarum sodium
o In primigravida
 This is pinkish Vitamin B9
o In multigravida  Folic Acid
 This is silvery white  For maturation of RBCs to
 Increased pigmentation is due to promote healing
estrogen  Increased RBC levels leads to
o This intensifies the activity increased oxygenation
of Melanin  Increased oxygenation facilitates
 For neurologic problem and heart healing
problem patients, give stool  Vitamin B12 is also for maturation
softeners and not laxatives of RBCs

Medications used in the Management CHOLELITHIASIS

of Liver Cirrhosis  Stones in the gall bladder
Neomycin
 Anti-biotic that reduces colonic CHOLECYSTITIS
bacteria  Inflammation of the gall bladder
 It decreases the number of  Not always due to the presence
microorganisms thriving in of stones
ammonia
 If normal flora in the colon Renal Calculi
becomes violent, there is Two (2) Types:
infection  Acidic Calculi
Pitressin or Vasopressin  Basic Calculi
 Decreases portal blood pressure
 This constricts the dilated veins Important Concepts!!!
 Gall Stones
Lactulose o Are alkali only
 Cephulac  The following are all basic:
o For ammonia o Bile
detoxification o Bile pigment
o As a laxative o Cholesterol
o Calcium

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  In Cholelithiasis and cholecystitis, o Initially, there will be
there is pain at the UPPER copious drainage from the
RIGHT QUADRANT JP drain
 In Appendicitis, there is pain at  This is because the
the RIGHT ILIAC or the RIGHT bile duct is
LOWER QUADRANT inflammed
 Murphy’s Sign  Failure to drain
o For Cholelithiasis with would result to
cholecystitis congestion
 McBurney’s Sign o Later, if there is less
o For Appendicitis drainage,
 Bile duct is no
Important Concepts in Cholelithiasis longer inflammed
and Cholecystitis  Bile goes to the
 Fatty foods are not given duodenum
 Steatorrhea
o Foul-smelling stool PANCREATITIS
o Fatty stool  The head of the pancreas is
o Frothy stool located posterior to the liver
 Frequent Stool (diarrhea)  The body and tail of the pancreas
is locate near the stomach at the
Important Interjected Concepts!!! left upper quadrant
In asthma  Therefore, pain in pancreatitis is
o Avoid antitussives situated at the left upper quadrant
o Avoid anti-biotics
Inflammation of the Pancreas is due
Important Concepts!!! to the following:
 Acholic Stool
1. Fat necrosis
o Clay-colored stool
 Increase in pancreatic amylase
 Liver Cirrhosis patients are with
and pancreatic lipase gives rise
nasogastric tube (NGT)
to lipolysis
 For Gall Bladder with stones,
 This can trigger autodigestion of
medical management may
the pancreas
involve LITHOTRIPSY
 Pancreatic Lipase levels is a
o Percutaneous Lithotripsy
much better determinant of the
o Extracorporeal Shockwave
presence of pancreatitis
Lithotripsy
 Cholelithotomy 2. Pancreatic Edema
o Removal of stones in the
gall bladder 3. Acute Hemorrhagic Pancreatitis
 Cholecystectomy Deadly
o Removal of the gall
bladder Important Concepts in Pancreatitis
o T-tube is used with  Demerol
Jackson-Pratt (JP) Drain

45
 o Drug of choice in the o Also known as Cullen’s
treatment of pancreatitis Sign
 Non-narcotic  Petechiae
o Does not cause
drowsiness Interjected Concept!
o Blocks prostaglandin  Cullen’s Sign is also present in
synthesis ECTOPIC PREGNANCY
 Morphine
o Can constrict the sphincter Important Additional Concepts in
of Oddi Pancreatitis
 Gray Turner’s Spot
Interjected Concepts!!! o Ecchymosis at the flank
In checking for the proper placement of o Indicative of Hemorrhagic
the Nasogastric Tube or NGT, the Pancreatitis
following could be done:  Increase in Trypsin levels
 X-ray o Pancreatic enzyme that
o Most effective promotes sleep
 Aspirate o Patient is not awakened by
o Second most effective way the pain he feels but
is to check the pH moaning is present
 Auscultate o Defecation and urination is
o This is the most common present in the late stages
method of checking of pancreatitis
o Gurgling sound at the
abdominal region indicates MUSCULOSKELETAL SYSTEM
proper placement Muscle is composed of three (3) types:
 Dipping the end of the tube in  Skeletal Muscle
water and noting for bubbles  Cardiac Muscle
o This indicates that the  Smooth Muscle
NGT is displaced and is in
the lungs Types of Skeleton:
o Not an advisable thing to  Axial Skeleton
do o Skull
 Damage to heart muscle is o Ribs
indicated by increased levels of o Spinal Cord
CK-MB and CK-MM  Appendicular Skeleton
o Troponin T and Troponin I o Clavicle
are more reliable o Scapula
indicators of cardiac tissue o Limbs
damage
Joints
Peculiarity of Pancreatitis  Also called arthroses
 Hematoma  Articulating joints
 Ecchymosis around the navel

