MEDSURGE - OXYGENATION PROBLEMS/ALTERATIONS.pdf

Care of Clients with Alterations/Problems in Oxygenation – Concept Maps

Concept maps for oxygenation problems help visualize conditions affecting respiratory function, their causes, symptoms, nursing assessments, and interventions.

1. NCM 112
Care of Clients with
Alterations/ Problems in
Oxygenation Concept Maps
Created by: Erlen Anne C. Orcine

2. Health Care
Situations
National
Mortality Rates
Noncommunicable Diseases (NCDs): 70% of
global deaths
Cardiovascular diseases
Cancers
Infectious Diseases: Surge during COVID-19
pandemic
COVID-19 deaths: 8.8 million (2021)
Tuberculosis (TB): Top infectious killer in 2023
Lower respiratory infections
Other Causes:
Diabetes
Alzheimer’s
Kidney diseases
Morbidity Rates
Obesity: Over 1 billion adults affected
Undernutrition: 500 million affected
Double Burden of Malnutrition: Undernutrition
and obesity co-exist
Disabilities: 1.3 billion people, 16% of global
population
Health inequities: Affecting people with
disabilities, refugees, and migrants
Global
Local
For mortality, the top causes:
Ischemic heart disease
Neoplasms (Cancer)
Cerebrovascular diseases
Chronic lower respiratory diseases
Diabetes mellitus
For morbidity, the leading diseases are:
Acute respiratory infections
Hypertension
Diabetes
Chronic obstructive pulmonary disease
(COPD)
Kidney diseases​
Leading Causes of Mortality:
Cardiovascular diseases
Pneumonia
Cancer
Stroke
COVID-19
Leading Causes of Morbidity:
Hypertension
Diabetes
Respiratory diseases
Kidney diseases
Acute respiratory infections

3. Health
& Illness
Phases of Chronic
Illness
Disease: A medical
condition with specific
signs, symptoms, and
causes, often diagnosed by
a healthcare provider.
Illness: A person's
subjective experience of
feeling unwell, which may or
may not be linked to a
specific disease.
Disease vs. Illness
Pre-trajectory: The phase before the illness
develops, involving risk factors or early signs.
Trajectory: The appearance of symptoms or
diagnosis of the illness.
Stable: The illness is under control, and
symptoms are managed.
Unstable: Symptoms worsen or
complications arise, requiring medical
intervention.
Acute: A sudden, severe phase of illness
requiring urgent care.
Crisis: A critical situation requiring
immediate medical attention.
Comeback: Recovery or return to a stable
state after a crisis or acute phase.
Downward: The illness progresses, and
health declines.
Dying: The final phase, where death is
imminent.
Risk Factors
Modifiable Risk Factors:
Smoking
Poor diet
Physical inactivity
Alcohol consumption
Stress
Obesity
Hypertension
Non-Modifiable Risk Factors:
Age
Gender
Genetic predisposition
Family history
Ethnicity
Birth defects
Chronic Disease vs.
Chronic Illness
Chronic Disease: A long-
lasting medical condition with
a defined cause and
symptoms (e.g., diabetes,
hypertension).
Chronic Illness: A person's
prolonged experience of
symptoms or health
challenges, regardless of a
specific diagnosis (e.g.,
fatigue, pain).
Direct Care:
Administering medications
Monitoring vital signs
Providing wound care
Assisting with activities of daily living
(ADLs)
Supportive Care:
Offering emotional support
Educating the patient and family
Coordinating with other healthcare
providers
Providing comfort measures (e.g., pain
management, relaxation techniques)
Nursing Care

4. Pleural
Effusion
Heart failure
Pneumonia
Malignancy (e.g., lung cancer,
breast cancer)
Pulmonary embolism
Tuberculosis
Autoimmune diseases (e.g.,
lupus, rheumatoid arthritis)
Trauma or injury to the chest
Chemical Pleurodosis
Pleurectomy
Pleuroperitoneal Shunt
(the fluid will transfer to the another
location)
Chest Tube
Medical Management
Complication
Clinical Manifestation
Fever
Pleuritic chest pain
Dry cough and coarse
crackles
Dyspnea
Decrease breath sounds
Dullness of Flatness &
Tactile Fremitus (Palpation)
Egophony sound
(Auscultation)
TYPES
Exudative (inflammatory)
Protein-rich fluid caused by local factors like
inflammation, infection, or lung injury. Exudative
effusions have a protein count of more than 3
grams per liter.
Transudative (non inflammatory)
Protein-poor, watery fluid caused by systemic
factors like heart failure or cirrhosis.
Transudative effusions have a protein count of
less than 3 grams per liter.
Nursing Management
Monitor the patient's vital signs, pain, lung
sounds, and oxygenation.
Monitor for signs of hypoxia, cyanosis,
tachycardia, respiratory changes, and
hemoptysis.
Maintain chest drainage
Educate the patient on how to brace or splint
when breathing.
Abnormal accumulation of fluid in
the pleural space, impairing lung
expansion and gas exchange.
Respiratory distress
Infection (empyema)
Atelectasis
Fibrosis
Sepsis
Trapped lung
Pleural thickening
Pneumothorax
Respiratory failure
Underlying disease
progression
Nursing diagnosis
Impaired gas exchange related to fluid
accumulation in the pleural space, as evidenced
by dyspnea, low oxygen saturation, and
cyanosis.
Ineffective breathing pattern related to lung
compression and dyspnea, as evidenced by use
of accessory muscles, tachypnea, and shallow
breathing.
Activity intolerance related to decreased
oxygenation and fatigue, as evidenced by
inability to perform daily activities, reports of
weakness, and increased need for rest.
Diagnostic Test
Causes
Chest xray
CT SCAN
Thoracentesis
(Use for therapeutic/
Diagnostic/ Lung
Expansion)
Blood Test

