Nursing Assessment: Etiology and Clinical Features of Acute Health Problems

This nursing assignment explains the etiology and clinical features of acute health problems such as acute kidney injury, acute gastrointestinal disorder, ischemic stroke, complex regional pain syndrome, asthma, acute unconscious state, angina pectoris, cellulitis, dehydration, haemorrhagic shock, concussion, myocardial infraction, and nephrolithiasis.

Running head: NURSING ASSIGNMENT
NURSING ASSIGNMENT
Name of the student:
Name of the university:
Author note:

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Q1. Explain the etiology and outline at least TWO (2) clinical features for each the
following acute health problems.
a. Acute kidney injury: Acute kidney injury (AKI), previously called acute renal failure
(ARF), is a common clinical problem. The term AKI has largely replaced acute renal
failure (ARF), as it more clearly defines renal dysfunction as a continuum rather than
a discrete finding of failed kidney function. The few reasons behind the occurrence of
the condition are acute tubular necrosis (ATN), severe or sudden dehydration, toxic
kidney injury from poisons or certain medications, autoimmune kidney diseases, such
as acute nephritic syndrome and interstitial nephritis and urinary tract obstruction
(Hoste et al., 2015).
Clinical feature: bloody stools and generalized swelling or fluid retention.
b. Acute gastrointestinal disorder: There are several different types of GI illnesses,
including viral gastroenteritis, food poisoning, and even constipation. Gastrointestinal
infections can be caused by viruses, bacteria, or parasites that settle in your GI tract.
Viral or bacterial infections normally resolve in a few days, whereas parasitic
infections may require medical treatment to resolve (Graziano, 2015).
Clinical feature: Vomiting and Watery diarrhoea
c. Ischemic stroke: Ischemic stroke is sudden neurologic deficits that result from focal
cerebral ischemia associated with permanent brain infarction (e.g., positive results on
diffusion-weighted MRI). Common causes are (from most to least common)
atherothrombotic occlusion of large arteries; cerebral embolism (embolic infarction);
no thrombotic occlusion of small, deep cerebral arteries (lacunar infarction); and
proximal arterial stenosis with hypotension that decreases cerebral blood flow in
arterial watershed zones (hemodynamic stroke) (Goyal et al., 2015).

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Clinical feature: increasing plaque build-up in the blood vessels and damaging the
lining of blood vessels
d. Complex regional pain syndrome (CRPS): The cause of complex regional pain
syndrome isn't completely understood. It's thought to be caused by an injury to or an
abnormality of the peripheral and central nervous systems. CRPS typically occurs as a
result of a trauma or an injury (Molus, Abd-Elsayed & Eldabe, 2019).
Clinical feature: Joint stiffness, swelling and damage and decreased ability to move
the affected body part
e. Asthma: Asthma exacerbations are common, and the major morbidity, mortality, and
health care costs associated with asthma are related to exacerbations. The majority are
related to viral infection, and although progress has been made in identifying the
mechanisms of virus-induced asthma exacerbations, there is still much to be learned.
Allergen exposure causes some exacerbations and can participate in virus-induced
exacerbations, as can other environmental exposures. A role for atypical bacterial
infection in exacerbations is also increasingly recognized (Akinbami, Simon &
Rossen, 2016).
Clinical feature: Trouble sleeping caused by shortness of breath, coughing or
wheezing and Chest tightness or pain
f. Acute unconscious state: Comas are caused by an injury to the brain. Brain injury
can be due to increased pressure, bleeding, loss of oxygen, or build-up of toxins. The
injury can be temporary and reversible. It also can be permanent.
Clinical feature: Autonomic dysfunction and Eye abnormalities (Threlkeld et al.,
2018)

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g. Angina pectoris: Angina is caused by reduced blood flow to your heart muscle. The
most common cause of reduced blood flow to your heart muscle is coronary artery
disease (CAD).
Clinical feature: Pressure, fullness or a squeezing pain in the centre of your chest that
lasts for more than a few minutes and Prolonged pain in the upper abdomen
(Borgeraas et al., 2016)
h. Cellulitis: Cellulitis may be caused by indigenous flora colonizing the skin and
appendages, like Staphylococcus aureus (S. Aureus) and Streptococcus pyogenes (S.
Pyogenes), or by a wide variety of exogenous bacteria. Bacteria gain entry into the
body in many ways: breaks in the skin, burns, insect bites, surgical incisions and
intravenous (IV) catheters are all potential pathways. S. Aureus cellulitis starts from a
central localized infection and spreads from there. Recurrent streptococcal cellulitis of
the lower extremities, seen in conjunction with chronic venous stasis or with
saphenous vein harvest for coronary artery bypass surgery, often comes from
organisms of group A, C or G. Cellulitis is also seen in patients with chronic
lymphedema resulting from elephantiasis, Milroy’s disease or lymph node dissection
such as that associated with mastectomy (Bystritsky & Chambers, 2018).
Clinical feature: Red area of skin that tends to expand and Skin dimpling.
i. Dehydration: Dehydration is a major cause of morbidity and mortality in infants and
young children worldwide. Each year approximately 760,000 children of diarrheal
disease worldwide. Most cases of dehydration in children are the consequence of
acute gastroenteritis. Acute gastroenteritis in the United States is usually infectious in
etiology. Viral infections, including rotavirus, norovirus, and enteroviruses cause 75
to 90 percent of infectious diarrhoea cases. Bacterial pathogens cause less than 20
percent of cases. Common bacterial causes include Salmonella, Shigella, and

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Escherichia coli. Approximately 10 percent of bacterial disease occurs secondary to
diarrheagenic Escherichia coli. Parasites such as Giardia and Cryptosporidium
account for less than 5 percent of cases (Ahmed, Qazi & Jamal, 2016).
Clinical feature: increased thirst and decreased urination
j. Haemorrhagic shock: Hypovolemic shock is the most common type of shock, with
very young children and older adults being the most susceptible. When heavy
bleeding occurs, there’s not enough blood flow to the organs in your body. Blood
carries oxygen and other essential substances to your organs and tissues. When heavy
bleeding occurs, these substances are lost more quickly than they can be replaced and
organs in the body begin to shut down. As your heart shuts down and fails to circulate
an adequate amount of blood through your body, symptoms of shock occur. Blood
pressure plummets and there’s a massive drop in body temperature, which can be life-
threatening.
Clinical feature: blue lips and fingernails and low or no urine output (Cannon, 2018)
k. Concussion: Motor vehicle accidents, falls, and sports injuries are common causes of
concussions. Any sport that involves contact can result in a concussion. Among
children, most concussions happen on the playground, while bike riding, or when
playing sports such as football, basketball, or soccer (Iverson et al., 2017).
Clinical feature: balance problems/dizziness and double or blurry vision
l. Myocardial infraction: Myocardial infarction (MI) usually results from an imbalance
in oxygen supply and demand, which is most often caused by plaque rupture with
thrombus formation in an epicardial coronary artery, resulting in an acute reduction of
blood supply to a portion of the myocardium.