46
Three (3) Types of Joints based on  For reciprocity of motion
Motion
Prime Mover
1. Synarthrosis  When they contract, maximum
 Fibrous joint amount of motion is created
 Creates no motion
 No movement Range of Motion
 360 degrees
2. Amphiarthrosis o Shoulder Joint
 Cartilaginous joint  180 degrees
 Creates small amount of motion o Cervical Joint

3. Diarthrosis FRACTURES
 Synovial joint  Break in the continuity of the
 Maximum amount of motion bone
 Creates large amount of motion o Trauma
o Accident
Muscle has two (2) types of protein o Crashing
 Actin o Twisting
 Myosin o Compression
 Pathologic
Important Concepts!!! o Pott’s Disease
 Calcium is needed in muscular  Tuberculosis of the
contraction spine
 Acetylcholine is a  Gibbus formation is
neurotransmitter needed in the pathognomonic
muscle contraction sign of Pott’s
 Myasthenia Gravis is an Disease
autoimmune disorder wherein the o Spina Bifida
body destroys acetylcholine  Neural Tube Defect
receptor sites o Cystica
 Presence of a bulge
Skeletal Muscle
o Meningocoel
1. Synergist Muscles  Meninges protrude
 Group of muscles  Cerebrospinal Fluid
 When they contract, they stabilize o Myelomeningocoel
the area  Spinal cord lesions
 Examples are:  Herniated Nucleus
o Pectoralis Polposus
o Intercostals o Occulta
 Presence of a
Antagonist Muscles depression or a
 When one muscle contracts, the dimpling
other relaxes o Lumbar Spine

47
  Bears most of the  Transverse
body weight  Oblique
o Lumbar Coma
o Slipped disk Important Concepts regarding
o Lordosis Fractures!!!
 Waddling walk  First Aid
o Not a flirting walk o At the site of the incident,
IMMOBILIZE
Types of Fractures  Treatment at the Hospital
o Bone Reduction
 Closed Fracture o Re-alignment of the bone
o Did not penetrate the skin
o Immediate care Treatment of Fractures
 Do not move
 Open Fracture 1. Reduction or Re-alignment
o Broken portion of the bone  For Closed Reduction
protrudes through the skin o Casting
o Splinting
Fracture Patterns o Sling
 Transverse  For Open Reduction
 Longitudinal o Surgical plates, pins, rods,
 Oblique wires
 Spiral o Uses plates (metal or
 Depressed stainless steel)
 Comminuted o Uses screws and nails
 Impacted o Uses pins – intramedullary
 Stellate pins
o Fracture radiates from a
point 2. Immobilization

Important Concepts!! 3. Restoration of Function

 In comminuted or crushed
Important Concepts!!!
fractures, bone debridement is
done  Casting
o Utilizes plaster of Paris
 Mandibular Wiring
o Use wire cutter  Scoliosis
o Suction o Utilizes Harrington Rod
 Anticipate vomiting  Wires
to prevent o Used for flat bones (i.e.
aspiration mandible)

Interjected Concept! TRACTION

Types of Fetal Lie  Two forces are applied in
 Longitudinal opposite direction

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Purposes of Traction  Crepitus
 To immobilize the affected part o Grating sound
 Bone re-alignment  Deformity
 Regain normal strength o Contracture
 Reduce muscle sprain  Shortening of bone
 Discoloration
Types of Traction o Bluish and reddish
 Mechanical Traction indicative of hematoma
o With screw and pin  Bleeding
o With invasion  Tenderness
o Steinman o Pain aggravated by touch
 Using pins STAGES OF WOUND HEALING
o Kirchner Important Concepts!!!
 Using wires  In pediatric patients
o Crutch-Field o Wound healing is faster
 Tongs for cervical o Occurs in about three (3)
affectations to four (4) weeks
 Balanced Suspension Traction o Due to quicker Basal
o Thomas Splint with Metabolic Rate
Pearson’s Attachment  In adults
 Skin Traction o Wound healing occurs in
o No invasion about eight (8) to twelve
o Pad areas which are (12) weeks
pressured
o Russell 1. Hematoma Formation
 For fractured femur  Occurs after twenty-four (24)
 Pulls the knees and hours
the foot
o Cervical 2. Cellular Proliferation
 Cervical spasm  Production of OSTEOIDS
o Pelvic  Bridging of blood vessels
 Relieves low back
3. Callous Formation
pain
 Bridging large mass of
Important Concepts!!! differentiated tissues
Bryant Traction
3. Ossification
 For children
 Fractured ends meet together
Signs and Symptoms of Fracture  Three lipids in cell membrane:
 Swelling o Glycolipids
 Heat o Phospholipids
 Impaired function o Cholesterol
 Redness
4. Remodelling
 Pain

