Table of contents

page

1. Table of contents.................................................................................2
2. A look at the surgery paper……………………………………….....3
3. Cover sheet for paper two……………………………………….......5
4. Complete paper two set up……………………………...….……... ..6
5. Answer booklet.……………………………………………….........12
6. Structuring of Questions……...……………………...………….......14
7. Cholecystectomy................................................................................15
8. Enlarged prostate gland......................................................................21
9. Acute abdomen................................................................................. 26
10. Head injury.........................................................................................31
11. Glaucoma...........................................................................................50
12. Corneal ulcers.................................................................................... 53
13. Retinal detachment.......................................................................... 56
14. Cataract..............................................................................................59
15. Antenatal care....................................................................................63
16. VVF...................................................................................................68
17. General pre op care............................................................................72
18. General post op care......................................................................... 77

A LOOK AT PAPER TWO

SURGERY

Paper two also called the surgery paper is one of the two papers that lead to your qualification as a registered
nurse. This paper comprises all aspects of general surgery, surgical nursing, IRH, Ear Nose and Throat
conditions, orthopedics and ophthalmology.

This is usually your second paper after paper one or the medicine paper.
The paper has got 8 questions and you are expected to answer 5 questions only. The time given is 3 hours only
for the whole paper. As you may see, you need just about 30 minutes for each question if you have to complete
all the five questions, with practice of course and a lot of concentration, this is not impossible.

1
 We can now take look at the breakdown of the paper.
The paper has three sections, A, B and C. in each of these sections there are some questions that you will be
expected to answer so you need to read each section instructions very carefully.

We will now look at each section one at a time so you can follow what needs to be done.

SECTION A

Section A. comprises all aspects of general surgery, surgical nursing.

There are three questions in this section. As indicated above there are all coming from the general surgery and
surgical nursing conditions that you have already studied in your surgery one course lectures.

Out of the 3 questions that are asked, you are expected to choose only 2. The order of our selection does not
matter, for example you can start with question number 3 if you are more familiar to it then go to any of the
remaining two.. It’s a good idea to start with a question you clearly understand as the first impression may have
a lasting impression on your examiner.

When preparing for this section, you need to master a fairly large number of general surgical conditions that
you clearly understand during your course lectures.
You should also balance up the selection of your conditions to cover all the systems that you studied during
your course lectures in surgery one.
For example, you need to remember that we have about 8 major systems of the human body, try as much as
possible to pick conditions from each of these systems say, may be 5 conditions from each and a little more
from some of the more I what I would call vulnerable systems or interactive systems that are more likely to
altered physiology because of disease in other parts of the body, such as the GIT.
Once you have picked your conditions try to study them under the following heading. This is like the minimum
information you need to know on each one of them, so it means you can actually study a little further than what
I have given you.
 The definition,
 Indications for surgery,
 Surgical approaches where applicable
 The causes or pre disposing factors,
 Presenting clinical signs and symptoms
 General investigations which should include focused history taking, physical examination, laboratory
tests, radiological tests, pathological tests if any etc.
 Surgical management which should include general investigations as above, non pharmacological care
and pharmacological care and operative procedures plus any preventive measures where applicable.
 Nursing care
 Complications

Section B.

This section comprises all aspects of IRH.

These are Gynecological conditions and Obstetrical conditions which you studied in your course lectures.

There not as many IRH conditions as you would find in General surgery and so this section will only have 2
questions from which you will be expected to choose only one question.
Very rarely will you be asked to draw some anatomical diagrams here. You will probably need about 8 questions
covering both areas to be on a safe side. You need to follow the same layout of the content as you study these
questions as above.
Be mindful that some of the conditions may be obstetrical /Gynecological emergencies and so they have to be
managed as such.

Section C.

2
THIS SECTION COMPRISES ALL ASPECTS OF ENT, OPTHALMOLOGY, ORTHOPAEDIC
CONDITIONS.

Probably the easiest of the three sections but poorly attempted, may be this time students realize that time is not on
their side and they end up hurrying through the questions. To avoid this occurrence, try to allocate enough time to
each question. We have already seen that each question needs about 30 minutes. If you have taken well over 40
minutes stop that question and progress further to answer other question
There are 3 questions from this section. You need only to answer two questions from this section, it does not
matter which two you pick nor in which order
We will now try to familiarize ourselves with the presentation of paper two from the cover sheet up to the
instructions given then have a look at a complete set up of paper two has also been given as an example.

GENERAL NURSING COUNCIL OF ZAMBIA

(The Nurses and Midwives Act., 1997)

ZAMBIA REGISTERED NURSE FINAL EXAMINATION

CANDIDATE’S NO………………………………………………….

PAPER………………………………..

DATE………………………………….
No. Marks

WRITE No. OF QUESTIONS ANSWERED/ATTEMPTED

No. No. No. No. No.

No. No. No. No. No.

Total

NO…………………………

3
COVERING ALL ASPECTS OF GENERAL SURGERY AND SURGICAL NURSING, IRH, ENT,
OPTHALMOLOGY AND ORTHOPAEDIC CONDITIONS

INSTRUCTIONS TO CANDIDATES

1. Write your examination number on each page of the answer book and question paper, which must be

returned.

2. Start each question on a new page.

3. Write on both sides of paper.

4. On the front cover of answer book, write the numbers of questions you have answered on the spaces

provided.

5. Name of the school and candidate MUST NOT appear in the answer book.

6. NO form of identity or mark (other than the examination number) should appear on the answer

booklet.

COVERING ALL ASPECTS OF GENERAL SURGERY AND SURGICAL NURSING, INTERGRATED

REPRODUCTIVE HEALTH (IRH).ORTHOPEADICS, EAR NOSE THROAT DISEASES AND
OPTHALMOLOGY.

SECTION A

GENERAL SURGERY AND SURGICAL NURSING

ANSWER TWO (2) QUESTIONS ONLY FROM THIS SECTION.

QUESTION 1.

CHOLECYSTITIS

A man in his middle age comes to your ward with complaints acute abdominal pains. The doctor suspects that he
could have Cholecystitis.

4
 a) State three factors responsible for formation of cholesterol gall stones. 15%

b) Mention (5)Five clinical features of Acute Cholecystitis 15%

c) Post operative care in the first 48 Hours 50%
d) Mention (5)Five possible complications following cholecystectomy
and how they can be prevented. 20%

QUESTION 2

BENIGN PROSTATIC HYPERTROPHY

Mr. Mwansa aged 52 years is admitted to the surgical ward with history of frequency and difficulties in maturation.
On examination, the diagnosis of benign prostatic hypertrophy is made and he is to undergo prostatectomy

a) (i)Define the term benign prostatic hypertrophy 3%

(ii) List six (6) other obstructive symptoms that Mr. Mwansa may present with
Other than the one mentioned in the question 12%
b) Mention four (4) approaches that could be used to perform prostatectomy 10%
c) Discuss the pre-operative nursing care you would give to Mr. Mwansa 50%
d) Discuss (5)five points that you would include in your IEC to the
Patient discharge 25%

QUESTION 3

APPENDECTOMY

Mrs. Mwanza has been complaining of chronic pain in the right Iliac fossa. After an abdominal scan, The Dr
suspects that she could have an inflamed Appendix and he decides to perform appendectomy

a) Define Appendectomy 5%

b) List two types of abdominal incisions that a Dr can use to approach the
appendix 6%

c) Discuss in detail the pre op care of a patient going for appendectomy 50%

d) Briefly discuss how you are going to manage the abdominal wound after surgery 20%.

Mention {4} four complications of abdominal surgery 15%

5
 SECTION B

INTERGRATED REPRODUCTIVE HEALTH (IRH)

ANSWER ONE (1) QUESTION ONLY FROM THIS SECTION.

QUESTION 4.

LABOUR

Mrs. Dinga Erickson aged 37years, gravid 12 is admitted to your labour ward complaining of show and backache,
on examination cervical dilation is 5cm; her last LMP was June 2010

a) Calculate
i. EED 5%
ii. Gestation as of today 10%
b) Explain how you would admit her to labour ward. 15%
(i)Using a partograph record her observations and explain the findings. 15%
c) Discuss the nursing care you would give her during the first of labour. 50%
d) State (5)five complications. 5%

QUESTION 5

CANCER OF THE BREAST

Kashibi Masaka a 30 year old lady Shuungu modeling centre was brought to gynae clinic with history of feeling a
growth in the left breast. A provisional disgnosis of breast cancer is made.

a) Give four clinical staging of cancer 8%

b) Draw a well labeled diagram of breast 22%
c) Describe the management of Masaka operatively 50%
d) Explain four (4) points that you would include in your information, education and communication to
Masaka regarding the care of the affected breast 20%

SECTION C

EAR NOSE AND THROAT DISEASES, OPHTHALMOLOGY AND ORTHOPAEDICS.

6
ANSWER TWO (2) QUESTIONS ONLY FROM THIS SECTION.

Arthritis

Mr. Monze, a famous cyclist, underwent knee surgery after suffering from acute septic arthritis which developed
after falling off his bicycle.

a) Define acute septic arthritis 5%

(i) List five{5} causes of arthritis 10%

b) Explain five {5} signs and symptom of acute septic arthritis. 10%

c) Discuss in detail the Pre operative care of a patient due for bone surgery 50%

d) Mention {4} four rehabilitative measures that you would inoperative in your teaching plan to your
patient 5%

Cataract

Naomi a 65 years old woman is admitted to the eye ward with a complaint of poor visibility in both eyes. After a
thorough investigation the specialist decides that Naomi should undergo surgery in one of the eyes to remove the
lens

a) List (5 ) five possible causes of cataracts in Zambia. 5%

(ii)Draw a well labeled diagram of the eye 10%

b) Discuss pre operative care would you give to your client 45%

c) Discuss the IEC that you would give you client upon discharge 15%

d) Mention five (5) Complication of contact extraction 15 %

OTITIS MEDIA

Given Hachundu has been complaining of pain the right ear after the swimming festival.
Its 4 weeks now and the pain seems to be getting worse.
You are the clinician at the health centre attending to this client.

a) Define Otitis Media. 2%

b) Mention six (6) signs and symptoms your patient is likely to present with 24%
c) Discuss the Medical management of your client 50%
d) State six (6) complications that could occur if there is further delay in the management of this client
24%

7
We will now try to familiarize ourselves with the presentation of paper the answer booklet. This is the booklet where
you will be expected to answer your questions.

GENERAL NURSING COUNCIL OF ZAMBIA

(The Nurses and Midwives Act., 1997)

ANSWER BOOKLET

CANDIDATE’S NO………………………………………………….

PAPER………………………………..

No. Marks

8
WRITE No. OF QUESTIONS ANSWERED/ATTEMPTED

No. No. No. No. No.

No. No. No. No. No.

Total

Index No.

9
 STRUCTURING AND ANSWERING OF QUESTIONS

We can now have a look at how most of the questions are asked and what you are expected to include as you attempt
the question.

1. Definitions
 Define………………….
 What is the definition of…………………….
 How do you define………………………….

Example. 2 Define a fracture. (5%)

A fracture is the discontinuity of bone tissue as a result of direct or indirect trauma manifested by loss of function,
deformity, and severe pain

If you analyze the definition, it attempts to answer the following

 What it is
 How it is caused
 Some common characteristics or features of a fracture.

When defining a concept, try as much as possible to follow the above pattern. This of course is most applicable to
conditions/diseases. If you trying to define a procedure, you can mention what it is and one or two common
indications.

2. MENTIONING

Example 3.

Mention five (5) causes of unconsciousness

Here you are expected to itemize the causes with some justification, as below
1. Reduced blood flow to the brain tissue as in severe shock
2. Sudden compression of the brain due to hematoma
3. ………………………………….
4. ………………………………….
5. ………….....................................

3. LISTING.

Example. 3 List five (5) causes of unconsciousness

Here you are also expected to itemize the causes as below

 …prolonged shock……………………………….
 …hematoma………………………………
 ………………………………….

 Identifying

Example. 4

Identity five (5) causes of unconsciousness.

Here you are expected to itemize the causes, it quiet similar to mentioning as below

1. Reduced blood flow to the brain tissue as in severe shock

2. Sudden compression of the brain due to hematoma
3. ............................................................................

10
6. Indicating, Stating, outline

Example.5 State five (5) causes of unconsciousness

Here you are expected to make a brief statement, an outline or a short sentence line on the causes as below

1. unconsciousness can be caused by prolonged hypoxia as a result of hypoventilation

2. unconsciousness can be caused by a sudden shake or movement of the brain as in concussion
3. …………………………
4. ………………………………….
5. …………………………………

7 . Discuss, explain, describe

You are expected to give a detailed argument of action, plan of care etc. for example you need to some of the
following aspects
What, why where who and when etc,
you are going to do observations for example.
 What are you doing
 Why are you doing observations
 Where and on who are you doing observations
 When or how frequent are you going to do observations, that way you will be able to comprehensively
discuss or explain your action. Your discussion must be comprehensive.

PAPER TWO /SURGERY QUESTIONS

CHOLECYSTITIS

(a State three (3)factors responsible for formation of cholesterol gall stones 15%

(b. List five clinical features of acute cholecystitis 15%

(c. Discuss in detail the post op nursing care you would give in the first 48hrs 50%

(d. Mention five (5) post operative complications and how you would prevent them. 20%

Suggested marking Key for cholecystitis

k
a. State three factors responsible for formation of cholesterol gall stones.

 Cholesterol super saturation of bile

This can occur as a result of excess cholesterol secretion into bile due to an increase of enzyme
activities.

 Crystallization- Promoting factors

Within bile there are a number of lipoproteins reported to be putative crystallizing factors.
 Motility of the gall bladder Gall bladder stasis leads to cholesterol crystallization.

11
(Note three points for the first five correct answers /ticks)

 Five clinical features of Acute Cholecystitis ( 15 marks)

 Colic pain that starts suddenly and persists for 1-4 hours.
 Aching pain with sensation of pressure in the epigastric region.
 Nausea and vomiting.
 Low –grade fever.
 Jaundice (Saver obstructive)
 Right upper Quadrant guarding
 Inability to take deep inspiration when examining finger are pressing below the hepatic margin.

(Note three points for the first five correct answers /ticks)

 POST OPERATIVE CARE IN THE FIRST 48 HOURS :( 50 Marks)

OBJECTIVES (1 mark each)

 To return the physiological function back to normal as early as possible.
 To promote wound healing.
 To prevent ………………………………………………………………

ENVIRONMENT (5 marks)
 Ensure post- operative equipment and tray is available for immediate access in case of the need for
resuscitation.
 The room should be well ventilated and clean to ensure a soothing environment and to prevent cross
infection
 ………………………………………………………………………………….
 ………………………………………………………………………………….
 …………………………………………………………………………………..
.(write at least five points here)

POSITION (5 Marks)
 Place the patient in low – fowler’s one side to allow easy flow of secretion, so as to prevent choking and
maintain patient airway for effective breathing.
This position will also promote easy observation of the patient
 Assist in regular change of position to encourage circulation of blood
 ……………………………………………………………………………………
 ……………………………………………………………………………………

OBSERVATION (5 Marks)

 Vital sign observation- Blood Pressure, Pulse, respiration and temperature, initially done at ¼ hourly, ½
hourly, 1 hourly, 2 hourly then 4 hourly if the general condition proves to be improving progressively.
 Observe the wound for bleeding if it is evident, apply pressure.
 Low blood pressure may indicate internal bleeding – inform the surgeon.
 Observe the tubing’s for patency especially the T tube
 Observe…………………………………………………………………….

