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NERVOUS SYSTEM Overview of structures and functions: Central Nervous System
Brain Spinal Cord Cranial Nerves Spinal Nerves Sympathetic nervous system Parasympathetic nervous system AUTONOMIC NERVOUS SYSTEM
Peripheral Nervous System
Autonomic Nervous System
Sympathetic Nervous System (ADRENERGIC) - Involved in fight or aggression response. - Release of Norepinephrine (cathecolamines) from adrenal glands and causes vasoconstriction. - Increase all bodily activity except GIT EFFECTS OF SNS - Dilation of pupils(mydriasis) in order to be aware. - Dry mouth (thickened saliva). - Increase BP and Heart Rate. - Bronchodilation, Increase RR - Constipation. - Urinary Retention. - Increase blood supply to brain, heart and skeletal muscles. - SNS I. Adrenergic Agents - Give Epinephrine. Signs and Symptoms: - SNS Contraindication: - Contraindicated to patients suffering from COPD (Broncholitis, Bronchoectasis, Emphysema, Asthma). II. Beta-adrenergic Blocking Agents - Also called Beta-blockers. - All ending with “lol” - Propranolol, Atenelol, Metoprolol. Effects of Beta-blockers B – roncho spasm E – licits a decrease in myocardial contraction. T – reats hypertension. A – V conduction slows down. Should be given to patients with Angina Pectoris, Myocardial Infarction, Hypertension. ANTI- HYPERTENSIVE AGENTS 1. Beta-blockers – “lol” 2. Ace Inhibitors – Angiotensin, “pril” (Captopril, Enalapril) 3. Calcium Antagonist – Nifedipine (Calcibloc) In chronic cases of arrhythmia give Lidocaine(Xylocaine)
Parasympathetic Nervous System (CHOLINERGIC, VAGAL, SYMPATHOLYTIC) - Involved in fight or withdrawal response. - Release of Acetylcholine. - Decreases all bodily activities except GIT. EFFECTS OF PNS - Constriction of pupils (meiosis). - Increase salivation. - Decrease BP and Heart Rate. - Bronchoconstriction, Decrease RR. - Diarrhea - Urinary frequency.
I. Cholinergic Agents - Mestinon, Neostigmine. Side Effects - PNS
II. Anti-cholinergic Agents - To counter cholinergic agents. - Atropine Sulfate Side Effects - SNS
CENTRAL NERVOUS SYSTEM
Brain and Spinal Cord.
I. CELLS A. NEURONS
Basic cells for nerve impulse and conduction.
PROPERTIES Excitability – ability of neuron to be affected by changes in external environment. Conductivity – ability of neuron to transmit a wave of excitation from one cell to another. Permanent Cell – once destroyed not capable of regeneration. TYPES OF CELLS BASED ON REGENERATIVE CAPACITY 1. Labile
Capable of regeneration. Epidermal cells, GIT cells, GUT cells, cells of lungs. Capable of regeneration with limited time, survival period. Kidney cells, Liver cells, Salivary cells, pancreas. Not capable of regeneration. Myocardial cells, Neurons, Bone cells, Osteocytes, Retinal Cells.
Support and protection of neurons.
TYPES 1. Astrocytes – maintains blood brain barrier semi-permeable. 2. Oligodendria 3. Microglia 4. Epindymal SUBSTANCES THAT CAN PASS THE BLOOD-BRAIN BARRIER 1. Ammonia
Majority of brain tumors (90%) arises from called astrocytoma.
Cerebral toxin Hepatic Encephalopathy (Liver Cirrhosis) Ascites Esophageal Varices asterixis (flapping hand tremors). Headache Dizziness Confusion Fetor hepaticus (ammonia like breath) Decrease LOC
Early Signs of Hepatic Encephalopathy
Late Signs of Hepatic Encephalopathy
PATHOGNOMONIC SIGNS 1. PTB – low-grade afternoon fever. 2. PNEUMONIA – rusty sputum. 3. ASTHMA – wheezing on expiration. 4. EMPHYSEMA – barrel chest. 5. KAWASAKI SYNDROME – strawberry tongue. 6. PERNICIOUS ANEMIA – red beefy tongue. 7. DOWN SYNDROME – protruding tongue. 8. CHOLERA – rice watery stool. 9. MALARIA – stepladder like fever with chills. 10. TYPHOID – rose spots in abdomen. 11. DIPTHERIA – pseudo membrane formation 12. MEASLES – koplik’s spots. 13. SLE – butterfly rashes. 14. LIVER CIRRHOSIS – spider like varices. 15. LEPROSY – lioning face. 16. BULIMIA – chipmunk face. 17. APPENDICITIS – rebound tenderness. 18. DENGUE – petechiae or (+) Herman’s sign. 19. MENINGITIS – Kernig’s sign (leg pain), Brudzinski sign (neck pain). 20. TETANY – HYPOCALCEMIA (+) Trousseau’s sign/carpopedal spasm; Chvostek sign (facial spasm). 21. TETANUS – risus sardonicus. 22. PANCREATITIS – Cullen’s sign (ecchymosis of umbilicus); (+) Grey turners spots. 23. PYLORIC STENOSIS – olive like mass. 24. PDA – machine like murmur. 25. ADDISON’S DISEASE – bronze like skin pigmentation. 26. CUSHING’S SYNDROME – moon face appearance and buffalo hump. 27. HYPERTHYROIDISM/GRAVE’S DISEASE – exopthalmus. 28. INTUSSUSCEPTION – sausage shaped mass 2. Carbon Monoxide and Lead Poisoning
Can lead to Parkinson’s Disease. Epilepsy Treat with ANTIDOTE: Calcium EDTA. Causes diabetic ketoacidosis. And increases breakdown of fats. And free fatty acids Resulting to cholesterol and (+) to Ketones (CNS depressant). Resulting to acetone breath odor/fruity odor. KUSSMAUL’S respiration, a rapid shallow respiration. Which may lead to diabetic coma. Signs of jaundice (icteric sclerae). Caused by bilirubin (yellow pigment) Increase bilirubin in brain (Kernicterus). Causing irreversible brain damage.
3. Type 1 DM (IDDM)
Maintains integrity of blood brain barrier. Produces myelin sheath in CNS Act as insulator and facilitates rapid nerve impulse transmission.
Agnosia – no recognition of inanimate objects. MULTIPLE SCLEROSIS Chronic intermittent disorder of CNS characterized by white patches of demyelination in brain and spinal cord. Amnesia – loss of memory. colostrums). Ig M – acute in inflammation. pressure.short term protection. tingling sensation paresthesia numbness euphoria (sense of well being) 3. . heat and cold. Ig A – present in all bodily secretions (tears. saliva. b. c. Ig E – for allergic reaction. Women ages 15-35 are prone Unknown Cause Slow growing virus Autoimmune disorders Pernicious anemia Myasthenia gravis Lupus Hypothyroidism GBS Ig G – only antibody that pass placental circulation causing passive immunity. pain. Visual disturbances blurring of vision (primary) diplopia (double vision) scotomas (blind spots) 2. . ALZHEIMER’S DISEASE Atrophy of brain tissues. *Receptive aphasia DRUG OF CHOICE: ARICEPT (taken at bedtime) and COGNEX. Impaired sensation to touch. *Expressive aphasia “motor speech center” Broca’s Aphasia inability to understand spoken words. Sign and Symptoms 4 A’s of Alzheimer a. d. * Give palliative or supportive care. Signs and Symptoms 1. Characterized by remission and exacerbation. Ig D – for chronic inflammation. Mood swings .DEMYELINATING DISORDERS 1. Aphasia – no speech (nodding). 2.Immediate action. Wernicke’s Aphasia General Knowing Gnostic Area or General Interpretative Area. Apraxia – no recognition of objects function.
Decrease sexual capacity DIAGNOSTIC PROCEDURE Nystagmus CSF analysis (increase in IgG and Protein). . d. Prophantheline Bromide (Promanthene) Acid ash diet like cranberry juice. 3. Impaired motor function weakness spasticity paralysis scanning speech TRIAD SIGNS OF MS Ataxia (Unsteady gait. ACTH (Adreno Corticotropic Hormone)/ Steroids for acute exacerbation to reduce edema at site of demyelination to prevent paralysis. b. Catheterization to prevent retention. Interferons – alter immune response. Monitor breath sounds 1 hour after subcutaneous administration. Monitor side effects bronchospasm and wheezing. c. Administer medications as ordered a. Urinary retention/incontinence 7. (+) Lhermitte’s sign a continuous and increase contraction of spinal column. For Urinary Incontinence Anti spasmodic agent a. Constipation 8. pineapple. a. 5. Impaired cerebral function CHARCOTS TRIAD IAN Intentional tremors 6.4. MRI (reveals site and extent of demyelination). c. Immunosupresants 2. a. Deep breathing exercises b. Bethanicol Chloride (Urecholine) Nursing Management Only given subcutaneous. prunes. Institute stress management techniques. Diuretics b. plums. NURSING MANAGEMENT 1. Increase fluid intake and increase fiber to prevent constipation. vitamin C and orange. Yoga 4. (+) Romberg’s test) 5. Maintain side rails to prevent injury related to falls. To acidify urine and prevent bacterial multiplication. Baclofen (Dioresal)/ Dantrolene Sodium (Dantrene) – muscle relaxants.
eating). Brain Mass PARTS OF THE BRAIN 1. pinocytosis (cell drinking). Temporal hearing short term memory for appreciation discrimination of sensory impulses to pain. heat. Functions of Cerebrum integrative sensory motor Lobes of Cerebrum 1. ORGAN Brain Blood Kidney Skin Lung MACROPHAGE Microglia Monocytes Kupffers cells Histiocytes Alveolar Macrophage EPINDYMAL CELLS Secretes a glue called chemo attractants that concentrate the bacteria. Parietal 4. 8 inches) urinate after intercourse Nursing Management Male MICROGLIA stationary cells that carry on phagocytosis (engulfing of bacteria or cellular debris. numbness. 2. 1-1 ½ inches) poor perineal hygiene vaginal environment is moist avoid bubble bath (can alter Ph of vagina). touch. avoid use of tissue papers avoid using talcum powder and perfume.COMMON CAUSE OF UTI Female short urethra (3-5 cm. 3. pressure. Occipital . Urethra (20 cm. Frontal higher cortical thinking controls personality controls motor activity Broca’s Area (motor speech area) when damaged results to garbled speech. cold. CEREBRUM largest part composed of the Right Cerebral Hemisphere and Left Cerebral Hemisphere enclosed in the Corpus Callosum. 80% brain mass 10% blood 10% CSF COMPOSITION OF BRAIN I.
vomiting. Cerebellum smallest part of the brain. INTERBRAIN/ DIENCEPHALON Parts of Diencephalon A. controls temperature (thermoregulatory center). swallowing. hearing acuity is 30 – 40 dB. DECREASE Myasthenia Gravis Parkinson’s Disease INCREASE Bi-polar Disorder Schizophrenia NEURO TRANSMITTER Acethylcholine Dopamine 3. BRAIN STEM located at lowest part of brain Parts of Brain Stem 1. . Hypothalamus 5. early sign for males are testicular and penile enlargement late sign is deepening of voice. equal size of pupil is isocoria. MIDBRAIN/ MESENCEPHALON acts as relay station for sight and hearing. Thalamus acts as relay station for sensation. Pons pneumotaxic center controls the rate. BASAL GAGLIA areas of grey matter located deep within each cerebral hemisphere. for vision visceral function activities of internal organ like gastric motility. unequal size of pupil is anisocoria. controls respiration. controls libido controls long term memory Insula (Island of Reil) Limbic System (Rhinencephalon) 2. controls smell and if damaged results to Anosmia (absence of smell). controls blood pressure controls thirst appetite/satiety sleep and wakefulness controls some emotional responses like fear. release dopamine (controls gross voluntary movement. size of pupil is 2 – 3 mm. lesser brain. B. anxiety and excitement. 2. hiccup. vasomotor center (dilation and constriction of bronchioles). positive PERRLA 4. rhythm and depth of respiration. early sign for females telarche and late sign is menarche. controls pituitary functions androgenic hormones promotes secondary sex characteristics. Medulla Oblongata 3. heart rate.
projective vomiting headache papilledema (edema of optic disc) abnormal posturing decorticate posturing (damage to cortex and spinal cord). posture and gait. Early closure of posterior fontanels causes posterior enlargement of skull in hydrocephalus. Foramen Magnum Medulla Oblongata Brain Herniation Increase intra cranial pressure * Alternate hot and cold compress to prevent HEMATOMA CSF cushions brain (shock absorber) Obstruction of flow of CSF will lead to enlargement of skull posteriorly called hydrocephalus. heart rate decrease respiratory rate decrease temperature increase directly proportional to blood pressure. equilibrium. Causes: head trauma/injury localized abscess cerebral edema hemorrhage decrease LOC restlessness/agitation irritability inflammatory condition (stroke) hydrocephalus tumor (rarely) Signs and Symptoms (Early) lethargy/stupor coma Signs and Symptoms (Late) changes in vital signs blood pressure (systolic blood pressure increases but diastolic remains the same). controls balance. NEUROLOGIC DISORDERS INCREASE INTRACRANIAL PRESSURE – increase in intra-cranial bulk brought about by an increase in one of the 3 major intra cranial components. widening of pulse pressure is neurologic in nature (if narrow cardiac in nature). INTRA CRANIAL PRESSURE Monroe Kellie Hypothesis Skull is a closed container Any alteration or increase in one of the intracranial components Increase intra-cranial pressure (normal ICP is 0 – 15 mmHg) Cervical 1 – also known as ATLAS. Cervical 2 – also known as AXIS. .
Prevention of hypoxia and hypercarbia Early signs of hypoxia restlessness agitation tachycardia Bradycardia Extreme restlessness Dyspnea Cyanosis Increase CO2 (most powerful respiratory stimulant) retention. Prevent complications of 6. 7. c. 3. monitor strictly input and output every 1 hour notify physician if output is less 30 cc/hr. Nursing Management . Before and after suctioning hyper oxygenate client 100% and done 10 – 15 seconds only. b. d. c. Loop diuretic (Lasix. avoid clustering of nursing activity together. In chronic respiratory distress syndrome decrease O2 stimulates respiration. 4. instruct client to avoid forms of valsalva maneuver like: straining stool excessive vomiting (use anti emetics) excessive coughing (use anti tussive like dextromethorphan) avoid stooping/bending avoid lifting heavy objects e. Limit fluid intake to 1200 – 1500 ml/day (in force fluids 2000 – 3000 ml/day). Furosemide) Drug of choice for CHF (pulmonary edema) Loop of Henle in kidneys. Prevent further increase ICP by: a. Assist in mechanical ventilation 2. Osmotic diuretic (Mannitol) for cerebral diuresis Nursing Management monitor vital signs especially BP (hypotension). maintain side rails. Administer medications like: a. b. Elevate bed of client 30 – 35o angle with neck in neutral position unless contraindicated to promote venous drainage. decerebrate posturing (damage to upper brain stem that includes pons. Monitor strictly input and output and neuro check 5. Late signs of hypoxia HYPERCARBIA b. cerebellum and midbrain). avoid use of restraints. provide an comfortable and quite environment. unilateral dilation of pupils called uncal herniation bilateral dilation of pupils called tentorial herniation resulting to mild headache possible seizure activity Nursing Management 1. Maintain patent and adequate ventilation by: a. administered via side drip regulated fast drip to prevent crystal formation.
