Section 1

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

1. Hypospadiasis

• Hypospadias is a congenital defect in males where the urethral opening is located on the underside (ventral surface) of the penis instead of at the tip.
• It may be associated with chordee (curved penis) and can affect urination and fertility if not corrected.

2. Infertility

• Infertility is the inability of a couple to conceive after one year of regular unprotected sexual intercourse. It may be due to male, female, or combined factors, and can be primary (no prior pregnancies) or secondary (difficulty after previous pregnancy).
• It may result from factors related to the male partner, female partner, or both, and may be primary (no previous pregnancy) or secondary (difficulty after a previous successful pregnancy).

3. Osteomalacia

• Osteomalacia is a bone disorder characterized by softening of bones in adults due to defective bone mineralization, primarily caused by vitamin D deficiency.

• It leads to bone pain, muscle weakness, and increased risk of fractures.

4. Meningitis

• Meningitis is an inflammation of the meninges, the protective membranes covering the brain and spinal cord, usually caused by bacterial, viral, or fungal infections.
• It is a medical emergency and can lead to complications like seizures, brain damage, or death if not treated promptly.

5. Arteriosclerosis

• Arteriosclerosis is a condition characterized by the thickening, hardening, and loss of elasticity of the arterial walls, which leads to reduced blood flow to organs and tissues.
• It is commonly associated with aging and increases the risk of hypertension, heart attack, and stroke.

6. Cardiac tamponade

• Cardiac tamponade is a medical emergency where fluid or blood accumulates rapidly in the pericardial sac, causing compression of the heart.
• This limits the heart’s ability to fill and pump effectively, leading to decreased cardiac output and shock

Q.2

a. Define COPD (2 mark)

COPD is a progressive, irreversible lung disease characterized by chronic airflow limitation that is not fully reversible. It includes conditions like chronic bronchitis and emphysema, which cause obstruction of the airways and impair gas exchange, leading to breathlessness, cough, and sputum production.

b. List complication of COPD (2 mark)

Respiratory Complications

• Acute Exacerbations
• Chronic Hypoxemia (↓ Oxygen in blood)
• Hypercapnia (↑ CO₂ retention)
• Respiratory Failure
• Pulmonary Hypertension
• Cor Pulmonale (Right-sided heart failure due to lung disease)
• Pneumothorax (especially in emphysematous COPD)
• Lung infections (e.g., pneumonia, bronchitis)

2. Cardiovascular Complications

• Right Heart Failure (Cor Pulmonale)
• Arrhythmias (like atrial fibrillation)
• Systemic Hypertension
• Increased risk of ischemic heart disease

3. Neurological Complications

• CO₂ narcosis (confusion, drowsiness due to high CO₂)
• Cognitive dysfunction (due to chronic hypoxia)

4. Nutritional & Musculoskeletal

• Weight loss and muscle wasting (cachexia)
• Osteoporosis
• Decreased exercise tolerance

c. Write a nursing process of patient with COPD (5 mark)

Impaired Gas Exchange related to alveolar-capillary membrane changes and airflow limitation

Goal : Patient will maintain optimal gas exchange

Nursing Interventions :

• Monitor respiratory rate, depth, and SpO₂ regularly
• Administer supplemental oxygen as prescribed (low-flow if CO₂ retainer)
• Position patient in high Fowler’s or tripod position to facilitate lung expansion
• Teach pursed-lip breathing and diaphragmatic breathing
• Encourage incentive spirometry use
• Provide bronchodilators, corticosteroids, and nebulization therapy as ordered.
• Assess for cyanosis, restlessness, confusion (signs of hypoxia)

Ineffective Airway Clearance related to excessive mucus production and weak cough effort

Goal : Patient will maintain a clear airway with effective cough and normal breath sounds.

Nursing Interventions :

• Encourage fluid intake (if not contraindicated) to thin secretions
• Provide chest physiotherapy and postural drainage as indicated
• Encourage coughing and deep breathing exercises
• Suction airway if necessary (esp. in acute phase)
• Administer expectorants or bronchodilators as ordered

Activity Intolerance related to imbalance between oxygen supply and demand

Goal : Patient will perform activities of daily living (ADLs) without excessive fatigue or dyspnea.

Nursing Interventions :

• Assess tolerance to activity and fatigue level
• Plan activities with rest periods
• Provide assistance with ADLs as needed
• Educate energy conservation techniques
• Administer medications like bronchodilators prior to activities

Imbalanced Nutrition less than Body Requirements related to anorexia, dyspnea during eating, increased metabolic demand as evidenced by weight loss, poor appetite

Nursing Interventions :

• Assess nutritional status using weight trends and dietary history.
• Provide high-protein, high-calorie, small frequent meals.
• Encourage rest before meals to reduce fatigue while eating.
• Avoid gas-forming foods that increase bloating and dyspnea.
• Collaborate with a dietitian for individualized nutrition plans.
• Monitor serum albumin and prealbumin levels.
• Consider nutritional supplements (e.g., protein shakes).

Anxiety related to breathlessness and fear of suffocation

Goal : Patient will verbalize reduced anxiety and demonstrate relaxation techniques.

Nursing Interventions :

• Stay with patient during episodes of breathlessnessUse calm, reassuring Communication
• Teach relaxation techniques (e.g., guided imagery, controlled breathing)
• Encourage expression of fears
• Avoid sudden changes in care or routine

Q.3 Write short notes on (any four) [20 mark]

1. 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. Iron deficiency anemia

Definition

Iron deficiency anemia is a type of microcytic, hypochromic anemia caused by insufficient iron availability in the body, which leads to reduced hemoglobin synthesis, resulting in decreased oxygen-carrying capacity of red blood cells and clinical signs of anemia.

