AHN-1-PAPER SOLUTION NO.10

Section-A

Q-1. (A) What is Angina pectoris? Write down the causes and risk factors of developing coronary artery disease. (2+3=5)

📘 Definition:

Angina pectoris is a clinical condition characterized by chest pain or discomfort that occurs when the heart muscle does not get enough oxygen-rich blood (myocardial ischemia). It is commonly described as a tightness, heaviness, pressure, or squeezing sensation in the chest.

✅ It is a symptom of coronary artery disease (CAD), not a disease itself.

🫀 Key Features:

• Usually triggered by physical exertion, emotional stress, or cold weather
• Pain may radiate to the left arm, neck, jaw, or back
• Relieved by rest or nitroglycerin
• Lasts for a few minutes (typically less than 10–15 min)

🔍 Causes of Coronary Artery Disease:

1️⃣ Atherosclerosis (Primary and Most Common Cause):

• A progressive condition in which lipid-rich plaques (composed of cholesterol, inflammatory cells, calcium, etc.) deposit inside the intima (inner lining) of coronary arteries.
• These plaques reduce the lumen diameter, decreasing blood flow and oxygen supply to cardiac tissue.
• Over time, plaque rupture may trigger clot formation (thrombosis), completely blocking the artery.

2️⃣ Coronary Artery Spasm (Vasospasm):

• A sudden, temporary tightening of the muscles within the coronary artery wall.
• It can occur even in the absence of atherosclerosis and is often associated with variant (Prinzmetal’s) angina.
• Triggers include cold exposure, stress, cocaine use, and smoking.

3️⃣ Coronary Thromboembolism:

• A blood clot may form at the site of a ruptured atherosclerotic plaque (thrombosis) or travel from another site (embolism), causing sudden obstruction.
• Leads to acute coronary syndrome (ACS) including unstable angina or myocardial infarction.

4️⃣ Inflammatory and Autoimmune Diseases:

• Conditions like vasculitis, rheumatoid arthritis, and systemic lupus erythematosus (SLE) can damage arterial walls and promote atherosclerosis.

5️⃣ Congenital Coronary Artery Abnormalities:

• Rare congenital malformations of the coronary arteries may impair blood flow and increase CAD risk, especially in younger individuals.

6️⃣ Radiation-Induced Coronary Damage:

• Patients receiving radiation therapy to the chest area (e.g., for breast or lung cancer) may develop fibrotic damage to coronary vessels.

⚠️ Risk Factors for Coronary Artery Disease:

Risk factors are the conditions or behaviors that increase the likelihood of developing CAD. They are broadly classified into modifiable and non-modifiable types.

🔹 A. Modifiable Risk Factors (Can Be Controlled or Prevented):

1. Hypertension (High Blood Pressure):

• Damages the inner lining (endothelium) of arteries, making them more susceptible to plaque buildup.
• Increases myocardial oxygen demand.

2. Hyperlipidemia (High Blood Cholesterol):

• Elevated LDL cholesterol and triglycerides directly contribute to plaque formation.
• Low HDL cholesterol fails to clear cholesterol from vessels.

3. Diabetes Mellitus:

• Chronic high blood glucose leads to glycation of vascular proteins and accelerates atherosclerosis.
• Also promotes inflammation and endothelial dysfunction.

4. Smoking and Tobacco Use:

• Nicotine increases sympathetic activity and vasoconstriction.
• Carbon monoxide reduces oxygen-carrying capacity of blood.
• Increases blood clotting, inflammation, and arterial damage.

5. Obesity and Sedentary Lifestyle:

• Associated with metabolic syndrome, insulin resistance, and chronic inflammation.
• Excess body fat, especially central obesity, is directly linked to cardiovascular risk.

6. Unhealthy Diet:

• Diets rich in saturated fats, trans fats, sugar, salt, and processed foods increase risk.
• Lack of fiber, fruits, and vegetables contributes to poor heart health.

7. Excessive Alcohol Intake:

• Raises blood pressure and triglyceride levels, increases risk of arrhythmias and cardiomyopathy.

8. Stress and Poor Emotional Health:

• Chronic stress raises cortisol levels, increasing blood pressure and promoting inflammation.
• Stress-related behaviors (smoking, overeating) add to risk.

🔸 B. Non-Modifiable Risk Factors (Cannot Be Changed):

1. Age:

• Risk increases with age due to gradual arterial stiffness and prolonged exposure to risk factors.
• Men >45 years and women >55 years are more prone.

2. Gender:

• Men have a higher early risk, though post-menopausal women show rapidly increasing risk due to decline in estrogen (which has protective effects).

3. Family History of CAD:

• Genetic predisposition plays a role. Having a first-degree relative (parent/sibling) with premature CAD (men <55, women <65) raises personal risk.

4. Ethnicity:

• Some ethnic groups (e.g., South Asians, African Americans) have higher risk of CAD due to genetic and lifestyle patterns.

5. Genetic Disorders:

• Conditions such as familial hypercholesterolemia cause early-onset atherosclerosis.

(B) Write down the nursing management of patient with angina pectoris (05 MARKS)

Angina pectoris is a clinical manifestation of myocardial ischemia, characterized by transient chest pain or discomfort due to inadequate oxygen supply to the heart muscles. It is most commonly associated with coronary artery disease (CAD) and is often triggered by physical exertion or emotional stress.

The role of the nurse is crucial in early identification, symptomatic relief, patient monitoring, education, and prevention of complications such as myocardial infarction.

🩺 Nursing Management of a Patient with Angina Pectoris:

Nursing care involves a multidimensional approach including assessment, pain management, oxygen therapy, medication administration, activity planning, psychological support, and health education.

1️⃣ Comprehensive Assessment and Monitoring:

• ✅ Assess the quality, duration, and location of chest pain (e.g., crushing, radiating, sharp).
• ✅ Ask about triggering and relieving factors (exertion, stress, nitroglycerin, rest).
• ✅ Monitor vital signs: BP, HR, RR, SpO₂, and temperature every 15–30 minutes during pain episodes.
• ✅ Continuous cardiac monitoring (telemetry/ECG) to detect ST changes or arrhythmias.
• ✅ Evaluate for associated symptoms: sweating, palpitations, nausea, pallor, dyspnea.
• ✅ Monitor intake-output, urine output, and signs of reduced perfusion (e.g., cold extremities).

2️⃣ Pain Relief During Angina Attack:

• 🛏 Place the patient in a semi-Fowler’s or high-Fowler’s position to enhance oxygenation and reduce preload.
• 💊 Administer Sublingual Nitroglycerin as prescribed:
  • One tablet every 5 minutes (up to 3 times) — monitor BP closely.
• 💨 Start oxygen therapy (2–5 L/min via nasal cannula) if oxygen saturation is <94%.
• 💊 Morphine sulfate may be given for unrelieved chest pain (also reduces preload).
• 👂 Stay with the patient, provide calm reassurance, and reduce environmental stimuli.

3️⃣ Medication Management and Administration:

• Administer prescribed cardiac medications:
  • Nitrates – vasodilation, reduced preload
  • Beta-blockers (e.g., Metoprolol) – reduce heart rate and myocardial oxygen demand
  • Calcium channel blockers – reduce vasospasm
  • Antiplatelet agents (Aspirin, Clopidogrel) – prevent clot formation
  • Statins – control cholesterol and stabilize plaques
• Monitor for adverse effects: hypotension, bradycardia, bleeding, dizziness.
• Ensure strict compliance with medication schedule and document response.

4️⃣ Oxygenation and Respiratory Care:

• Provide humidified oxygen therapy and assess lung sounds regularly.
• Maintain airway patency and observe for signs of hypoxia or cyanosis.
• Encourage deep breathing exercises and monitor arterial blood gases if ordered.

5️⃣ Rest and Activity Regulation:

• Enforce bed rest during acute episodes to minimize oxygen demand.
• Encourage limited physical activity only after pain subsides.
• Gradually increase activity level based on cardiac tolerance and physician advice.
• Teach the patient how to use a pain scale and report angina episodes.

6️⃣ Psychological and Emotional Support:

• Anxiety and fear can worsen angina due to catecholamine release.
• Provide a calm, supportive environment.
• Allow expression of feelings and involve family in counseling.
• Refer to mental health professionals if anxiety is severe or persistent.

7️⃣ Nutritional Management:

• Educate and assist in planning a heart-healthy diet:
  • Low-fat, low-sodium, low-cholesterol
  • Rich in fiber, fruits, vegetables, whole grains
• Encourage small, frequent meals to avoid cardiac overload.
• Advise avoiding heavy meals, caffeine, and alcohol, which may trigger angina.

8️⃣ Patient and Family Education:

• Teach the patient to:
  • Identify warning signs of angina and differentiate it from heartburn or other pain.
  • Proper use and storage of nitroglycerin tablets (dark glass bottle, keep dry).
  • Avoid known triggers: physical strain, emotional stress, cold exposure.
  • Adopt lifestyle changes: quit smoking, maintain healthy weight, manage stress.
• Emphasize importance of follow-up and adherence to medical therapy.
• Encourage participation in cardiac rehabilitation programs.

