Section 1

Q.1 Define following (any five) [10 marks]

1. Immunity

• Immunity is the body’s ability to recognize, resist, and defend itself against harmful agents like pathogens (bacteria, viruses, fungi, etc.), toxins, or foreign substances.
• It involves the immune system through specific (adaptive) and non-specific (innate) mechanisms to maintain health and prevent infections.

2. Emphysema

• Emphysema is a chronic obstructive pulmonary disease (COPD) characterized by irreversible enlargement and destruction of the alveoli (air sacs) in the lungs, leading to impaired gas exchange and breathing difficulty.
• It results in loss of lung elasticity, air trapping, and reduced oxygen exchange, commonly caused by long-term smoking or exposure to pollutants.

3. Hernia

• Hernia is the abnormal protrusion of an organ or tissue (commonly a part of the intestine) through a weak spot or opening in the surrounding muscle or connective tissue, especially in the abdominal wall.
• The herniated part is usually enclosed in a sac formed by the peritoneum. Common Sites includes Inguinal, Umbilical, Femoral, Incisional

4. Thalesemia

• Thalassemia is a group of inherited blood disorders characterized by reduced or absent synthesis of one or more globin chains of hemoglobin, leading to chronic microcytic hypochromic anemia.
• It results from mutations in the genes responsible for alpha or beta globin chain production

5. Poliomyelitis

Poliomyelitis, commonly known as polio, is a highly contagious viral disease caused by the poliovirus, which primarily affects the nervous system, especially the anterior horn cells of the spinal cord, leading to muscle weakness, flaccid paralysis, and in severe cases, permanent disability or death.

6. Psoriasis

• Psoriasis is a chronic, non-contagious, autoimmune skin disorder characterized by rapid skin cell turnover, leading to thick, red patches covered with silvery-white scales, commonly affecting the scalp, elbows, knees, and back.
• It is caused by immune system dysfunction, with triggers like stress, infections, certain medications, and has a genetic predisposition.

Q.2 Write answer following

1. Define MI (2)

Myocardial Infarction (MI) is also called heart attack. It is a medical emergency characterized by the death of heart muscle tissue (myocardial necrosis) due to sudden interruption of blood supply to the myocardium, usually caused by blockage of a coronary artery. This leads to ischemia, tissue damage, and loss of cardiac function in the affected area.

2. Enlist risk factors of MI (2)

Non-Modifiable Risk Factors :

Non-modifiable risk factors are those inherent characteristics of an individual that cannot be changed or controlled, but which increase the likelihood of developing a disease

• Age (Men >45 years, Women >55 years)
• Gender (Males are at higher risk)
• Family history of premature cardiovascular disease
• Genetic predisposition
• Ethnicity (South Asians have higher risk)

Modifiable Risk Factors :

Modifiable risk factors are those lifestyle or health-related factors that can be changed, controlled, or treated through behavioral changes, medical intervention, or both, in order to reduce the risk of developing a disease

• Smoking
• Hypertension (High blood pressure)
• Dyslipidemia
• High LDL, Low HDL, High triglycerides
• Diabetes mellitus (especially uncontrolled)
• Obesity, especially central (abdominal) obesity
• Sedentary lifestyle (lack of physical activity)
• Unhealthy diet
• High saturated fats, sugar, and salt
• Excessive alcohol consumption
• Psychological stress and depression
• Drug abuse – e.g., cocaine, amphetamines
• Poor sleep patterns
• Metabolic syndrome

3. Described nursing management of MI patient (4)

Acute Pain related to myocardial ischemia

Goal : Patient will report pain relief within 30 minutes of intervention.

Nursing Interventions :

• Assess characteristics of chest pain (location, intensity, duration, radiation).
• Use a pain scale (e.g., 0–10) for ongoing pain assessment.
• Administer prescribed analgesics (e.g., morphine sulfate) to relieve pain.
• Provide supplemental oxygen to improve myocardial oxygenation.
• Administer nitrates (e.g., nitroglycerin) as ordered.

• Ensure quiet and restful environment to reduce stimuli.
• Position patient in semi-Fowler’s position for comfort.
• Monitor ECG for changes indicating ischemia or infarction.
• Evaluate response to pain medications regularly.

Decreased Cardiac Output related to impaired myocardial contractility

Goal : Patient will maintain adequate cardiac output as evidenced by stable vital signs and adequate tissue perfusion.

Nursing Interventions :

• Monitor vital signs (heart rate, BP, respiratory rate, SpO₂) every 1–2 hours.
• Assess for signs of poor perfusion (cold extremities, weak pulses, low urine output).
• Administer cardiac medications as prescribed (beta-blockers, ACE inhibitors, diuretics).
• Monitor urine output (report if <30 mL/hr).
• Monitor central venous pressure (CVP) and jugular venous distension (JVD).
• • Monitor for new murmurs or S3 heart sounds (indicating left ventricular dysfunction).

• Provide IV fluids cautiously to maintain adequate preload without overloading.
• Keep patient in semi-Fowler’s to reduce preload and afterload.

Risk for Impaired Gas Exchange related to reduced cardiac output and pulmonary congestion

Goal : Maintain oxygen saturation ≥ 95% and normal respiratory pattern.

Nursing Interventions :

• Assess respiratory rate, depth, and pattern every 2–4 hours.
• Administer oxygen therapy via nasal cannula or mask as prescribed.
• Monitor arterial blood gases (ABG) and SpO₂.

• Auscultate lungs for crackles or wheezing indicating pulmonary edema.
• Encourage deep breathing and coughing exercises.
• Position patient in high Fowler’s if dyspnea is present.
• Avoid overexertion during oxygen therapy.
• Monitor for signs of respiratory distress (cyanosis, retractions).

Anxiety related to fear of death, pain, unfamiliar environment, and change in health status

Goal : Patient will verbalize reduced anxiety and demonstrate relaxed behavior.

Nursing Interventions :

• Establish trusting nurse-patient relationship.
• Allow patient to express fears and feelings without judgment.
• Provide clear, simple explanations about condition and treatments.
• Involve family members to offer emotional support.
• Maintain calm and quiet environment.
• Avoid overloading patient with too much information at once.
• Offer relaxation techniques (e.g., breathing exercises, music therapy).
• Administer anxiolytics as prescribed.
• Reassure the patient frequently about progress and monitoring.

Activity Intolerance related to imbalance between oxygen supply and demand

Goal : Patient will demonstrate increased tolerance to activity without chest pain or dyspnea.