5. Medical Management
Complication
Trauma (e.g., nose picking,
injury, or nasal fracture)
Dry air or low humidity
Upper respiratory infections
Hypertension
Nasal tumors or polyps
anticoagulants, antiplatelets, or
nasal sprays)
Bleeding disorders
Foreign body in the nose
Clinical Manifestation
TYPES Nursing Management
Nursing diagnosis
Diagnostic Test
Causes
EPISTAXIS
Bleeding from the nose, commonly
from nasal mucosa.
Anterior Epistaxis
More common (90%).
Source: Kiesselbach’s plexus
Posterior Epistaxis
Less common, more severe.
Source: Sphenopalatine artery.
Blood dripping or
running from the nose.
Pain from an injury or
sore tissue inside the
nose.
Other symptoms include
feeling weak or faint,
dizziness or
lightheadedness, and
pallor.
Hypovolemia
Anemia
Airway
obstruction
Aspiration of
blood
Hypoxia
Septic shock (if
infection occurs)
Physical exam
Complete blood count
(CBC), prothrombin time (PT), or
activated partial thromboplastin
time (PTT) if the patient has a
history of bleeding disorders or
recurrent nosebleeds.
CT scan of the sinuses or nose
Risk for bleeding related to fragile
nasal mucosa, as evidenced by
frequent nosebleeds.
Ineffective airway clearance related
to blood obstruction, as evidenced
by nasal congestion and difficulty
breathing.
Acute pain related to nasal trauma,
as evidenced by reports of
discomfort.
Nasal packing (anterior or posterior).
Vasoconstrictors (e.g., oxymetazoline).
Antibiotics to prevent infection with
nasal packing.
Control hypertension.
Adjust anticoagulant therapy as needed
Monitor vital signs, bleeding source,
and severity.
Sit upright, lean forward.
Pinch nostrils for 10-15 minutes.
Apply cold compress to the nose/neck
Watch for hypovolemia or airway
obstruction.

6. Medical Management
Complication
Clinical Manifestation
TYPES Nursing Management
Nursing diagnosis
Diagnostic Test
Causes
OBSTRUCTIVE
SLEEP APNEA
A sleep disorder characterized by
repeated episodes of upper airway
obstruction during sleep, leading to
disrupted breathing and oxygenation.
Mild OSA: AHI between 5 and 15
Moderate OSA: AHI between 15
and 30
Severe OSA: AHI greater than 30
Educate on proper CPAP use and fit.
Monitor oxygen saturation and signs of hypoxia.
Emphasize weight loss, avoid alcohol, sedatives,
and smoking
Administer oxygen as ordered by the doctor
Administer medication as per doctor’s order
Loud snoring
Gasping/choking
during sleep
Restless sleep
Episodes of apnea
(breathing
cessation)
Excessive daytime
sleepiness
Morning headaches
Difficulty
concentrating
Mood changes
Polysomnogram
Home sleep apnea
testing
Physical examination
Obesity
Enlargedtonsils/ adenoids
Small jaw or airway
Nasal congestion
Age-related airway
collapse
Medications
Sex (Male)
CPAP machine
Mouthpiece that keeps your
airways open while you sleep.
Using a saline nasal spray to keep
your nasal passages open
Surgery: patients with OSA.
Hypertension
Cardiovascular diseases
(e.g., arrhythmias, heart
failure)
Stroke
Daytime fatigue and
sleepiness
Impaired cognitive
function
Type 2 diabetes
Ineffective breathing pattern related to
airway obstruction during sleep, as
evidenced by snoring, gasping, and
pauses in breathing.
Disturbed sleep pattern related to
frequent apneic episodes, as evidenced
by daytime fatigue and reports of poor
sleep quality.
Risk for decreased cardiac output related
to hypoxemia, as evidenced by elevated
blood pressure and irregular heart rate.

7. Medical Management
Complication
Clinical Manifestation
TYPES Nursing Management
Nursing diagnosis
Diagnostic Test
Causes
Spontaneous
Occurs without external trauma
Open
-"sucking chest wound."
An open wound in the chest allows air to
flow freely
Tension
Emergency. where air enters the pleural
space but cannot escape.
PNEUMOTHORAX
Presence of air in the pleural space, causing
partial or complete lung collapse.
Sudden chest pain (sharp,
one-sided).
Dyspnea (shortness of
breath).
Diminished or absent breath
sounds on affected side.
Hyperresonance to
percussion.
Cyanosis (in severe cases).
Tension Pneumothorax:
Severe respiratory distress.
Hypotension.
Tracheal deviation (toward
unaffected side).
Chest X-ray: Visible air in
pleural space, lung collapse.
CT scan: More detailed
visualization if needed.
Arterial Blood Gas (ABG):
Hypoxemia or respiratory
acidosis.
Spontaneous:
Rupture of blebs or
bullae.
Open: Chest injury,
surgical procedures.
Mechanical
Ventilation:
Barotrauma from
high pressure.
Supplemental oxygen.
Immediate needle decompression
(tension pneumothorax).
Chest tube insertion to re-expand lung.
Close the chest wound
Pleurodesis for recurrent cases.
Respiratory failure.
Hemothorax (if
associated with
trauma).
Recurrent
pneumothorax.
Assess for dyspnea, O2 saturation, and breath
sounds.
Observe for signs of tension pneumothorax
High Fowler's to promote lung expansion.
Ensure proper functioning of the chest drainage
system.
Avoid activities that increase pressure
Impaired gas exchange related to lung
collapse, as evidenced by dyspnea,
cyanosis, and low oxygen saturation.
Ineffective breathing pattern related to
restricted lung expansion, as evidenced by
tachypnea and use of accessory muscles.
Acute pain related to pleural irritation, as
evidenced by reports of sharp chest pain
and guarding.