49
  Compact-bone formation
3. Congenital Club Foot
Complications of Fractures  Talipes Equinovarus
 Pulmonary Embolism  Use Dennis Browne shoe
 Fat Embolism  Cast
o Common embolus
o From the marrow 4. Hip Dislocation
o Pure cholesterol  Unilateral or Bilateral
 Gangrene  If unrelieved, TOTAL HIP
o Blood vessel problem REPLACEMENT using
o Massive avascularity prosthesis is done
 Tetanus  Kept abducted
o Burns o Use abductor splint or
o Fractures pillow between the legs
o Causative agent is o Reinforce with
Clostridium tetani TROCHANTER ROLL or
o Signs and Symptoms blanket
include:
5. Coxa Plana
 Risus sardonicus
 Aseptic necrosis of the femoral
 Lockjaw
head
 Ophistotonus
 Legg-Calves Perthes
• Seizure with
 No infections
arching of
 Ten times more common in white
the back
children than in blacks
 Vertigo
• Environment 6. Scoliosis
is moving,
 Gait is changed
swirling
 Spinal Column deformity
 Dizziness
 Lateral Curvature
o Preventive measure
 Based on Origin:
 Tetanus Toxoid
o Structural
vaccine
 Ligaments holding
MUSCULOSKELETAL DISORDERS the spine have
problems
1. Osteomyelitis  Can be relieved by
 Inflammation or infection of the exercise
bone marrow o Functional
 Affects weight-bearing bones  Work
 Causative agent is  Management
Staphylococcus aureus o Bottleblowing for scoliosis
o Swimming is best for
2. Supracondylar Fracture scoliosis
 Elbow affectation o Milwaukee brace

50
  Pelvis to chin cup
 Worn for twenty-
three (23) hours in
a day and one (1)
free hour for
inspections
 Scoliotic to the left
o Right hip is up
o Left shoulder is up
7. Pott’s Disease
 Tuberculosis of the Spine
o Blacks are mostly the ones
affected
CARE OF CASTS
1. If not yet dry, use the palm in moving
to avoid deforming its contour
2. If dry, also use the palm in moving for
safety
 Cast should not be too tight
 This may impede circulation
 Fingers and toes should be able
to wiggle
 Cast should not be too loose

8. Arthritis 3. Observe for cyanosis

 Rheumatoid Arthritis 4. Open fractures
o Systemic, bilateral,  Use window type of cast
symmetrical
 Osteoarthritis 5. Observe odor
o Weight-bearing joints  Foul odor may indicate infection
o Unilateral
 Gouty Arthritis Important Concept!!!
o Affects great toe  When there is itchiness, blow air
o Uric acid under the cast to eliminate
moisture
o Monosodium urate crystals
o Tophi
ASSISTIVE DEVICES
9. Slipped Disc 1. Cane
 Laminectomy is the surgery of  Principle in use:
choice o Use on the HAND ON
 Herniated Nucleus Polposus THE UNAFFECTED SIDE
10. Intertrochanteric Fracture 2. Walker
 Greater to lesser or letter to  If patient is a child
greater trochanteric break o Rota Walker
o “andador”
Interjected Concepts!!!
o No sense of direction
 Combination disorders:
o Scoliokyphosis  If patient is an adult
o Four-legged walker
o Kyphoscoliosis
o Lordokyphosis
3. Crutch (“saklay”)
o Kypholordosis
 Principle in use:
 Sickle Cell Anemia o Weight of body borne by
the ARM not by the axilla

51
 o Therefore, it should be
about two (2) inches from
the axilla (above the crutch
to the axilla – there should
be about two (2) inches)
o Tip of crutch from foot is
about six (6) to eight (8)
inches (to side)

 Four-Point Gait
o Two (2) crutches used
o Two (2) legs used
o First to move:
 Crutch before foot;
Left or Right
o Sequence of movement:
 Crutch, opposite leg
 Crutch, opposite leg
 Two-Point Gait
o An acceleration of the
Four-Point Gait
o Two (2) legs used
o Crutch and opposite leg
moves simultaneously
 Three-Point Gait
o Not both legs are used
o One may be amputated /
cemented
o Crutch is moved first
 In going upstairs, use FOOT
FIRST
o To remember this,
remember the saying
“good leg goes to heaven”
 In going downstairs, use
CRUTCH FIRST
 Swing Through / Swing To
o Two (2) legs are not used
o Both legs are not usable
o Principle is momentum

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