INTRODUCTION TO

MEDICAL SURGICAL
NURSING
MAIN OBJECTIVE:
To acquire knowledge on medical-surgical nursing and develop skills
and attitudes in the management of patients with medical and
surgical conditions.

SUB-OBJECTIVES
The student will be able to:
1. Discuss historical development of Medicine and Surgery.
2. Classify the disease/condition according to their etiology.
3. Describe the disease process (Pathophysiology)
4. Describe common medical-surgical conditions
 Assignment

1. Write notes on historical development of Medicine and Surgery

 Background
• Medical /surgical nursing- broad nursing specialty that provide
care for adult patients with either /both acute and chronic
conditions.
• This requires broad knowledge on body system, surgical and
medical pathologies, clinical skills, clinical decision making as well
as collaborative skills.
• According
. to Florence Nightingale, the goal of nursing was to put
the patient in the best condition for nature to act upon him.
 Cont’----
• Roles of the Nurse in medical surgical nursing

Nurse practitioner- makes interventions, teaches

patient,families and communities and also collaborates care
Leadership role- this role demands ,decision making,
facilitation,influencing and relating with other nurses in order to
meet patients, families and community health needs.
Reseacher role- every nurse should participate in research in
order to answer the questions and improve on the practice and
hence the need to understand research methods
Expanded nursing roles- an increase in health care demands
leads to the need for ability to independent decision making
hence the need for specialization e.g critical care nursing, family
health nursing, orthopedic nursing among many others.
Models of Nursing Care Delivery

 Task based/functional nursing

 Primary nursing
 Team nursing
 Case based management
Community-based / community health
• Health care delivery system
Changes in delivery of health care have been propelled by:

Demographic changes- increase in population due to improved

health care, expanded lifespan, flexible global
movement,urbanization etc
Emerging and reemerging diseases
Aging population- health promotion, disease prevention and
rehabilitative services led to prolongation of life as well as reduction
in acute ilnesses but an increase in chronic illneses
Technological advances- diagnostic and therapeutic
equipments.
Economical changes- high costs of health care
 Concepts and Definition of terms
• Medicine - The branch of medical science that deals with
nonsurgical techniques of treating illnesses
• Surgery - The branch of medical science that treats disease or injury
by operative procedures
• Health- state of complete physical, mental, and social well-being
and not merely the absence of disease.
• Sepsis - presence of pathogens or their toxins
• Surgical asepsis - Condition of being aseptic (sterile) aseptic
treatment and technique
• Aseptic technique - All steps taken to prevent contamination of
surgical site by infectious agents
• Sterile - complete absence of microbes via the cleansing process
• Curettage - surgery to remove tissue or growths from a bodily
cavity (as the uterus) by scraping with a curette
• Debridement - surgical removal of foreign material and dead
tissue from a wound in order to prevent infection and promote
healing
• Dehiscence - Bursting open of a wound, especially a surgical
abdominal wound
• Health–Illness continuum - considers a person as having neither
complete health nor complete illness. Instead, a person’s state of
health is ever-changing and has the potential to range from high-
level wellness to extremely poor health status.

• The patient/client: the one with health care needs. Care should
be focused on the patient /client. Identification of the immediate
health care need is a fundamental nursing requirement
PROCESS OF INFLAMMATION
 Introduction
INFLAMMATION:

• Definition 1: the local response

of living body tissues to injury
due to any agent.
• Definition 2: The complex
biological response of body
tissues to harmful stimuli,
such as pathogens,
damaged cells, or irritants
 Cont..

• Inflammation is a protective response involving;

 immune cells,
 blood vessels,
 molecular mediators

• It is also the body defense reaction – to eliminate or limit the

spread of injurious agent
 Causes of Inflammation

1. Infective agents like bacteria, viruses, fungi, parasites (and

their toxins).
2. Immunological agents like cell-mediated and antigen
antibody reactions.
3. Physical agents like heat, cold, radiation, mechanical
trauma.
4. Chemical agents like organic and inorganic poisons.
5. Inert materials such as foreign bodies (chemically
inactive)
 Signs of inflammation
• 4 cardinal signs
(according to Celsus)
– Redness
– Swelling
– Heat
– Pain
• 5th sign
- Loss of function –
(according to Virchow)
 Types of inflammation
Mainly of 2 types i.e. acute and chronic
• Acute Inflammation
– short duration
– represents the early body reaction- followed by
healing
• Chronic inflammation
– longer duration
– causative agent of acute inflammation persists for a
long time
INFLAMMATORY RESPONSE/PROCESS/THE PROCESS OF
INFLAMMATION

Involves the following events:

VASCULAR EVENTS/RESPONSE
a) Hemodynamic changes
b) Altered vascular permeability

CELLULAR EVENTS/RESPONSE
c) Exudation of leukocytes
d) Phagocytosis
VASCULAR EVENTS/RESPONSE

a) Hemodynamic changes

• Transient vasoconstriction: Is the immediate vascular response

to achieve hemostasis irrespective of type of injury .
• Persistent progressive vasodilation: Involves mainly arterioles
but to a lesser extent, capillaries. It results in increased blood
volume in the micro-vascular bed of the site of acute
inflammation.
• Elevated local hydrostatic pressure: Caused by progressive
vasodilation which results in transudation of fluid into the local
site causing edema.
• Slowing/stasis of microcirculation follows, causing increased
concentration of RBCs and thus raised blood viscosity.
b) Altered vascular –permeability

There are two mechanisms –:

• Chemical mediators of acute inflammation may cause retraction

of endothelial cells, leaving intercellular gaps (chemical
mediated vascular leakage).
• Toxins and physical agents may cause necrosis of vascular
endothelium, leading to abnormal leakage (injury induced
vascular leakage).
CELLULAR EVENTS/RESPONSE
Includes:

i) Formation of the Cellular Exudate

How do white blood cells get out of the circulation and into the area
where they are needed?
• The movement of leukocytes from the vessel lumen in a
directional fashion to the site of tissue damage is called
chemotaxis.
• All granulocytes and monocytes respond to chemotactic factors
and move along a concentration gradient (from an area of lesser
concentration of the factor to an area of greater concentration of
the factor).
ii) Phagocytosis

• The process whereby cells ingest solid particles is termed

phagocytosis.
• The first step in phagocytosis is adhesion of the particle to be
phagocytosed to the cell surface. The phagocyte ingests the
attached particle by sending out pseudopodia around it. These
meet and fuse so that the particle lies in a phagocytic vacuole
(also called a phagosome) bounded by cell membrane.
Lysosomes, then fuse with phagosomes to form
phagolysosomes. It is within these that intracellular killing of
microorganisms occurs.
INFLAMMATION PROCESS;
Factors that can influence chronic inflammation;

• Dietary factors,
• Physical activity,
• Smoking
• Obesity
• Alcohol consumption
• Stress can affect inflammation.
 DISORDERS OF INFLAMMATION
Inflammatory abnormalities are a large group of disorders that
underlie a vast variety of human diseases.

Examples of disorders associated with inflammation include:

 Acne vulgaris
 Asthma
 Autoimmune diseases
 Chronic prostatitis
 Diverticulitis
 Glomerulonephritis
 Hypersensitivities
MANAGEMENT OF PATIENTS WITH INFLAMMATION
FEVER/PYREXIA: Occurs due to bacteremia. Administer prescribed
antipyretics e.g paracetamol. Give high calorie diet in the form of
carbohydrates. This is to meet the increased metabolic demand in
patients with fever.

LEUCOCYTOSIS: Usually in bacterial infections there is neutrophilia,

viral infections cause lymphocytosis, parasitic infections cause
eosinophilia. Administer prescribed antibacterial agents.

DIET: Provide easily digestible diet (light diet), keep the fluid
balance, and give high protein diet for the formation of new tissue
to build up the destroyed tissue.
SEDATION: Inflammation will produce pain, therefore sedative
drugs may be given to induce sleep.

SHOCK: Systematic activation of coagulation pathway may occur

leading to microthrombi throughout the body and results into DIC,
bleeding and death. Severe tissue injury results in profuse systemic
vasodilation, increased vascular permeability and intravascular
volume loss causing hypotension and shock. Give plenty of I.V
fluids.

