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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.
Immediate action. pain. pressure. Visual disturbances blurring of vision (primary) diplopia (double vision) scotomas (blind spots) 2. tingling sensation paresthesia numbness euphoria (sense of well being) 3. . Signs and Symptoms 1. ALZHEIMER’S DISEASE Atrophy of brain tissues. Characterized by remission and exacerbation. Wernicke’s Aphasia General Knowing Gnostic Area or General Interpretative Area.DEMYELINATING DISORDERS 1. Apraxia – no recognition of objects function. * Give palliative or supportive care. *Expressive aphasia “motor speech center” Broca’s Aphasia inability to understand spoken words. heat and cold. *Receptive aphasia DRUG OF CHOICE: ARICEPT (taken at bedtime) and COGNEX. 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. . Impaired sensation to touch. Agnosia – no recognition of inanimate objects. b. d. Ig M – acute in inflammation.short term protection. 2. Ig E – for allergic reaction. Ig A – present in all bodily secretions (tears. c. Mood swings . colostrums). saliva. MULTIPLE SCLEROSIS Chronic intermittent disorder of CNS characterized by white patches of demyelination in brain and spinal cord. Aphasia – no speech (nodding). Ig D – for chronic inflammation. Amnesia – loss of memory. Sign and Symptoms 4 A’s of Alzheimer a.
Impaired motor function weakness spasticity paralysis scanning speech TRIAD SIGNS OF MS Ataxia (Unsteady gait. plums. Decrease sexual capacity DIAGNOSTIC PROCEDURE Nystagmus CSF analysis (increase in IgG and Protein). c. For Urinary Incontinence Anti spasmodic agent a. Constipation 8. 5. Baclofen (Dioresal)/ Dantrolene Sodium (Dantrene) – muscle relaxants. Maintain side rails to prevent injury related to falls. pineapple. Yoga 4. (+) Romberg’s test) 5. d.4. Increase fluid intake and increase fiber to prevent constipation. Institute stress management techniques. Monitor breath sounds 1 hour after subcutaneous administration. b. Diuretics b. (+) Lhermitte’s sign a continuous and increase contraction of spinal column. a. ACTH (Adreno Corticotropic Hormone)/ Steroids for acute exacerbation to reduce edema at site of demyelination to prevent paralysis. 3. a. Monitor side effects bronchospasm and wheezing. Prophantheline Bromide (Promanthene) Acid ash diet like cranberry juice. MRI (reveals site and extent of demyelination). Administer medications as ordered a. Urinary retention/incontinence 7. c. prunes. To acidify urine and prevent bacterial multiplication. Catheterization to prevent retention. Deep breathing exercises b. NURSING MANAGEMENT 1. Immunosupresants 2. Interferons – alter immune response. Impaired cerebral function CHARCOTS TRIAD IAN Intentional tremors 6. vitamin C and orange. . Bethanicol Chloride (Urecholine) Nursing Management Only given subcutaneous.
Brain Mass PARTS OF THE BRAIN 1. avoid use of tissue papers avoid using talcum powder and perfume. Functions of Cerebrum integrative sensory motor Lobes of Cerebrum 1. Parietal 4. 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. cold. 2. 80% brain mass 10% blood 10% CSF COMPOSITION OF BRAIN I. Occipital . eating). 3. CEREBRUM largest part composed of the Right Cerebral Hemisphere and Left Cerebral Hemisphere enclosed in the Corpus Callosum. pinocytosis (cell drinking). numbness.COMMON CAUSE OF UTI Female short urethra (3-5 cm. heat. Frontal higher cortical thinking controls personality controls motor activity Broca’s Area (motor speech area) when damaged results to garbled speech. Temporal hearing short term memory for appreciation discrimination of sensory impulses to pain. pressure. 8 inches) urinate after intercourse Nursing Management Male MICROGLIA stationary cells that carry on phagocytosis (engulfing of bacteria or cellular debris. 1-1 ½ inches) poor perineal hygiene vaginal environment is moist avoid bubble bath (can alter Ph of vagina). touch. Urethra (20 cm.
swallowing. Hypothalamus 5. positive PERRLA 4. release dopamine (controls gross voluntary movement. rhythm and depth of respiration. hiccup. controls respiration. Cerebellum smallest part of the brain. Medulla Oblongata 3. Pons pneumotaxic center controls the rate. controls pituitary functions androgenic hormones promotes secondary sex characteristics. hearing acuity is 30 – 40 dB. controls temperature (thermoregulatory center). for vision visceral function activities of internal organ like gastric motility. equal size of pupil is isocoria. size of pupil is 2 – 3 mm. BRAIN STEM located at lowest part of brain Parts of Brain Stem 1. controls smell and if damaged results to Anosmia (absence of smell). B. INTERBRAIN/ DIENCEPHALON Parts of Diencephalon A. heart rate. MIDBRAIN/ MESENCEPHALON acts as relay station for sight and hearing. Thalamus acts as relay station for sensation. vasomotor center (dilation and constriction of bronchioles). lesser brain. controls blood pressure controls thirst appetite/satiety sleep and wakefulness controls some emotional responses like fear. unequal size of pupil is anisocoria. . early sign for males are testicular and penile enlargement late sign is deepening of voice. 2. vomiting. controls libido controls long term memory Insula (Island of Reil) Limbic System (Rhinencephalon) 2. DECREASE Myasthenia Gravis Parkinson’s Disease INCREASE Bi-polar Disorder Schizophrenia NEURO TRANSMITTER Acethylcholine Dopamine 3. BASAL GAGLIA areas of grey matter located deep within each cerebral hemisphere. anxiety and excitement. early sign for females telarche and late sign is menarche.
