Nursing Path

CARING is the essence of NURSING. -Jean Watson

Nursing Path

Knowing is not enough, we must APPLY. Willing is not enough, we must DO. -Bruce Lee

Nursing Path

Treat the patient as a whole, not just the hole in the patient.

Nursing Path

Success is not final. Failure is not fatal. It is the courage to continue that counts. -Winston Churchill

Nursing Path

A problem is a chance for you to do your best. -Duke Ellington

Brain Abscess

  • A brain abscess is a collection of infectious material within the tissue of the brain.
  • Bacteria are the most common causative organisms. An abscess can result from intra-cranial surgery, penetrating head injury, or tongue piercing.
  • Organisms causing brain abscess may reach the brain by hematologic spread from the lungs, gums, tongue, or heart, or from a wound or intra-abdominal infection. It can be a complication in patients whoseimmune systems have been suppressed through therapy or disease.

  • To prevent brain abscess, otitis media, mastoiditis, rhinosinusitis, dental infections, and systemic infections should be treated promptly.
Clinical Manifestations
  • Generally, symptoms result from alterations in intracranial dynamics (edema, brain shift), infection, or the location of the abscess.
  • Headache, usually worse in morning, is the most prevailing symptom.
  • Fever, vomiting, and focal neurologic deficits (weakness and decreasing vision) occur as well.
  • As the abscess expands, symptoms of increased intracranial pressure (ICP) such as decreasing level of consciousness and seizures are observed.

Assessment and Diagnostic Methods
  • Neuroimaging studies such as MRI or CT scanning to identify the size and location of the abscess
  • Aspiration of the abscess, guided by CT or MRI, to culture and identify the infectious organism
  • Blood cultures, chest xray, electroencephalogram (EEG)

Medical Management
  • The goal is to eliminate the abscess.
  • Treatment modalities include antimicrobial therapy, surgical incision, or aspiration (CTguided stereotactic needle).
  • Medications used include corticosteroids to reduce the inflammatory cerebral edema and antiseizure medications for prophylaxis against seizures (phenytoin, phenobarbital).
  • Abscess resolution is monitored with CT scans.

Nursing Management
  • Nursing interventions support the medical treatment, as do patient teaching activities that address neurosurgical procedures.
  • Patients and families need to be advised of neurologic deficits that may remain after treatment (hemiparesis, seizures, visual deficits, and cranial nerve palsies).
  • The nurse assesses the family’s ability to express their distress at the patient’s condition, cope with the patient’s illness and deficits, and obtain support.

Bone Marrow Aspiration and Biopsy


Bone marrow
, the soft tissue contained in the medullary canals of long bone and the interstices of cancellous bone, may be removed by aspiration or needle biopsy under local anesthesia. In aspiration biopsy, a fluid specimen in which pustulae of marrow is suspended is removed. In needle biopsy, a core of marrows – cells, not fluid – its removed. These methods are commonly used concurrently to obtain the best possible marrow specimens. Red marrow, which constitutes about 50% of an adult’s marrow, actively produces stem cells that ultimately evolve into red blood cells, white blood cells and platelets. Yellow marrow contains fat cells and connective tissue and is inactive, but it can become active in response to the body’s needs.
Bleeding and infection may result from bone marrow biopsy at any site, but the most serious complications occur at the sternum. Such complications are rare but include puncture of the heart and major vessels, causing severe hemorrhage, and puncture of the mediastinum, causing mediastinitis of pneumomediastinum.

  • To diagnose thrombocytopenia, leukemia, granulomas, anemias, and primary and metastatic tumors.
  • To determine the causes of infection.
  • To help stage disease such as with Hodgin’s disease.
  • To evaluate chemotherapy.
  • To monitor myelosuppression.