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Clinical feature: pressure or tightness in the chest and pain in the chest, back, jaw,
and other areas of the upper body that lasts more than a few minutes or that goes away
and comes back (Sulzgruber et al., 2018).
m. Nephrolithiasis: Renal stones are crystalline mineral depositions that form from
microscopic crystals in the loop of Henle, distal tubules, or the collecting duct. This is
usually in response to elevated levels of urinary solutes, such as calcium, uric acid,
oxalate, and sodium, as well as decreased levels of stone inhibitors, such as citrate and
magnesium. Low urinary volume and abnormally low or high urinary ph also
contribute to this process. All of these can lead to urine super saturation with stone-
forming salts and subsequent stone formation .( Curhan et al., 2018)
Clinical feature: burning sensation during urination and persistent urge to urinate
n. Bacterial sepsis: bacteria (gram-positive and gram-negative) are identified as the
causative organism in approximately 90% of cases of sepsis, with gram-positive
bacterial and fungal infections increasing in frequency. The frequency of gram-
positive septicaemia (mainly caused by Staphylococcus aureus, coagulase-negative
staphylococci, enterococci, and streptococci) has surpassed that of gram-negative
septicaemia (mainly caused by Enterobacteriaceae, especially Escherichia coli and
Klebsiella pneumoniae, and by Pseudomonas aeruginosa). However, E coli remains
the most prevalent pathogen causing sepsis.
Clinical feature: patches of discoloured skin and chills due to fall in body
temperature.
Q2 a. List the eight (8) key principles of surgical nursing.
The key principles of surgical nursing are the following:

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 Assessment, planning, implementing and evaluating care using a nursing model or
framework.
 Managing fluid and electrolyte balance.
 Managing nutrition.
 Managing pain.
 Managing infection control.
 Managing wounds and wound care.
 Managing stress and anxiety.
 Managing possible altered body image (Williams & Hopper, 2015).
b. Explain briefly the following surgical procedures using correct surgical terminology.
a) Elective/emergency surgery: Elective surgeries may extend life or improve the quality of
life physically and/or psychologically. Cosmetic and reconstructive procedures, such as a
facelift (rhytidectomy), tummy tuck (abdominoplasty), or nose surgery (rhinoplasty) may not
be medically indicated, but they may benefit the patient in terms of raising self-esteem. Other
procedures, such as cataract surgery, improve functional quality of life even though they are
technically an "optional" or elective procedure (Bala et al., 2017).
Some elective procedures are necessary to prolong life, such as an angioplasty.
However, unlike emergency surgery (e.g., appendectomy), which must be performed
immediately, a required elective procedure can be scheduled at the patient's and surgeon's
convenience.
b) General, local, epidural and spinal anaesthetic and peripheral nerve block: Peripheral
nerve blocks (PNBs) possess many characteristics of the ideal outpatient anesthetic. They
provide site-specific surgical anesthesia and minimize the need for general anesthesia (GA).
By providing dense analgesia, opioid requirements are reduced, as are opioid-related side

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effects. A comfortable, symptom-free patient can be discharged home in a timely fashion. As
part of a multimodal approach to postoperative pain management, PNBs with long-acting
local anesthetic (LA) can provide prolonged analgesia. The placement of a perineural catheter
and subsequent continuous LA infusion at home can further lengthen the period of
postoperative analgesia (Desserud, Veen & Søreide, 2016).
c) Amputation: Removal of part or all of a body part that is enclosed by skin. Amputation
can occur at an accident site, the scene of an animal attack, or a battlefield. Amputation is
also performed as a surgical procedure. It is typically performed to prevent the spread of
gangrene as a complication of frostbite, injury, diabetes, arteriosclerosis, or any other illness
that impairs blood circulation. It is also performed to prevent the spread of bone cancer and to
curtail loss of blood and infection in a person who has suffered severe, irreparable damage to
a limb. When performing an amputation, surgeons generally cut above the diseased or injured
area so that a portion of healthy tissue remains to cushion bone. Sometimes the location of a
cut may depend in part on its suitability to be fitted with an artificial limb, or prosthesis.
d) Open reduction: Each ORIF surgery differs based on the location and type of fracture. In
general, a breathing tube may be placed to help you breathe while you are asleep. Then, the
surgeon will wash your skin with an antiseptic and make an incision. Next, the broken bone
will be put back into place. Next, a plate with screws, a pin, or a rod that goes through the
bone will be attached to the bone to hold the broken parts together. The incision will be
closed with staples or stitches. A dressing and/or cast will then be applied. General
anaesthesia may be used. It will block any pain and keep you asleep during the surgery. In
some cases, a spinal aesthetic, or more rarely a local block, may be used to numb only the
area where the surgery will be done. This will depend on where the fracture is located and the
time it will take to perform the procedure.