PAIN: Immobilize the affected limb, administer prescribed

analgesics. Give anti-inflammatory agents e.g ibuprofen,
indomethacin, steroids e.g prednisone and dexamethasone.
REST: Elevate the affected limb. The inflamed part is rested by
elevation. In case of arms use splints, and for lower limbs use
pillows and clear.

LOCAL TREATMENT: If the inflammation is broken and septic, use

antiseptics to kill the pathogenic microbes in in the wound.
Examples of antiseptics include: hydrogen peroxide, hibitane
(Chlorexidine).
Systemic effects of inflammation

• Fever : infectious form of inflammation

• Anaemia
• Leucocytosis
• Septic shock
CLASSIFICATION
OF
DISEASES
INTRODUCTION
• A disease is a particular abnormal condition that affects part
or all of an organism and is not caused by external force
(injury).
• Disease is often interpreted as a medical condition
associated with specific symptoms and signs.
• It may be caused by external factors such as pathogens or
by internal dysfunctions, particularly of the immune system,
such as an immunodeficiency, or by a hypersensitivity,
including allergies and autoimmunity.
• Diseases may be classified by cause, pathogenesis or by
symptom(s).
• Alternatively, diseases may be classified according to the
organ system involved, though this is often complicated
since many diseases affect more than one organ.
• The most known and used classification of diseases is the
World Health Organization's ICD (International
Statistical Classification of Diseases and Related Health
Problems). This is periodically updated.
 ICD
• The International Classification of Diseases (ICD) is the international
"standard diagnostic tool
for epidemiology, health management and clinical purposes".
• Its full official name is International Statistical Classification of Diseases
and Related Health Problems.
• The ICD is designed as a health care classification system, providing a
system of diagnostic codes for classifying diseases.
• It contains codes for diseases, signs and symptoms, abnormal findings,
complaints, social
circumstances, and external causes of injury or diseases.
• The first international classification edition, known as the International List
of Causes of Death, was adopted by the International Statistical Institute
in 1893.
 Disease classification :

There are four main classes of disease

i. Genetic disease
ii. Infectious disease (infections)
iii. Neoplasmic (benign or malignant) disease
iv. Traumatic disease (injuries)

• Diseases can also be classified as communicable and non-

communicable.
 i. Genetic disease
• A genetic disease is a genetic problem caused by one or more
abnormalities formed in the genome.

• Most genetic disorders are quite rare

• Genetic disorders may be hereditary or non-hereditary, meaning

that they are passed down from the parents' genes.
• However, in some genetic disorders, defects may be caused by
new mutations, altered phenotype, or changes to the DNA.
• Examples: albinism, sickle-cell disease, hemophilia etc
 ii. Infectious disease (infections)
• Infectious diseases are disorders caused by organisms — such as
bacteria, viruses, fungi or parasites.
• Some infectious diseases can be passed from person to person.
• Some are transmitted by insects or other animals. And one may
get others by consuming contaminated food or water or being
exposed to organisms in the environment.
• Signs and symptoms vary depending on the organism causing the
infection, but often include fever and fatigue.
• Mild infections may respond to rest and home remedies, while
some life-threatening infections may need hospitalization.
• Many infectious diseases, such as measles and chickenpox, can
be prevented by vaccines.
• Frequent and thorough hand-washing helps to protect
individuals from most infectious diseases.
 iii. Neoplasmic (benign or malignant) disease
• A neoplasm is a type of abnormal and excessive growth,
called neoplasia, of tissue.
• The growth of a neoplasm is uncoordinated with that of the
normal surrounding tissue, and it persists growing abnormally,
even if the original trigger is removed.
• This abnormal growth usually (but not always) forms a
mass. When it forms a mass, it may be called a tumor.
• ICD-10 classifies neoplasms into the following main
groups: benign neoplasms, malignant neoplasms, and neoplasms
of uncertain or unknown behavior. Malignant neoplasms are also
simply known as cancers and are the focus of oncology.
 Types of neoplasms
• A neoplasm can be benign or malignant (cancer).
• Benign tumors include uterine fibroids.
• They are circumscribed, localized and do not transform into
cancer.
• Malignant neoplasms are commonly called cancer.
• They invade and destroy the surrounding tissue, may form
metastases and, if untreated or unresponsive to treatment, will
generally prove fatal.
• Secondary neoplasm refers to any of a class of cancerous tumor
that is a metastatic offshoot of a primary tumor.
• If a metastatic neoplasm has no known site of the primary
cancer, it is classified as a cancer of unknown primary origin
 iv. Traumatic disease (injuries)
Trauma most often refers to:

• Psychological trauma, a type of damage to the psyche that

occurs as a result of a severely distressing event

• Traumatic injury, sudden physical injury caused by an external

force, which does not rise to the level of major trauma
 Disease Classification:

The other widely used classifications of disease are :

(1) Topographic, by bodily region or system,

(2) Anatomic, by organ or tissue,
(3) Physiological, by function or effect,
(4) Pathological, by the nature of the disease process,
(5) Etiologic (causal)
(6) Epidemiological
 1. Topographic classification
• In the topographic classification, diseases are subdivided into
such categories as gastrointestinal disease, vascular disease,
abdominal disease, and chest disease.
• Various specializations within medicine follow such topographic
or systemic divisions, so that there are physicians who are
essentially vascular surgeons, for example, or clinicians who are
specialized in gastrointestinal disease.
• Similarly, some physicians have become specialized in chest
disease and concentrate principally on diseases of the heart and
lungs.
 2. Anatomic classification

• In the anatomic classification, disease is categorized by the

specific organ or tissue affected; hence, heart disease, liver
disease, and lung disease.
• Medical specialties such as cardiology are restricted to diseases
of a single organ, in this case the heart.
• Such a classification has its greatest use in identifying the various
kinds of disease that affect a particular organ.
• The heart is a good example to consider.
 3. Physiological classification

• The physiological classification of disease is based on the

underlying functional derangement produced by a specific
disorder.
• Included in this classification are such subclasses as respiratory
and metabolic disease. Respiratory diseases are those that
interfere with the intake and expulsion of air and the exchange
of oxygen for carbon dioxide in the lungs.
• Metabolic diseases are those in which disturbances of the body’s
chemical processes are a basic feature. Diabetes and gout are
examples.
 4. Pathological classification
• The pathological classification of disease considers the nature of
the disease process.
• Neoplastic and inflammatory disease are examples.
• Neoplastic disease includes the whole range of tumors,
particularly cancers, and their effect on human beings.
• Examples of Inflammatory diseases include: appendicitis,
cellulitis, otitis media etc
 5. Etiologic classification
• The etiologic classification of disease is based on the cause, when
known.
• This classification is particularly important and useful in the
consideration of biotic disease.
• On this basis disease might be classified as bacterial (e.g.
staphylococcal) or fungal, etc.
• Bacteria for example, cause skin infections, pneumonia, meningitis,
abscesses in the liver, and kidney infections.
• Diseases such as amoebiasis (parasitic), chicken pox (viral), tinea
capitis (fungal) and gonorrhea (bacterial) are further examples of
diseases classified by etiology.
 6. Epidemiological classification
• The epidemiological classification of disease deals with
the incidence, distribution, and control of disorders in a
population.
• To use the example of typhoid, a disease spread through
contaminated food and water, it first becomes important to
establish that the disease observed is truly caused by Salmonella
typhi, the typhoid organism.
• Once the diagnosis is established, it is important to know the
number of cases, whether the cases were scattered over the
course of a year or occurred within a short period, and what the
geographic distribution is.
COMMON MEDICAL SURGICAL CONDITIONS
ABSCESS
 Abscess
• Definition 1: An abscess is a cavity filled with pus . It contains
white blood cells, dead tissue and bacteria.
• Definition 2: localized collection of pus surrounded by inflamed
tissue
TYPES OF ABSCESS
• Abscesses can develop anywhere in the body.