Patient Preparation
  1. Explain the procedure to the patient. A mild sedative will be given 1 hour before the test, if ordered.
  2. Tell the patient the test usually takes only 5 to 10 minutes and that more than one bone marrow specimen may be required.
  3. Let him know a blood sample will be collected before the biopsy for laboratory testing.
  4. Make sure the patient has signed a consent form.
  5. Check the patient for hypersensitivity to the local anesthetic.
  6. After confirming with the doctor, tell the patient which bone- sternum, anterior or posterior iliac crest, vertebral spinous process, ribs, or tibia – will be used as the biopsy site.
Aspiration Biopsy
  1. The doctor prepares the biopsy site and injects a local anesthetic. He then inserts the needle through the skin, the subcutaneous tissue, and the cortex of the bone.
  2. The doctor removes the stylet from the needle and attaches a 10 to 20 ml syringe. He aspirates 0.2 to 0.5 ml of marrow and withdraws the needle.
  3. Pressure is applied to the site for 5 minutes while the marrow slides are being prepared. If the patient has thrombocytopenia, pressure is applied for 10 to 15 minutes.
  4. The biopsy site is cleaned again, and a sterile adhesive bandage is applied.
  5. If the doctor doesn’t obtain an adequate marrow specimen on the first attempt, he may reposition the needle or remove and reinsert it in another site within the anesthetized area. If the second attempt fails, a needle biopsy may be necessary.
Needle Biopsy
  1. After preparing the biopsy site and draping the area, the examiner marks the skin at the site with an indelible pencil or marking pen.
  2. A local anesthetic is then injected intradermally, subcutaneously, and at the bone’s surface.
  3. The biopsy needle is inserted into the periosteum, and the needle guard is set as indicated. The needle is advanced with a steady boring motion until the outer needle passes through the bone’s cortex.
  4. The inner needle with trephine tip is inserted into the outer needle. By alternately rotating the inner needle clockwise and counterclockwise, the examiner directs the needle into the marrow cavity and then removes a tissue plug.
  5. The needle assembly is withdrawn, and the marrow is expelled into a labeled bottle containing Zenker’s acetic acid solution.
  6. After the biopsy site is cleaned, a sterile adhesive bandage or a pressure dressing is applied.
Nursing Interventions
  1. While the marrow slides are being prepared, apply pressure to the biopsy site until bleeding stops.
  2. Clean the biopsy site and apply a sterile dressing.
  3. Monitor the patient’s vital signs and the biopsy site for signs and symptoms of infection.

Normal Results
  1. Yellow marrow contains fat cells and connective tissue.
  2. Red marrow contains hematopoietic cells, fat cells, and connective tissue.
  3. The iron satin, which measures hemosiderin (storage iron), has a +2 level.
  4. The sudan black B satin, which shows granulocytes is negative.
  5. The periodic acid-Schiff (PAS) stain, which detects glycogen reactions, is negative.
Abnormal Results
  1. Decreased hemosiderin levels in an iron stain may indicate a true iron deficiency.
  2. Increased hemosiderin levels may suggest other types of anemias or blood disorders.
  3. A positive stain can differentiate acute myelogenous leukemia from acute lymphoblastic leukemia (negative stain).
  4. A positive stain may also suggest granulation in myeloblasts.
  5. A positive PAS stain may suggest acute or chronic lymphocyte leukemia, amyloidosis, thalasemia, lymphoma, infectious mononucleosis, iron-deficiency anemia, or sideroblastic anemia.

  1. Hemorrhage and infection
  2. Puncture of the mediastinum (sternum)

  • Know that bone marrow biopsy is contraindicated in the patient with a severe bleeding disorder.
  • Send the tissue specimen or slide to the laboratory immediately.

Interfering Factors
  • Failure to obtain a representative specimen.
  • Failure to use a fixative for histologic analysis.

Blood Urea Nitrogen (BUN)


Urea is the chief end product of protein metabolism. Formed in the liver from ammonia and excreted by the kidneys, urea constitutes 40% to 50% of the blood’s nonprotein nitrogen. Because the level of reabsorption of urea in the renal tubules is directly related to the rate of urine flow through the kidneys, the blood urea nitrogen (BUN) level is less reliable indicator or uremia than is the serum creatinine level. The BUN test measures the nitrogen fraction.


  • To confirm bacterecemia.
  • To identify causative organism in bacterecemia and septicemia.
  • To determine the cause of fever with an unknown origin.