Dexamethasone (Decadron) Hydrocortisone Prednisone (to reduce edema that may lead to increase ICP) Mild Analgesics (Codeine Sulfate for respiratory depression) Anti Convulsants (Dilantin. administered IV push or oral. given early morning immediate effect of 10 – 15 minutes. monitor strictly input and output every 1 hour notify physician if output is less 30 cc/hr. Phenytoin) c. maximum effect of 6 hours. Corticosteroids *CONGESTIVE HEART FAILURE Signs and Symptoms dyspnea orthopnea paroxysmal nocturnal dyspnea productive cough frothy salivation cyanosis rales/crackles bronchial wheezing pulsus alternans anorexia and general body malaise PMI (point of maximum impulse/apical pulse rate) is displaced laterally S3 (ventricular gallop) Predisposing Factors/Mitral Valve RHD Aging TREATMENT Morphine Sulfate Aminophelline Digoxin Diuretics Oxygen Gases. blood monitor RIGHT CONGESTIVE HEART FAILURE (Venous congestion) Signs and Symptoms jugular vein distention (neck) ascites pitting edema weight gain hepatosplenomegaly jaundice pruritus esophageal varices anorexia and general body malaise . Monitor vital signs especially BP (hypotension).
Hypokalemia decrease potassium level normal value is 3. Hyponatremia DECREASE decrease sodium level normal value is 135 – 145 meq/L Signs and Symptoms hypotension dehydration signs (Initial sign in adult is THIRST.4 – 5.Signs and Symptoms of Lasix in terms of electrolyte imbalances 1. Oral Potassium Chloride) increase intake of foods rich in potassium FRUITS Apple Banana Cantalop e Oranges 2. in infant TACHYCARDIA) agitation dry mucous membrane poor skin turgor weakness and fatigue .5 meq/L weakness and fatigue constipation positive U wave on ECG tracing Sign and Symptoms Nursing Management administer potassium supplements as ordered (Kalium Durule.5 – 11 mg/100 ml Signs and Symptoms tingling sensation paresthesia numbness (+) Trousseau’s sign/ Carpopedal spasm (+) Chvostek’s sign Complications Arrhythmia Seizures Nursing Management Calcium Gluconate per IV slowly as ordered * Calcium Gluconate toxicity – results to SEIZURE Magnesium Sulfate Magnesium Sulfate toxicity S/S BP Urine output Respiratory rate Patellar relfex absent 3. Hypocalcemia/ Tetany VEGETABLES Asparagus Brocolli Carrots Spinach decrease calcium level normal value is 8.
joint pain (great toes) swelling force fluids administer medications as ordered Drug of choice for gout. Allopurinol (Zyloprim) Side Effects Respiratory depression (check for RR) . Signs and Symptoms Nursing Management a. Mechanism of action: inhibits synthesis of uric acid. Allopurinol (Zyloprim) b. Colchecine * KIDNEY STONES Signs and Symptoms renal colic Cool moist skin force fluids administer medications as ordered Morphine Sulfate ANTIDOTE: Naloxone (Narcan) toxicity leads to tremors. Hyperglycemia normal FBS is 80 – 100 mg/dl polyuria polydypsia polyphagia monitor FBS Signs and Symptoms Nursing Management 5. Narcotic Analgesic b. Nursing Management a. Acute gout Mechanism of action: promotes excretion of uric acid. organ meats and anchovies) *Increase in tophi deposit leads to Gouty arthritis.Nursing Management force fluids administer isotonic fluid solution as ordered 4. Hyperuricemia increase uric acid (purine metabolism) foods high in uric acid (sardines.
Administer medications as ordered Anti Parkinsonian agents Levodopa (L-dopa) short acting Amantadine Hydrochloride (Symmetrel) Carbidopa (Sinemet) . Haloperidol(Haldol) d. Increase dosage of the following drugs: a. increase sweating b. increase lacrimation c. Monotone type speech mood lability (in state of depression) increase salivation (drooling type) autonomic changes a. constipation e. difficulty rising from sitting position. bradykinesia (slowness of movement) rigidity (cogwheel type) stooped posture shuffling and propulsive gait over fatigue mask like facial expression with decrease blinking of the eyes. Predisposing Factors 1. decrease sexual capacity Nursing Management 1. Arteriosclerosis 3. Poisoning (lead and carbon monoxide) 2.PARKINSON’S DISEASE/ PARKINSONISM Chronic progressive disorder of CNS characterized by degeneration of dopamine producing cells in the SUBSTANCIA NIGRA of the midbrain and basal ganglia. Reserpine(Serpasil) b. seborrhea d. Methyldopa(Aldomet) c. Hypoxia 4. Encephalitis 5. Phenothiazine AntipsychoticS AntihypertensiveS SIDE EFFECTS RESERPINE Major depression leading to suicide Aloneness Multiple loss causes suicide Loss of spouse direct approach towards the client close surveillance is a nursing priority Loss of Job time to commit suicide is on weekends early morning Signs and Symptoms for Parkinson’s pill rolling tremors of extremities especially the hands.
5 – 1. Assist/supervise in ambulation 7. Prevent complications of immobility 4. 6.Mechanism of Action increase level of dopamine GIT irritation (should be taken with meals orthostatic hypotension arrhythmia hallucinations clients with narrow angle closure glaucoma clients taking MAOI’s (no foods with triptophan and thiamine) urine and stool may be darkened no Vitamin B6 (Pyridoxine) reverses the therapeutic effects of Levodopa Side Effects Contraindications * Increase Vitamin B when taking INH (Isoniazid). Dopamine Agonist . Encourage increase fluid intake and fiber. Maintain side rails to prevent injury 3.6 – 1.to relieve tremors Mechanism of Action inhibits action of acethylcholine SNS Side Effects Anti Histamine (Dipenhydramine Hydrochloride) Side Effects Adult: drowsiness Children: CNS excitement (hyperactivity) because blood brain barrier is not yet fully developed. Decrease protein in morning and increase protein in afternoon to induce sleep 5. Assist in Stereotaxic Thalamotomy MAGIC 2’s IN DRUG MONITORING DRUG Digoxin/ Lanoxin (Increase force of cardiac output) Lithium/ Lithane (Decrease level of Ach/NE/Serotonin) Aminophylline (Dilates bronchial tree) Dilantin/ Phenytoin Acetaminophen/Tylenol NORMAL RANGE .relieves tremor rigidity Bromocriptene Hydrochloride (Parlodel) Side Effects Respiratory depression 2.5 meq/L . Isonicotinic Acid Hydrazide Anti Cholinergic Agents (ARTANE and COGENTIN) .2 meq/L 10 – 19 mg/100 ml 10 – 19 mg/100 ml 10 – 30 mg/100 ml TOXICITY LEVEL 2 2 20 20 200 INDICATION CHF Bipolar COPD Seizures Osteo Arthritis CLASSIFICATION Cardiac Glycoside Anti-Manic Agents Bronchodilators Anti-Convulsant Non-narcotic Analgesic .
1. Acetaminophen Toxicity Signs and Symptoms hepatotoxicity (monitor for liver enzymes) SGPT/ALT (Serum Glutamic Pyruvate Transaminace) SGOT/AST (Serum Glutamic Oxalo-Acetil Transaminace) nephrotoxicity monitor BUN (10 – 20) and Creatinine (.8 – 1) hypoglycemia Tremors. Aminophylline Toxicity Signs and Symptoms tachycardia palpitations CNS excitement (tremors. administered sandwich method avoid taking alcohol because it can lead to severe CNS depression avoid caffeine Nursing Management 4. agitation and restlessness) only mixed with plain NSS or 0. . tachycardia Irritability Restlessness Extreme fatigue Diaphoresis.9 NaCl to prevent development of crystals or precipitate. Lithium Toxicity Signs and Symptoms anorexia nausea and vomiting diarrhea dehydration causing fine tremors hypothyroidism force fluids increase sodium intake to 4 – 10 g% daily Nursing Management 3. depression Antidote: Acetylcisteine (mucomyst) prepare suction apparatus as bedside. irritability. Digitalis Toxicity Signs and Symptoms nausea and vomiting diarrhea confusion photophobia changes in color perception (yellowish spots) Antidote: Digibind 2. Dilantin Toxicity Signs and Symptoms gingival hyperplasia (swollen gums) hairy tongue ataxia nystagmus provide oral care massage gums Nursing Management 5.
infection Signs and Symptoms .over medication Signs and Symptoms .G. Nursing Management 1. diplipia mask like facial expression dysphagia hoarseness of voice respiratory muscle weakness that may lead to respiratory arrest extreme muscle weakness especially during exertion and morning Tensilon test (Edrophonium Hydrochloride) provides temporary relief of signs and symptoms for about 5 – 10 minutes and a maximum of 15 minutes.The client is unable to see.Administer anti cholinergic agents (Atropine Sulfate) Side Effects MYASTHENIC CRISIS Causes: . 8. institute NGT feeding 6. mmobility * assist in mechanical ventilation and monitor pulmonary function test * monitor strictly vital signs. speak. Assist in plasma paresis and removing auto immune anti bodies 9.G. breathe Treatment . administer medications as ordered a. Prevent complications . Incidence rate: women 20 – 40 years old Predisposing factors unknown autoimmune: it involves release of cholinesterase an enzyme that destroys Ach.administer cholinergic agents as ordered 7.under medication . Anti Cholenisterase (Neostegmin) Mechanism of Action maintain patent airway and adequate ventilation increase level of Ach PNS Cortocosteroids suppress immune response monitor for 2 types of crisis: CHOLINERGIC CRISIS Cause: . input and output and neuro check * monitor strength or motor grading scale 4. Assist in surgical procedure known as thymectomy because it is believed that the thymus gland is responsible for M. airway 2. aspiration 3. maintain side rails to prevent injury related to falls 5. swallow.stress . Cholinergic (Mestinon) b. if there is no effect there is damage to occipital lobe and midbrain and is negative for Signs and Symptoms Diagnostic Procedure M.PNS Treatment . initial sign is ptosis a clinical parameter to determine ptosis is palpebral fissure.MYASTHENIA GRAVIS neuromuscular disorder characterized by a disturbance in the transmission of impulses from nerve to muscle cells at the neuromuscular junction leading to descending muscle weakness.
general body malaise and weight loss Possible increase in ICP and seizure activity Abnormal posturing (decorticate and decerebrate) Signs of meningeal irritation a. Increase CHON and WBC 2. Signs and Symptoms headache photophobia projectile vomiting fever. Diagnostic Procedures Lumbar puncture: a hollow spinal needle is inserted in the subarachnoid space between the L3 – L4 to L5. Pia matter – inner layer subdural space between the dura and arachnoid subarachnoid space between the arachnoid and pia. Etiology 1. Mode of transmission airborne transmission (droplet nuclei) C. A. Dura matter – outer layer 2. Opisthotonus (arching of back) c. for support and protection for nourishment blood supply LAYERS OF THE MENINGES 1.causes adult meningitis 4. drainage and leakage to tissues. Nursing Management for LP Before Lumbar Puncture 1. Check punctured site for any discoloration.INFLAMMATORY CONDITIONS OF THE BRAIN MENINGITIS Meninges 3 fold membrane that covers brain and spinal cord. Increase CSF opening pressure (normal pressure is 50 – 100 mmHg) 4. Assess for movement and sensation of extremities. chills. Pneumococcus 3. 3. Increase wbc . Secure informed consent and explain procedure. Encourage to arch back to clearly visualize L3-L4. CSF analysis reveals 1. Empty bladder and bowel to promote comfort. Place flat on bed 12 – 24 o 2. CSF aspiration is done. Post Lumbar Puncture 1. 2. Arachnoid – middle layer 3. Meningococcus – most dangerous 2. anorexia. (+) Kernig’s sign (leg pain) d. (+) Brudzinski sign (neck pain) D. 4. Nuchal rigidity or stiff neck b. (+) cultured microorganism (confirms meningitis) CBC reveals 1. Decrease glucose 3. Hemophilus Influenzae – causes pediatric meningitis B. Streptococcus . Force fluids 3.
Signs and Symptoms of Pulmonary Embolism Sudden sharp chest pain Unexplained dyspnea Tachycardia Palpitations Diaphoresis Mild restlessness Headache and dizziness Confusion Restlessness Decrease LOC Signs and Symptoms of Cerebral Embolism Fat embolism is the most feared complications after femur fracture. Elevate head 30-45o 5. Prevent complications most feared is hydrocephalus hearing loss/nerve deafness is second complication consult audiologist mental retardation delayed psychomotor development c. Tetracycline) b. Mid Cerebral Artery b. Yellow bone marrow are produced from the medullary cavity of the long bones and produces fat cells. calories with small frequent feedings. Institute measures to prevent increase ICP and seizure. 9. If there is bone fracture there is hemorrhage and there would be escape of the fat cells in the circulation. 7. Provide a comfortable and darkened environment. Rehabilitation for neurological deficit CVA (STROKE/BRAIN ATTACK/ ADOPLEXY/ CEREBRAL THROMBOSIS) a partial or complete disruption in the brains blood supply. Incidence Rate men are 2-3 times high risk B. Administer medications as ordered a. input and output and neuro check 6. Nursing Management 1. Compartment syndrome (compression of arteries and nerves) . Institute strict respiratory isolation 24 hours after initiation of anti biotic therapy 4. Maintain good diet of increase CHO. Enforce complete bed rest 2. Internal Cerebral Artery – the 2 largest artery A.E. Maintain fluid and electrolyte balance. b. CHON. 8. Monitor strictly V/S. Provide client health care and discharge planning concerning: a. 2 most common cerebral artery affected by stroke a. Broad spectrum antibiotics (Penicillin. Mild analgesics c. Anti pyretics 3. Predisposing Factors thrombus (attached) embolus (detached and most dangerous because it can go to the lungs and cause pulmonary embolism or the brain and cause cerebral embolism.
homonymous hemianopsia (loss of half of visual field) 1. Post dependent on stages of development Initial sign of stroke or warning sign headache and dizziness tinnitus visual and speech disturbances paresis (plegia) possible increase ICP progression of signs and symptoms of stroke resolution phase characterized by: headache and dizziness Cheyne Stokes Respiration anorexia. alexia (difficulty reading) e. Risk Factors 1.C. Hyperlipidemia more on genetics/genes that binds to cholesterol 5. can do multiple tasks c. nausea and vomiting dysphagia (+) Kernig’s sign and Brudzinski sign which may lead to hemorrhagic stroke focal neurological deficits a. Obesity (increase 20% ideal body weight) 4. Valvular Cardiac Surgery (mitral valve replacement) 2. Type A personality a. CT Scan – reveals brain lesions 2. usually fells guilty when not doing anything 6. phlegia b. Prolong use of oral contraceptives promotes lypolysis (breakdown of lipids) leading to atherosclerosis that will lead to hypertension and eventually CVA. Diabetes Mellitus. D. aphasia c. Myocardial Infarction. Stroke in evolution 3. Signs and Symptoms Heart Disease. deadline driven b. Related stress physical and emotional 8. Hypertension. agraphia (difficulty writing) f. Cerebral Arteriography reveals the site and extent of malocclusion uses dye for visualization most of dye are iodine based check for shellfish allergy after diagnostic exam force fluids to release dye because it is nephro toxic check for distal pulse (femoral) check for hematoma formation . Diagnostic Procedure 1. Lifestyle (smoking). Related to diet: increase intake of saturated fats like whole milk 7. Atherosclerosis. TIA Signs and Symptoms 2. Complete stroke Signs and Symptoms E. sedentary lifestyle 3. dysarthria (inability to articulate words) d.
give Protamine Sulfate Comadin/ Warfarin (long acting) give simultaneously because Coumadin will take effect after 3 days check for prothrombin time if prolonged there is a risk for bleeding give Vit. Administer medications as ordered a. exercise. turn client to side b. Osmotic Diuretics (Mannitol) b. Anti Coagulants Heparin (short acting) check for partial thromboplastin time if prolonged there is a risk for bleeding. importance of follow up care . ulcer and unknown cause of headache because it may potentiate bleeding 11. Prevent complications of immobility by: a. non verbal cues b. provide egg crate mattresses or water bed c. Institute NGT feeding 8. Elevate head 30 – 45o 4. dietary modification (decrease salt. prevent complication (subarachnoid hemorrhage is the most feared complication) c. Maintain patent airway and adequate ventilation by: a. administrate O2 inhalation 2. assist in mechanical ventilation b. magic slate 9. saturated fats and caffeine) d. Monitor strictly vitals signs. Provide client health teachings and discharge planning concerning a. 6. Anti Platelet PASA (Aspirin) Contraindicated for dengue.F. smoking) b. Assist in passive ROM exercise every 4 hours to promote proper bodily alignment and prevent contractures 7. Nursing Management 1. Restrict fluids to prevent cerebral edema that might increase ICP 3. Provide alternative means of communication a. I & O and neuro check 5. provide sand bag or food board. K (Aqua Mephyton) g. If positive to hemianopsia approach client on unaffected side 10. Thrombolytic/Fibrinolytic Agents – dissolves thrombus Streptokinase Side Effect: Allergic Reaction Urokinase Tissue Plasminogen Activating Factor Side Effect: Chest Pain f. Cortecosteroids d. Mild Analgesics e. Loop Diuretics (Lasix. avoidance of modifiable risk factors (diet. Furosemide) c.
