CCM Nur1217

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Complete Course Module

NUR1217 – Medical Surgical Nursing 2

FEU – Institute of Nursing NUR1217 Team


FEU – Institute of Nursing NUR1217 Complete Course Module

FAR EASTERN UNIVERSITY


INSTITUTE OF NURSING

COMPLETE COURSE MODULE


SECOND SEMESTER
A.Y 2020 - 2021

NUR1217 – NCM 116 Care of Clients with. Problems in. Nutrition, and. Gastro-intestinal,. Metabolism
and. Endocrine,. Perception and. Coordination. (Acute and. Chronic)

Contents

Facilitator ......................................................................................................................................... 4
Course Information .......................................................................................................................... 4
Course Status ........................................................................................................................................................ 4
Course Purposes and Goals ............................................................................................................................... 4
Course Expected Learning Outcomes (CELO) ................................................................................ 4
FEU’s Core Competencies (FCC) ..................................................................................................... 5
The FEU Student-Centered Teaching and Learning Culture .......................................................... 6
The FEU Institute of Nursing Curriculum Principle ........................................................................ 6
Delivery Methods .............................................................................................................................. 7
The DLECCT Framework ..................................................................................................................................... 8
Outcomes-based Learning .................................................................................................................................... 8
Project and Problem-based Learning ................................................................................................................... 8
Authentic Assessment and Learning ..................................................................................................................... 8
Blended Learning ................................................................................................................................................. 8
Independent Study ................................................................................................................................................. 8
The Online Learning Environment .................................................................................................. 9
Assessment Methods ....................................................................................................................... 11
FEU Policy on Academic Integrity ................................................................................................. 14

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FEU – Institute of Nursing NUR1217 Complete Course Module

Policy on Plagiarism .......................................................................................................................................... 14


Policy on Late Submission .................................................................................................................................. 15
Learning Content and Activities ..................................................................................................... 15
Course Outline ................................................................................................................................ 16
Virtual RLE Daily Action Plan ....................................................................................................... 20
Scheme of Work and Important Dates (MOL and AOL) ............................................................... 22
Lecture Handouts……………………………………………………………………………………………………………………………23
Skills Laboratory Checklists ............................................................................................................ 181
RLE (Virtual) Evaluation Tools and Guidelines …………………………………………………...203
Student Support ............................................................................................................................ 214

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FEU – Institute of Nursing NUR1217 Complete Course Module

Facilitator

Name : Neugene Rowan S. Cu, MAN, CNN, CSSYB (Team Leader)


E-mail : ncu@feu.edu.ph
Section :
Course schedule : See IN official announcement on Schedule as it varies due to the line up of activities
Consultation hours: 8:00 am to 5:00 PM Mon - Fri

Course Information

Course Status

Ø Credits : 9 units (Theory 5 units – 90 hours; Skills Lab 1 unit – 51 hours;
Clinical 3 units – 153 hours)
Ø Total Learning Time : 294 hours (18 weeks)
Ø Course Status : Nursing Care Management 116
Ø Pre-requisite : NUR1213 (NCM 112 – Care of Clients with Problems in Oxygenation,
Fluid and Electrolyte, Infectious, Inflammatory and Immunologic Response, Cellular Aberration (Acute
and Chronic)) and NUR1214 (NCM 113 – Community Health Nursing (CHN) II: Population Groups and
Community as Clients)

Course Purposes and Goals

This course deals with concepts, principles, theories and techniques of nursing care of at-risk and sick adult
clients in any setting with alterations / problems in nutrition, and gastro-intestinal, metabolism and endocrine,
perception and coordination, acute and chronic toward health promotion, disease prevention, restoration and
maintenance, and rehabilitation.

Course Expected Learning Outcomes (CELO)

Upon completion of the course, you should be able to:

Expected Learning Outcome FEU Core Competencies


Apply knowledge of physical, social, natural and health sciences and FCC 1.1. 1.2. 2.2 2.3.
humanities in the practice.
Provide safe, appropriate and holistic care of clients applying the FCC 1.4 2.4 4.1
nursing informatics system in the nursing process as the framework
of care.
Apply guidelines and principles of evidence-based nursing practice in FCC 1.3 1.4 2.1 2.2. 2.3. 2.5
the delivery of care. FCC 3, 4
Practice nursing in accordance with existing legal, ethical, and moral FCC 1.3 1.4 2.4 2.5
principles. FCC 3, 4.1
Communicate effectively in speaking, writing and presenting, using FCC 1.1 1.2 2.1 2.2 2.3
culturally appropriate language. FCC 3, 4
Document client care accurately and comprehensively with the aid of FCC 1.1 1.2 2.1 2.2 2.3
information technology system. FCC 3, 4
Work effectively in collaboration with inter-, intra- and FCC 1.1 1.2 2.1 2.2 2.3
multidisciplinary and multi-cultural teams. FCC 3, 4
Practice beginning management and leadership skills using systems FCC 1.1. 1.2 1.3. 1.4. 2.3.
approach in the delivery of client care. 2.4. 2.5

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FEU – Institute of Nursing NUR1217 Complete Course Module

FCC 3
Conduct research with an experienced researcher. FCC 3, 4
Engage in lifelong learning with a passion to keep current with FCC 1.4. 2.1. 2.2. 4.1
national and global development in general and nursing and health
developments in particular.
Demonstrate responsible citizenship and pride as a Filipino nurse. FCC 1.1 1.2 2.1 2.2 2.3
FCC 3, 4
Apply techno-intelligent care systems and processes in health care FCC 1.2 1.3. 2.5
delivery.
Adopt the nursing core values in the application of Information FCC 1.1 1.2 2.1 2.2 2.3
Technology System in nursing practice. FCC 3, 4
Apply entrepreneurial skills in the delivery of nursing care. FCC 1.1 1.2 2.1 2.2 2.3
FCC 3, 4

FEU’s Core Competencies (FCC)

In addition to the Course Learning Outcomes, students are also expected to demonstrate and develop the
following skills:

FCC 1: Cognitive Knowledge

COGNITIVE 1.1. Critical Thinking


KNOWLEDGE 1.2. Creative Thinking
1.3. Problem Solving Skills
1.4. Life-long Learning

FCC 2: Soft Skills

SOFT SKILLS 2.1. Digital Literacy


2.2. Communication Skills
2.3. Inter and Intrapersonal skills
2.4. Work ethics
2.5. Values and leadership

FCC 3: Hard Skills

3.1. Office Suites Skills (Word Processing, Spreadsheets,


HARD SKILLS Presentation tools)

FCC 4: Discipline Specific Knowledge


DISCIPLINE
SPECIFIC 4.1. Scholarship in the specific discipline
4.2. Research-based knowledge development
KNOWLEDGE

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FEU – Institute of Nursing NUR1217 Complete Course Module

The FEU Student-Centered Teaching and Learning Culture

FEU practices, advances, and advocates for a learning culture that is student-centered. FEU affirms the ability of
students to produce valuable reactions to, reflections and questions on, and understandings and appreciations of
topics and issues in classroom. As such, the FEU classroom is set-up in a manner that will best solicit student
input and the FEU teacher’s responsibility is to ensure that the students participate in the generation of ideas
rather than be passive recipients of ideas. FEU and FEU teachers firmly believe that the atmosphere in which
learning and development happen best is an atmosphere where students are co-authors of ideas. The FEU
teachers’ role, therefore in the classroom is to coach and facilitate creation.

The characteristics of a culture of student-centered learning are that it is constructive. Teachers within a culture
of student-centered learning provide opportunities for students to construct knowledge and guide students in the
creation of new knowledge; they see assessment as an opportunity for learning and formation. It is also relevant
and responsive in that ensures that students are provided activities drawn from authentic and real-life situations
that will encourage students to connect learning with real-life situations. Its atmosphere is one that is democratic
in its insistence on the recognition and respect of the diversity of opinions and ideas and on its emphasis on an
understanding and appreciation of the context upon which these diverse ideas are born. Student-centered learning
values and encourages critical thinking and active learning by engaging students to ask essential questions and by
synthesizing and contextualizing viewpoints. Students, in this learning environment reflect and ask questions,
seek relevance and engage in scholarly discourse that leads to inferences, insights, and sound positions.

In FEU, student-centered learning is undertaken in a technology-enabled learning environment that promotes


digital literacy. It utilizes technology for more relevant and meaningful learning. The FEU student, in turn, sees
technology as a tool for learning and use it responsibly.

The student-centered classroom is interdisciplinary, integrative, and interactive. Its teachers challenge students to
interconnect disciplines and relevant issues and to find interconnections and patterns. The objective of student-
centered learning is the development of lifelong learners and creative thinkers and the cultivation of attitudes and
habit that ensure continuous self-enhancement and knowledge generation. As products of the FEU student-
centered experience, FEU students are models of competent and effective learners and of the continuous quest for
knowledge making.

The FEU Institute of Nursing Curriculum Principle

The Institute of Nursing offers Bachelor of Science in Nursing Program.

The curriculum, which is based on the three frameworks: competency, community, and evidence, is the core of
IN’s success in producing world class Nurses.

Course offerings evolve from a philosophical belief that the goal of nursing is to assist consumers of care to reach
their health goals. The nurse uses caring behaviors and the science of nursing to achieve these goals.

The product then, of the Institute of Nursing, is a nursing leader or a nurse with a potential for leadership who is
value driven, a critical thinker, technologically proficient, committed to the profession and who cares very deeply
about providing safe, quality, and humane care.

This mission is accomplished through modeling behavior, mentoring, and motivating by faculty members.

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FEU – Institute of Nursing NUR1217 Complete Course Module

The Bachelor of Science in Nursing (BSN) Program prepares graduates to provide and manage client care and to
become members of the discipline of Nursing. Graduates are eligible to take the National Licensure Examination
given by the Professional Regulations Commission Board of Nursing.

The BSN curriculum is organized around a clearly defined conceptual framework which combines general
education and nursing education. The nursing education courses, which are held in our beautiful campus are
enhanced by clinical instruction in both our state-of-the-art Virtual Integrated Nursing Education Simulation
(VINES) Laboratory and selected healthcare institutions in the community. Students gain valuable experience in
the care of clients of all ages in a variety of health care settings.

Delivery Methods

Total Contact Hours :Theory 45 hours; Skills Lab 25.5 hours; RLE Online 40.5 hours / 18 weeks
CANVAS :Theory 45 hours; Skills Lab 25.5 hours; RLE Online 40.5 hours / 18 weeks

The NUR1217 follows a three-phase schedule namely:

Phase 1 will follow a FAST-TRACK SCHEDULE (Number of hours shall be consumed within the
given time frame)
1. Theory Phase – Phase where all necessary didactics about the Care of Clients with Gastrointestinal,
Endocrine, Metabolic, Neurologic, Eye and Ear Alterations, and Musculoskeletal Alterations will be
discussed prior to moving to Phase 2 and 3.

Phase 2 and 3 will follow a REGULAR SCHEDULE


2. Skills Laboratory – Also known as Skills Lab, this is where all the necessary nursing skills including its
critical thinking component will be discussed and put emphasis to. 25.5. hours will be conducted online
for the instructional portion of skills lab, while the other half or 25.5 hours will be conducted on a face to
face basis with strict adherence to the IATF guidelines if permitted to do so. In case that face to face will
not push thru, an online meeting and/or asynchronous short video submission of a skill as well as
branching scenarios shall be considered.
3. Related Learning Experience (RLE) Online - A virtual learning environment wherein a real-life nurse-
patient interaction will be simulated through the virtual hospital exposure in partnership with affiliated
hospitals.

Primer on Virtual RLE

The BSN Program of the Institute of Nursing is notable for training student nurses to be competent in providing
actual patient care in varied clinical settings. This had been made possible, as the students were allowed hands on
experiences under the direct supervision of their clinical instructors/ preceptors.

The unexpected occurrence of the COVID-19 Pandemic has created a swift change in the educational landscape.
Higher education institutions were challenged to adapt to these sudden changes, especially in transition from face-
to-face learning to online learning. Moreover, online learning modality has greatly affected the academic
component on Related Learning Experience because learning was compromised as far as doing actual bedside
care and clinical procedures are concerned.

However, the Institute is committed to maintain the quality of education and learning capabilities of our nursing
students despite the changes in the educational landscape. Thus, in order to achieve the higher levels of
competency among our nursing students, a virtual RLE is proposed. To augment the lack of actual experiences,
the Institute conceptualized a virtual clinical exposure among its students through its affiliating hospitals.

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FEU – Institute of Nursing NUR1217 Complete Course Module

Concept: Medical-Surgical Nursing

Focus: Care of individuals with alterations or/at risk (Neuro, Eyes/ears

Endocrine/Metabolism, Musculoskeletal

Areas: Operating Room (, Intensive Care Unit and Orthopedic Ward

***Please see COURSE OUTLINE FOR THE DAILY ACTION PLAN

In reference to the FEU’s Teaching and Learning Philosophy, the following are the acceptable instructional
methods that can be adapted for this course:

The DLECCT Framework

A conceptual understanding on how teaching, assessment, and classroom dynamics must be approached in FEU.
It banks on the University’s aspiration for adaptive excellence: digital literacy, effective communication, and
critical thinking. These are the core competencies that every FEU student must manifest after completing their
academics in the University.

Outcomes-based Learning

This allows the students to be owners and constructors of their own learning by creating artifacts that solve
pressing problems in their respective communities and disciplines.

Project and Problem-based Learning

Inquiry and Collaborative Learning


To instil the value of scholastic independence, cooperative and cooperative learning must be part of the class
dynamics. Tasks done inside and outside the classroom promote collaboration and collaboration.

Authentic Assessment and Learning

FEU prioritizes non-traditional assessment approaches such as alternative assessment, performance-based, and
authentic assessment in observing and monitoring students’ performance. With non-traditional assessment, the
FEU students also participate in monitoring their learning progress.

Blended Learning

This allows every class to utilize traditional and non-traditional learning spaces including classroom, on-line,
communities, and industries.

Independent Study

This allows the students the needed time and space to read, write, and complete major tasks.

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FEU – Institute of Nursing NUR1217 Complete Course Module

The Online Learning Environment

The FEU online environment will vary depending on what mode of learning the student decides to take:

Modes of Learning (Taken from the FEU Freshmen Primer 2020-2021)

Mode of Learning Recommended Internet Learning Class meetings


for Connectivity materials
• Differs from class
to class
• Minimum of 8 and
Mixed Online Learning All kinds of Requires good and Through maximum of 24
(MOL) learners stable internet CANVAS teacher-student
engagement.
• Minimum of 4
Synchronous and individualized
Asynchronous Learning feedback of
academic progress
• Meetings through
conference, small
group discussions
or individual
consultations.
Asynchronous Online Highly Requires good Through • No regular
learning (AOL) independent and internet CANVAS meetings, only
responsible connection scheduled
learners consultations
Independent Learning (minimum of 4
requiring internet access scheduled
consultations).
Total Analogue Learning Highly Stable internet All learning • No regular
(TAL) independent and access is not material will be meetings, only
responsible required some compiled into a scheduled
learners access still USB and consultations
Independent learning necessary for couriered to the (minimum of 4
requiring minimal consultation and student scheduled
internet access research consultations)

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FEU – Institute of Nursing NUR1217 Complete Course Module

Responsibilities in the Online Learning Environment

For teachers
• Make learning materials available in the CANVAS Course Modules (MOL & AOL) and USB thumb
drive (TAL).
• Give comprehensive and clear instructions for the course activities, assignments and assessments.
• Provide reasonable and flexible deadlines for each learning tasks.
• Set simple and concrete guidelines on to how to communicate within the online classroom (MOL &
AOL).
• Facilitate conferences and discussion forums (MOL & AOL).
• Constantly give immediate and individualized feedback about student’s academic performances through
emails and chats.
For Students
• Acquire course materials. Save back-up copies of the course materials. This involves downloading and
storing learning materials such as the syllabus, reading list, video and audio files in their desktop
computer/laptop/tablet/mobile devices.
• Organize and manage schedule. Organize deadlines for their course assignments, quizzes and projects.
• Learn the course modules. Independently cover each learning modules in the course (e.g. reading and
annotating course modules).
• Attend class. Online attendance pertains to logging in CANVAS and actively participate in the course
activities required by the teacher. (MOL & AOL)
• Troubleshoot technical issues. Learn how to solve technical issues that would arise in their learning set-
up.
• Complete required assessments. Submit attached files, text entries and URL links as online assignments.
Accomplish online quizzes and participate in graded discussion forums. (MOL & AOL).
• Collaborate with peers. Work together with their fellow classmates by using collaborative tools such as
CANVAS Collaborations/Google Docs and Pages. (MOL & AOL)
• Communicate online. Utilize all the various means of communication to keep in touch with their teacher
and fellow students.
• Fulfil learning tasks with academic integrity. Observe professionalism and honesty in carrying out their
academic projects and assignments

FEU Ederp

Office Hours: 8:00 AM to 5:00 PM


E-mail for Student Central PASSWORD ISSUES: itshelpdesk@feu.edu.ph

E-mail for Student Central ENROLLMENT ISSUES: ederphelpdesk@feu.edu.ph


Contact No. for Student Central PASSWORD ISSUES: 87777338 local 609.

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FEU – Institute of Nursing NUR1217 Complete Course Module

Assessment Methods

Classroom assessment in FEU is a joint process that involves both teachers and learners. It is an integral part of
teaching and learning which holistically measures learners’ current and developing abilities. FEU encourages
authentic assessment which promotes real-life learning. Adhering to this paradigm, below are the guidelines in
classroom assessment in the university.

1. Grading periods will be limited into two: Preliminary and Final periods. The 18 weeks will be divided
equally. Each of the grading periods will be nine (9) weeks each.
2. Assessments in the university are classified into Formative and Summative. Below are the samples of
each type.

Formative Assessment Summative Assessment


• Quiz (short-long) • Departmental exams (Pen
• Seatwork and paper) – unit, chapter,
• Reporting preliminary and final
• Work samples (portfolio) exams.
• Demonstration & • Case study/problem analysis
observation of skill • Capstone/application
• Peer evaluation of project projects
work • Research/term paper
• External review of student • Performance test for skill-
projects based courses
• Self-evaluation of work

3. Each grading period, the minimum requirement for faculty to accomplish are the following:
a. Formative Assessment (FA) – 60 %
b. Summative Assessment (SA) – 40 %
4. The calculation for the grades will be based from the formula below:

1. Grade Per Concept


Formative 60%
Summative (Concept Exam) 40%

2. Partial Theory Grade = [(Metab Endo Grade 33%) + (Neuro Grade 28%) + (EE Grade 13%) +
(Ortho Grade 26%)]
3. Final Theory Grade = Partial Theory Grade 80% + Comprehensive Exam 20%

Skills Laboratory

1. Average of Skills Laboratory Activities

RLE Online

1. RLE Grade = [(Metab Endo Grade 25%) + (Neuro Grade 25%) + (EE Grade 25%) + (Ortho
Grade 25%)]

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FEU – Institute of Nursing NUR1217 Complete Course Module

Final Course Grade = Final Theory Grade 40% + Skills Laboratory Grade 24% + RLE Online
Grade 36%

*FA and SA are calculated through averaging.


*The new Grade Point Average (GPA) system will still be used.
*The weight between FA and SA can be changed based on the recommendation of the committee.
However, SA should not exceed 50%.

5. The general passing standard is 50%.

6. Grade Points will be based from the standards below:

Written Quality Numerical Grade Description


Grade Point Equivalent

A 4.00 92–100 Provides evidence of:


1. complete and comprehensive mastery of the concepts and
principles of the course;
2. outstanding proficiency in analytical, critical and creative thinking,
and problem-solving skills; and
3. excellent fluency in oral written and symbolic communication.
Exhibits an exemplary level of independent and self-regulatory
learning skills. Adheres to the University policy on academic
integrity.
B+
3.50 85–91 Provides evidence of:
1. full mastery of the concepts and principles of the course;
2. high proficiency in analytical, critical and creative, and problem-
solving skills; and
3. very good fluency in oral, written and symbolic communication.
Exhibits a high level of independent and self-regulatory learning
skills. Adheres to the University policy on academic integrity.

B 3.00 78-84 Provides evidence of:


1. considerable mastery of the concepts and principles of the course;
2. significant proficiency in analytical, critical and creative, and
problem-solving skills; and
3. good fluency in oral, written and symbolic communication.
Exhibits an above average level of independent and self-regulatory
learning skills. Adheres to the University policy on academic
integrity.

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FEU – Institute of Nursing NUR1217 Complete Course Module

C+ Provides evidence of:


2.50 71–77 1. intermediate mastery of the concepts and principles of the course;
2. adequate proficiency in analytical, critical and creative, and
problem-solving skills; and
3. Average fluency in oral, written and symbolic communication.
Exhibits an ample level of independent and self-regulatory learning
skills. Adheres to the University policy on academic integrity.

C 2.00 64–70 Provides evidence of:


1. satisfactory mastery of the concepts and principles of the course;
2. satisfactory proficiency in analytical, critical and creative, and
problem-solving skills; and
3. acceptable fluency in oral, written and symbolic communication.
Exhibits a sufficient level of independent and self-regulatory learning
skills. Adheres to the University policy on academic integrity.

D+ Provides evidence of:


1.50 57–63 1. elementary mastery of the concepts and principles of the course;
2. a certain proficiency in analytical, critical and creative, and
problem-solving skills; and
3. some fluency in oral, written and symbolic communication.
Exhibits a somewhat low level of independent and self-regulatory
learning skills. Adheres to the University policy on academic
integrity.
D Provides evidence of:
1.00 50–56 1. minimal mastery of the concepts and principles of the course;
2. minimal proficiency in analytical, critical and creative, and
problem-solving skills; and
3. basic fluency in oral, written and symbolic communication.
Exhibits a low level of independent and self-regulatory learning
skills. Adheres to the University policy on academic integrity.

F Provides evidence of:


0.00 Below 50 1. no mastery of the concepts and principles of the course;
2. no proficiency in analytical, critical and creative, and problem-
solving skills; and
3. no fluency in oral, written and symbolic communication.
Does not exhibits independent and self-regulatory learning skills.
Does not adheres to the University policy on academic integrity.

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FEU – Institute of Nursing NUR1217 Complete Course Module

FEU Policy on Academic Integrity

Policy on Plagiarism

Anchored on the core values of Fortitude, Excellence and Uprightness, Far Eastern University (FEU) believes that
its students, administration, faculty and staff should demonstrate academic integrity at all times. Academic
integrity means that the members of the entire academic community adhere to the fundamental values of honesty,
hard work, originality, respect and responsibility. FEU students are expected to always adhere to the highest
standards of academic excellence.

FEU students are expected to demonstrate beliefs, attitudes and behaviours associated with academic honesty.
Thus, all acts of academic dishonesty in FEU are not tolerated. Academic dishonesty comes largely in two forms:
cheating and plagiarism. It is considered a major offense subject to disciplinary actions if students cheat or
plagiarize their work.

Cheating is broadly defined as getting unauthorized help on an assignment, quiz or examination. The following
are considered as acts of cheating:
• Copying from another student during a test or examination, with or without his/her knowledge;
• Allowing another student to copy his/her work;
• Using unpermitted notes during a test or examination;
• Having in one’s possession written notes or electronic devices during a test or examination;
• Getting questions or answers from someone else who has already taken a test or examination;
• Turning in work done by someone else;
• Taking a test or examination for another student;
• Writing or providing an assignment for another student.
Cheating is broadly defined as getting unauthorized help on an assignment, quiz or examination. The
following are considered as acts of cheating:
• Copying from another student during a test or examination, with or without his/her knowledge;
• Allowing another student to copy his/her work;
• Using unpermitted notes during a test or examination;
• Having in one’s possession written notes or electronic devices during a test or examination;
• Getting questions or answers from someone else who has already taken a test or examination;
• Turning in work done by someone else;
• Taking a test or examination for another student;
• Writing or providing an assignment for another student.
• Repeating someone else’s words verbatim without acknowledgement;
• Presenting someone else’s ideas without acknowledgement;
• Paraphrasing, translating, or summarizing someone else’s ideas without acknowledgement;
• Improperly acknowledging of sources, as with incomplete/imprecise documentation;
• Having one’s work done by someone else or having one’s work substantially revised by someone
else.

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FEU – Institute of Nursing NUR1217 Complete Course Module

Policy on Late Submission

Assignment deadlines must be strictly adhered to as time management is a highly valued professional skill. The
facilitator would provide a five-day submission period. Assignments which are submitted late will be penalised as
follows:

Submitted one (1) day after deadline - deduct 5% from marks awarded
Submitted two (2) days after deadline - deduct 10% from marks awarded
Submitted three (3) days after deadline - deduct 15% from marks awarded
Submitted four (4) days after deadline - deduct 20% from marks awarded

Submitted five (5) days after deadline – ZERO (0) marks for the assignment.

For the purpose of assignment submission, Saturday and Sunday are also counted as working days.

Learning Content and Activities

1. Hinkle, Janice L. and Kerry H. Cheever (2018) Brunner & Suddarth’s Textbook of Medical
Surgical Nursing Volume 1 & 2. 14th edition. Lippincott Williams & Wilkins
2. Jarvis, Carolyn (2020) Physical Examination and Health Assessment. 8th edition. Elsevier
3. Udan, Josie Q. (2017) Medical Surgical Nursing: Concepts, Theories and Practice. Third
Edition. Jade Publishing House
4. Harding, Mariann, Jeffrey Kwong, Dottie Roberts (2020) Lewis’ Medical-Surgical Nursing.
11th Edition. Mosby

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FEU – Institute of Nursing NUR1217 Complete Course Module

Course Outline

Week/ Topics Content
Date
1 A. Orientation to Policies, Mission, Vision, Core Video-recorded lecture
(Jan 18 to Values, Professional Values and Institutional Quiz
23) Values Worksheet completion
(Analog)
B. Nursing Care of At-Risk and Sick Adult Clients
with Acute and Chronic alterations/problems in
Nutrition, and Gastro-intestinal, Metabolism and
Endocrine, Perception and Coordination

1. Assessment
a. Subjective Data
b. Objective Data
i. Review on Anatomy and Physiology
of Body Systems on Gastrointestinal,
Endocrine, Musculoskeletal and
Nervous
ii. Common Diagnostics for Clients with
Acute and Chronic
alterations/problems in Nutrition, and
Gastro-intestinal, Metabolism and
Endocrine, Perception and
Coordination

2-4 Responses to Acute and Chronic Alterations/ Video-recorded lecture


(Jan 25 to Problems and Its Pathophysiologic Basis in Quiz
Feb 16) Nutrition, and Gastro-intestinal, Metabolism Worksheet completion
and Endocrine, Perception and (Analog)
Coordination

Metab/End A. Nutritional-Metabolic Patterns/ Responses to


ocrine Altered Nutrition
BSN 301 1. Disturbances in Ingestion
to 305 • Gastroesophageal Reflux (GERD)
Jan • Hiatal Hernia
18,19,21,2 • Achalasia
2,23,25,26
2. Disturbances in Digestion
BSN 306 • Nausea and Vomiting
to 310 • Gastrointestinal Bleeding
Jan • Gastritis
18,19,20,2
• Peptic Ulcer Disease
1,22,25
3. Disturbances in Absorption and Elimination
• Disorders of Intestinal Motility

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FEU – Institute of Nursing NUR1217 Complete Course Module

• Malabsorption Syndromes
• Structural and Obstructive Bowel
Disorders

B. Nutritional-Metabolic Patterns/ Responses to


Altered Endocrine Function
1. Hyperfunction
2. Hypofunction
• Thyroid Gland
• Parathyroids
• Adrenal Glands
• Pituitary Glands
• Pancreas – Diabetes Mellitus

C. Responses to Altered Perception


Neuro
1. Neurologic Disturbances
BSN 301
1.1. Degenerative
to 305
• Multiple Sclerosis
Jan 28, 29,
• Parkinson’s Disease
30, Feb 2
• Myasthenia Gravis
BSN 306
to 310 1.2. Cerebrovascular Disease
Jan 26, 27, 1.3. Traumatic Lesions
28, 29, Feb • Head Injuries
2 • Spinal Injuries
1.4. Neuropathies

2. Disturbances in Visual and Auditory Function


Eyes & 2.1. Visual
Ears • Cataract
BSN 301 • Glaucoma
to 305 • Retinal Detachment
Feb 5, 6
BSN 306 2.2. Auditory
to 310 • Meniere’s Disease
Feb 3, 5, • Hearing Impairment
8*

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FEU – Institute of Nursing NUR1217 Complete Course Module

Ortho D. Responses to Altered Coordination Video-recorded lecture


BSN 301 1. Injuries Quiz
to 305 • Fracture Worksheet completion
Feb 8, 11, • Motor Vehicle Collision (Analog)
12, 15 • Sports Injury

BSN 306 2. Joint Disorders


to 310 • Osteoarthritis
Feb 8, 10, • Gout
15, 16 • Carpal Tunnel Syndromes
• Low Back Pains
3. Degenerative

5 to 17 1. Assessment List of Skills Procedure:


a. Subjective Data Metab
Skills Lab b. Objective Data • Glucose monitoring
BSN 301 i. Review on Anatomy and Physiology • NGT
to 305 of Body Systems on Gastrointestinal,
• Colostomy
Saturdays Endocrine, Musculoskeletal and
(Feb 20 to Nervous
• Enema
May 15) ii. Common Diagnostics for Clients with
Neuro and EE
Acute and Chronic
BSN 306 alterations/problems in Nutrition, and • Neuro Assessment
to 310 Gastro-intestinal, Metabolism and
Wednesda Endocrine, Perception and Ortho
ys Coordination • Skin Traction
(Feb 17 to • Casting
May 12) 2. Analysis/ Nursing Diagnosis • Gait Patterns
a. Actual Problems
b. Risk Diagnosis Video-recorded skills
demonstration
Quiz
3. Planning
Worksheet completion
a. Planning for Health Promotion (Analog)
b. Planning for Health Restoration and Maintenance

RLE 4. Implementation of Care of Clients RLE Online:


Online a. Independent Nursing Care Mediated Lecture
BSN 301 i. Physiologic Care (with power-point
to 305 ii. Psychosocial Care presentation, traditional
Mon-Tues iii. Spiritual Care oral essay lecture and
(March 8
web-page images)
to April
26)
b. Dependent Care
i. Pharmacological
BSN 306 ii. Therapeutics Interactive discussion
to 310 iii. Complementary and Alternative and group processing

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FEU – Institute of Nursing NUR1217 Complete Course Module

Thurs-Fri Therapies
(Feb 26 to iv. Nutritional and Diet Therapy Case study
April 8) v. Surgical Interventions
vi. Immunologic Therapy

5. Client Education
6. Evaluation of the Outcome of Care
a. Process Evaluation
b. Outcome Evaluation

7. Reporting and Documentation of Care


a. Common Documentation Practices on the Care of
At-risk and Sick Adult Clients with problems in
nutrition and gastro-intestinal, metabolic and
endocrine, perception and coordination, acute and
chronic.

b. Common anecdotal and strategies to enhance


performance and patient safety practices in the Care of
At-risk and Sick Adult Clients with problems in
nutrition and gastro-intestinal, metabolic and
endocrine, perception and coordination, acute and
chronic.

8. Evidence-Based Practices for the Care of


Clients with Acute and Chronic Alterations/
Problems and Its Pathophysiologic Basis in
Nutrition, and Gastro-intestinal, Metabolism
and Endocrine, Perception and Coordination
A. Importance of Evidence-Based Practice
B. Clinical Questioning Using PICOT format
C. Appraisal of Collected Evidences
D. Integration of Evidences to Care of Clients
E. Evaluation of Outcomes of Evidence-Based
Nursing
F. Documentation

9. A. Inter-professional Care Maps


B. Collaborative care of Clients with Acute and
Chronic Alterations/ Problems
1. Nutrition
2. Gastro-intestinal
3. Metabolism and Endocrine
4. Perception and Coordination

18 May 18 Comprehensive Examination

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FEU – Institute of Nursing NUR1217 Complete Course Module

Virtual RLE Daily Action Plan


DAY Expected Learning Learning Activities RESPONSIBLE Evaluative
Outcome PERSONS Assessment
Day At the end of 8 1.Orientation to the RLE Clinical 100% student
1 hours , students will Application of the Nursing Process as an Instructor participation
be able to: expected learning output (ELO) (both MOL and
1. Review the 1. Assessment AOL)
nursing 1.1. (Gordon’s Functional Patterns
process as 1.2. Physical Assessment
applied to a 1.3. Laboratories/Diagnostics
case
scenario; 2. Ecologic Model and Contextual
and Mapping (Pathophysiology)
2. Discuss the 3. Problem Identification &
learning Prioritization
expectation 4. Drug Study
s and 5. Nursing Care Plan
assessment 6. Evidence-based Nursing
.




2.Orientation to the Virtual Hospital Setting Clinical 100% student
Preceptor participation
2.1. VIRTUAL Hospital Tour ( (both MOL and
2.2. Tour of Area of Assignment (based on AOL)
Course Concept)
2.2.1. AREA
2.2.2. Daily Activities/Routine
2.2.3. Bedside Care
2.2.2. Documentation Forms and other
important activities
o Sample Patient’s Chart
o Sample Patient’s Profile Sheet with
Medical Diagnosis)
o Kardex (Medication Sheets,
Medication Cards, etc)
o I & O Forms
o Sample Doctors Order Sheets
o Sample Nurse’s Notes/Charting
o Vital Signs Sheet
o Sample Discharge Summary Sheet
o Other pertinent forms

3. Grading System

1. PATIENT CASE ASSIGNMENT 20%
2. Case Presentation 30%
(E-tool Rubrics*50%)
3. Peer Evaluation 10% Clinical
4. Nursing Care Plan 20% Instructor

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FEU – Institute of Nursing NUR1217 Complete Course Module

(individual) and
(Rubric *20%) Clinical
5. EBN (by Group) 10% Preceptor
6. Final Output 10%
( submission: of final output: 1 week after RLE)

4. Assign Case Scenarios to ASSIGNED
SUBGROUPS




Clinical
Instructor
and Clinical
Preceptor


2 1.Apply the Nursing 1.ACTUAL PATIENT CASE ASSIGNMENT 2 subgroups 100 % of MOL
Process using the for the Learners will
case scenario After an 8-hour virtual DUTY, students will be Clinical attend the
2. Analyze the case able to Instructor virtual handling
scenario of CASE
3. Delegate 1.Handle a case using the virtual CASE given
tasks/responsibilities during the First Day; 2 subgroups
to each member for the
4. Collaborate with 2.Using Virtual RLE and with the Aid of Media Clinical
group members Platforms like Zoom and MS teams, the students Preceptor
will be supervised by the Clinical
Instructor/Clinical Preceptor observing the
following activities during RLE:

o The Clinical Instructor and Clinical
Preceptor will endorse the case/s to
students during the PRE-CONFERENCE
o EACH subgroup will handle one virtual
patient with a case scenario. (5
students:1 patient)
o Students will perform bedside care
observing the vital information in the
case scenario (this may include specific
skills and procedures like IV
calculations, regulations, O2 inhalation,
etc…dependent on the case scenario
given)
o During the doctor’s rounds, the doctor
will give orders;
o The students will carry-out the doctor’s
orders and fill-out pertinent forms, duly
supervised by the assigned
CI/Preceptor
o Random Health Teachings and Case

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FEU – Institute of Nursing NUR1217 Complete Course Module

Discussion will be observed also during


the RLE Duty.
o ENDORSEMENT OF CASES to the
CI/Preceptor
o POST-CONFERENCE

DAY ASYNCHRONOUS MEETING**
3
o Subgroups will work on their Nursing
Process for Case Presentation on the
th th
4 and 5 Day.
o Submission of drafts for checking will
be done
o CI/Preceptor will submit annotated
file/feedback to the students

Day Present a Case Synchronous Class: Actual Case Presentation of 100 % of
4 Groups 1 & 2 assigned group
for the day will
**Group 3 & 4 may opt to attend or not attend present the case
the synch case presentation. comprehensively
and
systematically
Day Present a Case Actual Case Presentation of 100 % of
5 Groups 3 & 4 assigned group
for the day will
**Group 1 & 2 may opt to attend or not attend present the case
the synch case presentation. comprehensively
and
systematically

Scheme of Work and Important Dates (MOL and AOL)



1. Formative Assessment 1 on Metab/Endo - Jan 25
2. Formative Assessment 2 on Metab/Endo - Jan 26
3. Summative Assessment 1 (Concept Exam on Metab/Endo) - Feb 1
4. Formative Assessment 3 on Neuro – Feb 2
5. Formative Assessment 4 on Neuro – Feb 3
6. Summative Assessment 2 (Concept Exam on Neuro) - Feb 4
7. Formative Assessment 5 on EE – Feb 6
8. Summative Assessment 3 (Concept Exam on EE) - Feb 9
9. Formative Assessment 6 on Ortho – Feb 15
10. Formative Assessment 7 on Ortho – Feb 16
11. Summative Assessment 4 (Concept Exam on Ortho) – Feb 20
12. Grade Consultation – Mar 22 to 27 (Lecture Grades per Concept only)
13. Skills Laboratory – Feb 17 to May 15
14. RLE Online – Please refer to your respective Clinical Instructors per rotation
15. Comprehensive Examination – May 18

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FEU – Institute of Nursing NUR1217 Complete Course Module

Lecture Module – Care of Clients with Gastro-intestinal, Metabolic and Endocrine Disorders

Contents:

I. Review of Anatomy, Physiology and Functions of the Gastro Intestinal System


II. Assessment of the GIT
A. History
B. Physical Examination
C. Diagnostic Examinations
III. Latest update in GIT problems, treatment, and statistics

IV. Disturbances in GIT-Metabolism

1. Disturbances in Ingestion
a. Disorders of the Esophagus
1. GERD
2. Hiatal Hernia
3. Impaired esophageal motility
4. Esophageal Diverticula
2. Disturbances in Digestion
a. Nausea and vomiting
b. Peptic Ulcer disease
c. Gastritis
d. Food poisoning
3. Disturbances in Absorption and Elimination
a. Disorders of Intestinal Motility
1. Diarrhea
2. Constipation
3. Irritable Bowel Syndrome
4. Inflammatory Bowel Disease
- Crohn’s Disease
-Ulcerative Colitis
5. Fecal incontinence
b. Malabsorption syndromes
1. Sprue
2. Lactase Deficiency
3. Short bowel syndrome
c. Structural and obstructive bowel disorders
1. hernia
2. Intestinal Obstruction
3. Diverticular Disease
d. Anorectal Disorders
1. Hemorrhoids
2. Lesions – anal fissure; anorectal fistula; pilonidal disease
e. Appendicitis

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FEU – Institute of Nursing NUR1217 Complete Course Module

1. Review of Anatomy, Physiology and Functions of the Gastro Intestinal


System
The Gastrointestinal System is a 23- to 26 foot pathway for food, water, vitamins and minerals
for which has the primary function of breaking down food products that can fuel the body as a
source of energy.

All cells of the body require nutrients. These nutrients are derived from the intake of food that contains
proteins, fats, carbohydrates, vitamins and minerals, and cellulose fibers and other vegetable matter of
no nutritional value.

The primary digestive functions of the GI tract are the following:


1. Ingestion – is the consumption of solid or liquid food, usually through the mouth.
2. Digestion – is the breakdown of large organic molecules into smaller molecules that can be
absorbed. Digestion occurs through mechanical and chemical means.

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FEU – Institute of Nursing NUR1217 Complete Course Module

3. Absorption – is the movement of molecules out of the digestive tract and into the blood or
the lymphatic system. The epithelial cells that line the lumen of the small intestine absorbs
the small molecules of nutrients (amino acids, monosaccharaides, fatty acids, vitamins,
minerals and water) that result from the digestive process.
4. Elimination – is the removal of undigested material, such as fiber from food, plus other
waste products from the body as feces.

Organs of the Digestive System:

1. Alimentary Canal Organs


Ø Also called the gastrointestinal (GI) tract or gut, the alimentary canal (aliment- =
―to nourishǁ) is a one-way tube about 7.62 meters (25 feet) in length during life and
closer to 10.67 meters (35 feet) in length when measured after death, once smooth
muscle tone is lost. The main function of the organs of the alimentary canal is to
nourish the body. This tube begins at the mouth and terminates at the anus. Between
those two points, the canal is modified as the pharynx, esophagus, stomach, and small
and large intestines to fit the functional needs of the body.
Both the mouth and anus are open to the external environment; thus, food and wastes
within the alimentary canal are technically considered to be outside the body. Only
through the process of absorption do the nutrients in food enter into and nourish the
body’s ―inner space.ǁ

2. Accessory Organs /Structures


Ø Within the mouth, the teeth and tongue begin mechanical digestion, whereas the
salivary glands begin chemical digestion. Once food products enter the small intestine,
the gallbladder, liver, and pancreas release secretions—such as bile and enzymes—
essential for digestion to continue. Together, these are called accessory organs because
they sprout from the lining cells of the developing gut (mucosa) and augment its
function; indeed, you could not live without their vital contributions, and many
significant diseases result from their malfunction. Even after development is complete,
they maintain a connection to the gut by way of ducts.

Digestive System Processes and Regulation


The digestive system uses mechanical and chemical activities to break food down into absorbable
substances during its journey through the digestive system.

1) Process of Chewing or Mastication

(1) The salivation reflex is stimulated just by the sight, smell, or tasting food. About 1.5 liters of
saliva is secreted daily by the 3 pairs of glands – parotid, submaxillary, and sublingual glands.
(2) Saliva contains the enzyme ptyalin, or salivary amylase, which begins the digestion of
starches.

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FEU – Institute of Nursing NUR1217 Complete Course Module

2) Swallowing

Upon swallowing, the epiglottis moves to cover the tracheal opening and prevent swallowing.

3) Esophageal Peristalsis

A reflex action into the upper esophagus propels the bolus of food contracting in a rhythmic
sequence toward the stomach. The process of esophageal peristalsis simulataneously relaxes the
esophageal sphincter to permit this movement of food to the stomach.

4) Stomach

The stomach produces acidic fluid called the hydrochloric acid. Its purpose is to further breakdown
food into a more absorbable component and to aid in the destruction of ingested bacteria.
(1) The enzyme pepsin, initiates protein digestion.

(2) Intrinsic factor is also secreted by the gastric mucosa which combines with dietary vitamin
B12 so that it can be absorbed in the ileum. The absence of this intrinsic factor results to
pernicious anemia.

(3) Peristalsis in the Stomach

Peristalsis in the stomach (about half hour to several hours) propels food to the pylorus. The
pyloric sphincter contracts to allow food to move towards the small intestines. Food mixed with
gastric secretions is called chyme. Gastric secretions and motility is governed by hormones,
neuroregulators, and local regulators.

5) Small Intestines

Upon reaching the duodenum, accessory organs contribute to the secretions encountered by food
therein:
(1) Pancreas: secretes alkaline ph, high in concentrations of bicarbonate, to neutralize the acid
entering the duodenum from the stomach. Digestive enzymes involved from the pancreas
are:

a. Trypsin: digests proteins.


b. Amylase: digests starch.
c. Lipase: digests fats.
(2) Liver: secretes bile which emulsifies fats.

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FEU – Institute of Nursing NUR1217 Complete Course Module

(3) Gallbladder: stores bile secreted by the liver that will aid in the digestion and absorption of
fats.

Small, fingerlike projections called villi are present in the entire intestines that produce the
digestive enzymes and absorb nutrients from food. Absorption is the primary function of the small
intestines which begins in the jejunum by active transport and diffusion across the intestinal wall.

6) Large Intestines

After four hours of eating, waste residuals are passed in the terminal ileum into the proximal
portion of the colon through the ileoceccal valve. Bacteria make up a major component of its
contents which are neutralized by electrolyte secretions and mucus. Controlled by the autonomic
nervous system (parasympathetic nerve fibers as a spinal reflex), defecation is elicited by the
relaxation of the external anal sphincter.

27

Organs Process Hormones Enzymes Food Type Products

Mouth Mastication Salivary Carbohydrates Maltose


Salivary amylase
glands

Esophagus Swallowing

Stomach Digestion Gastrin pepsin Proteins Peptides


Serotonin
Liver Secretion

Pancreas secretion Pancreatic Carbohydrates Maltose


amylase Proteins Peptides
Trypsin Fats Fatty acids
Lipase & glycerol

Gall storage
bladder

Small Digestion Secretin


intestine absorption CCK

Large Absorption
intestine

rectum excretion

References:

Gulanick, M., (2014). Nursing Care Plans: Diagnoses, Interventions and Outcomes. Missouri : Elsevier
Mosby
Hinkle, J., (2018). Brunner & Suddarth’s textbook of medical-surgical nursing. Philadelphia : Wolters
Kluwer/Lippincott Williams & Wilkins.
Ignatavicius, D., (2016). Medical-surgical nursing: Patient-centered collaborative care.
Missouri : Elsevier/Saunders.
Ladwig, G., (2014). Mosby’s guide to nursing diagnosis. Missouri : Elsevier Saunders. Lilley, L., (2014).
Pharmacology and the nursing process. Missouri : Elsevier/Mosby
Rogers, K., (2011). Nurses test yourself in pathophysiology. Berkshire : Open University Press.



FEU – Institute of Nursing NUR1217 Complete Course Module

I. ASSESSMENT

A. Health History

– Demographic Data (age, sex)


– Personal & Family History
– Diet History
– Chief Complaint
v Onset
v Duration
v Quality & Severity
v Location
v Precipitating Factors
v Relieving Measures
v Associated Symptoms
v Family History
v Psychosocial History

B. Physical Examination/Review of Systems


v Inspection
v Palpation
v Percussion
v Auscultation

Diagnostic Procedures
1. Non-invasive:
Radiological Studies

1.1 Scout Film/Flat Plate of the Abdomen


> Plain X – ray of the abdomen
> Recumbent Position
ýbelts / jewelries

1.2 UGIS (Barium Swallow)


>To visualize the esophagus, stomach, duodenum and jejunum
> NPO for 6 – 8 hours
> Barium Sulfate (BaSO4) per orem
> X – rays taken on standing, lying position

After the procedure:


> Laxative
> Increase fluid intake
> Inform client that the stool is white for 24 – 72 hours
> Observe for Barium impaction : distended abdomen, constipation

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FEU – Institute of Nursing NUR1217 Complete Course Module

Barium Swallow

1.3 LGIS ( Barium Enema)


> To visualize the colon
> Low residue / clear liquid diet for 2 days
> Laxative for cleansing the bowel
> Suppository / cleansing enema in A.M.
> BaSO4 per rectum
> Care after the procedure – same as UGIS

Barium Enema

1.4 Ultrasound
> NPO for 8 – 12 HOURS
> Laxative as ordered (âbowel gas)

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FEU – Institute of Nursing NUR1217 Complete Course Module

Ultrasound

1.5 Magnetic Resonance Imaging


> produces cross sectional images of soft tissues and blood vessels using
magnetic fields.
> C/I: pacemakers, aneurysm clips, or orthopedic screws
> NPO 6h before
> Instruct to lie still for 60-90 mins.
> Remove all Metals (jewelry,
dentures, eyeglasses)

1.5 CT Scan
> produces cross sectional images of internal organs, bones, soft tissue and
blood vessels
> with or without contrast
> C/I:Allergy to shellfish; pregnancy
>NPO 4-6 hrs
>Remove all Metals (jewelry, dentures, eyeglasses)

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FEU – Institute of Nursing NUR1217 Complete Course Module

2.1 HIDA (hepatobiliary iminodiacetic acid scan) Scan


>tracks the flow of bile from the liver, gall bladder and bile ducts
>Uses radioactive tracers
> C/I: Allergy to shellfish;
pregnancy; barium or bismuth
(4 days)
>NPO 4-12 hrs

HIDA Scan

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FEU – Institute of Nursing NUR1217 Complete Course Module

3. invasive: Endoscopy
3.1 UGI Endoscopy
> Direct visualization of esophagus, stomach, and duodenum
> Obtain written consent
> NPO for 6 – 8 hours
> Anticholinergic (AtSO4) as ordered
> Sedatives, narcotics, tranquilizers E.g. Diazepam, Meperidine HCl

3.1.1 Esophagogastric duodenoscopy


3.1.2 Capsule Endoscopy
3.1.3 Double Balloon Endoscopy
>Remove dentures, bridges
>Local spray anesthetic on posterior
pharynx
>instruct : X swallow saliva

Capsule & Double Balloon Endoscopy

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FEU – Institute of Nursing NUR1217 Complete Course Module

Capsule Endoscopy

After the procedure


>Side – lying position
>NPO until gag reflex returns (2 – 4hrs)
>NSS gargle; throat lozenges
>Monitor VS
>Assess : bleeding, crepitus (neck), fever, neck / throat pain, dyspnea,
dysphagia, back / shoulder pain
>Advise to avoid driving for 12 hours if sedative was used.

Endoscopy

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FEU – Institute of Nursing NUR1217 Complete Course Module

3.2 LGI Endoscopy
3.2.1 Proctosigmoidoscopy
(sigmoid,rectum)
>Obtain written consent
>Clear liquid diet 24 hours before
>Administer cathartic / laxative as ordered
>Cleansing enema
>Knee – chest / lateral position

After the procedure


>Supine position for few minutes
>Assess for signs of perforation
Bleeding
Pain
Fever
>Hot sitz bath for discomfort

3.2 LGI Endoscopy


3.2.2 Colonoscopy
>Obtain written consent
>Clear liquid diet 24 hours before
>Sedation
>Position : left side, knees flexed

3.1 LGI Endoscopy


After the procedure
>Supine position for few minutes
>Assess for signs of perforation
Bleeding
Pain
Fever
>Hot sitz bath for discomfort

Endoscopy

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FEU – Institute of Nursing NUR1217 Complete Course Module

Endoscopy

3.3 Other Endoscopic Procedures


3.3.1 Endoscopic Retrograde Cholangio-pancreatography (ERCP)
> Visualization of common bile duct >C/I: Allergy to shellfish
>Obtain written consent
>Clear liquid diet 24 hours before
>Sedation
>Position : left side during insertion

Endoscopic Retrograde Cholangio-pancreatography (ERCP)

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FEU – Institute of Nursing NUR1217 Complete Course Module

3. Invasive: Other GI TESTS

3.4 Bernstein test


(Acid perfusion test)
>reproduce symptoms of heartburn
>Mild hcl followed by saline solution through NGT
>NPO for 8 hours
>Obtain written consent

3.5 Endoscopic Ultrasound

3.6 Peritoneoscopy
(Diagnostic Laparoscopy)
>General Anesthesia

3.7 Esophageal Manometry


>measure the pressure inside the lower part of the esophagus
>Dx of swallowing problems

Peritoneoscopy

3.8 Ambulatory Esophageal pH monitoring


>measures how often and for how long stomach acid enters the esophagus

3.9 Exfoliative Cytology


> Detect malignant cells
> Written consent
> Liquid diet
> UGI : NGT insertion
> LGI : laxative; enema
> Cells are obtained from saline
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FEU – Institute of Nursing NUR1217 Complete Course Module

Lavage – NGT / Proctoscope
Laboratory Tests

C. Laboratory Tests
1. D-Xylose absorption test
> Tests how well the intestines absorb a simple sugar (D-xylose)
> 8 ounces of water that contains 25 grams of D-xylose
> Blood sample (2 & 5 hrs post)
> Urine sample(5 & 8 hrs post)
> NPO 8-12 hrs
> Restrict activity
>(+) or (-)
> Celiac Dse
> Chron’s Dse
> Hookworm
> Viral Gastroenteritis
> Whipple’s Dse (Malabsorption)

2. Enzymes

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FEU – Institute of Nursing NUR1217 Complete Course Module

3. Liver Function tests (liver panel)

4. Liver Function tests (liver panel)

5. Fecal Analysis
5.1 Fecal occult blood Test (FOBT)
> Guaiac, Hemoccult
> Detect G.I. Bleeding
> fiber diet 48 – 72 hours
> ý red meats, poultry, fish, turnips, horseradish, coffee
> ý for 48 hrs: Iron, Steroids, Indomethacine, Colchicine
> 3 stool specimens ( 3 successive days)

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FEU – Institute of Nursing NUR1217 Complete Course Module

Fecal occult blood Test

Fecal occult blood Test

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FEU – Institute of Nursing NUR1217 Complete Course Module

Laboratory Tests

5. Fecal Analysis
5.1 ova and parasite
> Send fresh, warm stool specimen
5.2Stool Culture
> Sterile test tube / cotton – tipped applicator
5.3 qualitative fecal fat studies
> Assess steatorrhea
> ↑ fat diet, No alcohol ( 3 days )
> 72 hour stool specimen ( store on ice )
> ý mineral oil, neomycin SO4

5.4 quantitative fecal fat studies


> Assess steatorrhea
> 100G of fat (3 days)
> No alcohol (3 days)
> 72 hour stool specimen (store on ice)
> ý mineral oil
> 5-7 g/24 hr.
5. Fecal Analysis
5.4 qualitative fecal fat studies
> Assess steatorrhea
> Random stool specimen (frozen)
> <20% fat
5.5 Fecal pH test
pH of less than 5.5 = acidic

6. Gastric Analysis
>Evaluate gastric function by measuring
a. acidity
b. appearance
c. volume
>NPO for 12 hours
>NGT is inserted , connected to suction

> Gastric Analysis Cycle


>Basal secretion is collected every 15 minutes for 4 hours
> intramuscular administration of a drug that stimulates gastric acid output (betazole)
> stomach secretions is collected every 15 minutes for 90 minutes
> Saliva must be ejected

ANALYSIS/NURSING DIAGNOSIS

1) Imbalanced Nutrition: Less than Body Requirements as evidenced by decreased food intake, weight loss
20% or more of ideal body weight, dry and brittle hair, weakness, impaired tissue healing.