Patient Preparation
  1. Tell the patient that the BUN test is used to evaluate kidney function.
  2. Inform the patient that he need not to restrict food and fluids, but should avoid diet high in meat.
  3. Tell the patient that the test requires a blood sample. Explain who will perform the venipuncture and when.
  4. Explain to the patient that he may experience slight discomfort from the tourniquet and needle puncture.
  5. Notify the laboratory and physician of medications the patient is taking that may affect test results; they may need to be restricted.
  1. Clean the venipuncture site first with an alcohol swab and then with a providone-iodine swab, starting at the site and working outward in a circular motion.
  2. Wait at least 1 minute for the skin to dry.
  3. Perform a venipuncture and draw 10 to 20 ml of blood for an adult, or 2 to 6 ml for a child.
  4. Clean the diaphragm tops of the culture bottles with alcohol or iodine and change the needle on the syringe.
  5. If using broth, add blood to each bottle until achieving a 1:5 or 1:10 dilution. For example, add 10 ml of blood to a 100-ml bottle. Note that the size of the bottle may vary depending on hospital protocol.
  6. If using a special resin, add blood to the resin in the bottles according to facility protocol, and invert gently to mix it.
  7. Draw the blood directly into special collection processing tube if using lysis-centrifugation technique (Isolator).
  8. Document the tentative diagnosis and current or recent antimicrobial therapy on the laboratory request.
  9. Send each sample to the laboratory immediately.
  10. Collect blood cultures before giving antimicrobial agents whenever possible because previous or current antimicrobial therapy may give false-negative results.
  11. To detect most causative agents, it’s best to perform the blood cultures on 2 consecutive days.
Nursing Interventions
  1. Use alcohol to remove the iodine from the venipuncture site.
  2. Monitor the venipuncture site for bleeding and signs of infection.

Normal Results
  • BUN values normally range form 8 to 20 mg/dl (SI, 2.9 to 7.5 mmol/L)
  • In elderly patients, BUN will show slightly higher values, possibly to 69 mg/dl (SI, 25.8 mmol/L).
Abnormal Results
  • Elevated BUN levels occurs in renal disease, reduced renal blood flow (due to dehydration), urinary tract obstruction, and increased protein catabolism (such as with burns).
  • Low BUN levels occur in severe hepatic damage, malnutrition, and overhydration.

Interfering Factors
  • Hemolysis from rough handling of the sample.
  • Use of chloramphenicol may possible decrease the BUN.
  • Aminoglycosides, amphoterecin B, and methicillin may increase BUN by nephrotoxicity.

  • Hematoma at the puncture site.

  • Handle the sample gently to prevent hemolysis.

Blood Chemistry

Blood Chemistry
  • Is the chemical composition of the blood.
  • This is done to assess a wide range of conditions and the function of organs.
  • Usually it check the electrolytes, the minerals that help keep the body’s fluid levels in balance, and are necessary to help the muscles, heart, and other organs work properly.
  • Levels of various substances in the blood can provide clues to a patient’s condition, ranging from the presence of a liver disorder to a pregnancy.
  • Plays a major role in regulating the amount of water in the body.
  • Low level can be caused by loss of sodium through diarrhea or vomiting.
  • High level can be caused by intake of too much salt or not enough water.
  • Essential to regulate how the heart beats.
  • Low levels can be caused by use of diuretics, low dietary intake, severe vomiting or diarrhea, certain medications, alcohol abuse, and other medical conditions. It can cause muscle weakness and heart problems.
  • High levels can be caused by having kidney problems and excessive intake of potassium supplement.
  • Helps maintain a balance of fluids in the body.
  • Changes in the chloride level are usually associated with changes in the sodium level; when one goes up the other goes down and vice versa.
  • When there is too much or too little acid in the blood, chloride is an important clue that helps doctors determines the cause of the acid abnormality.
  • Prevents the body’s tissues from getting too much or too little acid.
  • The kidney and lungs balance the levels of bicarbonate in the body.
  • If bicarbonate levels are too high or low, it might indicate a problem with those organs.
Blood urea nitrogen (BUN)
  • A measure of how well the kidneys are working.
  • A waste product produced when proteins are broken down in the liver and excreted by the kidney.
  • Dehydration and blood loss can cause a high BUN level.
  • Low BUN level might indicate liver ailments, a low protein diet, or too much water intake.
  • Is a waste product that is formed when food is converted to energy and when muscles are injured.
  • Men have higher values than women because they have more muscle mass.
  • High levels of creatinine often mean that the kidneys are not doing a good job of clearing waste products and toxins from the blood.
  • Is the main type of sugar in the blood.
  • Is the chief source of energy for all living organisms and, as such, is very important for a healthy body.
  • High glucose levels after 12 hours of fasting is consistent with diabetes.