Institute NGT feeding to prevent aspiration 6. Assist in plasma pharesis (filtering of blood to remove autoimmune anti-bodies) 9. increase salivation b. Maintain side rails to prevent injury related to fall 4. Prevent complications of immobility by turning the client every 2 hours 5. Zylocaine Bretylium – blocks release of norepinephrine to prevent increase of BP 8. Arrythmia b. Assist in passive ROM exercise 7. Dysphagia 3. Autonomic symptoms that includes a. Signs and Symptoms 1. Predisposing Factors 1. monitor pulmonary function test 2. increase sweating c. Corticosteroids – suppress immune response b. Paralysis or respiratory muscles/Respiratory arrest * Sengstaken Blakemore Tube for liver cirrhosis to decompress bleeding esophageal verices (prepare scissor to cut tube incase of difficulty in breathing to release air in the balloon for hemodialysis prepare bulldog clips to prevent air embolism. Alternate hypotension to hypertension ** ARRYTHMIA (most feared complication) 6. vital signs b. Decreased of diminished deep tendon reflex 5. neuro check d. Diagnostic Procedures 1. Anti Cholinergic Agents – Atrophine Sulfate c. . intake and output c. ECG 3. Anti Arrythmic Agents Lidocaine. constipation C. Clumsiness (initial sign) 2. Maintain patent airway and adequate ventilation by: a. Nursing Management 1. Prevent complications a. A. Ascending muscle weakness leading to paralysis 4. Antecedent viral infections such as LRT infections B. CSF analysis reveals increase in IgG and protein D. Autoimmune 2.GUILLAIN BARRE SYNDROME a disorder of the CNS characterized by bilateral symmetrical polyneuritis leading to ascending muscle paralysis. Monitor strictly the following a. assist in mechanical ventilation b. Administer medications as ordered a.
Signs or aura with auditory. blank stare b. automatism – stereotype repetitive and non propulsive behavior b. Sudden withdrawal to anti convulsant drug is predisposing factor for status epilepticus (drug of choice is Diazepam. Status Epilepticus A continuous uninterrupted seizure activity. Grand mal Seizure (tonic-clonic seizure) a.contraction of extremities d. Post ictal sleep – unresponsive sleep 2. sensory experience b. Jacksonian Seizure (focal seizure) Characterized by tingling and jerky movement of index finger and thumb that spreads to the shoulder and other side of the body. Psychomotor Seizure (focal motor seizure) a. visual. Partial or Localized Seizure 1. Drug of choice: Diazepam. Seizure – first convulsive attack Epilepsy – second or series of attacks Febrile seizure – normal in children age below 5 years A. Toxicity from a. CT Scan – reveals brain lesions 2. mild hallucinatory sensory experience III. decrease blinking of eyes c. Valium) B. Head injury due to birth trauma 2. Physical and emotional stress 7.direct symmetrical extension of extremities Clonic contractions . Presence of brain tumor 4. 2. loss of consciousness (5 – 10 seconds) II. Nutritional and Metabolic deficiencies 6. Genetics 3. tactile. Valium and Glucose C. Epileptic cry – is characterized by fall and loss of consciousness for 3 – 5 minutes c. lead b carbon monoxide 5. Signs and Symptoms Dependent on stages of development or types of seizure I. Diagnostic Procedures 1. twitching of mouth d. clouding of consciousness – not in contact with environment c. Tonic contractions . EEG – reveals hyper activity of electrical brain waves . Generalized Seizure 1. Petit mal Seizure – absence of seizure common among pediatric clients characterized by a. if left untreated can lead to hyperpyrexia and lead to coma and eventually death. Predisposing Factors 1.CONVULSIVE DISORDER/ CONVULSION disorder of CNS characterized by paroxysmal seizure with or without loss of consciousness abnormal motor activity alternation in sensation and perception and changes in behavior. olfactory.
D. Nursing Management 1. Maintain patent airway and promote safety before seizure activity a. clear the site of blunt or sharp objects b. loosen clothing of client c. maintain side rails d. avoid use of restrains e. turn clients head to side to prevent aspiration f. place mouth piece of tongue guard to prevent biting or tongue 2. Avoid precipitating stimulus such as bright/glaring lights and noise 3. Administer medications as ordered a. Anti convulsants (Dilantin, Phenytoin) b. Diazepam, Valium c. Carbamazepine (Tegretol) – Trigeminal neuralgia d. Phenobarbital, Luminal 4. Institute seizure and safety precaution post seizure attack a. administer O2 inhalation b. provide suction apparatus 5. Document and monitor the following a. onset and duration b. types of seizures c. duration of post ictal sleep may lead to status epilepticus d. assist in surgical procedure cortical resection COMPREHENSIVE NEURO EXAM GLASGOW COMA SCALE
objective measurement of LOC sometimes called as the quick neuro check
Components 1. Motor response 2. Verbal response 3. Eye opening Conscious Lethargy Stupor Coma Deep Coma 15 – 14 13 – 11 10 – 8 7 3
Survey of mental status and speech a. LOC b. Test of memory Levels of orientation Cranial nerve assessment Sensory nerve assessment Motor nerve assessment Deep tendon reflex Autonimics Cerebellar test a, Romberg’s test – 2 nurses, positive for ataxia b. Finger to nose test – positive result mean dimetria (inability of body to stop movement at desired point) c. Alternate supination and pronation – positive result mean dimetria
I. LEVEL OF CONSCIOUSNESS 1. Conscious - awake 2. Lethargy – lethargic (drowsy, sleepy, obtunded) 3. Stupor
stuporous (awakened by vigorous stimulation) generalized body weakness decrease body reflex comatose light coma (positive to all forms of painful stimulus) deep coma (negative to all forms of painful stimulus)
DIFFERENT PAINFUL STIMULATION 1. Deep sternal stimulation/ deep sternal pressure 2. Orbital pressure 3. Pressure on great toes 4. Corneal or blinking reflex Conscious client use a wisp of cotton Unconscious client place 1 drop of saline solution II. TEST OF MEMORY 1. Short term memory
ask most recent activity positive result mean anterograde amnesia and damage to temporal lobe ask for birthday and validate on profile sheet positive result mean retrograde amnesia and damage to limbic system consider educational background
2. Long term memory
III. LEVELS OF ORIENTATION 1. Time – first asked 2. Person – second asked 3. Place – third asked CRANIAL NERVES CRANIAL NERVES I. OLFACTORY II. OPTIC III OCCULOMOTOR IV. TROCHLEAR V. TRIGEMINAL VI. ABDUCENSE VII. FACIAL VIII. ACOUSTIC IX. GLOSSOPHARYNGEAL X. VAGUS FUNCTION S S M M (Smallest) B (Largest) M B S B B
(Longest) XI. SPINAL ACCESSORY M XII. HYPOGLOSSAL M CRANIAL NERVE I: OLFACTORY
sensory function for smell
don’t use alcohol, ammonia, perfume because it is irritating and highly diffusible. use coffee granules, vinegar, bar of soap, cigarette test each nostril by occluding each nostril
Abnormal Findings 1. Hyposnia – decrease sensitivity to smell 2. Dysosmia – distorted sense of smell 3. Anosmia – absence of smell Indicative of 1. head injury damaging the cribriform plate of ethmoid bone where olfactory cells are located 2. may indicate inflammatory conditions (sinusitis) CRANIAL NERVE II: OPTIC
sensory function for vision or sight
Functions 1. Test visual acuity or central vision or distance
use Snellen’s Chart Snellen’s Alphabet chart: for literate clients Snellen’s E chart: for illiterate clients Snellen’s Animal chart: for pediatric clients normal visual acuity 20/20 numerator is constant, it is the distance of person from the chart (6 – 7 m, 20 feet) denominator changes, indicates distance by which the person normally can see letter in the chart. - 20/200 indicates blindness 20/20 visual acuity if client is able to read letters above the red line. a. Superiorly b. Bitemporaly c. Nasally d. Inferiorly
2. Test of visual field or peripheral vision
COMMON VISUAL DISORDERS 1. Glaucoma
increase IOP normal IOP is 12 – 21 mmHg preventable but not curable Common among 40 years old and above Hereditary Hypertension Obesity
A. Predisposing Factors
B. Signs and Symptoms 1. Loss of peripheral vision
pathognomonic sign is tunnel vision steamy cornea may lead to blindness
2. Headache, nausea, vomiting, eye pain (halos around light)
C. Diagnostic Procedures 1. Tonometry 2. Perimetry
Surgical Procedure Extra Capsular Cataract Lens Extraction . Cataract Decrease opacity of lens A. Acetazolamide (Diamox) – promotes increase outflow of aqueous humor or drainage 4.Total removal of cataract with its surrounding capsules Most feared complication post op is RETINAL DETACHMENT 3. Gonioscopy D.3. Epinephrine eyedrops – decrease formation of aqueous humor 3. Signs and Symptoms 1. Predisposing Factor 1. Pilocarpine Sodium. Timoptics (Timolol Maleate) E. Treatment 1. Aging 65 years and above 2. Blurring or hazy vision 2. Pathognomonic Signs 1. Carbachol 2. Loss of central vision C. Surgical Procedures 1. Prolonged exposure to UV rays B. Diagnostic Procedure 1. Miotics – constricts pupil a. Retinal Detachment Separation of epithelial surface of retina . Opthalmoscopic exam E. Milky white appearance at center of pupils 3.Partial removal Intra Capsular Cataract Lens Extraction . Diabetes Mellitus 4. Decrease perception to colors Complication is blindness D. Mydriatics (Mydriacyl) – constricts pupils 2. Cyclopegics (Cyclogyl) – paralyses cilliary muscle F. Carbonic Anhydrase Inhibitors a. Treatment 1. Related to congenital 3. TRABECULECTOMY (Peripheral Indectomy) – drain aqueous humor 2.
ABDUCENS Controls or innervates the movement of extrinsic ocular muscle (EOM) 6 muscles Superior Rectus Superior Oblique Lateral Rectus Medial Rectus Inferior Oblique Inferior Rectus trochlear controls superior oblique abducens controls lateral rectus oculomotor controls the 4 remaining EOM Oculomotor controls the size and response of pupil normal pupil size is 2 – 3 mm equal size of pupil: Isocoria Unequal size of pupil: Anisocoria Normal response: positive PERRLA CRANIAL NERVE V: TRIGEMINAL largest cranial nerve consists of ophthalmic. Predisposing Factors 1.A. Post Lens Extraction 2. VI: OCULOMOTOR. Floaters C. Diathermy – heat application 4. Surgical Procedures 1. Scleral Buckling 2. Signs and Symptoms 1. Curtain veil like vision 2. mandibular . IV. maxillary. Myopia (near sightedness) B. Signs and Symptoms 1. Macular Degeneration Degeneration of the macula lutea (yellowish spot at the center of retina) A. TROCHLEAR. Black Spots CRANIAL NERVE III. Cryosurgery – cold application 3.
VAGUS NERVE Glosopharyngeal: controls taste. soft palate and corneal reflex) motor: controls the muscle of mastication or chewing damage to CN V leads to trigeminal neuralgia/thickdolorum medication: Carbamezapine(Tegretol) CRANIAL NERVE VII: FACIAL Sensory: controls taste. Middle Ear 3. teeth. sensory: controls sensation of face. Inner Ear Vestibule: Meinere’s Disease Cochlea Mastoid Cells Endolymph and Perilymph COCHLEA: controls hearing. Outer Ear Pinna Eardrum Hammer Anvil Stirrup Malleus Incus Stapes 2. X: GLOSOPHARYNGEAL. Parts of the Ear 1. posterior 1/3 of tongue Vagus: controls gag reflex Uvula should be midline and if not indicative of damage to cerebral hemisphere Effects of vagal stimulation is PNS CRANIAL NERVE XI: SPINAL ACCESSORY Innervates with sternocleidomastoid (neck) and trapezius (shoulder) CRANIAL NERVE XII: HYPOGLOSSAL Controls the movement of tongue Let client protrude tongue and it should be midline and if unable to do indicative of damage to cerebral hemisphere and/or has short frenulum. anterior 2/3 of tongue pinch of sugar and cotton applicator placed on tip of tongue Motor: controls muscle of facial expression instruct client to smile. frown and if results are negative there is facial paralysis or Bell’s Palsy and the primary cause is forcep delivery. ENDOCRINE SYSTEM Overview of the structures and functions 1. mucous membrane. Pituitary Gland (Hypophysis Cerebri) . contains the Organ of Corti (the true organ of hearing) Let client repeat words uttered CRANIAL NERVE IX. CRANIAL NERVE VIII: ACOUSTIC/VESTIBULOCOCHLEAR Controls balance particularly kinesthesia or position sense. refers to movement and orientation of the body in space.
