MARKING GUIDE/ANSWERS

SECTION A: MCQ’S
1.B 6. D 11. D 16. D 21. B
2.A 7. D 12. D 17. A 22. B
3.D 8. D 13. C 18. A 23. D
4.C 9. D 14. D 19. A 24. A
5.D 10. D 15. B 20. B 25. B

SECTION B: ANSWER
a) Pneumonia is an infection that inflames the air sacs in one or both lungs. The air sacs
may fill with fluid or pus (purulent material), causing cough with phlegm or pus,
fever, chills, and difficulty breathing
b) - Bacteria. The most common cause of bacterial pneumonia is Streptococcus
pneumoniae. This type of pneumonia can occur on its own or after you've had a cold
or the flu. It may affect one part (lobe) of the lung, a condition called lobar
pneumonia.

Bacteria-like organisms. Mycoplasma pneumoniae also can cause pneumonia. It

typically produces milder symptoms than do other types of pneumonia. Walking
pneumonia is an informal name given to this type of pneumonia, which typically isn't
severe enough to require bed rest.

Fungi. This type of pneumonia is most common in people with chronic health
problems or weakened immune systems, and in people who have inhaled large doses
of the organisms. The fungi that cause it can be found in soil or bird droppings and
vary depending upon geographic location.

Viruses, including COVID-19. Some of the viruses that cause colds and the flu can
cause pneumonia. Viruses are the most common cause of pneumonia in children
younger than 5 years. Viral pneumonia is usually mild. But in some cases it can
become very serious. Coronavirus 2019 (COVID-19) may cause pneumonia, which
can become severe.

c) Signs and symptoms of pneumonia may include:

- Chest pain when you breathe or cough
- Confusion or changes in mental awareness (in adults age 65 and older)
- Cough, which may produce phlegm
- Fatigue
- Fever, sweating and shaking chills
- Lower than normal body temperature (in adults older than age 65 and people with
weak immune systems)
- Nausea, vomiting or diarrhea
- Shortness of breath

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2a) A chronic disorder of carbohydrate, protein and fat metabolism resulting from insulin
deficiency or abnormality in the use of insulin

b) – Polyuria, Polydipsia, Polyphagia

c) – Insulin maintains normal blood glucose levels by facilitating cellular glucose

uptake, regulating carbohydrate, lipid and protein metabolism and promoting cell
division and growth through its mitogenic effects.

- Glucagon counteracts the actions of insulin by stimulating hepatic glucose

production and thereby increases blood glucose levels.

d) - Eat healthy food low in fats and calories. Focus on fruits, vegetables and whole
grain

- Get more physical activity

-Advice patient to come for regular check up

- Stop the consumption of alcohol and stop smoking.

c) - Having a blood relative with asthma, such as a parent or sibling

Having another allergic condition, such as atopic dermatitis — which causes red,
itchy skin or hay fever which causes a runny nose, congestion and itchy eyes

Being overweight

Being a smoker

Exposure to secondhand smoke

Exposure to exhaust fumes or other types of pollution

Exposure to occupational triggers, such as chemicals used in farming, hairdressing

and manufacturing

3)-Control your blood pressure. High blood pressure (hypertension) can lead to serious
conditions such as stroke, cardiovascular disease and kidney failure. In many cases, you can
lower your blood pressure or maintain a healthy level by getting regular exercise;
maintaining a healthy weight; eating a diet rich in fresh fruits, vegetables and low-fat dairy
products; and limiting salt and alcohol.
-Watch your blood cholesterol. Cholesterol is one of several types of fats essential to good
health. But too much cholesterol can be too much of a good thing. Higher than normal
cholesterol levels can cause fatty deposits to form in your arteries, impeding blood flow and
increasing your risk of vascular disease.

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-But lifestyle changes can often keep your cholesterol levels low. Lifestyle changes may
include limiting fats (especially saturated fats); eating more fiber, fish, and fresh fruits and
vegetables; exercising regularly; stopping smoking; and drinking in moderation.
-Don't smoke. If you smoke and can't quit on your own, talk to your doctor about strategies
or programs to help you break a smoking habit. Smoking can increase your risk of
cardiovascular disease. Also avoid secondhand smoke.

