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MEDICAL SURGICAL MANAGEMENT

IDEAL MANAGEMENT ACTUAL MANAGEMENT


TYPE OF MANAGEMENT
A. Laboratory Indications
Examinations
Complete Blood Count (CBC) To determine your general
health status; to screen
for, diagnose, or monitor Done 11/20/2018
any one of a variety of
diseases and conditions
that affect blood cells,
such as anemia, infection,
inflammation, bleeding
disorder or cancer
NURSING RESPONSIBILITIES (CBC):
BEFORE:
-The nurse will carry out the doctor's order and tell the patient that he/she will have a
blood test or extraction.
DURING:
-Together with the midtech, tell the patient about the procedure and explain what the
procedure is to done.
AFTER:
-Document or record the procedure that has been done.
Prothrombin Time (PT) A prothrombin time (PT) is
a test used to help detect
and diagnose a bleeding
disorder or excessive
clotting disorder; the
international normalized
ratio (INR) is calculated
Not Done
from a PT result and is
used to monitor how well
the blood-thinning
medication
(anticoagulant) warfarin
(Coumadin®) is working to
prevent blood clots.
NURSING RESPONSIBILITIES (PT)
BEFORE:
-Explain to the patient that the plasma thrombin time test determines whether blood
clots normally.
-Notify the laboratory and physician of drugs the patient is taking that may affect test
results; it may be necessary to restrict them.
-Tell the patient that the test requires a blood sample.
-Explain who will perform the venipuncture and when.
-Explain to the patient that he may feel slight discomfort from the tourniquet and the
needle puncture.
-Inform the patient that he need not to restrict food and fluids.
DURING:
-Perform a venipuncture and collect the sample in a 3 to 4.5 ml siliconized tube.
-Completely fill the collection tube and invert it gently several times to mix the sample
and the anticoagulant thoroughly. If the tube isn’t filled to the correct volume, an excess
of citrate appears in the sample.
-To prevent hemolysis, avoid excessive probing during venipuncture and rough handling
of the sample.
-Immediately put the sample on ice and send it to the laboratory.
AFTER:
-Apply pressure to the venipuncture site until bleeding has stopped.
-If a hematoma develops at the venipuncture site, apply direct pressure. If the hematoma
is large, monitor pulses distal to the phlebotomy site.
-Tell the patient that he may resume any medication that was discontinued before the
test is ordered.
Partial Thromboplastin Time As part of an investigation
(PTT) of a possible bleeding
disorder or blood clot
(thrombotic episode); to
monitor unfractionated
Not Done
(standard) heparin
anticoagulant therapy; as
part of screening before
surgery or other invasive
procedure
NURSING RESPONSIBILITIES (PT)
BEFORE:
-Explain to the patient the procedure
-Notify the laboratory and physician of drugs the patient is taking that may affect test
results; it may be necessary to restrict them.
-Tell the patient that the test requires a blood sample.
-Explain who will perform the venipuncture and when.
-Explain to the patient that he may feel slight discomfort from the tourniquet and the
needle puncture.
-Inform the patient that he need not to restrict food and fluids.
DURING:
-Perform a venipuncture and collect the sample in a 3 to 4.5 ml siliconized tube.
-Completely fill the collection tube and invert it gently several times to mix the sample
and the anticoagulant thoroughly. If the tube isn’t filled to the correct volume, an excess
of citrate appears in the sample.
-To prevent hemolysis, avoid excessive probing during venipuncture and rough handling
of the sample.
-Immediately put the sample on ice and send it to the laboratory.
AFTER:
-Apply pressure to the venipuncture site until bleeding has stopped.
-If a hematoma develops at the venipuncture site, apply direct pressure. If the hematoma
is large, monitor pulses distal to the phlebotomy site.
-Tell the patient that he may resume any medication that was discontinued before the
test is ordered.
Glucose Test To determine if your blood
glucose level is within a
healthy range; to screen Done 11/20/2018 and
for and diagnose diabetes 11/21/2018
and prediabetes and to
monitor for high blood
glucose (hyperglycemia) or
low blood glucose
(hypoglycemia); to check