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FEU – Institute of Nursing NUR1217 Complete Course Module

2) Deficient Fluid Volume as evidenced by dry mucus membranes, poor skin turgor, thirst, increased body
temperature

3) Nausea as evidenced by complaints of stomach discomfort, increased salivation, tachycardia, and cold and
clammy skin

4) Impaired Skin Integrity as evidenced by disruption of skin surface, pain, itching

5) Acute Pain (Cognitive-Perceptual)

Disturbances in Metabolism
DISTURBANCES IN INGESTION

1. GASTRO ESOPHAGEAL REFLUX DISEASE (GERD)


Disorders of the Esophagus

1. GERD
> the backflow of gastric juices into the esophagus, mouth and lungs

1.1 Etiology:
A. Incompetent lower esophageal sphincter (LES)
B. Transient LES relaxation
C. Increased intragastric pressure

1.2 Contributing factors:


• obesity
• pregnancy
• caffeine
• chocolate
• high fatty food ingestion
• Smoking
• Hiatal Hernia

1.3 Assessment
a. Heartburn
b. Dysphagia
c. back pain/ Chest pain
d. coughing spells
e. Hoarseness/ sore throat
f. vomiting
g. Belching
— Symptoms typically occur after eating a meal
— can be especially noticeable with a large meal or spicy foods.
— Symptoms may be relieved by antacids.
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FEU – Institute of Nursing NUR1217 Complete Course Module

— Symptoms often are worse when lying flat, straining, bending at the waist or sleeping.

1.4 Diagnostic Procedures


• Barium swallow
• Ambulatory Esophageal pH monitoring
• Endoscopy (EGD)
• x-ray
• Esophageal Manometer
1.5 Complications
a. Esophageal strictures
b. Ulcers
c. Diverticulitis
d. Barrette's Esophagus
e. Esophageal cancer

Esophageal Strictures
- Severe scarring and narrowing of the esophagus
Diverticulosis
- outpouching of the walls of the esophagus
Barrette’s Esophagus
• replacement of the cells lining the esophagus with cells more typical of the stomach or intestines
(metaplasia)
• occurs in approx 10% of patients with GERD.
• Caused by long-term damage caused by GERD and acid
• Precancerous condition associated with cancer of the esophagus

Nursing Diagnoses
a. Acute pain related to tissue trauma
b. Imbalanced nutrition, less than body requirement related to malabsorption
c. Deficient Fluid Volume related to vomiting
d. Impaired tissue integrity related to surgery
e. Risk for infection related to surgery

1.5 Management
1.5.1 lifestyle changes
a. diet changes
• maintain normal weight
• low fat, low cholesterol
b. Avoid tight clothing/ belts
c. Avoid bending
d. stop smoking
e. Refrain eating 3 hrs. before bed time
f. stay upright 2 hours after a meal

1.5.2 Pharmacological
a. H2 receptor antagonist (Cimetidine, Ranitidine, famotidine,nizatidine)
- to Decrease acid production
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FEU – Institute of Nursing NUR1217 Complete Course Module

b. Proton Pump inhibitors (Prilosec, Prevacid, Protonix)
- Blocks acid production
c. Prokinetic medications (Cisapride, Metaclopromide)
-Enhances gastrointestinal motility
d. Antacids (Maalox, Kremil S)
- Neutralizes stomach acidity
1.5.3 Surgical Procedure
a. Fundoplication - wrapping the fundus of the stomach around the lower esophagus and suture the
fundus to itself.

Open Fundoplication
— a. The Nissen Fundoplication–a complete (360o) wrap of the stomach around
the esophagus

— b. The Toupet
Fundoplication–an incomplete (270o) wrap
of the stomach around the esophagus

1.5 Complications
a. Bleeding
b. Infection
c. Respiratory complications
d. Gas Bloat syndrome
-inability to eructate (bloating, borborygmi)
- avoid gas-producing food
- ambulation

1.5 Nursing responsibilities


1.5.1 Assessment
a. admission assessment
b. shift & focused assessment
1.5.2 Prepare client for procedure
1.5.3 Prepare client for surgery
a. Pre-op teaching
- deep breathing & coughing
- incentive spirometry
- ambulation
- possible complications
- NGT/ chest tube

b. Consent
c. NPO post MN

1.5.6 Post-op care


a. reinforce pre-op teaching
b. pain management

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FEU – Institute of Nursing NUR1217 Complete Course Module

c. semi-fowler’s position
d. NGT care
e. Diet
f. Assess for complications
1.5.4 Administer medications
1.5.5 Referral

HIATAL HERNIA
Ø Protrusion of the stomach upward into the mediastinal cavity through the esophageal hiatus of the
diaphragm
1.1 Types:
a. Sliding - 90% of cases
b. Rolling (paraesophageal)

a. Sliding
• part of the stomach moves up through an opening (hiatus) in
the diaphragm.
• increases the risk for GERD

b. Rolling (paraesophageal)
• The fundus and possibly portions of the stomach’s greater
curvature, rolls through the esophageal hiatus and into the
thorax beside the esophagus

1. Sliding Hiatal Hernia


1.2 Etiology
a. Increased intra-abdominal pressure
b. Weakening of muscles in diaphragm
c. Age
1.3 Contributing Factors
a. Obesity
b. Pregnancy
c. Bending
d. Frequent hard coughing/ sneezing
e. Weight lifting
f. Straining
g. Stress
1.4 Assessment
a. Heartburn
b. Regurgitation
b. Dysphagia
g. Belching

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2. Rolling Hiatal Hernia
1.4 Assessment
a. Feeling of fullness and breathlessness after eating
b. Feeling of suffocation
c. Chest pain/ back pain
*Symptoms worse in recumbent position
* No reflux symptoms
1.5 Diagnostic Procedures
• Barium swallow
• Endoscopy (EGD)
• CXR
• CBC
• Guaiac

1.6 Complications
• Hemorrhage/ Anemia
• Pulmonary Aspiration
• GERD
• Esophagitis
• Stenosis
• Ulcerations of herniated portion
• Strangulation of hernia

1.7 Planning: Nursing Diagnoses


a. Acute pain related to tissue trauma
b. Imbalanced nutrition, less than body requirement related to dysphagia
c. Impaired tissue perfusion related to bleeding/ low RBC count
d. Impaired tissue integrity related to trauma/ herniation
e. Activity intolerance related to anemia
f. Disturbed sleep pattern

1.5 Management
1.5.1 lifestyle changes
a. diet changes
• maintain normal weight
• low fat, low cholesterol
b. Avoid tight clothing/ belts
c. Avoid bending
d. Refrain eating 3 hrs. before bed time
e. Stay upright 2 hours after a meal

1.5.2 Pharmacological
a. H2 receptor antagonist (Cimetidine, Ranitidine,
famotidine,nizatidine)
b. Proton Pump inhibitors (Prilosec, Prevacid)
c. Prokinetic medications (Cisapride, Metaclopromide)
d. Antacids (Maalox, Kremil S)
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FEU – Institute of Nursing NUR1217 Complete Course Module

1.5.3 Surgical Intervention


a. Fundoplication
-wrapping the fundus of the stomach around the lower esophagus and suture the fundus to itself.

Open Fundoplication

b. Hill Operation
-Narrowing of the esophageal opening and anchoring of the stomach and the
esophagus in place
* May reinforce with fundoplication
c. Angelchik prosthesis
- a C-shaped silicone prosthesis is tied around the distal esophagus and
anchors the LES in the abdomen

1.5 Nursing Responsibilities


1.5.1 Assessment
a. admission assessment
b. shift & focused assessment
1.5.2 Prepare client for the procedure.
1.5.3 Prepare client for surgery
a. Pre-op teaching
- deep breathing & coughing
- incentive spirometry
- ambulation
- possible complications
- NGT/ chest tube
b. Consent
c. NPO post MN
1.5.4 Post-op care
a. reinforce pre-op teaching
b. pain management
c. semi-fowler’s position
d. NGT care
e. Diet
f. Asses for complications
1.5.4 Administer medications
1.5.5 Referral

DIVERTICULOSIS
1. Diverticulum
• the sac-like outpouching in one or more layers of the esophagus
1.1 Types:
a. Zenker’s Diverticulum
- above the UES (most common)
b. Midesophageal (rare)
c. Epiphrenic Diverticulum

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FEU – Institute of Nursing NUR1217 Complete Course Module

- above the LE
1.2 Etiology:
a. Esophageal weakness
b. Pulsion (pushing from inside)
c. Traction (pulling from outside)
1.3 Contributing Factors:
a. Congenital
b. Esophageal trauma
c. Scar Tissue
d. Chronic Inflammation
e. Achalasia
1.4 Assessment:
a. Dysphagia
b. Aspiration
c. Regurgitation*
d. Halitosis
e. Coughing
* Usually when recumbent
1.5 Diagnosis:
a. Barium swallow
b. Esophageal manometry
c. CXR
* Endoscopy is usually contraindicated
*Flexible UGI endoscopy
1.6 Planning: Nursing Diagnoses
a. Imbalanced nutrition, less than body requirement related to dysphagia
b. Fluid volume deficit related to dysphagia
c. Risk for aspiration
d. Impaired tissue integrity related to trauma
e. Disturbed sleep pattern
1.6 Management:
1.6.1 Lifestyle Changes
a. Diet management(semi-soft)
b. Stay upright 2 hours after a meal
c. Sleeping with HOB elevated

1.6.2 Pharmacologic
a. Botulinum toxin
- Injected into the LES to reduce resting
pressure

1.6.2 Surgical
a. Diverticulectomy
- Excision of the diverticulum and the esophageal mucosa is re-anastomosed

1.5 Nursing responsibilities

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1.5.1 Assessment
a. admission assessment
b. shift & focused assessment
1.5.2 Prepare client for procedure
1.5.3 Prepare client for surgery
a. Pre-op teaching
- deep breathing & coughing
- incentive spirometry
- ambulation
- possible complications
- NGT
b. Consent
c. NPO post midnight
1.5.4 Post-op care
a. reinforce pre-op teaching
b. pain management
c. semi-fowler’s position
d. NGT care
e. Diet
f. Assess for complications
1.5.4 Administer medications
1.5.5 Referral

4. Other esophageal conditions

4.1 Esophageal Varices


Ø Esophageal submucosal venous channel become dilated secondary to portal hypertension
*rupture may cause exsanguination

4.2 Achalasia
Ø Constant contraction of the LES & uncoordinated
muscle contraction
a. Dilation of the esophagus
b. Dysphagia
c. Retention of food bolus

4.3 Esophageal Stenosis


Ø Narrowing of the esophagus which causes obstruction
a. Intermittent Dysphagia
b. Dysphagia for solids
c. Pain when swallowing
c. Retention of food bolus

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Disturbances in Digestion
General GI symptoms
Common GI symptoms
1. Pain
• Most characteristic
• Caused by nerve irritation
• Caused by increased motility
2. Anorexia
• Common with malignancies
• Delayed Gastric emptying
• Gastric stasis
3. Nausea & Vomiting
• Stimulation of chemoreceptors
• Excitation of nerve impulses
4. Bleeding
• Caused by trauma
• Ulcers = 80%
5. Diarrhea
• Increased peristalsis
6. Indigestion
7. Flatulence & Belching

Peptic Ulcer Disease


1.1 Definition
Ø sore that forms in the lining of the stomach or of the duodenum
Types:
a) Gastric
b) Duodenal

1.3 Theory

HCl + Pepsin Mucous Secretion


(Aggressor) (Protector)

secretion: ↓ secretion:
§ stress § ↓ blood flow
§ stimulants § irritants
Damage of mucous
membrane

Peptic Ulcer DIsease

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1.2 Etiology
[Normal à Increased Attack Hyperacidity à Weak defense]
*Helicobacter pylori
*Stress, drugs, smoking

1.3 Predisposing Factors


A. Gastritis
Ø ↑HCl; mucous ulceration
B. H. Pylori infection
Ø Discovered in 1982
Ø gram-negative rod
Ø Positive in 70-100% of PUD patients
Ø Live in deeper parts under lumen where PH is 7.4
C. Irregular, hurried meals (stressful)
D. Fatty, spicy, highly acidic foods, (stimulants, irritants)
E. Type A personality
Ø “stress personality”
F. Type O blood
↑ pepsinogen levels → PEPSIN
G. Genetics
↑ in parietal cell mass → ↑ acid secretion
H. Drugs – Aspirin, anti-inflammatory(NSAIDs) & Corticosteroids

1. 4 Complications
A. HEMORRHAGE : most life threatening complication of PUD → hypovolemic shock
B. Fibrosis, Stricture obstruction – pyloric stenosis
C. Perforation – Peritonitis- emergency
D. Gastric carcinoma

Endoscopy Barium Swallow

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Rapid H. Pylori test

1.4 Diagnosis
A. Endoscopy
B. Barium swallow
C. Biopsy – bacteria & malignancy
D. H.Pylori:
– Endoscopic cytology
– Biopsy
– Special stains
– Culture – difficult
– Urea Breath test (UBT)
– ELISA – to detect antibody
1.5 Management
1.5.1 Medical
A. Diet modification
A. High fiber
B. Increase fluid intake
B. Prevent complications
C. Treat complications

1.5.2 Pharmacologic (H. Pylori)


A. Most popular treatment (first choice)
1. A proton pump inhibitor
2. Amoxicillin plus Clarithromycin BID for10-14 days
B. Most popular treatment (second choice)
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FEU – Institute of Nursing NUR1217 Complete Course Module

1. Bismuth subsalicylate + Tetracycline +Metronidazole QID for 10-14days
2. A proton pump inhibitor

1.5.3 Pharmacologic (other symptoms)


1. Antacids
2. H2 blockers
(Cimetidine, Ranitidine, Famotidine)
3. Proton pump inhibitors
• Omeprazole, Lansoprazole, Esomeprazole, Pantoprazole, Rabeprazol
4. Cytoprotective
• Coats ulcer
• ↑ prostaglandin synthesis
• Taken on an empty stomach (30 – 60 mins. before meals)
• Eg., Carafate (Sucralfate)
1.5.4 Pharmacologic (Side effects)
1. Antacids
• Magnesium based - diarrhea
• Aluminum based - constipation
2. H2 Blockers
• Diarrhea
• Abdominal cramps
• Confusion
• Dizziness
• Weakness
1.5.5 Surgical
1. Vagotomy
• Resection of the vagus nerve
• Decrease cholinergic stimulation

↓ HCl secretion
↓gastric motility

Vagotomy
• severing of part of the vagus nerve innervating the stomach to decrease gastric acid secretion

Pyroplasty
• Surgical dilation of the pyloric sphincter
• Improves gastric emptying of acidic chyme

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Antrectomy
• Removal of 50% of the lower part of the stomach
• Billroth I (Gastroduodenostomy) removal of the lower portion of
the stomach and duodenum with anastomosis of the remaining
portion of the duodenum

Billroth II (Gastrojejunostomy)
• removal of the antrum and distal portion of the
stomach and duodenum with anastomosis of the
remaining portion of the stomach to the jejunum
• The duodenum is bypassed to permit the flow of the
bile

1.5 Management

1.5.3 Gastric Bleeding

Photocoagulation laser
— Endoscopic procedure
— Can be achieved by use of the laser
— Laser light can be focused on a bleeding point to induce
rapid tissue healing
— This produces blood coagulation and tissue necrosis.

Electrocoagulation
— Endoscopic procedure
— Heat generated from high- frequency electrical current is
capable of coagulating or cutting tissue
— Thermal electrocoagulation- classic treatment for bleeding
during surgery and has recently been used to treat GI bleeding.

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Angiographic Therapy
— Radiological therapy when endoscopy has failed to be diagnostic
— Considered for patient at high risk for surgical intervention
— Embolic material such as an absorbable gelatin sponge, tissue adhesives, or other occlusion devices
(such as microcoils) can be inserted through a catheter into the area of bleeding.

Injection Therapy
— Alternative to heat therapy, is inexpensive, simple and widely used
— A catheter with a small retractable needle is passed through the endoscope, and vessels are treated with
one or more of several different chemical agents.

1.5.6 Nursing care


1. Assessment
1. Hx (predisposing factors)
2. Objective data
• s/s
• complications
2. Lifestyle modification
1. DIET
2. Smoking, ETOH
3. Stress

1.5.5 Complications of Sx
1. Dumping syndrome
1. Nausea
2. Sweating
3. Pallor
4. vertigo
2. Marginal ulcers
3. Paralytic Ileus
4. Hemorrhage
5. Acute gastric dilation

1.5 Management
1. Pre-op/
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FEU – Institute of Nursing NUR1217 Complete Course Module

1. NPO/ Enema
2. Consent
3. Health teaching
2. post-op care
1. Ambulation
2. NGT
3. Nutrition
4. Complications

1.5.7 Nursing diagnoses


1. Acute/ chronic pain r/t?
2. Imbalanced Nutrition r/t?

Gastritis
1.1 Definition
• Inflammation of gastric mucosa
• usually due to infectious agents (such as Helicobacter pylori) and
• autoimmune and hypersensitivity reactions
• Most common in clients 50-60 y/o
• Male
1.2 Types
a. Acute – short term inflammation
b. Chronic - long standing

Chronic gastritis
— Superficial gastritis- inflammatory changes are limited to the surface mucosa, which causes an
erythemic, edamatous mucosa with small erosions and hemorrhage. Gastric glands are intact at this
stage.
— Atrophic gastritis- inflammation extends deeper into the mucosa with progressive glandular
destruction.
— Invariably present in pernicious anemia.
— Characterized by decreased number of parietal and chief cells.
— Hypergastritis or gastric atrophy- hemorrhage occur frequently.
— Gastric glands undergo transformation at this stage and metaplastic changes are an important
predisposing factor for gastric cancer.

1.3 Etiology
1. Ingestion of irritants
1. Erosive
2. Corrosive
2. Microorganisms
H. Pylori infection
Staph infection
3. Autoimmune

1.4 PREDISPOSING FACTORS


1. Medications

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• Direct irritating effect on gastric mucosa
• Aspirin, NSAIDs, and corticosteroids
2. Diet
• Alcohol, spicy food, caffeine
3. Microorganisms

1.4 cont. PREDISPOSING FACTORS


1. Environmental factors
• Radiation, smoking
2. Pathophysiologic conditions
• Burns, renal failure, sepsis
3. Other factors
• Psychologic stress (surgery, burns, severe infection)
• NG tube

1.5 Assessment
1. Acute gastritis
1. Anorexia
2. Nausea/ vomiting
3. Epigastric Discomfort
4. Feeling of fullness
5. GI Bleeding
Common with alcohol abuse
May be only symptom
2. Chronic gastritis
1. Anorexia
2. Nausea/ vomiting
3. Epigastric Discomfort
4. Feeling of fullness
5. Intolerance of spicy/ fatty food

1.6 Diagnosis (medical)


1. Acute gastritis
• Diagnosis most often based on history of drug and alcohol abuse
2. Chronic gastritis
• Diagnosis may be delayed or missed due to nonspecific symptoms
1. Endoscopy
2. H. pylori tests
3. CBC
4. Guaiac
5. Gastric analysis
• Determines achlorhydria (lack of acid secretion)
• Associated with severe atrophic gastritis
6. Serum antibody tests
7. Schilling test
8. Tissue biopsy
9. Radiologic studies not helpful

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1.7 Complictions
1. Bleeding
2. Pernicious anemia
3. Cancer

1.7 Management
1. Medical Management
1. NPO (N/V)
2. NGT
• Monitor bleeding
• Lavage of irritants
• Keep stomach empty
3. Lifestyle changes
• Diet
• Alcohol
• Smoking

2. Pharmacologic Management
1. Antacids
2. H2 blockers
3. PPIs
4. Antibiotics
5. Cobalamin
6. Antiemetics

3. Surgical Management
7. Vagotomy
8. Pyloroplasty
9. gastrectomy

4. Nursing Management
1. Asessment
1. Hx (predisposing factors)
2. Objective data
• s/s
• complications
2. Lifestyle modification
1. DIET (bland, decaf, small meals)
2. Smoking, ETOH
3. Stress
3. Symptom management
1. Pain
2. n/v
4. Promote self-care
5. Health teaching

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1. Medication/ restrictions/side effects
2. Complications (S/S)

Food Poisoning
— Sudden illness that occurs after ingestion of contaminated food or drink.
— Botulism is a serious form of food poisoning that requires continual surveillance.
Cause:
— Contaminated food or drink
Signs and symptoms:
— Nausea and vomiting
— Diarrhea
Diagnostics:
— Food, gastric content, feces
— Serum electrolytes
Medical Management:
— Determining the source and type of food poisoning
— Assess for signs of fluid and electrolytes imbalance
— Assess for signs of hypovolemic shock
— Control nausea to prevent vomiting
Pharmacological:
— Anti emetic medication
Nursing Management:
— Monitor RR, BP, sensorium ,vp ( if indicated) , and muscular activity
— Encouraged the patient to take sips of weak tea, carbonated drinks or tap water for mild nausea
— If vomiting subsides, clear liquids are usually prescribed for 12 to 24 hrs then gradually progressed to
low- residue bland diet.

DISTURBANCE IN ABSORPTION AND ELIMINATION

Disorders of Intestinal Motility

Diarrhea
— Increased in frequency of bowel movements, increased amount of stool and altered consistency of stool.
— Is associated with urgency, perinal discomfort, incontinence or a combination of these factors.
— It occurs when fecal matter passes through the intestine rapidly, resulting in decreased absorption of
water, electrolytes, and nutrients and causing frequent, watery stools.
— Can be acute or chronic.
Types:
A) Secretory
B) Osmotic
C) Mixed

Etiology: Bacterial and viral infection

Causes:

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FEU – Institute of Nursing NUR1217 Complete Course Module

a) Medications ( e.g thyroid hormonereplacement, stool softeners and laxatives, antibiotics, chemotherapy,
antacids)
b) Metabolic and endocrine disorders ( e.g DM, Addisons disease, thyrotoxicosis)
c) Viral or bacterial infections ( e.g dysentery, shigellosis, food poisoning)
d) Nutritional and malabsorptive disordrers ( celiac,anal sphincter defect, zollinger-ellison syndrome,
intestinal obstruction)

Signs and Symptoms


— Increased frequency and fluid content of the stools
— Abdominal cramps
— Distention
— Intestinal rumbling
— Anorexia
— Thirst
— Painful spasmodic contractions of the anus
— Tenesmus

Diagnostics:
— CBC
— Urinalysis
— Stool exams
— Electrolytes
— Endoscopy
— Barium enema

Complications:
— Cardiac dysrhythmias (atrial and ventricular tachycardia, ventricular fibrillation, PVC)

Medical Management
a) Controlling the symptoms
b) Preventing complications
c) Eliminating or treating the underlying disease

Pharmacological management
— Antibiotics
— Anti inflammatory
— Anti diarrheal medications (diphenoxylate or loperamide)

Nursing Management:
a) Assessing and monitoring the characteristics and pattern of diarrhea
b) Encourage bed rest
c) Increase ofi
d) Bland low in bulk diet
e) Perianal care

Constipation

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FEU – Institute of Nursing NUR1217 Complete Course Module

— Abnormal infrequency or irregularity of defecation, abnormal hardening of stools that makes their
passage difficult and sometimes painful
— Decrease in stool volume or retention of stool in the rectum for a prolonged period
— Interference with one of three major functions of the colon
a) Mucosal transport
b) Myoelectric activity
c) Processes of defecation

Causes:
a) Medications ( tranquilizers, anticholinergics, anti depressants, opiods, antacids with aluminum and iron)
b) Rectal or anal disorder ( hemorrhoids, fissures)
c) Obstruction ( cancer of the bowel)
d) Metabolic, neurologic and neuromuscular conditions ( DM, hirschsprung’s dse, parkinsons dse,
multiple sclerosis)
e) Endocrine disorders ( hypothyroidism, pheochromocytoma
f) Lead poisoning
g) Connective tissue disorder ( scleroderma, lupus erythematosus)

Signs and Symptoms:


— Abdominal distention
— Borborygmus
— Pain and pressure
— Decreased appetite
— Headache
— Fatigue
— Indigestion
— Sensation of complete emptying
— Straining at stool
— Elimination of small-volume, hard, dry stools

Diagnostics:
— Barium enema
— Sigmoidoscopy
— FOBT
— Anorectal manometry
— Defecography and bowel transit studies

Complications:
— Hypertension
— Fecal impaction
— Hemorrhoids and fissures
— Megacolon

Medical Management:
a) Education
b) Bowel habit training
c) Increase fiber and fluid intake

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FEU – Institute of Nursing NUR1217 Complete Course Module

d) Judicious use of laxatives/ discontinuing laxative use
e) Routine exercise
f) Diet ( unprocessed bran)

Pharmacological management:
— Cholinergic agent ( e.g bethanecol)
— Cholinesterase inhibitors ( e.g neostigmine)
— Prokinetic agent ( e.g metoclopramide)
— Enemas and rectal suppositories are generally not recommended

Nursing Management:
— Patient education
— Health promotion

Goal of treatment:
— Restoring or maintaining a regular pattern of elimination
— Ensuring adequate intake of fluids and high fiber foods
— Relieving anxiety about bowel elimination patterns
— Avoiding complications

Irritable Bowel Syndrome


• aka spastic colon, intestinal neurosis,spastic colitis, irritable colon
• a functional bowel disorder of motility in the intestine
• chronic abdominal complaints without a structural or biochemical cause
• characterized by alternating periods of constipation and diarrhea

Types:
- Diarrhea-predominant (IBS-D)
- Constipation-predominant (IBS-C)
- Alternating diarrhea and constipation
• 20% Western Society, Mostly Women
• No known cause

• Etiology:
Ø abnormal communication between the enteric
nervous system and the central nervous system
Ø exaggerated reaction to stimuli
Ø an imbalance of serotonin in the gut
• Serotonin
intestinal motility
perception of pain
release of water

Irritable Bowel Syndrome


• Weight usually remains stable
• stools usually of small volume
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FEU – Institute of Nursing NUR1217 Complete Course Module

• may have mucus but usually not blood

Diagnostics
Ø Stool culture, occult blood
Ø Endoscopy*
Ø Barium Enema*
Ø CT Scan*
* For differential diagnosis

Goals of treatment
— Relief of gastrointestinal symptoms
— Relief of psychological distress
— Improve quality of life

Management
a. Lifestyle changes
- Decrease emotional stress
- Diet modification
limit coffee, tea, chocolates
increase fiber
frequent small meals

Pharmacological Management
a. Antispasmodics and anticholinergic
b. Tricyclic antidepressants (Elavil)
c. Anxiolytics (Diazepam, Xanax)
d. Laxatives with caution

Nursing Management
1. Assessment
a) s/s
b) Predisposing factors
c) Prepare for procedures
d) Hydration status
e) Skin assessment
f) Fecal impaction
2. Administer medication as necessary
3. Encourage fluids
4. Peri-anal care
5. Health Teaching
6. 6. Referral

Fecal Incontnence
Ø involuntary passage of stool from the rectum

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FEU – Institute of Nursing NUR1217 Complete Course Module

Ø can result from trauma, neurologic disorder, inflammation, infection, radiation, treatment, fecal
impaction, pelvic floor relaxation, laxative abuse, medications or advancing age.

Factors influence fecal incontinence


a) Ability of the rectum to sense and accommodate stool
b) Amount and consistency of stool
c) Integrity of the anal sphincter and musculature
d) Rectal motility

Signs and Symptoms:


— Occasional urgency and loss of control
— Complete incontinence
— Poor control of flatus

Diagnostics:
— Rectal examination
— Flexible sigmoidoscoy
— Barium enema
— CT scans
— Anorectal manometry
— Transit studies

Medical Management:
— Help the patient achieve a better quality of life
— Bowel training program

Surgical Management:
— Surgical reconstruction
— Sphincter repair
— Fecal diversion

Nursing Management:
— Assist the patient in to achieve fecal incontinence or
— Manage the problem so the patient can have predictable, planned elimination pattern.
— Maintaining perineal skin integrity

Care of Client with Problems in Endocrine System


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Course Outline

Contents:

I. Review of anatomy, physiology and functions of the Endocrine System


II. Review the sources of hormones and disturbances related to it.
III. Diagnostic tests
1. T3 T4 levels
2. PBI ( Protein -bound iodine )
3. RAIU ( Radioactive Iodine Uptake )
4. Thyroid scan
5. FNB ( Fine needle Biopsy )
6. BMR ( Basal Metabolic Rate )
7. Reflex Testing
IV. Disturbances in Endocrine
1. Hyperthyroidism
2. Hypothyroidism
3. Hyperparathyroidism
4. Hypoparathyroidism
5. Diabetes Mellitus
6. Addison’s disease
7. Cushing’s syndrome
8. Other endocrine disorderss

References:

Gulanick, M., (2014). Nursing Care Plans: Diagnoses, Interventions, and Outcomes. Missouri : Elsivier Mosby
Hinkle, J., (2018). Brunner & Suddarth’s textbook of medical-surgical nursing. Philadelphia : Wolters
Kluwer/Lippincott Williams & Wilkins
Holt, R., (2012). Essential endocrinology and diabetes. UK : Wiley-Blackwell
Ignatavicius, D., (2016). Medical-surgical nursing: Patient-centered collaborative care. Missouri :
Elsevier/Saunders
Ladwig, G., (2014). Mosby’s guide to nursing diagnosis. Missouri : Elsevier Saunders
Melmed, S., (2011). Williams textbook of endocrinology. Philadelphia : Elsevier/Saunders
Rogers, K., (2011). Nurses test yourself in pathophysiology. Berkshire : Eng. Open University
Press

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CARE OF CLIENTS WITH ENDOCRINE DISORDERS

THE ENDOCRINE SYSTEM

• The second great controlling system of the body.


• It coordinates and directs the activity of the body’s cells
• It allows communication within the distant sites of the body
• A collection of glands that produce hormones that regulate the body’s growth, metabolism and sexual
development and function.
• Hormones are released into the bloodstream and transported to tissues and organs throughout the body.

THREE COMPONENTS OF THE ENDOCRINE SYSTEM


1. Endocrine glands
2. The Chemical Messengers called HORMONES
3. Target cells or organs

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THE ENDOCRINE GLANDS

PINEAL BODY
• A small cone- shaped gland that hangs from the roof of the third ventricle of the brain.
• Secretes melatonin which is believed to be a “sleep trigger”

HYPOTHALAMUS
• Is a small area of the brain located in the section of the forebrain called the diencephalon.
• It is concerned with HOMEOSTASIS.
• Activates and controls the part of the nervous system that controls involuntary body functions, the
hormonal system & regulates sleep and stimulates appetite
• Secretes hypothalamic hormones

PITUITARY GLAND
• Approximately the size of a pea.
• It hangs by a stalk from the inferior surface of the hypothalamus.
• It has two functional lobes:
1. Anterior pituitary
2. Posterior pituitary

ANTERIOR PITUITARY
• Follicle Stimulating hormone
• Luteinazing Hormone
• Adrenocorticotropic Hormone
• Thyroid Stimulating Hormone
• Growth Hormone
• Pro lactin

POSTERIOR PITUITARY
• Oxytocin
• Antidiuertic Hormone
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FEU – Institute of Nursing NUR1217 Complete Course Module

THYROID GLAND
• Produces hormones that stimulate body heat production, bone growth, and the body’s metabolism.

PARATHYROID GLANDS
• Secretes a hormone that maintains the calcium level in the blood

THYMUS GLAND
• Plays a role in the body’s immune system

ADRENAL GLANDS
• Secretes hormones that influence the body’s metabolism, blood chemicals & body characteristics
• Influence the NS involved in the response & defense against stress.

PANCREAS
• Secretes a hormone (insulin) that controls the use of glucose by the body.

OVARIES AND TESTICLES


• Secretes hormones that influence female and male characteristics

THE ENDOCRINE SYSTEM

• FUNCTIONS
1. Maintainance and regulation of vital functions
2. Response to stress and injury
3. Growth and development
4. Energy metabolism
5. Reproduction
6. Fluid, electrolyte and acid-base balance

ENDOCRINE GLANDS
1. Pituitary
2. Adrenal
3. Thyroid
4. Parathyroid
5. Pancreas
6. Ovaries
7. Testes

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Sources of Hormones

SOURCE Hormone Function

Hypothalamus Releasing or Inhibiting Hormones Controls the release of pituitary


• Corticotropin-releasing hormones
hormone (CRH)
• Thyrotropin-releasing
hormone (TRH)
• Growth hormone-releasing
hormone (GHRH)
• Gonadotropin-releasing
hormone (GnRH)

Source Hormone Function

Anterior Pituitary Growth Hormone (GH) • Stimulates growth of bone


Adrenocorticotropic Hormone and muscle, promotes
(ACTH) protein synthesis and fat
Thyroid-stimulating hormone (TSH) metabolism, ↓ CHO
Follicle-stimulating hormone (FSH) metabolism
Luteinizing Hormone (LH) • Stimulates synthesis and

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secretion of adrenal cortical
hormones
• Stimulates the synthesis and
secretion of thyroid
hormone
• Females:growth of ovarian
follicle for ovulation
Males: sperm production
• Females: development of
corpus luteum, release of
oocyte, production of
estrogen and progesterone
Males: secretion of testosterone,
development of interstitial tissue of
testes

Source Hormone Function

Posterior Pituitary Antidiuretic Hormone (ADH) ↑ Water reabsorption by the kidney


Oxytocin Contracts pregnant uterus, milk
ejection from breast after childbirth

Adrenal Cortex Mineralocorticoids (aldosterone) • ↑Na reabsorption, K- loss


Glucocorticoid (cortisol) by the kidney
Androgen • Influences metabolism of all
nutrients; regulates blood
glucose, affects growth, has
anti-inflammatory action,
and decreases effects of
stress
• Androgenistic activity
Adrenal Medulla Epinephrine Neurotransmitters of the SNS
Norepinephrine

Source Hormone Function

Thyroid Gland Thyroid Hormones: triiodothyronine • ↑ metabolic rate; ↑CHON


(Follicular Cells) (T3), Thyroxine (T4) and bone turnover; ↑
responsiveness to
catecholamines; impt. for
fetal and infant growth and
development

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Thyroid Gland Calcitonin ↓ Blood calcium
(Follicular Cells)

Parathyroid glands Parathyroid hormone Regulates calcium in the blood

Pancreatic Islet cells Insulin • ↓ Blood glucose by


Glucagon facilitating glucose transport
Somatostatin across cell membranes of
the muscle, liver, and
adipose tissue
• ↑ blood glucose
concentration by stimulation
of glyconolysis and
glyconeogenesis
• Delays intestinal absorption
of glucose
Ovaries Estrogen • Development of sex organs
Progesterone and sex characteristics
Inhibin • Influences menstrual cycle;
stimulates growth of uterine
wall; maintains pregnancy
• Inhibits FSH secretion by
the ant. pituitary
Testes Androgens: testosterone • Develops males sex organ
Inhibin and secondary sex
characteristics; sperm
production
• Inhibits FSH secretion by
the ant. pituitary
Placenta Human Chorionic Gonadotropin • Maintains pregnancy

Adipose Tissue Leptin • Decreases appetite and food


Resistin intake, ↑ sympathetic
activity and metabolic rate,
↓insulin secretion to ↓ fat
storage
• Suppresses insulin’s ability
to stimulate glucose uptake
by adipose cells.

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PITUITARY GLAND
1. Anterior Pituitary (Adenohypophysis)
Growth hormone (Somatotropin)
Hypersecretion :
Children - Gigantism
Adult – Acromegaly
Hyposecretion :
Dwarfism
Prolactin (Mammotropic / Lactotropic Hormone)
Hypersecretion – Galactorrhea
Hyposecretion - X milk during lactation
ACTH (Adrenocorticotropic Hormone)
Hypersecretion - Sec. Cushing’s Disorder
Hyposecretion - Sec. Addison’s Disorder

Pituitary Gland
(Hypophysis)
TSH (Thyroid – Stimulating Hormone)
Hyposecretion – Sec. Hyperthyroidism
Hypersecretion - Sec. Hypothyroidism
Gonadotropin (FSH / LH)
Hypersecretion – Precocious Puberty
Hyposecretion
Males:
Small phallus and
testicles
X growth of body hair
↓ Libido
Impotence
Aspermia

Females:
Failure to develop the breasts
X growth of body hair
X ovulation
X menstruation
Infertility

MSH (Melanocyte – Stimulating Hormone)


Hypersecretion
“Eternal tan” / bronze appearance of the skin
Hyposecretion
Albinism

2. Posterior Pituitary (Neurohypophysis)


ADH (Antidiuretic Hormone)
Hypersecretion SIADH

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Edema, wt. Gain
HPN
Dilutional hyponatremia
Hyposecretion Diabetes Insipidus
Polyuria
Retarded growth
Dehydration
Constipation
Dilute urine, ↓ sp. gr.
Oxytocin

THYROID GLAND
1. T3 (Triidothyronine)
• Metabolism, growth
2. T4 (Thyroxine)
• Catabolism , body heat prod.
3. Thyrocalcitonin
• Regulates s. Ca levels

Diagnostic Tests
1. T3 T4 levels
• ↑ - hyperthyroidism
• ↓ - hypothyroidism
2. PBI (Protein – Bound Iodine)
• Preparation
• X Foods, drugs, test dyes with I 7 – 10 days before the test
3. RAIU (Radioactive I Uptake)
• Tracer dose of I131, p.o.
• 2°, 6°, 24° → exposure to scintillation camera
• X Foods, drugs, test dyes with I 7 – 10 to days before the test
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• Temporarily discontinue contraceptive pills
↑ Uptake – hyperthyroidism
↓ Uptake – hypothyroidism
4. Thyroid Scan
– Radioisotope / IV
– Exposure to scintillation camera
5. FNB (Fine Needle Biopsy)
6. BMR (Basal Metabolic Rate)
– Measures 02 consumption at the lowest cellular activity
6. BMR (Basal Metabolic Rate)
– Preparation
• NPO 10 – 12°
• Night Sleep 8 - 10°
• X get up from the bed the following morning until the test is done
• A device with a noseclip and a mouthpiece is used; the client performs deep breathing
exercises
• Normal : ± 20% (euthyroid)

– 7. Reflex Testing (Kinemometry)


– Tendon of Achilles Reflex

HYPERTHYROIDISM
• Grave’s Disorder/ Exophthalmic Goiter / TOXIC Diffuse Goiter
• ↑ - females , below 40 yrs.
• Severe emotional stress
• Autoimmune Disorder

3 Basic Concepts
a. Increased metabolic rate
b. Increased body heat production
c. Hypocalcemia

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ASSESSMENT

1. Thyroidal disturbances
• Restlessness, nervousness, irritability, agitation
• Fine tremors
• Tachycardia
• Hypertension
• ↑ appetite to eat
• Weight loss
• Diaphoresis
• Diarrhea
• Heat intolerance
• Amenorrhea
• Fine silky hair
• Pliable nails

ASSESSMENT
2. Ophthalmopathy
– Exophthalmos
• Accumulation of fluids at the fat pads behind the eyeballs, pushing the eyeballs forward.
CORNEAL ULCERATION
OPHTHALMITIS
BLINDNESS
-Von Graefe’s sign (LID LAG)
– Long and deep palpebral fissure when one looks down

• Jeffrey’s sign
– Forehead remains smooth when one looks up
• Dalyrimple’s sign (Thyroid stare)
– Bright – eyed stare
– Infrequent blinking
4. Dermopathy
Warm, flushed sweaty skin
Thickened hyperpigmented skin at the pretibial area

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MANAGEMENT
1. Rest.
– Non – stimulating cool environment
2. Diet
– ↑ caloric
– ↓ fiber
3. Promote safety
4. Protect the eyes
– Artificial tears at regular intervals
– Wear dark sunglasses when going out under the sun.
5. Replace fluid – electrolyte losses
6. Pharmacotherapy
a. Beta – blockers : Inderal
– To control tachycardia, HPN
b. Iodides : Lugol’s solution
c. SSKI
– To inhibit release of thyroid
– Mix with fruit juice with ice or glass of water
– Provide drinking straw
– Side effects
– Allergic reaction, Increased salivation, Coryza
c. Thioamides:
– PTU (Propylthiouracil) & Tapazole (Methimazole)
– To inhibit synthesis of thyroid hormones
– Side effects:
– AGRANULOCYTOSIS / NEUTROPENIA
– Fever, Sore throat, Skin rashes
d. Ca – channel blockers

e. Dexamethasone
– Inhibit the action of thyroid hormones
7. Radiation therapy (I131) – Isolation for few days
8. Surgery
– Subtotal Thyroidectomy
• 5/6 of the gland is removed

Pre-op Care
1. Promote euthyroid state
• Control of thyroid disturbance
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• Stable VS
2. Administer Iodides as ordered
• To reduce the size & vascularity of thyroid gland, thereby prevent postop hemorrhage ,thyroid
crisis
3. ECG
• Heart failure / cardiac damage results from HPN / tachycardia

Pre-op Care
1. Position : Semi – Fowler’s with head, neck & shoulder erect.
2. Prevent Hemorrhage
• Ice collar over the neck
3. Keep tracheostomy set available for the first 48° postop.
Parathyroid damage

Hypocalcemia

Laryngospasm

AW Obstruction
4. Ask the patient to speak q hr.
• To assess for recurrent laryngeal nerve damage
5. Keep Ca gluconate readily available
• Tetany occurs if hypoCa is present
6. Monitor B. Temperature
• Hyperthermia is an initial sign of thyroid crisis
7. Monitor BP
• To assess for Trousseau’s sign (hypocalcemia)
8. Steam inhalation to soothe irritated airways.
9. Advise to support neck with interlaced fingers when getting up from bed
10. Observe for s/sx of potential complications
a. Hemorrhage
b. Airway obstruction
c. Tetany
d. Recurrent laryngeal nerve damage
e. Thyroid crisis / storm / thyrotoxicosis
f. myxedema

11. Client Teaching


a. ROM exercises of the neck 3 – 4 x / day after discharge.
b. Massage incision site with cocoa butter lotion to minimize scarring
c. Regular follow – up care

HYPOTHYROIDISM

• Myxedema (Adult)
• Cretinism (Children)
• Causes
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– Autoimmune
– Surgery
– Radiation therapy
– Antithyroid drugs

3 Basic Concepts
1. Decreased metabolic rate
2. Decreased body heat production
3. Hypercalcemia

ASSESSMENT
• Slowed physical, mental reactions
• Dull look
• Anorexia
• Obesity
• Bradycardia
• Hyperlipidemia
• Cold intolerance
• Constipation
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• Coarse, dry, sparse hair
• Brittle nails
• Irregular menstruation

MANAGEMENT
1. Monitor VITAL SIGNS. Be alert for signs & symptoms of CV disorders
2. Diet
– ↓ caloric
– ↑ fiber
3. Provide warm environment during cold climate.
4. Pharmacotherapy
– Proloid (Thyroglobulin)
– Synthroid (Levothyroxine)
– Dessicated Thyroid Extract
– Cytomel (Liothyronine)
• BP , PR before administration
• Start with low dose , gradually increase

PARATHYROID GLAND

PTH (Parathormone)
↓ S. Ca levels

PTH release

Withdraws Ca from the bones

s. Ca levels
∴ Hyperparathyroidism : Hypercalcemia
Hypoparathyroidism : Hypocalcemia

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Parathyroid Hormone
Essential for the regulation of Ca2+ levels
Stimulates an increase in osteoclasts numbers, resulting in increased breakdown of bone.
Promotes Ca2+ reabsorption by the kidneys and the formation of active vitamin D by the kidneys.
Active vitamin D increases calcium absorption by the intestine.

Parathyroid Gland

These small glands, usually four, surround the posterior thyroid tissue, they are often difficult to
locate and maybe removed accidentally during thyroid or other surgery
In response to a low blood calcium level, the parathyroids produce PARATHORMONE, which
raises blood calcium levels by increasing calcium resorption from kidneys, intestines and bones

Hyperparathyroidism
Hyperparathyroidism
is a disorder caused by over activity of one or more of the parathyroid glands
is classified as primary, secondary, and tertiary hyperparathyroidism
usually occurs in clients 60 years of age, and those with renal failure
affects women twice as men

Primary Hyperparathyroidism
develops when the normal regulatory relationship between serum calcium levels and PTH secretion is
interrupted

Secondary Hyperparathyroidism
occurs when the glands are hyperplastic because of malfunction of another organ system
usually the result of renal failure but may also occurs as a result of cancer which includes:
- Multiple Myeloma
-Carcinoma with bone metastasis

Tertiary Hyperparathyroidism
occurs when PTH production is irrepressible (autonomous) in clients with normal or low serum calcium
levels.

Signs and Symptoms


fatigue, muscular weakness, restlessness
height loss and frequent fractures
renal calculi
anorexia, nausea, abdominal discomfort, and constipation
memory impairment
polyuria, polydipsia
back and joint pain
hypertension

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Clinical Manifestations of Primary Hyperparathyroidism:


“Bones, Stones, Moans, and Groans”

BONES
Osteitis Fibrosa with:
ü subperiosteal resorptions
ü osteoclastomas
ü bone cysts
Radiological “osteoporosis”
Osteomalacia or rickets
Arthritis

STONES
Renal stones
Nephrocalcinosis
Polyuria
Polydipsia

ABDOMINAL GROANS
• Constipation
• indigestion, nausea, vomiting
• peptic ulcer
• pancreatitis

PSYCHIC MOANS
• Lethargy, fatigue
• depression
• memory loss
• psychoses-paranoia
• personality change, neuroses
• confusion, stupor, coma

OTHERs
• Proximal muscle weakness
• keratitis, conjunctivitis
• hypertension
• itching

Laboratory and Diagnostic Findings


↓ serum phosphate level
hypercalciuria
hyperphosphaturia
bone demineralization
↑PTH level
parathyroid scan possibly detects abnormal findings

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↑ total and ionized calcium level

Nursing Management
prepare client for surgical treatment
prevent dehydration, constipation, kidney stone formation
reduce added calcium by eliminating over-the-counter antacids
assess for renal calculi: report hematuria or flank pain as necessary
provide relief of constipation as indicated
reinforce the health care follow-up schedule

Nursing Diagnosis
Impaired urinary elimination r/t renal involvement secondary to hypercalcemia and hyperphosphaturia
resulting in urolithiasis, painful urination, hematuria, and spasms
Risk for injury r/t preoperative drug sensitivities and post-operative complications

HYPOPARATHYROIDIS
is a parathyroid hormone (PTH) deficiency characterized by abnormally low serum calcium levels
(hypocalcemia), abnormally high phosphate levels (hyperphosphotemia), and neuromuscular
hyperexcitability (tetany).

TYPES OF HYPOPARATHYROIDISM
1. Acute Hypoparathyroidism
it is caused by accidental damage to parathyroid tissues during thyroidectomy.
it is characterized by greatly increased neuromuscular irritability, which results in tetany.
2. Chronic Hypoparathyroidism
it is usually idiopathic, resulting in lethargy; thin , patchy hair; brittle nails, scaly skin and
personality changes.

ETIOLOGY
1. Hypoparathyroidism may be iatrogenic; caused by accidental removal of or trauma to parathyroid
glands during thyroidectomy, parathyroidectomy or radical head or neck surgery
2. It can also result from autoimmune genetic dysfunction (affects more women than men).
3. A reversible form may be associated with hypomagnesemia, which interfere with PTH secretion.

II. CLINICAL MANIFESTATIONS

ACUTE:
Iatrogenic:
Anxiety and irritability
Numbness, tingling and cramps in extremities
Dysphagia
Evidence of neuromuscular hyperexcitability, such as (+)Chvostek’s and Trosseau’s signs, carpopedal
spasms, bronchospasms, laryngeal spasms, arrythmias and convulsions
Hyperactive deep tendon reflexes (DTRs)

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CHRONIC:
Idiopathic:
Lethargy
Thin patchy hair
Brittle nails
Dry and scaly skin
Personality changes
Ectopic or unexpected calcification may appear in the eyes and basal ganglia

Laboratory and Diagnostic

Total and ionized serum calcium levels are low


Serum parathyroid hormone level is low
Serum phosphate levels are elevated and decreased urine calcium
Radiographic studies of the skull or computed tomography (CT) of the head showing areas of
calcification
Opthalmic examination revealing calcification of the ocular lens, which may lead to cataract formation

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Medical Management
o Vitamin D
o Calcium Gluconate
o Oral calcium replacements
o Parathyroid Hormone
o High-Calcium, Low Phosphate Diet

IV. NURSING DIAGNOSIS & MANAGEMENT

Risk For Injury: Muscle Tetany Related To Decreased Serum Calcium Levels

1. Intervene for life-threatening tetany as indicated.


Administer IV Calcium gluconate to prevent calcium depletion
Be alert for possible laryngeal spasm resulting respiratory obstruction, keep a tracheostomy set
available.
Institute seizure precautions as per hospital protocol (padded side rails and bite blocks are
controversial)
Minimize environmental stimuli
After crisis resolves, closely monitor Calcium levels, keep IV Calcium gluconate in the client’s
room.
2. Provide client and family teaching about the medication regimen, including purpose, dosage schedule,
and signs & symptoms of hypocalcemia and hypercalcemia. Inform the client that dosage will be
adjusted periodically based on laboratory findings.

3. Provide care for chronic hypoparathyroidism


Encourage diet high in Calcium and low in phosphorus. Milk, milk products and egg yolks must
be avoided because they are high in phosphorus
Administer Vitamin D and Magnesium Supplementation, as indicated. In clients receiving
magnesium. Observe for symptoms of hypermagnesemia
Administer oral calcium preparations, such as calcium gluconate to supplement the diet

• Assessment:
• Hypo – low Ca & high P
- Trousseau or Chvostek sign
- hypotension
• Hyper – high Ca & low P
- cardiac dysrhythmias
- hypertension

Overview of Pancreatic Hormones

Hormones
The endocrine pancreas produces hormones necessary for the metabolism and cellular utilization of
CHO,CHON,fats.

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The cells that produce these hormones are clustered in groups of cells called the Islets of Langerhans. These
islets have three different types of cells.

Types of Cells

• Alpha Cells - produce the hormone glucagon, which stimulates the breakdown of glycogen in the liver,
the formation of CHO in the liver, and the breakdown of lipids in both the liver and adipose tissue.
- the primary function of glucagon is to decrease glucose oxidation and to increase blood glucose
levels.
- prevents blood glucose from decreasing below a certain level when the body is fasting or in
between meals.

• Beta Cells – secrete the hormone insulin, which facilitates the movement of glucose across the
membranes into cells,decreasing blood glucose levels.
- Insulin release is regulated by blood glucose; it increases when blood glucose levels increase,
and it decreases when blood glucose decreases.

