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Certificate in Nursing · 2023
Medical Nursing 1 & Pharmacology 1 Certificate UNMEB Pastpaper Revision Guide
SECTION A: Objective Questions (20 marks)
💡 System-Based Approach: This paper covers respiratory, cardiovascular, hematology, and pharmacology. Focus on pathophysiology and nursing priorities!
1
The earliest manifestation of chronic bronchitis is
(d) productive cough
Chronic bronchitis is defined clinically as productive cough for at least 3 months in each of two consecutive years. The cough results from chronic irritation of airways and excessive mucus production. Dyspnea and cyanosis develop later as disease progresses to COPD. Chest pain is not characteristic. Cough is the presenting symptom that leads to diagnosis.
CHRONIC BRONCHITIS TRIAD: “Cough-Phlegm-Wheeze” – Productive cough first, then sputum, then dyspnea
2
Which of the following signs are expected in a severely anaemic patient?
(b) Dyspnoea and tachycardia
Severe anemia (Hb <7 g/dL) causes tissue hypoxia, triggering compensatory mechanisms: tachycardia to increase cardiac output and dyspnea to increase oxygen intake. The heart works harder to deliver limited oxygen, causing effort intolerance, palpitations, and shortness of breath on exertion. These are the most consistent findings in severe anemia.
🫀 High-Output Heart Failure: Chronic severe anemia can cause high-output HF due to persistent tachycardia and volume overload, but dyspnea and tachycardia always precede this.
3
Which of the following populations is at high risk for hypertension?
(a) Blacks
Black populations have the highest age-adjusted prevalence of hypertension globally, with earlier onset, greater severity, and higher rates of complications (stroke, CKD). Genetic factors (salt sensitivity), higher obesity rates, socioeconomic factors, and reduced renin-angiotensin activity contribute. Response to treatment differs – better response to diuretics and calcium channel blockers than ACE inhibitors.
HTN RISK POPULATIONS: “BLACK-O” – Blacks, Latinos, Asians, CKD, Elderly, Obese
4
Which of the following blood components decreases in anaemia?
(b) Erythrocytes
Anemia is DEFINED as decreased hemoglobin, hematocrit, and red blood cell (erythrocyte) count. This results in reduced oxygen-carrying capacity. Granulocytes, leukocytes, and platelets are unchanged in pure anemia unless there is an underlying pancytopenia from bone marrow failure. Erythrocytes are the specific cells that decrease in anemia.
🔬 Definition Matters! Anemia = ↓Hemoglobin/↓Hematocrit/↓RBC count. Other cell lines (WBC, platelets) unaffected unless it’s a bone marrow problem.
5
Which of the following nursing diagnoses is appropriate for pitting edema in a patient with heart failure?
(a) Fluid volume excess
Pitting edema is the cardinal sign of fluid volume excess (hypervolemia) from sodium and water retention in heart failure. The cause is neurohormonal activation (RAAS) leading to renal retention. This is the primary nursing diagnosis that directly addresses the edema. While other options may be present, they are related but not the most specific diagnosis for edema itself.
NURSING DIAGNOSIS HIERARCHY: Problem (Fluid volume excess) → Cause (Decreased CO) → Symptom (Edema) → Risk (Impaired skin)
6
Which of the following factors is NOT associated with development of arteriosclerosis?
(a) Anaemia
Anemia is NOT a risk factor for arteriosclerosis (hardening of arteries). In fact, iron overload (hemochromatosis) can promote atherosclerosis, but anemia does not. Arteriosclerosis involves endothelial damage, lipid deposition, and calcification. Risk factors include hypertension, diabetes, genetics, smoking, hyperlipidemia. Anemia reduces oxygen delivery but doesn’t cause arterial wall pathology.
🧬 Arteriosclerosis vs Atherosclerosis: Arteriosclerosis = general hardening. Atherosclerosis = specific plaque formation from lipids. Risk factors overlap but anemia is not one!
7
The nurse should be suspicious of lobar pneumonia in a patient whose sputum is
(a) rusty
“Rusty” or blood-tinged sputum is classic for Streptococcus pneumoniae (pneumococcal) lobar pneumonia. The rust color comes from blood mixing with inflammatory exudate in alveoli, causing red blood cell breakdown and hemosiderin pigment. This is pathognomonic for pneumococcal pneumonia, which causes consolidation of entire lung lobes. Greenish/purulent suggests other bacteria (Pseudomonas, H. influenzae).