for glucose in your urine
NURSING RESPONSIBILITIES (GLUCOSE TEST)
-perform the test according to manufacturers’ instructions and local guidelines
-perform the test unsupervised, at the request of a registered nurse
-document and report the result according to local guidelines and procedures
-recognize and follow local quality assurance procedure, including disposal of sharps
-recognize hypoglycemia and be able to administer glucose
-Understand the normal range of glycaemia and report any readings outside this range to
the appropriate person.
Electrolytes To detect a problem with
the body's electrolyte Done 11/20/2018
balance
NURSING RESPONSIBILITIES (Electrolytes):
BEFORE:
-The nurse will carry out the doctor's order and tell the patient that he/she will have a
blood test or extraction.
DURING:
-Together with the midtech, tell the patient about the procedure and explain what the
procedure is to done.
AFTER:
-Document or record the procedure that has been done.
Cholesterol, -The test for cholesterol
measures total cholesterol
that is carried in the blood
HDL, by lipoproteins.
-To determine your risk of
Done 11/20/2018
LDL developing heart disease
-To determine your risk of
developing heart disease;
to monitor effectiveness of
lipid-lowering therapy
NURSING RESPONSIBILITIES (Cholesterol):
BEFORE:
-The nurse will carry out the doctor's order and tell the patient that he/she will have a
blood test or extraction.
-Hold drugs that could increase the serum level for 12 hours before the blood is drawn,
with the physician's permission.
-Explain to the patient and family what is considered a normal serum cholesterol level
and the effects of an elevated cholesterol
DURING:
-Together with the midtech, tell the patient about the procedure and explain what the
procedure is to done.
AFTER:
-Document or record the procedure that has been done.
B. Diagnostic Indications
Procedures
Chest x-ray An x-ray of the heart and
(CXR) lungs is a standard test for Done 11/20/2018
patients with acute
medical problems.
Abnormalities may alert
your doctor to important
problems such as
pneumonia or heart
failure.
CT scan A CT scan uses X-rays to
(CAT Scan, Computed axial produce a 3-dimensional
tomography) image of your head. A CT
- Tests that View the Brain, scan can be used to
Done 11/20/2018
Skull, or Spinal Cord diagnose ischemic stroke,
hemorrhagic stroke, and
other problems of the
brain and brain stem.
MRI scan An MRI uses magnetic
(Magnetic resonance imaging, fields to produce a 3-
MR) dimensional image of your
- Tests that View the Brain, head. The MR scan shows
Skull, or Spinal Cord the brain and spinal cord
in more detail than CT. MR
can be used to diagnose
ischemic stroke,
hemorrhagic stroke, and
other problems involving
the brain, brain stem, and
spinal cord
Carotid doppler Painless ultrasound waves
(Carotid duplex, Carotid are used to take a picture
ultrasound) of the carotid arteries in
- Tests that View the Blood your neck, and to show the
Vessels that Supply the Brain blood flowing to your
brain. This test can show if
your carotid artery is
narrowed by
arteriosclerosis
(cholesterol deposition).
Transcranial doppler Ultrasound waves are
(TCD) used to measure blood
- Tests that View the Blood flow in some of the
Vessels that Supply the Brain arteries in your brain.
MRA This is a special type of
(Magnetic resonance MRI scan (see above)
angiogram) which can be used to see
- Tests that View the Blood the blood vessels in your
Vessels that Supply the Brain neck or brain.
Cerebral arteriogram A catheter is inserted in an
(Cerebral angiogram, Digital artery in your arm or leg,
subtraction angiography, and a special dye is
[DSA]) injected into the blood
- Tests that View the Blood vessels leading to your
Vessels that Supply the Brain brain. X-ray images show
any abnormalities of the
blood vessels, including
narrowing, blockage, or
malformations (such as
aneurysms or arterio-
venous malformations).
Cerebral arteriogram is a
more difficult test than
carotid doppler or MRA,
but the results are the
most accurate.
NURSING RESPONSIBILITIES (Diagnostic Imaging/Scanning Procedures)
BEFORE:
-Patient may be asked not to eat or drink anything for 4 - 6 hours before the scan.
-Asked patient if they are afraid of close spaces or claustrophobia and inform the doctor.