i. Skin abscesses – which develop under the skin

ii. Internal abscesses – which develop inside the body, in an
organ or in the spaces between organs
iii. Incisional abscess - An incisional abscess is one that develops
as a complication secondary to a surgical incision.
• It presents as redness and warmth at the margins of the
incision with purulent drainage from it.
• If the diagnosis is uncertain, an abscess should be aspirated
with a needle, and the aspirated pus be presented for culture
and sensitivity
 Other abscesses
• There are many other types of abscess, including:
• Anorectal abscess – a build-up of pus in the rectum and anus
• Bartholin's abscess – a build-up of pus inside one of the Bartholin's
glands, which are found on each side of the opening of the vaginal
orifice.
• brain abscess – a rare but potentially life-threatening build-up of pus
inside the skull (cranium)
• Dental abscess – a build-up of pus under a tooth or in the
supporting gum and bone
• Quinsy (peritonsillar abscess) – a build-up of pus between one of
the tonsils and the wall of the throat (as complication of tonsilitis)
• spinal cord abscess – a build-up of pus around the spinal cord
Causes of abscesses

• Most abscesses are caused by a bacterial infection,

parasites, or foreign substances, but bacteria is most
common cause.
• When bacteria enter the body, the immune system sends
infection-fighting white blood cells to the affected area.
• As the white blood cells attack the bacteria, some nearby
tissues die, creating a space which then fills with pus to
form an abscess. The pus contains a mixture of dead tissue,
white blood cells and bacteria.
• Internal abscesses often develop as a complication of an existing
condition, such as an infection elsewhere in your body. For
example, if the appendix bursts as a result of appendicitis,
bacteria can spread inside the abdomen and cause an abscess to
form.
• The most common bacterial organism responsible for the
development of skin abscesses is Staphylococcus aureus
• With the emergence of methicillin-resistant Staphylococcus
aureus (MRSA), health care providers must now consider this
organism as the possible cause when a skin abscess is
encountered.
Pathophysiology:
• Upon entry of the organisms or foreign materials, Staphylococcus
aureus for example kills the local cells, resulting in the release of
cytokines.
• The cytokines trigger an inflammatory response, which draws
large numbers of white blood cells to the area and increases the
regional blood flow.
• The final structure of the abscess is an abscess wall, or capsule,
that is formed by the adjacent healthy cells in an attempt to keep
the pus from infecting neighboring structures.
• However, such encapsulation tends to prevent immune cells from
attacking bacteria in the pus, or from reaching the causative
organism or foreign object.
Signs and Symptoms of skin abscesses:

• A skin abscess often appears as a swollen, pus-filled lump

under the surface of the skin.
• Body malaise
• Other symptoms of an infection, such as a fever,
• chills.
• warmth
• redness (in the affected area)
• A boil is a common example of a skin abscess.
common signs and Symptoms of internal abscesses

• The signs and symptoms of an internal abscess can also vary

depending on exactly where in the body the abscess
develops.
• For example, a liver abscess may cause jaundice, whereas an
abscess in or near the lungs may cause a cough or shortness of
breath.
General signs and symptoms of an internal abscess can include:

• Discomfort in the area of the abscess

• Fever
• Increased sweating
• Vomiting
• Chills
• Pain or swelling in the abdomen
• Loss of appetite
• Weight loss
• Extreme tiredness (fatigue)
• Diarrhoea or constipation
Risk factors:

You’re at increased risk for this bacterial infection if you have:

• Close contact with an individual who has a staph infection,

(which is why these infections are more common in
hospitals)
• A chronic skin disease, like acne or eczema
• Diabetes
• A weakened immune system, which can be caused by
infections such as HIV
• Poor hygiene habits
 Risk factors cont..

Infected hair follicles (folliculitis)

• Infected hair follicles, or folliculitis, may cause abscesses to form
in the follicle. Follicles can become infected if the hair within the
follicle is trapped and unable to break through the skin, as can
happen after shaving.
• Trapped hair follicles are commonly known as ingrown hairs.
Ingrown hairs can set the stage for an infection. Abscesses that
are on or in a hair follicle will often contain this ingrown hair.
• Folliculitis may also occur after spending time in an inadequately
chlorinated pool or hot tub.
Investigations

• When taking medical history, ask:

• How long the abscess has been present
• If they recall any injury to that area
• What drugs one may be taking
• If they have any allergies
• If they had a fever

• Physical exam. Examine the abscess and surrounding areas.

• Take a culture or a small amount of fluid from the abscess to
test for the presence of bacteria
 Difference between cyst and abscess
CYST ABSCESS
• A cyst is a closed sac that • An abscess is a pus-filled
develops abnormally in some infection in the body caused by,
for example, bacteria or fungi.
body structure
Symptoms:
Symptoms:
• Pain, redness, and swelling and
• A cyst grows slowly and isn’t usually can cause symptoms elsewhere
painful, unless it becomes enlarged. in the body.
• When an already-formed cyst • An abscess doesn’t have to begin
as a cyst. It can form on its own.
becomes infected, it becomes an
abscess. • An abscess is infected
• Not infected.
Skin abscesses
• Some small skin abscesses may drain naturally & get better without the need
for treatment.
• For larger or persistent skin abscesses, a course of Antibiotics may be
prescribed to help clear the infection and prevent it from spreading.
Internal abscesses
• The pus usually needs to be drained from an internal abscess, either by using a
needle inserted through the skin (percutaneous abscess drainage) or with
surgery.
• The method used will depend on the size of the abscess and where it is in the
body.
• Antibiotics will usually be given at the same time, to help kill the infection and
prevent it from spreading. These may be given as orally or intravenously.
Treatment:

• A small skin abscess may drain naturally, or simply shrink,

dry up and disappear without any treatment.

• Abscesses can be treated in a number of different ways,

depending on the type of abscess and how large it is.

• The main treatment options include:

• antibiotics
• a drainage procedure
• warm compress
• Surgery
Surgery (Incision and drainage)
• If the skin abscess needs draining, the patient will have a minor
surgical operation carried out under anesthesia– usually a local
anesthetic
• During the procedure, an incision is made in the abscess, to
allow the pus to drain out. A sample of pus may also be taken for
testing.
• Once all of the pus has been removed, the resulting hole that is
left by the abscess is cleaned using sterile saline (a salt solution).
• The abscess will be left open but covered with a wound dressing,
so if any more pus is produced it can drain away easily.
• If the abscess is deep, an antiseptic dressing may be placed inside
the wound to keep it open. The procedure may leave a small scar.
Abscess five days after incision and drainage
Percutaneous drainage

• If the internal abscess is small, the surgeon may be able to

drain it using a fine needle.
• Depending on the location of the abscess, this may be carried
out using either a local or general anaesthetic.
• The surgeon may use ultrasound scans or computerised
tomography (CT) scans to help guide the needle into the right
place.
• Once the abscess has been located, the pus is drained using
the needle. A small incision may be made on the skin over
the abscess, then insert a thin plastic tube called a drainage
catheter into it.
• The catheter allows the pus to drain out into a bag and may have to
be left in place for up to a week.
• This procedure may be carried out as a day case procedure, which
means the patient may be able to go back home the same day,
although some people will need to stay in hospital for a few days.

You may need to undergo surgery if:

i. Your internal abscess is too large to be drained with a needle

ii. A needle can't get to the abscess safely
iii. Needle drainage hasn't been effective in removing all of the pus

The type of surgery will depend on the type of internal abscess and
where it is in the body.
Prevention of abscesses

• Proper hygiene is the best way to avoid infection.

• Keep cuts and wounds clean, dry, and covered to
protect them from microorganisms.
• Avoid sharing clothing, towels, razors, or bed linens with
anyone else.
• When these items get dirty, wash them separately in hot
water.
• Wash your hands well and often using soap and water for at
least 20 seconds each time. It's OK to use alcohol-based
instant hand sanitizers or wipes if you're not near any soap
and water.
CARBUNCLES AND FURUNCLES
 Carbuncles
• Definition: A carbuncle is a cluster of boils that have multiple pus
“heads.” They’re tender and painful, and cause a severe infection
which could leave a scar.
• Other names: Staph skin infection, Carbunculosis

• A carbuncle is a staph skin infection.