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. 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. . 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). heart rate decrease respiratory rate decrease temperature increase directly proportional to blood pressure. Early closure of posterior fontanels causes posterior enlargement of skull in hydrocephalus. Cervical 2 – also known as AXIS. posture and gait. NEUROLOGIC DISORDERS INCREASE INTRACRANIAL PRESSURE – increase in intra-cranial bulk brought about by an increase in one of the 3 major intra cranial components. controls balance. widening of pulse pressure is neurologic in nature (if narrow cardiac in nature). projective vomiting headache papilledema (edema of optic disc) abnormal posturing decorticate posturing (damage to cortex and spinal cord). equilibrium.
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. Nursing Management . avoid clustering of nursing activity together. Maintain patent and adequate ventilation by: a. 3. monitor strictly input and output every 1 hour notify physician if output is less 30 cc/hr. d. In chronic respiratory distress syndrome decrease O2 stimulates respiration. b. b. Prevention of hypoxia and hypercarbia Early signs of hypoxia restlessness agitation tachycardia Bradycardia Extreme restlessness Dyspnea Cyanosis Increase CO2 (most powerful respiratory stimulant) retention. Osmotic diuretic (Mannitol) for cerebral diuresis Nursing Management monitor vital signs especially BP (hypotension). Elevate bed of client 30 – 35o angle with neck in neutral position unless contraindicated to promote venous drainage. administered via side drip regulated fast drip to prevent crystal formation. Assist in mechanical ventilation 2. Before and after suctioning hyper oxygenate client 100% and done 10 – 15 seconds only. maintain side rails. avoid use of restraints. decerebrate posturing (damage to upper brain stem that includes pons. Limit fluid intake to 1200 – 1500 ml/day (in force fluids 2000 – 3000 ml/day). c. Furosemide) Drug of choice for CHF (pulmonary edema) Loop of Henle in kidneys. c. 7. Prevent complications of 6. Administer medications like: a. Loop diuretic (Lasix. 4. cerebellum and midbrain). unilateral dilation of pupils called uncal herniation bilateral dilation of pupils called tentorial herniation resulting to mild headache possible seizure activity Nursing Management 1. Prevent further increase ICP by: a. provide an comfortable and quite environment. Monitor strictly input and output and neuro check 5. Late signs of hypoxia HYPERCARBIA b.
Dexamethasone (Decadron) Hydrocortisone Prednisone (to reduce edema that may lead to increase ICP) Mild Analgesics (Codeine Sulfate for respiratory depression) Anti Convulsants (Dilantin. monitor strictly input and output every 1 hour notify physician if output is less 30 cc/hr. Monitor vital signs especially BP (hypotension). Phenytoin) c. given early morning immediate effect of 10 – 15 minutes. administered IV push or oral. 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 .
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. in infant TACHYCARDIA) agitation dry mucous membrane poor skin turgor weakness and fatigue . Oral Potassium Chloride) increase intake of foods rich in potassium FRUITS Apple Banana Cantalop e Oranges 2. Hypokalemia decrease potassium level normal value is 3.5 meq/L weakness and fatigue constipation positive U wave on ECG tracing Sign and Symptoms Nursing Management administer potassium supplements as ordered (Kalium Durule.4 – 5. Hyponatremia DECREASE decrease sodium level normal value is 135 – 145 meq/L Signs and Symptoms hypotension dehydration signs (Initial sign in adult is THIRST.Signs and Symptoms of Lasix in terms of electrolyte imbalances 1. Hypocalcemia/ Tetany VEGETABLES Asparagus Brocolli Carrots Spinach decrease calcium level normal value is 8.
Signs and Symptoms Nursing Management a.Nursing Management force fluids administer isotonic fluid solution as ordered 4. Narcotic Analgesic b. Mechanism of action: inhibits synthesis of uric acid. Nursing Management a. Acute gout Mechanism of action: promotes excretion of uric acid. joint pain (great toes) swelling force fluids administer medications as ordered Drug of choice for gout. 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. Allopurinol (Zyloprim) Side Effects Respiratory depression (check for RR) . Allopurinol (Zyloprim) b. Hyperglycemia normal FBS is 80 – 100 mg/dl polyuria polydypsia polyphagia monitor FBS Signs and Symptoms Nursing Management 5. organ meats and anchovies) *Increase in tophi deposit leads to Gouty arthritis. Hyperuricemia increase uric acid (purine metabolism) foods high in uric acid (sardines.