SPUTUM COLORS: “RUSTY Pneumonia, GREEN Pseudomonas, YELLOW Staph, FROTHY Pulmonary edema”
8
For which of the following reasons should patients with respiratory disease be nursed in sitting up position?
(d) Fix the shoulder girdle and expand the chest cavity
Semi-Fowler’s/high-Fowler’s position (45-90°) maximizes lung expansion by allowing gravity to pull the diaphragm down and preventing abdominal compression. This position fixes the shoulder girdle, enabling accessory muscles (scalenes, intercostals) to work more effectively, increasing tidal volume and improving ventilation. While other options have some benefit, this is the primary physiological reason.
🫁 ORTHO PNEA Position: Patients naturally sit up when dyspneic. This is their body’s wisdom – don’t fight it! Maximize backrest for respiratory patients.
9
The most appropriate preventive measure for pulmonary embolism is
(a) early ambulation
Early ambulation is the most effective preventive measure for pulmonary embolism because it prevents venous stasis – the primary trigger for DVT formation. Muscle contractions activate the calf muscle pump, promoting venous return and preventing clot formation in deep veins. Should begin within 24 hours post-surgery or during hospitalization unless absolutely contraindicated. It’s non-invasive, cost-free, and highly effective.
VTE PREVENTION: “AMBULATE” – Ambulate early, Mechanical compression, Blood thinners for high-risk, Use stockings, Leg exercises, Avoid dehydration, Turn frequently, Elevate legs
10
Most leukaemias involve changes in
(d) lymphocytes
Most leukemias arise from lymphoid lineage (acute lymphoblastic leukemia – ALL, chronic lymphocytic leukemia – CLL), which are malignancies of lymphocytes. These account for approximately 80% of childhood leukemias (ALL) and most adult chronic leukemias. While myelogenous leukemias involve granulocytes, the question asks “most” leukemias, and lymphocytic types are more prevalent overall.
🔬 Leukemia Classification: Either lymphoid (ALL, CLL) or myeloid (AML, CML). Lymphoid types are MORE common overall, especially in children.
11
The act of administering drugs during medical management of disease is referred to as
(a) therapeutics
Therapeutics is the branch of medicine concerned with treatment of disease and the art and science of healing. It specifically refers to the practical application of drugs and other modalities to treat disease. Pharmacology is the broader study of drug actions; toxicology studies harmful effects; pharmaceuticals are the drug products themselves.
MEDICAL BRANCHES: “TPP” – Therapeutics (treatment), Pharmacology (drug science), Pathology (disease study)
12
A drug that consists of two immiscible liquids that are uniformly dispersed is referred to as a/an
(d) emulsion
An emulsion is a dispersion of two immiscible liquids (oil and water) stabilized by an emulsifying agent. Examples: milk (fat in water), oil-in-water creams, some oral suspensions. Lotions are liquid preparations but not necessarily emulsions; mixtures are miscible substances; diluents are inert substances used to dilute. Emulsions require shaking before use as they tend to separate.
🔬 Emulsion Types: O/W (oil in water) – watery, absorbs quickly. W/O (water in oil) – greasy, occlusive. Must specify “shake well before use.”
13
Treatment of viral infections with antibiotics constitutes
(b) irrational use of drugs
Antibiotics are ineffective against viruses and their use for viral infections is a prime example of irrational prescribing. This practice contributes to antibiotic resistance, adverse drug reactions, unnecessary costs, and false sense of security. WHO identifies this as a major global health threat. Viral infections require symptomatic treatment or specific antivirals, not antibiotics.
🦠 Antimicrobial Resistance Crisis: Overuse of antibiotics for viral infections is creating superbugs. Nurses must educate patients: “Common cold = NO antibiotics!”
14
Drug effectiveness as a concept of selection of essential drugs requires that drugs must be
(c) able to cure diseases which they are intended for
Effectiveness means the drug produces the intended therapeutic effect under real-world conditions. For essential drug selection, a drug must demonstrate clinical efficacy for the target condition. Quality, safety, and tolerability are important but secondary to the drug actually working. A drug that is safe but ineffective is useless. WHO essential medicines criteria: efficacy, safety, quality, and cost-effectiveness.
