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MEDICAL-SURGICAL NURSING
By: Anthony T. Villegas R.N.
B. NEUROGLIA
 Support and protection of neurons.
Overview of structures and functions:
NERVOUS SYSTEM
TYPES
 The functional unit of the nervous system is the nerve cells or
1. Astrocytes
neurons
 maintains blood brain barrier semi-permiable.
 The nervous system is composed of the ff:
 majority of brain tumors (90%) arises from called astrocytoma.
Central Nervous System
 integrity of blood brain barrier.
 Brain
2. Oligodendria
 Spinal Cord – serves as a connecting link between the brain & the
 produces myelin sheath in CNS.
periphery.
 act as insulator and facilitates rapid nerve impulse transmission.
Peripheral Nervous System
3. Microglia
 Cranial Nerves –12 pairs; carry impulses to & from the brain.
 stationary cells that carry on phagocytosis (engulfing of bacteria
 Spinal Nerves – 31 pairs; carry impulses to & from spinal cord.
or cellular debris, eating), pinocytosis (cell drinking).
Autonomic Nervous System
4. Epindymal
 subdivision of the PNS that automatically controls body function such
 secretes a glue called chemo attractants that concentrate the
as breathing & heart beat.
bacteria.
 Special senses of vision and hearing are also covered in this section

 Sympathetic nervous system – generally accelerate some body MACROPHAGE ORGAN


functions in response to stress. Microglia Brain
 Parasympathetic nervous system – controls normal body functioning. Monocytes Blood
Kupffers Kidney
CELLS Histiocytes Skin
A. NEURONS Alveolar Macrophage Lung

 Primary component of nervous system


 Composed of cell body (gray matter), axon, and dendrites
 Basic cells for nerve impulse and conduction. Central Nervous System

Axon Composition Of Brain


 Elongated process or fiber extending from the cell body  80% brain mass
 Transmits impulses (messages) away from the cell body to dendrites  10% blood
or directly to the cell bodies of other neurons  10% CSF
 Neurons usually has only one axon Brain Mass
Dendrites Parts Of The Brain
 Short, blanching fibers that receives impulses and conducts them 1. Cerebrum
toward the nerve cell body.  largest part of the brain
 Neurons may have many dendrites.  outermost area (cerebral cortex) is gray matter
Synapse  deeper area is composed of white matter
 Junction between neurons where an impulse is transmitted  function of cerebrum: integration, sensory, motor
Neurotransmitter  composed of two hemisphere the Right Cerebral Hemisphere
 Chemical agent (ex. Acetylcholine, norepinephrine) involved in the and Left Cerebral Hemisphere enclosed in the Corpus Callosum.
transmission of impulse across synapse.  Each hemisphere divided into four lobes; many of the functional
Myelin Sheath areas of the cerebrum have been located in these lobes:
 A wrapping of myelin (whitish, fatty material) that protects and
insulates nerve fibers and enhances the speed of impulse Lobes of Cerebrum
conduction. 1. Frontal Lobe
o Both axons and dendrites may or may not have a myelin  controls personality, behavior
sheath (myelinated/unmyelinated)  higher cortical thinking, intellectual functioning
o Most axons leaving the CNS are heavily myelinated  precentral gyrus: controls motor function
by schwann cells  Broca’s Area: specialized motor speech area - when damaged
results to garbled speech.
Functional Classification 2. Temporal Lobe
1. Afferent (sensory) neurons  hearing, taste, smell
 Transmit impulses from peripheral receptors to the CNS  short term memory
2. Efferent (motor) neurons  Wernicke’s area: sensory speech area
 Conduct impulses from CNS to muscle and glands (understanding/formulation of language)
3. Internuncial neurons (interneurons) 3. Pareital Lobe
 Connecting links between afferent and efferent neurons  for appreciation
Properties  integrates sensory information
1. Excitability – ability of neuron to be affected by changes in external  discrimination of sensory impulses to pain, touch, pressure,
environment. heat, cold, numbness.
2. Conductility – ability of neuron to transmit a wave of excitetation  Postcentral gyrus: registered general sensation (ex. Touch,
from one cell to another. pressure)
3. Permanent Cell – once destroyed not capable of regeneration. 4. Occipital Lobe
 for vision
TYPES OF CELLS BASED ON REGENERATIVE CAPACITY
1. Labile Insula (Island of Reil)
 Capable of regeneration.  visceral function activities of internal organ like gastric motility.
 Epidermal cells, GIT cells, GUT cells, cells of lungs. Limbic System (Rhinencephalon)
2. Stable  controls smell - if damaged results to anosmia (absence of
 Capable of regeneration with limited time, survival period. smell).
 Kidney cells, Liver cells, Salivary cells, pancreas.  controls libido
3. Permanent  controls long term memory
 Not capable of regeneration. Corpus Callosum
 Myocardial cells, Neurons, Bone cells, Osteocytes, Retinal Cells.  large fiber tract that connects the two cerebral hemisphere

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2

Basal Ganglia
 In thoracic region, contain cells giving rise to autonomic
 island of gray matter within white matter of cerebrum fibers of sympathetic nervous system
 regulate & integrate motor activity originating in the cerebral
cortex White Matter
 part of extrapyramidal system 1. Ascending Tracts (sensory pathways)
 area of gray matter located deep within each cerebral a. Posterior Column
hemisphere.  Carry impulses concerned with touch,
 release dopamine (controls gross voluntary movement).
pressure, vibration, & position sense
b. Spinocerebellar
2. Diencephalon/interbrain  Carry impulses concerned with muscle
 Connecting part of the brain, between the cerebrum & the brain tension & position sense to cerebellum
stem
 Contains several small structures: the thalamus & hypothalamus c. Lateral Spinothalamic
are most important  Carry impulses resulting in pain
Thalamus & temperature sensations
 acts as relay station for discrimination of sensory signals (ex. d. Anterior Spinothlamic
Pain, temperature, touch)  Carry impulses concerned with crude touch
 controls primitive emotional responses (ex. Rage, fear) & pressure
Hypothalamus 2. Descending Tracts (motor pathways)
 found immediately beneath the thalamus a. Corticospinal (pyramidal, upper motor neurons)
 plays a major role in regulation/controls of vital function: blood  Conduct motor impulses from motor cortex
pressure, thirst, appetite, sleep & wakefulness, temperature to anterior horn cells (cross in the medulla)
(thermoregulatory center) b. Extrapyramidal
 acts as controls center for pituitary gland and affects both  Help to maintain muscle tone & to control
divisions of the autonomic nervous system. body movement, especially gross automatic
 controls some emotional responses like fear, anxiety and movements such as walking
excitement.
 androgenic hormones promotes secondary sex characteristics.
Reflex Arc
 early sign for males are testicular and penile enlargement
 Reflex consists of an involuntary response to a stimulus
 late sign is deepening of voice.
occurring over a neural pathway called a reflex arc.
 early sign for females telarch and late sign is menarch.  Not relayed to & from brain: take place at cord levels

3. Mesencephalon/Midbrain Components
 acts as relay station for sight and hearing. a. Sensory Receptors
 size of pupil is 2 – 3 mm.  Receives/reacts to stimulus
 equal size of pupil is isocoria. b. Afferent Pathways
 unequal size of pupil is anisocoria.  Transmits impulses to spinal cord
 hearing acuity is 30 – 40 dB. c. Interneurons
 positive PERRLA  Synapses with a motor neuron (anterior horn cell)
d. Efferent Pathways
4. Brain Stem  Transmits impulses from motor neuron to effector
 located at lowest part of brain. e. Effectors
 contains midbrain, pons, medulla oblongata.  Muscle or organ that responds to stimulus
 extends from the cerebral hemispheres to the foramen magnum
at the base of the skull. Supporting Structures
 contains nuclei of the cranial nerves and the long ascending and 1. Skull
descending tracts connecting the cerebrum and the spinal cord.
 Rigid; numerous bones fused together
 contains vital center of respiratory, vasomotor, and cardiac
 Protects & support the brain
functions.
2. Spinal Column
 Consists of 7 cervical, 12 thoracic, & 5 lumbar vertebrae as well
Pons
as sacrum & coccyx
 pneumotaxic center controls the rate, rhythm and depth of
 Supports the head & protect the spinal cord
respiration.
3. Meninges
Medulla Oblongata
 Membranes between the skull & brain & the vertebral column &
 controls respiration, heart rate, swallowing, vomiting, hiccup,
spinal cord
vasomotor center (dilation and constriction of bronchioles).
 3 fold membrane that covers brain and spinal cord.
 For support and protection; for nourishment; blood supply
5. Cerebellum
 Area between arachnoid & pia mater is called subarachnoid
 smallest part of the brain, lesser brain.
space: CSF aspiration is done
 coordinates muscle tone and movements and maintains position
 Subdural space between the dura and arachnoid
in space (equilibrium)
 Layers:
 controls balance, equilibrium, posture and gait.
Dura Mater
 outermost layer, tough, leathery
Spinal Cord
Arachnoid Mater
 serves as a connecting link between the brain and periphery
 middle layer,
 extends from foramen magnum to second lumbar vertebra
weblike Pia Mater
 H-shaped gray matter in the center (cell bodies) surrounded by
 innermost layer, delicate, clings to surface of brain
white matter (nerve tract and fibers)
4. Ventricles
 Four fluid-filled cavities connecting with one another &
Gray Matter
spinal canal
1. Anterior Horns
 Produce & circulate cerebrospinal fluid
 Contains cell bodies giving rise to efferent (motor) fibers
5. Cerebrospinal Fluid (CSF)
2. Posterior Horns
 Surrounds brain & spinal cord
 Contains cell bodies connecting with afferent (sensory)
 Offer protection by functioning as a shock absorber
fibers from dorsal root ganglion
 Allows fluid shifts from the cranial cavity to the spinal cavity
3. Lateral Horns
 Carries nutrient to & waste product away from nerve cells

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3

 Component of CSF: CHON, WBC, Glucose 4 out of 6 extraocular movement.


6. Vascular Supply Trochlear : CN IV Motor: muscles for downward, inward,
 Two internal carotid arteries anteriorly movement of the eye
 Two vertebral arteries leading to basilar artery posteriorly Trigeminal : CN V Mixed: impulses from face, surface of
 These arteries communicate at the base of the brain through eyes (corneal reflex); muscle
the circle of willis Controlling mastication.
 Anterior, middle, & posterior cerebral arteries are the main Abducens : CN VI Motor: muscles for lateral deviation of
arteries for distributing blood to each hemisphere of the brain eye
 Brain stem & cerebellum are supplied by branches of the Facial : CN VII Mixed: impulses for taste from anterior
vertebral & basilar arteries tongue; muscles for facial
 Venous blood drains into dural sinuses & then into jugular veins Movement.
7. Blood-Brain-Barrier (BBB) Acoustic : CN VIII Sensory: impulses for hearing (cochlear
 Protective barrier preventing harmful agents from entering the division) & balance (vestibular
capillaries of the CNS; protect brain & spinal cord Division).
Glossopharyngeal : CN IX Mixed: impulses for sensation to posterior
Substance That Can Pass Blood-Brain Barrier tongue & pharynx; muscle
1. Amonia For movement of pharynx
 Cerebral toxin (elevation) & swallowing.
 Hepatic Encephalopathy (Liver Cirrhosis) Vagus : CN X Mixed: impulses for sensation to lower
 Ascites pharynx & larynx; muscle for
 Esophageal Varices Movement of soft palate, pharynx,
Early Signs of Hepatic Encephalopathy & larynx.
 Asterexis (flapping hand tremors). Spinal Accessory : CN XI Motor: movement of sternomastoid
Late Signs of Hepatic Encephalopathy muscles & upper part of trapezius
 Headache Muscles.
 Dizziness Hypoglossal : CN XII Motor: movement of tongue.
 Confusion
 Fetor hepaticus (amonia like breath) Autonomic Nervous System
 decrease LOC  Part of the peripheral nervous system
2. Carbon Monoxide and Lead Poisoning  Include those peripheral nerves (both cranial & spinal) that regulates
 Can lead to Parkinson’s Disease. smooth muscles, cardiac muscles, & glands.
 Epilepsy  Component:
 Treated with calcium EDTA. 1. Sympathetic Nervous System
3. Type 1 DM (IDDM)  Generally accelerates some body function in response to
 Causes diabetic ketoacidosis. stress.
 And increases breakdown of fats. 2. Parasympathetic Nervous System
 And free fatty acids  Controls normal body functioning
 Resulting to cholesterol and positive to ketones (CNS
depressant).
 Resulting to acetone breath odor/fruity odor.
 And kusshmauls respiration a rapid shallow respiration.
 Which may lead to diabetic coma.
4. Hepatitis
 Signs of jaundice (icteric sclerae).
 Caused by bilirubin (yellow pigment)
5. Bilirubin
 Increase bilirubin in brain (kernicterus).
 Causing irreversible brain damage.

Peripheral Nervous System

Spinal Nerves
 31 pairs: carry impulses to & from spinal cord
 Each segment of the spinal cord contains a pair of spinal nerves (one
of each side of the body)
 Each nerve is attached to the spinal by two roots:
1. Dorsal (posterior) roots
 contains afferent (sensory) nerve whose cell body is in
the dorsal roots ganglion
2. Ventral (anterior) roots
 Contains efferent (motor) nerve whose nerve fibers
originate in the anterior horn cell of the spinal cord
(lower motor neuron)

Cranial Nerves
 12 pairs: carry impulses to & from the brain.
 May have sensory, motor, or mixed functions.

Name & Number Function


Olfactory : CN I Sensory: carries impulses for sense of
smell.
Optic : CN II Sensory: carries impulses for vision.
Oculomotor : CN III Motor: muscles for papillary constriction,
elevation of upper eyelid;
Sympathetic Nervous System Parasympathetic Nervous System
(Adrenergic) Effect (Cholinergic) Effect, Vagal,
Sympatholytic

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4

- Involved in fight or aggression - Involved in flight or withdrawal


response. response.
- Release of Norepinephrine - Release of Acetylcholine.
(cathecolamines) from adrenal - Decreases all bodily activities
glands and causes except GIT.
vasoconstriction.
- Increase all bodily activity except
GIT EFFECTS OF PNS
- Constriction of pupils (miosis).
EFFECTS OF SNS - Increase salivation.
- Dilation of pupils (mydriasis) in - Decrease BP and Heart Rate.
order to be aware. - Bronchoconstriction, Decrease RR.
- Dry mouth (thickened saliva). - Diarrhea
- Increase BP and Heart Rate. - Urinary frequency.
- Bronchodilation, Increase RR
- Constipation.
- Urinary Retention.
- Increase blood supply to brain,
heart and skeletal muscles. I. Cholinergic Agents
- SNS - Mestinon, Neostignin.
SE:
I. Adrenergic Agents - PNS effect
- Give
Epinephrine. SE:
- SNS effect
Contraindication:
- Contraindicated to patients II. Anti-cholinergic Agents
suffering from COPD (Broncholitis, - To counter cholinergic agents.
Bronchoectasis, Emphysema, - Atrophine Sulfate
Asthma).
SE:
II. Beta-adrenergic Blocking Agents - SNS effect
- Also called Beta-blockers.
- all ending with “lol”

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e. - Abnormal posturing
Propranolol, (may
Atenelol, occur spontaneously or in response to stimulus)
Metoprolol.
Decorticate
 Effect Posturing: extension of leg, internal rotation & abduction of arms with flexion of elbows, wrist, & finger: (damage to corticospinal tract; cerebral
of Beta-blockers
Bhemisphere)
– broncho spasm
E – elicits a decrease in myocardial  Decerebrate Posturing: back arched, rigid extension of all
contraction. four extremities with hyperpronation of arms & plantar
T – treats hypertension. flexion of feet: (damage to upper brain stem, midbrain, or
A – AV conduction slows down. pons)
- Should be given to patients with
Angina, Myocardial Infarction, 2. Glasgow Coma Scale
Hypertension  Objective measurement of LOC sometimes called as the quick
neuro check
ANTI- HYPERTENSIVE AGENTS  Objective evaluation of LOC, motor / verbal response
1. Beta-blockers – “lol”  A standardized system for assessing the degree of neurologic
2. Ace Inhibitors – Angiotensin impairment in critically ill client
“pril” (Captopril, Enalapril)
3. Calcium Antagonist – Nifedipine Components
(Calcibloc) 1. Eye opening
- In chronic cases of arrhythmia 2. Verbal response
give Lidocane,
Effectors Xylocane.
:Sympathetic (Adrenergic) Effect Parasympathetic (Cholinergic) 3. Motor response
Effect
GCS Grading / Scoring
Eye dilate pupil (mydriasis) constrict pupil 1. Conscious 15 – 14
(miosis) 2. Lethargy 13 – 11
3. Stupor 10 – 8
Gland of Head 4. Coma 7
Lacrimal no effect stimulate 5. Deep Coma 3
secretions
Salivary scanty thick, viscous secretions copious thin watery secretions 3. Pupillary Reaction & Eye Movement
Dry mouth a. Observe size, shape, & equality of pupil (note size in millimeter)
b. Reaction to light: pupillary constriction
Heart increase rate & force of contraction decrease rate c. Corneal reflex: blink reflex in response to light stroking of
cornea
d. Oculocephalic reflex (doll’s eyes): present in unconscious client
Blood Vessel constrict smooth muscles of the skin, no effect with intact brainstem
Abdominal blood vessels, and 4. Motor Function
Cutaneous blood vessels a. Movement of extremities (paralysis)
Dilates smooth muscles of bronchioles, b. Muscle strength
Blood vessels of the heart & skeletal 5. Vital Signs: respiratory patterns (may help localize possible lesion)
muscles a. Cheyne-Stokes Respiration: regular rhythmic alternating
between hyperventilation & apnea; may be caused by structural
Lungs bronchodilation bronchoconstriction cerebral dysfunction or by metabolic problems such as diabetic
coma
b. Central Neurogenic Hyperventilation: sustained, rapid, regular
GI Tract decrease motility increase motility respiration (rate of 25/min) with normal O2 level; usually due to
Constrict sphincters relaxed sphincters brainstem dysfunction
Possibly inhibits secretions stimulate secretions c. Apneustic Breathing: prolonged inspiratory phase, followed by a
Inhibits activity of gallbladder & ducts stimulate activity of gallbladder& 2-to-3 sec pause; usually indicates dysfunction respiratory
ducts center in pons
Inhibits glycogenolysis in liver d. Cluster Breathing: cluster of irregular breathing, irregularly
followed by periods of apnea; usually caused by a lesion in
Adrenal Gland stimulates secretion of epinephrine & no effect upper medulla & lower pons
Norepinephrine e. Ataxic Breathing: breathing pattern completely irregular;
indicates damage to respiratory center of the medulla
Urinary Tract relaxes detrusor muscles contract
detrusor muscles
Contract trigone sphincter (prevent voiding) relaxes trigone Neurologic Exam
sphincter (allows voiding) 1. Mental status and speech (Cerebral Function)
a. General appearance & behavior
NEURO TRANSMITTER Decrease Increase b. LOC
Acethylcholine Myesthenia Gravis Bi-polar Disorder c. Intellectual Function: memory (recent & remote), attention
Dopamine Parkinson’s Disease Schizophrenia span, cognitive skills
d. Emotional status
Physical Examination e. Thought content
Comprehensive Neuro Exam f. Language / speech
Neuro Check 2. Cranial nerve assessment
1. Level of Consciousness (LOC) 3. Cerebellar Function: posture, gait, balance, coordination
a. Orientation to time, place, person a. Romberg’s Test: 2 nurses, positive for ataxia
b. Speech: clear, garbled, rambling b. Finger to Nose Test: positive result mean dimetria (inability of
c. Ability to follow command body to stop movement at desired point)
d. If does not respond to verbal stimuli, apply a painful stimulus 4. Sensory Function: light touch, superficial pain, temperature,
(ex. Pressure on the nailbeds, squeeze trapezius muscle); note vibration & position sense
response to pain 5. Motor Function: muscle size, tone, strength; abnormal or involuntary
 Appropriate: withdrawal, moaning movements
 Inappropriate: non-purposeful 6. Reflexes

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a. Deep tendon reflex: grade from 0 (no response); to 4


1. Test visual acuity or central vision or distance
(hyperactive); 2 (normal)  Use Snellen’s Chart
b. Superficial
 Snellen’s Alphabet chart: for literate client
c. Pathologic: babinski reflex (dorsiflexion of the great toe with
 Snellen’s E chart: for illiterate client
fanning of toes): indicates damage to corticospinal tracts
 Snellen’s Animal chart: for pediatric client
 Normal visual acuity 20/20
Level Of Consciouness (LOC)
 Numerator: is constant, it is the distance of person from the
1. Conscious: awake
chart (6-7 m, 20 feet)
2. Lethargy: lethargic (drowsy, sleepy, obtunded)  Denominator: changes, indicates distance by which the person
3. Stupor normally can see letter in the chart.
 Stuporous: (awakened by vigorous stimulation)  20/200 indicates blindness
 Generalized body weakness  20/20 visual acuity if client is able to read letters above the red
 Decrease body reflex line.
4. Coma 2. Test of visual field or peripheral vision
 Comatose a. Superiorly
 light coma: positive to all forms of painful stimulus b. Bitemporaly
 deep coma: negative to all forms of painful stimulus c. Nasally
d. Inferiorly
Different Painful Stimulation
1. Deep sternal stimulation / deep sternal pressure CRANIAL NERVE III, IV, VI: OCULOMOTOR, TROCHLEAR, ABDUCENS
2. Orbital pressure  Controls or innervates the movement of extrinsic ocular muscle (EOM)
3. Pressure on great toes  6 muscles:
4. Corneal or blinking reflex Superior Rectus Superior Oblique
 Conscious Client: use a wisp of cotton
 Unconscious Client: place 1 drop of saline solution

Test of Memory
1. Short term memory
 Ask most recent activity Lateral Rectus Medial Rectus
 Positive result mean anterograde amnesia and damage to
temporal lobe
2. Long term memory
 Ask for birthday and validate on profile sheet Inferior Oblique Inferior Rectus
 Positive result mean retrograde amnesia and damage to limbic  Trochlear: controls superior oblique
system
 Abducens: controls lateral rectus
 Consider educational background
 Oculomotor: controls the 4 remaining EOM

Level of Orientation
Oculomotor
1. Time: first asked
 Controls the size and response of pupil
2. Person: second asked
 Normal pupil size is 2 – 3 mm
3. Place: third asked
 Equal size of pupil: Isocoria
 Unequal size of pupil: Anisocoria
Cranial Nerves
 Normal response: positive PERRLA
Cranial Nerves Function
1. Olfactory S
CRANIAL NERVE V: TRIGEMINAL
2. Optic S
 Largest cranial nerve
3. Oculomotor M
 Consists of ophthalmic, maxillary, mandibular
4. Trochlear M (smallest)
 Sensory: controls sensation of face, mucous membrane, teeth, soft
5. Trigeminal B (largest)
palate and corneal reflex
6. Abducens M  Motor: controls the muscle of mastication or chewing
7. Facial B
 Damage to CN V leads to Trigeminal Neuralgia / Tic Douloureux
8. Acoustic S
 Medication: Carbamezapine (Tegretol)
9. Glossopharengeal B
10. Vagus B (longest)
CRANIAL NERVE VII: FACIAL
11. Spinal Accessory M
 Sensory: controls taste, anterior 2/3 of tongue
12. Hypoglossal M
 Pinch of sugar and cotton applicator placed on tip of tongue
 Motor: controls muscle of facial expression
CRANIAL NERVE I: OLFACTORY
 Instruct client to smile, frown and if results are negative there is
 Sensory function for smell
facial paralysis or Bell’s Palsy and the primary cause is forcep
Material Used delivery.
 Don’t use alcohol, ammonia, perfume because it is irritating and highly
diffusible.
CRANIAL NERVE VIII: ACOUSTIC, VESTIBULOCOCHLEAR
 Use coffee granules, vinegar, bar of soap, cigarette  Controls balance particularly kinesthesia or position sense, refers to
Procedure movement and orientation of the body in space.
 Test each nostril by occluding each nostril
Abnormal Findings
CRANIAL NERVE IX, X: GLOSOPHARENGEAL, VAGUS
1. Hyposnia: decrease sensitivity to smell
 Glosopharenageal: controls taste, posterior 1/3 of tongue
2. Dysosmia: distorted sense of smell
 Vagus: controls gag reflex
3. Anosmia: absence of smell
 Uvula should be midline and if not indicative of damage to cerebral
Either of the 3 may indicate head injury damaging the cribriform plate of
hemisphere
ethmoid bone where olfactory cells are located may indicate inflammatory
 Effects of vagal stimulation is PNS
conditions (sinusitis) CRANIAL NERVE XI: SPINAL ACCESSORY
 Innervates with sternocleidomastoid (neck) and trapezius (shoulder)
CRANIAL NERVE II: OPTIC
 Sensory function for vision or sight CRANIAL NERVE XII: HYPOGLOSSAL
Functions
 Controls the movement of tongue

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7

 Let client protrude tongue and it should be midline and if unable to


 Incident: Affects women more than men ages 20-40 are
do indicative of damage to cerebral hemisphere and/or has short
prone & more frequent in cool or temperate climate.
frenulum.

 Ig G - only antibody that pass placental circulation causing passive


Pathognomonic Signs: immunity, short term protection
1. PTB – low grade afternoon fever  Ig A - present in all bodily secretions (tears, saliva, colostrums).
2. PNEUMONIA – rusty sputum.  Ig M - acute in inflammation.
3. ASTHMA – wheezing on expiration.  Ig E - for allergic reaction
4. EMPHYSEMA – barrel chest.  Ig D - for chronic inflammation.
5. KAWASAKI SYNDROME – strawberry tongue
6. PERNICIOUS ANEMIA – red beefy tongue * Give palliative or supportive care.
7. DOWN SYNDROME – protruding tongue
8. CHOLERA – rice watery stool. S/sx
9. MALARIA – step ladder like fever with chills. 1. Visual disturbances
10. TYPHOID – rose spots in abdomen.  blurring of vision (primary)
11. DIPTHERIA – pseudo membrane.  diplopia (double vision)
12. MEASLES – koplick’s spots  scotomas (blind spots)
13. SLE – butterfly rashes. 2. Impaired sensation
14. LIVER CIRRHOSIS – spider like varices  touch, pain, pressure, temperature, or position sense
15. LEPROSY – lioning face  paresthesia such as tingling sensation, numbness
16. BOLIMIA – chipmunk face. 3. Mood swings or euphoria (sense of elation)
17. APPENDICITIS – rebound tenderness 4. Impaired motor function
18. DENGUE – petichae or positive herman’s sign.  weakness
19. MENINGITIS – kernig’s sign (leg pain), brudzinski sign (neck pain).  spasticity
20. TETANY – hypocalcemia (+) trousseu’s sign or carpopedal spasm/  paralysis
(+) chvostek sign (facial spasm). 5. Impaired cerebral function
21. TETANUS – risus sardonicus  scanning speech
22. PANCREATITIS – cullen’s sign (echymosis of umbilicus) / (+) grey  ataxic gait
turners spots.  nystagmus
23. PYLORIC STENOSIS – olive like mass.  dysarthria
24. PDA – machine like murmur  intentional tremor
25. ADDISON’S DISEASE – bronze like skin pigmentation. 6. Bladder
26. CUSHING’S SYNDROME – moon face appearance and buffalo hump.  Urinary retention or incontinence
27. HYPERTHYROIDSM/GRAVES DISEASE – exopthalmus. 7. Constipation
8. Sexual impotence in male / decrease sexual capacity

DEMYELINATING DISORDERS
TRIAD SIGNS OF MS

Alzheimer’s disease
Ataxia
 Atrophy of brain tissue due to deficiency of acetylcholine.
(unsteady gait,
positive romberg’s test)
S/sx
4 A’s of Alzheimer
a. Amnesia – loss of memory. CHARCOTS TRIAD
b. Agnosia – unable to recognized inanimate/familiar objects.
c. Apraxia – unable to determine purpose/ function of objects.
d. Aphasia – no speech (nodding).

*Expressive aphasia
Intentional tremors
 “motor speech center” unable to speak
Nystagmus
 Broca’s Aphasia
*Receptive aphasia
Dx
 inability to understand spoken words.
1. CSF Analysis: increase in IgG and Protein.
 Common to Alzheimer’s
2. MRI: reveals site and extent of demyelination.
 Wernike’s Aphasia
3. CT Scan: increase density of white matter.
 General Knowing Gnostic Area or General Interpretative
4. Visual Evoked Response (VER) determine by EEG: maybe delayed
Area.
5. Positive Lhermittes Sign: a continuous and increase contraction of
spinal column.
DOC
 Aricept (taken at bedtime)
Nursing Intervention
 Cognex
1. Assess the client for specific deficit related to location of demyelination
2. Promote optimum mobility
Management
a. Muscles stretching & strengthening exercises
1. Palliative & supportive
b. Walking exercises to improve gait: use wide-base gait
c. Assistive devices: canes, walker, rails, wheelchair as necessary
3. Administer medications as ordered
Multiple Sclerosis (MS)
a. ACTH (adreno chorticotropic hormone), Corticosteroids
 Chronic intermittently progressive disorder of CNS
(prednisone) for acute exacerbations: to reduce edema at site
characterized by scattered white patches of demyelination
of demyelination to prevent paralysis.
in brain and spinal cord.
b. Baclofen (Lioresal), Dantrolene (Dantrium), Diazepam (Valium) -
 Characterized by remission and exacerbation.
muscle relaxants: for spacity
 S/sx are varied & multiple, reflecting the location of
c. Beta Interferons - Immunosuppresants: alter immune response.
demyelination within the CNS.
4. Encourage independence in self-care activities
 Cause unknown: maybe a slow growing virus or possibly
5. Prevent complications of immobility
autoimmune disorders.
6. Institute bowel program
7. Maintain side rails to prevent injury related to falls.

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8

8. Institute stress management techniques.


Medulla Oblongata
a. Deep breathing exercises
b. Yoga Brain Herniation
9. Increase fluid intake and increase fiber to prevent constipation.
10. Maintain urinary elimination Increase intra cranial pressure
1. Urinary Retention
Nursing Intervention
a. perform intermittent catheterization as ordered: to prevent
1. alternate hot and cold compress to prevent hematoma
retention.
b. Bethanecol Chloride (Urecholine) as ordered
 CSF cushions brain (shock absorber)
Nursing Management
 Obstruction of flow of CSF will lead to enlargement of skull
 only given subcutaneous.
posteriorly called hydrocephalus.
 monitor side effects bronchospasm and wheezing.
 Early closure of posterior fontanels causes posterior enlargement of
 monitor breath sounds 1 hour after subcutaneous administration.
skull in hydrocephalus.
2. Urinary Incontinence
a. Establish voiding schedule
DISORDERS
b. Anti spasmodic agent Prophantheline Bromide (Pro-
Increase Intracranial Pressure (IICP)
banthine) if ordered
 Increase in intracranial bulk brought due to an increase in any of the
3. Force fluid to 3000 ml/day.
3 major intracranial components: Brain Tissue, CSF, Blood.
4. Promote use of acid ash diet like cranberry juice, plums, prunes,
 Untreated increase ICP can lead to displacement of brain tissue
pineapple, vitamin C and orange: to acidify urine and prevent
(herniation).
bacterial multiplication.
 Present life threatening situation because of pressure on vital
11. Prevent injury related to sensory problems.
structures in the brain stem, nerve tracts & cranial nerve.
a. Test bath water with thermometer.
 Increase ICP may be caused:
b. Avoid heating pads, hot water bottles.
 head trauma/injury
c. Inspect body parts frequently for injury.
 localized abscess
d. Make frequent position changes.
 cerebral edema
12. Prepare client for plasma exchange if indicated: to remove antibodies
 hemorrhage
13. Provide psychologic support to client/significant others.
 inflammatory condition (stroke)
a. Encourage positive attitude & assist client in setting realistic
 hydrocephalus
goals.
 tumor (rarely)
b. Provide compassion in helping client adapt to changes in body
image & self-concept.
S/sx
c. Do not encourage false hope during remission.
(Early signs)
d. Refer to MS societies & community agencies.
1. Decrease LOC
14. Provide client teaching & discharge planning concerning:
2. Irritability / agitation
a. General measures to ensure optimum health.
3. Progresses from restlessness to confusion & disorientation to
 Balance between activity & rest
lethargy & coma
 Regular exercise such as walking, swimming, biking in
mild case.
(Late signs)
 Use energy conservation techniques
1. Changes in Vital Signs (may be a late signs)
 Well-balance diet
a. Systolic blood pressure increases while diastolic pressure
 Fresh air & sunshine
remains the same (widening pulse pressure)
 Avoiding fatigue, overheating or chilling, stress,
b. Pulse rate decrease
infection.
c. Abnormal respiratory patterns (cheyne-stokes respiration)
b. Use of medication & side effects.
d. temperature increase directly proportional to blood pressure.
c. Alternative methods for sexual counseling if indicated.
2. Pupillary Changes
a. Ipsilateral (same side) dilatation of pupil with sluggish
COMMON CAUSE OF UTI
reaction to light from compression of cranial nerve III
Female
b. unilateral dilation of pupils called uncal herniation
- short urethra (3-5 cm, 1-1 ½ inches)
c. bilateral dilation of pupils called tentorial herniation
- poor perineal hygiene
d. Pupil eventually becomes fixed & dilated
- vaginal environment is moist
3. Motor Abnormalities
Nursing Management
a. Contralateral (opposite side) hemiparesis from
- avoid bubble bath (can alter Ph of vagina).
compression of corticospinal tract
- avoid use of tissue papers
b. abnormal posturing
- avoid using talcum powder and perfume.
c. decorticate posturing (damage to cortex and spinal
Male
cord).
- urethra (20 cm, 8 inches)
d. decerebrate posturing (damage to upper brain stem
- do not urinate after intercourse
that includes pons, cerebellum and midbrain).
4. Headache
INTRACRANIAL PRESSURE ICP
5. Projective Vomiting
6. Papilledema (edema of optic disc)
Monroe Kelly Hypothesis
7. Possible seizure activity

Skull is a closed container Nursing Intervention


1. Maintain patent airway and adequate ventilation by:
Any alteration or increase in one of the intracranial components a. Prevention of hypoxia (decrease O2) and hypercarbia
(increase CO2) important:
Increase intracranial pressure  Hypoxia may cause brain swelling which increase ICP
(normal ICP is 0 – 15 mmHg)
 Early signs of hypoxia:
 Restlessness
Cervical 1 – also known as
 Tachycardia
atlas. Cervical 2 – also known
 Agitation
as axis.
 Late signs of hypoxia:
 Extreme restlessness
Foramen Magnum
 Bradycardia

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9

 Dyspnea
 Epidural Sensor: least invasive method; placed in space
 Cyanosis between skull & dura matter for indirect measurement of
 Hypercarbia may cause cerebral vasodilation which ICP.
increase ICP c. Monitor ICP pressure readings frequently & prevent
 Hypercabia
complications:
 Increase CO2 (most powerful respiratory stimulant)  Normal ICP reading is 0-15 mmHg; a sustained increase
retention. above 15 mmHg is considered abnormal.
 In chronic respiratory distress syndrome decrease  Use strict aseptic technique when handling any part of the
O2 stimulates respiration. monitoring system.
b. Before and after suctioning hyperventilate the client with  Check insertion site for signs of infection; monitor
resuscitator bag connected to 100% O2 & limit suctioning temperature.
to 10 – 15 seconds only.  Assess system for CSF leakage, loose connections, air
c. Assist with mechanical hyperventilation as indicated: bubbles in he line, & occluded tubing.
produces hypocarbia (decease CO2) causing cerebral 9. Provide intensive nursing care for clients treated with barbiturates
constriction & decrease ICP. therapy or administration of paralyzing agents.
2. Monitor V/S, input and output & neuro check frequently to detect a. Intravenous administration of barbiturates may be ordered: to
increase in ICP induce coma artificially in the client who has not responded to
3. Maintain fluid balance: fluid restriction to 1200-1500 ml/day may be conventional treatment.
ordered b. Paralytic agents such as [vercuronium bromide (Norcuron)]:
4. Position the client with head of bed elevated to 30-45o angle with may be administered to paralyzed the client
neck in neutral position unless contraindicated to improve venous c. Reduces metabolic demand that may protect the brain from
drainage from brain. further injury.
5. Prevent further increase ICP by: d. Constant monitoring of the client’s ICP, arterial blood gas,
a. Provide comfortable and quite environment. serum barbiturates level, & ECG is necessary.
b. Avoid use of restraints. e. EEG monitoring as necessary
c. Maintain side rails. f. Provide appropriate nursing care for the client on a ventilator
d. Instruct client to avoid forms of valsalva maneuver like: 10. Observe for hyperthermia secondary to hypothalamus damage.
 Straining stool: administer stool softener & mild
laxatives as ordered (Dulcolax, Duphalac)
 Excessive vomiting: administer anti-emetics as ordered
(Plasil - Phil only, Phenergan)
 Excessive coughing: administer anti- *CONGESTIVE HEART FAILURE
tussive (dextromethorphan) Signs and Symptoms
 Avoid stooping/bending - dyspnea
 Avoid lifting heavy objects - orthopnea
e. Avoid clustering of nursing care activity together. - paroxysmal nocturnal dyspnea
6. Prevent complications of immobility. - productive cough
7. Administer medications as ordered: - frothy salivation
a. Hyperosmotic agent / Osmotic Diuretic [Mannitol (Osmitrol)]: to - cyanosis
reduce cerebral edema - rales/crackles
Nursing Management - bronchial wheezing
 Monitor V/S especially BP: SE hypotension. - pulsus alternans
 Monitor strictly input and output every hour: (output should - anorexia and general body malaise
increase): notify physician if output is less 30 cc/hr. - PMI (point of maximum impulse/apical pulse rate) is displaced
 Administered via side drip laterally
 Regulate fast drip to prevent crystal formation. - S3 (ventricular gallop)
b. Loop Diuretics [Furosemide, (Lasix)]: to reduce cerebral edema - Predisposing Factors/Mitral Valve
 drug of choice for CHF (pulmonary edema) o RHD
 loop of henle in kidneys. o Aging
Nursing Management
 Monitor V/S especially BP: SE hypotension. Treatment
 Monitor strictly input and output every hour: (output should Morphine Sulfate
increase): notify physician if output is less 30 cc/hr. Aminophelline
 Administered IV push or oral. Digoxin
 Given early morning Diuretics
 Immediate effect of 10-15 minutes. Oxygen
 Maximum effect of 6 hours. Gases, blood monitor
c. Corticosteroids [Dexamethasone (Decadron)]: anti-inflammatory
effect reduces cerebral edema RIGHT CONGESTIVE HEART FAILURE (venous congestion)
d. Analgesics for headache as needed: Signs and Symptoms
 Small dose of Codein SO4 - jugular vein distention (neck)
 Strong opiates may be contraindicated since they potentiate - ascites
respiratory depression, alter LOC, & cause papillary - pitting edema
changes. - weight gain
e. Anti-convulsants [Phenytoin (Dilantin)]: to prevent seizures. - hepatosplenomegaly
8. Assist with ICP monitoring when indicated: - jaundice
a. ICP monitoring records the pressure exerted within the cranial - pruritus
cavity by the brain, cerebral blood, & CSF - esophageal varices
b. Types of monitoring devices: - anorexia and general body malaise
 Intraventricular Catheter: inserted in lateral ventricle to
give direct measurement of ICP; also allows for drainage of
CSF if needed.
 Subarachnoid screw (bolt): inserted through the skull &
dura matter into subarachnoid space.