Etiology / Causes

• Inadequate dietary intake of iron (especially in children, vegetarians)
• Malabsorption of iron (e.g., celiac disease, chronic diarrhea)
• Increased demand during periods of growth, pregnancy, or menstruation
• Chronic blood loss (e.g., gastrointestinal bleeding, heavy menstruation, hemorrhoids, hookworm infestation)
• Post-surgical states like gastrectomy or bariatric surgery
• Poor socioeconomic status and repeated pregnancies in women

Pathophysiology

• Iron is essential for the production of hemoglobin in red blood cells.
• In iron deficiency, there is insufficient iron available in the bone marrow for hemoglobin synthesis.
• This leads to the formation of small (microcytic) and pale (hypochromic) red blood cells.
• The resulting anemia causes inadequate oxygen delivery to tissues, leading to common symptoms like fatigue and pallor.
• The body tries to compensate by increasing cardiac output, leading to palpitations and breathlessness.

Clinical Manifestations

General signs of anemia :

• Fatigue
• Weakness
• Pallor
• Dizziness
• Headache
• Palpitations
• Dyspnea on exertion

Specific to iron deficiency :

• Koilonychia (spoon-shaped nails)
• Glossitis (inflamed tongue)
• Angular cheilitis (cracks at mouth corners)
• Pica (craving for non-food items like clay, ice)

Diagnostic Evaluation

• History collection
• Physical examination
• Complete blood count (CBC)
• Peripheral blood smear
• Serum ferritin
• Serum iron
• Total iron-binding capacity (TIBC)
• Stool test: for occult blood (to detect GI bleeding)
• Bone marrow biopsy (rarely needed)

Management

1. Identify and Treat Underlying Cause

• Investigate and manage sources of chronic blood loss (e.g., GI bleeding, heavy menstruation).
• Treat malabsorption disorders (e.g., celiac disease, H. pylori infection).
• Administer antiparasitic drugs for helminthic infestations (e.g., hookworm).

2. Iron Replacement Therapy

A. Oral Iron Therapy

• It is most common and preferred method.
• Use ferrous sulfate, ferrous fumarate, or ferrous gluconate.
• Administer on an empty stomach for best absorption (if tolerated).
• Vitamin C (ascorbic acid) may be given to enhance absorption.
• Continue therapy for 3–6 months after hemoglobin normalizes to replenish iron stores.

B. Parenteral Iron Therapy

• It is used when oral iron is not tolerated, absorbed, or in severe anemia.
• Administer intramuscular or intravenous iron (e.g., iron sucrose, iron dextran).
• Monitor for anaphylaxis or allergic reactions, especially with IV iron.

3. Blood Transfusion

• Indicated in severe anemia with hemodynamic instability or cardiac symptoms.
• It is used when hemoglobin <7 g/dL or rapid correction is needed.
• It should be done with monitoring and cross-matching.

4. Nutritional Management

• Encourage iron-rich foods :
• Red meat, liver, eggs, green leafy vegetables (spinach), pulses, jaggery, dates, nuts.
• Recommend vitamin C-rich foods (lemon, orange, amla) with meals.
• Advise to avoid tea, coffee, or calcium-rich foods with iron intake.

5. Health Education and Compliance

• Instruct on the importance of completing the full course of iron therapy.
• Educate on recognizing side effects of iron supplements (e.g., constipation, black stool).
• Promote regular follow-up for hemoglobin monitoring.
• Stress daily weight monitoring in children to track growth improvement.

6. Preventive Measures

• Deworming every 6 months in endemic areas.
• Iron-folic acid supplementation in pregnant women, lactating mothers, and adolescent girls.
• Implement nutrition education programs in schools and communities.
• Encourage use of iron cooking utensils to increase dietary iron intake.

Nursing Management

• Monitor hemoglobin and hematocrit levels regularly
• Educate the patient on compliance with iron therapy
• Advise on dietary sources of iron and proper cooking methods (use of iron utensils)
• Monitor for side effects of oral iron (e.g., constipation, black stools, GI upset)
• Encourage rest and energy conservation
• Instruct to take iron supplements on an empty stomach for better absorption
• Counsel pregnant women and growing children on preventive iron intake

3. Inflammation process

Definition

Inflammation is the body’s protective response to injury, infection, or irritation, involving immune cells, blood vessels, and molecular mediators, aimed at eliminating the cause, removing damaged cells, and initiating tissue repair.

Cardinal Signs of Inflammation (Celsus)

• Redness (Rubor)
• Heat (Calor)
• Swelling (Tumor)
• Pain (Dolor)
• Loss of function (Functio laesa)

Stages of the Inflammatory Process

Inflammation is a complex biological response to harmful stimuli such as pathogens, damaged cells, or irritants, and it proceeds through a series of overlapping stages that aim to eliminate the cause of injury and initiate healing.

1️⃣ Stage 1 – Tissue Injury / Initiation

The process of inflammation begins when the tissue is injured due to trauma, infection, or toxins, causing the damaged cells to release various chemical mediators such as histamine, prostaglandins, and cytokines, which act as alarm signals to recruit immune cells to the site of damage and initiate vascular changes.

2️⃣ Stage 2 – Vascular Response

In this stage, the released mediators cause vasodilation of arterioles, which increases blood flow to the affected area, resulting in the classical signs of redness and warmth, and simultaneously, the capillary permeability increases, allowing plasma proteins, fluid, and immune cells to leak into the tissues, leading to swelling (edema) and delivering essential components for defense and healing.

3️⃣ Stage 3 – Cellular Response (Leukocyte Migration)

Following the vascular changes, white blood cells (especially neutrophils and monocytes) adhere to the inner walls of blood vessels (a process called margination), then pass through the vessel walls (diapedesis) and migrate toward the site of injury under the guidance of chemical signals (chemotaxis), where they begin their protective functions.

4️⃣ Stage 4 – Phagocytosis and Microbe Destruction

Once at the site, the neutrophils and macrophages engulf and destroy invading pathogens, dead cells, and debris through a process known as phagocytosis, using powerful enzymes and reactive oxygen species, and this intense cellular activity often leads to the formation of pus in purulent inflammation, composed of dead leukocytes, pathogens, and tissue remnants.