Nursing Interventions :

• Assess baseline tolerance to activity.

• Monitor response to activity (vital signs, ECG, symptoms).
• Schedule rest periods between activities.
• Encourage gradual increase in activity as tolerated (e.g., sit, dangle legs, walk short distance).

• Educate patient on energy conservation techniques.
• Avoid straining during ADLs (assist with bathing, toileting as needed).
• Provide oxygen during activity if prescribed.
• Teach patient to report any chest pain or fatigue during activity.

Q.3 Write nursing care of following patient (any three) [12 marks]

1. A patient with pacemaker

1. Pre-Procedure Nursing Care (Before Pacemaker Insertion):

• Explain the procedure, purpose, risks, and post-op expectations to reduce anxiety.
• Obtain valid informed consent from the patient or legal guardian.
• Maintain NPO (nil per oral) status for 6–8 hours before the procedure.
• Record baseline data : vital signs, ECG, heart sounds, breath sounds, and oxygen saturation.
• Assess allergies (especially to iodine, latex, or anesthetics).
• Ensure IV access is in place for medications and fluids.
• Shave and clean the skin over the chest wall where the pacemaker will be inserted.
• Administer pre-op antibiotics as ordered to prevent infection.
• Educate the patient on limiting upper limb movements post-procedure.
• Remove dentures, jewelry, and metallic objects before the procedure.
• Provide psychological support and allow expression of concerns.

2. Immediate Post-Procedure Care (First 24–48 hours):

• Monitor vital signs, SpO₂, and ECG continuously to detect pacemaker function or rhythm changes.
• Inspect the pacemaker insertion site for bleeding, hematoma, infection, or swelling.
• Check for the presence of pacemaker spikes on ECG (indicates pacing).

• Maintain sterile dressing at the incision site and change as per protocol.
• Ensure bed rest for several hours post-op and avoid arm movement on the pacemaker side.
• Place a sling or immobilizer to limit arm motion if needed.
• Monitor for signs of pneumothorax: dyspnea, absent breath sounds, low oxygen saturation.

• Assess for pain and administer prescribed analgesics.
• Observe for signs of pacemaker malfunction (e.g., syncope, dizziness, palpitations).
• Check capillary refill, peripheral pulses, and extremity color.
• Maintain strict documentation of site care, vitals, ECG rhythm, and patient response.

3. Ongoing and Long-Term Nursing Care:

• Educate the patient on living with a pacemaker:
• Avoid strenuous activity for 4–6 weeks.
• No heavy lifting with the arm on the side of the implant.
• Avoid tight clothing over the insertion site.
• Avoid sleeping on the side of the pacemaker for 1 week.

• Advise the patient to avoid exposure to electromagnetic interference (EMI):
• MRI machines, microwave ovens (modern ones are safe but keep a distance), welding equipment, high-tension wires, and arc welders.

• Instruct to carry a pacemaker identification card at all times.
• Advise the patient to notify airport security as pacemakers may trigger alarms.
• Educate on the importance of regular follow-up visits for pacemaker interrogation and battery status.
• Teach how to take radial pulse and recognize abnormalities.

• Instruct to report immediately any of the following symptoms :
• Dizziness
• Fainting
• Palpitations
• Shortness of breath
• Prolonged hiccups (may indicate phrenic nerve stimulation)
• Educate about battery life (typically 5–10 years) and replacement planning.

• Encourage gradual resumption of normal activity based on physician guidance.

4. Discharge Instructions :

• Keep the wound clean and dry until healing is complete.
• Report signs of infection: redness, warmth, swelling, pus, or fever.
• Avoid lifting arm above the head or carrying heavy objects for 6 weeks.
• Avoid contact sports to prevent trauma to the device.
• Instruct to wear a medical alert bracelet or necklace.
• Inform all healthcare providers, dentists, physiotherapists, and radiologists about the pacemaker.
• Encourage emotional support and provide counseling if the patient feels anxious or dependent.
• Educate about battery warning signs (slowing pulse rate, fatigue) and the need for re-evaluation.
• Schedule timely device checkups for sensing and pacing thresholds.

2. A patient with COPD

Ineffective Airway Clearance related to increased mucus production and bronchospasm

Goal :

Patient will maintain a patent airway

Interventions :

• Encourage deep breathing and effective coughing every 2 hours.
• Provide humidified oxygen to moisten airways and loosen secretions.
• Administer bronchodilators, corticosteroids, and mucolytics as prescribed.
• Perform chest physiotherapy, including percussion and vibration.
• Elevate the head of the bed to improve lung expansion.
• Monitor respiratory rate, effort, and sputum characteristics regularly.
• Teach use of incentive spirometer if tolerated.

Impaired Gas Exchange related to alveolar-capillary membrane changes

Goal :

Patient will maintain SpO₂ ≥ 90% and normal ABG levels.

Interventions :

• Administer low-flow oxygen (1–2 L/min) cautiously.
• Monitor SpO₂ continuously and assess trends.
• Position patient in high Fowler’s or orthopneic position.
• Encourage pursed-lip breathing and monitor effectiveness.
• Monitor for signs of CO₂ retention (drowsiness, confusion, headache).
• Evaluate ABG results and notify provider for abnormal values.
• Encourage breathing control exercises during dyspnea episodes.

Activity Intolerance related to imbalance between oxygen supply and demand

Goals :

Patient will perform ADLs with minimal or no shortness of breath.

Interventions :

• Assess baseline level of activity and symptoms with exertion.
• Encourage short frequent rest periods between activities.
• Provide assistive devices (walker, chair) if needed.
• Teach energy conservation techniques (e.g., sitting while bathing).
• Support patient during gradual exercise programs like walking.
• Administer bronchodilators before activity to ease breathing.
• Evaluate heart rate, oxygen saturation, and fatigue after exertion.

Imbalanced Nutrition Less than Body Requirements related to dyspnea and fatigue

Goals :

Patient will consume adequate nutrients to maintain weight and energy.

Interventions :

• Offer small, frequent, high-protein, high-calorie meals.
• Allow rest before and after meals to reduce fatigue.
• Avoid gas-producing foods (beans, carbonated drinks).
• Monitor daily weight, serum albumin, and intake/output.
• Provide nutritional supplements or shakes between meals.
• Encourage nutrient-dense snacks like peanut butter, cheese, and nuts.
• Refer to a dietitian for personalized dietary planning.

Risk for Infection related to retained secretions and weakened immune defense

Goals :

Patient will remain free from signs of respiratory infection.