• Boils: A boil, also called a furuncle, begins as a painful infection of a
single hair follicle.
• So carbuncle is multiple furuncles.
Carbuncles
 Furuncle/Boils
• Definition: furuncle, begins as a painful infection of a single
hair follicle.
•Furuncles/Boils can grow to be
larger than a golf ball, and they
commonly occur on the buttocks,
face, neck, armpits and groin.
• A hair follicle is a part of the skin, which grows a hair.
• Attached inside the top of the follicle are sebaceous glands, which
are tiny sebum-
producing glands in almost all skin except on the palms, lips and
soles of the feet.

Causes:
• A carbuncle usually develops when Staphylococcus aureus
bacteria enter the hair follicles.
Entrance/Portal site:
• insect bite and broken skin make it easy for bacteria to enter the
body and cause an infection.
• This can result in boils or carbuncles (a cluster of boils) filled with
fluid and pus.
Location:
• Carbuncles are common on the back of the neck, shoulders, or
thigh. They can also appear on the face, armpits, or buttocks

Favourite environment of staph bacteria:

• The moist parts of the body are particularly susceptible to this
infection because bacteria thrive in these areas where you
sweat or experience friction.
Risk factors:
• Being in close contact with someone who has a carbuncle (the infection can
spread when people share space, materials, or devices, such as clothing)

The following factors also increase the risk of developing a carbuncle:

• Poor hygiene
• Diabetes (High levels of blood sugar, or glucose, can reduce the immune
system's ability to respond to infection.)
• a weak immune system
• Skin conditions: Psoriasis, eczema, and acne increase susceptibility.
• kidney disease (renal carbuncle may have metastasis
• Medications: Some medications weaken the immune system.
• shaving and other activities that break the skin
• Men get carbuncles more often than women. (scraps on face during shave)
Signs and Symptoms:
Boils can occur anywhere on your skin, but more likely on hair-bearing
areas, where you're most likely to sweat or experience friction. Appear
mainly on the face, back of the neck, armpits, thighs and buttocks.

Signs & symptoms include:

• A painful, red bump that starts out small and can enlarge to more
than 2 inches (5 centimeters)
• Tenderness
• Red, swollen skin around the bump
• An increase in the size of the bump over a few days as it fills with pus
• Development of a yellow-white tip that eventually ruptures
and allows the pus to drain out.
A carbuncle usually:

• Develops over several days

• Have a white or yellow center (contains pus)
• Weep, ooze, or crust
• Spread to other skin areas

Sometimes, other symptoms may occur including:

• Fatigue
• Fever
• General discomfort
• Skin itching before the carbuncle develops
Exams and Tests
• The diagnosis may base on clinical examination
• A sample of the pus may be sent to a lab to determine the
bacteria causing the infection (bacterial culture and
sensitivity).
• The test result helps determine the appropriate treatment.
Management :
• Warm compresses -
• Warn patient not to squeeze or incise the lesion
• Systemic antibiotics (cloxacillin, erythromycin)
• Bed Rest especially for genital area furuncles.
• For severe pain: codeine, morphine
• Antibiotics. Sometimes your doctor may prescribe antibiotics to
help heal severe or recurrent infections.
• For larger boils and carbuncles, treatment may include:
• Incision and drainage. (when it is fluctuant). Deep infections that
can't be completely drained may be packed with sterile gauze to
help soak up and remove additional pus.
Lifestyle and home remedies
For small boils, these measures may help the infection heal
more quickly and prevent it from spreading:
• Warm compresses. Apply a warm washcloth or compress to
the affected area several times a day, for about 10 minutes
each time. This helps the boil rupture and drain more
quickly.
• Prevent contamination. Wash your hands thoroughly after
treating a boil. Also, launder clothing, towels or compresses
that have touched the infected area.
Complications
• Rarely, bacteria from a boil or carbuncle can enter your bloodstream and
travel to other parts of your body.
• The spreading infection, commonly known as sepsis, can lead to infections
deep within your body, such as your heart (endocarditis) and bone
(osteomyelitis).

• Preventions:
• Wash your hands regularly with soap. Or use an alcohol-based hand
rub often. Careful hand-washing is your best defense against germs.
• Keep wounds covered. Keep cuts and abrasions clean and covered with
sterile, dry bandages until they heal.
• Avoid sharing personal items. Don't share towels, sheets, razors, clothing,
athletic equipment and other personal items
 Comparison: carbuncle & furuncle.
Furuncle Carbuncle
• Begins as a painful infection of a single hair • It involves a group of infected hair
follicle. follicles in one skin location.
• Also known as cluster of boils.
• Also known as boil • Is a deeper skin infection
• Not as deep as carbuncles. • Carbuncles affect the deeper layers, and
• Furuncles, affect a hair follicle and they can lead to scarring.
surrounding tissue. • Carbuncle infections tend to be deeper
and more severe
• This infection is not so deep. • They take longer to develop and to
resolve than furuncles. (often leave a
• Furuncles may go away without any scar)
intervention. May burst and heal without a
scar within 2 days to 3 weeks.
CELLULITIS
 CELLULITIS
• Inflammation of subcutaneous tissues as a result of bacterial
infection on any part of the body but mostly on lower limbs

Causative organisms
Streptococcus, staphylococus and H. influenzae after gaining
entry through bites, breaks in the skin.
Risk factors:

 Local trauma (e.g., lacerations, insect bites, wounds,

shaving)
 Skin infections such as impetigo, scabies, furuncle, tinea pedis
 Underlying skin ulcer
 Immunocompromised individuals
 Diabetes mellitus
Pathophysiology
Break on the skin followed by acute inflammatory process that
becomes chronic and may end up as an abcess

Signs and symptoms

The area is red ,hot and painful in the initial phase. It get
swollen later which is related to inflammation processes
Medical management

• Identify the port of entry

• Antibiotics – penicillins if no MRSA (methicillin resistant
staphylococcus aureus) but if any issue use
cephalosporins, erythromycin, clindamycycin for at least 7
days to prevent recurrence.
• If on limb elevate
 When to give IV not PO?
• Patients with mild infection ------> administer oral antibiotics.

• Administer IV if:
1. Systemic signs of toxicity (eg, fever >38°C, hypotension, or
sustained tachycardia)
2. Rapid progression of erythema
3. Progression of clinical findings after 48 hours of oral antibiotic
therapy
4. Inability to tolerate oral therapy
5. Proximity of the lesion to an indwelling medical device (ex:
prosthetic joint)
 Medical treatment for non-purulent cellulitis
Orals medications:
1.Clindamycin
2.Amoxicillin PLUS septrin
3.Amoxicillin PLUS doxycycline
4.Amoxicillin PLUS minocycline

Intravenous meds
5.Vancomycin
6.Oxacillin
Medical treatment for purulent cellulitis and Skin Abscesses

Start IV Rx, Switch to PO once signs of infection resolved.