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e) Hip replacement: Total hip replacement surgery aims to relieve hip pain and increase hip
function by resurfacing the bones that meet at the hip joint. The surgeon removes the femoral
head and replaces it with an artificial one. This prosthetic femur head is shaped like a ball,
and fits perfectly into the rounded cup prosthesis that becomes the new socket of the pelvis.
f) Craniotomy: A craniotomy is a surgical procedure in which a piece of the skull is
removed so the surgeon may access the brain beneath, for the treatment of a variety of
neurological disorders. The cut-away portion – called the bone flap – may be small or large,
and is typically put back in place after surgery on the brain is finished and before the incision
closed. A craniotomy may involve the removal of a small or large section of your skull.
Although the procedure varies from patient to patient, depending on the condition to be
treated and the specific needs of the patient and surgeon.
g) Tonsillectomy: Tonsillectomy (ton-sih-LEK-tuh-me) is the surgical removal of the tonsils,
two oval-shaped pads of tissue at the back of the throat — one tonsil on each side.
Tonsillectomy with or without adenoidectomy is one of the most common surgeries
performed in the United States of America, with more than 300,000 tonsillectomies
performed annually. The most common indication for tonsillectomy is a sleep-related
breathing disorder (obstructive sleep apnea), followed by recurrent tonsillitis. Other possible
indications for tonsillectomy include peritonsillar abscess unresponsive to medical treatment,
persistent foul taste or breath caused by chronic tonsillitis not responsive to medical therapy,
unilateral tonsil hypertrophy presumed neoplastic, and hypertrophy causing dental
malocclusion or adversely affecting orofacial growth documented by an orthodontist.
h) Appendectomy: An appendectomy is the surgical removal of the appendix. It is a
common procedure that surgeons usually carry out on an emergency basis. The appendix is a
long narrow tube (a few inches in length) that attaches to the first part of the colon. It is

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usually located in the lower right quadrant of the abdominal cavity. The appendix produces a
bacteria destroying protein called immunoglobulins, which help fight infection in the body.
Its function, however, is not essential. People who have had appendectomies do not have an
increased risk toward infection. Other organs in the body take over this function once the
appendix has been removed.
i) Laparotomy: A laparotomy is a surgical incision (cut) into the abdominal cavity. This
operation is performed to examine the abdominal organs and aid diagnosis of any problems,
including abdominal pain. In many cases, the problem – once identified – can be fixed during
the laparotomy. In other cases, a second operation is required. Another name for laparotomy
is abdominal exploration. A common reason for a laparotomy is to investigate abdominal
pain, but the procedure may be required for a broad range of indications. The abdominal
organs include the digestive tract (such as the stomach, liver and intestines) and the organs of
excretion (such as the kidneys and bladder).
j) Hysterectomy: An abdominal hysterectomy is a surgical procedure that removes your
uterus through an incision in your lower abdomen. Your uterus — or womb — is where a
baby grows if you're pregnant. A partial hysterectomy removes just the uterus, leaving the
cervix intact. A total hysterectomy removes the uterus and the cervix.
Sometimes a hysterectomy includes removal of one or both ovaries and fallopian
tubes, a procedure called a total hysterectomy with salpingo-oophorectomy (sal-ping-go-o-of-
uh-REK-tuh-me). A hysterectomy can also be performed through an incision in the vagina
(vaginal hysterectomy) or by a laparoscopic or robotic surgical approach — which uses long,
thin instruments passed through small abdominal incisions.
k) Prostatectomy: Radical prostatectomy is an operation to remove the prostate gland and
tissues surrounding it. This usually includes the seminal vesicles and some nearby lymph

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nodes. Radical prostatectomy can cure prostate cancer in men whose cancer is limited to the
prostate. In traditional method of radical prostatectomy, the surgeon makes a vertical 8- to
10-inch incision below the belly button. Radical prostatectomy is performed through this
incision. In rare cases, the incision is made in the perineum, the space between the scrotum
and anus (Mungovan et al., 2017).
l) Cataract extraction: Cataract removal is surgery to remove a clouded lens (cataract) from
the eye. Cataracts are removed to help you see better. The procedure almost always includes
placing an artificial lens (IOL) in the eye. Cataract surgery is an outpatient procedure. This
means you likely do not have to stay overnight at a hospital. The surgery is performed by an
ophthalmologist. This is a medical doctor who specializes in eye diseases and eye surgery
(Mercieca et al., 2019).
Adults are usually awake for the procedure. Numbing medicine (local anaesthesia) is
given using eye drops or a shot. This blocks pain. You will also get medicine to help you
relax. Children usually receive general anaesthesia. This is medicine that puts them into a
deep sleep so that they are unable to feel pain. The doctor uses a special microscope to view
the eye. A small cut (incision) is made in the eye.
m) Internal bleeding due to trauma. For bleeding because of traumatic brain injuries, a
surgeon may create a hole in the skull. This can relieve pressure and reduce further injury to
the brain, process called Craniotomy. A craniotomy is the surgical removal of part of the
bone from the skull to expose the brain. Specialized tools are used to remove the section of
bone called the bone flap. The bone flap is temporarily removed, then replaced after the brain
surgery has been done (Nahman et al., 2015).
Q3 Too Too Wadadi is a 16-year-old Maori boy from New Zealand who was rushed to
the Emergency department this morning with testicular torsion. After an initial blood

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work he was shifted to the operating room. The surgical procedure completed at 12
noon and the patient was shifted to the post-operative ICU.
What is the significance of holistic nursing care?
The American Holistic Nurses Association defines holistic nursing as “all nursing practice
that has healing the whole person as its goal.” Holism is more than certain actions performed
or words spoken to a patient. Holistic care is a philosophy; it’s a method to ensure care for all
parts of a patient. Holistic nurses are those that recognize and treat each individual
differently. Holistic nurses are often described by patients as those nurses that “truly care.”
While there is nothing inherently wrong with being task-oriented or goal-oriented in your
nursing care, if a nurse is overly task-oriented or appears severely rushed, it can leave
patients feeling like they are just a number or a diagnosis or worse, a burden. Every nurse is
guilty of having to rush at some point; we all know the dilemma of too many patients and not
enough time; too much charting and not enough time; too many family members to deal with
and not enough time. Between things like patient needs, fellow nurses, doctors, charting,
dealing with family members, and more, nurses have a lot to worry about. As nurses we must
find a way to balance all of the duties and responsibilities that come with the title. Once we
do this our duties and responsibilities become our privileges and success (Kinchen, 2015).
Outline the application of holistic nursing in the treatment of Too Too Wadadi
considering his age, gender and specific culture.
There are many easy ways to improve relationships with Too Too Wadadi and promote a
healthy psychological, emotional, and spiritual environment for his treatment:
 Learn his name and use it
 Make good, strong eye contact with him
 Ask how Too Too Wadadi is feeling and sincerely care