9
1
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5. Hyperuricemia
- increase uric acid (purine metabolism)
- foods high in uric acid (sardines, organ meats and anchovies)

*Increase in tophi deposit leads to gouty arthritis.


Signs and Symptoms
- joint pain (great toes)
Signs and Symptoms of Lasix in terms of electrolyte imbalances - swelling
1. Hypokalemia
- decrease potassium level Nursing Management
- normal value is 3.4 – 5.5 meq/L - force fluids
Sign and Symptoms - administer medications as ordered
- weakness and fatigue a. Allopurinol (Zylopril)
- constipation - drug of choice for gout.
- positive U wave on ECG tracing - mechanism of action: inhibits synthesis of uric acid.
Nursing Management b. Colchesine
- administer potassium supplements as ordered (Kalium Durule, Oral - acute gout
Potassium Chloride) - mechanism of action: promotes excretion of uric acid.
- increase intake of foods rich in potassium
* Kidney stones
Signs and Symptoms
- renal cholic
FRUITS VEGETABLES - cool moist skin
Apple Asparagus Nursing Management
Banana Brocolli - force fluids
Cantalope Carrots - administer medications as ordered
Oranges Spinach a. Narcotic Analgesic
- Morphine Sulfate
2. Hypocalcemia/Tetany - antidote: Naloxone (Narcan) toxicity leads to tremors.
- decrease calcium level b. Allopurinol (Zylopril)
- normal value is 8.5 – 11 mg/100 ml Side Effects
Signs and Symptoms - respiratory depression (check for RR)
- tingling sensation
- paresthesia Parkinson’s Disease/ Parkinsonism
- numbness  Chronic progressive disorder of CNS characterized by degeneration
- (+) Trousseus sign/Carpopedal spasm of dopamine producing cells in the substantia nigra of the midbrain
- (+) Chvostek’s sign and basal ganglia.
Complications  Progressive disorder with degeneration of the nerve cell in the basal
- arrythmia ganglia resulting in generalized decline in muscular function
- seizures  Disorder of the extrapyramidal system
Nursing Management  Usually occurs in the older population
- Calcium Glutamate per IV slowly as ordered  Cause Unknown: predominantly idiopathic, but sometimes disorder is
* Calcium Glutamate toxicity – results to seizure postencephalitic, toxic, arteriosclerotic, traumatic, or drug induced
(reserpine, methyldopa (aldomet) haloperidol (haldol),
Magnesium Sulfate phenothiazines).

Magnesium Sulfate toxicity Pathophysiology


S/S  Disorder causes degeneration of dopamine producing neurons in the
BP substantia nigra in the midbrain
Urine output DECREASE  Dopamine: influences purposeful movement
Respiratory rate  Depletion of dopamine results in degeneration of the basal ganglia
Patellar relfex absent
Predisposing Factors
3. Hyponatremia 1. Poisoning (lead and carbon monoxide)
- decrease sodium level 2. Arteriosclerosis
- normal value is 135 – 145 meq/L 3. Hypoxia
Signs and Symptoms 4. Encephalitis
- hypotension 5. Increase dosage of the following drugs:
- dehydration signs (initial sign in adult is thirst, in infant tachycardia) a. Reserpine (Serpasil)
- agitation b. Methyldopa (Aldomet) Antihypertensive
- dry mucous membrane c. Haloperidol (Haldol)
- poor skin turgor d. Phenothiazine Antipsychotic
- weakness and fatigue
Nursing Management Side Effects Reserpine: Major depression lead to suicide
- force fluids Aloneness
- administer isotonic fluid solution as ordered

4. Hyperglycemia
- normal FBS is 80 – 100 mg/dl Multiple loss
causes
Signs and Symptoms
suicide
- polyuria
- polydypsia Loss of spouse Loss of Job
- polyphagia Nursing Intervention for Suicide
Nursing Management  direct approach towards the client
- monitor FBS  close surveillance is a nursing priority
 time to commit suicide is on weekends early morning

1
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11

 No scattered rugs
S/sx  Hard-back or spring-loaded chair to make getting up easier
1. Tremor: mainly of the upper limbs “pill rolling tremors” of extremities 3. Provide measures to increase mobility
especially the hands; resting tremor: most common initial symptoms  Physical Therapy: active & passive ROM exercise; stretching
2. Bradykinesia: slowness of movement exercise; warm baths
3. Rigidity: cogwheel type  Assistive devices
4. Stooped posture: shuffling, propulsive gait  If client “freezes” suggest thinking of something to walk over
5. Fatigue 4. Encourage independence in self-care activities:
6. Mask like facial expression with decrease blinking of the eyes.  alter clothing for ease in dressing
7. Difficulty rising from sitting position.  use assistive device
8. Quite, monotone speech  do not rush the client
9. Emotional lability: state of depression 5. Improve communication abilities:
10. Increase salivation: drooling type  Instruct the client to practice reading a loud
11. Cramped, small handwriting  Listen to own voice & enunciate each syllable clearly
12. Autonomic Symptoms 6. Refer for speech therapy when indicated.
a. excessive sweating 7. Maintain adequate nutrition.
b. increase lacrimation  Cut food into bite-size pieces
c. seborrhea  Provide small frequent feeding
d. constipation  Allow sufficient time for meals, use warming tray
e. decrease sexual capacity 8. Avoid constipation & maintain adequate bowel elimination
9. Provide significant support to client/ significant others:
Nursing Intervention  Depression is common due to changes in body image & self-
1. Administer medications as ordered concept
Anti-Parkinson Drug 10. Provide client teaching & discharge planning concerning:
a. Levodopa (L-dopa) short acting a. Nature of the disease
 MOA: Increase level of dopamine in the brain; relieves b. Use prescribed medications & side effects
tremors; rigidity; bradykinesia c. Importance of daily exercise as tolerated: balanced activity &
 SE: GIT irritation (should be taken with meal); anorexia; rest
N/V; postural hypotension; mental changes: confusion,  walking
agitation, hallucination; cardiac arrhythmias; dyskinesias.  swimming
 CI: narrow-angled glaucoma; client taking MAOI inhibitor;  gardening
reserpine; guanethidine; methyldopa; antipsychotic; acute d. Activities/ methods to limit postural deformities:
psychoses  Firm mattress with small pillow
 Avoid multi-vitamins preparation containing vitamin B6  Keep head & neck as erected as possible
& food rich in vitamin B6 (Pyridoxine): reverses the  Use broad-based gait
therapeutic effects of Levodopa  Raise feet while walking
 Urine and stool may be darkened e. Promotion of active participation in self-care activities.
 Be aware of any worsening of symptoms with prolonged * Increase Vitamin B when taking INH (Isoniazid), Isonicotinic Acid Hydrazide
high-dose therapy: “on-off” syndrome. * Dopamine Agonist relieves tremor rigidity
b. Carbidopa-levodopa (Sinemet)
 Prevents breakdown of dopamine in the periphery & causes MAGIC 2’s IN DRUG MONITORING
fewer side effects. DRUG NORMAL RANGE TOXICITY INDICATION CLASS
c. Amantadine Hydrochloride (Symmetrel) LEVEL
 Used in mild cases or in combination with L-dopa to reduce Digoxin/Lanoxin .5 – 1.5 meq/L 2 CHF Cardia
rigidity, tremors, & bradykinesia (increase force of
cardiac output)
Anti-Cholinergic Drug Lithium/Lithane .6 – 1.2 meq/L 2 Bipolar Anti-M
a. Benztropine Mesylate (Cogentin) (decrease level of
b. Procyclidine (Kemadrine) Ach/NE/Serotonin)
c. Trihexyphenidyl (Artane) Aminophelline 10 – 19 mg/100 ml 20 COPD Bronch
 MOA: inhinit the action of acetylcholine; used in mild cases (dilates bronchial tree)
or in combination with L-dopa; relived tremors & rigidity Dilantin/Phenytoin 10 – 19 mg/100 ml 20 Seizures Anti-C
 SE: dry mouth; blurred vision; constipation; urinary Acetaminophen/Tylenol 10 – 30 mg/100 ml 200 Osteo Non-n
retention; confusion; hallucination; tachycardia Arthritis Analge
Anti-Histamines Drug
a. Diphenhydramine (benadryl) 1. Digitalis Toxicity
 MOA: decrease tremors & anxiety Signs and Symptoms
 SE: Adult: drowsiness Children: CNS excitement - nausea and vomiting
(hyperactivity) because blood brain barrier is not yet - diarrhea
fully developed. - confusion
b. Bromocriptine (Parlodel) - photophobia
 MOA: stimulate release of dopamine in the substantia nigra - changes in color perception (yellowish spots)
 Often employed when L-dopa loses effectiveness Antidote: Digibind
2. Lithium Toxicity
MAOI Inhibitor Signs and Symptoms
a. Eldepryl (Selegilene) - anorexia
 MOA: inhibit dopamine breakdown & slow progression of - nausea and vomiting
disease - diarrhea
- dehydration causing fine tremors
Anti-Depressant Drug - hypothyroidism
a. Tricyclic
 MOA: given to treat depression commonly seen in Nursing Management
Parkinson’s disease - force fluids
2. Provide safe environment - increase sodium intake to 4 – 10 g% daily
 Side rails on bed 3. Aminophelline Toxicity
 Rails & handlebars in the toilet, bathtub, & hallways Signs and Symptoms

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12

- tachycardia
Medical Management
- palpitations
1. Drug Therapy
- CNS excitement (tremors, irritability, agitation and restlessness)
a. Anti-cholinesterase Drugs: [Ambenonium (Mytelase),
Nursing Management Neostigmine (Prostigmin), Pyridostigmine (Mestinon)]
- only mixed with plain NSS or 0.9 NaCl to prevent development of crystals of  MOA: block the action of cholinesterase & increase the level
precipitate. of acetylcholine at the neuromuscular junction.
- administered sandwich method
 SE: excessive salivation & sweating, abdominal cramps, N/V,
- avoid taking alcohol because it can lead to severe CNS depression diarrhea, fasciculations (muscle twitching).
- avoid caffeine b. Corticosteroids: Prednisone
4. Dilantin Toxicity  MOA: suppress autoimmune response
Signs and Symptoms  Used if other drugs are not effective
- gingival hyperplasia (swollen gums) 2. Surgery (Thymectomy)
- hairy tongue a. Surgical removal of thymus gland: thought to be involve in the
- ataxia production of acetylcholine receptor antibodies.
- nystagmus b. May cause remission in some clients especially if performed
Nursing Management early in the disease.
- provide oral care 3. Plasma Exchange (Plasmapheresis)
- massage gums a. Removes circulating acetylcholine receptor antibodies.
5. Acetaminophen Toxicity b. Use in clients who do not respond to other types of therapy.
Signs and Symptoms
- hepatotoxicity (monitor for liver enzymes) Nursing Interventions
- SGPT/ALT (Serum Glutamic Pyruvate Transaminace) 1. Administer anti-cholinesterase drugs as ordered:
- SGOT/AST (Serum Glutamic Oxalo-Acetil Transaminace) a. Give medication exactly on time.
- nephrotoxicity monitor BUN (10 – 20) and Creatinine (.8 – 1) b. Give with milk & crackers to decrease GI upset
- hypoglycemia c. Monitor effectiveness of drugs: assess muscle strength & vital
Tremors, tachycardia capacity before & after medication.
Irritability d. Avoid use of the ff drugs:
Restlessness  Morphine SO4 & Strong Sedatives: respiratory
Extreme fatigue depressant effects
Diaphoresis, depression  Quinine, Curare, Procainamide, Neomycin,
Antidote: Acetylceisteine (mucomyst) prepare suction apparatus as bedside. Streptomycine, Kanamycine & other aminoglycosides:
skeletal muscle blocking effect
MYASTHENIA GRAVIS (MG) e. Observe for side effects
 neuromuscular disorder characterized by a disturbance in the 2. Promote optimal nutrition:
transmission of impulses from nerve to muscle cells at the a. Mealtime should coincide with the peak effect of the drugs: give
neuromuscular junction leading to descending muscle weakness. medication 30 minutes before meals.
 Incidence rate: b. Check gag reflex & swallowing ability before feeding.
 highest between 15 & 35 years old for women, over 40 for men. c. Provide mechanical soft diet.
 Affects women more than men d. If the client has difficulty in chewing & swallowing, do not leave
 Cause: alone at mealtime; keep emergency airway & suctioning
 Unknown/ idiopathic equipment nearby.
 Thought to be autoimmune disorder whereby antibodies destroy 3. Monitor respiratory status frequently: Rate, Depth, Vital Capacity;
acetylcholine receptor sites on the postsynaptic membrane of ability to deep breathe & cough
the neuromuscular junction. 4. Assess muscle strength frequently; plan activity to take advantage of
 Voluntary muscles are affected, especially those muscles innervated energy peaks & provide frequent rest periods.
by the cranial nerve. 5. Observe for signs of myasthenic or cholinergic crisis.
MYASTHENIC CRISIS CHOLINERGIC CRISIS
Pathophysiology  Abrupt onset of severe, generalized muscle  Symptoms similar to myasthen
 Autoimmune = Release of Cholinesterase Enzymes = Cholinesterase weakness with inability to swallow, speak, or addition the side effect of anti-c
destroy Acetylcholine (ACH) = Decrease of Acetylcholine (ACH) maintain respirations. drugs (excessive salivation & sw
 Acetylcholine: activate muscle contraction  Symptoms will improve temporarily abdominal carmp, N/V, diarrhea
 Autoimmune: it involves release of cholinesterase an enzyme that with tensilon test.  Symptoms worsen with tensilon
destroys Ach
Atropine Sulfate & emergency e
 Cholinesterase: an enzyme that destroys ACH hand.
Causes: Cause:
S/sx  under medication  over medication with the cholin
1. Initial sign is ptosis a clinical parameter to determine ptosis is  physical or emotional stress (anti-cholinesterase)
palpebral fissure: cracked or cleft in the lining or membrane of the  infection
eyelids Signs and Signs and Symptoms
2. Diplopia Symptoms  PNS
3. Dysphagia  the client is unable to see, swallow, speak,
4. Mask like facial expression breathe Treatment
5. Hoarseness of voice, weakness of voice Treatment  administer anti-cholinergic
6. Respiratory muscle weakness that may lead to respiratory arrest  administer cholinergic agents as ordered agen Sulfate)
7. Extreme muscle weakness especially during exertion and morning;
increase activity & reduced with rest. Nursing Care in Crisis:
a. Maintain tracheostomy set or endotracheal tube with mechanical
Dx ventilation as indicated.
1. Tensilon Test (Edrophonium Hydrochloride): IV injection of b. Monitor ABG & Vital Capacity
tensilon provides temporary relief of S/sx for about 5-10 minutes c. Administer medication as ordered:
and a maximum of 15 minutes.  Myasthenic Crisis: increase doses of anti-cholinesterase
 If there is no effect there is no damage to occipital lobe and drug as ordered.
midbrain and is negative for M.G.  Cholinergic Crisis: discontinue anti-cholinesterase drugs
2. Electromyography (EMG): amplitudes of evoked potentials decrease as ordered until the client recovers.
rapidly. d. Established method of communication
3. Presence of anti-acetlycholine receptors antibodies in the serum. e. Provide support & reassurance.

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13

6. Provide nursing care for the client with thymectomy.


d. ECG: due to arrhythmia
7. Provide client teaching & discharge planning concerning:
e. Observe signs of autonomic dysfunction: acute period of
a. Nature of the disease
hypertension fluctuating with hypotension
b. Use of prescribe medications their side effects & sign of toxicity f. Tachycardia
c. Importance of checking with physician before taking any new g. Arrhythmias
medication including OTC drugs 5. Maintain side rails to prevent injury related to fall
d. Importance of planning activities to take advantage of energy 6. Prevent complications of immobility: turning the client every 2 hrs
peaks & of scheduling frequent rest period 7. Assist in passive ROM exercise
e. Need o avoid fatigue, stress, people with upper respiratory 8. Promote comfort (especially in clients with sensory changes):
infection
a. Foot cradle
f. Use of eye patch for diplopia (alternate eyes)
b. Sheepskin
g. Need to wear medic-alert bracelet
c. Guided imagery
h. Myasthenia Gravis foundation & other community agencies
d. Relaxation techniques
9. Promote optimum nutrition:
Guillain-Barre Syndrome
a. Check gag reflex before feeding
 a disorder of the CNS characterized by bilateral, symmetrical,
b. Start with pureed food
peripheral polyneuritis characterized by ascending muscle paralysis.
c. Assess need for NGT feeding: if unable to swallow; to prevent
 Can occur at any age; affects women and men equally
aspiration
 Progression of disease is highly individual; 90% of clients stop
10. Administer medications as ordered
progression in 4 weeks; recovery is usually from 3-6 months; may
a. Corticosteroids: suppress immune response
have residual deficits.
b. Anti Cholinergic Agents:
Causes:
 Atrophine Sulfate
1. Unknown / idiopathic
c. Anti Arrythmic Agents:
2. May be autoimmune process
 Lidocaine (Xylocaine)
 Bretylium: blocks release of norepinephrine; to prevent
Predisposing Factors
increase of BP
1. Immunization
11. Assist in plasmapheresis (filtering of blood to remove autoimmune
2. Antecedent viral infections such as LRT infections
anti-bodies)
12. Prevent complications:
S/sx
a. Arrythmia
1. Mild Sensory Changes: in some clients severe misinterpretation of
b. Paralysis of respiratory muscles / respiratory arrest
sensory stimuli resulting to extreme discomfort
13. Provide psychologic support & encouragement to client / significant
2. Clumsiness (initial sign)
others
3. Progressive motor weakness in more than one limb (classically is
14. Refer for rehabilitation to regain strength & treat any residual deficits.
ascending & symmetrical)
4. Dysphagia: cranial nerve involvement
INFLAMMATORY CONDITIONS OF THE BRAIN
5. Ascending muscle weakness leading to paralysis
6. Ventilatory insufficiency if paralysis ascends to respiratory muscles
Meningitis
7. Absence or decreased deep tendon reflex
 Inflammation of the meninges of the brain & spinal cord.
8. Alternate hypotension to hypertension
 Cause by bacteria, viruses, & other M.O.
9. Arrythmia (most feared complication)
10. Autonomic disfunction: symptoms that includes
Etiology / Most Common M.O.
a. increase salivation
1. Meningococcus: most dangerous
b. increase sweating
2. Pneumococcus
c. constipation
3. Streptococcus: cause of adult meningitis
4. Hemophilus Influenzae: cause of pediatric meningitis
Dx
1. CSF analysis: reveals increased in IgG and protein
Mode of transmission
2. EMG: slowed nerve conduction
1. Airborne transmission (droplet nuclei)
2. Via blood, CSF, lymph
Medical Management
3. By direct extension from adjacent cranial structures (nasal, sinuses,
1. Mechanical Ventilation: if respiratory problems present
mastoid bone, ear, skull fracture)
2. Plasmapheresis: to reduce circulating antibodies
4. By oral or nasopharyngeal route
3. Continuous ECG monitoring to detect alteration in heart rate &
rhythm
Signs and Symptoms
4. Propranolol: to prevent tachycardia
2. Headache, photophobia, general body malaise, irritability,
5. Atropine SO4: may be given to prevent episodes of bradycardia
3. Projectile vomiting: due to increase ICP
during endotracheal suctioning & physical therapy
4. Fever & chills
5. Anorexia & weight loss
Nursing Intervention
6. Possible seizure activity & decrease LOC
1. Maintain patent airway & adequate ventilation:
7. Abnormal posturing: (decorticate and decerebrate)
a. Monitor rate & depth of respiration; serial vital capacity
8. Signs of Meningeal Irritation:
b. Observe for ventilatory insufficiency
a. Nuchal rigidity or stiff neck: initial sign
c. Maintain mechanical ventilation as needed
b. Opisthotonos (arching of back): head & heels bent backward &
d. Keep airway free of secretions & prevent pneumonia
body arched forward
2. Check individual muscle groups every 2 hrs in acute phase to check
c. PS: Kernig’s sign (leg pain): contraction or pain in the hamstring
progression of muscle weakness
muscles when attempting to extend the leg when the hip is
3. Assess cranial nerve function:
flexed
a. Check gag reflex
d. PS: Brudzinski sign (neck pain): flexion at the hip & knee
b. Swallowing ability
in response to forward flexion of the neck
c. Ability to handle secretion
d. Voice
4. Monitor strictly the following:
Dx
a. Vital signs
1. Lumbar Puncture:
b. Input and output
c. Neuro check

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 Measurement & analysis of CSF shows increased pressure,


3. SOB
elevated WBC & CHON, decrease glucose & culture positive for
4. Tachycardia
specific M.O.
5. Palpitations
 A hollow spinal needle is inserted in the subarachnoid space
6. Diaphoresis
between the L3-L4 or L4-L5.
7. Mild restlessness

Nursing Management Before Lumbar Puncture


S/sx of Cerebral Embolism
1. Secure informed consent and explain procedure.
1. Headache
2. Empty bladder and bowel to promote comfort.
2. disorientation
3. Encourage to arch back to clearly visualize L3-L4.
3. Confusion
4. Decrease LOC
Nursing Management Post Lumbar Puncture
o
1. Place flat on bed 12 – 24
S/sx Compartment syndrome
2. Force fluids
1. Fat embolism is the most feared complications w/in 24 hrs
3. Check punctured site for any discoloration, drainage and after a femur fracture.
leakage to tissues.
 Yellow bone marrow are produced from the medullary
4. Assess for movement and sensation of extremities.
cavity of the long bones and produces fat cells.
 If there is bone fracture there is hemorrhage and there
CSF analysis reveals would be escape of the fat cells in the circulation.
1. Increase CHON and WBC
2. Decrease glucose Risk Factors
3. Increase CSF opening pressure (normal pressure is 50 – 100 Disease:
mmHg) 1. Hypertension
4. (+) cultured microorganism (confirms meningitis) 2. Diabetes Mellitus
3. Atherosclerosis / Arteriosclerosis
CBC reveals 4. Myocardial Infarction
1. Increase WBC 5. Mitral valve replacement
6. Valvular Disease / replacement
Nursing Management 7. Chronic atrial Fibrillation
1. Administer large doses of antibiotic IV as ordered: 8. Post Cardiac Surgery
a. Broad spectrum antibiotics (Penicillin, Tetracycline)
b. Mild analgesics: for headaches Lifestyle:
c. Antipyretics: for fever 1. Smoking
2. Enforced strict respiratory isolation 24 hours after initiation of anti 2. Sedentary lifestyle
biotic therapy (for some type of meningitis) 3. Obesity (increase 20% ideal body weight)
3. Provide nursing care for increase ICP, seizure & hyperthermia if they 4. Hyperlipidemia more on genetics/genes that binds to cholesterol
occur 5. Type A personality
4. Provide nursing care for delirious or unconscious client as needed a. Deadline driven
5. Enforce complete bed rest b. Can do multiple tasks
6. Keep room quiet & dark: if the client has headache & photophobia c. Usually fells guilty when not doing anything
7. Monitor strictly V/S, I & O & neuro check 6. Related to diet: increase intake of saturated fats like whole milk
8. Maintain fluid & electrolyte balance 7. Related stress physical and emotional
9. Prevent complication of immobility 8. Prolong use of oral contraceptives: promotes lypolysis (breakdown of
10. Provide client teaching & discharge planning concerning: lipids) leading to atherosclerosis that will lead to hypertension &
a. Importance of good diet: high CHON, high calories with small eventually CVA.
frequent feedings.
b. Rehabilitation program for residual deficit Pathophysiology
 mental retardation 1. Interruption of cerebral blood flow for 5 min or more causes death
 delayed psychomotor development of neurons in affected area with irreversible loss of function.
c. Prevent complications 2. Modifying Factors:
 most feared is hydrocephalus a. Cerebral Edema:
 hearing loss/nerve deafness is second complication  Develops around affected area causing further impairment
 consult audiologist b. Vasospasm:
 Constriction of cerebral blood vessel may occur, causing
Cerebrovascular Accident (CVA) (Stroke/Brain Attack/Apoplexy/Cerebral further decrease in blood flow
Thrombosis) c. Collateral Circulation:
 Destruction (infarction) of brain cells caused by a reduction in  May help to maintain cerebral blood flow when there is
cerebral blood flow and oxygen compromise of main blood supply
 A partial or complete disruption in the brains blood supply.
 2 largest & most common cerebral artery affected by stroke: Stages of Development
a. Mid Cerebral Artery 1. Transient Ischemic Attack (TIA)
b. Internal Cerebral Artery a. Initial / warning signs of impending CVA / stroke
 Incidence Rate: b. Brief period of neurologic deficit:
a. Affects men more than women; Men are 2-3 times high risk;  Visual loss / Visual disturbance
Incidence increase with age  Hemiparesis
 Causes:  Slurred Speech / Speech disturbance
a. Thrombosis (attached)  Vertigo
b. Embolism (detached): most dangerous because it can go to the  Aphasia
lungs & cause pulmonary embolism or the brain & cause  Headache: initial sign
cerebral embolism.  Dizziness
c. Hemorrhage  Tinnitus
d. Compartment Syndrome: compression of nerves & arteries  Possible Increase ICP
c. May last less than 30 sec, but no more than 24 hrs with
S/sx Pulmonary Embolism complete resolution of symptoms
1. Sudden sharp chest pain 2. Stroke in Evolution
2. Unexplained dyspnea

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 Progressive development of stroke symptoms over a period of


a. Hyperosmotic agent: to decrease cerebral edema
hours to days
 Osmotic Diuretics (Mannitol)
3. Complete Stroke
 Loop Diuretics Furosemide (Lasix)
 Neurologic deficit remains unchanged for 2-3-days period
 Corticosteroids (Dexamethazone)
b. Anti-convulsants: to prevent or treat seizures
S/sx
c. Thrombolytic / Fibrinolytic Agents: given to dissolve clot
1. Headache
(hemorrhage must be ruled out)
2. Generalized Signs:
 Tissue Plasminogen Activating Factor (tPA, Alteplase): SE:
 Vomiting
allergic Reaction
 Seizure  Streptokinase, Urokinase: SE: chest pain
 Confusion d. Anticoagulants: for stroke in evolution or embolic stroke
 Disorientation (hemorrhage must be ruled out)
 Decrease LOC  Heparin: short acting
 Nuchal Rigidity  Check for Partial Thromboplastin Time (PTT): if
 Fever prolonged there is a risk for bleeding
 Hypertension  Antidote: Protamine SO4
 Slow Bounding Pulse  Warfarin (Comadin): long acting / long term therapy
 Cheyne-Strokes Respiration  Give simultaneously with Heparin cause Warfarin
 (+) Kernig’s & Brudzinski sign: may lead to hemorrhagic stroke (Coumadin) will take effect after 3 days
3. Focal Signs (related to site of infarction):  Check for Prothrombin Time (PT): if prolonged there is
 Hemiplegia a risk for bleeding
 Homonymous hemianopsia: loss of half of visual field  Antidote: Vitamin K (Aqua Mephyton)
 Sensory loss  Anti Platelet: to inhibit platelet aggregation in treating TIA’s
 Aphasia  PASA (Aspirin)
 Dysarthia: inability to articulate words  Contraindicated for dengue, ulcer and unknown cause
 Alexia: difficulty reading of headache because it may potentiate bleeding
 Agraphia: difficulty writing e. Antihypertensive: if indicated for elevated BP
f. Mild Analgesics: for pain
Dx 12. Provide client health teachings and discharge planning concerning
1. CT & Brain Scan: reveals brain lesions a. Avoid modifiable risk factors (diet, exercise, smoking)
2. EEG: abnormal changes b. Prevent complication (subarachnoid hemorrhage is the most
3. Cerebral Arteriography: invasive procedure due to injection of dye feared complication)
(iodine based); Uses dye for visualization c. Dietary modification (decrease salt, saturated fats and
 May show occlusion or malformation of blood vessels caffeine)
 Reveals the site and extent of malocclusion d. Importance of follow up care

Nursing Management Post Cerebral Arteriography Nursing Intervention: Rehabiltation


 Allergy Test (shellfish) 1. Hemiplegia: results from injury to cell in the cerebral motor cortex or
 Force fluids to release dye because it is nephro toxic to corticospinal tract (causes contralateral hemiplegia since tracts
 Check for peripheral pulse: distal (femoral) crosses medulla)
 Check for hematoma formation a. Turn every 2 hrs (20 min only on affected side)
b. Use proper positioning & repositioning to prevent deformities
Nursing Intervention: Acute Stage (foot drop, external rotation of hips, flexion of fingers, wrist
1. Maintain patent airway and adequate ventilation by: drop, abduction of shoulder & arms)
a. Assist in mechanical ventilation c. Support paralyzed arm on pillow or use sling while out of bed to
b. Administer O2 inhalation prevent subluxation of shoulders
2. Monitor strictly V/S, I & O, neuro check & observe signs of increase d. Elevate extremities to prevent dependent edema
ICP, shock, hyperthermia, & seizure e. Provide active & passive ROM exercises every 4 hrs
3. Provide CBR as ordered 2. Susceptibility to hazard
4. Maintain fluid & electrolyte balance & ensure adequate nutrition: a. Keep side rails up at all times
a. IV therapy for the first few days b. Institute safety measures
b. NGT for feeding the client who is unable to swallow c. Inspect body parts frequently for signs of injury
c. Fluid restriction as ordered: to decrease cerebral edema & might 3. Dysphagia: difficulty of swallowing
also increase ICP a. Check for gag reflex before feeding client
5. Maintain proper positioning & body alignment: b. Maintain a calm, unhurried approach
a. Elevate head 30-45 degree to decrease ICP c. Place client in upright position
b. Turn & reposition every 2 hrs (20 min only on the affected side) d. Place food in unaffected side of the mouth
c. Passive ROM exercise every 4 hrs: prevent contractures; e. Offer soft foods
promote body alignment f. Give mouth care before & after meals
6. Promote optimum skin integrity: turn client & apply lotion every 2 4. Homonymous Hemianopsia: loss of right or left half of each visual
hrs field
7. Prevent complications of immobility by: a. Approach the client on unaffected side
a. Turn client to side b. Place personal belongings, food etc., on unaffected side
b. Provide egg crate mattresses or water bed c. Gradually teach the client to compensate by scanning (ex.
c. Provide sand bag or food board. Turning the head to see things on affected side)
8. Maintain adequate elimination: 5. Emotional Lability: mood swings, frustrations
a. Offer bed pan or urinal every 2 hrs; catheterized only if a. Create a quiet, restful environment with a reduction in excessive
necessary sensory stimuli
b. Administer stool softener & suppositories as ordered: to prevent b. Maintain a calm, non-threatening manner
constipation & fecal impaction c. Explain to family that client’s behavior is not purposeful
9. Provide quiet, restful environment 6. Aphasia: most common in right hemiplegics; may be receptive /
10. Provide alternative means of communication to the client: expressive
a. Non verbal cues a. Receptive Aphasia
b. Magic slate: not paper & pen tiring for client  Give simple, slow directions
c. If positive to hemianopsia: approach client on unaffected side  Give one command at a time; gradually shift topics
11. Administer medications as ordered:

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 Use non-verbal techniques of communication (ex.


b. Absence Seizure (Petit mal Seizure):
Pantomime, demonstration)
 Usually non-organic brain damage present
b. Expressive Aphasia
 Must be differentiated from daydreaming
 Listen & watch very carefully when the client attempts
 Sudden onset with twitching & rolling of eyes that last 20-40 sec
to speak
 Common among pediatric clients characterized by:
 Anticipate client’s needs to decrease frustrations & feeling
 Blank stare
of helplessness
 Decrease blinking of eyes
 Allow sufficient time for client to answer
 Twitching of mouth
7. Sensory / Perceptual Deficit: more common in left hemiplegics;
 Loss of consciousness (5 – 10 seconds)
characterized by impulsiveness unawareness of disabilities, visual
neglect (neglect of affected side & visual space on affected side)
2. Partial or Localized Seizure
a. Assist with self-care
 Begins in focal area of brain & symptoms are related to a
b. Provide safety measures
dysfunction of that area
c. Initially arrange objects in environment on unaffected side
 May progress into a generalized seizure
d. Gradually teach client to take care of the affected & turn
a. Jacksonian Seizure (focal seizure)
frequently & look at affected side
 characterized by tingling and jerky movement of index
8. Apraxia: loss of ability to perform purposeful, skilled acts
finger and thumb that spreads to the shoulder and other
a. Guide client through intended movement (ex. Take object such
side of the body.
as wash cloth & guide client through movement of washing)
b. Psychomotor Seizure (focal motor seizure)
b. Keep repeating the movement
 May follow trauma, hypoxia, drug use
9. Generalizations about the clients with left hemiplegia vs.
 Purposeful but inappropriate repetitive motor acts
right hemiplegia & nursing care
 Aura is present: daydreaming like
a. Left Hemiplegia
 Automatism: stereotype repetitive and non propulsive
 Perceptual, sensory deficits: quick & impulsive behavior
behavior
 Use safety measures, verbal cues, simplicity in all area of
 Clouding of consciousness: not in contact with environment
care
 Mild hallucinatory sensory experience
b. Right Hemiplegia
 Speech-language deficits: slow & cautious behavior
3. Status Epilepticus
 Use pantomime & demonstration
 Usually refers to generalized grand mal seizure
 Seizure is prolong (or there are repeated seizures without
CONVULSIVE DISORDER/CONVULSION
regaining consciousness) & unresponsive to treatment
 disorder of CNS characterized by paroxysmal seizure with or without
 Can result in decrease in O2 supply & possible cardiac arrest
loss of consciousness abnormal motor activity alternation in
 A continuous uninterrupted seizure activity
sensation and perception and changes in behavior.
 If left untreated can lead to hyperpyrexia and lead to coma and
 Seizure: first convulsive attack
eventually death.
 Epilepsy: second or series of attacks
 DOC: Diazepam (Valium) & Glucose
 Febrile seizure: normal in children age below 5 years

C. Diagnostic Procedures
Predisposing Factors
1. CT Scan – reveals brain lesions
1. Head injury due to birth trauma
2. EEG – reveals hyper activity of electrical brain waves
2. Genetics
3. Presence of brain tumor
D. Nursing Management
4. Toxicity from the ff:
1. Maintain patent airway and promote safety before seizure activity
a. Lead
a. clear the site of blunt or sharp objects
b. Carbon monoxide
b. loosen clothing of client
5. Nutritional and Metabolic deficiencies
c. maintain side rails
6. Physical and emotional stress
d. avoid use of restrains
7. Sudden withdrawal to anti-convulsant drug: is predisposing factor for
e. turn clients head to side to prevent aspiration
status epilepticus: DOC: Diazepam (Valium) & Glucose
f. place mouth piece of tongue guard to prevent biting or tongue
2. Avoid precipitating stimulus such as bright/glaring lights and noise
S/sx
3. Administer medications as ordered
 Dependent on stages of development or types of seizure
a. Anti convulsants (Dilantin, Phenytoin)
1. Generalized Seizure
b. Diazepam, Valium
 Initial onset in both hemisphere, usually involves loss
c. Carbamazepine (Tegnetol) – trigeminal neuralgia
of consciousness & bilateral motor activity.
d. Phenobarbital, Luminal
a. Major Motor Seizure (Grand mal Seizure): tonic-clonic seizure
4. Institute seizure and safety precaution post seizure attack
 Signs or aura with auditory, olfactory, visual, tactile,
a. administer O2 inhalation
sensory experience
b. provide suction apparatus
 Epileptic cry: is characterized by fall and loss of
5. Document and monitor the following
consciousness for 3-5 minutes
a. onset and duration
 Tonic Phase:
b. types of seizures
 Limbs contract or stiffens
c. duration of post ictal sleep may lead to status epilepticus
 Pupils dilated & eye roll up to one side
d. assist in surgical procedure cortical resection
 Glottis closes: causing noise on exhalation
 May be incontinent
Overview Anatomy & Physiology of the Eye
 Occurs at same time as loss of consciousness last 20-
40 sec
External Structure of Eye
 Tonic contractions: direct symmetrical extension of
a. Eyelids (Palpebrae) & Eyelashes: protect the eye from foreign
extremities
particles
 Clonic Phase:
b. Conjunctiva:
 repetitive movement
 Palpebral Conjunctiva: pink; lines inner surface of eyelids
 increase mucus production
 Bulbar Conjunctiva: white with small blood vessels, covers
 slowly tapers
anterior sclera
 Clonic contractions: contraction of extremities
c. Lacrimal Apparatus (lacrimal gland & its ducts & passage): produces
 Postictal sleep: unresponsive sleep
tears to lubricate the eye & moisten the cornea; tears drain into the
 Seizure ends with postictal period of confusion, drowsiness
nasolacrimal duct, which empties into nasal cavity

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d. The movement of the eye is controlled by 6 extraocular muscles


Accommodation of lenses: based on thelmholtz theory of accommodation
(EOM)
Near Vision: Ciliary muscle contracts: Lens bulges