• Delta Cells – produce somatostatin which is believed to be neurotransmitter that inhibits the production
of both glucagon and insulin.
• PP Cells- ( F Cells ) secretes pancreatic polypeptides- self regulate the pancreas secretion activities (
endocrine and exocrine)

Regulation of blood glucose levels by Insulin and Gluca

• some of the food breaks down into sugars-one of these sugars is glucose, the body’s main fuel
• Sugar enters the bloodstream, and the level of sugar in your blood begins to rise

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• When your body senses an increase in sugar, it sends a signal to your
pancreas
• The pancreas make insulin and sends it into the bloodstream

Diagram of Normal Body Cell

• Insulin is the key that opens an “entrance” into the body’s cells and
allows sugar to pass from the bloodstream into the cells
• The level of sugar in the bloodstream falls as the sugar passes into the
cells
• The body’s cells use the sugar for fuel / energy

PANCREAS
• Glucagon
– Alpha cells of Islets of Langerhans
– ↑ s. glucose levels (gluconeogenesis)
– Insulin
– Beta cells of Islets of Langerhans
– ↓ s. glucose levels:
• Transcellular membrane transport of glucose
• Inhibits breakdown of fats and protein

DIABETES MELLITUS

• Diagnostic Tests
– FBS:
• 70 – 100 mg / dl
• DM: ↑ 126 mg / dl for 2 readings
– 2°PPBS
• Initial blood specimen is withdrawn
• 100 g. of carbohydrate in diet or special glucose instead of eating
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• 2° after meal blood specimen is withdrawn – blood sugar returns to normal level
• Diagnostic Tests
– OGTT / GTT (Oral Glucose Tolerance
– Fasting overnight
– Sugary liquid
– After 2 hours blood sugar level will be measured

Diabetes Mellitus (DM)


• Glycosylated Hgb
– Most accurate
– Reflects s. CHO levels for the past 3 – 4 mos.
excess glucose in the blood

attach to hemoglobin

hgb (component of rbc)
• Lifespan is 90 – 120 days
• 5.7-6.4 Prediabetes

• Cause – Unknown
• Predisposing Factors
– Stress
– Heredity
– Obesity
– Viral infection
– Autoimmune Disorder
– Women
• Multigravida with Large babies

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Type I

ü IDDM
ü Juvenile – onset
ü Brittle DM
ü Unstable DM
ü < 30 yrs.
ü Absolute Insulin deficiency
ü Thin
ü Prone to DKA

ü Management:
ü Diet
ü Activity/ Exercise
ü Insulin

Type II

ü NIDDM
ü Maturity – onset Stable DM
ü Ketosis – resistant DM
ü > 40 yrs.
ü With insulin sec., ↑ demands
ü Obese
ü Prone to HHNC
ü Management:
ü Diet
ü Activity/ Exercise
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ü OHA
ü Insulin – stress, surgery, infections, pregnancy

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Management

Education for Self – care


Diet
Activity / Exercise
Medications: OHA & Insulin
• Diet
– ↓ caloric diet
– 20% CHON, 30% HCHO, 50% CHO
– ↑ fiber diet
– Complex carbohydrates
• Activity
– ↑ CHO uptake by the cells
– ↓ Insulin requirements
– Allows additional sources of CHO
• Snacks
– Maintains IBW, S. CHO & S. Lipids
– Done 1 – 2° p.c.
– Regular pattern
• Medications
– OHA.
• Stimulates I of L to secrete insulin
• Indicated only in Type II DM
• E.g.
• Diabenese
• Orinase
• Tolinase
• Micronase
• Dymelor
• Glucotrol
• Daonil
• Diamicron
• Glucophage
• Glucobay
• Observe for s/sx of G.I. Upset
• Hypoglycemia

2. Insulin
• Rapid Acting Onset Peak Duration
– Lispro (Humalog)- 10-15mins - 1hr. 2-4h
– Aspart (Novalog)- 5-15mins - 40-50 mins. 2-4h
– Glusiline (Apidra)- 5-15 mins. 30-60 mins 2 hrs

• Short Acting Onset Peak Duration


-Regular (Humalog R,- 1 ½- 1hr 2-3h 4-6 hs
Novalin R, Iletin II Regular)
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• Intermediate – Acting: cloudy Onset Peak Duration


NPH (neutral protamine Hagedorn) 2-4hrs 4-12 hrs 16-20 hrs
– Humulin – N 3-4 hrs 4-12 hrs 16-20 hrs
– Iletin II Lente ,
– Iletin II NPH, Novolin N (NPH)

• Very Long Acting : Cloudy Onset Peak Duration


– Glargine (lantus) 1 hr. Continuous 24 hrs
– Detemir (levemir)

Nursing Responsibilities In Insulin Therapy

1. Route : SC – slow absorption


- less painful
IV – DKA
X massage site of injection
2. Administer insulin at room temperature
• Cold Insulin → LIPODYSTROPHY
3. Rotate the site of injection
• X lipodystrophy

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4. Store vial of insulin in current use @ room temperature


• Other vials should be refrigerated.
5. Gently roll vial in between the palms to redistribute insulin particles.
• X Shake; bubbles make it difficult to aspirate exact amount.
6. Observe for side – effects:
a. Localized :
– Induration or Redness
– Swelling
– Lesion at the site
– Lipodystrophy

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b. Generalized
– Edema
– Sudden resolution of hyperglycemia

retention of water
– Hypoglycemia
– Somogyi phenomenon
– Prolonged

↑ doses of INSULIN Tx

↓ s. CHO levels

Stress responses are triggered
Counterregulatory hormones are secreted
(EPI, NE, Glucocorticoid)

REBOUND HYPERGLYCEMIA
HYPOGLYCEMIA &
HYPERGLYCEMIA

HYPOGLYCEMIA
(Insulin Shock)
• Causes
– Omission of meals
– Overdose of insulin
– Strenuous exercise
– G.I. upset
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HYPERGLYCEMIA
(DKA)
• Causes
– Infections
– Overeating
– Underdose of insulin
– Stress
– Surgery

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Assessment

Hypoglycemia • Urine (-) CHO,ketones

• Restlessness
• Hunger pangs Hyperglycemia
• Yawning
• Weakness • Polyuria
• Tremors • Polydipsia
• Pallor • Polyphagia
• Diaphoresis • Warm, flushed dry skin
• Altered LOC • Soft eyeballs
• Cold, clammy skin Tachycardia
• H/A • n/v
• Dizziness • Abdominal pain
• Faintness • Kussmaul’s resp.
• Tachycardia • Fruity odor of breath
• Abdominal pain • Urine (+) CHO,
• Blurred vision Ketones
• Slurred speech • Altered LOC
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Management
HYPOGLYCEMIA

1. Simple Sugars p.o.


• 3 – 4oz. regular softdrink
• 8 oz. Fruit juice
• 5 – 7 pcs. Lifesaver’s candies
• 3 – 4 pcs. hard candies
• 1 tbsp. Sugar
• 5 mls. Pure honey / Karo syrup
• 10 – 15 gms. CHO

2. D50W 20 –50 mls / IV push


3. Monitor BS
4. Patient teaching
– Causes
– S & Sx
– Prevention
– Management

HYPERGLYCEMIA

1. Patent AW
2. O2 therapy
3. NSS + regular insulin / IV
4. D10 W once
s. CHO reaches 250 mg / dl level

5. KCl / Slow IV drip, once urine output is adequate


6. Monitor BS
7. Patient teaching
– Causes
– S & Sx
– Prevention
– Management

Foot Care
1. Inspect the feet daily.
2. Wash feet with warm water and mild soap.
3. Pat dry the feet – X rub
4. Wear comfortable properly – fitted pair of shoes (leather/ canvass)
5. Break – in new pair of shoes for 1 – 2° only until it becomes comfortable.
6. Use white cotton socks (males)
7. X go barefooted
8. Trim the toenails straight across. Do not cut at lateral edges, ingrowns may develop.
9. Apply lotion on the feet ( X interdigital spaces)
10. Exercise / massage the feet.
11. X wear knee – high / stay – up stockings
12. For any s & sx of injury; consult a PODIATRIST. 1


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DIABETES MELLITUS

2


FEU – Institute of Nursing NUR1217 Complete Course Module

Adrenal Cortex

ADDISON’S DISEASE
Causes
Autoimmune
TB
Fungal

Signs and Symptoms


fatigue
muscle weakness

Addison’s Disease

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FEU – Institute of Nursing NUR1217 Complete Course Module

• Hyperkalemia
• Anorexia
• Nausea and vomiting
• Weight loss
• Hypoglycemia
• Weak pulse
• Bronze pigmentation of the skin
• Inability to cope with stress

ASSESSMENT AND DIAGNOSTIC FINDINGS


• Greatly increased plasma ACTH
• Low than normal serum cortisol level or in the low normal range
• Decreased blood glucose and sodium levels
• Increased serum potassium concentration

MANAGEMENT

• restore blood circulation; administer fluids and corticosteroids; monitor v/s


• Administer IV hydrocortisone followed by 5% dextrose
• monitor I & O, Wt.
• moderate Na intake
• restrict/low K-rich foods
• x exposure to infection
• monitor urine & blood glucose levels
• gradual withdrawal of the drug
• MINERALOCORTICOID-Florinef
• CORTICOSTEROID-Prednisone

q LABORATORY
• low serum cortisol
• low fasting blood glucose
• elevated potassium
• increased BUN

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FEU – Institute of Nursing NUR1217 Complete Course Module

q DRUG THERAPY
• CORTISONE,PREDNISONE, HYDROCORTISONE, FLUDROCORTISONE

q NURSING DIAGNOSES
• decreased cardiac output related to decreased vascular volume and hyperkalemia
• risk for injury related to hypoglycemia
• fatigue related to disease

q NURSING MANAGEMENT
• promote fluid balance and monitor fluid deficit
• administer k excreting resins
• cortisol replacement given in divided 2/3 in the morning and 1/3 in the evening
• promote fluid balance and monitor fluid deficit
• administer k excreting resins
• cortisol replacement given in divided 2/3 in the morning and 1/3 in the evening

CUSHING’S SYNDROME

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FEU – Institute of Nursing NUR1217 Complete Course Module

Causes
o Tumor
o Prolonged steroid
o Therapy
o Adrenal gland hyperfunction

v CUSHING’S DISEASE – exaggerates normal actions of glucocorticoids due to excessive stimulation of acth
from the pituitary or from ectopic origin causes adrenocortical hyperplasia

SIGNS AND SYMPTOMS


v muscle weakness
v fatigue
v obese trunk, thin arms and legs
v moon face
v buffalo hump
v purple striae on trunk
v mood swings, irritability
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v acne


FEU – Institute of Nursing NUR1217 Complete Course Module

v masculinization (women)
v osteoporosis
v low resistance to infection
v poor wound healing
v hypertension, edema
v hyperglycemia

Implementation
Ø Adrenalectomy
Ø Hypophysectomy
Ø Radiation therapy

q LABORATORY
• ACTH level
• hyperglycemia
• leukopenia
• increased sodium
• decreased calcium
• decreased potassium

q NURSING DIAGNOSES
• Disturbed body image related to illness
• Fatigue related to sleep deprivation
• Excess fluid volume related to excess water & sodium reabsorption
• Risk for infection related to immunosuppression & inadequate primary defenses
• Risk for injury related to poor wound healing and bone density loss
• Imbalanced Nutrition: more than body requirements related to excess intake in relation to metabolic needs as a
result of appetite stimulation by cortisol

q MANAGEMENT
• drug therapy
ü Mitotane
ü Aminogluthetimide
ü Metyrapone
• Radiation therapy
• Surgical therapy

Assessment: ADDISON’S Disease and CUSHING’S Disease (Cushing’s Syndrome)

ADDISON’S DISEASE
Lethargy, fatigue, and muscle weakness
Gastrointestinal disturbances
Weight loss
Menstrual changes in women; impotence in men

CUSHING’S DISEASE AND SYNDROME


Generalized muscle wasting and weakness 7


FEU – Institute of Nursing NUR1217 Complete Course Module

Moon face, buffalo hump
Truncal obesity with thin extremities, supraclavicular fat pads; weight gain
Hirsutism (masculine) characteristics in female)

Hypoglycemia, hyponatremia
Hyperkalemia, hypercalcemia
Postural hypotension
Hyperpigmentation of skin (bronzed) with primary disease

Hyperglycemia, hypernatremia
Hypokalemia, hypocalcemia
Hypertension
Fragile skin that easily bruises
Reddish-purple striae on the abdomen and upper thights

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FEU – Institute of Nursing NUR1217 Complete Course Module

Care of Clients with Neurologic Alterations

The Nervous System
Functions of the Nervous System

1. Gathers information from both inside and outside the body - Sensory Function
2. Transmits information to the processing areas of the brain and spine
3. Processes the information in the brain and spine – Integration Function
4. Sends information to the muscles, glands, and organs so they can respond appropriately – Motor Function

It controls and coordinates all essential functions of the body including all other body systems allowing the body to
maintain homeostasis or its delicate balance.

The Nervous System is divided into Two Main Divisions: Central Nervous System (CNS) and the Peripheral Nervous
System (PNS)


Divisions of the Nervous System

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FEU – Institute of Nursing NUR1217 Complete Course Module

Basic Cells of the Nervous System

Neuron
• Basic functional cell of nervous system
• Transmits impulses (up to 250 mph)

Parts of a Neuron
• Dendrite – receive stimulus and carries it impulses
toward the cell body
• Cell Body with nucleus – nucleus & most of
cytoplasm
• Axon – fiber which carries impulses away from cell body
• Schwann Cells- cells which produce myelin or fat layer in the Peripheral Nervous System
• Myelin sheath – dense lipid layer which insulates the axon – makes the axon look gray
• Node of Ranvier – gaps or nodes in the myelin sheath
• Impulses travel from dendrite to cell body to axon

Three types of Neurons

o Sensory neurons – bring messages to CNS
o Motor neurons - carry messages from CNS
o Interneurons – between sensory & motor neurons in the CNS

Impulses
• A stimulus is a change in the environment with sufficient strength to
initiate a response.
• Excitability is the ability of a neuron to respond to the stimulus and
convert it into a nerve impulse
• All of Nothing Rule – The stimulus is either strong enough to start and impulse or nothing happens
• Impulses are always the same strength along a given neuron and they are self-propagation – once it starts it
continues to the end of the neuron in only one direction- from dendrite to cell body to axon
• The nerve impulse causes a movement of ions across the cell membrane of the nerve cell.

Synapse
o Synapse - small gap or space between the axon of one neuron and the dendrite of another - the
neurons do not actually tough at the synapse
o It is junction between neurons which uses neurotransmitters to start the impulse in the second
neuron or an effector (muscle or gland)
o The synapse insures one-way
transmission of impulses

Neurotransmitters

Neurotransmitters – Chemicals in the junction
which allow impulses to be started in the second
neuron

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Reflex Arc









Components of a Reflex Arc

A. Receptor - reacts to a stimulus
B. Afferent pathway (sensory neuron) - conducts
impulses to the CNS
C. Interneuron - consists of one or more synapses in the CNS (most are in the spine)
D. Efferent pathway (motor neuron) conducts impulses from CNS to effector.
E. Effector - muscle fibers (as in the Hamstring muscle) or glands responds by contracting or secreting a product.

Spinal reflexes - initiated and completed at the spinal cord level. Occur without the involvement of higher brain
centers.

Central Nervous System
• Brain
o Brain stem – medulla, pons, midbrain
o Diencephalon – thalamus & hypothalamus
o Cerebellem
o Cerebrum
• Spine
o Spinal Cord

Meninges
Meninges are the three coverings around the brain &
spine and help cushion, protect, and nourish the brain
and spinal cord.
· dura mater is the most outer layer, very
tough
· arachnoid mater is the middle layer and
adheres to the dura mater and has
weblike attachments to the innermost
layer, the pia mater
· pia mater is very thin, transparent, but
tough, and covers the entire brain,
following it into all its crevices (sulci) and spinal cord
· cerebrospinal fluid, which buffers, nourishes, and detoxifies the brain and spinal cord, flows through the
subarachnoid space, between the arachnoid mater and the pia mater
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FEU – Institute of Nursing NUR1217 Complete Course Module

Regions of the Brain

Cerebellum – coordination of movement and aspects
of motor learning
Cerebrum – conscious activity including perception,
emotion, thought, and planning Thalamus – Brain’s
switchboard – filters and then relays information to various
brain regions
Medulla – vital reflexes as heart beat and respiration
Brainstem – medulla, pons, and midbrain (involuntary
responses) and relays information from spine to upper
brain
Hypothalamus– involved in regulating activities internal
organs, monitoring information from the
autonomic nervous system, controlling the pituitary gland and its hormones, and regulating sleep and appetite


Cerebrum

· Is the largest portion of the brain encompasses
about two-thirds of the brain mass -
· It consists of two hemispheres divided by a fissure
– corpus callosum
· It includes the cerebral cortex, the medullary
body, and basal ganglia
· cerebral cortex is the layer of the brain often
referred to as gray matter because it has cell
bodies and synapses but no myelin
o The cortex (thin layer of tissue) is gray
because nerves in this area lack the insulation
or white fatty myelin sheath that makes most
other parts of the brain appear to be white.
o The cortex covers the outer portion (1.5mm to
5mm) of the cerebrum and cerebellum
o The cortex consists of folded bulges called
gyri that create deep furrows or fissures called sulci
o The folds in the brain add to its surface area
which increases the amount of gray matter and the quantity of information that can be processed
· Medullary body – is the white matter of the cerebrum and consists of myelinated axons
o Commisural fibers – conduct impulses between the hemispheres and form corpus callosum
o Projection fibers – conduct impulse in and out of the cerebral hemispheres
o Association fibers – conduct impulses within the hemispheres
· Basal ganglia – masses of gray matter in each hemisphere which are involved in the control of voluntary
muscle movements

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FEU – Institute of Nursing NUR1217 Complete Course Module

Lobes of the Cerebrum

· Frontal – motor area involved in
movement and in planning & coordinating
behavior
· Parietal – sensory processing, attention,
and language
· Temporal – auditory perception, speech,
and complex visual perceptions
· Occipital – visual center – plays a role in
processing visual information





Special regions
· Broca’s area – located in the frontal lobe – important in the production of speech
· Wernicke’s area – comprehension of language and the production of meaningful speech
· Limbic System – a group of brain structures (aamygdala, hippocampus, septum, basal ganglia, and
others) that help regulate the expression of emotions and emotional memory



Brain Waves

Brain waves are rhythmic fluctuation of electric potential between
parts of the brain as seen on an electroencephalogram (EEG).

• To measure brain waves electrodes are placed onto the
scalp using the EEG.
• There are four types of brainwaves:

o Beta
o Alpha
o Theta
o Delta

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FEU – Institute of Nursing NUR1217 Complete Course Module

• Peripheral Nervous System



Cranial nerves
• 12 pair
• Attached to undersurface of brain
Spinal nerves
• 31 pair
• Attached to spinal cord

Somatic Nervous System (voluntary)
• Relays information from skin, sense organs & skeletal muscles to CNS
• Brings responses back to skeletal muscles for voluntary responses

Autonomic Nervous System (involuntary)
• Regulates bodies involuntary responses
• Relays information to internal organs
• Two divisions
o Sympathetic nervous system – in times of stress
§ Emergency response
§ Fight or flight
o Parasympathetic nervous system – when body is at rest or with normal functions
§ Normal everyday conditions


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FEU – Institute of Nursing NUR1217 Complete Course Module

Major Sense Organs

Sensation and perception
• Vision – Eye
• Hearing – Ear
• Taste – Taste receptors (new)
• Smell – Olfactory system
• Skin – Hot, cold, pressure, pain

Sense Organs

Eye – the organ used to sense light

Three layers –
1. Outer layer consists of sclera and cornea
2. Middle layer consists of choroid, ciliary body
and iris
3. Inner layer consists of retina

Functions of the major parts of the eye:

Sclera or Scleroid Layer – (white of eye) a tough protective layer of connective tissue that helps maintain the shape
of the eye and provides an attachment for the muscles that move the eye
Cornea - the clear, dome-shaped part of the sclera covering the front of the eye through which light enters the eye
Anterior Chamber – a small chamber between the cornea and the pupil
Aqueous Humor - the clear fluid that fills that anterior chamber of the eye and helps to maintain the shape of the
cornea providing most of the nutrients for the lens and the cornea and involved in waste management in the front of
the eye
Choroid Layer - middle layer of the eye containing may blood vessels
Ciliary Body - the ciliary body is a circular band of muscle that is connected and sits immediately behind the iris-
produces aqueous humor, changes shape of lens for focusing, and
Iris - the pigmented front portion of the choroid layer and contains the blood vessels - it determines the eye color and
it controls the amount of light that enters the eye by changing the size of the pupil (an albino only has the blood
vessels – not pigment so it appears red or pink because of the blood vessels)
Lens - a crystalline structure located just behind the iris - it focuses light onto the retina
Pupil - the opening in the center of the iris- it changes size as the amount of light changes (the more light, the smaller
the hole)
Vitreous - a thick, transparent liquid that fills the center of the eye - it is mostly water and gives the eye its form and
shape (also called the vitreous humor)
Retina - sensory tissue that lines the back of the eye. It contains millions of photoreceptors (rods for black & white
and cones for color ) that convert light rays into electrical impulses that are relayed to the brain via the optic nerve
Optic nerve - the nerve that transmits electrical impulses from the retina to the brain
Common eye defects include – myopia or nearsightedness where the eyeball is too long or the cornea is too steep;
hyperopia or far sightedness where the eyeball is short or lens cannot become round enough: cataracts where the
lens becomes fogged; presbyopia where the muscles controlling the bulging of the lens become weak as we age;
nyctalopia or night blindness where vision is impaired in dim light and in the dark due to pigment rhodospin in the
rods not functioning properly
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FEU – Institute of Nursing NUR1217 Complete Course Module

Images
• the cornea and the lens help to produce the image on the retina
• images formed by the lens are upside down and backwards when they reach the retina
• two types of receptors on the retina
• Rods – 125 million on a single retina – extremely sensitive to all wavelengths of visible light but do
not distinguish different color – in dim light only rods are activated where one can see objects but not
as sharp images and are not able to distinguish their color – most dense in peripheral view –
nighttime vision Rods have a pigment called rhodospin
• As amount of light increases, the cones – 7 million on a single retina – mainly in central view are
stimulated and the color becomes clear – daytime vision
• There are three types of cones which distinguish the three colors – blue, red, green
• Fovea – point of central focus – great density of cones - center of the eye's sharpest vision and the
location of most color perception - the layers of the retina spread aside to let light fall directly on the
cones










• Light stimulates rods and cones and sends impulse via optic nerve to brain areas for vision
• The Optic Nerve exits the eye just off center near the Fovea - the Optic Nerve exits is referred to as
the Blind Spot due to the lack of the receptors in this area
• The two Optic Nerves come together at the Optic Chiasm located just under the hypothalamus - a
crucial part of vision and perception must happen - cross-over of information from the right eye
crosses over to the left side and visa versa happens here at the Optic Chiasm
• Information from each eye must be
processed in both halves of the brain
• Information leaves the chiasm via
the optic tract.
• Reorganized optic tract leaves the
Optic Chiasm and passes onto the
lateral geniculate nucleus
• At the lateral geniculate nuclei the
information is separated, organized,
and relayed to different areas of the
visual cortex
• The different zones of the visual
cortex process the different aspects
of vision and information, taken
from both visual fields, is processed
and an image is perceived
.
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FEU – Institute of Nursing NUR1217 Complete Course Module

EAR

Outer Ear & ear canal – brings sound into eardrum
Eardrum – vibrates to amplify sound & separates inner and middle ear
Middle ear has 3 small bones or Ossicles = anvil, stirrup, stapes – amplify sound (small bones) which vibrate sound
Eustachian tube – connects middle ear to throat and equalizes pressure on eardrum
Cochlea – in inner ear – has receptors for sound & sends signals to brain via Auditory Nerve

Process of hearing:
• Sound waves enter your outer ear and travel through your ear canal to the middle ear.
• The ear canal channels the waves to your eardrum, a thin, sensitive membrane stretched tightly over the
entrance to your middle ear.
• The waves cause your eardrum to vibrate.
• It passes these vibrations on to the hammer, one of three tiny bones in your ear. The hammer vibrating
causes the anvil, the small bone touching the hammer, to vibrate. The anvil passes these vibrations to the
stirrup, another small bone which touches the anvil. From the stirrup, the vibrations pass into the inner
ear.
• The stirrup touches a liquid filled sack and the vibrations travel into the cochlea, which is shaped like a
shell.
• Inside the cochlea, a vestibular system formed by three semicircular canals that are approximately at
right angles to each other and which are responsible for the sense of balance and spatial orientation. It
has chambers filled with a viscous fluid and small particles (otoliths) containing calcium carbonate. The
movement of these particles over small hair cells in the inner ear sends signals to the brain that are
interpreted as motion and acceleration. The brain processes the information from the ear and lets us

distinguish between different types of sounds.


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FEU – Institute of Nursing NUR1217 Complete Course Module

Taste and Smell – Chemical Receptors Taste buds
• The mouth contains around 10,000 taste buds, most of which
are located on and around the tiny bumps on your tongue.
Every taste bud detects five primary tastes:
o Sour
o Sweet
o Bitter
o Salty
o Umami - salts of certain acids (for example
monosodium glutamate or MSG)
• Each of your taste buds contains 50-100 specialised receptor
cells.
• Sticking out of every single one of these receptor cells is a tiny
taste hair that checks out the food chemicals in your saliva.
• When these taste hairs are stimulated, they send nerve
impulses to your brain.
• Each taste hair responds best to one of the five basic tastes.
Smell Receptors or Olfactory receptors
• Humans able to detect thousands of different smells
• Olfactory receptors occupy a stamp-sized area in the roof of the nasal cavity, the hollow space inside the
nose
• Tiny hairs, made of nerve fibers, dangle from all your olfactory receptors. They are covered with a layer of
mucus.
• If a smell, formed by chemicals in the air, dissolves in this mucus, the hairs absorb it and excite your olfactory
receptors.
• A few molecules are enough to activate these extremely sensitive receptors.
• Olfactory Hairs easily fatigued so you do not notice smells
• Linked to memories - when your olfactory receptors are stimulated, they transmit impulses to your brain and
the pathway is directly connected to the limbic system - the part of your brain that deals with emotions so
you usually either like or dislike a smell
• Smells leave long-lasting impressions and are strongly linked to your memories
• Much of what we associate as taste also involves smell – that is why hot foods “taste” different than
“cold” foods

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FEU – Institute of Nursing NUR1217 Complete Course Module

Skin receptors:

Your skin and deeper tissues contain millions of sensory receptors. Most of your touch receptors sit close to your
skin's surface.
Light touch
• Meissner's corpuscles are enclosed
in a capsule of connective tissue
• They react to light touch and
are located in the skin of your
palms, soles, lips, eyelids, external
genitals and nipples
• these areas of your body are
particularly sensitive.
Heavy pressure
• Paccinian corpuscules sense
pressure and vibration changes
deep in your skin.
• Every square centimeter of your
skin contains around 14 pressure
receptors
Pain
• skin receptors register pain
• pain receptors are the most
numerous
• each square centimeter of your
skin contains around 200 pain receptors

Temperature
• skin receptors register warmth and cold
• each square centimeter of your skin contains 6 receptors for cold and 1 receptor for warmth
• Cold receptors start to perceive cold sensations when the surface of the skin drops below 95 º F. They are
most stimulated when the surface of the skin is at 77 º F and are no longer stimulated when the surface of
the skin drops below 41 º F. This is why your feet or hands start to go numb when they are submerged in icy
water for a long period of time.
• Hot receptors start to perceive hot sensations when the surface of the skin rises above 86 º F and are most
stimulated at 113 º F. Beyond 113 º F, pain receptors take over to avoid damage being done to the skin and
underlying tissues.
• thermoreceptors are found all over the body, but cold receptors are found in greater density than heat
receptors – most of the time of our environment is colder than our body temperature
• The highest concentration of thermoreceptors can be found in the face and ears so your nose and ears
always get colder faster than the rest of your body on a chilly winter day

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FEU – Institute of Nursing NUR1217 Complete Course Module

Disorders of the Nervous System – symptoms, prevention, treatment
• Epilepsy - common and diverse set of chronic neurological disorders characterized by seizures.
• Seizures - the physical findings or changes in
behavior that occur after an episode of abnormal
electrical activity in the brain and are caused by
abnormal electrical discharges in the brain
• Alzheimer’s Disease - a degenerative disease of the
brain that causes dementia, which is a gradual loss
of memory, judgment, and ability to function. - the
most common form of dementia- affects an
estimated 1 in 10 people over age 65
• Multiple Sclerosis - an autoimmune disease that
affects the brain and spinal cord (central nervous
system) - body's immune system eats away at the protective myelin sheath that covers the
axons of the neurons and interferes with the communication - MS can affect vision, sensation,
coordination, movement, and bladder and bowel control.
• Parkinson’s Disease - disorder of the brain that leads to shaking (tremors) and difficulty with
walking, movement, and coordination. People with Parkinson's disease have low brain
dopamine concentrations.
• Shingles (herpes zoster) - painful, blistering skin rash due to the varicella-zoster virus, the virus
that causes chickenpox – the virus remains inactive (becomes dormant) in certain nerves in the
body. Shingles occurs after the virus becomes active again
• Cerebral Palsy - group of disorders that can involve brain and nervous system functions such as
movement, learning, hearing, seeing, and thinking resulting from damage to certain parts of the
developing brain
• Glaucoma - a group of eye conditions that lead to damage to the optic nerve due to increased
pressure in the eye - the eye’s drainage system becomes clogged so the intraocular fluid cannot
drain and as the fluid builds up, it causes pressure to build within the eye. High pressure
damages the sensitive optic nerve.
• Pink eye (Conjunctivitis) – infection of the conjunctiva of the eye

Effects of Drugs on the Nervous System
• Alcohol - central nervous system depressant – cell membranes are highly permeable to alcohol
so once in the bloodstream it can diffuse into almost all body tissues. It is absorbed in the
stomach so it gets into the blood stream quickly and slows down function of the nervous
system
• Caffeine - acts as a central nervous system stimulant - caffeine suppresses melatonin for up to
10 hours and also promotes adrenalin. Melatonin is strongly associated with quality sleep,
while adrenalin is the neurotransmitter associated with alertness.
• Nicotine - small doses of nicotine have a stimulating action on the central nervous system – it is
highly addictive nicotine's effects on the brain cause an increased release of neurotransmitters
associated with pleasure. The brain quickly adjusts to repeated nicotine consumption by
decreasing the amount of neurotransmitters released. The effect of this increased tolerance is
that the smoker must continue to use nicotine in order to avoid the feelings of discomfort

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FEU – Institute of Nursing NUR1217 Complete Course Module

associated with withdrawal from the drug. Irritability and anxiety often ensue during nicotine
withdrawal.
• Marijuana - THC, the main active ingredient in marijuana, binds to membranes of nerve cells in
the central nervous system that have protein receptors. After binding to nerve cells, THC
initiates a chemical reaction that produces the various effects of marijuana use. One of the
effects is suppression of memory and learning centers (called the hippocampus) in the brain.

Neurosurgical Dysfunctions
There’s no known cure for any neurologic dysfunctions. The NURSING GOAL is to help the client adapt to
dysfunctions & continue with life in as meaningful and way as possible. Many clients with neurologic dysfunctions
face a wide variety of possible nursing diagnoses.

Management of Client with ICP Increased Intracranial Pressure (ICP)


The skull is a hard, bony vault filled with brain tissue, blood and cerebrospinal fluid (CSF). Balances between these 3
Components maintain the pressure within the cranium.

Normal range of ICP : 5-15 mmHg

Cerebral Response to Increased ICP


l Monro-Kellie Hypothesis:

Intracranial Pressure is the pressure exerted in the Cranium by its content: Component of the Intracranial Pressure
2. The blood 4%
3. CSF 12%

Pathophysiology of Increased ICP

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FEU – Institute of Nursing NUR1217 Complete Course Module

Cushing Triads

1. Hypertension
2. Bradycardia
3. Widening pulse pressure

Things to avoid if there is a suspected ICP

1. Do not manipulate the head and neck if the status of cervical spine has not been determined.
2. The nasal passage should not be used for suctioning if a Basal skull fracture or a dural tear is suspected.

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Nurses Responsibilities:
1. Recognize early sign of neurologic deterioration.
2. Avoid Morphine SO4
3. Maintain mech. Ventilator & maintaining PaCO2 @ 30-35mmHg will result in vasoconstriction of the cerebral
blood flow and therefore decreased ICP.
4. Avoid Shivering
5. Instruct the client if conscious and still coherent & SO to avoid straining activities
6. Prepare for CT scan and lab test
Ø mass lesion or subarachnoid hemorrhage
Ø No mass lesion or subarachnoid hemorrhage

Nurses Responsibilities after lumbar puncture:

Clinical Manifestation of Increased ICP

Early Stage Middle Stage Late Stage

a. Deteriorating LOC such as a. Ipsilateral pupil is a. Pupils become bilaterally dilated and fixed
confusion, restlessness gradually dilates.
& lethargy. b. Hemiplegia, decorticate or decerebrate
b. Blurring of vision, decreased develops due to increasing pressure on the
visual acuity brain stem
and diplopia
c. HR and BP are stable
d. Headache

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Increase ICP indications for Infant:

High pitched cry Bulging fontanelles

Symptoms of Inc. ICP and SHOCK:

Nursing Diagnoses

• Ineffective Airway Clearance


• Ineffective Breathing Pattern
• Decrease Tissue perfusion
• Impaired gas exchange
• Infection
• Imbalance Nutrition less than body requirements
• Altered bowel elimination
• Self Care deficit, etc.

Intracranial HPN

Definition : is sustained elevated ICP of 15mmHg or higher. Common Causes : Growth of Tumor
Edema/ Inflammation Trauma
Hemorrhage Hydrocephalus

TWO CATEGORIES OF intracranial hypertension

• Primary or Idiopathic Intracranial Hypertension (IIH)


• Secondary Intracranial Hypertension Assessment Findings:
1. Restlessness
2. Headache, Nausea & Vomiting, Diplopia
3. Decreased LOC

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FEU – Institute of Nursing NUR1217 Complete Course Module

5. V/S changes
a. Systole
b. Diastole
c. Widening of Pulse Pressure
d. Slow PR & RR
e. Elevated body temp or subnormal
f. ANISOCORIA
PINPOINT – Pons involvement
• Hemiplegia
• decorticate
• decerebrate posture develops
• Bilateral flaccidity
• Loss of brain stem reflexes: pupillary reflexes, gag reflex

Headaches

Migraine Headache

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FEU – Institute of Nursing NUR1217 Complete Course Module

Tension Headache

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FEU – Institute of Nursing NUR1217 Complete Course Module

Diagnostic Test

§ CT Scan
§ MRI Medications:
NSAID Analgesics > these medications, such as aspirin, acetaminophen & ibuprofen, naproxen may help to reduce the
pain.

Triptans > specific medication if taken during a migraine attack will either lessen or abort the headache

DihydroErgotamine > given in parenteral form


> these medications interfere with the widening of the vessels in the head & decrease the pain assoc. with intractable
migraine

Seizures

Any disorder that alters the neuronal environment resulting to disorderly discharge of neurons & is characterized by a
sudden, transient alteration in brain function, usually involving motor, sensory or psychic clinical manifestations and
altered level of arousal.

Clinical Manifestation
• Simple Partial Seizure Example:
• If the electrical discharge occurs in the part of the brain that controls the R hand muscle movements, the R hand may
begin to shake & jerk.

• A person who has a psychic manifestation, a person may experience an aura like strange smell, noise or a sense of
rising or welling up in the epigastric region and “déjà vu” in which unfamiliar surroundings inexplicably seem
familiar to him.

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FEU – Institute of Nursing NUR1217 Complete Course Module

Medication:

Clorazepate (Tranxene)

• Myoclonic Seizure: Intermittent contractions of muscles without loss of consciousness


• Tonic Seizure: Prolonged involuntary muscle contractions and loss of consciousness for several minutes

Grand mal/ Tonic-clonic seizure


Known also as Convulsive seizure

1. Prodromal Syndrome
2. Experience aura S/SX
• Temporary loss of consciousness
• severe muscle spasm
• intense turning of the head to one side
• clenching of teeth
• temporarily confuse and feel extremely tired.
• A person does not remember what happened during the seizure.
• loss of bladder control followed by intense headache

Eliciting stimuli:

• Hypoglycemia
• Fatigue
• Emotional or physical stress
• Fever
• Hyperventilation
• Environmental stimuli

Phases of a grand mal seizure

1. Tonic phase ( 10 -20 seconds) – muscle contraction Epileptic cry – respiration stops

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2. Clonic phase – (1/2 -2 minutes) muscle spasms; respiration is ineffective; autonomic nervous system active
3. Terminal phase (about 5 minutes) –limp and quiet, EEG flat lines

Petit Mal (Absence Seizure)

• Begins in childhood, usually before aged 5.


• S/sx > fluttering eyelids or twitching facial muscles that last for 10-30secs.

Medication: ( Absence Seizure ) Benzodiazepines


Side Effects:

Ø Ataxia
Ø Respiratory & cardiac Depression
Ø Medication Tolerance & Drug dependency

Succinamides Side Effects:


Ø Anorexia
Ø Blood Dyscrasias

Oxazolidinediones Side Effects:


Ø sedation
Ø photophobia

Nursing Management During a seizure


Ø Assess and document
a. Clinical manifestation (types of seizure)

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b.Site of origin
c.EEG findings
d.How may times it occurs
Ø Position the client to side-lying to drain any secretions, and suction if needed.
Ø Protect client from injury
Ø Have O2 & suction at bedside for use after following seizure if needed.
Ø Do not try to force an object, such as bite stick, into the mouth of a client is seizing, as this may break teeth
or cause other injury.
Ø Do not restrain

Nursing Intervention

• Educate the client and family


• Provide counseling so as to improve client’s coping mechanisms.

Pharmacotherapy

• Diazepam (Valium) status epilecticus


• Carbamazepine ( Tegretol) SE : Low count of RBC & WBC
• Phenobarbital (Luminal)
Monitor L functions & drowsiness, sedation
Administer these medications slowly thru IV in an attempt to halt the seizure.

Epilepsies

Episodes of abnormal electrical discharge in the brain characterized by recurrent seizures, often accompanied
by convulsions

Investigative Studies
• EEG
– Helps classify particular type of seizure
– Diagnostic of choice
• Video EEG
– Patient is video taped

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Cerebral Circulation

Internal Carotid Artery

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STROKE AND CEREBROVASCULAR ACCIDENT

Care of Client with Stroke

Stroke is a term used to describe neurologic changes caused by an interruption in blood supply to a part of the brain.

CVA results in cerebral anoxia and impaired cerebral metabolism, which damages brain tissues. CVA results from
occlusion of the intracranial or extracranial artery, commonly associated with
ATHEROSCLEROTIC PLAQUE

TWO MAJOR TYPES OF STROKE

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Cerebrovascular disorders (CVA) is the third leading cause of death in the United States and account for about 167,000
mortalities annually.

Ischemic Stroke

Subarachnoid Hemorrhage

Most common cause:


aneurysm rupture Other causes:
• Vessel malformation
• Tumor, bleeding abnormalities

Subarachnoid Hemorrhage

Types of Stroke

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Hematoma

TWO MAJOR TYPES OF STROKE

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FEU – Institute of Nursing NUR1217 Complete Course Module

THROMBOTIC STROKE

TWO MAJOR TYPES OF STROKE

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Cincinnati Prehospital Stroke Screening
• Check for facial drooping have patient smile or show teeth.
• Check for arm drift by having patient close eyes and hold arms out for 10 seconds Have the Patient say a phrase to
see if there is any abnormal speech pattern.
Such as: “The Sky is Blue in Cincinnati”

Patients with 1 of these 3 findings -as a new event – have a 72% probability of an ischemic stroke. If all 3 findings are
present the probability of an acute stroke is more than 85%

Terms to Describe Motor Dysfunction

• -plegia = stroke or paralysis


• Paralysis = loss of movement
• Paresis = weakness
• Mono- = one limb
• Hemi- = both limbs on one side
• Di- or para- = both upper limbs or both lower limbs
• Quadri- or tetra- = all four limbs

Nursing Diagnoses

• Impaired verbal Communication


• Unilateral neglect r/t perceptual Disruption
• Impaired swallowing r/t neuromuscular impairment
• Disturbed body image r/t actual change in body structure, function & appearance
• Deficit knowledge : Discharge regimen r/t lack of previous exposure to information

3 types Aphasia Global Aphasia


Ø Affects both comprehension & speech production

FOUR LOBES OF THE CEREBRAL HEMESPHERE

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Intracranial aneurysm

("cerebral aneurysm," "brain aneurysm") is a protruding bubble or sac on a brain artery that balloons out over time.
Aneurysms have thin, weak walls and have a tendency to rupture causing hemorrhage into and around vital brain
structures.
Common site: Anterior portion of the Circle of Willis .

Pathogenesis of Hemorrhagic Stroke

Nursing Responsibilities Nimodipine (Nimotop)


Ø Produces selective blockade of calcium-channels I cerebral blood flow.
Ø Nimodipine is the ONLY APPROVED application is prophylaxis of neurologic injury following rupture of
INRACRANIAL ANEURYSM.

Instruct client to swallow sustained-release formulations whole without crushing or chewing

Ø Prevents cerebral arterial spasm that follows subarachnoid Hemorrhage that can result to neurologic deficit.
Ø Dosing ( 60mg every 4hrs) should be given within 96hrs of SAH and continue for 21 days.
Ø MUST NOT be given parenterally (e.g IM or IV) owing to a risk of potentially fatal cardiovascular events.

Nursing Diagnoses

• Ineffective airway clearance r/t accumulation of secretion


• Ineffective cerebral perfusion r/t effects of increase ICP
• Risk for fluid volume deficit r/t dehydration
• Risk for infection r/t ICP monitoring system
• Ineffective breathing pattern r/t neurologic dysfunction ( brain stem dysfunction)

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Nursing Care : A Review of the Evidence – ICP

• The Glasgow Coma Scale (GCS) is the most recognized and widely used neurological assessment tool
(Price, 2000)
• Price et al. (2000) showed that most treatment for the acute head-injured patient in the ICU is based on ICP
measurements
• ICP monitoring takes the following into consideration: accuracy, the equipment required, risk of infection,
duration of monitoring and skill of staff using the method (Woodrow, 2000)
• Many critical care areas do not routinely use ICP monitoring because of the lack of skilled personnel to
insert the device or the ability to interpret the significant findings

DRUG THERAPY

a. Administer stool softener ( Lactulose- cephulac) and suppositories as ordered to prevent constipation and fecal
impaction due to immobility.

Nursing Management for Client Using Lactulose

1. Report DIARRHEA
2. Administer with juice to disguise the taste

2. Administer medication as ordered


a. corticosteroids to decrease cerebral edema
b. Anticonvulsant drug to prevent seizures
c. Anticoagulants for stroke in evolution or embolic stroke.

Nursing Management for AntiCoagulant (Warfarin Na Coumadin)


1. Prevent thrombus formation
2. Avoid Green Leafy vegetables as the Vit. K content of these vegetables interfere with the absorption of the
drug.
3. Avoid contact sports
4. Assess for sign of bleeding
5. Keep the vit. K at bedside (Antidote)

1. Osmotic Diuretics ( Cerebral edema reduction)


2. Chlorpromazine (Thorazine) to control shivering
3. Barbiturates decrease cellular metabolic demand
4. Phenytoin NA( anticonvulsant)
**** Administer after meal to prevent GI upset
5. Antipyretic for fever control fever
6. Meperidine HCl (Demerol) relaxes the smooth muscle & reduces shivering

Nursing Management for Client taking Phenytoin

1. Best taken with food to enhance absorption


2. Massage the gums, it causes gingival hypertrophy
3. Inform client that the urine will turn to pink, red or reddish brown.

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4. Do not discontinue abruptly & monitor for s/sx of bone marrow depression
5. Use SALINE flush before & after IV administration
6. Report for skin rash, sore throat, nosebleeds as sign of blood dyscrasia.

The therapeutic level of phenytoin is 10-20mcg/mL


Ø greater than 20mcg/mL, involuntary movements of the eyeball (nystagmus)
Ø greater than 30mcg/mL ataxia and slurred speech occurs.

Inform the female client that Phenytoin decreased effectiveness of the birth control pills because it enhances the rate of
estrogen metabolism while taking the drugs

Critical Thinking Exercises:

1. Which of the following is not a risk factor for a CVA?


D: Obesity may indirectly cause other risk factors but is not a direct risk factor.

1. A client sustains a CVA & is paralyzed on the L side Which of the following best describes this condition?
A: Hemiplegia means loss of motor function on one side of the body.
Care of Client with Inflammatory Disease Intracranial infection
Infection or inflammation of the membranes covering the brain and spinal cord

Brain Abscess
The brain has a free or encapsulated collection of pus that usually occurs in the temporal, Cerebellum or frontal lobe.

Meningitis
Is an inflammation of the meninges, which, if severe, may become encephalitis, an inflammation of the brain.

What is meningitis?
The brain and spinal cord are covered by 3 connective tissue layers collectively called the meninges which form the
blood-brain barrier.

- the pia mater (closest to the CNS)


- the arachnoid mater
- the dura mater (farthest from the CNS). The meninges contain cerebrospinal fluid (CSF).

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Dura Mater

• Has two layers


• Inner layer bends over to form a fold (falx cerebri) that separates the cerebral hemispheres
• It forms a second fold (tentorium) that holds the cerebrum up off the cerebellum

• Between the layers of the dura, at the base of each fold, venous blood drains out of the brain in a sinus
• Bridging veins carry blood from the brain across the inner layer of the dura mater to the sinus
• The sinus also collects cerebrospinal fluid

Arachnoid

• Lies just beneath the dura mater


• Waterproof
• Cerebrospinal fluid (CSF) lies under the arachnoid to cushion the brain
• Extensions of the arachnoid (villi) poke through the inner layer
of the dura mater into the sinuses, to let CSF drain into the sinuses

Pia Mater

• Lies right on the surface of the brain


• Holds the cerebral arteries in place

Meninges and Meningeal Spaces

• Epidural space: meningeal arteries


• Dura mater
– Subdural space: bridging veins
• Arachnoid
– Subarachnoid space: cerebral arteries, cerebrospinal fluid
• Pia mater

Cerebrospinal Fluid

• Leaks out of capillaries inside the brain’s hollow ventricles


– Composition controlled by the blood–brain barrier
• Passes out an opening below the cerebellum
• Circulates around the brain and spinal cord in the subarachnoid space
• Passes through arachnoid villi into blood in the dural sinuses and is returned to the heart

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FEU – Institute of Nursing NUR1217 Complete Course Module

Meningitis
Classified into 2

1. Aseptic Meningitis. : bacteria are not cause of the inflammation, the cause could be viral or secondary to
lymphoma, leukemia or brain abscess.
2. Septic Meningitis. : refers to meningitis cause by bacteria, most commonly :
a. Neisseria Meningiditis assoc. with petechial rash
b. Haemophilus Influenzae
c. Streptococcus Pneumoniae ( common to adult)
d. meningococcus

Spots or Rashes of Meningitis

Symptoms of meningitis
Neonates and the elderly often present atypically .
Adults and children

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Clinical Manifestations
• Fever tends to remain high throughout the course of the illness
• Headache, usually severe as a result of meningeal irritation S/Sx of menigeal Irritation
> (+) Nuchal rigidity ( stiff neck) is an early sign
> Miningismus ( inability to touch one’s chin to neck)

(+) Kernig’s sign


when the pt. is lying with the thigh flexed on the abdomen, the leg cannot be completely extended.

(+) Brudzinski’s Sign


when the pt’s neck is flexed, flexion on the knees & hips is produced.

Photophobia – extreme sensitivity to light, this finding is common, although the cause is unclear.

• Disorientation & memory impairment


• Behavioral manifestations as the illness progresses such as lethargy, unresponsiveness * coma.
• Seizures & increase ICP due to accumulation of purulent exudates

Diagnostic test for meningitis: lumbar puncture

Permits the urgent distinction of bacterial meningitis from viral meningitis and examination of the CSF allows precise
diagnosis.

Diagnostic Test CSF Analysis


§ Gold standard

Findings

ü Turbid & cloudy


ü Increased WBC count
ü Increased Protein level
ü Decreased glucose level

A lumbar puncture collects cerebrospinal fluid to check for the presence of disease or injury.
A spinal needle is inserted, usually between the 3rd and 4th lumbar vertebrae in the lower spine.
Diagnostic Test Lumbar Puncture
1. After the procedure
Ø Maintain client on NPO & flat on bed for 4-6hrs to Prevent post LP headache

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Typical CSF findings in Meningitis

Nursing Diagnoses

• Ineffective Breathing Pattern


• Infection r/t to presence of bacteria in the CSF
a. Intravenous PENICILLIN is the drug of choice
- Best taken on empty stomach with a full glass of water
Diagnostic Test Lumbar Puncture
CSF Tube Content:
#1 – Total Cell , RBC, WBC Differential Count #2 – Protein, Sugar
#3 – G/S,C/S,AFB, Indian Ink to detect presence of cryptococcus #4 – Sabouraud’s Agar – Fungal Meningitis
#5 – TB ELIZA Determination
#6 – CALAS ( Crytoccocal Ag Latex Agglutination)

Pharmacotherapy
• Antimicrobial/ Antibiotic ( ampicillin, piperacillin, ceftrioxone Na )
• Vancomycin HCl alone or with Refampicin may be used if resistant stains of bacteria are identified.
• Dexamethasone for bacterial meningitis & in pneumococcal meningitis if given 15-20minutes before 1st dose of
antibiotics q 6hrs for the next 4 days.
• Phenytoin ( dilantin) for seizure

Therapy Based on Specific Etiologic Agent


1. Streptococcus Pneumoniae – PenG 4 Mil units IV q 4hrs.
2. Staphyloccocus Aureus - Oxacillin 2gm IV q 4-6hrs
3. Neisseria Meningidites - Pen G 4 Mil Units q 4 hours

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4. 4.Hemophilus Influenzae
4.1 :Ceftriaxome ( Rocephin) 2g IV q 4-6hrs.
4.2 : Cefotaxime ( Claforan) 1-2g IV q 4-6hrs
5. TB Meningitis - Isoniazid , rifampicin, pyrazinamide & ethambutol Vitamin supplement should be given
with INH Pyridoxine (B6)

Neurologic Trauma

Head Injury - is an insult to the brain that is capable of producing physical, intellectual, emotional, social, and
vocational changes.
In the United States, a head injury is experienced approximately every 15 seconds. In more than 30% of cases, head
injuries are fatal.

Incidence:

Ø It occur in about seven million Americans every year.


Ø More than 500,000 are hospitalized
Ø 100,000 experience chronic disability
Ø 2000 left in a persistent vegetative state

Persistent Vegetative State:.


1. Patients in this state have no thinking abilities or awareness of their surroundings.
2. They do, however, retain non-cognitive function and normal sleep patterns.
3. Although those in a persistent vegetative state lose these higher brain functions, others, such as breathing
and circulation, remain intact.
4. Spontaneous movement may occur and the eyes may open in response to stimuli.
5. Individuals in a persistent vegetative state may appear normal, but they can not speak or respond to
commands.

Causes

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Clients with head injury often have other major injuries:

2 Types of Primary Injury:

Focal Brain Injury

• The force of impact usually produces contusions from direct contact that in turn produces epidural
hemorrhage and subdural and intracerebral hematoma

Contusion
Petecchiation and Hemorrhage in cortex +/- edema and necrosis; Leading to focal signs which can resolve or progress
(Brainstem hemorrhage more likely with twisting impact.)

• In contusion, the epidermis (outer layer of the skin) remains intact;In the dermis ( the underlying skin)
,however, cells are damaged and Blood vessels are torn.

Contusion
Petecchiation and Hemorrhage in cortex +/- edema and necrosis; Leading to focal signs which can resolve or progress
(Brainstem hemorrhage more likely with twisting impact.)

Contusion

Ø Are found usually in the FRONTAL LOBES and TEMPORAL LOBES


Ø Less common occurrence are in parietal and occipital lobes

Contusion Clinical Manifestations

• Changes in attention
• Disorientation to Time, Place or person.
• Memory, emotion, behavior
• Local pain and swelling
• The affected area will turn black or blue as blood and fluid leak into the damaged tissue

Diffuse Brain Injury


Immediately following concussion

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Concussion
Transient loss of Function without obvious structural damage
Clinical Manifestations Concussion
• Loss of consciousness <5minutes
• Headache & Dizziness
• Post-traumatic amnesia
• Nausea & vomiting
• Loss of reflexes

Transient alterations in the following:


a. Respiratory Brief apneic period
b. Cardiovascular bradycardia
c. Hemodynamic function BP

Raccoon Sign > periorbital ecchymosis


> It results from blood from skull tracking down into soft tissue around the eyes.
Battle Sign > mastoid ecchymosis
> is an indication of fracture of the base of the posterior portion of the skull and may suggest underlying brain trauma.