8. Medical Management
Complication
Clinical Manifestation
TYPES Nursing Management
Nursing diagnosis
Diagnostic Test
Causes
Simple - Single break , not affecting nearby organs.
Multiple- More than one, can cause instability in the
chest wall and lead to complications.
Flail Chest: Two or more ribs in two or more places,
leading to a segment of the chest wall moving
independently.
Comminuted- Bone is broken into several pieces,
increasing the risk of damage to internal organs.
Rib Fracture
A break or crack in one or more of the
ribs, typically caused by trauma or injury
to the chest.
Pain: Sharp, localized,
aggravated by deep
breathing, coughing, or
movement.
Bruising or swelling around
the injury site.
Shallow breathing to avoid
pain.
Shortness of breath (if
associated with lung injury).
Crepitus: Feeling or hearing
a crackling sound upon
palpation.
Respiratory distress (in severe
cases, particularly with flail
chest).
Physical Exam: Tenderness,
crepitus, pain with palpation.
Chest X-ray: To identify
fractures, lung injuries, and
rib displacement.
CT Scan: For more detailed
assessment.
Blunt Trauma
Penetrating Trauma
Osteoporosis
Bone metastasis
Coughing (in severe
cases, especially in
elderly)
NSAIDs, opioids, or acetaminophen for pain
relief.
Oxygen therapy (if hypoxic).
Supportive care, avoid binding the chest
Surgical Intervention:
For displaced fractures or if there is significant
organ damage.
Pneumothorax
Hemothorax
Lung contusion
Infection
Respiratory failure
Monitor and administer prescribed pain relief.
Assess lung sounds, oxygen saturation, and breathing
patterns.
Use incentive spirometry to prevent pneumonia.
Elevate the head of the bed to reduce discomfort and
promote lung expansion.
Observe for signs of pneumothorax, hemothorax, or
respiratory distress.
Acute Pain
Related to fractured rib and tissue injury, as
evidenced by patient reports of sharp, localized
pain, especially with breathing or movement.
Impaired Gas Exchange
Related to shallow breathing and reduced lung
expansion, as evidenced by decreased oxygen
saturation, increased respiratory rate, and use of
accessory muscles.
Ineffective Breathing Pattern
Related to pain from rib fractures and fear of
further injury, as evidenced by shallow, rapid
breathing.

9. Medical Management
Complication
Clinical Manifestation
TYPES Nursing Management
Nursing diagnosis
Diagnostic Test
Causes
Mild
Limited injury, mild symptoms.
Moderate
More extensive injury, moderate respiratory symptoms.
Severe
Significant injury with severe respiratory distress, often
requiring intensive care.
Pulmonary
Contusion
A bruise of the lung tissue caused by
blunt trauma, leading to damage of
blood vessels and tissue, which impairs
gas exchange.
Shortness of breath
(dyspnea).
Chest pain (worsened by
deep breathing or coughing).
Cough, possibly with blood-
tinged sputum.
Tachypnea (rapid breathing).
Hypoxia (low oxygen
saturation).
Crackles or diminished
breath sounds on
auscultation.
Cyanosis (in severe cases).
Chest X-ray
CT scan
Arterial Blood Gas (ABG):
To assess oxygenation
and carbon dioxide
levels.
Pulse Oximetry:
To monitor oxygen
saturation.
Blunt Trauma:
Motor vehicle
accidents
Falls
Sports injuries
Penetrating Trauma
(less common):
Stab wounds
Gunshot wounds
Analgesics (e.g., opioids) to control pain.
Intubation and Mechanical Ventilation
Chest Tube Insertion
Antibiotics to prevent or treat pneumonia.
Monitoring for ARDS.
Respiratory failure (due
to impaired gas
exchange).
Pneumonia (due to
impaired lung tissue
and shallow breathing).
Pneumothorax (air in
the pleural space).
Hemothorax (blood in
the pleural space).
Acute Respiratory
Distress Syndrome
(ARDS).
Assess lung sounds, oxygen saturation, respiratory
rate, and depth of breathing.
Administer analgesics
Use incentive spirometry to maintain lung expansion
and prevent atelectasis.
Keep the patient in an upright position (high Fowler’s)
to facilitate breathing.
Provide Oxygen Therapy
Monitor for Complications:
Impaired Gas Exchange
Related to damaged lung tissue and reduced
oxygenation, as evidenced by hypoxia and
tachypnea.
Acute Pain
Related to chest injury and inflammation, as
evidenced by patient reports of sharp, localized
pain and difficulty breathing.
Ineffective Breathing Pattern
Related to pain and respiratory distress, as
evidenced by shallow breathing and use of
accessory muscles.