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 Smiling and laughing when appropriate
 Use therapeutic touch
 Assist Too Too Wadadi to see himself as someone that deserves dignity
 Preserve their dignity
 Educate him on the importance of self-care
 Ask Too Too Wadadi how you can reduce their anxiety or pain
 Use non-pharmacological methods of pain control such as imagery, relaxation
techniques, and more
 Encourage him and assist as needed with alternative treatment modalities; never
underestimate the benefit of a massage, aromatherapy, or music(Kinchen, 2015).
 Ask if Too Too Wadadi have certain religious, cultural, or spiritual beliefs; be
sensitive and accepting if they do.
Q4 Mrs. Kabita Kandel, a 55-year-old female was admitted in the female general ward.
She was diagnosed with bilateral osteoarthritis of the hip and has been posted for a
Total hip replacement. She has a family history of type 2 Diabetes Mellitus and also
coronary artery disease. The anaesthetist reviewed the blood work and after
consultation with the patient, gave the clearance for surgery. The surgery took place at
9 am the next day and the patient was shifted to the post-operative room at 12 noon.
The doctors have ordered to commence patient mobilization at 8 pm today.
Name any two (2) Risk Assessments that are required to be performed to ensure
patient’s stability on feet before mobilization.
 Assessment of the condition of obesity in the patient.
 Assessment of any other injury or weakness due to age.

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Q5 A Briefly outline the purpose, complications and nursing management of the
following procedures:
 I/V Intravenous fluid intake:
Purpose: rehydration after becoming dehydrated from illness or excessive activity,
treatment of an infection using antibiotics, cancer treatment through chemotherapy drugs and
management of pain using certain medications.
Complications: Complications related to the regulation of fluids include giving too much
fluid too rapidly, causing fluid overload. Alternatively, not enough fluid may be given or it’s
released too slowly. Overload can cause symptoms such as a headache, high blood pressure,
anxiety, and trouble breathing.
Nursing management: When administering I.V. fluids to patients with CHF or HFpEF,
closely monitor for signs of cardiac distress caused by fluid overload. A daily weight should
be obtained at the same time each morning and recorded per your healthcare facility's policy.
If any signs of cardiac distress arise, consider stopping the I.V. fluid and consult with the
medical team immediately. Continuing the rapid infusion of I.V. fluid can lead to complete
cardiovascular collapse. Rapidly infusing large volumes of I.V. fluid in a patient with CHF,
HFpEF, or a reduced EF can cause the pressure within the heart and blood vessels to increase
as fluid accumulates. This fluid may be forced to shift into other organs such as the lungs.
When administering I.V. fluid, closely monitor your patient's cardiac, respiratory, and
neurologic status for changes. Research has shown that I.V. fluid should be tailored to each
individual based on his or her known medical history, age, and sex for optimal patient
outcomes (ARE, 2018).
 Central venous catheter (CVC):

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Purpose: Central venous catheters (CVCs) are also called central venous access
devices (CVADs), or central lines. They are used to put medicines, blood products,
nutrients, or fluids right into your blood. They can also be used to take out blood for
testing.
Complication: Damage to central veins, including injury, bleeding and hematoma (a
swelling that consists of clotted blood), can occur during CVC placement. Studies
shows that puncture of a vein occurs in 4.2–9.3% of catheter placements. Injury to the
vein occurs more often when the catheter is inserted into the femoral, or leg vein, and
less often when it’s placed in the internal jugular vein. Cardiac complications such as
abnormal heart rhythms or, although rare, a complete shutdown of the heart, called
cardiac arrest, may occur during placement of a CVC (Gulati & Brazg, 2018).
Nursing management: maximal barrier precautions, including a large sterile drape
covering the patient head to toe (with a small opening at the insertion site) and head
covers, masks, sterile gowns, and gloves for all personnel directly involved in line
insertion. Also, chlorhexidine skin antisepsis at the insertion site. it also involves optimal
site selection; the inserting clinician reviews risks and benefits of line placement in the
various veins.
Q5B What is Total Parenteral Nutrition?
Total parenteral nutrition (TPN) is the standard therapy for people who have this
problem. TPN can be used to treat a severe disorder that is expected to last for a relatively
short time, such as intractable vomiting during pregnancy. It is also used as a long-term
therapy.
With total parenteral nutrition, a solution of essential nutrients (including proteins,
fluids, electrolytes, and fat-soluble vitamins) is given into the veins (intravenously). Because

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TPN solutions are highly concentrated and thick, the solutions must be given through
catheters that are placed in large central veins in the neck, chest, or groin. An infusion pump
controls the rate at which the TPN solution is given, so that the concentrated food does not
overload other digestive organs. For many patients receiving TPN, the pump is portable
(Perinel et al., 2016).
Outline at least three (3) indications of Total Parenteral Nutrition.
 Inadequate absorption resulting from short bowel syndrome.
 Gastrointestinal fistula.
 Bowel obstruction.
What is the composition of a Standard TPN solution?
TPN is made up of two components: amino acid/dextrose solution and a lipid emulsion
solution. It is ordered by a physician, in consultation with a dietitian, depending on the
patient’s metabolic needs, clinical history, and blood work. The amino acid/dextrose solution
is usually in a large volume bag (1,000 to 2,000 ml), and can be standard or custom-made. It
is often yellow in colour due to the multivitamins it contains (Kolarcyzk & Forte, 2015).
Q6 What is the rationale for undertaking the following pre and post anesthetic
observations in a patient who has been admitted for surgery?
Pre-operative assessment is required prior to the majority of elective surgical procedures,
primarily to ensure that the patient is fit to undergo surgery, whilst identifying issues that may
need to be dealt with by the surgical or anaesthetic teams.
The post-operative management of elective surgical patients begins during the peri-operative
period and involves several health professionals. Appropriate monitoring and repeated

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clinical assessments are required in order for the signs of surgical complications to be
recognised swiftly and adequately (Grigg et al., 2017).
Q7 a. List two (2) functions and two (2) complications associated with Peripherally
inserted central catheter (PICC).
Function:
 Peripherally inserted central catheter (PICC) is used to draw blood and give
treatments, including intravenous fluids, drugs, or blood transfusions.
 A PICC line (peripherally inserted central catheter line) is used to give someone
chemotherapy treatment or other medicines (Sharp et al., 2015).
Complications:
 PICCs appear to be associated with a greater risk for venous thrombosis overall
(superficial and deep thrombosis) compared with centrally inserted catheters (CICCs;
including ports), particularly in those who are critically ill or who have malignancy.
 Accidental withdrawal.
b. Outline the Nursing Management of a patient prior and post PICC insertion
procedure.
 Prior:
 Pain –arm, shoulder neck or chest
 Redness
 Swelling, engorged veins in the arm, neck or chest.
 Exudate, redness, pain at exit site
 Pyrexia or a history of rigors post flushing.