Types and Mechanisms of Injury:

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Investigative Studies

• CT Scan w/o contrast


– Diagnostic of choice
• Lumbar Puncture
– C/I: in ICP

Outcome Management

¨ Medical Therapeutics
¡ Oxygen
¡ Hyperventilation
¡ Mannitol
¡ Indwelling urinary catheter
¡ Sedations
ú High dose barbiturate
ú coma

Propofol (Diprivan)
sedation of ventilated adult client receiving intensive care

Nursing Care : A Review of the Evidence – Respiratory

• Many severe head injuries with a GCS of 8 or below require intubation and mechanical ventilation, which
subsequently requires admisssion to ITU (Hillman and Bishop, 1996)
• Endotracheal suctioning (ETS) and coughing can lead to sharp increases in ICP (Johnson, 1999)
with cerebral ischemia (Golenberg-Klein, 1999)
• A key intervention is to pre-oxygenate the patient with 100% oxygen for 1 min prior to ETS
(Hall, 1997)
• ETS should be limited to 15s per suction pass, using a maximum of two suction passes and allowing 10 min
for ICP to return to baseline before further interventions (Palmer, 2000)

Critical Thinking Exercises:

1. Mr. Lazaro ,a 57 yo an alcoholic man has fallen & is told he has a hematoma that is on the top of his brain. Which of
the following types of hematoma would most likely occur to him?

A : Subdural hematoma are commonly found in the older adults and people who abuse alcohol would mostly occur.

1. Mr. Abad has sustained contusion. He has changes in attention, memory, Affect & emotion. In which region of the
brain is usually the cause?

B : Contusions are most commonly found in the frontal Lobes particularly @ the poles & along the inferior orbital
Surfaces. They result in changes in attention, memory, etc.

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Brain Tumor

• A mass of cells that grow & have no use.


• Brain tumors grow from glia & other support cells, not the neurons themselves.
• Tumor growth varies depending on type of tumor, where its located, & type of cell that it grows from.

Focal Neurologic Defects

• distorted Vision, smell, hearing and touch


• Weakness / hemiparesis
• clumsiness
• Paralysis & Seizures

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Types of Brain Tumors

1. Gliomas- tumors that arise from glial cells & infiltrate the brain. May be benign to malignant. About 45% of all
tumors are gliomas.
A. Astrocytomas-result from growth of astrocytes. Usually not malignant & may be treated fairly easily. Prognosis is
good.
B. Glioblastomas-highly malignant, rapidly growing.
2. Meningiomas- attached to meninges. Are encapsulated on outside of brain. Usually benign.
3. Metastatic Tumors- a tumor that results in the brain from tumor cells carried from the body elsewhere (breast, liver,
lung, etc.).

2 Classifications of Brain Tumor:

Extracerebral tumors originate outside substances


of the brain and include meningiomas, acoustic nerve tumors and tumors of the pituitary and pineal glands

50% of Metastatic Carcinomas arise from the lungs, 13% from melanomas,6% from the breast and 4% from the
kidneys,etc. Like gallbladder, liver, testes, uterus, ovary and pancreas

Goal of Care : Removal of tumor through surgery CRANIOTOMY


Craniotomy
– involves opening the skull surgically to gain access to intracranial structures.
- performed to remove the tumor, relieved elevated ICP, evacuate a blood clot & control hemorrhage

When to Seek Medical Care


• Unexplained, persistent vomiting
• Double vision or unexplained blurring of vision, especially on only one side
• Lethargy or increased sleepiness
• New seizures
• New pattern or type of headaches

Treatments and procedures before surgery.

• steroid drug, such as dexamethasone (Decadron), to relieve swelling


• anticonvulsant drug, such as carbamazepine (Tegretol), to relieve or prevent seizures
• If there is excess cerebrospinal fluid collecting around the brain, a thin, plastic tube called a shunt may be
placed to drain the fluid VENTRICULOPERITONEAL SHUNT
• One end of the shunt is placed in the cavity where fluid collects; the other is threaded under the skin to
another part of the body.

Chemotherapy is the use of powerful drugs to kill tumor cells.

A single drug or a combination may be used. Antimetabolites or alkylating agents

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The side effects of chemotherapy include nausea and vomiting, mouth sores, loss of appetite, loss of hair, and many
others. Some of these side effects can be relieved or improved by medication.

Nursing Diagnoses

• Ineffective airway clearance r/t accumulation of secretion


• Ineffective cerebral perfusion r/t effects of increase ICP
• Risk for fluid volume deficit r/t dehydration
• Risk for infection r/t ICP monitoring system
• Ineffective breathing pattern r/t neurologic dysfunction ( brain stem dysfunction)

Spinal Cord Injury

Occurs predominantly in men as result of motor vehicular accidents, falls, gunshot wounds, and sports- related injuries

Most commonly occurs in cervical and lower thoracic-upper lumbar vertebrae.

Signs and Symptoms (According to Level of Injury)

LEVELS OF SIGNS and SYMPTOMS


INJURY
C-1 to C-3 tetraplegia with total loss of
muscular/respiratory function
C-4 to C-5 tetralegia with impairment, poor pulmonary
capacity, complete
dependency for ADLs

C-6 to C-7 tetraplegia with some arm/hand movement allowing


some independence in ADLs

C-7 to T-1 tetraplegia with limited use of thumb, increasing


independence

T-2 to L-1 tetraplegia with intact arm function and varying


function of intercostals and
abdominal muscles

L-1 to L-2 Mixed motor-sensory loss, bowel bladder


dysfunction

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Nursing Consideration for Medication:


Ø is prescribed for a client with spinal cord injury for discomfort caused by spasticity Laboratory Test :
Ø > Liver function studies

Autonomic Hyperreflexia

An exaggerated sympathetic response to noxious stimulus (considered as a medical emergency) Occurs in clients with
injury above T6

Stimuli
Distended bladder or other visceral organs
Stimulation of the skin (pressure ulcer, tactile, pain and thermal stimuli)

Manifestations

-Extreme hypertension, pounding headache


-Flushing, diaphoresis
-Bradycardia
-Blurred vision
-Restlessness

Nursing Management

• Identify and alleviate the cause by removing the triggering stimulus.


• Provide the client with instruction about prevention and management measures.

The goal of management are to prevent further spinal cord injury and to observe for symptoms of progressive
neurologic deficits

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Resuscitate as necessary and maintain oxygenation and cardiovascular stability.

Nursing Diagnosis

Urinary retention related to effects of spinal cord injury

Nursing Interventions:
1. Place the client in a sitting position to help lower the bladder pressure.
2. Catheterize the client to prevent bladder distention

Skeletal Reduction and traction

Spinal cord injury requires immobilization, reduction of dislocation, and stabilization of the vertebral column.

Reduce the cervical fracture and align the cervical spine with a form of skeletal traction, i.e., skeletal tongs/calipers or
the halo-vest technique.

SURGICAL INTERVENTION: LAMINECTOMY

Keep the back as straight as possible, to prevent twisting the spine

Nursing Intervention
1. Implement an exercise program to maintain mobility and strength of unaffected parts and to promote self-care.

• Encourage fluid intake of about 2.5 L daily and intake of fiber diet to manage bladder and bowel problems
• Promote skin integrity. Teach client pressure-relieving techniques and instruct not to remain in any position
for more than 2 hours

Critical Thinking Question :

Answer : C
Rationale : Above the T6, client with spinal cord injury are at risk for Autonomic hyperreflexia .

a. Malignant HPN
b. Pulmonary embolism
c. Autonomic hyperreflexia
d. Spinal shock

CARE OF CLIENT WITH NEUROMUSCULAR IMPAIRMENT

Multiple Sclerosis (MS)

• Chronic progressive demyelinating disease of the CNS


• Small patches of demyelination of brain and spinal cord impair the transmission of nerve impulses

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Cause: unknown, but may be viral in origin or secondary to an autoimmune disease

Signs and Symptoms


Primary Symptoms: Fatigue, weakness, numbness, poor coordination and loss of balance

Multiple Sclerosis (MS)-Clinical Manifestations Motor assessment


1. Fatigue/stiffness of extremities
2. Flexor spasms at night
3. Hyperactive, deep tendon reflexes
4. Clonus, positive Babinski's reflex
5. Absent abdominal reflexes
6. Unsteady gait

Cerebellar findings
1. Intention tremor, dysmetria
2. Dysdiadochokinesia, clumsy motor movements
3. Loss of balance, poor coordination

Cranial nerves/brainstem
1. Tinnitus, vertigo, hearing loss
2. Facial weakness, dysphagia
3. Dysarthria, ataxia, slow, scanning speech
4. Blurred vision, diplopia, decreased visual acuity
5. Scotomas, nystagmus

Sensory
1. Hypalgesia, paresthesia

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2. Facial pain, decreased temperature perception
3. Numbness, tingling, burning, crawling sensations
4. Bowel/bladder dysfunctions
5. Alteration in sexuality

Cognitive
1. Decreased short-term memory
2. Decreased concentration
3. Decreased ability to perform calculations
4. Inattentiveness
5. Impaired judgment

Psychosocial
1. Anxiety
2. Apathy, emotional lability
3. Depression
4. Euphoria (or giddy)

Diagnostic Studies

• Lumbar puncture reveals elevated CSF protein and gamma globulin.


• Electrophorosis of CSF reveals oligoclonal banding.
• MRI reveals presence of 3-4 lesion of greater than 3 mm in diameter on the brain

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MYATHENIA GRAVIS

Ø Is a chronic autoimmune disease that affects the neuromuscular junction and characterized by muscle
weakness and fatigability.
Ø Early onset 20-30 years old
Ø women are more often affected than men.

Physiology (MG):

• The antibodies which released by the IMMUNE System attacks the foreign bodies like the bacteria
• The neuromuscular junction , a nerve cell tells the muscle to contract by releasing the chemical
acetylcholine that is attached to Ach receptor
• Ach receptor – a pore or channel found in the surface of the muscle allow an electrical current that triggers
the muscle to contract.

Pathophysiology (MG):

• Cause is UNKNOWN (autoimmune)

• In autoimmune ds., Antibodies mistakenly Invades, attack and destroy the Ach receptor

• Inadequate release of the neurotransmitter (ACh) from the Presynaptic terminal of the axon for the
transmission of the nerve Impulse to the neuromuscular junction

• damage the muscle cells and delays the time of the impulse to the muscle from the neuromuscular
junction

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s/sx weak and tired muscles

Signs and Symptoms:

Ø Weakness & easy fatigability of voluntary muscles (those we can move at will).
Ø ocular weakness of the eyes and eyelids
Ø Weakness and fatigue in the neck and jaw
Ø speech is slurred with nasal quality
Ø weakness tends to spread sequentially from the face and neck
Ø weakness of the respiratory muscles
Ø weakness of the upper limbs, the hands and then the lower limbs.

Difficulty to :
1. lift the arms over the head
2. rise from a sitting position
2. walk long distances
4. climb stairs or grip heavy objects

Laboratory & Diagnostic Tests


A. physical exam
To look for evidence of increased weakness following exertion
Ø to look up without blinking for one or two minutes
Ø hold the arms up for as high as possible
Ø climb up steps
B. blood test may reveal (+) antibodies to the ACh receptor.

Intravenous injection of edrophonium (Tensilon), a fast-acting cholinesterase inhibitor. A temporary increase in


strength after this "Tensilon test" is consistent with MG
Endrophonium (Tensilon) 2mg is administered intravenously to determine the diagnosis

Endrophonium is a short acting acetylcholinesterase Inhibitor used as a diagnostic agent.


1. Initial dose given 2mg of the medication intravenously Expected result : in muscle strength within 30-60
seconds
If no response occurs, another 4-10mg of endrophonium is given over the next 2 minutes and muscle strength is tested
again.

Endrophonium (Tensilon) 2mg is administered intravenously to determine the diagnosis

If no increase in muscle strength occurs with this higher dose, the muscle weakness is not caused by MG.
Side effect :
Ø drop in blood pressure
Ø dizziness
Ø flushed skin

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Rapidly Alternating Movement Evaluation
1. Ask the patient to place their hands on their thighs and then rapidly turn their hands over and lift them off their
thighs.
2. Instruct the client to repeat it rapidly for 10 seconds. Expected outcome :
Normally this is possible without difficulty. This is considered a rapidly alternating movement.

Dysdiadochokinesis inability to perform rapidly alternating movements.

Dysdiadochokinesia is usually caused by :

a. multiple sclerosis, MG in adults b. cerebellar tumors in children.

Point-to-Point Movement Evaluation

1. Instruct the patient to extend their index finger and touch their nose, and then touch the examiner's outstretched
finger with the same finger.
2. Ask the patient to go back and forth between touching their nose and examiner's finger.
3. Once this is done correctly a few times at a moderate cadence, ask the patient to continue with their eyes closed.

Expected outcome :
Normally this movement remains accurate when the eyes are closed. Repeat and compare to the other hand.

Dysmetria
Is the clinical term for the inability to perform point-to-point movements due to over or under projecting ones fingers.

Drug of Choice :

cholinesterase inhibitors Pyridostigmine Bromide (Mestinon )

Blocks the action of acetylcholinesterase and increasing the amount of acetylcholine at the neuromuscular junction &
controls the involuntary movements .

Ø increases muscle tone of client with muscular weakness resulting from MG Must be given every 3-6hours
Side effects :
1. Diarrhea
2. abdominal cramps
3. excessive saliva.

Prostigmine ( Neostigmine )
Ø A short acting AChE inhibitor with a half life to 1 hour.

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Ø Given every 2-4hrs to prevent muscle weakness

Ambenonium Chloride (Mytelase )


Ø is a long acting AChE inhibitor
Ø prescribed when the client does not respond to neostigmine or pyridostigmine

Immunosuppressant Drugs
Corticosteroids. These drugs ( prednisone and prednisolone)

Disadvantage of corticosteroids is that they can produce many side effects some of them potentially serious including
:
Ø osteoporosis (weakening of bones),
Ø mood disturbances
Ø gastrointestinal problems, weight gain
Ø high blood pressure
> cataracts and stunted growth (in children)

Surgical Management Thymectomy

Crisis Management

¨ Cholinergic Crisis
¡ Cause:
ú Overmedication
ú Signs
– Abdominal cramps
– Blurred vision
– Nausea & vomiting
– Hypotension
– Pallor
– Diarrhea

¡ To determine whether the client is reacting to overdose of medication, when the endrophonium
injection is given and the conditions of the client is in cholinergic crisis there is temporarily
worsening the condition .
¡ This is known as negative (-)tensilon test.

Antidote : AtSO4

¨ Myasthenic Crisis
¡ Exacerbation of the disease
¡ Common Causes
ú Rapid progression of disease
ú Under medication
ú Infection
ú Fatigue

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ú Stress
¡ Signs
ú Increased BP, HR, RR
ú (-) swallow reflex
ú Decreased urine output

Antidote : Mestinon Myasthenia Crisis


Danger sign : RESPIRATORY ARREST Nursing Care Focus
• Aspiration precaution
• Maintain adequate respiratory exchange
• Watch out for possible crisis

Amytropic Lateral Sclerosis

ALM is a degenerative disorder diffusely involving the lower & upper motor neurons resulting in progressive muscle
weakness.

Amyotropic > without muscle nutrition or progressive muscle wasting

Lateral Sclerosis > scarring of the corticospinal tract in the lateral column of the spinal cord.

Amytropic Lateral Sclerosis

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Primary Symptoms:

• Progressive muscle weakness of hands and feet or in any part of the body
• Cramps
• Incoordination
• Atrophy of the tongue
• Fasciculations of face ( Twitching)

Clinical Manifestations

• Lower Motor Neuron


– Fasciculation
– Weakness
– Muscle Atrophy
– Hyporeflexia
• Other Symptoms
– Fatigue
– Depression
– Respiratory difficulty
• Upper Motor Neuron
– Weakness
– Spasticity
– Impaired fine motor
• LMN & UMN (Brainstem)
– Dysphagia
– Dysarthria
– Dysphonia

Nursing Diagnoses

1. Ineffective health maintenance


2. Impaired physical mobility
3. Ineffective airway clearance

Pharma and Nursing Management

No known cure
Riluzole (Rilutek), a neuroprotective agent which slows deterioration of motor neurons

Antispasmodic (Baclofen, dantrolene ) used for spasticity/ muscle relaxant

Anticonvulsant Gabapentin (Neurontin) Quinine for muscle cramps

NGT insertion, PEG

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( percutaneous endoscopic gastronomy) mechanical ventilation
Nursing Management

1. Maintaining tucked chin position while eating or drinking.


2. Use tonsillar suction tip to clear the airway
3. Use prosthetic devices to assist with ADL

Diagnostic Outcome Electromyography (EMG)

Parkinson’s Ds.

Is a chronic, progressive, neurologic disorder thatresults from the loss of the neurotransmitter DOPAMINE in a group
of brain structures that control movements.

Neurotransmitter
Chemical agents involves in transmission toward synapse.

Dopamine
Function: affects control of behavior & fine movement.Source of Secretion: Substancia nigra that sends fibers to the
basal ganlia that involves in coordination.

Ø Begins at the age of 40 with peak age of onset between 58-62 yo


Ø Common with male client

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Signs and symptoms

Classic symptoms:
Ø Rigidity
Ø Bradykinesia (excessive slowness of voluntary movement and speech )
Ø resting tremor
Ø impaired postural reflexes
Ø Pill-rolling and cogwheeling (jerky movement of extremities)
Ø Freezing phenomenon
Ø Micrographia (as the disease progresses)

Suspected causes include:

the Viral infection Chemical toxicity Cerebrovascular disease


Effects of drugs, such as major tranquilizers and reserpine
The disease is most prevalent among persons in their 60’s and is the second most common neurologic disorder of
elderly.

Parkinsonian gait

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Pharmacologic study:
Dopamine hydrochloridergics: Levodopa (L-Dopa) allowing for normal function of the movement control centers of
the brain.
a. Larodopa
b. Dopar

Pharmacologic study:
Carbidopa/Levodopa (Sinemet®) Levodopa is a substance that is converted into dopamine by an enzyme in the brain.
It is then released by brain cells and activates dopamine receptors allowing for normal function of the movement
control centers of the brain.
helps restore a proper balance between dopamine and ACh

Ø anticholinergics - minimize extrapyramidal effects & to controls rigidity & tremors


• benzotropine mesylate (Cogentin)
• procyclidine (Kemadrin)
Side Effects:

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1. Blurred Vision 5. Urinary retention
2. Dry mouth & dry secretion 6. Restlessness & confusion
3. Increased PR 7. Photophobia
4. Constipation ( low CHON diet ) such as legumes, cereals

Antiparkinsonian agent: restores the balance of the neurotransmitters Ach and Dopamine in the CNS decreasing the
s/sx of Parkinson’s ds.
Ø amantadine HCl (Symmetrel) reduces rigidity and tremor

Nursing Management

• Provide warm baths and massage to relax the muscles.


• Teach patient special walking techniques
• Encourage intake of increased fluid and foods with moderate fiber content
• Manage dysphagia by instructing patient to place the food on the tongue,close the lips, and lift the tongue up
and back and swallow

4. Remind the patient to keep the head upright and swallow to control build up of saliva.
5. Massage the facial and neck muscles before meals to facilitate swallowing.
6. Advice patient to face the person when talking and exaggerate the pronunciation, and speak in short sentences.

Huntington’s Disease

Ø Involuntary choreiform (dancelike) movement and dementia. Autosomal dominant genetic disorder affecting
the basal ganglia, with chromosome 4 as the defective gene and some parts of cerebral cortex

Triad of symptoms:
Ø Motor
Ø cognitive and
Ø emotional disturbances

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Huntington's disease is an inherited disease that causes nerve cells in the brain to stop working properly.

Signs and Symptoms

Ø Chorea
Ø Dystonia
Ø Intellectual decline, emotional disturbance
Ø Facial tics and grimace
Ø Restlessness and fidgety appearance
Ø Rapid, jerky choreiform movements involving all muscles
Ø Dysphagia and difficulty in chewing
Ø Poor balance
Ø Slurred, hesitant explosive speech
Ø Bowel and bladder incontinence
>dementia

• Antidepressants and antipsychotics are given for depression & suicidal tendency
• Psychotherapy to allay anxiety & to reduce stress

DYSTONIA

• Antidepressants and antipsychotics are given for depression & suicidal tendency
• Psychotherapy to allay anxiety & to reduce stress

Complication:

• Overmedicated patient may develop

AKATHISIA (motor restlessness) Disorders of Peripheral Nervous System

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Peripheral Neuropathies

Disorder affecting the peripheral motor, sensory, or autonomic nerves Mononeuropathy: Affectation of a single nerve

Multiple Mononeuropathy: Involvement of multiple single peripheral nerves or their branches

Polyneurophaties: Bilateral and symmetric affectation of function; begins distally then progress proximally

Signs and Symptoms


• Loss of sensation
• Muscle atrophy
• Weakness
• Diminished reflexes
• Pain and paresthesia of the extremities

Guillain-Barré syndrome (GBS)

Ø is a temporary disorder that affects the nerves in the body. S/sx of GBS
Ø muscle weakness
Ø pain
Ø temporary paralysis of the facial, chest, and leg muscles. NOTE: Paralysis of the chest muscles can lead to breathing
problems.

Guillain Barre Syndrome 5 A’s

1. Acute
2. Autoimmune

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3. Ascending Paralysis
4. Aching Deep Pain
5. Areflexia

Signs and Symptoms

1. decreased feeling or pain in fingers and toes


2. leg weakness or pain progressing to the arms
3. problems walking
5. breathing problems
6. facial weakness

Nursing Diagnoses

1. Ineffective breathing pattern r/t musculoskeletal fatigue or neuromuscular impairment


2. Acute pain r/t transmission and perception of cutaneus , visceral, muscular impulses
3. Activity intolerance r/t to prolong bed rest or disconditioning of muscles
4. Imbalance Nutrition less than body requirements r/t lack of nutrients or increase metabolic demand
5. Powerlessness r/t lack of control over current situation and/ or disease progression
6. Deficient knowledge : Discharge regimen r/t lack of previous exposure to information

Nursing Care Focus

• Assess respiratory function


• Administer oxygen as ordered
• Be prepared for possible intubation
• Assess sensory & motor function
• Monitor cardiac functions
• Hook patient to cardiac monitors Take note of arrhythmias
2 Types of Treatment Intravenous immunoglobulin
> Immunoglobulin contains healthy antibodies from blood donors. High doses of immunoglobulin can
block the damaging antibodies that may contribute to Guillain-Barre syndrome.

Medical and/or Surgical Management

Plasmapheresis – a process in which a fluid part ofthe blood, called plasma is removed from blood cells by a device
known as a cell separator. Cells are returned to the person undergoing treatment while the plasma, which contains the
antibodies, is discarded and replaced with other fluids.

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Diagnostic Tests
Lumbar Tap with CSF Analysis
CSF results may reveal elevated levels of CHONS related to inflammation of the nerve root.

Vital Capacity Test


Provide the nurse with information related to effects of motor weakness of the respiratory muscles.

Electromyography
> reads electrical activity the muscle to determine the weakness caused by muscle damage or nerve damage.

Nerve conduction studies


Ø assess how the nerves and muscles respond to small electrical stimuli.

Cranial Nerve Disorders


Trigeminal Neuralgia (tic douloureux)

Affectation of the fifth cranial nerve characterized by paroxysms of pain similar to an electric shock or burning
sensation in the area innervated by the trigeminal nerve

Cause : Unknown

Affected Trigeminal nerves:


• Opthalmic
• Maxillary
• Mandibular

Type of Pain:

Shooting & stubbing pain

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Drug Therapy: Anticonvulsant Drugs
• Carbamazepine ( Tegretol)
• Gabapentin (Neurontin)
– given with meals , in doses gradually increased until relief is obtained.

Side effect:
Nausea, dizziness, drowsiness, hepatic dysfunction bone marrow suppression Monitor WBC with 3000cells /ul

Surgical Interventions:

1. An Alcohol injection along the affected portion of the nerve to produce anesthesia of the nerve may provide relief of
pain for up to 16 months.
2. Retrogasserian Rhizotomy or total severance of the sensory root of the trigeminal nerve may give relief.
3. Jannetta Procedure surgically relocates the artery that is compressing the trigeminal nerve
4. Electrocoagualtion or Radiofrequency Rhizotomy creates a heat lesion.

Bell's Palsy

Ø is a peripheral palsy of the facial nerve that results in muscle weakness on one side of the face. Affected
patients develop unilateral facial paralysis over one to three days with forehead involvement and no other
neurologic abnormalities.

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Pharmacotherapy :

1. Oral corticosteroids ( prednisone ) Ex: Deltasone


Ø to reduce facial nerve inflammation & improve nerve conduction and blood flow.
2. acetaminophen (Tylenol)
Ø is taken daily for the relief of generalized discomfort
Ø is 10-20mcg/mL normal therapeutic serum level

A toxic level is greater than 50mcg/mL levels of greater than 200mcg/mL could indicate
HEPATOTIXICITY.

Antidote : acetylcysteine ( MUCOMYST)

laboratory value would indicate toxicity > Direct Bilirubin level of 2mg/dL
The normal direct bilirubin is 0 to 0.3mg/dL Direct Bilirubin > indicator of liver function

Care of Clients with Visual and Auditory Problems

Vision Protection and General Eye Care


• Regular ocular and physical examinations
• Avoid dangerous items (toys, guns, arrows, fireworks, rocks, sticks, etc.)
• Early identification and treatment of strabismus in children
• Routine eye assessment programs in school
• Early treatment when eye symptoms occur
• Routine instillation of appropriate drops in the eyes of every newborn
• Early treatment when eye symptoms occur
• Routine instillation of appropriate drops in the eyes of every newborn
• Blood tests during pregnancy to identify syphilis
• Inoculation against rubella
• Regulation of oxygen concentrations administered to premature infants


FEU- Institute of Nursing NUR 1217 Complete Course Module

• Avoid habitual rubbing of the eyes
• Have adequate lighting when using the eyes
• Periodically rest eyes during prolonged periods of close eye work, reading, or watching
television or from gadgets
• Reduce glare and wear protective eye wear
• Keep eye glasses clean, protected from scratching and breakage and properly aligned.
• Do not use eyewashes, eye drops, or any medications in the eyes unless prescribed by a
doctor.
• Never use a soiled washcloth around eyes.
• Use care when using aerosol sprays.
• Maintain a state of good health and Balance diet with eat a well adequate vitamins A, B and C.
• Use care when using solvents, lye solutions, ammonia, caustic solutions to avoid splashing or
spilling into eyes.

Preoperative Care of the Client for Eye Surgery


• Orient the client to the staff and physical environment if both eyes will be covered after
surgery.
• If the client is a child, practice covering the eyes. To decrease postoperative fear and
restlessness
• Administer mydriatics/ cyciopegics as prescribed
o lsopto Atropine, Oculropine, Atropair, Atropisol (Atropine Sulfate)
o Cyclomydril (Cyclopentolate and Phenylephrine)
o Cyclogyl (Cyclopentolate HCI)
o Scopolamine
o Mydriacyl (Tropicamide)
• Mydriatics and cyclopegies dilate the pupils (mydriasis) and relax the ciliary muscles
(cyclopegia).
• These medications are contraindicated in glaucoma because of the risk of increase in
intraocular pressure.

Post Operative Care of the Client In Eye Surgery


General goals of postoperative care:
• 'To prevent or relieve the following:
o Increased intraocular pressure.
o Stress on the suture side.
o Hemorrhage into the anterior chamber (hyphema)
o Infection
o Pain

1. Position the client supine or turned to the unaffected side to prevent pressure on the operated
eye and to prevent possible contamination of the dressings with vomitus.
2. A burning sensation about one hour after surgery usually means that the anesthetic is wearing off.
This is normal.
3. The eye is protected with eye patch and eye shield for 5 to 7 days.
Use eye shield during the night for 4 weeks.

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4. The client should be instructed to avoid the following to prevent increase in intraocular pressure:
• Rubbing the eyes.
• Lifting the head or hips.
• Sudden, jerky head movement.
• Sneezing, coughing (follow through with open mouth if these cannot be avoided).
• Nausea and vomiting (keep eyelids open if vomiting occurs).
• Straining at stool.
• Bending, stooping.
• Heavy lifting (more than 5 lbs.)
• Reading (for few days)
• Watching fast-moving objects

5. The feeling of "something in the eye" 4 to 5 days postop usually is because of the sutures. This is
normal.
6. Sensation of pressure within the eye and sharp pain in the eye indicate bleeding. These
should be reported to the surgeon immediately.
7. Administer miotics as prescribed. These medications constrict the pupils.
• Carbotic (Carbachol)
• Humorsol (Demecarium Bromide)
• Floropryl (lsoflurophate)
• lsopto Carpine (Pilocarpine HCI)

Part I. Common Disorders of the Eye


Eyelid Disorders
• Blepharitis
o Inflammation of eyelid margins.
o Irritation, burning, itching, ulceration, eyelashes fall out.
• Chalazion
o Internal stye.
o Inflammation of Meibomian gland.
o Painless, slowgrowing, hard, nontender round mass on eyelid.
• Hordeolum
o External stye.
o Pustular infection of eyelash follicle or sebaceous gland on an eyelid margin.
o Painful, red swelling on eyelid margin.
o Commonly caused by staphylococcus.

Extraocular Muscle Disorders


• Strabismus (squint, tropia, heterotropia)
o Is a condition in which the patient cannot consistently focus 2 eyes simultaneously on
the same object.
• Eye deviations
o Esotropia - inward / convergent deviation of the eyes
o Exotropia - outward / divergent deviation of the eyes

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o Hypertropia - upward deviation of the eyes ("sunrise eyes")
o Hypotropia - downward deviation of the eyes. ("sunset eyes")
• Collaborative Management
o Corrective eyeglasses
o Surgery
§ Advancement, resection, tucking
§ Tenotomy, recession
Note: Cover/ patch the "good eye" to train the eye.

Disorders of the Conjunctiva, Sclera and Cornea


• Conjunctivitis
o Inflammation of the conjunctiva which results from bacterial / viral infections.
o Redness, swelling, lacrimation, pain, itching, discharge from the eye. E.g., acute
bacterial, gonococcai conjunctivitis

• Trachoma
o A chronic infectious disease of the conjunctiva and comes caused by Chlamydia
trachomatis.
o Spread by direct contact and very contagious, causes blindness
o Treatment
§ Sulfonamides, Tetracyclines, Erythromycin

• Scleritis/Iritis
o Very red eye, painful to move.

• Corneal Inflammation (Keratitis) and Corneal Ulceration


o Assessment
§ Pain
§ Photophobia
§ Lacrimation
§ Blepharospasm
§ Decreased vision
o Treatment
§ Trifluridine (\/coptic), ldoxuridine (IDU), Adenine Arabinoside (Vira-A)
o Mechanical / Chemical Debridement

• Conceal Ulcerations medical emergency


o May result to corneal perforation, scarring or intraocular infection, permanent
impairment of vision.
o Causes
§ Trauma
§ Exposure
§ Allergy
§ Vitamin deficiency
§ Lowered resistance
§ Bacterial, viral, fungal infections

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• Corneal Opacity - lack of corneal transparency due to inflammation, ulceration or injury.


o Conceal Transplantation (Keratoplasty)
§ To repair corneal opacity, perforation of corneal ulcer.
§ Donor eyes for corneal transplantations come from cadavers.
§ Ideally, a donated eye is transplanted immediately or is removed from the body
within 24 hours of death.
§ Cornea may still be viable within 12 hours after death if the body has been
refrigerated, may be transplanted up to 48 hours after death if it is kept in a
sterile container, on a piece of gauze soaked in NSS at 4 C

Uveal Tract Disorders


• Uveal Tract - middle vascular layer of the eye, contributing to the retina's blood supply- lt is
composed of iris, ciliary body, and choroid
• Uveitis
o Iritis inflammation of iris
o Iridocyclitis - inflammation of the iris and ciliary body
o Choroiditis - inflammation of the choroid
o Choroiretinitis - inflammation of choroid and retina
§ Causes
• Local or systemic disease
• Injury
• Unidentified factors
§ Assessment
• Pain in the eyeball radiating to the forehead and temple.
• Blurred vision
• Redness of eyes without purulent discharge
• Small pupil
• Lacrimation
§ Collaborative Management
• Mydiatics (Atropine Sulfate 1% or 0.25%, Scopolamine)
o To dilate pupils.
o To prevent adhesion between anterior capsule of the lens and the
iris.
o To relieve pain and
o To reduce congestion.
o To rest the iris and the ciliary body.
• Steroids (local/systemic)
• Dark glasses (to relieve
• Analgesics (Aspirin, Acetaminophen)

o Sympathetic Ophthalmia (Sympathetic Uveitis)


§ a rare, severe, bilateral, granulomatous uveitis of unknown cause
§ occurs anytime from 10 days to several years following penetrating injury near
the ciliary body or following a retained foreign body.

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§Leads to bilateral blindness.
§Assessment
• Inflammation of the injured or previously operated eye (exciting eye),
followed by the other eye (sympathizing eye),
o Blurred vision
§ Collaborative Management
o Enucleation. Done if with perforation of sclera and ciliary body,
§ vitreous humor loss, retinal damage
§ Steroids
§ Local atropine

Retinal Disorders
• Retinitis
• Inflammation of the retina.
• Often associated with disease of the choroid.
• Caused by bacteria, fungi, toxoplasmosis, cytomegalovirus.
• Assessed through opthalmoscopy.
• Assessment
o Reduced visual acuity
o Changes in the visual field
o Alterations in the shape of objects
o Discomfort in the eyes
o Photophobia
• Collaborative Management
o Rest the eyes.
o Protect eyes from light.
o Atropine Sulfate.

• Retinal Detachment. The separation of the two primitive layers of the retina (melanin
epithelial pigment and the rods and cones layer). It may be also the separation of the entire
retina from the choroid due to the presence of a tumor.
o The different causes of retinal detachment are as follows:
§ Myopic degeneration
§ Trauma
§ Hemorrhage
§ Exudates in front or behind the retina,
§ Aphakia (absence of lens),
§ Sudden and severe physical exertion among debilitated clients.
o The clinical manifestations of retinal detachment are as follows:
§ Floating spots or opacities before the eyes. These are blood and retinal cells
that cast shadows on the retina.
§ Flashes of light. The light that enters the eye is not absorbed by the detached
melanin epithelial pigment.
§ Progressive constriction of vision in one area (Curtain Vision). There is
sensation that a curtain has been drawn before the eyes or as if one is looking
over a fence.

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Ophthalmoscopy shows cloudy vitreous and portion of retina appears like a
§
hanging gray cloud.
o Collaborative management for retinal detachment include the following:
§ Promote bedrest and cover the eyes. To prevent further detachment.
§ Position the head so that the retinal hole is in the lowest part of the eye
(dependent position).
§ Early surgery is required (e.g. scleral buckling).
o Preop care (refer to Care of Client for Eye Surgery)
o Postop Care
o Position: the area affected should be in upper part of the eye (superior position).
§ Apply pressure patch over the eye.
§ Activity and ambulation will be prescribed by the surgeon.
§ Sedentary activities are resumed after 3 weeks.
§ Activities or occupations requiring heavy physical exertion may be
§ permitted after 6 weeks.
• Glaucoma. An eye disorder characterized by increase in pressure.
o Aqueous humor
§ Crystal dear fluid, fills anterior and posterior chambers of the eye. It is a
refraction medium, provides nutrition to the lens and cornea, helps maintain IOP
o Acute Glaucoma (Narrow Angle or Close Angle Glaucoma)
§ Eye disease characterized by suddenly impaired vision due to intraocular tension
caused by an imbalance in production and excretion of aqueous humor. It is the
result of an abnormal displacement of iris against the angle of the anterior
chamber.
o Chronic Glaucoma (Simple, Wide Angle or Open Angle Glaucoma)
§ Eye disease characterized by impaired vision due. to intraocular tension caused
by an actual obstruction in the excretion of aqueous humor. It develops slowly, at
first, and symptoms may be absent.
§ Permanent vision loss may occur before the individual is aware of having the
disease.
§ It may be due to hereditary thickening of the trabecular meshwork or
degenerative narrowing of the canal of Schlemm.
o Vision loss in glaucoma is IRREVERSIBLE due to compression and damage of the
retina and/or optic nerve. The blockage to the circulation of the aqueous humor may be
secondary to:
§ Infection e.g. uveitis (acute glaucoma)
§ Injury (acute glaucoma)
§ Hereditary predisposition to thickening of the trabecular meshwork (found at the
angle of the anterior chamber of the eye where the peripheral iris and the cornea
meet) (chronic glaucoma)
§ Narrowing of the canal of Schlemm (chronic glaucoma)

o Chronic / Simple Glaucoma


§ Assessment
• Characteristic sign: before central vision is affected, the peripheral visual
fields are impaired so that objects to the side are ignored (tunnel vision).

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• lnsiduous onset - generally no discomfort.
• Patients may bump into other person in the street or fail to see passing
vehicles, yet not realize that the fault lies on their own vision.
• The loss of peripheral vision ("tunnel vision") can progress until the person
is legally blind, yet the person may be able to see well straight ahead
• Usually begins in one eye, if it is left untreated both eyes often become
affected
• Persistent dull eye pain in the morning
• Frequent changes of glasses, difficulty in adjusting to darkness failure to
detect changes in color accurately
• Steamy appearance of the cornea and further blurring of vision
• Tearing, misty vision, blurred appearances of the iris (which becomes
fixed and dilated), headache, pain behind the eyeball nausea and vomiting
• Rainbows or halos resembling street lights seen through a steamy
windshield may be seen around lights

§ Nursing Diagnoses for the Patient with Glaucoma


• Risk for injury related to visual acuity deficits
• Self-care deficits related to visual acuity deficits
• Acute pain related to pathophysiologic process and surgical correction
• Noncompliance related to inconvenience and side effects of glaucoma
medications

§ Collaborative management for the client with chronic glaucoma.


• Objective: To reduce intraocular pressure and keep it at a safe level
o Miotics. Used to constrict the pupil and to draw the smooth muscle
of the iris away from the canal of Schlemm to permit aqueous
humor to drain out at this point
o Drug Alert: Miotics
§ Warn patients about decreased visual acuity especially in
the daylight
o Acetazolamide (Diamox). A drug that tends to reduce the formation
of aqueous humor; is used successfully for some types of chronic
glaucoma
o The patient is advised to avoid fatigue or stress and to avoid
drinking large quantities of fluids.
o Surgery may be performed to produce a permanent filtration
pathway for aqueous fluid. Filtering procedures such as sclerotomy,
iridectomy, iridencleisis, trabeculectomy and trephine operations
provide a permanent fistula from the anterior chamber to the sub-
conjunctival space.
o In some cases, the production of aqueous fluid may be decreased
by destroying part of the ciliary body.


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o Acute Glaucoma
§ Assessment
• Rapid onset of severe pain in eye(s)
• Blurred vision
• Headache
• Rainbows or halos around lights
• Nausea and vomiting
• Inflamed eye(s)
• Fixed, dilated
• Visual impairment

§ Collaborative management for the client with acute glaucoma:


• Maintain bed rest in quiet, darkened elevate head 30 degrees.
• Monitor vital signs.
• Administer miotic eyedrops as ordered
• Administer acetazolamide, glycerol orally as ordered.
• Acetazolamide is carbonic anhydrase inhibitor. lt reduces aqueous humor
production. Thereby, decreasing intraocular pressure.
• Glycerol is an osmotic drug which act to reduce intraocular pressure.
• Provide emotional support.
• Assess patient's ability to see.
• Assist according to degree of visual impairment.
• Prepare for eye examinations as ordered tonometry is 25 mmHg and
above in glaucoma).
• Avoid Atropine preparations and other mydriatics. These dilate the pupils,
and the iris is brought closer to the angle of outflow of aqueous humor.
This causes further obstruction in thexcretion of aqueous humor. In
glaucoma, avoid ABC:
o A tropine
o B enadryl
o C ogentin
• Administer antiemetics as ordered for nausea
• Provide diet as tolerated.
• Prepare for surgery if ordered

§ Drug Therapy in Acute and Chronic Glaucoma


• 1. Beta-adrenergic blockers
o These drugs decrease aqueous humor production
§ Betaxolol (Betoptic)
§ Carteolol (Ocupress)
§ Levobunolol (Betagan)
§ Metipranolol (Optipranolol)
§ Timolol Maleate (Timoptic, lstalol)


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• 2. Alpha-adrenergic Agonists
o These drugs decrease aqueous humor production and enhance
outflow facility
§ Dipivefrin (Propine)
§ Epinephrine (Epifrin, Eppy Gaucon, Epitrate, Epinal,
§ Apraclomidine (Lopidine)
§ Brimonidine (Alphagan)
§ Latanoprost (Xalatan)

• 3. Cholinergic Agents (Miotics)


o These drugs are parasympathomimetics; causing constriction of
pupils, opening of trabecular meshwork, facilitating aqueous
outflow.
§ Carbachol (lsopto Carbachol)
§ Pilocarpine (Okarpine, lsopto Carpine, Pilocar Pilopine,
Piloptic, Pilostat)

• 4. Carbonic Anhydrase Inhibitors


o These drugs decrease aqueous humor production
§ Systemic
• Acetazolamide (Diamox)
• Dichlorphenamide (Daramide)
• Methazolamin e (Neptazane)
§ Topical
• Brinzolamide (Azopt)
• Dorzolamide (Truzopt)

• 5. Combination Therapy
o Timolol Maleate and Dorzolamide (Cosopt)

• 6. Hyperosmolar Agents
o These drugs increase extracellular osmolality, so intracellular fluid
moves to the extracellular and vascular spaces reducing IOP
§ Glycerin Liquid (Ophthalgan, Osmoglyn)
§ Isosorbide solution
§ Mannitol solution (Osmitrol)

o Cataract
§ Etiology
• Cataract is a clouding, or opacity of the lens that leads to blurring of vision
and eventual loss of sight. The opacity of the lens is caused by chemical
changes in the protein of the lens because of slow degenerative changes
of age, injury, poison or intraocular infection.


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• Cataracts occur so often in the aged. At 80 years of age, about 85% of all
people have some clouding of the lens.
• Classification of Cataracts
o Senile. Those associated with aging.
o Traumatic. Those associated with injury.
o Congenital. Those that occur at birth
o Secondary. Those that occur following other eye or systemic
diseases.

§ Collaborative management for the client with cataract:


• Surgery is the only satisfactory treatment for cataracts. It is advised when
the cataract interferes with a person's mobility and ability to carry out
normal activities.
• lntracapsular technique or the Intracapsular Cataract Extraction (ICCE).
Removal of cataract within its capsule.
• Extracapsular Technique or the Extracapsular Cataract Extraction
(ECCE). An opening is made in the capsule and the lens is lifted without
disturbing the membrane. A person with aphakia (absence of lens) is very
farsighted (hyperopic).
• Cryoextraction. The cataract is lifted from the eye by a small probe that
has been cooled to a temperature below zero and adheres to the wet
surface of the cataract.
• lridectomy. Done preceding cataract extraction to create an opening for
the flow of the aqueous humor that may become blocked post op when
the viterous humor moves forward. This is to prevent secondary glaucoma
• Phacoemulsion. A method of cataract removal that breaks up the lens and
flushes it out in tiny pieces.
• Preop Care: (refer to general care for eye surgery)
• Postop Care
o The eye is covered with a dressing (eyepad) and eye shield to
protect it from injury.
o The patient is usually allowed out of bed the day following surgery.
o Daily change of dressing is done. After 7 to 10 days, all dressings
are usually removed.
o During the first month, protect the eye with a shield at night.
o Administer eye drops as ordered
o Note: Temporary glasses may be prescribed 1 to 4 weeks after
surgery. Usually within 6 to 12 weeks healing has been sufficient
for fitting of permanent glasses or contact lenses.
o Remember: Cataract glasses (aphakic glasses) magnify so that
everything appears about one fourth closer than it is. Patients need
to know that it will take time to learn to judge distance, to climb
stairs and do other simple things. Use of contact lens improves
visual correction and better cosmetic appearance.


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o Intraocular lens implant. It is an alternative to cataract glasses
and contact lenses. The lens, which is made of polylethyl
methacrylate, is implanted at the time of cataract extraction, may be
held in position either by suture to the iris or by implanting it into the
capsular sac (The main advantage of the implanted lens is better
binocular vision).

Tumors of the Eye and Related Structures


o Benign or malignant tumors
o Displace the eyeball and interfere with vision.
o Retinoblastomas (children), malignant melanomas (adult):
o Are the most common primary intraocular tumors.
o Collaborative management for the client with tumor of the eyes:
o Enucleation (removal of the eyeball)
o Brachytherapy (internal radiation therapy).

Refraction Errors
o Emmetropia. Normal refractive state.
o Ammetropia. Abnormal refractive state. "Sight not in proper measure”
o Hyperopia
o Farsightedness.
o Parallel rays of light focus behind the retina.
o Corrected with convex lens.
o Myopia
o Nearsightedness.
o Parallel rays of light focus in front of the retina.
o Corrected with concave lens.
o Radial keratotomy (RK Surgery).
o Presbyopia
o "Old sight"
o Lessening of the effective powers of accommodation, occurs because of hardening of
the lens due to aging process.
o Blurring of near objects or visual fatigue when doing "close eye work."
o Convex reading glasses are recommended

o Astigmatism
o "Distorted vision."
o Caused by variation in refractive power along different meridians of the eye.
o Optical distortion is most often caused by irregular corneal curvature, which prevents
clear focus of light from any point.

o Aphakia
o Is the absence of lens. It may be absent congenitally or it may be removed during
cataract surgery.
o Images are projected behind the retina (farsightedness)

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Non-Surgical Corrections
1. Corrective Glasses
• Myopia requires concave lens
• Hyperopia, aphakia, presbyopia require convex lens
• Glasses for presbyopia are often called "reading glasses” because they are usually worn for
close work only.
• Presbyopia maybe corrected with the "no-line' bifocal which is actually a multifocal lens that
allows the patient to see clearly at any distance.

2. Contact Lenses
• These are made of plastic and silicone substances which are very permeable to oxygen and
have high water content which allows greater wearing time with greater comfort.
• The patient should know the signs and symptoms of contact lens problems that must be
managed by the eye care professional which are as follows (DANGER SIGNS - RSVP):
R edness V ision problems
S ensitivity Pain
• The nurse must stress the importance removing the contact lens immediately if any of these
problems occur.

3. Corneal Molding
• Also called orthokeratology. lt is the use of specially designed, rigid, gas permeable contact
lenses to alter the shape of the cornea.
• It reduces or corrects myopia and moderate degrees of astigmatism.

Surgical Therapy
1.Laser
• Laser-assisted-in-situ keratomileusis (LASIK) maybe considered for patients with low to
moderately high amounts of myopia, hyperopia, and astigmatism

2. Refractive intraocular lens implant


• It is usually done following cataract removal.

3. Thermal Procedure
• Laser Thermal Keratoplasty (LTK) and conductive keratoplasty (CK) are indicated for patients
with hyperopia or presbyopia.
• These procedures use laser or high radio frequency, and heat is applied to the peripheral area
of the cornea to tighten it like a belt and make the central cornea steeper.
• Only the less dominant eye is treated and the desired effect is monovision, which enables one
eye to focus at close is treated proximity, the other eye is left untreated if needed to focus at a
distance.

Trauma to the Eye and Related Structures


• Penetrating Eye Injuries
o Requires surgery (repair/enucleation).

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o Bed rest with bathroom privileges for 1 to 2 days.
o Observe for sympathetic ophthalmia.

• Intraocular Foreign Bodies


o Wash hands thoroughly before touching the eye
o Immediate copious flushing of the eye with water when acid, alkali or other irritating
substance has been introduced.
o If foreign body is lodged into the comes, do not attempt to remove see a physician.
o Avoid pressure on the eye, do not touch, do not rub the eye.
o Cover with dressing or plastic or metal eye shield for protection, to limit eye movement
and prevent further trauma.
o Avoid activities that increase IOP.
o Use sterile technique, when treating the eyes.
o Consult ophthalmologist immediately.

• Sympathetic Ophthalmia. Occurs from 10 days to several years following penetrating injury
near the ciliary body or retention of foreign body in the eye. This may lead to bilateral
blindness.
o This requires enucleation, steroids, topical atropine.

• Eye Surgeries
o Enucleation. Removal of the eyeball.
o Evisceration. Removal of the entire eyeball contents and comes, except the sclera.
o Exanteration. Removal of the eyelid, eyeball and orbital contents.

• Legal Blindness
o Central visual acuity for distance of 20/200 or worse in the better eye (with correction)
o Visual field no greater than 20 degrees in its widest diameter or in the better eye.

Rehabilitation of a Blind Person


• Refer blind persons to available facilities.
• Orient to the environment. Describe the surroundings and things.
• Promote independence through ADL (Activities of Daily living).
• May have a guide or use cane for direction.
• When approaching talk before touching.
• When assisting in ambulation, have the patient hold your forearm so that you are a step ahead
of him.
• Talk to the patient frequently, so he I she doesn't feel neglected.
• Be relaxed and unhurried when performing nursing procedures.
• Explain what is being done and what is to be done next.
• Do not change location of objects in the room or in the environment without describing the
change.
• Promote safety in the environment.
• Do not rush up and offer help to a blind person unless it is clear that the person wants help.


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• If significant others ask advise about gifts for a blind person, suggest gifts that appeal to
senses other than vision (i.e. stuff toys, perfume, music devices)

Care of the Clients with Common Ear Disorders

Diagnostics Tests for Auditory Acuity Tuning Fork Tests


Rinne's Test

• Compares air conduction from bone conduction, differentiates conductive and sensorineural
hearing loss.
• The vibrating tuning fork is placed against the mastoid bone/behind the ear lobe (bone
conduction); then, it is placed 2 inches from the opening of the ear canal (air conduction)
• Interpretation of results is as follows:

o Normal: air conduction is better than bone conduction

(the tone is louder in front of the ear)


o Conductive hearing loss: bone conduction is better

than air conduction (the tone is louder behind the ear)


o Sensorineural hearing loss; same as the normal finding

It is more accurate in diagnosing conductive hearing loss like in otosclerosis.

Weber Test

• The rounded tip of the handle of the vibrating tuning fork is placed on the client's head or teeth.
• Interpretation of results is as follows:

o Normal: tone is heard in center of head or equally in both ears. o Conductive hearing loss; tone is
heard in poorer ear, e.g.

otosclerosis
o Sensorineural hearing loss: tone is heard in better ear.
o The test is useful in cases of unilateral loss.
o It is more accurate in diagnosing sensorineural hearing loss like in Meniere's disease.

Whisper Voice Test

• The examiner covers one ear with the palm of the hand, then whispers softly2- syllable words
from a distance of 1 or 2 feet from the unoccluded ear, and out of the patient's sight (e.g. thirteen,
fourteen, fifteen).
• The person with normal hearing acuity can correctly repeat what was whispered.

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Audiometry

• It is the singlemost important diagnostic instrument in detecting hearing loss.


• Types of Audiometry

o Pure-tone Audiometry. The louder the tone before the client

perceives it, the greater the hearing loss.


o Speech Audiometry. Spokenword is used to determine the

ability to hear and discriminate sounds and words. The louder the sound before the client perceives it,
the greater the hearing loss.

Tympanogram or Impedance Audiometry

• It measures middle ear muscle reflex to sound stimulation and compliance ofthe tympanic
membrane, by changing the air pressure in a sealed ear canal.
• Compliance is impaired with middle ear disease. Oculovestibular Test/ Ice Water Caloric Test

• Irrigate the ear with cold water.


• Normal result: lateral conjugate nystagmus of the eyes away area of stimulation.
• Abnormal result: dysconjugate nystagmus of the eyes.
• Then, irrigate the ear with warm water.
• Normal result: lateral conjugate nystagmus of the eyes toward from the area of stimulation.
• Abnormal result: dysconjugate nystagmus of the eyes
• Remember COWS: Cold Opposite Warm Same

Symptoms of Ear Diseases

Deafness
o Means that the patient has a hearing loss, which may be mild or severe.
o Hearinglossmaybeconductive,sensorineuralormixedtypes.

o The most common cause of deafness in childhood is serous otitis media whereas in adults,
presbycussis is most common cause.

o Presbycussis means deafness of the elderly and it is a sensorineural hearing loss caused by the
degeneration of the nervous tissue.It is more common among men, over 50 years of age.

o Hearing loss in presbycussis is predominantly in the higher frequencies (high-pitched sounds like
women's voice).