10. Medical Management
Complication
Clinical Manifestation
TYPES Nursing Management
Nursing diagnosis
Diagnostic Test
Causes
Acute Exacerbation of Chronic
Bronchitis:
Periodic worsening of symptoms due to
infection or environmental irritants.
Chronic Persistent Bronchitis:
Continuous symptoms that do not improve
without intervention.
Chronic
Bronchitis
A chronic inflammation of the bronchi (airways) in
the lungs, characterized by cough and sputum
production for at least 3 mos per year over 2
consecutive years. A type of COPD.
Chronic cough:
Often productive, worse in
the mornings.
Excessive sputum production:
Thick, mucopurulent sputum,
particularly during
exacerbations.
Difficulty breathing,
especially with physical
exertion.
Wheezing and crackles on
auscultation of the lungs.
Cyanosis (blue bloaters)
Fatigue
Chest X-ray
Pulmonary Function
Tests (PFTs)
Arterial Blood Gases
(ABG)
Sputum Culture
Spirometry
Cigarette Smoking:
Long-term exposure
to environmental
pollutants, dust, and
chemicals.
Respiratory
Infections.
Alpha-1 antitrypsin
deficiency
Bronchodilators & Inhaled Corticosteroids
Antibiotics
Oxygen Therapy
Pulmonary Rehabilitation- to improve exercise
tolerance and breathing efficiency.
Mucolytics
Respiratory Failure
Pulmonary Hypertension
leading to right-sided
heart failure (cor
pulmonale).
Pneumonia
Chronic Hypoxemia
Bronchiectasis
Assess lung sounds, oxygen saturation, and
respiratory rate regularly.
Encourage coughing and deep breathing exercises.
Use of postural drainage or chest physiotherapy if
needed.
Ensure proper use of bronchodilators, inhalers, and
corticosteroids.
Administer oxygen as prescribed and monitor for
effectiveness.
Teach about smoking cessation, medication
adherence, and avoiding environmental triggers.
Encourage Fluid Intake.
Impaired Gas Exchange
Related to chronic airway obstruction and inadequate
ventilation, as evidenced by low oxygen saturation,
cyanosis, and dyspnea.
Ineffective Airway Clearance
Related to excessive mucus production and inflammation,
as evidenced by productive cough and abnormal breath
sounds.
Imbalanced Nutrition: Less Than Body Requirements
Related to increased energy expenditure from labored
breathing, as evidenced by weight loss or poor appetite.

11. Medical Management
Complication
Clinical Manifestation
TYPES Nursing Management
Nursing diagnosis
Diagnostic Test
Causes
Centrilobular
Affects the upper lobes, primarily the central parts of the
acinus. Most commonly seen in smokers.
Panlobular
Affects the entire acinus, leading to the destruction of
alveolar walls. Common in individuals with alpha-1
antitrypsin deficiency.
Paraseptal
Affects the distal parts of the acinus near the pleura, often
causing spontaneous pneumothorax.
Emphysema
A type of Chronic Obstructive Pulmonary Disease
(COPD) characterized by the destruction of alveolar
walls, leading to enlarged air spaces and reduced
gas exchange.
Dyspnea - progressive and worse
with exertion, eventually
occurring at rest.
Chronic Cough: w/o sputum
often worse in the mornings.
Wheezing
Barrel Chest:
An increase in anterior-posterior
chest diameter due to
hyperinflation of the lungs.
Pursed-Lip Breathing
Fatigue
Decreased Breath Sounds:
On auscultation, due to air trapping
and reduced lung expansion.
Cyanosis:
Bluish tint to skin or lips due to
low oxygen levels.
Chest X-ray:
To identify hyperinflation,
flattened diaphragm, and
other changes due to
emphysema.
Spirometry
Arterial Blood Gases
(ABG)
CT Scan
Alpha-1 Antitrypsin Levels
Cigarette Smoking
Air Pollution
Alpha-1 Antitrypsin
Deficiency:
Exposure to fumes,
dust, and chemicals
in certain jobs.
Respiratory Infections
Bronchodilators & Inhaled Corticosteroids
Antibiotics
Oxygen Therapy
Pulmonary Rehabilitation- to improve exercise tolerance
and breathing efficiency.
Lung Volume Reduction Surgery or Lung Transplantation
Respiratory Failure
Pulmonary
Hypertension
Cor Pulmonale
(Right-sided heart
failure)
Spontaneous
Pneumothorax
Pneumonia
Assess lung sounds, oxygen saturation, and
respiratory rate regularly.
Encourage deep breathing, coughing, and the use of
expectorants.
Chest physiotherapy or postural drainage if needed.
Administer Medications
Encourage Smoking Cessation
Administer oxygen as prescribed and monitor for
effectiveness.
Encourage regular physical activity as tolerated to
improve endurance.
Impaired Gas Exchange
Related to alveolar destruction and reduced surface area
for gas exchange, as evidenced by low oxygen saturation
and dyspnea.
Ineffective Airway Clearance
Related to hypersecretion of mucus and weakened cough
reflex, as evidenced by wheezing, dyspnea, and inability to
clear secretions.
Activity Intolerance
Related to dyspnea and fatigue, as evidenced by shortness
of breath with physical exertion.