5️⃣ Stage 5 – Resolution and Tissue Repair

After the offending agent is neutralized, the inflammation begins to subside, with anti-inflammatory mediators such as interleukin-10 (IL-10) and transforming growth factor-beta (TGF-β) being released to suppress further inflammation, neutrophils undergo apoptosis, and macrophages clear the debris, leading to tissue healing either by regeneration of normal tissue or by fibrosis and scar formation if damage is extensive or irreversible.

Nursing Management in Inflammation

A. Assessment and Monitoring

• It is essential to assess pain, swelling, redness, and heat at the site of inflammation.
• It is important to monitor vital signs regularly, especially if systemic infection is suspected.
• It is necessary to monitor WBC count, CRP, ESR, and signs of sepsis or systemic involvement.

B. Pharmacological Management

• It is crucial to administer NSAIDs (like ibuprofen, diclofenac) to reduce pain and inflammation.
• It is sometimes indicated to administer antibiotics if bacterial infection is the cause of inflammation.
• It is important to evaluate for adverse effects of medications such as gastric irritation from NSAIDs.

C. Comfort Measures and Positioning

• It is beneficial to elevate the affected limb to reduce edema and pain.
• It is helpful to apply cold compresses in acute phase to decrease swelling.
• It is important to maintain rest of the affected part to avoid further tissue damage.

D. Patient Education and Follow-Up

• It is essential to educate the patient about signs of worsening infection or inflammation.
• It is required to encourage compliance with medications and follow-up investigations.
• It is necessary to teach the patient about infection prevention and personal hygiene practices.

4. Pulmonary embolism

Definition

Pulmonary embolism (PE) is a life-threatening condition in which one or more arteries in the lungs are blocked by a blood clot (thrombus), usually originating from the deep veins of the legs (deep vein thrombosis – DVT).

Etiology / Causes

• Deep vein thrombosis (DVT) – most common cause
• Prolonged immobilization (e.g., post-surgery, bed rest)
• Hypercoagulable states (e.g., malignancy, genetic clotting disorders)
• Surgery or trauma (especially orthopedic)
• Pregnancy and postpartum period
• Oral contraceptive pills or hormone replacement therapy
• Obesity and smoking

Pathophysiology

• Clot forms in deep vein (usually leg – DVT).
• Clot dislodges → travels to lungs via venous system.
• Blocks pulmonary artery → reduces blood flow to lungs.
• Causes ventilation-perfusion mismatch → leads to hypoxemia.
• Pulmonary pressure rises → right heart strain → possible failure.
• Decreased cardiac output → may lead to shock or death.

Clinical Manifestations

• Sudden onset dyspnea (shortness of breath)
• Chest pain (pleuritic type)
• Tachycardia (fast heart rate)
• Tachypnea (rapid breathing)
• Hemoptysis (coughing up blood)
• Cyanosis
• Syncope (fainting) in massive PE
• Anxiety and restlessness

Diagnostic Evaluation

• History collection
• Physical examiination
• D-dimer test (elevated)
• Chest X-ray (often normal or shows atelectasis)
• CT pulmonary angiography (gold standard)
• Ventilation-perfusion (V/Q) scan
• ECG (shows right heart strain pattern)
• Ultrasound of lower limbs (to detect DVT)
• ABG analysis (may show hypoxemia, respiratory alkalosis)

Management

1. Emergency Management and Initial Stabilization

• The first step in managing a patient with pulmonary embolism (PE) is to stabilize the airway, breathing, and circulation (ABC).
• Oxygen therapy is administered via nasal cannula or mask to maintain oxygen saturation above 90%.
• Establish IV access for fluid administration and medications.
• Continuous cardiac monitoring and frequent checking of vital signs and oxygen saturation are essential.
• If the patient is in shock or hypotension, IV fluids and vasopressors (like norepinephrine) may be used.
• Arterial blood gas (ABG) is assessed to monitor oxygenation and acid-base balance.

2. Anticoagulant Therapy (Mainstay of Treatment)

• Anticoagulation prevents further clot formation and reduces the risk of new thromboembolic events.
• Unfractionated Heparin (UFH) – given intravenously for rapid anticoagulation. The dose is adjusted according to activated partial thromboplastin time (aPTT).
• Low Molecular Weight Heparin (LMWH) – such as enoxaparin is preferred for stable patients as it has a predictable effect and does not need frequent monitoring.
• Warfarin (oral anticoagulant) – started along with heparin and continued for several months. The dose is adjusted based on INR (target 2.0–3.0).
• Direct Oral Anticoagulants (DOACs) – such as rivaroxaban or apixaban are increasingly used due to ease of administration and fewer monitoring requirements.

3. Thrombolytic Therapy (Clot Dissolution)

• It is sed in patients with massive pulmonary embolism (PE with hypotension or shock) to rapidly dissolve the clot.
• Drugs like Alteplase (tPA) or Streptokinase are used.
• It is contraindicated in patients with recent surgery, stroke, or active bleeding due to risk of hemorrhage.

4. Interventional and Surgical Management

• Catheter-directed thrombolysis or thrombectomy: Performed using a catheter to deliver thrombolytic drugs or mechanically remove the clot directly from the pulmonary artery.
• Surgical Pulmonary Embolectomy: Reserved for life-threatening PE where thrombolytics are contraindicated or have failed.
• Inferior Vena Cava (IVC) Filter: Implanted in the inferior vena cava to prevent further emboli from reaching the lungs, used in patients with contraindications to anticoagulation.

Nursing Management

• Monitor vital signs, oxygen saturation, and respiratory status
• Administer oxygen therapy as prescribed
• Administer anticoagulants and monitor PT, INR, aPTT
• Encourage early ambulation and leg exercises
• Use compression stockings to prevent DVT
• Educate the patient on anticoagulant therapy and bleeding precautions
• Monitor for signs of bleeding (e.g., gums, urine, stool)

5. Edema

Definition

Edema is the abnormal accumulation of fluid in the interstitial spaces (tissues) of the body, leading to visible swelling.

Types of edema

1️⃣ Peripheral edema

It refers to the accumulation of fluid in the tissues of the extremities, most commonly affecting the legs, ankles, feet, hands, or arms, and is often associated with conditions like congestive heart failure, venous insufficiency, or deep vein thrombosis.