Internal Structure of Eye


Far Vision: ciliary muscle dilates / relaxes: lens is flat
A. 3 layers of the eyeball
1. Outer Layer
a. Sclera: tough, white connective tissue (“white of the eye”);
Convergence of the eye:
located anteriorly & posteriorly
Error:
b. Cornea: transparent tissue through which light enters the
1. Exotropia:1 eye normal
eye; located anteriorly
2. Esophoria: corrected by corrective
2. Middle Layer
eye surgery
a. Choroid: highly vascular layer, nourishes retina; located
3. Strabismus: squint eye
posteriorly
4. Amblyopia: prolong squinting
b. Ciliary Body: anterior to choroid, secrets aqueous humor;
muscle change shape of lens Common Visual Disorder
c. Iris: pigmented membrane behind cornea, gives color to Glaucoma
eye; located anteriorly  Characterized by increase intraocular pressure resulting in
d. Pupil: is circular opening in the middle of the iris that progressive loss of vision
constrict or dilates to regulate amount of light entering the  May cause blindness if not recognized & treated
eye  Early detection is very important
3. Inner Layer  preventable but not curable
a. Light-sensitive layer composed of rods & cones (visual cell)  Regular eye exam including tonometry for person over age 40 is
 Cones: specialized for fine discrimination & color recommended
vision; (daylight / colored vision)
 Rods: more sensitive to light than cones, aid Predisposing Factors
in peripheral vision; (night twilight vision) 1. Common among 40 years old and above
b. Optic Disk: area in retina for entrance of optic nerve, has 2. Hereditary
no photoreceptors 3. Hypertension
4. Obesity
B. Lens: transparent body that focuses image on retina 5. History of previous eye surgery, trauma, inflammation
C. Fluid of the eye
1. Aqueous Humor: clear, watery fluid in anterior & posterior
chambers in anterior part of eye; serves as refracting medium & Types of Glaucoma:
provides nutrients to lens & cornea; contribute to maintenance 1. Chronic (open-angle) Glaucoma:
of intraocular pressure  Most common form
2. Vitreous Humor: clear, gelatinous material that fills posterior  Due to obstruction of the outflow of aqueous humor, in
cavity of eye; maintains transparency & form of eye trabecular meshwork or canal of schlemm
Visual Pathways 2. Acute (close-angle) Glaucoma:
a. Retina (rods & cones) translates light waves into neural impulses  Due to forward displacement of the iris against the cornea,
that travel over the optic nerves obstructing the outflow of the aqueous humor
b. Optic nerves for each eye meet at the optic chiasm  Occurs suddenly & is an emergency situation
 Fibers from median halves of the retinas cross here & travel  If untreated it will result to blindness
to the opposite side of the brain 3. Chronic (close-angle) Glaucoma:
 Fibers from lateral halves of retinas remain uncrossed  similar to acute (close-angle) glaucoma, with the potential for
c. Optic nerves continue from optic chiasm as optic tracts & travels to an acute attack
the cerebrum (occipital lobe) where visual impulses are perceived &
interpreted S/sx
1. Chronic (open-angle) Glaucoma: symptoms develops slowly
 Impaired peripheral vision (PS: tunnel vision)
Canal of schlemm: site of aqueous humor drainage  Halos around light
Meibomian gland: secrets a lubricating fluid inside the eyelid  Mild discomfort in the eye
Maculla lutea: yellow spot center of retina  Loss of central vision if unarrested
Fovea centralis: area with highest visual acuity or acute vision 2. Acute (close-angle) Glaucoma
 Severe eye pain
2 muscles of iris:  Blurred cloudy vision
Circular smooth muscle fiber: Constricts the pupil  Halos around light
Radial smooth muscle fiber: Dilates the pupil  N/V
 Steamy cornea
Physiology of vision  Moderate pupillary dilation
4 Physiological processes for vision to occur: 3. Chronic (close-angle) Glaucoma
1. Refraction of light rays: bending of light rays  Transient blurred vision
2. Accommodation of lens  Slight eye pain
3. Constriction & dilation of pupils  Halos around lights
4. Convergence of eyes
Dx
Unit of measurements of refraction: diopters 1. Visual Acuity: reduced
Normal eye refraction: emmetropia 2. Tonometry: reading of 24-32 mmHg suggest glaucoma; may be 50
Normal IOP: 12-21 mmHg mmHg of more in acute (close-angle) glaucoma
3. Ophthalmoscopic exam: reveals narrowing of small vessels of optic
Error of Refraction
disk, cupping of optic disk
1. Myopia: nearsightedness: Treatment: biconcave lens
4. Perimetry: reveals defects in visual field
2. Hyperopia: farsightedness: Treatment: biconvex lens
5. Gonioscopy: examine angle of anterior chamber
3. Astigmatisim: distorted vision: Treatment: cylindrical
4. Presbyopia: “old sight” inelasticity of lens due to aging: Treatment:
Medical Management
bifocal lens or double vista
1. Chronic (open-angle) Glaucoma
a. Drug Therapy: one or a combination of the following

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 Miotics eye drops (Pilocarpine): to increase outflow of


aqueous humor
Nursing Intervention
 Epinephrine eye drops: to decrease aqueous humor
1. Prepare client for cataract surgery:
production & increase outflow
a. Performed when client can no longer remain independent
 Carbonic Anhydrase Inhibitor: Acetazolamide (Diamox): to
because of reduced vision
decrease aqueous humor production
b. Surgery performed on one eye at a time; usually in a same day
 Timolol Maleate (Timoptic): topical beta-adrenergic blocker:
surgery unit
to decrease intraocular pressure (IOP)
c. Local anesthesia & intravenous sedation usually used
b. Surgery (if no improvement with drug)
d. Types of cataract surgery:
 Filtering procedure (Trabeculectomy / Trephining): to
 Extracapsular Extraction: lens capsule is excised & the lens
create artificial openings for the outflow of aqueous humor
is expressed; posterior capsule is left in place (may be used
 Laser Trabeculoplasty: non-invasive procedure performed
to support new artificial lens implant); partial removal of
with argon laser that can be done on an out-client basis;
lens
procedure similar result as trabeculectomy
 Phacoemulsification: type of extracapsular extraction; a
2. Acute (close-angle) Glaucoma
hollow needle capable of ultrasonic vibration is inserted
a. Drug Therapy: before surgery
into lens, vibrations emulsify the lens, which is aspirated
 Miotics eye drops (Pilocarpine): to cause pupil to contract &
 Intracapsular Extraction: lens is totally removed within its
draw iris away from cornea
capsules, may be delivered from eye by cryoextraction (lens
 Osmotic Agent (Glycerin oral, Mannitol IV): to decrease
is frozen with metal probe & removed); total removal of
intraocular pressure (IOP)
lens & surrounding capsules
 Narcotic Analgesic: for pain
e. Peripheral Iridectomy: may be performed at the time of surgery;
b. Surgery
small hole cut in iris to prevent development of secondary
 Peripheral Iridectomy: portion of the iris is excised to
glaucoma
facilitate outflow of aqueous humor
f. Intraocular Lens Implant: often performed at the time of
 Argon Laser Beam Surgery: non-invasive procedure using
surgery
laser produces same effect as iridectomy; done in out-client
2. Nursing Intervention Pre-op
basis
a. Assess vision in the unaffected eye since the affected eye will be
 Iridectomy: usually performed on second eye later since a
patched post-op
large number of client have an acute acute attack in the
b. Provide pre-op teaching regarding measures to prevent
other eye
intraocular pressure (IOP) post-op
3. Chronic (close-angle) Glaucoma
c. Administer medication as ordered:
a. Drug Therapy:
 Topical Mydriatics (Mydriacyl) & Cyclopegics (Cyclogyl): to
 miotics (pilocarpine)
dilate the pupil
b. Surgery:
 Topical antibiotics: to prevent infection
 bilateral peripheral iridectomy: to prevent acute attacks
 Acetazolamide (Diamox) & osmotic agent (Oral Glycerin or
Mannitol IV): to decrease intraocular pressure to provide
Nursing Intervention
soft eyeball for surgery
1. Administer medication as ordered
3. Nursing Intervention Post-op
2. Provide quite, dark environment
a. Reorient the client to surroundings
3. Maintain accurate I & O with the use of osmotic agent
b. Provide safety measures:
4. Prepare client for surgery if indicated
 Elevate side rails
5. Provide post-op care
 Provide call bells
6. Provide client teaching & discharge planning
 Assist with ambulation when fully recovered from
a. Self-administration of eye drops
anesthesia
b. Need to avoid stooping, heavy lifting or pushing, emotional c. Prevent intraocular pressure & stress on the suture line:
upsets, excessive fluid intake, constrictive clothing around the
 Elevate head of the bed 30-40 degree
neck
 Have the client lie on back or unaffected side
c. Need to avoid the use antihistamines or sympathomimetic drugs
 Avoid having the client cough, sneeze, bend over, or move
(found in cold preparation) in close-angle glaucoma since they
head too rapidly
may cause mydriasis
 Treat nausea with anti-emetics as ordered: to prevent
d. Importance of follow-up care
vomiting
e. Need to wear medic-alert tag  Give stool softener as ordered: to prevent straining
 Observe for & report signs of intraocular pressure (IOP):
Cataract  Severe eye pain
 Decrease opacity of ocular lens  Restlessness
 Incidence increases with age  Increased pulse
4. Protect eye from injury:
Predisposing Factor a. Dressing usually removed the day after the surgery
1. Aging 65 years and above b. Eyeglasses or eye shield used during the day
2. May caused by changes associated with aging (“senile” cataract) c. Always use eye shield during the night
3. Related to congenital 5. Administer medication as ordered:
4. May develop secondary to trauma, radiation, infection, certain drugs a. Topical mydriatics & cycloplegic: to decrease spasm of ciliary
(corticosteroids) body & relieve pain
5. Diabetes Mellitus b. Topical antibiotics & corticosteroids
6. Prolonged exposure to UV rays c. Mild analgesic as needed
6. Provide client teaching & discharge planning concerning:
S/sx a. Technique of eyedrop administration
1. Loss of central vision b. Use of eye shield at night
2. Blurring or hazy vision c. No bending, stooping, or lifting
3. Progressive decrease of vision d. Report signs & symptoms of complication immediately
4. Glare in bright lights to physician:
5. Milky white appearance at center of pupils  Severe eye pain
6. Decrease perception to colors  Decrease vision
 Excessive drainage
Diagnostic Procedure  Swelling of eyelid
1. Ophthalmoscopic exam: confirms presence of cataract e. Cataract glasses / contact lenses

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 If a lens implant has not been performed the client


f. Need to check to physician regarding combing & shampooing
will need glasses or contact lenses
hair & shaving
 Temporary glasses are worn for 1-4 weeks then permanent g. Need to report complications such as recurrence of detachment
glasses fitted
 Cataract glasses magnify object by 1/3 & distortion
Overview of Anatomy & Physiology Of Ear (Hearing)
peripheral vision
External Ear
 Have the client practice manual coordination with
1. Auricle (Pinna): outer projection of ear composed of cartilage &
assistance until new spatial relationship becomes
covered by skin; collects sound waves
familiar
2. External Auditory Canal: lined with skin; glands secretes cerumen
 Have client practice walking, using stairs, reaching for
(wax), providing protection; transmits sound waves to tympanic
articles
membrane
 Contact lenses cause less distortion of vision; prescribe at
3. Tympanic Membrane (Eardrum): at end of external canal; vibrates in
one month
response to sound & transmits vibrations to middle ear

Retinal Detachment
Middle Ear
 Separation of epithelial surface of retina
1. Ossicles
 Detachment or the sensory retina from the pigment epithelium of
a. 3 small bones: malleus (Hammer) attached to tympanic
the retina
membrane, incus (anvil), stapes (stirrup)
b. Ossicles are set in motion by sound waves from tympanic
Predisposing Factors
membrane
1. Trauma
c. Sound waves are conducted by vibration to the footplate of
2. Aging process
the stapes in the oval widow (an opening between the
3. Severe diabetic retinopathy
middle ear & the inner ear)
4. Post-cataract extraction
2. Eustachian Tube: connects nasopharynx & middle ear; bring air
5. Severe myopia (near sightedness)
into middle ear, thus equalizing pressure on both sides of eardrum

Pathophysiology
Inner Ear
 Tear in the retina allows vitreous humor to seep behind the sensory
1. Cochlea
retina & separate it from the pigment epithelium
 Controls hearing
 Contains Organ of Corti (the true organ of hearing): the
S/sx
receptor end-organ for hearing
1. Curtain veil like vision coming across field of vision
 Transmit sound waves from the oval window & initiates
2. Flashes of light
nerve impulses carried by cranial nerve VIII (acoustic
3. Visual field loss
branch) to the brain (temporal lobe of cerebrum)
4. Floaters
2. Vestibular Apparatus
5. Gradual decrease of central vision
 Organ of balance
 Composed of three semicircular canals & the utricle
Dx
3. Endolymph & Perilymph
1. Ophthalmoscopic exam: confirms diagnosis
 For static equilibrium
4. Mastoid air cells
Medical Management  Air filled spaces in temporal bone in skull
1. Bed rest with eye patched & detached areas dependent to prevent
further detachment Disorder of the Ear
2. Surgery: necessary to repair detachment Otosclerosis
a. Photocoagulation: light beam (argon laser) through dilated pupil  Formation of new spongy bone in the labyrinth of the ear
creates an inflammatory reaction & scarring to heal the area causing fixation of the stapes in the oval window
b. Cryosurgery or diathermy: application of extreme cold or heat to  This prevent transmission of auditory vibration to the inner ear
external globe; inflammatory reaction causes scarring & healing
of area Predisposing Factor
c. Scleral buckling: shortening of sclera to force pigment 1. Found more often in women
epithelium close to retina
Cause
Nursing Intervention Pre-op 1. Unknown / idiopathic
1. Maintain bed rest as ordered with head of bed flat & detached area 2. There is familial tendency
in a dependent position 3. Ear trauma & surgery
2. Use bilateral eye patches as ordered; elevate side rails to prevent
injury S/sx
3. Identify yourself when entering the room 1. Progressive hearing loss
4. Orient the client frequently to time of date & surroundings; explain 2. Tinnitus
procedures
5. Provide diversional activities to provide sensory stimulation Dx
Nursing Intervention Post-op 1. Audiometry: reveals conductive hearing loss
1. Check orders for positioning & activity level: 2. Weber’s & Rinne’s Test: show bone conduction is greater than
a. May be on bed rest for 1-2 days air conduction
b. May need to position client so that detached area is in
dependent position Medical Management
2. Administer medication as ordered: 1. Stapedectomy: procedure of choice
a. Topical mydriatics  Removal of diseased portion of stapes & replacement with
b. Analgesic as needed prosthesis to conduct vibrations from the middle ear to
3. Provide client teaching & discharge planning concerning: inner ear
a. Techniques of eyedrop administration  Usually performed under local anesthesia
b. Use eye shield at night  Used to treat otoscrlerosis
c. No bending from waist; no heavy work or lifting for 6 weeks
d. Restriction of reading for 3 weeks or more Nursing Intervention Pre-op
e. May watch TV 1. Provide general pre-op nursing care, including an explanation of
post-op expectation

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2. Explain to the client that hearing may improve during surgery &
 Mild sedative or tranquilizers: Diazepam (Valium)
then decrease due to edema & packing
 Antihistamines: Diphenhydramine (Benadryl)
 Meclizine (antivert)
Nursing Intervention Post-op
b. Diet:
1. Position the client according to the surgeon’s orders (possibly
 Low sodium diet
with operative ear uppermost to prevent displacement of the
 Restricted fluid intake
graft)
 Restrict caffeine & nicotine
2. Have the client deep breathe every 2 hours while in bed, but no
3. Surgery:
coughing
a. Surgical destruction of labyrinth causing loss of vestibular &
3. Elevate side rails; assist the client with ambulation & move
cochlear function (if disease is unilateral)
slowly: may have some vertigo
b. Intracranial division of vestibular portion of cranial nerve
4. Administer medication as ordered:
VIII
 Analgesic
c. Endolymphatic sac decompression or shunt to equalize
 Antibiotics
pressure in endolymphatic space
 Anti-emetics
 Anti-motion sickness drug: Meclesine Hcl (Bonamine) Nursing Intervention
5. Check for dressing frequently for excessive drainage or bleeding 1. Maintain bed rest in a quiet, darkened room in position of
6. Assess facial nerve function: Ask the client to do the ff: choice; elevate side rails as needed
 Wrinkle forehead 2. Only move the client for essential care (bath may not be
 Close eyelids essential)
 Puff out checks for any asymmetry 3. Provide emesis basin for vomiting
7. Question the client about the ff: report existence to physicians 4. Monitor IV Therapy; maintain accurate I&O
 Pain 5. Assist in ambulation when the attack is over
 Headaches 6. Administer medication as ordered
 Vertigo 7. Prepare client for surgery as indicated (pot-op care includes
 Unusual sensations in the ear using above measures)
8. Provide client teaching & discharge planning concerning: 8. Provide client care & discharge planning concerning:
a. Warning against blowing nose or coughing; sneeze with a. Use of medication & side effects
mouth open b. Low sodium diet & decrease fluid intake
b. Need to keep ear dry in the shower; no shampooing until c. Importance of eliminating smoking
allowed
c. No flying for 6 mos. Especially if upper respiratory tract Overview of Anatomy & Physiology of Endocrine System
infection is present
d. Placement of cotton balls in auditory meatus after packing Endocrine System
is removed; change twice daily  Is composed of an interrelated complex of glands (Pituitary G,
Adrenal G, Thyroid G, Parathyroid G, Islets of langerhans of the
Meniere’s Disease pancreas, Ovaries & Testes) that secretes a variety of hormones
 Disease of the inner ear resulting from dilatation of the directly into the bloodstream.
endolymphatic system & increase volume of endolymph  Its major function, together with the nervous system: is to regulate
 Characterized by recurrent & usually progressive triad of symptoms: body function
vertigo, tinnitus, hearing loss

Hormones Regulation
Predisposing Factor
1. Hormones: chemical substance that acts s messenger to specific
1. Incidence highest between ages 30 & 60
cells & organs (target organs), stimulating & inhibiting various
processes
Cause Two Major Categories
2. Unknown / idiopathic a. Local: hormones with specific effect in the area of secretion (ex.
3. Theories include the ff: Secretin, cholecystokinin, panceozymin [CCK-PZ])
a. Allergy b. General: hormones transported in the blood to distant sites
b. Toxicity where they exert their effects (ex. Cortisol)
c. Localized ischemia 2. Negative Feedback Mechanisms: major means of regulating
d. Hemorrhage hormone levels
e. Viral infection a. Decreased concentration of a circulating hormones triggers
f. Edema production of a stimulating hormones from pituitary gland; this
hormones in turn stimulates its target organ to produce
S/sx hormones
1. Sudden attacks of vertigo lasting hours or days; attacks occurs b. Increased concentration of a hormones inhibits production of
several times a year the stimulating hormone, resulting in decreased secretion of the
2. N/V
target organ hormone
3. Tinnitus 3. Some hormones are controlled by changing blood levels of specific
4. Progressive hearing loss substances (ex. Calcium, glucose)
5. Nystagmus 4. Certain hormones (ex. Cortisol or female reproductive hormones)
follow rhythmic patterns of secretion
Dx 5. Autonomic & CNS control (pituitary-hypothalamic axis):
1. Audiometry: reveals sensorineural hearing loss hypothalamus controls release of the hormones of the anterior
2. Vestibular Test: reveals decrease function pituitary gland through releasing & inhibiting factors that stimulate
or inhibits hormone secretions
Medical Management
1. Acute: Hormone Function
 Atropine (decreases autonomic nervous system activity) Endocrine G Hormone Functions
 Diazepam (Valium) Pituitary G
 Fentanyl & Droperidol (Innovar)  Anterior lobe : TSH : stimulate thyroid G
2. Chronic: to release thyroid hormones
a. Drug Therapy: : ACTH : stimulate adrenal
 Vasodilators (nicotinic Acid) cortex to produce &
 Diuretics release adrenocoticoids

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: FSH, LH : stimulate growth,


Maintenance of
maturation, & function of primary
pregnancy
& secondary sex organ Testes : Testosterone : development of
: GH, Somatotropin : stimulate growth of secondary sex characteristics in the
body tissues & bones Male maturation of the
: Prolactin or LTH : stimulate sex organs, sexual functioning
development of mammary gland
&
Lactation Pituitary Gland (Hypophysis)
 Posterior lobe : ADH : regulates H2O
 Located in sella turcica at the base of brain
metabolism; release during stress
 “Master Gland” or master clock
Or in response to an
 Controls all metabolic function of body
increase in plasma osmolality
3 Lobes of Pituitary Gland
To stimulate
1. Anterior Lobe PG (Adenohypophysis)
reabsorption of H2O & decrease
a. Secretes tropic hormones (hormones that stimulate target
urine
glands to produce their hormones): adrenocorticotropic H
Output
(ACTH), thyroid-stimulating H (TSH), follicle-stimulating H
: Oxytocin : stimulate
(FSH), luteinizing H (LH)
uterine contractions during delivery & the
 ACTH: promotes development of adrenal cortex
Release of milk in
 LH: secretes estrogen
lactation
 FSH: secretes progesterone
 Intermediate lobe : MSH : affects skin
b. Also secretes hormones that have direct effects on tissues:
pigmentation
somatotropic or growth H, prolactin
 Somatotropic / GH: promotes elongation of long bones
Adrenal G
 Hyposecretion of GH: among children results to
 Adrenal Cortex : Mineralocorticoid : regulate fluid &
dwarfism
electrolyte balance; stimulate
 Hypersecretion of GH: among children results to
(ex. Aldosterone) reabsoption of sodium,
gigantism
chloride, & H2O; stimulate
 Hypersecretion of GH: among adults results to
potassium excretion
acromegaly (square face)
: Glucocorticoids : increase blood
 DOC: Ocreotide (Sandostatin)
glucose level by increasing rate of
 Prolactin: promotes development of mammary gland;
(ex. Cortisol, glyconeogenesis;
with help of oxytocin it initiates milk let down reflex
increase CHON catabolism; increase
c. Regulated by hypothalamic releasing & inhibiting factors & by
corticosterone) mobilization of fatty
negative feedback system
acid; promote sodium & H2O
2. Posterior Lobe PG (Neurohypophysis)
retention; anti-inflammatory effect; aid body in coping
 Does not produce hormones
with stress
 Store & release anti-diuretic hormones (ADH) & oxytocin
: Sex Hormones : influence
produced by hypothalamus
development of secondary sex
 Secretes hormones oxytocin (promotes uterine contractions
(androgens, estrogens characeristics
preventing bleeding or hemorrhage)
progesterones)
 Administer oxytocin immediately after delivery to prevent
 Adrenal Medulla : Epinephrine, : function in acute
uterine atony.
stress; increase HR, BP; dilates
 Initiates milk let down reflex with help of hormone prolactin
Norepinephrine bronchioles; convert
3. Intermediate Lobe PG
glycogen to glucose when
 Secretes melanocytes stimulating H (MSH)
Needed by the muscles
 MSH: for skin pigmentation
for energy
 Hyposecretion of MSH: results to albinism
 Hypersecretion of MSH: results to vitiligo
Thyroid G : T3, T4 : regulate metabolic
 2 feared complications of albinism:
rate; CHO, fats, & CHON
1. Lead to blindness due to severe photophobia
Metabolism; aid in
2. Prone to skin cancer
regulating physical & mental

Growth & development Adrenal Glands


: Thyrocalcitonin : lowers serum calcium  Two small glands, one above each kidney; Located at top of
& phosphate levels each kidney

Parathyroid G : PTH : regulates serum


2 Sections of Adrenal Glands
calcium & phosphate levels
1. Adrenal Cortex (outer portion): produces mineralocorticoids,
glucocorticoids, sex hormones
Pancreas (islets of
 3 Zones/Layers
Langerhans)
 Zona Fasciculata: secretes glucocortocoids (cortisol):
 Beta Cells : Insulin : allows glucose to
controls glucose metabolism: Sugar
diffuse across cell membrane;
 Zona Reticularis: secretes traces of glucocorticoids &
Converts glucose to
androgenic hormones: promotes secondary sex
glycogen
characteristics: Sex
 Alpha Cells : Glucagon : increase blood
 Zona Glumerulosa: secretes mineralocorticoids
glucose by causing glyconeogenisis
(aldosterone): promotes sodium and water reabsorption
& glycogenolysis in the
and excretion of potassium: Salt
liver; secreted in
2. Adrenal Medulla (inner portion): produces epinephrine,
response to
norepinephrine (secretes catecholamines a power hormone):
low blood sugar
vasoconstrictor
 2 Types of Catecholamines:
Ovaries : Estrogen, Progesterone : development of
 Epinephrine (vasoconstrictor)
secondary sex characteristics in the
 Norepinephrine (vasoconstrictor)
Female, maturation of
o Pheochromocytoma (adrenal medulla): Increase
sex organ, sexual functioning
secretion of norepinephrine: Leading to hypertension

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which is resistant to pharmacological agents leading


to CVA: Use beta-blockers Dx
1. Urine Specific Gravity (NV: 1.015 – 1.030): less than 1.004
Thyroid Gland 2. Serum Na: increase resulting to hypernatremia
 Located in anterior portion of the neck
3. H2O deprivation test: reveals inability to concentrate urine
 Consist of 2 lobes connected by a narrow isthmus
 Produces thyroxine (T4), triiodothyronine (T3), thyrocalcitonin
Nursing Intervention
 3 Hormones Secreted:
1. Maintain F&E balance / Force fluids 2000-3000 ml/day
 T3: 3 molecules of iodine (more potent)
a. Keep accurate I&O
 T4: 4 molecule of iodine
b. Weigh daily
 T3 and T4 are metabolic hormone: increase brain activity;
c. Administer IV/oral fluids as ordered to replace fluid loss
promotes cerebration (thinking); increase V/S
2. Monitor strictly V/S & observe for signs of dehydration &
 Thyrocalcitonin: antagonizes the effects of parathormone to
hypovolemia
promote calcium reabsorption.
3. Administer hormone replacement as ordered:
a. Vasopressin (Pitressin) & Vasopressin Tannate (Pitressin
Parathyroid Gland
Tannate Oil): administered by IM injection
 4 small glands located in pairs behind the thyroid gland
 Warm to body temperature before giving
 Produce parathormone (PTH)
 Shake tannate suspension to ensure uniform dispersion
 Promotes calcium reabsorption
b. Lypressin (Diapid): nasal spray
4. Prevent complications: hypovolemic shock is the most feared
Pancreas
complication
 Located behind the stomach
5. Provide client teaching & discharge planning concerning:
 Has both endocrine & exocrine function (mixed gland)
a. Lifelong hormone replacement: Lypressin (Diapid) as needed to
 Consist of Acinar Cells (exocrine gland): which secretes pancreatic
control polyuria & polydipsia
juices: that aids in digestion
b. Need to wear medic-alert bracelet
 Islets of langerhans (alpha & beta cells) involved in endocrine
function:
Syndrome of Inappropriate Anti-diuretic Hormone Secretion (SIADH)
 Alpha Cell: produce glucagons: (function: hyperglycemia)
 Hypersecretion of anti-diuretic hormone (ADH) from the PPG even
 Beta Cell: produce insulin: (function: hypoglycemia)
when the client has abnormal serum osmolality
 Delta Cells: produce somatostatin: (function: antagonizes the
effects of growth hormones)
Predisposing Factors
1. Head injury
Gonads
2. Related to presence of bronchogenic cancer
 Ovaries: located in pelvic cavity; produce estrogen & progesterone
 Initial sign of lung cancer is non productive cough
 Testes: located in scrotum; produces testosterone
 Non invasive procedure is chest x-ray
3. Related to hyperplasia of pituitary gland (increase size of organ
Pineal Gland
brought about by increase of number of cells)
 Secretes melatonin
 Inhibits LH secretion
S/sx
 It controls & regulates circadian rhythm (body clock)
1. Person with SIADH cannot excrete a dilute urine
2. Fluid retention & Na deficiency
a. Hypertension
Diabetes Incipidus (DI)
b. Edema
 DI: dalas-ihi
c. Weight gain
 Decrease of anti-diuretic hormone (ADH)
3. Water intoxication: may lead to cerebral edema: lead to increase
 Hyposecretion of ADH
ICP; may lead to seizure activity
 Hypofunction of the posterior pituitary gland (PPG) resulting in
deficiency of ADH
Dx
 Characterized by excessive thirst & urination
1. Urine specific gravity: is increase
2. Serum Sodium: is decreased

Anti-diuretic Hormone: Pitressin (Vasopressin)


Medical Management
Function: prevents urination thereby conserving water
1. Treat underlying cause if possible
 Note: Alcohol inhibits release of ADH 2. Diuretics & fluid restriction

Predisposing Factor Nursing Intervention


1. Related to pituitary surgery 1. Restrict fluid: to promote fluid loss & gradual increase in serum Na
2. Trauma 2. Administer medications as ordered:
3. Inflammation a. Loop diuretics (Lasix)
4. Presence of tumor b. Osmotic diuretics (Mannitol)
3. Monitor strictly V/S, I&O & neuro check
S/sx 4. Weigh patient daily and assess for pitting edema
1. Severe polyuria with low specific gravity 5. Monitor serum electrolytes & blood chemistries carefully
2. Polydipsia (excessive thirst) 6. Provide meticulous skin care
3. Fatigue 7. Prevent complications
4. Muscle weakness
5. Irritability
6. Weight loss
7. Hypotension

8. Signs of dehydration HYPOTHYROIDISM


a. Adult: thirst; Children: tachycardia - all are decrease except weight and menstruation
b. Agitation - memory impairment
c. Poor Skin turgor Signs and Symptoms
d. Dry mucous membrane - there is loss of appetite but there is weight gain
9. Tachycardia, eventually shock if fluids is not replaced - menorrhagia
10. If left untreated results to hypovolemic shock (late sign anuria) - cold intolerance

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- constipation
 Levothyroxine (Synthroid)
 Liothyronine (Cytomel)
HYPERTHYROIDISM  Thyroid Extracts
- all are increase except weight and menstruation
Signs and Symptoms
Nursing Intervention when giving Thyroid Hormones:
- increase appetite but there is weight loss
1. Instruct client to take in the morning to prevent insomnia
- amenorrhea
2. Monitor vital signs especially heart rate because drug causes
- exophthalmos
tachycardia and palpitations
3. Monitor side effects:
Thyroid Disorder
 Insomnia
 Tachycardia and palpitations
Simple Goiter
 Hypertension
 Enlargement of thyroid gland due to iodine deficiency
 Heat intolerance
 Enlargement of the thyroid gland not caused by inflammation of
2. Increase dietary intake of foods rich in iodine:
neoplasm
 Seaweeds
 Low level of thyroid hormones stimulate increased secretion of TSH
 Seafood’s like oyster, crabs, clams and lobster but not
by pituitary; under TSH stimulation the thyroid increases in size to
shrimps because it contains lesser amount of iodine.
compensate & produce more thyroid hormone
 Iodized salt: best taken raw because it is easily destroyed
by heat
Predisposing Factors 3. Assist in surgical procedure of subtotal thyroidectomy
1. Endemic: caused by nutritional iodine deficiency, most common in
4. Provide client teaching & discharge planning concerning:
the “goiter belt” area, areas where soil & H2O are deficient in iodine;  Used of iodized salt in preventing & treating endemic goiter
occurs most frequently during adolescence & pregnancy  Thyroid hormone replacement
 Goiter belt area:
a. Midwest, northwest & great lakes region
Hypothyroidism (Myxedema)
b. Places far from sea
 Slowing of metabolic processes caused by hypofunction of the
c. Mountainous regions
thyroid gland with decreased thyroid hormone secretion
2. Sporadic: caused by  Hyposecretion of thyroid hormone
 Increase intake of goitrogenic foods (contains agent that
 Decrease in all V/S except wt & menses
decrease the thyroxine production: pro-goitrin an anti-thyroid
 Adults: myxedema non pitting edema
agent that has no iodine). Ex. cabbage, turnips, radish,
 Children: cretinism the only endocrine disorder that can lead to
strawberry, carrots, sweet potato, rutabagas, peaches, peas,
mental retardation
spinach, broccoli, all nuts  In severe or untreated cases myxedema coma may occur:
 Soil erosion washes away iodine
 Characterized by intensification of S/sx of hypothyroidism &
 Goitrogenic drugs:
neurologic impairment leading to coma
a. Anti-Thyroid Agent: Propylthiouracil (PTU)  Mortality rate high; prompt recognition & treatment essential
b. Large doses of iodine  Precipitating factors: failure to take prescribed medications;
c. Phenylbutazone infection; trauma; exposure to cold; use of sedatives, narcotics
d. Para-amino salicylic acid or anesthetics
e. Lithium Carbonate
f. PASA (Aspirin) Predisposing Factors
g. Cobalt 1. Primary hypothyroidism: atrophy of the gland possibly caused
3. Genetic defects that prevents synthesis of thyroid hormones by an autoimmune process
2. Secondary hypothyroidism: caused by decreased stimulation
S/sx from pituitary TSH
1. Enlarged thyroid gland 3. Iatrogenic: surgical removal of the gland or over treatment of
2. Dysphagia hyperthyroidism with drugs or radioactive iodine; disease
3. Respiratory distress caused by medical intervention such as surgery
4. Mild restlessness 4. Related to atrophy of thyroid gland due to trauma, presence of
tumor, inflammation
Dx 5. Iodine deficiency
1. Serum T4: reveals normal or below normal 6. Autoimmune (Hashimotos Disease)
2. Thyroid Scan: reveals enlarged thyroid gland. 7. Occurs more often to women ages 30 & 60
3. Serum Thyroid Stimulating Hormone (TSH): is increased
(confirmatory diagnostic test) S/sx
4. RAIU (Radio Active Iodine Uptake): normal or increased 1. Loss of appetite: but there is wt gain
2. Anorexia
Medical Management 3. Weight gain: which promotes lipolysis leading to atherosclerosis
1. Drug Therapy: and MI
 Hormone replacement with levothyroxine (Synthroid) (T4), 4. Constipation
dessicated thyroid, or liothyronine (Cytomel) (T3) 5. Cold intolerance
 Small dose of iodine (Lugol’s or potassium iodide solution): for 6. Dry scaly skin
goiter resulting from iodine deficiency 7. Spares hair
2. Avoidance of goitrogenic food or drugs in sporadic goiter 8. Brittleness of nails
3. Surgery: 9. Decrease in all V/S: except wt gain & menses
 Subtotal thyroidectomy: (if goiter is large) to relieve pressure a. Hypotension
symptoms & for cosmetic reasons b. Bradycardia
c. Bradypnea
Nursing Intervention d. Hypothermia
1. Administer Replacement therapy as ordered: 10. Weakness and fatigue
a. Lugol’s Solution / SSKI (Saturated Solution of Potassium Iodine) 11. Slowed mental processes
 Color purple or violet and administered via straw to prevent 12. Dull look
staining of teeth.
13. Slow clumsy movement
 4 Medications to be taken via straw: Lugol’s, Iron,
14. Lethargy
Tetracycline, Nitrofurantoin (DOC: for pyelonephritis)
15. Generalized interstitial non-pitting edema (Myxedema)
b. Thyroid Hormones:
16. Hoarseness of voice

23
24

17. Decrease libido


f. Stress & infection
18. Memory impairment
g. Use of anesthetics, narcotics, and sedatives
19. Psychosis
20. Menorrhagia
Hyperthyroidism
 Secretion of excessive amounts of thyroid hormone in the blood
Dx causes an increase in metabolic process
1. Serum T3 and T4: is decreased  Increase in T3 and T4
2. Serum Cholesterol: is increased  Grave’s Disease or Thyrotoxicosis
3. RAIU (Radio Active Iodine Uptake): is decreased  Increase in all V/S except wt & menses
Medical Management
1. Drug Therapy:
Predisposing Factors
 Levothyroxine (Synthroid)
1. More often seen in women between ages 30 & 50
 Thyroglobulin (Proloid)
2. Autoimmune: involves release of long acting thyroid stimulator
 Dessicated thyroid
causing exopthalmus (protrusion of eyeballs) enopthalmus (late
 Liothyronine (Cytomel)
sign of dehydration among infants)
2. Myxedema coma is a medical emergency: 3. Excessive iodine intake
 IV thyroid hormones
4. Related to hyperplasia (increase size of TG)
 Correction of hypothermina
 Maintenance of vital function S/sx
 Treatment of precipitating cause 1. Increase appetite (hyperphagia): but there is weight loss
2. Heat intolerance
Nursing Intervention 3. Weight loss
1. Monitor strictly V/S & I&O, daily weights; observe for edema & 4. Diarrhea: increase motility
signs of cardiovascular complication & to determine presence of 5. Increased in all V/S: except wt & menses
myxedema coma a. Tachycardia
2. Administer thyroid hormone replacement therapy as ordered & b. Increase systolic BP
monitor effects:
c. Palpitation
a. Observe signs of thyrotoxicosis:
6. Warm smooth skin
 Tachycardia & palpitation
7. Fine soft hair
 N/V
8. Pliable nails
 Diarrhea
9. CNS involvement
 Sweating
a. Irritability & agitation
 Tremors
b. Restlessness
 Agitation
c. Tremors
 Dyspnea
d. Insomnia
b. Increase dosage gradually, especially in clients with
e. Hallucinations
cardiac complication
f. Sweating
3. Provide comfortable and warm environment: due to cold
g. Hyperactive movement
intolerance
10. Goiter
4. Provide a low calorie diet
11. PS: Exopthalmus (protrusion of eyeballs)
5. Avoid the use of sedatives; reduce the dose of any sedatives,
12. Amenorrhea
narcotics, or anesthetic agent by half as ordered
6. Provide meticulous skin care: to prevent skin breakdown
Dx
7. Increase fluid & food high in fiber: to prevent constipation;
1. Serum T3 and T4: is increased
administer stool softener as ordered
2. RAIU (Radio Active Iodine Uptake): is increased
8. Observe for signs of myxedema coma; provide appropriate
3. Thyroid Scan: reveals an enlarged thyroid gland
nursing care
a. Administer medication as ordered
Medical Management
b. Maintain vital functions:
1. Drug Therap:
 Correct hypothermia
a. Anti-thyroid drugs: Propylthiouracil (PTU) & methimazole
 Maintain adequate ventilation
(Tapazole): blocke synthesis of thyroid hormone; toxic
9. Myxedema coma:
effect include agranulocytosis
 A complication of hypothyroidism & an emergency case
b. Adrenergic Blocking Agent: Propranolol (Inderal): used to
 A severe form of hypothyroidism is characterized by:
decrease sympathetic activity & alleviate symptoms such
 Severe hypotension
as tachycardia
 Bradycardia
2. Radioactive Iodine Therapy
 Bradypnea
a. Radioactive isotope of iodine (ex. 131I): given to destroy
 Hypoventilation
the thyroid gland, thereby decreasing production of thyroid
 Hyponatremia
hormone
 Hypoglycemia
b. Used in middle-aged or older clients who are resistant to, or
 Hypothermia
develop toxicity from drug therapy
 Leading to progressive stupor and coma c. Hypothyroidism is a potential complication
3. Surgery: Thyroidectomy performed in younger client for whom
Nursing Management for Myxedema Coma
drug therapy has not been effective
1. Assist in mechanical ventilation
2. Administer thyroid hormones as ordered
Nursing Intervention
3. Administer IVF replacement isotonic fluid solution as
1. Monitor strictly V/s & I&O, daily weight
ordered / Force fluids
2. Administer anti-thyroid medications as ordered:
10. Provide client health teaching and discharge planning
a. Propylthiouracil (PTU)
concerning:
b. Methimazole (Tapazole)
a. Thyroid hormone replacement
3. Provide for period of uninterrupted rest:
b. Importance of regular follow-up care
a. Assign a private room away from excessive activity
c. Need in additional protection in cold weather
b. Administer medication to promote sleep as ordered
d. Measures to prevent constipation
4. Provide comfortable and cold environment
e. Avoid precipitating factors leading to myxedema coma &
5. Minimized stress in the environment
hypovolemic shock
6. Encourage quiet, relaxing diversional activities

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7. Provide dietary intake that is high in CHO, CHON, calories,