9️⃣ Discharge Planning and Community Support:

• Ensure the patient and caregiver are prepared for home care and emergency actions.
• Provide written instructions on:
  • Medication schedule and dose
  • Angina diary to track episodes
  • Emergency steps during chest pain
• Refer to support groups or tele-nursing follow-ups for long-term monitoring.

🔟 Documentation:

• Record:
  • Onset, duration, location, and severity of pain
  • Vital signs and SpO₂ trends
  • Medication given and response
  • Patient education provided
  • Nursing interventions and evaluation

Q-2. Write short notes (Any Four)

1) Management of Acute Renal Failure.

Acute Renal Failure (ARF), now commonly termed Acute Kidney Injury (AKI), refers to a sudden, rapid decline in kidney function over hours to days, resulting in the accumulation of nitrogenous wastes, electrolyte imbalance, and fluid retention.

ARF may be reversible if managed appropriately. It is a medical emergency that requires prompt diagnosis, multidisciplinary care, and nursing vigilance to restore renal function, correct biochemical disturbances, and prevent progression to chronic kidney disease (CKD).

🎯 Goals of Management:

• Identify and treat the underlying cause
• Restore and maintain renal perfusion
• Manage fluid and electrolyte balance
• Prevent or treat life-threatening complications
• Support renal function
• Provide nutritional and psychological care

🧪 1️⃣ Medical Management of ARF:

A. Identification and Treatment of Underlying Cause:

• Prerenal Causes: (e.g., dehydration, hemorrhage, shock)
  → Administer IV fluids (e.g., isotonic saline), treat sepsis, correct hypotension
• Intrinsic Renal Causes: (e.g., nephrotoxic drugs, glomerulonephritis)
  → Discontinue nephrotoxic agents (e.g., aminoglycosides, NSAIDs), treat infection/inflammation
• Postrenal Causes: (e.g., urinary obstruction)
  → Catheterize bladder, relieve ureteral obstruction via stenting/surgery

B. Fluid Management:

• Oliguric phase:
  • Restrict fluids based on urine output + insensible loss (approx. 600 mL/day)
  • Monitor for signs of overload: edema, hypertension, dyspnea
• Diuretic phase:
  • Carefully replace fluid loss with IV fluids
  • Prevent dehydration and hypotension
• Use of Diuretics:
  • Furosemide may be used to promote diuresis in selected cases

C. Electrolyte and Acid-Base Management:

• Hyperkalemia:
  • Emergency: IV calcium gluconate, insulin + dextrose, sodium bicarbonate
  • Sodium polystyrene sulfonate (Kayexalate) or dialysis if severe
• Hyponatremia:
  • Fluid restriction or cautious sodium correction
• Metabolic Acidosis:
  • IV sodium bicarbonate for severe acidosis (pH <7.2)

D. Renal Replacement Therapy (Dialysis):

Indications:

• Severe fluid overload
• Persistent hyperkalemia
• Uremic symptoms: pericarditis, encephalopathy
• Severe acidosis
• Creatinine >8–10 mg/dL (in some cases)

Types:

• Intermittent Hemodialysis (IHD)
• Continuous Renal Replacement Therapy (CRRT) – for critically ill
• Peritoneal Dialysis (PD) – in selected cases

E. Pharmacological Management:

• Avoid nephrotoxic medications
• Adjust doses of antibiotics and other drugs based on renal clearance
• Use of dopamine (low dose) is controversial and rarely effective
• Anti-hypertensives if BP rises in later stages
• Proton pump inhibitors to prevent GI bleeding

F. Nutritional Support:

• High calorie, low protein diet to minimize uremic waste
• Restrict potassium, sodium, and phosphorus
• Oral or enteral nutrition preferred
• Parenteral nutrition if GI tract not functional

👩‍⚕️ 2️⃣ Nursing Management of ARF:

A. Continuous Assessment and Monitoring:

• Monitor:
  • Vital signs hourly during critical phase
  • Urine output (report <30 mL/hour)
  • Daily weight for fluid retention
  • Serum creatinine, BUN, electrolytes, ABG
  • Signs of uremia: confusion, nausea, pruritus
• Use indwelling catheter if needed (ensure strict asepsis)

B. Fluid and Electrolyte Balance:

• Maintain accurate intake-output chart
• Administer IV fluids cautiously as per prescription
• Monitor for:
  • Fluid overload: edema, lung crackles, high CVP
  • Electrolyte abnormalities: ECG changes (peaked T waves – hyperkalemia)

C. Infection Prevention:

• Use strict aseptic technique for all invasive procedures
• Regularly assess catheter and IV sites
• Encourage hand hygiene and hygiene care
• Monitor for fever, elevated WBC, foul-smelling urine

D. Skin and Pressure Injury Prevention:

• Risk increases due to edema, uremic toxins, and immobility
• Provide:
  • Frequent repositioning
  • Use pressure-relieving devices
  • Maintain clean, dry, moisturized skin

E. Nutritional Care:

• Collaborate with dietitian for:
  • Individualized meal plan
  • Educate on dietary potassium and protein restrictions
• Encourage small frequent meals, maintain fluid restrictions

F. Psychosocial and Emotional Support:

• Address patient anxiety, fear of dialysis or complications
• Educate:
  • Importance of medication compliance
  • Avoiding OTC nephrotoxic drugs
  • Warning signs: decreased urine, swelling, breathlessness
• Involve family in care planning
• Prepare the patient for long-term follow-up or rehabilitation

G. Education and Discharge Planning:

• Teach:
  • Dietary restrictions
  • Fluid monitoring at home
  • Medication adherence
  • When to seek immediate care (e.g., chest pain, shortness of breath, confusion)
• Schedule follow-up renal function tests
• Encourage participation in kidney support groups

⚠️ Complications to Prevent and Manage:

• Hyperkalemia → Cardiac arrest
• Pulmonary edema
• Metabolic acidosis
• Sepsis
• Uremic encephalopathy
• Chronic kidney disease (CKD) if unresolved

2) Hemorrhoid

Hemorrhoids, commonly known as piles, are swollen and inflamed veins in the anal canal and rectum, which may cause pain, bleeding, itching, and discomfort. They are one of the most common anorectal conditions, often caused by increased pressure due to straining during bowel movements, constipation, or pregnancy.

Hemorrhoids can be either internal (inside the rectum) or external (under the skin around the anus).

🔍 Etiology / Causes:

• Chronic constipation or diarrhea
• Straining during bowel movements
• Prolonged sitting (e.g., on the toilet)
• Low-fiber diet
• Obesity
• Pregnancy and childbirth
• Aging (weakening of vein walls)
• Heavy lifting or physical strain
• Hereditary tendency (weak vein walls)

🧬 Pathophysiology:

1. Increased pressure in rectal veins causes them to become dilated and tortuous.
2. Over time, the vascular cushions of the anal canal become enlarged.
3. These dilated veins can become inflamed, prolapse, or thrombosed.
4. The resulting hemorrhoids may bleed, protrude, or cause significant discomfort.

🧾 Types of Hemorrhoids:

🔹 1. Internal Hemorrhoids

• Arise above the dentate line
• Usually painless but may bleed
• Graded into:
  • Grade I – No prolapse, only bleeding
  • Grade II – Prolapse during defecation, reduces spontaneously
  • Grade III – Prolapse requires manual reduction
  • Grade IV – Irreducible prolapse

🔹 2. External Hemorrhoids

• Arise below the dentate line
• Covered by skin
• May be painful, especially when thrombosed
• Can form clots (thrombi) and swell significantly

⚠️ Signs and Symptoms:

• Bright red rectal bleeding (especially after defecation)
• Anal pain or discomfort
• Swelling or lump near the anus
• Itching or irritation around the anal region
• Mucus discharge
• Feeling of incomplete evacuation
• Thrombosed hemorrhoid: sudden, severe pain and bluish lump

🧪 Diagnostic Evaluation:

• History and physical examination
• Digital rectal examination (DRE)
• Proctoscopy or anoscopy
• Sigmoidoscopy or colonoscopy (to rule out other causes of bleeding)
• Hemoglobin level if chronic bleeding is suspected

💊 Medical Management:

🔹 Conservative Treatment:

• High-fiber diet (fruits, vegetables, whole grains)
• Adequate hydration
• Stool softeners (e.g., docusate sodium)
• Bulk-forming laxatives (e.g., psyllium husk)
• Topical ointments: hydrocortisone, lidocaine
• Warm sitz baths 2–3 times/day
• Anal hygiene

🔹 Non-surgical procedures:

• Rubber band ligation – most common outpatient method
• Infrared coagulation
• Sclerotherapy – injecting a solution to shrink hemorrhoids
• Cryotherapy

🏥 Surgical Management:

• Hemorrhoidectomy – excision of hemorrhoids (indicated in Grade III/IV)
• Stapled hemorrhoidopexy – newer technique with faster recovery
• Doppler-guided hemorrhoidal artery ligation (DGHAL)

👩‍⚕️ Nursing Management:

A. During Conservative Care:

• Educate on dietary changes and importance of fluid intake
• Encourage regular bowel habits and avoiding straining
• Administer prescribed ointments or laxatives
• Instruct on sitz bath technique
• Provide psychological support and privacy during care

B. Preoperative Nursing Care (if surgery needed):

• Explain surgical procedure
• Ensure bowel preparation if advised
• Assess for allergies and obtain informed consent
• Start IV line, NPO status as per policy

C. Postoperative Nursing Care:

• Monitor pain, bleeding, and infection
• Administer analgesics, stool softeners
• Encourage early ambulation to prevent constipation
• Reinforce hygiene and sitz baths
• Provide emotional support as patients may feel embarrassed

🚫 Complications:

• Anemia due to chronic bleeding
• Thrombosed hemorrhoids
• Infection or abscess formation
• Anal fissures or strictures (post-op)
• Recurrence if lifestyle not modified
• Fecal incontinence (rare)

Hemorrhoids are a common and distressing condition that significantly affects quality of life. With early detection, lifestyle modification, proper hygiene, medical treatment, and when necessary, surgical intervention, most cases can be effectively managed. Nurses play a key role in education, symptom relief, post-op care, and emotional support, promoting recovery and preventing recurrence.

3) Medical management of patient with diabetes mellitus

Diabetes Mellitus (DM) is a chronic metabolic disorder characterized by hyperglycemia (high blood sugar levels) due to defective insulin secretion, insulin action, or both. It includes Type 1 (insulin-dependent), Type 2 (non–insulin dependent), gestational diabetes, and other specific types.

Effective medical management is essential to control blood glucose levels, prevent acute and chronic complications, and improve the patient’s quality of life.

🎯 Goals of Medical Management:

• Maintain blood glucose within normal range
• Prevent acute complications (e.g., hypoglycemia, ketoacidosis)
• Delay or prevent long-term complications (neuropathy, nephropathy, retinopathy)
• Promote healthy lifestyle and self-care
• Improve quality of life and life expectancy

💊 1️⃣ Pharmacological Management:

🔹 A. Insulin Therapy (Mainly for Type 1 and severe Type 2):

• Short-acting insulin: Regular insulin
• Intermediate-acting insulin: NPH
• Long-acting insulin: Glargine, Detemir
• Rapid-acting insulin: Lispro, Aspart
• Mixed preparations: Premixed insulins (e.g., 70/30)

📝 Administration Route: Subcutaneous (SC) injection
🧪 Monitoring: Capillary blood glucose or continuous glucose monitoring
📅 Regimen: Basal-bolus, sliding scale, or fixed-dose

🔹 B. Oral Hypoglycemic Agents (Mainly for Type 2 DM):

📌 Note: Drug choice depends on patient’s age, weight, kidney/liver function, and co-morbidities.

🔹 C. Adjunctive Medications:

• Statins – to manage dyslipidemia
• ACE inhibitors/ARBs – to protect kidneys
• Low-dose Aspirin – for cardiovascular protection
• Antihypertensives – if hypertensive

🍎 2️⃣ Dietary and Nutritional Management:

• Balanced diabetic diet planned by dietitian
• Complex carbohydrates (whole grains), low glycemic index foods
• Adequate fiber intake
• Limit sugars, fats, and salty foods
• Monitor carbohydrate counting or follow plate method
• Avoid alcohol or use in moderation
• Maintain meal timing with medications/insulin

🏃‍♀️ 3️⃣ Exercise and Lifestyle Modification:

• Regular aerobic exercise (e.g., brisk walking, cycling) – at least 30 mins/day, 5 days/week
• Weight loss (especially in Type 2 DM) improves insulin sensitivity
• Avoid sedentary lifestyle
• Foot care and appropriate footwear
• Smoking cessation and alcohol limitation

🧪 4️⃣ Blood Glucose Monitoring:

• Self-monitoring of blood glucose (SMBG) – by glucometer
• Fasting blood glucose (FBS), Postprandial (PPBS), and HbA1c (every 3 months)
• Target HbA1c: <7%

🚑 5️⃣ Management of Acute Diabetic Emergencies:

🔸 Hypoglycemia:

• Immediate administration of 15–20 g of glucose orally
• IV dextrose 25–50% or IM glucagon if unconscious
• Monitor glucose every 15 minutes until stabilized

🔸 Diabetic Ketoacidosis (DKA):

• Hospitalization, IV insulin infusion
• IV fluids and electrolyte replacement (especially potassium)
• Monitor ABGs, ketones, and glucose regularly

🔸 Hyperosmolar Hyperglycemic State (HHS):

• Similar to DKA, but usually without ketosis
• Requires aggressive fluid and insulin therapy

👩‍⚕️ 6️⃣ Patient Education and Counseling:

• Importance of medication adherence
• Recognizing signs of hypoglycemia/hyperglycemia
• Proper insulin storage and injection techniques
• Routine foot inspection
• Eye, kidney, and dental check-ups
• Sick day rules: Continue medication, stay hydrated, monitor sugar more frequently
• Encourage participation in diabetic education programs

🧠 7️⃣ Long-term Follow-Up and Screening:

• Retinopathy screening – annual eye exams
• Nephropathy monitoring – urine microalbumin test
• Neuropathy check – sensation testing (monofilament)
• Cardiovascular risk screening – ECG, lipid profile

Medical management of diabetes mellitus is comprehensive and lifelong. It involves a combination of pharmacologic therapy, dietary regulation, exercise, blood glucose monitoring, and patient education. Timely intervention and consistent follow-up can prevent acute crises and reduce the risk of long-term complications, thus improving patient outcomes and quality of life. Nurses play a vital role in monitoring therapy, educating patients, and ensuring safe and effective diabetes control.

4) Alopecia

Alopecia is a medical term for partial or complete loss of hair from areas of the body where it normally grows, especially the scalp. It may be temporary or permanent, and it can affect both men and women of any age. Alopecia may be due to genetic, autoimmune, nutritional, environmental, or psychological factors.

Alopecia can significantly affect a person’s self-esteem, emotional well-being, and quality of life, and requires a holistic management approach, especially by nurses and healthcare providers.

🧠 Definition:

Alopecia is defined as the loss of hair from the scalp or any part of the body. It can be diffuse, patchy, or complete, and may be scarring (permanent) or non-scarring (reversible) depending on the cause.

🔍 Types of Alopecia:

1. Androgenetic Alopecia (Male or Female Pattern Baldness):

• Most common type
• Caused by genetic predisposition and hormonal factors
• Gradual thinning over the crown or hairline

2. Alopecia Areata:

• Autoimmune condition
• Sudden patchy hair loss on scalp, beard, eyebrows
• Can progress to Alopecia Totalis (total scalp loss) or Alopecia Universalis (total body loss)

3. Telogen Effluvium:

• Temporary hair loss due to stress, illness, surgery, childbirth
• Hair enters resting phase (telogen) prematurely

4. Traction Alopecia:

• Caused by constant pulling or tension on hair (tight hairstyles, rollers)
• Common in certain cultural practices

5. Cicatricial (Scarring) Alopecia:

• Permanent hair loss due to inflammation, infection, burns, lupus, or skin conditions
• Destroys hair follicles

6. Anagen Effluvium:

• Rapid hair loss during active growth phase, often due to chemotherapy or radiation therapy

🔍 Causes and Risk Factors of Alopecia (Refined in Points):

1. Genetic Factors:
   • Family history of baldness or early-onset hair loss significantly increases the risk of developing androgenetic alopecia (male or female pattern baldness).
2. Autoimmune Disorders:
   • Conditions like alopecia areata, systemic lupus erythematosus, and thyroid autoimmune disease can lead to the immune system attacking hair follicles, resulting in patchy or widespread hair loss.
3. Infectious Causes:
   • Fungal infections like tinea capitis, bacterial infections, or syphilis can damage the scalp and hair follicles, leading to localized hair loss.
4. Hormonal Imbalances:
   • Disorders such as polycystic ovarian syndrome (PCOS), hypothyroidism, hyperthyroidism, and post-pregnancy hormonal shifts can contribute to hair thinning or shedding.
5. Nutritional Deficiencies:
   • Deficiencies in iron, zinc, biotin, vitamin D, and protein can impair hair growth and strength, causing diffuse hair loss.
6. Medications and Treatments:
   • Drugs such as chemotherapy agents, retinoids, anticoagulants, antidepressants, and beta-blockers may cause reversible or irreversible hair loss.
7. Stress and Psychological Factors:
   • Both physical stress (surgery, high fever, childbirth) and emotional stress (depression, anxiety) can trigger telogen effluvium, leading to sudden diffuse hair shedding.
8. Hair Styling and Chemical Exposure:
   • Frequent use of tight hairstyles (braids, ponytails), hair coloring, perms, straightening, and heat styling tools can damage hair roots, leading to traction alopecia.
9. Radiation or Physical Trauma:
   • Burn injuries, radiation therapy to the head, or mechanical trauma to the scalp can destroy hair follicles, resulting in permanent (scarring) hair loss.
10. Chronic Illnesses:

• Conditions like diabetes mellitus, liver disease, and chronic kidney disease may interfere with normal hair growth cycles, contributing to hair loss.