2️⃣ Pulmonary edema

It is a serious condition in which fluid collects within the alveoli of the lungs, making it difficult for the patient to breathe and resulting from causes such as left-sided heart failure, renal failure, or acute respiratory distress syndrome (ARDS).

3️⃣ Cerebral edema

It is the swelling of brain tissue caused by the excessive accumulation of fluid within the brain, which can lead to increased intracranial pressure and is commonly seen in traumatic brain injuries, stroke, brain tumors, or infections like meningitis or encephalitis.

4️⃣ Macular edema

It is a condition in which fluid accumulates in the macula, the central part of the retina, leading to vision problems such as blurriness or distortion and is most commonly seen in diabetic retinopathy or retinal vein occlusion.

5️⃣ Lymphedema

It occurs when there is an obstruction or damage to the lymphatic system, resulting in poor lymph drainage and chronic swelling, usually in one or both arms or legs, and it can be congenital or secondary to cancer treatments, infections like filariasis, or surgical removal of lymph nodes.

6️⃣ Pitting edema

It is characterized by an indentation or “pit” that remains for some time after pressure is applied to the swollen area, and it commonly occurs in conditions such as heart failure, kidney disease, liver cirrhosis, and hypoalbuminemia.

7️⃣ Non-pitting edema

It is refers to a type of swelling where no indentation is left when pressure is applied to the area, often indicating lymphatic or thyroid-related causes such as lymphedema or myxedema in hypothyroidism.

8️⃣ Angioedema

It is a rapid and often severe swelling of the deeper layers of the skin and mucous membranes, frequently involving the eyes, lips, tongue, or throat, and is usually caused by allergic reactions, hereditary conditions, or side effects of medications like ACE inhibitors.

9️⃣ Generalized edema

It is also called anasarca, is a condition in which there is a widespread, severe accumulation of fluid throughout the body, often resulting from advanced heart failure, liver cirrhosis, nephrotic syndrome, or severe protein deficiency as seen in malnutrition.

🔟 Dependent edema

It occurs in areas of the body that are most affected by gravity, such as the feet in ambulatory patients or the sacral area in bedridden individuals, and it is commonly seen in patients with cardiac failure, immobility, or prolonged sitting or standing.

Causes of Edema

• Heart failure (reduced heart pumping causes fluid backup.)
• Kidney disease (poor filtration leads to fluid retention.)
• Liver cirrhosis (reduced albumin causes fluid leakage.)
• Malnutrition (especially protein deficiency (hypoalbuminemia).
• Medications (steroids, NSAIDs, calcium channel blockers.)
• Infections or inflammation (increased capillary permeability.)
• Excessive salt intake (it leads to water retention.)
• Venous obstruction (like thrombosis or varicose veins.)

Clinical Features

• Visible swelling in limbs or face.
• Weight gain.
• Tightness of skin.
• Shiny, stretched skin.
• Reduced mobility in affected limb.
• Shortness of breath (if pulmonary edema).

Diagnostic Evaluation

• History collection
• Physical examination (pitting test).
• Blood tests : kidney function, liver function, serum albumin.
• Urinalysis : proteinuria in nephrotic syndrome.
• Chest X-ray (for pulmonary edema).
• ECG or echocardiogram (for cardiac causes).
• Doppler ultrasound (to check for venous thrombosis).

Management of Edema

Treat Underlying Cause

• Treat the cause of edema
• Manage heart failure, kidney disease, liver cirrhosis, or malnutrition.

Diuretics

• Given prescribed diuretics to reduce edema
• Furosemide
• Torsemide
• Spironolactone
• Monitor electrolytes and dehydration.

Sodium Restriction

• Encourage for intake of Low-salt diet
• it helps to reduce water retention.

Fluid Restriction

• In cases like renal or heart failure, ristrict the fluid.
• As per doctor’s advice.

Compression Therapy

• Use the compression stockings or bandages over the affected area
• It is useful in venous edema or lymphedema.

Elevation of Limbs

• Elevate legs above heart level.
• It reduces gravity-dependent edema.

Encourage Mobility

• To do regular movement or walking
• It prevents fluid stasis in dependent areas.

Section 2

Q.4

a. Define congestive cardiac failure (2 mark)

Congestive cardiac failure is a chronic or acute condition in which the heart is unable to pump blood effectively to meet the metabolic needs of the body, leading to congestion of blood in the lungs, liver, and peripheral tissues, resulting in symptoms like dyspnea, edema, and fatigue.

b. List the causes of congestive cardiac failure (2 mark)

• Coronary Artery Disease (CAD)
• Myocardial Infarction (Heart Attack)
• Hypertension (High Blood Pressure)
• Cardiomyopathy (Dilated, Hypertrophic, or Restrictive)
• Valvular Heart Diseases (e.g., mitral or aortic stenosis/regurgitation)
• Congenital Heart DefectsArrhythmias (e.g., atrial fibrillation)
• Pericardial Diseases (e.g., constrictive pericarditis)
• Chronic Lung Diseases (e.g., COPD, pulmonary hypertension)
• Diabetes Mellitus
• Severe Anemia
• Thyroid Disorders (e.g., hyperthyroidism, hypothyroidism)
• Excessive Alcohol or Drug Use
• Infections affecting the heart (e.g., myocarditis, endocarditis)
• Renal Failure or Fluid Overload States

c. Explain the pathophysiology of congestive cardiac failure (3 mark)

1. Primary Cardiac Injury or Overload

• CCF begins with a primary insult to the heart such as myocardial infarction, hypertension, valvular disease, or cardiomyopathy.
• This leads to impaired pumping ability of the heart (systolic dysfunction) or impaired filling (diastolic dysfunction).

2. Reduced Cardiac Output

• Due to weakened or stiff ventricles, the stroke volume (amount of blood ejected per beat) decreases.
• This leads to decreased cardiac output, failing to meet the body’s metabolic demands.