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Post:
 Dressing allergy –redness, blistering, itching, pain under the dressing.
 PICC migration
 Leaking of fluid beneath the dressing
Q8 Outline any three (3) strategies a Nurse can use for pain management in a patient
after surgery with the exception of using analgesics.
The role of the nurse in control of postoperative pain also includes the following:
• Administer pain medication in a timely manner before the scheduled painful procedures
such as, dressing change, physical therapy etc.
• Monitor pain treatment outcome.
• Utilize of non-pharmacological means to make the pain tolerable.
• Eliminate other sources of discomfort, such as full bladder, infiltration of IV etc.
Q9 A. In terms of a patient who is not regaining consciousness, how would you assess
their level of consciousness?
The tool we use to assess the level of consciousness is the Glasgow Coma Scale (GCS). This
tool is used at the bedside in conjunction with other clinical observations and it allows us to
have a baseline and ongoing measurement of the level of consciousness (LOC) for our
patients. The GCS has been in use in clinical practice for approximately forty years and is
used universally around the world.
B. What signs and symptoms of deterioration you need to monitor?
 Tachypnea (increased respiratory rate)

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 Retractions - in the child this is due to a soft compliant chest wall, horizontally placed
ribs and poorly developed intercostal muscles
 Tachycardia (increased heart rate) - this is an early sign of cardiovascular compromise
 Pale and cool extremities
 Normal blood pressure
 Oliguria - this occurs when the kidneys are not adequately perfused. The child
produces <1mL/kg/hr of urine (Zainuddin et al., 2018)
Assess for changes in Level of Consciousness (LOC) including:
 Irritability
 Restlessness
 Lethargy
Q10 Draw a neatly labelled diagrammatic flow chart representation of the management
of a case of paediatric Cardio Pulmonary Resuscitation for a 5-year-old male in a
hospital where 2 certified CPR givers are available.
Infant or child collapses with possible cardiac arrest, if unresponsive
Activate emergency response system and call for defibrillator but do not
delay CPR
Assess for pulses and breathing, if not breathing and no pulse
Start CPR
C: give 30 chest compressions
A: open airways
B: give 2 slow (1-sec) breaths
If >1 rescuer is present, give 2 breaths after every 15
compressions.
Attach monitor when available.
If not breathing
but has pulse
Give rescue
breaths 12-20
breaths per min
once every 3-5
sec.

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Q11 Explain the physiology behind the progression of a respiratory arrest into a cardiac
arrest.
Sudden cardiac arrest (SCA) and sudden cardiac death (SCD) refer to the sudden cessation of
cardiac activity with hemodynamic collapse, typically due to sustained
ventricular tachycardia/ventricular fibrillation. These events mostly occur in patients with
structural heart disease (that may not have been previously diagnosed), particularly coronary
heart disease. One of the reasons of the condition can be respiratory assert. Respiratory
arrest is the cessation of breathing, and it may occur for a variety of reasons. When a patient
goes into respiratory arrest, they are not getting oxygen to their vital organs and may suffer
brain damage or cardiac arrest within minutes if not promptly treated.
Q12 A. Excluding Deep Vein Thrombosis, outline at least four (4) complications
associated with bed rest.
1. The cardiovascular system undergoes dramatic and extensive changes after long
periods of immobility. Water loss and a phenomenon known as cardiac
deconditioning are triggered by redistribution of fluids in a supine person.
2. In a healthy mobile person, ANP and ADH (together with other hormones) are very
effective at maintaining fluid levels. But, in long periods of bedrest, the delicate
balance between these two hormones is disrupted (Watson, Broderick & Armon,
2016).
3. When a person is supine, the shift of blood from the legs into the thorax increases
atrial stretch, stimulating the release of ANP. This initiates diuresis leading to
significant water loss. The result is an increase in urine output and a progressive
reduction in blood volume that can often lead to dehydration. Healthcare professionals

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can avoid severe dehydration in bedridden patients by carefully monitoring fluid
intake and urine output, and ensuring they have access to fresh water. Unconscious
patients usually need isotonic saline drips to maintain hydration.
4. After four weeks of bedrest, the resting heart rate typically increases by around 10
beats per minute. Also, the heart rate after exercise is up to 40 beats per minute faster
in patients who have just had four weeks of bedrest. Exercise tolerance in these
patients does not fully return to normal for 5-10 weeks after they become mobile
again
B. Describe in brief the complex nursing management of a patient who was recently
diagnosed with DVT.
The nursing management involves:
1. Assess a full neuro exam, assess Breathing-Pulse oximetry, difficulty in breathing,
chest pain, obtain an EKG. Assess and monitor for potential complications d/t the
blood clot moving into another area such as the lungs (PE), heart (MI), or brain
(CVA).
2. Heparin- initial therapy to break up clot. Transition into a SubQ or oral anticoagulant
to prevent future clots. This is an anticoagulant that breaks up blood clots (as well as
prevents them). Monitor aPTT or Anti-Xa Q6H to adjust and maintain therapeutic
levels.
Bolus: 80 units/kg
Initial dose: 18 units/kg/hr
Adjust according to your organization's nomogram (Q6H- based on results of aPPT or
Anti-Xa)

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3. Educate about avoiding vitamin K (both supplements as well as food): Vitamin K
works to help increase clotting, this is opposite of what we are trying to do for this
patient, unless of course they are bleeding out, in which case the treatment may be
vitamin K with Fresh Frozen Plasma (FFP) (Watson, Broderick & Armon, 2016).
4. Bleeding/fall precautions because of anticoagulant therapy: This isn’t just for in the
hospital, it is also for when the patient goes home. The patient is at major risk for
bleeding out, thus educating about s/sx of internal bleeding as well as educating about
fall precautions is vital.
Q13 List five (5) clinical manifestations and five (5) complex nursing interventions of
Acute Pancreatitis.
five (5) clinical manifestations
 Upper abdominal pain.
 Abdominal pain that radiates to your back.
 Abdominal pain that feels worse after eating.
 Fever.
 Rapid pulse.
five (5) complex nursing interventions
 Investigating verbal reposts of the pain and noting the specific locations and intensity.
 Maintaining bed rest and avoiding stressful condition during attack.
 Maintain meticulous skin care while draining abdominal wall fistulas.
 Insulin injection
 Aggressive respiratory care and oxygen supply.