Interventions :

• Instruct on hand hygiene, coughing etiquette, and mask use.
• Encourage adequate fluid intake to help mobilize secretions.
• Administer antibiotics or antivirals as prescribed during exacerbations.
• Monitor for fever, increased sputum production, and purulence.
• Promote influenza and pneumococcal vaccination compliance.
• Perform oral care regularly to reduce bacterial colonization.
• Educate on avoiding crowded or polluted environments.

3. A patient with cirrhosis of liver

Assessment

• Assess for jaundice, ascites, edema, spider angiomas, and pruritus
• Monitor vital signs, especially blood pressure and respiratory rate
• Evaluate mental status for hepatic encephalopathy (confusion, asterixis)
• Monitor abdominal girth, daily weight, and intake-output
• Assess for bleeding tendencies (petechiae, hematemesis, melena)
• Check lab values: LFTs, bilirubin, PT/INR, albumin, ammonia levels

Nursing Diagnoses and Interventions

Impaired Liver Function related to hepatocellular damage

Goal :

Maintain stable liver function and prevent further damage.

Interventions :

• Monitor liver function tests (ALT, AST, bilirubin, albumin).
• Administer prescribed medications (e.g., lactulose, diuretics, vitamin K).
• Avoid hepatotoxic drugs (e.g., NSAIDs, alcohol).
• Educate on a low sodium, low protein diet (in hepatic encephalopathy).
• Observe for signs of hepatic encephalopathy (confusion, lethargy).
• Provide emotional support as chronic illness may cause distress.

Fluid Volume Excess related to portal hypertension and hypoalbuminemia (ascites, edema)

Goal :

Patient will maintain fluid balance as evidenced by reduced edema and stable weight.

Interventions :

• Monitor daily weight and abdominal girth.
• Record intake and output meticulously.
• Administer diuretics (spironolactone, furosemide) as ordered.
• Restrict fluid and sodium intake as per medical advice.
• Position in semi-Fowler’s to ease breathing.
• Assist in paracentesis preparation and monitor post-procedure.
• Assess for signs of fluid overload (crackles, dyspnea).

Risk for Bleeding related to decreased clotting factors (prolonged PT, low platelets)

Goal :

Patient will remain free from active bleeding episodes.

Interventions :

• Monitor for signs of bleeding: gums, stool, urine, bruises, petechiae.
• Monitor PT/INR, platelet count, and hemoglobin levels regularly.
• Administer vitamin K, fresh frozen plasma, or platelets as needed.
• Use soft toothbrushes, avoid injections unless necessary.
• Avoid rectal temperatures, enemas, or invasive procedures.
• Educate about avoiding straining during bowel movements.

Imbalanced Nutrition: Less than Body Requirements related to anorexia and malabsorption

Goal :

Patient will maintain or gain weight and demonstrate improved nutritional status.

Interventions :

• Provide small, frequent, high-calorie, high-protein meals (unless protein is restricted).
• Administer vitamin supplements (fat-soluble: A, D, E, K).
• Monitor dietary intake, serum albumin, and prealbumin levels.
• Provide enteral or parenteral nutrition if needed.
• Encourage appetite-stimulating foods and allow food preferences.
• Collaborate with a dietitian for personalized dietary guidance.

Risk for Impaired Skin Integrity related to pruritus, edema, immobility

Goal :

Patient will maintain intact, healthy skin throughout hospitalization.

Interventions :

• Monitor for skin breakdown, rashes, or pressure injuries.
• Apply emollients or antihistamines to relieve itching.
• Keep nails trimmed to prevent skin damage from scratching.
• Reposition the patient every 2 hours if bedridden.
• Use pressure-relieving devices (foam mattress, heel protectors).
• Maintain skin hygiene and avoid friction during care.

Q.4 A patient with thirodectomy

1. Pre-operative nursing care

Assessment & Preparation:

• Assess for signs of hyperthyroidism or hypothyroidism
• Monitor vital signs, especially pulse and BP
• Record baseline voice quality (to compare post-op for nerve injury)
• Administer anti-thyroid drugs, iodine, and beta-blockers as prescribed
• Ensure euthyroid state before surgery to reduce surgical risk
• Explain surgical procedure and post-op expectations
• Provide psychological support to reduce anxiety
• Ensure NPO status as ordered
• Obtain informed consent

2. Immediate Post-operative Nursing Care (First 24–48 hours)

Airway and Breathing :

• Monitor for airway obstruction due to edema or hematoma
• Keep tracheostomy tray and suction at bedside
• Place patient in semi-Fowler’s position to decrease swelling
• Assess for stridor, dyspnea, restlessness, or cyanosis

Bleeding and Circulation :

• Inspect dressing for blood every 1–2 hours
• Check for bleeding under the neck and shoulders (back of the neck)
• Monitor pulse, BP, and signs of hypovolemia

Voice and Nerve Monitoring :

• Assess voice quality every shift (risk of recurrent laryngeal nerve injury)
• Encourage limited talking during first 24 hours

Calcium Monitoring :

• Monitor for hypocalcemia due to accidental removal of parathyroid glands
• Watch for tingling, numbness, muscle cramps, Chvostek’s or Trousseau’s signs
• Keep IV calcium gluconate ready

Pain Management and Comfort :

• Administer analgesics as prescribed
• Support neck with hands while coughing or moving
• Provide semi-Fowler’s position for comfort and airway clearance

Wound Care :

• Monitor incision site for infection or hematoma
• Maintain dry and clean dressing
• Report excessive drainage or swelling

Discharge Instructions

• Instruct patient to avoid neck strain or heavy lifting
• Educate on signs of hypocalcemia and when to seek help
• Teach wound care and signs of infection
• Explain the importance of regular thyroid hormone follow-up tests
• If on lifelong thyroxine replacement, emphasize compliance
• Encourage regular follow-up with surgeon and endocrinologist

Q.4 Write short notes (8 mark)

1. Dialysis

Definition

Dialysis is a renal replacement therapy used to perform the filtering functions of the kidneys when they are no longer able to maintain fluid, electrolyte, and waste product balance. It helps remove urea, creatinine, excess water, and toxins from the blood, restoring internal balance in cases of acute kidney injury (AKI) or chronic kidney disease (CKD).

Types of Dialysis

1️⃣ Hemodialysis (HD) :

• In which Blood is drawn out via a vascular access (AV fistula, graft, or central line), passed through a dialyzer, and cleaned before returning to the body.
• It is Performed in a hospital or dialysis center, typically 3 times/week for 3–5 hours.
• Rapid fluid and toxin removal but may cause hypotension, cramps.