SECTION C: ANSWER

1a) LOOP COLOSTOMY

Have 2 orifices the active and the none-active orifices respectively. The active orifice
is that which fecal materials is discharge, while the non- active orifice leads distally toward
the growth. Usually only mucus is discharge from this opening
A loop of the colon is brought out via an abdominal incision and securely held in position by
a glass rod connected to the rubber tubing
TERMINAL COLOSTOMY (END COLOSTOMY)
This has only one active orifice since the bowel below it usually the rectum has been
removed surgically. More often the colostomy is open as the last step in the operation and
covered with colostomy disposable bag. This bag collects fecal matter directly and minimizes
the spread of infection from the fecal matter.

b) NURSING CARE PLAN OF MR SCOT WITH AND END COLOSTOMY

POSTOPERATIVELY TILL DISCHARGE FROM THE HOSPITAL

Colostomy is the opening of some portion of the colon onto the abdominal due to any
condition where the rectum or anus is nonfunctional because of disease, a birth defect or a
traumatic condition. In the case of Mr Scot it is due to cancer the level of the descending
colon where the after part is removed surgically and the health colon brought out to serve as
an artificial anus for life and the stump toward the rectum is left unfunctional

 ASSESSMENT OF MR SCOT
 Name: Mr Scot
 Age: 55years
 Occupation: business
 Medical diagnosis: cancer at the level of the descending colon
 Surgical intervention: end colostomy (sigmoid colostomy)

Nursing problems

- Impaired airways due to the effect of anesthesia

- Risk of skin broke down due to the stoma and it discharges
- Disturbed sleep patterns
- Pain
- Risk of constipation, deficient fluid volume
- Lack of knowledge on his condition

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 Nursing Priorities

1. Assist patient/SO in psychosocial adjustment.

2. Prevent complications.
3. Support independence in self-care.
4. Provide information about procedure/prognosis, treatment needs, potential
complications, and community resources.

Discharge Goals

1. Adjusting to perceived/actual changes.

2. Complications prevented/minimized.
3. Self-care needs met by self/with assistance depending on specific situation.
4. Procedure/prognosis, therapeutic regimen, potential complications understood and
sources of support identified.
5. Plan in place to meet needs after discharge.

Nursing Diagnosis1

 Skin Integrity, risk for impaired due to Absence of sphincter at stoma or

Character/flow of effluent and flatus from stoma or Reaction to product/chemicals;
improper fitting/care of appliance/skin

Possibly evidenced by

 Not applicable. A risk diagnosis is not evidenced by signs and symptoms, as the
problem has not occurred and nursing interventions are directed at prevention.

Desired Outcomes

 Maintain skin integrity around stoma.

 Identify individual risk factors.
 Demonstrate behaviors/techniques to promote healing/prevent skin breakdown.

Nursing Interventions Rationale

Inspect stoma and peristomal skin area with each Monitors healing process and
pouch change. Note irritation, bruises (dark, effectiveness of appliances and identifies
bluish color), rashes areas of concern, need for further
evaluation and intervention. Early
identification of stomal necrosis or
ischemia or fungal infection (from
changes in normal bowel flora) provides
for timely interventions to prevent serious
complications. Stoma should be red and
moist. Ulcerated areas on stoma may be
from a pouch opening that is too small or
a faceplate that cuts into stoma. In patients
with an ileostomy, the effluent is rich in

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Nursing Interventions Rationale

enzymes, increasing the likelihood of skin

irritation. In patient with a colostomy, skin
care is not as great a concern because the
enzymes are no longer present in the
effluent.

Clean with warm water and pat dry. Use soap

only if area is covered with sticky stool. If paste Maintaining a clean and dry area helps
has collected on the skin, let it dry, then peel it prevent skin breakdown.
off.

As postoperative edema resolves (during

first 6 wk), the stoma shrinks and size of
Measure stoma periodically: at least weekly for
appliance must be altered to ensure proper
first 6 wk, then once a month for 6 mo. Measure
fit so that effluent is collected as it flows
both width and length of stoma.
from the ostomy and contact with the skin
is prevented.

Prevents trauma to the stoma tissue and

Verify that opening on adhesive backing of pouch protects the peristomal skin. Adequate
is at least 1⁄16 to 1⁄8 in (2–3 mm) larger than the adhesive area prevents the skin barrier
base of the stoma, with adequate adhesiveness left wafer from being too tight. Note: Too
to apply pouch. tight a fit may cause stomal edema or
stenosis.

A transparent appliance during first 4–6

wk allows easy observation of stoma
Use a transparent, odor-proof drainable pouch.
without necessity of removing
pouch/irritating skin.