WHO CRITERIA: “ESQeC” – Efficacy, Safety, Quality, cost-Effectiveness
15
Movement of administered medication from general circulation into different organs and fluids of the body is referred to as
(c) distribution
Distribution is the process by which drug moves from the systemic circulation to tissues and organs. It depends on blood flow, tissue binding, lipid solubility, and plasma protein binding. This determines where the drug exerts its effect and its volume of distribution. Absorption is movement into bloodstream; metabolism is chemical alteration; transfer is not a standard pharmacology term.
ADME: Absorption → Distribution → Metabolism → Excretion
16
The measure of how much drug is needed to produce a desired pharmacological response is called
(c) potency
Potency refers to the amount of drug required to produce a given effect (usually EC50). A highly potent drug produces its effect at low concentrations. For example, fentanyl is more potent than morphine (100x) – much smaller dose needed for same analgesia. Potency is about dose, not maximal effect. Efficacy is maximal effect; toxicity is harmful effects; synergy is combined drug effect.
📊 Potency vs Efficacy: Potent = small dose works. Efficacious = works really well. Fentanyl is more potent but not more efficacious than morphine (both relieve pain completely at right doses).
17
Which of the following is NOT a quality of good prescribers?
(c) Prescribe medicine as requested by patient
Good prescribers practice evidence-based medicine, not demand-driven prescribing. Prescribing based on patient requests leads to antibiotic resistance, polypharmacy, and inappropriate treatment. Good prescribers evaluate clinical need, use shared decision-making, and may refuse requests that are not clinically indicated (e.g., antibiotics for viral infections, unnecessary opioids).
GOOD PRESCRIBER: “SMEAR” – Scientific basis, Monitor, Educate, Assess need, Rational choice
18
Which of the following sites offers the greatest rate of drug absorption?
(b) Small intestine
The small intestine is the primary site of drug absorption due to its massive surface area (villi, microvilli), rich blood supply, and neutral pH. It accounts for 90% of oral drug absorption. Large intestine has minimal absorption (mainly water); stomach has limited surface area and acidic pH; rectum has variable absorption and is used when oral route is unavailable. Factors: surface area, permeability, residence time.
📏 Surface Area Matters! Small intestine = 250 m² (size of tennis court!). Stomach = 1 m². No contest!
19
Which of the following parameters should be observed when deciding on time of drug administration?
(a) Eating
Food intake significantly affects drug absorption and tolerance. Drugs may need to be given with food to reduce GI irritation (NSAIDs, metformin) or on an empty stomach for optimal absorption (levothyroxine, tetracyclines). Meal timing affects gastric emptying, pH, and drug interactions. While elimination (half-life) determines frequency, eating determines optimal timing relative to meals for safety and efficacy.
TIMING FACTORS: “MEALS” – Meals affect absorption, Effect desired, Activity, Lifestyle, Sleep pattern
20
Which of the following is a major hindrance to oral administration of drugs?
(d) Unconsciousness
Unconsciousness is an absolute contraindication to oral drug administration. It impairs swallowing reflex, causing high risk of aspiration pneumonia and airway obstruction. Drugs given orally to unconscious patients can enter lungs instead of stomach, causing severe complications. Requires alternative routes: IV, IM, rectal, or sublingual if feasible. Age, dental caries, and lifestyle are considerations but not absolute barriers.
⚠️ Airway First! NEVER give oral medications to unconscious patient. Check Glasgow Coma Scale <8=high aspiration risk. Use IV/IM instead.
SECTION B: Fill in the Blank Spaces (10 marks)
21
Awareness of one’s own heart beat is referred to as ________________
Palpitations
Palpitations are the subjective awareness of heartbeats that may feel rapid, irregular, pounding, or fluttering. Can be physiological (exercise, anxiety) or pathological (arrhythmias, hyperthyroidism, anemia). Nurses should assess onset, duration, triggers, associated symptoms (syncope, chest pain), and obtain ECG if persistent.
22
The expected outcome of a disease is called ________________
Prognosis
Prognosis is the predicted course and outcome of a disease, including likelihood of recovery, complications, and survival time. Based on clinical features, disease stage, patient factors, and evidence. Terms: excellent, good, fair, poor, guarded. Nurses use prognosis to plan care, set realistic goals, and counsel patients/families.