11. Aging:

• As a natural part of aging, hair may thin and fall due to slower cell turnover and hormonal changes, especially in post-menopausal women and elderly men.

⚠️ Signs and Symptoms:

• Gradual or sudden hair thinning or shedding
• Patchy bald spots (smooth or inflamed)
• Scalp itching, burning, or discomfort (in some types)
• Hair that breaks easily
• Loss of eyebrows, eyelashes, or body hair (in advanced forms)
• Visible scars or redness (in scarring alopecia)

🧪 Diagnostic Evaluation:

• History and Physical Examination
• Hair pull test – to assess shedding
• Scalp biopsy – especially for scarring types
• Dermatoscopy – for hair follicle patterns
• Blood tests – to check:
  • CBC, thyroid profile (T3, T4, TSH)
  • ANA (autoimmune screen)
  • Ferritin, iron, vitamin B12, zinc
  • Hormonal tests in females (testosterone, DHEA)
• Fungal culture – for suspected tinea infections

💊 Medical Management:

🔹 1. Topical Medications:

• Minoxidil (2% or 5%) – promotes hair growth, commonly used for androgenetic alopecia
• Corticosteroid creams or injections – for alopecia areata
• Anthralin, Tacrolimus – used in autoimmune-related cases

🔹 2. Systemic Therapy:

• Oral corticosteroids – short-term use in alopecia areata
• Immunosuppressants – e.g., methotrexate, cyclosporine (in severe autoimmune cases)
• Finasteride (in males) – reduces DHT, slows androgenetic alopecia
• Hormonal therapy – for PCOS or female hormonal imbalance

🔹 3. Surgical Management:

• Hair transplant surgery – in stable cases of pattern baldness
• Scalp reduction – rarely used now
• Micrografting/Follicular unit extraction (FUE)

🔹 4. Cosmetic and Supportive Options:

• Wigs, hairpieces
• Scalp camouflage products (sprays, fibers)
• Cosmetic tattooing (for eyebrows)
• Counseling and psychological support

👩‍⚕️ Nursing Management:

A. Assessment and Monitoring:

• Assess extent and pattern of hair loss
• Identify potential triggers: stress, recent illness, diet
• Monitor treatment response and side effects

B. Patient Education:

• Teach proper hair care practices
• Advise on avoiding harsh chemicals and heat styling
• Emphasize importance of nutrition (protein, iron, zinc)
• Encourage compliance with prescribed medications

C. Psychological Support:

• Provide emotional reassurance and support body image concerns
• Refer to counseling if patient has depression or low self-esteem
• Encourage support groups or peer counseling

D. Skin and Scalp Care:

• Maintain clean scalp to prevent infections
• Use hypoallergenic, mild shampoos
• Apply topical medications as prescribed

🚫 Complications:

• Permanent baldness in scarring alopecia
• Psychological impact: depression, anxiety, poor self-image
• Social withdrawal due to embarrassment
• Scalp infections if hygiene neglected
• Poor treatment adherence due to slow results

Alopecia is a complex condition that affects not just hair but also a patient’s mental and emotional health. Management requires a comprehensive, multidisciplinary approach involving medical treatment, nutritional support, hair care guidance, and psychological counseling. Nurses have a key role in early recognition, education, emotional reassurance, and continuous care to help patients manage alopecia effectively and regain confidence.

5) Transmission of HIV infections.

Human Immunodeficiency Virus (HIV) is a retrovirus that attacks and weakens the human immune system, specifically targeting CD4+ T-lymphocytes. Over time, if untreated, HIV leads to Acquired Immunodeficiency Syndrome (AIDS) – a life-threatening condition characterized by profound immune suppression and susceptibility to opportunistic infections.

HIV does not spread through casual contact but is transmitted through specific body fluids via certain modes of transmission. Understanding its transmission is essential for prevention, education, and reducing stigma.

🌡️ Causative Agent:

• HIV-1 and HIV-2 are the two main types of the virus
• HIV-1 is more prevalent globally and more virulent
• It is a bloodborne, sexually transmitted virus

🔬 Body Fluids That Can Transmit HIV:

HIV is present in the following body fluids of an infected person:

1. Blood
2. Semen
3. Vaginal and cervical secretions
4. Rectal fluids
5. Breast milk

🛑 Note: Saliva, sweat, tears, and urine do not transmit HIV unless visibly mixed with blood.

🔄 Modes of Transmission of HIV:

1. Sexual Transmission:

• The most common route globally
• Occurs during unprotected vaginal, anal, or oral sex with an HIV-infected partner
• High risk with:
  • Presence of genital sores or STDs
  • Receptive anal intercourse (especially high risk)
  • Multiple sexual partners
  • Lack of condom use

2. Blood and Blood Product Transmission:

• Through transfusion of infected blood or blood products
• Rare now due to rigorous screening in blood banks
• May occur through:
  • Contaminated needles/syringes
  • Unsafe blood transfusion (especially in resource-poor settings)
  • Sharing razors, tattooing needles, or piercing tools without sterilization

3. Mother-to-Child Transmission (Vertical Transmission):

• Occurs during:
  • Pregnancy
  • Labor and delivery
  • Breastfeeding
• Risk is 15–45% without treatment
• Can be reduced to <2% with antiretroviral therapy (ART), safe delivery practices, and avoidance of breastfeeding or formula feeding with precautions

4. Occupational Exposure:

• Risk to healthcare workers through:
  • Needle-stick injuries
  • Contact with infected blood through broken skin or mucous membranes
• Risk is low but Post-Exposure Prophylaxis (PEP) must be initiated within 72 hours

5. Injection Drug Use:

• Sharing of contaminated needles, syringes, or drug preparation equipment
• High prevalence in populations who inject drugs
• HIV spreads rapidly in this group if harm reduction strategies (like needle-exchange programs) are not followed

6. Organ or Tissue Transplantation:

• Rare but possible if donor screening is missed
• HIV testing of donors has made this route extremely rare

❌ Routes Through Which HIV is NOT Transmitted:

• Shaking hands, hugging, or touching
• Sharing utensils, toilets, or food
• Coughing, sneezing, or air transmission
• Mosquito or insect bites
• Swimming pools or public spaces

👩‍⚕️ Nursing Role in Preventing HIV Transmission:

1. Health education and awareness on safe sex practices and use of condoms
2. Promote routine HIV testing and counseling (VCT, ICTC)
3. Provide pre- and post-test counseling
4. Encourage single-use needles and safe blood transfusion practices
5. Educate pregnant mothers about ART and safe infant feeding
6. Ensure PEP availability and training for healthcare workers
7. Help reduce stigma and discrimination

HIV is not a casually communicable disease. It spreads through specific body fluids via preventable routes, and its transmission can be effectively interrupted with awareness, protective measures, early diagnosis, and antiretroviral treatment. Nurses play a crucial role in prevention, education, counseling, and supporting both infected and at-risk individuals, helping control the spread of the virus and reducing stigma in society.

Q-3. Answer the following

(A) Explain the infection control measures to prevent transmission of communicable diseases.

Infection control is a critical aspect of public health and clinical nursing practice. Communicable diseases are caused by pathogens such as bacteria, viruses, fungi, or parasites that can spread directly or indirectly from one person to another. Infection control measures aim to break the chain of infection and protect individuals, families, communities, and especially vulnerable populations such as children, elderly, and immunocompromised individuals.

These measures are particularly vital in healthcare settings, where the risk of nosocomial (hospital-acquired) infections is high, and in communities facing epidemics or pandemics (e.g., COVID-19, TB, dengue, hepatitis).

🧬 Chain of Infection and Its Interruption:

To effectively prevent communicable diseases, each link in the chain of infection must be interrupted:

1. Infectious Agent – Identification and control
2. Reservoir – Elimination or control of the source
3. Portal of Exit – Barrier protection (PPE)
4. Mode of Transmission – Hand hygiene, disinfection
5. Portal of Entry – Aseptic technique
6. Susceptible Host – Immunization and health promotion

✅ Detailed Infection Control Measures:

🔹 1. Hand Hygiene:

• Most effective and simplest method of preventing disease transmission.
• Includes handwashing with soap and water for at least 20 seconds or using alcohol-based hand sanitizers (minimum 60% alcohol).
• Essential in community, clinical, and home settings.
• Should be done:
  • Before and after patient contact
  • After contact with blood, secretions, or contaminated surfaces
  • Before preparing food and after using the toilet

🔹 2. Use of Personal Protective Equipment (PPE):

• PPE includes gloves, gowns, masks, goggles, face shields, and shoe covers.
• Prevents contact with infectious agents in blood, droplets, or body fluids.
• Proper donning (putting on) and doffing (removal) techniques prevent contamination.
• Selection of PPE depends on the level of exposure risk and mode of transmission.