Patient may be given a medicine to help them feel sleepy and less anxious, or the doctor
may suggest an "open" scan, in which the machine is not as close to the body.
-Before the test, asked the patient if they have the following:
Artificial heart valves
Brain aneurysm clips
Heart defibrillator or pacemaker
Inner ear (cochlear) implants
Kidney disease or dialysis (patient may not be able to receive contrast)
Recently placed artificial joints
Vascular stents
Worked with sheet metal in the past (patient may need tests to check for metal pieces in
their eyes)
-Asked patients to remove the following:
>Items such as jewelry, watches, credit cards, and hearing aids - may be damaged.
>Pens, pocketknives, and eyeglasses - may fly across the room.
Pins, hairpins, metal zippers, and similar metallic items - can distort the images.
>Removable dental work should be taken out just before the scan. Because the scan
contains strong magnets, metal objects are not allowed into the room with the scanner.
>It is important to inform the health care provider of any pregnancy or suspected
pregnancy prior to the procedure.
DURING:
-Patient will be asked to remain perfectly still during the time the imaging takes place, but
between sequences some minor movement may be allowed. The Scan Technologist will
advise accordingly.
-When scan procedure begins, patient may breathe normally, however, for certain
examinations it may be necessary for you to hold your breath for a short period of time.
-Monitoring is indicated to patients who are great potential for change in physiologic
status (respiratory rate, oxygen saturation, temperature, heart rate and blood pressure)
during the procedure or whenever a patient requires observations of vital physiologic
parameters due to an underlying health problem.
AFTER:
-Monitoring is imperative to patients who are using sedative or anesthesia to ensure
patient safety
C. Treatment
There are steps that can be taken to prevent a stroke and
drugs that can be given in the event of a stroke.
●Preventive measures involve identifying risk factors such
as hypertension, atrial fibrillation, and diabetes so they can
be treated and taking medications such as anticoagulants
(e.g., warfarin) and antiplatelet agents (e.g., aspirin,
clopidogrel) if someone is at risk or have had an ischemic
stroke. Certain procedures may be performed to remove
blockages from blood vessels.
●If a person is having a stroke, immediate action is
necessary. A drug called tissue plasminogen activator (tPA),
a "clot-buster," can be given for ischemic stroke within 3
hours of the start of symptoms, which may reduce the
chances of long-term disability.
●Surgical procedures may be recommended for those who
have had a hemorrhagic stroke to prevent known
aneurysms from rupturing or to remove abnormal vessels.
●For those who have disabilities as a result of a stroke, such
as weakness or paralysis on one side of the body and
speech or memory problems, rehabilitation can be helpful.
D. Medication
Drug type Class Summary
Thrombolytic more accurately,
fibrinolytic—agents
convert entrapped
plasminogen to plasmin
and initiate local
fibrinolysis by binding to
fibrin in a clot.
Anticonvulsants, Other Generally, agents used for
treating recurrent
convulsive seizures are
also used in patients with
seizures after stroke.
Benzodiazepines, typically
diazepam and lorazepam,
are the first-line drugs for
ongoing seizures.
Antiplatelet Agents Although antiplatelet
agents have proved useful
for preventing recurrent
stroke or stroke after
transient ischemic attacks
(TIAs), efficacy in the
treatment of acute
ischemic stroke has not
been demonstrated. Early
aspirin therapy is
recommended within 48
hours of the onset of
symptoms but should be
delayed for at least 24
hours after rt-PA
administration. Aspirin
should not be considered
as an alternative to
intravenous fibrinolysis or
other therapies aimed at
improving outcomes after
stroke.
Anticoagulants, Hematologic Anticoagulants such as
warfarin are used for
secondary stroke
prevention.
Analgesics, Other Hyperthermia in acute
stroke is potentially
harmful and should be
treated. Agents with
potential bleeding risk
should be avoided, if
possible.
Beta Blockers, Alpha Activity Optimal blood pressure
management in acute