INTRAVENOUS INFUSION (5 Marks)

 Ensure that the IV line is running well.
 Infuse as per Doctors orders
 Observe for fluid overload and stop drip if face looks puffy with breathing difficulties.
 Record intake and out on the fluid balance chart.
 ……………………………………………………………………………..

12
PHYSIOLOGICAL CARE (5 Marks)
 Explain to the patient to the patient the nature of the disease process to ally anxiety.
 Explain to her the treatment regime and expectations regarding the care.
 Reinforce on knowledge of the possible outcome of the surgery.
 ……………………………………………………………………..
 ………………………………………………………………………

DRUG ADMINISTRATION AND PAIN RELIEF. (3 Marks)

 Give medications as ordered, such as prophylactic antibiotic and analgesics such as pethedine to relieve
pain.
 Observe relieving pain and any drug reactions
 …………………………………………………………………………………..

NUTRITION
 Patient is kept nil orally on zero day until bowl sound are head, flatus is passed and this is usually by the 5 th
day post operatively and prevents paralytic ileus
 Ideally, the surgeon will order when to start sips of water. During this time, nutrition is by IV fluids up to
2nd day post operative.
 The patient then progresses to free fluids the following day, soft food and then full diet according to
surgeon orders.
 Low fat diet is given because there is hardly bile to fats cholecystectomy as there is bile leakage in the few
days post operative give food rich in proteins and vitamins for wound healing.
 Asses for nausea and vomiting and administer antiemetic.
 Encourage a lot of fluid intake to replace discharged and leaking bile from the T-tube.
 Test food tolerance by clamping the T-tube when indicated.
Note this part is specific and you need as many points as you can

BOWEL ELIMINATION (1 Mark)

 Patient should begin to open bowels soon after beginning to take normal diet above two days.

CARE OF NASO GASTRIC TUBE: (5 Marks)

 Mrs.Chanda will have a naso gastric tube, to relieve the complication of vomiting bile.
 Aspirations must be done in the 1st 24 hours.
 Care of the tube and nostrils as well as oral care must be done.
 Measure inspects and records the aspirate all these measures help to keep the\tube patent
 ……………………………………………………………………………………….

Note this part is specific and you need as many points as you can

CARE OF DRAINAGE TUBES (6Marks)

 Care and observation of the drainage tube in the sub hepatic pouch be done recode the drainage.
 The purpose of the tube is to drain the oozing blood from the liver bed and leaking bile.
 It is also useful for revealing internal reactionary hemorrhage.
 It also helps to reveal reactionary hemorrhage.
 It is removed after 48 hours.
 Note this part is specific and you need as many points as you can

T-TUBE FROM COMMON BILE DUCT (7Marks)

 Un clamp the tube immediately the patient is put on her bed.
 Measure and record the bile draining into a bag, specifying colour and amount at least every 2 hours.
 Administer replacement fluids if indicated.
 Clamp the Tube when indicated.
 Report any increase or decrease of drainage.
 Maintain patency of the tube.
13
  The tube may be removed on the 7th-10th day meaning it will be in situ in the 1st 48 hours post operatively.
 Note this part is specific and you need as many points as you can

WOUND CARE
5 Marks)

 Maintain a dry and intact dressing, usually drains that is working is left in situ.
 If wound is bleeding apply pressure.
 First dressing is removed by the surgeon.
 There after the wound is cleaned aseptically. Inspect for any swelling, discharging and gasping.
 Maintain skin integrity by adequate hydration, remove the soiled dressing around the T tube and replace
with the clean sterile one.

CATHETER CARE (2 Mark)

 Aseptic catheter toilet to be done to prevent urinary infection.
 Observe urine for colour, sediments and amount. Record findings.

EXERCISES AND EARLY AMBULATION (4 Marks)

 Breathing and coughing then exercises to prevent hypostatic pneumonia at regular intervals such as 1-2
hourly.
 Passive exercises the actively to prevent deep vein thrombosis.
 Promote early ambulation to prevent respiratory leg and renal complications.
 Assist the patient to sit up in bed and to sit in chair when the doctor has ordered ambulatory exercises.
 Note this part is specific and you need as many points as you can

OTHER ASPECTS OF GENARAL CARE (2 marks each)

 Bed baths to remove dirty on the body and maintain general hygiene
 Two hourly turnings to prevent pressure sore formation
 Hair care to improve hygiene self care image
 Nail care to improve hygiene and prevent infection
 Pressure area care to prevent pressure formation
 Oral toilet to improve oral hygiene and enhance appetite

HEALTH EDUCATION (2marks each)

 Low fat diet as there is little or no bile to help in the digestion
 To encourage weight loss as reduces the amount of fats to be deposited in the body
 Encourage rest.
 Care of the healing wound.

C ) Five possible complications following cholecystectomy and how they can be prevented. (20 Marks)

 Pulmonary Embolism
o Give analgesics and anticoagulants as well as early ambulation coupled with breathing exercises.
 Hemorrhage and leakage of bile
o From the gall bladder bed which may accumulate to cause abdominal distension and peritonitis. It
is necessary to ensure patency of sub hepatic drainage tube.
 Renal failure and liver failure
o In jaundiced patients, renal failure and liver failure may occur. This is prevented by post-operative
administration of IV fluids with osmotic diuretic during surgery.
 Recurrences
o Recurrence stones in the common bile duct. Endoscopic division of the splinter of oddi will help
prevent this.
 Backache
o Backache by use of bridge on the operation table. Avoid its use in early patients.

Four marks for each correct answer

14
 ENLARGED PROSTATE

BENIGN PROSTATIC HYPERTROPHY

Mr. Mansa aged 52 years is admitted to the surgical ward with history of frequency and difficulties in
micturition. On examination, the diagnosis of benign prostatic hypertrophy is made and he is to undergo
prostatectomy

a) Define the term benign prostatic hypertrophy 3%

b) List six (6) other obstructive symptoms that Mr. Mwansa may present with other than the one mentioned in
the question. 12%
c) Mention two (2) closed and three (3) open approaches of prostatectomy 10%
d) Discuss the pre-operative nursing care you would give to Mr. Mwansa 50%
e) Mention 5 five complications PBH 25%

a) Definition

Benign prostatic hypertrophy (BPH) or enlarged prostate is enlargement or hypertrophy of the prostate gland.

b. Obstructive symptoms

1. Hesitancy in starting urination

2. Increased frequency of urination
3. Nocturia
4. Urgency and abdominal straining
5. Decrease in size and force of urine stream.
6. Dribbling in which urine dribbles out after urination.
 Sensation of incomplete emptying of the bladder.
 Acute urinary retention (more than 60mls)
 Recurrent urinary tract infections
 Interruption of urinary stream
 Ultimately azotenia and renal failure can occur.
12%

(c) Mention two (2) closed and three (3) open approaches of prostatectomy 10%
Closed approaches
 Transurethral resection
 Transurethral incision
Open approaches
 Suprapubic prostatectomy
 Perineal prostatectomy
 Retropublic prostatectomy

Discuss the pre-operative nursing care you would give to Mr. Mwansa 50%

15
 objectives
 To prepare Mr. Mwansa psychologically and physically for operation.
 …………………………………………………………………………………………….
 …………………………………………………………………………………………….

Admission

Preferably the patient will admitted 48 hrs before surgery. This will help in acquainting him to the new environment
 Welcome Mr. Mwansa into the ward and introduce him to other members of staff and other patients in the
ward to familiarize the environment.
 Check Mr. Mwansa’s vital signs thus the pulse, respiration, temperature and blood pressure to serve as
baseline data and to assess any deviation. Record all readings for reference.

 Environment
 Put him in a clean room to minimize the risk of infection
 Maintain a restful environment by keeping the rock clean and well ventilated and by minimizing
environmental irritants (e.g. noise, smoking)
 ……………………………………………………………………………………………………..
 ……………………………………………………………………………………………………..
 ……………………………………………………………………………………………………..

 Assessment.
 Assess Mr. Mwansa’s physical state to detect any abnormalities or deviate from normal which may need to
be corrected before surgery
 Assess the client’s nutritional status by checking hair texture, skin status and color of the mucous
membrane.
 Assess the respiratory status for optimal pulmonary function by checking for breathing pattern, nail bed for
pallor or cyanosis because ventilation is potentially compromised during all phases of surgery.
 Pre-operative medication

 Depending on the findings during assessment, give the prescribed medication and monitor him for desired
effects and side effects of the drug
 Atropine 0.5mg, pethedine and diazepam usually given.

 Pre-operative education

 Teach Mr. Mwansa some deep breathing and coughing exercises to promote lung
expansion

 Teach him about mobility and active body movement to prevent post operative
complications like deep vein thrombosis
 Teach him also about cognitive coping strategies to relieve tension, overcome anxiety
and achieve relaxation

 Nursing Care
i. Psychological care

 Continue giving psychological support to allay anxiety

 Reinforce the doctors explanation on the kind of operation and outcome
 Encourage Mr. Mwansa to verbalize his concerns and ask questions. Answer honestly or refer
the question to the highest authority if you are not able to. This is done to relieve tension due
to worries
 Identify significant others of family members and involve the in planning care for Mr.
Mwamba

ii. Consent Form

 Before Mr. Mwansa signs the consent form, ensure that the surgeon has provided a sample and clear
explanation of what prostatectomy entails, expected outcomes and possible risks if operation is not done.
 After being sure that Mr. Mwansa knows and understands what will happen, then witness the signing of the
consent form.
16
 iii Investigations

1. Collect blood sample for

 Hemoglobin to rule out anemia

 Grouping and cross match in case blood transfusion will be needed
 Bleeding and clotting time to rule out the bleeding disorders which may have a negative bearing in
post operatively.

 Collect urine sample for urinalysis to rule out diabetes mellitus and renal disease which may have negative
bearing in post operative period.
 Chest X-rays or ultra sound to rule out chest infections
iv. Nutrition and fluids
 Mr. Mwansa will be starved for 6-8 hours prior to surgery
 For this reason, advise him after he has his super not to take anything by mouth such as solid floods, juice
and water fro midnight to prevent vomiting and aspiration during surgery.

v. Physical preparation
 Clean Mr. Mwansa’s abdomen from the umbilical line to the middle thigh with soap and water to reduce on
the number of micro-organisms. If he is hairy use a scissors to trim the hair.
 Give Mr. Mwansa another cleansing enema in the late evening to allow satisfactory visualizing of the
surgical site and prevent trauma to intestine

 Immediate Pre- operative care

 Give Mr. Mwansa another cleaning enema in the early hours of the morning of the operation, around 04:00
hours for example
 Give him the morning bath in the morning to remove sweat and dead epithelial cell on the body
 Mr. Mwansa will be dressed in a fresh, clean theatre gown to prevent infection
 Advise Mr. Mwansa to take off any jewelry to prevent electrocution
 Insert an canular to keep the vein open for intravenous infusion
 Insert also urinary catheter to employ the bladder and prevent accidental injury when it is full
 Insert a naso gastric tube to aspirate the stomach
 To prevent mistaken operation, provide an identity band of Name, age, sex, ward, type of surgery to be
done

 Immediate pre- operative observations

 Check vital signs i.e. temperature, pulse, respirations and blood pressure to act detect any deviation from
normal and act baseline date intra operatively
 Report and note on Mr. Mwansa s chart any observation that might have bearing on anesthesia or surgery
e.g. raised blood pressure.

 Pre anesthetic medication

 As ordered, give pre-anesthetic medication to allay anxiety, decrease the flow of

pharyngeal secretions and to reduce the amount of anesthesia to be given, and also
create amnesia for the event that precede surgery

 Escorting the patient to the theatre

 Complete the pre-operative checking list to be sure that it bears information such as clinical data
patient preparation and communication assessment

17
  Attach together surgical consent form, all laboratory reports or results, X-ray and scan films and
other relevant documents
 Transfer Mr. Mwansa from bed to a stretcher covered with sufficient number of linen to ensure
warmth
 Once at the theatre, hand over Mr. Mwansa to the theatre nurse according to the hospital policy
 After escorting Mr. Mwansa to the theatre, come back to the ward and continue reassuring his
family members

(d) Mention five (5) Complications of prostatectomy and state how each one can be prevented
1. Hemorrhage................................................................................................................
2. Infections...................................................................................................................
3. Renal failure.............................................................................................................
4. Pulmonary complications............................................................................................
5. Epididymo-orchits.......................................................................................................
 Obstruction/ stenosis of urinary bladder neck
 Sexual dysfunction such as :

ACUTE ABDOMEN

1. Mrs. Margret Zulu, a 60 year old marketer is admitted to your ward with severe abdominal pains. After
thorough examination, a diagnosis of acute abdominal is made.

a. Define acute abdomen 5%

b. Explain five(5) common causes of acute abdomen 20%
c. Describe the pre-operative management you would give to Mrs. Zulu 50%
d. Explain five (5) points you would include in your information, education and communication to
Mrs. Zulu before discharge 25%

MARKING KEY FOR ACUTE ABDOMEN

1. Definition of acute abdomen

 This is an acute intra-abdominal condition of abrupt onset, usually associated with pain due to
inflammation, perforation, obstruction, infarction or rupture of abdominal organs and usually
requiring emergency surgical intervention

18
 . Five (5) common causes of acute abdomen
 Inflammation e.g.:

 Acute appendicitis- where the appendix is inflamed. There is sudden severe abdominal
pain such that if inflammation continues without treatment the appendix can rapture
 Acute diverticulitis- acute inflammation of the diverticulum (pouch or pocket of any
portion e.g. of the G.I.T). This commonly occurs in the large intestine. There is severe
pain and tenderness usually in the lower left part of the abdomen among others
 Acute cholecystitis- acute inflammation of the gall bladder
 Acute salpingitis- acute inflammation of the fallopian tubes

1) Acute intestinal obstruction

 May be a mechanical obstruction where the blockage could completely stop or seriously impair the passage
of intestinal contents. The part above the obstruction may swell up when filled with food, fluid, digestive
secretions, etc. Mechanical obstruction is commonly caused by:

 Volvulus-Which is the twisting of the intestine causing obstruction. In the this case, blood supply
is cut off to the affected part and gangrene may occur if not managed properly
 Intussusceptions-prolapsed of one of the intestine into another part immediately adjacent to the
part

 Intestinal obstruction can be non mechanical e.g. in paralytic ileus-where the normal contractile movement
of the intestinal wall temporarily stops.

3) Peritonitis- inflammation is usually caused by an infection or inflammation of the lining of the abdominal
cavity (peritoneum). Usually infection spreads from an infected organ in the abdomen. Common sources are:
Perforation of the stomach/ intestine (e.g. perforated peptic ulcers), gall bladder, appendix), also perforation of the
fallopian tube (e.g. ruptured ectopic pregnancy)

4) Ischemia- This is where there is deficiency in blood supply which could be as a result of:
 Strangulated hernia- This is a hernia of the bowel in which the neck of the sac containing the bowel is so
constricted that the blood supply is impeded and gangrene may result if not managed promptly.
 Volvulus- the blood supply is cut off and gangrene may result if not managed promptly
 Torsion of the ovarian cyst- This is where the long pedicles of an ovarian cyst twists leading to impaired
blood supply to the affected part, gangrene may result if not managed promptly.