Weakness and fatigue 4. Hypotension 5. Administer medications as ordered a. Polyuria 2. If left untreated results to hypovolemic shock (sign is anuria) C. Poor Skin turgor d. Predisposing Factor o o o o 1. Nursing Management . Prevent complilcations – HYPOVOLEMIC SHOCK is the most feared complication Normal value: 1. initiates milk let down reflex with help of hormone prolactin called as adenohypophysis called as neurohypophysis secretes hormones oxytocin -promotes uterine contractions preventing bleeding/ 2.015 – 1.030 Ph 4 – 8 Increase resulting to hypernatremia Related to pituitary surgery Trauma Inflammation Presence of tumor B. Diagnostic Procedures 1.o o o Located at base of brain particularly at sella turcica Master gland or master clock Controls all metabolic function of body PARTS OF THE PITUITARY GLAND 1. Posterior Pituitary Gland 2. Serum Sodium D. Signs of dehydration a. Dry mucous membrane 3. Force fluids 2. Signs and Symptoms 2. Antidiuretic Hormone o o o Pitressin (Vasopressin) Function: prevents urination thereby conserving water Diabetes Insipidus/ Syndrome of Inappropriate Anti Diuretic Hormone DIABETES INSIPIDUS o Decrease production of anti diuretic hormone A. Anterior Pituitary Gland o o o hemorrhage o o administrate oxytocin immediately after delivery to prevent uterine atony. Monitor strictly vital signs and intake and output 3. Urine Specific Gravity o o o 1. Adult: thirst b. Weight loss 6. Agitation c. Pitressin (Vasopresin Tannate) – administered IM Z-tract 4.
Hypertension b. Monitor strictly vital signs. Lead to blindness due to severe photophobia b. Related to hyperplasia (increase size of organ brought about by increase of number of cells) of pituitary 2. Osmotic diuretics (Mannitol) 3. Nursing Management 1. Weight gain 2. Head injury 2. Fluid retention a. Weigh patient daily and assess for pitting edema 5. Prevent complications ANTERIOR PITUITARY GLAND o also called ADENOHYPOPHYSIS secretes Promotes elongation of long bones Hyposecretion of GH among children results to Dwarfism Hypersecretion of GH results to Gigantism Hypersecretion of GH among adults results to Acromegaly (square face) Drug of choice: Ocreotide (Sandostatin) 1. Adrenochorticotropic hormone (ACTH) o promotes development of adrenal cortex . Water intoxication may lead to cerebral edema and lead to increase ICP – may lead to seizure activity C. B. intake and output and neuro check 4. Provide meticulous skin care 6. Related to presence of bronchogenic cancer o o gland. Serum Sodium is decreased D. Urine specific gravity is increased 2. Administer medications as ordered a. Edema c. Loop diuretics (Lasix) b. Predisposing Factors 1. Growth hormones (somatotropic hormone) o o o o o initial sign of lung cancer is non productive cough non invasive procedure is chest x-ray 3. Restrict fluid 2. Melanocyte Stimulating hormone o o o for skin pigmentation Hyposecretion of MSH results to Albinism Most feared complications of albinism a.SIADH o hypersecretion of anti diuretic hormone A. Diagnostic Procedure 1. Prone to skin cancer o Hypersecretion of MSH results to Vitiligo 3. Signs and Symptoms 1.
cabbage. Thyroxine) o o T3 and T4 are metabolic or calorigenic hormone promotes cerebration (thinking) 3. Thyrocalcitonin – antagonizes the effects of parathormone to promote calcium resorption. Leutinizing hormone 6. HYPOTHYROIDISM o o o o o o all are decrease except weight and menstruation memory impairment there is loss of appetite but there is weight gain menorrhagia cold intolerance constipation Signs and Symptoms HYPERTHYROIDISM o o o o all are increase except weight and menstruation increase appetite but there is weight loss amenorrhea exophthalmos Signs and Symptoms THYROID DISORDERS SIMPLE GOITER o enlargement of thyroid gland due to iodine deficiency A.3 molecules of iodine (more potent) 2. radish.4. all nuts soil erosion washes away iodine . strawberry. Mountainous regions 2. places far from sea b. Follicle stimulating hormone PINEAL GLAND o o o secretes melatonin inhibits LH secretion it controls/regulates circadian rhythm (body clock) THYROID GLAND o located anterior to the neck 3 Hormones secreted 1. Predisposing Factors 1. T3 (Tri iodothyronine) . Increase intake of goitrogenic foods o o o contains pro-goitrin an anti thyroid agent that has no iodine. turnips. sweet potato. Goiter belt area a. Lactogenic homone (Prolactin) o o o o promotes development of mammary gland with help of oxytocin it initiates milk let down reflex secretes estrogen secretes progesterone 5. T4 (tetra iodothyronine. broccoli. carrots.
Signs and Symptoms 1. Related to atrophy of thyroid gland due to trauma. Serum T3 and T4 – reveals normal or below normal 2. Monitor vital signs especially heart rate because drug causes tachycardia and palpitations 3. 4 Medications to be taken via straw: Lugol’s.if goiter is caused by B. Phenylbutazones (NSAIDs) . Thyroid Scan – reveals enlarged thyroid gland. presence of tumor. clams and lobster but not shrimps because it contains lesser amount of iodine. best taken raw because it it is easily destroyed by heat 5.o goitrogenic drugs a. Predisposing Factors 1. Instruct client to take in the morning to prevent insomnia 2. Increase dietary intake of foods rich in iodine A. inflammation . Nitrofurantoin (drug of choice for pyelonephritis) b. Diagnostic Procedures 1. Lithium Carbonate c. Administer medications as ordered a. 3. Anti Thyroid Agent – Prophylthiuracil (PTU) b. Cobalt e. Iatrogenic Cause – disease caused by medical intervention such as surgery 2. Lugol’s Solution/SSKI ( Saturated Solution of Potassium Iodine) o o color purple or violet and administered via straw to prevent staining of teeth. Enlarged thyroid gland 2. Thyroid Hormones o o o Levothyroxine (Synthroid) Liothyronine (Cytomel) Thyroid Extracts Nursing Management when giving Thyroid Hormones 1. Mild restlessness C. Tetracycline. Assist in surgical procedure of subtotal thyroidectomy HYPOTHYROIDISM o o o hyposecretion of thyroid hormone adults: MYXEDEMA non pitting edema children: CRETINISM the only endocrine disorder that can lead to mental retardation 4. iodized salt. Monitor side effects o o o o o o o insomnia tachycardia and palpitations hypertension heat intolerance seaweeds seafood’s like oyster. Nursing Management 1. PASA (Aspirin) d. Mild dysphagia 3. crabs. Enforce complete bed rest 2. Iron. Serum Thyroid Stimulating Hormone (TSH) – is increased (confirmatory diagnostic test) D.
Administer medications as ordered Thyroid Hormones a. bradypnea. Administer isotonic fluid solution as ordered 4. Cold intolerance 5. Signs and Symptoms (Early Signs) 1. Provide meticulous skin care 8. Serum T3 and T4 is decreased 2. Leothyronine c. Nursing Management 1. Hoarseness of voice 4. Dry skin 4. Avoid precipitating factors leading to myxedema coma o o stress infection Assist in mechanical ventilation Administer thyroid hormones as ordered Force fluids . Serum Cholesterol is increased 3. hypothermia leading to pregressive stupor and coma. Decrease libido 5. bradycardia. Nursing Management for Myxedema Coma 2. Constipation (Late Signs) 1. Autoimmune (Hashimotos Disease) B. Provide client health teaching and discharge planning concerning a.3. Thyroid Extracts 5. Provide dietary intake that is low in calories 6. Diagnostic Procedures 1. bradypnea. Levothyroxine b. Monitor strictly vital signs and intake and output to determine presence of o o Myxedema coma is a complication of hypothyroidism and an emergency case a severe form of hypothyroidism is characterized by severe hypotension. hypothermia 6. Provide comfortable and warm environment 7. Non pitting edema (Myxedema) 3. Loss of appetite but with weight gain which promotes lipolysis leading to atherosclerosis and MI 3. hypoglycemia. Decrease in all vital signs – hypotension. hypoventilation. CNS changes o o o o lethargy memory impairment psychosis menorrhagia C. Force fluids 3. Iodine deficiency 4. RAIU (Radio Active Iodine Uptake) is decreased D. Brittleness of hair and nails 2. Weakness and fatigue 2. hyponatremia. bradycardia.
hypovolemic shock hormonal replacement therapy for lifetime importance of follow up care increase in T3 and T4 Grave’s Disease or Thyrotoxicosis developed by Robert Grave HYPERTHYROIDISM A. Goiter 8. Comfortable and cold environment 6. Autoimmune – it involves release of long acting thyroid stimulator causing exopthalmus (protrusion of eyeballs) enopthalmus (late sign of dehydration among infants) 2. Insomnia e. Nursing Management 1. Methymazole (Tapazole) Side Effects of Agranulocytosis o o o o increase lymphocytes and monocytes fever and chills sore throat (throat swab/culture) leukocytosis (CBC) 3. and sedatives prevent complications (myxedema coma. Serum T3 and T4 is increased 2. Provide dietary intake that is increased in calories.o o o o o o o o cold intolerance use of anesthetics. Increase appetite (hyperphagia) but there is weight loss 2. Amenorrhea C. Administer medications as ordered Anti Thyroid Agent a. Moist skin 3. Provide meticulous skin care 5. CNS involvement a. RAIU (Radio Active Iodine Uptake) is increased 3. Exopthalmus 9. Excessive iodine intake 3. Maintain side rails . Tremors d. Predisposing Factors 1. Irritability and agitation b. Prophythioracill (PTU) b. Related to hyperplasia (increase size) B. Signs and Symptoms 1.reveals an enlarged thyroid gland D. Hallucinations 7. Monitor strictly vital signs and intake and output 2. narcotics. 4. Restlessness c. All vital signs are increased 6. Heat intolerance 4. Diarrhea 5. Diagnostic Procedures 1. Thyroid Scan.
input and output and neuro check. Watch out for signs of thyroid storm/ thyrotoxicosis Agitation TRIAD SIGNS Hyperthermia o administer medications as ordered a. Beta-blockers o o o monitor strictly vital signs. Watch out for accidental Laryngeal damage which may lead to hoarseness of voice Nursing Management o encourage client to talk/speak immediately after operation and notify physician 4. Watch out for accidental removal of parathyroid gland that may lead to Hypocalcemia (tetany) Signs and Symptoms o o o (+) trousseau’s sign (+) chvostek sign Watch out for arrhythmia. 5. 8. 1. maintain side rails offer TSB Tachycardia 2. Signs of bleeding (feeling of fullness at incisional site) Nursing Management o Check the soiled dressings at the back or nape area.7. Assist in surgical procedures known as subtotal thyroidectomy ** Before thyroidectomy administer Lugol’s Solution (SSKI) to decrease vascularity of the thyroid gland to prevent bleeding and hemorrhage. Anti Pyretics b. Provide bilateral eye patch to prevent drying of the eyes. seizure give Calcium Gluconate IV slowly as ordered 3. Importance of follow up care PARATHYROID GLAND o o o o o A pair of small nodules behind the thyroid gland Secretes parathormone Promotes calcium reabsorption Hypoparathyroidism Hyperparathyroidism HYPOPARATHYROIDISM o o Decrease secretion of parathormone leading to hypocalcemia Resulting to hyperphospatemia . POST OPERATIVELY. Hormonal replacement therapy for lifetime 6.
5 mg/100 ml) 3.5 – 11 mg/100 ml) 2. laryngospasm/broncospasm h. anorexia. Vitamin D (Cholecalciferol) for absorption of calcium CHOLECALCIFEROL ARE DERIVED FROM Drug Diet (Calcidiol) Sunlight (Calcitriol) feared complications d. Acute Tetany Calcium Gluconate IV slowly b.5 – 4. Serum Calcium is decreased (normal value: 8. Acute tetany a. dysphagia e.C MAD . agitation and memory impairment C. Administer medications as ordered such as: a. nausea and vomiting d. trauma B. loss of tooth enamel c. photophobia and cataract formation b. Atrophy of parathyroid gland due to: a. Serum Phosphate is decreased (normal value: 2. Phosphate binder Aluminum Hydroxide Gel (Ampogel) Side effect: constipation ANTACID A.A. tumor c. seizure i. Signs and Symptoms 1. paresthesia c. Chronic Tetany Oral Calcium supplements Calcium Gluconate Calcium Lactate Calcium Carbonate c. positive chvostek sign g. inflammation b. Diagnostic Procedures 1. CT Scan – reveals degeneration of basal ganglia D. tingling sensation b. Predisposing Factors 1. numbness d. arrhythmia 2. Following subtotal thyroidectomy 2.A. Nursing Management 1. Chronic tetany a. X-ray of long bones reveals a decrease in bone density 4. positive trousseu’s sign/carpopedal spasm f.
anchovies b. Agitation and memory impairment C. Prevent complications 8. Provide warm sitz bath 4. 6. Importance of follow up care. Encourage increase intake of foods rich in calcium a. Kidney stones a. Nursing Management 1. Administer medications as ordered a. cool moist skin 3. Provide acid ash in the diet to acidify urine and prevent bacterial growth 7. Force fluids to prevent kidney stones 2.▼ Aluminum Containing Antacids ▼ Aluminum Hydroxide Gel ▼ Side Effect: Constipation ▼ Magnesium Containing Antacids ▼ Side Effect: Diarrhea 2. Prepare trache set at bedside for presence of laryngo spasm 7. Predisposing Factors 1. Over compensation of parathyroid gland due to vitamin D deficiency a. Hyperplasia of parathyroid gland 2. X-ray of long bones reveals bone demineralization D. Bone pain especially at back (bone fracture) 2. salmon c. Serum Calcium is increased 2. green turnips 4. Institute seizure and safety precaution 5. Strain all the urine using gauze pad for stone analysis 3. Children: Ricketts b. Encourage client to breathe using paper bag to produce mild respiratory acidosis result. Avoid precipitating stimulus such as glaring lights and noise 3. Signs and Symptoms 1. HYPERTHYROIDISM o o o Decrease parathormone Hypercalcemia: bone demineralization leading to bone fracture (calcium is stored 99% in bone and 1% blood) Kidney stones A. Hormonal replacement therapy for lifetime 9. Serum Phosphate is decreased 3. Maintain side rails . Diagnostic Procedures 1. Adults: Osteomalacia B. Anorexia. renal cholic b. Encourage increase intake of foods rich in phosphate but decrease in calcium 6. Assist/supervise in ambulation 8. Morphine Sulfate (Demerol) 5. nausea and vomiting 4.
Adrenal Medulla – innermost (secretes catecholamines a power hormone) 2 Types of Catecholamines o o o o o Epinephrine and Norepinephrine (vasoconstrictor) Pheochromocytoma (adrenal medulla) Increase secretion of norepinephrine Leading to hypertension which is resistant to pharmacological agents leading to CVA Use beta-blockers ADRENAL CORTEX 3 Zones/Layers 1. Decrease tolerance to stress 3.Sex 3.9.function: promotes sodium and water reabsorption and excretion of potassium . metabolic disturbance – Sugar b.hypotension .secretes mineralocorticoids (aldosterone) . Prevent complications (seizure and arrhythmia) 10. Hypoglycemia – TIRED 2. deficiency of neuromuscular function – Salt/Sex A. Assist in surgical procedure known as parathyroidectomy 11.function: controls glucose metabolism .signs of dehydration . Signs and Symptoms 1.Salt ADDISON’S DISEASE o Hyposecretion of adreno cortical hormone leading to a.weight loss . Zona Reticularis . Zona Fasciculata . Fungal infections B. Importance of follow up care ADRENAL GLAND o o Located atop of each kidney 2 layers of adrenal gland a. Related to atrophy of adrenal glands 2. Adrenal Cortex – outermost b. Predisposing Factors 1.Sugar 2. Hormonal replacement therapy for lifetime 12. Hyponatremia . Zona Glumerulosa .secretes traces of glucocorticoids and androgenic hormones .secretes glucocortocoids (cortisol) . fluid and electrolyte imbalance – Salt c.function: promotes secondary sex characteristics .