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Pain
o Earache or otalgia is a very common complaint.
o Inchildren,themostcommoncauseisacuteotitismedia

whereas in adults, it is otitis externs.


o The pain may arise from the ear itself or from an adjacent site

withasharednerve supply.
o Themostcommonsiteforreferredpainisthethroat,where

infections more rarely, malignant tumors are responsible.

Discharge
o Adischargefromtheearmaybepurulentorbloody.Itmustbe

distinguished from the escape of which is a normal process o Commonly the cause of a discharge is otitis
externa or otitis

media and in the latter event, a perforation will be present in

the tympanic membrane.


o If perforation of the tympanic membrane is suspected or

diagnosed, irrigation of the ear should be avoided.

Vertigo
o A form of dizziness where the patient experiences a spinning

sensation. It is a common symptom when the balance or vestibular system of the inner ear is diseased. It
is accompanied by nausea and vomiting.

• Tinnitus
o Noise in the ear is a very common complaint.
o Its quality varies from a high-pitched whistle to the clanging of

bells or recognizable snatches of music.

• Classification of Hearing Loss

o Conductive hearing loss. It involves interference with

conduction of sound impulses through the external auditory canal, the eardrum or the middle ear. It is
validated by Rinne's Test


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o Sensorineural hearing loss. It results from disease or trauma to the inner ear or acoustic nerve. It is
validated by Weber's Test.

o Mixed hearing loss. It involves both conductive and sensorineural hearing loss.

Assessment in a Client with Hearing Loss

o Irritable, hostile or hypersensitive in interpersonal relations. o Has difficulty in following directions.


o Complains about people mumbling.
o Turns up volume on TV.

o Asks for frequent repetition.


o Answers questions inappropriately.
o Leans forward to hear better, face looks serious and strained. o Loses sense of humor, becomes grim
and lonely.
o Experiences social isolation.
o Develops suspicious attitude.
o Has abnormal articulation.
o Complains of ringing in the ears.
o Has unusually soft or loud voice.
o Dominates conversation.

Guidelines for Communicating with the Client with Hearing Impairment

o Talk directly facing the person in order to allow reading of lip movements.

o Speak in clearly enunciated words, using normal tone of voice. Do not shout. High-pitched sound is
used when shouting. This is more difficult to understand especially among older people.

o Use gestures with speech.


o Do not whisper to anybody in front of the hearing-impaired client
o Do not avoid conversation with a person who has hearing loss
o Do not show annoyance by careless facial expression.
o Move closer to the person or toward the better ear if he/she does not hear you.
o Do not smile, do not chew gum or cover the mouth when talking to the person. So the person can read
the lip movements.
o Encourage the use of hearing aid if the client has one.

IN CAPSULE

Communication with Hearing Impaired Patient

A. Nonverbal Aids


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1. Draw attention with hand movements.
2. Have speaker's face in good light.
3. Avoid covering face and mouth with hands.
4. Avoid chewing, eating, smoking while talking.

5. Maintain eye contact.


6. Avoid distracting environments.
7. Avoid careless expression that the patient may misinterpret
8. Use touch.
9. Move close to the better ear.
10. Avoid light behind speaker. The patient will not be able to see the speaker's face and facial
expressions that will help him understand what is being communicated.

B. Verbal

1. Speak normally and slowly.


2. Do not over exaggerate facial expressions.
3. Do not over enunciate
4. Use simple sentences.
5. Rephrase sentence, use different words.
6. Write name or difficult words.
7. Avoid shouting.
8. Speak in normal voice directly into better ear.

Diseases of the Outer Ear Bat Ear

o The pinna protrudes from the side of the head because the ridge of the antihelix has not formed. The
child maybe the object of mockery

o The antihelix can be reconstructed fairly easily through an incision on the back of the pinna.

Wax (Impacted Cerumen)

o Waxorcerumenisanormalsubstanceproducedintheexternalear canal.
Itismadeupofepithelialscalesmixedwiththesecretions from special glands in the skin of the outer ear.

o In most people, the wax escapes as it is formed but in some, it remains in the ear canal, obstructing it
and causing deafness.

o Olive oil or liquid paraffin eardrops or hydrogen peroxide will soften the impact wax, which is then
removed by irrigation.

o Itisimportantthatthewaterinthesyringeshouldbeatbody temperature so as not to stimulate the inner


ear and cause dizziness. o The jet of water is directed at the wall of the ear canal and the wax is washed


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out. The ear must be dried gently after the irrigation and it should be examined by a doctor to exclude
any damage to the tympanic membrane.

Foreign Bodies

o These are commonly found in the ears of children and the variety is immense. Sometimes they can be
removed by a probe or irrigation

Aids with warm water but the child is often frightened and uncooperative and a general anesthetic will be
necessary.
o The ear must always be checked to exclude any underlying damage. o An insect in the ear is treated
similarly to the above-mentioned intervention.
o If the foreign body is a vegetable seed, do not irrigate the ear. Vegetable seeds expand when exposed
to water.

Otitis Externa

o This is an inflammation of the outer ear that is lined by skin. The condition is usually bilateral and the
symptoms start with itching.

o The patient scratches the ear that becomes infected, painful and sometimes blocked by a thin
mucopurulent discharge.

o Allergy, stress and the presence of contaminated water may all play a part but the treatment is the
same.

o Any precipitating cause is removed and a swab is taken for culture and sensitivity. The ear canal is
cleaned gently, thoroughly and frequently using a wisp of cotton wool on the tip of a suitable probe.

o Drops are then instilled directly or used to infuse a small wick of ribbon gauze which is left in the ear
for one or two days. The drops may be simple disinfectants or may be combinations of topical antibiotics
(to kill the bacteria) and steroids (to reduce inflammation).

o The condition tends to recur. Boils

o A boil or furuncle is found in the outer hair-bearing skin of the ear canal.

o It is very painful because the skin at this site is firmly tethered to the underlying cartilage. Like boils
elsewhere, it is caused by staphylococcus and the relevant antibiotic is only necessary when the
symptoms are severe. Analgesics are necessary and the possibility of underlying diabetes must be
excluded.


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Tumors

o Malignant tumors of the ear are most common in the outer ear where both basal cell carcinoma and
squamous carcinoma are found. The small lesion is treated with radiotherapy but the larger will need
surgical excision.

Serous (Secretory) Otitis Media

o When the Eustachian tube becomes blocked, the air trapped in the middle ear is absorbed into the
surrounding tissues and is replaced by thin fluid. In time, small glands appear in the lining of the middle
ear and the mucus which they secrete, explain the popular name of "glue ears" which is given to this
condition. It is seen most in those children whereanimmature musculatureandrepeatedupperrespiratory
tract infections, predispose to tubal obstruction.

o The child develops a hearing loss that may pass unnoticed. However, the parents may have noted that
the child's schoolwork has deteriorated or that he turns up the television. There may also be associated
episodes of earache caused by a supurative infection of the fluid. An examination of the ear will reveal the
presence of fluid behind the tympanic membrane and a simple whisper test or an audiogram will confirm
the presence of a hearing loss.

o If the condition is temporary or intermittent, nothing needs to be done since most children outgrow
the condition. If it is more severe, an alternative means of allowing air into the middle ear, must be found.
A hole is made in the tympanic membrane (a myringotomy) and the hole is prevented from healing by
inserting a small plastic tube (grommet, dottle or stopple). At the same time, any underlying cause
(sinusitis or enlarged adenoids) is treated.

o As long as the grommet remains in place and remains unblocked the hearing is normal. However, the
grommet drops out after tubes may be the middle ear. The majority of patients with grommets in place
can be allowed to go swimming although earplugs are advisable. It is hoped that the patient will have
outgrown the problem by then, but a grommet may need to be reinserted if fluid reaccumulates.

Acute Otitis Media

o The middle ear is in continuity with the nasopharynx and is therefore very prone to infection from it.
This is especially so in the presence of serous otitis media when a convenient culture medium is available
for the invading bacteria. The middle ear mucosa becomes inflamed and the cavity fills with which
escapes by bursting out through the tympanic membrane into the external ear.

o The patient, who is usually a child with a cold, develops an earache of increasing severity that ceases
when the membrane bursts.

o The perforation usually heals after 2 to 3 days but this should be checked after one month and the
presence of an underlying serous otitis media excluded.

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o The patient should be confined to bed andgiven analgesics. A covered hot water bottle applied to the
ear is helpful and warm olive oil drops will soothe the inflamed membrane. If a patient is seen before the
perforation occurs, penicillin should be given and should be continued for at least 5 days and until the
inflammation has settled. A swab should be taken from the discharging ear and sent for culture and
sensitivity. Complications may arise but these are now rare. The most common is acute mastoiditis, a
condition in which an abscess develops in the mastoid bone and burst out behind the ear. It is now

only seen in children whose natural defense mechanisms are not functioning normally.

Chronic Otitis Media

o When a middle ear infection becomes persistent it is called chronic otitis media. Permanent damage is
done to the tympanic membrane and to the ossicles and the patient may be very deaf with a large central
perforation and a persistent discharge. The discharge is particularly likely to occur when the patient has
a cold because infected secretions pass up the Eustachian tube.

o An attempt is made to remove any source of infection in the nose or and the local discharge can be
controlled by regular irrigation and the instillation of eardrops. When the ear has been dry for several
months it is suitable for a surgical repair of perforation. Apiece of fasciais taken from the surface of the
temporalis muscle and the thin tissue is grafted over the perforation. The graft may be laid on the inner
or the outer surface of the tympanic membrane and the operation is known as a myringoplasty.

o Similarly, any loss of ossicuiar continuity can be corrected by repositioning a damaged ossicle or by
replacing it with a piece of bone or a prosthesis. This operation is called tympanoplasty. More recently it
has become possible to remove the tympanic membrane and its attached ossicies in one block from a
cadaver. These homograft tissues can then be implanted into a suitable patient but the operation is
technically very difficult.

Cholesteatoma

o This cyst lined by squamous epithelium and filled with layers of epithelial scales. The cyst forms from
an in pouching of the upper segment of the tympanic membrane, into the middle ear cavity

o Initially, the epithelial scales escape into external canal, but as the mouth of the pouch narrows they
are retained and accumulate.

o The cholesteatoma is unique that it has the property of eroding most of the tissues that encounters.
The contents of the cyst becomes infected and the condition may be regarded as a for of chronic otitis
media

o The extent of the damage determined by the direction in which the cholesteatoma enlarges. Usually
the ossicles are damaged, but an upward extension will produce a brain abscess or meningitis. Similarly,
a downward extension may produce a facial paralysis or damage the inner ear


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o The patient complains of deafness and an offensive scanty discharge. There may be evidence of a
complication and an examination of the ear will reveal a marginal perforation with white epithelial scales
protruding.

o The treatment will include surgical and some form of radical mastoidectomy, which is necessary for its
removal.

Otosclerosis

o In otosclerosis, abnormal, spongy, highly vascularized bone grows across the margins of the oval
window and to the footplate of the stapes that longer vibrate condition is more common in women.

o It begins in early adulthood and the deafness progressively worsens. It causes conductive hearing loss.
Rinne's test indicates that bone conduction is better than air conduction

o The treatment is a choice between a hearing aid and surgery and the operation is known as
stapedectomy.

o The mobile part of the stapes is removed and hole is made in the fixed footplate. A Piston (or a similar
prosthesis) is placed in the hole and hooked around the incus to reestablish sound transmission. The
inner ear is at risk during the operation and this must be clearly explained to the patient. Some dizziness
almost always occur temporarily and this is countered by anti-vertigo drugs.

Diseases of the Inner Ear

o Any disease affecting the inner ear causes damage to the delicate news endings responding for hearing
and balance and the patient may complain of vertigo, deafness or tinnitus.

o Trauma,loudnoisesandsomedrugsmaydamagetheinnerearand
they should be avoided if possible, In Meniere's disease, there is
an accumulation of endolymph in the inner ear and the patient suffers from episodes of severe vertigo.

o A tumor known as an acoustic neuroma may occur in the internal auditory canal and its symptoms
will mimic those of inner ear disease. The ear, nose and throat surgeon carries out many investigations to
distinguish between these in anattempt to diagnose a neuroma at an early age.

Meniere's Disease (Endolymphatic Hydrops)

o It is characterized by accumulation of endolymph in the inner ear. o It is chronic, with remissions and
exacerbations.
o Causes


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o Unknown
o Virus
o Emotional Stress

o Assessment in Meniere's disease


o Vertigo (most characteristicmanifestation)
o Unilateral or bilateral gradual hearing loss
o "Drop attacks" (the patient experiences the feeling of being

pulled to the ground)


o Feeling of as if one is whirling in space
o Tinnitus (described as "roar" or "like the ocean")
o Nausea and vomiting
o Weber Test shows that tonelateralizes better in the good ear.

Collaborative management for the client with Meniere's disease

o Bed rest during exacerbation.


o Low sodium diet. To prevent retention of water.
o Avoid drinking large volumes of fluids.
o Avoid reading during vertigo.
o Provide quiet, darkened room during vertigo.
o Provide soft, mellow music during tinnitus to dived the patient's attention.
o Avoid alcohol, caffeine, tobacco. These cause exacerbation of symptoms.
o Stress therapy.
o Medications: tranquilizers, vagal blockers (atropine), antihistamines, vasodilators, diuretics
o To reduce vertigo, the following medications may be prescribed:

• Diazepan (Valium)
• Meclizine (Antivert/ Bonamine plus nicotinic acid)
• Fentanyl with Droperidol (lnnovar)

Acoustic neuroma

o A benign tumor of the vestibular or acoustic nerve.


o The tumor may cause damage to hearing and to facial movements and sensations.
o Symptoms begin with tinnitus and progress to gradual sensorineural hearing loss.
o Treatment includes surgical removal of the tumor via craniotomy. Care is taken to preserve the
function of the facial nerve.
o Postop nursing care is similar to post operative craniotomy care.

“An acoustic neuroma expands out of the internal auditory canal, displacing the cochlear, facial, and
trigeminal nerves located in the cerebellopontine angle.


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*Note: After surgery, the patient may experience asymmetry of the face due to affectation of the facial nerve.
This will spontaneously be resolved in few months.

There will be dryness of the eye on the affected side and this eye will not be able to produce tears for
sometime. Artificial tears may be instilled into the eye at regular basis to prevent corneal uiceration.

*There will be absent or diminished taste sensation due to affectation of the facial nerve.

Different Types of Ear Surgeries

o Myringoplasty. It involves closure of perforatedtympanic membrane. o Tympanoplasty. It involves


closure of perforated tympanic membrane, if the middle ear is involved.
o Myringotomy. It involves a simple incision in the tympanic membrane.
o Ossiculoplasty. It involves ossicular reconstruction.
o Stapedectomy. It involves surgicalremoval of the stape followed by replacement with prosthesis.
o Stapedotomy. It involves use of laser to create a hole in the footplate of the stapes and prosthesis is
placed in the hole.
o Labyrinthectomy. It involves surgical removal of the membranous labyrinth through the oval
window or through the mastoid bone.

Care of the Client Undergoing Ear Surgery


o Preop Care
o Assess for upper respiratory tract infection.
o Shampoo the hair.
o Inform the client that he/she will be under local anesthesia but sedated during surgery.

Postop Care: Instructions include the following:
o Lie on the unoperated side.
o Blow nose gently one side at a time, sneeze or cough with mouth open for 1 week after surgery.
o Avoid strenuous physical activity like heavy lifting for 1 week and avoid exercises or sports for
three weeks postop.
o Change cotton ball in ear daily.
o Keep ear dry for 6 weeks postop.
o Do not shampoo hairfor 1 week
o Protect ear with 2 pieces of cotton (outer piece saturated with petrolatum)
o Avoid airplane travel for 1 week postop. For sensation of ear pressure hold nose, close mouth
and swallow to equalize pressure
o Report any drainage other than slight amount of bleeding to the physician.
o Avoid reading, watching TV or fast moving objects for 1 week postop. This is to prevent vertigo
o Advise patient to seek for supervision when ambulating for the first time, dizziness or
lightheadedness may occur. This is to prevent falls.


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Far Eastern U niversity


Institute of Nursing

NCM 104 : Nursing Care of Clients with Disturbances in Locomotion

Course Title : Nursing Care of Clients with Disturbances in Locomotion


Course Description : The concept deals with nursing management of clients with musculoskeletal
disorders utilizing the nursing process approach and integrating the 11 core
competencies
Course Credit : 25 Hours (5 Hrs. / week)
Course Objective : At the end of 25 hrs. session, using varied teaching and learning strategies, the
students will gain basic knowledge, to be equipped with the appropriate nursing
skills and the right attitude in the delivery of quality nursing care to clients with
musculoskeletal disorders

SKELETAL SYSTEM
Functions
1. Support
• Maintains upright posture
2. Hematopoiesis
• Formation of blood or of blood cells in the living body
3. Allowing bodily movement
• Serve as a lever that magnifies speed of movement or force (long bones are the levers & the axes
(fulcrum) are the joints where bones meet
4. Protection
• Protects the brain and internal organs
5. Store minerals such as calcium and phosphorus
• Calcium : 99% in skeleton; 1% in teeth and soft tissues
• Phosphorus: 85% in bones; 15% spread throughout the soft tissues

— Bone is a living tissue surrounded by soft tissue with vascular connections


— Enclosed by a dense layer of fibrous tissue called periosteum
— Composed of cells, protein matrix, and mineral deposits
— includes 206 bones connected by joints
— 14 % of the body’s total weight
— joints are connected by ligaments and cushioned by cartilages
— Tendons attached muscles to the bones


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Bone consists of:
1. Organic components
— Collagen fibers impart flexibility
2. Inorganic minerals
— Calcium & Phosphorus
(give bone its hardness, strength, and rigidity to resist compressive forces)
— Magnesium, Potassium, and other trace elements
(act as "mortar" bonding the calcium and phosphorous)

THREE LAYERS OF A LIVING BONE


1. Periosteum (outside covering)
2. Compact bone (hard bone)
3. Spongy bone (bone marrow)
a. Red marrow - producing red blood
cells which carry oxygen
b. White blood cells - which fight infection
c. Platelets - help stop bleeding
d. Yellow marrow (at center) - used to store fats

Functioning unit of the Bone


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Three types of cells:


1. Osteoblast
— found in deeper layer of periosteum and the bone marrow
— secretes bone matrix thus involved in bone formation

2. Osteocytes
— found inside the lamellae mature bone cells involved in bone
maintenance

3. Osteoclasts
— found just beneath the periosteum
— multinuclear cells involved in bone destruction, resorption &
remodeling

Bone Metabolism
1. Osteon
— microscopic functioning unit of mature bone which is surrounded by lamellae
2. Bone Marrow
— vascular tissue located in the shaft of long bones and flat bones
Types of marrow :
1. Yellow Marrow – composed mostly of fat cells & myelocytes
2. Red Marrow – contains immature RBCs

Hormones
1. Parathyroid Hormone
• raises levels of calcium in the blood while increasing the release of calcium from the bone, it increases the
absorption of calcium from the intestine and makes the kidneys excrete less calcium
2. Calcitonin
• decreases levels of calcium in the blood by increasing the deposition of calcium in the bones
3. Vitamin D
• causes absorption of calcium from the intestine
• deficiency of Vitamin D, can cause the body to release large levels of parathyroid hormone which can lead to
bone weakening

Human Skeleton
• Adult skeleton has 206 bones
• Babies are born with 270 soft bones until age 20 or 25
• Trabecular bone loss begin at 30 - 35 yo
• Women - 50%
• Men - 30%

Two Main Divisions:


1. AXIAL - 80 bones
• consists of bones that form the axis of the body and support
and protect the organs of the head, neck, and trunk
A. Skull C. Ribs
B. Spine D. Sternum


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2. APPENDICULAR - 126 bones
• composed of bones that anchor the appendages to the axial
skeleton
A. Shoulders
B. Pelvis
C. Upper extremities
D. Lower extremities

A. BONES OF THE SKULL (The Cranium)


(1) Frontal bone
• conscious thought, speech, primary motor area
(2) Parietal bone
• body awareness, language, taste, primary sensory area
(1) Occipital bone
• vision
(2) Temporal bone
• hearing, reading

BONES OF THE FACE


(2) orbit
(2) nasal
(2) zygomatic or cheek bone
(2) maxillary bone
(1) mandible (chin bone)


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B. Ribs

1st to 7th - True ribs


8th to 12th - false ribs
11th and 12th - Floating ribs

C. STERNUM (The Breast Bone)

1. Manubrium
2. Body or Gladiolus
3. Xiphoid Process

D. VERTEBRA OR SPINAL COLUMN

(7) Cervical bones


Atlas – 1st cervical bone
Axis – 2nd cervical bone
(12) Thoracic
(5) Lumbar
(5) Sacral bones (fused into one)
(4) Coccygeal bones (fused into one)


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C3 – Spontaneous breathing
C5 – Shoulder abduction, shrugging
C6 – Supination / wrist extension
C7 – Wrist flexion
C8 to T1 – Digital abduction & adduction
T1 to T12 – Accessory respiration &
abdominal muscles
L1 to L2 – Hip flexion
L2 to L4 – Hip adduction
L5 – Dorsiflexion
S1 to S2 - Plantarflexion

Appendicular
A. Bones of the Shoulder

1. Collarbone (clavicle)
2. Shoulder bone (scapula)

Humerus

B. Upper Extremity
a. Humerus
b. Ulna and Radius
c. Metacarpals (palm)
d. Carpals (wrist)
e. Phalanges
(proximal, middle, distal)


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Radius/Ulna

C. Pelvis
(3 hip bones which fuse together when
growth is completed)
a. Ilium
b. Ischium
c. Pubis

D. Lower extremity
a. Femur (thigh bone)
b. Patella (knee cap)
c. Tibia (Shin bone)
d. Fibula
e. Tarsals
f. Metatarsals

Patella

TRAUMA & INJURY


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I. Sprain
— Is an injury to the ligaments around a joint
— Twisting
— Around the ankle

Clinical Manifestation
— Joint pain or muscle pain
— Swelling
— Joint stiffness
— Discoloration of the skin, especially bruising

Pain Assessment (OPQRST)


— Onset
— Provocation
— Quality
— Radiation
— Severity
— Time

Management
R est
I ce
C ompression
E levation
S plinting

Management
Analgesic and Anti-inflammatory medications
Ibuprofen (Motrin and Advil)
Naproxen (Aleve or Naprosyn)
Brace or cast to reduce motion of the ankle.
Crutches to prevent bearing weight on the injured ankle

II. STRAIN
— Stretching or tearing of muscle
— Sudden and powerful contraction
— Hamstring and back injuries are among the most common strains

Possible Causes
— Running
— Jumping
— Throwing, lifting a heavy object
— Lifting in an awkward position.
— A chronic strain results from prolonged, repetitive movement of a muscle

Clinical Manifestation
Mild — last a few days
Moderate — last one to three weeks
Severe — The muscle is torn apart or ruptured
— bleeding, swelling and bruising around the muscle


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SYMPTOMS
Swelling, bruising or redness, or open cuts as a consequence of the injury
Pain at rest
Pain when the specific muscle or the joint in relation to that muscle is used
Weakness of the muscle or tendons
Inability to use the muscle at all

III. DISLOCATION
— Displacement of a bone from its normal joint position, contact
Causes:
1. Trauma
2. Disease
3. Congenital condition

Clinical Manifestation
1. Burning pain to joint 3. Stiffness and loss of function
2. Deformity 4. Moderate to severe edema around joint

IV. Concussion
— is a violent jarring or shaking resulting in disturbance of brain function

Signs & Symptoms:


— Brief loss of consciousness — Feeling of nausea and vomiting
— Headache — Numbness of extremities
— Dizziness

V. Contusion
— a bruise to the brain which causes bleeding and swelling inside of the brain

Signs & Symptoms:


— Increased ICP
— Nausea and vomiting
— Sensory & motor reflex is affected

Management (for both Contusion and Concussion)


— Assess ABCs (airway, breathing, circulation)
— With head-injured patients, cervical spine stabilization is paramount
— For patients who need airway assistance, the jaw thrust maneuver is appropriate to
maintain cervical spine control

Level of Consciousness
Alert – responds to voice
Lethargic – responds to voice slowly
Obtunded – responds to touch more than voice
Stuporous – responds to pain only


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Semi Coma – responds inconsistently to pain
Coma – unresponsive to stimulus

VI. FRACTURE
— A crack or break in the continuity of the bone
— An interruption of a bone’s wholeness

Causes of fracture:
1. More stress is placed upon a bone than it is able to absorb such as:
— Direct blow or a crushing form
— Twisting force
— Powerful muscle contractions
— Fatigue and stress
2. Bones weakened by disease or tumors are subject to pathological fractures
3. Age
4. Genetics
5. Gender
6. Diet
7. Hormonal Imbalance

Broad Classification
A. Simple (Closed) Fracture
B. Compound (Open) Fracture

Classification as to Pattern
Transverse
— a fracture that is straight across a bone

Oblique
— breaks runs in slanting direction

Spiral
— breaks coils around the bone

Classification as to Appearance
Comminuted
— bone splintered into fragments

Impacted
— one end of the fractured bone is forcefully
driven into the interior of the other.

Compression
— vertebra collapses in itself

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Depressed fracture
— broken bone being driven inward

Longitudinal fracture
— break runs parallel with bone

Fracture dislocation
— fracture is accompanied by a bone out of
a joint

Other Types of Fracture

Pathologic
— Results from a diseased bone

Burst
— Resulting from direct pressure
leading to impaction of the disc

Avulsion
— A pulling away of a fragment of a bone by
a ligament or tendon and its attachment

Greenstick
— Bone bends without fracturing across
completely


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Ping-Pong Fracture
— a type of depressed skull fracture usually seen in young children,
resembling the indentation that can be produced with the finger
in a ping-pong ball

Blow-out Fracture
— fracture of the orbital floor caused by a sudden increase of intraorbital
pressure due to traumatic force;
— the orbital contents herniate into the maxillary sinus

Teardrop fracture
— compression fracture of the body of a vertebrae
with separation of bone fragments

Jefferson's Fracture
— fracture of the atlas (first cervical vertebra)

Hangman's Fracture
— fracture through the pedicles of the axis
(C2) with or without subluxation of the
second cervical vertebra or the third

Gartland Fracture
— supracondylar fracture of the humerus

Neer Fracture
— Shoulder and humeral displaced fracture
resulting in three or more fragments

Colles' Fracture
— displacement of the wrist joint rests behind its
normal anatomic position

Galeazzi Fracture
— fracture of the distal third of radius
with radio-ulnar dislocation

Monteggia fracture
— fracture of the shaft of the ulna with dislocation
of the radial head within the elbow joint

Bennett’s Fracture
— fracture plus dislocation of the metacarpal
bone at the base of the thumb

Femoral Fracture
— extends from the hip joint down to
the knee joint


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Garden’s Fracture
— femoral neck fracture

Winquist Fracture
— fracture of middle 3rd femur

Barton’s fracture
— dorsal rim fracture of the radius

Boxer’s Fracture
— a fracture at the neck of a metacarpal

Butterfly Fracture
— with slight comminution at fracture site which
looks largely like a butterfly; fracture site has
butterfly fragments

Bimalleolar Fracture
— involves the lateral malleolus and the medial
Malleolus

Jones Fracture
— a fracture of the fifth metatarsal

March Fracture
— a fracture of the distal third of one of the
metatarsals because of recurrent stress

Supracondylar Fractures of the Femur


— above the knee joint; often involve the
cartilage surface of the knee joint

Intertrochanteric Hip Fracture


— Between the greater and lesser trochanter

Cotton’s fracture (trimalleolar fracture)


— consists of fractures of the medial, lateral,
and posterior malleoli of the tibia

Malgaigne’s Fracture
— double fracture of the pelvic ring causing pelvic
instability


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Salter’s Fracture
— Growth plate fractures

Pott’s Fracture; Dupuytren Fracture;


Pott’s Syndrome
— fracture of the fibula including malleoli
of the ankle, resulting in outward &
backward displacement of the leg
while foot is fixed; due to inversion
injuries

Classification in Relation to the Joint

a. Intracapsular
— within the capsule
b. Extracapsular
— outside the capsule
c. Intra-articular
— in the joint
Classification as to Location
a. Proximal
b. Midshaft
c. Distal

Clinical Manifestation
1. Pain (especially at the time of injury) 5. Deformity
2. Tenderness at the site 6. Crepitus
3. Swelling 7. Dislocation
4. Bleeding from an open wound with protrusion of bone ends 8. Loss of function

COMPLICATIONS
1. Blood loss
2. Injuries to organs
3. Growth problems

Principles of Fracture Treatment


1. Recognition
2. Reduction
A. Closed Reduction - manual manipulation is used
B. Open Reduction - done by nails, screws, pins, plates wires or rods
Open Reduction Internal Fixation (ORIF)
Open Reduction External Fixation (OREF)
3. Retention
— obtaining union of fracture fragments
4. Restoration of Function (Rehabilitation)
A. Surgery

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B. Therapy
C. Exercise

Conservative Management
— Rest for 4-6 wks.
— Ice packs for the 1st 48 hrs. to control swelling then warm treatment
— Anti-inflammatory (Ibuprofen)
— Elevate extremity to lessen swelling
— Pain management
— Assess for signs of neurovascular problems like pain, absent pulse, paresthesia, pallor, paralysis
— Exercise – ROM; deep breathing, muscle setting
— Traction

Stages of Bone Healing


A. Reactive Stage
1. Hematoma Formation
— After a fracture, macrophages invade the area due to hematoma
— Edema, inflammation, pain, massive disruption to the channels of blood supply and a large
amount of bleeding from the fracture fragments causes immediate swelling and bruising
— Blood clots (Fracture Hematoma) are formed after injury up to 24 hrs

2. Cellular Proliferation / Collagen Formation


— 24 hrs up to 1-2 wks
— The combination of periosteal elevation and granulation tissue containing blood vessels,
fibroblast and osteoblast (bone- producing cells) produce collagen (tensile strength of bone)
to form a substance called osteoids forming a bridge across the fractured site

B. Reparative Stage
3. Callus Formation
— 2 wks to 1 or 1 ½ months
— Minerals are deposited in the osteoid forming a large mass of differentiated tissue, bridging the
fracture gaps called callus

4. Bone Ossification
— 1 ½ months to 4 months
— Mineral deposition continues and produce firmly reunited bone thus, fracture ends knit together

C. Remodeling
5. Remodeling
— 4 months to 1 year or more
— When consolidation is completed, excess cells or devitalized tissues are absorbed
— The primary cancellous bone is remodeled, compact bone is being formed and reorganization
of the new bone into its former structural arrangement is done; absorption and depositing
strength and laminae
Complications of Healing
1. Loss of circulation 4. Inadequate fixation
2. Infection 5. Necrosis due to fixation device
3. Interrupted or improper immobilization 6. Metabolic disturbance

Average Period for Bone Healing


Phalanges (3 wks) Humerus (6 wks) Femur (12 wks)
Clavicle (3 – 4 wks) Tarsals (6–8 wks) Fibula (12 – 14 wks)


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Metacarpals (4 wks) Radius (6 – 13 wks)
Metatarsals (5–6 wks) Tibia (8-12 wks)

Classification of Soft Tissue Injury


Grade 0 – negligible soft tissue injury
Grade 1 – superficial abrasion / contusion
Grade 2 – deep contusion from direct trauma
Grade 3 – extensive contusion & crush injury with possible severe muscle injury, compartment syndrome

Gustilo and Anderson Classification System (Classification of Open Fracture)


Type I - Wound less than 1 cm; without contamination; minimal injury of soft tissue
Type II - Wound between 1 and 10 cm; mild contamination; extensive soft tissue damage; minimal to moderate
crushing component
Type III-A - Wound larger than 10 cm; severe contamination; severe crushing component
Type III-B - Wound larger than 10 cm; severe contamination; severe loss of tissues requiring flap advancement or
free flap
Type III-C - Wound larger than 10 cm; severe contamination; neurovascular injury Requiring repair

Staging of Pressure Sore

Stage I - erythema / redness


Stage II - superficial lesion affecting the epidermis and dermis
Stage III - lesion affecting the subcutaneous tissues
Stage IV - lesion affecting muscles exposing the bones
Stage V - extensive lesion extending to the cavities and joints

Goal of Treatment:
— Regain and maintain correct position and alignment
— Regain function of involved part
— Return client to ADL in the shortest time

Surgical Management
a. Vertebroplasty
– insertion of a glue-like material (methylmethacrylate) into the center of the collapsed spinal vertebra in
order to stabilize and strengthen the crushed bone. The glue is inserted with a needle and syringe
through anesthetized skin into the midportion of thevertebra under the guidance of specialized x-ray
equipment. Once inserted, the glue soon hardens, forming a cast-like structure with the locally broken
bone.
b. Open Reduction External Fixation
c. Endoprosthetic replacement
d. External fixation device
– until bone is repaired and healed


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Nursing Intervention of Patients with Fracture
1. Comfort
2. Adequate oxygen to tissues
3. Rest
4. Total body mobility while keeping the injured part at rest
5. Protect against infection

Complications
1. Deep Vein Thrombosis
2. Pulmonary Embolism
3. Contractures
4. Mal union
S bones heal but become crooked
5. Non union
S fractures that never heal
6. Carpal Tunnel Syndrome
7. Compartment syndrome
S a serious condition that involves increased pressure in a muscle compartment

Slings & Bandages


Bandage
— are any materials that hold the dressing in place, hold pressure on a wound, as a support or to secure a
splint like dressing, bandages can be bought or improvised.
Sling
— provide support & protection for an arm. Can be improvised with a scarf, belt, necktie etc.
Exercise
— The active contraction and relaxation of the muscles

Passive Exercise Active Exercise


— movement of the body usually of the limbs, — movement of the body with effort of the patient.
without effort by the patient.

1. ISOTONIC (DYNAMIC) 2. ISOMETRIC (STATIC / SETTING)


♦ muscle tension is constant ♦ there is change in muscle tension but no change in
♦ muscle shortens to produce muscle contraction and muscle length.
movement ♦ No muscle or joint movement occurs
♦ size, shape & strength of the muscles & joint mobility ♦ To strengthen abdominal, gluteal and quadriceps
are maintained muscles used in ambulation but are not useful in
♦ increases muscle strength and endurance preventing joint contractures because joint movement
♦ improves cardiac - respiratory function is absent
♦ running, walking, swimming, cycling, ADLs, active ♦ Valsalva maneuver
ROM, pushing or pulling against a stationary object,
pressing the feet against a foot board, using trapeze
to lift the body off the bed, lifting buttocks off the bed

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by pushing with hands against the mattress, pushing
the body to a sitting position

3. ISOKINETIC (RESISTIVE) AEROBIC EXERCISE


♦ Muscle contraction & joint movement ♦ The amount of oxygen taken into the body is greater
♦ person moves or tenses against resistance than or equal to the amount the body requires
♦ Special machines/devices provides the resistance ♦ Improves cardiovascular fitness
to the movement ♦ Brisk walking & swimming
♦ Used in Physical conditioning
♦ To build up certain muscle groups

ANAEROBIC EXERCISE RANGE OF MOTION EXERCISE


♦ Activity in which the amount of oxygen taken into the ♦ The totality of movement a joint is capable of doing
body is insufficient to meet the body’s needs
♦ Oxygen need is made up later PASSIVE ROM
♦ To develop muscle tone and to improve cardio- ♦ Another person moves each of the client’s joints
respiratory function through their complete ROM, maximally stretching all
♦ Running up 3 flights of stairs muscle groups within each plane over each joint to
maintain joint flexibility

ACTIVE ROM ACTIVE-ASSISTIVE ROM


♦ Isotonic exercise in which client moves each joint in ♦ Client uses a stronger opposite arm or leg to move
the body through its complete ROM, maximally each of the joints of a limb incapable of active motion
stretching all muscle groups within each plane, over ♦ Increases active movement on the strong side of the
the joint patient’s body
♦ Maintains/increase muscle strength and endurance ♦ Maintains joint flexibility on the weak side
♦ Help to maintain cardio-respiratory function in an (for stroke patients)
immobilized client
♦ Prevent deterioration of joint capsules, ankylosis &
contractures

Heat & Cold TENS (Transcutaneous Electric Nerve Stimulation)


Heat Application ♦ Sends a painless electrical current to specific nerve.
♦ Heat pad maybe applied to warm up the muscle The current maybe delivered intermittently. The mild
prior to doing exercising & stretching. electrical current generates heat that serves to relieve
stiffness, improve mobility & relieve pain.
Cold Application ♦ Stimulate the body’s production of endorphins
♦ Ice pack after exercise to sooth the muscles & (natural pain killer)
soft tissues.


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NEUROVASCULAR ASSESSMENT FOR PATIENT WITH CAST
(Maggie Chewed Nuts Everywhere She Went)
Movement, Color, Numbness, Edema, Sensation, Warmth

CAST CARE CAST SYNDROME PLASTER SORE


1. Do not wet, cut or heat 1. Impaired venous circulation 1. Burning, itching or stabbing pain
2. Allow the cast to dry naturally in a. Swelling 2. Disturbed sleep
circulating air b. Pain / discomfort 3. Elevated temperature
c. Cyanosis of nail beds
3. If the cast becomes loose, cracked d. Muscle spasm 4. Heat and swelling of the digits
and soft it is no longer keeping the 2. Impaired arterial supply 5. Visible pus or staining of the cast
injured body immobilized a. Slow capillary refill
4. Do not push any objects inside the 3. Abdominal pressure
cast 4. Feeling of tightness or bloating
5. Check the circulation of the finger 5. Inability to take deep breath
or toes
6. Don’t scratch under the cast with
sharp objects
7. Trim rough edges

SPINAL CORD INJURY


♦ An injury to the spinal cord, vertebral column, supporting soft tissue or intervertebral disk resulting in a change, either
temporary or permanent, in its normal motor, sensory, or autonomic function

Causes
1. Traumatic 2. Non-traumatic
a. Motor Vehicle Accident a. Tumors
b. Falls Accident b. Aneurysm
c. Sports Injuries Accident c. Hematoma
d. Diving in a Shallow Water d. Congenital Defects
e. Violence (Gun Shot or Stab Wounds)

Risk Factors
A. Modifiable:
1. Occupation 3. Certain diseases
2. Drugs and Alcohol Abuse 4. Lifestyle
B. Non Modifiable:
1. Age
2. Gender
3. Season (summer)

Four general types of spinal cord injury


1. Cord maceration
the cord is severely distorted
2. Cord lacerations
gun shot or knife wounds
­ In the first two injuries, the surface of the cord is lacerated and a prominent connective tissue response is invoked
3. Contusion
bruise injury


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leads to a central hematomyelia (hemorrhage into the spinal cord) that may evolve to syringomyelia
(formation of cavities filled with liquid within the spinal cord)
4. Solid cord injury
there is no central focus of necrosis as in contusion injury
­ In the latter two the spinal cord surface is not breached and the connective tissue component is minimal

Classifications of Incomplete SCI


1. Central Cord Syndrome
usually occurs in older patients after a hyperextension trauma to the neck.
There may be significant loss of function in the upper limbs and hands.
2. Brown- Sequard Syndrome
involves hemisection of the spinal cord, commonly seen in stabbing or gunshot injuries.
There is loss of voluntary motor control on the same side as the cord damage;
3. Anterior cord syndrome
the most common form of incomplete lesion and occurs after high-velocity impact trauma.
The lesion develops as a result of physical trauma, bony compression and ischaemia associated with a
lesion causing variable loss of motor function and sensitivity to pain and temperature; proprioception is
preserved
4. Posterior cord syndrome
occurs with posterior impact injury or hyperextension of the neck.
There may be a resultant loss of position (proprioception), vibration & touch sense
5. Conus Medullaris Syndrome
associated with injury to the sacral cord and lumbar nerve roots leading to areflexic bladder, bowel, and
lower limbs, while the sacral segments occasionally may show preserved reflexes (bulbocavernosus
and micturition reflexes)
6. Cauda Equina Syndrome
due to injury to the lumbosacral nerve roots in the spinal canal, leading to Areflexic bladder, bowel and
lower limbs

Clinical Manifestations Depends on the Level & Extent of the Injury:


1. Incomplete injury
patient has sensory function but no motor function
2. Complete injury
there is complete loss of sensation & muscle control below the level of injury can result into paraplegia
or quadriplegia

Cervical SCI Thoracic SCI Lumbar SCI Sacral SCI


(Above C4-FATAL)
■ Quadriplegic ■ Paraplegic ■ Paraplegic ■ Above S4 - w/ erection
■ Respiratory Muscle Paralysis ■ Poor Control of the upper trunk ■ Bladder & Bowel but no ejaculation
■ Bladder & Bowel Retention ■ Bladder & Bowel Retention Retention ■ S2-S4 both will lose bladder
and bowel retention

ASIA IMPAIRMENT SCALE (American Spinal Injury Association)


A = Complete
No motor or sensory function preserved in S4-S5.
B = Incomplete
There is Sensory but no motor function preserved below the neurological level and includes S4-S5
C = Incomplete
Motor function is preserved below the neurological level, and have a muscle grade less than 3


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D = Incomplete
Motor function is preserved below the neurological level, and have a muscle grade of 3 or more
E = Normal
Motor and sensory function are normal

MUSCLE GRADING
0 = Total paralysis
1 = Palpable or visible contraction
2 = Active movement, full range of motion, gravity eliminated
3 = Active movement, full range of motion, against gravity
4 = Active movement, full range of motion, against gravity and provides some resistance
NT = Not testable.
Patient unable to reliably exert effort or muscle available for testing due to factors such as immobilization, pain on
effort or contracture

Medical Management
Immediate Treatment
1. Reduction of edema and/or the inflammatory response with steroids
2. Methylprednisolone, a glucocorticosteroid, if given within eight hours in patients with both complete and
incomplete SCI, may exacerbate acute neuronal necrosis
■ Proper handling during transfer or movement

Surgical Management
1. Laminectomy
surgical excision of a part of posterior vertebral arch & removal of protruded disc.
2. Spinal fusion
fusion of spinous process w/ bone graft from iliac crest to provide spinal stability
3. Harrington Rod
installation of a steel rod along the spine

Nursing Interventions
1. Promote Adequate Breathing/ Airway Clearance
monitoring O2 saturation assist to do chest physical therapy
instruct deep breathing exercise measuring vital capacity
monitoring arterial blood gas values
2. Improving Mobility
maintain body alignment
reposition the pt. frequently as soon as the spinal column is established.
Principles in turning patient with SCI:
a. Use log rolling technique
b. Turn the patient as a unit
c. Support the cervical and the lumbar area
3. Provide General Comfort
Sponge Bath Bed Rest in a firm mattress
Provide bedpan for defecation & urination Provide privacy

Leading cause of death in SCI


1. Pneumonia and other respiratory conditions 5. Suicide (higher among individuals younger than 25 yrs)
2. Heart disease 6. Alcohol-related deaths
3. Subsequent trauma 7. Cancer
4. Septicemia


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Grading for ADL’s
0: Completely Able
■ Activity completed without modification, within reasonable time
1: Able with Aids/Difficulty
■ Activity completed with prior preparation or with assistive devices or aids, or beyond a reasonable time
2: Able with Helper
■ Activity completed only with help or assistance of another person, or under supervision by cuing.
Individual performs at least half the effort to complete the activity
3: Unable
■ Individual assists minimally (less than half of effort), or is totally dependent
MUSCULO-SKELETAL INFECTION

I. Osteomyelitis
♦ is a progressive infection of the bone marrow and cortex
osteo : bone ; myelo : bone marrow ; itis : inflammation

Synonyms
Bone infection Pathogenic bone inflammation
Bacterial osteomyelitis Bone marrow infection
Hematogenous osteomyelitis Contiguous focus osteomyelitis
Vascular insufficiency Septic osteomyelitis in infants
Central osteitis Direct inoculation osteomyelitis
Contiguous inoculation osteomyelitis Chronic osteomyelitis
Vertebral osteomyelitis

Causative Organisms:
1. Staphylococcus aureus 3. Haemophilus influenzae 5. Pseudomonas species
2. Enterobacter species 4. Streptococcus species 6. Salmonellae species

Incidence:
♦ Infants, children and older adults
♦ Males greater than females
♦ People with weakened immune systems

Predisposing Factors
♦ People with diabetes ♦ Intravenous drug abusers
♦ Patients receiving hemodialysis ♦ The elderly
♦ People with weakened immune systems & poorly nourished ♦ Those who have Cancer
♦ People with sickle cell anemia ♦ Previous injury

Classifications of Osteomyelitis
A. Exogenous osteomyelitis
1. Contiguous spread
♦ from infected tissue or an infected prosthetic joint
2. Direct inoculation
♦ bacteria are delivered direct to the bone tissue via
a. Surgery or trauma
b. Open wounds
B. Endogenous Osteomyelitis
1. Hematogenous spread
♦ occurs from bacteria circulating in the bloodstream

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♦ primary infection of the blood or infection from somewhere else in the body is delivered to the
bone via the blood stream
♦ Bacteria are drawn to areas of rich blood supply, thus, the infection tends to target the growing
parts at the ends of the long bones (metaphysis); tibia, femur, or humerus; In adults –
vertebrae

Classifications of Osteomyelitis Accdg to Onset


1. Acute osteomyelitis
♦ the infection develops within two weeks of an injury
2. Chronic osteomyelitis
♦ the bone infection starts at least more than 6 weeks after an injury or is recurrent

Risk Factors
♦ Poorly nourished ♦ Impaired immune system
♦ Elderly ♦ Chronic illness (Diabetes, Rheumatoid Arthritis)
♦ Obese ♦ Receiving long term corticosteroid therapy

Symptoms of osteomyelitis
♦ Swelling and warmth in the infected area ♦ Fever & chills
♦ Swelling of the ankles, feet, and legs ♦ Nausea
♦ General discomfort, uneasiness / irritability, or ill feeling / malaise ♦ Fatigue
♦ Restriction of movement (pseudoparalysis of limb in neonates) ♦ Lower back pains
♦ Drainage of pus through the skin / sinus tract drainage ♦ Redness in the affected area
♦ Changes in gait (walking pattern that is painful, yielding a limp) ♦ Pain and/or tenderness
Diagnosis
1. Physical Examination
(Localized classic physical findings of bony tenderness, with overlying soft-tissue erythema or edema; Progressive
pain and swelling)
2. Medical History
(History of compound fracture)
3. Purulent material on aspiration from affected bone
4. CBC
■ WBC, C-Reactive Protein and Erythrocyte Sedimentation Rate are elevated
5. Positive findings of bone tissue or blood culture
6. Bone tissue biopsy
7. Radiography
■ there is overlying soft-tissue edema 3-5 days after infection
a. MRI
■ uses a magnetic field and radio waves to diagnose conditions such as tumours, joint or spinal injuries or
diseases, soft tissue injuries or diseases of internal organs
b. Radionuclide bone scanning
■ a nuclear scanning test using technetium 99m to find certain abnormalities in the bone that are triggering
the bone's attempts to heal
c. CT scanning
■ an imaging method that uses x-rays to detect calcium deposits, cysts, and abscesses, detect tumors
and distinguish between malignant and benign
8. Ultrasonography
■ use of high-frequency sound waves to visualize muscles, tendons, and many internal organs, to capture
their size, structure and any pathological lesions to demonstrate changes as early as 1-2 days after
onset of symptoms


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Goal for Treatment Rule of Thumb :
1. Eliminate the infection v If no bone necrosis
2. Minimize complications ■ antibiotics alone
3. Maintain immobilization of affected leg v If with bone necrosis
4. Promote drainage of wound ■ surgery
5. Build up resistance of the patient v If bone aspirate has pus
■ surgery to remove nonviable tissue & antibiotics

Medical Intervention
1. Analgesic, anti inflammatory drug (Nafcillin, methecillin. (4-6 wks.)
2. Antimicrobial, antibiotic to combat infection
3. Antipyretic to control fever
4. Muscle relaxant to control spasm and pain
5. Multivitamins (Zinc,Vit. E,Vit. A,Vit C) to build resistance
6. Immobilization (mold, splints, traction)
7. Antibiotic Beads

Surgical Intervention
1. Wound irrigation
■ use sterile physiologic saline solution performed for 7-8 days
2. Incision & drainage
■ surgical procedures to release pus or pressure built up under the skin
3. Debridement
■ Surgical excision of dead, devitalized, or contaminated tissue and removal of foreign matter from a
wound
4. Osteotomy
■ cutting the bone to shorten, lengthen, or change its alignment
5. Sequestrectomy
■ removal of enough involucrum to enable the surgeon to remove the sequestrum
6. Saucerization
■ removal of sufficient bone to convert a deep cavity into a shallow saucer
7. Antibiotic impregnated beads
■ may be placed in the wound for direct application of antibiotics for 2 to 4 weeks
8. Removal of Implant
9. Skin / bone grafting
10. Amputation

Nursing Management
1. Elevation & Immobilization of the affected part
2. Careful handling and proper support
3. Strict asepsis
a. Use of sterile instruments, cleaning of wound from the periphery
b. Proper disposal of soiled dressings
c. Proper handwashing
d. Cover insertion points of pin tracks with small dry dressing
e. Instruct not to touch the skin around the pins and wires
4. Relieving Pain
a. immobilize affected area with a splint to decrease pain & muscle spasm
b. warm wet soaks for 20 minutes several times a day to increase circulation
5. Administer IV fluids to maintain adequate hydration
6. Provide a diet high in protein and Vitamin C

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7. Assess vital signs & wound appearance daily, and monitor for new pain, which may indicate secondary infection
8. Carefully monitor suctioning equipment
9. ROM exercises of unaffected extremities

Prevention Complications
1. A healthy, well-balanced diet 1. Bone abscess
2. Don't smoke 2. Bacteremia
3. Good Hygiene 3. Fracture
4. Complete immunization 4. Loosening of the prosthetic implant
5. Regular exercise 5. Overlying soft-tissue cellulitis
6. Alcohol in moderation 6. Draining soft-tissue sinus tracts
7. Take precautions to avoid cuts and scrapes 7. Involucrum
8. Appropriate diagnosis and treatment of 8. Reduced limb or joint function
primary bacterial infections 9. Amputation

II. POTT’S DISEASE


♦ An extra pulmonary tuberculosis that affects the spine
♦ the most common site of bone infection in TB
♦ the lower thoracic and upper lumbar vertebrae are the areas of the spine most often affected
♦ named after Percival Pott, a London surgeon

Synonyms
♦ Tuberculous spondylitis ♦ Kyphosis ♦ Pott’s curvature
♦ David’s Disease ♦ Pott’s Caries ♦ Tuberculosis of the Spine
♦ Pott’s Paraplegia ♦ Disk disease ♦ Tuberculous Spondyloarthropathy

Causative Organism : Mycobacterium tuberculosis

Risk factors
A. Modifiable:
1. Close contact w/people with active PTB 6. Poor Nutrition
2. Therapeutic immunosuppression 7. HIV Infection
3 Immunocompromised people 8. Chronic disease
4. Healthcare worker 9. IV drug abuse
5. Living in overcrowded substandard housing 10. History of trauma
B. Non-modifiable:
1. Race (primarily affects African Americans, Hispanic Americans, Asian Americans)
2. Sex (more common in males)
3. Age (young adults and older children)
4. Family history of pulmonary tuberculosis

Clinical Manifestations
♦ Localised back pain ♦ Stiffness
♦ Afternoon Fever ♦ Night sweats
♦ Paravertebral swelling (Gibbus formation) ♦ Weight loss
♦ Neurological signs may occur, leading to paraplegia ♦ Anorexia


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Laboratory Examinations:
♦ Blood tests (elevated ESR & CRP)
♦ Acid-fast stain and culture for Mycobacterium tuberculosis

Diagnostic Tests
♦ MRI (spinal compression) ♦ Radiographs of the spine (vertebral destruction)
♦ Tuberculine test or PPD test ♦ CT of the spine
♦ Bone scan ♦ Needle biopsy of bone or synovial tissue
Objective of Management:
1. Immobilize the spine 3. Minimize the disease
a. Bed rest a. Surgical decompression
b. Immobilization by splinting (2 or 3 months) b. Physiotherapy
2. Control the infection 4. Build up resistance of patient
a. Drainage of abscess a. Nutritious, high protein, Vitamin C rich diet