Protects skin from pouch adhesive,

enhances adhesiveness of pouch, and
Apply appropriate skin barrier: hydrocolloid facilitates removal of pouch when
wafer, karaya gun, extended-wear skin barrier, or necessary. Note: Sigmoid colostomy may
similar products. not require use of a skin barrier once stool
becomes formed and elimination is
regulated through irrigation.

Frequent pouch changes are irritating to

the skin and should be avoided. Emptying
Empty, irrigate, and cleanse ostomy pouch on a and rinsing the pouch with the proper
routine basis, using appropriate equipment. solution not only removes bacteria and
odor-causing stool and flatus but also
deodorizes the pouch.

Support surrounding skin when gently removing Prevents tissue irritation or destruction
appliance. Apply adhesive removers as indicated,

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Nursing Interventions Rationale

then wash thoroughly. associated with “pulling” pouch off.

Indicative of effluent leakage with

Investigate reports of burning, itching, or
peristomal irritation, or possibly Candida
blistering around stoma.
infection, requiring intervention.

Evaluate adhesive product and appliance fit on Provides opportunity for problem solving.
ongoing basis. Determines need for further intervention.

Helpful in choosing products appropriate

for patient’s particular rehabilitation
Consult with certified wound, ostomy, continence
needs, including type of ostomy,
nurse.
physical/mental status, abilities to handle
self-care, and financial resources.

Assists in healing if peristomal irritation

persists and/or fungal infection
Apply corticosteroid aerosol spray and prescribed
develops. Note: These products can have
antifungal powder as indicated.
potent side effects and should be used
sparingly.

Nursing Diagnosis2

 Body Image, disturbed body image related to

 Biophysical: presence of stoma; loss of control of bowel elimination

 Psychosocial: altered body structure
 Disease process and associated treatment regimen, e.g., cancer, colitis Possibly
evidenced by

 Verbalization of change in body image, fear of rejection/reaction of others, and

negative feelings about body
 Actual change in structure and/or function (ostomy)
 Not touching/looking at stoma, refusal to participate in care

Desired Outcomes

 Verbalize acceptance of self in situation, incorporating change into self-concept

without negating self-esteem.
 Demonstrate beginning acceptance by viewing/touching stoma and participating in
self-care.
 Verbalize feelings about stoma/illness; begin to deal constructively with situation.

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Nursing Interventions Rationale

Ascertain whether support and counseling Provides information about patient’s/SO’s

were initiated when the possibility and/or level of knowledge and anxiety about
necessity of ostomy was first discussed. individual situation.

Encourage patient/SO to verbalize feelings Helps patient realize that feelings are not
regarding the ostomy. Acknowledge unusual and that feeling guilty about them is
normality of feelings of anger, depression, not necessary or helpful. Patient needs to
and grief over loss. Discuss daily “ups and recognize feelings before they can be dealt
downs” that can occur. with effectively.

Patient may find it easier to accept or deal

with an ostomy done to correct chronic or
long-term disease than for traumatic injury,
even if ostomy is only temporary. Also,
Review reason for surgery and future
patient who will be undergoing a second
expectations.
procedure (to convert ostomy to a continent or
anal reservoir) may possibly encounter less
severe self-image problems because body
function eventually will be “more normal.”

Note behaviors of withdrawal, increased Suggestive of problems in adjustment that

dependency, manipulation, or non may require further evaluation and more
involvement in care. extensive therapy.

Although integration of stoma into body

Provide opportunities for patient/SO to view image can take months or even years, looking
and touch stoma, using the moment to point at the stoma and hearing comments (made in a
out positive signs of healing, normal normal, matter-of-fact manner) can help
appearance, and so forth. Remind patient that patient with this acceptance. Touching stoma
it will take time to adjust, both physically and reassures patient/SO that it is not fragile and
emotionally. that slight movements of stoma actually
reflect normal peristalsis.

Provide opportunity for patient to deal with Independence in self-care helps improve self-
ostomy through participation in self-care. confidence and acceptance of situation.

Promotes sense of control and gives message

Plan/schedule care activities with patient. that patient can handle situation, enhancing
self-concept.

Assists patient and SO to accept body changes

Maintain positive approach during care and feel all right about self. Anger is most
activities, avoiding expressions of disdain or often directed at the situation and lack of
revulsion. Do not take angry expressions of control individual has over what has happened
patient and SO personally. (powerlessness), not with the individual
caregiver.