Hematocrit (HCT)
The word hematocrit means “to separate blood,” a procedure which is followed following the blood draw through the proper use of a centrifuge. Hematocrit is the measurement of the percentage of red blood cells in whole blood. It is an important determinant of anaemia (decreased), polycythemia (increased), dehydration (elevated), increased R.B.C. breakdown in the spleen (elevated), or possible over hydration (elevated)
  • Normal Adult Female Range: 37 – 47 %
  • Optimal Adult Female Reading: 42%
  • Normal Adult Male Range: 40 – 54%
  • Optimal Adult Male Reading: 47
  • Normal Adult Newborn Range: 50 – 62%
  • Optimal Adult Newborn Reading: 56
Hemoglobin (HGB)
Hemoglobin is the main transport of oxygen and carbon dioxide in the blood. It is composed of globin a group of amino acids that from a protein and heme which contains iron atoms and red pigment, porphyrin. As with Hematocrit, it is an important determinant of anaemia (decreased), dehydration (increased), polycythemia (increased), poor diet/nutrition, or possibly a malabsorption problem.
  • Normal Adult Female Range: 12 – 16 %
  • Optimal Adult Female Reading: 14
  • Normal Adult Male Range: 14 – 18%
  • Optimal Adult Male Reading: 16
  • Normal Adult Newborn Range: 14 – 20%
  • Optimal Adult Newborn Reading: 17

R.B.C. (Red Blood Cell Count)
Red blood cells main function is to carry oxygen to the tissues and to transfer carbon dioxide to the lungs. This process is possible through the R.B.C. containing hemoglobin which combines easily with oxygen and carbon dioxide.
  • Normal Adult Female Range: 3.9 – 5.2 mill/mcl
  • Optimal Adult Female Reading: 4.55
  • Normal Adult Male Range: 4.2 – 5.6 mill/mcl
  • Optimal Adult Male Reading: 4.9
  • Lower ranges are found in Children, newborn and infants

W.B.C (White Blood Cell Count)
White blood cells main function is to fight infection, defend the body by phagocytosis against invasion by foreign organism, and to produce, or at least transport and distribute, antibodies in the immune response. There are a number of types of leukocytes (see differential) that are classified as follows.
  • Granulocytes
  • Neutrophiles
  • Neutrophils
  • Eosinophils
  • Basophils
  • Nongranulocytes
  • Lymphocytes
  • Monocytes
  • Normal Adult Range: 130 – 400 thous/mcl
  • Optimal Adult Reading: 265
  • Higher ranges are found in Children, newborn and infants

Liver Enzymes
SGOT (Serum Glutamic-Oxalocetic Transaminase – AST)
Serum Glutamic Oxalocetic Transaminase or AST is an enzyme found primarily in the liver, heart, kidney, pancreas, and muscles. Seen is tissue damage, especially heart and liver this enzyme is normally elevated. Vitamin B deficiency and pregnancy are two instances where the enzyme may be decreased.
Normal Adult Range: 0 – 42 U/L
Optimal Adult Reading: 21
ALT – alanine aminotransferase
AST – aspirate aminotransferase
SGPT (Serum Glutamic-Pyruvic Transaminase-ALT)
Serum Glutamic Pyruvic Transaminase or ALT is an enzyme found primarily in the liver but also to a lesser degree, the heart and other tissues. It is useful in diagnosing liver function more so than SGOT levels. Decreased SGPT in combination with increased cholesterol levels is seen in case of a congested liver. We also see increased levels in mononucleosis, liver damage, kidney infection, chemical pollutants or myocardial infarction.
Normal Adult Range: 0 – 48 U/L
Optimal Adult Reading: 24