Prednisone c. carbohydrates.sudden withdrawal to steroids b. Diagnostic Procedures 1. Administer medications as ordered Corticosteroids a. hypertension b.hypovolemic shock .4. increase susceptibility to infection e.5 – 4. protein but decrease in potassium 6. severe hypotension b. Bronze like skin pigmentation C. hyponatremia leading to progressive stupor and coma Nursing Management for Addisonian Crisis 1. Instruct client to take 2/3 dose in the morning and 1/3 dose in the afternoon to mimic the normal diurnal rhythm 2. Administer isotonic fluid solution as ordered 3. Monitor strictly vital signs. Provide dietary intake. Serum Sodium is decrease (normal value: 135 – 145 meq/L) 4. Monitor side effects a. edema c.arrhythmia 5. Provide meticulous skin care 7. avoid precipitating factor leading to addisonian crisis leading to . Dexamethasone (Decadrone) b. Serum Potassium is increased (normal value: 3. Mineralocorticoids (Flourocortisone) 5. increase calories.stress . Decrease libido 6.diarrhea .administer steroids as ordered . prevent complications . hirsutism d. moon face appearance 4. Hyperkalemia . hypovolemic shock c. Nursing Management 1. input and output to determine presence of Addisonian crisis (complication of addison’s disease) o Addisonian crisis results from acute exacerbation of addison’s disease characterized by a.force fluids 2. Assist in mechanical ventilation. Provide client health teaching and discharge planning a. Force fluids 4.infection .agitation . Loss of pubic and axillary hair 7.addisonian crisis . Taper dose (withdraw gradually from drug) 3. Hydrocortisone (Cortison) Nursing Management when giving steroids 1. FBS is decreased (normal value: 80 – 100 mg/dl) 2.5 meq/L) D. Plasma Cortisol is decreased 3. .
Nursing Management 1. Plasma Cortisol is increased 3. Serum Sodium is increased 4. Hormonal replacement for lifetime 10. FBS is increased 2.c. Prevent complications (DM) 8. Restrict sodium intake 5. importance of follow up care CUSHING SYNDROME o Hypersecretion of adenocortical hormones A. Provide meticulous skin care 6. Hypernatremia a. obese trunk f. edema c. Monitor strictly vital signs and intake and output 2.Mixed gland (exocrine and endocrine) . Hypokalemia a. Easy bruising 8. pendulous abdomen g. Measure abdominal girth daily and notify physician 4. Spinarolactone – potassium sparring diuretics 7. Assist in surgical procedure (bilateral adrenoraphy) 9. Serum Potassium is decreased C. Increase masculinity among females B.Located behind the stomach . constipation c. hormonal replacement for lifetime d. Administer medications as ordered a. Diagnostic Procedures 1. thin extremities 4. Increase susceptibility to infections 3. hypertension b. U wave upon ECG (T wave hyperkalemia) 5. Acne and striae 7. Weigh patient daily and assess for pitting edema 3. weight gain d. moon face appearance and buffalo hump e. Hirsutism 6. Importance of follow up care PANCREAS . Predisposing Factors 1 Related to hyperplasia of adrenal gland 2. weakness and fatigue b.
Ketotic 5.Beta cells secretes insulin (function: hypoglycemia) . Steroids 4.Consist of islets of langerhans . Signs and Symptoms 1. Osmolar 3.Adult onset . Obesity – because obese persons lack insulin receptor binding sites . Diet 3. Glucosuria 5. Predisposing Factors 1. Polyphagia 5. Related to carbon tetrachloride toxicity C. Hyper 2. Polydypsia 3. Weight gain Type 2 (NIDDM) . Pancreatitis DIABETES MELLITUS . Diabetic Ketoacidosis D.. Drugs a. Signs and Symptoms 1. Hereditary (total destruction of pancreatic cells) 2.Juvenile onset type . Polyuria 3. Polyuria 2.Brittle disease A.Maturity onset type .metabolic disorder characterized by non utilization of carbohydrates. Weight loss 6. Non 4. Polydypsia 4. Blurring of vision 8. Predisposing Factors 1. Glucosuria 6. Insulin therapy 2.10% general population has type 1 DM B. Related to viruses 3.90% of general population has type 2 DM B. protein and fat metabolism CLASSIFICATION OF DM Type 1 (IDDM) . nausea and vomiting 7.Has alpha cells that secretes glucagons (function: hyperglycemia) . Incidence Rate . Exercise E. Incidence Rate . Complication 1. Treatment 1. Anorexia.Consist of acinar cells which secretes pancreatic juices that aids in digestion thus it is an exocrine gland . Usually asymptomatic 2. Treatment 1. Polyphagia 4. Pancreatic Tumor/Cancer 2. Oral Hypoglycemic agents 2.Obese over 40 years old A. Diet 3. Diabetes Mellitus 3. Complications 1. Delayed/poor wound healing D. Coma C.Delta cells secretes somatostatin (function: antagonizes the effects of growth hormones) 3 Main Disorders of Pancreas 1. Exercise E. Increase susceptibility to infection 9. Lasix b.
Protein 3. Fats ANABOLISM CATABOLISM Glucose Amino Acids Fatty Acids Glycogen Nitrogen Free Fatty Acids .Ketones HYPERGLYCEMIA Increase osmotic diuresis Glycosuria Cellular starvation – weight loss Stimulates the appetite/satiety center (Hypothalamus) Polyphagia Polyuria Cellular dehydration Stimulates the thirst center (Hypothalamus) Polydypsia * Liver has glycogen that undergo glycogenesis/ glycogenolysis GLUCONEOGENESIS Formation of glucose from non-CHO sources Increase protein formation ▼ Negative Nitrogen balance ▼ Tissue wasting (Cachexia) ▼ INCREASE FAT CATABOLISM ▼ Free fatty acids Cholesterol ▼ Atherosclerosis ▼ Hypertension MI CVA Ketones ▼ Diabetic Keto Acidosis Acetone Breath odor Kussmaul’s Respiration Death Diabetic Coma .Cholesterol .MAIN FOODSTUFF 1. Carbohydrates 2.
Predisposing Factors 1. Insulin therapy (regular acting insulin/rapid acting insulin peak action of 2 – 4 hours) b. BUN (normal value: 10 – 20) 3.8 – 1) 4. Diagnostic Procedures 1. Glucosuria 5. intake and output and blood sugar levels 4. Sodium Bicarbonate to counteract acidosis c.9 NaCl followed by . Restlessness 3. Blurring of vision 8. Decrease LOC – diabetic coma . male 42 – 48) due to severe dehydration D.Hyperosmolar: increase osmolarity (severe dehydration) . Hyperglycemia 2. Administer 0. Signs and Symptoms 1.Non ketotic: absence of lypolysis (no ketones) A. Kussmaul’s Respiration (rapid shallow breathing) 10 CNS depression leading to coma C. Signs and Symptoms 1. Nursing Management 1. Seizure activity 4. Creatinine (normal value: . Headache and dizziness 2. Weight loss 6. nausea and vomiting 7.45 NaCl (hypotonic solutions) to counteract dehydration and shock 3. Acetone breath odor 9. FBS is increased 2. Administer medications as ordered a. Antibiotics to prevent infection HYPER OSMOLAR NON KETOTIC COMA . Monitor strictly vital signs. Infection B. Polyphagia 4. Stress – number one precipitating factor 3.Acute complication of type 1 DM due to severe hyperglycemia leading to severe CNS depression A. Polydypsia 3.DIABETIC KETOACIDOSIS . Polyuria 2. Hct (normal value: female 36 – 42. Assist in mechanical ventilation 2. Anorexia.
Rarely used because it can cause severe allergic reaction . Sources of Insulin 1. Intermediate Acting Insulin (cloudy) . Nursing Management 1. Lipodystrophy c. Administer insulin either 45o – 90o depending on amount of clients tissue deposit 6. Administer at room temperature to prevent development of lipodystrophy (atrophy.9 NaCl followed by .Derived from beef and pork 2. Monitor strictly vital signs. Chlorpropamide (Diabenase) b. When mixing 2 types of insulin aspirate first the clear insulin before cloudy to prevent contaminating the clear insulin and promote proper calibration.Peak action is 8 – 16 hours 3. Rapid Acting Insulin (clear) . Antibiotics to prevent infection INSULIN THERAPY A. Avoid shaking insulin vial vigorously instead gently roll vial between palm to prevent formation of bubbles 4.Regular acting insulin (IV only) .Peak action is 16 – 24 hours C. Place in refrigerator once opened 3. Administer medications as ordered a. Tolbutamide (Orinase) .for DKA use rapid acting insulin b. Human Sources . Long Acting Insulin (cloudy) . Most accessible route is abdomen 9. Artificially Compound Insulin B. Administer 0.Stimulates the pancreas to secrete insulin A.Non Protamine Hagedorn Insulin (NPH) . Classsification 1. Use gauge 25 – 26 needle 5. 10. Allergic reactions b. First Generation Sulfonylureas a. Somogyis Phenomenon – rebound effect of insulin characterized by hypoglycemia to hyperglycemia ORAL HYPOGLYCEMIC AGENTS .Frequently used type because it has less antigenicity property thus less allergic reaction 3. Rotate insulin injection sites to prevent development of lipodystrophy 8. Nursing Management for Insulin Injections 1.Peak action is 2 – 4 hours 2.45 NaCl (hypotonic solutions) to counteract dehydration and shock 3. No need to aspirate upon injection 7. Assist in mechanical ventilation 2. intake and output and blood sugar levels 4. Insulin therapy (regular acting insulin peak action of 2 – 4 hours) . Animal sources .Ultra Lente .B. hypertrophy of subcutaneous tissues) 2. Monitor for signs of local complications such as a. Types of Insulin 1.
assist in surgical wound debriment (give analgesics 15 – 30 mins prior) 9. Provide nutritional intake of diabetic diet that includes: carbohydrates 50%. HPN and DM major cause of renal failure d. Monitor for signs of DKA and HONKC 11. Oral glucose tolerance test is increased – most sensitive test 4. instruct client to avoid wearing constrictive garments d.for hypoglycemia (cold and clammy skin) give simple sugars .diarrhea/constipation . Random Blood Sugar is increased 3. Shock due to dehydration . Instruct client to have an annual eye and kidney exam 10. instruct client to cut toenails straight c. polydypsia. Blood II. Monitor for signs of hypoglycemia and hyperglycemia . FBS is increased (3 consecutive times with signs or polyuria.administer simple sugars .Blindness KIDNEY -RECURRENT PYELONEPHRITIS .Renal failure c. Nursing Management 1. Administer insulin and OHA therapy as ordered 3. Microangiopathy (affects small minute blood vessels of eyes and kidneys) EYES -PREMATURE CATARACT . Instruct client to exercise best after meals when blood glucose is rising 7. polyphagia and glucosuria confirmatory for DM) 2. Institute foot care management a.c.sexual impotence 8. Tolamazide (Tolinase) 2. CVA) b. Instruct the client to avoid taking alcohol because it can lead to severe hypoglycemia reaction or Disulfiram (Antabuse) toxicity symptoms B. intake and output and blood sugar levels 4. protein 30% and fats 20% or offer alternative food substitutes 6.peripheral neuropathy . Glipzide (Glucotrol) b. Atherosclerosis (HPN. Monitor signs for complications a.for hyperglycemia (dry and warm skin) 5. Assist in surgical procedure HEMATOLOGICAL SYSTEM I. instruct client to avoid walking barefooted b. Blood Vessels III. Diabeta (Micronase) Nursing Management when giving OHA 1. Monitor for peak action of insulin and OHA and notify physician 2. Instruct the client to take it with meals to lessen GIT irritation and prevent hypoglycemia 2. Second Generation Sulfonylureas a. MI. Diagnostic Procedures 1. encourage client to apply lanolin lotion to prevent skin breakdown e. Monitor strictly vital signs. Alpha Glycosylated Hemoglobin is increased C. Blood Forming Organs . Gangrene formation e.
Polymorpho Neutrophils .Maintains osmotic pressure preventing edema GLOBULINS .hematocrit red cell percentage in wholeblood . Lymphoid Organ 5.hemoglobin: normal value female 12 – 14 gms% male 14 – 16 gms% .transport steroids.consist of molecules of hgb (red pigment) bilirubin (yellow pigment) biliverdin (green pigment) hemosiderin (golden brown pigment) . Liver 3. Monocytes .Gamma globulins a. prothrombin and fibrinogen clotting factors FORMED ELEMENTS 1.normal value: 5000 – 10000/mm3 A. anti-bodies and immunoglobulins b. Polymorphonuclear Basophils .Largest and numerous plasma CHON . folic acid b.Beta globulins – iron and copper . Non Granulocytes 1. WBC (LEUKOCYTES) .normal value: 4 – 6 million/mm3 . vitamin c d. RBC (ERYTHROCYTES) .60 – 70% of WBC . iron c. Bone Marrow ALBUMIN .Normal life span of RBC is 80 – 120 days and is killed in red pulp of spleen 2. Veins Plasma CHON (formed in liver) 1.Alpha globulins . Lymph Nodes 6. Albumin 2.responsible for the release of chemical mediation for inflammation 3.transports and carries oxygen to tissues . Spleen 4.macrophage in blood . vitamin b6 (pyridoxine) f. Prothrombin and Fibrinogen 1.only unnucleated cell .for allergic reaction B.substances needed for maturation of RBC a.biconcave discs . Granulocytes 1.largest WBC .normal value: female 36 – 42% male 42 – 48% .55% Plasma Serum 45% Formed 1.involved in short term phagocytosis for acute inflammation 2. Arteries 2. Polymorphonuclear Eosinophils .for parasite infections . Globulins 3. vitamin b12 (cyanocobalamin) e. bilirubin and hormones . intrinsic factor .