Orals medications:
Clindamycin, septrin, doxycycline, minocycline

Intravenous meds
Vancomycin PLUS one of the following:
1.Ampicillin
2.Ceftriaxone + metronidazole
3.Ciprofloxacin + metronidazole
4.Levofloxacin + metronidazole
• PO options after s/s resolution:
• clindamycin, SEPTRIN, or tetracyclines (doxycycline or
minocycline)

• Duration of treatment:
• In general ----> 5 days

• Up to 14 days if:
1. Severe infection
2. Slow response to therapy
3. Immunosuppression.
Non-pharmacologic Interventions
Apply warm or, if more comfortable, cool saline
compresses to affected areas QID for 15 minutes.
Mark border of erythema with pen to monitor spread.
Elevate, rest and gently splint the affected limb.
Nursing management
Assess the patient

subjective data may include

• Pain
• Chills
• Headache
•Nausea

Objective data
Redness/tenderness Swelling
Warmth on the tisses affected
Nursing Diagnosis
Acute pain related to tissue inflammation as evidenced by
patient’s
verbalization/ body expression/ tarchycardia

Interventions
 Rate the pain by the scales
 Administer analgesics as prescribed
 Use other pain relieving measures such as elevation of limb/
rest the limb
 Impaired tissue integrity (subcutenous )related to microbial
invasion as evidenced by swelling, redness and tenderness
Interventions

• Place warm moist cloths on the swollen area

• Give antibiotics
• Administer pain relieving drugs as prescribed
• If on lower limb elevate the leg
• Monitor the progress
Complications:

1. Bacteremia
2. Endocarditis
3. Osteomyelitis
4. Sepsis
LYMPHANGITIS
 LYMPHANGITIS
• Acute inflammation of the lymphatic channels.
•Causative organisms- Hemolytic streptococus, staph aureus,
pseudomonas, fungi

Signs and symptoms

Focal point –a skin lesion or wound
Tender red streaks radiating from the wound towards nearest
lymph node
Fever, chills
General malaise
Swollen lymph nodes
Medical management

As outpatient or if severe as in patient

• Antibiotics
• Antinflammatory agents
• Analgesics
• Hot moist compressions on affected areas
• Drainage of abscess if any

Nursing management
Manage Pain, Fever, General
malaise
Lymphangitis can spread quickly, leading
to complications such as:

• Cellulitis
• Bacteremia
• Sepsis,
• Abscess
SEPTICAEMIA
 SEPTICAEMIA
• Definition: Infection in the bloodstream also refered to as
bacteremia

Causes
Results from other outbrown focal infections e.g. Lungs, urinary
system or introduced through invasive procedures
 CAUSATIVE ORGANISMS
• Staphylococcus
• Streptococcus
• Pseudomonas
• Escherichia coli (E.coli)

Pathophysiology
Entry of bacteria into the blood stream, Triggers an immune
response, inflammatory process, leading to shut down of infection
fighting system and shock then death
 CLINICAL MANIFESTATIONS
Early symptoms include:

• Fever/hyperthermia
• Rapid breathing rate (tachypnea) or shortness of breath.
• Rapid heart rate (tachycardia)
• Low blood pressure
• Anxiety
• Reduced urine output/oliguria
• Malaise
• Loss of appetite, nausea and vomiting.
As the septicaemia progresses, the symptoms become more
severe and includes:

• Change in mental status,

• Delusions
• coma.
• Red spots on the skin (petechiae) due to blood clotting
problems.
 DIAGNOSTIC TESTS

• Blood culture to detect the causative organism

• Blood gases analysis
• Complete blood count (CBC)
• Clotting studies
• CSF Culture
• Culture of any suspected skin lesions
 NURSING DIAGNOSES
Ineffective tissue perfusion related to contracted peripheral
capillaries as evidenced by pale/cold clammy skin/
tarchycardia/confusion
Hyperthermia related to increased metabolic rate as
evidenced by patient verbalization / sweating / vital sign
reading
Anxiety related to unknown outcome.
Risk for fluid volume deficit related to hyperventilation
Risk for altered nutrition: less than body requirements related
to loss of appetite.
 MANAGEMENT / TREATMENT

• Antibiotics
• Analgesics/Antipyretics
• Blood transfusion if the patient is anemic.
• Oxygen administration
• Fluid replacement
• Provide adequate nutrition
• Preventive measures for pressure ulcers.
 PREVENTION
• Can be prevented by appropriately treating the infections which
often precede it. Treat bacterial infections thoroughly to
minimize the risk of spread.
• Good personal hygiene
• Use sterile instruments during invasive procedures.
• Immunize children against Haemophilus influenza B (HIB), and
pneumonia to reduce cases of septicaemia in children.
Medical management

Investigations- Fbc, blood culture,urine culture, L/punture

Admit patient
Iv fluids
Oxygen if necessary
Broad spectrum antibiotics
BURN
S
 BURNS
• Destruction of the skin by heat leading to a loss in fuction
of the skin as a barrier

Causes
• Open fire,
• Hot liquds,
• Chemicals
• Electrical causes
Pathophysiology
• After destruction of skin there is a marked loss of fluid from the
body of about 10-20 times more through evaporation and
damage of the blood vessels.
• The trauma of the burn triggers an inflammatory response that
increases vessel permeability leading to increase in fluid loss
(both salt, water and proteins) leading to burn wound edema that
is worst in the first 72hrs
• Loss of skin barrier to microorganisms combined with the
immunosuppression leads to increased bacterial proliferation and
infection with gram +ve and later gram –ve leading to other
infections e.g pneumonia, septicemia and wound infections
Signs and symptoms
Depends with type and degree of burns

Classification

FIRST-DEGREE BURN:
• Confined exclusively to the outer surface and is not considered a
significant burn.
• No barrier functions are altered.
• The most common form is a Sunburn which heals by itself in less
than a week without scar.
Superficial Second-Degree Burn:

• Involves the entire epidermis and no more than the upper third
of the dermis.
• Rapid healing occurs in 1-2 weeks, because of the large amount
of remaining skin and good blood supply.
• Scar is uncommon.
• Initial pain is the most severe of than any other burn, as the
nerve endings of the skin are now exposed.
DEEP SECOND DEGREE BURN:

• Most of skin is destroyed except for small amount of remaining

dermis.
• The wound contains some dead tissue.
• Blood flow is compromised and a layer of dead dermis or eschar
adheres to the wound surface.
• Pain is much less as the nerves are actually destroyed by the
heat.
• Usually, one cannot distinguish a deep dermal from a full
thickness (third degree) by visualization.
• The presence of sensation to touch usually indicates the burn is
a deep partial injury.
THIRD DEGREE (FULL THICKNESS) BURN:

• Both layers of skin are completely destroyed leaving no cells to

heal.
• Any significant burn will require skin grafting.
• Small burns will heal with scar.
• Complete destruction of both layers
• High risk for infection and needs to be excised and skin grafted
4TH DEGREE

• Burns involves tissues beyond the dermis such as muscles,

tendons, bone, etc
• Note that electrical and chemical burn superficial appearance
does not show the depth and how much the underlying tissues
are destroyed
Medical management
An emergency approach

•Primary survey-

A Airway
B Breathing
C Circulation
D Disability
E Exposure
F Fluid resuscitation
• Secondary survey-mechanism of injury
• Head to toe exam- All body systems
• Burnt surface area
• Burn wound depth

Investigations
• Blood Gas Analysis
• F/hemogram
• Urea/Electrolytes/Creatinine
• LFTS
• Total Protein and Albumin
Treatment
• Fluid resuscitation
• Pain mangement
• Wound management
• Prophylactic antibiotics

Nursing management (consider the following)

• Manage according to nursing assessment (use nursing process)
• Assess Level of injury
• Assess Level of consciousness
• Assess Type of burns
• Pain asssessment
Fluid resuscitation

IV volume must be maintained following a burn in order to

provide sufficient circulation to perfuse not only the organs but
also the peripheral tissues, especially damaged skin

Iv resuscitation is appropriate for any child with a burn greater

Then 10% and 15% for TBSA for adults

Most common fluid used is ringer‘s lactate

10/22/2016 127
Fluid volume is relatively constant in proportion to the area Of
body burned. Therefore there are formulae that calculate the
approximate volume of fluid needed for the pt of a given Body
weight with a given % of the body burned

Formulas to calculate the fluid replacement

1. Parkland regime / formula (commonly used). Also known as

Baxter formula
2. Evan’s formula
3. Muir and barclay
4. Modified brook formula
39
The formula
The Parkland formula for the total fluid requirement in 24 hours is as
follows:

4ml x TBSA (%) x body weight (kg);

50% given in first eight hours;

50% given in next 16 hours.

Children receive maintenance fluid in addition, at an hourly rate of:

4ml/kg for the first 10kg of body weight plus;
2ml/kg for the second 10kg of body weight plus;
1ml/kg for >20kg of body weight.
Fluids used
Crystalloid resuscitation

1. Ringer lactate is the most commonly used crystalloid

These are as effective as colloids for maintaining intra-
-vascular volume
Less expensive

2. Hypertonic saline
it produces hyperosmolarity and hypernatremia
Reduces shift of intracellular water to extracellular space

Advantage - Include less tissue oedema

10/22/2016 130
Colloid resuscitation

Colloids are gelatinous solutions that maintain a high osmotic

pressure in the blood.