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Nursing Interventions Rationale

A person who is living with an ostomy can be

a good support system/role model. Helps
Ascertain patient’s desire to visit with a
reinforce teaching (shared experiences) and
person with an ostomy. Make arrangements
facilitates acceptance of change as patient
for visit, if desired.
realizes “life does go on” and can be relatively
normal.

Nursing Diagnosis 3

Acute Pain May be related to

 Physical factors: e.g., disruption of skin/tissues (incisions/drains)

 Biological: activity of disease process (cancer, trauma)
 Psychological factors: e.g., fear, anxiety

Possibly evidenced by

 Reports of pain, self-focusing

 Guarding/distraction behaviors, restlessness
 Autonomic responses, e.g., changes in vital signs

Desired Outcomes

 Verbalize that pain is relieved/controlled.

 Display relief of pain, able to sleep/rest appropriately
 Demonstrate use of relaxation skills and general comfort measures as indicated for
individual situation.

Nursing Interventions Rationale

Helps evaluate degree of discomfort and

effectiveness of analgesia or may reveal
developing complications. Because abdominal
pain usually subsides gradually by the third or
Assess pain, noting location, characteristics,
fourth postoperative day, continued or
intensity (0–10 scale).
increasing pain may reflect delayed healing or
peristomal skin irritation. Note: Pain in anal
area associated with abdominal-perineal
resection may persist for months.

Encourage patient to verbalize concerns.

Active-listen these concerns, and provide Reduction of anxiety/fear can promote
support by acceptance, remaining with relaxation or comfort.
patient, and giving appropriate information.

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Nursing Interventions Rationale

Provide comfort measures, e.g., mouth care, Prevents drying of oral mucosa and associated
back rub, repositioning (use proper support discomfort. Reduces muscle tension,
measures as needed). Assure patient that promotes relaxation, and may enhance coping
position change will not injure stoma. abilities.

Encourage use of relaxation techniques, e.g., Helps patient rest more effectively and
guided imagery, visualization. Provide refocuses attention, thereby reducing pain and
diversional activities. discomfort.

Reduces muscle/joint stiffness. Ambulation

returns organs to normal position and
promotes return of usual level of
Assist with ROM exercises and encourage functioning. Note: Presence of edema,
early ambulation. Avoid prolonged sitting packing, and drains (if perineal resection has
position. been done) increases discomfort and creates a
sense of needing to defecate. Ambulation and
frequent position changes reduce perineal
pressure.

Investigate and report abdominal muscle

Suggestive of peritoneal inflammation, which
rigidity, involuntary guarding, and rebound
requires prompt medical intervention.
tenderness.

Administer medication as indicated, e.g., Relieves pain, enhances comfort, and

narcotics, analgesics, patient-controlled promotes rest. PCA may be more beneficial,
analgesia (PCA). especially following anal-perineal repair.

Relieves local discomfort, reduces edema, and

Provide sitz baths.
promotes healing of perineal wound.

Apply/monitor effects of transcutaneous Cutaneous stimulation may be used to block

electrical nerve stimulator (TENS) unit. transmission of pain stimulus.

Nursing Diagnosis 4

Risk for Imbalanced Nutrition: Less Than Body Requirements Risk factors may include

 Prolonged anorexia/altered intake preoperatively

 Hypermetabolic state (preoperative inflammatory disease; healing process)
 Presence of diarrhea/altered absorption
 Restriction of bulk and residue-containing foods

Desired Outcomes

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  Maintain weight/demonstrate progressive weight gain toward goal with normalization
of laboratory values and be free of signs of malnutrition.
 Plan diet to meet nutritional needs/limit GI disturbances.

Nursing Interventions Rationale

Identifies deficiencies/needs to aid in choice

Obtain a thorough nutritional assessment.
of interventions.

Return of intestinal function indicates

Auscultate bowel sounds.
readiness to resume oral intake.

Reduces incidence of abdominal cramps,

Resume solid foods slowly.
nausea.

Sensitivity to certain foods is not uncommon

Identify odor-causing foods (e.g., cabbage,
following intestinal surgery. Patient can
fish, beans) and temporarily restrict from diet.
experiment with food several times before
Gradually reintroduce one food at a time.
determining whether it is creating a problem.

Recommend patient increase use of yogurt, May help prevent gas and decrease odor
buttermilk, and acidophilus preparations. formation.

