2803NRS END OF TRIMESTER EXAM

o Strength required/Strength in stock x volume of stock

o DPM=Volume (mls) x drop factor
o Time in hours x 60

CARE OF CLIENTS WITH ACUTE MEDICAL/SURGREICAL CONDITIONS

THE ROLE OF THE NURSE
The Nurse as Caregiver:
While care-giving has always been a fundamental part of nursing, further education and nursing research has resulted in a
growing knowledge base, enhanced critical thinking and reasoning abilities and increased recognition that nurses are well-
informed professionals able to provide evidence-based, holistic, culturally inclusive, and person-centred care. Nurses are able to
make independent assessments, plan, and implement care based on knowledge and skills, and awareness of individual clients’
needs. In broadening their level of knowledge, skills and responsibility, nurses have become participatory members of the wider
healthcare team, thus adding collaboration as an important skill in the care-giver role.

The Nurse as Educator:

Providing patient education has long been considered a recognised part of the nurse role. However, in healthcare today several
factors have contributed to nurses having to take greater responsibilities as educators in order to support patients manage their
care. These factors include:
- An increasing emphasis on health promotion
- The ageing population and increasing numbers of people living with chronic conditions
- Shorter length of stay in hospital, early discharge and day procedures

The Nurse as Advocate:

As clients today have ready access to a wide range of health information, nurses are positioned to support the person’s decision-
making, and right to be self-determining. Nurses advocate for the clients when they are unable to do so for themselves (e.g.
unconscious or not competent).

The Nurse as Leader and Manager:

All nurses are leaders and managers as they direct, delegate and coordinate care activities and manage time, resources and the
environment in which they provide care. Nurses must be knowledgeable about processes and responsibilities in order to carry
out this aspect of the role effectively.

The Nurse as Researcher:

Nurses identify problems or issues and find solutions to such matters every day as part of the care-giving. However, to develop
the science of nursing and the body of evidence-based knowledge, it is important that solutions are developed through rigorous,
scientific processes. While experienced, qualified nurse researchers lead the development of the scientific nursing knowledge
base, nurses in day to day clinical practice have much to contribute as they are at the forefront of patient care and therefore
positioned to recognise the issues and possible solutions. Thus the researcher role is integral to nursing practice.

SUBJECTIVE AND OBJECTIVE DATA

Subjective data: Objective data:

• Sourced data • Observed data
• What the patient says • What the nurse observes or measures
• Can be primary (from the patient) or secondary • Sign
(from significant other)
• Symptom
PRE-OP & POST OP CARE – NIL BY MOUTH (COMPLICATIONS), PAIN ASSESSMENTS
PRE-OP ASSESMENT & CONSIDERATIONS
- Health history and risk assessments (falls risk, pressure
injury risk)
- Weight
- Specific observations as needed e.g. BSL / BGL
- Verifying and completing pre-procedure orders
- Verifying consent
- Patient education - verifying the patient’s understanding
and expectations
- Supporting psychological and cultural factors and beliefs to
relieve anxiety and stress. This may also involve the family.
- Pre-operative checklist – details of processes to be
completed prior to surgery
- Consent form
- Clinical pathway (where applicable)
- Allergy status – wristbands and labels on charts
PRE-OP COMPLICATIONS
Advanced age
- Older adults have age-related changes that affect
physiological, cognitive and psychosocial responses to the
stress of surgery; decreased tolerance of general
anaesthesia and postoperative medications; and delayed
wound healing.
Obesity
- The obese person is at increased risk of delayed wound
healing, wound dehiscence, infection, pneumonia,
atelectasis, thrombophlebitis, arrhythmias and heart
failure.
Dehydration/ electrolyte imbalance
- Depending on the degree of dehydration and/or type of
electrolyte imbalance, cardiac arrhythmia or heart failure
may occur. Liver and renal failure may also result.
- Closely monitor fluid intake (oral and parenteral) to
prevent circulatory overload.
Cardiovascular disorders
- Presence of cardiovascular disease increases the risk of
haemorrhage and shock, hypotension, thrombophlebitis,
pulmonary embolism, stroke (especially in the older
person) and fluid volume
Respiratory disorders
- Respiratory complications such as bronchitis, atelectasis
and pneumonia are some of the most common and serious
postoperative complications. Respiratory depression from
general anaesthesia and acid–base imbalance may also
occur. People with pulmonary disease are more at risk of
developing these complications.
Diabetes mellitus
- Diabetes causes an increased risk of fluctuating blood
glucose levels, which can lead to life threatening
hypoglycaemia or ketoacidosis. Diabetes also increases the
risk of cardiovascular disease, delayed wound healing and
wound infection.
POST-OP ASSESMENT & CONSIDERATIONS
- General appearance and overall status
- Vital signs, airway, circulation
- Level of consciousness
- Nausea / vomiting
- Surgical site and drainage
- Ability to respond and move limbs
- Urine output / IDC drainage
- Pain including operation of analgesia devices
- IV fluids and orders
- Other medications
- Re-orientation and reassurance, and overall status
- Specific observation required for the procedure
- Assessment requirements change as the client
recovers and progresses towards discharge.
- Assessment of needs for discharge – co-ordinate and
plan with interdisciplinary team (interprofessional
care) and involve family.
POSTOPERATIVE COMPLICATIONS:
 Early complications (within 24 hours):
- Shock
- Haemorrhage: hypovolaemia, anaemia
- Pain
- Failed analgesia, surgical reasons, psychological
reasons
- Nausea and vomiting (PONV)
- Ischaemia: global or local
- Hypotension: ischaemia, PE
- Anaesthesia: effects of, or reaction to
- Hypoxia: obstruction, hypoventilation
 Intermediate complications (within 24-72 hours)
- Myocardial Infarction (MI)
- Deep Vein thrombosis (DVT), Pulmonary Embolism (PE)
- Infection
- Chest infection: pneumonia
o
 Late complications (72 hours+)
- Everything previously mentioned, and
- Wound dehiscence
- Vomiting
- Skin breakdown/ Wound Infection / ongoing drainage
- Malnutrition
- Altered bowel elimination
- Psychological dysfunction
CONTRA-INDICATIONS AND CONSIDERATION – MEDICATIONS
Anticoagulants (including aspirin)
- May cause intraoperative and postoperative haemorrhage. Monitor for bleeding.
Diuretics (particularly thiazides)
- May lead to fluid and electrolyte imbalances, producing altered cardiovascular response and respiratory depression.
Monitor fluid input and output and electrolytes. Assess cardiovascular and respiratory status.
Antihypertensives (particularly phenothiazines)
- Increase the hypotensive effects of anaesthesia. Closely monitor blood pressure.
Antidepressants (particularly monoamine oxidase inhibitors)
- Increase the hypotensive effects of anaesthesia. Closely monitor blood pressure.
Antibiotics (particularly the ‘mycin’ group)
- May cause apnoea and respiratory paralysis. Monitor respirations.
Herbal supplements
- Some may prolong the effects of anaesthesia. Others may increase the risks of bleeding or raise blood pressure. Inquire
about the use of herbs or other dietary supplements. These should be discontinued at least 2 weeks before surgery.
Anti-emetics (metoclopramide, prochlorperazine, ondansetron)
- Enhance gastric emptying. Often used with narcotic analgesics to alleviate side effects of nausea and vomiting Monitor for
sedation and extra-pyramidal reaction (involuntary movement, muscle tone changes and abnormal posture).
Anticholinergics (atropine sulfate, scopolamine) Reduce oral and respiratory secretions to decrease risk of aspiration;
decrease vomiting and laryngospasm