3. Compensatory Mechanisms Activate (Initially Helpful)

The body attempts to maintain perfusion through :

Sympathetic Nervous System Activation :

• Increases heart rate and contractility
• It causes vasoconstriction (↑ afterload)

Renin-Angiotensin-Aldosterone System (RAAS) :

• Activated due to reduced renal perfusion
• Leads to vasoconstriction and sodium and water retention → ↑ preload

ADH (Vasopressin) Release :

• Causes further fluid retention and vasoconstriction

Ventricular Remodeling :

• Myocardium undergoes hypertrophy and dilation to compensate for increased workload

4. Consequences of Compensation (Maladaptive Over Time)

• Increased preload → leads to pulmonary congestion (in left heart failure) and systemic congestion (in right heart failure)
• Increased afterload → worsens ventricular dysfunction
• Myocardial oxygen demand increases → further ischemia
• Dilated ventricles become ineffective, leading to worsening failure

5. Fluid Congestion and Symptoms

• In left-sided failure: blood backs up into lungs → pulmonary edema, dyspnea, orthopnea
• In right-sided failure: blood backs up into systemic veins → peripheral edema, ascites, hepatomegaly, jugular venous distension

6. End Result – Decompensated Heart Failure

• Progressive worsening of cardiac function
• Severe fluid overload, multi-organ hypoperfusion, exercise intolerance, and fatigue
• If untreated, can lead to cardiogenic shock and death

d. Write the nursing management of patient with congestive cardiac failure (5 mark)

Decreased Cardiac Output related to impaired myocardial contractility, increased preload/afterload as evidenced by hypotension, weak pulses

Nursing Interventions :

• Monitor vital signs (BP, HR, RR, SpO₂) every 1–2 hours initially
• Monitor ECG for arrhythmias (common in heart failure)
• Assess for peripheral pulses, capillary refill, and skin temperature
• Administer inotropic agents like digoxin as prescribed
• Administer vasodilators (e.g., ACE inhibitors) if ordered
• Place in semi-Fowler’s or Fowler’s position to reduce cardiac workload
• Maintain strict input/output charting and assess for oliguria
• Monitor urinary output hourly in acute settings
• Evaluate for mental status changes, which may indicate poor perfusion
• Educate about avoiding strenuous activity that increases workload

Impaired Gas Exchange related to pulmonary congestion due to left-sided heart failure as evidenced by dyspnea, orthopnea, tachypnea

Nursing Interventions :

• Administer humidified oxygen as prescribed
• Monitor respiratory rate, pattern, and effort
• Auscultate lung sounds for crackles or wheezing every 4–6 hrs
• Position patient in high Fowler’s to enhance lung expansion
• Encourage coughing and deep breathing exercises
• Assist with incentive spirometry to promote alveolar ventilation
• Prepare for possible non-invasive ventilation (CPAP/BiPAP)
• Monitor ABG values and notify physician of hypoxemia
• Avoid use of sedatives unless prescribed due to risk of respiratory depression
• Provide a calm environment to reduce oxygen demand

Excess Fluid Volume related to compromised regulatory mechanism, decreased renal perfusion as evidenced by edema, weight gain, jugular vein distention

Nursing Interventions :

• Monitor daily weights at the same time every day
• Assess for dependent edema, sacral edema in bed-bound patients
• Monitor abdominal girth for ascites
• Administer loop diuretics (e.g., furosemide) and monitor for side effects
• Monitor electrolytes (especially potassium, sodium)
• Maintain fluid restriction if ordered (e.g., < 1500 mL/day)
• Educate patient to avoid high-sodium foods (canned, pickles, chips)
• Elevate lower limbs on pillows to promote venous return
• Monitor for signs of pulmonary edema: pink frothy sputum, dyspnea
• Encourage frequent position change to prevent pressure injury and fluid pooling

Activity Intolerance related to imbalance between oxygen supply and demand, fatigueas evidenced by shortness of breath on exertion, weakness

Nursing Interventions :

• Assess baseline activity level and tolerance
• Schedule rest periods before and after meals and care
• Encourage slow, progressive increase in activity as tolerated
• Use mobility aids if needed (walker, cane)
• Avoid strenuous activities like climbing stairs or walking long distances
• Provide assistance with ADLs when needed
• Monitor pulse rate, respiratory rate, SpO₂ before and after activity
• Teach pacing techniques (e.g., take breaks, avoid rushing)
• Collaborate with physiotherapy for cardiac rehab
• Instruct to stop activity immediately if chest pain or severe fatigue occurs

Anxiety related to fear of death, breathlessness, hospitalization as evidenced by restlessness, facial tension

Nursing Interventions :

• Create a reassuring and calm environment
• Encourage verbal expression of feelings
• Use therapeutic communication techniques (active listening, empathy)
• Involve family in the care process
• Provide clear and simple explanations about treatment and progress
• Offer spiritual or chaplain support if desired by patient
• Minimize environmental stimuli (noise, bright lights)
• Teach relaxation techniques – deep breathing, guided imagery
• Assess for panic attacks or need for pharmacological support (anxiolytics)
• Reassure patient about safety and monitoring availability

Deficient Knowledge regarding condition and self-care related to lack of prior exposure or understanding of CCF as evidenced by poor medication adherence, dietary errors.

Nursing Interventions :

• Educate about CHF causes, symptoms, and chronic nature
• Explain the importance of medications: diuretics, ACE inhibitors, beta blockers
• Instruct on monitoring daily weight and when to report changes (>2 kg in 2 days)
• Teach low-sodium diet with examples (fresh food, label reading)
• Explain fluid restriction and strategies (e.g., ice chips, chewing gum)
• Use teach-back method to ensure understanding
• Educate on recognizing worsening signs: edema, fatigue, cough, dyspnea
• Involve family or caregiver in all teaching sessions
• Reinforce importance of follow-up visits and lab tests

Q.5 Write the short notes on (any three) [12 mark]

1. Peritoneal dialysis

Definition

Peritoneal dialysis is a renal replacement therapy that uses the patient’s peritoneal membrane (lining of the abdominal cavity) as a semi-permeable membrane to remove waste products, excess fluids, and electrolytes from the blood, in cases of renal failure, especially chronic kidney disease.