 Positive trousseu’s sign
vitamin & minerals with supplemental feeding between meals &
 Positive chvostek sign
at bedtime; omit stimulant  Observe for arrhythmia, seizure: give Calcium Gluconate IV
8. Observe for & prevent complication
slowly as ordered
a. Exophthalmos: protects eyes with dark glasses & artificial 6. Ecourage clients voice to rest:
tears as ordered
a. Some hoarseness is common
b. Thyroid Storm
b. Check every 30-60 min for extreme hoarseness or any
9. Provide meticulous skin care
accompanying respiratory distress
10. Maintain side rails
7. Observe for signs of thyroid storm / thyrotoxicosis: due to
11. Provide bilateral eye patch to prevent drying of the eyes
release of excessive amount of thyroid hormone during surgery
12. Assist in surgical procedures subtotal Thyroidectomy:
13. Provide client teaching & discharge planning concerning: Agitation
a. Need to recognized & report S/sx of agranulocytosis (fever,
sore throat, skin rash): if taking anti-thyroid drugs
b. S/sx of hyperthyroidism & hypothyroidism

Thyroid Storm TRIAD SIGNS


 Uncontrolled & potentially life-threatening hyperthyroidism caused
by sudden & excessive release of thyroid hormone into the
bloodstream
Hyperthermia
Tachycardia
Precipitating Factors  Administer medications as ordered:
1. Stress
 Anti Pyretics
2. Infection
 Beta-blockers
3. unprepared thyroid surgery
 Monitor strictly vital signs, input and output and neuro
check.
S/sx  Maintain side rails
1. Apprehension  Offer TSB
2. Restlessness 8. Administer IV fluids as ordered: until the client is tolerating
3. Extremely high temp (up to 106 F / 40.7 C)
fluids by mouth
4. Tahchycardia 9. Administer analgesics as ordered: for incisional pain
5. HF 10. Relieve discomfort from sore throat:
6. Respiratory Distress a. Cool mist humidifier to thin secretions
7. Delirium b. Administer analgesic throat lozenges before meals prn as
8. Coma ordered
11. Encourage coughing & deep breathing every hour
Nursing Intervention 12. Assist the client with ambulation: instruct the client to place the
1. Maintain patent airway & adequate ventilation; administer O2 as hands behind the neck: to decrease stress on suture line if
ordered added support is necessary
2. Administer IV therapy as ordered 13. Hormonal replacement therapy for lifetime
3. Administer medication as ordered: 14. Watch out for accidental laryngeal damage which may lead to
a. Anti-thyroid drugs hoarseness of voice: encourage client to talk/speak immediately
b. Corticosteroids after operation and notify physician
c. Sedatives 15. Provide client teaching& discharge planning concerning:
d. Cardiac Drugs a. S/sx of hyperthyroidism & hypothyroidism
b. Self administration of thyroid hormone: if total
Thyroidectomy thyroidectomy is performed
 Partial or total removal of thyroid gland c. Application of lubricant to the incision once suture is
 Indication: removed
 Subtotal Thyroidectomy: hyperthyroidism d. Perform ROM neck exercise 3-4 times a day
 Total Thyroidectomy: thyroid cancer e. Importance of follow up care with periodic serum calcium
level
Nursing Intervention Pre-op
1. Ensure that the client is adequately prepared for surgery
a. Cardiac status is normal
b. Weight & nutritional status is normal Hypoparathyroidism
2. Administer anti-thyroid drugs as ordered: to suppressed the  Disorder characterized by hypocalcemia resulting from a deficiency
production of thyroid hormone & to prevent thyroid storm of parathormone (PTH) production
3. Administer iodine preparation Lugol’s Solution (SSKI) or  Decrease secretion of parathormone: leading to hypocalcemia:
Potassium Iodide Solution: to decrease vascularity of the thyroid resulting to hyperphospatemia
gland & to prevent hemorrhage.  If calcium decreases phosphate increases

Nursing Intervention Post-Op Predisposing Factors


1. Monitor V/S & I&O 1. May be hereditary
2. Check dressing for signs of hemorrhage: check for wetness 2. Idiopathic
behind the neck 3. Caused by accidental damage to or removal of parathyroid
3. Place client in semi-fowlers position & support head with pillow gland during thyroidectomy surgery
4. Observe for respiratory distress secondary to hemorrhage, 4. Atrophy of parathyroid gland due to: inflammation, tumor,
edema of glottis, laryngeal nerve damage, or tetany: keep trauma
tracheostomy set, O2 & suction nearby
5. Assess for signs of tetany: due to hypocalcemia: due to S/sx
secondary accidental removal of parathyroid glands: keep 1. Acute hypocalcemia (tetany)
Calcium Gluconate available: a. Paresthesia: tingling sensation of finger & around lip
 Watch out for accidental removal of parathyroid which may b. Muscle spasm
lead to hypocalcemia (tetany) c. laryngospasm/broncospasm
Classic S/sx of Tetany d. Dysphagia

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26

e. Seizure: feared complications 7. For tetany or generalized muscle cramp: may use rebreathing
f. Cardiac arrhythmia: feared complications bag or paper bag to produce mild respiratory acidosis: to
g. Numbness promote increase ionized Ca levels
h. Positive trousseu’s sign: carpopedal spasm 8. Monitor serum calcium & phosphate level
i. Positive chvostek sign 9. Provide high-calcium & low-phosphorus diet
2. Chronic hypocalcemia (tetany) 10. Provide client teaching & discharge planning concerning:
a. Fatigue a. Medication regimen: oral calcium preparation & vit D to be
b. Weakness taken with meal to increase absorption
c. Muscle cramps b. Need to recognized & report S/sx of hypo/hypercalcemia
d. Personality changes c. Importance of follow-up care with periodic serum calcium
e. Irritability level
f. Memory impairment d. Prevent complications
g. Agitation e. Hormonal replacement therapy for lifetime
h. Dry scaly skin
i. Hair loss Hyperparathyroidism
j. Loss of tooth enamel  Increase secretion of PTH that results in an altered state of calcium,
k. Tremors phosphate & bone metabolism
l. Cardiac arrhythmias  Decrease parathormone
m. Cataract formation  Hypercalcemia: bone demineralization leading to bone fracture
n. Photophobia (calcium is stored 99% in bone and 1% blood)
o. Anorexia  Kidney stones
p. N/V
Predisposing Factors
Diagnostic Procedures 1. Most commonly affects women between ages 35 & 65
1. Serum Calcium level: decreased (normal value: 8.5 – 11 mg/100 2. Primary Hyperparathyroidism: caused by tumor & hyperplasia of
ml) parathyroid gland
2. Serum Phosphate level: increased (normal value: 2.5 – 4.5 3. Secondary Hyperparathyroidism: cause by compensatory over
mg/100 ml) secretion of PTH in response to hypocalcemia from:
3. Skeletal X-ray of long bones: reveals a increased in bone density a. Children: Ricketts
4. CT Scan: reveals degeneration of basal ganglia b. Adults: Osteomalacia
c. Chronic renal disease
Nursing Management d. Malabsorption syndrome
1. Administer medications as ordered such as:
a. Acute Tetany: Calcium Gluconate slow IV drip as ordered S/sx
b. Chronic Tetany: 1. Bone pain (especially at back); Bone demineralization;
 Oral calcium preparation: Calcium Gluconate, Calcium Pathologic fracture
Lactate, Calcium Carbonate (Os-Cal) 2. Kidney stones; Renal colic; Polyuria; Polydipsia; Cool moist skin
 Large dose of vitamin D (Calciferol): to help absorption 3. Anorexia; N/V; Gastric Ulcer; Constipation
of calcium 4. Muscle weakness; Fatigue
5. Irritability / Agitation; Personality changes; Depression; Memory
CHOLECALCIFEROL ARE DERIVED FROM impairment
6. Cardiac arrhythmias; HPN
Drug Diet (Calcidiol)
Sunlight (Calcitriol) Dx
1. Serum Calcium: is increased
 Phosphate Binder: Aluminum Hydroxide Gel 2. Serum Phosphate: is decreased
(Amphogel) or aluminum carbonate gel, basic 3. Skeletal X-ray of long bones: reveals bone demineralization
(basaljel): to decrease phosphate levels
Nursing Intervention
ANTACID 1. Administer IV infusions of normal saline solution & give diuretics
as ordered:
A.A.C 2. Monitor I&O & observe fluid overload & electrolytes imbalance

MAD 3. Assist client with self care: Provide careful handling, Moving,
Ambulation: to prevent pathologic fracture
Aluminum 4. Monitor V/S: report irregularities
Magnesium Containing 5. Force fluids 2000-3000 L/day: to prevent kidney stones
Containing 6. Provide acid-ash juices (ex. Cranberry, orange juice): to acidify
Antacids urine & prevent bacterial growth
Antacids 7. Strain urine: using gauze pad: for stone analysis
8. Provide low-calcium & high-phosphorus diet
9. Provide warm sitz bath: for comfort
Aluminum 10. Administer medications as ordered: Morphine Sulfate (Demerol)
Hydroxide 11. Maintain side rails
Gel 12. Assist in surgical procedure: Parathyroidectomy
13. Provide client teaching & discharge planning concerning:
Side Effect: Constipation Side a. Need to engage in progressive ambulatory activities
Effect: Diarrhea
b. Increase fluid intake
2. Institute seizure & safety precaution
c. Use of calcium preparation & importance of high-calcium
3. Provide quite environment free from excessive stimuli
diet following a parathyroidectomy
4. Avoid precipitating stimulus such as glaring lights and noise
d. Prevent complications: renal failure
5. Monitor signs of hoarseness or stridor; check for signs for
e. Hormonal replacement therapy for lifetime
Chvostek’s & Trousseau’s sign
f. Importance of follow up care
6. Keep emergency equipment (tracheostomy set, injectable
Calcium Gluconate) at bedside: for presence of laryngospasm
Addison’s Disease

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27

 Primary adrenocortical insufficiency; hypofunction of the adrenal


c. Need to avoid stress, trauma & infection: notify the
cortex causes decrease secretion of the mineralcorticoids,
physician if these occurs as medication dosage may need to
glucocorticoids, & sex hormones
be adjusted
 Hyposecretion of adrenocortical hormone leading to:
d. Stress management technique
 Metabolic disturbance: Sugar
e. Diet modification
 Fluid and electrolyte imbalance: Na, H2O, K
f. Use of salt tablet (if prescribe) or ingestion of salty foods
 Deficiency of neuromascular function: Salt, Sex
(potato chips): if experiencing increase sweating
g. Importance of alternating regular exercise with rest periods
Predisposing Factors
h. Avoidance of strenuous exercise especially in hot weather
1. Relatively rare disease caused by:
i. Avoid precipitating factor: leading to addisonian crisis:
 Idiopathic atrophy of the adrenal cortex: due to an
stress, infection, sudden withdrawal to steroids
autoimmune process j. Prevent complications: addisonian crisis, hypovolemic shock
 Destruction of the gland secondary to TB or fungal
k. Importance of follow up care
infections

S/sx
1. Fatigue, Muscle weakness
2. Anorexia, N/V, abdominal pain, weight loss
Addisonian Crisis
3. History of hypoglycemic reaction / Hypoglycemia: tremors,
 Severe exacerbation of addison’s diseasecaused by acute adrenal
tachycardia, irritability, restlessness, extreme fatigue,
insufficiency
diaphoresis, depression
4. Hyponatremia: hypotension, signs of dehydration, weight loss,
Predisposing Factors
weak pulse
1. Strenuous activity
5. Decrease tolerance to stress
2. Stress
6. Hyperkalemia: agitation, diarrhea, arrhythmia
3. Trauma
7. Decrease libido
4. Infection
8. Loss of pubic and axillary hair
5. Failure to take prescribe medicine
9. Bronze like skin pigmentation
6. Iatrogenic:
 Surgery of pituitary gland or adrenal gland
Dx
 Rapid withdrawal of exogenous steroids in a client on
1. FBS: is decreased (normal value: 80 – 100 mg/dl)
long-term steroid therapy
2. Plasma Cortisol: is decreased
3. Serum Sodium: is decrease (normal value: 135 – 145 meq/L)
S/sx
4. Serum Potassium: is increased (normal value: 3.5 – 4.5 meq/L)
1. Generalized muscle weakness
2. Severe hypotension
Nursing Intervention
3. Hypovolemic shock: vascular collapse
1. Administer hormone replacement therapy as ordered:
4. Hyponatremia: leading to progressive stupor and coma
a. Glucocorticoids: stimulate diurnal rhythm of cortisol release,
give 2/3 of dose in early morning & 1/3 of dose in
Nursing Intervention
afternoon
1. Assist in mechanical ventilation
 Corticosteroids: Dexamethasone (Decadrone)
2. Administer IV fluids (5% dextrose in saline, plasma) as
 Hydrocortisone: Cortisone (Prednisone)
ordered: to treat vascular collapse
b. Mineralocorticoids:
3. Administer IV glucocorticoids: Hydrocortisone (Solu-Cortef)
 Fludrocortisone Acetate (Florinef)
& vasopressors as ordered
4. Force fluids
Nursing Management when giving steroids
5. If crisis precipitate by infection: administer antibiotics as
1. Instruct client to take 2/3 dose in the morning and 1/3 dose
ordered
in the afternoon to mimic the normal diurnal rhythm
6. Maintain strict bed rest & eliminate all forms of stressful
2. Taper dose (withdraw gradually from drug)
stimuli
3. Monitor side effects:
7. Monitor V/S, I&O & daily weight
 Hypertension
8. Protect client from infection
 Edema
9. Provide client teaching & discharge planning concerning:
 Hirsutism
same as addison’s disease
 Increase susceptibility to infection
Cushing Syndrome
 Moon face appearance
 Condition resulting from excessive secretion of corticosteroids,
2. Monitor V/S
particularly glucocorticoid cortisol
3. Decrease stress in the environment  Hypersecretion of adrenocortical hormones
4. Prevent exposure to infection
5. Provide rest period: prevent fatigue Predisposing Factors
6. Weight daily 1. Primary Cushing’s Syndrome: caused by adrenocortical tumors
7. Provide small frequent feeding of diet: decrease in K, increase or hyperplasia
cal, CHO, CHON, Na: to prevent hypoglycemia, & hyponatremia 2. Secondary Cushing’s Syndrome (also called Cushing’s disease):
& provide proper nutrition caused by functioning pituitary or nonpituitary neoplasm
8. Monitor I&O: to determine presence of addisonian crisis
secreting ACTH, causing increase secretion of glucocorticoids
(complication of addison’s disease) 3. Iatrogenic: cause by prolonged use of corticosteroids
9. Provide meticulous skin care 4. Related to hyperplasia of adrenal gland
10. Provide client teaching & discharge planning concerning: 5. Increase susceptibility to infections
a. Disease process: signs of adrenal insufficiency
b. Use of prescribe medication for lifelong replacement S/sx
therapy: never omit medication
1. Muscle weakness 7. Frequent mood swings
2. Fatigue 8. Moon face
3. Obese trunk with thin arms & legs 9. Buffalo hump
4. Muscle wasting 10. Pendulous abdomen
5. Irritability 11. Purple striae on trunk
6. Depression 12. Acne

27
2

13. Thin skin


19. Hypernatremia
14. Signs of masculinization in women: menstrual dysfunction,
20. Weight gain
decrease libido
21. Hypokalemia
15. Osteoporosis
22. Constipation
16. Decrease resistance to infection
23. U wave upon ECG (T wave hyperkalemia)
17. Hypertension
24. Hirsutis
18. Edema
25. Easy bruising
1. CHO Glucose Glycogen
Dx
2. CHON Amino Acids Nitrogen
1. FBS: is increased
3. Fats Fatty Acids Free Fatty Acids
2. Plasma Cortisol: is increased : cholesterol
3. Serum Sodium: is increased : ketones
4. Serum Potassium: is decreased

Nursing Intervention
HYPERGLYCEMIA
1. Maintain muscle tone
Increase osmotic diuresis
a. Provide ROM exercise
b. Assist in ambulation Glycosuria
2. Prevent accidents fall & provide adequate rest
Polyuria
3. Protect client from exposure to infection
4. Maintain skin integrity Cellular starvation: weight loss Cellular
dehydration
a. Provide meticulous skin care
b. Prevent tearing of the skin: use paper tape if necessary Stimulates the appetite / satiety center Stimulates the
thirst center
5. Minimize stress in the environment
(Hypothalamus)
6. Monitor V/S: observe for hypertension & edema
(Hypothalamus)
7. Monitor I&O & daily weight: assess for pitting edema: Measure
abdominal girth: notify physician
Polyphagia
8. Provide diet low in Calorie & Na & high in CHON, K, Ca,
Polydypsia
Vitamin D
* liver has glycogen that undergo glycogenesis/glycogenolysis
9. Monitor urine: for glucose & acetone; administer insulin
as ordered
GLUCONEOGENESIS
10. Provide psychological support & acceptance
Formation of glucose from non-CHO sources
11. Prepare client for hypophysectomy or radiation: if condition is
caused by a pituitary tumor
Increase protein formation
12. Prepare client for Adrenalectomy: if condition is caused by an
adrenal tumor or hyperplasia
13. Restrict sodium intake Negative Nitrogen balance

14. Administer medications as ordered: Spironolactone (Aldactone):


Tissue wasting (Cachexia)
potassium sparring diuretics
15. Provide client teaching & discharge planning concerning:
INCREASE FAT CATABOLISM
a. Diet modification
b. Importance of adequate rest
Free fatty acids
c. Need to avoid stress & infection
d. Change in medication regimen (alternate day therapy or
reduce dosage): if caused of condition is prolonged Cholesterol

corticosteroid therapy Ketones


e. Prevent complications (DM)
Atherosclerosis Diabetic Keto
f. Hormonal replacement for lifetime: lifetime due to adrenal
gland removal: no more corticosteroid! Acidosis

g. Importance of follow up care Hypertension


Acetone Breath
Kussmaul’s Respiration
Diabetes Mellitus (DM) odor
MI CVA
 Represent a heterogenous group of chronic disorders characterized
by hyperglycemia
 Hyperglycemia: due to total or partial insulin deficiency or
Death
insensitivity of the cells to insulin Diabetic Coma
 Characterized by disorder in the metabolism of CHO, fats, CHON,
as well as changes in the structure & function of blood vessels
Classification Of DM
 Metabolic disorder characterized by non utilization of carbohydrates,
1. Type I Insulin-dependent Diabetes Mellitus (IDDM)
protein and fat metabolism
 Secondary to destruction of beta cells in the islets of langerhans
in the pancreas resulting in little of no insulin production
Pathophysiology
 Non-obese adults
Lack of insulin causes hyperglycemia (insulin is necessary for the transport of
 Requires insulin injection
glucose across the cell membrane) = Hyperglycemia leads to osmitic diuresis
 Juvenile onset type (Brittle disease)
as large amounts of glucose pass through the kidney result polyuria &
glycosuria = Diuresis leads to cellular dehydration & F & E depletion causing
Incidence Rate
polydipsia (excessive thirst) = Polyphagia (hunger & increase appetite) result
1. 10% general population has Type I DM
from cellular starvation = The body turns to fat & CHON for energy but in the
absence of glucose in the cell fat cannot be completely metabolized & ketones
Predisposing Factors
(intermediate products of fat metabolism) are produced = This leads to
1. Autoimmune response
ketonemia, ketonuria (contributes to osmotic diuresis) & metabolic acidosis
2. Genetics / Hereditary (total destruction of pancreatic cells)
(ketones are acid bodies) = Ketone sacts as CNS depressants & can cause
3. Related to viruses
coma = Excess loss of F & E leads to hypovolemia, hypotension, renal failure
4. Drugs: diuretics (Lasix), Steroids, oral contraceptives
& decease blood flow to the brain resulting in coma & death unless treated.
5. Related to carbon tetrachloride toxicity

MAIN FOODSTUFF ANABOLISM CATABOLISM


S/sx

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43

1. Polyuria
7. Anorexia
2. Polydipsia
8. N/V
3. Polyphagia
9. Blurring of vision
4. Glucosuria
10. Increase susceptibility to infection
5. Weight loss
11. Delayed / poor wound healing
6. Fatigue

1. Diabetic Ketoacidosis (DKA)


Dx
1. FBS:
2. Type II Non-insulin-dependent Diabetes Mellitus (NIDDM)
a. A level of 140 mg/dl of greater on at two occasions
 May result to partial deficiency of insulin production &/or an
confirms DM insensitivity of the cells to insulin
b. May be normal in Type II DM
 Obese adult over 40 years old
2. Postprandial Blood Sugar: elevated  Maturity onset type
3. Oral Glucose Tolerance Test (most sensitve test): elevated
4. Glycosolated Hemoglobin (hemoglobin A1c): elevated Incidence Rate
1. 90% of general population has Type II DM
Medical Management
1. Insulin therapy Predisposing Factors
2. Exercise 1. Genetics
3. Diet: 2. Obesity: because obese persons lack insulin receptor binding
a. Consistency is imperative to avoid hypoglycemia sites
b. High-fiber, low-fat diet also recommended
4. Drug therapy: S/sx
a. Insulin: 1. Usually asymptomatic
 Short Acting: used in treating ketoacidosis; during 2. Polyuria
surgery, infection, trauma; management of poorly 3. Polydypsia
controlled diabetes; to supplement long-acting insulins 4. Polyphagia
 Intermediate: used for maintenance therapy 5. Glycosuria
 Long Acting: used for maintenance therapy in clients 6. Weight gain / Obesity
who experience hyperglycemia during the night with 7. Fatigue
intermediate-acting insulin
8. Blurred Vision
b. Insulin preparation can consist of mixture of pure pork,
9. Increase susceptibility to infection
pure beef, or human insulin. Human insulin is the
10. Delayed / poor wound healing
purest insulin & has the lowest antigenic effect
c. Human Insulin: is recommended for all newly diagnosed
Dx
Type I & Type II DM who need short-term insulin therapy;
5. FBS:
the pregnant client & diabetic client with insulin allergy or
c. A level of 140 mg/dl of greater on at two occasions
severe insulin resistance
confirms DM
d. Insulin Pumps: externally worn device that closely d. May be normal in Type II DM
mimic normal pancreatic functioning
6. Postprandial Blood Sugar: elevated
5. Exercise: helpful adjunct to therapy as exercise decrease the
7. Oral Glucose Tolerance Test (most sensitve test): elevated
body’s need for insulin
8. Glycosolated Hemoglobin (hemoglobin A1c): elevated

Characteristics of Insulin Preparation


Medical Management
Drug Synonym Appearance Onset Peak
1. Ideally manage by diet & exercise
Duration Compatible Mixed
2. Oral Hypoglycemic agents or occasionally insulin: if diet &
Rapid Acting
exercise are not effective in controlling hyperglycemia
Insulin Injection Regular Ins Clear ½-1 2-4 6-8 3. Insulin is needed in acute stress: ex. Surgery, infection
All insulin prep
4. Diet: CHO 50%, CHON 30% & Fats 20%
a. Weight loss is important since it decreases
except lente
insulin resistance
b. High-fiber, low-fat diet also recommended
Insulin, Zinc Semilente Ins Cloudy ½-1 4-6 12-16
5. Drug therapy:
Lente prep
a. Occasional use of insulin
suspension,
b. Oral hypoglycemic agent:
prompt
 Used by client who are not controlled by diet &
exercise
Intermediate Acting
 Increase the ability of islet cells of the pancreas to
Isophane Ins NPH Ins Cloudy 1-1 ½ 8-12 18-24
secret insulin; may have some effect on cell receptors
Regular Ins
to decrease resistance to insulin
injection
6. Exercise: helpful adjunct to therapy as exercise decrease the
injection
body’s need for insulin

Insulin Zinc Lente Ins Cloudy 1-1 ½ 8-12 18-24 Oral Hypoglycemic Agent
Regular Ins & Drug Onset Peak Duration
Suspension Comments
semilente prep Oral Sulfonylureas
Acetohexamide (Dymelor) 1 4-6 12-24
Long Acting
Insulin Zinc Ultralente Ins Cloudy 4-8 16-20 30-36
Chlorpropamide (Diabinase) 1 4-6 40-60
Regular Ins &
Glyburide (Micronase, Diabeta) 15 min- 1 hr 2-8 10-24
suspension,
semilente prep Oral Biguanides
extended Metformin (Glucophage) 2-2.5 10-16
:Decrease glucose
Complication

43
46

 Draw up insulin using sterile technique


production in liver  If mixing insulin, draw up clear insulin, before
cloudy insulin
:Decrease intestinal  Injection technique
 Systematically rotate the site: to prevent
absorption of glucose & lipodystrophy: (hypertrophy or atrophy of tissue)
 Insert needle at a 45 (skinny clients) or 90 (fat or
improves insulin sensitivity obese clients) degree angle depending on amount
of adipose tissue
Oral Alpha-glucosidose Inhibitor  May store current vial of insulin at room temperature;
Acarbose (Precose) Unknown 1 Unknown refrigerate extra supplies
:Delay glucose absorption  Somogyi’s phenomenon: hypoglycemia followed by
periods of hyperglycemia or rebound effect of insulin.
& digestion of CHO,  Provide many opportunities for return demonstration
d. Oral hypoglycemic agent
lowering blood sugar  Stress importance of taking the drug regularly
Miglitol (Glyset) 2-3  Avoid alcohol intake while on medication: it can lead to
Troglitazone (Rezulin) Rapid 2-3 Unknown severe hypoglycemia reaction
:Reduce plasma glucose &  Instruct the client to take it with meals: to lessen GIT
irritation & prevent hypoglycemia
insulin e. Urine testing (not very accurate reflection of blood glucose
level)
:Potetiates action of insulin  May be satisfactory for Type II diabetics since they are
more stable

in skeletal muscle &  Use clinitest, tes-tape, diastix, for glucose testing
 Perform test before meals & at bedtime

decrease glucose  Use freshly voided specimen


 Be consistent in brand of urine test used

production in liver  Report results in percentage


 Report result to physician if results are greater
Complications that 1%, especially if experiencing symptoms of

1. Hyper Osmolar Non-Ketotic Coma (HONKC) hyperglycemia


 Urine testing for ketones should be done by Type I

Nursing Intervention diabetic clients when there is persistent glycosuria,

1. Administer insulin or oral hypoglycemic agent as ordered: increase blood glucose level or if the client is not

monitor hypoglycemia especially during period of drug peak feeling well (acetest, ketostix)

action f. Blood glucose monitoring

2. Provide special diet as ordered:  Use for Type I diabetic client: since it gives exact blood

a. Ensure that the client is eating all meals glucose level & also detects hypoglycemia

b. If all food is not ingested: provide appropriate substitute  Instruct client in finger stick technique: use of monitor

according to the exchange list or give measured amount of device (if used), & recording & utilization of test results

orange juice to substitute for leftover food; provide snack g. General care

later in the day  Perform good oral hygiene & have regular dental exam

3. Monitor urine sugar & acetone (freshly voided specimen)  Have regular eye exam

4. Perform finger sticks to monitor blood glucose level as ordered  Care for “sick days” (ex. Cold or flu)

(more accurate than urine test)  Do not omit insulin or oral hypoglycemic agent:

5. Observe signs of hypo/hyperglycemia since infection causes increase blood sugar

6. Provide meticulous skin care & prevent injury  Notify physician

7. Maintain I&O; weight daily  Monitor urine or blood glucose level & urine

8. Provide emotional support: assist client in adapting change ketones frequently

in lifestyle & body image  If N/V occurs: sip on clear liquid with simple sugar

9. Observe for chronic complications & plan of care accordingly:


a. Atherosclerosis: leads to CAD, MI, CVA & Peripheral h. Foot care

Vascular Disease  Wash foot with mild soap & water & pat dry

b. Microangiopathy: most commonly affects eyes & kidneys  Apply lanolin lotion to feet: to prevent drying &

c. Kidney Disease cracking

 Recurrent Pyelonephritis  Cut toenail straight across

 Diabetic Nephropathy  Avoid constrictive garments such as garters

d. Ocular Disorder  Wear clean, absorbent socks (cotton or wool)

 Premature Cataracts  Purchase properly fitting shoes & break new shoes in

 Diabetic Retinopathy gradually

e. Peripheral Neuropathy  Never go barefoot

 Affects PNS & ANS  Inspect foot daily & notify physician: if cut, blister, or

 Cause diarrhea, constipation, neurogenic bladder, break in skin occurs

impotence, decrease sweating i. Exercise

10. Provide client teaching & discharge planning concerning:  Undertake regular exercise; avoid sporadic, vigorous

a. Disease process exercise

b. Diet  Food intake may need to be increased before

 Client should be able to plan a meal using exercising

exchange lists before discharge  Exercise is best performed after meals when the blood

 Emphasize importance of regularity of meals; never sugar is rising

skip meals
c. Insulin j. Complication

 How to draw up into syringe  Learn to recognized S/sx of hypo/hyperglycemia: for

 Use insulin at room temp hypoglycemia (cold and clammy skin), for

 Gently roll the vial between palms

46
47

hyperglycemia (dry and warm skin): administer simple


 Occurs in insulin-dependent diabetic clients
sugars
 Onset slow: maybe hours to days
 Eat candy or drink orange juice with sugar added for
insulin reaction (hypoglycemia)
Predisposing Factors
 Monitor signs of DKA & HONKC
1. Undiagnosed DM
k. Need to wear a Medic-Alert bracelet
2. Neglect to treatment
3. Infection
Diabetic Ketoacidosis (DKA)
4. cardiovascular disorder
 Acute complication of DM characterized by hyperglycemia &
5. Hyperglycemia
accumulation of ketones in the body: cause metabolic acidosis
6. Physical & Emotional Stress: number one precipitating factor
 Acute complication of Type I DM: due to severe hyperglycemia
leading to severe CNS depression
S/sx
1. Polyuria
10. Dry mucous membrane; soft eyeballs
2. Polydipsia
11. Blurring of vision
3. Polyphagia
12. PS: Acetone breath odor
4. Glucosuria
13. PS: Kussmaul’s Respiration (rapid shallow breathing) or
5. Weight loss
tachypnea
6. Anorexia
14. Alteration in LOC
7. N/V
15. Hypotension
8. Abdominal pain
16. Tachycardia
9. Skin warm, dry & flushed
17. CNS depression leading to coma
c. Monitor blood glucose level frequently
Dx
5. Administer medications as ordered:
1. FBS: is increased
a. Sodium Bicarbonate: to counteract acidosis
2. Serum glucose & ketones level: elevated
b. Antibiotics: to prevent infection
3. BUN (normal value: 10 – 20): elevated: due to dehydration
6. Check urine output every hour
4. Creatinine (normal value: .8 – 1): elevated: due to dehydration
7. Monitor V/S, I&O & blood sugar levels
5. Hct (normal value: female 36 – 42, male 42 – 48): elevated:
8. Assist client with self-care
due to dehydration
9. Provide care for unconscious client if in a coma
6. Serum Na: decrease
10. Discuss with client the reasons ketosis developed & provide
7. Serum K: maybe normal or elevated at first
additional diabetic teaching if indicated
8. ABG: metabolic acidosis with compensatory respiratory alkalosis

Hyperglycemic Hyperosmolar Non-Ketotic Coma (HHNKC)


Nursing Intervention
 Characterized by hyperglycemia & a hyperosmolar state without
1. Maintain patent airway
ketosis
2. Assist in mechanical ventilation
 Occurs in non-insulin-dependent diabetic or non-diabetic persons
3. Maintain F&E balance:
(typically elderly clients)
a. Administer IV therapy as ordered:
 Hyperosmolar: increase osmolarity (severe dehydration)
 Normal saline (0.9% NaCl), followed by hypotonic
 Non-ketotic: absence of lypolysis (no ketones)
solutions (.45% NaCl) sodium chloride: to counteract
dehydration & shock
Predisposing Factors
 When blood sugar drops to 250 mg/dl: may add 5%
1. Undiagnosed diabetes
dextrose to IV
2. Infection or other stress
 Potassium will be added: when the urine output is
3. Certain medications (ex. dilantin, thiazide, diuretics)
adequate
4. Dialysis
b. Observe for F&E imbalance, especially fluid overload,
5. Hyperalimentation
hyperkalemia & hypokalemia
6. Major burns
4. Administer insulin as ordered: regular acting insulin/rapid
7. Pancreatic disease
acting insulin
a. Regular insulin IV (drip or push) & / or subcutaneously (SC)
S/sx
b. If given IV drip: give small amount of albumin since
insulin adheres to IV tubing
1. Polyuria
10. Dry mucous membrane; soft eyeballs
2. Polydipsia
11. Blurring of vision
3. Polyphagia
12. Hypotension
4. Glucosuria
13. Tachycardia
5. Weight loss
14. Headache and dizziness
6. Anorexia
15. Restlessness
7. N/V
16. Seizure activity
8. Abdominal pain
17. Alteration / Decrease LOC: diabetic coma
9. Skin warm, dry & flushed

 Normal saline (0.9% NaCl), followed by hypotonic


Dx
solutions (.45% NaCl) sodium chloride: to counteract
1. Blood glucose level: extremely elevated
dehydration & shock
2. BUN: elevated: due to dehydration
 When blood sugar drops to 250 mg/dl: may add 5%
3. Creatinine: elevted: due to dehydration
dextrose to IV
4. Hct: elevated: due to dehydration
 Potassium will be added: when the urine output is
5. Urine: (+) for glucose
adequate
b. Observe for F&E imbalance, especially fluid overload,
Nursing Intervention
hyperkalemia & hypokalemia
1. Maintain patent airway
4. Administer insulin as ordered:
2. Assist in mechanical ventilation
a. Regular insulin IV (drip or push) & / or subcutaneously (SC)
3. Maintain F&E balance:
b. If given IV drip: give small amount of albumin since insulin
a. Administer IV therapy as ordered:
adheres to IV tubing
c. Monitor blood glucose level frequently
5. Administer medications as ordered:

47
50

a. Antibiotics: to prevent infection


c. 2150 ml venous
6. Check urine output every hour
7. Monitor V/S, I&O & blood sugar levels
Plasma
8. Assist client with self-care
 Liquid part of the blood; yellow in color because of pigments
9. Provide care for unconscious client if in a coma
 Consists of serum (liquid portion of plasma) & fibrinogen
10. Discuss with client the reasons ketosis developed & provide
 Contains plasma CHON such as albumin, serum, globulins,
additional diabetic teaching if indicated
fibrinogen, prothrombin, plasminogen
1. Albumin
 Largest & numerous plasma CHON
 Involved in regulation of intravascular plasma volume
Overview of Anatomy & Physiology of Hematologic System
 Maintains osmotic pressure: preventing edema
2. Serum Globulins
 The structure of the hematological of hematopoietic system includes
a. Alpha: role in transport steroids, lipids, bilirubin &
the blood, blood vessels, & blood forming organs (bone marrow,
hormones
spleen, liver, lymph nodes, & thymus gland).
b. Beta: role in transport of iron & copper
 The major function of blood: is to carry necessary materials (O2,
c. Gamma: role in immune response, function of antibodies
nutrients) to cells & remove CO2 & metabolic waste products.
3. Fibrinogens, Prothrombin, Plasminogens: clotting factors to
 The hematologic system also plays an important role in hormone
prevent bleeding
transport, the inflammatory & immune responses, temperature
regulation, F&E balance & acid-base balance.
Cellular Components or Formed Elements
1. Erythrocytes (RBC)
a. Normal value: 4 – 6 million/mm3
HEMATOLOGICAL SYSTEM
b. No nucleus, Biconcave shape discs, Chiefly sac of hemoglobin
c. Call membrane is highly diffusible to O2 & CO2
I. Blood II. Blood Vessels III. d. Responsible for O2 transport via hemoglobin (Hgb)
Blood Forming Organs
 Two portion: iron carried on heme portion; second portion
1. Arteries 1. is CHON
Liver
55% Plasma 45% Formed 2. Veins 2.  Normal blood contains 12-18 g Hgb/100 ml blood; higher
Thymus (14-18 g) in men than in women (12-14 g)
(Fluid) cellular elements 3. Capillaries 3.
e. Production
Spleen
4.  Start in bone marrow as stem cells, release as reticulocytes
Lymphoid Organ
(immature cells), mature into erythrocytes
Serum Plasma CHON 5.
Lymph Nodes  Erythropoietin stimulates differentiation; produced by
(formed in liver) 6. kidneys & stimulated by hypoxia
Bone Marrow
 Iron, vitamin B12, folic acid, pyridoxine vitamin B6, &
1. Albumin
2. Globulins other factors required for erythropoiesis
3. Prothrombin and Fibrinogen
f. Hemolysis (Destruction)
 Normal life span of RBC is 80 – 120 days and is killed in
Bone Marrow red pulp of spleen
 Contained inside all bones, occupies interior of spongy bones &  Immature RBCs destroyed in either bone marrow or other
center of long bones; collectively one of the largest organs in the reticuloendothelial organs (blood, connective tissue, spleen,
body (4-5% of total body weight) liver, lungs and lymph nodes)
 Primary function is Hematopoiesis: the formation of blood cells  Mature cells remove chiefly by liver and spleen
 All blood cells start as stem cells in the bone marrow; these mature  Bilirubin (yellow pigment): by product of Hgb (red pigment)
into different, specific types of cells, collectively referred to as released when RBCs destroyed, excreted in bile
Formed Elements of Blood or Blood Components:  Biliverdin (green pigment)
1. Erythrocytes  Hemosiderin (golden brown pigment)
2. Leukocytes  Iron: feed from Hgb during bilirubin formation; transported
3. Thrombocytes to bone marrow via transferring and and reclaimed for new
 Two kinds of Bone Marrow: Hgb production
1. Red Marrow  Premature destruction: may be caused by RBC membrane
 Carries out hematopoiesis; production site of erythroid, abnormalities, Hgb abnormalities, extrinsic physical factors
myeloid, & thrombocytic component of blood; one source of (such as the enzyme defects found in G6PD)
lymphocytes & macrophages  Normal age RBCs may be destroyed by gross damage as
 Found in the ribs, vertebral column, other flat bones in trauma or extravascular hemolysis (in spleen, liver,
2. Yellow Marrow bone marrow)
 Red marrow that has changed to fats; found in long bone; g. Hemoglobin: normal value female 12 – 14 gms% male 14 – 16
does not contribute to hematopoiesis gms%
h. Hematocrit red cell percentage in wholeblood (normal value:
Blood female 36 – 42% male 42 – 48%)
 Composed of plasma (55%) & cellular components (45%) i. Substances needed for maturation of RBC:
 Hematocrit a. Folic acid
1. Reflects portion of blood composed of red blood cells b. Iron
2. Centrifugation of blood results in separation into top layer of c. Vitamin c
plasma, middle layer of leukocytes & platelets, & bottom layer d. Vitamin b12 (Cyanocobalamin)
of erythrocytes e. Vitamin b6 (Pyridoxine)
3. Majority of formed elements is erythrocytes; volume of f. Intrinsic factor
leukocytes & platelets is negligible
 Distribution 2. Leukocytes (WBC)
1. 1300 ml in pulmonary circulation a. Normal value: 5000 – 10000/mm3
a. 400 ml arterial b. Granulocytes and mononuclear cells: involved in the protection
b. 60 ml capillary from bacteria and other foreign substances
c. 840 ml venous c. Granulocytes:
2. 3000 ml in systemic circulation  Polymorphonuclear Neutrophils
a. 550 ml arterial - 60 – 70% of WBC
b. 300 ml capillary