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Q14 a. List three (3) indications of tracheostomy suctioning.
(1) acute respiratory failure and need for prolonged mechanical ventilation (representing two
thirds of all cases) and
(2) traumatic or catastrophic neurologic insult requiring airway, or mechanical ventilation or
both.
(3) Upper airway obstruction is a less common indication for tracheostomy (Schreiber, 2015).
b. Briefly outline the nursing management involved in tracheostomy suctioning.
 Patients return from theatre with stay sutures (nylon sutures) inserted on either side of
the tracheal opening. The stay sutures are taped to the chest and labelled left and right.
Pulling the stay sutures up and out will apply traction to the stoma opening to assist
with insertion of the replacement tube.
 The stay sutures should remain in situ and securely attached to the chest wall until the
first or second successful tube change.
 Trache stoma maturation takes approximately 5 – 7 days after insertion of the
tracheostomy tube or 2 – 3 days if stoma maturation sutures are placed.
 The ENT team, in consultation with the parent medical team, will perform the first
tube change, including the removal of the stay sutures.
 It is imperative that the first tracheostomy tie change is dealt with in the same manner
as the first tracheostomy tube change with both nursing and medical staff present who
are competent in tracheostomy management.
 The tracheal stoma in the immediate post-operative period requires regular assessment
and wound management including once daily dressing change following cleaning of
the stoma area or more frequently if required (Schreiber, 2015).

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Q16 Describe in detail the nursing management of a patient with an intercostal catheter
and an underwater chest drainage tube (UWSD)?
UWSD Unit and tubing
 Never lift drain above chest level
 The unit and all tubing should be below patient’s chest level to facilitate drainage
 Tubing should have no kinks or obstructions that may inhibit drainage
 Ensure all connections between chest tubes and drainage unit are tight and secure
 Connections should have cable ties in place
 Tubing should be anchored to the patient’s skin to prevent pulling of the drain
 In PICU and NICU tubing should also be secured to patient bed to prevent accidental
removal
 Ensure the unit is securely positioned on its stand or hanging on the bed
 Ensure the water seal is maintained at 2cm at all times (Altree, Jersmann & Nguyen,
2018)
Q17 Outline the nursing management of a patient on BIPAP and CPAP
The patient receiving any form of CPAP/ BIPAP needs to be medically assessed for their
capacity to self-ventilate adequately in case of ventilator, circuit or interface failure. Where a
patient cannot self-ventilate adequately there should be provision for the immediate
availability of a backup mechanical device/driver, battery, circuit and interface.
 Document start of shift primary and secondary patient survey
 Complete standard bedside safety checks
 Check that ventilator settings correlate with documented medical orders
 Familiarize yourself with equipment checklist at the start of shift

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 Enteral feeds can be administered during periods of CPAP/ BIPAP. However, carers
should be mindful of the increased risk of abdominal distension and need for
increased venting/aspiration of nasogastric (NGT) or other gastrostomy tubes (Chung
et al., 2016).
 Time spent on NIV may impinge on the patient’s ability and opportunity to take
adequate nutrition and/or fluids orally. Therefore, alternate feeding methods may need
to be used.
Q18. Outline the function of each of the following equipment that is present in an Acute
care environment.
Items Functions
Bad and Mask, Endotracheal tube,
Laryngoscope
Endotracheal tube has a primary purpose
of establishing and maintaining a patent
airway and to ensure the adequate exchange
of oxygen and carbon dioxide.
Laryngoscope are used as the primary tool
for examination of the interior of the larynx
and for placement of an endotracheal tube.
Pulse oximetry The purpose of pulse oximetry is to check
how well your heart is pumping oxygen
through your body. It may be used to
monitor the health of individuals with any
type of condition that can affect blood
oxygen levels, especially while they're in
the hospital (Hwang, Dejong & O'neil,

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2016).
Vaccum pump and suction catheter Vacuum pump and suction catheter are
used to extract bodily secretions, such as
mucus or saliva from the upper airway. A
suction catheter connects to a suction
machine or collection canister.
Electrocardiograph painless test that measures your heart's
electrical activity.
Defibrillator used to prevent or correct an arrhythmia, a
heartbeat that is uneven or that is too slow
or too fast. Defibrillators can also restore the
heart’s beating if the heart suddenly stops.
Standard IV fluids and administration
sets
to deliver insulin under the skin. It is a
complete tubing system to connect an
insulin pump to the pump user
Infusion pumps delivers fluids, such as nutrients and
medications, into a patient's body in
controlled amounts.
Large bore IV catheters High volume fluid resuscitation may be
required for the trauma patient, in which
case at least two large bore (14-16 G) IV
catheters are usually inserted.
Supplies for thoracotomy used to treat or diagnose a problem with one

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of these organs or structures. The most
common reason to have a thoracotomy is to
treat lung cancer, as the cancerous part of
the lung can be removed through the
incision. It can also be used to treat some
heart and chest conditions.
Nasal gastric/oral gastric tubes to drain gastric contents, decompress the
stomach, obtain a specimen of the gastric
contents, or introduce a passage into the GI
tract. This also treats gastric immobility, and
bowel obstruction.
Hard Cervical collars used for spine problems or injuries. It limits
forward and backward movement more than
a soft one does. Hard collars are sometimes
used to support a person's neck right after
an injury. They also may be used for neck
strain.
Q19 Classify burns based on causative factors. Describe the 4 degrees of burns as a
result of fire with clinical features.
Burns are tissue damage that results from heat, overexposure to the sun or other radiation, or
chemical or electrical contact. Burns can be minor medical problems or life-threatening
emergencies.