stroke remains subject to
some debate. Treatment
parameters depend
largely on whether the
patient is a candidate for
fibrinolytic therapy. While
the target blood pressures
may differ, the
therapeutic agents are
primarily the same.
ACE Inhibitors Angiotensin-converting
enzyme (ACE) inhibitors
prevent the conversion of
angiotensin I to
angiotensin II, a potent
vasoconstrictor, resulting
in lower aldosterone
secretion.
Calcium Channel Blockers A calcium channel blocker,
inhibits calcium ion influx
into vascular smooth
muscle and myocardium.
Optimal blood pressure
management in acute
stroke remains subject to
some debate.
Vasodilators Vasodilators lower blood
pressure through direct
vasodilation and
relaxation of the vascular
smooth muscle. They are
used more for blood
pressure lowering in
severe or refractory
situations and should be
used with caution.
E. Dietary
Ischemic stroke is associated with vascular dementia;
stroke survivors have almost double the rate of dementia
than the general population. Patients may be helped by
following the Mediterranean-DASH Intervention for
Neurodegenerative Delay (MIND) diet, according to a 2018
study. The diet may help prevent dementia as well.
The MIND diet recommends:
● at least three servings of whole grains a day,
● six servings of green leafy vegetables,
● two servings of berries a week,
● and it encourages regular consumption of other
vegetables, fish, poultry, beans, and nuts,
● As well, it recommends olive oil as the primary oil and
alcohol once per day.
● The diet restricts intake of red meats, fast foods, cheese,
desserts, and butter.
F. Activity/Exercise
The promotion of physical activity in stroke survivors
should emphasize:
● low- to moderate-intensity aerobic activity,
● muscle-strengthening activity,
● reduction of sedentary behavior,
● and risk management for secondary prevention of stroke.
G. Surgery
Name Description
Mechanical Embolectomy is a minimally invasive
surgery with significant
benefits. Basically, a tiny
plastic tube is inserted
into an artery within the
upper part of the leg.
Using X-ray technology, a
surgeon then guides the
tube into the obstructed
artery of the brain. Once
the tube is in place, the
surgeon will then use a
device that is slipped
inside the tube and
transferred to the
blockage, where it will be
flushed out or reclaimed.
Hemicraniectomy is a major surgical
operation during which a
section (half or greater) of
the patient’s skull is
removed to allow the
swelling in the brain to
increase past the
limitation of the cranium.
Carotid Angioplasty and Stent Carotid Angioplasty is a
procedure that opens and
reduces congestion within
the carotid artery—the
major artery which allows
blood flow to the brain. In
this operation, a small
balloon is inserted and
inflated into the carotid
artery, widening the
pathway and freeing it
from excessive buildup.
Along with this procedure,
a stent (metal coil) is also
used to keep the artery
open, preventing it from
narrowing again once the
balloon is in place.
Carotid Endarterectomy traditional carotid surgery,
this operation completely
eradicates any blockage
from it and expands it. A
surgeon will remove any
plaque on the arterial
walls so that blood flows
smoothly to the brain. In
the same respect as the
angioplasty, this
procedure can be done for
both stroke prevention
and stroke management.
Cerebral Revascularization— is a procedure where a
also known as Bypass Surgery new blood supply is
connected to the part of
the brain that is cut off
from blood flow. A
surgeon will essentially
take another artery from
the scalp and reposition
its pathway to restore
blood to the brain. Once
blood flow is reinstalled,
the brain will operate
under normal conditions,
clearing away prior
symptoms. For patients
who suffer from mini-
strokes or TIAs (Transient
Ischemic Attacks), this
operation can be a good
preventative choice.
Aneurysm Clipping and Coil >An Aneurysm Clipping is
Embolization a procedure that cuts off
the aneurysm to blood
vessels in the brain,
helping to prohibit any
more blood leaking from
the aneurysm itself. A
surgeon will make a small
cut inside the brain,
installing a tiny clamp to
the base of the aneurysm.
Typically, this operation
requires a patient to stay
in the Intensive Care Unit
(ICU) for a few days
afterward.