12. Medical Management
Complication
Clinical Manifestation
TYPES Nursing Management
Nursing diagnosis
Diagnostic Test
Causes
Cylindrical
The bronchi are uniformly dilated, often seen in
early or mild disease.
Varicose
The bronchi exhibit irregular and bulbous dilations.
Cystic
The bronchi are dilated into cyst-like structures,
often with more severe disease and significant
mucus accumulation.
Bronchiectasis
A chronic condition characterized by the
abnormal, irreversible dilation and thickening of
the bronchi, leading to the accumulation of
mucus, frequent infections, and impaired
clearance of respiratory secretions.
Persistent, productive
cough with large amounts
of purulent sputum.
Frequent episodes of
pneumonia, bronchitis,
and other infections.
Dyspnea especially during
physical exertion.
Wheezing
Hemoptysis (Coughing up
blood):
Clubbing of the Fingers
and Toes
Chest Pain
Chest X-ray
High-Resolution CT
Scan
Sputum Culture:
Pseudomonas
Pulmonary Function
Tests (PFTs)
Bronchoscopy
Blood Tests
Chronic Respiratory
Infections: pneumonia or
tuberculosis
Cystic Fibrosis
Inhalation of Foreign
Objects or Toxic
Substances
Primary Ciliary Dyskinesia
Autoimmune Disorders:
rheumatoid arthritis or
inflammatory bowel disease
Antibiotics
Bronchodilators & Inhaled Corticosteroids:
Mucolytics:
Techniques like postural drainage, percussion, and vibration
to help clear mucus.
Oxygen Therapy:
Lung Transplantation
Respiratory
Failure
Pulmonary
Hypertension
Recurrent
Pneumonia
and Lung
Infections
Massive
Hemoptysis
Assess lung sounds, oxygen saturation, and
respiratory rate regularly.
Encourage deep breathing, coughing, and the use
of expectorants.
Chest physiotherapy or postural drainage if needed.
Administer Medications
Administer oxygen as prescribed and monitor for
effectiveness.
Encourage regular physical activity as tolerated to
improve endurance.
Implement strict infection control measures and
monitor for signs of respiratory infections.
Ineffective Airway Clearance
Related to excessive mucus production and impaired ciliary
function, as evidenced by productive cough and abnormal
breath sounds.
Impaired Gas Exchange
Related to airway obstruction and inadequate ventilation,
as evidenced by low oxygen saturation and dyspnea.
Risk for Infection
Related to recurrent respiratory infections and impaired
muco-ciliary clearance, as evidenced by frequent
hospitalizations or pneumonia.

13. Medical Management
Complication
Clinical Manifestation
TYPES Nursing Management
Nursing diagnosis
Diagnostic Test
Causes
Allergic (Extrinsic) – Triggered by allergens
(e.g., dust, pollen).
Non-Allergic (Intrinsic) – Triggered by stress,
infections, or exercise.
Exercise-Induced – Triggered by physical
activity.
Occupational – Triggered by workplace
irritants.
Nocturnal – Worsens at night due to hormonal
changes.
ASTHMA
It is a chronic respiratory condition
characterized by airway inflammation,
bronchospasm, and increased mucus
production, leading to wheezing, coughing,
and difficulty breathing.
Wheezing
Shortness of breath
Chest tightness
Cough (especially at night
or early morning)
Prolonged expiration
Pulmonary Function
Test (PFT)
Peak Expiratory Flow
Rate (PEFR)
Allergy Testing
Chest X-Ray (to rule
out other conditions)
Arterial Blood Gas
(ABG)
Environmental: Allergens,
air pollution
Genetic predisposition
Respiratory infections
Triggers: Exercise, cold air,
stress, strong odors
Bronchodilators (e.g., albuterol)
Corticosteroids (e.g., prednisone)
Leukotriene receptor antagonists (e.g., montelukast)
Anticholinergics (e.g., ipratropium bromide)
Oxygen therapy during acute attacks.
Status
asthmaticus
Respiratory
failure
Pneumonia
Atelectasis
Assessment: Monitor respiratory status, oxygen
saturation, and lung sounds.
Interventions:
Administer prescribed medications.
Teach breathing techniques (e.g., pursed-lip
breathing).
Educate about trigger avoidance.
Monitor Peak Expiratory Flow Rate (PEFR).
Ensure proper inhaler use.
Encourage flu and pneumonia vaccinations.
Ineffective airway clearance is evidenced by wheezing,
coughing, use of accessory muscles, and increased
respiratory rate.
Impaired gas exchange is evidenced by low oxygen
saturation, cyanosis, restlessness, and ABG results
showing hypoxemia.
Anxiety is evidenced by verbalization of fear,
restlessness, tachycardia, and inability to focus.