50
51

- Involved in short term phagocytosis for acute


b. Anti-Rh antibodies not automatically formed in Rh (-) persons,
inflammation
but if Rh (+) blood is given, antibody formation starts & second
- Mature neutrophils: polymorphonuclear leukocytes
exposure to Rh antigen will trigger a transfusion reaction
- Immature neutrophils: band cells (bacterial infection
c. Important for Rh (-) woman carrying Rh (+) baby; 1st
usually produces increased numbers of band cells)
pregnancy not affected, but subsequent pregnancy with an Rh
 Polymorphonuclear Basophils
(+) baby, mother’s antibodies attack baby’s RBC
- For parasite infections
- Responsible for the release of chemical mediation for
Complication of Blood Transfusion
inflammation
Type Causes Mechanism Occurrence S/sx
- Involved in prevention of clotting in microcirculation
Intervention
and allergic reactions
 Polymorphonuclear Eosinophils
Hemolytic ABO Antibodies in Acute:
- Involved in phagocytosis and allergic reaction
Headache, Stop transfusion.
 Eosinophils & Basophils: are reservoirs of
Incompatibility; recipient plasma first 5 min
histamine, serotonin & heparin
lumbar or continue saline IV
d. Non Granulocytes
Rh react w/ antigen after completion
 Mononuclear cells: large nucleated cells
sternal pain, send blood unit &
a. Monocytes:
Incompatibility; in donor cells. of transfusion
 Involved in long-term phagocytosis for chronic
diarrhea, fever, client blood
inflammation
Use of dextrose Agglutinated cell chills,
 Play a role in immune response
flushing, sample to lab.
 Macrophage in blood
solutions; block capillary Delayed: heat
 Largest WBC
along vein, Watch for
 Produced by bone marrow: give rise to histiocytes
Wide temp blood flow to days to 2
(kupffer cells of liver), macrophages & other
restlessness, hemoglobinuria.
components of reticuloendothelial system
fluctuation organs. weeks after
b. Lymphocytes: immune cells; produce substances
anemia, jaundice, Treat or prevent
against foreign cells; produced primarily in
Hemolysis (Hgb
lymph tissue (B cells) & thymus (T cells)
dyspnea, signs shock, DIC, &
Lymphocytes
into plasma & of
shock, renal renal shutdown
B-cell T-cell Natural killer cell urine)
- bone marrow - thymus - anti-viral and anti-
shutdown, DIC
tumor property
for immunity

Complication of Blood Transfusion


HIV
Type Causes Mechanism Occurrence S/sx
c. Thrombocytes (Platelets)
Intervention
 Normal value: 150,000 – 450,000/mm3
 Normal life span of platelet is 9 – 12 days
Allergic Transfer of an Immune Within 30 min
 Fragments of megakaryocytes formed in bone
Uticaria, larygeal Stop transfusion.
marrow
antigen & sensitivity to start of
 Production regulated by thrombopoietin
edema, wheezing Administer
 Essential factors in coagulation via adhesion,
antibody from foreign serum transfusion
aggregation & plug formation
dyspnea, antihistamine &
 Release substances involved in coagulation
donor to CHON
 Promotes hemostasis (prevention of blood loss)
bronchospasm, or epinephrine.
 Consist of immature or baby platelets or
recipient;
megakaryocytes which is the target of dengue
headache, Treat
virus
Allergic donor
anaphylaxis life-threatening
Signs of Platelet Dysfunction
1. Petechiae
reaction
2. Echhymosis
3. Oozing of blood from venipunctured site

Pyrogenic Recipient Leukocytes Within 15-90


Blood Groups
 Erythrocytes carry antigens, which determine the different blood Fever, chills, Stop transfusion.
group possesses agglutination min after
 Blood-typing system are based on the many possible antigens, but flushing, Treat temp.
the most important are the antigens of the ABO & Rh blood groups antibodies bacterial initiation of
because they are most likely to be involved in transfusion reactions palpitation, Transfuse with
directed against organism transfusion
1. ABO Typing tachycardia, leukocytes-poor
a. Antigens of systems are labeled A & B WBC; bacterial
b. Absence of both antigens results in type O blood occasional blood of washed
c. Presence of both antigen is type AB contamination;
d. Presence of either type A or B results in type A & type lumbar pain RBC.
B, respectively Multitransfused
e. Type O: universal donor Administer
f. Antibodies are automatically formed against ABO antigens not client;
on persons own RBC antibiotics prn
2. Rh Typing multiparous
a. Identifies presence or absence of Rh antigens (Rh + or Rh -) client

51
52

Circulatory Too rapid Fluid volume During & after


 Conversion of fluid blood into a solid clot to reduce blood loss when
Dyspnea, Slow infusion rate blood vessels are ruptured
Overload infusion in overload transfusion
increase BP, Used packed cells System that Initiating Clotting
Susceptible
1. Intrinsic System: initiated by contact activation following endothelial
tachycardia, instead of whole
injury (“intrinsic” to vessel itself)
Client
a. Factor XII: initiate as contact made between damaged vessel &
orthopnea, blood.
plasma CHON
b. Factors VIII, IX & XI activated
cyanosis, anxiety Monitor CVP
2. Extrinsic System:
t a. Initiated by tissue thromboplastins released from injured vessels
h (“extrinsic” to vessel)
r b. Factor VII activated
o
u Common Pathways: activated by either intrinsic or extrinsic pathways
g 1. Platelet factor 3 (PF3) & calcium react with factor X & V
h 2. Prothrombin converted to thrombin via thromboplastin
a 3. Thrombin acts on fibrinogens, forming soluble fibrin
4. Soluble fibrin polymerized by factor XIII to produce a stable,
separate line. insoluble fibrin clot

Clot Resolution: takes place via fibrinolytic system by plasmin &


Air Embolism Blood given Bolus of air Anytime
proteolytic enzymes; clots dissolves as tissue repairs.
Dyspnea, Clamp tubing.
under air blocks pulmonary
increase pulse, Turn client on
Spleen
pressure artery outflow
 Largest Lymphatic Organ: functions as blood filtration system &
wheezing, chest left side
reservoir
following severe pain,
 Vascular bean shape; lies beneath the diaphragm, behind & to the
decrease BP,
left of the stomach; composed of fibrous tissue capsule surrounding
blood loss
a network of fiber
apprehension
 Contains two types of pulp:
a. Red Pulp: located between the fibrous strands, composed of
Thrombo- Used of large Platelets
RBC, WBC & macrophages
When large Abnormal Assess for signs
b. White Pulp: scattered throughout the red pulp, produces
cytopenia amount of deteriorate amount of blood
lymphocytes & sequesters lymphocytes, macrophages, &
bleeding of bleeding.
antigens
banked blood rapidly in stored given over 24 hr
 1%-2% of red cell mass or 200 ml blood/minute stored in the
Initiate bleeding
spleen; blood comes via splenic artery to the pulp for cleansing, then
blood
passes into splenic venules that are lined with phagocytic cells &
precautions.
finally to the splenic vein to the liver.
 Important hematopoietic site in fetus; postnatally procedures
Use fresh blood.
lymphocytes & monocytes
 Important in phagocytosis; removes misshapen erythrocytes,
unwanted parts of erythrocytes
Citrate Large amount Citrate binds After large
 Also involved in antibody production by plasma cells & iron
Neuromascular Monitor/treat
metabolism (iron released from Hgb portion of destroyed
Intoxication of citrated blood ionic calcium amount of
erythrocytes returned to bone marrow)
irritability hypocalcemia.
 In the adult functions of the spleen can be taken over by the
in client with banked blood
reticuloendothelial system.
Bleeding due to Avoid large
decrease liver
Liver
decrease calcium amounts of
 Involved in bile production (via erythrocyte destruction & bilirubin
function
production) & erythropoeisis (during fetal life & when bone marrow
citrated blood.
production is insufficient).
 Kupffer cells of liver have reticuloendothelial function as histiocytes;
Monitor liver fxn
phagocytic activity & iron storage.
 Liver also involved in synthesis of clotting factors, synthesis of
antithrombins.
Hyperkalemia Potassium level Release of In client
with Nausea, colic, Administer blood
Blood Tranfusion
increase in potassium into renal
Purpose
diarrhea, muscle less than 5-7
1. RBC: Improve O2 transport
stored blood plasma with insufficiency
2. Whole Blood, Plasma, Albumin: volume expansion
spasm, ECG days old in client
3. Fresh Frozen Plasma, Albumin, Plasma Protein Fraction:
red cell lysis
provision of proteins
changes (tall with impaired
4. Cryoprecipitate, Fresh Frozen Plasma, Fresh Whole Blood:
provision of coagulation factors
peaked T-waves, potassium
5. Platelet Concentration, Fresh Whole Blood: provision of platelets
short
Q-T excretion
Blood & Blood Products
segm
1. Whole Blood: provides all components
ents)
a. Large volume can cause difficulty: 12-24 hr for Hgb & Hct
to rise
Blood Coagulation
b. Complications: volume overload, transmission of hepatitis
or AIDS, transfusion reacion, infusion of excess potassium

52
53

& sodium, infusion of anticoagulant (citrate) used to keep


8. Regulate BT 10-15 gtts/min or KVO rate or equivalent to 100
stored blood from clotting, calcium binding & depletion
cc/hr: to prevent circulatory overload
(citrate) in massive transfusion therapy
9. Monitor strictly vital signs before, during & after BT especially
2. Red Blood Cell (RBC)
every 15 minutes for first hour because majority of transfusion
a. Provide twice amount of Hgb as an equivalent amount of
reaction occurs during this period
whole blood a. Hemolytic reaction
b. Indicate in cases of blood loss, pre-op & post-op client & b. Allergic reaction
those with incipient congestive failure c. Pyrogenic reaction
c. Complication: transfusion reaction (less common than with d. Circulatory overload
whole blood: due to removal of plasma protein)
e. Air embolism
3. Fresh Frozen Plasma
f. Thrombocytopenia
a. Contains all coagulation factors including V & VIII
g. Cytrate intoxication
b. Can be stored frozen for 12 months; takes 20 minutes to
h. Hyperkalemia (caused by expired blood)
thaw
c. Hang immediately upon arrival to unit (loses its coagulation
S/sx of Hemolytic reaction
factor rapidly)
1. Headache and dizziness
4. Platelets
2. Dyspnea
a. Will raise recipient’s platelet count by 10,000/mm3 3. Diarrhea / Constipation
b. Pooled from 4-8 units of whole blood 4. Hypotension
c. Single-donor platelet transfusion may be necessary for 5. Flushed skin
clients who have developed antibodies; compatibilities
6. Lumbasternal / Flank pain
testing may be necessary 7. Urine is color red / portwine urine
5. Factor VIII Fractions (Cryoprecipitate): contains factor VIII,
fibrinogens & XIII
Nursing Management
6. Granulocytes
1. Stop BT
a. Do not increase WBC: increase marginal pool (at tissue
2. Notify physician
level) rather than circulating pool
3. Flush with plain NSS
b. Premedication with steroids, antihistamine
4. Administer isotonic fluid solution: to prevent shock and acute
& acetaminophen
tubular necrosis
c. Respiratory distress with shortness of breath, cyanosis & 5. Send the blood unit to blood bank for re-examination
chest pain may occur; requires cessation of transfusion &
6. Obtain urine & blood sample & send to laboratory for re-
immediate attention
examination
d. Shaking chills or rigors common, require brief cessation of 7. Monitor vital signs & I&O
therapy, administration of meperdine IV until rigors are
diminished & resumption of transfusion when symptoms S/sx of Allergic reaction
relieved 1. Fever
7. Volume Expander: albumin; percentage concentration varies 2. Dyspnea
(50-100 ml/unit); hyperosmolar solution should not be used in
3. Broncial wheezing
dehydrated clients 4. Skin rashes
5. Urticaria
Goals / Objectives
6. Laryngospasm & Broncospasm
1. Replace circulating blood volume
2. Increase the O2 carrying capacity of blood
Nursing Management
3. Prevent infection: if there is a decrease in WBC
1. Stop BT
4. Prevent bleeding: if there is platelet deficiency
2. Notify physician
3. Flush with plain NSS
Principles of blood transfusion
4. Administer medications as ordered
1. Proper refrigeration
a. Anti Histamine (Benadryl): if positive to hypotension,
a. Expiration of packed RBC is 3-6 days anaphylactic shock: treat with Epinephrine
b. Expiration of platelet is 3-5 days 5. Send the blood unit to blood bank for re examination
2. Proper typing and cross matching 6. Obtain urine & blood sample & send to laboratory for re-
a. Type O: universal donor examination
b. Type AB: universal recipient 7. Monitor vital signs and intake and output
c. 85% of population is RH positive
3. Aseptically assemble all materials needed for BT S/sx Pyrogenic reactions
a. Filter set 1. Fever and chills
b. Gauge 18-19 needle 2. Headache
c. Isotonic solution (0.9 NaCl / plain NSS): to prevent 3. Tachycardia
hemolysis 4. Palpitations
4. Instruct another RN to re check the following 5. Diaphoresis
a. Client name 6. Dyspnea
b. Blood typing & cross matching
c. Expiration date Nursing Management
d. Serial number 1. Stop BT
5. Check the blood unit for bubbles cloudiness, sediments and 2. Notify physician
darkness in color because it indicates bacterial contamination 3. Flush with plain NSS
a. Never warm blood: it may destroy vital factors in blood.
4. Administer medications as ordered
b. Warming is only done: during emergency situation & if you a. Antipyretic
have the warming device b. Antibiotic
c. Emergency rapid BT is given after 30 minutes & let natural 5. Send the blood unit to blood bank for re examination
room temperature warm the blood.
6. Obtain urine & blood sample & send to laboratory for re-
6. BT should be completed less than 4 hours because blood that is examination
exposed at room temperature more than 2 hours: causes blood 7. Monitor vital signs & I&O
deterioration that can lead to bacterial contamination 8. Render TSB
7. Avoid mixing or administering drugs at BT line: to prevent
hemolysis

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S/sx of Circulatory reaction


c. Related to GIT bleeding resulting to hematemasis
1. Orthopnea
and melena (sign for upper GIT bleeding)
2. Dyspnea d. Fresh blood per rectum is called hematochezia
3. Rales / Crackles upon auscultation 2. Inadequate intake or absorption of iron due to:
4. Exertional discomfort a. Chronic diarrhea
b. Related to malabsorption syndrome
Nursing Management c. High cereal intake with low animal CHON digestion
1. Stop BT d. Partial or complete gastrectomy
2. Notify physician e. Pica
3. Administer medications as ordered 3. Related to improper cooking of foods
a. Loop diuretic (Lasix)

S/sx
Nursing Care 1. Usually asymptomatic (mild cases)
1. Assess client for history of previous blood transfusions & any 2. Weakness & fatigue (initial signs)
adverse reaction
3. Headache & dizziness
2. Ensure that the adult client has an 18-19 gauge IV catheter in 4. Pallor & cold sensitivity
place 5. Dyspnea
3. Use 0.9% sodium chloride
6. Palpitations
4. At least two nurse should verify the ABO group, RH type, client
7. Brittleness of hair & nails, spoon shape nails (koilonychias)
& blood numbers & expiration date
8. Atrophic Glossitis (inflammation of tongue)
5. Take baseline V/S before initiating transfusion a. Stomatitis PLUMBER
6. Start transfusion slowly (2 ml/min) VINSON’S SYNDROME
7. Stay with the client during the first 15 min of the transfusion & b. Dysphagia
take V/S frequently 9. PICA: abnormal appetite or craving for non edible foods
8. Maintain the prescribed transfusion rate:
a. Whole Blood: approximately 3-4 hr Dx
b. RBC: approximately 2-4 hr 1. RBC: small (microcytic) & pale (hypochromic)
c. Fresh Frozen Plasma: as quickly as possible 2. RBC: is decreased
d. Platelet: as quickly as possible 3. Hgb: decreased
e. Cryoprecipitate: rapid infusion 4. Hct: moderately decreased
f. Granulocytes: usually over 2 hr 5. Serum iron: decreased
g. Volume Expander: volume-dependent rate 6. Reticulocyte count: is decreased
9. Monitor for adverse reaction 7. Serum ferritin: is decreased
10. Document the following: 8. Hemosiderin: absent from bone marrow
a. Blood component unit number (apply sticker if available)
b. Date of infusion starts & end Nursing Intervention
c. Type of component & amount transfused 1. Monitor for s/sx of bleeding through hematest of all elimination
d. Client reaction & vital signs including urine, stool & gastrict content
e. Signature of transfusionist 2. Enforce CBR / Provide adequate rest: plan activities so as not to
over tire the client
HIV 3. Provide thorough explanation of all diagnostic exam used to
- 6 months – 5 years incubation period
determine sources of possible bleeding: help allay anxiety &
- 6 months window period
ensure cooperation
- western blot opportunistic 4. Instruct client to take foods rich in iron
- ELISA
a. Organ meat
- drug of choice AZT (Zidon Retrovir)
b. Egg yolk
c. Raisin
2 Common fungal opportunistic infection in AIDS
d. Sweet potatoes
1. Kaposis Sarcoma
e. Dried fruits
2. Pneumocystic Carini Pneumonia
f. Legumes
g. Nuts
Blood Disorder
5. Instruct the client to avoid taking tea and coffee: because it
contains tannates which impairs iron absorption
Iron Deficiency Anemia (Anemias)
6. Administer iron preparation as ordered:
 A chronic microcytic anemia resulting from inadequate absorption of
a. Oral Iron Preparations: route of choice
iron leading to hypoxemic tissue injury
 Ferrous Sulfate
 Chronic microcytic, hypochromic anemia caused by either
 Ferrous Fumarate
inadequate absorption or excessive loss of iron
 Ferrous Gluconate
 Acute or chronic bleeding principal cause in adults (chiefly from
trauma, dysfunctional uterine bleeding & GI bleeding)
Nursing Management when taking oral iron
 May also be caused by inadequate intake of iron-rich foods or by
preparations
inadequate absorption of iron
 Instruct client to take with meals: to lessen GIT
 In iron-deficiency states, iron stores are depleted first, followed by a
irritation
reduction in Hgb formation
 Dilute in liquid preparations well & administer using a
straw: to prevent staining of teeth
Incidence Rate
 When possible administer with orange juice as vitamin
1. Common among developed countries & tropical zones (blood-
C (ascorbic acid): to enhance iron absorption
sucking parasites)
 Warn clients that iron preparations will change stool
2. Common among women 15 & 45 years old & children affected
color & consistency (dark & tarry) & may cause
more frequently, as are the poor
constipation
3. Related to poor nutrition
 Antacid ingestion will decrease oral iron effectiveness

Predisposing Factors
b. Parenteral: used in clients intolerant to oral preparations,
1. Chronic blood loss due to:
who are noncompliant with therapy or who have continuing
a. Trauma
blood losses
b. Heavy menstruation

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Nursing Management when giving parenteral iron


Predisposing Factors
preparation 1. Usually occurs in men & women over age of 50 with an increase
 Use one needle to withdraw & another to administer in blue-eyed person of Scandinavian decent
iron preparation as tissue staining & irritation are a
2. Subtotal gastrectomy
problem
3. Hereditary factors
 Use Z-track injection technique: to prevent leakage
4. Inflammatory disorders of the ileum
into tissue
5. Autoimmune
 Do not massage injection site but encourage
6. Strictly vegetarian diet
ambulation as this will enhance absorption; advice
S/sx
against vigourous exercise & constricting garments
1. Anemia
 Observe for local signs of complication:
2. Weakness & fatigue
 Pain at the injection site
3. Headache and dizziness
 Development of sterile abscesses
4. Pallor & cold sensitivity
 Lymphadenitis
5. Dyspnea & palpitations: as part of compensation
 Fever & chills
6. GIT S/sx:
 Headache
a. Mouth sore
 Urticaria
b. PS: Red beefy tongue
 Pruritus
c. Indigestion / dyspepsia
 Hypotension
d. Weight loss
 Skin rashes
e. Constipation / diarrhea
 Anaphylactic shock
f. Jaundice
7. CNS S/sx:
Medications administered via straw
a. Tingling sensation
 Lugol’s Solution
b. Numbness
 Iron
c. Paresthesias of hands & feet
 Tetracycline
d. Paralysis
 Nitrofurantoin (Macrodentin)
e. Depression
7. Administer with Vitamin C or orange juice for absorption
f. Psychosis
8. Monitor & inform client of side effects
g. Positive to Romberg’s test: damage to cerebellum resulting
a. Anorexia
to ataxia
b. N/V
c. Abdominal pain
Dx
d. Diarrhea / constipation
1. Erythrocytes count: decrease
e. Melena
2. Blood Smear: oval, macrocytic erythrocytes with a proportionate
9. If client can’t tolerate / no compliance administer parenteral iron
amount of Hgb
preparation 3. Bilirubin (indirect): elevated unconjugated fraction
a. Iron Dextran (IM, IV)
4. Serum LDH: elevated
b. Sorbitex (IM)
5. Bone Marrow:
10. Provide dietary teaching regarding food high in iron
a. Increased megaloblasts (abnormal erythrocytes)
11. Encourage ingestion of roughage & increase fluid intake: to
b. Few normoblasts or maturing erythrocytes
prevent constipation if oral iron preparation are being taken
c. Defective leukocytes maturation
6. Positive Schilling’s Test: reveals inadequate / decrease
Pernicious Anemia
absorption of Vitamin B12
 Chronic progressive, macrocytic anemia caused by a deficiency of
a. Measures absorption of radioactive vitamin B12 bothe before
intrinsic factor; the result is abnormally large erythrocytes &
& after parenteral administration of intrinsic factor
hypochlorhydria (a deficiency of hydrochloric acid in gastric
b. Definitive test for pernicious anemia
secretion)
c. Used to detect lack of intrinsic factor
 Chronic anemia characterized by a deficiency of intrinsic factor
d. Fasting client is given radioactive vitamin B12 by mouth &
leading to hypochlorhydria (decrease hydrochloric acid secretion)
non-radioactive vitamin B12 IM to permit some excretion of
 Characterized by neurologic & GI symptoms; death usually resuls if
radioactive vitamin B12 in the urine if it os absorbed
untreated
e. 24-48 hour urine collection is obtained: client is encourage
 Lack of intrinsic factor is caused by gastric mucosal atrophy (possibly
to drink fluids
due to heredity, prolonged iron deficiency, or an autoimmune
f. If indicated, second stage schilling test performed 1 week
disorder); can also results in clients who have had a total gastrctomy
after first stage. Fasting client is given radioactive vitamin
if vitamin B12 is not administer
B12 combined with human intrinsic factor & test is repeated
Pathophysiology 7. Gastric Analysis: decrease free hydrochloric acid
1.
Intrinsic factor is necessary for the absorbtion of vitamin B12 into 8. Large number of reticulocytes in the blood following parenteral

small intestines vitamin B12 administration


2.
B12 deficiency diminished DNA synthesis, which results in
defective maturation of cell (particularly rapidly dividing Medical Management
cells such as blood cells & GI tract cells) 1. Drug Therapy:
3.
B12 deficiency can alter structure & function of peripheral a. Vitamin B12 injection: monthly maintenance
nerves, spinal cord, & the brain b. Iron preparation: (if Hgb level inadequate to meet increase
numbers of erythrocytes)
STOMACH
c. Folic Acid
Pareital cells/Argentaffin or Oxyntic cells  Controversial
 Reverses anemia & GI symptoms but may intensify
Produces intrinsic factors Secretes neurologic symptoms
hydrochloric acid  May be safe if given in small amounts in addition
to vitamin B12
Promotes reabsorption of Vit B12 Aids in 2. Transfusion Therapy
digestion Nursing Intervention
1. Enforce CBR: necessary if anemia is severe
Promotes maturation of RBC 2. Adminster Vitamin B12 injections at monthly intervals for lifetime
as ordered

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 Never given orally because there is possibility of developing


5. Identification & withdrawal of offending agent or drug
tolerance
 Site of injection for Vitamin B12 is dorsogluteal and
Nursing Intervention
ventrogluteal 1. Removal of underlying cause
 No side effects
2. Administer Blood Transfusion as ordered
3. Provide a dietary intake that is high in CHON, vitamin c and iron 3. Administer O2 inhalation
(fish, meat, milk / milk product & eggs)
4. Enforce CBR
4. Avoid highly seasoned, coursed, or very hot foods: if client has
5. Institute reverse isolation
mouth sore
6. Provide nursing care for client with bone marrow transplant
5. Provide safety when ambulating (especially when carrying hot
7. Administer medications as ordered:
item)
a. Corticosteroids: caused by immunologic injury
6. Instruct client to avoid irritating mouth washes instead use soft
b. Immunosuppressants: Anti Lymphocyte Globulin
bristled toothbrush
7. Avoid heat application to prevent burns Given via central venous catheter
8. Provide client teaching & discharge planning concerning: Given 6 days to 3 weeks to achieve maximum therapeutic
a. Dietery instruction effect of drug
b. Importance of lifelong vitamin B12 therapy 8. Monitor for signs of infection & provide care to minimize risk:
c. Rehabilitation & physical therapy for neurologic deficit, as a. Monitor neuropenic precautions
well as instruction regarding safety b. Encourage high CHON, vitamin diet: to help reduce
incidence of infection
Aplastic Anemia c. Provide mouth care before & after meals
 Stem cell disorder leading to bone marrow depression leading to d. Fever
pancytopenia e. Cough
 Pancytopenia or depression of granulocytes, platelets & erythrocytes 9. Monitor signs of bleeding & provide measures to minimize risk:
production: due to fatty replacement of the bone marrow a. Use soft toothbrush when brushing teeth & electric razor
 Bone marrow destruction may be idiopathic or secondary when shaving: prevent bleeding
b. Avoid IM, subcutaneous, venipunctured sites: Instead
PANCYTOPENIA provide heparin lock
c. Hematest urine & stool
Decrease RBC Decrease WBC d. Observe for oozing from gums, petechiae or ecchymoses
Decrease Platelet
10. Provide client teaching & discharge planning concerning:
(anemia) (leukopenia)
a. Self-care regimen
(thrombocytopenia)
b. Identification of offending agent & importance of avoiding it
(if possible) in future
Predisposing Factors
1. Chemicals (Benzene and its derivatives)
Disseminated Intravascular Coagulation (DIC)
2. Related to radiation / exposure to x-ray
 Diffuse fibrin deposition within arterioles & capillaries with
3. Immunologic injury
widespread coagulation all over the body & subsequent depletion of
4. Drugs:
clotting factors
a. Broad Spectrum Antibiotics: Chloramphenicol
 Acute hemorrhagic syndrome characterized by wide spread bleeding
(Sulfonamides)
and thrombosis due to a deficiency of prothrombin and fibrinogen
b. Cytotoxic agent / Chemotherapeutic Agents:
 Hemorrhage from kidneys, brain, adrenals, heart & other organs
 Methotrexate (Alkylating Agent)
 May be linked with entry of thromboplasic substance into the blood
 Vincristine (Plant Alkaloid)
 Mortality rate is high usually because underlying disease cannot be
 Nitrogen Mustard (Antimetabolite)
corrected
 Phenylbutazones (NSAIDS)

S/sx
Pathophysiology
1. Anemia
1. Underlying disease (ex. toxemia of pregnancy, cancer) cause
a. Weakness & fatigue
release of thromboplastic substance that promote the deposition
b. Headache & dizziness
of fibrin throughout the microcirculation
c. Pallor & cold sensitivity
2. Microthrombi form in many organs, causing microinfarcts &
d. Dyspnea & palpitations
tissue necrosis
2. Leukopenia
3. RBC are trapped in fibrin strands & are hemolysed
a. Increase susceptibility to infection
4. Platelets, prothrombin & other clotting factors are destroyed,
3. Thrombocytopenia
leading to bleeding
a. Petechiae (multiple petechiae is called purpura)
5. Excessive clotting activates the fibrinolytic system, which inhibits
b. Ecchymosis
platelet function, causing futher bleeding.
c. Oozing of blood from venipunctured sites
Dx
Predisposing Factors
1. CBC: reveals pancytopenia
1. Related to rapid blood transfusion
2. Normocytic anemia, granulocytopenia, thrombocytopenia
2. Massive burns
3. Bone marrow biopsy: aspiration (site is the posterior iliac crest):
3. Massive trauma
marrow is fatty & contain very few developing cells; reveals fat
4. Anaphylaxis
necrosis in bone marrow
5. Septecemia
6. Neoplasia (new growth of tissue)
Medical Management
7. Pregnancy
1. Blood transfusion: key to therapy until client’s own marrow
begins to produce blood cells
S/sx
2. Aggressive treatment of infection
1. Petechiae & Ecchymosis on the skin, mucous membrane, heart,
3. Bone marrow transplantation
eyes, lungs & other organs (widespread and systemic)
4. Drug Therapy:
2. Prolonged bleeding from breaks in the skin: oozing of blood
a. Corticosteroids & / or androgens: to stimulate bone marrow
from punctured sites
function & to increase capillary resistance (effective in
3. Severe & uncontrollable hemorrhage during childbirth or surgical
children but usually not in adults)
procedure
b. Estrogen & / or progesterone: to prevent amenorrhea in
4. Hemoptysis
female clients

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5. Oliguria & acute renal failure (late sign)


 Visceral: inner layer
6. Convulsion, coma, death Epicardium
 Covers surface of the heart, becomes continuous with visceral layer
Dx of serous pericardium
1. PT: prolonged  Outer layer
2. PTT: usually prolonged Myocardium
3. Thrombin Time: usually prolonged  Middle muscular layer
4. Fibrinogen level: usually depressed  Myocarditis can lead to cardiogenic shock and rheumatic heart
5. Fibrin splits products: elevated disease
6. Protamine Sulfate Test: strongly positive Endocardium
7. Factor assay (II, V, VII): depressed  Thin, inner membrabous layer lining the chamber of the heart
8. CBC: reveals decreased platelets  Inner layer
9. Stool occult blood: positive Papillary Muscle
10. ABG analysis: reveals metabolic acidosis  Arise from the endocardial & myocardial surface of the ventricles &
11. Opthamoscopic exam: reveals sub retinal hemorrhages attach to the chordae tendinae
Chordae Tendinae
Medical Management  Attach to the tricuspid & mitral valves & prevent eversion during
1. Identification & control the underlying disease is key systole
2. Blood Tranfusions: include whole blood, packed RBC, platelets,
plasma, cryoprecipitites & volume expanders Chambers of the Heart
3. Heparin administration Atria
a. Somewhat controversial  2 chambers, function as receiving chambers, lies above the
b. Inhibits thrombin thus preventing further clot formation, ventricles
allowing coagulation factors to accumulate  Upper Chamber (connecting or receiving)
 Right Atrium: receives systemic venous blood through the
Nursing Intervention superior vena cava, inferior vena cava & coronary sinus
1. Monitor blood loss & attemp to quantify  Left Atrium: receives oxygenated blood returning to the heart
2. Monitor for signs of additional bleeding or thrombus formation from the lungs trough the pulmonary veins
3. Monitor all hema test / laboratory data including stool and GIT Ventricles
4. Prevent further injury  2 thick-walled chambers; major responsibility for forcing blood out
a. Avoid IM injection of the heart; lie below the atria
b. Apply pressure to bleeding site  Lower Chamber (contracting or pumping)
c. Turn & position the client frequently & gently  Right Ventricle: contracts & propels deoxygenated blood into
d. Provide frequent nontraumatic mouth care (ex. soft pulmonary circulation via the aorta during ventricular systole;
toothbrush or gauze sponge) Right atrium has decreased pressure which is 60 – 80 mmHg
5. Administer isotonic fluid solution as ordered: to prevent shock  Left Ventricle: propels blood into the systemic circulation via
6. Administer oxygen inhalation aortaduring ventricular systole; Left ventricle has increased
7. Force fluids pressure which is 120 – 180 mmHg in order to propel blood to
8. Administer medications as ordered: the systemic circulation
a. Vitamin K
b. Pitressin / Vasopresin: to conserve fluids Valves
c. Heparin / Comadin is ineffective  To promote unidimensional flow or prevent backflow
9. Provide heparin lock Atrioventricular Valve
10. Institute NGT decompression by performing gastric lavage: by  Guards opening between
using ice or cold saline solution of 500-1000 ml  Mitral Valve: located between the left atrium & left ventricle;
11. Monitor NGT output contains 2 leaflets attached to the chordae tandinae
12. Prevent complication  Tricuspid Valve: located between the right atrium & right
a. Hypovolemic shock: Anuria (late sign of hypovolemic shock) ventricle; contains 3 leaflets attached to the chordae tandinae
13. Provide emotional support to client & significant other
14. Teach client the importance of avoiding aspirin or aspirin- Functions
containing compounds  Permit unidirectional flow of blood from specific atrium to specific
ventricle during ventricular diastole
 Prevent reflux flow during ventricular systole
Overview of the Structure & Functions of the Heart  Valve leaflets open during ventricular diastole; Closure of AV valves
give rise to first heart sound (S1 “lub”)
 Cardiovascular system consists of the heart, arteries, veins & Semi-lunar Valve
capillaries. The major function are circulation of blood, delivery of O2  Pulmonary Valve
& other nutrients to the tissues of the body & removal of CO2 &  Located between the left ventricle & pulmonary artery
other cellular products metabolism  Aortic Valve
Heart  Located between left ventricle & aorta
 Muscular pumping organ that propel blood into the arerial system & Function
receive blood from the venous system of the body.  Pemit unidirectional flow of the blood from specific ventricle to
 Located on the left mediastinum arterial vessel during ventricular diastole
 Resemble like a close fist  Prevent reflux blood flow during ventricular diastole
 Weighs approximately 300 – 400 grams  Valve open when ventricle contract & close during ventricular
 Covered by a serous membrane called the pericardium diastole; Closure of SV valve produces second heart sound (S2
“dub”)
Heart Wall / Layers of the Heart
Pericardium Extra Heart Sounds
 Composed of fibrous (outermost layer) & serous pericardium S3: ventricular gallop usually seen in Left Congestive Heart Failure

(parietal & visceral); a sac that function to protect the heart from
 S4: atrial gallop usually seen in Myocardial Infarction and
friction
Hypertension
 In between is the pericardial fluid which is 10 – 20 cc: Prevent
pericardial friction rub
Coronary Circulation
 2 layers of pericardium
Coronary Arteries
 Parietal: outer layer

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 Branch off at the base of the aorta & supply blood to the  Major function of the blood vessels isto supply the tissue with blood,
myocardium & the conduction system remove wastes, & carry unoxygenated blood back to the heart
 Arises from base of the aorta
 Types of Coronary Arteries Types of Blood Vessels
 Right Main Coronary Artery Arteries
 Left Main Coronary Artery  Elastic-walled vessels that can stretch during systole & recoil during
Coronary Veins
diastole; they carry blood away from the heart & distribute
 Return blood from the myocardium back to the right atrium via the
oxygenated blood throughout the body
coronary sinus
Arterioles
 Small arteries that distribute blood to the capillaries & function in
Conduction System controlling systemic vascular resistance & therefore arterial pressure
Sinoatrial Node (SA node or Keith Flack Node)
Capilliaries
 Located at the junction of superior vena cava and right atrium
 The following exchanges occurs in the capilliaries
 Acts as primary pacemaker of the heart  O2 & CO2
 Initiates the cardiac impulse which spreads across the atria & into  Solutes between the blood & tissue
AV node
 Fluid volume transfer between the plasma & interstitial space
 Initiates electrical impulse of 60-100 bpm
Venules
 Small veins that receive blood from capillaries & function as
Atrioventricular Node (AV node or Tawara Node)
collecting channels between the capillaries & veins
 Located at the inter atrial septum
Veins
 Delays the impulse from the atria while the ventricles fill
 Low-pressure vessels with thin small & less muscles than arteries;
 Delay of electrical impulse for about .08 milliseconds to allow
most contains valves that prevent retrograde blood flow; they carry
ventricular filling
deoxygenated blood back to the heart. When the skeletal
surrounding veins contract, the veins are compressed, promoting
Bundle of His
movement of blood back to the heart.
 Arises from the AV node & conduct impulse to the bundle branch
system
 Located at the interventricular septum
Cardiac Disorders
 Right Bundle Branch: divided into anterior lateral & posterior;
Coronary Arterial Disease / Ischemic Heart Disease
transmits impulses down the right side of the interventricular
myocardium
Stages of Development of Coronary Artery Disease
 Left Bundle Branch: divided into anterior & posterior
1. Myocardial Injury: Atherosclerosis
 Anterior Portion: transmits impulses to the anterior
2. Myocardial Ischemia: Angina Pectoris
endocardial surface of the left ventricle
3. Myocardial Necrosis: Myocardial Infarction
 Posterior Portion: transmits impulse over the posterior
& inferior endocardial surface of the left ventricle
ATHEROSCLEROSIS
ATHEROSCLEROSIS ARTERIOSCLEROSIS
Purkinje Fibers
 Narrowing of artery  Hardening of artery
 Transmit impulses to the ventricle & provide for depolarization after
 Lipid or fat deposits  Calcium and protein
ventricular contraction
 Tunica intima deposits
 Located at the walls of the ventricles for ventricular contraction
 Tunica media

Predisposing Factors
1. Sex: male
2. Race: black
SA NODE
3. Smoking
AV NODE
4. Obesity
5. Hyperlipidemia
6. Sedentary lifestyle
BUNDLE OF HIS
7. Diabetes Mellitus
8. Hypothyroidism
9. Diet: increased saturated fats
10. Type A personality

PURKINJE FIBERS S/sx


1. Chest pain
Electrical activity of heart can be visualize by attaching electrodes to the skin 2. Dyspnea
& recording activity by ECG 3. Tachycardia
Electrocadiography (ECG) Tracing 4. Palpitations
 P wave (atrail depolarization) contraction 5. Diaphoresis
 QRS wave (ventricular depolarization)
 T wave (ventricular repolarization) Treatment
 Insert pacemaker if there is complete heart block P - Percutaneous
 Most common pacemaker is the metal pacemaker and lasts up to 2 – T - Transluminal
5 years C - Coronary
A – Angioplasty
Abnormal ECG Tracing
 Positive U wave: Hypokalemia C - Coronary
 Peak T wave: Hyperkalemia A - Arterial
 ST segment depression: Angina Pectoris B - Bypass
 ST segment elevation: Myocardial Infarction A - And
 T wave inversion: Myocardial Infarction G - Graft
 Widening of QRS complexes: Arrythmia S - Surgery