Suggest patient with ileostomy limit prunes,

These products increase ileal effluent.
dates, stewed apricots, strawberries, grapes,
Digestion of cellulose requires colon bacteria
bananas, cabbage family, beans, and avoid
that are no longer present.
foods high in cellulose, e.g., peanuts.

Drinking through a straw, snoring, anxiety,

smoking, ill-fitting dentures, and gulping
Discuss mechanics of swallowed air as a
down food increase the production of flatus.
factor in the formation of flatus and some
Too much flatus not only necessitates
ways patient can exercise control.
frequent emptying, but also can cause leakage
from too much pressure within the pouch.

Nursing Diagnosis 5

8. Disturbed Sleep Pattern May be related to

 External factors: necessity of ostomy care, excessive flatus/ostomy effluent

 Internal factors: psychological stress, fear of leakage of pouch/injury to stoma

Possibly evidenced by

 Verbalizations of interrupted sleep, not feeling well rested

 Changes in behavior, e.g., irritability, listlessness/lethargy

Desired Outcomes

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  Sleep/rest between disturbances.
 Report increased sense of well-being and feeling rested.

Nursing Interventions Rationale

Patient is more apt to be tolerant of

Explain necessity to monitor intestinal
disturbances by staff if he or she understands
function in early postoperative period.
the reasons for or importance of care.

Provide necessary pouching system. Empty Excessive flatus can occur despite
pouch before retiring and on a pre-agreed interventions. Emptying on a regular schedule
schedule. minimizes threat of leakage.

Let patient know that stoma will not be Helps the patient to rest better if he is secure
injured when sleeping. about stoma and ostomy function.

Caffeine may delay patient’s falling asleep

Restrict intake of caffeine containing foods or and interfere with REM (rapid eye movement)
fluid. sleep, resulting in patient not feeling well
rested.

Support continuation of usual bedtime rituals. Promotes relaxation and readiness for sleep.

Determine cause of excessive flatus or Identification of cause enables institution of

effluent. Confer with dietitian regarding corrective measures that may promote
restriction of foods if diet-related. sleep/rest.

Pain can interfere with patient’s ability to fall

or remain asleep. Timely medication can
Administer analgesics, sedatives at bedtime as enhance rest and sleep during initial
indicated postoperative period. Note: Pain pathways in
the brain lie near the sleep center and may
contribute to wakefulness.

Nursing Diagnosis 6

Risk for Constipation or Diarrhea

Risk factors may include

 Placement of ostomy in descending or sigmoid colon

 Inadequate diet/fluid intake

Desired Outcomes

 Establish an elimination pattern suitable to physical needs and lifestyle with effluent
of appropriate amount and consistency.
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Nursing Interventions Rationale

Assists in formulation of a timely or effective

Ascertain patient’s previous bowel habits and
irrigating schedule for patient with a
lifestyle.
colostomy, if appropriate.

Postoperative paralytic and/or adynamic ileus

usually resolves within 48–72 hr, and
ileostomy should begin draining within 12–24
Investigate delayed onset or absence of hr. Delay may indicate persistent ileus or
effluent. Auscultate bowel sounds. stomal obstruction, which may occur
postoperatively because of edema, improperly
fitting pouch (too tight), prolapse, or stenosis
of the stoma.

Although the small intestine eventually begins

Inform patient with an ileostomy that initially to take on water-absorbing functions to permit
the effluent is liquid. If constipation occurs, it a more semi solid, pasty discharge,
should be reported to enterostomal nurse or constipation may indicate an obstruction.
physician. Absence of stool requires emergency medical
attention.

Adequate intake of fiber and roughage

Review dietary pattern and amount, type of
provides bulk, and fluid is an important factor
fluid intake.
in determining the consistency of the stool.

Review physiology of the colon and discuss

This knowledge helps patient understand
irrigation management of sigmoid ostomy, if
individual care needs.
appropriate.

Irrigations may be done on a daily basis if

Demonstrate use of irrigation equipment per appropriate, although there are differing views
institution policy or under guidance of on this practice. Many believe cleaning the
physician or certified wound, ostomy, bowel on a regular basis is helpful. Others
continence nurse. believe that this interferes with normal
functioning.

Instruct patient in the use of closed-end pouch

or a patch, dressing or Band-Aid when Enables patient to feel more comfortable
irrigation is successful and the sigmoid socially and is less expensive than regular
colostomy effluent becomes more ostomy pouches.
manageable, with stool expelled every 24 hr.