2️⃣ Peritoneal Dialysis (PD) :

• In which Utilizes the peritoneal membrane in the abdomen to filter blood.
• A dialysate solution is introduced via a catheter, dwells, and then is drained.
• It Can be done at home (CAPD/APD), allowing more independence.
• Risk of peritonitis is a concern.

3️⃣ Continuous Renal Replacement Therapy (CRRT) :

• It is used in ICU settings for critically ill patients with unstable BP.
• It is a continuous, gentle form of dialysis over 24 hours.

Indications

Dialysis is indicated when :

• Glomerular filtration rate (GFR) drops significantly (usually <15 mL/min in CKD)
• Fluid overload causes pulmonary edema or hypertension
• Electrolyte imbalance, especially severe hyperkalemia (↑ K⁺)
• Uremic symptoms like pericarditis, confusion, vomiting, seizures
• Metabolic acidosis unresponsive to medication
• Drug overdose or poisoning with dialyzable toxins (e.g., lithium)

Nursing Care of a Patient with Dialysis

1. Pre-Dialysis Nursing Care :

• Assess vital signs – especially blood pressure, pulse, temperature, and respiratory rate.
• Weight the patient and compare with previous readings to assess fluid retention.

Check access site :

• Hemodialysis – inspect AV fistula or graft for bruit and thrill.
• Peritoneal dialysis – check catheter site for signs of infection.
• Withhold medications that can lower BP (antihypertensives) or are water-soluble (e.g., some antibiotics), as per physician’s instructions.
• Educate the patient about the procedure, expected sensations, and importance of diet/fluid restrictions.
• Ensure all pre-dialysis lab reports (electrolytes, BUN, creatinine) are reviewed.
• Maintain NPO status if required for certain forms of dialysis or invasive procedures.

2. Nursing Care During Dialysis :

• Monitor vital signs every 15–30 minutes during dialysis.
• Observe the patient for any complications :
• Hypotension
• Muscle cramps
• Nausea/vomiting
• Chest pain or dizziness
• Ensure the dialysis machine settings are correct as prescribed.
• Monitor the access site for signs of bleeding, clotting, or displacement.
• Maintain a calm environment and provide comfort measures (blankets, correct positioning).
• Use aseptic technique when handling any lines, catheters, or connections.
• Document any adverse reactions or patient complaints during the procedure.

3. Post-Dialysis Nursing Care :

• Reassess vital signs and weight immediately after dialysis.
• Check the access site for bleeding, hematoma, or infection.
• Monitor for post-dialysis fatigue, weakness, or dizziness.

Educate the patient about :

• Fluid and dietary restrictions (e.g., low sodium, potassium, phosphate)
• Signs of infection or access complications
• Importance of keeping dialysis appointments
• • Encourage rest and provide a light meal if allowed.
• Monitor for signs of disequilibrium syndrome – headache, confusion, restlessness.
• Evaluate intake-output records and document dialysis response.

Common Complications

• Hypotension (common in HD due to fluid shift)
• Electrolyte imbalance (esp. ↓ potassium, calcium)
• Infection at AV fistula/graft site or PD catheter
• Muscle cramps
• Peritonitis (fever, abdominal pain, cloudy dialysate in PD)
• Dialysis disequilibrium syndrome (headache, confusion due to rapid fluid shift)

2. Shock

Definition

Shock is a life-threatening condition characterized by inadequate tissue perfusion, leading to cellular hypoxia, organ dysfunction, and if untreated, multi-organ failure and death.
It results from a mismatch between oxygen supply and demand at the cellular leve

Types of Shock

1️⃣ Hypovolemic Shock
Hypovolemic shock is a type of shock that occurs due to a significant loss of intravascular fluid volume, which leads to decreased venous return, reduced cardiac output, and impaired tissue perfusion.

2️⃣ Cardiogenic Shock
Cardiogenic shock results from the heart’s inability to pump blood effectively, leading to decreased cardiac output and inadequate perfusion of vital organs despite an adequate circulating blood volume.

3️⃣ Septic Shock (a form of Distributive Shock)
Septic shock is a serious and potentially fatal condition that occurs as a result of severe infection, which leads to widespread vasodilation, increased capillary permeability, and abnormal blood distribution, ultimately causing hypotension and organ dysfunction.

4️⃣ Anaphylactic Shock (a form of Distributive Shock)
Anaphylactic shock is a severe, life-threatening allergic reaction triggered by exposure to allergens such as certain foods, medications, or insect stings, which leads to massive vasodilation, bronchospasm, airway edema, and circulatory collapse.

5️⃣ Neurogenic Shock (a form of Distributive Shock)
Neurogenic shock occurs due to disruption of the autonomic nervous system, particularly loss of sympathetic tone, leading to unopposed parasympathetic stimulation, resulting in vasodilation, bradycardia, and hypotension.

6️⃣ Obstructive Shock
Obstructive shock is caused by a mechanical obstruction that impedes blood flow and prevents adequate cardiac output despite normal myocardial function.
It may result from conditions such as massive pulmonary embolism, cardiac tamponade, or tension pneumothorax.

General Signs and Symptoms

• • Hypotension (low BP)
• • Tachycardia (fast heart rate)
• Cold, clammy, pale skin
• Weak pulses
• Rapid, shallow breathing
• Confusion, restlessness, or altered mental state
• Oliguria or anuria (low/no urine output)
• Cyanosis (late sign)

General Medical Management for All Types of Shock

Airway Management

• Ensure patency of airway
• Administer oxygen (nasal cannula, mask, or mechanical ventilation) to correct hypoxia

Fluid Replacement (Fluid Resuscitation)

• Administer IV crystalloids : Normal Saline (NS), Ringer’s Lactate (RL)
• Administer IV Colloids (e.g., albumin) in some cases
• Blood transfusions in hypovolemic/hemorrhagic shock

Vasoactive Medications

• Vasopressors : To raise BP (e.g., norepinephrine, dopamine, vasopressin)
• Inotropes : To improve heart contractility (e.g., dobutamine, epinephrine)
• Vasodilators : Sometimes used in cardiogenic shock to reduce afterload (e.g., nitroglycerin)

Monitoring

• Continuous ECG, BP, oxygen saturation
• Central venous pressure (CVP) and urine output (goal: ≥ 30 mL/hr)
• ABG, lactate levels, and electrolytes for perfusion and acidosis evaluation