Examples of colloids are

Albumin,
Dextran,
Hydroxyethyl starch (or hetastarch),
Haemaccel
Gelofusine
10/22/2016 131
Why are Crystalloids used instead of colloids for fluid resuscitation?

• Crystalloids have small molecules, are cheap, easy to use, and

provide immediate fluid resuscitation, but may increase oedema .

• Colloids have larger molecules, cost more, and may induce allergic
reactions, blood clotting disorders, and kidney failure
Monitoring of resuscitation

The key to monitoring of resuscitation is urinary output

Output should be between 0.5ml and 1.0ml/kg/hour
If urine output is below this, the infusion rate should increase
By 50%
If still output is inadequate then a bolus of 10ml/kg given
2ml/kg/hr urinary output signals decrease in the rate of tissue
Perfusion
Haematocrit measurement is a useful tool in confirming
Suspected under or overhydration

10/22/2016 133
 Treating the burn wound

Open method
Silver sulfadiazine application without dressings commonly Used
in burns of face,head and neck.

Closed method
Dressing done to soothen and to protect the wound
To reduce the pain
As an absorbent

44
Dressings

Paraffin gauze
Hydrocolloids ( e.g duoderm)
Full-thickness and deep dermal burns need antibacterial
dressings to delay microbial colonisation prior to surgery
Tangential excision

Can be done within 48 hours with skin grafting in patients with less
than 25% burn
Usually done in deep dermal
burns
Dead dermis is removed layer by
layer Until fresh bleeding occurs
Later, skin grafting done

10/22/2016 45
Escharotomy

 Circumferential full-thickness burns to the limbs require

emergency Surgery
 The tourniquet effect of this injury is easily treated by incising the
whole length of full-thickness burns. (done avoiding major Nerves)
 Full thickness burns and deep partial-thickness burns that will
require operative treatment will need to be dressed with an
antibacterial dressing to delay the onset of colonisation of the
wound by microorganisms

46
A full-thickness burn to the upper limb with a mid-axial escharotomy.
The soot and debris have been washed off.

138
 Superficial partial thickness burns

After 24 hours after burn After 2 weeks

10/22/2016 139
Superficial partial thickness burn after 3 months
Pigment returning
10/22/2016 140
 Effects of burns
 Shock due to hypovolaemia
 Renal failure (toxins from burn)
Pulmonary oedema, resp infections, Acute resp. distress
syndrome, resp failure, Infection by staph aureus,
pseudomonas, etc leads to Septicemia
 Fungal and viral infections may also occur.
Fluid and electrolyte imbalance.
Immunosuppression predisposes to severe opportunistic
infection.
Eschar formation and its problems e.g. ischaemia when it is
circumferential. (eschar is a dry, dark scab made of dead
skin) 141
 Effects of burn (cont…..)
Inhalation burn causes pulmonary oedema, respiratory
arrest
Severe malnutrition with catabolic status,
Toxic shock syndrome: It is a life-threatening exotoxin
mediated disease caused by Staphylococcus aureus. It is
common in children, presents with rashes, myalgia,
diarrhoea, vomiting, and multiorgan failure with high
mortality
Development of contracture is a late problem. It may
lead to disability of different joints, defective hand
functions, growth retardation causing shortening etc
10/22/2016 142
.
COMPLICATIONS OF BURNS CONTRACTURES

Ectropion of eyelid ( eyelid turns outward) causing

keratitis and corneal ulcer.
Disfigurement in face.
Narrowing of mouth (microstomia).
Contracture in the neck causing restricted neck
movements.
Disability and nonfunctioning of joints due to
10/22/2016 143
 Contracture
Severe contracture at knee joint causing deformity

10/22/2016 144
 Complication of contracture

Hypertrophic scar

10/22/2016 145
 Treatment of burn contracture

• Release of contracture surgically and use of skin graft.

• Proper physiotherapy and rehabilitation is essential.

• Management of itching in the scar using antihistamines and

moisturizing creams.

10/22/2016 146
 Prevention of development of
contracture

•Joint exercise in full range during recovery period of burns

10/22/2016 147
 ASSESSEMENT OF TOTAL BODY
SURFACE AREA (TBSA) FOR BURNS
METHODS
i. By depth
ii. Rule of 9 -Estimated percentage of total body surface area (TBSA)
in the adult is arrived at by sectioning the body surface into areas
with a numerical value related to nine. . Head-9%, trunk anterior
and posterior 36%,upper limbs 18%, lower limbs 36%,
gentalia1%. Any burn with above 25% provokes a systemic
response. The patient’s palm for small burns- 1%
iii. Lund and Browder chart – allocates percentage as per the body
anatomical parts.
WOUND HEALING
 WOUND HEALING
Wound healing is a mechanism by which the body attempts to restore
the integrity of the injured part.

Factors influencing healing of a wound

• Site of the wound
• Structures involved
• Mechanism of wounding
• Type of incision
• Contamination (foreign bodies/bacteria)
• Loss of tissue on the wound
 Cont’----
Local factors -
• Vascular insufficiency (arterial or venous)
• Previous radiation

Systemic factors
• Malnutrition or vitamin and mineral deficiencies
• Disease (e.g. diabetes mellitus)
• Medications (e.g. steroids)
• Immune deficiencies [e.g. chemotherapy, acquired
immunodeficiency syndrome (AIDS)]
• Smoking
Types of wounds
• Surgical- created intentionally to attend to a pathology
• Traumatic wounds- accidental wounds e.g burns, crush, cuts etc
• Chronic – develop due to chronic conditions e.g pressure ulcers,
skin conditions, abscesses etc (more classifications exist)

Healing may occur in one of the following:

1. Healing by Primary intention

• Healing through primary intention occurs when wounds are
created aseptically, with a
minimum of tissue destruction tissue reaction.
Conditions in healing by primary intention

• Edges of an incised wound in a healthy individual are promptly

and accurately approximated.
• Contamination is held to a minimum by rigid adherence to
• aseptic technique.
• Trauma is minimal.
• No tissue loss occurs.
• On completion of closure, no dead space remains to become a
potential site of infection.
• Drainage is minimal.
 Cont---
-
2. Healing by secondary intention

• These type of wounds are characterized by tissue loss with an

inability to approximate wound edges.
• The wound heals from the inside toward the outer surface.
• In infected wounds this process allows cleaning and
dressing.
• Healing is by granulation and eventually there is scarring .
• These type of wounds include chronic , septic and traumatic
wounds
3. Healing by tertiary intention

• Occurs when approximation of wound edges is intentionally

delayed by 3 or more days after injury or surgery.
• This could be due to heavy contamination of wound or
condition of patient.
• Debridement may be done then wound closed later
Phases of wound healing
i. Hemostasis – Contraction of carpillaries to stop the bleeding

ii. Inflammatory(Reactive ) – A vascular and cellular response to

dispose off bacteria, foreign material and dead tissue.
 Leukocytes (Neutrophils, Monocytes and macrophages) increase
in number to fight bacteria in the wound area and by
phagocytosis, help to remove damaged tissues, and foreign
bodies.
 There is also an increase in platelets.
Cont,.

 The vascular response is about dilatation of blood vessels to

allow permability of exudate for supply of more oxygen, plasma
proteins and bradykinins for healing process. This causes
redness, local warmth, and swelling.
 The damaged tissue is glued together by strands of fibrin and a
thin layer of clotted blood, forming a scab. Plasma seeps to the
surface to form a dry, protective crust. This seal helps to prevent
fluid loss and bacterial invasion.
iii. Proliferative(Regenerative )
• Epithelial cells migrate and proliferate to the wound area, covering
the surface of the wound .
• Collagen synthesis, deposit and contraction of the wound occur in
this phase. Underneath the epithelium layer, granulation
continues. Epithelialization is limited to small wounds while larger
ones may require grafting.
iv. Remolding(Maturation)
• The phase starts 2-4 wks after injury and may continue for years.
• There is deposition of collagen fibres and breakdown of earlier
deposits, as well as realignment of the fibres till the scar is
strongly formed.
SHOC
K
 SHOCK

• Definition: Shock is a systemic state of low tissue perfusion,

which is inadequate for normal cellular respiration.