🔹 3. Respiratory Hygiene and Cough Etiquette:

• Encouraging individuals to cover mouth and nose with tissue or elbow while sneezing or coughing.
• Use of masks by patients with respiratory infections.
• Educating the public through posters, campaigns, and counseling on respiratory hygiene reduces droplet spread.

🔹 4. Environmental Cleaning and Sanitation:

• Routine cleaning and disinfection of high-touch surfaces (bed rails, door handles, mobile devices).
• Use of appropriate disinfectants such as sodium hypochlorite, phenyl, and alcohol solutions.
• Proper ventilation and clean water supply.
• Maintaining toilet hygiene in public and healthcare settings.

🔹 5. Safe Injection and Sharps Practices:

• Always use sterile, single-use disposable syringes and needles.
• Never recap needles after use; use needle destroyers.
• Dispose of sharps in puncture-proof containers.
• Follow universal precautions during any invasive procedure.

🔹 6. Biomedical Waste Management:

• Segregation at source using color-coded bins:
  • Yellow – human and anatomical waste
  • Red – contaminated plastic waste
  • Blue – glassware
  • White – sharps
• Follow national/institutional biomedical waste handling protocols.
• Prevents environmental contamination and accidental exposure.

🔹 7. Isolation and Quarantine Practices:

• Isolation refers to separating sick individuals with communicable diseases (e.g., TB, measles).
• Quarantine involves restricting movement of individuals who have been exposed but are not yet symptomatic (e.g., during COVID-19).
• Use of negative pressure rooms, proper PPE, and restricted entry protocols are essential.

🔹 8. Vaccination and Immunization:

• A highly effective primary prevention tool.
• Ensures herd immunity and prevents disease outbreaks.
• Includes:
  • Childhood immunization schedule (e.g., BCG, DPT, Polio)
  • Adult vaccines (e.g., hepatitis B, influenza, HPV)
  • Healthcare worker immunizations (e.g., Hepatitis B, COVID-19)

🔹 9. Vector Control Measures:

• Eliminate breeding sites by removing stagnant water (e.g., old tires, water tanks).
• Use of insecticide-treated nets (ITNs), repellents, and indoor residual spraying (IRS).
• Educate the public on preventing mosquito-borne diseases like malaria, dengue, and chikungunya.

🔹 10. Public Health Education and Awareness:

• Educate communities on:
  • Safe food and water handling
  • Sexual hygiene (use of condoms to prevent STIs)
  • Importance of early diagnosis and treatment
  • Myth-busting and removing stigma related to diseases like HIV/AIDS, leprosy, TB.
• Use mass media, health talks, posters, and interpersonal communication.

🔹 11. Disease Surveillance and Early Notification:

• Active surveillance helps in early detection of outbreaks.
• Timely reporting of notifiable diseases to local health authorities (e.g., cholera, TB, COVID-19).
• Facilitates early intervention, contact tracing, and community protection.

🔹 12. Post-Exposure Prophylaxis (PEP):

• Initiated within 72 hours of exposure (e.g., HIV, rabies, hepatitis B).
• Involves antiviral or antiserum administration, counseling, and follow-up testing.
• Nurses must ensure availability and educate peers on PEP protocols.

👩‍⚕️ Role of Nurses in Infection Control:

1. Adhering to infection control protocols in clinical settings
2. Educating patients and families on personal hygiene, disease prevention, and vaccination
3. Conducting screening and surveillance during community visits
4. Ensuring availability of PPE, disinfectants, and waste disposal tools
5. Supporting patients under isolation/quarantine and reducing stigma
6. Participating in infection control committees and training programs

Infection control is a core responsibility in public health and nursing practice. With increasing globalization, migration, and emerging infections, it is essential to apply evidence-based infection control measures at individual, institutional, and community levels. Nurses serve as advocates, educators, and implementers, playing a vital role in protecting healthcare workers, patients, and the public from the spread of communicable diseases.

(B) Post operative care of patient undergone coronary CABG

Coronary Artery Bypass Grafting (CABG) is a major open-heart surgery performed to restore blood flow to the myocardium in patients with coronary artery disease (CAD). It involves grafting a healthy vessel (usually from the leg or arm) to bypass blocked coronary arteries.

The post-operative period is critical for recovery, prevention of complications, and restoring functional capacity. Nurses play a vital role in monitoring, supporting, educating, and rehabilitating patients post-CABG.

🧪 Goals of Post-Operative Care:

• Maintain hemodynamic stability
• Promote cardiac and pulmonary function
• Prevent complications (e.g., infection, arrhythmias, thromboembolism)
• Provide pain management and wound care
• Support psychological well-being and rehabilitation

✅ Immediate Post-Operative Care (First 24–72 Hours):

🔹 1. Monitoring Vital Signs and Hemodynamics:

• Continuous ECG monitoring for arrhythmias
• Hourly BP, pulse, respiratory rate, oxygen saturation
• Invasive monitoring: central venous pressure (CVP), arterial line, urine output
• Watch for signs of cardiogenic shock, tamponade, or bleeding

🔹 2. Ventilatory Support and Pulmonary Care:

• Patient usually on mechanical ventilation for 6–12 hours post-op
• Weaning as per ABG and respiratory status
• Encourage deep breathing, coughing, incentive spirometry once extubated
• Prevent atelectasis and pneumonia

🔹 3. Pain Management:

• Administer IV analgesics (morphine, fentanyl) as prescribed
• Monitor pain levels using numeric or verbal rating scales
• Educate patient on splinting the chest during coughing

🔹 4. Bleeding and Drainage Monitoring:

• Monitor chest tube output (normal: <150 mL/hr initially, decreasing)
• Observe for sudden increase in output or signs of cardiac tamponade
• Assess dressing for signs of saturation or hematoma

🔹 5. Fluid and Electrolyte Balance:

• Monitor for fluid overload or dehydration
• Replace electrolytes (K⁺, Mg²⁺) as needed
• Strict input-output monitoring

✅ Intermediate Post-Operative Care (Days 2–5):

🔹 6. Cardiac Monitoring and Management:

• Observe for arrhythmias (e.g., atrial fibrillation, PVCs)
• Administer anti-arrhythmic drugs if ordered
• Monitor for myocardial ischemia or infarction

🔹 7. Wound and Infection Care:

• Inspect sternal incision and graft site daily for redness, swelling, discharge
• Maintain aseptic dressing technique
• Watch for fever, elevated WBC, signs of sepsis

🔹 8. Early Ambulation and Mobility:

• Start gradual mobilization 24–48 hours post-op
• Prevent DVT and pulmonary embolism
• Provide TED stockings, leg exercises, and physiotherapy

🔹 9. Gastrointestinal and Renal Monitoring:

• Monitor for ileus and provide laxatives if needed
• Encourage early oral fluids and diet as tolerated
• Monitor urine output and renal function tests

✅ Later Post-Operative Care and Discharge Planning:

🔹 10. Psychological Support:

• Address anxiety, fear, depression
• Encourage emotional expression
• Provide reassurance and counseling

🔹 11. Patient Education:

• Teach about sternal precautions (no lifting >5 kg, avoid pushing/pulling)
• Educate on wound care, medications (antiplatelets, beta-blockers)
• Lifestyle changes: low-fat diet, exercise, stress control, smoking cessation

🔹 12. Discharge and Rehabilitation:

• Enroll in cardiac rehabilitation program
• Follow-up appointments with cardiologist and surgeon
• Monitor for late complications (sternal infection, angina, heart failure)

⚠️ Common Complications Post-CABG:

• Infection (sternal wound, pneumonia, UTI)
• Arrhythmias (especially atrial fibrillation)
• Bleeding or cardiac tamponade
• Stroke or transient ischemic attack (TIA)
• Renal dysfunction
• Depression or anxiety

👩‍⚕️ Nursing Responsibilities After CABG (Pointwise)

🛌 1. Monitoring and Assessment

• Monitor vital signs (BP, HR, RR, SpO₂) every 15–30 minutes initially, then hourly.
• Continuous ECG monitoring to detect arrhythmias.
• Assess level of consciousness and neurological status.
• Monitor central venous pressure (CVP) and arterial line if present.
• Observe for signs of cardiac tamponade (muffled heart sounds, hypotension).

💉 2. Pain and Comfort Management

• Administer prescribed IV analgesics (e.g., morphine).
• Use pain scales to assess intensity and response.
• Encourage splinting of chest during coughing or movement.

💨 3. Respiratory Care

• Maintain airway patency and support ventilation (if intubated).
• Encourage deep breathing exercises and use of incentive spirometry post-extubation.
• Monitor for signs of pulmonary complications (e.g., atelectasis, pneumonia).