5) Ruptured arterial aneurysm

 This is the rupture of an aneurysm (bulge or dilatation in the wall of an artery) usually the abdominal aortic
aneurysm
 There s excruciating pain in the lower abdomen and back, also tenderness over the aneurysm
 With severe internal bleeding, a person may rapidly go into shock

 PREOPERATIVE MANAGEMENT GIVEN TO ZULU

Emergency care
 The management is emergency pre-operative
 Patient should be nil orally because if patient eats may aspirate the food under the influence of anesthesia
 Inset a nasal gastric tube in order to empty the stomach (especially if the patient has eaten within 4-6 hours.
 If there is blood loss, or if patient has vomited a lot ( causing circulatory failure or dehydration or where
these are anticipated), Intravenous fluids are given
 A fluid balance chart is monitored in all cases
 In case patient is in shock or urinary retention is suspected, a catheter is put up
 Vitale signs are monitored regularly e.g. 2 hourly depending on condition, low Bp, fast and feeble pulse
indicate patient going in shock. High temperature will show that there is infection.
 Blood is collected for grouping and cross match since the patient may need blood transfusion.

19
GENERAL CARE
 Remove any dentures, jewelers, etc
 Will explain to the patient the type of operation and why is going to theatre
 Thereafter, patient will be asked to sign the consent form for operation
 The abdomen will be trimmed up to the vulva
 I will put an identification band on the wrist
 Theater nurse will be informed of the patient going for laparotomy
 When ready will take the patient and handover to the theatre nurse
 Will come back to the ward to prepare the environment including the post –operative bed.
Five (5) points that can be included in the IEC to Mrs. Zulu before discharge

 IEC is given on the importance of good nutrition; high protein and vitamin diet. Proteins help in the
building of worn out tissues, while vitamins help in healing of the wound and boosting of the immunity.
Also need roughage in the diet to help in making the stool bulk and promote peristalsis thereby preventing
constipation. Constipation leads to staining while opening bowels and this would cause pressure on the
incision site which may open up.
 The patient will also be given IEC on the importance of not touching the incision site with dirty hands as
they may introduce microorganisms which may cause infection
 She will also be advised on not lifting heavy objects as this can cause strain on the incision site thereby on
the importance of coming back to the hospital for review so that the progress could be assessed. However,
she would be told that in case of having problems. Should come back even before the review date.
 Drug compliance- advise the patient on the importance of drug compliance
DEFINITION

 Prostatectomy refers to the surgical removal of part of the prostate gland or the entire prostate (radical
prostatectomy).

Indications
 Benign prostate enlargement.

Path physiology of benign disease

 When men rich their mid 40s.the prostate gland begins to enlarge. This condition, benign prostatic
hyperplasia (BPH) is present in more than half of men in their 60s and as many as 90% of those over 90.
Because the prostate surrounds the urethra, the tube leading urine from the bladder out of the body, the
enlarging prostate narrows this passage and makes urination difficult. The bladder does not empty complete
each time a man urinates, and as a result, he must urinate with greater frequency, night and day. In time, the
bladder can overfill, and urine escapes from the urethra, resulting in incontinence. An operation called
transurethral resection of the prostate (TURP) relieves symptoms of BPH by removing the prostate tissue
that is blocking the urethra. No incision is needed. Instead a tube (retro scope) is passed through the penis
to the level of the prostate, and tissue is either removed or destroyed, so that urine can freely pass from the
body

Path Physiology of Malignant disease

 Prostate cancer is the single most common form of non –skin cancer in the United State and the most
common cancer in men over 50. Half of men over 70 and almost all men over the age of 90 have prostate
cancer, and the American Cancer Society estimates that 198000 new cases will be diagnosed in 2001. This
condition does not always require surely, In fact, many elderly men adopt a policy of watchful waiting
“especially if their cancer is growing slowly. Younger men often elect to have their prostate gland totally
removed along with the cancer it contains- an operation called radical prostatectomy. The two main types
of this surgery, radical retro pubic prostatectomy and radical pineal prostatectomy, are performed only
patient whose cancer is limiting to the prostate. If cancer has broken out of the capsule surrounding the
prostate gland and spread in the area to distant sites, removing the prostate will not prevent the remaining
cancer from growing and spread throughout the body.

GENERAL SURGICAL MANAGEMENT FOR PROSTATE CANCER

20
PRECAUTIONS BEFORE SURGERY.

 Open (incision) prostatectomy for cancer should not be done if the cancer has spread bound the prostate, as
serious side effects may occur with the benefit of removing all the cancer. If the bladder is retaining urine,
it is necessary to insert a catheter before starting surgery. Patients should be in the best possible general
condition before radical prostatectomy. Before surgery, the bladder is inspected using instrument called a
cyst scope to help determine the best surgical technique to use and to rule out other local problems.

TYPES OF SURGERY THAT COULD BE PERFORMED

 TRANS _URETHRA RESECTON OF PROSTATE (TURP)

 This procedure does not require an abdominal incision. With the patient under either general or spinal
anesthesia, a cutting instrument or heated wire loop is inserted to remove as much prostate tissue as
possible and seal blood vessels. The excised tissue is washed into the bladder, and then flushed out at the
end of the operation. A catheter is left in the bladder for one to five days to drain urine and blood.
Advanced laser technology enables surgeons to five days to drain urine and blood. Advanced laser
technology enables surgeons to safely and affectively burn off exceed prostate tissue blocking the bladder
opening with fewer of the early and late complications associated with other forms of prostate surgery. This
procedure can be performed on an outpatient basis, but urinary symptoms do not improve until swelling
subsides several weeks after surgery.

 RADICAL RETROPUBIC PROSTATECTOMY

 This is a useful approach if the prostate is very large, or cancer is suspected. With the patient under general
or spinal anesthesia or an epididural, a horizontal incision is made in the center of the lower abdomen.
Some surgeons begin the operation by removing pelvic lymph nodes to determine whether cancer has
invaded them. But recent findings suggest there is no need to sample them in patients whose like hood of
lymph node metastases is less than 18%. A doctor who removes the lymph nodes for examination will not
continue the operation if they contain cancer cells, because the surgery will not cure the patient. Other
surgeons remove the glad before examining the lymph nodes. A tube (catheter) inserted into the penis to
drain fluid from the body is left in place for 14-21 days.

 Originally, this operation also removed a thin rim of bladder tissue in the area of the urethra sphincter- a
muscular structure that keeps urine from escaping from the bladder. In addition, the nerves supplying the
penis often were damaged, and many men found themselves important (unable to achieve erections) after
prostatectomy. A newer surgical method called potency-sparing radical prostatectomy preserves sexual
potency in 75% of patients fewer than 5% become incontinent following this procedure.

 RADICAL PERINAL PROSTATECTOMY

 This procedure is just as curative as radical retro public prostatectomy but is performed less often because it
does not allow the surgical to spar the nerves associated with erection or, or because the incision is made
above the rectum and below the scrotum, to remove lymph nodes. Radical Perineal prostatectomy is
sometimes used when the cancer is limited to the prostate and there is no need spare nerves or when
patient’s health might be compromised by the longer procedure. The Perineal operation is less invasive
than retro pubic prostatectomy. Some parts of the prostate can be seen batter, and blood loss is limited. The
absence of an abdominal incision allows patients to recover more rapidly. Many urologic surgeons have not
been trained to perform this procedure. Radical prostatectomy procedure last one to four hours, with radical
Perineal prostatectomy taking less time than radical retro pubic prostatectomy. The patient remains in the
hospital three to five days following surgery and can return to work in three to five weeks.
 Ongoing research indicates that laparoscopic radical prostatectomy may be as effective as open surgery in
treatment of early- stage disease.

CRYOSURGERY

21
  Also called cry therapy or cry ablation, this minimally invasive procedure uses very low temperature to
freeze and destroy cancer cells in and around the prostate gland. A catheter circulates warm fluid through

HEAD INJURY

DEFINITION
This is injury that affects the scalp, skull and or brain.
Causes
 The main causes of head injury are forceful trauma to the head.

Clinical manifestation
 Loss of consciousness
 Severe headache
 Vertigo
 Altered respirations, temperature, BP,
 Confusion
 Vomiting
 Leakage of C SF from the nose ears, or throat
 Blurred vision
 Loss of various sensory perception
 Paralysis on one side of the body

Investigations
 history
 physical examination
 CT scan
 MRI
 skull xray
 PET scan
 EEG

NURSING CARE OF A PATIENT WITH A HEAD INJURY

OBJECTIVES

 Maintain a clear and patent airway

 To ensure that the patient remains safe and free from further damage/injury to the head.
 To reduce/prevent complications that could arise as a result of the injury
 To anticipate and timely begin to rehabilitate the patient in case of a life long disability.

A patient with a scalp/skull may have a minor injury. A thorough assessment needs to be to ascertain this. The
patient will therefore be admitted for observations close to 24hrs. during this time the nurse needs to monitor the
vital signs, signs of impending shock, worsening of pain and other neurological signs.
A patient with brain injury is definitively in danger and the condition should be treated as an emergency.

ENVIROMENT.

The patient should be admitted in an acute bay or preferably in ICU. This is to allow for close observations.
It should be clean enough and well dumped dusted to prevent infections. There should be adequate light that will
facilitate easy observations in case of change of condition
The environment should be quiet to allow the patient to have enough rest.
Visitors should be allowed to visit patent but only for short periods of time and in fewer numbers to promote rest.
The patient is better nursed in a rail bed that will prevent accidental falls as the patient attempt to turn.
POSITION
22
All patients with a head injury should be treated with assumption that they also have cervical spinal injury until
proved otherwise. The patient is therefore nursed on a flat hard board with head and neck kept in body alignment.
Where cervical spinal injury has being ruled out, a 30 degree pillow may be put to prevent increased intra cranial
pressure.
Generally main a clear and patent air way for adequate ventilation.
As patient may be unconscious ensure two hourly turnings to prevent pressure sore development.

REST VS ACTIVITY

Initially the patient should given enough time to rest .This helps to reduce tension and ICP.
An unconscious patient need not to disturb so often unless indicated when doing certain procedures like bed bath.
Attempt to do procedures in blocks so that you disturb patient little.
However passive limb exercises will greatly help the patient improve circulation.

OBSERVATIONS
The focus of your care should be aimed at thorough observations.
Initially quarter hourly observations for the vital signs should be done to monitor the progress of the patient.
Patient’s condition tends to deteriorate so fast because of altered cerebral functions.
Check the temperature, pulse respirations and B.P every 15minutes until condition stabilizes.
Observe the patency of the airway as the tongue could fall back or secretions easily build up.
Observe for any leakage of fluid {blood or CSF} from the ears, thorax or nose.
Observe the level of consciousness’ use the Glasgow coma scale to assess the levels of consciousness.

INTRAVENOUS INFUSION
Insert an intravenous line for infusion of fluids and medication. Patient is give plasma expanders that alternate with
5% dextrose for energy.. Keep the veins open for easy access incase of resuscitation.
Monitor the IV insertion site for any swelling, infection or blockage

NUTRITION.

The patient obtains his food through the intravenous infusion, ensure that this is supplement ed by NG feeds if the
patient does not have fracture of the base of the head
Where food has to be given by NG , encourage a high nutritious diet that could easily be digested to prevent
stomach upsets

ELIMINATION
Maintain a intake and output regime, all fluids given to the patient should be documented and al the output should
equally be noted.
A urinary catheter should be left in situ for easy monitoring of output and documentation
Ensure that catheter hygiene is done to prevent URTI
Come up with routine bed pan round for easy evacuation of the bowels and prevention of constipation.
This will increase the comfort of the patient

HYGIENE
Activities of daily living such as mouth wash body wash hair should not be abandoned.
Do routine mouth wash, bed bath, elimination, change of linen and clothes nail care etc. This helps to prevent
infections which could acquire on the ward.
A bath also helps to improve circulation of blood to vital centers of the body.
While bathing you can also observe for pressure sore development and be able to take appropriate intervention.
Bathing will also help you to do passive limb exercises and thus be able to prevent use syndrome

MEDIACTION
Administer the prescribed drugs to the patient following the 5 ‘Rs”.
The patient will particularly benefit from manitol which reduces ICP.

23
Test doses for antibiotic should be done as patient is unconscious. This helps to prevent incidental reactions.
Continue monitoring the patient for any other incidental /adverse reaction.

REHABILITATION
Develop a rehabilitation plan for the patient because of the likelihood of long term disability.
Involve the relatives or significant others throughout your care plan as these patient will stay much longer with them
in a deficit situation.
Help them to copy up with realities of the condition so that they could give maximum support,
Patient should also be fully involved if he’s is in a capable position to participate in the rehabilitation plan. This will
help him come to terms with situation.
The Psychotherapist, speech therapist dietitians, physiotherapists should be involved in the care of the patient.
NURSING CARE OF A PATIENT WITH A HEAD INJURY
OBJECTIVES
 Maintain a clear and patent airway
 To ensure that the patient remains safe and free from further damage/injury to the head.
 To reduce/prevent complications that could arise as a result of the injury
 To anticipate and timely begin to rehabilitate the patient in case of a life long disability.

A patient with a scalp/skull may have a minor injury. A thorough assessment needs to be to ascertain this. The
patient will therefore be admitted for observations close to 24hrs. During this time the nurse needs to monitor the
vital signs, signs of impending shock, worsening of pain and other neurological signs.
A patient with brain injury is definitively in danger and the condition should be treated as an emergency.

ENVIROMENT.
The patient should be admitted in an acute bay or preferably in ICU. This is to allow for close observations.
It should be clean enough and well dumped dusted to prevent infections. There should be adequate light that will
facilitate easy observations in case of change of condition
The environment should be quiet to allow the patient to have enough rest.
Visitors should be allowed to visit patent but only for short periods of time and in fewer numbers to promote rest.
The patient is better nursed in a rail bed that will prevent accidental falls as the patient attempt to turn.
POSITION
All patients with a head injury should be treated with assumption that they also have cervical spinal injury until
proved otherwise. The patient is therefore nursed on a flat hard board with head and neck kept in body alignment.
Where cervical spinal injury has being ruled out, a 30 degree pillow may be put to prevent increased intra cranial
pressure.
Generally main a clear and patent air way for adequate ventilation.
As patient may be unconscious ensure two hourly turnings to prevent pressure sore development.

REST VS ACTIVITY

Initially the patient should given enough time to rest. This helps to reduce tension and ICP.
An unconscious patient need not to disturb so often unless indicated when doing certain procedures like bed bath.
Attempt to do procedures in blocks so that you disturb patient little.
However passive limb exercises will greatly help the patient improve circulation.

OBSERVATIONS

The focus of your care should be aimed at thorough observations.

Initially quarter hourly observations for the vital signs should be done to monitor the progress of the patient.
Patient’s condition tends to deteriorate so fast because of altered cerebral functions.
Check the temperature, pulse respirations and B.P every 15minutes until condition stabilizes.
Observe the patency of the airway as the tongue could fall back or secretions easily build up.
Observe for any leakage of fluid {blood or CSF} from the ears, thorax or nose.
Observe the level of consciousness’ use the Glasgow coma scale to assess the levels of consciousness.