• **With insufficient delivery of oxygen and glucose, cells

switch from aerobic to anaerobic metabolism. If perfusion is
not restored in a timely fashion, cell death occurs.
Classification of shock
• Hypovolaemic- caused by a reduced circulating volume.
• Cardiogenic- failure of the heart to pump out
enough blood to the tissues.
• Obstructive- there is a reduction in preload
because of
mechanical obstruction of cardiac filling e.g
pulmonary /air embolism
•Distributive- include septic, neurogenic, anaphylactic and
Signs and symptoms of shock
General S&S

• Confusion and weakness

• Low blood pressure
• Decreased urine output
• Tachycardia (a fast heart rate)
• Rapid, shallow breathing
• Cold, clammy skin
• Rapid, weak pulse
• Dizziness or fainting
• Weakness
Stages of shock

i) Compensatory stage
• The body tries to compensate for the low blood volume by:
Contactibility of heart
Peripheral vasoconstriction
Reduced urine output

Signs and symptoms of this stage may include:

• Normal BP, tarchycardia, hypervetilation,raised pH level,confusion
or anxiety, cold clammy skin. etc
ii) Progressive
stage

Characterised
by:
Failed cardiac ability of meet the demand and myocardial
ischemia and hypoperfusion of all organs
Systemic vasodilation as a result of release of chemical
mediators into blood stream
Signs and symptoms in this stage:
• Slow heart rate of below 60 beat /min
• Low BP below 90mmhg
• Rapid and shallow respirations
• Crackles due to fluid in the lungs
• Unconcious state
• Stress ulcers may lead to intestinal bleeding
• Signs of acute renal failure
• Raised bilirubin levels
• Low ph
• Jaudice
• Tissue oedema
iii) Irreversible stage

• Most of the organs are damaged beyond repair and death

is likely.
• Signs and symptoms remain as those of the progresive
phase.
MANAGEMENT OF SHOCK

• Depending on the type or the cause of the shock, treatments differ.

• In general, fluid resuscitation (giving a large amount of fluid to raise
blood pressure quickly) with an IV in the ambulance or emergency
room is the first-line treatment for all types of shock.
• The doctors or nurses will also administer medications such as
epinephrine, norepinephrine, or dopamine to the fluids to try to
raise a patient's blood pressure to ensure blood flow to the vital
organs.
• Tests (for example, blood tests, EKGs) will determine the underlying
cause of the shock and uncover the severity of the patient's illness.
• Nutritional needs
 Rx
• Septic shock is treated with prompt administration of antibiotics
depending on the source and type of underlying infection.
• These patients are often dehydrated and require large amounts
of fluids to increase and maintain blood pressure.

• Anaphylactic shock is treated with diphenhydramine (Benadryl),

epinephrine, steroid medications methylprednisolone
 Rx
• Cardiogenic shock is treated by identifying and treating the
underlying cause.
• A patient with a heart attack may require cardiac catheterization to
unblock an artery.
• A patient with congestive heart failure may need medications to
support and increase the force of the heart's beat. In severe or
prolonged cases, a heart transplant may be the only treatment.

• Hypovolemic shock is treated with fluids (saline) in minor cases, but

may require multiple blood transfusions in severe cases. The
underlying cause of the bleeding must also be identified and
corrected.
• Neurogenic shock is the most difficult to treat.
• Damage to the spinal cord is often irreversible and causes
problems with the natural regulatory functions of the body.
• Besides fluid monitoring:
 Immobilization (keeping the spine from moving),
 Anti-inflammatory drugs such as steroids
 Sometimes surgery are the main parts of
treatment.
Nursing management

• In CCU setting
•Monitoring – hemodynamic monitoring( ECG, ABGs, renal
function tests Etc)
• Cordination of Collaborative management
• Administration of drugs and fluids
• Family involvement
• Documentation of care
FLUID AND ELECTROLYTE
IMBALANCE
(60% of body wt is made up of fluids )
 FLUID AND ELECTROLYTE IMBALANCE
Fluid compartments
 Extra cellular
 Intravascular
 interstitial
 Intracellular (within
the cells)
 Transcellular –(cerebrospinal, pericardial, synovial,
intraocular, and Pleural spaces)
 Third space- abnormal amount of fluid trapped in
peritonial, plueral or other tissues.
• To maintain homeostasis the body regulates the output to match
the input by the renal system, adrenal glands, pituitary glands
( renin, angiotensin II, aldosterone and ADH)
A. FLUID IMBALANCE
CAUSES

Fluid volume deficit: caused by:

• Trauma- burns, excessive bleeding
• Diseases such as diarrheal, systemic dieases leading to third
spacing. Eg. Ascites, pleural effusion, edema, internal heamorrhage
etc
• Insufficient intake
• Renal disease
• Congestive cardiac failure
• Diabetis mellitus,
• Diuretic overuse
Effects of imbalances

• Low fluid volume - poor cardiac output- poor tissue perfusion -

shock
• Poor cell metabolism
• Reduced skin targor, muscle clamps, dizziness, hypotension,
peripheral constriction, reduced renal output, sunken eyes,
nausea, lethargy, confusion , acute brain failure and ureamia
Management

• Fluid replacement – oral or intravenous

• Transfusion – whole or plasma depending with what was lost
• Over a litre – give colloids e.g dextran hemacel etc
• Treat underlying conditions

Fluid overload is rare in a functioning renal system but could

be related to other sytemic illnesses e.g CCF.
 Fluid volume excess: caused by
Administration of Excessive amounts of hypo- osmolar
fluids- e.g 0.45% Saline/ 5% Dextrose in water.
Excessive intake of fluid
Inability to excrete excess water(Renal)
Poor sodium intake
Use of diuretics
Loss of sodium and water & replaced only by water
Fluid overload i.e., water and sodium retention.
Stressful conditions cause increase in release of ADH and
aldosterone which increases water reabsorption from renal
tubules.
Clinical manifestations

1. Cerebral Edema- Behavioral changes,

headache Inc. ICP, & pupillary changes

2. Vital Signs alterations-

• Bradycardia
• Increased systolic B.P.
• Increased respiration
• Pulse?
Clinical manifestations
Others-
 Nausea
 Projectile vomiting
 Irritability
 Disorientation
 Confusion
 Drowsiness
 Decreased co-ordination
 Increase in weight
 Convulsions.
 Clinical manifestations
• Peripheral or generalized oedema
• Circulatory overload causes:
 Bounding pulse
 Distended neck and peripheral vein
 Cough , dyspnoea , orthopenea
 Crackles in lungs
 Increased urine output
• Ascites
• Altered mental status and anxiety
Lab findings

Serum sodium level

Decrease hematocrit value.

 Management
1. Medication: Diuretics- commonly used to treat fluid volume
excess.
• They inhibit sodium and water reabsorption,
increasing urine output.

 LOOP DIURETICS: Furosemide [Lasix].

 THIAZIDE LIKE DIURETICS: Chlorothiazide [Diuril].
 POTASSIUM SPARING DIURETICS: Spironolactone [Aldactone]
2. Fluid Management:
Fluid intake may be restricted to client having fluid volume
excess.

3. Dietary management:
Because sodium retention is a primary cause of fluid volume excess,
so sodium restriction diet is often prescribed.

Check- Reflexes and pupillary response.

Monitor I/V therapy hourly.
Check weight daily.
Safety measures- if client shows behavioral changes.
 NURSING MANAGEMENT
Assessment

Assess early signs of cerebral edema and Increased

intracranial pressure.
Assess absence of thirst, Decreased hematocrit, & Serum
Sodium levels.
 NURSING
1.
DIAGNOSIS
Excess fluid volume:
Assess vital signs, heart sounds and BP.
Assess for the presence of edema.
Obtain weight daily at same time of day.
Provide oral hygiene 2hourly.
Teach client about sodium restricted diet.
Report significant changes in serum electrolytes.
Administer oral fluids cautiously
Administer diuretics as prescribed.
2. Risk for impaired skin integrity :
Assess skin in pressure area and over bony prominences.
Change position of client 2hourly.
Provide alternating pressure mattress, foot cradle, heel
protectors, to reduce pressure on tissues.