Principle of Peritoneal Dialysis

Dialysis fluid (dialysate) is introduced into the peritoneal cavity through a catheter; waste products and excess electrolytes diffuse across the peritoneal membrane into the dialysate by osmosis and diffusion, and after a dwell time, the fluid is drained out.

Type of perotoneal dialysis

Continuous Ambulatory Peritoneal Dialysis (CAPD)

This method involves manually performing exchanges of dialysis fluid four to five times a day. Each exchange includes filling the peritoneal cavity with dialysate, allowing it to dwell for several hours, and then draining it. CAPD does not require a machine and can be conducted in various clean environments, providing patients with greater flexibility and independence.

Automated Peritoneal Dialysis (APD)

Also known as Continuous Cycling Peritoneal Dialysis (CCPD), this method uses a machine called a cycler to perform multiple exchanges automatically, typically overnight while the patient sleeps. APD allows for a longer dwell time during the day and is often preferred by individuals seeking minimal disruption to their daytime activities.

Indications for Peritoneal Dialysis

• End-Stage Renal Disease (ESRD)
• Hemodynamic Instability
• Vascular Access Issues
• Pediatric Patients
• Patient Preference
• Geographical Constraints

Contraindications for Peritoneal Dialysis

Absolute Contraindications

• Loss of Peritoneal Function
• Active Intra-Abdominal Infections
• Abdominal Wall Defects
• Severe Cognitive or Psychiatric Disorders

Relative Contraindications :

• Severe Malnutrition
• Multiple Abdominal Surgeries
• Ostomies
• Obesity
• Poor Home Environment

Nursing Care in Peritoneal Dialysis

Before Procedure

• Ensure sterile technique
• Warm dialysate to prevent abdominal cramping
• Check baseline weight, vitals, and lab values
• Assess for catheter site infection

During Procedure

• Monitor for signs of discomfort or leakage
• Maintain strict aseptic technique
• Observe dialysate for color (should be clear) and volume
• Keep catheter and connections secure and below abdominal level

After Procedure

• Record input/output volumes
• Assess for complications (e.g., cloudy fluid, abdominal pain, hypotension)
• Provide patient education on home care, hand hygiene, and signs of infection

Complications of Peritoneal Dialysis

• Peritonitis (most common)
• Exit-site infection
• Dialysate leakage
• Hernia formation
• Electrolyte imbalance or hyperglycemia
• Protein loss through dialysate
• Hypotension

2. Typhoid

Definition

Typhoid fever is a systemic bacterial infection caused by Salmonella enterica serotype Typhi (S. Typhi), characterized by prolonged fever, abdominal pain, and rash, often transmitted through contaminated food or water.

Causative Agent

Salmonella enterica serotype Typhi (Gram-negative bacillus)

Mode of Transmission

• Feco-oral route (ingestion of contaminated food or water)
• Close contact with a carrier

Incubation Period

7 to 14 days (range: 3 to 60 days depending on exposure dose and immunity)

Pathophysiology of Typhoid

• Ingestion of Salmonella Typhi through contaminated food or water.
• Bacteria survive stomach acid and reach the small intestine.
• Invade Peyer’s patches in the ileum and are taken up by macrophages.
• Spread via lymphatics to the bloodstream → primary bacteremia.
• Disseminate to liver, spleen, bone marrow, multiply inside cells.

• Return to bloodstream → secondary bacteremia → symptoms start.
• Reach gallbladder, re-enter intestine → cause ulceration and bleeding.
• Possible intestinal perforation or carrier state if bacteria persist in gallbladder.

Clinical Manifestations

• Step-ladder high-grade fever
• Abdominal pain, constipation (early), diarrhea (later)
• Rose spots (pink maculopapular rash on trunk)
• Headache, malaise, anorexia
• Relative bradycardia (Faget sign)
• Hepatosplenomegaly
• Coated tongue

Diagnostic evaluation

• History collection
• Physical examination
• Blood culture (gold standard – early stage)
• Widal test (detects agglutinins; reliable after 1st week)
• Stool and urine culture
• CBC : leukopenia, anemia, thrombocytopenia

Medical Management (Pharmacological Treatment)

Antibiotic Therapy (based on local resistance patterns) :

💊 Ciprofloxacin (for sensitive strains)

• Dose : 500 mg twice daily for 7–10 days
• Not preferred in children due to cartilage effects

💊 Azithromycin

• Dose: 500–1000 mg once daily for 5–7 days
• Effective for uncomplicated cases

💊 Ceftriaxone (IV)

• Dose: 1–2 g/day for 10–14 days
• Used in MDR (multi-drug-resistant) or severe typhoid

💊 Chloramphenicol, Amoxicillin, Cotrimoxazole (rarely used now due to resistance)

Supportive Therapy

• Antipyretics : Paracetamol for fever
• ORS / IV fluids : For dehydration from diarrhea
• Nutritional support : High-calorie, easily digestible diet

Nursing Management

Assessment

• Monitor vital signs, especially temperature
• Assess for signs of complications: GI bleeding, perforation

Interventions

• Provide bed rest in acute phase
• Maintain fluid and electrolyte balance
• Administer prescribed medications
• Ensure personal hygiene and infection control
• Educate patient about handwashing and food safety
• Provide psychological support if needed

3. Plural effusion

Definition

Pleural effusion is the abnormal accumulation of fluid in the pleural space (between the parietal and visceral pleura), which can impair normal lung expansion and cause respiratory symptoms.

Causes

Transudative Causes

• Congestive heart failure
• Nephrotic syndrome
• Liver cirrhosis
• Hypoalbuminemia

Exudative Causes

• • Tuberculosis
• Pneumonia (parapneumonic effusion)
• Pulmonary embolism
• Lung cancer
• Rheumatoid arthritis, lupus

Pathophysiology of Pleural Effusion

• Normal pleural space contains a small amount of lubricating fluid.
• Due to systemic or local factors, fluid production increases or drainage decreases.
• Excess fluid accumulates in the pleural cavity.
• This causes lung compression, reduces lung expansion.
• Results in dyspnea, chest pain, and impaired gas exchange.