. Chronic diarrhea b. Common among women 15 – 35 years old 4. Platelets (THROMBOCYTES) . Related to GIT bleeding resulting to hematemesis and melena (sign for upper GIT bleeding) c. Weakness and fatigue (initial signs) 3.thymus for immunity Natural killer cell . Related to improper cooking of foods C. fresh blood per rectum is called hematochezia 2. Lymphocytes B-cell T-cell . Related to poor nutrition B. Pneumocystis Carinii Pneumonia 3. Common among developed countries 2. Inadequate intake of iron due to a. Subtotal gastrectomy 4.000/mm3 . Kaposi’s Sarcoma 2. Echhymosis 3.Normal life span of platelet is 9 – 12 days Signs of Platelet Dysfunction 1. Heavy menstruation b.6 months – 5 years incubation period . Signs and Symptoms 1.Promotes hemostasis (prevention of blood loss) .western blot opportunistic . Incidence Rate 1. Predisposing Factors 1. Related to malabsorption syndrome c.bone marrow . High cereal intake with low animal protein digestion d.Normal value: 150. Common among tropical zones 3.ELISA . Usually asymptomatic 2. Petechiae 2. Chronic blood loss due to trauma a.000 – 450.drug of choice AZT (Zidon Retrovir) 2 Common fungal opportunistic infection in AIDS 1.Consist of immature or baby platelets or megakaryocytes which is the target of dengue virus .involved in long term phagocytosis for chronic inflammation 2. Oozing of blood from venipunctured site BLOOD DISORDERS Iron Deficiency Anemia .anti viral and anti tumor property HIV . Headache and dizziness .6 months window period .A chronic microcytic anemia resulting from inadequate absorption of iron leading to hypoxemic tissue injury A.
discoloration and leakage to tissues 2. Ferrous Sulfate b.Lugol’s solution . Diarrhea/constipation e. Monitor and inform client of side effects a. Instruct client to take foods rich in iron a. Ferrous Fumarate c. Pallor and cold sensitivity 5. Pain at injection site PLUMBER VINSON’S SYNDROME . Monitor for signs of bleeding of all hema test including urinw. Abdominal pain d.Stomatitis . Egg (yolk) c.Nitrofurantoin (Macrodentin) 3. Dyspnea 6. If client cant tolerate/no compliance administer parenteral iron preparation a. Ferritin is decreased E. Diagnostic Procedures 1. Nursing Management 1. Monitor side effects a. Hct is deceased 4. Iron is decreased 5. Administer Z tract technique to prevent discomfort. Enforce CBR so as not to over tire client 3. PICA (abnormal appetite or craving for non edible foods D. When diluting it in liquid iron preparations administer with straw to prevent staining of teeth Medications administered via straw . Instruct client to take with meals to lessen GIT irritation 2. Anorexia b. Organ meat b. Brittleness of hair and spoon shape nails (koilonychias) 8. Legumes g. Ferrous Gluconate . Nuts 4. Nausea and vomiting c. Iron Dextran (IM. Sorbitex (IM) Nursing Management when giving parenteral iron preparations 1.Iron . IV) b.Tetracycline . Hgb is decreased 3. Palpitations 7. Reticulocyte is decreased 6. stool and GIT 2. Instruct the client to avoid taking tea and coffee because it contains tannates which impairs iron absorption 5. Administer with Vitamin C or orange juice for absorption 4. Avoid massaging the injection site instead encourage to ambulate to facilitate absorption 3. Sweet potatoes e. RBC is decreased 2.300 mg/day Nursing Management when taking oral iron preparations 1.Dysphagia 9. Dried fruits f. Melena 5. Raisin d.4. Atropic Glossitis (inflammation of tongue) . Administer medications as ordered Oral Iron Preparations a.
Lymphadenopathy d. jaundice 6. Subtotal gastrectomy 2. Autoimmune 5. weight loss e.b. Diagnostic Procedure Schilling’s Test – reveals inadequate/decrease absorption of Vitamin B12 D. numbness c. Weakness and fatigue 2. positive to Romberg’s test – damage to cerebellum resulting to ataxia e. Fever and chills e. GIT changes that includes a. Hereditary factors 3. result to psychosis C.Never given orally because there is possibility of developing tolerance Secretes hydrochloric acid ▼ Aids in digestion . indigestion/dyspepsia d. mouth sore b.Chronic anemia characterized by a deficiency of intrinsic factor leading to hypochlorhydria (decrease hydrochloric acid secretion) A. Pruritus/orticaria g. Headache and dizziness 3. CNS changes a. red beefy tongue c. Strictly vegetarian diet STOMACH ▼ Pareital cells/ Argentaffin or Oxyntic cells Produces intrinsic factors ▼ Promotes reabsorption of Vit B12 ▼ Promotes maturation of RBC B. Skin rashes f. Pallor and cold sensitivity 4. Localized abscess c. Hypotension (anaphylactic shock) PERNICIOUS ANEMIA . Nursing Management 1. Predisposing Factors 1. Enforce CBR 2. Dyspnea and palpitations as part of compensation 5. Signs and Symptoms 1. Administer Vitamin B12 injections at monthly intervals for lifetime as ordered . Inflammatory disorders of the ileum 4. tingling sensation b. paresthesia d.
Diagnostic Procedures 1. Dyspnea and palpitations 2.. Nursing Management 1. Provide a dietary intake that is high in carbohydrates.Stem cell disorder leading to bone marrow depression leading to pancytopenia PANCYTOPENIA Decrease RBC (anemia) A. Headache and dizziness c. Administer oxygen inhalation 4. Enforce CBR 5. Leukopenia a. vitamin c and iron 4. Nitrogen Mustard (Antimetabolite) Phenylbutazones (NSAIDS) B. Chemicals (Benzine and its derivatives) 2. Related to irradiation/exposure to x-ray 3. Pallor and cold sensitivity d. Methotrexate (Alkylating Agent) b. Predisposing Factors 1.Site of injection for Vitamin B12 is dorsogluteal and ventrogluteal . Anemia a. Weakness and fatigue b. Institute reverse isolation 6. Ecchymosis c. Monitor for signs of infection a. fever Decrease WBC (leucopenia) Decrease Platelet (thrombocytopenia) . Petechiae (multiple petechiae is called purpura) b. protein. CBC reveals pancytopenia 2. Chloramphenicol (Sulfonamides) Chemotherapeutic Agents a. Drugs Broad Spectrum Antibiotics a.No side effects 3. Bone marrow biopsy/aspiration (site is the posterior iliac crest) – reveals fat necrosis in bone marrow D. Increase susceptibility to infection 3. Thrombocytopenia a. Institute BT as ordered 3. Oozing of blood from venipunctured sites C. Instruct client to avoid irritating mouth washes instead use soft bristled toothbrush 5. Avoid heat application to prevent burns APLASTIC ANEMIA . Removal of underlying cause 2. Signs and Symptoms 1. Immunologic injury 4. Vincristine (Plant Alkaloid) c.
Administer oxygen inhalation 4. Opthamoscopic exam reveals sub retinal hemorrhages D. Immunosuppressants Anti Lymphocyte Globulin ▼ Given via central venous catheter ▼ Given 6 days to 3 weeks to achieve Maximum therapeutic effect of drug DISSEMINATED INTRAVASCULAR COAGULATION Acute hemorrhagic syndrome characterized by wide spread bleeding and thrombosis due to a deficiency of prothrombin and fibrinogen A. Institute NGT decompression by performing gastric lavage by using ice or cold saline solution of 500 – 1000 ml 8. Pitressin/ Vasopresin to conserve fluids c. CBC reveals decreased platelets 2. Administer isotonic fluid solution as ordered 3. Instruct client to use electric razor when shaving 10. Pregnancy B. Related to rapid blood transfusion 2. Heparin/Coumadin is ineffective 6. Force fluids 5. Septecemia 6. lungs and lower extremities 2. Oozing of blood from punctured sites 4. Nursing Management 1. Oliguria (late sign) C.b. Prevent complication . Anaphylaxis 5. Predisposing Factors 1. Neoplasia (new growth of tissue) 7. Corticosteroids – caused by immunologic injury b. Hemoptysis 6. Administer medications as ordered a. Signs and Symptoms 1. Massive burns 3. Massive trauma 4. Monitor NGT output 9. subcutaneous. Provide heparin lock 7. ABG analysis reveals metabolic acidosis 4. Petechiae (widespread and systemic) eye. Monitor for signs of bleeding of all hema test including stool and GIT 2. Administer medications as ordered a. Vitamin K b. cough 7. Avoid IM. Ecchymosis 3. Stool occult blood positive 3. venipunctured sites 8 Instead provide heparin lock 9. Diagnostic Procedures 1.
Type AB – universal recipient c. Isotonic solution (0. BT should be completed less than 4 hours because blood that is exposed at room temperature more than 2 hours causes blood deterioration that can lead to BACTERIAL CONTAMINATION 7. 85% of population is RH positive 3. Thrombocytopenia g.a.Expiration of platelet is 3 – 5 days 2. Check the blood unit for bubbles cloudiness. Pyrogenic reaction d. Blood typing and cross matching c. Hemolytic reaction b. Gauge 18 – 19 needle c. Anuria – late sign BLOOD TRANSFUSION Goals/Objectives 1. Proper refrigeration .9 NaCl/plain NSS) to prevent hemolysis 4. Hypovolemic shock b. Allergic reaction c. Increase the oxygen carrying capacity of blood 3. Filter set b.Expiration of packed RBC is 3 – 6 days . Cytrate intoxication h. Serial number 5. sediments and darkness in color because it indicates bacterial contamination . Proper typing and cross matching a.Warming is only done during emergency situation and if you have the warming device . . during and after BT especially every 15 minutes for first hour because majority of transfusion reaction occurs during this period a. 6. Hyperkalemia (caused by expired blood) . Circulatory overload e. Aseptically assemble all materials needed for BT a. Instruct another RN to re check the following a. Expiration date d. Monitor strictly vital signs before. Replace circulating blood volume 2. Avoid mixing or administering drugs at BT line to prevent HEMOLYSIS 8.Never warm blood as it may destroy vital factors in blood. Air embolism f. Regulate BT 10 – 15 gtts/min or KVO rate or equivalent to 100 cc/hr to prevent circulatory overload 9. Prevent bleeding if there is platelet deficiency Principles of blood transfusion 1. Client name b. Prevent infection in there is a decrease in WBC 4. Type O – universal donor b.Emergency rapid BT is given after 30 minutes and let natural room temperature warm the blood.
Flushed skin 6. Notify physician 3. Send the blood unit to blood bank for re examination 6. Obtain urine and blood sample and send to laboratory for re examination 7. Flush with plain NSS 4. Send the blood unit to blood bank for re examination 6. Broncial wheezing 4. Dyspnea 3. Urine is color red/ portwine urine Nursing Management 1. Administer isotonic fluid solution to prevent shock and acute tubular necrosis 5. Hypotension 5. Notify physician 3. Headache 3.if positive to hypotension. Diarrhea/Constipation 4. Tachycardia 4. Laryngospasm and Broncospasm Nursing Management 1. Urticaria 6. Stop BT 2. Notify physician 3. Obtain urine and blood sample and send to laboratory for re examination 7. Administer medications as ordered a. Anti Histamine (Benadryl) . Flush with plain NSS . Diaphoresis 6. anaphylactic shock treat with Epinephrine 5. Stop BT 2. Lumbasternal/ Flank pain 7. Palpitations 5. Fever and chills 2. Skin rashes 5. Monitor vital signs and intake and output SIGNS AND SYMPTOMS OF ALLERGIC REACTION 1. Dyspnea 3. Dyspnea Nursing Management 1. Fever 2. Monitor vital signs and intake and output SIGNS AND SYMPTOMS PYROGENIC REACTIONS 1.Signs and Symptoms of Hemolytic reaction 1. Stop BT 2. Headache and dizziness 2. Flush with plain NSS 4.
Obtain urine and blood sample and send to laboratory for re examination 7.Prevent pericardial friction rub . Antibiotic 5. Administer medications as ordered a. Dyspnea 3. Exertional discomfort Nursing Management 1. Visceral – inner layer . Endocardium – inner layer . tricuspid valve . Ventricles .Right atrium has decreased pressure which is 60 – 80 mmHg C. Render TSB SIGNS AND SYMPTOMS OF CIRCULATORY REACTION 1. Epicardium – outer layer 2. Atria 2.Left ventricle has increased pressure which is 120 – 180 mmHg . Chambers of the Heart 1. Myocardium – middle layer 3. Loop diuretic (Lasix) CARDIOVASCULAR SYSTEM OVERVIEW OF THE STRUCTURE AND FUNCTIONS OF THE HEART HEART .Common among MI. Send the blood unit to blood bank for re examination 6.Resemble like a close fist .Covered by a serous membrane called the pericardium 2 layers of pericardium a. Parietal – outer layer b. Stop BT 2. Administer medications as ordered a. Rales/Crackles upon auscultation 4. Layers of Heart 1. . Atrioventricular Valves – guards opening between a.In order to propel blood to the systemic circulation . Valves .Myocarditis can lead to cardiogenic shock and rheumatic heart disease B.Weighs approximately 300 – 400 grams .Muscular pumping organ of the body. pericarditis. Antipyretic b. Lower Chamber (contracting or pumping) a. Upper Chamber (connecting or receiving) a.Located on the left mediastinum . Cardiac tamponade A. Orthopnea 2.To promote unidimensional flow or prevent backflow 1. Monitor vital signs and intake and output 8.In between is the pericardial fluid which is 10 – 20 cc . Notify physician 3.4.
QRS WAVE (ventricular depolarization) .Closure of AV valves give rise to first heart sound (S1 “lub”) 2. Semi – lunar Valves a.Located at the junction of superior vena cava and right atrium .Located at the interventricular septum 4. Atrio – Ventricular Node (AV or Tawara Node) .Initiates electrical impulse of 60 – 100 bpm 2. Cardiac Conduction System 1.08 milliseconds to allow ventricular filling 3.b.Supplies the myocardium E. Left Main Coronary Artery .Left Main Bundle of His . S4 – atrial gallop usually seen in Myocardial Infarction and Hypertension D.Located at the inter atrial septum . Bundle of His . Coronary Arteries .Located at the walls of the ventricles for ventricular contraction SA NODE AV NODE BUNDLE OF HIS JLJLJLJJLJLJL PURKINJE FIBERS .P WAVE (atrial depolarization) contraction .Arises from base of the aorta Types of Coronary Arteries 1. Sino – Atrial Node (SA or Keith Flack Node) .Right Main Bundle of His . Right Main Coronary Artery 2. aortic . S3 – ventricular gallop usually seen in Left Congestive Heart Failure 2. pulmonic b. mitral valve .Closure of SV valve give rise to second heart sound (S2 “dub”) Extra Heart Sounds 1. Purkinje Fibers .Acts as primary pacemaker of the heart .T WAVE (ventricular repolarization) .Delay of electrical impulse for about .
Atherosclerosis 2. ST segment depression – Angina Pectoris 4. Myocardial Necrosis – Myocardial Infarction ATHEROSCLEROSIS ATHEROSCLEROSIS . Tachycardia 4. Duaphoresis C. Hyperlipidemia 6. Peak T wave – Hyperkalemia 3. Diabetes Mellitus 8. Increase survival rate ARTERIOSCLEROSIS . Myocardial Ischemia – Angina Pectoris 3. Type A personality B. To prevent angina 3. Sex – male 2. Predisposing Factors 1. Hypothyroidism 9. Treatment Percutaneous Transluminal Coronary Angioplasty Objectives of PTCA 1. sedentary lifestyle 7. Palpitations 5. Signs and Symptoms 1.calcium and protein deposits . Widening of QRS complexes – Arrythmia CARDIAC DISORDERS Coronary Arterial Disease/ Ischemic Heart Disease Stages of Development of Coronary Artery Disease 1. T wave inversion – Myocardial Infarction 6. ST segment elevation – Myocardial Infarction 5. Revascularize myocardium 2.lipid or fat deposits . Positive U wave . Obesity 5. Smoking 4. Chest pain 2.hardening of artery . Insert pacemaker if there is complete heart block Most common pacemaker is the metal pacemaker and lasts up to 2 – 5 years ABNORMAL ECG TRACING 1.narrowing of artery . Myocardial Injury .tunica intima A.tunica media .Hypokalemia 2. Diet – increased saturated fats 10. Dyspnea 3. Race – black 3.