🚰 4. Fluid and Electrolyte Balance

• Maintain strict intake-output records.
• Monitor urine output (≥0.5 mL/kg/hr).
• Observe for fluid overload or hypovolemia.
• Replace potassium and magnesium as ordered.

🩸 5. Bleeding and Drainage Observation

• Monitor chest tube output hourly and report if >150 mL/hr.
• Assess dressing for bleeding or hematoma formation.
• Observe for signs of internal bleeding (tachycardia, low BP).

🧼 6. Wound and Infection Control

• Perform sterile dressing changes as ordered.
• Inspect sternal and graft site wounds daily.
• Monitor for redness, swelling, discharge, and fever.

🧠 7. Neurological and Psychological Support

• Assess for postoperative confusion or delirium.
• Provide reassurance and emotional support.
• Educate family and patient about expected progress.

🧍‍♂️ 8. Early Mobilization and DVT Prevention

• Encourage gradual ambulation starting Day 1–2 post-op.
• Perform passive and active leg exercises.
• Apply anti-embolism stockings if prescribed.
• Administer anticoagulants (e.g., LMWH) as ordered.

🍽️ 9. Nutritional Support

• Begin with clear fluids and progress to cardiac diet as tolerated.
• Monitor for nausea, vomiting, ileus.
• Encourage adequate protein intake for wound healing.

📚 10. Patient and Family Education

• Teach sternal precautions (e.g., avoid lifting, pushing, pulling).
• Educate about cardiac medications (antiplatelets, beta-blockers, statins).
• Instruct on wound care and signs of complications at home.
• Promote lifestyle modifications (no smoking, heart-healthy diet, stress management).

🏃‍♀️ 11. Discharge Planning and Rehabilitation

• Prepare patient for cardiac rehab program enrollment.
• Schedule follow-up appointments.
• Reinforce importance of medication adherence and physical activity.

Section-B

Q-4. Define the following terms (Any Five)

1) Electro cardiogram

📌 Definition:
Atelectasis is a condition characterized by the partial or complete collapse of lung tissue (alveoli), resulting in impaired gas exchange and reduced oxygenation, commonly seen after surgery or due to airway obstruction.

🩺 It is commonly used to detect heart rhythm disorders, myocardial infarction, and other cardiac abnormalities.

2) Flank pain

📌 Definition:
A hypotonic solution is a type of fluid that has a lower solute concentration (osmolarity) than plasma, which causes water to move into the body’s cells, leading to cellular swelling and expansion of intracellular volume.

🩺 It is often associated with kidney disorders, such as renal stones, infections, or trauma.

3) Atelectasis

📌 Definition:
Atelectasis is a condition characterized by the partial or complete collapse of lung tissue (alveoli), resulting in impaired gas exchange and reduced oxygenation, commonly seen after surgery or due to airway obstruction.

🫁 It results in reduced or absent gas exchange, often occurring after surgery or due to obstruction of airways.

4) Hypotonic solution

📌 Definition:
A hypotonic solution is a type of fluid that has a lower solute concentration (osmolarity) than plasma, which causes water to move into the body’s cells, leading to cellular swelling and expansion of intracellular volume.

💧 When administered, it causes water to move into cells, potentially leading to cell swelling.
🧪 Example: 0.45% Normal Saline.

5) Opportunistic infection

📌 Definition:
An opportunistic infection is an infection caused by organisms that take advantage of a weakened immune system, occurring primarily in immunocompromised individuals and rarely affecting those with normal immunity.

🦠 Common in HIV/AIDS, cancer patients, or those on immunosuppressants.
Example: Pneumocystis jirovecii pneumonia.

6) Neurogenic shock

📌 Definition:
Neurogenic shock is a form of distributive shock caused by disruption of sympathetic nervous system pathways, usually due to spinal cord injury, leading to vasodilation, hypotension, and bradycardia.

🧠 It causes vasodilation, hypotension, and bradycardia, and commonly occurs after spinal cord injuries.

Q-5. Answer the following (Any Four)(4×5=20)

1) Role of Circulatory nurse

🩺 Role of Circulatory Nurse

A Circulatory Nurse, also known as a Circulating Nurse, plays a critical role during surgical procedures in the operating room. Unlike the scrub nurse, the circulatory nurse maintains a non-sterile role, focusing on coordination, communication, patient safety, and documentation throughout the perioperative phase. Their responsibilities encompass preoperative, intraoperative, and immediate postoperative care.

🔹 1. Preoperative Responsibilities

• The circulatory nurse ensures that the operating room is properly set up, including checking availability and functionality of equipment, surgical instruments, and sterile supplies.
• Verifies patient identity, surgical consent, and the correct surgical site, following “time-out” protocols.
• Assists in positioning the patient safely on the operating table to prevent nerve damage or pressure injuries.
• Ensures that skin preparation and draping are done using aseptic techniques, collaborating with the scrub nurse.

🔹 2. Intraoperative Responsibilities

• Acts as the patient’s advocate by maintaining the patient’s privacy, dignity, and comfort throughout the procedure.
• Coordinates and communicates with the surgical team, including the surgeon, anesthetist, and scrub nurse.
• Supplies necessary sterile instruments or items to the sterile field by opening them in a sterile manner.
• Monitors sterility and maintains the sterile field, ensuring there are no breaks in aseptic technique.
• Maintains accurate counts of surgical instruments, sponges, needles, and sharps with the scrub nurse to prevent retention.
• Documents intraoperative events in the surgical record, including time of incision, medications given, vital signs, complications, and specimen collection.
• Facilitates specimen labeling, handling, and transport to the laboratory with proper documentation.

🔹 3. Postoperative Responsibilities

• Assists in transferring the patient to the post-anesthesia care unit (PACU) safely, ensuring all monitoring lines and drains are secured.
• Communicates essential hand-off information to the recovery nurse, such as fluid loss, vital signs trends, and intraoperative events.
• Ensures the OR is cleaned and restocked for the next procedure.

🔹 4. Patient Safety and Advocacy

• The circulatory nurse is a key safety officer, constantly watching for equipment hazards, breaks in sterility, or signs of patient distress.
• Ensures adherence to WHO Surgical Safety Checklist and infection control protocols.
• Protects the patient’s rights, particularly in emergency situations when they cannot advocate for themselves.

🔹 5. Communication and Coordination

• Serves as the liaison between sterile and non-sterile team members.
• Communicates effectively with support departments like radiology, pathology, and central sterile supply.
• Manages equipment troubleshooting, such as electrocautery, monitors, suction devices, and cautery pads.

The circulating nurse plays a pivotal role in ensuring the safety, coordination, and efficiency of surgical procedures. By providing non-sterile support and advocating for the patient, the circulatory nurse helps ensure the best possible surgical outcomes while maintaining the highest standards of nursing and surgical practice.

2) Emergency management for cardiac arrest

Cardiac arrest is a sudden and unexpected loss of cardiac function, breathing, and consciousness due to the heart’s failure to effectively pump blood. It is a life-threatening emergency that requires immediate recognition and rapid response to prevent death or irreversible brain damage.

💥 Causes of Cardiac Arrest

• Coronary artery disease (most common)
• Myocardial infarction (heart attack)
• Severe electrolyte imbalance (e.g., hyperkalemia)
• Hypoxia
• Massive hemorrhage
• Trauma or shock
• Drug overdose or poisoning
• Cardiac arrhythmias (e.g., ventricular fibrillation, asystole)

🆘 Emergency Management of Cardiac Arrest

The management of cardiac arrest follows the ACLS (Advanced Cardiovascular Life Support) and BLS (Basic Life Support) protocols, guided by the CAB approach:

➤ C – Circulation

➤ A – Airway

➤ B – Breathing

🔴 1. Immediate Recognition and Activation

• Check for responsiveness: tap and shout.
• Assess breathing and pulse (within 10 seconds).
• If no pulse and no breathing → Activate emergency response system and start CPR immediately.

🔵 2. Cardiopulmonary Resuscitation (CPR)

a) Chest Compressions

• Begin high-quality chest compressions at a depth of 5–6 cm (2 inches) at a rate of 100–120 compressions per minute.
• Ensure full chest recoil after each compression.
• Minimize interruptions in chest compressions.

b) Airway Management

• Open the airway using head-tilt–chin-lift or jaw-thrust maneuver.
• If trained and able, use a bag-valve-mask or advanced airway (endotracheal tube).

c) Breathing Support

• Deliver 2 rescue breaths after every 30 compressions (for untrained rescuers, compression-only CPR is acceptable).
• Ensure adequate chest rise with each breath.

⚡ 3. Defibrillation (Early Electrical Therapy)

• Attach an AED (Automated External Defibrillator) or manual defibrillator.
• Analyze rhythm and deliver shock if indicated:
  • Shockable rhythms: Ventricular fibrillation (VF), Pulseless ventricular tachycardia (VT)
  • Non-shockable rhythms: Asystole, Pulseless electrical activity (PEA)
• Resume CPR immediately after shock delivery.