23
Hardening and thickening of arteries associated with normal ageing process is termed as ________________
Arteriosclerosis
Arteriosclerosis is age-related loss of arterial elasticity due to collagen deposition and calcification of media (Monckeberg’s sclerosis). Differs from atherosclerosis (lipid plaques). Causes increased systolic pressure, widened pulse pressure, and risk for aneurysm. Affects all arteries, leading to decreased organ perfusion. Management: blood pressure control, exercise, statins.
24
Spoon shaped nails are medically referred to as ________________
Koilonychia
Koilonychia is concave, spoon-shaped nails with central depression and raised edges. Classic sign of iron deficiency anemia, but also seen in hemochromatosis, Plummer-Vinson syndrome, and occupational exposure to petroleum products. Results from impaired nail bed vascular supply. Reversible with iron supplementation. Inspect nails during routine assessment for early anemia detection.
25
Abnormally low level of white blood cells is referred to as ________________
Leukopenia
Leukopenia is WBC count <4,000 /μL. Causes: viral infections, chemotherapy, radiation, aplastic anemia, HIV, drugs (clozapine, carbamazepine). Severe form (<2,000) is called neutropenia if neutrophils affected. Increases risk of severe infections. Requires reverse isolation, infection precautions, prompt antibiotic therapy for fever. Monitor CBC regularly in at-risk patients.
26
The organ that is associated with first pass effect of drugs is called the ________________
Liver
First-pass effect is metabolism of orally administered drugs by liver before reaching systemic circulation. Drugs absorbed from GI tract travel via portal vein to liver, where CYP enzymes may metabolize a large fraction. High first-pass drugs (morphine, propranolol, nitroglycerin) have low oral bioavailability. Can be bypassed by sublingual, rectal, IV routes.
27
Drugs transformed into active components while in the body are termed as ________________
Prodrugs
Prodrugs are inactive or weakly active compounds that undergo metabolic conversion in the body (usually liver) to active metabolites. Designed to improve absorption, reduce side effects, or target specific tissues. Examples: enalapril → enalaprilat, levodopa → dopamine, codeine → morphine. Allows oral administration of drugs that would otherwise be poorly absorbed or toxic.
28
A substance that binds to a receptor and produces no pharmacological response is called ________________
Antagonist
Antagonists bind to receptors but do NOT activate them. They block the action of endogenous ligands or agonist drugs. Types: competitive (reversible) and non-competitive (irreversible). Examples: naloxone (opioid antagonist), atropine (muscarinic antagonist), ranitidine (H2 antagonist). Used to reverse toxicity or treat conditions of excess neurotransmitter activity.
29
Expected undesired effects of drug are collectively called ________________
Side effects
Side effects are unintended, often predictable, pharmacological effects occurring at therapeutic doses. Related to drug’s primary mechanism of action. May be harmless, bothersome, or dangerous. Examples: antihistamine sedation, beta-blocker bradycardia, antibiotic GI upset. Distinguished from adverse drug reactions (more severe, unpredictable) and toxic effects (overdose-related).
30
Intra-articular route of drug administration involves injection of the drug into ________________
The joint space (synovial cavity)
Intra-articular injections deliver medication directly into synovial joints for local effect, minimizing systemic side effects. Used for: corticosteroids (inflammatory arthritis), hyaluronic acid (osteoarthritis), radioisotopes (radiation synovectomy). Requires strict aseptic technique to prevent septic arthritis. Common sites: knee, shoulder, hip joints. Provides rapid, localized relief of pain and inflammation.
SECTION B: Short Essay Questions (20 marks)
31
(a) State five (5) routes of drug excretion. (5 marks)
1. Renal excretion (urine): Primary route – glomerular filtration, tubular secretion, reabsorption. Most water-soluble drugs and metabolites eliminated here. Requires adequate renal function.
2. Hepatic/biliary excretion (feces): Drugs and metabolites secreted into bile, passed to intestine, eliminated in feces. Important for large molecules. Enterohepatic recycling can prolong action.
3. Pulmonary exhalation: Gaseous and volatile drugs (anesthetic gases, alcohol) diffuse from blood into alveoli and are exhaled. Rate depends on blood:gas partition coefficient.
4. Sweat and saliva: Minor routes for some lipophilic drugs and heavy metals. Can cause skin irritation or be used for therapeutic drug monitoring (saliva).
5. Breast milk: Lactation excretes drugs that are lipid-soluble and non-ionized. Important consideration to avoid infant exposure to harmful medications.