Medical Management
1. Immobilization
■ prolonged bed rest, body cast
2. External bracing when patient is ready for ambulation
■ Taylor, Jewette, SOMI
3. Antituberculous drugs
■ Therapy requires combination regimens with at least 3 anti - tuberculous drugs for 9-12 mos.
a. Rifampin (Rifadin, Rimactane)
■ For use in combination with at least one other antituberculous drug
■ Causes red orange discoloration of urine
b. Isoniazid (Laniazid, Nydrazid)
■ Highly active against Mycobacterium tuberculosis, Has good GI absorption
■ May cause peripheral neuropathy
c. Pyrazinamide
■ Bactericidal; Has good GIT absorption
■ Hepatotoxicity may appear
d. Ethambutol (Myambutol)
■ Bacteriostatic; Has good GI absorption
■ May cause blindness
e. Streptomycin
■ Bactericidal; not absorbed from the GI tract, thus must be administered parenterally
■ Cause ringing in the ears (Ototoxicity)
f. Vitamin B Complex
Surgical Management
(Required if there is spinal deformity or neurological signs of spinal cord compression)
1. Costotransversectomy - excision of a part of a rib along with the transverse process of a vertebra
2. Anterior Decompression Spinal Fusion
■ Debridement and Fusion with bone grafting
■ treatment is usually six months
3. Laminectomy - removes a portion of the vertebral bone called the lamina
4. Arthrodesis - surgical fixation of a joint, ultimately resulting in bone fusion

Nursing Management
1. Proper nutrition 5. Strict compliance to therapy
2. Proper immobilization 6. Close monitoring on response to therapy
3. Avoid overcrowding 7. Adequate rest periods
4. Proper hygiene 8. Observe for possibility of antimicrobial drug resistance


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Prevention Signs that infection is under control
1. BCG vaccination 1. ESR is decreased 3. Appetite improved
2. Proper nutrition 2. Fever subsided 4. Weight gain
3. Avoid congested places

Complications
1. Spine deformities (Kyphosis) 5. Sinus Formation
2. Vertebral collapse a. Psoas Abscess - comes from a tuberculous
3. Hypostatic pneumonia abscess of the lumbar vertebra that tracks
4. Pott’s Paraplegia from the spine inside the sheath of the psoas
■ Paravertebral abscess muscle
■ Bone fragments encroaching on the cord b. Cold Abscess - if infection extends to adjacent
■ Granulomatous tissues formed around the cord ligaments and soft tissues
■ Spinal cord compression

III. SEPTIC ARTHRITIS


♦ A serious infection of the joints which cause damage to bone as well as cartilage, and its potential for creating septic
shock

Synonyms:
Septic Arthritis
Infectious Arthritis
Pyogenic Arthritis

Causes
1. Previous trauma to joints
2. Joint replacements
3. Coexisting arthritis
4. Diminished host resistance

Risk factors
1. Advanced age
2. Diabetes mellitus
3. Rheumatoid arthritis
4. Preexisting joint disease
5. Joint replacement

Sign & Symptoms


♦ Warmth and pain in the joint ♦ Swollen joint
♦ Decreased range in motion ♦ Systemic chills
♦ Fever

Diagnostic Studies
♦ Physical Examination ♦ Aspiration of synovial fluid
♦ Culture of the synovial fluid ♦ Radioisotope scanning


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Goal of Treatment
1. Treat inflammation
2. Prevent deformity and contractures
3. Promote comfort

Medical Management
♦ Prompt treatment ♦ Broad-spectrum IV antibiotics
♦ Analgesics are given to control pain ♦ NSAIDs to limit joint damages
♦ Removal of excessive fluid, exudates and debris
♦ Support, Splinting, and immobilization of the inflamed joint to increase patient comfort

Surgical Management
1. Fluid Aspiration / Drainage
2. Debridement

Nursing Management
1. Warm compress
2. Support, Splinting, and immobilization of the inflamed joint to increase patient comfort
3. Proper nutrition

INFLAMMATORY CONDITIONS

I. OSTEOARTHRITIS
♦ Breakdown / tearing or thinning of cartilage resulting in friction on the ends of the bones as they move
♦ is limited to the joints
♦ Unilateral but becomes symmetrical later

Synonyms:
OA Osteoarthrosis
DJD Degenerative Joint Disease
Hypertrophic Arthritis

Predisposing Factors Precipitating Factors


M Over age 40 M Diabetes
M Collagen disturbances M Obesity
M Trauma to the bones
M Wear & Tear (overuse)
M Infected joints, chronic gout, and
rheumatoid disease, Paget’s
disease, Unequal leg length

Body part affected: Joints in the spine, hips, knees and hands


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Clinical Manifestations:
♦ Stiffness or difficulty moving the joints and in
some cases bone spurs (hard lumps)
♦ Commonly occurs in the morning after
awakening
♦ Lasts only for less than 30 minutes
♦ Decreases with movement, but worsens after
increased weight bearing activity
♦ Crepitation may be elicited
♦ Swelling
♦ Pain may get worse with overuse and may occur
at night; pain can occur at rest
Heberden’s Nodes Bouchard’s Nodes
♦ abnormal cartilaginous or bony enlargement ♦ abnormal cartilaginous or bony enlargement of a
of a distal inter- phalangeal joint of the finger proximal inter- phalangeal joint of the finger

Laboratory Examinations for Osteoarthritis


1. Joint fluid analysis
M fluid is extracted from the knee with a needle
2. CBC, C-Reactive Protein, ESR
Diagnostics for Osteoarthritis :
1. X-rays
♦ show narrowing of the space between the joint (articular surface), osteophytes, cyst formation, and hardening
of the underlying bone
2. MRI
♦ complex, noninvasive imaging technique capable of visualizing all structures within the joint
3. CT Scan
♦ provides information on the bony structures of the joint but in greater detail
4. Arthroscopy
♦ a tiny camera that can see inside the joint to diagnose the source of pain

Four Phases in Osteoarthritis :


I. Stationary phase
♦ formation of osteophytes (bony outgrowths, at the joint margins) and joint space narrowing
II. Obliteration phase
♦ Eventually fissures (splitting) and pits (small holes) develop in the cartilage to increase the surface area to
offload the pressure on that joint by distributing the weight; thus, joint space is obliterated
III. Erosive phase
♦ appearance of subchondral cysts (cysts in the bone underneath the cartilage)
IV. Bone repair & remodelling
♦ damaged bone attempts to repair itself


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Goal of Treatment for OA
1. To control pain 3. To maintain normal body weight
2. To improve joint function 4. To achieve a healthy lifestyle

Medical Interventions for OA


1. Acetaminophen
2. NSAIDs –
a. Ibuprofen (Advil, Motrin)
b. Naproxen sodium (Aleve)
3. COX 2 medicines (Celecoxib)
a. [Celebrex])
4. Duloxetine (Cymbalta) antidepressant
♦ for chronic musculoskeletal pain (joint and muscle pain)
5. Orthoses
♦ Assistive devices to improve moveable body parts or to support, align, prevent, or correct deformities
a. Splints or braces
♦ joint alignment and weight redistribution
b. Walkers, crutches or canes, and orthopedic footwear

Surgical Interventions for OA


1. Arthroscopy
♦ examination of the inside of a joint using a small camera (endoscope)
2. Arthroplasty
♦ repair of a joint in which the joint surfaces are replaced with artificial materials, usually metal or plastic.
3. Osteotomy
♦ incision or cutting of bone
4. Chondroplasty
♦ surgical repair of the cartilage
5. Arthrodesis
♦ surgical fusion of the bony ends of a joint preventing joint movement
6. Joint replacement
♦ removal of diseased or damaged bony ends and replacement with a manmade joint composed of a
combination of metal and plastic
7. Tidal Irrigation
♦ introduction of large volume of saline into the joint through cannulas and the removal of this fluid

Nursing Intervention for OA


1. Weight loss 4. Avoid high-impact sports
2. Diet 5. Hot soaks and warm wax (paraffin)
♦ supplements of antioxidant Vitamins C and E 6. Orthoses
♦ Vitamin D (400 IU) ♦ splints, braces, walkers, crutches, or canes, and
♦ Calcium (1000 mg-1200 mg.) orthopedic footwear to support, align, prevent, or
3. Regular exercise correct deformities
♦ to help strengthen the muscles and potentially 7. Physical therapy
stimulate cartilage growth 8. Occupational therapy

Complications:
a. Joint damage
b. Deformity
c. Disability


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Prognosis for Osteoarthritis :
♦ Osteoarthritis cannot be cured, but early diagnosis and treatment can help to reduce symptoms and minimize
complications
II. RHEUMATOID ARTHRITIS
♦ an autoimmune disease in which the body's immune system attacks itself
♦ involves numerous cell types, including macrophages, T cells, B cells, fibroblasts, chondrocytes, and dendritic cells

Rheuma
♦ a substance that flows; Humorous substance that flow through the body come to stop in certain parts of the body,
causing pain and swelling

Synonym: RA

Body Part Affected in RA


M Joints on both sides of the body equally affected
M Wrists, fingers, knees, feet, and ankles

Predisposing Factors Precipitating Factors


a. Age - 40 and 50 a. Infection c. Smokers
b. Gender – Women more than men b. Hormone changes d. Rheumatoid factor positive
c. Genes

Clinical Manifestations for RA


1. Attacks multiple joints simultaneously and
symmetrically
2. Usually hands and other joints like hips are affected
3. Pain & stiffness worse in the morning
4. Sjogren Syndrome
♦ Dry mouth (xerostomia)
♦ Dry eyes (keratoconjunctivitis sicca)
♦ Dry vagina

5. Swan neck Deformity 6. Boutonniere Deformity


♦ flexion of the distal inter-phalangeal joint & hyper- ♦ Flexion of the proximal inter- phalangeal joint
extension of the proximal inter- phalangeal joint with hyper- extension of the distal inter-
phalangeal joint of the finger

7. Pannus
♦ Vascularised granulation tissue rich in fibroblasts,
lymphocytes and macrophages, derived from
synovial tissue, overgrows the bearing surface of
the joint


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Classification of Severity of RA
Stage I
S no damage seen on x-ray, though there may be signs of bone thinning
Stage II
S on x-ray, with evidence of bone thinning around a joint with or without slight bone damage
S joint mobility may be limited
S Atrophy of adjacent muscles
Stage III
S on x-ray, evidence of cartilage and bone damage and bone thinning around the joint
S Joint deformity without permanent stiffening or fixation of the joint
S Extensive muscle atrophy
Stage IV
S on x-ray, evidence of cartilage & damage & osteoporosis around joint
S Joint deformity without permanent stiffening or fixation of the joint
S Extensive muscle atrophy

Functional Status of patients with RA


Class I
S Completely able to perform usual ADLs
Class II
S Able to perform usual self-care and work activities but limited in activities outside of work (playing sports,
household chores)
Class III
S Able to perform usual self-care activities but limited in work and other activities
Class IV
S Limited in ability to perform usual self-care, work and other activities

Laboratory Examinations for RA


1. Reumatoid Factor
M During the first year of illness, rheumatoid factor is more likely to be negative with some individuals
converting to seropositive status overtime
2. Complete Blood Count
3. C-Reactive Protein
M appears in higher amounts when there's swelling
M Normal is 2- 4.9mg/L
4. Erythrocyte Sedimentation Rate (ESR)
M measure of the presence and severity of inflammatory and other morbid processes
M Normal is 0-10mm
5. Antinuclear Antibody/ANA)
M substances produced by the immune system that attack the body's own tissues
M Low titers are in the range of 1:40 to 1:60
6. Serological Point–of-Care Test (POCT)
M for early detection of RA
7. Ferritin levels
M Ferritin is a blood cell protein that contains iron
M Normal range: Increased in arthritis Men = 24 to 336 mcg/liter (iu) ; Female = 11 to 307 mcg/l (iu)
8. Anti-Citrullinated Protein Antibodies (ACPA)
M present in many cases even before onset of disease
9. Liver enzyme test

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Melevated alanine amino-transferase (ALT), aspartate aminotransferase (AST) and possibly the bilirubin
connotes inflammation of hepatic cells
10. Renal function test

Diagnostics Examinations for RA


1. X-ray
♦ demonstrate juxta-articular osteopenia, soft tissue swelling and loss of joint space, bony erosions and
subluxation
2. Color & Power Doppler Ultrasound
♦ show vascular signals of active synovitis

The goal of treatment for RA:


1. Alleviate current symptoms
2. Prevent future destruction of joints resulting to handicap if left unchecked

Medical Intervention for RA


1. Disease-Modifying Antirheumatic Drugs 4. Corticosteroids
(DMARDs) ♦ to reduce joint swelling and inflammation
♦ needs frequent blood tests ♦ with long-term side effects; thus should be taken only
a. Methotrexate (Rheumatrex) for a short time and in low doses
b. Leflunomide (Arava) 5. Anti-inflammatory agents
c. Sulfasalazine a. Aspirin
2. Analgesics b. Non Steroidal Anti-Inflammatory Drugs
3. Antimalarial medications (NSAIDs)
♦ used along with Methotrexate. ♦ can cause stomach problems
♦ Pain & inflammation b.1. Ibuprofen
a. Hydroxychloroquine (Plaquenil) b.2. Naprosen.
b. Sulfasalazine (Azulfidine) c. Celecoxib (Celebrex)

Surgical Interventions for RA


1. Synovectomy
♦ removal of the joint lining
2. Arthroscopic or Open synovectomy
♦ removal of the inflammed synovia & prevents a quick destruction of affected joints
3. Total joint replacement

Nursing Interventions for RA


1. Three types of exercise:
a. Range-of-motion exercises 3. Splints or orthotic devices
♦ help maintain usual joint movement & relieve stiffness 4. Occupational therapy
♦ Helps uphold or increase flexibility 5. Physiotherapy
b. Strengthening exercises 6. Immunoadsorption therapy
♦ help keep or augment muscle strength 7. Jointprotection techniques
c. Aerobic or endurance exercises 8. 8-10 hours of sleep per night
♦ perks up cardio-vascular fitness 9. Deep heat or electrical
♦ help control weight, and improve overall function treatment
2. Special tools to improve hand movements (e.g., special tin-openers)

Prognosis for RA Complications of RA


♦ No known prevention 1. Damage to the lung tissue (Rheumatoid lung)
♦ Early treatment = decreased joint pain and 2. Increased risk of hardening of the arteries

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damage 3. Spinal injury when the neck bones become damaged
♦ RA at younger ages = get worse more quickly 4. Inflammation of the blood vessels (rheumatoid vasculitis)
♦ No proper treatment = permanent joint damage 5. Swelling and inflammation of the outer lining of the heart
♦ No known cure for RA, but many different types (pericarditis) and of the heart muscle (myocarditis),
of treatment can alleviate symptoms and/or which can lead to congestive heart failure
modify the disease process

III. GOUTY ARTHRITIS


♦ a chronic, progressive disease caused by an overload of uric acid in the body, resulting in painful arthritic attacks and
deposits of lumps of uric acid crystals in body tissues

Synonyms Predisposing Factors for Gout


♦ “King’s Disease” ♦ More common in men
♦ “Rich man’s Disease” ♦ Puberty with peak age of 75

Precipitating Factors for Gout


♦ High Purine diet (meat, seafoods) ♦ Menopause
♦ Obesity ♦ Moderate to heavy alcohol intake
♦ High blood pressure ♦ Chronic kidney problems
♦ Leukemia, Lymphomas, Lead poisoning
♦ Diuretics, Aspirin, Pyrazinamide, Ethambutol, Cyclosporine, Chemotherapeutic Drugs

Clinical Manifestations for Gout


1. Nighttime attack of sharp pain in the affected joint (big toe then ankles and knees are the next) followed by
warmth, swelling, reddish discoloration, and marked tenderness
2. Attacks one joint at a time
3. Tophi
♦ nodular masses of uric acid crystals commonly found as hard nodules around the fingers, at the tips of the
elbows, in the ears, and around the big toe (Podagra)

Laboratory Examination:
♦ Uric acid levels in blood test
♦ CBC, ESR, CRP

Diagnostic Examinations:
1. X-rays
♦ to show tophi-crystal deposits and bone damage
2. Arthrocentesis
♦ aspiration of fluid from the inflamed joint to analyze for uric acid crystals & Infection

Phases of Gout
First stage: Asymptomatic Hyperurecemia


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♦ The uric acid level in the blood is higher than normal, but there are no symptoms of gout
Second stage: Acute Gout
♦ Hyperuricemia has caused the deposit of uric acid crystals in joint spaces and leads to a sudden onset of
intense pain and swelling of joints
♦ Commonly occurs at night
Third stage: Intercritical or Interval gout
♦ Uric acid crystals begin to form in the joint fluid and the body often responds with a sudden
inflammatory reaction: a gout attack
♦ Acute episodes separated by periods without symptoms within days until the next attack, usually within
2 years
Fourth Stage: Chronic Tophaceous Gout
♦ Enough uric acid crystals have accumulated in the body to form gritty nodules called tophi
♦ Symptoms may become ongoing (chronic) and frequently affect more than one joint
♦ There may no longer be periods of time between attacks

Goal of Treatment:
1. To reduce pain and inflammation
2. Prevention of future gout attacks
3. Reduce disability quickly and safely
4. Prevention of long-term complications, such as joint destruction and kidney damage

Medical Intervention for Gout


1. Analgesics
a. Acetaminophen (Tylenol)
2. Anti-inflammatory agents
a. NSAIDS
a.1. Indomethacin (Indocin)
a.2. Naproxen (Naprosyn)
b. Corticosteroids (Prednisone)
3. Treat elevated levels of uric acid in the blood
a. Probenecid (Benemid)
♦ used to increase excretion of uric acid into the urine
b. Allopurinol
♦ prevents uric acid production
♦ blocks the metabolic conversion from purines in foods to uric acid

Surgical Intervention for Gout : Excision of tophi

Nursing Intervention for Gout


1. Weight reduction
♦ Reduce dietary fat & calorie intake with a regular aerobic exercise program
2. Dietary changes
♦ Shellfish and organ meats such as liver, brains, kidneys, sweetbreads (high purine)
♦ Cherries and an herb called devil's claw are folk medicine remedies that have been used as anti-
inflammatories

3. Folic acid
♦ may be helpful in inhibiting the enzyme needed to produce uric acid
4. Maintain adequate fluid intake
5. Reduce alcohol consumption
a. Alcohol impedes or slow down the excretion of uric acid from the kidneys
b. Causes dehydration which contribute to precipitation of uric acid crystals in the joints

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♦ Beer has high purine
6. Avoid aspirin-containing medications
♦ Aspirin prevents kidney excretion of uric acid
7. Rest the affected joint until the attack ceases & for 24 hours after the attack
8. Elevate painful joints
9. Follow a moderate exercise program
OSTEOARTHRITIS RHEUMATOID ARTHRITIS GOUTY ARTHRITIS
Other OA RA “King’s Disease
Name DJD “Rich man’s Disease
Degenerative Joint Disease
Osteoarthrosis
Hypertrophic Arthritis
Definition — Breakdown / Tearing / Thinning of — Rheumatoid arthritis is an autoimmune — Gout is a chronic,
cartilage resulting in friction on the ends of disease in which the body's immune system progressive
the bones as they move attacks itself disease that is caused by
— Osteoarthritis is limited to the joints an overload of uric acid
in the body, resulting in
painful arthritic attacks
and deposits of lumps of
uric acid crystals in body
tissues
Incidence Men Women Men
Age of 40 years old 25 to 50 years old 40 and 50 years old
Onset Gradual Without warning Gradual
Risk — Over age 40 — Age - 40 and 50 — More common in men
Factors — Diabetes — Gender - Women more often — Puberty with peak age
— Obesity than men 75
— Trauma — Infection — After menopause
— Repetitive movements or — Genes — Obesity
overuse (Wear & Tear) — Hormone changes — Moderate to heavy
— Infected joints — Smokers alcohol
— Unequal leg length — Rheumatoid factor positive intake
— Collagen disturbances — High blood pressure
— Diuretics, Aspirin, PZA,
Ethambutol,
Cyclosporine,
Chemotherapeutic drugs
— Leukemia,
Lymphomas,
Lead poisoning
— High Purine diet (meat,
seafoods)
— Chronic kidney
problems
Body Part — Joints in the spine, hips, — Joints on both sides of the — Big toe
affected knees and hands body equally. — Ankles and knees are
— Wrists, fingers, knees, feet, the
and ankles next
Clinical — Joint Stiffness — Hands & other joints like hips — Tophi found around the
Manifesta — Bone spurs (hard lumps) — Pain & stiffness worse in the fingers, at the tips of the
tions — Swelling morning elbows, in the ears, and
— Pain worse with overuse — Sjogren Syndrome around the big toe
— Pain may occur at night — Swan neck deformity (Podagra)
— Pain can occur at rest — Boutonniere — Nighttime attack of
— Heberden’s Nodes — Pannus sharp pain in affected
— Bouchards Nodes — Attacks multiple joints joint followed by warmth,
— Unilateral but becomes simultaneously & symmetrically swelling, reddish
symmetrical later — Joints feel warm and spongy discoloration, and
— Feels cool and hard to touch — Joints have a crinkling marked
— Joints have a popping, cellophane sound tenderness


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OSTEOARTHRITIS RHEUMATOID ARTHRITIS GOUTY ARTHRITIS
clicking or banging sound — Attacks one joint at a
time
Lab / — X-rays — X-ray — Arthrocentesis
Diagnosti — MRI — Color and Power Doppler USG — X-rays
cs — CT scan — Reumatoid Factor — Uric acid levels in blood
— Joint fluid analysis — Anti-citrullinated protein
— CBC antibodies (ACPA) / Anti-CCP
— C Reactive Protein — Serological point-of-care test
— ESR (POCT)
— Arthroscopy — C-reactive protein
— Erythrocyte Sedimentation
Rate (ESR)
— Antinuclear antibody/ANA)
— Ferritin level
— Complete Blood Count
— Liver enzyme test
— Renal function test
Phases I. Stationary phase I. Small joints I. High blood uric levels
II. Obliteration phase II. Large joints II. Intercritical or Interval
III. Erosive phase Gout
IV. Bone repair & remodelling III. Chronic Tophaceous
Gout
Surgical — Arthroscopy — Synovectomy — Excision of tophi
Interventi — Arthroplasty — Total joint replacement
ons — Osteotomy — Arthroscopic or open
— Chondroplasty Synovectomy
— Arthrodesis
— Joint replacement
Medical 1. Acetaminophen 1. Disease-Modifying 1. Analgesics
Interventi 2. NSAIDs Antirheumatic Drugs (DMARDs) 2. Anti-inflammatory
ons 3. Celecoxib a. Methotrexate a. NSAIDS
4. Antidepressant b. Leflunomide (Arava) a.1. Indomethacin
5. Orthoses c. Sulfasalazine (Indocin)
a. Splints or braces 2. Anti-inflammatory agents a.2. Naproxen
b. Walkers, crutches or a. Aspirin (Naprosyn)
canes, and orthopedic b. NSAIDs b. Colchicine
footwear b.1. Ibuprofen b.1. Allopurinol
b.2. Naprosen. b.2. Febuxostat
c. Celecoxib (Celebrex) - shrinking tophi
3. Analgesics deposit
4. Antimalarial medications of uric acid in
a. Hydroxychloroquine tissues
(Plaquenil) c. Corticosteroids
b. Sulfasalazine (Prednisone,)
5. Corticosteroids 3. Treat levels of uric
acid in
the blood
a. Probenecid
- to increase
excretion
of uric acid
b. Allopurinol
- prevents uric acid
production
Nursing — Weight loss — Deep heat or electrical treatment — Weight reduction
Interventi — Regular exercise — Joint protection techniques — Regular aerobic
ons — Avoid high-impact sports — Cold treatments exercise
— Diet (Vit. C and E) — Splints or orthotic devices program
Vitamin D (400 IU) — 8 to 10 hours of sleep / night — Dietary changes
Calcium (1000 mg-1200 mg.) — Occupational therapy — Folic acid to inhibit the


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OSTEOARTHRITIS RHEUMATOID ARTHRITIS GOUTY ARTHRITIS
— Hot soaks and warm wax — Physiotherapy enzyme needed to
(paraffin) — Immunoadsorption therapy produce uric acid.
— Orthoses — Joint injection — Maintain adequate
— Physical therapy — Special tools to improve hand fluid
— Occupational therapy movements intake
— Three types of exercise: — Reduce alcohol intake
a. Range-of-motion — Avoid aspirin-
b. Strengthening exercises containing
c. Aerobic/endurance exercise medications
The goal of treatment is 2-fold: — Rest the affected joint
1. Alleviate current symptom until the attack eases &
2. Prevent future destruction for 24 hours after the
of joints resulting to attack.
handicap if unchecked — Elevate painful joints
— Follow a moderate
exercise program
Prognosis — Osteoarthritis cannot be cured, but early — There is no known prevention. However,
diagnosis early treatment have decreased joint pain &
and treatment can help to damage.
reduce symptoms and — People who develop RA at
minimize complications younger ages seem to get worse more quickly.
— Without proper treatment,
permanent joint damage
may occur.
— There is no known cure for
RA, but many different types of treatment can
alleviate
symptoms and/or modify the
disease process

Complicat — Joint Damage — Damage to the lung tissue


ions — Deformity (Rheumatoid lung)
— Disability — Increased risk of hardening of
the arteries
— Spinal injury when the neck
bones become damaged
— Inflammation of blood vessels
(rheumatoid vasculitis)
— Swelling and inflammation of
the outer lining of the heart
(Pericarditis) and of the heart
muscle (Myocarditis), which can
lead to Congestive Heart failure

IV. BUERGER’S DISEASE


♦ It is an obliterative disease of arteries and veins characterized by acute and chronic inflammation in the blood vessels
of the lower and upper extremities which begins in the small arteries and progresses to the larger vessels that result
in thrombus formation and occlusion of the vessels
♦ It is an autoimmune reaction (body’s immune system attacks body’s own tissue) triggered by tobacco use
♦ Buerger's disease was first reported by Felix Von Winiwater in 1879 in Germany
♦ It was described in detail by Dr. Leo Buerger in 1908 in New York, who called it Presenile Spontaneous Gangrene after
studying amputations in 11 patients


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SYNONYMS
♦ Thromboangiitis Obliterans (TAO) ♦ Vaso occlusive Disease
♦ Presenile Spontaneous Gangrene ♦ Critical Limb Ischemia
♦ Endophlebitis ♦ Corkscrew Collaterals
♦ Distal Ischemic Rest Pain ♦ Ischemic Ulcerations

PREDISPOSING FACTORS
1. RACE:
♦ Buerger disease is relatively less common in people of northern European descent.
Natives of India, Korea, and Japan, and Israel have the highest incidence of the disease
2. SEX:
♦ More common in males (male-to-female ratio, 3:1)
3. AGE:
♦ 20-45 years

PRECIPITATING FACTORS
1. Current (or recent) history of tobacco use 3. Diabetes
2. Presence of distal extremity ischemia 4. Hypertension
t indicated by claudication, pain at rest, ischemic ulcers or gangrene 5. High cholesterol levels
t documented by noninvasive vascular testing such as ultrasound

Triad of symptoms and signs:


1. Digital arteries occlusion
♦ Decrease in the blood supply (arterial ischemia/Diminished distal pulses)
2. Raynaud’s phenomenon / Claudication
♦ Distal extremities (fingers, toes, hands, feet) turn cold, white, blue then intense rubor upon exposure to cold.
3. PAIN
♦ Pain induced by insufficient blood flow during exercise or physical exertion and cold temperatures which
typically begins in the legs or gastrocnemius muscle often located in the arch of the foot
♦ Pain is relieved by rest or if client returns to room temperature

Other Signs and Symptoms


1. Superficial (near the skin surface) phlebitis 6. Atrophy of extremities
2. Edema 7. Non-healing wound
3. Erythema, tenderness and warmth 8. Numbness
4. Gangrene 9. Homan’s sign
5. Thick malformed nails
Laboratory Tests
1. Complete Blood Count with differential Count 5. C – Reactive Protein
2. Erythrocyte Sedimentation Rate (ESR) 6. Rheumatoid Factor
3. Liver Function Tests 7. Renal Function Tests
4. Fasting Blood Glucose 8. Urinalysis
9. Antinuclear Antibody
♦ measures the pattern and amount of autoantibody which can attack the body's tissues
10. Anticentromere Antibody
♦ To detect the presence of anticentromere antibodies
♦ To help diagnose limited cutaneous scleroderma
11. Antiphospholipid Antibodies
♦ Tests for presence of proteins in the blood which can increase risk for blood clots or pregnancy losses


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Diagnostic Tests
1. History
♦ Age younger than 45 years
♦ Current (or recent) history of tobacco use
♦ Presence of distal extremity ischemia (indicated by claudication, pain at rest, ischemic ulcers or gangrene)
(documented by noninvasive vascular testing such as ultrasound)

2. Allen’s Test 3. Homan’s sign


♦ used to test blood supply to the hand, specifically, ♦ a sign of deep vein thrombosis (DVT)
the patency of the radial and ulnar arteries ♦ Positive sign is present when there is pain in
the calf on dorsiflexion of patient's foot at the
ankle while the knee is fully extended

Imaging Tests
1. Arteriography
2. Digital Subtraction Angiography
♦ computer-assisted x-ray technique that subtracts images of bone and soft tissue to permit viewing of the
cardiovascular system
3. Plethysmography
♦ used to measure changes in volume in different parts of the body to check for blood clots in the arms
and legs
4. Duplex Scanning
♦ a non invasive procedure using ultrasound to assess the blood flow of the body's arteries and veins
♦ obtains an image of the carotid artery being studied
5. Arteriography of extremity
♦ a special dye is injected into an artery, after which patient undergo X-rays or other imaging tests
6. Doppler Ultrasound of extremity
7. Biopsy of the blood vessel

Management
There is no cure …
♦ Goal of treatment is to control symptoms
♦ Immediate and absolute cessation of tobacco use
♦ Early and aggressive treatment injuries to protect against infections


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Medical Management Surgical Management


1. Thrombolytics - to lyse already formed blood clots 1. Arteriography - examination of the arteries using
where ischemia may be fatal x-rays following injection of a radiopaque substance
2. Intravenous ILOPROST 2. Artificial AV fistula
♦ to treat scleroderma, Raynaud’s phenomenon 3. Lumbar sympathectomy - cutting the nerves to the
♦ to slow progressive tissue loss and reduce the area to control pain
need for amputation during the period when 4. Spinal Cord Stimulator Implantation - a device used
they first discontinue cigarette smoking to exert pulsed electrical signals to the spinal cord
3. Vasodilators to control chronic pain
4. Vitamins 5. Autologous vein Bypass - to improve distal arterial
5. Calcium Channel blockers flow in patients
6. Phentofylline - decreases blood viscosity that 6. Omental Transfer
prevents further thrombus formation 7. Angioplasty - a procedure to open narrowed/blocked
7. NSAIDS, preferably Aspirin - thinning of the blood blood vessels that supply blood to the legs
with aspirin, etc. to prevent clots have not proven 8. Atherectomy
effective 9. Sympathectomy - cutting the nerves to the area to
8. Antibiotics control pain
9. Analgesics 10. Stent Placement - wire mesh stainless steel tube to
10. Anti-inflammatory Drugs - steroids have not been hold an artery open to keep it from closing again
shown to be beneficial 11. Amputation
Indications for amputation:
a. Severe Rest Pain
b. Sepsis Secondary to Gangrene
c. Worsening Gangrene
Types of Amputation:
a. Above Elbow c. Below Knee
b. Above Knee d. Above Knee

Nursing Management
1. Cessation of tobacco, cigarette, or any nicotine replacement 6. Adequate hydration
2. Gently massage and warm patient to increase circulation 7. Hygiene
3. Avoid conditions that reduce circulation to the extremities 8. Low cholesterol Low salt diet
a. cold temperatures 9. Protect against cold weather
b. use of vasoconstrictors 10. Keep hands and feet warm
c. use of tight or restrictive clothing 11. Avoid walking barefoot
4. Avoid sitting or standing in one position for long periods of time 12. Use well-fitting protective footwear
5. Regular exercise to lose weight if obese 13. Protect against infections

Complications
1. Ulcerations 4. Need for Amputation
2. Gangrene 5. Rare occlusion of coronary, renal, splenic, or mesenteric arteries
3. Infection

Prognosis
1. Symptoms of thromboangiitis obliterans may disappear if the person stops tobacco use
2. For some, amputation is unavoidable


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V. RAYNAUD’S DISEASE
♦ A painful condition caused by spasms of arteries after exposure to cold resulting from poor circulation in the
extremities

Synonyms
♦ Vasospasm ♦ Raynaud's phenomenon
♦ Reversible ischemia of peripheral arterioles ♦ Stress-related ischemia
♦ Systemic sclerosis scleroderma ♦ Ischemic Ulcerations

Predisposing Factors
♦ Women
♦ 15 to 40 years

Precipitating Factors
1. Diseases of the arteries
— Atherosclerosis - the gradual buildup of plaques in blood vessels that feed the heart (coronary arteries)
— Buerger's disease - blood vessels of the hands and feet become inflamed
— Primary pulmonary hypertension - a type of high blood pressure that affects only the arteries of the lungs
2. Carpal tunnel syndrome
— The carpal tunnel is a narrow passageway in the wrist that protects a major nerve to the hand
3. Injuries
— Prior injuries to the hands or feet, such as wrist fracture, surgery or frostbite
4. Repetitive Trauma
— that damages nerves serving blood vessels in the hands and feet. Some people who type or play the piano
for long periods of time, workers who operate vibrating tools can develop a type of Raynaud's phenomenon
called vibration-induced white finger
5. Chemicals
— Smoking - constricts blood vessels
— Chemical exposure - workers in the plastics industry exposed to vinyl chloride develop an illness similar to
scleroderma
6. Vasoconstricting Medications
a. Beta blockers d. Some Chemotherapy agents
b. Ergotamine (migraine) e. Some cold medications
c. Estrogen containing medications
7. Other Causes
a. Underactive thyroid gland (hypothyroidism)
b. Certain cancers
8. Colder Climate

Signs & Symptoms


♦ Pale (lack of blood flow)
♦ Bluish (lack of oxygen)
♦ Numb, cold, or painful


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♦ Reddened and throb or tingle as blood returns to the affected area
♦ Can affect the fingers, toes, rarely the nose, ears, nipples, or lips
♦ Usually last about 15 minutes or less than a minute or as long as several hours; daily or weekly
♦ Affect one or two fingers or toes. Different areas may be affected at different times

Figure A shows the normal digital arteries with normal blood


flow to the fingers. The inset images show cross-sections of a
normal artery. Fig. B shows white discoloration of the fingertips
caused by blocked blood flow. Figure C shows narrowed
digital arteries, causing blocked blood flow and purple
discoloration of the fingertips. The inset images show cross-
sections of a narrowed artery blocking the flow of blood.

Laboratory Examinations
1. Antinuclear antibodies (ANA) test
— A positive test = stimulated immune system
— Common in people with connective tissue diseases or other autoimmune disorders
2. Erythrocyte sedimentation rate (ESR)
— determines the rate at which red blood cells settle to the bottom of a tube in the space of an hour. A faster
than normal rate signals an underlying inflammatory or autoimmune disease commonly associated with
Raynaud’s

Diagnostic Tests
1. Cold Simulation Test
— Temperature sensors are taped to the fingers of the hand. The hand is then briefly exposed to the cold by
dunking it in ice water. If the patient likely has Raynaud's, it will take more than the normal time for the finger
temperature to return to what it was at the start of the test
2. Nailfold Capillaroscopy
— the doctor puts a drop of oil on the skin at the base of the fingernail and then looks at it under a microscope.
If doctor sees abnormal looking blood vessels, this suggests an inflammatory disorder such as scleroderma
3. Modified Allen’s Test
a. Have patient clench fist
b. Occlude both the ulnar and radial arteries of patient with your fingers to obstruct blood flow to the hand
c. While applying occlusive pressure, have patient relax his hand. There should be blanching of the palm and
fingers
d. Release occlusive pressure
Result:
Positive - Flushing of the hand w/in 5 to 15 seconds means good blood flow to ulnar artery
Negative - No flushing of the hand w/in 5 to 15 seconds means ulnar circulation is inadequate or
nonexistence

Treatment : Self-care and preventive treatment usually are effective in alleviating mild symptoms of Raynaud's

The goals of treatment:


1. to reduce the number and severity of attacks

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2. to prevent tissue damage
3. To widen (dilate) blood vessels & promote circulation

Medical Management
Goal: To widen (dilate) blood vessels & promote circulation
1. Calcium channel blockers
♦ Relax and open up small blood vessels of hands and feet
♦ Ex: Nifedipine (Adalat, Procardia), Amlodipine (Norvasc), Diltiazem (Cardizem, Dilacor), Felodipine (Plendil),
Nisoldipine (Sular)
2. Alpha blockers
♦ Counteract actions of norepinephrine (hormone w/c constricts blood vessels)
♦ Ex: Prazosin (Minipress) and Doxazosin (Cardura)
3. Vasodilators
♦ Relaxes blood vessels
♦ Ex: Nitroglycerin cream
4. Angiotensin-converting enzyme inhibitors
♦ Used for vasodilation and possible antifibrotic and anti-inflammatory properties
♦ Benazepril (Lotensin)
5. Angiotensin II receptor antagonists
♦ Used for vasodilation and for their possible antifibrotic and anti-inflammatory effects
♦ Losartan (Cozaar)
6. Endothelin inhibitors
♦ Inhibits vessel constriction and elevation of blood pressure
♦ Bosentan (Tracleer)

Surgical Management
1. Nerve surgery (Sympathectomy)
— Through small incisions in the affected hands or feet, a doctor strips away these tiny sympathetic nerves
around the blood vessels to interrupt their exaggerated response. Sympathetic nerves in your hands and
feet control the opening and narrowing of blood vessels in your skin
2. Chemical injection
— Injection of chemicals to block sympathetic nerves in affected hands or feet
3. Amputation
— Done when blood supply has been completely blocked and tissue has gangrene

Nursing Interventions
1. Dress warmly outdoors
— Wear a coat, hat, scarf, socks, boots, mittens, gloves
— Do not drive in cold weather
2. Take precautions indoors
— Wear socks
— When taking food out of the freezer or refrigerator, wear gloves
— Turn down the air conditioner to help prevent attacks
3. Control stress
4. Consider moving to a location with milder climate
5. Don't smoke
— Nicotine in cigarettes causes skin temperature to drop by constricting blood vessels
6. Exercise regularly
— Exercise can increase circulation
7. Take care of your hands and feet
a. Guard your hands and feet from injury
b. Don't walk barefoot


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c. Take care of your nails to avoid injuring sensitive toes and fingertips
d. Avoid wearing tight wristbands, rings or footwear that compresses blood vessels in hands or feet
e. Avoid tools that vibrate the hand
8. Avoid workplace triggers

Complications
1. Deformities of fingers or toes
— If Raynaud's is severe, blood circulation to the fingers or toes could permanently diminish, causing
deformities of fingers or toes
2. Ulcers and gangrene
— If an artery to an affected area becomes blocked completely, sores (skin ulcers) or dead tissue (gangrene)
may develop

Prevention
1. Dress warmly outdoors
— Wear a hat, scarf, socks and boots, and mittens or gloves under mittens
2. Take precautions indoors
— Wear socks, use insulated drinking glasses.
— When taking food out of the freezer or refrigerator, wear gloves,
— Turn down the air conditioning to prevent attacks
3. Consider moving to a location with a milder climate

VI. CARPAL TUNNEL SYNDROME


— A disorder caused by compression at the wrist, of the median nerve supplying the hand, causing numbness and
tingling
— At the base of the palm is a tight canal or “tunnel” through which tendons and nerves must pass
— Median Nerve
— narrow passage between the forearm and hand “The Carpal Tunnel”
— Is an entrapment neuropathy that occurs when the median nerve at the wrist is compressed by a thickened flexor
tendon sheath, skeletal encroachment, edema or a soft tissue mass
— CTS may develop spontaneously without a known cause, or may result from disease or Injury

Precipitating Factors:
1. Repetitive activities
those who do repetitive movement more than 6 hours per day are at risk
2. May be associated with other diseases
a. Arthritis c. Pregnancy
b. Hypothyroidism d. Diabetes or other metabolic disorders
3. Edema from trauma which can compress median nerve
4. Obesity
5. Intake of caffeine, tobacco smoking

Predisposing Factors:
1. Adults age 40 to 60


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2. Women more than men
3. Acromegaly

Clinical Manifestation
1. Drop objects more than usual
2. Have trouble grasping or pinching objects
3. Have trouble using your hands for certain tasks, such as buttoning a shirt, handwriting, or opening a jar lid
4. The muscles at the base of your thumb are smaller and weaker (atrophy) than they used to be (Thenal
Eminence )
5. Cold intolerance
6. Pain, tingling, and numbness in the thumb, index, middle, or ring fingers, or tingling in the entire hand
7. Pain that shoots from the hand up the arm as far as the shoulder
8. A swollen sensation in your fingers, even though they may not be visibly swollen
9. Symptoms are worse at night after strenuous activity
10. Hands feel weak in the morning
— Early diagnosis and treatment are important to avoid permanent damage to the median nerve
— A physical examination of the hands, arms, shoulders, and neck can help determine if the patient's
complaints are related to daily activities or to an underlying disorder

Diagnostic Test

1. Tinel’s Sign 2. Phalen's Test


— The doctor will gently tap the front of your wrist to — The doctor will ask you to bend your wrist down
see if you feel tingling or pain in your hand or as far as it will go and hold this position up to 3
forearm minutes to see if you feel tingling or pain

3. Nerve conduction test


— performed to evaluate nerve function
— Measures the nerve's ability to send electrical
impulses to the hand muscles, to see if the
electrical impulses slow down the carpal tunnel

Medical Management
1. Rest Splint worn during the day to prevent hyperextension & prolonged flexion of the wrist
2. Use of Ergonomic changes at work to reduce wrist strain (avoidance of repetitive flexion of the wrist
3. NSAIDs
4. Carpal Canal Cortisone injections to relieve the symptoms
5. Yoga postures, relaxation & acupuncture to provide non-traditional alternatives to relieve CTS

Surgical Management
(surgery is recommended if symptoms last over 6 months)
1. Traditional or endoscopic laser surgical release of the transverse carpal ligament
— To perform a carpal tunnel release, the surgeon makes an incision in the palm of the hand, above the area
of the carpal tunnel (B). The carpal ligament going across the hand is severed (C), releasing pressure on
the median nerve (D).
— patient wears a hand splint after surgery & limits hand use during healing


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— Full recovery of motor & sensory function after nerve release surgery may take several weeks or months

Nursing Interventions
1. Assist patient with personal care & ADLs
2. Exercise

Prognosis
— Generally Recurrence of Carpal Tunnel Syndrome is rare.
— The majority of patients recover completely

VII. COMPARTMENT SYNDROME


♦ Condition that results from swelling of the muscles in the compartment of the limb which raises the pressure within the
compartment so that the blood supply to the muscle is cut off, causing ischemia and further swelling

Causes: Symptoms:
1. Traumatic Injury 1. Pain intensely out of proportion to the injury especially
2. Rigid Cast or dressing if no bone is broken
3. A severely bruised muscles 2. Tingling or burning sensation (paresthesia) in the muscle
4. A complication after surgery 3. Muscle may feel tight or full
5. Blockage of circulation such as from pressure 4. If area becomes numb or paralysis sets in, cell death
over a blood vessel for too long while asleep has begun & efforts to lower the pressure in the
6. A crush injury compartment may not be successful in restoring function

Chronic Compartment Syndrome


♦ characterized by pain & swelling caused by exercise
♦ Symptoms dissipate quickly when activity stops

Diagnosis
♦ Physician measures the intramuscular pressure before exercise, 1 min. after exercise & 5 mins. after exercise. If
pressures remain high then it is CCS

Goal of Treatment
1. To relieve the pressure
2. Reduce inflammation

Medical Management Surgical Treatment Nursing management


1. Avoiding activities that cause pain ♦ Incision is done to cut open the skin 1. Avoid pressure on the
& swelling and fascia covering the affected legs and hands
2. Applying ice & elevating the limb compartment to reduce the 2. Elevate legs
slightly pressure in the compartment. 3. Exercise
3. Taking aspirin or ibuprofen to ♦ Skin incision is surgically repaired
reduce inflammation when swelling recedes.
4. Increase cushioning in shoes ♦ Sometimes a skin graft maybe
5. Do not wrap the leg because this needed
will increase the pressure and
aggravate the conditions


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MALIGNANCY

I. OSTEOGENIC SARCOMA
— a primary malignant tumour of the skeleton characterized by the direct formation of immature bone or osteoid tissue by
the tumour cells

Synonym:
— Osteosarcoma
— Osteogenic sarcoma
Incidence of Osteogenic sarcoma
— Most common primary malignant bone tumour
— Vast majority are metastatic
— More rarely Osteogenic sarcoma may arise in the soft tissue
— More than 75% occur in patients younger than 20 years (with
peaks at 10-14 for girls and 15-18 for boys) but a second
smaller peak also occurs in the elderly
— Twice as common in males
— Tends to occur in the:
♦ Shin (near the knee) = 19% ♦ Skull and jaw = 8%
♦ Thigh (near the knee) = 42% ♦ Pelvis = 8%
♦ Upper arm (near the shoulder) = 10%

Predisposing Factors:
1. Rapid bone growth 3. Twice as common in males between the ages of
— Osteosarcoma usually develops from osteoblasts 15 – 18 years
(the cells that make growing bone), it most 4. Slightly higher incidence in blacks than in whites
commonly affects teens who are experiencing a 5. Genetic predisposition
growth spurt — Bone dysplasias, including Paget disease,
2. Common in females 10-14 years fibrous dysplasia, & retinoblastoma

Precipitating Factors:
1. Radiation
— especially post-radiotherapy for a solid organ tumour in childhood
2. Environmental factors
a. Exposure to radiation
b. Water fluoridation

Clinical Manifestations
1. Patient limps 7. Dull aching unilateral bone pain for several months
2. Muscle atrophy 8. Night pain may awaken patient from sleep
3. Decreased joint range of motion 9. May be misdiagnosed associated with minor injury
4. Pathologic fracture 10. Uncommon features
5. Swelling or Mass (may be tender and warm, — Fever — Weight loss
Increased skin vascularity over the mass) — Night sweats — Lymphadenopathy
6. Pain, particularly pain with activity

Diagnostic Examinations
1. X-rays 3. Magnetic resonance imaging (MRI)
— uses invisible electromagnetic energy beams to — uses a combination of large magnets,
produce images of internal tissues, bones, and radiofrequencies, and a computer to produce


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organs onto film detailed images of organs and structures within
2. Bone scans the body.
— a nuclear imaging method to evaluate any — to rule out any associated abnormalities of the
degenerative and/or arthritic changes in the joints spinal cord and nerves
— to detect bone diseases and tumors 4. Computed tomography scan
— to determine the cause of bone pain or — a diagnostic imaging procedure that uses a
inflammation combination of x-rays and computer technology
— to rule out any infection or fractures to produce cross-sectional images (often called
slices), both horizontally and vertically, of the
body
— shows detailed images of any part of the body,
including the bones, muscles, fat, and organs

Laboratory Examinations
1. Complete Blood Count (CBC)
— a measurement of size, number, and maturity of different blood cells in a specific volume of blood
2. Blood tests (including blood chemistries)
3. Biopsy of the tumor

The Enneking Staging System or Musculoskeletal Tumour Society Staging System: (Used for planning treatment)
1. Tumour grade (histologic grade of the tumor)
I = low grade
II = high grade
2. Tumour extension (anatomic location of the tumor)
A = intraosseous involvement only
B = intra- and extraossseous extension
3. Presence of distant metastases (III)
Low-grade tumor, intracompartmental - I-A High-grade tumor, intracompartmental - II-A
Low-grade tumor, extracompartmental - I-B High-grade tumor, extracompartmental - II-B

— Any tumor with evidence of metastasis - III

Goal of Treatment
1. To slow, stop, or eliminate the cancer
2. Relieve symptoms and side

Medical Management:
1. Chemotherapy
— the use of medical drugs to kill cancer cells and shrink the cancer to minimize chances of the cancer coming
back
— may be given before (neoadjuvant) or after (adjuvant) surgery
Common chemotherapy medicines include:
a. Cisplatin d. Doxorubicin (Adriamycin)
b. Cyclophosphamide (Cytoxan) e. High-dose methotrexate w/ Leucovorin
c. Carboplatin (Paraplatin) f. Ifosfamide (Ifex)
Short-term effects include:
a. Anemia e. Hearing loss h. Increased risk of infection
b. Abnormal bleeding f. Liver damage i. Heart and skin problems
c. Kidney damage g. Bladder inflammation j. Menstrual irregularities
d. Risk for other cancers

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2. Radiation
3. Rehabilitation (Physical and Occupational therapy)
4. Psychosocial adapting
5. Antibiotics (to prevent and treat infections)
6. Continued follow-up care
— to determine response to treatment, detect recurrent disease, and manage the side effects of treatment
7. Prosthesis fitting and training

Surgical Management
1. Wide Resection
— the entire malignant tumor has been surgically excised, and no microscopic evidence of tumor cells at the
resection margins remains
2. Limb-Salvage/Sparing surgery
— remove the tumor while saving the affected limb to preserve function
Complications:
a. Infection c. Non-union
b. Prosthetic loosening d. Local tumor recurrence
3. Rotationplasty
— foot being turned around and reattached to allow the ankle joint to be used as a knee
4. Bone / Skin Grafts
5. Reconstructions
6. Amputation
— usually takes at least 3 to 6 months until a young person learns to use a prosthetic leg or arm
a. Autologous bone graft
— bone from same individual
— chin, iliac crest, fibula, ribs, mandible, skull
b. Allograft (Prosthetic device)
— from another human (Cadaver)
7. Physical therapy and rehabilitation for 6 to 12 months following surgery usually enable the child to walk initially
with a walker or crutches and then without any assistive devices
Early complications after surgery:
a. Infection
b. Slow healing of the surgical wound
c. Metal prosthetic device or the bank bone may need to be replaced in the long term

Late problems might include:


a. Fracture of the bank bone
b. Failure of the bank bone to heal to the child's bone (might require more surgery)

Radiation therapy
1. Adjuvant chemotherapy
— Postoperative chemotherapy
— Mode of treatment is for about five weeks, different combination drugs are used for the treatment
2. Neo-adjuvant
— Preoperative Chemotherapy
— preferred especially when a limb sparing procedure is being contemplated


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Nursing Management

1. Supportive environment 8. Diversional care


2. Comfort of client 9. Spiritual care
(Rest, proper ventilation, massage) 10. Continued follow-up care
3. Fluids for hydration 11. Teach patient how to use assistive devices safely
4. Small frequent feeding and ice chips for and how to strengthen unaffected extremities
nausea and vomiting 12. Monitor full cycles of chemotherapy
5. Balanced meal for anemia 13. Monitor IV antibiotics, fever and neutropenia
6. Accurate Intake and output monitoring while 14. Assist in passive ROM and consider some
on chemotherapy restrictions
7. Care of chemotherapeutic drugs

Complications
— Pathologic fractures
— Lung metastasis
— Limb removal

Prognosis
1. Recurrence of osteosarcoma in more than 90% of patients is located in the lung
2. A 5-year survival rate of 20% to 45% following complete resection of metastatic pulmonary lesions
3. 10% to 15% following complete resection of metastases in other sites
4. Survival rates of 60% to 80% are possible if it hasn't spread beyond the tumor, depending on the success of
chemotherapy
5. Combined neoadjuvant treatment gives a cure rate of 60%–70% for patients with nonmetastatic osteosarcoma
of the extremities and of about 30% for tumours of the axial skeleton
6. Osteosarcoma that has spread cannot always be treated as successfully
7. A child whose osteosarcoma is located in an arm or leg generally has a better prognosis than one whose
disease involves the ribs, shoulder blades, spine, or pelvic bones

DEVELOPMENTAL CONDITIONS OF THE SPINE

I. SCOLIOSIS
♦ A Lateral or sideways curve in the spine that is apparent when viewing the spine from behind

Synonyms
Spinal curvature
Kyphoscoliosis
Kyphosis

Prevalence
1. Scoliotic curves greater than 10° affect 2-3% of the US population
2. The prevalence of curves less than 20° is about equal in males and females
3. Curves greater than 20° affect about one in 2500 people
4. Curves convex to the right are more common than those to the left
5. Single or "C" curves are slightly more common than double or "S" curve patterns
6. Males are more likely to have infantile or juvenile scoliosis, but there is a high female predominance of
adolescent scoliosis
7. Female-to-male ratio ranges from 5:1 to 8:1
8. 80% of cases are idiopathic


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The Spine has Three types of Curves:
Kyphotic curves - refer to the outward curve of the thoracic spine (at the level of the ribs)
Lordotic curves - refer to the inward curve of the lumbar spine (just above the buttocks)
Scoliotic curve - refer to the lateral (sideways) deviation of the spine

Predisposing Factors:
1. Gender
■ Girls ages 3 and older are more likely to have scoliosis than boys
■ Boys are more likely to have the disorder than girls before age 3
2. Age
■ The younger a child is when scoliosis begins, the more severe the condition is likely to become
3. Angle of the curve
■ The greater the angle of curve, the increased likelihood that the condition will get worse
4. Genetic Inheritance
5. Location
■ Curves in the middle to lower spine are less likely to worsen than those of the upper spine
6. Spinal problems at birth
■ Children who are born with scoliosis (congenital scoliosis) may experience rapid worsening of the curve
7. Growth
a. Infantile Idiopathic Scoliosis common in male (birth - 3 yrs)
b. Congenital juvenile (3-10)
c. Adolescent is common in girls(10-18)
d. Adult – over 20 yrs.