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The treatment of burns depends on the location and severity of the damage. Sunburns and
small scalds can usually be treated at home. Deep or widespread burns need immediate
medical attention. Some people need treatment at specialized burn centers and month-long
follow-up care (Cassier & Vazquez, 2018).
Third-degree burn
1st-degree burn. This minor burn affects only the outer layer of the skin (epidermis). It may
cause redness and pain.
2nd-degree burn. This type of burn affects both the epidermis and the second layer of skin
(dermis). It may cause swelling and red, white or splotchy skin. Blisters may develop, and
pain can be severe. Deep second-degree burns can cause scarring.
3rd-degree burn. This burn reaches to the fat layer beneath the skin. Burned areas may be
black, brown or white. The skin may look leathery. Third-degree burns can destroy nerves,
causing numbness.
Fourth-degree burns. Fourth-degree burns go through both layers of the skin and underlying
tissue as well as deeper tissue, possibly involving muscle and bone. There is no feeling in the
area since the nerve endings are destroyed.
Clinical features: Unlike first- or second-degree burns, fourth-degree burns aren’t painful.
This is because the damage extends to the nerves, which are responsible for sending pain
signals to brain. It involves injury to deeper tissues, such as muscle, tendons, or bone.
Q20. What is Venous thromboembolism (VTE)?
Venous thromboembolism (VTE) is a condition in which a blood clot forms most often in the
deep veins of the leg, groin or arm (known as deep vein thrombosis, DVT) and travels in the
circulation, lodging in the lungs (known as pulmonary embolism, PE). Together, DVT and

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PE are known as VTE - a dangerous, potentially deadly medical condition (Lyman et al.,
2015).
Outline the types of VTE.
Types of Thrombosis
1. Deep vein thrombosis (DVT): A blood clot that forms in a deep vein, usually the leg,
groin or arm.
2. Pulmonary embolism (PE): A blood clot that occurs when a DVT clot breaks free
from a vein wall and travels to the lungs blocking some or all of the blood supply. PE
can often be fatal.
3. DVT + PE = VTE: DVT and PE are collectively referred to as VTE.
Mention at least two (2) clinical features for each type of VTE.
1. Deep vein thrombosis (DVT): swelling in your foot, ankle, or leg, usually on one side
and cramping pain in your affected leg that usually begins in your calf.
2. Pulmonary embolism (PE): Seizures and decreasing level of consciousness.
3. DVT + PE = VTE: Leg pain or tenderness of the thigh or calf and Reddish
discoloration or red streaks.
Q21. a. Outline at least TWO (2) extrinsic and TWO (2) intrinsic causes of fractures.
Falls due to extrinsic reasons took place at all hours of the day and night, mainly in people
who were alone and who wore shoes or sandals at the time of the fall and who either suffered
from slight or no disturbances in attention and concentration. Falls due to intrinsic reasons
occurred mainly during rest or sleep hours, in people who walked barefoot or with socks or
slippers and who suffered moderate or severe disturbances in attention and concentration.

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b. What is a green stick fracture? What age group does it affect?
A greenstick fracture occurs when a bone bends and cracks, instead of breaking completely
into separate pieces. The fracture looks similar to what happens when you try to break a
small, "green" branch on a tree. Most greenstick fractures occur in children younger than 10
years of age. This type of broken bone most commonly occurs in children because their bones
are softer and more flexible than are the bones of adults. The risk of greenstick fractures is
higher in young children because their bones are softer and more flexible than adult bones. In
a greenstick fracture, the bone bends and cracks instead of breaking into separate pieces.
Most greenstick fractures occur in children under age 10.
c. Outline three (3) clinical features of green stick fractures.
The symptoms of a greenstick fracture vary depending on the severity of the fracture. You
may only develop a bruise or general tenderness in more mild fractures. In other cases, there
might be an obvious bend in the limb or fractured area, accompanied by swelling and pain.
Symptoms also depend on the location of the injury. For example, if the injury occurs in your
finger, you might not be able to move the finger for a period of time. Alternatively, a fracture
in your arm might be painful with swelling and tenderness while you maintain mobility.
Q22. Write the indications of use for the following emergency medications that are used
in acute situations.
Drugs Indication
Adrenaline
(1000 microgram in 1 mL injection
equivalent to 1:1000)
This medication is used in emergencies to
treat very serious allergic reactions to insect
stings/bites, foods, drugs, or other
substances. Epinephrine acts quickly to

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1000 microgram = 1 mg improve breathing, stimulate the heart,
raise a dropping blood pressure, reverse
hives, and reduce swelling of the face, lips,
and throat.
Atropine
(0.6 mg in 1 mL injection)
It is used to treat some poisonings. In
surgery, it is used to lower secretions such
as saliva. It is used to treat muscle spasms of
the GI (gastrointestinal) tract, gallbladder
system, or urinary system. It is used when
the heart is not beating.
Benztropine
(2 mg in 2 mL injection)
Benztropine is used to treat symptoms of
Parkinson's disease or involuntary
movements due to the side effects of certain
psychiatric drugs (antipsychotics such as
chlorpromazine/haloperidol).
Benzylpenicillin
(600 mg or 3 g powder, dissolve in
water for injections)
Benzylpenicillin is indicated for most
wound infections, pyogenic infections of the
skin, soft tissue infections and infections of
the nose, throat, nasal sinuses, respiratory
tract and middle ear, etc.
It is also indicated for the following
infections caused by penicillin-sensitive
microorganisms: Generalised infections,
septicaemia and pyaemia from susceptible

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bacteria. Acute and chronic osteomyelitis,
sub-acute bacterial endocarditis and
meningitis caused by susceptible organisms.
Suspected meningococcal disease.
Chlorpromazine
(50 mg in 2 mL injection)
is used to treat certain mental or emotional
conditions. It is also used to control hiccups,
reduce anxiety and treat nausea and
vomiting.
Dexamethasone sodium phosphate
(4 mg in 1 mL injection)
This medication is used to treat various
conditions such as severe allergic reactions,
arthritis, blood diseases, breathing
problems, certain cancers, eye diseases,
intestinal disorders, and skin diseases. It is
also used to test for an adrenal gland
disorder (Cushing's syndrome).
Diazepam
(10 mg in 2 mL injection)
Diazepam is used to treat anxiety, muscle
spasms, and alcohol withdrawal. The
injection form is used when prompt relief is
desired or when the medication cannot be
taken by mouth. This medication is also
used for the short-term treatment of serious
seizures that do not stop (status epilepticus).
Dihydroergotamine Dihydroergotamine injection is used to treat
a migraine or cluster headache attack.