Vascular System

Objectives

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59

1. Revascularize myocardium
2. Give prompt pain relievers with nitrates or narcotic analgesic as
2. To prevent angina
ordered
3. Increase survival rate 3. Administer medications as ordered:
4. Done to single occluded vessels a. Nitroglycerine (NTG): when given in small doses will act as
5. If there is 2 or more occluded blood vessels CABG is done venodilator, but in large doses will act as vasodilator
 Give 1st dose of NTG: sublingual 3-5 minutes
3 Complications of CABG
 Give 2nd dose of NTG: if pain persist after giving 1st dose
1. Pneumonia: encourage to perform deep breathing, coughing
with interval of 3-5 minutes
exercise and use of incentive spirometer
 Give 3rd & last dose of NTG: if pain still persist at 3-5
2. Shock
minutes interval
3. Thrombophlebitis

Nursing Management when giving NTG


Angina Pectoris
1. NTG Tablets (sublingual)
 Transient paroxysmal chest pain produced by insufficient blood flow
 Keep the drug in a dry place, avoid moisture and exposure
to the myocardium resulting to myocardial ischemia
to sunlight as it may inactivate the drug
 Clinical syndrome characterized by paroxysmal chest pain that is
 Relax for 15 minutes after taking a tablet: to prevent
usually relieved by rest or nitroglycerine due to temporary
dizziness
myocardial ischemia
 Monitor side effects:
 Orthostatic hypotension
Predisposing Factors
 Transient headache & dizziness: frequent side effect
1. Sex: male
 Instruct the client to rise slowly from sitting position
2. Race: black
 Assist or supervise in ambulation
3. Smoking
2. NTG Nitrol or Transdermal patch
4. Obesity
 Avoid placing near hairy areas as it may decrease drug
5. Hyperlipidemia
absorption
6. Sedentary lifestyle
 Avoid rotating transdermal patches as it may decrease drug
7. Diabetes Mellitus
absorption
8. Hypertension
 Avoid placing near microwave ovens or during defibrillation
9. CAD: Atherosclerosis
as it may lead to burns (most important thing to remember)
10. Thromboangiitis Obliterans
b. Beta-blockers
11. Severe Anemia
 Propanolol: side effects PNS
12. Aortic Insufficiency: heart valve that fails to open & close efficiently
 Not given to COPD cases: it causes bronchospasm
13. Hypothyroidism
c. ACE Inhibitors
14. Diet: increased saturated fats
 Enalapril
15. Type A personality
d. Calcium Antagonist
 Nefedipine
Precipitating Factors
4. Administer oxygen inhalation
4 E’s of Angina Pectoris
5. Place client on semi-to high fowlers position
1. Excessive physical exertion: heavy exercises, sexual activity
6. Monitor strictly V/S, I&O, status of cardiopulmonary fuction & ECG
2. Exposure to cold environment: vasoconstriction
tracing
3. Extreme emotional response: fear, anxiety, excitement, strong
7. Provide decrease saturated fats sodium and caffeine
emotions
8. Provide client health teachings and discharge planning
4. Excessive intake of foods or heavy meal
 Avoidance of 4 E’s
 Prevent complication (myocardial infarction)
S/sx
 Instruct client to take medication before indulging into physical
1. Levine’s Sign: initial sign that shows the hand clutching the chest
exertion to achieve the maximum therapeutic effect of drug
2. Chest pain: characterized by sharp stabbing pain located at sub
 Reduce stress & anxiety: relaxation techniques & guided
sterna usually radiates from neck, back, arms, shoulder and jaw
imagery
muscles usually relieved by rest or taking nitroglycerine (NTG)
 Avoid overexertion & smoking
3. Dyspnea
 Avoid extremes of temperature
4. Tachycardia
 Dress warmly in cold weather
5. Palpitations
 Participate in regular exercise program
6. Diaphoresis
 Space exercise periods & allow for rest periods
 The importance of follow up care
9. Instruct the client to notify the physician immediately if pain occurs
Dx
& persists despite rest & medication administration
1. History taking and physical exam
2. ECG: may reveals ST segment depression & T wave inversion during
Myocardial Infarction
chest pain
 Death of myocardial cells from inadequate oxygenation, often
3. Stress test / treadmill test: reveal abnormal ECG during exercise
caused by sudden complete blockage of a coronary artery
4. Increase serum lipid levels
 Characterized by localized formation of necrosis (tissue destruction)
5. Serum cholesterol & uric acid is increased
with subsequent healing by scar formation & fibrosis
 Heart attack
Medical Management  Terminal stage of coronary artery disease characterized by
1. Drug Therapy: if cholesterol is elevated malocclusion, necrosis & scarring.
 Nitrates: Nitroglycerine (NTG)
 Beta-adrenergic blocking agent: Propanolol Types
 Calcium-blocking agent: nefedipine 1. Transmural Myocardial Infarction: most dangerous type
 Ace Inhibitor: Enapril characterized by occlusion of both right and left coronary artery
2. Modification of diet & other risk factors 2. Subendocardial Myocardial Infarction: characterized by occlusion of
3. Surgery: Coronary artery bypass surgery either right or left coronary artery
4. Percutaneuos Transluminal Coronary Angioplasty (PTCA)

The Most Critical Period Following Diagnosis of Myocardial Infarction


Nursing Intervention  6-8 hours because majority of death occurs due to arrhythmia
1. Enforce complete bed rest leading to premature ventricular contractions (PVC)

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Predisposing Factors
10. Maintain quiet environment
1. Sex: male
11. Administer stool softeners as ordered: to facilitate bowel evacuation
2. Race: black
& prevent straining
3. Smoking 12. Relieve anxiety associated with coronary care unit (CCU)
4. Obesity environment
5. CAD: Atherosclerotic 13. Administer medication as ordered:
6. Thrombus Formation a. Vasodilators: Nitroglycirine (NTG), Isosorbide Dinitrate, Isodil
7. Genetic Predisposition (ISD): sublingual
8. Hyperlipidemia b. Anti Arrythmic Agents: Lidocaine (Xylocane), Brithylium
9. Sedentary lifestyle  Side Effects: confusion and dizziness
10. Diabetes Mellitus c. Beta-blockers: Propanolol (Inderal)
11. Hypothyroidism d. ACE Inhibitors: Captopril (Enalapril)
12. Diet: increased saturated fats e. Calcium Antagonist: Nefedipine
13. Type A personality
f. Thrombolytics / Fibrinolytic Agents: Streptokinase, Urokinase,
Tissue Plasminogen Activating Factor (TIPAF)
S/sx  Side Effects: allergic reaction, urticaria, pruritus
1. Chest pain  Nursing Intervention: Monitor for bleeding time
 Excruciating visceral, viselike pain with sudden onset located at
g. Anti Coagulant
substernal & rarely in precordial
 Heparin
 Usually radiates from neck, back, shoulder, arms, jaw &
 Antidote: Protamine Sulfate
abdominal muscles (abdominal ischemia): severe crushing
 Nursing Intervention: Check for Partial Thrombin Time
 Not usually relieved by rest or by nitroglycerine
(PTT)
2. N/V
 Caumadin (Warfarin)
3. Dyspnea
 Antidote: Vitamin K
4. Increase in blood pressure & pulse, with gradual drop in blood
 Nursing Intervention: Check for Prothrombin Time (PT)
pressure (initial sign)
h. Anti Platelet: PASA (Aspirin): Anti thrombotic effect
5. Hyperthermia: elevated temp
 Side Effects: Tinnitus, Heartburn, Indigestion / Dyspepsia
6. Skin: cool, clammy, ashen
 Contraindication: Dengue, Peptic Ulcer Disease, Unknown
7. Mild restlessness & apprehension
cause of headache
8. Occasional findings:
14. Provide client health teaching & discharge planning concerning:
 Pericardial friction rub
a. Effects of MI healing process & treatment regimen
 Split S1 & S2
b. Medication regimen including time name purpose, schedule,
 Rales or Crackles upon auscultation
dosage, side effects
 S4 or atrial gallop
c. Dietary restrictions: low Na, low cholesterol, avoidance of
caffeine
Dx d. Encourage client to take 20 – 30 cc/week of wine, whisky and
1. Cardiac Enzymes brandy: to induce vasodilation
 CPK-MB: elevated e. Avoidance of modifiable risk factors
 Creatinine phosphokinase (CPK): elevated f. Prevent Complication
 Heart only, 12 – 24 hours  Arrhythmia: caused by premature ventricular contraction
 Lactic acid dehydrogenase (LDH): is increased  Cardiogenic shock: late sign is oliguria
 Serum glutamic pyruvate transaminase (SGPT): is increased  Left Congestive Heart Failure
 Serum glutamic oxal-acetic transaminase (SGOT): is increased  Thrombophlebitis: homan’s sign
2. Troponin Test: is increased  Stroke / CVA
3. ECG tracing reveals  Dressler’s Syndrome (Post MI Syndrome): client is resistant
 ST segment elevation to pharmacological agents: administer 150,000-450,000
 T wave inversion units of streptokinase as ordered
 Widening of QRS complexes: indicates that there is g. Importance of participation in a progressive activity program
arrhythmia in MI h. Resumption of ADL particularly sexual intercourse: is 4-6 weeks
4. Serum Cholesterol & uric acid: are both increased post cardiac rehab, post CABG & instruct to:
5. CBC: increased WBC  Make sex as an appetizer rather than dessert
 Instruct client to assume a non weight bearing position
Nursing Intervention  Client can resume sexual intercourse: if can climb or use
 Goal: Decrease myocardial oxygen demand the staircase
i. Need to report the ff s/sx:
1. Decrease myocardial workload (rest heart)  Increased persistent chest pain
 Establish a patent IV line  Dyspnea
 Administer narcotic analgesic as ordered: Morphine Sulfate IV:  Weakness
provide pain relief (given IV because after an infarction there is  Fatigue
poor peripheral perfusion & because serum enzyme would be  Persistent palpitation
affected by IM injection as ordered)  Light headedness
 Side Effects: Respiratory Depression j. Enrollment of client in a cardiac rehabilitation program
 Antidote: Naloxone (Narcan) k. Strict compliance to mediation & importance of follow up care
 Side Effects of Naloxone Toxicity: is tremors
2. Administer oxygen low flow 2-3 L / min: to prevent respiratory arrest Congestive Heart Failure
or dyspnea & prevent arrhythmias  Inability of the heart to pump an adequate supply of blood to meet
3. Enforce CBR in semi-fowlers position without bathroom privileges the metabolic needs of the body
(use bedside commode): to decrease cardiac workload  Inability of the heart to pump blood towards systemic circulation
4. Instruct client to avoid forms of valsalva maneuver
5. Place client on semi fowlers position Types of Heart Failure
6. Monitor strictly V/S, I&O, ECG tracing & hemodynamic procedures 1. Left Sided Heart Failure
7. Perform complete lung / cardiovascular assessment 2. Right Sided Heart Failure
8. Monitor urinary output & report output of less than 30 ml / hr: 3. High-Output Failure
indicates decrease cardiac output
9. Provide a full liquid diet with gradual increase to soft diet: low in Left Sided Heart Failure
saturated fats, Na & caffeine

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 Left ventricular damage causes blood to back up through the left  If CVP is less than 4 cm of water: Hypovolemic shock: increase
atrium & into the pulmonary veins: Increased pressure causes IV flow rate
transudation into interstitial tissues of the lungs which result  If CVP is more than 10 cm of water: Hypervolemic shock:
pulmonary congestion. Administer loop diuretics as ordered
 Nursing Intervention:
Predisposing Factors  When reading CVP patient should be flat on bed
1. 90% is mitral valve stenosis due to RHD: inflammation of mitral  Upon insertion place client in trendelendberg position: to
valve due to invasion of Group A beta-hemolytic streptococcus promote ventricular filling and prevent pulmonary
2. Myocardial Infarction embolism
3. Ischemic heart disease 3. Echocardiography: reveals increased size of cardiac chambers
4. Hypertension (cardiomyopathy)
5. Aortic valve stenosis 4. Liver enzymes: SGPT & SGOT: is increased
5. ABG: decreased pO2

S/sx
Medical Management
1. Dyspnea 1. Determination & elimination / control of underlying cause
2. Paroxysmal nocturnal dyspnea (PND): client is awakened at night 2. Drug therapy: digitalis preparations, diuretics, vasodilators
due to difficulty of breathing 3. Sodium-restricted diet: to decrease fluid retention
3. Orthopnea: use 2-3 pillows when sleeping or place in high fowlers 4. If medical therapies unsuccessful: mechanical assist devices (intra-
4. Tiredness aortic balloon pump), cardiac transplantation, or mechanical heart
5. Muscle Weakness may be employed
6. Productive cough with blood tinged sputum 5. Treatment for Left Sided Heart Failure Only:
7. Tachycardia  M – Morphine SO4
8. Frothy salivation  A – Aminophylline
9. Cyanosis  D – Digitalis
10. Pallor  D – Diuretics
11. Rales / Crackles  O – O2
12. Bronchial wheezing  G – Gases
13. Pulsus Alternans: weak pulse followed by strong bounding pulse
14. PMI is displaced laterally: due to cardiomegaly Nursing Intervention
15. Possible S3: ventricular gallop Goal: Increase cardiac contractility thereby increasing cardiac output of 3-6 L
/ min
Dx

1. Chest X-ray (CXR): reveals cardiomegaly 1. Monitor respiratory status & provide adequate ventilation (when HF
2. Pulmonary Arterial Pressure (PAP): measures pressure in right progress to pulmonary edema)
ventricle or cardiac status: increased a. Administer O2 therapy: high inflow 3-4 L / min delivered via
3. Pulmonary Capillary Wedge Pressure (PCWP): measures end systolic nasal cannula
and dyastolic pressure: increased b. Maintain client in semi or high fowlers position: maximize
4. Central Venous Pressure (CVP): indicates fluid or hydration status oxygenation by promoting lung expansion
 Increase CVP: decreased flow rate of IV c. Monitor ABG
 Decrease CVP: increased flow rate of IV d. Assess for breath sounds: noting any changes
5. Swan-Ganz catheterization: cardiac catheterization 2. Provide physical & emotional rest
6. Echocardiography: shows increased sized of cardiac chamber a. Constantly assess level of anxiety
(cardiomyopathy): dependent on extent of heart failure b. Maintain bed rest with limited activity
7. ABG: reveals PO2 is decreased (hypoxemia), PCO2 is increased c. Maintain quiet & relaxed environment
(respiratory acidosis) d. Organized nursing care around rest periods
3. Increase cardiac output
Right Sided Heart Failure
a. Administer digitalis as ordered & monitor effects
 Weakened right ventricle is unable to pump blood into he pulmonary
 Cardiac glycosides: Digoxin (Lanoxin)
system: systemic venous congestion occurs as pressure builds up
 Action: Increase force of cardiac contraction
 Contraindication: If heart rate is decreased do not give
Predisposing Factors
b. Monitor ECG & hemodynamic monitoring
1. Right ventricular infarction
c. Administer vasodilators as ordered
2. Atherosclerotic heart disease
 Vasodilators: Nitroglycerine (NTG)
3. Tricuspid valve stenosis
d. Monitor V/S
4. Pulmonary embolism
4. Reduce / eliminate edema
5. Related to COPD
a. Administer diuretics as ordered
6. Pulmonic valve stenosis
 Loop Diuretics: Lasix (Furosemide)
7. Left sided heart failure
b. Daily weight
c. Maintain accurate I&O
S/sx
d. Assess for peripheral edema
1. Anorexia
e. Measure abdominal girth daily
2. Nausea
f. Monitor electrolyte levels
3. Weight gain
g. Monitor CVP & Swan-Ganz reading
4. Neck / jugular vein distension
h. Provide Na restricted diet as ordered
5. Pitting edema
i. Provide meticulous skin care
6. Bounding pulse
5. If acute pulmonary edema occurs: For Left Sided Heart Failure only
7. Hepatomegaly / Slenomegaly
a. Administer Narcotic Analgesic as ordered
8. Cool extremities
 Narcotic analgesic: Morphine SO4
9. Ascites
 Action: to allay anxiety & reduce preload & afterload
10. Jaundice
b. Administer Bronchodilator as ordered
11. Pruritus
 Bronchodilators: Aminophylline IV
12. Esophageal varices
 Action: relieve bronchospasm, increase urinary output &
Dx
increase cardiac output
1. Chest X-ray (CXR): reveals cardiomegaly
c. Administer Anti-arrythmic as ordered
2. Central Venous Pressure (CVP): measure fluid status: elevated
 Anti-arrythmic: Lidocaine (Xylocane)
 Measure pressure in right atrium: 4-10 cm of water

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6. Assist in bloodless phlebotomy: rotating tourniquet, rotated


2. Administer medications as ordered
clockwise every 15 minutes: to promote decrease venous return or  Analgesics
reducing preload
 Vasodilators
7. Provide client teaching & discharge planning concerning:
 Anti-coagulants
a. Need to monitor self daily for S/sx of Heart Failure (pedal
3. Foot care management:
edema, weight gain, of 1-2 kg in a 2 day period, dyspnea, loss
 Need to avoid trauma to the affected extreminty
of appetite, cough)
4. Importance of stop smoking
b. Medication regimen including name, purpose, dosage, frequency
5. Need to maintain warmth especially in cold weather
& side effects (digitalis, diuretics)
6. Prepare client for surgery: below knee amputation (BKA)
c. Prescribe diet plan (low Na, cholesterol, caffeine: small frequent
7. Importance of follow-up care
meals)
d. Need to avoid fatigue & plan for rest periods
Raynaud’s Phenomenon
e. Prevent complications
 Intermittent episodes of arterial spasm most frequently involving
 Arrythmia
the fingers or digits of the hands
 Shock
 Right ventricular hypertrophy
Predisposing Factors
 MI
1. High risk group: female between the teenage years & age 40 years
 Thrombophlebitis
old & above
f. Importance of follow-up care 2. Smoking
3. Collagen diseases
Peripheral Vascular Disorder
a. Systemic Lupus Erythematosus (SLE): butterfly rash
b. Rheumatoid Arthritis
Arterial Ulcer
4. Direct hand trauma
1. Thromboangiitis Obliterans (Buerger’s Disease)
a. Piano playing
2. Raynaud’s Phenomenon
b. Excessive typing
c. Operating chainsaw
Venous Ulcer
1. Varicose Veins
S/sx
2. Thrombophlebitis (deep vein thrombosis)
1. Coldness
2. Numbness
Thromboangiitis Obliterans (Buerger’s Disease)
3. Tingling in one or more digits
 Acute inflammatory disorder affecting the small / medium sized
4. Pain: usually precipitated by exposure to cold, Emotional upset &
arteries & veins of the lower extremities
Tobacco use
 Occurs as focal, obstructive, process; result in occlusion of a vessel
5. Intermittent color changes: pallor (white), cyanosis (blue), rubor
with a subsequent development of collateral circulation
(red)
6. Small ulceration & gangrene a tips of digits (advance)
Predisposing Factors
1. High risk groups - men 25-40 years old
Dx
2. High incident among smokers
1. Doppler UTZ: decrease blood flow to the affected extremity
2. Angiography: reveals site & extent of malocclusion
S/sx
1. Intermittent claudication: leg pain upon walking
Medical Management
2. Cold sensitivity & changes in skin color 1st white (pallor) changing to 1. Administer medications as ordered
blue (cyanosis) then red (rubor) a. Catecholamine-depliting antihypertinsive drugs:
3. Decreased or absent peripheral pulses (posterior tibial & dorsalis
 Reserpine
pedis)
 Guanethidine Monosulfate (Ismelin)
4. Trophic changes
b. Vasodilators
5. Ulceration & Gangrene formation (advanced)
Nursing Intervention
1. Importance of stop smoking
Dx
2. Need to maintain warmth especially in cold weather
1. Oscillometry: may reveal decrease in peripheral pulse volume
3. Need to wear gloves when handling cold object / opening a freezer
2. Doppler (UTZ): reveals decrease blood flow to the affected extremity
or refrigerator door
3. Angiography: reveals location & extent of obstructive process

Medical Management
1. Drug Therapy
Varicose Veins
a. Vasodilators: to improve arterial circulation (effectiveness ?)
 Dilated veins that occurs most often in the lower extremities & trunk.
 Papaverine
As the vessel dilates the valves become stretched & incompetent
 Isoxsuprine HCL (Vasodilan)
with result venous pooling / edema
 Nylidrin HCL (Arlidin)
 Abnormal dilation of veins of lower extremities and trunks due to
 Nicotinyl Alcohol (Roniacol)
incompetent valve resulting to increased venous pooling resulting to
 Cyclandelate (Cyclospasmol) venous stasis causing decrease venous return
 Tolazoline HCL (Priscoline)
b. Analgesic: to relieve ischemic pain Predisposing Factors
c. Anti-coagulant: to prevent thrombus formation 1. Hereditary
2. Surgery 2. Congenital weakness of the veins
a. Bypass Grafting 3. Thrombophlebitis
b. Endarterectomy 4. Cardiac disorder
c. Balloon Catheter Dilation 5. Pregnancy
d. Lumbar Sympathectomy: to increase blood flow 6. Obesity
e. Amputation: may be necessary 7. Prolonged standing or sitting

Nursing Intervention
S/sx
1. Encourage a slow progressive physical activity
1. Pain after prolonged standing: relieved by elevation
 Walking at least 2 times / day
2. Swollen dilated tortuous skin veins
 Out of bed at least 3-4 times / day
3. Warm to touch

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4. Heaviness in legs
2. Doppler ultrasonography: impairment of blood flow ahead of
thrombus
Dx
3. Venous pressure measurement: high in affected limb until collateral
1. Venography circulation is developed
2. Trendelenburg Test: veins distends quickly in less than 35 seconds
3. Doppler Ultrasound: decreased or no blood flow heard after calf or Medical Management
thigh compression 1. Anti-coagulant therapy
a. Heparin
Medical Management  Action: block conversion of prothrombin to thrombin &
1. Vein Ligation: involves ligating the saphenous vein where it joins the reduces formation or extension of thrombus
femoral vein & stripping the saphenous vein system fro groin to  Side effects:
ankles  Spontaneous bleeding
2. Sclerotherapy: can recur & only done in spider web varicosities &  Injection site reaction
danger of thrombosis (2-3 years for embolism)  Ecchymoses
 Tissue irritation & sloughing
Nursing Intervention
 Reversible transient alopecia
1. Elevate legs above heart level: to promote increased venous return
 Cyanosis
by placing 2-3 pillows under the legs
 Pan in the arms or legs
2. Measure the circumference of ankle & calf muscle daily: to
 Thrombocytopenia
determine if swollen
b. Warfarin (Coumadin)
3. Apply anti-embolic / knee-length stockings
 Action: block prothrombin synthesis by interfering with vit.
4. Provide adequate rest
K synthesis
5. Administer medications as ordered
 Side effects:
a. Analgesics: for pain
 GI:
6. Prepare client for vein ligation if necessary
 Anorexia
a. Provide routine pre-op care: usually OPD
 N/V
b. In addition to routine post-op care:
 Diarrhea
 Keep affected extremity elevated above the level of the
 Stomatitis
heart: to prevent edema
 Hypersensitivity:
 Apply elastic bandage & stockings which should be
 Dermatitis
removed every 8 hours for short periods & reapplied
 Urticaria
 Assist out of bed within 24 hours ensuring the
 Pruritus
elastic stockings is applied
 Fever
 Assess for increase of bleeding particularly in groin area
 Other:
7. Provide client teaching & discharge planning
 Transient hair loss
 Burning sensation of feet
 Bleeding complication
Thrombophlebitis (Deep vein thrombosis)
2. Surgery
 Inflammation of the vessel wall with formation of clot (thrombus),
a. Vein ligation & stripping
may affect superficial or deep veins
b. Venous thrombectomy: removal of cloth in the iliofemoral region
 Inflammation of the veins with thrombus formation
c. Plication of the inferior vena cava: insertion of an umbrella-like
 Most frequent veins affected are the saphenous, femoral & popliteal
prosthesis into the lumen of the vena cava: to filter incoming
 Can result in damage to the surrounding tissue, ischemia & necrosis
cloth

Predisposing Factors
Nursing Intervention
1. Obesity
1. Elevate legs above heart level: to promote increase venous return &
2. Smoking
decreased edema
3. Related to pregnancy
2. Apply warm moist pack: to reduce lymphatic congestion
4. Severe anemia
3. Administer anti-coagulant as ordered:
5. Prolong use of oral contraceptives: promotes lipolysis
a. Heparin
6. Prolonged immobility
 Monitor PTT: dosage should be adjusted to keep PTT
7. Trauma
between 1.5-2.5 times normal control level
8. Dehydration
 Use infusion pump to administer heparin
9. Sepsis
 Ensure proper injection technique
10. Congestive heart failure
 Use 26 or 27 gauge syringe with ½-5/8 inch needle,
11. Myocardial infarction
inject into fatty layer of abdomen above iliac crest
12. Post-op complication: surgery
 Avoid injecting within 2 inches of umbilicus
13. Venous cannulation: insertion of various cardiac catheter
 Insert needle at 45-90o to skin
14. Increase in saturated fats in the diet.
 Do not withdraw plunger to assess blood return
 Apply gentle pressure after removal of needle: avoid
S/sx
massage
1. Pain in the affected extremity
 Assess for increased bleeding tendencies (hematuria,
2. Superficial vein: Tenderness, redness induration along course of the
hematemesis, bleeding gums, petechiae of soft palate,
vein
conjunctiva retina, ecchymoses, epistaxis, bloody spumtum,
3. Deep vein:
melena) & instruct the client to observe for & report these
 Swelling
 Have antidote (Protamine Sulfate) available
 Venous distention of limb
 Instruct the client to avoid aspirin, antihistamines 7 cough
 Tenderness over involved vein
preparations containing glyceryl guaiacolate & obtain MD
 Positive homan’s sign: pain at the calf or leg muscle upon dorsi
permission before using other OTC drugs
flexion of the foot
b. Warfarin (Coumadin)
 Cyanosis
 Assess PT daily: dosage should be adjusted to maintain PT
at 1.5-2.5 times normal control level; INR of 2
Dx
 Obtain careful medication history (there are many drug-
1. Venography (Phlebography): increased uptake of radioactive
drug interaction)
material  Advise client to withhold dose & notify MD immediately if
bleeding occur

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 Have antidote (Vitamin K) available 4. The initial sign of complete airway obstruction is the inability to
 Alert client to factors that may affect the anticoagulant cough
response (high-fat diet or sudden increased in vit. K-rich
food) Lower Respiratory System
 Instruct the client to wear medic-alert bracelet
 Consist of trachea, bronchi & branches, & the lungs & associated
4. Assess V/S every 4 hours structures
5. Monitor chest pain or shortness of breath: possible pulmonary  For gas exchange
embolism
6. Measure thigh, calves, ankles & instep every morning Trachea
7. Provide client teaching & discharge planning  AKA “Windpipe”
a. Need to avoid standing, sitting for long period, constrictive  Air move from the pharynx to larynx to trachea (length 11-13 cm,
clothing, crossing legs at the knee, smoking, oral contraceptives diameter 1.5-2.5 cm in adult)
b. Importance of adequate hydration: to prevent hypercoagubility
 Extend from the larynx to the second costal cartilage, where it
c. Use elastic stockings when ambulatory bifurcates & is supported by 16-20 C-shaped cartilage rings
d. Importance of planned rest periods with elevation of the feet  The area where the trachea divides into two branches is called the
e. Drug regimen carina
f. Plan for exercise / activity  Consist of cartilaginous rings
 Begin with dorsiflexion of the feet while sitting or lying  Serves as passageway of air going to the lungs
down  Site of tracheostomy
 Swim several times weekly
 Gradually increased walking distance Bronchi
g. Importance of weight reduction: if obese  Right main bronchus
h. Monitor for signs of complications  Larger & straighter than the left
a. Pulmonary Embolism  Divided into three lobar branches (upper, middle & lower
 Sudden sharp chest pain bronchi) to supply the three lobes of right lung
 Unexplained dyspnea  Left main bronchus
 Tachycardia  Divides into the upper & lower lobar bronchi to supply the left
 Palpitations lobes
 Diaphoresis
 Restlessness Bronchioles
 In the bronchioles, airway patency is primarily dependent upon
Overview of Anatomy & Physiology of the Respiratory System elastic recoil formed by network of smooth muscles
 The tracheobronchial tree ends at the terminal bronchials. Distal to
Upper Respiratory System the terminal bronchioles the major function is no longer air
 Structure of the respiratory system, primarily an air conduction conduction but gas exchange between blood & alveolar air
system, include the nose, pharynx & larynx. Air is filtered warmed &  The respiratory bronchioles serves as the transition to the alveolar
humidified in the upper airway before passing to lower airway. epithelium

Nose Lungs
1. External nose is a frame work of bone & cartilage , internally divided  Right lung (consist of 3 lobes, 10 segments)
into two passages or nares (nasal cavity) by the septum: air enters  Left lung (consist of 2 lobes, 8 segments)
the system through the nares
 Main organ of respiration, lie within the thoracic cavity on either side
2. The septum is covered with mucous membrane, where the olfactory of the heart
receptors are located. Turbinates, located internally, assist in  Broad area of lungs resting on diaphragm is called the base & the
warming & moistening the air narrow superior portion called the apex
3. The major function of the nose are warming, moistening & filtering
air. Pleura
4. Consist of anastomosis of capillaries known as Keissel Rach Plexus:  Serous membranes covering the lungs, continuous with the parietal
the site of nose bleeding pleura that lines the chest wall

Pharynx Parietal Pleura


1. A muscular passageway commonly called the throat  Lines the chest walls & secretes small amounts of lubricating fluid
2. Air passes through the nose to the pharynx into the intrapleural space (space between the parietal pleura &
3. Serves as a muscular passageway for both food and air visceral pleura) this fluid holds the lungs & chest wall together as a
single unit while allowing them to move separately
Composed of three section
1. Nasopharynx: located above the soft palate of the mouth, contains Chest Wall
the adenoids & opening to the eustachian tubes  Includes the ribs cage, intercostal muscles & diaphragm
2. Oropharynx: located directly behind the mouth & tongue, contains  Chest is a C shaped & supported by 12 pairs of ribs & costal
the palatine tonsils; air & food enter the body through oropharynx cartilages, the ribs have several attached muscles
3. Laryngopharynx: extends from the epiglotitis to the sixth cervical  Contraction of the external intercostal muscles raises the ribs
level cage during inspiration & helps increase the size of the thoracic
cavity
Larynx  The internal intercoastal muscles tends to pull ribs down & in &
1. Sometimes called “voice Box” connects upper & lower airways play a role in forced expiration
2. Framework is formed by the hyoid bone, epiglotitis & thyroid, cricoid
& arytenoids cartilages Diaphragm
3. Larynx opens to allow respiration & closes to prevent aspiration  A major muscle of ventilation (the exchange of air between the
when food passes through the pharynx atmosphere & the alveoli).
4. Vocal cords of larynx permit speech & are involved in the cough
reflex Alveoli
5. For phonation (voice production)  Are functional cellular unit of the lungs; about half arise directly from
Glottis alveolar ducts & are responsible for about 35% of alveolar gas
1. Opening of larynx exchange
2. Opens to allow passage of air  Produces surfactants
3. Closes to allow passage of food going to the esophagus  Site of gas exchange (CO2 and O2)

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 Diffusion (Dalton’s law of partial pressure of gases) 15. Bronchial wheezing


16. Cyanosis
Surfactant 17. Chest pain
 A phospholipids substance found in the fluid lining the 18. Abdominal distention leading to paralytic ileus (absence of
alveolar epithelium peristalsis)
 Reduces surface tension & increase stability of the alveoli & prevents
their collapse Dx
1. Sputum Gram Staining & Culture Sensitivity: positive to cultured
Alveolar Ducts microorganisms
 Arises from the respiratory bronchioles & lead to the alveoli 2. Chest x-ray: reveals pulmonary consolidation over affected area
3. ABG analysis: reveals decrease PO2
Alveolar Sac 4. CBC: reveals increase WBC, erythrocyte sedimentation rate is
 Form the last part of the airway increased
 Functionally the same as the alveolar ducts they are surrounded by
alveoli & are responsible for the 65% of the alveolar gas exchange
Nursing Intervention
Type II Cells of Alveoli
1. Facilitate adequate ventilation
 Secretes surfactant
 Administer O2 as needed & assess its effectiveness: low inflow
 Decrease surface tension
 Place client semi fowlers position
 Prevent collapse of alveoli
 Turn & reposition frequently client who are immobilized
 Composed of lecithin and spingomyelin
 Administer analgesic as ordered: DOC: codeine: to relieve pain
 Lecitin / Spingomyelin ratio: to determine lung maturity
associated with breathing
 Normal Lecitin / Spingomyelin ratio: is 2:1
 Auscultate breath sound every 2-4 hour
 In premature infants: 1:2
 Monitor ABG
 Give oxygen of less 40% in premature: to prevent atelectasis
2. Facilitate removal of secretions
and retrolental fibroplasias
 General hydration
 Retinopathy & blindness: in premature
 Deep breathing & coughing exercise: tends to promote
expectoration
Pulmonary Circulation
 Tracheobronchial suctioning as needed
 Provides for reoxygenation of blood & release of CO2
 Administer Mucolytic or Expectorant as ordered
 Gas transfers occurs in the pulmonary capillary bed
 Aerosol treatment via nebulizer
 Humidification of inhaled air
Respiratory Distress Syndrome
 Chest physiotherapy (Postural Drainage): tends to promote
 Decrease oxygen stimulates breathing
expectoration
 Increase carbon dioxide is a powerful stimulant for breathing
3. Observe color characteristics of sputum & report any changes:
encourage client to perform good oral hygiene after expectoration
Pneumonia
4. Provide adequate rest & relief control of pain
 Inflammation of the alveolar spaces of the lungs, resulting
 Enforce CBR with limited activity
in consolidation of lung tissue as the alveoli fill with
 Limit visits & minimized conversation
exudates
 Plan for uninterrupted rest periods
 Inflammation of the lung parenchyma leading to
 Maintain pleasant & restful environment
pulmonary consolidation as the alveoli is filled with
5. Administer antibiotic as ordered: monitor effects & possible toxicity
exudates
 Broad Spectrum Antibiotic
 Penicillin
Etiologic Agents
 Tetracycline
1. Streptococcus Pneumonae: causing pneumococal pneumonia
 Microlides (Zethromax)
2. Hemophylus Influenzae: causing broncho pneumonia
 Azethromycin: Side Effect: Ototoxicity
3. Diplococcus Pneumoniae
6. Prevent transmission: respiratory isolation client with staphylococcal
4. Klebsella Pneumoniae
pneumonia
5. Escherichia Pneumoniae
7. Control fever & chills:
6. Pseudomonas
 Monitor temperature A
 Administer antipyretic as ordered
High Risk Groups
 Increased fluid intake
1. Children below 5 years old
 Provide frequent clothing & linen changing
2. Elderly
8. Assist in postural drainage: uses gravity & various position to
1. Smoking stimulate the movement of secretions
Predisposing Factors
2. Air pollution
3. Immuno compromised Nursing Management for Postural Drainage
4. Related to prolonged immobility (CVA clients): causing hypostatic a. Best done before meals or 2-3 hours: to prevent gastro
pneumonia esophageal reflux
5. Aspiration of food: causing aspiration pneumonia b. Monitor vital signs
c. Encourage client deep breathing exercises
S/sx d. Administer bronchodilators 20-30 minutes before procedure
1. Productive cough with greenish to rusty sputum e. Stop if client cannot tolerate procedure
2. Rapid shallow respiration with expiratory grunt f. Provide oral care after procedure
3. Nasal flaring g. Contraindicated with
4. Intercostal rib retraction  Unstable V/S
5. Use of accessory muscles of respiration  Hemoptysis
6. Dullness to flatness upon auscultation  Clients with increase intra ocular pressure (Normal IOP 12 –
7. Possible pleural friction rub 21 mmHg)
8. High-pitched bronchial breath sound  Increase ICP
9. Rales / crackles (early) progressing to coarse (later) 9. Provide increase CHO, calories, CHON & vitamin C
10. Fever 10. Provide client teaching & discharge planning
11. Chills a. Medication regimen / antibiotic therapy
12. Anorexia b. Need for adequate rest, limited activity, good nutrition, with
13. General body malaise adequate fluid intake & good ventilation
14. Weight loss

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c. Need to continue deep breathing & coughing exercise for at


Predisposing Factors
least 6-8 weeks after discharge 1. Smoking
d. Availability of vaccines
2. Air pollution
e. Need to report S/sx of respiratory infection
 Persistent or recurrent fever
S/sx
 Changes in characteristics color of sputum
1. Productive copious cough (consistent to all COPD)
 Chills
2. Dyspnea on exertion
 Increased pain
3. Use of accessory muscle of respiration
 Difficulty in breathing
4. Scattered rales / rhonchi
 Weight loss
5. Feeling of gastric fullness
 Persistent fatigue
6. Slight Cyanosis
f. Avoid smoking
7. Distended neck veins
g. Prevent complications
8. Ankle edema
 Atelectasis
9. Prolonged expiratory grunt
 Meningitis
10. Anorexia and generalized body malaise
h. Importance of follow up care
11. Pulmonary hypertension
a. Leading to peripheral edema
Histoplasmosis b. Cor Pulmonale (right ventricular hypertrophy)
 Systemic fungal disease caused by inhalation of dust contaminated
by histoplasma capsulatum which is transmitted to bird manure
Dx
 Acute fungal infection caused by inhalation of contaminated dust or
1. ABG analysis: reveals PO2 decrease (hypoxemia): causing cyanosis, PCO2
particles with histoplasma capsulatum derived from birds manure
increase

S/sx
Bronchial Asthma
1. Similar to PTB or Pneumonia  Immunologic / allergic reaction results in histamine release which
2. Productive cough produces three mainairway response: Edema of mucus membrane,
3. Fever, chills, anorexia, general body malaise Spasm of the smooth muscle of bronchi & bronchioles, Accumulation
4. Chest and joint pains of tenacious secretions
5. Dyspnea  Reversible inflammatory lung condition due to hypersensitivity to
6. Cyanosis allergens leading to narrowing of smaller airways
7. Hemoptysis
8. Sometimes asymptomatic Predisposing Factors (Depending on Types)
1. Extrinsic Asthma (Atopic / Allergic)
Dx Causes
1. Chest X-ray: often appears similar to PTB  Pollen
2. Histoplasmin Skin Test: positive  Dust
3. ABG analysis: PO2 decrease  Fumes
 Smoke
Medical Management
 Gases
1. Anti-fungal Agent: Amphotericin B (Fungizone)
 Danders
 Very toxic: toxicity includes anorexia, chills, fever, headaches &
 Furs
renal failure
 Lints
 Acetaminophen, Benadryl & Steroids is given with
Amphotericin B: to prevent reaction
2. Intrinsic Asthma (Non atopic / Non allergic)
Causes
Nursing Intervention
 Hereditary
1. Monitor respiratory status
 Drugs (aspirin, penicillin, beta blocker)
2. Enforce CBR
 Foods (seafoods, eggs, milk, chocolates, chicken)
3. Administer oxygen inhalation
 Food additives (nitrates)
4. Administer medications as ordered
 Sudden change in temperature, air pressure and humidity
a. Antifungal: Amphotericin B (Fungizone)
 Physical and emotional stress
 Observe severe side effects:
 Fever: acetaminophen given prophylactically
3. Mixed Type: 90 – 95%
 Anaphylactic reaction: Benadryl & Steroids given
prophylactically
S/sx
 Abnormal renal function with hypokalemia & azotemia:
1. Cough that is non productive
Nephrotoxicity, check for BUN and Creatinine,
2. Dyspnea
Hypokalemia
3. Wheezing on expiration
5. Force fluids to liquefy secretions
4. Cyanosis
6. Nebulize & suction as needed
5. Mild Stress or apprehension
7. Prevent complications: bronchiectasis
6. Tachycardia, palpitations
8. Prevent the spread of infection by spraying of breeding places
7. Diaphoresis