TYPES OF IV FLUIDS & IVC CARE

INTRAVENOUS FLUIDS
IV fluids for hydration and increase circulating blood volume
- Crystalloid → increase fluid vol in intravascular and interstitial space - contain dextrose and / or electrolytes dissolved in
water.
o Isotonic (Normal Saline 0.9%, Hartmans / Ringers lactate),
o Hypotonic (e.g. 0.45% saline, 5% dextrose and D/S solutions)
o Hypertonic (higher concentrations of glucose and electrolytes) ― Colloid → increased circulating blood volume (do not
diffuse through capillary walls (e.g. Albuminim, Gelofusion. Haemaccel, Dextran)

IVC CARE
• Assess the site ― Every shift ― Before and after medication administration
• Monitor for signs of infection, extravasation / infiltration: ― Erythema, tracking, heat, pain / tenderness, Oedema, swelling,
purulent discharge, leakage, bleeding ― Ensure dressing is clean and secure
• Assess cannula patency before each use ― Flush cannula and line before and after medication administration – ensures no
residual from previous medication and clears line of current medication
• Assess Infusion Fluids (where fluids connected) ― Fluid type & rate (with orders), remaining volume, compatibility
CARE OF CLIENTS WITH ACUTE CARDIOVASCULAR CONDITIONS

Conditions can be inter-related but are grouped according to the affect:

• Coronary Heart Disease • Cardiac Disorders • Vascular and Lymphatic Disorders

Symptoms - Chest pain - Palpitations - Dysponea -Syncope (fainting) -Feeling of dread/impending doom - Fatigue
Signs - Colour - HR - Finger clubbing - Abnormal sputum - Abnormal Heart sounds - Abnormal ECG

ECG – WHAT IT DOES, USED FOR AND PLACEMENT OF THE LEADS

An Electrocardiogram (ECG) is a graphic record of the heart’s electrical activity
• Allows examination of the magnitude and direction of the heart’s electrical circuitry
• Detects arrhythmias and areas of damaged myocardium as deviations or changes to the normal pattern

ECG lead placement - principles

•Comfortable client = happy client + better trace – no muscle tremor
•Limb leads x4 – away from bony structures
•Chest leads in correct positions
•Good contact between electrodes and skin

V1 (C1) Fourth intercostal space at the right sternal border

V2 (C2) Fourth intercostal space at the left sternal border
V3 (C3) Halfway between leads V2 and V4
V4 (C4) Fifth intercostal space in the midclavicular line
Left anterior axillary line on the same horizontal plane
V5 (C5)
as V4
Left midaxillary line on the same horizontal plane as V4
V6 (C6)
and V5
RA (R) Right arm (inner wrist)
LA (L) Left arm (inner wrist)
RL (N) Right leg (inner ankle)
LL (F) Left leg (inner ankle)

A “lead” is a picture of the heart and the 10 electrodes give you 12 pictures: 4 limb leads give 6 views, and 6 chest leads give 6
views
CHEST PAIN TREATMENT & MANAGEMENT
Assume it is Cardiac until it is ruled out
• Primary survey: A,B,C,D,E
• Vital signs – manual BP preferred – Check pulse rhythm as well as rate and volume
• Pain assessment – P,Q,R,S,T
• Rapid top-to-toe assessment – note general appearance, colour – May be pale, cool, clammy
• Work quickly but calmly – client will likely be anxious – Cultural / language diversity
• Document obs and report
• Immediate ECG – correct electrode placement

Treatments
• Prevention – lifestyle education to reduce incidence – Manage of other conditions ↓ impact on CV system e.g. Diabetes •
Treatments of acute CV conditions – depends on cause
• Medications
- Aspirin – prevents platelet aggregation
- Anticoagulant therapy o IV / SC heparin, SC clexane, oral warfarin – newer agents
- Anti- hyperlipidaemia, and anti-hypertension
- Glyceryl trinitrate (GTN) Sublingual tabs / spray for angina
- Anti-arrythmic agents
- Diuretic agents to reduce fluid load
• Investigative and Corrective procedures