24
INTRAVENOUS INFUSION
Insert an intravenous line for infusion of fluids and medication. Patient is give plasma expanders that alternate with
5% dextrose for energy.. Keep the veins open for easy access incase of resuscitation.
Monitor the IV insertion site for any swelling, infection or blockage

NUTRITION.
The patient obtains his food through the intravenous infusion, ensure that this is supplement by NG feeds if the
patient does not have fracture of the base of the head
Where food has to be given by NG , encourage a high nutritious diet that could easily be digested to prevent
stomach upsets

ELIMINATION
Maintain a intake and output regime, all fluids given to the patient should be documented and al the output should
equally be noted.
A urinary catheter should be left in situ for easy monitoring of out put and documentation
Ensure that catheter hygiene is done to prevent URTI
Come up with routine bed pan round for easy evacuation of the bowels and prevention of constipation.
This will increase the comfort of the patient

HYGIENE
Activities of daily living such as mouth wash body wash hair should not be abandoned.
Do routine mouth wash, bed bath, elimination, change of linen and clothes nail care etc. This helps to prevent
infections which could acquire on the ward.
A bath also helps to improve circulation of blood to vital centers of the body.
While bathing you can also observe for pressure sore development and be able to take appropriate intervention.
Bathing will also help you to do passive limb exercises and thus be able to prevent use syndrome

MEDIACTION
Administer the prescribed drugs to the patient following the 5 ‘Rs”.
The patient will particularly benefit from manittol which reduces ICP.
Test doses for antibiotic should be done as patient is unconscious. This helps to prevent incidental reactions.
Continue monitoring the patient for any other incidental /adverse reaction.

REHABILITATION

Develop a rehabilitation plan for the patient because of the likelihood of long term disability.
Involve the relatives or significant others through out your care plan as these patient will stay much longer with
them in a deficit situation.
Help them to copy up with realities of the condition so that they could give maximum support,
Patient should also be fully involved if he’s is in a capable position to participate in the rehabilitation plan. This will
help him come to terms with situation.
The Psychotherapist, speech therapist dietitians, physiotherapists should be involved in the care of the patient.

IEC
Relatives should be taught to observe any usual behavior after discharge and encouraged to bring the patient quickly
to the health facility for further assessment

25
APPENDECTOMY

Mrs. Mwanza has been complaining of chronic pain in the right Iliac fossa. After an abdominal scan, The Dr
suspects that she could have an inflamed Appendix and he decides to perform appendectomy

a) Define Appendectomy 5%

b) List two types of abdominal incisions that a Dr can use to approach the
appendix 6%

c) Discuss in detail the pre op care of a patient going for appendectomy 50%

d) Briefly discuss how you are going to manage the abdominal wound after surgery 20%.

Mention {4} four complications of abdominal surgery 15%

26
 OTHORPAEDIC QUESTIONS

OSTEOMYLITIS

Mrs. Joyce Wenu aged 35 years; Married with five (5) children is admitted to your ward complaining of
tenderness in the left leg and general body malaise. After thorough examination, a diagnosis of Osteomyelitis is
made.

a. Draw a well labeled diagram of the femur 15%

b. List five (5) signs and symptoms Mrs. Wenu is likely to present with other than the ones mentioned in the
stem 10%
c. Identify five (5) problems Mrs. Wenu is likely to present with and using the nursing care plan, describe the
management of Mrs. Wenu 50%
d. Explain five(5) complications of Osteomyelitis 25%

MARKING KEY FOR OSTEOMYELITIS

b. SIGNS AND SYMPTOMS OF OSTEOMYELITIS

 Pain in the left leg fever

 Redness on affected leg
 Warmth on the affected leg
 Drain sinus (when the inflammation has become chronic)
 Selling on the left leg

NURSING CARE PLAN

Problem Objective/Goal Intervention Rationale Outcome/Evaluation

Pain on the To relieve pain through  Give prescribed To relieve pain (aspirin Patient verbalizes less or
affected site out the patients stay in analgesics/ant- relieves inflammatory no pain at all through out
hospital inflammatory drug processes including pain hid stay in hospital
e.g. Aspirin

Risk for To prevent extension of  Clean the wound Hydrogen peroxide is a Infection has not extended
extension of infection to other parts daily with hydrogen strong disinfectant to another part of the bone
infection of of the bone and peroxide using cleaning solution (kills and surrounding soft
infections to surrounding tissues aseptic technique some of the infection tissue evidenced by
other parts of  Give prescribed producing micro- swelling, not increasing
the bone and antibiotics such as organism) and absence of draining
surrounding crystalline penicillin, sinus
soft tissue Gentamycin etc. Antibiotics are bacterial
 Observe the affected (kill bacterial) and
site for increase in bacteriostatic(Arrest the
swelling and draining growth of bacteria)

To see if the infection is
extending to another parts
of the bone .
Impaired Physical mobility will  Immobilize affected Assistive device increase Physical mobility is
physical be increased during the leg with splint, but physical mobility. increased during the
mobility patients stay in hospital use assistive device To increase physical patients stay in hospital
27
 to increase to mobility
increase mobility.
 Ensure full function
of unimpaired
extremities
 Ensure patient
participate in self –
care activities.
Patient will be  Listen carefully to Listening helps in Patient is knowledgeable
Knowledge knowledgeable about what the patient says detection of about the disease and its
deficit the disease and its about the illness misunderstanding and treatment within 48 hours
treatment within 48  Prepare a teaching misinformation and of admission
hours of admission plan and provide an provides opportunity for
explanation about the education.
disease, cause, signs
and symptoms and Knowledge about disease
treatment, etc and treatment usually
increase compliance
Allow patient to ask  The patient ‘s
questions question indicate
issues that need
clarification
5 Prevent development  Immobilize affected  Avoids
Risk of of pathological fracture leg with a splint pressure/stress to
developing  Use assistive device the weakened (or
pathological  Ensure full unction of affected ) bone
fracture unaffected  Assistive device
extremities. will bear the
pressure/stress/
 The will help
bear pressure,

No pathological fracture
develops.
6 Patient will not have  Give prescribed  These antibiotics There is absence of
Risk of bacteria and their antibiotics,e.g x-pen are bacteria and their toxins in
septicemia toxins in her blood gentamycine,etc. bactericidal(kill the patient’s blood stream
stream  Clean the wound bacteria) and evidenced by temperature
daily with hydrogen bacteriostic which is within the
peroxide using arrest the growth normal range.
aseptic technique. of (Hydrogen
 Take temperature 2-4 peroxide is a
hourly daily strong
depending on the disinfectant
condition which kills
some micro-
organisms
 Monitoring
temperature
helps to detect
fever which is a
sign of
7. Swelling To reduce on the  Elevate the affected  This promotes Swelling is reduced
swelling of the affected limb with pillows venous drainage within 72 hours of
part within 72 hours of  Give proscribed anti thereby reducing admission
admission inflammatory drug the swelling
e.g. Aspirin  Aspirin
counteracts the
28
 inflammatory
processes
including
swelling

EXAMPLE 2 IF USING LOPER ROGAN MODEL OSTEOMYELITIS

Problem Objective/Goal Intervention Rationale Outcome/Evaluation

1.Pain as a To  Immobilization left To reduce movement and Pain is relieved within
result of relieved pain within 48 leg with a splint stress on the affected leg 48hours of admission
immobilization hours of intervention  Elevation of affected thereby reducing pain. evidenced by facial
of affected after admission leg on pillows expression.
limb  Putting bed cradle To reduce on the swelling
over the affected leg and pressure to the
affected site, thereby
reducing pain.

To Lift weight of the

linen (or pressure) from
affected leg thereby
reducing pain

D. COMLICATIONS OF OSTEOMYELITIS

 Pathological fracture- the bone on the affected part becomes weak and may end up breaking
 Septic arthritis – Infection may spread from the nearby joint causing inflammation of the joint.
 Septicemia- Bacteria’s and their toxin may invade the blood stream causing widespread infection
 Draining sinus – this discharge from the infected bone (bone abscess) through the surrounding soft tissue
 Sequestrum- this is the dead bone tissue where the abscess has formed. There is deprivation.

ANSWER KEY TWO

DEFINATION
 Osteomyelitis is the infection of bone tissue from pathogenic, organism particularly staphylococcus aurues,
which irresponsible to 80% of infections.

CAUSES.
 This mainly a staphylococcal aurues, infection (80%), occasionally, species of proteins pseudomonas and
E.Coli are responsible.

PRE – DISPOSING FACTORS

The people that are at high risk of getting this infection are
 The poorly nourished
 The Elderly
 The obese
 People with impaired immune system
 Those with chronic illness such as diabetes, rheumatoid arthritis.
 Patients receiving corticosteroids
 Invasive bone surgery.
29
MODES OF INFECTION
Bone tissues can become infected by one of the three modes
 Extension of infection to soft tissue as in infected ulcer, vascular ulcer or incision infection.
 Direct bone contamination from bone surgery, open fracture gunshot or traumatic ulcer.
 Haematogenic spread from other side from the body i.e. infected tonsils, boils, URTI.
Path physiology of Osteomyelitis.

 Osteomyelitis is mainly caused by staphylococcal aurues.. The initial response to the infection is
inflammation, followed by increased vascular and oedema.
 If the infection is blood bone, the onset is usually sudden, causing (acute Osteomyelitis) It is accompanied
by chills fever rapid pulse and general malaise. These systematic symptoms may at first overshadow the
local symptoms.
 As the infection progress it involves the periosteumm, extends to the cortex of bone and the eventually the
soft tissue .Because of the swelling and pressure from oedema, the infection area becomes painful and very
tender. Increased vascular makes the area to feel warm and swollen.

 2 to 3 days after infection, a thrombus of blood vessels occurs. This may occlude blood supply thereby
causing ischemia and bone necrotic forming pus. The patient feels a pulsating pain as pus accumulates.

 The resulting necrotic tissue forms sequestrum which does easily liquefy and drain, therefore the cavity
does not collapse and heal.

 The increased in pressure results in whole being formed known as a sinus through which the pus attempts
to escape. New bone growth (involuculum) begins to form around the sequestrum through the sequestrum
remains infected even when healing has occurred.
 This produces recurrent abscess throughout the patient’s life.
 This condition is referred to as chronic Osteomyelitis.
 A patient with Osteomyelitis present with a continuous draining sinus or experiences recurrent periods of
pain, inflammation, low grade fever, swelling and drainage.

CLINICAL FEATURES OF OSTEOMYLITIS (SIGNS AND SYMPTOMS)

 Onset is usually sudden, especially if it is blood bone
 Increased actuality and oedema
 High fever
 Rapid pulse
 Chills
 General malaise
 Infected area is painful, swollen and tender
 Area may feel warm
 Sinus formation in chronic Osteomyelitis

DIAGNOSIS / INVESTIGATIONS
 History of underlying predisposing factors is collected
 X- ray of affected part may demonstrate soft tissue swelling in the early stages.
 Blood studies review elevated WBC counts.
 Wound culture swabs are collected to isolate causative organism
 Blood culture is done to determine infective organism and for appropriate antibiotics therapy.
 Sinuses are observed in chronic Osteomyelitis
 Increased ESR is evident.

MEDICAL MANAGEMENT..
OBJECTIVES
 The main objective is to control or halt the infection process
 Immobilize the effected part
 Relieve and discomfort
 Prevent Complication.
 The medical management aims at controlling the process of infection so that blood supply for the area is
not diminished

30
  Antibiotic therapy is immediately. This should be based on the blood and culture results. The I.V anti biotic
therapy should continue for 3 to 6 weeks. After the infection appears to have been controlled, oral
administration continues for up to 3 months.
To enhance absorption oral antibiotics should not be administered with food
Other supportive measures in include:
 Hydration
 Good nutrition with high vitamins and proteins
 Correction of anemia
 Analgesia may be prescribed to relieve comfort and pain.

SURGICAL MANAGEMENT.

 The main objective is to halt the infective process

 Relieve pain
 Prevent pathological fractures and deformity.

 If patient does not respond to antibiotics therapy, the infected bone is surgically exposed, and the pus and
necrotic tissue is removed. The area 1 irrigates with sterile saline solution. This is s called Surgical
Debridement, followed by sequestectomy.
 Sequestectomy is the removal of sequerum or the involuclum, In most cases sufficient bone tissue is
removed such that the deep cavity appears shallow like a saucer the term (Saucerization)
 Because surgical Debridment weakens the bone, internal fixation or external supportive devices may be
used to stabilize support the bone to prevent pathological fracture.

NURSING CARE /MANAGEMENT.

The objectives of nursing care management are

 Provide a safe and conducive environment for rapid recovery from the disease process
 Help to relieve discomfort and pain.
 Prevent occurrence of complications such as pathological fractures.

ENVIRONMENT.
 The patient with Osteomyelitis is nursed in a surgical ward preferable in a side ward aw ay from routine
ward traffic to ensure maximum rest and com fort.

 The ward should be cleaned everyday by through dump dusting, mopping all the surfaces. It should be well
ventilated with adequate light. These measures prevent cross infection. Provide a comfortable and soothing
environment

POSITION
 The patient is nursed in a position he find more comfort regimes, such as immobilization, he should ensure
frequent turnings (at least 2 hourly ) to promote circulation and prevent development of pressure sores.

PSYCHOLOGICAL CARE
 The patient may be apprehensive about the outcome of the disease process at the possibility of long term
treatment or immobilization.
 Explain to the patient the disease process, its eventful outcomes without alarming the patient. Focus on the
positive outcomes but avoid giving false hopes, patient should understand the need to restrict certain
vigorous activities while remaining productive.
 Involve the significant others in the care of the patient as home care will be inevitable

REST AND ACTIVITY.

 The patient should understand the rationale for the activity restrictions. The joint above and below the
affected part should be gently placed through a range of motions. The nurse encourages full range of ADLs
within the physical limitations to promote the general well being
PAIN RELIEF
 The effected part is usually immobilized in a split to decrease pain and muscle spasm.
31
  The nurse monitors the neuromuscular status of the affected extremity. The wounds are usually very
painful thus should be handled with care and gentleness.
 Elevation reduces swelling and the associated discomfort while the pain can be controlled prescribed
analgesia.

OBSERVATIONS
 Vital signs of temperature and pulse rate are taken to monitor the disease process.

 Monitoring of the neuromuscular function is cardinal to ensure that ischemia is not developing.
 The general well being of the patient is frequently assessed, his reaction to pain, his nutritional status,
compliance to the treatment regimes such a immobilization and generally his reaction to hospitalization.
 Development of sinus or drainage of pus from the wound site is checked.
 Daily wound care with the prescribed antiseptic solution should be done. This helps to halt the infective
process. Sterile equipment and material should be used each time dressings are done.
 Patient is also encouraged to assume personal hygiene measure such as general body hygiene oral care and
hair care.
 The clothes worn should be clean and linen where patient is lying should be frequently changed.