Rehabilitation can be facilitated by

Involve patient in care of the ostomy on an
encouraging patient independence and
increasing basis.
control.

Instruct in use of TENS unit if indicated. Electrical stimulation has been used in some
patients to stimulate peristalsis and relieve

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Nursing Interventions Rationale

postoperative ileus.

Nursing Diagnosis7

 Knowledge, deficient regarding condition, prognosis, treatment, self-care, and

discharge needs

May be related to

 Lack of exposure/recall information misinterpretation

 Unfamiliarity with information resources

Possibly evidenced by

 Questions; statement of misconception/misinformation

 Inaccurate follow-through of instruction/performance of ostomy care
 Inappropriate or exaggerated behaviors (e.g., hostile, agitated, apathetic, withdrawal)

Desired Outcomes

 Verbalize understanding of condition/disease process, prognosis, and potential

complications.

 Verbalize understanding of therapeutic needs.

 Correctly perform necessary procedures, explain reasons for the action.
 Initiate necessary lifestyle changes.

Nursing Interventions Rationale

These factors affect patient’s ability to master

Evaluate patient’s emotional, cognitive, and
care-tasks and willingness to assume
physical capabilities.
responsibility for ostomy care.

Provides references for obtaining support,

Include written, picture (photo, video, equipment, and additional information after
Internet) learning resources. discharge to support patient efforts for
independence in self-care.

Review anatomy, physiology, and Provides knowledge base from which patient
implications of surgical intervention. Discuss can make informed choices, and offers an
future expectations, including anticipated opportunity to clarify misconceptions
changes in character of effluent. regarding individual situation.

Instruct patient/SO in stomal care. Allot time Promotes positive management and reduces

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Nursing Interventions Rationale

for return demonstrations and provide positive risk of improper ostomy care and
feedback for efforts. development of complications.

Loss of normal colon function of conserving

Recommend increased fluid intake during
water and electrolytes can lead to dehydration
warm weather months.
and constipation.

Salt can increase ileal output, potentiating risk

of dehydration and increasing frequency of
Discuss possible need to decrease salt intake.
ostomy care needs and/or patient’s
inconvenience.

Loss of colon function altering fluid and

Identify symptoms of electrolyte depletion:
electrolyte absorption may result in sodium or
anorexia, abdominal muscle cramps, feelings
potassium deficits requiring dietary correction
of faintness or “cold” in arms, legs, general
with foods and fluids high in sodium
fatigue, weakness, bloating, decreased
(bouillon, Gatorade) or potassium (orange
sensations in arms or legs.
juice, prunes, tomatoes, bananas, Gatorade).

Discuss need for periodic evaluation and Depending on portion and amount of bowel
administration of supplemental vitamins and resected, lack of absorption may cause
minerals as appropriate. deficiencies.

Stress importance of chewing food well,

adequate intake of fluids with or following Reduces risk of bowel obstruction, especially
meals, only moderate use of high-fiber foods, in patient with ileostomy.
avoidance of cellulose.

These foods may be restricted or eliminated,

Review foods that may be a source of flatus.
based on individual reaction, for better
For example: carbonated drinks, beans, beer,
ostomy control, or it may be necessary to
cabbages, onions, fish and highly seasoned
empty the pouch more frequently if they are
food.
ingested.

Identify foods associated with diarrhea, such

Promotes more even effluent and better
as green beans, broccoli, highly seasoned
control of evacuations.
foods.

Recommend foods used to manage

Proper management can prevent or minimize
constipation (bran, celery, raw fruits), and
problems of constipation.
discuss importance of increased fluid intake.

Discuss resumption of presurgery level of With a little planning, patient should be able
activity. Suggest emptying the ostomy to manage same degree of activity as
appliance before leaving home and carrying a previously enjoyed and in some cases increase
fanny pack with fresh supplies. Recommend activity level. A cummerbund can provide
resources for obtaining attractive appliances both physical and psychological support when
and decorative cummerbunds as appropriate. patient is involved in activities such as tennis

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Nursing Interventions Rationale

and swimming.

“Homecoming depression” may occur, lasting

Talk about the possibility of sleep
for months after surgery, requiring patience
disturbance, anorexia, loss of interest in usual
and support and ongoing evaluation as patient
activities.
adjusts to living with a stoma.