3. Risk for impaired gas exchange:

Auscultate lungs for presence of wheezes and crackles.
Place in fowler’s position if having dyspnea or orthopenea.
Monitor oxygen saturation level and ABG’s.
Administer oxygen as indicated.
 B. ELECTROLYTE IMBALANCE
Electrolyte functions:
• Transmission of neural impulses
• Muscle contraction and majorly the cardiac
muscle( myocardium)
• Body fluid movement & retention- intra /extracellular
compartments
• Acid-base balance

**In cases of imbalance of electrolytes then the transmission of

impulses and muscle contraction is affected
Most important electrolytes
• Na- extra cellular-135 - 142 mmol/l
• K- intracellular 3.5 - 5.5mmol/l
• Ca- extra cellular-2.15 – 2.5 mmol/L
• Mg- intracellular-0.65 – 1.25mmol/l
• Cl – extra cellular-97–107 mmol/L
• Phosphorus- intracellular-0.87–1.45mmol/l
• Hydrogen carbonate- extracellular- 110-
124mmol/l

Imbalances may occur when there is loss or

retention as a result of illnesses.
Hyponatremia

- Sodium level lower than 135mmol/l

Causes:
• Diarrhea,
• Vomiting,
• Excessive sweating,
• Impaired kidneys,
• Addison’s disease (insufficient production of aldosterone),
• Overuse of diuretics,
• Excess water retention
Effects
• Blood volume is low,
• Hypotention abdominal muscle cramps,
• Nausea,
• Fatigue,
• In severe cases: confusion, muscle twitching and convulsions.

Management
Normal diet with salt if not severe, Iv N/s (restriction of fluids if
causes
related to fluid retention), salt tablets,
• Close monitoring of serum levels
• Management of systemic conditions
Hypernatremia
Caused by:
• Reduced water intake,
• Cushings syndrome,
• Fasting,
• Vomiting,
• Burns,
• Hypertonic solutions such as 4.5% N/S etc
Effects

• Thirst,
• Nausea and vomiting,
• Confusion
• Lethargy and weakness,
• Hallucination in severe cases
• Peripheral and pulmonary edema,
• Postural hypotension
Management

• Treat the cause e.g. Give water or fluids with low sodium
(hypotonic solution) with care not to bring down the levels so fast
which may lead to brain edema.
• Promptly manage systemic causes.
• Monitor the serum sodium levels
 Cont’--
Hyperkalemia -
Potassium levels above 5.5 mmol/l

Causes:
• Hemolysis due to trauma,
• Renal failure,
• Acidosis and physiologically after exercises,
• Iatrogenic causes (treatment related, potassium chloride,
heparin, ACE inhibitors, nsaids, and potassium-sparing diuretics)
Effects
• Muscle weakness, at times paralysis,
• ECG changes such as narrow T waves and a shortened QT interval.
• Nausea,
• Diarrhea.
Management

• Monitor Serum potassium levels and ECG changes

• Restriction of dietary potassium for patients using potasium
retention diuretics
• Calcium gluconate intravenously (Ca salts antagonize the
effects of potassium in cells)
• Continous monitoring of patient on ECG
Hypokalemia-
Serum potasium below 3.5mmol/l
Causes
• Diarrhea
• Vomiting,
• Ileostomies,
• Metabolic alkalosis,
• Prolonged intestinal suctioning,
• Hyperaldostronism,
• Potassium-losing diuretics,
• Elderly,
Signs and symptoms

• Fatigue ,
• Anorexia,
• Nausea,
• Vomiting,
• Muscle weakness,
• Leg cramps,
• Paresthesias (numbness and tingling),
• ECG changes - flat T wave
Management
• If not severe, dietary measures could elevate the levels
• If severe ( below 2mmol/l) then intravenous infusions with
potasium is administered with care and should be at 10-
20mmol/hr and not more
• ECG monitoring
• Serum potasium monitoring

Read and make notes on hypo/hypercalcemia,

hypo/hypermagnesia and hyper/hypo
phosphatemia**
ACID-BASE
IMBALANCE
 Acid-Base Imbalance
• The imbalance is measured as per the serum pH level which is
basically a measure of acidity.
• Normal serum pH is 7.35-7.45

Types of imbalances
Acidosis- a state when the PH level in the blood is below 7.3 and
the alkaline buffers eg. Sodium bicarbonate has been used up.
Alkalosis – the ph level of blood is above 7.5 and the acidic reserve is
used up.
The buffer system, kidneys and lungs are unable to contain the
situation of regulating the pH therefore the 2 states develop.
Clinically, the following scenarios are significant:

a) Metabolic acidosis
b) Metabolic alkalosis
c) Respiratory acidosis
d) Respiratory alkalosis
a) Metabolic acidosis
• Can be acute or chronic.
• A state where there is low pH and low bicarbonate in serum

Causes
• Ketoacidosis,
• Lactic acidosis,
• Late phase of salicylate poisoning,
• Uremia
• Methanol toxicity
Signs and symptoms

• Headache,
• Confusion,
• Drowsiness,
• Increased respiratory rate and depth,
• Nausea, and vomiting,
• Peripheral vasodilation
• Decreased cardiac output occur when the pH falls below 7.
Management

• Blood gas analysis- ph level,

• Sodium bicarbonate level,
• Co2 and potasium levels.
• ECG monitoring
• Sodium bicarbonate is administered in low pH
below 7 treat the underlying cause
• Calcium gluconate is administered in chronic metabolic acidosis to
prevent tetany
b) Metabolic alkalosis
Characterized by increased pH of above 7.5 and an increased
sodium bicarbonate level

Causes
• Gastric fluid loss through vomiting or suctioning,
• Hyperaldosteronism
• Cushing’s syndrome,
• Hypokalemia,
• Long term diuretic therapy,
• Overuse of antacids,
• Chronic ingestion of milk and calcium carbonate.
Signs and symptoms
• Tingling of fingers,
• Depressed respiratory rate,
• Decreased motility,
• Hypertonic muscles ,
• Hypokalemia

Management
• Blood gas analysis – level of ph is increased, the bicarbonate is
high, the CO2 is high since the pt is hypoventilitating
• Restoration of fluid volume
• In order for kidneys to excrete bicarbonate, NaCl is given
• Treat the underlying condition.
c) Respiratory acidosis
•Could be either acute or chronic
•Characterized by pH less than 7.35

Causes
• Conditions that lead to retention of co2 e,g.
• Acute pulmonary edema,
• Obstruction by foreign object,
• Atelectasis,
• Pneumothorax,
• Overdose of sedatives,
• Severe pneumonia
• Acute respiratory distress syndrome
Signs and symptoms

• High pulse rate,

• Increased respiratory rate,
• Increased blood pressure,
• Mental cloudiness,
• Feeling of fullness in the head.
• Cerebrovascular vasodilation and increased cerebral blood
flow,
• Increased intracranial pressure (icp)
Management

• Blood gas analysis

• Improve ventilation by positioning or removal of obstructing
body, put pt on mechanical ventilator if very severe. Otherwise
administer oxygen via mask
• Give medications which could address the cause e.g antibiotics,
bronchodilator etc.
• Give fluids
• Monitor on ECG
d) Respiratory alkalosis
A state when the arterial pH is greater than 7.45.

Causes
• Extreme anxiety,
• Hypoxemia,
• The early phase of salicylate intoxication,
• Gram-negative bacteremia,
• Poor setting of mechanical ventilator machine
Signs and symptoms

• Lightheadedness - decreased cerebral blood flow,

• Inability to concentrate,
• Numbness and tingling from decreased calcium ionization,
• Tinnitus,
• Loss of consciousness,
• Tachycardia
Management

• Investigations: Blood U&E- low potasium ,decreased

phosphate, hypercalcemia
• Relieve anxiety by reassurannce or sedation
• Treat underlying cause.
END