Chronic Obstructive Pulmonary Disease (COPD)


Dx
1. Pulmonary Function Test Incentive spirometer: reveals decrease vital
Chronic Bronchitis
lung capacity
 Excessive production of mucus in the bronchi with accompanying
2. ABG analysis: PO2 decrease
persistent cough
3. Before ABG test for positive Allens Test, apply direct pressure to
 Characteristic include hypertrophy / hyperplasia of the mucus
ulnar & radial artery to determine presence of collateral circulation
secreting gland in the bronchi, decreased ciliary activity, chronic
inflammation & narrowing of the airway Medical Management
 Inflammation of bronchus resulting to hypertrophy or hyperplasia of 1. Drug Therapy
goblet mucous producing cells leading to narrowing of smaller a. Bronchodilators: given via inhalation or metered dose inhaler or
airways MDI for 5 minutes
 AKA “Blue Bloaters” b. Steroids: decrease inflammation: given 10 min after
bronchodilator

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c. Mucomysts (acetylceisteine): at bed side put suction machine


overdistension, sputum accumulation & loss of diaphragmatic muscle
d. Mucolytics / expectorants
tone
e. Anti histamine
 These changes cause a state of CO2 retention, hypoxia & respiratory
2. Physical Therapy acidosis
3. Hyposensitization  Irreversible terminal stage of COPD characterized by
4. Execise  Inelasticity of alveoli
Nursing  Air trapping
Intervention  Maldistribution of gases
1. Enforce CBR
 Overdistention of thoracic cavity (barrel chest)
2. O2 inhalation: low flow 2-3 L/min: to prevent respiratory distress
3. Administer medications as ordered
Predisposing Factors
4. Force fluids 2-3 L/day
1. Smoking
5. Semi fowlers position: to promote lung expansion
2. Inhaled irritants: air pollution
6. Nebulize & suction when needed
3. Allergy or allergic factor
7. Provide client health teachings and discharge planning concerning
4. High risk: elderly
a. Avoidance of precipitating factor
5. Hereditary: it involves deficiency of Alpha 1 anti-trypsin: to release
b. Prevent complications
elastase for recoil of alveoli
 Emphysema
 Status Asthmaticus: severe attack of asthma which cause
S/sx
poor controlled asthma
1. Productive cough
 DOC: Epinephrine
2. Sputum production
 Steroids
3. Anorexia & generalized body malaise
 Bronchodilators
4. Weight loss
c. Regular adherence to medications: to prevent development of
5. Flaring of nostrils (alai nares)
status asthmaticus
6. Use of accessory muscles
d. Importance of follow up care
7. Dyspnea at rest
8. Increased rate & depth of breathing
Bronchiectasis
9. Decrease respiratory excursion
 Permanent abnormal dilation of the bronchi with destruction of
10. Resonance to hyper resonance
muscular & elastic structure of the bronchial wall
11. Decrease or diminished breath sounds with prolong expiration
 Abnormal permanent dilation of bronchus leading to destruction of
12. Decrease tactile fremitus
muscular and elastic tissues of alveoli
13. Prolong expiratory grunt
14. Rales or rhonchi
Predisposing Factors
15. Bronchial wheezing
1. Caused by bacterial infection
16. Barrel chest
2. Recurrent lower respiratory tract infections
17. Purse lip breathing: to eliminates excess CO2 (compensatory
3. Chest trauma
mechanism)
4. Congenital defects (altered bronchial structure)
5. Related to presence of tumor (lung tumor)
Dx
6. Thick tenacious secretion
1. Pulmonary Function Test: reveals decrease vital lung capacity
Sx 2. ABG analysis: reveals
1. Productive cough with mucopurulent sputum Panlobular/centrilobular

2. Dyspnea in exertion  Decrease PO2 (hypoxemia leading to chronic bronchitis,
3. Cyanosis “Blue Bloaters”)
4. Anorexia & generalized body malaise  Decrease ph
5. Hemoptysis (only COPD with sign)  Increase PCO2
6. Wheezing  Respiratory acidosis
7. Weight loss  Panacinar/centriacinar
 Increase PO2 (hyperaxemia, “Pink Puffers”)
Dx  Decrease PCO2
1. CBC: elevation in WBC  Increase ph
2. ABG: PO2 decrease  Respiratory alkalosis
3. Bronchoscopy: reveals sources & sites of secretion: direct

visualization of bronchus using fiberscope Nursing Intervention


1. Enforce CBR
Nursing Management before Bronchoscopy 2. Administer oxygen inhalation via low inflow
1. Secure inform consent and explain procedure to client 3. Administer medications as ordered
2. Maintain NPO 6-8 hours prior to procedure a. Bronchodilators: used to treat bronchospam
3. Monitor vital signs & breath sound  Aminophylline
 Isoproterenol (Isuprel)
Post Bronchoscopy  Terbutalin (Brethine)
1. Feeding initiated upon return of gag reflex  Metaproterenol (Alupent)
2. Avoid talking, coughing and smoking, may cause irritation  Theophylline
3. Monitor for signs of gross  Isoetharine (Bronkosol)
4. Monitor for signs of laryngeal spasm: prepare tracheostomy set b. Corticosteroids:
 Prednisone
Medical Management c. Anti-microbial / Antibiotics: to treat bacterial infection

1. Surgery  Tetracycline

 Pneumonectomy: 1 lung is removed & position on affected side  Ampicilline

 Segmental Wedge Lobectomy: promote re-expansion of lungs d. Mucolytics / expectorants

 Unaffected lobectomy: facilitate drainage 4. Facilitate removal of secretions:


a. Force fluids at least 3 L/day
Emphysema b. Provide chest physiotherapy, coughing & deep breathing

 Enlargement & destruction of the alveolar, bronchial & bronchiolar c. Nebulize & suction when needed

tissue with resultant loss of recoil, air tapping, thoracic d. Provide oral hygiene after expectoration of sputum
5. Improve ventilation

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a. Position client to semi or high fowlers


 Rate at which a tumor grows involves both increased cell division &
b. Instruct the client diaphragmatic muscles to breathe increased survival time of cells.
c. Encourage productive cough after all treatment (splint abdomen  Malignant cells do not form orderly layers, but pile on top of each
to help produce more expulsive cough) other to eventually form tumors.
d. Employ pursed-lip breathing techniques (prolonged slow relaxed
expiration against pursed lips) Pre-disposing Factors
e. Institute pulmonary toilet  G – Genetics
6. Institute PEEP (positive end expiratory pressure) in mechanical  Some cancers shows familial pattern
ventilation promotes maximum alveolar lung expansion
 Maybe caused by inherited genetics defects
7. Provide comfortable & humid environment  I – Immunologic
8. Provide high carbohydrates, protein, calories, vitamins and minerals
 Failure of the immune system to respond & eradicate cancer
9. Provide client teachings and discharge planning concerning cells
a. Prevention of recurrent infection  Immunosuppressed individuals are more susceptible to cancer
 Avoid crowds & individual with known infection
 V – Viral
 Adhere to high CHON, CHO & increased vit C diet o Viruses have been shown to be the cause of certain tumors
 Received immunization for influenza & pneumonia in animals
 Report changes in characteristic & color of sputum o Viruses ( HTLV-I, Epstein Barr Virus, Human Papilloma
immediately Virus) linked to human tumors
 Report of worsening of symptoms (increased tightness of o Oncovirus (RNA – Type Viruses) thought to be culprit
chest, fatigue, increased dyspnea)  E – Environmental
b. Control of environment o Majority (over 80%) of human cancer related to
 Use home humidifier at 30-50% environmental carcinogens
 Wear scarf over nose & mouth in cold weather: to prevent o Types:
bronchospasm  Physical
 Avoid smoking & contact with environmental smoke  Radiation: X – ray, radium, nuclear
 Avoid abrupt change in temperature explosion & waste, UV
c. Avoidance of inhaled irritants  Trauma or chronic irritation
 Stay indoor: if pollution level is high  Chemical
 Use air conditioner with efficiency particulate air filter: to  Nitrates, & food additives, polycyclic
remove particles from air
hydrocarbons, dyes, alkylating agents
d. Increase activity tolerance
 Drugs: arsenicals, stilbestol, urethane
 Start with mild exercise: such as walking & gradual
 Cigarette smoke
increase in amount & duration hormones

 Used breathing techniques: (pursed lip, diaphragmatic) Classification of Cancer
during activities / exercise: to control breathing
Tissue Typing:
 Have O2 available as needed to assist with activities
 Carcinoma – arises from surface, glandular, or parenchymal
 Plan activities that require low amount of energy
epithelium
 Plan rest period before & after activities
1. Squamous Cell Carcinoma – surface epithelium
e. Prevent complications
2. Adenocarcinoma – glandular or parenchymal tissue
 Atelectasis
 Sarcoma – arises from connective tissue
 Cor Pulmonale: R ventricular hypertrophy
 Leukemia – from blood
 CO2 narcosis: may lead to coma
 Lymphoma – from lymph glands
 Pneumothorax: air in the pleural space
 Multiple Myeloma – from bone marrow
f. Strict compliance to medication Stages of Tumor Growth
g. Importance of follow up care A. Staging System:
 TNM System: uses letters & numbers to designate the extent of
Oncology Nursing tumors
Pathophysiology & Etiology of Cancer o T– stands for primary growth; 1-4 with increasing size; T1S

Evolution of Cancer Cells indicates carcinoma in situ


 All cells constantly change through growth, degeneration, repair, & o N – stands for lymph nodes involvement: 0-4 indicates
adaptation. Normal cells must divide & multiply to meet the needs of progressively advancing nodal disease
the organism as a whole, & this cycle of cell growth & destruction is o M – stands for metastasis; 0 indicates no distant
an integral part of life processes. The activities of the normal cell in metastases, 1 indicates presence of metastases
the human body are all coordinated to meet the needs of the  Stages 0 – IV: all cancers divided into five stages incorporating size,
organism as a whole, but when the regulatory control mechanisms nodal involvement & spread
of normal fail, & growth continues in excess of the body needs,
neoplasia results. B. Cytologic Diagnosis of Cancer
 The term neoplasia refers to both benign & malignant growths, 1. Involves in the study of shed cells (ex. Pap smear)
but malignant cells behave very differently from normal cells & 2. Classified by degree of cellular abnormality
have special features characteristics of the cancer process.  Normal
 Since the growth control mechanism of normal cells is not  Probably normal (slight changes)
entirely understood, it is not clear what allows the  Doubtful (more severe changes)

uncontrolled growth, therefore no definitive cure has  Probably cancer or precancerous

been found.  Definitely cancer


Client Factors
1. Seven warning signs of cancer
Characteristics of Malignant Cells
2. BSE – breast self – examination
 Cancer cells are mutated stem cells that have undergone structural
3. Importance of retal exam for those over age 40
changes so that they are unable to perform the normal functions of
4. Hazards of smoking
specialized tissues.
5. Oral self – examination as well as annual exam of mouth & teeth
 They may function is a disorderly way to crease normal function
6. Hazards of excess sun exposure
completely, only functioning for their own survival & growth.
7. Importance of pap smear
 The most undifferentiated cells are also called anaplastic.
8. P.E. with lab work – up: every 3 years ages 20-40; yearly for
age 40 & over
Rate of Growth
9. TSE – testicular self – examination
 Cancer cells have uncontrolled growth or cell division
 Testicular Cancer

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i. Most common cancer in men between the age


B. Hematologic System
of 15 & 34
 Warning signs that men should look for:
 Thrombocytopenia
i. Painless swelling
o Avoid bumping or bruising the skin.
ii. Feeling of heaviness
o Protect client from physical injury.
iii. Hard lump (size of a pea)
o Avoid aspirin or aspirin products.
iv. Sudden collection fluid in the scrotum
o Avoid giving IM injections.
v. Dull ache in the lower abdomen or in the groin
o Monitor blood counts carefully.
vi. Pain in the testicle or in the scrotum
o Assess for signs of increase bleeding tendencies (epistaxis,
vii. Enlargement or tenderness of the breasts petechiae, ecchymoses)

7 Warning Signs of Cancer


 Leukopenia
C: change in bowel or bladder habits
o Use careful handwashing technique.
A: a sore that doesn’t heal
o Maintain reverse isolation if WBC count drops below
U: unusual bleeding or discharge
1000/mm
T: thickening of lump in breast or elsewhere o Assess for signs of respiratory infection
I: indigestion or dysphagia o Avoid crowds/persons with known infection
O: obvious change in wart or mole
N: nagging cough or hoarseness
 Anemia
o Provide adequate rest period
Treatment of Cancer
o Monitor hemoglobin & hematocrit
Therapeutic Modality
o Protect client from injury
o Administer O2 if needed
Chemotherapy

 Ability of the drug to kill cancer cells; normal cells may also be
C. Integumentary System
damaged, producing side effects.
 Different drug act on tumor cell in different stages of the cell growth
 Alopecia
cycle.
o Explain that hair loss is not permanent
o Offer support & encouragement
Types of Chemotherapeutic Drugs
o Scalp tourniquets or scalp hypothermia via ice pack may be
ordered to minimize hair loss with some agent
1. Antimetabolites
o Advice client to obtain wig before initiating treatment
o Foster cancer cell death by interfering with cellular
metabolic process.
D. Renal System
2. Alkylating Agent
o act with DNA to hinder cell growth & division.
 Encourage fluid & frequent voiding to prevent accumulation of
3. Plant Alkaloids
metabolites in bladder; R: may cause direct damage to kidney by
o obtained from periwinkle plant.
excretion of metabolites.
o makes the host’s body a less favorable environment for the
 Increased excretion of uric acid may damage kidney
growth of cancer cells.
 Administer allopurinol (Zyloprim) as ordered; R: to prevent uric acid
4. Antitumor Antibiotics
formation; encourage fluids when administering allopurinol
o affect RNA to make environment less favorable for cancer
growth.
E. Reproductive System
5. Steroids & Sex Hormones
o alter the endocrine environment to make it less conducive
 Damage may occur to both men & women resulting infertility &/or
to growth of cancer cells.
mutagenic damage to chromosomes
 Banking sperm often recommended for men before chemotherapy
Major Side Effects & Nursing Intervention
 Clients & partners advised to use reliable methods of contraception
during chemotherapy
A. GI System

F. Neurologic System
 Nausea & Vomiting
o Administer antiemetics routinely q 4-6 hrs as well
 Plant alkaloids (vincristine) cause neurologic damage with repeated
as prophylactically before chemotherapy is initiated.
doses
o Withhold food/fluid 4-6 hrs before chemotherapy
 Peripheral neuropathies, hearing loss, loss of deep tendon reflex, &
o Provide bland food in small amounts after treatment
paralytic ileus may occur.

 Diarrhea
Radiation Therapy
o Administer antidiarrheals.
 Uses ionizing radiation to kill or limit the growth of cancer cells,
o Maintain good perineal care.
maybe internal or external.
o Give clear liquids as tolerated.
 It not only injured cell membrane but destroy & alter DNA so that
o Monitor K, Na, Cl levels.
the cell cannot reproduce.
 Effects cannot be limited to cancer cells only; all exposed cells
 Stomatitis (mouth sore)
including normal cells will be injured causing side effects.
o Provide & teach the client good oral hygiene, including
 Localized effects are related to the area of the body being treated;
avoidance of commercial mouthwashes.
generalized effects maybe related to cellular breakdown products.
o Rinse with viscous lidocaine before meals to provide
analgesic effect.
Types of Energy Emitted
o Perform a cleansing rinse with plain H2O or dilute a H2O
 Alpha – particles cannot passed through skin, rarely used.
soluble lubricant such as hydrogen peroxide after meal.
 Beta – particle cannot passed through skin, more penetrating than
o Apply H2O lubricant such as K-Y jelly to lubricate cracked
alpha, generally emitted from radioactive isotopes, used for internal
lips.
source.
o Advice client to suck on Popsicles or ice chips to provide
 Gamma – penetrate more deeper areas of the body, most common
moisture.
form of external radiotherapy (ex. Electromagnetic or X-ray)

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Methods of Delivery
1. Depth: all skin layers & nerve endings; may involve
 External Radiation Therapy – beams high energy rays directly to the
muscles, tendons & bones
affected area. Ex. Cobalt therapy 2. Causes: flames, chemicals, scalding, electric current
 Internal Radiation Therapy – radioactive material is injected or
3. Sensation: little or no pain
implanted in the client’s body for designated period of time.
4. Characteristics: wound is dry, white, leathery, or hard
o Sealed Implants – a radioisotope enclosed in a container so
it does not circulate in the body; client’s body fluids should Overview Of Anatomy & Physiology Of Musculoskeletal System
not be contaminated.
 Consist of bones, muscles, joints, cartilages, tendons, ligaments,
o Unsealed source – a radioisotope that is not encased in a
bursae
container & does circulate in the body & contaminate body  To provide a structural framework for the body
fluids.
 To provide a means for movement

Factors Controlling Exposure


Bones
 Half-life – time required for half of radioactive atoms to decay.
 Function of Bones
1. Each radioisotope has different half-life.
 Provide support to skeletal framework
2. At the end of half-life the danger from exposure decreases.
 Assist in movement by acting as levers for muscles
 Time – the shorter the duration the less the exposure.
 Protect vital organ & soft tissue
 Distance – the greater the distance from the radiation source the
 Manufacture RBC in the red bone marrow (hematopoiesis)
less the exposure.
 Provide site for storage of calcium & phosphorus
 Shielding – all radiation can be blocked; rubber gloves for alpha &
1. Types of Bones
usually beta rays; thick lead or concrete stop gamma rays.
 Long Bones
 Central shaft (diaphysis) made of compact bone & two end
Side Effects of Radiation Therapy & Nursing Intervention
(epiphyses) composed of cancellous bones (ex. Femur &
A. Skin - itching, redness, burning, oozing, sloughing.
humerus)
 Keep skin free from foreign substances.
 Short Bones
 Avoid use of medicated solution, ointment, or powders that contain
 Cancellous bones covered by thin layer of compact bone
heavy metals such as zinc oxide.
(ex. Carpals & tarsals)
 Avoid pressure, trauma, infection to skin; use bed cradle.
 Flat Bones
 Wash affected areas with plain H2O & pat dry; avoid soap.
 Two layers of compact bone separated by a layer of
 Use cornstarch, olive oil for itching; avoid talcum powder.
cancellous bone (ex. Skull & ribs)
 If sloughing occurs, use sterile dressing with micropore tape
 Irregular Bones
 Avoid exposing skin to heat, cold, or sunlight & avoid constricting
 Sizes and shapes vary (ex. Vertebrae & mandible)
irritating clothing.
B. Anorexia, N/V
Joints
 Arrange meal time so they do not directly precede or follow
 Articulation of bones occurs at joints
therapy.
 Movable joints provide stabilization and permit a variety of
 Encourage bland foods.
movements
 Provide small attractive meals.
 Avoid extreme temperature.
Classification
 Administer antiemetics as ordered before meals.
1. Synarthroses: immovable joints
C. Diarrhea
2. Amphiarthroses: partially movable joints
 Encourage low residue, bland, high CHON food.
3. Diarthroses (synovial): freely movable joints
 Administer antidiarrheal as ordered.
 Have a joint cavity (synovial cavity) between the articulating
 Provide good perineal care.
bone surfaces
 Monitor electrolytes particularly Na, K, Cl
 Articular cartilage covers the ends of the bones
D. Anemia, Leukopenia, Thrombocytopenia
 A fibrous capsule encloses the joint
 Isolate from those with known infection.
 Capsule is lined with synovial membrane that secretes
 Provide frequent rest period.
synovial fluid to lubricate the joint and reduce friction.
 Encourage high CHON diet.
Muscles
 Avoid injury.
 Functions of Muscles
 Assess for bleeding.
 Provide shape to the body
 Monitor CBC, WBC, & platelets.
 Protect the bones
 Maintain posture
Burns
 Cause movement of body parts by contraction
 direct tissue injury caused by thermal, electric, chemical & smoke
 Types of Muscles
inhaled (TECS)
 Cardiac: involuntary; found only in heart
Type:
 Smooth: involuntary; found in walls of hollow structures (e.g.
1. Thermal
intestines)
2. Smoke Inhalation
 Striated (skeletal): voluntary
3. Chemical
4. Electrical
1. Characteristics of skeletal muscles
 Muscles are attached to the skeleton at the point of origin
Classification
and to bones at the point of insertion.
 Partial Thickness
 Have properties of contraction and extension, as well as
1. Superficial partial thickness (1st degree)
elasticity, to permit isotonic (shortening and thickening of
 Depth: epidermis only
the muscle) and isometric (increased muscle tension)
 Causes: sunburn, splashes of hot liquid
movement.
 Sensation: painful
 Contraction is innervated by nerve stimulation.
 Characteristics: erythema, blanching on pressure,
no vesicles
Cartilage
2. Deep Partial Thickness (2nd degree)
 A form of connective tissue
 Depth: epidermis & dermis
 Major functions are to cushion bony prominences and offer
 Causes: flash, scalding, or flame burn
protection where resiliency is required
 Sensation: very painful
 Characteristics: fluid filled vesicles; red, shinny,
Tendons and Ligaments
wet after vesicles ruptures
 Composed of dense, fibrous connective tissue
 Full Thickness (3rd & 4th degree)

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 Functions  Diarrhea
1. Ligaments attach bone to bone d. Corticosteroids
2. Tendons attach muscle to bone  Intra-articular injections: temporarily suppress inflammation
in specific joints.
Rheumatoid Arthritis (RA)  Systemic administration: used only when client does
 Chronic systemic disease characterized by inflammatory changes in not respond to less potent anti-inflammatory drugs.
joints and related structures. e. Methotrexate: given to suppress immune response
 Joint distribution is symmetric (bilateral): most commonly affects  Cytoxan
smaller peripheral joints of hands & also commonly involves wrists,  SI: bone marrow suppression.
elbows, shoulders, knees, hips, ankles and jaw. 2. Physical therapy: to minimize joint deformities.
 If unarrested, affected joints progress through four stages of
3. Surgery: to remove severely damaged joints (e.g. total hip
deterioration: synovitis, pannus formation, fibrous ankylosis, and
replacement; knee replacement).
bony ankylosis.
Cause
Nursing Interventions
1. Cause unknown or idiopathic
1. Assess joints for pain, swelling, tenderness & limitation of motion.
2. Maybe an autoimmune process
2. Promote maintenance of joint mobility and muscle strength.
3. Genetic factors
a. Perform ROM exercises several times a day: use of heat prior to
4. Play a role in society (work)
exercise may decrease discomfort; stop exercise at the point of
pain.
Predisposing factors b. Use isometric or other exercise to strengthen muscles.
1. Occurs in women more often than men (3:1) between the ages 35- 3. Change position frequently: alternate sitting, standing & lying.
45.
4. Promote comfort & relief / control of pain.
2. Fatigue
a. Ensure balance between activity & rest.
3. Cold
b. Provide 1-2 scheduled rest periods throughout day.
4. Emotional stress
c. Rest & support inflamed joints: if splints used: remove 1-2
5. Infection times/day for gentle ROM exercises.
5. Ensure bed rest if ordered for acute exacerbations.
S/sx a. Provide firm mattress.
1. Fatigue b. Maintain proper body alignment.
2. Anorexia & body malaise c. Have client lie prone for ½ hour twice a day.
3. Weight loss d. Avoid pillows under knees.
4. Slight elevation in temperature e. Keep joints mainly in extension, not flexion.
5. Joints are painful: warm, swollen, limited in motion, stiff in morning
f. Prevent complications of immobility.
& after a period of inactivity & may show crippling deformity in long- 6. Provide heat treatments: warm bath, shower or whirlpool; warm,
standing disease. moist compresses; paraffin dips as ordered.
6. Muscle weakness secondary to inactivity a. May be more effective in chronic pain.
7. History of remissions and exacerbations b. Reduce stiffness, pain & muscle spasm.
8. Some clients have additional extra-articular manifestations:
7. Provide cold treatments as ordered: most effective during acute
subcutaneous nodules; eye, vascular, lung, or cardiac problems. episodes.
8. Provide psychologic support and encourage client to express
Dx
feelings.
1. X-rays: shows various stages of joint disease 9. Assists clients in setting realistic goals; focus on client strengths.
2. CBC: anemia is common 10. Provide client teaching & discharge planning & concerning.
3. ESR: elevated
a. Use of prescribed medications & side effects
4. Rheumatoid factor positive b. Self-help devices to assist in ADL and to increase independence
5. ANA: may be positive c. Importance of maintaining a balance between activity & rest
6. C-reactive protein: elevated d. Energy conservation methods
e. Performance of ROM, isometric & prescribed exercises
Medical Management
f. Maintenance of well-balanced diet
1. Drug therapy g. Application of resting splints as ordered
a. Aspirin: mainstay of treatment: has both analgesic and anti- h. Avoidance of undue physical or emotional stress
inflammatory effect. i. Importance of follow-up care
b. Nonsteroidal anti-inflammatory drugs (NSAIDs): relieve pain and
inflammation by inhibiting the synthesis of prostaglandins. Osteoarthritis
 Ibuprofen (Motrin)
 Chronic non-systemic disorder of joints characterized by
 Indomethacin (Indocin) degeneration of articular cartilage
 Fenoprofen (Nalfon)  Weight-bearing joints (spine, knees and hips) & terminal
 Mefenamic acid (Ponstel) interphalangeal joints of fingers most commonly affected
 Phenylbutazone (Butazolidin)
 Piroxicam (Feldene) Incident Rate
 Naproxen (Naprosyn) 1. Women & men affected equally
 Sulindac (Clinoril) 2. Incidence increases with age
c. Gold compounds (Chrysotherapy)
 Injectable form: given IM once a week; take 3-6 months to Predisposing Factors
become effective 1. Most important factor in development is aging (wear & tear on
 Sodium thiomalate (Myochrysine) joints)
 Aurothioglucose (Solganal) 2. Obesity
 SI: monitor blood studies & urinalysis frequently 3. Joint trauma
 Proteinuria
 Mouth ulcers S/sx
 Skin rash 1. Pain: (aggravated by use & relieved by rest) & stiffness of joints
 Aplastic anemia. 2. Heberden’s nodes: bony overgrowths at terminal interphalangeal
 Oral form: smaller doses are effective; take 3-6 months to joints
become effective 3. Decreased ROM with possible crepitation (grating sound when
 Auranofin (Ridaura) moving joints)
 SI: blood & urine studies should be monitored.

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Dx
Nursing Interventions
1. X-rays: show joint deformity as disease progresses
1. Assess joints for pain, motion & appearance.
2. ESR: may be slightly elevated when disease is inflammatory
2. Provide bed rest & joint immobilization as ordered.
3. Administer anti-gout medications as ordered.
Nursing Interventions
4. Administer analgesics as ordered: for pain
1. Assess joints for pain & ROM. 5. Increased fluid intake to 2000-3000 ml/day: to prevent formation of
2. Relieve strain & prevent further trauma to joints. renal calculi.
a. Encourage rest periods throughout day. 6. Apply local heat or cold as ordered: to reduce pain
b. Use cane or walker when indicated. 7. Apply bed cradle: to keep pressure of sheets off joints.
c. Ensure proper posture & body mechanics. 8. Provide client teaching and discharge planning concerning
d. Promote weight reduction: if obese a. Medications & their side effects
e. Avoid excessive weight-bearing activities & continuous standing. b. Modifications for low-purine diet: avoidance of shellfish, liver,
3. Maintain joint mobility and muscle strength. kidney, brains, sweetbreads, sardines, anchovies
a. Provide ROM & isometric exercises. c. Limitation of alcohol use
b. Ensure proper body alignment. d. Increased in fluid intake
c. Change client’s position frequently. e. Weight reduction if necessary
4. Promote comfort / relief of pain. f. Importance of regular exercise
a. Administer medications as ordered:
 Aspirin & NSAID: most commonly used Systemic Lupus Erythematosus (SLE)
 Corticosteroids (Intra-articular injections): to relieve pain &  Chronic connective tissue disease involving multiple organ systems
improve mobility.
b. Apply heat or ice as ordered (e.g. warm baths, compresses, hot Incident Rate
packs): to reduce pain. 1. Occurs most frequently in young women
5. Prepare client for joint replacement surgery if necessary.
6. Provide client teaching and discharge planning concerning
Predisposing Factors
a. Used of prescribed medications and side effects
1. Cause unknown
b. Importance of rest periods
2. Immune
c. Measures to relieve strain on joints
3. Genetic & viral factors have all been suggested
d. ROM and isometric exercises
e. Maintenance of a well-balanced diet
Pathophysiology
f. Use of heat/ice as ordered.
1. A defect in body’s immunologic mechanisms produces
autoantibodies in the serum directed against components of the
client’s own cell nuclei.
Gout
2. Affects cells throughout the body resulting in involvement of many
 A disorder of purine metabolism; causes high levels of uric acid in
organs, including joints, skin, kidney, CNS & cardiopulmonary
the blood & the precipitation of urate crystals in the joints
system.
 Inflammation of the joints caused by deposition of urate crystals
in articular tissue
S/sx
1. Fatigue
Incident Rate
2. Fever
1. Occurs most often in males
3. Anorexia
2. Familial tendency
4. Weight loss
5. Malaise
S/sx
6. History of remissions & exacerbations
1. Joint pain
7. Joint pain
2. Redness
8. Morning stiffness
3. Heat
9. Skin lesions
4. Swelling
 Erythematous rash on face, neck or extremities may occur
5. Joints of foot (especially great toe) & ankle most commonly affected
 Butterfly rash over bridge of nose & cheeks
(acute gouty arthritis stage)
 Photosensitivity with rash in areas exposed to sun
6. Headache
10. Oral or nasopharyngeal ulcerations
7. Malaise
11. Alopecia
8. Anorexia
12. Renal system involvement
9. Tachycardia
 Proteinuria
10. Fever
 Hematuria
11. Tophi in outer ear, hands & feet (chronic tophaceous stage)
 Renal failure
13. CNS involvement
Dx
 Peripheral neuritis
1. CBC: uric acid elevated
 Seizures
 Organic brain syndrome
Medical Management
 Psychosis
1. Drug therapy
14. Cardiopulmonary system involvement
a. Acute attack:
 Pericarditis
 Colchicine IV or PO: discontinue if diarrhea occurs
 Pleurisy
 NSAID: Indomethacin (Indocin)
15. Increase susceptibility to infection
 Naproxen (Naprosyn)
 Phenylbutazone (Butazolidin)
Dx
b. Prevention of attacks
1. ESR: elevated
 Uricosuric agents: increase renal excretion of uric acid
2. CBC: RBC anemia, WBC & platelet counts decreased
 Probenecid (Benemid)
3. Anti-nuclear antibody test (ANA): positive
 Sulfinpyrazone (Anturanel)
4. Lupus Erythematosus (LE prep): positive
 Allopurinal (Zyloprim): inhibits uric acid formation
5. Anti-DNA: positive
2. Low-purine diet may be recommended
6. Chronic false-positive test for syphilis
3. Joint rest & protection
4. Heat or cold therapy
Medical Management
1. Drug therapy

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a. Aspirin & NSAID: to relieve mild symptoms such as fever &


C. Assessment findings
arthritis D. Nursing interventions
b. Corticosteroids: to suppress the inflammatory response in acute
exacerbations or severe disease
Overview of Anatomy & Physiology Gastro Intestinal Track System
c. Immunosuppressive agents: to suppress the immune response
 The primary function of GIT are the movement of food, digestion,
when client unresponsive to more conservative therapy absorption, elimination & provision of a continuous supply of the
 Azathioprine (Imuran)
nutrients electrolytes & H2O.
 Cyclophosphamide (Cytoxan)
2. Plasma exchange: to provide temporary reduction in amount of
Upper alimentary canal: function for digestion
circulating antibodies.
Mouth
3. Supportive therapy: as organ systems become involved.
 Consist of lips & oral cavity
 Provides entrance & initial processing for nutrients & sensory data
Nursing Interventions
such as taste, texture & temperature
1. Assess symptoms to determine systems involved.
 Oral Cavity: contains the teeth used for mastication & the
2. Monitor vital signs, I&O, daily weights.
tongue which assists in deglutition & the taste sensation &
3. Administer medications as ordered.
mastication
4. Institute seizure precautions & safety measures: with CNS
 Salivary gland: located in the mouth produce secretion
involvement. containing pyalin for starch digestion & mucus for lubrication
5. Provide psychologic support to client / significant others.
 Pharynx: aids in swallowing & functions in ingestion by
6. Provide client teaching & discharge planning concerning providing a route for food to pass from the mouth to the
a. Disease process & relationship to symptoms esophagus
b. Medication regimen & side effects.
c. Importance of adequate rest. Esophagus
d. Use of daily heat & exercises as prescribed: for arthritis.  Muscular tube that receives foods from the pharynx & propels it into
e. Need to avoid physical or emotional stress the stomach by peristalsis
f. Maintenance of a well-balanced diet
g. Need to avoid direct exposure to sunlight: wear hat & other Stomach
protective clothing  Located on the left side of the abdominal cavity occupying the
h. Need to avoid exposure to persons with infections hypochondriac, epigastric & umbilical regions
i. Importance of regular medical follow-up  Stores & mixes food with gastric juices & mucus producing chemical
j. Availability of community agencies & mechanical changes in the bolus of food
 The secretion of digestive juice is stimulated by smelling, tasting
& chewing food which is known as cephalic phase of digestion
Osteomyelitis  The gastric phase is stimulated by the presence of food in the
 Infection of the bone and surrounding soft tissues, most commonly stomach & regulated by neural stimulation via PNS & hormonal
caused by S. aureus. stimulation through secretion of gastrin by the gastric mucosa
 Infection may reach bone through open wound (compound fracture  After processing in the stomach the food bolus called chyme is
or surgery), through the bloodstream, or by direct extension from released into the small intestine through the duodenum
infected adjacent structures.  Two sphincters control the rate of food passage
 Infections can be acute or chronic; both cause bone destruction.  Cardiac Sphincter: located at the opening between the
esophagus & stomach
S/sx  Pyloric Sphincter: located between the stomach & duodenum
1. Malaise  Three anatomic division
2. Fever  Fundus
3. Pain & tenderness of bone  Body
4. Redness & swelling over bone  Antrum
5. Difficulty with weight-bearing  Gastric Secretions:
6. Drainage from wound site may be present.  Pepsinogen: secreted by the chief cells located in the fundus aid
in CHON digestion
Dx  Hydrocholoric Acid: secreted by parietal cells, function in CHON
1. CBC: WBC elevated digestion & released in response to gastrin
2. Blood cultures: may be positive  Intrinsic Factor: secreted by parietal cell, promotes absorption
3. ESR: may be elevated of Vit B12
 Mucoid Secretion: coat stomach wall & prevent auto digestion
Nursing Interventions
1. Administer analgesics & antibiotics as ordered. 1st half of duodenum
2. Use sterile techniques during dressing changes.
3. Maintain proper body alignment & change position frequently: to Middle Alimentary canal: Function for absorption; Complete absorption: large
prevent deformities. intestine
4. Provide immobilization of affected part as ordered. Small Intestines
5. Provide psychologic support & diversional activities (depression may  Composed of the duodenum, jejunum & ileum
result from prolonged hospitalization)  Extends from the pylorus to the ileocecal valve which regulates flow
6. Prepare client for surgery if indicated. into the large intestines to prevent reflux to the into the small
 Incision & drainage: of bone abscess intestine
 Sequestrectomy: removal of dead, infected bone & cartilage  Major function: digestion & absorption of the end product of
 Bone grafting: after repeated infections digestion
 Leg amputation  Structural Features:
7. Provide client teaching and discharge planning concerning  Villi (functional unit of the small intestines): finger like
 Use of prescribed oral antibiotic therapy & side effects projections located in the mucous membrane; containing goblet
 Importance of recognizing & reporting signs & complications cells that secrets mucus & absorptive cells that absorb digested
(deformity, fracture) or recurrence food stuff
 Crypts of Lieberkuhn: produce secretions containing digestive
FRACTURES enzymes
A. General information  Brunner’s Gland: found in the submucosaof the duodenum,
1. secretes mucus
B. Medical management

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2nd half of duodenum  Amylase: breakdown starch to disacchardes


Jejunum  Lipase: for fat digestion
Ileum
 Endocrine function related to islets of langerhas
1st half of ascending colon

Physiology of Digestion & Absorption


Lower Alimentary Canal: Function: elimination  Digestion: physical & chemical breakdown of food into absorptive
Large Intestine substance
 Divided into four parts:  Initiate in the mouth where the food mixes with saliva & starch
 Cecum (with appendix) is broken down
 Colon (ascending, transverse, descending, sigmoid)  Food then passes into the esophagus where it is propelled into
 Rectum the stomach
 Anus  In the stomach food is processed by gastric secretions into a
 Serves as a reservoir for fecal material until defecation occurs substance called chyme
 Function: to absorb water & electrolytes  In the small intestines CHO are hydrolyzed to monosaccharides,
 MO present in the large intestine: are responsible for small amount fats to glycerol & fatty acid & CHON to amino acid to complete
of further breakdown & also make some vitamins the digestive process
 Amino Acids: deaminated by bacteria resulting in  When chymes enters the duodenum, mucus is secreted to
ammonia which is converted to urea in the liver neutralized hydrocholoric acid, in response to release
 Bacteria in the large intestine: aid in the synthesis of vitamin K secretin, pancreas releases bicarbonate to neutralized acid
& some of the vitamin B groups chyme
 Feces (solid waste): leave the body via rectum & anus  Cholecystokinin & Pancreozymin (CCKPZ)
 Anus: contains internal sphincter (under involuntary control) &  Are produced by the duodenal mucosa
external sphincter (voluntary control)  Stimulate contraction of the gallbladder along with
 Fecal matter: usually 75% water & 25% solid wastes relaxation of the sphincter of oddi (to allow bile flow
(roughage, dead bacteria, fats, CHON, inorganic matter) from common bile duct into the duodenum) &
a. 2nd half of ascending colon stimulate release of the pancreatic enzymes
b. Transverse Salivary Glands
c. Descending colon 1. Parotid – below & front of ear
d. Sigmoid 2. Sublingual
e. Rectum 3. Submaxillary