EXCRETION ROUTES: “UR-BIPS” – Urine, Rectum/Feces, Breath, Integument, Perspiration, Saliva, Milk
(b) List five (5) disadvantages of the intravenous route of drug administration. (5 marks)
1. Risk of infection and sepsis: Breaks skin barrier, introducing bacteria directly into bloodstream. Can cause phlebitis, cellulitis, or life-threatening sepsis if aseptic technique not maintained.
2. Immediate toxicity and adverse reactions: Rapid onset means no time to withdraw drug if adverse reaction occurs. Anaphylaxis can be fatal. Errors in dose calculation have immediate severe consequences.
3. Technical complications: Extravasation causes tissue necrosis (vesicants), infiltration leads to swelling and pain, air embolism can be fatal, thrombophlebitis is common.
4. Requires skilled personnel and equipment: Needs trained nurses, IV cannulas, infusion pumps, sterile supplies. Not suitable for home use in most cases. More expensive than oral route.
5. Reduced patient mobility and discomfort: IV line restricts movement, risk of dislodgement, discomfort at insertion site limits activities of daily living.
32
(a) State five (5) clinical features of anaemia. (5 marks)
1. Pallor: Most common sign – pale conjunctiva, nail beds, palms. Best assessed by examining conjunctiva (no melanin). Reflects reduced hemoglobin concentration in microvasculature.
2. Fatigue and weakness: Most common symptom – reduced oxygen-carrying capacity leads to tissue hypoxia, impaired cellular metabolism, and decreased energy production.
3. Dyspnea on exertion: Shortness of breath with minimal activity as body compensates by increasing respiratory rate to maximize oxygen uptake. Cardiac output increases to maintain tissue perfusion.
4. Tachycardia and palpitations: Compensatory increase in heart rate to maintain cardiac output and tissue oxygen delivery. May progress to high-output cardiac failure in chronic severe anemia.
5. Dizziness, headache, and syncope: Cerebral hypoxia causes lightheadedness, reduced concentration, fainting spells. Severe cases may have tinnitus and visual disturbances.
(b) Outline five (5) preventive measures of anaemia. (5 marks)
1. Dietary diversification and nutrition education: Promote iron-rich foods (red meat, organ meats, leafy greens, legumes) and vitamin C sources to enhance absorption. Teach food combinations.
2. Iron and folic acid supplementation: Routine supplementation for pregnant women (60 mg iron + 400 µg folic acid daily), adolescents, and postpartum women to meet increased demands.
3. Control of parasitic infections: Periodic deworming (albendazole) and malaria prevention/prophylaxis to prevent blood loss and hemolysis. Improve sanitation and hygiene.
4. Food fortification programs: Fortify staple foods (wheat flour, maize meal) with iron, folic acid, vitamin B12 at population level to reach entire community.
5. Early diagnosis and treatment of underlying conditions: Screen for and treat menorrhagia, peptic ulcers, hemorrhoids, malignancies, and chronic diseases that cause blood loss or anemia of chronic disease.
ANEMIA PREVENTION: “SAFE-IRON” – Supplements, Awareness, Food fortification, Education, Iron-rich diet, Regular screening, Orphan causes treated, Nutrition
SECTION C: Long Essay Questions (50 marks)
33
(a) State five (5) clinical features of congestive cardiac failure. (5 marks)
(b) Outline fifteen (15) specific nursing actions performed for a 50 year old man admitted with congestive cardiac failure, for the first 48 hours of admission. (15 marks)
(c) Outline five (5) pieces of advice a nurse should share with the patient of CCF at discharge. (5 marks)
(b) Outline fifteen (15) specific nursing actions performed for a 50 year old man admitted with congestive cardiac failure, for the first 48 hours of admission. (15 marks)
(c) Outline five (5) pieces of advice a nurse should share with the patient of CCF at discharge. (5 marks)
(a) Clinical Features of Congestive Cardiac Failure:
1. Dyspnea: Progressive shortness of breath on exertion, orthopnea (difficulty breathing when supine), paroxysmal nocturnal dyspnea (sudden breathlessness at night requiring upright position).
2. Peripheral edema: Dependent pitting edema of ankles, feet, sacrum; may progress to anasarca (generalized fluid accumulation).
3. Fatigue and weakness: Reduced cardiac output leads to decreased tissue perfusion, causing exercise intolerance and generalized weakness.