💉 4. Administration of Emergency Drugs (ACLS)

• Establish IV/IO access as early as possible.
• Administer drugs according to rhythm:
  • Epinephrine 1 mg IV/IO every 3–5 minutes (for all rhythms)
  • Amiodarone 300 mg IV bolus (for shockable rhythms if unresponsive to defibrillation)
  • Lidocaine, Magnesium sulfate, Sodium bicarbonate (if indicated by cause)

🧠 5. Identify and Treat Reversible Causes (H’s & T’s)

🔬 H’s:

• Hypoxia
• Hypovolemia
• Hypo-/Hyperkalemia
• Hypothermia
• Hydrogen ion (acidosis)

🩸 T’s:

• Tension pneumothorax
• Tamponade (cardiac)
• Toxins (drug overdose)
• Thrombosis (coronary or pulmonary)

🩺 6. Post-Resuscitation Care

• If return of spontaneous circulation (ROSC) is achieved:
  • Maintain airway and oxygenation
  • Support blood pressure (IV fluids, vasopressors)
  • Perform ECG, cardiac enzymes, and labs
  • Consider therapeutic hypothermia to reduce brain injury
  • Transfer to ICU for monitoring and further management

👩‍⚕️ Nursing Responsibilities in Cardiac Arrest

• Rapid recognition and response to signs of arrest
• Initiate BLS immediately and assist in ACLS protocol
• Call for help and activate code blue
• Maintain clear documentation of times, medications, rhythm changes, and interventions
• Ensure airway equipment, crash cart, defibrillator are functional and ready
• Provide psychological support to family after the event
• Assist in post-resuscitation care and monitoring in ICU or recovery area

Cardiac arrest is a medical emergency that demands immediate, organized, and skilled intervention. Early recognition, prompt initiation of CPR, timely defibrillation, and drug administration can significantly improve survival. Nurses play a critical frontline role in recognizing arrest, initiating emergency protocols, and providing high-quality resuscitative care.

3) Nursing care of patient with colostomy

A colostomy is a surgically created opening in the abdominal wall through which a portion of the colon (large intestine) is diverted to allow fecal matter to pass into an external pouch or bag. The externalized portion is known as the stoma.

Colostomies may be temporary or permanent, depending on the underlying medical condition, and may be placed in the ascending, transverse, descending, or sigmoid colon. Common indications include colorectal cancer, bowel obstruction, perforation, diverticulitis, trauma, or inflammatory bowel diseases.

The nurse’s role is essential in helping the patient recover physically, adapt emotionally, and become independent in colostomy care.

🔹 Objectives of Nursing Care

• Promote healing and comfort following surgery
• Prevent infection and stoma-related complications
• Maintain peristomal skin integrity
• Support the patient in accepting body image changes
• Educate for independent colostomy care and rehabilitation
• Facilitate early mobilization and nutrition

🔵 1. Preoperative Nursing Care

• Psychological Preparation:
  • Encourage the patient to express concerns and fears about the colostomy and its impact on lifestyle.
  • Offer emotional support and involve family in education.
• Patient Education:
  • Explain the purpose of the surgery, what a stoma is, how it functions, and the use of ostomy appliances.
  • Use models, diagrams, or videos to assist learning.
• Site Selection and Marking:
  • Collaborate with the surgeon and wound care nurse to mark the optimal stoma site, ensuring it is easily visible and accessible to the patient.
  • Avoid skin folds, bony prominences, or areas near scars.
• Physical Preparation:
  • Administer prescribed laxatives or enemas for bowel cleansing.
  • Maintain NPO status (nothing by mouth) as ordered preoperatively.
  • Perform skin preparation and shaving around the site.

🔵 2. Postoperative Nursing Care

a) Assessment of Stoma and Peristomal Skin

• Inspect the stoma regularly: It should be pink/red, moist, and protruding slightly.
• Monitor for dusky, pale, or black stoma, which may indicate poor perfusion or necrosis.
• Watch for excessive bleeding, prolapse, or retraction.
• Check for peristomal skin irritation, erythema, or breakdown, which may result from leakage or poor fitting of the pouch.

b) Colostomy Appliance and Drainage Bag Care

• Empty the bag when one-third to half full to avoid weight pulling on the stoma.
• Change the appliance every 3–5 days or sooner if there is leakage.
• Teach correct pouching techniques, including cutting the flange to the correct stoma size.
• Use skin barrier creams or wafers to protect the skin.
• Ensure appliance is odor-proof and leak-proof.

c) Dietary and Fluid Management

• Begin with clear liquids and progress to a low-fiber diet, avoiding gas-forming foods like cabbage, beans, carbonated beverages, and onions.
• Encourage frequent small meals and adequate fluid intake (at least 2–3 liters/day).
• Gradually reintroduce high-fiber foods if advised in the long term.
• Advise chewing food thoroughly to avoid blockage.

d) Bowel Function Monitoring

• Observe output consistency, amount, and frequency.
  • Ascending colostomy: more liquid stool
  • Transverse: semi-formed
  • Descending or sigmoid: solid/formed stool
• Monitor for signs of obstruction, such as cramping, decreased output, or nausea.
• Watch for dehydration or electrolyte imbalances in high-output colostomies.

e) Pain and Wound Care

• Monitor the surgical incision and stoma for signs of infection.
• Administer prescribed analgesics and evaluate pain levels regularly.
• Support the abdominal wall during coughing or movement with a pillow splint.
• Encourage early mobilization to promote circulation and bowel motility.

f) Psychosocial Support

• Acknowledge the emotional impact of a colostomy.
• Address concerns about body image, sexuality, clothing, and odors.
• Promote self-esteem and autonomy in managing care.
• Involve the patient in care as early as possible to build confidence.
• Refer to support groups or ostomy associations for continued counseling.

🔵 3. Patient and Family Education

• Provide hands-on demonstration of colostomy care techniques.
• Teach how to:
  • Clean the stoma using lukewarm water and soft cloth
  • Change the pouch system
  • Recognize signs of infection, skin irritation, or stoma changes
• Instruct on:
  • Dietary guidelines and hydration
  • Clothing modifications if needed
  • Travel, work, and intimacy considerations
• Offer written educational material and return demonstration sessions.

🔵 4. Discharge Planning and Home Care

• Plan for follow-up with stoma care nurse or outpatient clinic.
• Ensure supplies (bags, barriers, wipes) are available for home use.
• Guide the family in assisting with care if the patient is dependent.
• Ensure the patient knows when to seek medical help, e.g.:
  • Change in stoma color or shape
  • Bleeding, blockage, or excessive pain
  • Persistent leakage or peristomal irritation

⚠️ 5. Prevention of Complications

• Regular skin inspection to prevent dermatitis or fungal infection.
• Avoid ill-fitting appliances that can lead to leakage.
• Prevent stoma prolapse by avoiding heavy lifting or straining.
• Educate on safe exercises and use of abdominal binder if needed.

The nursing care of a patient with colostomy involves comprehensive physical, psychological, educational, and rehabilitative support. The nurse plays a critical role in preventing complications, promoting independence, and assisting the patient in reintegrating into normal life with confidence and dignity. With empathetic care and proper training, patients can live a normal and fulfilling life despite having a colostomy.

4) Methods of physical examinations

Physical examination is a critical component of clinical assessment, involving a systematic and structured approach to evaluate a patient’s physical health status. It helps healthcare providers identify deviations from normal health, detect early signs of disease, and gather essential data for diagnosis and care planning. There are four core techniques used during physical examination: inspection, palpation, percussion, and auscultation. These methods are applied in sequence and tailored to each body system being assessed.

🔍 1. Inspection

Inspection is the first and most basic method of physical examination. It involves careful, close, and deliberate observation of the patient’s body to detect any visible signs of abnormality. The examiner visually assesses the patient’s general appearance, behavior, body movements, posture, skin color, and symmetry of body parts. Good lighting and adequate exposure of the body part being examined are essential for accurate inspection. The nurse or examiner should observe both anterior and posterior aspects of the body and compare both sides for symmetry. For example, observing chest expansion during breathing or identifying skin rashes, swelling, or wounds are typical uses of inspection. This technique is non-invasive but provides valuable information when performed attentively.

✋ 2. Palpation

Palpation is the technique of using the hands and fingers to feel body structures through touch. This method helps assess characteristics such as temperature, moisture, texture, size, shape, consistency, mobility, and tenderness of an organ or body part. It is performed after inspection and is divided into light palpation and deep palpation. Light palpation is used to feel surface abnormalities and detect tenderness, while deep palpation assesses deeper organs such as the liver or kidneys. Palpation should be done gently and respectfully, ensuring the patient’s comfort and privacy. Fingertips are best for feeling texture, while the back of the hand is more sensitive to temperature changes. The examiner should always observe the patient’s facial expression for any signs of discomfort during palpation.