Accessory Organ - Produces saliva – for mechanical digestion


Liver - 1200 -1500 ml/day - saliva produced
 Largest internal organ: located in the right hypochondriac &
epigastric regions of the abdomen Disorder of the GIT
 Liver Loobules: functional unit of the liver composed of hepatic cells Peptic Ulcer Disease (PUD)
 Hepatic Sinusoids (capillaries): are lined with kupffer cells which Gastric Ulcer
carry out the process of phagocytosis  Ulceration of the mucosal lining of the stomach
 Portal circulation brings blood to the liver from the stomach, spleen,  Most commonly found in the antrum
pancreas & intestines  Excoriation / erosion of submucosa & mucosal lining due to:
 Function:  Hypersecretion of acid: pepsin
 Metabolism of fats, CHO & CHON: oxidizes these nutrient for  Decrease resistance to mucosal barrier
energy & produces compounds that can be stored  Caused by bacterial infection: Helicobacter Pylori
 Production of bile
 Conjugation & excretion (in the form of glycogen, fatty acids, Doudenal Ulcer
minerals, fat-soluble & water-soluble vitamins) of bilirubin  Most commonly found in the first 2 cm of the duodenum
 Storage of vitamins A, D, B12 & iron
 Characterized by gastric hyperacidity & a significant rate of gastric
 Synthesis of coagulation factors emptying
 Detoxification of many drugs & conjugation of sex hormones

Predisposing factor
Salivary gland  Smoking: vasoconstriction: effect GIT ischemia
Verniform appendix  Alcohol Abuse: stimulates release of histamine: Parietal cell release
Liver Hcl acid = Ulceration
Pancreas: auto digestion  Emotional Stress
Gallbladder: storage of bile  Drugs:
 Salicylates (Aspirin)
Biliary System  Steroids
 Consist of the gallbladder & associated ductal system (bile ducts)  Butazolidin
 Gallbladder: lies under the surface of the liver
 Function: to concentrate & store bile S/sx
 Ductal System: provides a route for bile to reach the intestines Gastric Ulcer Duodenal Ulcer
 Bile: is formed in the liver & excreted into hepatic duct
 Hepatic Duct: joins with the cystic duct (which drains the Site Antrum or lesser Duodenal bulb
gallbladder) to form the common bile duct curvature
 If the sphincter of oddi is relaxed: bile enters the duodenum, if  Pain  30 min-1 hr  2-3 hrs after
contracted: bile is stored in gallbladder after eating eating
 Left  Mid
Pancreas
epigastrium epigastrium
 Positioned transversely in the upper abdominal cavity  Gaseous &  Cramping &
 Consist of head, body & tail along with a pancreatic duct which burning burning
extends along the gland & enters the duodenum via the common  Not usually  Usually
bile duct relieved by relieved by
 Has both exocrine & endocrine function food & food &
 Function in GI system: is exocrine antacid antacid
 Exocrine cells in the pancreas secretes:  12 MN – 3am
 Trypsinogen & Chymotrypsin: for protein digestion pain

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 Hypersecretion  Normal  Increased Nursing Intervention Post op


gastric acid gastric acid 1. Monitor NGT output
secretion secretion  Immediately post op should be bright red
 Vomiting  Common  Not common  Within 36-42 hrs: output is yellow green
 Hemorrhage  Hematemeis  Melena  After 42 hrs: output is dark red
 Weight  Weight loss  Weight gain 2. Administer medication
 Complications  Stomach  Perforation  Analgesic
cause  Antibiotic
 Hemorrhage  Antiemetics
 High Risk  60 years old  20 years old 3. Maintain patent IV line
Dx 4. Monitor V/S, I&O & bowel sounds
 Hgb & Hct: decrease (if anemic) 5. Complications:
 Endoscopy: reveals ulceration & differentiate ulceration from gastric  Hemorrhage: Hypovolemic shock: Late signs: anuria
cancer  Peritonitis
 Gastric Analysis: normal gastric acidity  Paralytic ileus: most feared
 Upper GI series: presence of ulcer confirm  Hypokalemia
 Thromobphlebitis
Medical Management  Pernicious anemia
1. Supportive:
 Rest Nursing Intervention
 Bland diet 1. Administer medication as ordered
 Stress management 2. Diet: bland, non irritating, non spicy
2. Drug Therapy: 3. Avoid caffeine & milk / milk products: Increase gastric acid secretion
 Antacids: neutralizes gastric acid 4. Provide client teaching & discharge planning
 Aluminum hydroxide: binds phosphate in the GIT a. Medical Regimen
& neutralized gastric acid & inactivates pepsin  Take medication at prescribe time
 Magnesium & aluminum salt: neutralized gastric acid &  Have antacid available at all times
inactivate pepsin if pH is raised to >=4  Recognized situation that would increase the need for
antacids
Aluminum containing Antacids Magnesium containing  Avoid ulcerogenic drugs: salicylates, steroids
Antacids  Know proper dosage, action & SE
Ex. Aluminum OH gel (Amphojel) Ex. Milk of Magnesia b. Proper Diet
SE: Constipation SE: Diarrhea  Bland diet consist of six meals / day
 Eat slowly
 Avoid acid producing substance: caffeine, alcohol, highly
seasoned food
Maalox  Avoid stressfull situation at mealtime
SE: fever  Plan rest period after meal
 Avoid late bedtime snacks
 Histamines (H2) receptor antagonist: inhibits gastric acid c. Avoidance of stress-producing situation & development of stress
secretion of parietal cells production methods
 Ranitidine (Zantac): has some antibacterial action against  Relaxation techniques
H. pylori  Exercise
 Cimetidine (Tagamet)  Biofeedback
 Famotidine (Pepcid)
 Anticholinergic: Dumping syndrome
 Atropine SO4: inhibit the action of acetylcholine at post  Abrupt emptying of stomach content into the intestine
ganglionic site (secretory glands) results decreases GI  Rapid gastric emptying of hypertonic food solutions
secretions  Common complication of gastric surgery
 Propantheline: inhibit muscarinic action of acetylcholine  Appears 15-20 min after meal & last for 20-60 min
resulting decrease GI secretions  Associated with hyperosmolar CHYME in the jejunum which draws
 Proton Pump Inhibitor: inhibit gastric acid secretion regardless fluid by osmosis from the extracellular fluid into the bowel.
of acetylcholine or histamine release Decreased plasma volume & distension of the bowel stimulates
 Omeprazole (Prilosec): diminished the accumulation of acid increased intestinal motility
in the gastric lumen & healing of duodenal ulcer
 Pepsin Inhibitor: reacts with acid to form a paste that binds to S/sx
ulcerated tissue to prevent further destruction by digestive 1. Weakness
enzyme pepsin 2. Faintness
 Sucralfate (Carafate): provides a paste like subs that coats 3. Feeling of fullness
mucosal lining of stomach 4. Dizziness
 Metronidazole & Amoxacillin: for ulcer caused by Helicobacter 5. Diaphoresis
Pylori 6. Diarrhea
3. Surgery:
7. Palpitations
 Gastric Resection
 Anastomosis: joining of 2 or more hollow organ Nursing Intervention
 Subtotal Gastrectomy: Partial removal of stomach 1. Avoid fluids in chilled solutions
 Before surgery for BI or BII 2. Small frequent feeding: six equally divided feedings
 Do Vagotomy (severing or cutting of vagus nerve) & Pyloroplasty 3. Diet: decrease CHO, moderate fats & CHON
(drainage) first 4. Flat on bed 15-30 min after q feeding

Billroth I (Gastroduodenostomy) Billroth II (Gastrojejunostomy) Disorders of the Gallbladder


 Removal of ½ of  Removal of ½ -3/4 of Cholecystitis / Cholelithiasis
stomach & anastomoses stomach & duodenal bulb &  Cholecystitis:
of gastric stump to the anastomostoses of gastric  Acute or chronic inflammation of the gallbladder
duodenum. stump to jejunum.  Most commonly associated with gallstones

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 Inflammation occurs within the walls of the gallbladder 10. Drugs: Thiazide, steroids, diuretics, oral contraceptives
& creates thickening accompanied by edema
 Consequently there is impaired circulation, ischemia
S/Sx:
& eventually necrosis
1. Severe left upper epigastric pain radiates from back & flank area:
 Cholelithiasis:
aggravated by eating with DOB
 Formation of gallstones & cholesterol stones
2. N/V
 Inflammation of gallbladder with gallstone formation.
3. Tachycardia
4. Palpitation: due to pain
Predisposing Factor:
5. Dyspepsia: indigestion
1. High risk: women 40 years old
6. Decrease bowel sounds
2. Post menopausal women: undergoing estrogen therapy
7. (+) Cullen’s sign: ecchymosis of umbilicus Hemorrhage
3. Obesity
8. (+) Grey Turner’s spots: ecchymosis of flank area
4. Sedentary lifestyle
9. Hypocalcemia
5. Hyperlipidemia
6. Neoplasm
Dx
1. Serum amylase & lipase: increase
S/sx: 2. Urinary amylase: increase
1. Severe Right abdominal pain (after eating fatty food): Occurring 3. Blood Sugar: increase
especially at night 4. Lipids Level: increase
2. Intolerance of fatty food 5. Serum Ca: decrease
3. Anorexia 6. CT Scan: shows enlargement of the pancreas
4. N/V
5. Jaundice Medical Management
6. Pruritus 1. Drug Therapy
7. Easy bruising Narcotic Analgesic:
 for pain
8. Tea colored urine  Meperidine Hcl (Demerol)
9. Steatorrhea  Don’t give Morphine SO4: will cause spasm of Sphincter of
Oddi
Dx  Smooth muscle relaxant: to relieve pain
1. Direct Bilirubin Transaminase: increase  Papaverine Hcl
2. Alkaline Phosphatase: increase  Anticholinergic: to decrease pancreatic stimulation
3. WBC: increase  Atrophine SO4
4. Amylase: increase  Propantheline Bromide (Profanthene)
5. Lipase: increase  Antacids: to decrease pancreatic stimulation
6. Oral cholecystogram (or gallbladder series): confirms presence of  Maalox
stones  H2 Antagonist: to decrease pancreatic stimulation
Medical Management  Ranitidin (Zantac)
1. Supportive Treatment: NPO with NGT & IV fluids  Vasodilators: to decrease pancreatic stimulation
2. Diet modification with administration of fat soluble vitamins  Nitroglycerine (NTG)
3. Drug Therapy  Ca Gluconate: to decrease pancreatic stimulation
 Narcotic analgesic: DOC: Meperdipine Hcl (Demerol): for pain 2. Diet Modification
 (Morpine SO4: is contraindicated because it causes spasm 3. NPO (usually)
of the Sphincter of Oddi) 4. Peritoneal Lavage
 Antocholinergic: (Atrophine SO4): for pain 5. Dialysis
 (Anticholinergic: relax smooth muscles & open bile ducts)
 Antiemetics: Phenothiazide (Phenergan): with anti emetic Nursing Intervention
properties 1. Administer medication as ordered
4. Surgery: Cholecystectomy / Choledochostomy 2. Withhold food & fluid & eliminate odor: to decrease pancreatic
stimulation / aggravates pain
Nursing Intervention 3. Assist in Total Parenteral Nutrition (TPN) or hyperalimentation
1. Administer pain medication as ordered & monitor effects  Complication of TPN
2. Administer IV fluids as ordered  Infection
3. Diet: increase CHO, moderate CHON, decrease fats  Embolism
4. Meticulous skin care: to relieved priritus  Hyperglycemia
4. Institute non-pharmacological measures: to decrease pain
Disorders of the Pancreas
 Assist client to comfortable position: Knee chest or fetal like
Pancreatitis
position
 An inflammatory process with varying degrees of pancreatic edema,
 Teach relaxation techniques & provide quiet, restful
fat necrosis or hemorrhage
environment
 Proteolytic & lipolytic pancreatic enzymes are activated in the
5. Provide client teaching & discharge planning
pancreas rather than in the duodenum resulting in tissue damage &
 Dietary regimen when oral intake permitted
auto digestion of pancreas
 High CHO, CHON & decrease fats
 Acute or chronic inflammation of pancreas leading to pancreatic
 Eat small frequent meal instead of three large ones
edema, hemorrhage & necrosis due to auto digestion
 Avoid caffeine products
 Bleeding of Pancreas: Cullen’s sign at umbilicus
 Eliminate alcohol consumption
 Maintain relaxed atmosphere after meals
Predisposing factors:
 Report signs of complication
1. Chronic alcoholism
 Continued N/V
2. Hepatobilary disease
 Abdominal distension with feeling of fullness
3. Trauma
 Persistent weight loss
4. Viral infection
 Severe epigastric or back pain
5. Penetrating duodenal ulcer
 Frothy foul smelling bowel movement
6. Abscesses
 Irritability, confusion, persistent elevation of temperature (2
7. Obesity
day)
8. Hyperlipidemia
9. Hyperparathyroidism
Apendicitis

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 Inflammation of the appendix that prevents mucus from passing


into the cecum
S/sx
 Inflammation of verniform appendix
Fatigue
 If untreated: ischemia, gangrene, rupture & peritonitis
Anorexia
 May cause by mechanical obstruction (fecalith, intestinal parasites)
N/V
or anatomic defect
Dyspepsia: Indigestion
 May be related to decrease fiber in the diet
Weight loss
Flatulence
Predisposing factor: Change (Irregular) bowel habit
1. Microbial infection
Ascites
2. Feacalith: undigested food particles like tomato seeds, guava seeds Peripheral edema
etc. Hepatomegaly: pain located in the right upper quadrant
3. Intestinal obstruction
Atrophy of the liver
Fetor hepaticus: fruity, musty odor of chronic liver disease
S/Sx: Aterixis: flapping of hands & tremores
1. Pathognomonic sign: (+) rebound tenderness Hard nodular liver upon palpation
2. Low grade fever Increased abdominal girth
3. N/V Changes in moods
4. Decrease bowel sound Alertness & mental ability
5. Diffuse pain at lower Right iliac region Sensory deficits
6. Late sign: tachycardia: due to pain Gynecomastia
Decrease of pubic & axilla hair in males
Dx Amenorrhea in female
1. CBC: mild leukocytosis: increase WBC Jaundice
2. PE: (+) rebound tenderness (flex Right leg, palpate Right iliac area: Pruritus or urticaria
rebound) Easy bruising
3. Urinalysis: elevated acetone in urine Spider angiomas on nose, cheeks, upper thorax & shoulder
Palmar erythema
Medical Management Muscle atrophy
 Surgery: Appendectomy 24-45 hrs

Dx
Nursing Intervention Liver enzymes: increase
1. Administer antibiotics / antipyretic as ordered SGPT (ALT)
2. Routinary pre-op nursing measures: SGOT (AST)
 Skin prep LDH Alkaline Phosphate
 NPO Serum cholesterol & ammonia: increase
 Avoid enema, cathartics: lead to rupture of appendix Indirect bilirubin: increase
3. Don’t give analgesic: will mask pain CBC: pancytopenia
 Presence of pain means appendix has not ruptured PT: prolonged
4. Avoid heat application: will rupture appendix Hepatic Ultrasonogram: fat necrosis of liver lobules
5. Monitor VS, I&O bowel sound
Nursing Intervention
Nursing Intervention post op CBR with bathroom privileges
1. If (+) Pendrose drain (rubber drain inserted at surgical wound for Encourage gradual, progressive, increasing activity with planned rest
drainage of blood, pus etc): indicates rupture of appendix period
2. Position the client semi-fowlers or side lying on right: to facilitate Institute measure to relieve pruritus
drainage Do not use soap & detergent
3. Administer Meds: Bathe with tepid water followed by application of emollient lotion
 Analgesic: due post op pain Provide cool, light, non-constrictive clothing
 Antibiotics: for infection Keep nail short: to avoid skin excoriation from scratching
 Antipyretics: for fever (PRN) Apply cool, moist compresses to pruritic area
4. Monitor VS, I&O, bowel sound Monitor VS, I & O
5. Maintain patent IV line Prevent Infection
6. Complications: Peritonitis, Septicemia Prevent skin breakdown: by turning & skin care
Provide reverse isolation for client with severe leukopenia: handwashing
Liver Cirrhosis technique
Chronic progressive disease characterized by inflammation, fibrosis & Monitor WBC
degeneration of the liver parenchymal cell Diet:
Destroyed liver cell are replaced by scar tissue, resulting in architectural Small frequent meals
changes & malfunction of the liver Restrict Na!
Lost of architectural design of liver leading to fat necrosis & scarring High calorie, low to moderate CHON, high CHO, low fats with
supplemental Vit A, B-complex, C, D, K & folic acid
Types Monitor / prevent bleeding
Laennec’s Cirrhosis: Measure abdominal girth daily: notify MD
Associated with alcohol abuse & malnutrition With pt daily & assess pitting edema
Characterized by an accumulation of fat in the liver cell progressing to Administer diuretics as ordered
widespread scar formation Provide client teaching & discharge planning
Postnecrotic Cirrhosis Avoidance of hepatotoxicity drug: sedative, opiates or OTC drugs
Result in severe inflammation with massive necrosis as a complication of detoxified by liver
viral hepatitis How to assess weight gain & increase abdominal girth
Cardiac Cirrhosis Avoid person with upper respiratory infection
Occurs as a consequence of right sided heart Reporting signs of reccuring illness (liver tenderness, increase jaundice,
failure Manifested by hepatomegaly with some increase fatigue, anorexia)
fibrosis Avoid all alcohol
Biliary Cirrhosis Avoid straining stool vigorous blowing of nose & coughing: to decrease

Associated with biliary obstruction usually in the common bile duct incidence of bleeding

Results in chronic impairment of bile excretion

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Complications:
Filters blood going to kidneys
Ascites: accumolation of free fluid in abdominal cavity
Renal Tubule
Divided into proximal convoluted tubule, descending loop of
Nursing Intervention Henle, acending loop of Henle, distal convoluted tubule &
Meds: Loop diuretics: 10-15 min effect
collecting ducts
Assist in abdominal paracentesis: aspiration of fluid
Void before paracentesis: to prevent accidental puncture of bladder Ureters
as trochar is inserted Two tubes approximately 25-35 cm long
Extend from the renal pelvis to the pelvic cavity where they enter the
Bleeding esophageal varices: Dilation of esophageal veins bladder, convey urine from the kidney to the bladder
Passageway of urine to bladder
Nursing Intervention Ureterovesical valve: prevent backflow of urine into ureters
Administer meds:
Vit K Bladder
Pitrisin or Vasopresin (IM) Located behind the symphisis pubis
NGT decompression: lavage Composed of muscular elastic tissue that makes it distensible
Give before lavage: ice or cold saline solution Serve s as reservoir of urine (capable of holding 1000-1800 ml & 500 ml
Monitor NGT output moderately full)
Assist in mechanical decompression Internal & external urethral sphincter controls the flow of urine
Insertion of sengstaken-blackemore tube Urge to void stimulated by passage of urine past the internal sphincter
3 lumen typed catheter (involuntary) to the upper urethra
Scissors at bedside to deflate balloon. Relaxation of external sphincter (voluntary) produces emptying of the
bladder (voiding)
Hepatic encephalopathy

Urethra
Nursing Intervention Small tube that extends from the bladder to the exterior of the body
Assist in mechanical ventilation: due coma Passage of urine, seminal & vaginal fluids.
Monitor VS, neuro check Females: located behind the symphisis pubis & anterior vagina &
Siderails: due restless approximately 3-5 cm
Administer meds Males: extend the entire length of the penis & approximately 20 cm
Laxatives: to excrete ammonia
Function of kidneys
Overview of Anatomy & Physiology Of GUT System Kidneys remove nitrogenous waste & regulates F & E balance &
acid base balance
GUT: Genito-urinary tract Urine is the end product
GUT includes the kidneys, ureters, urinary bladder, urethra & the male &
female genitalia Urine formation: 25 % of total cardiac output is received by kidneys
Function: Glomerular Filtration
Promote excretion of nitrogenous waste products Ultrafiltration of blood by the glomerulus, beginning of urine
Maintain F&E & acid base balance formation
Requires hydrostatic pressure & sufficient circulating volume
Kidneys Pressure in bowman’s capsule opposes hydrostatic pressure & filtration
Two of bean shaped organ that lie in the retroperitonial space If glomerular pressure insufficient to force substance out of the blood into the
on either side of the vertebral column tubules filtrate formation stops
Retroperitonially (back of peritoneum) on either side of vertebral Glomerular Filtration Rate (GFR)
column Amount of blood filtered by the glomeruli in a given time
Adrenal gland is on top of each kidneys Normal: 125 ml / min
Encased in Bowmans’s capsule Filtrate formed has essentially same composition as blood plasma
without the CHON; blood cells & CHON are usually too large to
Renal Parenchyma pass the glomerular membrane
Cortex
Outermost layer Tubular Function
Site of glomeruli & proximal & distal tubules of nephron Tubules & collecting ducts carry out the function of
Medulla reabsorption, secretion & excretion
Middle layer Reabsorption of H2O & electrolytes is controlled by anitdiuretics
Formed by collecting tubules & ducts hormones (ADH) released by the pituitary & aldosterone
secreted by the adrenal glands
Renal Sinus & Pelvis Proximal Convoluted Tubule
Papillae Reabsorb the ff:
Projection of renal tissues located at the tip of the renal pyramids 80% of F & E
Calices H2O
Minor Calyx: collects urine flow from collecting ducts Glucose
Major Calyx: directs urine from renal sinus to renal pelvis Amino acids
Urine flows from renal pelvis to ureters Bicarbonate
Secretes the ff:
Nephron Organic substance
Functional unit of the kidney Waste
Basic living unit Loop of Henli
Reabsorb the ff:
Renal Corpuscle (vascular system of nephron) Na & Chloride in the ascending limb
Bowman’s Capsule: H2O in the descending limb
Portion of the proximal tubule surrounds the glomerulus Concentrate / dilutes urine
Glomerulus: Distal Convoluted Tubule
Capillary network permeable to water, electrolytes, nutrients & Secretes the ff:
waste Potassium
Impermeable to large CHON molecules Hydrogen ions

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Ammonia
Reabsorb the ff:
S/Sx:
H2O
Pain: flank area
Bicarbonate
Urinary frequency & urgency
Regulate the ff:
Burning pain upon urination
Ca
Dysuria
Phosphate concentration
Hematuria
Collecting Ducts
Nocturia
Received urine from distal convoluted tubules & reabsorb H2O (regulated
Fever
by ADH)
Chills
Anorexia
Normal Adult: produces 1 L /day of urine
Gen body malaise

Regulation of BP
Dx
Through maintenance of volume (formation / excretion of urine)
Urine culture & sensitivity: (+) to E. coli
Rennin-angiotensin system is the kidneys controlled mechanism that can
contribute to rise the BP
Nursing Intervention
When the BP drops the cells of the glomerulus release rennin which then
Force fluid: 3000 ml
activates angiotensin to cause vasoconstriction. Warm sitz bath: to promote comfort
Monitor & assess urine for gross odor, hematuria & sediments
Acid Ash Diet: cranberry, vit C: OJ: to acidify urine & prevent bacterial
Filtration – Normal GFR/ min is 125 ml of blood
multiplication
Tubular reabsorption – 124ml of ultra infiltrates (H2O & electrolytes is for
Administer Medication as ordered:
reabsorption)
Systemic Antibiotics
Tubular secretion – 1 ml is excreted in urine
Ampicillin
Cephalosporin
Regulation of BP:
Aminoglycosides
Sulfonamides
Predisposing factor:
Co-trimaxazole (Bactrim)
Ex CS – hypovolemia – decrease BP going to kidneys
Gantrism (Gantanol)
Activation of RAAS Antibacterial
Nitrofurantoin (Macrodantin)
Release of Renin (hydrolytic enzyme) at juxtaglomerular
Methenamine Mandelate (Mandelamine)
apparatus
Nalixidic Acid (NegGram)
Urinary Tract Anagesic
Angiotensin I mild vasoconstrictor
Urinary antiseptics: Mitropurantoin (Macrodantin)
Urinary analgesic: Pyridium
Angiotensin II vasoconstrictor Provide client teachings & discharge planning
Importance of Hydration
Void after sex: to avoid stagnation
Adrenal cortex increase CO increase PR Female: avoids cleaning back & front (should be front to back)
Bubble bath, Tissue paper, Powder, perfume
Aldosterone Complications: Pyelonephritis
Increase BP
Increase Na & Pyelonephritis
H2O reabsorption Acute / chronic inflammation of 1 or 2 renal pelvis of kidneys
leading to tubular destruction & interstitial abscess
Hypervolemia formation
Acute: infection usually ascends from lower urinary tract
Chronic: a combination of structural alteration along with
infection major cause is ureterovesical reflux with infected
urine backing up into ureters & renal pelvis
Recurrent infection will lead to renal parenchymal deterioration
Color – amber & Renal Failure
Odor – aromatic
Consistency – clear or slightly Predisposing factor:
turbid pH – 4.5 – 8 Microbial invasion
Specific gravity – 1.015 – 1.030 E. Coli
WBC/ RBC – (-) Streptococcus
Albumin – (-) Urinary retention /obstruction
E coli – (-) Pregnancy
Mucus thread – few DM
Amorphous urate (-) Exposure to renal toxins

S/sx:
UTI Acute Pyelonephritis
CYSTITIS Severe flank pain or dull ache
Inflammation of bladder due to bacterial infection Costovertibral angle pain / tenderness
Fever
Predisposing factors: Chills
Microbial invasion: E. coli N/V
High risk: women Anorexia
Obstruction Gen body malaise
Urinary retention Urinary frequency & urgency
Increase estrogen levels Nocturia
Sexual intercourse Dsyuria

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Hematuria
Intravenous Pyelography (IVP): identifies site of obstruction & presence
Burning sensation on urination
of non-radiopaque stones
KUB: reveals location, number & size of stone
Chronic Pyelonephritis: client usually not aware of disease Cytoscopic Exam: urinary obstruction
Bladder irritability Stone Analysis: composition & type of stone
Slight dull ache over the kidney
Urinalysis: indicates presence of bacteria, increase WBC, RBC & CHON
Chronic Fatigue
Weight loss
Medical Management
Polyuria
Surgery
Polydypsia
Percutaneous Nephrostomy:
HPN
Tube is inserted through skin & underlying tissue into renal pelvis to
Atrophy of the kidney
remove calculi
Percutaneous Nephrostolithotomy
Medical Management
Delivers ultrasound wave through a probe placed on the calculus
Urinary analgesic: Peridium
Extracorporeal Shockwave Lithotripsy:
Acute
Non-invasive
Antibiotics
Delivers shockwaves from outside of the body to the stone causing
Antispasmodic
pulverization
Surgery: removal of any obstruction
Pain management & diet modification
Chronic
Antibiotics
Nursing Intervention
Urinary Antiseptics
Force fluid: 3000-4000 ml / day
Nitrofurantoin (macrodantin)
Strain urine using gauze pad: to detect stones & crush all cloths
SE: peripheral neuropathy
Encourage ambulation: to prevent stasis
GI irritation
Warm sitz bath: for comfort
Hemolytic anemia
Administer narcotic analgesic as ordered: Morphine SO4: to relieve pain
Staining of teeth
Application warm compress at flank area: to relieve pain
Surgery: correction of structural abnormality if possible
Monitor I & O
Provide modified diet depending upon the stone consistency
Dx
Calcium Stones
Urine culture & sensitivity: (+) E. coli & streptococcus
Limit milk & dairy products
Urinalysis: increase WBC, CHON & pus cells
Provide acid ash diet (cranberry or prune juice, meat, fish, eggs,
Cystoscopic exam: urinary obstruction
poultry, grapes, whole grains): to acidify urine
Take vitamin C
Nursing Intervention
Oxalate Stone
Provide CBR: acute phase
Avoid excess intake of food / fluids high in oxalate (tea,
Monitor I & O
chocolate, rhubarb, spinach)
Force fluid
Maintain alkaline-ash diet (milk, vegetable, fruits except
Acid ash diet
cranberry, plums & prune): to alkalinize urine
Administer medication as ordered
Uric Acid Stone
Chronic: possibility of dialysis & transplant if has renal deterioration
Reduce food high in purine (liver, brain, kidney, venison,
Complication: Renal Failure
shellfish, meat soup, gravies, legumes)
Maintain alkaline urine
Nephrolithiasis / Urolithiasis
Administer Allopurinol (Zyloprim) as ordered: to decrease uric acid
Presence of stone anywhere in the urinary tract
production: push fluids when giving allopurinol
Formation of stones at urinary tract Provide client teaching & discharge planning
Frequent composition of stones
Prevention of urinary stasis: increase fluid intake especially during hot
Calcium
weather & illness
Oxalate
Mobility
Uric acid
Voiding whenever the urge is felt & at least twice during night
Adherence to prescribe diet
Calcium Oxalate Uric Acid Complications: Renal Failure

Milk Cabbage Anchovies


Benign Prostatic Hypertrophy (BPH)
Cranberries Organ meat
Mild to moderate glandular enlargement, hyperplsia & over growth
Nuts tea Nuts
of the smooth muscles & connective tissue
Chocolates Sardines
As the gland enlarges it compresses the urethra: resulting to urinary
retention
Predisposing factors:
Enlarged prostate gland leading to
Diet: increase Ca & oxalate
Hydroureters: dilation of urethers
Increase uric acid level
Hydronephrosis: dilation of renal pelvis
Hereditary: gout or calculi
Kidney stones
Immobility
Renal failure
Sedentary lifestyle
Hyperparathyroidism
Predisposing factor:
High risk: 50 years old & above & 60-70 (3-4x at risk)
S/sx
Influence of male hormone
Abdominal or flank pain
Renal colic
S/sx
Cool moist skin (shock)
Urgency, frequency & hesitancy
Burning sensation upon urination
Nocturia
Hematuria
Enlargement of prostate gland upon palpation by digital rectal
Anorexia
exam
N/V
Decrease force & amount of urinary stream
Dysuria
Dx
Hematuria

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Burning sensation upon urination


Tumors
Terminal bubbling
Stricture
Backache
Blood cloths
Sciatica: severe pain in the lower back & down the back of thigh Urolithiasis
& leg BPH
Anatomic malformation
Dx
Digital rectal exam: enlarged prostate gland
S/sx
KUB: urinary obstruction
Oliguric Phase: caused by reduction in glomerular filtration rate
Cystoscopic Exam: reveals enlargement of prostate gland & Urine output less than 400 ml / 24 hrs; duration 1-2 weeks
obstruction of urine flow
S/sx
Urinalysis: alkalinity increase
Hypernatremia
Specific Gravity: normal or elevated
Hyperkalemia
BUN & Creatinine: elevated (if longstanding BPH)
Hyperphosphotemia
Prostate-specific Antigen: elevated (normal is < 4 ng
Hypermagnesemia
/ml) Hypocalcemia
Nursing Intervention Metabolic acidosis
Prostate message: promotes evacuation of prostatic fluid Dx
Force fluid intake: 2000-3000 ml unless contraindicated BUN & Creatinine: elevated
Provide catheterization Diuretic Phase: slow gradual increase in daily urine output
Administer medication as ordered: Diuresis may occur (output 3-5 L / day): due to partially regenerated
Terazosine (Hytrin): relaxes bladder sphincter & make it easier tubules inability to concentrate urine
to urinate Duration: 2-3 weeks
Finasteride (Proscar): shrink enlarge prostate gland S/sx
Surgery: Prostatectomy Hyponatremia
Transurethral Resection of Prostate (TURP): insertion of a resectoscope Hypokalemia
into urethra to excise prostatic tissue Hypovolemia
Assist in cystoclysis or continuous bladder irrigation. Dx
Nursing Intervention BUN & Creatinine: elevated
Monitor symptoms of infection Recovery or Covalescent Phase: renal function stabilized with gradual
Monitor symptoms gross / flank bleeding. Normal bleeding improvement over next 3-12 mos
within 24h
Maintain irrigation or tube patent to flush out clots: to prevent Nursing Intervention
bladder spasm & distention Monitor / maintain F&E balance
Obtain baseline data on usual appearance & amount of client’s
urine
Measure I&O every hour: note excessive losses
Acute Renal Failure Administer IV F&E supplements as ordered
Sudden inability of the kidney to regulate fluid & electrolyte balance & Weight daily
remove toxic products from the body Monitor lab values: assess / treat F&E & acid base imbalance as
Sudden immobility of kidneys to excrete nitrogenous waste products & needed
maintain F&E balance due to a decrease in GFR (N 125 ml/min) Monitor alteration in fluid volume
Monitor V/S. PAP, PCWP, CVP as needed
Causes Monitor I&O strictly
Pre-renal cause: interfering with perfusion & resulting in decreased blood Assess every hour fro hypervolemia
flow & glomerular filtrate Maintain ventilation
Inter-renal cause: condiion that cause damage to the nephrons Decrease fluid intake as ordered
Post-renal cause: mechanical obstruction anywhere from the tubules to Administer diuretics, cardiac glycosides & hypertensive
the urethra agent as ordered
Assess every hour for hypovolemia: replace fluid as ordered
Pre renal cause: decrease blood flow & glomerular filtrate Monitor ECG
Ischemia & oliguria Check urine serum osmolality / osmolarity & urine specific
Cardiogenic shock gravity as ordered
Acute vasoconstriction Promote optimal nutrition
Septicemia Administer TPN as ordered
Hypovolemia Decrease flow to Restrict CHON intake
kidneys Prevent complication from impaired mobility
Hypotension Pulmonary Embolism
CHF Skin breakdown
Hemorrhage Contractures
Dehydration Atelectesis
Prevent infection / fever
Intra-renal cause: involves renal pathology: kidney problem Assess sign of infection
Acute tubular necrosis Use strict aseptic technique for wound & catheter care
Endocarditis Take temperature via rectal
DM Administer antipyretics as ordered & cooling blankets
Tumors Support clients / significant others: reduce level of anxiety
Pyelonephritis Provide care for client receiving dialysis
Malignant HPN Provide client teaching & discharge
Acute Glomerulonephritis planning Adherence to prescribed dietary
Blood transfision reaction regime S/sx of recurrent renal disease
Hypercalemia Importance of planned rest period
Nephrotoxin (certain antibiotics, X-ray, dyes, pesticides, Use of prescribe drugs only
anesthesia) S/sx of UTI or respiratory infection: report to MD

Post renal cause: involves mechanical obstruction Chronic Renal Failure

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Progressive, irreversible destruction of the kidneys that continues until


Loss of appetite
nephrons are replaced by scar tissue
Decreased urine output
Loss of renal function gradual
Apathy

Irreversible loss of kidney function


Confusion
Elevated BP
Predisposing factors:
Edema of face &
DM
feet Itchy skin
HPN
Restlessness
Recurrent UTI/ nephritis
Seizures
Urinary Tract obstruction
Monitor for changes in mental functioning
Exposure to renal toxins
Orient confused client to time, place, date & person
Institute safety measures to protect the client from falling out of
Stages of CRF
bed
Diminished Reserve Volume – asymptomatic
Monitor serum electrolytes, BUN & creatinine as ordered
Normal BUN & Crea, GFR < 10 – 30%
Promote optimal GI function
2. Renal Insufficiency
Provide care for stomatitis
3. End Stage Renal disease
Monitor N/V & anorexia: administer antiemetics as ordered
Monitor signs of GI bleeding
Monitor & prevent alteration in F&E balance
S/Sx:
Monitor for hyperphosphatemia: administer aluminum hydroxides gel
N/V
(amphojel, alternagel) as ordered
Diarrhea / constipation
Paresthesias
Decreased urinary output
Muscle cramps
Dyspnea
Seizures
Stomatitis
Abnormal reflex
Hypotension (early)
Maintenance of skin integrity
Hypertension (late)
Provide care for pruritus
Lethargy
Monitor uremic frost (urea crystallization on the skin): bathe in plain
Convulsion
water
Memory impairment Pericardial Friction
Monitor for bleeding complication & prevent injury to client
Rub HF
Monitor Hgb, Hct, platelets, RBC
Hematest all secretions
Administer hematinics as ordered
Avoid IM injections
Urinary System Metabolic Disturbance
Maintain maximal cardiovascular function
Polyuria Azotemia (increase BUN &
Monitor BP
Nocturia Creatinine)
Auscultate for pericardial friction rub
Hematuria Hyperglycemia
Perform circulation check routinely
Dysuria Hyperinsulinemia Administer diuretics as ordered & monitor I&O
Oliguria Modify digitalis dose as ordered (digitalis is excreted in kidneys)
CNS GIT Provide care for client receiving dialysis
Headache N/V Disequilibrium syndrome: from rapid removal of urea & nitrogenous
Lethargy Stomatitis waste prod leading to:
Disorientation Uremic breath N/V
Restlessness Diarrhea / HPN
Memory impairment constipation Leg cramps
Respiratory Hematological Disorientation
Kassmaul’s resp Normocytic anemia Paresthes
Decrease cough reflex Bleeding tendencies Enforce CBR
Monitor VS, I&O
Fluid & Electrolytes Integumentary Meticulous skin care. Uremic frost – assist in bathing pt
Hyperkalemia Itchiness / 4. Meds:
Hypernatermia pruritus a.) Na HCO3 – due Hyperkalemia
Hypermagnesemia Uremic frost b.) Kagexelate enema
Hyperposphatemia c.) Anti HPN – hydralazine
Hypocalcemia d.) Vit & minerals
Metabolic acidosis e.) Phosphate binder
(Amphogel) Al OH gel - S/E constipation
Dx f.) Decrease Ca – Ca gluconate
Urinalysis: CHON, Na & WBC: elevated 5. Assist in hemodialysis

Specific gravity: decrease Consent/ explain procedure


Platelets: decrease Obtain baseline data & monitor VS, I&O, wt, blood
Ca: decrease exam
Strict aseptic technique
Medical Management Monitor for signs of complications:
Diet restriction B – bleeding
Multivitamins E – embolism
Hematinics D – disequilibrium syndrome
Aluminum Hydroxide Gels S – septicemia
Antihypertensive S – shock – decrease in tissue perfusion
Disequilibrium syndrome – from rapid removal of urea & nitrogenous waste
Nursing Intervention prod leading to:
Prevent neurologic complication n/v
Monitor for signs of uremia HPN
Fatigue Leg cramps
Disorientation

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Paresthesia

Avoid BP taking, blood extraction, IV, at side of shunt or fistula.


Can lead to compression of fistula.
Maintain patency of shunt by:
Palpate for thrills & auscultate for bruits if (+) patent
shunt!
Bedside- bulldog clip
- If with accidental removal of fistula to prevent
embolism.
- Infersole (diastole) – common dialisate used
7. Complication
- Peritonitis
- Shock

8. Assist in surgery:
Renal transplantation : Complication – rejection. Reverse
isolation

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