Done to single occluded vessels . arms. Exposure to cold environment 3. Signs and Symptoms 1. Diabetes Mellitus 8. Sex – male 2. Excessive intake of foods rich in saturated fats – skimmed milk C. Diet – increased saturated fats 10. Extreme emotional response – fear. History taking and physical exam 2. usually relieved by rest or taking nitroglycerine 3. shoulder. Stress test – treadmill test. Chest pain characterized by sharp stabbing pain located at sub sterna usually radiates from back. Precipitating Factors 4 E’s of Angina Pectoris 1. Diagnostic Procedure 1. Enforce complete bed rest 2. Palpitations 6. coughing exercise and use of incentive spirometer 2. Dyspnea 4. Levine’s Sign – initial sign that shows the hand clutching the chest 2. reveal abnormal ECG 4. Diaphoresis D. Predisposing Factors 1. Thrombophlebitis ANGINA PECTORIS (SYNDROME) Clinical syndrome characterized by paroxysmal chest pain that is usually relieved by rest or nitroglycerine due to temporary myocardial ischemia A. Nitroglycerine (NTG) – when given in small doses will act as venodilator. Type A personality B. Excessive physical exertion – heavy exercises 2. sedentary lifestyle 7. Hypothyroidism 9. excitement 4. Race – black 3. Obesity 5. Shock 3.Give first dose of NTG (sublingual) 3 – 5 minutes . Serum cholesterol and uric acid is increased E. Nursing Management 1. anxiety.5 minutes . Tachycardia 5..If there is 2 or more occluded blood vessels CABG is done Coronary Arterial Bypass And Graft Surgery 3 Complications of CABG 1. ECG tracing reveals ST segment depression 3. Smoking 4.Give second dose of NTG if pain persist after giving first dose with interval of 3 . axilla and jaw muscles. but in large doses will act as vasodilator . Pneumonia – encourage to perform deep breathing. Administer medications as ordered a. Hyperlipidemia 6.
Race – black 3. The Most Critical Period Following Diagnosis of Myocardial Infarction ** 6 – 8 hours because majority of death occurs due to arrhythmia leading to PVC’s C. avoid moisture and exposure to sunlight as it may inactivate the drug Monitor side effects o o Orthostatic hypotension Transient headache and dizziness Instruct the client to rise slowly from sitting position Assist or supervise in ambulation When giving nitrol or transdermal patch o o o Avoid placing near hairy areas as it may decrease drug absorption Avoid rotating transdermal patches as it may decrease drug absorption Avoid placing near microwave ovens or duting defibrillation as it may lead to burns (most important thing to remember) b. Subendocardial Myocardial Infarction – characterized by occlusion of either right or left coronary artery B.NIfedipine 3. necrosis and scarring.. ACE Inhibitors . Avoidance of 4 E’s b.Enalapril d. Beta-blockers . Transmural Myocardial Infarction – most dangerous type characterized by occlusion of both right and left coronary artery 2. Predisposing Factors 1. intake and output and ECG tracing 6.Give third and last dose of NTG if pain still persist at 3 – 5 minutes interval Nursing Management when giving NTG Keep the drug in a dry place. Smoking 4. Provide client health teachings and discharge planning a.Propanolol . Prevent complication (myocardial infarction) c.Not given to COPD cases because it causes bronchospasm c. A. Hyperlipidemia . Administer oxygen inhalation 4. Sex – male 2. Obesity 5. Instruct client to take medication before indulging into physical exertion to achieve the maximum therapeutic effect of drug d. Provide decrease saturated fats sodium and caffeine 7. The importance of follow up care MYOCARDIAL INFARCTION Heart attack Terminal stage of coronary artery disease characterized by malocclusion.side effects PNS . Calcium Antagonist . Place client on semi fowlers position 5. Types 1. Monitor strictly vital signs.
12 – 24 hours b. Enforce CBR without bathroom privileges a. ST segment elevation b.Side Effects of Naloxone Toxicity is tremors 2. Widening of QRS complexes indicates that there is arrhythmia in MI 4.Excruciating visceral. T wave inversion c. arms. Pericardial friction rub b.Creatinine phosphokinase is increased . sedentary lifestyle 7.Heart only. Diet – increased saturated fats 10. Chest pain . CPK – MB . SGOT – Serum glutamic oxal-acetic transaminase is increased 2.Not usually relieved by rest or by nitroglycerine 2. Administer oxygen low inflow to prevent respiratory arrest at 2 – 3 L/min 3. Dyspnea 3. shoulder. ECG tracing reveals a. Hypothyroidism 9. Instruct client to avoid forms of valsalva maneuver 5. SGPT – Serum glutamic pyruvate transaminase is increased d. Using bedside commode 4.Antidote: Narcan/Naloxone . S4 or atrial gallop E. Rales/Crackles upon auscultation d. Diagnostic Procedure 1.Side Effects: respiratory depression . CBC – increased WBC F. Troponin Test – is increased 3. Mild restlessness and apprehension 7.Administer narcotic analgesic/morphine sulfate . jaw and abdominal muscles (abdominal ischemia) . Hyperthermia 5. Place client on semi fowlers position . LDH – Lactic acid dehydroginase is increased c. Signs and Symptoms 1. Diabetes Mellitus 8. Split S1 and S2 c. viselike pain located at substernal and rarely in precordial .6. Nursing Management Goal: Decrease myocardial oxygen demand 1. Serum Cholesterol and uric acid are both increased 5. axilla. Ashen skin 6. Decrease myocardial workload (rest heart) .Usually radiates from back. Occasional findings a. Increase in blood pressure (initial sign) 4. Cardiac Enzymes a. Type A personality D.
Urokinase .Side Effects: confusion and dizziness . Thrombophlebitis . ACE Inhibitors e. Administer medication as ordered a.PASA (Aspirin) . Provide client health teaching and discharge planning concerning a.homan’s sign e. Anti Coagulant . Beta-blockers d.TIPAF (tissue plasminogen activating factor) .6. intake and output and ECG tracing 7.Heparin (check for partial thrombin time) . Anti Arrythmic Agents .Monitor for bleeding time g. whisky and brandy to induce vasodilation 9.Streptokinase . Cardiogenic shock . sodium and caffeine 8. Vasodilators .Contraindication Dengue Peptic Ulcer Disease Unknown cause of headache 10.ISD (Isosorbide Dinitrate.arrhythmia (caused by premature ventricular contraction) b. Thrombolytics/ Fibrinolytic Agents .Nitroglycerine . Stroke/CVA .late sign is oliguria c.Coumadin/ Warfarin Sodium (check for prothrombin time) . Encourage client to take 20 – 30 cc/week of wine. Isodil) sublingual b. Left Congestive Heart Failure d.Brutylium c. Avoidance of modifiable risk factors .Antidote: protamine sulfate .Anti thrombotic effect .Side Effects: chest pain .Side Effects of Aspirin Tinnitus Heartburn Indigestion/Dyspepsia . pruritus . Monitor strictly vital signs.Antidote: Vitamin K h.Lidocaine (Xylocane . Calcium Antagonist f. Anti Platelet . Provide a general liquid to soft diet that is low in saturated fats.Side Effects: allergic reaction.
Strict compliance to mediation and importance of follow up care CONGESTIVE HEART FAILURE Inability of the heart to pump blood towards systemic circulation Types of Heart Failure 1. Chest x-ray – reveals cardiomegaly 2. Aortic valve stenosis B. LEFT SIDED HEART FAILURE A. S3 – ventricular gallop C.f. Predisposing Factors 1.dietary modification h. Cyanosis 7. Post MI Syndrome/Dressler’s Syndrome .make sex as an appetizer rather than dessert . Diagnostic Procedure 1. RIGHT SIDED HEART FAILURE . PAP (pulmonary arterial pressure) – measures pressure in right ventricle or cardiac status PCWP (pulmonary capillary wedge pressure) – measures end systolic and dyastolic pressure both are increased done by cardiac catheterization (insertion of swan ganz catheter) 3. Orthopnea – use 2 – 3 pillows when sleeping or place in high fowlers 4. dependent on extent of heart failure 4. ABG – reveals PO2 is decreased (hypoxemia). A beta-hemolytic streptococcus .instruct client to assume a non weight bearing position . 90% is mitral valve stenosis due to a. There is anorexia and generalized body malaise 12. Productive cough with blood tinged sputum 5. RHD – inflammation of mitral valve due to invasion of Grp.Common among children .client is resistant to pharmacological agents. Ecocardiography – enlarged heart chamber (cardiomyopathy). Ischemic heart disease 4. Hypertension 5. Myocardial Infarction 3. Signs and Symptoms 1.client can resume sexual intercourse if can climb staircase . Resumption of ADL particularly sexual intercourse is 4 – 6 weeks post cardiac rehab. administer 150. Aging 2.ASO Titer (Anti streptolysin O titer) . Paroxysmal nocturnal dyspnea – client is awakened at night due to difficulty of breathing 3.000 units of streptokinase as ordered g.Formation of aschoff bodies in the mitral valve . Frothy salivation 6.Penicillin .000 – 450. Dyspnea 2. PMI is displaced laterally due to cardiomegaly 11.Aspirin b. post CABG and instruct to . Rales/Crackles 8. Bronchial wheezing 9. PCO2 is increased (respiratory acidosis) 2. Pulsus Alternans – weak pulse followed by strong bounding pulse 10.
Central venous pressure (CVP) .Upon insertion place client in trendelendberg position to promote ventricular filling and prevent pulmonary embolism 3.If CVP is less than 4 cm of water hypovolemic shock .Digoxin (Lanoxin) . Pitting edema 3. Tricuspid valve stenosis 2.Increase force of cardiac contraction . Ascites 4. Bronchodilators d.A. Administer medications as ordered a. Narcotic analgesics . Jaundice 7.If heart rate is decreased do not give b.Measure pressure in right atrium (4 – 10 cm of water) . Liver enzymes – SGPT and SGOT is increased D. Vasodilators . Weight gain 5. Pulmonary embolism 3. Pruritus 8.When reading CVP patient should be flat on bed .Nitroglycerine f.Do the fluid challenge (increase IV flow rate) . Enforce CBR 2. Esophageal varices C. Left sided heart failure B.If CVP is more than 10 cm of water hypervolemic shock . High fowlers position . Related to COPD 4. Administer oxygen inhalation with high inflow.Lasix (Furosemide) c.Lidocaine (Xylocane) 3.Morphine Sulfate e. Signs and Symptoms (venous congestion) 1. Cardiac glycosides . 3 – 4 L/min. Pulmonic valve stenosis 5. delivered via nasal cannula 4. Chest x-ray – reveals cardiomegaly 2. Diagnostic Procedures 1. Neck/jugular vein distension 2. Anti Arrhythmic . Nursing Management Goal: increase cardiac contractility thereby increasing cardiac output (3 – 6 L/min) 1. Predisposing Factors 1. Hepatosplenomegaly 6.Administer loop diuretics as ordered . Loop Diuretics .CVP fluid status measure . Ecocardiography – reveals enlarged heart chambers (cardiomyopathy 4. Anorexia 9.
Thrombo Angitis Obliterans Venous Ulcer 1. Doppler UTZ – decrease blood flow to the affected extremity 3. Nursing Management 1. intake and output and ECG tracing 6. Strict compliance to medications PERIPHERAL VASCULAR DISORDER Arterial Ulcer I. Provide client health teaching and discharge planning a. Signs and Symptoms 1. Monitor strictly vital signs. High risk groups – men 30 years old and above 2.Arrythmia . walking 3 – 4 times a day b. Analgesics Burger’s Disease Reynaud’s Disease . Prevent complications . Predisposing Factors 1. Dietary modification c. Oscillometry – decrease in peripheral pulses 2. Angiography – reveals site and extent of malocclusion D. Provide meticulous skin care 9.MI . Assist in bloodless phlebotomy – rotating tourniquet. rotated clockwise every 15 minutes to promote decrease venous return 10. Encourage a slow progressive physical activity a. Administer medications as ordered a. Measure abdominal girth daily and notify physician 7.Right ventricular hypertrophy . cholesterol and caffeine 8. Thrombophlebitis (deep vein thrombosis) THROMBOANGITIS OBLITERANS Acute inflammatory disorder usually affecting the small medium sized arteries and veins of the lower extremities A. Decreased peripheral pulses 4. Diagnostic Procedures 1. Provide a dietary intake of low sodium. Gangrene formation C.Thrombophlebitis b. Cold sensitivity and changes in skin color (pallor. cyanosis then rubor) 3.Shock . Intermittent claudication – leg pain upon walking 2. Trophic changes 5. Smoking B. out of bed 3 – 4 times a day 2.5. Varicose Veins 2. Ulceration 6.
Hereditary 2. Administer medications as ordered a. Ulceration 5. Thrombophlebitis 4. Rheumatoid Arthritis 4. Gangrene formation C. Trophic changes 4. Collagen diseases a. Operating chainsaw B. Diagnostic Procedures 1. Smoking 3. Cardiac disorder 5. Intermittent claudication – leg pain upon walking 2. Vasodilators c. Angiography – reveals site and extent of malocclusion D. Piano playing b. High risk group – female 40 years old and above 2. Institute foot care management 4. Direct hand trauma a. Anti coagulants 3. SLE (butterfly rash) b. Instruct client to avoid smoking and exposure to cold environment 5. Nursing Management 1. Doppler UTZ – decrease blood flow to the affected extremity 2. Vasodilators 2. cyanosis then rubor) 3. Encourage to wear gloves 3. Congenital weakness of veins 3. Pregnancy . Analgesics b. Instruct client on importance of cessation of smoking and exposure to cold environment VARICOSITIES Abnormal dilation of veins of lower extremities and trunks due to Incompetent valve resulting to Increased venous pooling resulting to Venous stasis causing Decrease venous return A. Cold sensitivity and changes in skin color (pallor. Predisposing Factors 1. Predisposing Factors 1. Excessive typing c. Assist in surgical procedure – bellow knee amputation REYNAUD’S DISEASE Disorder characterized by acute episodes of arterial spasm involving the fingers or digits of the hands A. Signs and Symptoms 1.b.
Warm to touch 4. Congestive heart failure 8. Analgesics 5. Dilated tortuous skin veins 4. Prolong use of oral contraceptives – promotes lipolysis 6. Myocardial infarction 9. Obesity 2. Post op complication 10. Signs and Symptoms 1. Measure the circumference of leg muscle to determine if swollen 3. Diabetes mellitus 7. Elevate legs above heart level to promote increased venous return by placing 2 – 3 pillows under the legs 2. Trendelenburg’s Test . Nursing Management . Sclerotherapy – can recur and only done in spider web varicosities and danger of thrombosis (2 – 3 years for embolism) THROMBOPHLEBITIS Deep vein thrombosis Inflammation of the veins with thrombus formation A. Nursing Management 1. Chronic anemia 5. Assist in surgical procedure a.6.veins distends quickly in less than 35 seconds D. Smoking 3. Obesity 7. Pain at affected extremity 2. Dilated tortuous skin veins 3. Prolonged standing or sitting B. Vein stripping and ligation (most effective) b. Pain after prolonged standing 2. Post cannulation – insertion of various cardiac catheter 11. Administer medications as ordered a. Heaviness in legs C. Diagnostic Procedure 1. Positive Hpman’s Signs – pain at the calf or leg muscle upon dorsi flexion of the foot C. B. Signs and Symptoms 1. Venography 2. Angiography D. Venography 2. Wear anti embolic stockings 4. Warm to touch 3. Predisposing Factors 1. Increase in saturated fats in the diet. Related to pregnancy 4. Diagnostic Procedure 1.