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(1 mg in 1 mL injection)
Diphtheria and tetanus booster vaccine
(0.5 mL pre-filled syringe)
The tetanus and diphtheria toxoids vaccine
(also called Td) is used to help prevent these
diseases in adults and children who are at
least 7 years old.
Frusemide
(20 mg in 2 mL injection)
Furosemide is used to treat fluid retention
(edema) in people with congestive heart
failure, liver disease, or a kidney disorder
such as nephrotic syndrome.
Glucagon
(injection kit containing 1 mg glucagon
and 1 mL solvent in syringe)
It is used to quickly increase blood sugar
levels in diabetics with low blood sugar
(hypoglycemia). This medication may also
be used during certain medical tests.
Glyceryl trinitrate
(400 microgram per dose, 200 doses as
sublingual spray)
used to relieve angina (chest pain). When
sprayed under the tongue, it relaxes and
widens blood vessels in the heart and in the
rest of the body. You should carry your
GTN spray with you at all times but only
use it if you develop chest pain or
discomfort.
Haloperidol
(5 mg in 1 mL injection)
Haloperidol injection is used to treat severe
symptoms of certain mental/mood disorders
(e.g., schizophrenia, schizoaffective

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disorders).
Hydrocortisone sodium succinate
(100 mg or 250 mg with
2 mL solvent for injection)
Hydrocortisone Sodium Succinate
relieves inflammation in various parts of the
body. To treat or prevent allergic reactions.
As treatment of certain kinds of
autoimmune diseases, skin conditions,
asthma and other lung conditions.
Lignocaine
(100 mg in 5 mL injection)
Lignocaine (Cadila) 2 % Injection is an
effective numbing medicine used before
surgical procedures. It blocks nerve signals
from a specific part of the body and is
categorized as a local anesthetic medicine. It
is also used to treat arrhythmia characterized
by an improper beating of the heart.
Metoclopramide
(10 mg in 2 mL injection)
used for the relief of symptoms associated
with acute and recurrent diabetic gastric
stasis, to prevent nausea and vomiting from
chemotherapy, to prevent postoperative
nausea and vomiting, to facilitate small
bowel intubation, and to stimulate gastric
emptying.
Methoxyflurane primarily used to reduce pain following
trauma. It may also be used for short

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(3 mL plus inhaler) episodes of pain as a result of medical
procedures. Onset of pain relief is rapid and
of a short duration. Use is only
recommended with direct medical
supervision.
Morphine sulfate
(15 mg or 30 mg in 1 mL injection)
This medication is used to treat severe pain.
Morphine belongs to a class of drugs known
as opioid (narcotic) analgesics. It works in
the brain to change how your body feels and
responds to pain.
Naloxone
(2 mg in 5 mL injection)
Naloxone injection is used to treat a
narcotic overdose in an emergency situation.
Procaine penicillin
(1.5 g in 3.4 mL injection)
This should read
(1.5 g in 3.4 mL injection)
Corrected May 2013
Procaine penicillin is used to treat many
different types of infections caused by
bacteria, including syphilis (a sexually
transmitted disease).
Prochlorperazine
(12.5 mg in 1 mL injection)
To control severe nausea and vomiting. For
the treatment of schizophrenia.
Promethazine hydrochloride
(50 mg in 2 mL injection)
Promethazine is used to prevent and treat
nausea and vomiting related to certain
conditions (such as before/after surgery,

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motion sickness). It is also used with other
medication to treat severe allergic reactions
(anaphylaxis) and reactions to blood
products. It may also be used to treat milder
allergic reactions when you cannot take
promethazine by mouth.
Salbutamol inhaler
(100 microgram per dose,
200 doses)
Salbutamol is used to relieve symptoms of
asthma and COPD such as coughing,
wheezing and feeling breathless. It works by
relaxing the muscles of the airways into the
lungs, which makes it easier to breathe.
Salbutamol comes in an inhaler (puffer).
Salbutamol nebuliser solution
(2.5 mg or 5 mg in 2.5 mL per dose, 30
doses)
Salbutamol Nebuliser Solution is
indicated for use in the routine management
of chronic bronchospasm unresponsive to
conventional therapy and the treatment of
acute severe asthma. Salbutamol Nebuliser
Solution should be administered by a
suitable nebuliser, via a face mask or T
piece or via an endotracheal tube
Terbutaline
(500 microgram in 1 mL injection)
Terbutaline injection is used to treat
wheezing, shortness of breath, coughing,
and chest tightness caused by asthma,
chronic bronchitis, and emphysema.

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Tramadol
(100 mg in 2 mL injection)
This medication is used to help relieve
moderate to moderately severe pain.
Tramadol is similar to opioid (narcotic)
analgesics. It works in the brain to change
how your body feels and responds to pain
(Miotto et al., 2017).
Verapamil
(5 mg in 2 mL injection)
Verapamil is used for controlling
ventricular rate in supraventricular
tachycardia and migraine headache
prevention. It is a class-IV antiarrhythmic
and more effective than digoxin in
controlling ventricular rate (Fitzgerald &
Howes, 2016).
Q23. a. What are the clinical manifestations of Acute Myocardial Infarction?
Acute myocardial infarction is the medical name for a heart attack. A heart attack is a life-
threatening condition that occurs when blood flow to the heart muscle is abruptly cut off,
causing tissue damage. This is usually the result of a blockage in one or more of
the coronary arteries. A blockage can develop due to a build-ups of plaque, a substance
mostly made of fat, cholesterol, and cellular waste products. The classic crushing substernal
chest pain decreases with age, whereas the symptom of dyspnea gradually increases.
Neurologic symptoms, confusional states, weakness, and worsening heart failure are common
clinical presentations of an acute infarction in elderly patients (Ibanez et al., 2017).
b. Outline the complex steps involved in its nursing management.

NURSING ASSESMENT
Nursing interventions should be anchored on the goals in the nursing care plan.
 Administer oxygen along with medication therapy to assist with relief of symptoms.
 Encourage bed rest with the back rest elevated to help decrease chest discomfort and
dyspnea.
 Encourage changing of positions frequently to help keep fluid from pooling in the
bases of the lungs.
 Check skin temperature and peripheral pulses frequently to monitor tissue perfusion
(Reed, Rossi & Cannon, 2017).
 Provide information in an honest and supportive manner.
 Monitor the patient closely for changes in cardiac rate and rhythm, heart sounds,
blood pressure, chest pain, respiratory status, urinary output, changes in skin color,
and laboratory values.

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