Clinical Manifestations

• Dyspnea (difficulty breathing)
• Dry cough
• Chest pain (pleuritic)
• Decreased breath sounds on affected side
• Dullness on percussion
• Reduced chest expansion
• Mediastinal shift (in large effusion)

Diagnostic Evaluation

• History collection
• Physical examination
• Chest X-ray
• Ultrasound
• CT chest
• Thoracentesis
• Protein, LDH, glucose, pH, cell count
• Pleural biopsy (if TB or malignancy suspected)

Management

Identification and Treatment of Underlying Cause

• Management begins with identifying the type (transudate or exudate) and underlying condition, such as :
• Congestive heart failure (CHF)

• Pneumonia (parapneumonic effusion)
• Tuberculosis
• Malignancy
• Liver cirrhosis (hepatic hydrothorax)
• Pulmonary embolism
• Treatment of the primary condition is essential to resolve the effusion.

Therapeutic Thoracentesis

• Done in moderate to large effusions causing respiratory distress.
• Usually, 500–1500 ml fluid is removed at a time.
• Care must be taken to avoid re-expansion pulmonary edema.
• It may be repeated in recurrent effusions.

Chest Tube Insertion (Intercostal Drainage – ICD)

• It is used in massive pleural effusions, empyema, or malignant effusions.
• A chest tube is inserted into the pleural space to allow continuous drainage.
• Connected to an underwater seal drainage system.
• Monitored for fluid volume, color, and air leaks.

Pleurodesis (for Recurrent Effusions)

• Especially done in malignant pleural effusion.
• A sclerosing agent like talc, bleomycin, or doxycycline is instilled into pleural space.
• It Causes inflammation and adhesion between pleural layers to prevent further fluid accumulation.

Medications

• Diuretics (e.g., furosemide) – in transudative effusions from CHF
• Antibiotics – in parapneumonic or empyema cases
• Anti-tubercular therapy (ATT) – in TB effusions
• Corticosteroids – in autoimmune or inflammatory effusions
• Chemotherapy/Radiotherapy – for malignant causes

Surgical Management (if needed)

• Decortication – surgical removal of thickened pleura in chronic empyema
• Pleurectomy – removal of pleura in recurrent/malignant effusions

Nursing Management

• Monitor vital signs and respiratory status
• Positioning: High-Fowler’s to improve lung expansion
• Assist during thoracentesis and ensure sterile technique
• Observe for signs of pneumothorax after fluid removal
• Maintain and monitor chest tube drainage system
• Encourage coughing and deep breathing exercises
• Provide emotional support and oxygen therapy as needed

4. Traction

Definition of Traction

Traction is a therapeutic technique used to apply a pulling force to part of the body, usually a limb, to align fractured bones, reduce dislocations, prevent or correct deformities, and relieve muscle spasms and pain.

Purposes of Traction

• To immobilize a fractured bone or dislocated joint
• To reduce and maintain alignment of a fracture
• To decrease muscle spasm and relieve pain
• To prevent or correct deformities
• To promote healing by proper alignment
• To reduce pressure on nerves, especially in spinal injuries

Type of traction

1️⃣ Skin Traction

It involves the application of a pulling force to the skin using adhesive materials, straps, or foam boots, and it is primarily used to control muscle spasms and immobilize a limb temporarily before surgery or fracture reduction, without directly penetrating the bone.

2️⃣ Skeletal Traction

It is a more invasive technique in which traction is applied directly to the bone by surgically inserting pins, wires, or screws through the bone under sterile conditions, allowing for stronger and longer-term force application, commonly used in complex fractures or when prolonged immobilization is necessary.

3️⃣ Cervical Traction

It is a specific form of traction used to treat neck injuries or cervical spine disorders by applying a pulling force to the head and neck region using devices such as head halters, tongs, or halo rings, which help relieve pressure on the vertebrae and align the cervical spine.

4️⃣ Manual Traction

It is a short-duration method where a healthcare provider applies a pulling force with their hands to reposition a dislocated joint or fractured bone, often used during emergency care or surgical preparation.

5️⃣ Bryant’s Traction

It is a pediatric traction technique used for children under the age of two or weighing less than 12–14 kg, where both legs are suspended vertically in the air at a 90-degree angle to the body with the knees slightly flexed, helping to align femur fractures or treat congenital hip dislocations.

6️⃣ Balanced Suspension Traction

In which uses a system of pulleys, ropes, and weights to maintain a continuous pulling force while allowing limited movement, commonly employed in femoral fractures to keep the limb aligned without shifting the patient’s body position.

Nursing Care in Traction

Traction requires meticulous nursing care to prevent complications, ensure proper alignment, and promote recovery.

Maintain Traction Effectiveness

• Ensure weights are hanging freely and not touching the floor or bed.
• Check that ropes are free of knots, correctly aligned, and move smoothly over pulleys.
• Verify prescribed weight and angle are maintained as ordered.
• Do not remove or lift weights unless prescribed by the doctor.

Positioning and Comfort

• Maintain proper body alignment to avoid muscle fatigue or joint stiffness.
• Use pillows and supports to prevent pressure points.
• Reposition the patient as allowed, without disturbing the traction setup.
• Provide a fracture bedpan to avoid movement of the affected limb.

Neurovascular Assessment (CMS Check)

• Perform frequent neurovascular checks:
• C – Circulation: check color, warmth, capillary refill.
• M – Motion: assess ability to move fingers or toes.
• S – Sensation: detect numbness, tingling, or pain.
• Assess every 2–4 hours or as needed.

Skin Care and Hygiene

• Inspect skin under straps or traction devices for signs of redness or breakdown.
• Use padding or foam protectors to prevent pressure sores.
• Provide daily hygiene and linen changes with minimal movement.
• Turn patient as per protocol, using log-rolling if necessary.

Pin Site Care (for Skeletal Traction)

• Use aseptic technique to clean pin sites.
• Clean with normal saline or antiseptic solution (e.g., chlorhexidine).
• Observe for infection signs: redness, swelling, discharge, foul smell.
• Document any changes and report to physician promptly.