MEDICATIONS
 Patient may be put on long term antibiotic therapy, thus adherence to the therapeutic regime will be critical
to avoid resistance developing. The nurse monitors the patient for super infection as a result of long term
use of antibiotics. These could be vaginal candidacies oral candidacies or foul smelling stools.

PATIENT TEACHING /IEC

 Patient relative must learn and recognize the importance of adhering to the therapeutic regimes, preventing
falls and other injuries.
 Patient may need to know how to manage IV at home
 Identification of additional painful sites should be reported
 Report any elevation in temperature

Arthritis

Mr. Monze, a famous cyclist, underwent knee surgery after suffering from acute septic arthritis which developed
after falling off his bicycle.

a) Define acute septic arthritis 5%

(i) List five{5} causes of arthritis 10%

b) Explain five {5} signs and symptom of acute septic arthritis. 10%

c) Discuss in detail the Pre operative care of a patient due for bone surgery 50%

d) Mention {4} four rehabilitative measures that you would inoperative in your teaching plan to your
patient 5%

32
 EAR NOSE AND THROAT DISEASES QUESTIONS

OTITIS MEDIA

Definition
 Otitis media is inflammation of the middle ear, or middle are infection (the word Otitis is Latin and it
means “inflammation of the are”. And media means middle)
 Otitis media occurs in the are between the ear drum (the end of the outer ear) and the inner are, including a
duct known as the EUSTACHIAN TUBE. It has one two categories of inflammation that can underlay
what is commonly called an earache, the other being OTITIS EXTERNA. Disease other than the
infections can also cause pain, including cancer of any structure that shares supply with the ear.
 Otitis media is very common in childhood. With the average toddler having two or three episodes a year,
almost always accompanied by a viral upper respiratory infection (URI); mostly the common cold. The
rhinoviruses (nose viruses) that cause the common cold infect the Eustachian tube that goes from the back
of the nose to the middle ear. Causing swelling and compromise of pressure equalization, which is the
normal function of the tube. In general, the more severe and prolonged the compromise of Eustachian tube
function, the more the severe the consequences are to the middle ear and its delicate structures. If a person
is born with poor Eustachian tube function. This greatly increases the likelihood of more frequent and
severe episode of Otitis media. Progression to chronic Otitis media is much more common in this group of
people, who often have a family history off middle ear disease.

TYPES

 Otitis media has many degree of severity, and various names used to describe each. The terminology is
sometimes confusing because of multiple terms being used to describe the same condition. A common
misconception with ear infection is that sufferers think that a symptom is itchy ear. Although sufferers may
feel discomfort, an itchy ear is not a symptom of ear infection.

 ACUTE OTITIS MEDIA

 Acute Otitis media (AOM) is most often purely viral and self-limited, as its usual accompanying viral
URL. There is congestion of the ears and perhaps mid discomfort and popping, but the symptoms resolve
with the underlying URL. If the middle ear, which is normally sterile, becomes contaminated with bacteria,
pus and pressure in the middle ear can result, and this is called acute bacteria Otitis media. Viral acute
media can lead to bacterial Otitis media in a very short time, especially in children, but it usually does not.
The individual with bacterial acute media has the classic “earache”

33
  Pain that is more severe and continuous and is often accompanied by fever of 102 F (39 c) of more
.Bacterial causes may result of the ear drum. Infection of the mastoid space (mastoiditis) and in very rare
cases further spread to cause meningitis.

 OTITIS MEDIA WITH EFFUSION.

 Otitis media with effusion (OME), also called serious secretory Otitis media (SOM).Is simply a collection
of fluid that occurs within the middle ear space as a result of the negative pressure produced by altered
Eustachian tube function. This can occur purely from a viral URI, with no pain or bacterial infection, or it
can precede and /or follow acute bacterial Otitis media. Fluid n the middle ear sometimes causes
conductive hearing impairment, But only when it interferes with the normal vibration of the eardrum by
sound waves.

 Over weeks and months, middle ear fluid can become very thick and glue like (thus the name glue ear),
which increases the likelihood of its causing conductive hearing impairment. Early-onset OME is
associated with feeding while lying down and early entry into group Child care, While parental smoking, a
short period of breastfeeding and greater amount of time spent in group child care increased the duration of
OME in the first two years of life.

 CHRONIC SUPPURATIVE OTITIS MEDIA

 Chronic Suppurative Otitis media involves a perforation (hole) in the eardrum and active bacterial infection
within the middle ear space for several weeks or more. There may be enough pus that it drains to the
outside of the ear (otorrhea), or the purulence may be minimal enough to only be seen on examination
using a binocular microscope. This disease is much more common in persons with poor Eustachian tube
function. Hearing impairment often accompanies this disease.

PROGRESSION

 Typically, acute Otitis media follows a cold: after a few days of a stuffy nose the ear becomes involved and
can cause severe pain. The pain will usually settle within a day or two, but can last over a week. Sometimes
the ear drum ruptures, discharging pus from the ear, but ruptured drum will usually heal rapidly.

 At an anatomic level, the typical progression of acute Otitis media occurs as follows: the tissues
surrounding the Eustachian tube swell due to an upper respiratory infection, allergies, or dysfunction of the
tubes. The Eustachian tube remains blocked most of the time. The air present in the middle are is slowly
absorbed into the surrounding tissues. A strong negative pressure creates a vacuum in the middle ear, and
eventually the vacuum reaches a point where fluid from the surrounding tissues accumulates in the middle
ear. This is seen as a progression from a type A tympanogram to a type C to a type B tympanogram. The
fluid may become infected. It has been found dormant bacteria behind the Tympanum (eardrum) multiply
when the conditions are ideal, infecting the middle ear fluid.

 OTORRHEA: INFECTED DRAINAGE FROM THE MIDDLE EAR

 When the middle ear becomes acutely infected by bacteria, pressure builds up behind the ear drum, usually
but not always causing pain. In severe or untreated cases, the tympanic membrane may rupture, allowing
the pus in the middle ear space to drain into the ear canal. If there is enough of it, this drainage may be
obvious. Even though the rupture of the tympanic membrane suggests a traumatic process, it is almost
always associated with the dramatic relief of pressure and pain. In a case of acute Otitis media in an
otherwise health person, the body’s defenses are likely to resolve the infection and the ear drum nearly
heals. Antibiotic administration can prevent perforation of the eardrum and hasten recovery of the ear.

 Instead of the infection and eardrum perforation resolving, however, drainage from the middle ear can
become a chronic condition. As long as there is active middle ear infection, the eardrum will not heal. The
world Health Organization defines chronic Suppurative Otitis Media (CSOM) as “a stage of ear disease in
which there is chronic infection of the middle ear cleft, a non-intact tympanic membrane ( i.e. perforated
eardrum) and discharge (otorrhea), For at least the preceding two weeks” (WHO 1998).(notice WHO’s use
of the term serous to denote a bacterial process, where the same term is generally used by ear physician in
34
 the United State to denote simple fluid collection within the middle ear behind an intact eardrum. Chronic
Otitis media is the term used by moist ear physician’s world wide to describe a chronically infected middle
ear with eardrum peroration.)

 CAUSES

 Streptococcus pneumonia and non type B Haemophilus influenza are the most common bacterial causes of
Otitis media. Tubal dysfunction leads to the ineffective clearing of bacteria from the middle ear. In older
adolescents and young adults, the most common cause of ear infections during their childhood was
Haemophilus influenza. The role of the anti-H. influenza vaccine that children are regularly given in
changing patterns of ear infections is unclear, as this vaccine is only against strains of serotype b, which
rarely cause Otitis media.

 As well as being caused by Streptococcus pneumonia and Haemophilus influenza. It can also be caused by
the common cold. Cold indirectly cause of Otitis media by damaging the normal defenses of the epithelial
cells in the upper respiratory tract.

 Another common culprit of Otitis media includes Moraxella catahalis, a gram –negative, aerobic, oxidaese
positive diplococcus. Less commonly Otitis media can be caused by Mycobacterium tuberculosis.
TRACHEOSTOMY

Mr. Lubinda a regular cigarette smoker is admitted with a complication of cancer of the larynx.
He is to have a permanent colostomy.

a) Define tracheostomy 5%
b) Mention (5 )five predisposing factors to Ca of the larynx 15%
c) Discuss in detail the post op care of Mr. lubinda 50%
d) Mention five (5 )complication that Mr. lubinda is likely to present with 10%

KEY TRACHEOSTOMY

Predisposing factors of cancer of larynx

 Cigarette smoking
 Alcohol
 Vocal cord straining
 Chronic laryngitis
 Noxious fumes
 Family predisposition
 Asbestos wound and cement

POST-OPERATIVE CARE

 The aim of the post-operative care is to promote a patent airway, allay and prevent complications.
 ……………………………………………………………………………………………….
 …………………………………………………………………………………………………

ENVIROMENT
 The patient will be nursed in an intensive care unity or near the nurse’s bay for close observations. The
environment should be well ventilated and clean to prevent the patient from inhaling contaminated air.

 The room should be humidified to prevent irritation of the tracheobronchial mucosa as the tracheotomy by
passes the part that humidifies, warm and filters the air. The environment should have the mechanical
ventilator /oxygen cylinder, suctioning machine, sterile catheters and a tracheotomy care set for immediate
use when needed.

35
POSITION AND CLEARANCE OF AIR- WAY

 Initially when the patient comes from the theatre he will be positioned in a supine position but as he awakes
from anesthesia, he will be nursed in a semi- fowler’s position to promote proper lung expansion and
coughing up of secretions.
 Suctioning of secretion is done frequently when need arises to promote expansion, reduce risk of
atelectasis, pulmonary infection and ineffective gas exchange.

OBSERVATIONS
 Vital signs are observed every 15 minutes initially until the patient stabilizes, that is temperature which can
be low due to the effect of anesthesia or high because of some infection, pulse, blood pressure and
respirations if increased will indicate hypoxia. Assess for cyanosis especially around the lips and palms of
the patient that may be as a result of hypoxia and necessitating administration of oxygen.
 Observe for dyspnoea and restlessness which will indicate secretion in the airway. Suctioning should be to
clear the air way and promote ventilation.
 Monitor the fluid intake and output of the patient to prevent dehydration which can make the
tracheobronchial secretions to be thick and hence block the air-way.

TRACHEOSTOMY CARE

 TUBE: Securing the tube in the place using either twill tape or velcrotracheostomy hold to prevent
dislodgement and decannulation. This intervention reduces movement and traction on the tube from oxygen
or ventilator tubing or accidental pulling by the patient.

Complications

 Air embolism Emphysema, Laryngeal nerve damage, posterior tracheal wall penetration
 Airway obstruction, Protrusion of the calf, Infection, Dysphasia

OTITIS MEDIA

Given Hachundu has been complaining of pain the right ear after the swimming festival.
Its 4 weeks now and the pain seems to be getting worse.
You are the clinician at the health centre attending to this client.

e) Define Otitis Media. 2%

f) Mention six (6) signs and symptoms your patient is likely to present with 24%
g) Discuss the Medical management of your client 50%
h) State six (6) complications that could occur if there is further delay in the management of this client
24%

OPTHALMOLOGY QUESTIONS

Trabeculectomy

Mr. Lumbama has of late been complaining of having blurred vision and progressive visual loss. The doctor strongly
suspects the possibility of secondary glaucoma and considers doing a trabeculectomy.

a) Define trabeculectomy 5%
b) With aid of a well labelled diagram, describe the flow of aqueous humour in the eye 20%
c) Identify five 5 signs and symptoms that the patient may present with 15%
d) Mention two investigations that the Doctor may carry out to confirm the diagnosis 10%
e) Discuss in detail the management of a patient with glaucoma 50%

36
Trabeculectomy is an opening made into the trabecular mess to allow fluid to flow out so as to help in decreasing
intra ocular pressure

Glaucoma can be divided roughly into two main categories

 "Open angle" Open angle, chronic glaucoma tends to progress at a slower rate and the patient may not
notice that they have lost vision until the disease has progressed significantly.

 "Closed angle" glaucoma. Closed angle glaucoma can appear suddenly and is often painful; visual loss can
progress quickly but the discomfort often leads patients to seek medical attention before permanent damage
occurs.

Diagram showing the flow of aqueous humor in the eye here.

Signs and symptoms

Open-angle Glaucoma It is painless and does not have acute attacks. The only signs are gradually progressive
visual field loss, and optic nerve changes (increased cup-to-disc ratio on fundoscopic examination).

Closed-angle Glaucoma). About 10% of patients with closed angles present with acute angle closure crises
characterized by sudden ocular pain, seeing halos around lights, red eye, very high intraocular pressure (>30
mmHg), nausea and vomiting, sudden decreased vision, and a fixed, mid-dilated pupil. Acute angle closure is an
ocular emergency.

Investigations

 measurements of the 0 via tonometry,

 changes in size or shape of the eye, anterior chamber angle examination or gonioscopy,
 Examination of the optic nerve to look for any visible damage to it, or change in the cup-to-disc ratio and
also rim appearance and vascular change.

Management

Objectives
37
  The modern goals of glaucoma management are to avoid glaucomatous damage, nerve damage, preserve
visual field and total quality of life for patients with minimal side effects.

This requires appropriate diagnostic techniques and follow up examinations and judicious selection of treatments
for the individual patient. Although intraocular pressure is only one of the major risk factors for glaucoma, lowering
it via various pharmaceuticals and/or surgical techniques is currently the mainstay of glaucoma treatment. Vascular
flow and neurodegenerative theories of glaucomatous optic neuropathy have prompted studies on various
neuroprotective therapeutic strategies including nutritional compounds some of which may be regarded by clinicians
as safe for use now, while others are on trial.

Medical management

 Intraocular pressure can be lowered with medication, usually eye drops. There are several different classes
of medications to treat glaucoma with several different medications in each class.
 Poor compliance with medications and follow-up visits is a major reason for vision loss in glaucoma
patients..
 The possible neuroprotective effects of various topical and systemic medications are also being
investigated.

 Prostaglandin analogs like latanoprost (Xalatan), bimatoprost (Lumigan) and travoprost (Travatan) increase
uveoscleral outflow of aqueous humor.
 Less-selective sympathomimetics such as epinephrine decrease aqueous humor production through
vasoconstriction of ciliary body blood vessels.
 Miotic agents (parasympathomimetics) like pilocarpine work by contraction of the ciliary muscle,
tightening the trabecular meshwork and allowing increased outflow of the aqueous humour. Ecothiopate is
used in chronic glaucoma.
 Carbonic anhydrase inhibitors like dorzolamide (Trusopt), brinzolamide (Azopt), acetazolamide (Diamox)
lower secretion of aqueous humor by inhibiting carbonic anhydrase in the ciliary body.
 Physostigmine is also used to treat glaucoma and delayed gastric emptying.

Surgical management

Trabeculectomy

The most common conventional surgery performed for glaucoma is the trabeculectomy. Here, a partial thickness
flap is made in the scleral wall of the eye, and a window opening made under the flap to remove a portion of the
trabecular meshwork. The scleral flap is then sutured loosely back in place. This allows fluid to flow out of the eye
through this opening, resulting in lowered intraocular pressure and the formation of a bleb or fluid bubble on the
surface of the eye. Scarring can occur around or over the flap opening, causing it to become less effective or lose
effectiveness altogether. One person can have multiple surgical procedures of the same or different types.