🥁 3. Percussion

Percussion is the technique of tapping on the body surface to produce sounds that help assess the condition of underlying structures. The sound produced varies depending on the density of the underlying tissues. This method is used to determine the location, size, and borders of organs, and to detect the presence of air, fluid, or solid masses. There are two common types: direct percussion, where the examiner taps directly on the body surface, and indirect percussion, where one hand is used as a platform while the other taps on it. The tone and pitch of the sounds provide clues about the organ beneath—air-filled structures such as the lungs produce a resonant sound, whereas solid organs like the liver produce a dull sound. This technique is especially useful in assessing the thorax and abdomen.

🎧 4. Auscultation

Auscultation involves listening to internal body sounds using a stethoscope. It is typically performed last, except during abdominal examination where it is done before palpation and percussion to avoid altering bowel sounds. Auscultation allows the examiner to hear heart sounds, lung sounds, bowel movements, and vascular bruits. The diaphragm of the stethoscope is used for high-pitched sounds like breath and normal heart sounds, while the bell is used for low-pitched sounds such as certain heart murmurs. For accurate auscultation, the environment must be quiet and the patient should be positioned comfortably. The stethoscope should be warm and placed firmly on the skin to eliminate external noises. Through auscultation, the nurse can detect abnormalities like wheezing in the lungs, murmurs in the heart, or absent bowel sounds in intestinal obstruction.

➕ 5. Supporting Techniques

In addition to the four core techniques, other methods such as olfaction (smell) and vital sign monitoring also support physical assessment. For example, a fruity odor from the breath may indicate diabetic ketoacidosis, while foul-smelling discharge may suggest infection. Measuring temperature, pulse, respiration, blood pressure, and oxygen saturation gives essential baseline information and complements the physical findings obtained through the main examination technique

Physical examination is a foundational clinical skill that enables nurses and healthcare professionals to assess a patient’s condition systematically and effectively. By mastering the four main techniques—inspection, palpation, percussion, and auscultation—a nurse can identify physical changes, monitor disease progression, and contribute meaningfully to diagnosis and care. These methods, when applied with precision, respect, and attention to detail, ensure safe and holistic patient care. Proper technique, clinical knowledge, and patient-centered communication are vital for conducting an accurate and thorough physical examination.

5) DOT therapy in Tuberculosis

Tuberculosis (TB) is a chronic infectious disease caused primarily by Mycobacterium tuberculosis. It mainly affects the lungs but can involve any organ. TB remains a major public health problem in many countries, including India. One of the key strategies for TB control is DOT therapy, which ensures regular and complete intake of anti-TB drugs.

📌 Definition of DOT Therapy

DOT stands for Directly Observed Treatment. It is a strategy under the Revised National Tuberculosis Control Program (RNTCP) (now National TB Elimination Program – NTEP), where a trained health worker or treatment supporter directly observes the patient taking each dose of TB medication.

🎯 Objectives of DOT Therapy

• Ensure adherence to treatment
• Prevent drug resistance and relapse
• Promote early recovery and cure
• Reduce TB transmission in the community
• Improve treatment completion rates

🏥 Key Features of DOT Therapy

1. Supervised Drug Intake
   • The patient takes the medicine in front of a trained DOT provider, usually thrice weekly (or daily under newer regimens).
   • Ensures no dose is missed, especially during the intensive phase.
2. Free Drug Supply
   • Anti-TB drugs are provided free of cost by the government.
3. Patient-Centered Approach
   • DOT provider may be a health worker, ASHA, community volunteer, or trained family member.
   • Convenient location and timing are selected for the patient’s comfort.
4. Treatment Monitoring
   • Regular monitoring for side effects, compliance, and sputum conversion.
   • Follow-up sputum examinations are done at 2, 4, and 6 months.
5. Two Phases of DOT Treatment
   a) Intensive Phase (IP):
   • First 2 months (typically 4 drugs – HRZE)
   • Aims to rapidly kill TB bacilli
   b) Continuation Phase (CP):
   • 4 months (typically 2 drugs – HR)
   • Prevents relapse and clears remaining bacteria
6. Daily Fixed-Dose Combination (FDC)
   • Now, daily regimen using FDC tablets based on body weight is followed under NTEP.

👩‍⚕️ Role of Nurse in DOT Therapy

• Educate the patient and family about TB and DOT
• Identify and counsel a suitable DOT provider
• Monitor and record each supervised dose intake
• Report side effects and arrange for management
• Follow up on sputum tests and clinical improvement
• Motivate the patient to complete the full course of therapy
• Maintain treatment cards and documentation

⚠️ Benefits of DOT Therapy

• Improves treatment adherence and cure rates
• Reduces treatment default and drug resistance
• Builds trust and patient-provider relationship
• Essential to achieving TB elimination goals

DOT therapy is a cornerstone in TB control and prevention of multidrug-resistant TB. By ensuring that every patient takes every dose under supervision, DOT helps improve outcomes and reduce the spread of TB. Nurses and community health workers play a vital role in implementing DOT and supporting patients throughout treatment. With proper implementation, DOT significantly contributes to the goal of TB elimination by 2025 in India.

Q-6. (A) Explain the features of Ideal O.T (4 marks)

An Operation Theatre (O.T.), also known as a Surgical Suite, is a specialized, sterile environment where surgical procedures are performed under strict aseptic conditions. An ideal O.T. is designed to ensure maximum patient safety, efficient workflow, infection control, and comfort for the surgical team.

🔷 Key Features of an Ideal Operation Theatre

1️⃣ Location and Accessibility

• The O.T. should be located near surgical wards, ICUs, and emergency rooms.
• It should have controlled access, limiting entry to authorized personnel only.
• Zoning (Unrestricted, Semi-restricted, Restricted) is followed to prevent contamination.

2️⃣ Sterile and Aseptic Environment

• All surfaces including floors, walls, and ceilings should be made of smooth, washable, non-porous, and non-reflective material to facilitate disinfection.
• Use of laminar airflow and HEPA filters to reduce airborne microbes.
• Minimum bacterial count, dust, and humidity should be maintained.

3️⃣ Proper Ventilation and Air Conditioning

• Equipped with centralized air-conditioning and positive pressure airflow to keep contaminants out.
• 12–20 air changes per hour is recommended in modern O.T.s.
• Temperature (20–24°C) and humidity (50–60%) should be regulated.

4️⃣ Adequate Lighting and Electrical Supply

• High-intensity shadowless operating lights over the operating table for clear visibility.
• Emergency power backup for uninterrupted electricity supply.
• Well-marked and shockproof electrical outlets for surgical equipment.

5️⃣ Well-Planned Layout and Space

• O.T. should be spacious enough to accommodate staff, equipment, and patient safely.
• Should have separate areas for sterile and non-sterile functions (scrub area, preparation area, anesthesia room, recovery room).
• Easy-to-clean, slip-resistant flooring with no sharp corners to avoid dust accumulation.

6️⃣ Modern Surgical Equipment and Facilities

• Fully equipped with anaesthesia machines, surgical tables, suction units, monitors, defibrillators, and electrosurgical units.
• Provision for laparoscopic, orthopedic, neurosurgical, and other advanced procedures.
• All instruments should be sterile and well-maintained.

7️⃣ Strict Infection Control Measures

• Adherence to unidirectional flow of personnel and materials.
• Proper use of PPE (gloves, gowns, masks, caps) by the surgical team.
• Regular fumigation, UV disinfection, and environmental cleaning.

8️⃣ Trained Surgical Team and Support Staff

• Qualified and trained surgeons, anesthetists, scrub nurses, circulating nurses, and technicians.
• Defined roles and responsibilities for each team member during surgery.
• Continuous in-service training and emergency preparedness.

9️⃣ Efficient Waste Disposal and Biomedical Management

• Proper segregation and disposal of biomedical waste, sharps, soiled linen, and fluids.
• Use of color-coded bins and PPE during waste handling.
• Compliance with Bio-Medical Waste Management Rules.

🔟 Safety and Emergency Protocols

An ideal operation theatre is a sterile, well-equipped, and efficiently organized environment that prioritizes patient safety, infection control, and surgical excellence. Through proper design, staff training, and adherence to protocols, the risk of surgical complications and infections can be minimized. Nurses play a vital role in maintaining asepsis and ensuring the smooth functioning of the O.T.

(B) Write difference between Gastric ulcer and Duodenal ulcer (3 marks)

1️⃣ Location

• Gastric Ulcer: Occurs in the lining of the stomach.
• Duodenal Ulcer: Occurs in the first part of the small intestine (duodenum).

2️⃣ Timing of Pain

• Gastric Ulcer: Pain typically starts 30 minutes to 1 hour after eating.
• Duodenal Ulcer: Pain usually occurs on an empty stomach, before meals, or at night, and is relieved by food.

3️⃣ Risk of Malignancy

• Gastric Ulcer: Has a higher risk of progressing to gastric cancer.
• Duodenal Ulcer: Generally has a low or negligible risk of malignancy.