>As for a Coil


Embolization, this
procedure is much like the
Mechanical Embolectomy
mentioned earlier. A
surgeon will insert a small
plastic tube into an artery
in the leg, transferring it to
the location of the
aneurysm. Once it is in
place, a coil is transferred
through the tube directly
into the aneurysm. This
process will cause a blood
clot to form, halting blood
flow through the
aneurysm, which keeps it
from bursting.

NURSING RESPONSIBILITIES (Surgery)


Pre-operative care:
-Educating the patient on any pre-operative instructions leading up the surgery
-Ensuring that all pre-operatives tests and bloodwork are completed
-Ensuring that the patient’s chart is comprehensive and all paperwork is completed and
signed
-Settling patient into the room and prepping the patient for surgery
-Interviewing and assessing the patient on the day of the surgery

Intra-operative care:
-Scrub nurse: Assists the physician by selecting and passing instruments and supplies
during the surgery
-Circulating nurse: Manages the overall operating room as to ensure a safe and
comfortable operating room environment
-RN first assistant: Directly assists the surgeon

Post-operative care:
-Monitoring the patient and addressing any signs of distress, infection, shock, bleeding, or
other problems
-Dressing wounds
-Assisting patients by helping them deal with the effects of the surgical procedure or by
providing pain management
-Instructing the patient and patient’s family on at-home, post-operative care (discharge
orders)
-Ensuring that the patient is comfortable
H. Rehabilitation/Referral
Stroke rehabilitation involves consultations to a variety of
specialists. Specialists who can help with physical needs
include:
●Physicians. Your primary care doctor — as well as
neurologists and specialists in physical medicine and
rehabilitation — can guide your care and help prevent
complications. These physicians can also help you to gain
and maintain healthy lifestyle behaviors to avoid another
stroke.
●Rehabilitation nurses. Nurses who specialize in caring for
people with limitations to activities can help you
incorporate the skills you learn into your daily routines.
Rehabilitation nurses can also offer options for managing
bowel and bladder complications of a stroke.
●Physical therapists. These therapists help you relearn
movements such as walking and keeping your balance.
●Occupational therapists. These therapists help you relearn
hand and arm use for daily skills such as bathing, tying your
shoes or buttoning your shirt. Occupational therapists can
also address swallowing and cognitive issues, and safety in
your home.

Specialists who focus on cognitive, emotional and


vocational skills include:
●Speech and language pathologists. These specialists help
improve your language skills and ability to swallow. Speech
and language pathologists can also work with you to
develop tools to address memory, thinking and
communication problems.
●Social workers. Social workers help connect you to
financial resources, plan for new living arrangements if
necessary and identify community resources.
●Psychologists. These specialists assess your thinking skills
and help address your mental and emotional health
concerns.
●Therapeutic recreation specialists. These specialists help
you resume activities and roles you enjoyed before your
stroke, including hobbies and community participation.
●Vocational counselors. These specialists help you address
return-to-work issues if that is a goal.
DISCHARGE PLAN

Instruct the patient to take the medication as


prescribed by the doctor,
MEDICATION Follow strictly the course regimen of the
medication and taking on the right time and
right dose
Advise the patient to have complete bed rest
until strength is regained. Have the
patient turn side to side every 2 hours to
Environment/ Exercise prevent bed sores.
Have ROM exercises to enhance body
function
Insist physical therapy for improving strength
and walking.
Therapy/Treatment Should undergo speech therapy to learn
talking and swallowing

Instruct the client how to have a healthy


lifestyle, right foods to eat and foods to
avoid.
Health Teaching Instruct the family members how to prepare
low sodium and low fat diet
Instruct the patient's family to provide a safe
environment

Advise the patient's family to follow up


Out-Patient checkup as physician's ordered

Advise the patient's family to eat nutritious


foods such as fruits and vegetables
Diet Instruct the patient to have a proper diet that
she can tolerate. Such as fruits, to
help promote wellness.

Encourage the patient to pray daily and ask


Spiritual for God's continuous healing.
CONCLUSION
The global burden of CVA is increasing with frequent lasting disability, but holistic care
plans and biopsychosocial models may reduce rehabilitation time and retain dignity of the patient
by being involved in their recovery. CVA is a sudden crisis; patients are often fearful of the future
and left feeling trapped within a non-responsive body. Being a nursing staff is in a unique position
to aid with mobility and continence by encouragement. It is of great help to discuss with patients
about their personal goals for recovery and pass this information to the stroke team allowing
patient-orientated goals to be devised; and to aiding in the bereavement process CVA victims
suffer. For a few, mobility will never fully return but with changes to the environment around
them, they can retain some independence and return to a meaningful life.

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