CORNEAL ULCERS

Milambo a welder comes to your clinic with complaints of pain in the eyes. You suspect that he could have a
corneal ulceration and you begin a series of investigations to determine the cause of pain.

a) Define corneal ulcers 5%

b) State five other possible causes of corneal ulceration other than the one mentioned 10%
c) Explain five(5) investigations that could lead you to the diagnosis of corneal ulcers 20%
d) Discuss the medical management of a patient with corneal ulcers 45%
e) Mention four 4 likely complications of corneal ulceration 20%

Definition.

A corneal ulcer, or ulcerative keratitis, or eyesore is an inflammatory or more seriously, infective condition of the
cornea involving disruption of its epithelial layer with involvement of the corneal stoma.

38
 CAUSES
1. Trauma, particularly with vegetable matter,
2. Chemical injury,
3. Contact lenses
4. Infections.
5. Entropion,

 Corneal dystrophy,
 keratoconjunctivitis sicca (dry eye).

Many micro-organisms cause infective corneal ulcer. Among them are bacteria, fungi, viruses, protozoa, and
chlamydia:

 Bacterial keratitis is caused by Staphylococcus aureus, Streptococcus viridans, Escherichia coli,

Enterococci, Pseudomonas, Nocardia and many other bacteria.

 Fungal keratitis causes deep and severe corneal ulcer. It is caused by Aspergillus sp., Fusarium sp., Candida
sp., as also Rhizopus, Mucor, and other fungi. The typical feature of fungal keratitis is slow onset and
gradual progression, where signs are much more than the symptoms. Small satellite lesions around the ulcer
are a common feature of fungal keratitis and hypopyon is usually seen.

 Viral keratitis causes corneal ulceration. It is caused most commonly by Herpes simplex, Herpes Zoster and
Adenoviruses. Also it can be caused by coronaviruses & many other viruses. Herpes virus causes a
dendritic ulcer, which can recur and relapse over the lifetime of an individual.

 Protozoa infection like Acanthamoeba keratitis is characterized by severe pain and is associated with
contact lens users swimming in pools.

 Chlamydia trachomatis can also contribute to development of corneal ulcer.

Symptoms

 Corneal ulcers are extremely painful due to nerve exposure,

 Can cause tearing,
 squinting,
 Vision loss of the eye.
 There may also be signs of anterior uveitis, such as miosis (small pupil), aqueous flare (protein in the
aqueous humour), and redness of the eye. An axon reflex may be responsible for uveitis formation —
stimulation of pain receptors in the cornea results in release inflammatory mediators such as prostaglandins,
histamine, and acetylcholine.

Diagnosis

Diagnosis is done by

 Direct observation under magnified view of slit lamp revealing the ulcer on the cornea.

39
  The use of fluorescein stain, which is taken up by exposed corneal stoma and appears green, helps in
defining the margins of the corneal ulcer, and can reveal additional details of the surrounding epithelium.
 Doing a corneal scraping and examining under the microscope with stains like Gram's and KOH
preparation may reveal the bacteria and fungi respectively.
 Microbiological culture tests may be necessary to isolate the causative organisms for some cases. Other
tests that may be necessary include a Schirmer's test for keratoconjunctivitis sicca
 Analysis of facial nerve function for facial nerve paralysis.

Treatment

 Proper diagnosis is essential for optimal treatment. Bacterial corneal ulcer requires intensive fortified
antibiotic therapy to treat the infection.
 Fungal corneal ulcers require intensive application of topical anti-fungal agents.
 Viral corneal ulceration caused by herpes virus may respond to antiviral like topical acyclovir ointment
instilled at least five times a day.
 Supportive therapy like pain medications is given, including topical cycloplegics like atropine or
homatropine to dilate the pupil and thereby stop spasms of the ciliary muscle. Superficial ulcers may heal
in less than a week.
 Deep ulcers and descemetoceles may require conjunctival grafts or conjunctival flaps, soft contact lenses,
or corneal transplant.
 Proper nutrition, including protein intake and Vitamin C are usually advised. In cases of Keratomalacia,
where the corneal ulceration is due to a deficiency of Vitamin A, supplementation of the Vitamin A by oral
or intramuscular route is given.
 Drugs that are usually contraindicated in corneal ulcer are topical corticosteroids and anesthetics - these
should not be used on any type of corneal ulcer because they prevent healing, may lead to superinfection
with fungi and other bacteria and will often make the condition much worse.

Mwale a known case repeated elevation of intra ocular pressure suffers yet another injury to his eye resulting
in the detachment of the retina.

a) Define retinal detachment

b) Mention two types of retinal detachment
c) Outline six (6) signs and symptoms of retinal detachment
d) Discuss in detail the management of a patient with retinal detachment
e) State five possible complications of retinal detachment

Retinal detachment

Definition.

 Retinal detachment – A retinal detachment occurs due to a break in the retina that allows fluid to pass
from the vitreous space into the sub retinal space between the sensory retina and the retinal pigment
epithelium.

TYPES OF DETACTMENT

Retinal breaks are divided into three types - holes, tears and dialyses.

 Holes form due to retinal atrophy especially within an area of lattice degeneration.
 Tears are due to vitreoretinal traction.

40
  Dialyses which are very peripheral and circumferential may be either tractional or atrophic, the
atrophic form most often occurring as idiopathic dialysis of the young.

1. Exudative, serous, or secondary retinal detachment – An Exudative retinal detachment occurs due to
inflammation, injury or vascular abnormalities that results in fluid accumulating underneath the retina
without the presence of a hole, tear, or break. In evaluation of retinal detachment it is critical to exclude
Exudative detachment as surgery will make the situation worse not better.
2. Tractional retinal detachment – A tractional retinal detachment occurs when fibrous or fibro
vascular tissue, caused by an injury, inflammation or revascularization, pulls the sensory
retina from the retinal pigment epithelium.

Symptoms

A retinal detachment is commonly preceded by a posterior vitreous detachment which gives rise to these symptoms:

 flashes of light (photopsia) – very brief in the extreme peripheral (outside of center) part of vision
 a sudden dramatic increase in the number of floaters
 a ring of floaters or hairs just to the temporal side of the central vision
 a slight feeling of heaviness in the eye

Although most posterior vitreous detachments do not progress to retinal detachments, those that do produce the
following symptoms:

 a dense shadow that starts in the peripheral vision and slowly progresses towards the central vision
 the impression that a veil or curtain was drawn over the field of vision
 straight lines (scale, edge of the wall, road, etc.) that suddenly appear curved (positive Amsler grid test)
 central visual loss

(None of this is to be confused with the broken retina which is generally the tearing of muscle and nerve behind the
eye)

Treatment of Retinal Detachment

There are several methods of treating a detached retina which all depend on finding and closing the breaks which
have formed in the retina. All three of the procedures follow the same 3 general principles:

1. Find all retinal breaks

2. Seal all retinal breaks
3. Relieve present (and future) vitreoretinal traction

 Cryopexy and Laser Photocoagulation

Cryotherapy (freezing) or laser photocoagulation are occasionally used alone to wall off a small area of
retinal detachment so that the detachment does not spread.
 Scleral buckle surgery

41
 Scleral buckle surgery is an established treatment in which the eye surgeon sews one or more silicone
bands (bands, tyres) to the sclera (the white outer coat of the eyeball). The bands push the wall of the eye
inward against the retinal hole, closing the break or reducing fluid flow through it and reducing the effect of
vitreous traction thereby allowing the retina to re-attach. Cryotherapy (freezing) is applied around retinal
breaks prior to placing the buckle. Often subretinal fluid is drained as part of the buckling procedure. The
buckle remains in situ. The most common side effect of a scleral operation is myopic shift. That is, the
operated eye will be shorter sighted after the operation. Radial scleral buckle is indicated to U-shaped tears
or Fishmouth tears and posterior breaks. Circumferential scleral buckle indicated to multiple breaks,
anterior breaks and wide breaks. Encircling buckles indicated to breaks more than 2 quadrant of retinal
area, lattice degeration located on more than 2 quadrant of retinal area, undetectable breaks, and
proliferative vitreous retinopathy.

 Vitrectomy

Vitrectomy is an increasingly used treatment for retinal detachment. It involves the removal of the vitreous
gel and is usually combined with filling the eye with either a gas bubble (SF6 or C3F8 gas) or silicon oil.
Advantages of using gas in this operation are that there is no myopic shift after the operation and gas is
absorbed within a few weeks. Silicon oil (PDMS), if filled needs to remove after a period of 2–8 months
depending on surgeons preference. Silicon oil is more commonly used in cases associated with proliferative
vitreo-retinopathy (PVR). A disadvantage is that a vitrectomy always leads to more rapid progression of a
cataract in the operated eye. In many places vitrectomy is the most commonly performed operation for the
treatment of retinal detachment.

Prevention

 Retinal detachment can sometimes be prevented. The most effective means is by educating people to seek
ophthalmic medical attention if they suffer symptoms suggestive of a posterior vitreous detachment. Early
examination allows detection of retinal tears which can be treated with laser or cryotherapy. This reduces
the risk of retinal detachment in those who have tears from around 1:3 to 1:20.
 There are some known risk factors for retinal detachment. There are also many activities which at one time
or another have been forbidden to those at risk of retinal detachment, with varying degrees of evidence
supporting the restrictions.
 Cataract surgery is a major cause, and can result in detachment even a long time after the operation. The
risk is increased if there are complications during cataract surgery, but remains even in apparently
uncomplicated surgery. The increasing rates of cataract surgery, and decreasing age at cataract surgery,
inevitably lead to an increased incidence of retinal detachment.
 Trauma is a less frequent cause. Activities which can cause direct trauma to the eye (boxing, kickboxing,
karate, etc.) may cause a particular type of retinal tear called a retinal dialysis. This type of tear can be
detected and treated before it develops into a retinal detachment. For this reason governing bodies in some
of these sports require regular eye examination.
 Individuals prone to retinal detachment due to a high level of myopia are encouraged to avoid activities
where there is a risk of shock to the head or eyes, although without direct trauma to the eye the evidence
base for this may be unconvincing.
 Some Doctors recommend avoiding activities that increase pressure in the eye, including diving, skydiving,
again with little supporting evidence. According to one medical website, retinal detachment does not
happen as a result of straining your eyes, bending or, heavy lifting.
 Roller coasters and other activities that could cause trauma should be avoided for those who have had a
family history of retinal detachment, but those who are at low risk because of nearsightedness should be
alright, just nothing extreme like skydiving, bungee jumping etc., but those who have had cataract surgery
should not participate in thrill rides or any activity that could cause trauma to the head or eyes. In order to
cause retinal detachment for those at a low risk, one must hit the head extremely hard like a car accident for
instance. For those at high risk, activities that have nothing to do with the head or eyes would be alright.
Therefore, heavy weightlifting would appear to be fine. However, two recent scientific articles have noted
cases of retinal detachment or maculopathy due to weightlifting (specifically with the Valsalva method),
and a third documented an increase in blood pressure in the eye during weightlifting Moreover, a recent
case-control study focusing on myopic subjects supports the hypothesis that occupational heavy lifting (or
manual handling) requiring Valsalva maneuver may be a risk factor for retinal detachment
 Activities that involve sudden acceleration or deceleration also increase eye pressure and are discouraged
by some doctors.
42
Cataract

Naomi a 65 years old woman is admitted to the eye ward with a complaint of poor visibility in both eyes. After a
thorough investigation the specialist decides that Naomi should undergo surgery in one of the eyes to remove the
lens

a) List (5 ) five possible causes of cataracts in Zambia. 5%

(ii)Draw a well labeled diagram of the eye 10%

b) Discuss pre operative care would you give to your client 45%

c) Discuss the IEC that you would give you client upon discharge 15%

d) Mention five (5) Complication of contact extraction 15 %

CATARACT.

List the possible causes of cataract in Zambia

a. Causes (list)
 Aging
 Congenital predisposition
 Eye injuries
 Some diseases such as diabetes mellitus uveitis
 Exposure to radiation.
 Down syndrome
 Renal disorders
 Retinal detachment
 Electronic shock
 Obey skeletal
 Dehydration with chronic diarrhea
 Smoking
 Glaucoma
 Retinitis
 Hypoprathyrordism
 Atopic dermatitis
 Toxic cataract (chemical toxicity.

State five types of cataract that you may come across

b. Types (state)
 Senile cataract, the most common and it is related lens opacity. The most affected people are 50
years old and above. If it occurs before this age then it is called “pre-senile cataract”.
 Congenital cataract, is usually bilateral and be familial or result from intrauterine infection like
Rubella or from drug taken during pregnancy.
 Traumatic cataract- this one may be due to blunt trauma to the eye ball.
 Toxic cataract- this one is due to ingestion or taking of certain drug for a long period of time (e.g.
Corticosteroids)
 Posture sub capsular
 Secondary cataract-this one is associated with disease such as diabetes mellitus, uveitis Keratits.
 Nuclear cataract

C. Preoperative care of Mrs. Lunsonga

Aims:
 To prepare Mrs. Lunsonga psychologically and physically for operation
 To promote normal function of the eye

43
Admission
 Welcome Mrs. Lunsonga into the ward. Introduce yourself to her. Introduce other members of staff and
other patient in the war for Lunsonga to familiarize the new environment
 Check Mrs. Lunsonga vital signs to act as baseline date and to assess any deviation from normal. Record all
findings for reference.
Environment

 Provide a clean room to minimize the risk of infection

 Maintain a restful environment by keeping Mrs. Lunsonga room clean and well ventilated and by
minimizing environment irritants e.g. noise, direct light of eyes, and smoking.

Assessment
 Assess Mrs. Lunsonga physical state to dictate any abnormalities or deviations from normal which may
need may need to be corrected before surgery.
 Assess Mrs. Lunsonga nutritional status by checking hair texture , skin status and color of mucous
membrane
 Assess pattern, nail beds for pallor because ventilation is potentially compromised during all phases of
surgery
Preoperative medication

Depending on the finding during assessment:

 Giving the prescribed medication
 Monitor for desired effects and side effects of the drugs
Preoperative Education
 Teach Mrs. Lunsonga some deep breathing and coughing exercise to promote lung expansion
 Teach her about mobility and active body movement to prevent post-operative complications like deep vein
thrombosis.
 Teach her also about cognitive coping strategies to relive tension, overcome anxiety and achieve relaxation.

Nursing care the day before operation

Psychological care

 refer the question to the highest authority if you cannot do it

 This is done to Continue giving psychological support to allay anxiety
 Reinforce the Doctor’s explanation on the kind of operative its outcome
 Encourage Mrs. Lunsonga to verbalize her concerns and ask questions.
 Answer honestly or relieve tension due to worries.

Consent Form
 Before Mrs. Lunsonga Sign the consent form, ensure that the surgeon has provided a simple and clear
explanation of what cataract extraction entails, expected outcome and possible risk if operation is not done
 After being sure that Mrs. Lunsonga knows and understands what will happen, then witness the signing of
consent form.