STEMI VS NSTEMI
ST Elevation Myocardial Infarction Non ST Elevation Myocardial Infarction
Viewed on an ECG as elevation in the ST segment Viewed on an ECG as no elevation in ST segment or can be
ST segment depression or T wave inversion.
 ANGINA/HYPERTENSION – TREATMENT & CAUSES
- Angina Pectoris is usually a chronic condition.
- Pain caused by a temporary shortage of blood supply to the
myocardium.
- Angina is not usually life-threatening but associated with
increased risk of heart attack.
- Stable angina occurs when the work of the heart is increased by
physical exertion, exposure to cold or by stress.
- Prinzmetal’s (variant) angina occurs unpredictably (unrelated to
activity) and often at night. It is caused by coronary artery
spasm with or without an atherosclerotic lesion.
- Unstable angina occurs with increasing frequency, severity and
duration. Pain is unpredictable and occurs with decreased levels
of exercise, stress and may occur at rest.
Hypertension – may be chronic or acute: BP > 180/110 +
symptoms
- Hypertensive crisis – rapid significant elevation of BP –
Acute medical emergency – May cause organ, vascular and
brain damage – Weakened, thin vessels or aneurysms may
rupture → bleeding – Administer vasodilatory meds
- Hypotension – Inadequate blood flow to peripheral tissues
and organs can cause cellular and organ dysfunction and
damage. – ↓ renal perfusion → acute renal failure
↓blood supply to heart, brain, and lungs

Angina Medication – Atenolol & Metropolol Hypotension Medication – Midodrine

Hypertension Medication – Atenolol & Metropolol

CARDIAC INVESTIGATIONS – TESTS, PROCEDURE USED

Diagnostic tests for cardiovascular conditions
• Depends on client’s presentation and condition
• In addition to ECG, history and examination, diagnostic tests include:
- Blood tests – full blood count, Hb, electrolytes, cardiac enzymes / Troponin, triglycerides, cholesterol
- Echocardiogram
- Angiography
- Other Imaging: X-ray, CT, MRI, PET scans
- Stress tests - Various methods

RISK FACTORS FOR CARDIAC CONDITIONS

Non-Modifiable: Modifiable:
- Age - Weight
- Gender - Diet
- Genetics - Physical Activity
- Previous History - Smoking
- Ethnicity - Alcohol consumption
- Stressors
- Medication
- High levels of Cholesterol

NURSING MANAGEMENT OF ACUTE CARDIOVASCULAR CONDITIONS

- Co-ordination of safe, holistic, evidence-based person-centred care, including liaison with interdisciplinary team and client’s
family
- Monitoring of client’s condition, the effects of care delivery, accurate documentation and prompt reporting of deterioration
- Administration of medications, transfusions / other treatments and monitoring the effect of these.
o Knowledge of medications, expected effects and potential side effects and complications is therefore essential
- Education and care of clients undergoing specific tests or procedures:
Although it is the medical officer’s responsibility to provide medical information and gain client consent for specific
procedures, it the role of the nurse to ensure the client is provided with education about all aspects of the treatment and
care (the nurse as educator).
o Detailed information for each test and procedure is usually accessible within the clinical area.
o Refer also to Diagnostic Tests: Cardiac Disorders on pages 958 – 968 in LeMone et al., (2017)
- Actioning standard care plans when needed – for example standard protocol for management of chest pain
- Education, and preparation for discharge including:
o Education about medications (in liaison with the pharmacist)
o Information on follow-up care
o Education and arrangements for cardiac rehabilitation as prescribed
o Education about management of their condition at home
CARE OF CLIENTS WITH ACUTE RESPIRATORY CONDITIONS
Respiratory disease - one of the five highest burdens of disease groups in Australia (AIHW, 2016).
• Acute respiratory disease and conditions can range from mild to a life-threatening event
• Classified as:
- Upper respiratory tract: Nose paranasal sinuses, tonsils, adenoids, pharynx, and larynx
o Sinusitis – inflammation of mucosal lining of sinuses – commonly associated with colds and flu
o Influenza (flu): Haemophilus influenzae A (most common), B & C identified.
o Pertussis (Whooping cough). Caused by the bacterium Bordetella pertussis.
- Lower respiratory system: Areas below the larynx including the trachea, bronchi, bronchioles, alveoli and pleura
o Acute Bronchitis / Bronchiolitis – an acute inflammation of the bronchi and bronchioles.
o Pneumonia – inflammation of the lung parenchyma (bronchioles and alveoli). May be infectious or non-
infectious and is more common in Indigenous populations.
o Asthma: A chronic inflammatory disorder characterised by episodes of coughing, wheezing, breathlessness and
chest tightness. Poorly managed asthma may result in severe ‘attacks’ and even death
o Obstructive pulmonary disease: Chronic airflow obstruction from diseases such as chronic bronchitis and
emphysema are described as Chronic Obstructive Pulmonary Disease (COPD).

Signs Symptoms
- Altered general colour - Congestion
- ↓O2 Sats - Sore throat
- Productive cough – Abnormal (colour, consistency, blood) - Body aches Fatigue / Malaise
- Use of accessory muscles - Dyspnoea, Shortness of breath
- Abnormal breath sounds - Wheezing
- Abnormal chest movements - Cough
- Tachypnoea - Chest pain

RESPIRATORY SYSTEM ASSESSMENTS

• Primary Survey
- Life-threatening risks: ABCDE
- Vital signs including O2 Saturations and breathing pattern
- Physical assessment – Inspection – Palpation – Percussion – Auscultation – Peak flow/spirometry
• Secondary survey and focused assessments
- Rapid Systematic assessment (head-to-toe) - note colour, posture
- Extended respiratory assessment
- Pain assessment – differentiate if pain is worse on inspiration
- Health history and medications
- History of current / presenting situation and impact on life and activity
- Consider urgency and client’s distress
- Psychological, cultural and language considerations

TYPES OF BREATH SOUNDS

Vesicular - Soft, low-pitched, gentle sounds
- Heard over all areas of the lungs except the major bronchi
- Have a 3:1 ratio for inspiration and expiration, respectively
Bronchovesicular - Medium pitch and intensity of sounds
- Have a 1:1 ratio, with inspiration and expiration being equal in duration
Bronchial - Loud, high-pitched sounds
- Gap between inspiration and expiration
- Have a 2:3 ratio for inspiration and expiration, respectively
Rales - Small clicking, bubbling, or rattling sounds in the lungs.
- Heard when a person breathes in (inhales).
- They are believed to occur when air opens closed air spaces.
Rhonchi - Sounds that resemble snoring.
- They occur when air is blocked or air flow becomes rough through the large airways.
Stridor - Wheeze-like sound heard when a person breathes. Usually due to a blockage of airflow in the
windpipe (trachea) or in the back of the throat.
Wheezing - High-pitched sounds produced by narrowed airways.
- Wheezing and other abnormal sounds can sometimes be heard without a stethoscope.
COPD/ASTHMA/EMPHYSEMA – PRESENTATION. MANAGEMENT & EDUCATION
COPD Individuals with chronic - Breathlessness - Immunisation against pneumococcal
airflow obstruction due - Recurrent chest pneumonia and influenza is recommended
to chronic bronchitis infections yearly to reduce the risk of respiratory
and/or emphysema are - Frequency may infections.
said to have chronic increase with - Bronchodilators improve airflow and reduce air
obstructive pulmonary severity trapping in COPD, resulting in improved
disease (COPD). - Increasing dyspnoea dyspnoea and exercise tolerance.
- Cough and sputum - Corticosteroid therapy may be used when
production asthma is a major component of COPD. It also
- Dyspnoea improves symptoms and exercise tolerance and
- Chronic cough may reduce the severity of exacerbations and
the need for hospitalisation