4. Tachycardia and gallop rhythm: Compensatory increase in heart rate; S3 gallop heard on auscultation indicating volume overload.
5. Pulmonary congestion: Bibasal crackles on auscultation, productive cough (pink frothy sputum in acute pulmonary edema), pleural effusion.
(b) First 48-Hour Nursing Actions for CCF:
1. Continuous cardiac and vital sign monitoring: HR, BP, RR, SpO₂ every 1-2 hours to detect deterioration, arrhythmias, or response to treatment.
2. Strict intake and output monitoring: Measure all fluids in/out, aim for negative balance (output > input by 500-1000 mL/day). Insert urinary catheter if necessary.
3. Daily weight at same time: Most sensitive indicator of fluid status – target weight loss 1-1.5 kg/day indicates effective diuresis.
4. Administer prescribed medications promptly: Diuretics (furosemide IV), ACE inhibitors, digoxin, nitrates. Observe for therapeutic effect and adverse reactions.
5. Position in semi-Fowler’s (45°): Reduces preload, decreases respiratory effort, improves lung expansion, and promotes comfort.
6. Oxygen therapy titrated to SpO₂ >95%: Reduces hypoxia, decreases work of breathing, prevents end-organ damage.
7. Low-salt diet (2g sodium/day): Reduces fluid retention, decreases circulating volume, and minimizes further cardiac workload.
8. Restrict fluids to 1.5-2 L/day: Prevents volume overload and pulmonary congestion exacerbation.
9. Monitor lung sounds every 4 hours: Assess for crackles, wheezes, diminished breath sounds indicating pulmonary edema or pleural effusion.
10. Assess edema every shift: Check pitting grade (1-4+), location, extent. Measure abdominal girth if ascites present.
11. Monitor for medication side effects: Diuretics cause electrolyte loss (hypokalemia), ACE inhibitors cause hypotension and cough, digoxin causes toxicity (nausea, arrhythmias).
12. Electrolyte monitoring: Check K+, Na+, Mg2+ daily – diuretics cause hypokalemia which predisposes to arrhythmias. Replace as ordered.
13. Psychological support and anxiety reduction: Reassure patient, explain procedures, provide calm environment to reduce catecholamine release that worsens heart failure.
14. Skin care for edematous areas: Inspect skin folds, keep dry, turn 2-hourly, apply barrier creams to prevent breakdown and infection.
15. Monitor renal function (creatinine, urea): Diuretics and reduced renal perfusion can worsen kidney function. Report rising creatinine >30% from baseline.
(c) Discharge Advice for CCF Patient:
1. Medication adherence: Take all medications exactly as prescribed – diuretics, ACE inhibitors, beta-blockers. Never skip or double doses. Bring medication list to all appointments.
2. Daily weight monitoring: Weigh yourself every morning before breakfast and after urinating. Call doctor if weight increases >2 kg (4.4 lbs) in 3 days or >1 kg overnight (fluid retention).
3. Sodium restriction: Limit salt to <2 g/day (1 teaspoon). Avoid processed foods, canned soups, chips, salted fish. Read food labels carefully.
4. Fluid restriction: Drink no more than 1.5-2 liters (6-8 cups) of fluid daily including water, tea, soup, juice. Measure daily to avoid overconsumption.
5. Recognize and report warning signs early: Return immediately if you experience: increasing shortness of breath, sudden weight gain, swelling of ankles, waking up breathless at night, reduced urine output, dizziness, or chest pain.
CCF DISCHARGE TEACHING: “WFMSR” – Weigh daily, Fluid restriction, Medication adherence, Sodium restriction, Report symptoms
💊 Medication Adherence is Critical! Up to 50% of HF patients are non-adherent. Use pill organizers, set alarms, involve family members. Non-adherence = leading cause of readmission!
34
(a) State six (6) clinical features of severe pneumonia. (6 marks)
(b) Outline fifteen (15) specific nursing actions for an adult male admitted with severe pneumonia, till discharge. (15 marks)
(c) State four (4) complications that a patient with pneumonia may develop. (4 marks)
Copy(b) Outline fifteen (15) specific nursing actions for an adult male admitted with severe pneumonia, till discharge. (15 marks)
(c) State four (4) complications that a patient with pneumonia may develop. (4 marks)
(a) Clinical Features of Severe Pneumonia:
1. High fever (>39°C/102.2°F) with rigors: Marked systemic inflammatory response to infection, indicating severe bacterial invasion and bacteremia risk.