Complication of traction

• Pressure sores
• Nerve damage
• Circulatory impairment
• Pin site infection
• Osteomyelitis
• Muscle atrophy
• Joint stiffness/contractures
• DVT/PE

Q.6

a. What is the electrolyte imbalance (1 mark)

Electrolyte imbalance refers to an abnormal level of electrolytes (such as sodium, potassium, calcium, magnesium, chloride, phosphate) in the body fluids, which can disrupt various physiological functions like nerve conduction, muscle contraction, hydration, and acid–base balance.

b. Enlist the symptoms of electrolyte imbalance (2 mark)

Hyponatremia (↓ Sodium)

• Headache
• Nausea
• Confusion
• Seizures
• Coma in severe cases
• Muscle cramps
• Lethargy

Hypernatremia (↑ Sodium)

• Thirst
• Dry, sticky mucous membranes
• Restlessness
• Irritability
• Muscle twitching
• Convulsions
• Coma

Hypokalemia (↓ Potassium)

• Muscle weakness
• Leg cramps
• Fatigue
• Constipation
• Irregular heartbeat (arrhythmias)
• Flattened T waves on ECG

Hyperkalemia (↑ Potassium)

• Muscle weakness or paralysis
• Numbness or tingling
• Palpitations
• Bradycardia
• Tall peaked T waves on ECG
• Risk of cardiac arrest

Hypocalcemia (↓ Calcium)

• Numbness and tingling (especially around mouth and extremities)
• Muscle cramps or spasms
• Positive Chvostek’s sign (facial twitching)
• Positive Trousseau’s sign (carpal spasm with BP cuff)
• Seizures
• Laryngospasm

Hypercalcemia (↑ Calcium)

• Nausea and vomiting
• Constipation
• Abdominal pain
• Bone pain
• Confusion
• Weakness
• Kidney stones
• Depression

Hypomagnesemia (↓ Magnesium)

• Muscle tremors
• Neuromuscular irritability
• Positive Chvostek’s and Trousseau’s signs
• Seizures
• Cardiac arrhythmias

Hypermagnesemia (↑ Magnesium)

• Drowsiness
• Hypotension
• Flushing
• Bradycardia
• Respiratory depression
• Loss of deep tendon reflexes
• Cardiac arrest (in severe cases)

c. Write the management of patient with electrolyte imbalance (4 mark)

Medical Management (Electrolyte-Specific)

Hyponatremia :

• Fluid restriction
• Administer IV hypertonic saline (3% NaCl) for severe cases
• Treat the underlying cause (e.g., SIADH, diarrhea)

Hypernatremia :

• IV hypotonic fluids (0.45% NaCl or D5W)
• Encourage for oral water intake
• Monitor neurological status closely

Hypokalemia :

• Oral or IV potassium chloride (KCl)
• Never give IV KCl as a bolus (must be diluted and given slowly)
• Monitor ECG and renal function

Hyperkalemia :

• IV calcium gluconate to stabilize cardiac membrane
• Insulin + dextrose, sodium bicarbonate, or beta-agonists to shift K⁺ intracellularly
• Loop diuretics, kayexalate, or dialysis to remove excess potassium

Hypocalcemia :

• IV calcium gluconate or oral calcium carbonate
• Vitamin D supplementation
• Monitor for tetany (Chvostek’s, Trousseau’s signs)

Hypercalcemia :

• IV normal saline to promote excretion
• Loop diuretics (e.g., furosemide) after hydration
• Bisphosphonates or calcitonin for severe cases

Hypomagnesemia :

• IV magnesium sulfate
• Monitor reflexes and respiratory function

Hypermagnesemia :

• IV calcium gluconate
• Supportive care and dialysis if levels are critical

Nursing Management

Continuous Monitoring :

• Regular vital signs, especially BP and pulse
• Monitor neurological signs and muscle tone
• Frequent ECG monitoring for at-risk patients

Fluid and Electrolyte Replacement :

• Administer IV fluids and electrolytes as prescribed.
• Monitor for signs of fluid overload or rapid shifts (e.g., pulmonary edema)

Skin and Pressure Area Care :

• Reposition frequently
• Use pressure-relieving devices if patient is bedridden

Dietary Management :

• Educate and assist in diet modification:
• Increase K⁺ with bananas, oranges, potatoes if low
• Limit Na⁺ in hypernatremia
• Provide calcium-rich foods like dairy products if hypocalcemia

Patient Education :

Teach patient/family about :

• Importance of fluid intake and medication adherence
• Symptoms to watch for (e.g., palpitations, confusion, muscle cramps)
• Avoidance of over-the-counter medications (e.g., antacids with magnesium)

Prevent Complications :

• Use seizure precautions in hyponatremia/hypocalcemia
• Prevent falls by keeping side rails up in confused or weak patients
• Encourage deep breathing exercises to prevent respiratory complications

Q.7 Define following (any three) [6 mark]

1. Cholecystitis

Cholecystitis is the inflammation of the gallbladder, usually caused by obstruction of the cystic duct, most commonly due to gallstones (cholelithiasis), leading to bile accumulation, irritation, and infection.

2. Paralytic ileus

• Paralytic ileus, also known as adynamic ileus is a condition where the intestines lose their ability to contract and move contents through the digestive tract, leading to a functional obstruction without any physical blockage.
• This disruption in normal peristalsis can result in the accumulation of gas and fluids, causing discomfort and potential complications.

3. Hepatic encephalopathy

• Hepatic Encephalopathy (HE) is a neuropsychiatric syndrome resulting from liver dysfunction, leading to the accumulation of toxins—primarily ammonia—in the bloodstream, which adversely affects brain function.
• This condition is commonly observed in individuals with advanced liver diseases such as cirrhosis.

4. Haitus hernia

• A hiatal hernia is a condition where part of the stomach pushes upward through the diaphragm into the chest cavity.
• The diaphragm has a small opening (hiatus) through which the esophagus passes before connecting to the stomach. In a hiatal hernia, the stomach bulges up through this opening into the chest.