Nitrogen Elements
B.U.N (Blood Urea Nitrogen)
The nitrogen component of urea, B.U.N. is the end product metabolism and its concentration is influenced by the rate of excretion. Increases can be caused by exercise protein intake, intestinal bleeding, exercise or heart failure. Decreased levels may be dur to a poor diet, malabsorption, liver damage or low nitrogen intake.
Normal Adult Range: 7 – 25 mg/dl
Optimal Adult Reading: 16
Creatinine is the waste product of muscle metabolism. Its level is a reflection of the bodies muscle mass. Low levels are sometimes seen in kidney damage, protein starvation, liver disease or pregnancy. Elevated levels are sometimes seen in kidney disease due to the kidneys job of excreting creatinine, muscle degeneration, and some drugs involved in impairment of kidney function.
Normal Adult Range: 7 – 1.4 mg/dl
Optimal Adult Reading: 1.05
Uric acid
Uric acid is the end product of urine metabolism and is normally excreted through the urine. High levels are noted in gout, infections kidney disease, alcoholism, high protein diets, and with toxaemia in pregnancy. Low levels may be indicative of kidney disease, malabsorption, poor diet, liver damage or an overly acid kidney.
Normal Adult Female Range: 2.5 – 7.5 mg/dl
Optimal Adult Female Reading: 5.0
Normal Adult Male Range: 3.5 – 7.5 mg/dl
Optimal Adult Male Reading: 5.5

Cholestirol is a critical fat that is a structural component of cell membrane and plasma lipoproteins, and is important in the synthesis of steroid hormones, glucocorticoids, and bile acids. Mostly synthesis in the liver, some is absorbed (HLD) is desired as posed to the low density lipoproteins (LDL), two types of cholesterol. Elevated cholesterol has been in artherosclerosis, diabetes, hypothyroidism and pregnancy. Low levels are seen in depression, malnutrition, liver insufficient, malignancies, anemia and infection.
Normal Adult Range: 120 – 240 mg/dl
Optimal Adult Reading: 180
Triglycerides, stored in adipose tissues as glycerol, fatty acids and monoglyceroids, are reconverted as triglycerides by the liver. Ninety percent of the dietary intake and 95% of the fat stored in tissues are triglycerides. Increased levels may be present in artherosclerosis, hypothyroidism, liver disease, pancreatitis, myocardial infarction, metabolic disorders, toxemia, and nephrotic syndrome. Decreased levels may be present in chronic obstructive pulmonary disease, brain infarction, hyperthyroidism, malnutrition, and malabsorption.

Blepharoplasty Surgery

Excision of a protrusion of periorbital fat, and resection of excessive redundant skin of the eyelids.

  • The procedure may be performed on both the upper and lower lids, and may be both cosmetic and functional, since sagging skin from the upper lids may interfere with the patient’s eye sight.
  • The amount of tissue removed depends on the severity or deformity and the age of the patient.
  • Local anesthesia with conscious I.V. sedation is usually the anesthesia method of choice.

  • Supine with arms tucked in the sides.
  • The head may be supported on a headrest.
  • A nasal preparation is usually performed prior to begin the skin preparation.

Packs/ Drapes
  • Head and neck pack or basic pack with split sheet and head drape.

  • Basic plastic tray

Supplies/ Equipment
  • Small basin set
  • Suction
  • Local anesthetic with epinephrine
  • 10-ml Control Leur-lock syringes
  • 25-or-27 gauge needles
  • Blades
  • Needle counter
  • Cotton-tipped applicators or cellulose sponges
  • Solutions
  • Sutures

Procedure Overview
  1. An elliptical incision is made in the recess of the upper eyelid, following the premarked lines.
  2. Grasping the subcutaneous fatty tissue with a fine forceps, the tissue is gently dissected with a small scissors and removed.
  3. The upper lid incisions are covered with moist saline sponges (or eye pads) while the resection of a portion of the lower lid is performed.
  4. Small bleeders are controlled with cautery.
  5. The skin edges are approximated and closed with fine interrupted sutures.
  6. A topical antibiotic ointment or dressing (nonpressure) is applied.