Types of Scoliotic Curves


1. As to Location
a. Thoracic curve
■ curve at upper part of back; convex to the right
■ 90 % of the curves occur on the right side
b. Thoracolumbar Curve
■ curve is in the mid back or thoracolumbar back
■ 80 % of the curves occur on the right side
c. Lumbar Curve
■ lower lumbar section of the back
■ creates uneven hips and a lot of back pain
■ 70 % of the curves occur on the left side
d. Double major
■ curves that occur in both the thoracic & lumbar area
2. As to Appearance
a. Dextroscoliosis ■ scoliosis with the convexity on the right side
b. Levoscoliosis ■ scoliosis with the convexity on the left side
c. Rotoscoliosis ■ refers to scoliosis in which the rotation of the vertebrae is particularly pronounced


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Classifications of Scoliosis
1. Nonstructural or Functional scoliosis
■ spine is structurally normal yet appears curved
■ caused by an underlying condition such as difference in leg length, muscle spasms or inflammatory
conditions such as appendicitis
■ a temporary curve often relieved when the underlying condition is treated
2. Structural scoliosis
■ a fixed curve used to describe cases involving a twisting of the spine in three dimensions rather than a
sideways curvature
■ Some cases of structural scoliosis are the result of disease, such as:
a. Inherited connective tissue disorder (Marfan’s syndrome) e. Infection
b. Neuromuscular diseases (cerebral palsy, poliomyelitis) f. Tumors
c. Birth defects g. Metabolic diseases
d. Injury h. Rheumatic diseases
Types of Scoliosis
1. Congenital Scoliosis
■ result of malformation of part of the spine or fused ribs during 3rd - 6th wk. prenatal development when the
spine starts to develop
2. Neuromuscular Scoliosis
■ the spine usually takes on a long, C - shaped curve because the children have very weak trunks and aren't
able to support their bodies
■ caused by problems such as poor muscle control or muscular weakness or paralysis due to diseases such
as cerebral palsy, muscular dystrophy, spina bifida, and polio.
3. Adult or Degenerative Scoliosis
■ usually occurs when the disease went unnoticed or was not treated during childhood (Osteoporosis, disc
degeneration, a spinal compression fracture)
■ becomes apparent in later life
4. Genetic
■ if someone else in the family has or has had scoliosis, there is a greater risk for developing it
5. Idiopathic Scoliosis
■ “without known cause"
a. “Infantile” Idiopathic scoliosis (0-3 yo)
b. “Juvenile” idiopathic scoliosis (3-10 yo)
c. “Adolescent” idiopathic scoliosis (10-18 yo)
■ skeletal maturity (18 yo)
d. “Adult onset scoliosis” or “Degenerative scoliosis”
■ detected in adulthood when skeletal maturity is reached

Signs and Symptoms:


1. Head is not centered with the rest 9. Unequal distance between arms
of the body and body
2. The spine curves abnormally to 10. Uneven waist line
the side 11. Appearance of a raised,
3. Leaning of entire body to one side prominent hip
4. Difference in shoulder height; 12. One leg appears shorter than the
5. A rib "hump" and/or a prominent other
shoulder blade 13. Clothes that do not hang right
6. Uneven rib cage (Spine rotate or (uneven hemline)
twist and the ribs on one side of 14. Changes in look or texture of skin
the body to stick out farther than overlying the spine (dimples,
on the other side) hairy patches, color changes)
7. Rib protrusion on one side of the 15. Difficulty breathing

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spine 16. Back ache or low back pain
8. Asymmetric size or location of 17. Fatigue
breast in females 18. Slow nerve action (in some
cases)

Diagnostic Examinations
■ done to help determine the treatment plan by determining:
a. the severity of the scoliosis
b. the cause of scoliosis
1. Physical Examination
a. Observe posture, range of motion, note any movements that cause pain, feel the spine, note its curvature
and alignment, and feel for muscle spasm
b. Abdominal reflexes
c. Muscle tone for spasticity

d. Skin for café au lait spots indicative of e. The feet for cavovarus deformity
neurofibromatosis

2. Neurological Examination
■ test reflexes, muscle strength, other nerve changes, and pain spread
3. Pulmonary function test
■ a test designed to measure how well the lungs are working

4. Adam's Forward Bend Test


■ Bend forward at the waist and reach his or her
arms straight outward, positioned as though
diving into a swimming pool
■ This usually reveals abnormalities, like rib
hump or an incorrect shape of the back

5. Plumb Line test


■ a quick visual check to see if the spine is
straight
■ In scoliosis, the plumb line will fall to the left or
right of the spine instead of through the middle
of the buttocks

6. Scoliometer
■ used to measure the size of the hump
■ Angle is taken from the vertebra at the apex of
the curve


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7. Cobb’s Angle
■ a measure of the curvature of the spine in
degrees

Radiological Tests
a. Spine X-ray
■ confirm scoliosis by showing exactly which spine is affected & extent of the curve
■ In growing individuals, serial radiographs are obtained at 3-12 month intervals to follow curve progression
b. Wrist X-ray
■ to determine skeletal maturity, skeletal age, how much growth is left and if the scoliosis is likely to progress
c. Computed Tomography Scan (CT or CAT scan)
■ a diagnostic imaging procedure that uses a combination of x-rays and computer technology to produce
cross-sectional images (or slices), both horizontally and vertically, of the body
■ shows detailed images of any part of the body, including the bones, muscles, fat, and organs.
d. Magnetic Resonance Imaging (MRI)
■ uses a combination of large magnets, radiofrequencies, & a computer to produce detailed images of organs
& structures within the body

Goal of treatment
1. Stop the progression of the curve
2. Prevent deformity

Rule of Thumb

Cobb’s Angle Course of Action


Below 10 Not Scoliosis
10 – 20 Regular Checkups every three to six months
Body Brace
20 – 40
(done when the patient has bone growth remaining)
Scoliosis Surgery/Spinal Fusion
40 and up
(six-month recovery time)

Medical Management
1. Milwaukee brace
■ to prevent progression of spinal curvature
2. Thoracolumbosacral Orthosis
■ to correct curves whose apex is at or below the eight thoracic vertebra; it fits under the arm and around the
rib cage, lower back, and hips
3. Exercise
4. Chiropractic and physical therapy
■ utilize joint mobilization techniques and therapeutic exercise
■ to increase a patient's flexibility and strength
5. Traction / Brace
Halo Femoral Traction Yamamoto Brace
Cotrel Traction Milwaukee Brace
6. Electronic Muscle Stimulation (EMS)

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■ to reduce muscle spasm and strengthen atrophied muscles
7. Best exercise is swimming
8. Body casting in 6-12 months following spinal fusion

Surgical Management
1. Harrington rod
■ one of the oldest and most proven forms of spinal instrumentation
■ used to straighten and stabilize the spine when curvature is greater than 60 degrees
■ simple to install, low rate of complications, and proven to reduce curvature of the spine.
■ patient must remain in body cast for about six months, then wear a brace for another three to six months
while the bone fusion solidifies
2. Luque rod
■ are custom contoured metal rods that are fixed to each segment (vertebra) in the affected part of the spine
■ patient may not need to wear a cast or brace after the procedure
■ risk of injury to the nerves and spinal cord is higher because wires must be threaded through each vertebra
near the spinal column
3. Cotrel-dubousset instrumentation
■ uses hooks and rods in a cross-linked pattern to realign the spine and redistribute the biomechanical stress
■ because of the extensive cross-linking, the patient may have to wear a cast or brace after surgery
■ complexity of the operation and the number of hooks and cross-links may fail
4. Posterior Spinal Fusion
■ individual bones are made solid each to the one above and below (10 or more segments are included).
Screws are attached to both sides of the back of individual vertebrae then these are connected to two metal
rods which have been pre-bent to desired contour.
■ Bone (either harvested from elsewhere in the body, or donor bone) is grafted to the vertebrae so that when it
heals, they will form one solid bone mass and the vertebral column becomes rigid
5. Endoscopic Discectomy
■ endoscope is used to go into the chest in front where the actual vertebra are and take out the discs in front
thus loosening up the spine so there is better correction when fusion is done in the back
6. Hibbs fusion
■ a technique for posterior spinal fusion
■ the spinous processes are removed, the facet joints are excised and the laminae are scraped. Additional
bone graft material is applied
7. Dwyer instrumentation and anterior spinal fusion
■ involves a cable that is inserted to assist in maintaining the corrected curvature while the fusion heals
8. Costoplasty (or thoracoplasty)
■ to achieve a more pleasing cosmetic result to completely straighten and untwist a scoliotic spine
9. Vertical Expandable Prosthetic Titanium Ribs (VEPTR)
■ provide the benefit of expanding the thoracic cavity and straightening the spine in all three dimensions while
allowing the spine to grow.
■ only suitable for growing patients

Nursing Management
1. Promote comfort with proper fit of brace or cast
2. Positive body image
3. Preserve skin integrity around the brace or cast
4. Provide good skin care to prevent breakdown around any pressure areas
5. Prepare the child for casting or immobilization procedure
6. Provide opportunity for child to express fears

Complications
1. Lung and heart damage (curve greater than 70 degrees) 5. Spinal cord nerve damage

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2. Back problems 6. Failure of the bone to join together
3. Body image 7. Spine infection
4. Lowered self esteem 8. Low back arthritis and pain

Prognosis
The general rules of progression are:
1. Larger curves carry a higher risk of progression than smaller curves
2. Thoracic and double primary curves carry a higher risk of progression than single lumbar or thoraco lumbar
curves
3. Patients who have not yet reached skeletal maturity have a higher likelihood of progression

Prevention
■ Check ups every 3-6 months

Treatment of scoliosis is based on:


1. Age, overall health, and medical history
2. Extent of the condition
3. Tolerance for specific medications, procedures, or therapies
4. Expectations for the course of the condition
5. Patients opinion or preference

Complications
1. Emotional problems or lowered self-esteem
2. Spinal cord or nerve damage
3. Failure of the bone to fuse together
4. Spine infection after surgery
5. Low back arthritis & pain
6. Respiratory problems

II. HERNIATED NUCLEUS PULPOSUS


■ A condition in which part of or all of the soft, gelatinous central portion of an intervertebral disk (the nucleus pulposus)
is forced through a weakened part of disk (Annulus fibrosus), resulting in back pain and leg pain caused by nerve root
irritation.

Synonyms
■ Herniated intervertebral disk ■ Ruptured disk ■ Cervical radiculopathy
■ Prolapsed intervertebral disk ■ Slipped disk ■ Thoracic radiculopathy
■ Herniated Slipped disk ■ Bulging disk ■ Compressed disk
■ Lumbar radiculopathy ■ Prolapsed disk ■ HNP

Risk Factors
A. Modifiable:
1. Trauma

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a. Accidents
■ falling from a ladder, landing in a sitting position
b. Strain
■ strenuous physical activity
■ bending over
■ lifting from a bent over position
c. Repeated minor stresses
■ lifting, twisting
d. Direct injury
e. High-impact sports
2. Physically-taxing occupations that require continual lifting and/or frequent bending
3. Obesity
4. Sedentary lifestyle
5. Cigarette smoking
6. Vigorous exercise for more than 15 years or in person over 20 years of age
7. Over-exertion (increased coughing; prolonged sitting; long driving)
B. Non-modifiable:
1. Advanced age (middle aged and older men)
a. The aging process weakens the annulus fibers of the disc and repeated injuries that add up over time
and causes small amount of force
b. Our necks and backs receive continued stress and pressure from the weight of our bodies which can
cause intervertebral discs to break down (or degenerate) over time.
c. The amount of water in a disc decreases as a person gets older, allowing the disc to provide less
cushion and support to the vertebrae
d. Continued wear from everyday activities like walking and sitting can weaken the exterior of a disc
2. Male gender
3. History of back trauma
4. Congenital predisposition that affect the size of the lumbar spinal canal

Clinical Manifestation
A. Cervical Disc
■ Pain and stiffness
■ Spasm in neck muscle, top of shoulder, and in region of scapula
■ Pain in upper extremities and head
■ Paresthesia and numbness of upper extremities
■ Pain radiating to the shoulder, upper arm, forearm, and rarely the hand, fingers or chest
■ Pain made worse with coughing, straining, or laughing
B. LUMBAR DISC
1. Sciatica
■ Severe low back pain (sharp & shooting or deep aching pain) radiating to the buttocks, legs and feet
■ Pain often starts slowly & may get worse:
« After standing or sitting
« At night
« When sneezing, coughing, or laughing due to increased spinal pressure
« When bending backwards or walking more than a few yards

Consider the following examples:


« Cervical - Pain in the neck, shoulders, and arms
« Thoracic - Pain radiates into the chest
« Lumbar - Pain extends into the buttocks, thighs, legs
« L3 = pain radiating to the anterior thigh
« L4 = lower thigh and medial upper tibia


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« L5 = lateral calf and great toe
« S1 = back of the calf and lateral heel

2. Tingling or numbness in legs or feet 8. Muscle spasm


3. Muscle weakness or atrophy of legs or feet in later stages 9. Impaired range of motion
4. Spastic paravertebral muscles 10. Loss of normal curve of back
5. Loss of the reflexes in one or both legs 11. Loss of bowel and bladder control
6. Positive straight-leg raising test
7. Cauda Equina Syndrome
■ occurs from a central disc herniation
■ symptoms include bilateral leg pain, loss of perianal sensation (anus), paralysis of the bladder, and
weakness of the anal sphincter

Diagnosis
1. Spine X-ray
■ to rule out causes of back or neck pain
2. Spine CT
■ to show spinal canal compression
3. Spine MRI
■ magnetic field, radio waves and computers demonstrates abnormalities such as tumors or narrowing of
tissue pathways through the bone and soft tissue
4. Myelography
■ a radiographic examination to detect pathology, size and the location of a spinal cord injury, cysts, & tumors
5. Electromyography (EMG)
■ a technique for evaluating and recording the activation signal of muscles
6. Nerve conduction velocity test
■ an electrical test (using patch electrodes) commonly used to evaluate the function, the adequacy of nerve
impulse conduction

The four stages of HNP:


1. Disc Degeneration
■ chemical changes associated with aging causes discs to
weaken, or disk bulges without rupturing the annulus fibrosus
2. Prolapse
■ the nucleus pulposus migrates or slightly impinges to the
outermost fibers of the annulus fibrosus
■ Also called a bulge or protrusion

3. Extrusion
■ the gel-like nucleus pulposus breaks or perforates and material
of the nucleus moves into the epidural space through annulus
fibrosus but remains within the disc.
4. Sequestration or Sequestered Disc
■ the nucleus pulposus breaks through the annulus fibrosus. Thus,
fragments from the annulus fibrosus and nucleus pulposus are
outside the disk proper and lies in the spinal canal (HNP)


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Diagnostic Examinations
A. History Taking
B. Neurological Examination
■ to evaluate muscle reflexes, sensation, and muscle strength
1. Leg pain that occurs when you sit down on an exam table and lift your leg straight up
Radiculopathy
■ any disease that affects the spinal nerve roots like herniated disk

2. Positive straight-leg raising test 3. Foraminal compression test of Spurling


(Laseque’s Sign) ■ done to diagnose cervical radiculopathy
a. With the patient lying supine, the leg is a. Bend head forward and to the sides while health
raised with knee extended. care provider provides slight downward
b. Test is positive if pain occurs in leg below pressure to the top of the head
the knee or if radicular (spinal nerve root) b. Increased pain or numbness usually indicate
pain ensues cervical radiculopathy

Medical Management
1. Non-steroidal anti-inflammatory medications
2. Narcotic pain killers
3. Muscle relaxants
4. Steroids
5. Epidural Steroid Injection (ESI): for more severe pain due to a herniated disc
6. Anti-inflammatory medications
7. Analgesics and sedatives
8. Steroid injections into the back in the area of the herniated disk to help control pain for several months. Guided
by x-ray to identify the area for injection

Surgical Management
1. Hemilaminotomy
■ to remove the disk fragment that is impinging on the nerves
2. Laminectomy
■ excision of vertebral lamina to remove the posterior arch to expose the spinal cord
3. Diskectomy
■ removal of a protruding disk under general anesthesia through Laminotomy ("make an opening in the
lamina“)
4. Micro-diskectomy
■ removing fragments of nucleated disk through a very small opening
5. Spinal Fusion
■ bone grafts harvested from the iliac crest are placed between the intervertebral bodies after the disk material
is removed
6. Percutaneous disk excision
■ Suction is applied and the disk is sliced and aspirated to reduce the volume of the affected disk by partial
removal of the nucleus pulposus


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7. Arthroscopic microdiscectomy
■ A video discoscope is introduced to search and extract the nuclear fragments under direct visualization
8. Laser disk decompression
■ laser energy is percutaneously introduced thru a needle to vaporize a small volume of nucleus pulposus
9. Endoscopic Discectomy
■ TV camera is inserted into the spinal canal, the surgeon watches the TV screen & directs the instruments to
remove the disc material
10. Percutaneous Arthroscopic Discectomy
■ laser spine procedure to remove the portion of the extruding or herniated disc that is pressing against a nerve
11. Foraminotomy
■ cutting to produce a hole or opening to relieve pressure on nerves that are being compressed by the
intervetebral foramen
12. Percutaneous Laser Disc Decompression (PLDD)
■ application of laser energy to evaporate water in the nucleus pulposus
13. Chemonucleolysis
■ injection of an enzyme (chymopapain) into the herniated disk to dissolve the protruding gelatinous substance
■ Chymopapain, a purified enzyme derived from the papaya plant, injected percutaneously into the disk space
to reduce the size of the herniated disks

Post operative Care


■ Walking as primary form of exercise for 1st several wks.
■ Bicycling and swimming 2 wks after surgery
■ Avoid any activities that cause pain
■ Avoid sitting for longer than 15 to 20 minutes
■ May return to office work within 2-4 wks; physical labor in 8-12 wks. After surgery

Alternative Medicine
1. Acupuncture
■ involves the use of fine needles inserted along the pathway of the pain to move energy locally & relieve pain
2. Massage therapy may provide short-term relief from a herniated disk
3. Chiropractic treatment includes manipulation to correct muscle and joint malfunctions
4. Naturopathy
■ Ayurveda (ancient Indian), traditional Chinese medicine
5. Mind-body interventions (biofeedback, cognitive-behavioral therapy)
6. Biologically based therapies (herbal supplements, homeopathy, pain patches)
7. Manipulative and body-based methods (acupuncture, massage, chiropractic, yoga)
8. Energy therapies (magnets, ultrasound, transcutaneous electrical nerve stimulation (TENS))

Physical Therapy
Goals: 4. For recovery and long-term protection
1. Strengthen the muscles of the abdomen 5. Help take pressure off inflamed nerve structures
and lower back to help support the spine 6. Proper lifting, dressing, walking, and performing other
2. Flexibility of the spine and legs activities
3. Help improve posture

1. Traction
a. Head halter traction c. Buck’s Extension Traction
b. Pelvic girdle traction d. Anklet traction


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2. Brace
a. Cervical collar
b. Chairback brace
3. Ultrasound and Diathermy to project heat deep into the tissues of the back
4. Manual therapy
5. Transcutaneous Electrical Nerve Stimulation (TENS)

Nursing Management
1. Carry out a weight control program
2. Lifestyle changes
a. Encourage proper posture while standing, sitting, and working
b. Avoid pushing or pulling with arms
c. Avoid sitting or standing for prolonged periods of time
d. Increase activities according to tolerance
e. Avoid prolonged sitting - do not cross legs (use lumbar roll/pillow for sitting)
f. Do not lift or carry weight in excess of 5 lbs.
g. Avoid driving car
h. Avoid stairs
3. Diet to prevent constipation: Stool softeners, Increase fluids and roughage in diet
4. Use log rolling technique
5. Maintain proper alignment of spine
6. Maintain mobility (Use of cervical collar, traction, braces)
7. Assist with ADL
8. Deep breathing and sighing (no coughing)
9. Minimize pain
a. Immobilize / stabilize the spine
b. Bedrest to reduce inflammation and edema in soft tissues around disc, relieving pressure on nerve roots;
relieves cervical spine of supporting weight of head
c. Heat or cold therapy
d. Encourage to assume comfortable and proper position
e. Sleep on side with knees and hips flexed
f. Moist heat compress and massage to relax muscle spasm (10 – 20 min. several times daily)
10. May not lift or carry anything heavier than 5kg
11. Regular exercise
a. help strengthen the back muscles
b. strengthen the abdomen, arms, and legs to reduce back strain
c. Stretching to reduce risk of muscle spasms
d. Weight bearing exercises to help prevent loss of bone mass
e. Aerobic exercise to release the natural chemicals of the body that combat pain, endorphins

Complications
1. Chronic back pain
2. Permanent SCI

Prevention Prognosis
1. Safe work and play practices 1. Most people improve with conservative treatment
2. Weight control 2. It may take several months to a year or more to
3. Firm mattress resume all activities without pain or strain to the back


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4. Proper body mechanics 3. Only 5-10% of patients with unrelenting sciatica and
5. Avoid sudden twisting of spine neurological involvement, need to have surgery
6. Proper exercises to strengthen the lower back and 4. Nerve regeneration will depend on how long those
abdominal muscles nerves were crushed and how much damage has
7. Good posture been done
8. Choose proper footwear to reduce impact forces to ■ it can take two years for the bones to regenerate
lumbar disks while walking on hard surfaces ■ when the axon is crushed and the myelin sheath is
9. Wear back support devices if heavy lifting is required disrupted, the nerve will try to grow it's axon at a
with combinations of twisting rate of 1 mm per day (1 inch per month)

CONGENITAL MALFORMATIONS

I. CLUBFOOT
— a congenital deformity of the foot, characterized by inward and downward position of the foot
— Congenital – means a deformity at birth.
— Talipes :
Talus = ankle
Pes = foot
Equinus: (Latin = horse)
- Foot that is in a position of plantar flexion at the ankle, looks like that of the horse
Varus – refers to the position of the foot, which points downwards and inwards
Calcaneus: Full dorsiflexion at the ankle
Planus: flatfoot
Cavus: highly arched foot
Varus: heal going towards the midline
Valgus: heel going away from the midline
Adduction: forefoot going towards the midline
Abduction: forefoot going away from the midline

Synonyms/Other Names:
— Congenital Talipes Equinovarus
— Rockerbottom deformity
— Hindfoot varus
— Forefoot varus
— Foot deformity
— Rockerbottom foot
— Hindfoot equinos
— Clubfoot
— CTEV

Incidence
— Occurs approximately in one of every 1000 live birth
— In affected families, clubfeet are about 30 times more frequent in offspring
— Twice in males than in females
— Bilateral cases are as high as 30–40 %
— People of Polynesian descent are most at risk, and those of Asian descent are least at risk

Predisposing Factors:
— Genetic
— Sex (likely affects males; male-female ratio 2:1)


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— Ethnicity (Polynesian descent most at risk)
— Position of baby in the uterus as a result of muscle or nerve diseases
— Children with neuromuscular disorders:
a. Cerebral Palsy (CP)
b. Spina Bifida

Precipitating Factors
— Oligohydramnios / amniotic band syndrome due to intrauterine compression
— Women who smoke during pregnancy
— Factors that may affect pre natal growth:
a. Infection
b. Drugs (Ecstacy)
c. Disease or other factors in the uterine or outside environment (10th to 12th weeks of gestation)

Two Categories of clubfoot


1. Structural TEV 2. Postural TEV
Caused by: Caused by external influences in the final trimester:
a. Genetic factors a. Oligohydramnios
b. Growth arrests at roughly 9 weeks b. Amniotic band syndrome
c. Compartment syndrome of the affect limb
d. Family history

Four Main Types of CTEV

Signs and Symptoms:


Fixed Plantar Flexion (equinus) of the ankle
— characterized by the drawn up position of the heel and inability
to bring the foot to a plantigrade (flat) standing position
— caused by a tight achilles tendon (heel cord)
Adduction (varus) or turning in of the heel or hindfoot
Adduction (turning under), of the forefoot and midfoot giving the
foot a kidney-shaped appearance.

Abnormal (slightly smaller) size of foot & calf muscles

Physical Assessment :
1. Newborn physical examination 6. Foot is smaller in unilateral affection
2. Internal torsion of the leg 7. Callosities at abnormal pressure areas
3. Calf muscles wasting 8. No creases behind Heel
4. Short Achilles tendon 9. Abnormal crease in middle of the foot
5. High and small heel


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Diagnostic Examinations:
1. X-ray of the foot to see if bones in the foot are abnormally shaped
2. Ultrasound examination before birth

Goal of Treatment
1. Correct the deformity early
2. Correct the deformity fully
3. Hold the correction until growth stops
4. Obtain a plantigrade foot that is functional, painless, and stable over time
5. A cosmetically pleasing appearance

Medical Management:
1. NSAIDS
— used mainly for management of pain of low to moderate intensity (e.g. Ibuprofen)
2. Casting
— can be started on the day of birth or within several weeks after birth.
The orthopedist pushes and twists the foot into an over corrected position and then cast is applied to ensure
holding of foot in same manner (Kite Method)
3. Ponsetti Method
— Treatment involves serial manipulation and plaster casting of the clubfoot.
The ligaments and tendons of the foot are gently stretched with weekly, gentle manipulations. A plaster cast
is then applied after each weekly sessions to retain the degree of correction obtained and to soften the
ligaments. Thereby, the displaced bones are gradually brought into the correct alignment. Four to five long
leg (from the toes to the hip) are applied with the knee at a right angle.

4. Dennis Brown Splint


— used when long leg cast is removed after 3 weeks of treatment. The bar is fit shoulder width apart and worn
with reverse last shoes. It is worn full time for the 1st 2 months after the last cast is removed.
5. Physiotherapy
— started after the child becomes more than 3 months old. The physiotherapist tapes or manipulates the foot.


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Surgical Management
— for children above the age of 6 months
— Needed if cast treatment fails or club foot is rigid
1. Club foot repair / Club foot release
a. Percutaneous Tenotomy (Achilles tendon is cut to allow the foot to drop)
a.1 Posterior Release
b.2 Medial Release
c.3 Subtarsal Release
b. Tendon Transfer (Forefoot supination)
b.1 Complete Tendon Transfer
b. 2 Complete Soft Tissue Release
— tight tissues around the joints are released & results in lengthening of tendons so the foot can
assume a more corrected position
b.3 Varus Derotation Osteotomy
c. Progressive Surgical Release (Equinos correction)
a. Postero-Medial Release
b. Postero-Soft Tissue Release
c. Tendon Achilles Repair

Nursing Management:
— Elevate child’s feet with pillows
— Check the toes every 1-2 hours for temperature, color, sensation, motion, and capillary refill
— Insert plastic petals over the top edges of a new cast while it is still wet to keep urine from soaking and softening
the cast.
— Perform exercises as ordered
— Stimulate movement of toes to promote circulation
— Provide diversional activities
— Provide comfort measures such as soft music, pacifier, teething ring, or rocking to promote relaxation and may
enhance patient’s coping abilities by refocusing attention

Complications
1. Arthritis
2. Feet Calluses
3. Awkward Gait
4. Talipes Calcaneo-Valgus
— foot dorsiflex and everted
5. Talipes Equino Valgus or Vertical Talus
— hindfoot is in equinos, forefoot is dorsiflexed and everted and talus is abnormally vertical
6. Talipes Equino Varus
— whole foot and legs are shortened, hindfoot is in equinos and inverted and forefoot is supinated and hooked
7. Metatarsus Adductus
— foot is plantigrade but forefoot points inward

IV. CONGENITAL HIP DISLOCATION


— an abnormal formation of the hip joint in which the ball at the top of the thighbone (femoral head) is not stable in the
socket acetabulum)
— the ligaments of the hip joint may be loose and stretched


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Synonyms
— Traumatic hip dislocation
— Congenital dysplasia of the hip
— Developmental hip dysplasia
— Congenital dislocation of the hip (CDH)
— Developmental dislocation of the hip joint
— Developmental dysplasia of the hip (DDH)
— Hip dysplasia
— Hip subluxation
— Hip dislocation
— Teratologic hip dislocation
— Hip instability
— Displaced hip
— Dislocated hip
— Hip fracture-dislocation
— Prosthetic hip dislocation
— Teratologic Congenital Hip Dislocation

Classification:

A: Normal B: Dysplasia C: Subluxation D: Luxation / Dislocation

1. Acetabular dysplasia or preluxation


— deficient development of the acetabulum & femoral head
— the hip socket is shallow and remains shallow, so that the hip is unstable
— there are cases that have apparently normal hips at birth, but develop the problem in the first year of life
2. Subluxation
— partial displacement of a joint with some contact remaining between the articular surface
— there is incomplete contact between the articular surfaces of the femoral head and acetabulum, thus,
dislocates partially when stressed
3. Complete dislocation
— head of the femur is completely displaced from the acetabulum; most severe form
a. Teratologic dislocation
— refers to antenatal dislocation of the hip
b. Congenital hip dislocation
— the hip is frankly dislocated at birth
c. Congenital dislocatable hip
— the hip is in place at birth, but dislocates fully when stressed


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Predisposing Factors
— Female
— Family history (first-degree relatives)
— First born child (Left hip)
— Fetal position : Breech delivery
— Intake of terratogens by pregnant mothers
— Oligohydramnios (34 wks-800 ml; 40 wks-600 ml) ; Can result in fetal compression
— Large for Gestational Age (LGA)
— Maternal hormone (Relaxin)
— Certain practices
a. infant swaddling
b. use of cradle-board
c. infants wrapped with the legs together and extended out straight

Signs and Symptoms


1. Tenderness and edema 7. Asymmetric ROM / limited abduction
2. Groin pain with hip motion 8. Diminished movement in affected side
3. Associated bruising, discoloration 9. Wide perineum
4. Loss of pulse in the affected leg 10. Thighs appear short
5. Loss of sensation in the affected leg 11. Limping or Waddling gait
6. Leg shorter on affected side and may turn outward

12. Ortolani sign


— “hip click” on routine post–natal exam
a. Initial downward pressure further dislocates the hip
b. Relocates as the thigh is adducted

13. Barlow’s Test


a. The leg is pulled forward and then
b. Adducted in an attempt to dislocate the femur

14. Galeazzi’s sign / Allis sign 16. Extra Gluteal Folds


— leg may appear shorter on the side of the dislocated hip

15. Trendelenburg test


— used if child is old enough to walk
a. Have the child walk on affected leg only
b. Pelvis will dip on normal side as child attempts to
stay erect


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Diagnostic Examinations:
1. X-Ray 4. Magnetic Resonance Imaging
2. Ultrasonography 5. Arthrograms
3. Computed Tomography Scan

Objective of Treatment :
1. To replace the head of the femur into the acetabulum
2. Apply constant pressure to enlarge and deepen the socket

Medical Management

1. Pain medications 9. Pavlik harness


2. Sedation (used in the first 4 to 6 months of life)
3. Muscle relaxants
4. Triple diaper
5. Rolled cotton diapers
6. Pillow between thighs
7. Frejka pillow
8. Traction for 10-14 days, bracing & casting if hip continues
to be partially/completely dislocated

Surgical Management
1. Osteotomy
— bone is cut to shorten, lengthen, or change its alignment
2. Tenotomy
— to cut the tightly contracted tendons or muscles in the hip area to relax the tight structures around the hip
joint and allow the hip to be placed in the socket
3. Hip Replacement Arthroplasty
— For 12 weeks after the procedure, a pseudocapsule is formed

Nursing Management
1. Maintain proper positioning
a. keep legs abducted
b. use tripled diapering
c. use Frejka pillow to keep legs abducted
d. place infant on abdomen with legs in “frog position”
e. use immobilization devices (splints, casts, braces)
2. Provide adequate nutrition
3. Promote growth & development
(by providing age & condition appropriate diversional activities)
4. Help child maintain muscle tone and strength in unaffected areas by encouraging regular ROM exercises and
other activities
5. For older children, encourage activities of daily living by assisting in feeding, bathing, dressing and toileting
6. Provide comfort
a. Administer pain medication
b. Change child’s position frequently, using pads and pillows for support.
7. Help prevent circulatory impairment due to cast:
a. Elevate casted extremities
b. Monitor cardiovascular status


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c. Assess for pain, swelling, coldness and cyanosis
8. Help prevent skin breakdown:
a. Inspect for irritation
b. Keep skin clean and dry
c. Change positions frequently
9. Help prevent complications of immobility
10. Ambulating stairs after hip surgery
— "Up with the good and down with the bad"
— When going up stairs, patient leads with the non-operative extremity and then follows with the crutches and
operative extremity, taking one step at a time
— When descending, patient leads with crutches and the operative extremity and then follows with the non-
operative extremity

Complications :
1. Stiffness
2. Arthritis
3. Delay in walking
4. Redislocation
5. Infection
6. Avascular necrosis
7. Skin irritation from reduction device
8. Femoral nerve compression related to hyperflexion
9. Limb length discrepancies may persist despite appropriate treatment

Prevention :
1. Proper regular pre natal care to determine position of baby in the womb
2. Avoid excessive and prolonged infant hip adduction

II. COXA PLANA


— flattening of the ball of the head of the femur

Synonyms

Legg-Calvé-Perthes Disease LCPD


Ischemic Necrosis of the Hip Coxa Plana
Avascular Necrosis of the Femoral Head Osteochondritis
Legg–Perthes Disease Perthes Disease

Incidence
1. Occur in 1 per 1000
2. Caucasians are affected more frequently; rare in blacks
3. Males affected 4-5 times more often than females
4. 1 in 100 male children of adults with Legg–Calvé–Perthes syndrome also exhibit the syndrome
5. Commonly seen in persons aged 3–12 years, with a median of 6 years of age


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Predisposing Factors

1. Delayed bone maturity 8. Positive family history


2. Short stature 9. Abnormal birth presentation
3. Being born to older parents 10. Low birth weight
4. Male 11. Those with abnormalities in genetics, hormonal changes,
5. Age 4 to 10 years old trauma, infection and metabolic abnormalities
6. Abnormal birth presentation 12. Often in Asians, Eskimos, and Whites, lower incidence in
7. Those with blood clotting disorders Australian, Native American, Polynesians and Blacks.

Precipitating Factors
1. Those with blood clotting disorders
2. Low birth weight
3. Children exposed to second hand smoke

Signs and Symptoms


1. Knee, or groin pain, exacerbated by hip/leg movement lasts for an hour or so and returns nightly on inactivity
2. Reduced ROM at the hip joint and a painful or antalgic gait
3. Atrophy of thigh muscles from disuse
4. Limping or other guarding of the joint, particularly when tired
5. Hip stiffness restricting movement in the hip
6. Muscle spasm
7. Leg length inequality due to collapse
8. Short stature: Children with LCPD often have delayed bone age
9. Late phase: Trendelenburg gait

Diagnostic Examinations
Diagnosed between 5 and 12 yrs old or as early as 2 yrs
1. Physical Examination 3. Imaging Studies
a. Hip stiffness with loss of internal rotation a. Plain x-rays of the hip
and abduction — demonstrate a flattened, & later fragmented
b. Limb length discrepancy femoral head
c. Trendelenburg gait (head collapse leads to b. Frog leg views of the affected hip
decreased tension of abductors) c. Technetium 99 bone scan
2. Laboratory — delineate the extent of avascular changes
a. CBC before they are evident on plain radiographs
b. Erythrocyte sedimentation rate d. MRI
e. Dynamic arthrography
— Assesses sphericity of the head of the femur

Four Stages of LCPD


I. Initial Phase (6-2 mos)
— Femoral head become more dense with possible fracture of supporting bone
II. Reabsorption Phase (1yr or more)
— Fragmentation and reabsorption of bone
III. Reossification Phase
— when new bone has regrown
IV. Healing Phase


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— when new bone reshapes
— Phase 3 and 4 may go on for many years
Stages of Legg-Calves-Perthes (Waldenström)

Stages Description Length of Time


♦ Radiographs may remain occult for 3 to 6 mos. 6-2 months
Stage I ♦ Infarction occurs.
♦ The blood supply to the upper femoral epiphysis is halted
Initial Stage spontaneously and bone growth is halted
(Avascularity) ♦ Femoral head becomes more dense with possible fracture of
supporting bone
♦ Lateral pillar classification based on this stage one year or
Stage II ♦ Femoral head appears to fragment or dissolve more
♦ New blood vessels arise to supply the necrotic area, and bone
Fragmentation Stage resorption and deposition take place.
(Revascularization) ♦ However the new bone lacks strength and pathologic fractures
may occur; the weakened epiphysis may be progressively
deformed
Stage III ♦ New bone appears or regrow May last up to
♦ The head of the femur gradually reforms as dead bone is 18 months
Reossification Stage replaced with new bone, which gradually spreads to heal the
lesion
Stage IV ♦ Femoral head reossifies or reshapes back to normal bone density May go on for
♦ The femoral head becomes permanently distorted, with resultant many years
Healed or Reossified Stage joint misalignment
(Post recovery)
The goal of treatment is four-fold
1. To reduce hip irritability
2. Restore and maintain hip mobility
3. To prevent the ball from extruding or collapsing
4. To regain a spherical femoral head

Medical Management
— These devices internally rotate the femoral head and abduct the leg(s) at 45 degrees
1. Traction
— to separate the femur from the pelvis & reduce wear and tear
2. Crutches, canes
— for non-weight bearing treatment for pain to minimize pressure on
the hip
3. Casts
— to produce containment
4. Braces
— to restore range of motion and mobility
5. Orthotics
— to maintain activities of daily living
6. Swimming
— highly recommended, as it allows exercise of the hip muscles with full range of motion while reducing the
stress to a minimum
7. Cycling
— also keeps stress to a minimum
8. Physiotherapy


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— exercises focus on improving and maintaining a full range of motion of the femur within the hip socket
9. Hip aspiration if a septic joint is suspected
10. NSAIDS

Surgical Management
1. Tenotomy
— performed to release an atrophied muscle that has shortened due to limping.
Then cast is applied for about six to eight weeks to allow the muscle to regrow to a more natural length.
2. Osteotomy
— cutting the bone to reposition the hip socket in such a way that the femoral head will have less tendency to
become deformed.

Nursing Responsibilities
1. Maintain activities that promote range of motion
— swimming and bicycling, but to avoid contact sports and high impact-running
2. Limitation of activities
3. Provide equipment to assist with mobility
4. Teach parents and siblings to assist only as needed
5. Allow child to care for self and participate as able
6. Reinforce to child that he or she is only temporarily restricted. Stress positive aspects of activity
7. Encourage follow up
8. Salicylates or anti-inflammatory agents

Prognosis
1. At least 50% of involved hips do well with no treatment
— less than 6 years of age: outcome is good, regardless of treatment
— between 6-8 years of age: results not always satisfactory with containment
— greater than 9 years of age: questionable benefit from containment
— children older than 8-9 yrs at initial onset will have poor prognosis & may have significant symptoms &
restricted ROM
2. Patients whose femoral head does not shape well and does not fit well in the socket usually develop
degenerative arthritis before the age of 50
3. Although Legg-Calvé-Perthes disease cannot be prevented, much has been accomplished toward minimizing
its effects

Complications
1. Residual head and neck deformity 5. Flattening of femoral head
2. Coxa magna (widening) 6. Overgrowth of greater trochanter
3. Coxa breva (shortening) 7. Osteochondritis dissecans of hip
4. Coxa valga (tilting of femoral neck)

III. OSTEOGENESIS IMPERFECTA


— a genetic disorder characterized by bones that break easily without specific cause
— Osteo - bone
— Genesis - creation
— Imperfecta - imperfect


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SYNONYMS
— Brittle-bone disease — Fragilitas Osseum
— Broken bone — Fragile bone disease
— OI

ETIOLOGY
— Congenital
— Hereditary
— usually transmitted as an autosomal-dominant trait
(you only need to get the abnormal gene from one
parent for you to inherit the disease)

INCIDENCE
— relatively rare, congenital type occurring in approximately 1 of every 40,000 births
— more frequent in females than males

Causes:
— a genetic defect that affects the body’s production of collagen (the major protein of the body’s connective tissue
which gives bones its tensile strength)
— In OI, the body produces either:
a. less collagen than normal or
b. a poorer quality of collagen than normal

Signs and Symptoms


1. Fractures occurring with little or no trauma 11. Spinal deformities
2. Brittle or opalescent teeth (dentinogenesis imperfecta) 12. High-pitched voice
3. Blue – gray sclera 13. Bone deformity
4. Progressive, post-pubertal hearing loss 14. Constipation
5. Triangular face 15. Heart Defects
6. Delays in motor development 16. Muscle Fatigue
7. Breathing problems 17. Curved Limbs
8. Excessive sweating 18. Short stature
9. Easy bruisability 19. Joint laxity
10. Thin, smooth skin 20. Flat feet

Types of OI
Types 1-5 (caused by Dominant Mutation)
Types 6-8 (due to Recessive Mutations)

Type I (Mild)
— Mildest and most common type
— Collagen structure is normal, but the amount is less than normal
— Most fractures occur before puberty
— Normal or near-normal stature
— Dominantly inherited; spontaneous mutations are common. (It can be passed from parent to child, or occur in
a previously unaffected family due to a new mutation)
a. Loose joints and muscle weakness e. Bone deformity absent or minimal
b. Sclera have a blue, purple, or gray tint f. Brittle teeth possible
c. Triangular face g. Hearing loss possible, often early 20s or 30s
d. Tendency toward spinal curvature


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Type II (Perinatal Lethal)
— Most severe form
— Collagen is not of sufficient quality or quantity
— Frequently lethal at or shortly after birth, often due to respiratory problems
— Results from new dominant mutations to type 1 collagen genes, parental mosaicism or recessive inherited
mutation to CRTAP (cartilage-associated protein) gene
— Some people with type II have lived into young adulthood but:
a. Numerous fractures and severe bone deformity evident at birth
b. Small stature with underdeveloped lungs and low birth weight

Type III (Progressive Deforming)


— Most severe form in people who survived the perinatal period
— Enough collagen is made but it is defective
— Have a shortened life expectancy and necessity for a wheelchair
— Results from dominant mutations in type I collagen genes, (often the result of spontaneous mutation, parental
mosaicism) or recessive inheritance of a mutation to CRTAP gene
a. Bones fracture easily; fractures often present at f. Loose joints and poor muscle development in
birth, and x-rays may reveal healed fractures arms & legs
that occurred before birth g. Brittle teeth possible
b. Short stature h. Respiratory problems possible
c. Sclera have a blue, purple, or gray tint i. Bone deformity, often severe
d. Triangular face j. Barrel-shaped rib cage
e. Spinal curvature k. Hearing loss possible

Type IV (Moderate Severe)


— Between type I and type III in severity
— Collagen quantity is sufficient but is not of a high enough quality
— Leads to normal life expectancy and causes a necessity for crutches or braces
— Results from dominant mutations in type I collagen genes, (often the result of spontaneous mutation, parental
mosaicism) or recessive inheritance of a mutation to CRTAP gene
a. Bones fracture easily, most before puberty f. Tendency toward spinal curvature
b. Hearing loss possible g. Triangular face
c. Shorter than average stature h. Brittle teeth possible
d. Mild to moderate bone deformity i. Sclera are white or near-white
e. Barrel-shaped rib cage j. Spinal curvature

Type V
— Does not have type I collagen mutation
— Dominant inheritance pattern
— Has similar symptoms to type IV, like:
a. A dense band seen on x-rays adjacent to the growth plate of the long bones
b. Calcification of the membrane between the radius and ulna leading to restriction of forearm rotation
c. Unusually large callus formation (hypertrophic calluses), at the sites of fractures or surgical procedures
d. White sclera and Normal teeth
e. Bone has a "mesh-like" appearance when viewed under the microscope

Type VI (moderate to severe)


— Similar to Type IV in appearance & symptoms
— Does not have type I collagen mutation


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— Mode of inheritance is unknown
a. Have normal (white or slightly blue) sclera
b. Teeth are not affected
c. Alkaline phosphatase (an enzyme linked to bone-forming cell activity) activity level is slightly elevated
d. Bone biopsy is the only method by which type VI can be diagnosed with certainty.
e. Bone has a distinctive "fish-scale" appearance when viewed under the microscope

Type VII
— First described cases resemble Type IV
— Results from recessive inheritance of a mutation to CRTAP gene
— Limited to a set of Canadian Natives
— In others, appearance and symptoms are similar to Type II lethal OI
a. Infants had white sclera d. Short stature, short humerus and femur
b. Small head e. Round face
c. Coxa vera is common (the acutely angled femur head affects the hip socket)

Type VIII
— Resembles lethal Type II or Type III OI in appearance and symptoms except that infants have white sclera
— Caused by absence/severe deficiency of P3H1 (causes a recessive metabolic bone disorder) due to a
mutation to the LEPRE1 gene
a. Severe growth deficiency c. Severe growth deficiency
b. Extreme skeletal under mineralization d. Extreme skeletal under mineralization

Laboratory
1. Collagen synthesis analysis 4. Normal Serum calcium and serum phosphorus levels
2. Prenatal DNA 5. Analysis of deoxyribonucleic acid
3. Bone mineral density analysis

Diagnostic Examinations
1. Physical examination
2. Family’s medical history
3. X-rays
— show evidence of multiple old fractures and skeletal deformities
4. Skull X-ray
— shows wide sutures with small, irregularly shaped islands of bone (wormian bones) between them
5. Prenatal diagnosis:
a. Ultrasound
— to examine fetus's skeleton for bowing of the leg or arm bones, fractures, shortening, or other bone
abnormalities that may indicate OI
b. Chorionic villus sampling
— performed at ten to 12 weeks of pregnancy to obtain a sampling of cells from the placenta for fetal
collagen proteins in the tissue to test about the quantitative or qualitative collagen defects that
leads to OI
c. Amniocentesis
— performed at 16 to 18 weeks of pregnancy that involves inserting a thin needle into the uterus, into the
amniotic sac to withdraw a small amount of amniotic fluid to test for the specific mutation known to
cause OI in that family


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Goal of Treatment
1. Managing the symptoms 3. Developing and maintaining bone mass and muscle strength
2. Prevention of complications 4. INDEPENDENCE in all life functions with ADL's as needed

Medical Management Physical Therapy


1. Bisphosphonates (BPs) to increase bone mass 1. Exercises to increase muscular strength
and reduce incidence of fracture 2. Mastery of gross motor skills
2. Steroids 3. Application of adaptive equipment:
3. Vitamin intake (Calcium, Vit. C, & Vit. D) for bone (adult/child car seats, toilets, (shorter) walkers, seat
growth and repair elevating/lowering power wheelchairs, home
4. Growth hormones adaptations (ie. countertops lowered, modified
5. Hearing aids toilets), sock donners, long-handled scrub brushes,
6. Early capping of teeth bath seats, toilet paper reachers, safety harness
7. Casts, splints, or braces to allow movement and cushions to adaptive potty chairs, electric can
openers)
Surgical Management 4. Education on protective movement, positioning, and
1. Multiple osteotomies handling
2. Rodding 5. Swimming, walking, stationary cycling, & water
— a surgical procedure in which a metal rod is therapy
implanted within a bone (usually the long bones — to allow independent movement with little fracture
of the thigh and leg), performed when bowing or risk
repeated fractures interfere with a child's ability
to walk

Alternative Treatment
1. Acupuncture 3. Hypnosis 5. Visual imagery
2. Naturopathic therapies 4. Relaxation training 6. Biofeedback

Nursing Management
1. Support limbs. Never pull, push, or bend a limb to 10. Encourage mobility when possible
prevent fractures 11. Promote preventive dental care and repair of
2. Position with care dental caries
3. Check the patient’s circulatory and motor sensory 12. Avoid smoking, caffeine, and alcohol intake
abilities 13. Refer the parents and child for genetic
4. Provide emergency care of fractures counseling to assist recurrence of risk
5. Encourage diet high in protein and vitamins to 14. Monitor hearing needs
promote healing 15. Teach patient to avoid activities which has a
6. Encourage fluids to prevent constipation, renal negative impact on bone density (such as
calculi and UTI’s smoking, drinking and taking steroids)
7. When a fracture is suspected, minimize handling of 16. Aggressively treat all URI
the affected limb 17. Maintain a healthy weight to reduce bone stress
8. Provide care for client with traction, cast or open 18. Eat a balanced diet (low in fat, salt and added
reduction sugar and contains a variety of vitamins and
9. Provide psychological support and diversional minerals)
activities

Prevention


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1. Genetic counseling to determine their chances of having a child with OI
2. The risk of fractures can be minimized by:
a. Bone- and muscle-strengthening exercises
b. Rehabilitative therapy
c. Use of leg braces
3. Children with OI should consume an adequate amount of calcium (500 mg for children 1-3 years old; 800 mg for
children 4-8 yrs old; 1,300 mg a day for preteens and teenagers)

Prognosis
1. Lifespan of people with OI types I, III, and IV is not generally shortened.
Prognosis is quite variable, depending on the number and severity of the fractures and bony deformities
2. Fifty percent of all babies with OI type II are stillborn. The rest usually die w/in a very short time after birth

METABOLIC CONDITIONS

I. OSTEOPOROSIS
— a condition that causes thinning and weakening of normal bone
— a decrease of the density of bone mass thus patient has increased risk of bone fracture
— The underlying mechanism in all cases of osteoporosis is an imbalance between bone resorption and bone formation
— Either bone resorption is excessive, or bone formation is diminished
— is a disease of the bone in which:
— bone mineral density (BMD) is reduced,
— bone microarchitecture is disrupted, and
— the amount and variety of non-collagenous proteins in the bone is changed

Osteo - Greek “osteon” meaning bones


Por - Greek “poros” meaning a very small hole (in a tissue)
Osis - Greek referring to a condition or a process
Osteoporosis means "porous bone"

Two main categories:


Type I - Primary Osteoporosis Type II - Secondary osteoporosis
— due to estrogen deficiency — Calcium deficiency over many years
— aging — Steroid overuse
— Renal failure

Predisposing Factors
1. Gender
— Women have less bone tissue and lose bone faster due to hormones rate of bone loss in women is greater
than men
2. Age
— Bones become thinner and weaker as you age bone mass peaks in both men and women between the ages
of 25 and 35
3. Body size
— Small, thin-boned women are at greater risk
4. Ethnicity


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— Caucasian and Asian women are at highest risk
5. Family history
6. Over active parathyroid gland
— Controls how much calcium is released out of the blood stream and the body

Precipitating Factors
1. Sex hormones
— Abnormal absence of menstrual periods (amenorrhea), low estrogen level (menopause), & low testosterone
level in men
— Early menopause (<45 years) or bilateral oophorectomy
— Estrogen deficiency
— Testosterone deficiency
— Estrogen and testosterone increase osteoblast activity, causing bone growth
— The loss of estrogen following menopause causes a phase of rapid bone loss.
Similarly, testosterone levels in men diminish with advancing age and are related to male osteoporosis
2. Anorexia nervosa - an irrational fear of weight gain
3. Calcium and vitamin D deficiency
— Calcium and vitamin D are nutrients required for normal bone growth
4. Medication use
— Long-term use of glucocorticoids and some anticonvulsants can lead to loss of bone density and fractures
5. Lifestyle
a. inactive lifestyle or extended bed rest tends to weaken bones
b. Cigarette smoking
c. Alcohol intake
d. Intake of soft drinks
6. History/Recurrent falls
7. Glucocorticoid or thyroxine excess
— Cause osteoclast activity to increase, causing bone resorption