Presence of ostomy may alter rate and extent

of absorption of oral medications and increase
Explain necessity of notifying healthcare risk of drug-related complications, e.g.,
providers and pharmacists of type of ostomy diarrhea or constipation or peristomal
and avoidance of sustained-release excoriation. Liquid, chewable, or injectable
medications. forms of medication are preferred for patients
with ileostomy to maximize absorption of
drug.

Patient with an ostomy has two key problems:

altered disintegration and absorption of oral
Counsel patient concerning medication use
drugs and unusual or pronounced adverse
and problems associated with altered bowel
effects. Some of the medications that these
function. Refer to pharmacist for teaching
patients may respond to differently include
and/or advice as appropriate.
laxatives, salicylates, H2receptor antagonists,
antibiotics, and diuretics.

Discuss effect of medications on effluent, i.e.,

Understanding decreases anxiety regarding
changes in color, odor, consistency of stool,
intestinal function and enhances independence
and need to observe for drug residue
in self-care.
indicating incomplete absorption

Monitoring of clinical symptoms and serum

Stress necessity of close monitoring of
blood levels is indicated because of altered
chronic health conditions requiring routine
drug absorption requiring periodic dosage
oral medications.
adjustments.

1) a) Definition: Acute rheumatic heart disease is an acute inflammatory condition of the

heart due to damage from rheumatic fever that may involve the pericardium,
myocardium or the lining of the heart (endocardium) including the valves resulting in
scar formation distortion and stenosis of the valves

b) Rheumatic heart disease is caused by beta hemolytic streptococcus bacteria

following a rheumatic fever followed by a strep sore throat after a lapse of 7 – 21 days

c)Following a rheumatic fever which is a general infection that affect the heart
causing rheumatic endocarditis, myocarditis or pericarditis, joints are also affected
causing a non- suppurative arthritis. Rheumatic endocarditis is an inflammation of the
lining of the heart affecting particularly the valves of the heart resulting in swelling
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 and distortion of the valves. Due to the beta hemolytic streptococci bacteria effect on
the heart, characteristic lesions called vegetations occur on the valves as a result of the
inflammation. These vegetative lesions consist of small clots or thrombi which look
like a small roll of small beats on the valves. In contrast to the vegetations which
occur in bacteria endocarditis, there is rarely break off of these vegetative lesions to
travel in the circulation to cause embolism. Inflammation of the heart muscle
(myocarditis) in the acute stage of the disease is usually evident by unduly rapid and
occasional irregular pulse. Death in the acute stage of this condition is usually due to
failure of the heart. When the pericardium is affected it becomes dry or wet in the
severe cases and a large pericardial effusion may pressed on the heart causing severe
embarrassment to an already damage part

d) Clinical manifestations
a. Onset is often precedent by a streptococci sore throat
b. Symptoms depend on the extend and type of heart part damage
c. General malaise with high temperature and heavy sweating
d. Characteristic fleeting joint pain
e. Very rapid pulse rate and heart murmurs heard on auscultation showing signs
of heart involvement
f. Painful and tender fibrous nodules (rheumatic nodules0 occurring around the
joints and tendons

e) Medical and Nursing Management

The management of acute rheumatic heart disease fever is geared toward the reduction of
inflammation

g. Anti- inflammatory drugs e.g. prednisolone

h. Aspirin has a dramatic relieve on joint pains
i. Antibiotics e-g penicillin injections for the start of the treatment e.g.
benzathine benzyl penicillin

Nursing Management

o keep patient on complete bed rest with everything done for the patient i.e. feeding,
bathing and others
o position patient in the fowlers or semi fowlers position
o the nurse should be kind and persuasive to achieve the patients calm in bed
o the nurse should wrap the swollen and painful joints in a warm cotton wool cloth to
relieve pain
o use a bed cradle to take-off weight of bedding from the painful joints
o ensure the environment is quiet and airy to encourage complete bed rest

2) a) Congestive Heart Failure (CHF): which is a condition in which the heart's function
as a pump is inadequate to meet the body's needs.

 b) disease. Coronary (CAD), a disease of the arteries that supply blood and oxygen to
the heart, causes decreased blood flow to the heart muscle. If the arteries become
blocked or severely narrowed, the heart becomes starved for oxygen and nutrients.