ASTHMA Asthma is a chronic - Dyspnoea - The primary drugs in this group are anti-
inflammatory disorder of - Tachypnoea inflammatory agents, long-acting
the airways - Tachycardia bronchodilators and leukotriene receptor
characterised by - Chest tightness antagonists.
recurrent episodes of - Wheezing - Quick relief medications provide prompt relief
wheezing, - Cough of bronchoconstriction and airflow obstruction
breathlessness, chest - Anxiety with associated wheezing, cough and chest
tightness and coughing. tightness.
- Short-acting adrenergic stimulants (rapid-acting
Inflammation causes bronchodilators), anticholinergic drugs and
increased methylxanthines fall into this category.
responsiveness of the
airways to multiple
stimuli.
EMPHYSEMA Emphysema is - Frequent lung
characterised by infections.
destruction of the walls - Over production of
of the alveoli, with mucus.
resulting enlargement of - Wheezing.
abnormal air spaces. - Reduced appetite
and weight loss.
- Fatigue.
- Blue-tinged lips or
fingernail beds, or
cyanosis

THE ROLE OF BRONCHODILATORS

- B2 Receptors are located on smooth muscle of bronchioles, skeletal muscle, mast cells, Uterus, liver cells and blood vessels.
- Activation of β adrenergic receptors leads to relaxation of smooth muscle in the lung, and dilation and opening of the
airways
- Acetylcholine produces bronchoconstriction. By inhibiting its actions, anticholinergic produce relaxation of airway smooth
muscle.
- Salbutamol & Salmetrol are commonly used as B2 agonist
- Budesonide is a common corticosteroid used for asthma

NURSING MANAGEMENT OF ACUTE RESPIRATORY CONDITIONS

- Coordination of holistic, evidence-based person-centred care, in collaboration with interdisciplinary team and client's family
- Interdisciplinary team – Physiotherapists – Dieticians – Social workers – Psychologists – Pharmacists – Occupational
Therapists
- Psychosocial support and cultural safety
- Critical thinking and reasoning – use knowledge and assessment skills to accurately assess client, plan, carry out and
evaluate care
- Monitor client’s progress – Monitor vital signs, O2 Sats, respiratory effort – Recognition of deterioration (prn assessment)
and prompt action
- Accurate Clinical Handover: ISOBAR
CARE OF CLIENTS WITH ACUTE RENAL CONDITIONS

The functions of the renal system (also called the urinary system) are to regulate and maintain body fluids and electrolyte
balance, to filter metabolic wastes from the bloodstream, to reabsorb needed substances and water into the bloodstream, and
to eliminate metabolic wastes and water as urine.

The renal system also indirectly maintains the body’s the blood pressure, acid–base balance and an endocrine function. Any
alteration in the structure or function of the renal system afects the whole body. In turn, healthy renal system function depends
on the health of other body systems, especially the circulatory, endocrine and nervous systems.

• Disorders of urinary drainage

- Urinary tract infections
- Renal calculi
- Urinary tract tumours
- Urinary retention
• Disorders of the kidney
- Acute kidney injury
- Kidney trauma
- Kidney / renal tumour

RENAL SYSTEM FUNCTION (MALE & FEMALE)

UTI MANAGEMENT
The urinary tract facilitates drainage / excretion of urine: Kidneys → external meatus
• Includes: – Cystitis – Catheter-associated UTIs – Acute Pyelonephritis

• UIT is a frequent reason for seeking medical care in Australia • A contributing factor to kidney chronic disease
• UTI’s are commonly caused by bacteria ascending upwards from the urinary meatus:
- Gram negative bacteria: o Escherichia coli (80-90% ), Proteus, Klebsiella, Serratia and Pseudomonas.
- Gram positive bacteria: o Staphylococcus saprophyticus

IDC CARE/INDICATIONS
Insertion of in-dwelling catheter (IDC) • Sterile tube inserted into bladder
• Intermittent Urethral
• Indwelling Urethral Catheter
• Suprapubic (SPC) – via abdominal wall
Purpose: – Drain urine and fluids from bladder – Maintain urethral patency (not SPC) – Intravesical medications
ASSESSING FLUID STATUS/RENAL SYSTEM NURSING ASSESSMENT
• Urine may be tested through routine analysis, a urine culture, a post-voiding residual urine and a 24-hour collection for
creatinine. Results of these tests include findings to serve as baseline data, to support diagnosis of various health problems,
to evaluate the ability to empty the bladder of urine and to evaluate renal function.
• The ability to empty the bladder of urine may be evaluated by a portable bladder scan to evaluate for residual urine,
uroflowmetry to measure the volume of urine voided per second and a cystometrogram (CMG) to evaluate bladder
capacity, neuromuscular functions of the bladder, urethral pressures and causes of bladder dysfunction.
• Radiological examinations include an intravenous pyelogram, a retrograde pyelogram and a renal arteriogram or angiogram.
These examinations are useful in visualising (via x-ray film) the urinary tract to identify abnormal size, shape and function of
the kidneys, the kidney pelvis and ureters; and to detect renal calculi (stones), tumours or cysts.
• A cystoscopy allows direct visualisation of the bladder wall and urethra. During the procedure small stones can be removed,
a sample of tissue may be taken for biopsy and a retrograde pyelogram may be done at the same time. If a contrast dye is
instilled in the bladder, fistulas, tumours or ruptures can be identified.
• Non-invasive tests include a renal ultrasound, computed tomography (CT) scan, magnetic resonance imaging (MRI) and
renal scan. These tests are used to identify and evaluate kidney size and structure, as well as renal or perirenal masses and
obstructions. In addition, a renal scan may be used to evaluate kidney blood flow, perfusion and urine production.
• A kidney biopsy is done to obtain tissue to diagnose or monitor kidney disease.