Perioperative Nursing Considerations
  1. Do not allow the preparation solution to pool in or around the eyes or ears.
  2. A head drape should be used for all facial surgery.
  3. The table may be flexed for added patient comfort.
  4. A foam mattress should be used for extra support.

Blalock-Taussig Operation

Blalock-Taussig operation (also called Blalock-Thomas-Taussig shunt) is a palliative surgical procedure used in cyanotic heart defects. More specifically it is used for the palliative repair of blue babies or those infants diagnosed with Tetralogy of Fallot (TOF). In this procedure the blood flow is directed to the lungs to relive cyanosis while the infant is waiting for the corrective surgery.
Children with TOF and other cyanotic defects have problems with oxygenation. Cyanosis develops as a result of low oxygen levels in the blood. Placement of a blalock-taussig shunt alleviate symptoms of poor oxygenation (e.g. cyanosis) which is done by anastomosing the subclavian artery to the pulmonary artery (bypassing the stenosed pulmonary artery) so that part of hypoxemic blood in the aorta will be oxygenated in the lungs.

The procedure was named after Alfred Blalock, a surgeon and Helen B. Taussig, a cardiologist. The procedure was developed by the two physicians together with Blalock’s laboratory technician Vivien Thomas. Taussig (cardiologist) observed that children with cyanotic heart defect and patent ductus arteriosus (PDA) live longer than those without PDA. The cardiologist then formulated a theory that placement of a shunt mimicking the function of PDA might provide relief for tetralogy of fallot’s problem on oxygenation. Dr. Taussig approached Dr. Blalock and Thomas in their laboratory. After meeting with Taussig the two men set about perfecting the procedure on animals which later on they performed on infants. This operation was first done on November 29, 1944 at the Johns Hopkins Hospital in Baltimore and is a major landmark in the history of children’s heart surgery.

Indications Blalock-Taussig Operation

  • Cyanotic heart defects
  • Tetralogy of Fallot – congenital heart disease that is characterized by four anomalies: ventricular septal defect, pulmonary stenosis, dextroposition (overriding) of aorta and hypertrophy of right ventricle.

Nursing Management

Before the procedure
  1. Discontinue Aspirin 14 days before the operation to decrease the risk of excessive bleeding. Check the medication regimen with the cardiologist because there may be a medical reason for the continued use of aspirin.
  2. Blood typing is done prior to surgery and blood should be ready for transfusion anytime within and after surgery in cases of excessive bleeding.
  3. Chest x-ray, electrocardiogram and laboratory work will be performed as a preoperative process
  4. Have the parents sign the informed consent.
  5. NPO post midnight.
  6. IV fluids.
  7. Explore feelings of anxiety of the patient (if adult and older children) and/or child’s parents (for infants and children).
After the procedure
  1. Monitor patient’s heart rate and rhythm closely.
  2. Chest x-ray is performed after the operation.
  3. Administer medications that reduce pain.
  4. Comfort measures should be done.
  5. Once surgical dressing is removed, the incision will remain open to air.
  6. Incision should be cleansed twice a day with a Betadine solution.
  7. Small gauze is placed over the insertion sites of chest tubes, intracardiac lines and pacing wires.
  8. Prophylactic antibiotic.
  9. Patients with sternotomy should avoid strenuous activity that causes strain on the chest for at least 6-8 weeks to promote healing of the breastbone.
  10. Avoid picking infants by arms rather scoop them to avoid straining the chest area.
  11. Older children and adults should avoid contact games or sports and activities involving pushing and pulling with arms.
  12. Instruct the family to observe the following after discharge and report immediately to the doctor if noticed:
  • Redness, swelling or oozing of blood from the incision
  • Fever
  • Altered mental status
  • Feeding problems
  • Excessive fatigue
  • Prolonged and worsening pain

Possible Complications of Blalock-Taussig Surgery

  • Bleeding
  • Infection
  • Nerve damage (in the chest area)
  • Need for re-operation
  • Adverse reaction to anesthesia
  • Brain damage
  • Death