Restlessness b. cholecystitis characterized by pain at the right upper quadrant with tenderness RESPIRATORY SYSTEM OVERVIEW OF THE STRUCTURES AND FUCNTIONS OF THE RESPIRATORY SYSTEM I.Consist of anastomosis of capillaries known as Keissel Rach Plexus (the site of nose bleeding) B.Serves as passageway of air going to the lungs . Larynx . Filtering of air 2.Tachycardia .Opening of larynx .Decrease LOC • MURPHY’S SIGN is seen in clients with cholelithiasis.Consist of cartilaginous rings . Pulmonary . Apply warm moist pack – to reduce lymphatic congestion 3.1.Diaphoresis .Serves as a muscular passageway for both food and air C. Lower Respiratory System .Left nostril . Cerebral . Pharynx/Throat .Palpitations . Measure circumference of leg muscle to determine if swollen 4. Elevate legs above heart level to promote increase venous return 2.For gas exchange A.Cartillage .Sudden sharp chest pain . Anti Coagulant .Headache . Trachea/Windpipe . Encourage to wear anti embolic stockings or knee elastic stockings 5.Right nostril .Closes to allow passage of food going to the esophagus .For phonation (voice production) .Heparin 6. Nose .Opens to allow passage of air . Administer medications as ordered a.Dizziness . Monitor for signs of complications Embolism a.Separated by septum . Warming and moistening of air 3.Unexplained dyspnea . Upper Respiratory System 1.The initial sign of complete airway obstruction is the inability to cough II.For cough reflex Glottis . Humidification A. Analgesics b.
Overcrowded places 3.Diffusion (Dalton’s law of partial pressure of gases) Respiratory Distress Syndrome .Right main bronchus .Site of gas exchange (CO2 and O2) .Left lung (consist of 2 lobes..Increase carbon dioxide is a powerful stimulant for breathing Type II Cells of Alveoli . Lungs .In premature infants 1:2 . Over fatigue 5. PTB/Pulmonary Tuberculosis (Koch’s Disease) . Mode of Transmission 1. Precipitating Factors 1. Signs and Symptoms 1.Left main bronchus C. Airborne transmission via droplet nuclei C. Ingestion of an infected cattle with mycobacterium bovis 6. Malnutrition 2.Secretes surfactant . Pleural fluid c. Low grade afternoon fever.Prevent collapse of alveoli . Pleural effusion c. 10 segments) .L/S ratio to determine lung maturity . Bronchus .Site of tracheostomy B. night sweats 2. Hydrothorax (air and blood in pleural space Alveoli .An acid fast. Alcoholism 4. Pneumonia b.Composed of lecithin and spingomyelin . Pareital b.Normal L/S ratio is 2:1 . Virulence (degree of pathogenecity) of microorganism B.Give oxygen of less 40% in premature to prevent atelectasis and retrolental fibroplasias . gram negative.Decrease oxygen stimulates breathing . Productive cough (yellowish sputum) .Serous membranes Pleural Cavity a.Infection of lung tissue caused by invasion of mycobacterium tuberculosis or tubercle bacilli .Decrease surface tension . aerobic and easily destroyed by heat or sunlight A.Right lung (consist of 3 lobes.retinopathy/blindness in prematurity Disorders of Respiratory System 1. 8 segments) . Visceral With Pleuritic Friction Rub a.
Kanamycin . generalized body malaise 4. Sputum Acid Fast Bacillus .DOH 8 – 10 mm induration.WHO 10 – 14 mm induration.PZA (Pyrazinamide) .Side Effect INH: peripheral neuritis/neuropathy (increase intake of Vitamin B6/Pyridoxine) . Place client on semi fowlers position to promote expansion of lungs 6. Force fluids to liquefy secretions 5. Enforce CBR 2. Encourage deep breathing and coughing exercise 7. Nursing Management 1. Institute short course chemotherapy a.Side Effect Rifampicin: all bodily secretions turn to red orange color .Reveals increase WBC E.Side Effect Ethambutol: optic neuritis b. Dyspnea 6.PZA can be replaced by Ethambutol .Positive Mantoux test (previous exposure to tubercle bacilli but without active TB) 2. 48 – 72 hours .Purified protein derivative . Chest pain 7.Injection of streptomycin (aminoglycoside) .INH (Isonicotinic Acid Hydrazide) .3. CBC .Amikacin .Given everyday simultaneously to prevent resistance . Mantoux Test (skin test) . Chest X-ray . Administer oxygen inhalation 4. Comfortable and humid environment 9. nephrotoxicity . taken after meals to facilitate absorption .Gentamycin . Standard phase .Rifampicin (Rifampin) .Neomycin .INH and Rifampicin is given for 4 months.Positive to cultured microorganism 3. Institute strict respiratory isolation 3.Side Effect PZA: allergic reaction.PZA is given for 2 months. Diagnostic Procedure 1. 48 – 72 hours . Anorexia.Reveals pulmonary infiltrates 4. Weight loss 5. taken before meals to facilitate absorption . Nebulize and suction when needed 8. Intensive phase . hepatotoxicity. Hemoptysis (chronic) D.
Bronchial wheezing .Give aspirin if there is fever . Bronchogenic Cancer .Side Effect: . Smoking 2. Rales/crackles 6.Initial sign is non productive cough .Adrenal gland c. Avoidance of precipitating factors b. Provide increase carbohydrates.Bones (potts) . Predisposing Factors 1. military tuberculosis) PTB . Prevent complications (atelectasis. Signs and Symptoms 1. Elderly C. chills. Provide client health teaching and discharge planning a. Escherichia Pneumoniae 6.Pneumocystic carini pneumonia .Drug of choice is Retrovir b.Eyes . High Risk Groups 1. Air pollution 3.Nephrotoxicity check for BUN and Creatinine . Fever. Aspiration of food causing aspiration pneumonia D.Ototoxicity damage to the 8th cranial nerve resulting to tinnitus leading to hearing loss . Immuno compromised a. Klebsella Pneumoniae 5..Chest x-ray confirms lung cancer 4. anorexia and general body malaise 4. vitamin C and calories 11. protein. Streptococcus Pneumonae – causing pneumococal pneumonia 2. Strict compliance to medications d. Pseudomonas B. causing hypostatic pneumonia 5. Dyspnea with prolong expiratory grunt 3. Etiologic Agents 1.Meninges . Productive cough with greenish to rusty sputum 2. Related to prolonged immobility (CVA clients). AIDS . dyspepsia. Children below 5 years old 2.Side Effect: tinnitus. heartburn 10.Skin . Weight loss 5. Importance of follow up care PNEUMONIA Inflammation of the lung parenchyma leading to pulmonary consolidation as the alveoli is filled with exudates A. Diplococcus Pneumoniae 4. Hemophylus Influenzae – causing broncho pneumonia 3.
Provide oral care after procedure g.7. Nebulize and suction as needed 8.Coughing exercises . CBC – reveals increase WBC.Clients with increase intra ocular pressure (Normal IOP 12 – 21 mmHg) . Sputum Gram Staining and Culture Sensitivity – positive to cultured microorganisms 2. Administer medications as ordered Broad Spectrum Antibiotic a. ABG analysis – reveals decrease PO2 4. Prevent complications . Avoid smoking b. Place on semi fowlers position 6. Pleuritic friction rub 9. Tetracycline c. Provide increase carbohydrates. Force fluid 5.Hemoptysis .Increase ICP 9. Enforce CBR 2.Deep breathing exercises . Chest x-ray – reveals pulmonary consolidation 3.Chest physiotherapy . Institute pulmonary toilet (tends to promote expectoration) .Drain uppermost area of lungs . Stop if client cannot tolerate procedure f. Best done before meals or 2 – 3 hours to prevent gastro esophageal reflux b. Cyanosis 8. Encourage client deep breathing exercises d. Administer bronchodilators 15 – 30 minutes before procedure e.Unstable vital signs . Contraindicated with . Microlides (Zethromax) Azethromycin (Side Effect: Ototoxicity) Antipyretics Mucolytics/Expectorants Analgesics 4.Placed on various position Nursing Management for Postural Drainage a. calories. Abdominal distention leading to paralytic ileus (absence of peristalsis) E. Nursing Management 1. Penicillin b. Diagnostic Procedure 1. Assist in postural drainage . protein and vitamin C 10. Chest pain 10. Monitor vital signs c. erythrocyte sedimentation rate is increased F. Health teaching and discharge planning a. Administer oxygen inhalation low inflow 3.Turning and reposition 7.
Nebulize and suction as needed 6. Diagnostic Procedures 1.Atelectasis . Smoking 2. Importance of follow up care HISTOPLASMOSIS Acute fungal infection caused by inhalation of contaminated dust or particles with histoplasma capsulatum derived from birds manure A. Predisposing Factors 1. Productive cough 2. Dyspnea on exertion 3. Prevent complications – bronchiectasis 7. Mucolytics d. Hemoptysis 6. Air pollution B. Signs and Symptoms PTB or Pneumonia like 1.. Antifungal . Administer medications as ordered a. Nursing Management 1. Steroids c. Histoplasmin Skin Test – positive 2. Regular adherence to medications d. Fever. Productive cough (consistent to all COPD) 2. anorexia. Enforce CBR 2.Fungizone (Nephrotoxicity. Chest and joint pains B. Signs and Symptoms 1. Prolonged expiratory grunt 4. general body malaise 4. check for BUN and Creatinine.Meningitis (nerve deafness. Cyanosis 5.Amphotericin B . Administer oxygen inhalation 3. Anorexia and generalized body malaise . Force fluids to liquefy secretions 5. chills. hydrocephalus) c. Antipyretics 4. Dyspnea 3. Hypokalemia) b. ABG analysis PO2 decrease C. Prevent the spread of infection by spraying of breeding places COPD (Chronic Obstructive Pulmonary/Lung Disease) Chronic Bronchitis Inflammation of bronchus resulting to hypertrophy or hyperplasia of goblet mucous producing cells leading to narrowing of smaller airways A.
beta blocker) c. Physical and emotional stress 3. Diagnostic Procedure ABG analysis – reveals PO2 decrease (hypoxemia). Sudden change in temperature. Intrinsic Asthma (Non atopic/Non allergic) Causes a. PCO2 increase. Fumes d.5. Cough that is non productive 2. Mild Stress/apprehension 6. Food additives (nitrates) e. Diagnostic Procedure 1. chicken d. air pressure and humidity f. chocolates. palpitations 7. Diaphoresis C.Before ABG test for positive Allens Test. milk. Lints 2. Peripheral edema b. Smoke e. Drugs (aspirin. Furs h. Pollen b. Dyspnea 3. ABG analysis – PO2 decrease . Cyanosis 7. Nursing Management 1. Dust c. Cor Pulmonale (right ventricular hypertrophy) C.Incentive spirometer reveals decrease vital lung capacity 2. Hereditary b. Scattered rales/ronchi 6. eggs. Tachycardia. Gases f. apply direct pressure to ulnar and radial artery to determine presence of collateral circulation D. pH decrease Bronchial Asthma Reversible inflammatory lung condition due to hypersensitivity to allergens leading to narrowing of smaller airways A. Pulmonary hypertension a. Signs and Symptoms 1. Foods (seafoods. Cyanosis 5. Enforce CBR . Danders g. penicillin. Mixed Type 90 – 95% B. Predisposing Factors (Depending on Types) 1. Pulmonary Function Test . Extrinsic Asthma ( Atopic/ Allergic ) Causes a. Wheezing on expiration 4.
Nebulize and suction when needed 7. Anorexia and generalized body malaise 5. Bronchodilators – given via inhalation or metered dose inhalaer or MDI for 5 minutes b. coughing and smoking. Diagnostic Procedure 1. Cyanosis 4. Importance of follow up care BRONCHIECTASIS Abnormal permanent dilation of bronchus leading to destruction of muscular and elastic tissues of alveoli A.Status Asthmaticus (give drug of choice) . Prevent complications . Signs and Symptoms 1. Provide client health teachings and discharge planning concerning a.Bronchodilators c. Mucomysts (acetylceisteine) d. Maintain NPO 6 – 8 hours prior to procedure 3. Administer medications as ordered a.Steroids . Regular adherence to medications to prevent development of status asthmaticus d. Recurrent lower respiratory tract infections 2. Mucolytics/expectorants e. Chest trauma 3. Anti histamine 4. Hemoptysis (only COPD with sign) C. Bronchoscopy – direct visualization of bronchus using fiberscope Nursing Management PRE Bronchoscopy 1. Force fluids 5.2.Emphysema . Secure inform consent and explain procedure to client 2. Semi fowlers position 6. Monitor for signs of laryngeal spasm – prepare tracheostomy set D. Monitor vital signs and breath sound POST Bronchoscopy 1. Feeding initiated upon return of gag reflex 2. Productive cough 2. Oxygen inhalation. may cause irritation 3. ABG – PO2 decrease 2. Avoid talking. Dyspnea 3. Steroids – decrease inflammation c. Predisposing Factors 1. Avoidance of precipitating factor b. Treatment . with low inflow of 2 – 3 L/min 3. Congenital defects 4. Related to presence of tumor B. Monitor for signs of gross 4.Epinephrine .
Decrease ph . for recoil of alveoli) B. Rales or ronchi 9.Increase PCO2 . Dyspnea at rest 3. Diagnostic Procedure 1.Unaffected lobectomy facilitate drainage EMPHYSEMA Irreversible terminal stage of COPD characterized by a. Pulmonary Function Test – reveals decrease vital lung capacity 2. Resonance to hyperresonance 6.Respiratory alkalosis D. Panacinar/ centriacinar . Prolong expiratory grunt 4. Decrease or diminished breath sounds 8. Over distention of thoracic cavity (barrel chest) A. Predisposing Factors 1. Decrease tactile fremitus 7. ABG analysis reveals a. Smoking 2. 1 lung is removed and position on affected side) 2. Signs and Symptoms 1. Productive cough 2. Hereditary – it involves deficiency of ALPHA-1 ANTI TRYPSIN (needed to form Elastase.Decrease PCO2 .Increase ph . High risk: elderly 5.Increase PO2 (hyperaxemia. Bronchial wheezing 10.Decrease PO2 (hypoxemia leading to chronic bronchitis. Surgery (pneumonectomy . Maldistribution of gases d. Purse lip breathing to eliminates excess CO2 (compensatory mechanism) C. Air trapping c.1. Allergy 4. Segmental Wedge Lobectomy (promote re expansion of lungs) . Flaring of alai nares 12. Enforce CBR . “Blue Bloaters”) . Panlobular/ centrilobular .Respiratory acidosis b. Barrel chest 11. Nursing Management 1. “Pink Puffers”) . Inelasticity of alveoli b. Air pollution 3. Anorexia and generalized body malaise 5.
Provide comfortable and humid environment 10.Cor Pulmonale . Provide high carbohydrates.CO2 narcosis may lead to coma .Atelectasis . vitamins and minerals 11. Bronchodilators b. Prevent complications . High fowlers position 5. Antibiotics d. Strict compliance to medication d. Importance of follow up care . Force fluids 6. Health teachings and discharge planning concerning a. protein. calories. Nebulize and suction when needed 8. Administer medications as ordered a. Mucolytics/expectorants 4.Pneumothorax c. Steroids c. Administer oxygen inhalation via low inflow 3. Avoid smoking b. Institute pulmonary toilet 7. Institute PEEP (positive end expiratory pressure) in mechanical ventilation promotes maximum alveolar lung expansion 9.2.
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