RENAL MEDICATIONS
• Anti-biotics such as Cephalexin, ceftriaxone, gentamicin amoxicillin/clavulanic acid, trimethoprim or ciprofloxacin common
for UTIs, pyelonephritis, urinary tract abnormalities, stones or a history of previous infections with anti-biotic resistant
infections
• Analgesic such as morphine is given, often intravenously, to relieve pain and reduce ureteral spasm.
• Oral or intravenous fluids reduce the risk of further stone formation and promote urine output.

NURSING MANAGEMENT OF ACUTE RENAL CONDITION

• Co-ordination of safe, holistic, evidence-based person centred care, including liaison with interdisciplinary team and client’s
family
• Interdisciplinary team: dietician, pharmacist, medical staff, renal nurse
• Psychosocial support, and cultural safety
• Monitor client’s condition &, accurate documentation
• Assist the client with ADLs as needed
• Administration of medications, intravenous fluids / other treatments, and monitor effect.
• Critical thinking and reasoning – use knowledge and assessment skills to accurately assess client, plan, carry out, and
evaluate care
• Monitor client’s progress – Monitor vital signs, Fluid Balance, pain – Recognition of deterioration (prn assessment) and
prompt action
• Accurate, timely documentation and promptly report changes / deterioration
• Client Education
CARE OF CLIENTS WITH ACUTE GASTROINTESTINAL CONDITIONS
While there are many diseases, disorders and conditions that affect the Gastrointestinal tract and system, this topic will focus on
those of an acute nature or acute presentation. Diseases and conditions may be grouped according to area or function:
• Nutritional disorders - Malnutrition
• Upper GI tract disorders – Stomatitis, Gastrointestinal bleeding, Gastroenteritis, Nausea and Vomiting
• Bowel disorders – Diarrhoea, Constipation, Bowel Cancer / Colorectal cancer, Acute appendicitis
• Gall bladder, liver and pancreatic disorders - Gall stones, Gallbladder cancer, Hepatitis, Liver cancers, Acute pancreatitis

COMMON GI MEDICATIONS
• Antacids - Sodium bicarbonate (Alka-Seltzer)
• Proton Pump Inhibitors - Pantoprazole
• Histamine2 Blockers - GERD, esophagitis, or peptic ulcers
• Promotility Agents - Metoclopramide

GORD MANAGEMENT
• GORD is a chronic condition. Dietary and lifestyle changes are important to reduce symptoms and long-term efects of the
disorder.
• Contributing factors to GORD include obesity, smoking, alcohol and certain foods, and therefore lifestyle interventions are
an essential adjunct to pharmacological therapy for GORD.
• Smoking cessation, alcohol avoidance, stress reduction, weight loss and elevating the head of the bed are recommended for
symptom relief

MANAGING NAUSEOUS PATIENTS

• Nausea and vomiting are common gastrointestinal symptoms. Nausea is a subjective, unpleasant sensation of sickness or
queasiness.
• The vomiting centre can be stimulated by input from several different sources:
- The gastrointestinal tract, produced by distension, irritation or infection
- Chemoreceptors outside the blood–brain barrier that are stimulated by drugs, chemotherapeutic agents, toxins,
systemic disorders and pregnancy
- Disorders such as acute myocardial infarction and heart failure commonly produce nausea and vomiting, possibly
due to direct stimulation of the vomiting centre by hypoxia
- Increased intracranial pressure (e.g. due to intracranial bleeding or a tumour) produces vomiting that may or may
not be accompanied by nausea.
• Potential complications of vomiting include: – Dehydration, – Hypokalaemia / electrolyte imbalance – Metabolic alkalosis
(from loss of hydrochloric acid from the stomach) – Aspiration with resulting pneumonia – Rupture (and bleeding) or tears
of the oesophagus
• Medication - Anti-emetic – Ondansetron, metoclopramide, haloperidol

NURSING MANAGEMENT OF ACUTE GASTRONINTESTINAL CONDITIONS

• Primary Survey
- Life-threatening risks: ABCDE (refer to Module 1). Acute GI haemorrhage may be life-threatening
- Vital signs
• Secondary survey and focused assessments
- Systematic assessment (head to toe): Include mouth assessment and extend assessment as needed, for example
abdominal assessment, general appearance / nutritional /hydration status
- Weight and girth measurement as needed
- Detailed pain assessment as required
- History of current / presenting situation and impact on life and activity
- Health history, and medication history
• Ongoing or other assessment
- Assess the effectiveness of interventions and client progress
- Specific assessment are required post procedures or post surgical procedures
- Assess all intravenous devices, drains, wounds
COMMON DIAGNOSTIC TESTS, PROCEDURES AND TREATMENTS
Diagnostic tests and procedures:
• Blood tests including serum lipase and amylase
• Stool sample - to identify infective causes of diarrhoea or presence of blood (occult blood)
• Direct smears / swabs of the area such as the mouth and oropharynx
• Endoscopy – the use of a flexible fibre-optic endoscope (inserted or swallowed down by the client) to directly visualise the
internal surfaces and structures of the oesophagus, stomach (sometimes call a gastroscopy) or a far as the duodenum. May
be done in conjunction with ultrasound. Allows for a biopsy or a sample of contents to be collected for laboratory analysis
• Colonoscopy – examination of the lower GI tract using a fibre-optic scope to directly visualise the internal tract. Biopsies
may be taken
• Virtual colonoscopy (colonography) – examination of the internal lower GI tract using special 3D & 4D computerised
topography imaging technologies. Examination is external and does not facilitate specimens to be taken. Generally
considered useful as a screening test
• X-ray - chest, abdominal