Cardinal control tests

Collect blood sample for:
 Hemoglobin to rule anemia
 Grouping and cross matching in case blood transfusion will be needed.
 Bleeding and clothing time to rule out the bleeding disorder which may have a negative bearing post
operatively.
 Collect urine sample for urinalysis to rule out diabetes mellitus and renal disease which may have negative
bearing in post operative period.
 Chest x-ray or ultra sound to rule out chest infections.
Nutrition and Fluid

 Mrs. Lunsonga will be staved for 6-8s prior to surgery

44
  For this reason, advise her after she has supper not to take anything by mouth from midnight to prevent
vomiting and aspiration during surgery.
Nursing care the day of operation
Personal care
 Give Mrs. Lunsonga an assisted bath in the morning, to remove sweat and dead epithelial cell on the body.
 Mrs. Lunsonga will be dressed in a fresh, clean theatre gown to prevent infection
 Advise Mrs. Lunsonga to take off any jewelers to prevent electrocution
 Insert a canula to keep Mrs. Lunsonga vein open for intravenous infusions.
 To prevent mistaken operation, provide an identity band of name, age sex, ward, type of surgery to be done.

Immediate pre- operative observation

 Check vital signs i.e. T, P, R and BP to act as baseline date in intra-operative phase.
 Report and not on Mrs. Lunsonga chart at the front of the file any unusual observation that might have a
bearing on anesthesia or surgery, e.g. raised BP.

Pre Anaesthetic Medication

 As ordered, give pre-anesthetics medication to alley anxiety, decrease the flow of pharyngeal secretion and
to reduce the amount of anesthesia to be given and also to create amnesia for the event that precede
surgery.

Escorting Mrs. Lunsonga to pre-surgical suite

 Complete the pre-operative checklist to be sure that it bears information such as clinical data, patient
preparation and communication assessment.
 Attach together surgical consent form, all laboratory reports or results, x-rays and scan films other
necessary documents.
 Transfer Mrs. Lunsonga form bed to a stretcher cover with sufficient number of blankets to ensure warmth.
 Once at the hand over Mrs. Lunsonga to the theatre according to the hospital policy

Attending to Mrs. Lunsonga Family

 Come back to the ward and continue reassuring Mrs. Lunsonga family members.
D. Complication of contact extract
 Hemoglobin- into the anterior chamber, thus “hyphema” Occurs to strain on the eye.
 Wound rapture- due to loosing of a suture or pressure on the eye
 Iris prolapsed- may occur at the site of rapture in the incision.
 Infection- for example endophthalmisis due to poor aseptic techniques post operatively.
 Retinal detachment due to vitreous loss.
 Glucose due to adhesion forming between iris and the cornea blocking filtrate angle.
 Anterior uveitis to vitreous loss.
 Shall owing of anterior chamber.
 Blindness
 Astigmatism- loss of refractive indices leading to disruptive change.

GYNAECOLOGY AND OBSTETRICS QUESTIONS

ANTENATAL CARE

Mrs. Mary Kauseni age 24 years a prime gravid is attending antenatal clinic for the first time .Her last
menstrual period LMP) was 26th June 2009.During history taking ,Mrs. Kauseni tells you that she was
recently tested positive and she is not on ARVs, Her CD4 count is 600/mm3.

a. Define Antenatal care 6%

(ii)Show by calculation hr expected date of delivery 10%
b. List five (5) factors that would increase mother to child transmission of HIV
10%
c. Explain the activities that will be carried out on Mrs. Kauseni on her first visit.
50%
45
 d. Outline four (4) points you would include in your information, education communication (IEC) to Mrs.
Kauseni in relation to mother tom child transmission of HIV. 24%

ANSWER KEY.

 Antenatal care is the attention, supervision and care given to a pregnant woman from conception to
delivery.

OR
 Antenatal care refers in the care that is given to a pregnant woman from the time that conception is
conformed until; the beginning of labour.

a. 26 06 09
+7 09
33 11 09
30 12
03 11 09

EDD 03 11 09

B FACTORS INCREASING MOTHER TO CHILD TRANSMISSION OF HIV.

During Pregnancy
 High vital load
 New infection (vital spike)
 Clinical AIDs
 Poor immune status (low CD4 count)
 Placental infection
 Chorioamnionitis
 STIs
 Viral strain
 Immune response
 Nutritional status
 Other diseases

During labour and Delivery

 Prematurity
 Vaginal Delivery
 Prolonged rupture of membranes
 Prolonged labour
 Instrumental deliveries
 Invasive obstetric procedures.
 Episiotomy.

During Postnatal.
 Breast feeding beyond six months
 Mastitis
 Mixed feeding A

ATIVITIES DONE DURING ANTRNATAL

1 History Taking

Comprehensive history from Mrs. Kauseni is elicited. Open ended questions that she understands are asked and she
is encouraged to talk. This information acts as baseline data for subsequent visits for detection of deviation from
normal. The history taken is as follows.

46
  Social history: is obtained for identification of the client as it is necessary for follow up and health
education. The client is asked on
 Name
 Age
 Educational level
 Occupation
 Marital status
 Name of Husband
 His occupation
 Religion
 Residential Address
 Type of house
 Water supply
 Sanitation
 Source of power, Environmental hygiene
 Family History :is obtained in order to find out if Mrs. Kauseni is suffering any of the conditions that tend
to run into if there are any family members suffering from any of the following conditions :
 Diabetes mellitus
 Asthma
 Hypertension
 Mental illness
 Sickle cell diseases
 History of multiple pregnancies
 Also ask for history of contact of Tuberculosis.

 Personal Medical History: is taken to identify conditions Mrs. Kauseni may be suffering from that may
complicate pregnancy. Examples of such conditions are :
 Hypertension
 Asthma
 Cardiac disease
 Diabetes Mellitus
 Mental illness
 Sickle cell disease
 Epilepsy
 Tuberculosis

 Surgical History: is obtained to find out if Mrs. Kauseni had injuries or operations involving the pelvic
bone, spine or lower limbs that could result in alteration of the pelvic diameter and angle of inclination
leading to CPD .She I s also asked for any operations involving the lower abdomen especially the uterus to
exclude risk of uterine rupture. History of blood transfusion is asked to exclude Iso-immunization if she is
Rhesus negative.

 Menstrual History – Mrs. Kauseni is asked when she reached menarche, type of menstrual cycle, duration
of menses, flow and menstrual problems
 Methods of contraception used – When, for how long and reasons for stopping.
 Present obstetric history – Mrs. Kauseni is asked about.
 The first day of her last normal menstrual period (LMP) and calculate the expected date of delivery.
 Her health during his pregnancy.
 Drugs been taken
 Minor disorders
 Sleeping pattern
 Nutrition – the type of foods she eats, any pie for non- nutritious foods, her appetite
 Any fetal movements
 Tetanus Toxoid immunization
 Availability of a social support person
 Any concern during this pregnancy.

2 Physical Examination

47
 Physical examination serves to screen the woman for any existing abnormalities or high risk factors in order to
intervene early to prevent complications.
 Preparation
 Explain procedure to Mrs. Kauseni and get consent
 Ensure privacy
 Ask her to empty the bladder.
 Prepare necessary equipment
 Encourage her to talk during the examination.

Procedure.
 Wash hands and fellow the principles of infection prevention throughout.
 Observe the general appearance to assess her psychological and emotional state.
 Collect urine and test for
 Protein to rule out protenuria
 Sugar to rule
 Acetone to rule keto acidosis.

 Take her weight – Short stature is associated with some complications of pregnancy and birth such as CPD.
 Not her gait :If sliming may be indication of altered angle of inclination
 Take her vital signs
 Temperature to rule out infection
 Blood pressure to rule out pre-eclampsia.

 Examine her from head to toe.

 Skin for the general appearance for signs of malnutrition, check for any rash
 Check for personal hygiene
 Hair whether well kept and combed
 Face for any puffiness
 Eyes for pallor and signs for jaundice
 Noise for any obstruction ,polyps
 Ears for any discharge
 Mouth for any signs of anemia on the lips, mucous membranes, guns and tongue, check for dental caries.
 Check for lympadenopathy by palpating the enlargement of the peri auricular submandibular and cervical
lymph nodes, Lympadenopathy is an indication of chronic illness.
 Examine for enlargement of the thyroid gland in the neck
 Hands for any signs of anemia on the palms and venous return on the nail beds, Ask the woman to make a
fist and if there is tightness it’s an indication oedema.
 Inspect the breast for presumptive signs of pregnancy such as Montgomery’s tubercles, darking of the
primary areola. Inspect for suitability for breast feed by looking at the prominence of the nipples. Also
check for the skin changes such as appearance like an orange skin, rash, discoloration and dimpling which
could be an indication of a lump.
 Palpate the breast for any abnormal lumps in both breast and teach the woman on how to examine her
breasts.
 Check the valve and perineum for hygiene, rash, warts, or lesions, any abnormal discharge, any offensive
odors, varicose veins or oedema.
 Check the scar and anal region for oedema, and region for hemorrhoids and fissures, rash and abscess.

 Investigation are done such as

 Blood for hemoglobin
 Blood for grouping and cross matching
 Blood for rhesus factor
 Blood for rapid plasma reagent (RPR)
 Blood for HIV test after counseling.

3 Health education.
 Importance of antennal clinic
 Good hygiene i.e. taking baths, breast care, maintaining hair, clean environment, clean cloths etc.
48
  Dressing of loose clothing and avoid wearing high heeled shoes.
 Labour and baby layette, to start preparing early.
 Feeding option exclusive breast feeding or formula feed.
 Good nutrition, Eating balanced meals such as carbohydrates (maize, rice, millet, sorghum, wheat,
potatoes etc) Proteins such as beans, groundnuts, all forms of meat, vitamins and minerals.
 Safer sex practice by use of condoms and having one sexual partner
 Dinger signs of pregnancy
 Rest and minimal exercises.

Mrs. Kauseni is advised on when to return (IEC)

Discuss with her the following:

 How HIV infection is transmitted from mother to child during pregnancy, in labour and delivery
and after delivery.
 Need for short course of ARVs to prevent mother to child transmission of HIV i.e. AZT 300mg bd
after 28 weeks of pregnancy.AZT is given till labour for a woman who has never had AZT,is
given single dose nevirapine;AZT + 3TC.
 Safer feeding options
o Exclusive breast feeding for 6 moths followed by introducing of other foods
o Formula
 Safer sex practices by use of condom each time with one (1) sexual partner to avoid reinfection.
 Good nutrition to boast the immunity
 Mode of deliveries with minimal risk i.e. caesarian section as there is no direct contact with the
mother’s blood or other body fluids.

 Mrs. Martha Mutasmba aged 17years is admitted to a Gynecological ward with the diagnosis of
Vesico vaginal fistula.

 Define Fistula 5%
 Explain five (5) predisposing factor of vesico vaginal fistula 15%
 Discuss in detail the preoperative management of Mrs. Mutasmba 50%
 Outline five (5) preventive measures of vesico vaginal fistula 30%

ANSWERS

Definition of fistula 5%
 It is an abnormal duct or passage resulting from injury, disease, or a congenital disorder that connect on
abscess, cavity, or hallow organ to the body surface or to another hallow organ.

 Five (5) predisposing factors of VVF. 15%

o Trauma. Direct trauma or injury on the tissue between the urinary blander and the vagina may lead
to formation of a fistula. For example penetrating injury due to sharp objects.
o Child birth. Prolonged application of pressure on the tissue between the vagina and urinary
bladder may lead to necrosis of this tissue. This is common in prolonged obstructed labour.
o Surgery. Surgery on the perineum. Accidental surgical injury can lead to VVF.
o Infection: Infection which affects the lining or tissue of the vagina and urinary bladder predisposes
to VVF, especially where there is abscess for formation and ulceration of tissue.
o Radiation therapy
 Internal radiotherapy, due to its destructive effect on the cell, contributes to weakening
and development of VVF.
 Carcinoma of the vesico vaginal tissue as it progress and during its treatment predisposes to fistula
formation.
 Traditional practices. Traditional practices such as female circumcision predispose to development of
vesico vaginal fistula.

49
pre- operative management: 50%
 The following points should be considered in the pre-operative management of Mrs. Mutumba.

Objectives 2%
 To prepare the patient for surgery
 To prevent postoperative complications

Investigations: 5%
 Screen the patient of any infection, especially urinary tract infection to avo9id post operative infection.
 Samples of urine can be collected for urinalysis.
 Ensure that the patient is not anemic by checking the hemoglobin level.
 Fistulogram may be done. Injection of dye is given into the vagina to assess the exact location and seventy
of the fistula.
 History on how the problem stated should be obtain to determine health education to be given ton the
patient.

o Psychological care: 5%

 The condition should be explained to the patient and caretaker. That is leakage of urine into the vagina as a
result of the perforation between the two cavities.
 Treatment option should be explain such as healing on its own if it is small or surgical intervention.
 If there is any patient whose operation was successful can be introduced to encourage her.
 Allow the patient and relatives to air out their views to relieve anxiety.
 Provide adequate information to the client and patient.
 Procedure should be explained before carrying them out.
 All these measures will enable the patient to accept her condition cooperate in the management and
promote self care.
 Obtaining written consent: 4%

 The patient or a relative should sign the consent form to show that an agreement was reached and the
patient consented that she should be operated.

Observation:

 General observations should be done such as TPR and BP

 Routine urinalysis if the procedure is delayed should be done to detect infection.
 Nutrition status
 Psychological status.

Urinary Output: 4%

 Catheterize the patient to ensure that the perinea area is dry.

 Nephrostomy catheter may be used to keep the area well drained.
 Treatment of other illness or inflammation at the local site,
 Ensure that the patient is treated of any infraction which can complicate surgery,
o e .g urinary tract infections.
 If there is inflammation around the fistula, treat the patient before surgery.

 Hygiene: 5%
 Perineal hygiene in this case is very important.
 Advise the patient to clean the perineum with soap and water every 4 hours to prevent
excoriation and of the vagina and vulva tissue.
 Warm sitz bath should be done 3 times every day.
50
  Change perineal pads as often as possible.

Nutrition 5%

o Give the patient nutritious food, low in residue. Enema may be given to
reduce the constant flow of faeces.
o Maintain adequate hydration by encouraging oral fluid intake.
o If the patient is dehydrated IV fluids can be given.

Immediate Pre- Operative care: 10%

 Nil orally
 Premedication
 Identify band
 Perineal care
 Assembly all investigation results
 Gown the patient to theatre
 Give a thorough hand over to the theatre Nurse.

d. Five (5) preventive measure of VVF 30%

 Avoid traditional practices such as female circumcision and others which predisposes to VVF.
 Discourage early marriage. These put young woman at risk of prolonged and obstructed labor to their
underdevelopment physiologically
 Malnutrition. Some feeding practice favors boys. This must be avoided. Girls and woman need to be eating
well for growth and health. Malnourished woman usually have obstetric complications.
 Education. Lack of health education hinders VVF prevention. Most rural woman see obstetric
complications as a result of the pregnant woman’s sin, a curse, Heredity. Health education must be
intensified.
 Decision making. Woman should be encouraged to make decisions concerning their health, e.g. if there is
obstructed labor, they should not wait for the husband or any other person, they need to be taken to the
hospital.
 Family planning, This is important for the woman‘s health.
 Traditional Birth Attendants. Woman sound be encouraged contact trained TBAs and avoid home delivery.