Correction of Acid-Base and Electrolyte Imbalance

• Administer sodium bicarbonate for severe metabolic acidosis
• Correct hypokalemia, hyperkalemia, or other electrolyte imbalances

Nursing Management of Shock

Assessment

• Monitor vital signs frequently (BP, HR, RR, SpO₂)
• Assess for signs of poor perfusion (cool extremities, cyanosis, confusion)
• Measure urine output hourly
• Watch for changes in mental status and skin color

Interventions

• Establish airway, administer oxygen therapy
• Start IV access for fluid resuscitation (NS or RL)
• Administer vasopressors or inotropes if ordered (e.g., dopamine, norepinephrine)
• Keep patient in supine or modified Trendelenburg position unless contraindicated
• Provide blankets to prevent hypothermia
• Monitor lab values: ABG, lactate, CBC, electrolytes
• Treat underlying cause (e.g., antibiotics for sepsis, epinephrine for anaphylaxis)

Psychosocial Support :

• Reassure the patient and family
• Provide emotional support
• Involve family in care discussions

Section 2

Q.5 Define following (any five) [10 mark]

1. Pleural effusion

Pleural effusion is a medical condition characterized by the abnormal accumulation of fluid in the pleural space, which is the thin cavity between the visceral and parietal pleura surrounding the lungs. This can impair normal lung expansion, leading to breathing difficulties.

2. Leukemia

Leukemia is a malignant (cancerous) disorder of the blood-forming tissues, including the bone marrow and lymphatic system, characterized by abnormal and excessive proliferation of immature white blood cells (leukocytes), leading to impaired normal blood cell production.

3. Nephrosis

Nephrosis, also known as nephrotic syndrome, is a non-inflammatory kidney disorder characterized by excessive protein loss in the urine (proteinuria), low blood protein levels (hypoalbuminemia), high cholesterol levels (hyperlipidemia), and generalized body swelling (edema) due to damage to the glomerular basement membrane of the kidneys.

4. Alopecia

Alopecia is the loss of hair from the scalp or other parts of the body, which may be temporary or permanent, and is caused by factors such as genetics, autoimmune disorders, stress, hormonal imbalance, or certain medications.

Common Types :

Alopecia areata – patchy hair loss due to autoimmune cause

Androgenetic alopecia – hereditary hair thinning (male/female pattern baldness)

Telogen effluvium – temporary shedding due to stress or illness

5. Arthritis

Arthritis is a chronic disorder that causes inflammation of one or more joints, leading to pain, swelling, stiffness, and limited joint movement, and can result from aging, autoimmune disorders, infections, or metabolic causes.

Common Types :

Osteoarthritis – caused by wear and tear of joint cartilage

Rheumatoid arthritis – an autoimmune condition affecting multiple joints

6. Mumps

Mumps is an acute, contagious viral infection caused by the mumps virus, paramyxovirus primarily affecting the salivary glands, especially the parotid glands, causing their painful swelling, and is transmitted through respiratory droplets or direct contact with saliva of an infected person.

Q.6 Write answer following

1. Define peptic ulcer (1 mark)

A peptic ulcer is a localized erosion or sore that forms in the mucosal lining of the stomach or the first part of the small intestine (duodenum) due to the corrosive effects of gastric acid and pepsin, commonly associated with Helicobacter pylori infection or prolonged NSAID use.

2. Write surgical management of peptic ulcer (2 mark)

Surgical management of peptic ulcer is considered when there are complications like perforation, bleeding, obstruction, or non-healing ulcers. Common procedures include :

Vagotomy:

• In which surgical cutting of the vagus nerve to reduce acid secretion

Antrectomy:

• Removal of the antrum, the lower part of the stomach that stimulates acid production.

Pyloroplasty:

• In which surgical widening of the pyloric canal to improve gastric emptying.It is usually performed alongside vagotomy to prevent gastric stasis.

Gastrojejunostomy:

• In which bypassing the duodenum by connecting the stomach to the jejunum.
• It is used in cases of gastric outlet obstruction or severe duodenal ulcer.

3. Describe nursing management for peptic ulcer patient (4 mark)

Acute pain related to irritation of the gastric mucosa and ulceration.

Goal :
Patient will report relief from pain and demonstrate use of comfort measures.

Nursing Interventions :

• Assess the level, location, and characteristics of pain regularly.
• Administer prescribed medications such as antacids, proton pump inhibitors (PPIs), or H2 blockers.
• Encourage the patient to avoid spicy, acidic, and irritating foods.
• Promote relaxation techniques and position changes.
• Monitor for signs of complications (e.g., perforation).

Imbalanced nutrition: less than body requirements related to anorexia, nausea, or dietary restrictions.

Goal :
Patient will maintain optimal nutritional status and gain/maintain weight.

Nursing Interventions :

• Monitor daily weight and dietary intake.
• Encourage small, frequent, non-irritating meals.
• Consult a dietitian for a peptic ulcer-friendly diet plan.
• Avoid caffeine, alcohol, and smoking.
• Monitor for signs of malnutrition or vitamin deficiencies.

Risk for bleeding related to ulcer erosion of blood vessels

Goal :
Patient will remain free from signs of gastrointestinal bleeding.

Nursing Interventions :

• Monitor stools and vomitus for signs of bleeding (black stools or coffee-ground emesis).
• Check vital signs for tachycardia, hypotension (early signs of hemorrhage).
• Monitor hemoglobin and hematocrit levels.
• Administer IV fluids and blood transfusion as ordered if bleeding occurs.
• Keep emergency equipment ready in case of acute hemorrhage.

Deficient knowledge related to disease condition, management, and prevention of recurrence.

Goal :
Patient will verbalize understanding of the disease, treatment, and preventive measures.

• Educate the patient on causes and risk factors (e.g., H. pylori, NSAIDs, stress).
• Explain the importance of medication adherence (e.g., completing antibiotic course for H. pylori).
• Instruct on dietary modifications and lifestyle changes.
• Discuss the importance of follow-up care and reporting warning signs like bleeding, severe pain, or vomiting.
• Provide written materials or resources for reinforcement.

Nursing Interventions :

Risk for fluid volume deficit related to vomiting or bleeding.

Goal :
Patient will maintain adequate hydration and electrolyte balance.

Nursing Interventions :

• Monitor intake and output closely.
• Assess skin turgor, mucous membranes, and urine output.
• Administer IV fluids as prescribed.
• Monitor electrolyte levels and correct imbalances.