14. Medical Management
Complication
Clinical Manifestation
TYPES
Nursing Management
Nursing diagnosis
Diagnostic Test
Causes
Iron-Deficiency Anemia
Vitamin B12 Deficiency Anemia
Folic Acid Deficiency Anemia
Aplastic Anemia
Hemolytic Anemia
Sickle Cell Anemia
Chronic Disease Anemia
ANEMIA
Anemia is a condition where there is a deficiency
of red blood cells or hemoglobin in the blood,
leading to reduced oxygen delivery to tissues and
organs.
Fatigue
Weakness
Pallor
Shortness of breath
Dizziness or
lightheadedness
Tachycardia
Cold hands and feet
Headache
CBC: Evaluates overall blood components.
Hemoglobin & Hematocrit: Measure oxygen-
carrying capacity.
Iron Studies: Assess ferritin and transferrin levels.
Reticulocyte Count: Indicates bone marrow
activity.
Vitamin B12 & Folate: Check for deficiencies.
Bone Marrow Biopsy: Examines marrow (if
needed).
Peripheral Blood Smear: Detects abnormal cells.
Nutritional deficiencies
(Iron, B12, Folate)
Chronic disease (e.g.,
chronic kidney disease)
Blood loss (e.g.,
gastrointestinal bleeding,
heavy menstruation)
Bone marrow disorders
(e.g., aplastic anemia)
Genetic conditions (e.g.,
sickle cell disease)
Iron Supplements: For iron deficiency.
Vitamin B12/Folic Acid: For deficiencies.
Blood Transfusions: For severe anemia or blood loss.
Erythropoiesis-Stimulating Agents (ESAs): For anemia from
chronic disease.
Treat Underlying Cause: Manage chronic conditions or
infections.
Heart failure
Organ
damage (due
to hypoxia)
Increased risk
of infections
Development
of arrhythmias
Monitor vital signs (especially heart rate and
respiratory rate)
Provide oxygen therapy if necessary
Educate on diet (iron-rich foods, B12, folic acid)
Administer prescribed medications (iron, B12, folic
acid)
Monitor lab results (CBC, iron studies)
Encourage rest and assist with energy conservation
Assess for complications (e.g., signs of bleeding,
infections)
Provide emotional support and education on
managing chronic anemia.
Ineffective Tissue Perfusion related to
low hemoglobin, evidenced by fatigue,
pallor, and shortness of breath.
Fatigue related to low oxygenation,
evidenced by weakness and need for
rest.
Risk for Decreased Cardiac Output
related to tachycardia, evidenced by
dizziness.

15. Medical Management
Complication
Clinical Manifestation
TYPES Nursing Management
Nursing diagnosis
Diagnostic Test
Causes
Stable Angina: Occurs with exertion or stress
and is relieved by rest or medication.
Unstable Angina: Occurs unpredictably and
may last longer, indicating a higher risk of
heart attack.
Variant (Prinzmetal’s) Angina: Caused by
spasms in the coronary arteries, often
occurring at rest.
Angina
Pectoris
It is a chest pain or discomfort caused by
reduced blood flow to the heart muscle,
often due to coronary artery disease.
Chest pain or discomfort
(pressure, squeezing, or
heaviness)
Shortness of breath
Nausea
Sweating
Dizziness or
lightheadedness
Pain radiating to the
arms, neck, jaw, or back
Electrocardiogram (ECG): Detects
ischemia or infarction.
Coronary Angiography: Visualizes
blockages in coronary arteries.
Cardiac Biomarkers (e.g., troponin):
Indicates myocardial damage.
Echocardiogram: Assesses heart
function and structure.
Lipid Profile: Checks cholesterol and
triglyceride level.
Atherosclerosis
Coronary artery
spasm
Hypertension:
Increased heart
workload
High cholesterol
or high blood
sugar
Stress or
emotional strain
Nitrates, Antiplatelets, Beta-blockers & ACE inhibitors,
Statins
Percutaneous Coronary Intervention (PCI): Angioplasty or
stent placement.
Coronary Artery Bypass Grafting (CABG): Surgical
intervention to bypass blocked arteries.
Myocardial
infarction
(heart attack)
Heart failure
Arrhythmias
Cardiogenic
shock
Monitor vital signs and ECG
Administer medications as prescribed (e.g.,
nitroglycerin)
Provide oxygen therapy if needed
Educate on lifestyle changes (e.g., diet, exercise)
Monitor for complications (e.g., heart attack)
Encourage stress management techniques
Impaired gas exchange related to reduced coronary
blood flow as evidenced by dyspnea, low oxygen
saturation, fatigue, and chest discomfort.
Acute pain related to myocardial ischemia as
evidenced by patient reports of chest pain, radiating
discomfort to the arm or jaw, and restlessness.
Activity intolerance related to reduced oxygen delivery
to tissues as evidenced by fatigue, dyspnea with
exertion, and inability to perform daily activities.
Diagnostic Test