Other Imaging: CT scan, and MRI scans

• Endoscopic retrograde cholangiopancreatography (ERCP) scope inserted orally into duodenum and common bile duct to
visualise and retrieve gallstones
• Biopsies of specific areas and organs such as liver biopsy

Treatments:
• Pain management
• Antibiotics specific to identified organisms
• Blood transfusion to correct blood loss / Hb
• Nasogastric tubes: The insertion of a tube via the nose (or orogastric if via mouth) to allow for:
• Various procedures and techniques to remove and / or repair damage from foreign bodies, growths, tumours, abnormalities
or dysfunctional tissue - for example appendectomy, bowel resection stoma formation, laparoscopic cholecystectomy
• Diagnostic / exploratory surgery
CARE OF CLIENTS WITH ACUTE NEUROLOGICAL CONDITIONS
Acquired brain injuries may be intracranial or intravascular in nature. Disorders of the nervous system overall may be grouped
as:
1. Acute Intracranial disorders
2. Cerebrovascular and spinal cord disorders
3. Neurological disorders

1. Acute Intracranial disorders:

- Altered cerebral function occurs as a result of illness, disease or injury.
- Altered level of Consciousness (LOC) - multiple causes
- Acute increased intracranial pressure (ICP) - caused by an increase in intracranial content such as tumour growth,
oedema, excessive CSF or haemorrhage
- Epilepsy – abnormal, re-occurring excessive discharge from neurones. A chronic condition but acute episodes occur as a
single event of abnormal electrical neurone discharge or seizure (convulsions)
- Traumatic brain injury (TBI) (also called craniocerebral trauma) refers to any injury of the scalp, skull (cranium or facial
bones) or brain.

2. Cerebrovascular and Spinal cord disorders:

- Cerebrovascular disorders
- Cerebrovascular accident (CVA or ‘Stroke’) – a major cause of disability in Australia and New Zealand
- May be ischaemic (thrombotic, embolic) or haemorrhagic

3. Acute Neurological disorders

Many neurological disorders are classified as chronic conditions and will be covered in later courses. However, there are some
conditions that present as acute conditions.
- Guillain–Barré syndrome (GBS) is an acute inflammatory demyelinating disorder of the peripheral nervous system
characterised by an acute onset of motor paralysis
Other infective diseases (rarely seen in Australia)
- Rabies
- Tetanus
- Botulism

COMMON DIAGNOSTIC TESTS, PROCEDURES AND TREATMENTS

Diagnostic tests and procedures:
Specific tests and procedures vary according to the client’s clinical presentation and condition. In addition to medical clinical
assessment and neurological examination, tests and procedures may include:
- X-ray – skull, spine
- CT scan (with or without contrast)
- PET scan – useful for detailed view of brain and cerebral circulation
- MRI (urgent MRI is the diagnostic test of choice for suspected cases of acute spinal cord compression
- Cerebral angiogram
- Carotid duplex studies – evaluates blood flow to the brain
- Lumbar puncture – access to a specimen of cerebrospinal fluid for laboratory analysis (for example diagnosis of infection)
- Blood tests including cell counts, coagulation factors, electrolytes, proteins, and glucose

Treatments may include:

- Medications such as anticoagulant therapy to prevent further clots in ischaemic stroke, diuretics and steroids to reduce
brain oedema or inflammation, and anticonvulsants to reduce seizure activity
- Anticoagulant therapy is contraindicated in haemorrhagic strokes
- Mechanical ventilation may be needed to support airway and respiratory function in the initial phase
- Surgical intervention: Evacuation of the clot / haematoma, repair vascular damage, repair / stabilise fractures, release
compression on brain or spinal cord
- Prevention /management of metabolic and electrolyte imbalances
- Antibiotics, antiviral or other anti-infective agents to treat infectious conditions
- Urgent radiation to relieve malignant spinal cord compression
THE GSC ASSESSMENT
• Established, validated tool
• Evaluation of several key indicators of neurological status
- LOC
- Pupils
- Limb Movements
- Vital Signs
• The GCS is divided into three categories:
o 1. Arousal
o 2. Orientation
o 3.Motor response
• Responses to applied stimuli are scored and the summation of these scores is plotted on a graph which provides a visual
perspective of deterioration, improvement and/or stabilisation

BRAIN INJURY MANAGEMENT

• Nutrition is vital; If oral intake not possible then MD considers NG route for nutritional intake
• Sedation may be considered
• Temp control
• Patient positioning
• Episodes of nursing care
• Short-term diuretics
• Mannitol used with caution
• Urinary catheter with hourly measurements

TYPES OF HAEMOTOMAS
- Epidural haematoma: results from bleeding between the dura and the skull, usually caused by tearing of the
middle meningeal artery in the temporal region. Signs of trouble usually arise within a few hours of injury, when
the person loses consciousness after a brief period of responsiveness
- Subdural haematoma: develops between the dura and the arachnoid. Frequently there is a small tear in a vein,
which causes blood to accumulate slowly. Also, a tear in the arachnoid can allow CSF to leak into the subdural
space (hygroma), creating additional pressure
- Intracerebral Haematoma: may be single or multiple bleed in any lobe of the brain commonly in the frontal or
temporal lobes. Results from contusions or shearing injuries and may develop several days after injury

STROKE MANAGEMENT
• Blood pressure control
• Anticoagulation: Tissue Plasminogen Activator (t-PA) if conditions are met
• Following goals should be met:
• Initial ED assessment with 10 mins
• Notify stroke team within 15 mins
• CT within 25 mins
• CT interpretation 45 mins
• TPA within 60 mins
• Transfer to inpatient bed within 3 hrs