2. Severe dyspnea and tachypnea (RR >30/min): Respiratory distress from impaired gas exchange, shunting, and decreased lung compliance.
3. Chest pain (pleuritic): Sharp pain worsened by breathing due to pleural inflammation. May cause splitting and shallow breathing.
4. Productive cough with purulent/rusty sputum: Copious amounts of inflammatory exudate containing bacteria, WBCs, and damaged alveolar cells.
5. Cyanosis and hypoxemia (SpO₂ <90%):< /strong> Severe oxygenation impairment from alveolar consolidation and ventilation-perfusion mismatch.
6. Confusion and altered mental status: Hypoxemia, sepsis, and fever cause cerebral dysfunction, especially in elderly (CURB-65 criteria).
PNEUMONIA FEATURES: “F-D-C-S-C-C” – Fever, Dyspnea, Chest pain, Sputum, Cyanosis, Confusion
(b) Nursing Actions for Severe Pneumonia (Admission to Discharge):
1. Immediate assessment and vital signs monitoring: Obtain baseline vitals, SpO₂, conscious level. Monitor every 2-4 hours for deterioration. Use early warning scores.
2. Oxygen therapy management: Initiate O₂ via nasal cannula or mask to maintain SpO₂ >94%. Titrate according to ABG results. Monitor for CO₂ retention in COPD patients.
3. Position for optimal ventilation: Semi-Fowler’s (45°) to promote lung expansion, reduce aspiration risk, and facilitate diaphragmatic movement.
4. Administer antibiotics promptly: Give first dose within 1 hour of diagnosis as per protocol (e.g., ceftriaxone + azithromycin). Ensure correct dose and timing.
5. Fluid balance management: Maintain adequate hydration with IV fluids if unable to drink, but avoid overload. Monitor I/O, daily weight, edema.
6. Airway clearance and sputum management: Encourage deep breathing, coughing, use of incentive spirometer. Perform chest physiotherapy. Collect sputum for culture.
7. Antipyretic administration: Give paracetamol for fever >38.5°C to reduce metabolic demand and discomfort. Monitor temperature every 4 hours.
8. Pain management for pleuritic chest pain: Administer analgesics (paracetamol, NSAIDs if no contraindications) to allow effective coughing and breathing.
9. Continuous pulse oximetry: Monitor SpO₂ trends, alarm for desaturation. Early warning of respiratory failure requiring mechanical ventilation.
10. Laboratory monitoring: Track CBC (leukocytosis), CRP, renal function, electrolytes. Obtain ABG if SpO₂ <92% or respiratory distress worsens.
11. Sepsis screening and management: Look for hypotension, tachycardia, altered mental status. If septic, initiate sepsis bundle (blood cultures, IV fluids, vasopressors).
12. Nutrition support: Provide high-calorie, high-protein diet to meet increased metabolic demands. Small frequent meals if dyspneic. Supplement with vitamins.
13. Infection control measures: Isolation if MRSA suspected, hand hygiene, use of personal protective equipment to prevent spread to other patients.
14. Mobilization as tolerated: Gradual ambulation to prevent deconditioning and VTE. Start with bed exercises, progress to chair, then walking.
15. Patient education and discharge planning: Teach about medication adherence, smoking cessation, vaccination (influenza, pneumococcal), recognising relapse symptoms, follow-up appointments.
(c) Complications of Pneumonia:
1. Pleural effusion and empyema: Fluid accumulation in pleural space may become purulent (empyema). Requires chest tube drainage and prolonged antibiotics.
2. Lung abscess: Localized necrosis and cavitation filled with pus. Presents with persistent fever, weight loss, foul-smelling sputum. Needs prolonged antibiotics, sometimes surgical drainage.
3. Sepsis and septic shock: Bacteremia leading to systemic inflammatory response, hypotension, multi-organ dysfunction. Mortality 20-50%. Requires ICU care.
4. Respiratory failure: Severe gas exchange impairment requiring mechanical ventilation. May develop ARDS (Acute Respiratory Distress Syndrome) with high mortality.
⚠️ CURB-65 Score for Severity: Confusion, Urea >7, RR >30, BP <90 /60, Age>65. Score ≥3 = severe pneumonia requiring hospitalization!
Original examination paper