Q.7 Write short notes (any four) [20 mark]

1. HIV / AIDS

Definition

AIDS is a chronic, potentially life-threatening condition caused by the Human Immunodeficiency Virus (HIV), which damages the immune system by destroying CD4+ T-helper lymphocytes, making the body vulnerable to opportunistic infections and certain cancers.

Causative Agent

HIV (Human Immunodeficiency Virus) – a retrovirus that belongs to the Lentivirus group.

Two main types :

• HIV-1 (most common worldwide)
• HIV-2 (mainly in West Africa)

Pathophysiology of AIDS

• HIV enters the body through blood, semen, vaginal fluids, or breast milk.
• It targets CD4+ T-helper cells, binding via CD4 receptors and co-receptors (CCR5/CXCR4).
• Using reverse transcriptase, the virus converts its RNA into DNA.
• The viral DNA integrates into the host genome using the enzyme integrase.
• Virus remains latent or becomes active, producing new HIV particles.
• Continuous replication causes destruction of CD4+ cells.
• Immune system weakens, reducing defense against infections and cancers.
• When CD4 count <200 cells/mm³ or AIDS-defining illnesses occur → diagnosed as AIDS.

Mode of Transmission:

• Unprotected sexual contact with an infected person
• Contaminated blood transfusion or blood products
• Sharing of infected needles (e.g., IV drug users)
• From mother to child (vertical transmission – during pregnancy, delivery, or breastfeeding)
• Organ or tissue transplant from HIV-positive donor

Clinical Manifestations (AIDS symptoms):

• Persistent fever
• Weight loss and chronic diarrhea
• Fatigue
• Night sweats
• Recurrent infections (oral thrush, TB, herpes)
• Swollen lymph nodes
• Neurological symptoms (memory loss, confusion)

Diagnostic Tests

• History collection
• Physical examination
• ELISA (Enzyme-Linked Immunosorbent Assay) – screening test
• Western Blot – confirmatory test
• Rapid diagnostic tests (RDTs)
• CD4 cell count – to assess immune status
• Viral load testing (PCR) – to measure HIV RNA levels in blood

Medical Management

Antiretroviral Therapy (ART):

• Combination of drugs to suppress HIV replication
• Common drug classes :
• NRTIs (e.g., Zidovudine)
• NNRTIs (e.g., Efavirenz)
• Protease inhibitors (e.g., Lopinavir/Ritonavir)
• Integrase inhibitors (e.g., Dolutegravir)

Opportunistic infection treatment

• Cotrimoxazole for Pneumocystis pneumonia
• Antitubercular drugs for TB
• Antifungals for candidiasis

Nursing Management of AIDS Patient

• Maintain infection control and aseptic technique
• Provide nutritional support and manage weight loss
• Offer psychological support and counseling
• Monitor for drug side effects and adherence to ART
• Educate about safe sex practices and disease transmission
• Support in managing opportunistic infections
• Maintain hydration and hygiene
• Ensure regular CD4 and viral load monitoring

Prevention of AIDS

• Practice safe sex by using condoms during all sexual activities.
• Avoid multiple sexual partners and promote monogamous relationships.
• Screen all blood and blood products before transfusion to avoid HIV-contaminated blood.
• Use sterile/disposable needles for injections and avoid sharing needles.
• Prevent mother-to-child transmission by providing ART to HIV-positive pregnant women.
• Promote Pre-Exposure Prophylaxis (PrEP) and Post-Exposure Prophylaxis (PEP) in high-risk individuals.

• Educate the public through awareness programs about HIV transmission and safe practices.
• Ensure proper sterilization of surgical and dental instruments.
• Provide Voluntary Counseling and Testing (VCT) services to encourage early diagnosis.
• Avoid breastfeeding if the mother is HIV-positive and safe alternatives are available.

2. Standard safety measure of OT

The Operation Theatre (OT) is a sterile environment where surgical procedures are carried out. Ensuring safety and infection control is crucial to protect both patients and healthcare workers. Standard safety measures help in minimizing risks like surgical site infections, equipment hazards, fire, and exposure to harmful substances.

1. Aseptic Techniques and Infection Control

• Strict hand hygiene (using antiseptic solution before and after procedures)
• Sterilization of instruments and linen (autoclaving, chemical sterilants)
• Use of personal protective equipment (PPE) – sterile gloves, gown, mask, cap, and goggles
• Laminar airflow and HEPA filters to reduce microbial load
• Positive air pressure in OT to prevent entry of contaminated air
• Cleaning and disinfection of OT surfaces before and after surgery
• Antiseptic skin preparation of the surgical site
• Restricted OT entry (only authorized, properly dressed personnel)

2. Electrical and Fire Safety

• Use of properly grounded electrical equipment to prevent shocks
• No sparking equipment near oxygen or anesthetic gases
• Fire extinguishers must be present and staff trained in use
• Avoid use of alcohol-based solutions near cautery or laser devices
• Use of fire-retardant materials in OT design
• Emergency shutdown switches for power and gas lines

3. Surgical Safety Protocols

• Implementation of the WHO Surgical Safety Checklist:
• Patient identity and consent verified
• Surgical site and procedure confirmed
• Instrument and sponge counts before closure
• Use of time-out procedure before surgery begins
• Safe handling and disposal of sharps to prevent injury

4. Anesthesia and Gas Safety

• Regular maintenance and calibration of anesthesia machines
• Use of scavenging systems to remove waste anesthetic gases
• Ensure adequate oxygen supply and backup cylinders
• Monitor for gas leaks and staff exposure using detectors

5. Environmental Controls

• Temperature: Maintained between 20–24°C
• Humidity: 40–60% to prevent static electricity and microbial growth
• Noise control: To reduce stress and ensure focus
• Proper lighting: Adjustable and shadow-free for precision

6. Waste Management and Biomedical Safety

• Segregation of biomedical waste in color-coded bins
• Immediate disposal of contaminated materials
• Needle stick injury protocols followed strictly
• Use of puncture-proof containers for sharps

7. Documentation and Safety Audits

• Maintain incident reports for any error or injury
• Regular audits of OT practices and safety drills
• Training of OT staff in emergency response and infection control

3. Types of anesthesia

General anesthesia

• It is a medically induced state of complete unconsciousness in which the patient loses all sensations, reflexes, and awareness
• It is usually administered through intravenous agents or inhalation gases.
• It is used in major surgical procedures such as cardiac, abdominal, or brain surgeries without causing pain or distress.
• Examples : Propofol, Thiopentone, Sevoflurane, Isoflurane.

