Med Surg Notes
Med Surg Notes
Med Surg Notes
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
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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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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.
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4
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5
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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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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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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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.
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5. Hyperuricemia
- increase uric acid (purine metabolism)
- foods high in uric acid (sardines, organ meats and anchovies)
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
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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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- 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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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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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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- 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
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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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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
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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
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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
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
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in skeletal muscle & Use clinitest, tes-tape, diastix, for glucose testing
Perform test before meals & at bedtime
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)
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:
7. Maintain I&O; weight daily Monitor urine or blood glucose level & urine
in lifestyle & body image If N/V occurs: sip on clear liquid with simple sugar
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 &
Premature Cataracts Purchase properly fitting shoes & break new shoes in
Affects PNS & ANS Inspect foot daily & notify physician: if cut, blister, or
10. Provide client teaching & discharge planning concerning: Undertake regular exercise; avoid sporadic, vigorous
exchange lists before discharge Exercise is best performed after meals when the blood
skip meals
c. Insulin j. Complication
Use insulin at room temp hypoglycemia (cold and clammy skin), for
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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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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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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
Vascular System
Objectives
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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
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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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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
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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
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1. Surgery Tetracycline
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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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
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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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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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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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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
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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
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Paresthesia
8. Assist in surgery:
Renal transplantation : Complication – rejection. Reverse
isolation
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