NURSING MANAGEMENT OF ACUTE NEUROLOGICAL CONDITIONS

• Primary Survey
- Life-threatening risks: ABCDE
- Vital signs including, Neurological observations (Glasgow Coma scale, pupil reaction), breathing patterns and
O2 Saturations
• Secondary survey and focused assessments
- Systematic assessment (head to toe) – extend assessment as needed, for example neurological assessment
- Detailed pain assessment
- History of current / presenting situation and impact on life and activity
- Health history and family needs
• Ongoing or other assessment
- Assess the effectiveness of interventions and client progress ongoing neurological observations as required. Initial
neurological deficits are not necessarily indicative of long term effects. Provision of information and ongoing
psychological support is needed to reduce client and family anxiety.
- Specific assessment are required post surgical procedures – refer to post-operative orders and unit protocols /
guidelines
- Assessment of all Intravenous lines, drains, wounds
 CARE OF CLIENTS WITH ACUTE ENDOCRINE CONDITIONS
Common Acute Hormone Conditions
1. Pituitary conditions
- Pituitary gland has two parts: anterior pituitary and posterior pituitary
- Pituitary gland stimulates other glands e.g. thyroid, adrenal cortex, ovaries, mammary glands, testes and organs sucas
uterus and kidneys
- Anterior pituitary - secretes at least 6 major hormones: GH (bones and muscles), PRL (mammary glands), TSH (thyroid),
ACTH (adrenal cortex), FSH & LH (testes and ovaries)
- Alterations in it’s function may have a diverse and widespread impact on the body

2. Thyroid conditions
- The thyroid uses iodine to secrete thyroid hormone (TH)
- Manufactures two essential hormones – thyroxine (T4) and triiodothyronine
- Regulates metabolic rate of almost all the cells of the body

Hyperthyroidism Caused by excessive • Graves disease • Insomnia, restlessness
functional activity of • Toxic • Tremor, hand shaking, joint
thyroid gland multinodular pain
goitre • Mood: nervousness, difficulty
• Thyroid crisis concentrating
• Heat intolerance
• Frequent bowel movements
• Weight loss despite normal /
↑ intake Excessive sweating
Ammenorrheoa
• Eyelid retraction
• Early recognition &
prevention of:
hypertension, heart
failure & tachyarrhythmia
• Eye protection
• Nutrition
Antithyroid drugs
Radioactive iodine
Surgery – thyroidectomy

Hypothyroidism Thyroid gland produces Hashimoto’s • Fatigue and low energy levels Iodine deficiency can be easily
insufficient TH disease • Depression relieved by increasing the
• Slow heart rate intake of iodine through
Multi system effects Insufficient dietary • Unexplained weight gain iodised salt or iodine rich
iodine • Intolerance to cold foods.
Worldwide cause is temperatures Hypothyroidism may be
iodine deficiency • Fatigued and aching muscles caused by the failure of - or
• Dry, coarse skin damage to - the thyroid gland,
• Puffy face pituitary or hypothalamus. In
• Hair loss these cases, treatment
• Constipation focuses on boosting thyroid
• Problems with concentration hormone levels with thyroxine
• Goitre (enlarged thyroid tablets, a form of hormone
gland) replacement.

3. Adrenal conditions
Cushing’s syndrome
• Cushing's syndrome is a hormonal disorder caused by prolonged exposure of the body's tissues to high levels of the
hormone cortisol.
• Signs and Symptoms vary, but most people with the disorder have upper body obesity, a rounded face, increased fat
around the neck, and relatively slender arms and legs.
Addison’s disease
• Adrenal glands do not produce enough of the hormone cortisol and in some cases, the hormone aldosterone.
• Signs and Symptoms: Chronic, worsening fatigue, muscle weakness, loss of appetite, and weight loss. Nausea,
vomiting, and diarrhea occur in about 50 percent of cases.
 4. Diabetes Melitus

- Diabetic ketoacidosis (DKA) is a state of absolute or relative insulin deficiency aggravated by ensuing hyperglycaemia,
dehydration, and acidosis-producing derangements in intermediary metabolism
- The most common causes are underlying infection, disruption of insulin treatment, and new onset of diabetes

Type 1 - An absolute insulin deficiency - Diagnosis is usually clear cut: - Insulin

- Commonly genetic predisposition very high BGL - Oral hypoglycaemics
- Selective destruction of Beta cells in the Islets of - Young, usually under 30 years Sulphonylureas
Langerhans caused by a chronic autoimmune old Biguanides
process ‘triggered’ by: Geography, age and - Significant weight loss - usually - Alpha glucosidase
seasonal variations lean inhibitors
- Viruses: Mumps, influenza, Coxsackie B4, - Quick onset with - Glitazones
congenital rubella unquenchable thirst / polyuria
- Often present in ketoacidosis
- Extreme lethargy

Type 2 - RELATIVE insulin deficiency - Family history - Insulin

- Described as a 2 step model - Overweight or obese - Oral hypoglycaemics
1. Insulin resistance leads to a state of impaired - Thirst Sulphonylureas
glucose tolerance - Polyuria/Nocturia Biguanides
2. Increasing Beta cell dysfunction then causes a - Tiredness - Alpha glucosidase
transition to overt diabetes - Frequent infections/skin inhibitors
- The process is governed by genetic infections - Glitazones
susceptibility; environmental factors including
diet (energy imbalance leads to obesity)

NURSING MANAGEMENT OF DIABETES

Primary Survey:
- Life-threatening risks: ABCDE (refer to Module 1). Some conditions such as SIADH, DKA or severe hypoglycaemia are
commonly life-threatening and need urgent treatment
- Vital signs including level of consciousness, peripheral Blood glucose / sugar level (BGL / BSL)
Secondary survey and focused assessments:
- Systematic assessment (head to toe): Extend assessment as needed, for example general appearance, skin turgor,
neurological / neurovascular / abdominal / cardiac / respiratory / pain assessments - depending on presentation and
symptoms
- Nutritional / hydration status
Skin assessment
- Weight: In all situations and client conditions, client safety is paramount but options for weighting clients include chair
scales, lifting hoist or, in some cases electric beds have in-built scales
- History of current / presenting situation and impact on life and activity
- Health history, and medication history, include family
Ongoing or other assessment
- Assess all intravenous devices, other devices, drains, wounds
- Assess the effectiveness of interventions and client progress: For example regular or frequent Blood Glucose Levels (BGLs)
- Specific assessment are required post investigative or surgical procedures – refer to procedural or postoperative orders in
the client’s chart
- Maintain accurate documentation of vital signs , fluid balance, and client status
- Psychosocial status and needs of clients and family
CARE OF CLIENTS WITH ACUTE REPRODUCTIVE CONDITIONS
Acute disorders for males:
Men are at risk of disorders of the penis, scrotum, testes, prostate gland, and breasts
Disorders may be inflammatory, structural, benign or malignant
Disorders may pose a risk to fertility, sexual function and urinary function, and in some cases may be life-threatening.