Regional anesthesia

• It involves the injection of a local anesthetic near major nerves or into the spinal cord area to block sensation in a larger region of the body.
• In which patient remains awake but feels no pain in the anesthetized area.
• It is commonly used during childbirth, orthopedic procedures, or surgeries on the lower body.

Types of Regional Anesthesia :

• Spinal Anesthesia – Injected into the subarachnoid space, used in lower abdominal or leg surgeries.
• Epidural Anesthesia – Injected into the epidural space, commonly used in childbirth and orthopedic surgeries.
• Nerve Block Anesthesia – Injected near specific nerves or plexuses, used in limb surgeries.
• Caudal Anesthesia – A form of epidural given in the lower spine, often used in pediatric surgeries.

Local anesthesia

• It refers to the use of drugs that are injected directly into the tissues of a specific small area.
• It is used to temporarily block sensation without affecting consciousness.
• It is often used in minor surgical procedures like wound suturing, dental extractions, or skin biopsies.
• Examples : Lidocaine, Procaine, Bupivacaine.

Topical anesthesia

• It is the application of anesthetic agents in the form of creams, gels, sprays, or eye drops directly onto the surface of the skin or mucous membranes.
• It is used to numb only the superficial tissues, which is useful for minor procedures like eye examinations, throat endoscopies, or catheter insertions.
• Examples : Benzocaine spray, Lidocaine gel.

Conscious sedation

• Conscious sedation also known as moderate sedation.
• It is a technique in which the patient is given sedative and analgesic drugs to achieve a calm, sleepy state in which they remain responsive to verbal commands and breathing independently.
• It is ideal for short and minimally invasive procedures such as endoscopy, colonoscopy, or dental treatments.
• Drugs used in conscious sedation are Midazolam, Diazepam, Fentanyl.

4. Enema

Definition

An enema is a medical procedure in which liquid is introduced into the rectum and colon via the anus for the purpose of stimulating bowel movement, administering medication, or cleansing the lower intestinal tract. It may be therapeutic, diagnostic, or preparatory for medical or surgical procedures.

Purposes of Enema

• To relieve constipation or fecal impaction
• To cleanse the bowel before surgery or diagnostic procedures (e.g., colonoscopy)
• To administer drugs or nutrients rectally
• To relieve gas or distension
• For bowel training in children or patients with neurogenic bowel

Types of enema

1️⃣ Cleansing Enema

It is used to remove fecal matter from the rectum and colon by introducing a large volume of fluid such as normal saline, tap water, or soap-suds solution, and is commonly given before surgeries, childbirth, or diagnostic procedures to ensure a clean bowel.

2️⃣ Retention Enema

It involves the introduction of a small amount of fluid that is intended to be retained in the rectum for a prolonged period (15–30 minutes or more) in order to soften the stool, deliver medications, or provide nutrients; subtypes include oil retention enema (to soften hard feces), medicated enema (to deliver drugs like corticosteroids), and nutrient enema (to provide nutritional support in rare cases).

3️⃣ Carminative Enema

It is given to relieve flatulence (gas) and abdominal distension by introducing a small volume of gas-relieving solution, typically containing ingredients like magnesium sulfate, glycerin, or milk and molasses.

4️⃣ Return-Flow Enema

Return floe enema also known as Harris flush, is used primarily to expel gas by alternately introducing and withdrawing small amounts of warm fluid in and out of the rectum, thereby stimulating peristalsis and relieving discomfort caused by gas accumulation.

5️⃣ Astringent Enema

It is administered to reduce inflammation and excessive secretions in the large intestine, particularly in cases of diarrhea, using a solution containing astringent substances like tannic acid.

6️⃣ Emollient Enema

It is used to soothe and protect the mucous membranes of the rectum and lower bowel, especially in cases of irritation or inflammation, by using oily or glycerin-based substances that act as a lubricant.

7️⃣ Cooling Enema

It is introduced into the rectum using cold or cool water in order to lower the body temperature during cases of high fever or hyperthermia when other methods of temperature control are not effective or practical.

Contraindications

• Severe abdominal pain of unknown cause
• Rectal bleeding or recent rectal surgery
• Suspected appendicitis or bowel obstruction
• Hemorrhoids (for certain types of enemas)

Side Effects

• Abdominal cramping or bloating
• Rectal irritation
• Fluid and electrolyte imbalance (with repeated use)
• Dependency if used frequently for constipation

Articles Required

• Enema can (with tubing and nozzle)
• Enema solution (saline, soap solution, etc.)
• Lubricant (e.g., petroleum jelly)
• Bedpan
• Protective sheet and towel
• Gloves
• Kidney tray and toilet paper

Procedure (Cleansing Enema Example)

• Explain procedure to the patient.
• Gather equipment and ensure privacy.
• Position the patient in left lateral (Sims’) position.
• Lubricate nozzle and insert 3–4 inches gently into the rectum.
• Slowly instill fluid (usually 500–1000 ml of warm solution).
• Ask patient to retain fluid for 5–10 minutes.
• Assist with elimination into bedpan or toilet.
• Document procedure and patient response.

Nurse’s Responsibilities

• Assess bowel sounds and last bowel movement.
• Maintain privacy and dignity.
• Monitor for cramping, dizziness, or discomfort.
• Ensure correct fluid temperature (around 37–40°C).
• Prevent fluid overload, especially in children or cardiac patients.
• Educate patient on after-care and potential outcomes.

5. Pain management technique

Pain management refers to the methods used to reduce or control pain and improve the comfort and quality of life of the patient. It can involve both pharmacological and non-pharmacological approaches, depending on the type, intensity, and cause of pain.