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  Heart attack. A heart attack occurs when a coronary artery becomes suddenly blocked,
stopping the flow of blood to the heart muscle. A heart attack damages the heart
muscle, resulting in a scarred area that does not function properly.
 Cardiomyopathy. Damage to the heart muscle from causes other than artery or blood
flow problems, such as from infections or alcohol or drug abuse.
 Conditions that overwork the heart. Conditions including high blood pressure,
valve disease, thyroid disease, kidney disease, diabetes, or heart defects present at
birth can all cause heart failure. In addition, heart failure can occur when several
diseases or conditions are present at once.

 Viral infections of the heart can lead to inflammation of the muscular layer of the
heart and subsequently contribute to the development of heart failure. Heart damage
can predispose a person to develop heart failure later in life and has many causes
including systemic viral infections (e.g., HIV), chemotherapeutic agents such as
daunorubicin and trastuzumab.
 Acute decompensation: Chronic stable heart failure may easily decompensate. This
most commonly results from an intercurrent illness (such as pneumonia), myocardial
infarction (a heart attack), abnormal heart rhythms, uncontrolled hypertension, or a
patient's failure to maintain a fluid restriction, diet, or medication.
 Other well recognized factors that may worsen CHF include the following: anemia
and hyperthyroidism which place additional strain on the heart muscle, excessive fluid
or salt intake, and medication that causes fluid retention such as NSAIDs and
thiazolidinediones. NSAIDs in general increase the risk twofold.
 Medications: A number of medications may cause or worsen the disease. This
includes NSAIDS, a number of anesthetic agents such as ketamine,
thiazolidinediones, a number of cancer medications, salbutamol, tamsulosin among
others
 Valve conditions: heart valves regulate blood flow through the heart by opening and
closing to let blood in and out of the chambers. Valves that don’t open and close
correctly may force the ventricles to work harder to pump blood. This can be a result
of a heart infection or defect.

c) Three Classes of Drugs in The Treatment Regime

1)Angiotensin-converting enzyme inhibitors (ACE inhibitors) open up narrowed blood

vessels to improve blood flow. Vasodilators are another option if you cannot tolerate ACE
inhibitors. Examples of ACE include,benazepril (Lotensin),captopril (Capoten), enalapril
(Vasotec),ramipril (Altace), moexipril (Univasc) etc

ACE inhibitors shouldn’t be taken with the following medications, as they may cause an
adverse reaction:

 Thiazide diuretics can cause an additional decrease in blood pressure.

 Potassium-sparing diuretics, such as triamterene (Dyrenium), eplerenone (Inspra), and
spironolactone (Aldactone), can cause potassium build-up in the blood. This may lead
to abnormal heart rhythms.
 Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, aspirin, and
naproxen, can cause sodium and water retention. This may reduce the ACE inhibitors
effect on the blood pressure.

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Beta-blockers can reduce blood pressure and slow a rapid heart rhythm.

This may be achieved with:, acebutolol (Sectral), atenolol (Tenormin), bisoprolol (Zebeta),
carteolol (Cartrol), esmolol (Brevibloc), metoprolol (Lopressor), nadolol (Corgard), nebivolol
(Bystolic), propranolol (Inderal LA)

blockers shouldn’t be taken with the following medications, as they may cause an adverse
reaction:

 Antiarrhythmic medications, such as amiodarone (Nexterone), can increase

cardiovascular effects, including reduced blood pressure and slowed heart rate.
 Antihypertensive medications, such as lisinopril (Zestril), candesartan (Atacand), and
amlodipine (Norvasc), may also increase the likelihood of cardiovascular effects.
 Albuterol’s (AccuNeb) effects of bronchodilation may be amplified by beta-blockers.
 Fentora (Fentanyl) may cause low blood pressure.
 Antipsychotics, such as thioridazine (Mellaril), may also cause low blood pressure.
 Clonidine (Catapres) may cause high blood pressure.

Diuretics reduce the body’s fluid content. CHF can cause the body to retain more fluid than
it should.

 Thiazide diuretics, which cause blood vessels to widen and help the body remove
any extra fluid. Examples include metolazone (Zaroxolyn), indapamide (Lozol), and
hydrochlorothiazide (Microzide).
 Loop diuretics, which cause the kidneys to produce more urine. This helps remove
excess fluid from your body. Examples include furosemide (Lasix), ethacrynic acid
(Edecrin), and torsemide (Demadex).
 Potassium-sparing diuretics, which help get rid of fluids and sodium while still
retaining potassium. Examples include triamterene (Dyrenium), eplerenone (Inspra),
and spironolactone (Aldactone).

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