• Phimosis – constriction of the foreskin in uncircumcised males such that it cannot be retracted over the glans penis. If not
corrected promptly it may result in ischemia and necrosis.
• Priapism is an involuntary, sustained painful erection. Priapism is caused by i) conditions such as tumours, infections or
trauma (primary priapism), or ii) blood disorders, neurological conditions kidney failure and some medications (secondary
priapism), and may result in ischaemia and fibrosis of erectile tissue and subsequence impotence.
• Epididymitis: inflammation of the epididymis
• Testicular torsion: twisting of the spermatic cord with scrotal pain and swelling, vascular engorgement and ischaemia of the
testes. Potentially a medical emergency
• Prostatitis: Inflammation of the prostate gland. Often a chronic condition but may present as an acute condition, as a result
of a bacterial infection
• Cancers: Uncommon, but men may develop benign or malignant lesions / tumours of the scrotum, testes, prostate or breast

Acute disorders for females:

Disorders range from menstrual cramping to life threatening disease, and may affect a woman’s sexuality, ability to bear
children, and sense of self as a woman. Disorders that present for acute healthcare include:

Menstrual disorders:
Severe pre-menstrual syndrome (PMS) and dysmenorrhoea - more severe physiological and psychological symptoms associated
with menstruation. More common in teenage girls / young women
• Dysfunctional uterine bleeding (DUB) excessive amount or prolonged uterine bleeding that may or may not be associated
with menstrual cycle
• Vaginal fistula (abnormal opening or connection). May be:
- Vesicovaginal fistula (vagina and urinary bladder) or
- Rectovaginal fistula (rectum and vagina)

Cysts: While many cysts are slow in forming, large cysts may be infective, cause pain, rupture and bleed. For example:
• Bartholin’s gland cyst (one or both sides of the vulva)
• Ovarian cysts
• Benign and malignant tumours.
• Leiomyomas (benign fibroid tumours)

• Cervical cancer: Most commonly caused by human papilloma virus (HPV). Second most common cancer in women
worldwide but low incidence in Australia. Higher incidence in Indigenous Australians
• Endometrial cancer – the most common invasive gynaecological cancer in Australia
• Cancer of the vulva
• Ovarian cancer - limited and vague early signs result in late diagnosis when the disease is more advanced and treatment less
effective
• Breast Cancer – the third most common invasive cancer in Australia. Although less prevalent in indigenous women
compared to Caucasian women, Indigenous women are more likely to die from the disease because of a reduced
participation level in screening programs resulting in the disease being more advanced at diagnosis.

NURSING MANAGEMENT OF ACUTE REPORDUCTIVE CONDITION

Diagnostic tests and procedures:
Specific tests and procedures vary according to the client’s clinical presentation and condition. In addition to medical history
and general medical examination, tests and procedures may include:
• Physical examination
- Blood tests:
- Blood cell counts and electrolytes
- Serum proteins
- Hormone levels and specific antigens (e.g. prostate specific antigen or PSA)
- Genetic testing / DNA analysis
• Other Specimens:
- Swabs / smears (e.g. vaginal swab, Papanicolaou [PAP] smear, Human papilloma virus (HPV) test, or infective agents)
- Urinalysis, semen analysis
- Aspiration of cysts for laboratory assay and histology
• Imaging:
- Ultrasound: abdominal / pelvic, breast, scrotum / testes and vaginal
 - Mammogram (mammography)
- CT scan, MRI scan, Gallium scan
- Diagnostic procedures:
- Biopsy of external node, or gland
- Laparoscopy - examine , explore and collect biopsy of internal organs e.g. ovaries
- Colposcopy – allows detailed examination of the vaginal cervix
- Dilatation (of cervix) and Endometrial biopsy
- Core or needle biopsy - for example of breast lump

Treatment:
• Treatment is determined by the specific condition and associated cause.
• Medications such as anti-inflammatory medications and antibiotics where appropriate
• Drainage of cystic lesions such as Bartholin’s cyst
• Surgical circumcision to release phimosis
• For priapism: Iced saline enemas, intravenous ketamine (Ketalar) administration to induce anaesthesia and spinal
anaesthesia. Blood may be aspirated from the corpus through the dorsal glans, followed by catheterisation and pressure
dressings to maintain decompression.
• Dilatation and Curettage (D&C) – scraping of uterine walls and removal of excess tissue (This procedure is also done to
remove remaining placental and other tissue after a miscarriage)
• Various surgical procedures and techniques:
• Surgery to remove tumours, lumps, masses, nodes, dysfunctional tissue or whole gland(s) or associated organ. For
example: orchidectomy, oophorectomy, hysterectomy, mastectomy
• If you are unsure of these terms, look them up and write your findings in your Journal
• Surgery to repair damage to surrounding tissues where possible
• Reconstructive surgery (for example breast reconstruction)

NURSING ASSESSMENTS OF CLIENTS WITH ACUTE REPRODUCTIVE DISORDERS

For many clients, it may be embarrassing and difficult to talk about issues related to their reproductive system, and genitalia,
and this may interfere with their willingness to seek medical advice or disclose important information. It is important to provide
explanation, ensure privacy and the client’s modesty throughout all assessments.
The assessment required depends on the client’s presenting condition, underlying conditions, and current status. Nursing
assessments include:

• Primary Survey:
- Life-threatening risks: ABCDE (refer to Module 1).
- Vital signs including pain
• Secondary survey and focused assessments:
- Systematic assessment (head to toe): Extend assessment as needed, for example physical examination of palpable
lumps, swollen or inflamed genitalia,
- History of current / presenting situation and impact on life and activity
- Health history, and medication history, and include family
• Ongoing or other assessment
- Assess all intravenous devices, drains, and wounds
- Assess the effectiveness of interventions and client progress: Specific assessment are required post investigative or
surgical procedures – refer to procedural or postoperative orders in the client’s chart
- Maintain accurate documentation of vital signs , fluid balance, and client status