1. Pharmacological Techniques

These involve the use of medications to relieve pain.

a) Non-opioid analgesics

• It is used for mild to moderate pain
• Examples: Paracetamol, NSAIDs (e.g., Ibuprofen, Diclofenac)
• Action : Reduce inflammation and pain

b) Opioid analgesics

• It is used for moderate to severe pain
• Examples : Morphine, Fentanyl, Tramadol
• Action : Act on CNS to block pain perception

c) Adjuvant drugs

• It is used in neuropathic and chronic pain
• Examples :
• Antidepressants (Amitriptyline)
• Anticonvulsants (Gabapentin)
• Corticosteroids (Prednisolone)
• Action : Enhance pain relief when used with analgesics

d) Topical agents

• It is used for localized pain relief
• Examples: Lidocaine patch, Capsaicin cream

2. Non-Pharmacological Techniques

These are supportive, drug-free methods to reduce pain perception.

a) Physical methods

• Cold therapy: Reduces inflammation and numbs pain
• Heat therapy: Relaxes muscles and improves circulation
• Massage therapy: Reduces tension and improves blood flow
• TENS (Transcutaneous Electrical Nerve Stimulation): Blocks pain signals using electrical currents

b) Psychological and Behavioral methods

• Distraction : Using music, games, or TV to shift attention
• Relaxation techniques : Deep breathing, progressive muscle relaxation
• Cognitive Behavioral Therapy (CBT) : Alters negative thoughts about pain
• Biofeedback : Teaches control over bodily functions using monitoring devices

c) Complementary methods

• Acupuncture : Needle stimulation on specific points
• Aromatherapy : Use of essential oils for calming effects
• Yoga and Meditation : Improve body-mind harmony, reduce stress

3. Invasive Techniques

• Used in chronic or unmanageable pain.
• Nerve blocks: Local anesthetics block pain conduction
• Epidural or spinal analgesia: Common in surgery/labor pain
• Surgical methods : Used when pain is caused by structural problems (e.g., tumor, herniated disc)

6. Age related problem in geriatic patient

Neurological and Cognitive Problems

• Dementia and Alzheimer’s Disease :
  With aging, cognitive abilities decline. Dementia is a chronic, progressive syndrome that affects memory, reasoning, orientation, and language. Alzheimer’s disease is the most common form, leading to severe memory loss and dependency.
• Parkinson’s Disease :
  It is a degenerative neurological disorder commonly seen in older adults. It causes tremors, rigidity, slow movement (bradykinesia), and postural instability.
• Stroke (Cerebrovascular Accident) :
  Older adults are at higher risk due to atherosclerosis, hypertension, and heart conditions. A stroke may result in paralysis, loss of speech, memory problems, or permanent disability.
• Delirium :
  This is an acute, fluctuating disturbance in attention and cognition, often due to medications, infections, or metabolic disturbances. It is reversible but requires immediate treatment.

Musculoskeletal Problems

• Osteoarthritis :
  Degeneration of cartilage in joints leads to pain, stiffness, and difficulty in movement. Weight-bearing joints like knees and hips are commonly affected.
• Osteoporosis :
  With aging, bone density reduces, especially in post-menopausal women. This makes bones fragile and prone to fractures even with minor falls.
• Sarcopenia (Muscle Loss) :
  Decreased muscle mass and strength in elderly people lead to weakness, increased risk of falls, and reduced mobility.

Sensory Impairments

• Vision Impairment :
• Presbyopia – difficulty in near vision due to lens stiffening.
• Cataracts – clouding of the lens causing blurred vision.
• Glaucoma – increased intraocular pressure that can lead to blindness.
• Macular degeneration – affects central vision, making reading or recognizing faces difficult.
• Hearing Impairment (Presbycusis) :
  Gradual loss of hearing, especially for high-frequency sounds. It can lead to social withdrawal, communication difficulty, and depression.
• Reduced Taste and Smell :
  These changes can reduce appetite, causing malnutrition or poor medication compliance.

Cardiovascular and Respiratory Problems

• Hypertension :
  Common due to stiffening of blood vessels with age. If untreated, it can lead to stroke, heart failure, or kidney disease.
• Ischemic Heart Disease / Myocardial Infarction (MI) :
  Atherosclerosis and aging increase the risk. Chest pain, breathlessness, or fatigue are common symptoms.
• Heart Failure :
  Age-related cardiac muscle weakening leads to poor pumping function, causing fluid retention and breathlessness.
• Chronic Obstructive Pulmonary Disease (COPD) :
  Includes chronic bronchitis and emphysema. It is worsened by smoking and air pollution and leads to breathlessness and poor oxygenation.

Gastrointestinal and Nutritional Problems

• Constipation :
  A very common issue due to slow bowel motility, reduced physical activity, inadequate fluid intake, and medications (like opioids, calcium supplements).
• Dysphagia (Difficulty Swallowing) :
  Often due to stroke or age-related muscle weakening, it increases the risk of aspiration pneumonia.
• Malnutrition :
  Poor dentition, reduced taste sensation, economic limitations, and chronic illness may lead to undernutrition and weight loss.
• Incontinence :
  Urinary and sometimes fecal incontinence occur due to weak pelvic floor muscles or neurological issues, affecting self-esteem and hygiene.

Endocrine and Metabolic Disorders

• Type 2 Diabetes Mellitus :
  Due to insulin resistance and poor glucose metabolism. Complications such as neuropathy, retinopathy, and nephropathy are common in elderly diabetics.
• Hypothyroidism :
  Metabolic functions slow down, leading to fatigue, weight gain, and cold intolerance.
• Electrolyte Imbalances :
  Due to decreased kidney function and drug effects, leading to confusion, arrhythmias, or muscle weakness.

Integumentary (Skin) and Dental Problems

• Skin Changes :
• Thinning and dryness of the skin increase the risk of pressure sores.
• Bruising and tearing occur easily due to fragile blood vessels.
• Healing is slower in elderly skin.
• Pressure Ulcers (Bedsores):
  Prolonged immobility leads to skin breakdown, especially over bony areas like the sacrum, heels, and elbows.
• Dental Issues :
  Tooth loss, gum disease, and ill-fitting dentures can cause chewing difficulty and poor nutrition.

Psychological Problems

• Depression :
  May result from loneliness, chronic illness, or death of spouse. Often underdiagnosed because symptoms are mistaken as part of aging.
• Anxiety and Fear of Death or Dependency :
  Many elderly people fear becoming a burden to others, loss of dignity, or institutionalization.
• Sleep disturbance : Aging affects circadian rhythms, causing early awakening or insomnia. Medications or chronic pain can worsen this.

Social Problems

• Loneliness and Social Isolation:
  Due to retirement, death of spouse, or children living away. This contributes to depression and cognitive decline.
• Financial Dependence :
  Loss of income after retirement can lead to poor access to healthcare and proper nutrition.
• Elder Abuse :
  May be physical, emotional, or financial. Elderly persons may be neglected or mistreated by caregivers or family.
• Loss of Social Role and Identity :
  Many elderly people experience a loss of respect or usefulness, impacting their self-worth.

Polypharmacy and Medication-Related Issues

• Polypharmacy :
  The use of multiple medications increases the risk of adverse drug reactions, drug interactions, and confusion about dosages.
• Medication non-compliance :
  Memory loss, visual impairment, or financial issues can cause improper intake or missed doses.