CANCER OF THE BREAST

Kashibi Masaka a 30 year old lady Shuungu modeling centre was brought to gynae clinic with history of feeling a
growth in the left breast. A provisional disgnosis of breast cancer is made.

a) Give four clinical staging of cancer 8%

b) Draw a well labeled diagram of breast 22%
c) Describe the management of Masaka operatively 50%
d) Explain four (4) points that you would include in your information, education and communication to
Masaka regarding the care of the affected breast 20%

QUESTION 4.

LABOUR

Mrs. Dinga Erickson aged 37years, gravid 12 is admitted to your labour ward complaining of show and backache,
on examination cervical dilation is 5cm; her last LMP was June 2010

e) Calculate
iii. EED 5%
iv. Gestation as of today 10%
f) Explain how you would admit her to labour ward. 15%
51
 (i)Using a partograph record her observations and explain the findings. 15%
g) Discuss the nursing care you would give her during the first of labour. 50%
h) State (5)five complications. 5%

General Preoperative Nursing Care. {Suggested format of your write up when attempting surgery questions}

The questions may appear in the following forms; asking you

 The general preoperative nursing care

 Specific preoperative nursing care
 Immediate preoperative nursing care
 Emergency nursing care

 It important that you begin by giving a brief introduction of the kind of preoperative nursing care you are
going to describe i.e.

 Preoperative nursing care is the care that I will give my patient from the time of admission to a surgical unit
up until the time immediately before the patient is transferred to the operating dept.

 Or
 The immediate preoperative nursing care is the care that I will give to my client immediately {30min to one
hr} before transferring him to the operating dept.

 Specific preoperative nursing care focuses on special preoperative nursing activities which MUST be done
before the patient is taken to Theatre i.e. a patient going for rectal surgery will need to have an enema done,
a patient going for repair of the ureters will need to be catheterized, but these will not be as necessary as in
a patient going for amputation of a finger or cataract extraction.

Consideration however needs to taken also on the type of anesthesia to be used.

Remember your write up should be in an active form. Put your self as the person who is going to carry out the
nursing activities instead of referring to what the other nurse would have done

Then you need to write your objectives of care {most of these objectives apply to a number of surgical conditions,
so you can use them generally} i.e.

The general objectives of my care during this period are as follows;

 To prepare the patient;

 physically, psychologically, emotionally spiritually so as to be enable him withstand the effects of surgery
and administration of anesthesia and to ensure that he recovers rapidly and safely from the surgical
procedure.
 Anticipate and prevent potential complications during surgery

 To achieve these objectives, I will provide my nursing care in the following manner;
 History {Data collection}.
 On admission, I will obtain subjective and objective information from my patient. This will help me
identify my patient, identify the immediate needs of my patient and thus be able to give a refocused nursing
care plan based on the needs as well as provide an opportunity for giving I.E.C
 {Note history taking is often omitted in many cases, but it forms an integral part in your nursing care plan}

 2. Psychological care
 This care will help my patient's mind to be ready for surgery.
 I will provide him information on the type of surgery he is to undergo, for example where and how that
surgery will be done, some expectations of that surgery particularly, its benefits in comparison to other
forms of treatment without causing undue anxiety. This will be done using a simple language which he
52
 clearly understands.
 I will provide him an opportunity to ask questions, express his fears or anxiety, as verbalizing can help
reduce tension prior and during surgery.
 If there are any patients nearby who have had similar operations, I will introduce these patients to him so
that they can have a one to one chart and share there experiences
 I will also consider the relatives and significant others in the care plan for the patient so as to promote a
sense of belonging .This will help him uplift his self concept and feel loved
 All procedures to be done him will be explained to him in advance to gain his cooperation
 Privacy will be maintained at all times and all his realistic wishes respected
 An informed consent will be obtained after providing him with all the necessary information concerning his
surgery.

 3. Physical preparations of my client/patient

 Bowel preparation.

 I will begin the bowel preparations, where I will starve my patient at least 8 hours from solid foods, 6 hours
semi solid foods, and 2 hours from fluids before the operation.
 For operations involving the GIT laxatives and enema will be given a day before the operation.
 In an emergency, I will insert an N.G tube o aspirate the contents of the stomach so as to prevent vomiting
and aspiration, which can lead to aspiration pnuemonia
 I will also administer prescribe antibiotics for sterilizing the abdomen.

 {Countercheck with the Doctors orders}

 Skin preparation.

 I will give an antiseptic bath or shower a day prior to surgery or in the morning of the day of surgery to
cleanse him of micro bacteria from the body.
 The site of operation will be shaved, being cleaned with an antiseptic solution and left dry
 I will provide a clean gown to be worn over the body to allow the skin to remain clean

 Bladder care

 In Situ

 I will ask my patient to empty the bladder in the morning before surgery
 I will also put an indwelling catheter to allow continuous drainage of the urine. This is important as it
prevents accidental perforation of the bladder in abdominal surgery .It also helps to monitor the status of
urinary output during surgery

 Observations
o Do vital signs of TPR to for base line data
o Observe the patient reaction to the idea of surgery
o Observe the pain threshold.

 Intravenous infusion
 I will put an intravenous infusion line for administration of solutions and medicines during surgery.
 An intravenous line also provides a quick access of the veins when you want to resuscitate the patient
 It also provides a means of providing nutrition post operatively

 Gowns
 I will give a gown and a head dress to cover the hair. this is to limit micro organism from the head and
body contaminating the incision site

 Name tag
 A name tag or identity band will be placed on the patient forehead or arm bearing his name ,sex age ,and
53
 type of operation to be done

 Removal of valuables
 I will remove the entire valuables such as ring hair pieces dentures or jewelry as some of theses may easily
ignite static electricity in an environment where there will be high concentration of oxygen.
 some metal valuables also can cause accidental burns or electric shock to the patient where a diathermy
machine is in use
 Medical records
 I will arrange all the necessary medical records for the patient, all the lab and x-ray results which were
ordered, the doctors and nurses documents will accompany the patient as he will be transferred to the
theatre

Care of the relatives

 I will inform the relatives of the impending transfer of the patient to theatre and ask them to wait in the
waiting lounge for the return of their relative.
 Once every thing is in place, i will inform the O.T dept that patient is ready for surgery and arrangement to
have him transferred made.
 Soon after the patient has being transferred , I will make a post operative bed in anticipation of his arrival
with all the necessary bed accessories

 Consent form.
 Sufficient information needs to be given to the client/patient through out the preparation.

 Refer the notes below on the physical preparation of a pt undergoing elective surgery

 Preparing the client just prior to surgery {immediate preoperative care

 Consult the physician’s orders for preoperative instructions.

 Examine the patient's health record to confirm that all essential information is included such as
 The physician's medical history and physical examination
 Nurses’ documentation
 Urinalysis report
 Blood type and cross match
 Chest X-ray and electro cardiogram
 Other pertinent diagnostic tests
 Medication administration record
 Confirm that an informed consent has been signed by the client
 Use the check list to see what has been done for the patient
 Check the patients identity
 Take and record the vital signs
 Instruct the client to take a shower or an antiseptic bath {follow hospital policy}
 Instruct client to remove all make -up and nail polish
 Provide the client with a clean hospital gown after the bath
 Ask the client to remove all jewelry and other valuables and place them in a secured place, if client
refuses to remove ring, secure it with a tape. Don’t cover nail beds with tape
 Remain alert to the clients anxiety or questions
 Carry out the prescribed orders such as;
 Insertion of I.V line, solutions and medications
 Urinary catheterization
 Naso gastric intubation

 Before giving the preoperative medication

 Instruct the patient to empty his bladder
 Remove all prosthesis from the patient such as
 Dentures
 Eye glasses or contact lenses
 Artificial limbs
 Administer the preoperative medications
54
 Explain to the patient that they may feel sleepy or have a dry mouth


Post operative care

Objectives

 The Nurse’s broader objective is to return the patient to an optimal state of function possible.
 With that in mind, the nurse therefore provides
 Comfort,
 maintains health body systems,
 prevents complications
 and teaches client to manage his own health needs.

 The immediate post operative period

 Surgery ends when the surgeon closes the skin. The client is transported immediately to what is called the
recovery room or post anesthetic care unit. {PACU}
 If the client was at high risk before surgery, has a complication or had a life threatening event during the
surgery, had prolonged exposure to anesthesia, he may be transferred to the intensive care unit.

 Recovery from anesthesia is the reverse of induction; the client moves from surgical anesthesia into the
stage of excitement and analgesia before consciousness returns

 Objectives in the immediate Post op. care

 The main objectives in the care of a patient in the immediate post period fall under three aims; {ABC’s}
 Airway
 Breathing
 Circulation
 Until the patient returns to a state of full consciousness and awareness, the nurse ensures that the airway is
clear or patent. She can do this by removing aspirations {any secretions} from the mouth, ensuring that the
airway is not blocked from a falling tongue or dentures.
 Repositioning patient in Sims position or recovery position aids drainage of secretions.
 The patient should not have labored breathing.
 The breathing needs to be spontaneous and regular; the circulatory function is of prime importance.
 The nurse also monitors the client’s level of consciousness and awareness.
 Vital signs, color and temperature are checked every 15 minutes.
 Intravenous fluids or blood transfusions should be running as prescribed.
 Body fluids, wound drainage and other critical signs that give clues to the patient’s progress need to be
monitored.
 The physical safety is the other priority in the nursing care as the unconscious patient.
 Is patient enabling to manage his own needs?
 The nurse also needs to provide comfort measures of which the utmost important is pain control. The pain
becomes acute and more intense as the patient recovers. Giving a full prescribed dose of analgesia before
full recovery may depress the CNS dangerously so the recovery room nurse judges the condition of he
client to determine the exact dose of narcotic to be given. So analysis of the type of anesthesia and dose,
vital signs and level of consciousness will be important factors to consider.

 The nurse thus gives a fractional dose at frequent intervals via the intravenous line.
 Other comfort measures to be done include;
 Changing of patient position,
 regulating patient temperature
 and responding to clients complaints
 Other consideration are to explain to the client the gadgets or equipment such as respirators that could be
55
 mounted on the patient as he recovers to avoid anxiety.

 The immediate post operative care is complete when

 Patient returns to full consciousness;
 Vital signs are stable for at least one hour
 No excessive drainage/bleeding
 No adverse physiologic effects from analgesia
 All recovery room orders have been done
 The surgical unit staff is ready to receive the client

General Post op care in the ward.

 The main objectives for post op care is to

 Ensure that the patient recovers fully from the effects of surgery and anesthesia
 Returns to his premorbid state as quickly as possible
 Ensure an optimal respiratory function
 Return of bowel and bladder function
 Relief of pain
 Optimal cardiovascular function
 Maintenance of nutritional balance
 Quick wound healing
 Prevention of any complications

Environment.

 The PACU communicates with the ward on the impending transfer of the patient and if there is any need
for additional items/equipment to be prepared for the care of the patient
 The patient room is made ready by assembling the necessary equipment and supplies such as the I.V.pole,
suction machine, oxygen machine, bed accessories, drainage receptacles, emesis basin, disposable pads,
and blankets.
 The patient is admitted to the acute bay near the nurses’ station for easy observations.
 The environment should be quiet to ensure undue stress as patient is recovering. It should be well light,
clean and have good ventilation.
 The bed needs to have rails and in low position to avoid accidental falls.
Position
 The position of the patient will depend on the type of surgery done. It should be such that it does not
interfere with the patency of the airway, In a number of situations, Position the patient in the semi prone
until fully recovery has taken place after which time the patient can assume a position he finds comfortable.
This prevents secretion from accumulating along the airway or the tongue from falling back. An idea
position also reduces pain and helps to maintain the integrity of the skin.
 2hrly turnings should be done when a patient is unable to move himself in bed.
 A patient on traction can be assisted to sit up in bed or move slightly side to side to prevent pressure sore
development.
Observations
 Monitor the vital signs of temp, B.P pulse and respirations every 15min. progress to half hourly and hourly
as the condition stabilizes. A lowered B.P may signify post operative bleeding; Low pulse and respiration
rates are suggestive of impending shock. A high temp after 48 hrs may be suggestive of pot operative
infection.
 Observe the general condition of the patient
 Noting the level of consciousness, orientation and ability to move extremities.
 Note skin warmth moisture and color.
 Check the wound site and wound drainage systems. Connect the drainage tubes to gravity or suction.
 Note if there is any bleeding from the wound site reinforce bandage if necessary.
 Check I.V sites for patency and infusion for correct rate and solutions.

 Pain relief

 Comprehensive preoperative information on the nature of surgery is a sufficient factor in reducing post
56
 operative pain
 Assess pain level, pain characteristics {location and quality}
 Position patient to enhance comfort
 Administer prescribed analgesics .These are usually narcotics such as pethidine or morphine

 Rest and activity

 Most patients will be reluctant to get of bed after surgery. reminding them of the importance of early
ambulation is critical in the prevention of post op complications.
 Surgical patients should be out o f bed as soon as possible to prevent atelectasis, hypostatic pneumonia
gastrointestinal discomfort and circulatory problems
 Ambulation increases ventilation
 Passive limb exercises should be done
 Pain is often reduced when early ambulation is done
 Hospital stay and cost are also reduced when a patient is allowed to ambulate early

Care of the wound

 An on going inspection of the surgical wound should is done.
 This involves observing the approximation of the wound edges, integrity of the sutures, redness of the
wound discoloration, warmth, swelling, tenderness and drainage.
 Ensure that wound drainage continues if there is a drain
 Increasing or excessive drainage should be reported to the Doctor
 Dressing change should be done following Dr orders
 The first post operative dressing is usually changed by the Dr
 Wound is cleaned on a daily basis with prescribed solutions
 Keep the sutures clean and covered by a dressing
 Sutures are removed on the 7 to the 8 post operative day
 Patient is instructed on how to care about the wound at home
Diet/Nutrition
 Patients may be nil orally the first few days after surgery.
 Nausea hiccups and vomiting is common after anesthesia
 Follow the Dr Orders on how you will proceed I introducing food to the patient.
 Initially patient’s may start with sips of water to keep he moth moistened the progress to intake of fluid
diet.
 Monitor the return of bowel sounds before semi-solid foods and solid food can be given.
 The patient continues on Intravenous infusion usually alternating with dextrose and normal saline
 Maintain a balanced nutritional diet to enhance quick wound healing


 Elimination
 Constipation is common among post op cases this may be a result of decreased mobility, reduced oral
intake and some analgesics. In addition patients wound fear to go to the toilet
 Stool softeners can be given
 Inform the Dr if you observe abdominal distension
 Monitor the fluid intake and out put decreased urinary out put could indicate impending shock

 Medications
 Administer the prescribed analgesics and antibiotics
 Monitor the patients tolerance to drugs and any drug reaction
 Give blood transfusion when ordered
 Intravenous fluids continue as per Dr orders
I.E.C

 The I.E.C should focus on promoting home and community based care
 Teach patient about self care
 Good health living habits
 Continued ambulation
 Good nutrition
57
 Importance of taking prescribed drugs
 Importance of review
 Community support groups

Common post Operative Complications

 Respiratory dysfunction
 Fluid and electrolyte imbalance
 Dehydration
 Bleeding/hemorrhage
 Infection of wound
 Unrelieved pain
 Heart failure
 Hypothermia and hyperthermia
 Urinary retention
 Constipation
 Wound dehiscence

58