16. Medical Management
Complication
Clinical Manifestation
TYPES Nursing Management
Nursing diagnosis
Diagnostic Test
Causes
Non-ST-Elevation Myocardial Infarction
(NSTEMI): Partial blockage with elevated
biomarkers.
ST-Elevation Myocardial Infarction (STEMI):
Complete blockage with ST-segment
elevation on ECG.
Myocardial
Infarction
commonly known as a heart attack, occurs
when blood flow to a part of the heart
muscle is blocked, causing tissue damage.
Chest pain or discomfort
(pressure, squeezing,
tightness)
Shortness of breath
Nausea and vomiting
Sweating
Dizziness or
lightheadedness
Pain radiating to the arm,
neck, jaw, or back
Fatigue
Electrocardiogram (ECG): Identifies
ischemia or infarction.
Cardiac Biomarkers (Troponin, CK-MB):
Elevated in MI.
Coronary Angiography: Visualizes
blockages.
Echocardiogram: Assesses cardiac
function.
Stress Test: Evaluates ischemia (if
patient is stable).
Atherosclerosis
Coronary artery
spasm
Hypertension
High cholesterol or
diabetes
Excessive physical
stress or emotional
stress
Smoking and poor
lifestyle choices
Aspirin, Nitroglycerin,Thrombolytic, Beta-blockers &
Anticoagulants.
Percutaneous coronary intervention (PCI) or coronary artery
bypass graft (CABG) in severe cases
Heart failure
Arrhythmias
(e.g.,
ventricular
fibrillation)
Cardiogenic
shock
Death
Pericarditis
Monitor vital signs, ECG, and oxygen saturation
Administer medications as prescribed (e.g., aspirin,
nitroglycerin)
Provide oxygen therapy
Educate on lifestyle modifications (diet, exercise,
smoking cessation)
Offer emotional support and manage anxiety
Prepare for possible interventions (e.g., PCI, CABG)
if necessary
Acute Pain related to myocardial ischemia, as
evidenced by chest pain, sweating, and nausea.
Decreased Cardiac Output related to impaired heart
function, as evidenced by hypotension, weak pulse, and
dyspnea.
Anxiety related to fear of death or health
deterioration, as evidenced by restlessness and verbal
expression of concern.
Diagnostic Test

17. Medical Management
Complication
Clinical Manifestation
TYPES Nursing Management
Nursing diagnosis
Diagnostic Test
Causes
Acute Cardiogenic Shock: Sudden onset due
to events like myocardial infarction.
Chronic Cardiogenic Shock: Develops over
time due to progressive heart failure.
Cardiogenic Shock
It is a life-threatening condition where the
heart fails to pump enough blood to meet
the body’s oxygen demands, leading to
severe tissue hypoxia.
Hypotension (low blood
pressure)
Tachycardia
Cold, clammy skin
Shortness of breath
Decreased urine output
Chest pain
Altered mental status
(confusion, restlessness)
Electrocardiogram (ECG)
Echocardiogram
Cardiac biomarkers (e.g., troponin)
Chest X-ray
Hemodynamic monitoring (e.g., central
venous pressure, pulmonary artery
pressure)
Myocardial
infarction (most
common)
Heart failure
Arrhythmias
Pulmonary
embolism
Severe valvular
disease
Vasopressors: To maintain blood pressure (e.g.,
norepinephrine, dopamine)
Inotropic Agents: To improve heart contractility (e.g.,
dobutamine)
Oxygen Therapy: High-flow oxygen or mechanical
ventilation
Diuretics: To reduce fluid overload
Revascularization: PCI or CABG for underlying coronary
artery blockages
Multi-organ
failure
Cardiac
arrest
Death
Monitor vital signs, ECG, and hemodynamic
parameters
Administer medications and oxygen as prescribed
Maintain strict intake and output monitoring
Position patient to optimize oxygenation (e.g., semi-
Fowler’s)
Provide emotional support and prepare for
advanced interventions if needed
Decreased Cardiac Output related to impaired heart
pumping ability, as evidenced by hypotension,
tachycardia, and weak peripheral pulses.
Impaired Gas Exchange related to inadequate oxygen
delivery, as evidenced by dyspnea and low oxygen
saturation.
Ineffective Tissue Perfusion related to decreased
cardiac output, evidenced by cool skin and weak
pulses.
Diagnostic Test

18. Medical Management
Complication
Clinical Manifestation
TYPES Nursing Management
Nursing diagnosis
Diagnostic Test
Causes
Abdominal Aortic Aneurysm (AAA):
Enlargement of the abdominal aorta.
Thoracic Aortic Aneurysm (TAA): Enlargement
of the thoracic aorta.
Cerebral Aneurysm: Ballooning in a brain
artery, often leading to subarachnoid
hemorrhage if ruptured.
Aneurysm
It is a localized dilation or ballooning of a blood
vessel due to weakness in the vessel wall, which can
impair blood flow and oxygenation.
Pulsating mass in the
abdomen (for AAA)
Back or chest pain
Shortness of breath (for
TAA)
Neurological symptoms
(for cerebral aneurysm,
e.g., headache, vision
changes)
Hypotension and shock if
ruptured
CT scan
Ultrasound
MRI
Angiography
Atherosclerosis
Hypertension
Genetic
disorders (e.g.,
Marfan
syndrome)
Trauma
Infection
(mycotic
aneurysm)
Antihypertensives: To reduce pressure on vessel walls
Endovascular Repair (EVAR): Minimally invasive procedure t
place a stent graft
Surgical Repair: Open surgery for large or ruptured
aneurysms
Rupture,
leading to
hemorrhage
Thrombosis
and embolism
Organ
ischemia
Death
Monitor vital signs and signs of rupture (e.g., sudden
pain, hypotension)
Administer prescribed medications (e.g.,
antihypertensives)
Educate about lifestyle changes (e.g., smoking
cessation, stress reduction)
Prepare for surgery if necessary
Risk for Ineffective Tissue Perfusion related to altered
blood flow, evidenced by diminished pulses.
Acute Pain related to aneurysm pressure, evidenced by
verbalization of pain.
Risk for Bleeding related to weakened blood vessel,
evidenced by unstable vital signs.
Diagnostic Test