Clinical Manifestations
1. Backache
2. Gradual loss of height
3. Hunchback appearance of many elderly women, called "dowager's" hump or "widow's" hump
4. Fractures of the spine, wrist, or hip
5. Osteoporotic fractures
— those that occur under slight amount of stresses that would not normally lead to fractures in non-osteoporotic
people.
— Common sites are: the wrist, the hip & spine
6. Collapse of a vertebra ("compression fracture") can cause :
a. acute onset of back pain d. limited mobility
b. a hunched forward or bent stature e. possibly disability
c. loss of height f. bedrest


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Laboratory Examinations
1. Blood Exams
a. To check for high bone formation:
a.1. Bone Specific Alkaline Phosphate (BALP)
a.2. Osteocalcin
b. Vitamin D levels
— checks for deficiency and absorption of calcium
2. Urine Tests
a. Urinary N-Telopeptide of Type I Collagen
— maker of bone resorption (loss of bone)

Diagnostic Examinations
1. Complete medical history 5. Ultrasound
2. Physical exam 6. BMD (Bone Mineral Density)
3. X rays — translated as a T-score
a. DEXA (dual energy x-ray absorptiometry) T-score -1.0 or greater is "normal“
— a double x-ray beam takes pictures of the T-score -1.0 and -2.5 is "low bone mass"
spine, hip, or entire body (or "osteopenia")
4. Quantitative computed tomography T-score -2.5 or below as osteoporosis

Goal of Treatment for Osteoporosis


1. Control pain 3. Prevent bone fractures
2. Slow down or stop bone loss 4. Minimize the risk of falls

Medical Management
1. Hormone Replacement Therapy (HRT) / Estrogen replacement therapy
— to increase bone mass after menopause
2. Calcitonin
— slows down bone-eating osteoclasts
— slows bone loss
— decrease pain associated with osteoporosis fractures
3. Sodium fluoride
4. Vitamin D metabolites
5. Biphosphonates
a. Alendronate (Fosamax)
— produce increased bone mass by attaching itself to bone that has been targeted by bone-eating
osteoclasts thereby inhibiting the osteoclasts
b. Raloxifene
— Similar effects with estrogen
— increases bone mass
— regulate calcium and prevent bone breakdown
6. Calcium supplementation
— at least 1200 to 1500 mg every day = 5 glasses of milk each day

Alternative treatment
1. A healthy diet
— Low in fats and animal products and containing whole grains, fresh fruits and vegetables, and calcium-rich

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foods (such as dairy products, dark-green leafy vegetables, sardines, salmon, and almonds)
2. Nutritional supplements
— Such as calcium, magnesium, and vitamin D
3. Weight-bearing exercises
4. Herbal supplements (to help slow bone loss)
a. Horsetail (Equisetum arvense) d. Licorice (Glycyrrhiza galbra)
b. Oat straw (Avena sativa) e. Marsh mallow (Althaea officinalis)
c. Alfalfa (Medicago sativa) f. Yellow dock (Rumex crispus)

Nursing Management
1. Careful positioning, ambulation
2. Administer analgesics and heat to relieve back pain:
a. Rest in bed in a supine or side-lying position.
b. Mattress should be firm and non-sagging.
c. Intermittent local heat and back rubs to promote muscle relaxation.
d. Encourage good posture and good body mechanics.
3. Check skin daily for redness, warmth, and new pain sites
4. Advise patient to report any new pain sites immediately, especially after trauma
5. Monitor pain level, and assess response to analgesic’s, heat therapy, and diversional activities
6. Daily weight-bearing exercises to maintain and increase bone mass
7. Encourage high calcium and high fiber diet
8. Encourage vitamin D supplementation.
9. Advice to avoid smoking and reduce use of caffeine (e.g. coffee, soda) and alcohol
— it decrease calcium absorption
10. Include patient and family in all phases of care
11. Encourage patient to perform as much self-care as immobility and pain allow
12. Make sure patient and her family clearly understand prescribed drug regimen
13. Provide emotional support and reassurance to help cope with limited mobility

Prevention
1. Healthy lifestyle
2. Exercise three to four times per week for 20-30 minutes each time
— aerobics, dancing, jogging, stair climbing, tennis, walking, and lifting weights, weight training, and resistance
exercises
— to maintain and increase bone density
3. Avoid smoking (2 per day)
4. Limit alcoholic drinks
— 1 ½ oz hard liquor, 12 oz beer, or 5 oz wine
5. Calcium Supplements accompanied by 6 to 8 glasses of water a day, to support bone growth, and bone healing
— 1,000 mg/day
— 1,500 mg/day for adolescents, pregnant or breastfeeding women, older adults (over 65), and
post menopausal women not using hormone replacement therapy
Source of Calcium: Milk, cheese, and yogurt have the highest amounts; green leafy vegetables, tofu,
shellfish, sardines, and almonds
6. Moderate supplies of dairy products, vegetables, nuts, & even seafood to increase calcium and vitamin D intake.
7. Vitamin D
— helps the body absorb calcium to increase bone density (400 mg daily)


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Sources: sunshine with a quick (15-20 min) walk each day, foods such as liver, fish oil, and vitamin-D fortified
milk

Prognosis : There is no cure for osteoporosis, but it can be controlled

II. OSTEOMALACIA
— a metabolic bone disease characterized by inadequate mineralization of bone due to a lack of vitamin D leading to
softening of the bones to osteoid failing to ossify

Synonyms
Osteomalacia (Adults)
Rickets (Children)
Soft Bone Disease

Precipitating Factors
1. Not enough vitamin D in the diet
a. Children and the elderly
b. Pregnant
c. Breastfeeding infants for long periods of time without vitamin D supplementation
d. Poverty
e. Those who avoid drinking milk
2. Not enough exposure to sunlight
a. Covering of the face and body most of the time
b. Living in northern latitudes
c. Individuals who do not venture outdoors
Factors that reduce formation of vitamin D in the body
a. Use of very strong sunscreen c. Short days of sunlight
b. Limited exposure of the body to sunlight d. Smog
3. Malabsorption of vitamin D by the intestines
a. Steatorrhea
— Fats are passed directly out the body in the stool because body can't absorb fat properly . As a result,
vitamin D, which is usually absorbed with fat, & calcium are poorly absorbed
4. Hereditary or acquired disorders of vitamin D metabolism
a. Lactose intolerance
b. Celiac disease (Gluten Intolerance)
5. Alcoholism
6. Vegetarianism
7. Kidney failure and acidosis
— The kidneys don't work properly. As a result of this, there is more acid in body fluids (tubular acidosis); this
increased acid gradually dissolves the skeleton
8. Liver disease
9. Cancer
10. Phosphate depletion
11. Side effects of medications used to treat seizures

Predisposing Factors


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1. Darker-skinned individuals
2. Family history

Signs and Symptoms


— Muscular weakness and softening of the skeleton, resulting from decalcification
— Skeletal pains and swelling and numerous fracture
— Brittleness of bone
— Waddling or limping gait

Clinical Manifestations
1. Rickets
a. Delayed growth e. Thickening at the wrists and ankles
b. Bowed legs (genu varum) f. Delayed closure of the anterior fontanelles (4 to 26 mos)
c. Abnormal curvature of the spine g. Bone pain particularly in the spine, legs and pelvis
d. Muscle weakness h. Protruding breastbone (‘pigeon chest’)

2. Osteomalacia
a. Bone pain worse in the legs, hips, pelvis, lower spine and ribs
b. Abnormal curvature of the spine
c. Dental deformities
d. Muscle weakness particularly in the arms and legs
e. Changes in gait (waddling)
f. Hyporeflexia (reduced or absent reflexes)
g. Difficulty walking up stairs or getting up from a chair
h. Frequent bone fractures with little cause
i. Tiredness

Symptoms due to low calcium levels


1. Abnormal heart rhythms 3. Numbness of arms and legs
2. Numbness around the mouth 4. Spasms of hands or feet

Laboratory Examinations Diagnostic Examinations


1. Blood Exams 1. Confirmatory tests
a. Vitamin D level a. Bone biopsy
b. Creatinine level — reveals bone softening (increased amount
c. Calcium level of osteoid)
d. Phosphate level b. Bone x-rays
e. Kidney problem check: — generalized demineralization of bone
e.1. ALP (alkaline phosphatase) c. Bone density test
e.2. ParaThyroid — help detect pseudofractures, bone loss,
2. Urine exam bone softening
— low excretion of calcium and creatinine
3. Low serum calcium and phosphorus levels, and
moderately elevated alkaline phosphatase concentration

Goals of Treatment
1. To relieve symptoms and
2. Correct the cause of the condition.
3. Prevent recurrence of the disease


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Medical Management
1. Vitamin D, Calcium, and Phosphorus
supplements
2. Regular blood tests to monitor blood levels of
phosphorus and calcium
3. Increased exposure to ultraviolet light

Nursing Management
1. Careful positioning, ambulation, and prescribed exercises
a. Assist in position changes
b. Handle gently
c. Use pillows to support the body
2. Give Vitamin D supplementation
3. Give Analgesics as ordered
4. Check patient’s skin daily for redness, warmth, and new pain sites

Surgical Management
1. Joint replacement
2. Removal of tumors associated with Paget's disease (enlarged & misshapen bones)
3. Correcting deformities Splintage – braces to correct deformities
4. Osteotomy (cutting the bone to realign)
5. Monitor patient’s pain level, and assess her response to analgesic
6. Advise adequate exposure to sunlight (for ultraviolet radiation to transform cholesterol substance
(7- dehydrocholesterol) present in the skin into vitamin D)
7. Encourage adequate protein and increased calcium and vitamin D diet
8. Monitor serum calcium levels

Prognosis
1. Improvement can be seen within a few wks. in some people with vitamin deficiency disorders
2. Complete healing with treatment takes place in 6 months

Complications
— Return of symptoms is a possible complication

Prevention
1. A diet rich in vitamin D
2. Get plenty of sunlight


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SKILLS Laboratory


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Far Eastern University


Institute of Nursing



STUDENT PERFORMANCE EVALUATION TOOL

NASOGASTRIC TUBE INSERTION


Name:_____________________________ Sec/Group No:________________ Date:________________

Area:______________________________ Faculty:__________________ Concept:___________________


DIRECTION: Rate the learner based on the competencies listed below


KEY:
4 – Competent Works competently & independently at all times even without guidance and
supervision.
3 – Very Good Requires minimum guidance and supervision
2 – Satisfactory Requires frequent guidance and supervision
1 – Needs Improvement Requires close guidance and supervision
0 – Poor Did not exhibit expected behavior even under close guidance and supervision

CRITERIA SCORE
A. ATTENDANCE AND ATTITUDE
1. Report on time and attend to activities punctually
2. Display proper grooming and wears complete uniform
3. Behaves appropriately towards teachers, classmates and
clients
4. Accepts constructive criticism
B. PREPARATION
1. Introduce yourself and verify the client’s identity. Explain
to the client what you are going to do. Why it is
necessary, and how the client can cooperate
2. Perform hand hygiene and observe other appropriate
infection control procedure
3. Assess the client nares oral cavity
4. Check the chart for doctor’s order of nasogastric tube
insertion
5. Prepare necessary equipment and supplies
6. Provide for client privacy
7. Position client in high fouler’s position with pillows behind
head and shoulders. Raise the head of the bed
8. Stand on client right side, if right handed and left side if
left handed


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9. If the NGT is to pliable, place the tube in emesis basin and
cover with ice
10. Instruct client to relax & breath normally while occluding
one nostril then repeat this action to the other nostril.
Select the nostril with greater air flow
11. Use the tube to mark off the distance from the tip of the
client’s nose to the top of the earlobe and then from the
tip of the earlobe to the tip of the xyphoid process of the
sternum
12. Mark the length of the tube with adhesive tape, if the
tube does not have markings
13. Put on the gloves
14. Lubricate the tip of the tube well with water. Soluble
lubricant
15. Insert the tube, with its natural curved toward the client,
into the selected nostril. Ask the client to hyper extend
the neck, and gently advance the tube toward the
nasopharynx
16. Direct the tube along the floor the nostril and toward
the ear on that side

17. Slight pressure is sometimes required to pass the tube
into nasopharynx, and some client eyes nay water at this
point. Provide the client with tissues as needed
18. If the tube meets resistance, withdraw it relubricate it,
and insert it in the other nostril
19. Once the tube reaches the orapharynx ( throat), the client
will feel the tube in the throat and may gag and retch. Ask
the client to tilt head forward, and encourage the client to
drench and swallow
20. If client gags, stop passing the tube momentarily, have the
client rest, take a few breath and take rips of water to calm
the gag reflex
21. In cooperation with the client, pass the tube 5-10 cm ( 2-4
inches) with each swallow until it indicated length is
inserted
22. If the client begin to cough, gag or choke, stop the
advancement. If client continues to cough pull the tube
back slightly
23. As certain correct placement of the tube
• Aspirate stomach contents
• X-ray as per agency policy
• Place stethoscope over the client epigastric, and inject
10-30 ml of air into the tube while listening for a
whooshing sound
24. If the signs do not indicate placement in the stomach


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advance the tube 5cm (2inches) and repeat the test
25. Secure the tube by taping it to the bridge of the clients
nose
26. Attach the tube to a section source of feeding apparatus
as ordered, or the clamp the end of the tubing
27. Document the insertion of the tube

TOTAL SCORE =





_________________________________ __________________________________
Signature of Student Signature of Faculty





























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Far Eastern U niversity
Institute of Nursing


PERFORMANCE EVALUATION TOOL FOR
NGT FEEDING

NAME: __________________________________________________ DATE: ______________ SCORE: _______________


SEC & GRP NO: ________________ CONCEPT: ______________________ FACULTY: __________________________

Direction: Rate the learners based on the competencies listed below.

NUMERICAL RATING DESCRIPTION


3 Performs expected competencies in a very consistent manner.
2 Performs expected competencies in a moderately consistent manner.
1 Performs expected competencies in a rarely consistent manner.
0 Does not perform expected competencies.

A. PREPARATION RATING REMARKS


1. Checks the doctor’s order 0 1 2 3
2. Introduces self to patient and verifies patient’s name 0 1 2 3
3. Informs patient of the procedure and its importance 0 1 2 3
4. Performs handwashing 0 1 2 3
5. Assembles articles and equipments needed at the bedside 0 1 2 3
6. Elevates head of bed at least 30 to 45 degree angle 0 1 2 3
7. Prepares feeding and allow to reach room temperature before feeding 0 1 2 3
B. PROCEDURE
1. Stands on patient’s left side, if right handed and right side if left handed.
0 1 2 3
Puts a towel on top of patient’s chest
2. Puts on gloves 0 1 2 3
3. Checks for correct placement of tube by injecting 3-5 ml of air and listens
0 1 2 3
for a whooshing or gurgling sound
4. Clamps the tube and inserts the tip of the asepto syringe to end of gastric tube 0 1 2 3
5. Aspirates the tubing to check and measure amount of residual 0 1 2 3
6. Flush NGT with 15 to 30 ml water 0 1 2 3
7. Pours feeding into the asepto syringe 0 1 2 3
8. Raises the syringe 12 to 18 inches above the stomach or at the level of
0 1 2 3
patient’s forehead (Depends on consistency of feeding). Opens the clamp.
9. Allows feeding to flow by gravity into the stomach. Raise and lower the
0 1 2 3
syringe to control the rate of flow


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RATING REMARKS
10. Adds feeding to the asepto syringe as it empties, not allowing the syringe to
0 1 2 3
become empty until feeding is completed
11. Terminates feeding when completed and flush with appropriate amount of
0 1 2 3
water (15 to 30 ml)
12. Kinks or closes the end of the feeding tube 0 1 2 3
13. Removes gloves and performs hand hygiene 0 1 2 3
C. AFTER CARE
1. Keeps the patient’s head elevated for 20-30 min. 0 1 2 3
2. Performs after care of all articles and equipment used 0 1 2 3
D. DOCUMENTATION
1. Documents the procedure and all nursing assessment
a. The nature of aspirate, color, amount
0 1 2 3
b. The amount of feeding and water given
c. The patients’ reaction to feeding

Total Score ÷ 69 X 100 = ________________

___________________________________ _________________________________________
Signature of Student Signature of Faculty


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Far Eastern University


Institute of Nursing



STUDENT PERFORMANCE EVALUATION TOOL

COLOSTOMY CARE


Name:_____________________________ Sec/Group No:________________ Date:________________

Area:______________________________ Faculty:__________________ Concept:___________________


DIRECTION: Rate the learner based on the competencies listed below


KEY:
4 – Competent Works competently & independently at all times even without guidance and
supervision.
3 – Very Good Requires minimum guidance and supervision
2 – Satisfactory Requires frequent guidance and supervision
1 – Needs Improvement Requires close guidance and supervision
0 – Poor Did not exhibit expected behavior even under close guidance and supervision

CRITERIA SCORE
A. ATTENDANCE AND ATTITUDE
1. Report on time and attend to activities punctually
2. Display proper grooming and wears complete uniform
3. Behaves appropriately towards teachers, classmates and
clients
4. Accepts constructive criticism
B. PROCEDURE
1. Assist the client to a comfortable sitting or lying position
and expose only the stoma area
2. Don Gloves
3. Empty the pouch when 1/3 to ½ full & assess for the
consistency & amount of effluent
4. Remove the appliance and discard.
5. Using warm water and mild soap, clean the peristomal
skin and the stoma
6. Dry the area thoroughly by patting with a towel or cotton
swabs
7. Assess the stoma & peristomal skin. Place a piece of tissue
or gauze pad over the stoma, and change it as needed
8. Measure the size of the stoma by tracing a circle on the
backing of the skin barrier the same size as the stomal
opening. Cut out the traced stoma pattern to make an


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opening in the skin barrier. Remove the backing to expose
the sticky adhesive side.
9. Remove the tissue or gauze pad on the stoma
10. Center the skin barrier over the stoma & gently press it
onto the skin, smoothing out any wrinkles or bubbles
11. Remove the air from the pouch

TOTAL SCORE =









_________________________________ __________________________________
Signature of Student Signature of Faculty
























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Far Eastern U niversity


Institute of Nursing

PERFORMANCE EVALUATION TOOL FOR
BLOOD GLUCOSE MONITORING

NAME: ________________________________________________ DATE: _________________ SCORE: _______________


SEC & GRP NO: _______________ CONCEPT: __________________________ FACULTY: _______________________


Direction: Rate the learners based on the competencies listed below.

NUMERICAL RATING DESCRIPTION
3 Performs expected competencies in a very consistent manner.
2 Performs expected competencies in a moderately consistent manner.
1 Performs expected competencies in a rarely consistent manner.
0 Does not perform expected competencies.

A. PREPARATION RATING REMARKS


1. Checks for physician’s order for time or frequency of measurement 0 1 2 3
2. Introduces self to patient and verifies patient’s name 0 1 2 3
3. Informs patient of the procedure and its importance 0 1 2 3
4. Determines if specific condition needs to be met and if risk exist
0 1 2 3
before sample collection
5. Does handwashing 0 1 2 3
6. Assembles articles and equipments needed at the bedside 0 1 2 3
7. Positions patient comfortably in chair or in semi fowler’s position 0 1 2 3


B. PROCEDURE
1. Assesses area of skin to be used as puncture site.
0 1 2 3
Inspect fingers, toes or heals
2. Instructs patient to wash hand with soap and warm water 0 1 2 3
3. Removes reagent strips from container and tightly seal caps 0 1 2 3
4. Turns glucometer on and allows to calibrate 0 1 2 3
5. Wears disposable gloves 0 1 2 3
6. Holds finger to be punctured in dependent position while gently massaging
finger toward puncture site. Use side of the finger (adult) or outer aspect of 0 1 2 3
heel (infant)
7. Cleanse site with warm water & allow to dry completely 0 1 2 3
8. Removes cover of lancet or blood-letting device 0 1 2 3


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9. Holds lancet perpendicular to puncture site and pierces finger or heel
0 1 2 3
quickly in one continuous motion
10. Wipes away first droplet of blood with cotton balls 0 1 2 3


RATING REMARKS
11. Lightly squeezes puncture site (but do not touch) until large droplet of
0 1 2 3
blood has formed and lightly transfer droplet to test pad without smearing
12. Immediately presses timer on glucometer and place reagent strip
0 1 2 3
on paper towel or on side of timer
13. Applies pressure to skin puncture site for 1 min. to 5 min. if patient
0 1 2 3
is taking an anticoagulant
14. Puts reagent strip into meter while timer continues to count 0 1 2 3
15. Reads meter, noting reading on display 0 1 2 3
16. Turns meter off and informs patient of the result 0 1 2 3
17. Remove disposable gloves and dispose properly 0 1 2 3


C. AFTER CARE
1. Position patient comfortably 0 1 2 3
2. Dispose of test strip, cotton balls, uncapped lancet in sharps box 0 1 2 3


D. DOCUMENTATION
1. Document the procedure and all nursing assessment
a. Time blood glucose monitoring was done 0 1 2 3
b. Result of the test



Total Score ÷ 81 X 100 = _________________






______________________________________ _________________________________________
Signature of Student Signature of Faculty










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Far Eastern U niversity


Institute of Nursing



PERFORMANCE EVALUATION TOOL FOR
ENEMA
NAME: __________________________________________________ DATE: ______________ SCORE: _______________
SEC & GRP NO: ________________ CONCEPT: ______________________ FACULTY: __________________________

Direction: Rate the learners based on the competencies listed below.

NUMERICAL RATING DESCRIPTION
3 Performs expected competencies in a very consistent manner.
2 Performs expected competencies in a moderately consistent manner.
1 Performs expected competencies in a rarely consistent manner.
0 Does not perform expected competencies.

A. PREPARATION RATING REMARKS


1. Assesses the patient’s over all condition 0 1 2 3
2. Assembles articles, and supplies 0 1 2 3
3. Do hand washing and wear clean gloves 0 1 2 3


B. PROCEDURE
1. Informs the client of the procedure 0 1 2 3
2. If using an enema bag fill it with 750-1000ml of warm tap water with
0 1 2 3
soap suds
3. Clamps tubing of the enema can 0 1 2 3
4. Assists client on left side lying position. Ask client to remain in that position
until the procedure is completed. Be sure client is in a comfortable position 0 1 2 3
and maintain privacy.
5. Positions waterproof pad or dry sheet under hips and buttocks 0 1 2 3
6. Drapes client with blanket exposing only the rectal area. 0 1 2 3
7. Lubricates 7.5 to 10cm (3-4 in) of tip of rectal tube with lubricating jelly 0 1 2 3
8. Gently separates buttocks and locate anus 0 1 2 3
9. Instructs client to relax by breathing out slowly through the mouth. 0 1 2 3
10. Inserts tip of rectal tube slowly by pointing tip in direction of client’s
0 1 2 3
umbilicus. Adult 3-4in. Child 2-3in.
11. Holds tubing in rectum constantly until end of fluid instillation 0 1 2 3
12. With container at client’s hip level open regulating clamp and allows
0 1 2 3
solution to enter slowly


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RATING REMARKS
13. Raises height of enema bag slowly to 35 – 45cm (12-18in) above the anus.
Infusion varies with volume of solution administered 0 1 2 3
(1L may take 7-10 mins)
14. Hangs container to IV pole 0 1 2 3
15. Lowers container or clamps tubing if client complains of cramping
0 1 2 3
or fluid escapes around the rectal tube
16. Clamps tubing after all the solution is infused 0 1 2 3
17. Informs client that the procedure is completed and that the rectal tube
0 1 2 3
will be removed. Gently remove rectal tube.
18. Explains to client that feeling of distention is normal. Asks client to retain
0 1 2 3
solution as long as possible (5-10mins) while lying quietly in bed.
19. Assists client to bathroom or commode if possible 0 1 2 3
20. If client is with cardiovascular history problem, asks to exhale while
0 1 2 3
expelling enema to avoid valsalva maneuver
21. Assists client to wash anal area with warm soap and water 0 1 2 3


C. AFTER CARE
1. Positions patient comfortably 0 1 2 3
2. Does after care of all articles and equipment used 0 1 2 3


D. DOCUMENTATION
1. Document :
a. Time and date enema was done
b. Reason for enema
0 1 2 3
c. Type of enema given
d. Amount, color, and appearance of stools
e. Assessment before and after the procedure



Total Score ÷ 69 X 100 = _________________




______________________________________ _________________________________________
Signature of Student Signature of Faculty


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Far Eastern U niversity


Institute of Nursing


PERFORMANCE EVALUATION TOOL FOR
NEUROLOGIC ASSESSMENT

NAME: _________________________________________________ DATE: __________________ SCORE: ______________
SEC & GRP NO: _______________ CONCEPT: ____________________________ FACULTY: _____________________

Direction: Rate the learners based on the competencies listed below.

NUMERICAL RATING DESCRIPTION
3 Performs expected competencies in a very consistent manner.
2 Performs expected competencies in a moderately consistent manner.
1 Performs expected competencies in a rarely consistent manner.
0 Does not perform expected competencies.


A. PREPARATION RATING REMARKS


1. Introduces self to patient and verifies patient’s name 0 1 2 3
2. Informs patient of the procedure and its importance 0 1 2 3
3. Gathers articles needed for neurologic assessment 0 1 2 3
4. Asks patient to put on a gown 0 1 2 3
5. Positions and drapes patient 0 1 2 3
6. Performs handwashing 0 1 2 3


B. MENTAL STATUS
1. Assesses level of consciousness 0 1 2 3
2. Observes appearance and behavior 0 1 2 3
3. Observes mood, feelings and expression 0 1 2 3
4. Observes thought processes and perceptions 0 1 2 3
5. Observes cognitive abilities 0 1 2 3

C. CRANIAL NERVE ASSESSMENT


1. Cranial Nerve I – Olfactory 0 1 2 3
2. Cranial Nerve II – Optic 0 1 2 3
3. Cranial Nerve III – Oculomotor 0 1 2 3
4. Cranial Nerve IV – Trochlear 0 1 2 3
5. Cranial Nerve VI – Abducens 0 1 2 3
6. Cranial Nerve V – Trigeminal 0 1 2 3


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7. Cranial Nerve VII – Facial 0 1 2 3
8. Cranial Nerve VIII – Acoustic 0 1 2 3
9. Cranial Nerve IX – Glossopharyngeal 0 1 2 3


RATING REMARKS
10. Cranial Nerve X – Vagus 0 1 2 3
11. Cranial Nerve XI – Spinal Accessory 0 1 2 3
12. Cranial Nerve XII - Hypoglossal 0 1 2 3

D. MOTOR AND CEREBELLAR SYSTEM


1. Tests condition and movement of muscles 0 1 2 3
2. Tests balance 0 1 2 3
3. Tests coordination 0 1 2 3

E. SENSORY SYSTEM
1. Tests light, touch, pain and temperature sensations 0 1 2 3
2. Tests vibratory sensation 0 1 2 3
3. Tests position sensation 0 1 2 3
4. Tests tactile discrimination (fine touch) 0 1 2 3

F. REFLEXES
1. Tests deep tendon reflexes (biceps, brachio radialis, triceps, patellar,
0 1 2 3
Achilles and ankle clonus)
2. Tests superficial reflexes (plantar, abdominal, cremasteric) 0 1 2 3
3. Tests for meningeal irritation/inflammation
0 1 2 3
(Brudzinski ‘s and Kernig’s sign if indicated)

G. AFTER CARE
1. Puts patient in a comfortable position 0 1 2 3
2. Does after care of all articles and equipment used 0 1 2 3

H. DOCUMENTATION
1. Documents the procedure and all deviations 0 1 2 3



Total Score ÷ 108 X 100 = _________________




______________________________________ _________________________________________
Signature of Student Signature of Faculty


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BALANCE SKELETAL TRACTION (BST)

SECTION / GROUP NO: __________________ DATE: ________________ FACULTY: ___________________


A. PREPARATION
1. Checks doctor’s order
2. Introduces self to patient and verifies patient’s name
3. Informs patient of the procedure and its importance
4. Performs handwashing
5. Assembles and identifies articles and equipment needed to the bedside
6. Positions and drapes patient accordingly
B. PROCEDURE
1. Measures the distance from trochanter to knee
2. Sets up the Thomas splint, Pearson’s attachment and the rest splint
3. Applies the slings following the principles in the application of slings
4. Applies slip knot at the medial upright of Thomas splint
5. Decides on the three manpower to position affected leg on the Thomas
6. Give clear instruction to patient in chronological sequence
7. Applies the traction weight
8. Applies the suspension weight
9. Able to do clove hitch knot
10. Removes the rest splint
11. Applies foot pedal using ribbon knot
12. Checks for the efficiency of traction
TRANSPORT / REMOVING TRACTION
1. Hangs the suspension bag
2. Applies the rest splint
3. Removes the suspension rope and suspension bag
4. Applies manual traction and removes the traction weight bag
5. Ties the traction rope to the rest splint using a single knot, then a clove
hitch knot to the Thomas splint, and another clove hitch knot to PA
C. AFTER CARE
1. Puts patient in a comfortable position
2. Gives health teachings about common problems for patients on traction
3. Performs after care of all articles and equipment used
D. DOCUMENTATION
1. Documents the procedure and nursing assessment
a. Reason for doing the procedure
b. Extremity placed on traction

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c. Time traction was applied
d. Weight of the traction bag
e. Effect of the procedure to the patient
f. Health teachings imparted to the patient


________________________________________
SIGNATURE OF FACULTY


































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Far Eastern University


Institute of Nursing


PERFORMANCE EVALUATION TOOL FOR
CRUTCH USE (GUIDE ONLY NO RETURN DEMONSTRATION)

NAME: ____________________________ DATE: _________ SCORE: ______________
SEC & GRP NO: _______________ CONCEPT: ________________________________ FACULTY:
__________________________________________________________________

Direction: Rate the learners based on the competencies listed below.

NUMERICAL RATING DESCRIPTION
3 Performs expected competencies in a very consistent manner.
2 Performs expected competencies in a moderately consistent manner.
1 Performs expected competencies in a rarely consistent manner.
0 Does not perform expected competencies.


A. PREPARATION RATING REMARKS


1. Introduces self to patient and verifies patient’s name 0 1 2 3
2. Informs patient of the procedure and its importance 0 1 2 3
3. Gathers articles needed for crutch use
• crutches with rubber tips on crutch ends 0 1 2 3
• supportive shoes with non-skid soles.
4. Inspect crutch/crutches condition:
• rubber tips in place, without cracks 0 1 2 3
• arm pads snug, in good shape.
5. Performs handwashing 0 1 2 3
B. PROCEDURE
1. Assess patient’s upper body strength, ROM in arms. 0 1 2 3
2. Teach patient importance of exercising arms. 0 1 2 3
3. Measure crutches to fit patient based on height:
a. Patient in tripod position crutches 6 inches (15cm) in front of feet
and 6 inches
(15cm) out laterally from center.
b. There should be at least 3 fingerbreadths of space between axilla
0 1 2 3
and top of crutch.
c. Hand grips should be even with the top of the hipline.
d. Crutch handgrips should be adjusted so that hands carry weight
when arms are correctly positioned.
Elbows must be 30 degrees relaxed


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4. Crutch Walking:
Check with physician or physical therapy for which gait to instruct patient
on. Crutches should be positioned 1-2 feet ahead.
From Tripod Stance:
TWO POINT GAIT:
a. Move RIGHT foot and LEFT crutch forward at same time.
b. Move LEFT foot and RIGHT crutch forward at same time.
THREE POINT GAIT:
0 1 2 3
a. Swing weaker leg in front of you while moving both crutches
forward at same time.
b. Then, move stronger leg forward alongside weaker leg.
FOUR POINT GAIT:
a. Advance RIGHT crutch 6 inches (15 cm).
b. Advance LEFT foot.
c. Advance LEFT crutch.
Advance RIGHT foot.
5. Ascending Stairs Using
Crutches:
a. Put strong foot up one step. 0 1 2 3
b. Bring crutches and body onto same step.
Repeat above until desired destination is reached.
6. Descending Stairs Using
Crutches:
a. Put crutches and weaker leg down first. 0 1 2 3
b. Then move strong foot.
Repeat until desired destination is reached.
7. Getting In Chair Using
Crutches:
a. Select sturdy chair with arms (no wheels).
0 1 2 3
b. Stand in front of chair with strongest leg against chair.
c. Move crutches to weak side of body holding them with hand bar.
With strong side, grasp arm of chair and lower self into chair.
8. Getting out of Chair Using
Crutches:
a. From sitting position, with crutches on weaker side, hold hand bar.
b. Move to edge of chair, stronger foot positioned to support weight 0 1 2 3
when standing.
c. With hand from strong side of body, grasp arm of chair.
Push self out of chair by pushing down on arm of chair and crutch.
9. Swing through Gait.
0 1 2 3
Using both crutches forward then swing pass where the crutch placement
10. Document mobility and patient’s tolerance of procedure. 0 1 2 3


Total Score ÷ 75 X 100 = _________________



______________________________________ _________________________________________
Signature of Student Signature of Faculty


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Far Eastern University
Institute of Nursing


PERFORMANCE EVALUATION TOOL FOR
ASSISTING WITH CAST (GUIDE ONLY NO RETURN DEMONSTRATION)

NAME: ____________________________ DATE: _________ SCORE: ______________
SEC & GRP NO: _______________ CONCEPT: ________________________________ FACULTY:
__________________________________________________________________

Direction: Rate the learners based on the competencies listed below.

NUMERICAL RATING DESCRIPTION
3 Performs expected competencies in a very consistent manner.
2 Performs expected competencies in a moderately consistent manner.
1 Performs expected competencies in a rarely consistent manner.
0 Does not perform expected competencies.


A. PREPARATION RATING REMARKS


1. Review the medical record and medical orders to determine the need
0 1 2 3
for the cast. ENSURE THAT THE RESULT OF X-RAY IS OBTAINED.
2. Perform hand hygiene. Put on gloves and/or other PPE, as indicated. 0 1 2 3
3. Identify the patient. Explain the procedure to the patient and verify
0 1 2 3
area to be casted.
4. Perform a pain assessment and assess for muscle spasm. Administer
prescribed medications in sufficient time to allow for the full effect of the 0 1 2 3
analgesic and/or muscle relaxant.
5. Close curtains around bed and close the door to the room, if possible.
Place the bed at an appropriate and comfortable working height, if 0 1 2 3
necessary.
6. Position the patient as needed, depending on the type of cast being
applied and the location of the injury. Support the extremity or body part to 0 1 2 3
be casted.
7. Drape the patient with the waterproof pads. 0 1 2 3
8. Cleanse and dry the affected body part. 0 1 2 3
B. PROCEDURE
1. Cleanse and dry the affected body part. 0 1 2 3
2. Position and maintain the affected body part in the position
indicated by the physician as the stockinette, sheet wadding, and
0 1 2 3
padding is applied. The stockinette should extend beyond the ends of
the cast. As the wadding is applied, check for wrinkles.

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3. Continue to position and maintain the affected body part in the
position indicated by the physician or advanced practice professional
0 1 2 3
as the casting material is applied. Assist with finishing by folding the
stockinette or other padding down over the outer edge of the cast.
4. Support the cast during hardening. Handle hardening plaster casts
with the palms of hands, not fingers. Support the cast on a firm,
0 1 2 3
smooth surface. Do not rest it on a hard surface or sharp edges. Avoid
placing pressure on the cast.
5. Elevate the injured limb above heart level with pillow or bath
blankets, as ordered, making sure pressure is evenly distributed under 0 1 2 3
the cast.
6. Place the bed in the lowest position, with the side rails up. 0 1 2 3
Make sure the call bell and other necessary items are within easy
0 1 2 3
reach.
7. Remove gloves and any other PPE, if used. Perform hand hygiene. 0 1 2 3
8. Instruct the patient to report pain, odor, COLOR OF DISTAL PART OF
EXTREMITY, drainage, changes in sensation, abnormal sensation, or 0 1 2 3
the inability to move fingers or toes of the affected extremity.
9. Leave the cast uncovered and exposed to the air. Reposition the
patient every 2 hours. Depending on facility policy, a fan may be used
to dry the cast. AS MUCH AS POSSIBLE WE DON’T ENCOURAGE USING
0 1 2 3
A FAN TO DRY THE CAST BECAUSE CHANCES ARE THE OUTER PART IS
DRY BUT THE INNER PART IS NOT WHICH CAN DESTROY THE
EFFICIENCY OF THE CAST






















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Far Eastern University
Institute of Nursing


PERFORMANCE EVALUATION TOOL FOR
CARE OF CAST (GUIDE ONLY NO RETURN DEMONSTRATION)

NAME: ____________________________ DATE: _________ SCORE: ______________
SEC & GRP NO: _______________ CONCEPT: ________________________________ FACULTY:
__________________________________________________________________

Direction: Rate the learners based on the competencies listed below.

NUMERICAL RATING DESCRIPTION
3 Performs expected competencies in a very consistent manner.
2 Performs expected competencies in a moderately consistent manner.
1 Performs expected competencies in a rarely consistent manner.
0 Does not perform expected competencies.



A. PREPARATION RATING REMARKS
1. Review the medical record and the nursing plan of care to
0 1 2 3
determine the need for cast care and care for the affected body part.
2. Perform hand hygiene. Put on PPE, as indicated. 0 1 2 3
3. Identify the patient. Explain the procedure to the patient. 0 1 2 3
4. Close curtains around bed and close the door to the room, if
possible. Place the bed at an appropriate and comfortable working 0 1 2 3
height, if necessary.
B. PROCEDURE
1. If a plaster cast was applied, handle the casted extremity or body
area with the palms of your hands for the first 24 to 36 hours, until 0 1 2 3
the cast is fully dry.
2. If the cast is on an extremity, elevate the affected area on pillows
covered with waterproof pads. Maintain the normal curvatures and 0 1 2 3
angles of the cast.
3. Keep cast (plaster) uncovered until fully dry. 0 1 2 3
4. Assess the condition of the cast. Be alert for cracks, dents, or the
presence of drainage from the cast. Perform skin
and neurovascular assessments according to facility policy, as often as 0 1 2 3
every 1 to 2 hours. Check for pain, edema, inability to move body
parts distal to the cast, pallor, pulses, and abnormal sensations. If the


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cast is on an extremity, compare it with the uncasted extremity.
5. If breakthrough bleeding or drainage is noted on the cast, mark the
area on the cast, according to facility policy. Indicate the date and
time next to the area. Follow physician orders or facility policy 0 1 2 3
regarding the amount of drainage that needs to be reported to the
physician.
6. Assess for signs of infection. Monitor the patient’s temperature.
Assess for a foul odor from the cast, increased pain, or extreme 0 1 2 3
warmth over an area of the cast.
7. Reposition the patient every 2 hours. Provide back and skin care
frequently. Encourage range-of-motion exercises for unaffected 0 1 2 3
joints. Encourage the patient to cough and deep breathe.
8. Instruct the patient to report pain, odor, drainage, and changes in
sensation, abnormal sensation, or the inability to move fingers or toes 0 1 2 3
of the affected extremity.
9. Remove PPE, if used. Place bed in lowest position. Perform hand
0 1 2 3
hygiene.
10. Document procedure. 0 1 2 3




























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RLE ONLINE LEARNING


PACKET












Page 203

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Far Eastern
U niversity
Institute of N ursing

INDIVIDUAL/ GROUP NURSING PROCESS FORMAT

I. TITLE PAGE (1 whole page)

A Case of:
(Diagnosis)___________

Presented by:
Name of Student / Group / Section

Presented to/Submitted to:


Name of Faculty__________

Submitted on:
Date Submitted_________

II. DEMOGRAPHIC PROFILE (Page 2)

Demographic Data
Name:
Address:
Age: Birth Date: Birth Place:
Gender:
Religion: Race/Ethnic Origin:
Occupation: Educational Attainment:
Marital Status: Name of Spouse:
Number of Children:
Chief Complaints:
Date of Admission:
Room & Bed Number:
Attending / Admitting Physician:
Admitting/Final Diagnosis:
Medical Insurance:

III. NURSING HEALTH HISTORY


A. History of Present Illness
1. Signs and Symptoms 4. Effect to other body parts/functions
2. Inclusive dates 5. Intervention/treatment done
3. Precipitating and alleviating factors 6. Effect of intervention/treatment

B. Past Health History


1. Immunizations 5. Accidents/Injuries

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2. Childhood Illness 6. Hospitalizations
3. Past Illnesses 7. Surgical procedures done
4. Heredofamilial disease 8. Travels local and abroad

C. Obstetric History (For OB Patients ONLY)


D. Pediatric History (For PEDIA Patients ONLY)
(Developmental Milestone)
• Focus on the discussion of physical, motor, cognitive, psychosocial development for growth and
development concept

E. Family History (Include genogram with legend)

Grandparents Grandparents

Aunts/Uncles Father Mother Aunts/Uncles

C
o
m
m
i
n
u
t
e

d

Spouse Patient Siblings

Children

Legend:
- Female ------ - Committed relationship (Married) X - Deceased
- Male --//-- - Broken relationship (Divorced)


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FEU- Institute of Nursing NUR 1217 Complete Course Module

IV. GORDON’S HEALTH ASSESSMENT


1. NARRATIVE form /
2. Analysis (with reference) & interpretation after each pattern

A. Health Perception – Health Management Pattern


♦ client’s perceived pattern of health and well-being and how health is managed.

B. Cognitive – Perceptual Pattern


♦ sensory, perceptual, and cognitive pattern according to age level

C. Self-perception – Self-concept Pattern


♦ self-concept and perception of self (body comfort, image, feeling state)

D. Role – Relationship Pattern


♦ pattern of role engagements & relationships according to ordinal position & role in society)

E. Sexuality – Reproductive Pattern


♦ pattern of satisfaction and dissatisfaction with sexuality pattern, describes reproductive
patterns according to age level

F. Coping – Stress Tolerance Pattern


♦ general coping patterns and effectiveness of the pattern in terms of stress tolerance

G. Value – Belief Pattern


♦ pattern of values and beliefs, including spiritual and moral that guide choices or
decisions according to age level
H. Nutritional- Metabolic Pattern
• Pattern of food and fluid consumption relative to metabolic need
• 3 day food recall

I. Elimination Pattern
• Pattern of excretory function (bowel, bladder, & sweating/vomiting)

J. Activity – Exercise Pattern


• Pattern of exercise, activity, leisure, and recreation (7 days)
K. Sleep – Rest Pattern
• Patterns of sleep, rest, and relaxation (7days)

V. PHYSICAL ASSESSMENT ( CEPHALO CAUDAL)


a. General Survey
b. Measurements (Height, Weight, BMI, Vital signs)

Assessment Body Part Norms Actual Findings Analysis & Interpretation


Method Used (Cephalo-caudal) (with reference)


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FEU- Institute of Nursing NUR 1217 Complete Course Module

VI. LABORATORY/DIAGNOSTIC EXAMINATIONS

Date Done Laboratory/Diagnostic Normal Values Actual Results Clinical Interpretation


Examination Interpretation & Analysis
(with reference)

VII. DRUG STUDY

Mechanism of
Contraindi- Adverse
Name of Drug Action Indication Side Nursing
cation Effects
Effects Responsibilities
Generic Name Classification

Brand Name Peak Effect

Route & Dosage

VIII. Problem Identification and Prioritization

Nursing Diagnosis Rank Justification


Cues according to Maslows

IX. NURSING CARE PLAN

Cues Nursing Analysis Goal Intervention Rationale Evaluation


Diagnosis
(with references) (Based on
Nsg prob)
Subjective a. Brief Objective a. Independent (With OUTCOME
NANDA explanation in reference) EVALUATION:
Objective narrative form (Based on Narrative
(at least 3 Etiology) Based on
each) b. Start from b. Dependent objective
diagnosis, to SMART
Measurement the etiology to PROCESS
symptoms c.Collaborative EVALUATION
then end point Parameters:
is the nursing Adequacy
problem Effectiveness
Appropriateness
Efficiency
Acceptability


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Far Eastern
U niversity
Institute of N ursing

THE EBN

A. EBN FORMAT FOR LEVEL II


1. General Question
2. Reconstruction of General Question related to client’s problem identified in the RLE.

PICO

Patient Intervention Comparison Outcome


Focus population

3. Critical Review with Summary of the Literature (Attach Literature to output)


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FEU- Institute of Nursing NUR 1217 Complete Course Module

Far Eastern
U niversity
Institute of N ursing

EVIDENCE BASED NURSING

Research journals should be up-to-date (year 2014 and up) from research databases (e.g. EBSCO) or from original
sources. Writing style and citation of sources should follow the APA format.

A. Anatomy of a good clinical question consists of:


1. How would you describe a group of patient similar to your client?
2. What are the most important characteristics of the patient? (This may include the primary problem,
disease or co-existing conditions)
3. Sometimes the gender, age, or race of a patient may be relevant to the diagnosis or treatment of a
disease.
B. Intervention, Prognostic Factor or Exposure
` 1. What main intervention, prognostic factor or exposure are you considering?
2. What do you want to do with a client? Why? And How?
a. Prevent a complication
b. Promote a healthy lifestyle
c. Resolve nursing problems
d. Facilitate nursing interventions
C. What factor may influence the prognosis of the client?
1. Age 3. Co-existing problems
2. Economic status 4. Familial factor
D. What was the client exposed to?
1. Cigarette smoke
2. Pollen
3. Asbestos
4. Pollutants
5. Others
E. Comparison
1. What is the main alternative to compare with the intervention?
2. Are you trying to decide between two interventions?
F. Outcome
1. What do you hope to accomplish, measure or effect
2. What are you trying to do for the patient
a. Relieve or eliminate the symptoms/discomfort
b. Reduce the number of adverse events
c. Improve functions

Note: The clinical question does not always need a specific comparison.

Patient/Problem Low back pain


Intervention Acupuncture
Comparison, if any Application of hot and cold compress
Outcome/s Relieves back pain
Promotes relaxation

G. From the given example, a clinical question can be devised:


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FEU- Institute of Nursing NUR 1217 Complete Course Module

Example: “Low Back Pain: Is acupuncture more effective than the application of hot and cold compress in
relieving back pain and promoting relaxation?”

H. Related Literature from research databases (e.g. EBSCO) and other sources.


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Far Eastern U niversity


Institute of Nursing

CLINICAL PERFORMANCE EVALUATION TOOL

NAME: ________________________________________________________ SEC & GRP NO: _________________________


CONCEPT: _____________________________INSTITUTION: _______________________ SHIFT: ________________
INCLUSIVE DATES: ________________________________________________________________ AREA: ______________

Direction: Rate the learners based on the competencies listed below.

NUMERICAL RATING DESCRIPTION
3 Performs expected competencies in a very consistent manner.
2 Performs expected competencies in a moderately consistent manner.
1 Performs expected competencies in a rarely consistent manner.
0 Does not perform expected competencies.

I. PATIENT CARE COMPETENCIES RATING REMARKS



A. Safe and Quality Nursing care
1. Gathers and analyzes comprehensive nursing health history 0 1 2 3
2. Performs appropriate physical assessment techniques 0 1 2 3
3. Identifies and analyzes the priority needs of patients 0 1 2 3
4. Determines appropriate nursing care to address needs/problems 0 1 2 3
5. Explains interventions to patients and family before implementation 0 1 2 3
6. Implements age-specific nursing intervention that is safe and comfortable 0 1 2 3
7. Performs nursing activities effectively and in a timely manner 0 1 2 3
8. Monitors effectiveness of nursing interventions 0 1 2 3
9. Conforms to the 10 golden rules in medication administration 0 1 2 3
10. Revises care plan based on expected outcomes 0 1 2 3


B. Health Education
1. Develops health education plan based on assessed and anticipated needs 0 1 2 3
2. Provides comprehensive & appropriate teaching relevant to patient’s condition 0 1 2 3
3. Utilizes appropriate strategies that maximize opportunities for behavior change 0 1 2 3


C. Communication
1. Establishes rapport with patient, significant others & members of the team 0 1 2 3
2. Demonstrates therapeutic communication skills during patient care 0 1 2 3
3. Identifies and interprets verbal and non-verbal cues 0 1 2 3
4. Utilizes effective channels of communication relevant to patient care 0 1 2 3

D. Collaboration and Team Work


1. Recommends appropriate intervention to improve patient care 0 1 2 3


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FEU- Institute of Nursing NUR 1217 Complete Course Module

2. Refers patient to other health team members whenever necessary 0 1 2 3
3. Provides for continuity of care through correct and comprehensive endorsement 0 1 2 3
4. Updates health team members on patient’s condition 0 1 2 3

II. ENABLING COMPETENCIES RATING REMARKS


A. Management of Resources and Environment


1. Identifies tasks or activities based on priorities 0 1 2 3
2. Finishes work assignment on time 0 1 2 3
3. Maximizes available resources to support patient care 0 1 2 3
4. Observes proper disposal of wastes 0 1 2 3
5. Observes proper hand washing and aseptic technique at all times 0 1 2 3


B. Records management
1. Presents comprehensive, neat, legibly written documents 0 1 2 3
2. Maintains accurate and updated Kardex, etc. 0 1 2 3
3. Documents/monitors proper record storage, retention and disposal 0 1 2 3

III. ENHANCING COMPETENCIES


A. Quality Improvement
1. Reports significant changes in patients’ condition /environment 0 1 2 3
2. Gives an objective and accurate report on observations rather than an
0 1 2 3
interpretation of the event

B. Research
1. Specifies researchable problems regarding patient care 0 1 2 3
2. Makes use of EBN to enhance nursing practice 0 1 2 3

IV. EMPOWERING COMPETENCIES


A. Legal Responsibility
1. Confirms information/orders given by the doctor 0 1 2 3
2. Acts in accordance with the established norms of conduct of the unit 0 1 2 3
3. Accomplishes accurate documentation in all matters in accordance to
0 1 2 3
the standards of nursing practice

B. Ethico Moral Responsibility


1. Renders nursing care consistent with the patient’s Bill of Rights 0 1 2 3
2. Understands the degree or responsibility and accountability based on
0 1 2 3
nursing actions and judgments
3. Justifies basis for nursing actions and judgment 0 1 2 3
4. Projects a positive image of the profession 0 1 2 3

C. Personal Growth and Development


1. Demonstrates punctuality in reporting for duty with complete
0 1 2 3
paraphernalia ready for use
2. Assists and observes in treatments and procedures 0 1 2 3
3. Behaves appropriately at all times 0 1 2 3
4. Listens to suggestions and recommendations 0 1 2 3
Total Score ÷ 132 X 100 = _________________
______________________________________ _________________________________________
Signature of Student Signature of Faculty

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Far Eastern U niversity


Institute of Nursing


PEER EVALUATION TOOL

GROUP & SECTION: __________________ DATE: ________________ SCORE: _________________________
CONCEPT: __________________________________ INCLUSIVE DATES: ______________________________________
Direction: Rate the learners based on the competencies listed below.

NUMERICAL RATING DESCRIPTION
3 Performs expected competencies in a very consistent manner.
2 Performs expected competencies in a moderately consistent manner.
1 Performs expected competencies in a rarely consistent manner.
0 Does not perform expected competencies.




BEHAVIOR
1. Has the initiative to work
2. Performs responsibility beyond task
3. Submits quality work
4. Submits work on time
5. Accepts constructive criticism
6. Relates well with peers
7. Able to share ideas during discussions
8. Punctual in group meetings/ activities
9. Participates actively in group activities
10. Accepts/Respects other’s opinions
11. Appropriately attired at all times


TOTAL



Total Score ÷ 33 X 100 = _________________

_______________________________________
Signature of Evaluator


Page 213

FEU- Institute of Nursing NUR 1217 Complete Course Module

Student Support

GUIDANCE OFFICE

Office Hours: 9:00 AM to 5:00 PM


E-mail: feuguidance@gmail.com
Contact No.: +63 287777338

INSTITUTE OF NURSING

Philip I. Prudencio
Secretary
Email: pprudencio@feu.edu.ph

Alma Trinidad R. Taragua, PhD


Department Head
Email: ataragua@feu.edu.ph


Page 214

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