19. Medical Management
Complication
Clinical Manifestation
TYPES Nursing Management
Nursing diagnosis
Diagnostic Test
Causes
Primary Raynaud’s (Disease): No underlying
cause, milder form.
Secondary Raynaud’s (Phenomenon):
Associated with other conditions like
scleroderma or lupus, more severe.
Raynaud’s Disease
It is a condition characterized by episodic
vasospasm of small arteries, primarily in the fingers
and toes, triggered by cold or stress, leading to
reduced oxygenation in affected areas.
Cold, pale, or blue
fingers/toes
Numbness or tingling
Redness and throbbing
upon rewarming
Episodes triggered by
cold or stress
Nailfold capillaroscopy
Blood tests (ANA, ESR) for autoimmune
diseases
Cold stimulation test
Cold exposure or
emotional stress
Autoimmune
disorders (e.g.,
lupus, scleroderma)
Occupational
factors (e.g.,
vibrating tools)
Smoking and certain
medications
Calcium Channel Blockers: To relax blood vessels (e.g.,
nifedipine).
Vasodilators: To improve circulation (e.g., nitroglycerin
cream).
Lifestyle Changes: Smoking cessation, avoiding cold
exposure, and stress management.
Tissue
ischemia
Ulceration
Gangrene in
severe cases
Educate on avoiding cold and wearing warm
clothing.
Monitor for signs of ulceration or infection.
Encourage stress-reduction techniques.
Administer prescribed medications to improve blood
flow.
Ineffective Peripheral Tissue Perfusion related to
vasospasm, evidenced by pallor and cyanosis of
extremities.
Acute Pain related to ischemia, evidenced by
verbalization of pain in fingers/toes.
Risk for Impaired Skin Integrity related to prolonged
ischemia, evidenced by skin discoloration or ulcer
formation.
Diagnostic Test

20. Medical Management
Complication
Clinical Manifestation
TYPES
Nursing Management
Nursing diagnosis
Diagnostic Test
Causes
Proximal DVT: Clot occurs in large veins (e.g.,
femoral, iliac).
Distal DVT: Clot forms in smaller veins (e.g.,
calf veins).
Deep Vein
Thrombosis
It is the formation of a blood clot in a deep vein,
usually in the legs, impairing venous return and
oxygenation of tissues.
Swelling of the affected
limb
Pain or tenderness (often
in the calf)
Warmth and redness over
the clot site
Positive Homan’s sign
(pain with dorsiflexion,
though not always
reliable)
Doppler Ultrasound: imaging test that
uses sound waves to detect blood flow
and identify clots in deep veins.
D-dimer Blood Test: Measures clot
formation and breakdown.
Venography: Invasive imaging test using
contrast dye and X-rays to visualize vein
structure and detect clots, used if other
tests are inconclusive.
Prolonged immobility
(e.g., surgery, long
flights)
Hypercoagulable
states (e.g., cancer,
pregnancy)
Endothelial damage
(e.g., trauma,
surgery)
Smoking and obesity
Anticoagulants: To prevent clot growth (e.g., heparin,
warfarin).
Thrombolytics: For severe cases to dissolve clots (e.g.,
alteplase).
Compression Therapy: Graduated compression stockings.
Pulmonary
embolism (PE)
Chronic
venous
insufficiency
Post-
thrombotic
syndrome
Elevate the affected limb to reduce swelling.
Encourage early ambulation or leg exercises as
prescribed.
Administer prescribed anticoagulants and monitor
for bleeding.
Educate the patient about signs of pulmonary
embolism and medication adherence.
Ineffective Peripheral Tissue Perfusion related to venous
obstruction, evidenced by swelling and pain in the
affected limb.
Acute Pain related to inflammation and clot formation,
evidenced by tenderness and reported pain.
Risk for Impaired Skin Integrity related to venous
congestion, evidenced by redness and swelling.
Diagnostic Test

21. Varicose Veins
Varicose veins are enlarged, twisted veins resulting
from weakened valves and poor blood flow,
primarily affecting the legs.
Compression Therapy: Use of compression stockings to
improve circulation.
Sclerotherapy: Injection to close off small varicose veins.
Surgical Treatment: Vein stripping or endovenous laser
therapy for severe cases.
Medical Management
Complication
Clinical Manifestation
TYPES Nursing Management
Nursing diagnosis
Diagnostic Test
Causes
Primary Varicose Veins: Develop in superficial
veins due to valve dysfunction.
Secondary Varicose Veins: Result from deep
vein obstruction or damage, often related to
DVT.
Bulging, twisted veins
visible under the skin
Leg heaviness or aching,
especially after standing
Swelling in the legs and
ankles
Itching or skin
discoloration near
affected veins
Doppler Ultrasound: Evaluates blood
flow and valve function in veins.
Venography: Uses contrast dye to assess
vein structure, if needed.
Prolonged
standing or
sitting
Obesity
Pregnancy
Family history of
varicose veins
Aging and
hormonal
changes
Ulcer formation
(venous ulcers)
Thrombophlebitis
(inflammation with
clot formation)
Bleeding from
ruptured veins
Educate on leg elevation and avoiding prolonged
standing/sitting.
Encourage use of compression stockings as
prescribed.
Monitor for complications like ulcers or
thrombophlebitis.
Promote regular exercise to enhance venous return.
Ineffective Peripheral Tissue Perfusion related to venous
stasis, evidenced by swelling and skin discoloration.
Chronic Pain related to vein distension, evidenced by
reports of aching legs.
Risk for Impaired Skin Integrity related to venous
congestion, evidenced by itching or ulcer formation.
Diagnostic Test