Monotone type speech mood lability (in state of depression) increase salivation (drooling type) autonomic changes a. 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. 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. seborrhea d. Poisoning (lead and carbon monoxide) 2. constipation e. Increase dosage of the following drugs: a. increase lacrimation c. Arteriosclerosis 3. increase sweating b. difficulty rising from sitting position. Methyldopa(Aldomet) c. Encephalitis 5. Reserpine(Serpasil) b.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. decrease sexual capacity Nursing Management 1. Haloperidol(Haldol) d. Predisposing Factors 1. Administer medications as ordered Anti Parkinsonian agents Levodopa (L-dopa) short acting Amantadine Hydrochloride (Symmetrel) Carbidopa (Sinemet) . Hypoxia 4.
Assist/supervise in ambulation 7.6 – 1.5 meq/L . Dopamine Agonist . 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 . Decrease protein in morning and increase protein in afternoon to induce sleep 5.2 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 .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). Isonicotinic Acid Hydrazide Anti Cholinergic Agents (ARTANE and COGENTIN) .5 – 1. Encourage increase fluid intake and fiber. Prevent complications of immobility 4.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. Maintain side rails to prevent injury 3. 6.relieves tremor rigidity Bromocriptene Hydrochloride (Parlodel) Side Effects Respiratory depression 2.
9 NaCl to prevent development of crystals or precipitate.1. agitation and restlessness) only mixed with plain NSS or 0. irritability. 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 (. administered sandwich method avoid taking alcohol because it can lead to severe CNS depression avoid caffeine Nursing Management 4. Digitalis Toxicity Signs and Symptoms nausea and vomiting diarrhea confusion photophobia changes in color perception (yellowish spots) Antidote: Digibind 2. 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 3.8 – 1) hypoglycemia Tremors. Dilantin Toxicity Signs and Symptoms gingival hyperplasia (swollen gums) hairy tongue ataxia nystagmus provide oral care massage gums Nursing Management 5. depression Antidote: Acetylcisteine (mucomyst) prepare suction apparatus as bedside. Aminophylline Toxicity Signs and Symptoms tachycardia palpitations CNS excitement (tremors. tachycardia Irritability Restlessness Extreme fatigue Diaphoresis. .
swallow. 8. if there is no effect there is damage to occipital lobe and midbrain and is negative for Signs and Symptoms Diagnostic Procedure M.G.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. 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: . Prevent complications . Assist in surgical procedure known as thymectomy because it is believed that the thymus gland is responsible for M. Incidence rate: women 20 – 40 years old Predisposing factors unknown autoimmune: it involves release of cholinesterase an enzyme that destroys Ach. breathe Treatment . Cholinergic (Mestinon) b. speak.administer cholinergic agents as ordered 7.infection Signs and Symptoms . Assist in plasma paresis and removing auto immune anti bodies 9. initial sign is ptosis a clinical parameter to determine ptosis is palpebral fissure. institute NGT feeding 6.over medication Signs and Symptoms .under medication .The client is unable to see.Administer anti cholinergic agents (Atropine Sulfate) Side Effects MYASTHENIC CRISIS Causes: . 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.G. aspiration 3.PNS Treatment . Nursing Management 1. administer medications as ordered a. input and output and neuro check * monitor strength or motor grading scale 4. maintain side rails to prevent injury related to falls 5. airway 2. mmobility * assist in mechanical ventilation and monitor pulmonary function test * monitor strictly vital signs.stress .
Assess for movement and sensation of extremities. (+) cultured microorganism (confirms meningitis) CBC reveals 1. Hemophilus Influenzae – causes pediatric meningitis B. Empty bladder and bowel to promote comfort. Encourage to arch back to clearly visualize L3-L4. Nuchal rigidity or stiff neck b. (+) Brudzinski sign (neck pain) D.causes adult meningitis 4. Pneumococcus 3. Pia matter – inner layer subdural space between the dura and arachnoid subarachnoid space between the arachnoid and pia. Decrease glucose 3. Increase CSF opening pressure (normal pressure is 50 – 100 mmHg) 4. Diagnostic Procedures Lumbar puncture: a hollow spinal needle is inserted in the subarachnoid space between the L3 – L4 to L5. Check punctured site for any discoloration. Increase wbc . CSF analysis reveals 1. Signs and Symptoms headache photophobia projectile vomiting fever. 3. 2. A. Mode of transmission airborne transmission (droplet nuclei) C. Force fluids 3. CSF aspiration is done. drainage and leakage to tissues. Secure informed consent and explain procedure. Opisthotonus (arching of back) c. Increase CHON and WBC 2. 4. Etiology 1. Dura matter – outer layer 2.INFLAMMATORY CONDITIONS OF THE BRAIN MENINGITIS Meninges 3 fold membrane that covers brain and spinal cord. anorexia. Meningococcus – most dangerous 2. (+) Kernig’s sign (leg pain) d. Arachnoid – middle layer 3. chills. Place flat on bed 12 – 24 o 2. Streptococcus . for support and protection for nourishment blood supply LAYERS OF THE MENINGES 1. Post Lumbar Puncture 1. general body malaise and weight loss Possible increase in ICP and seizure activity Abnormal posturing (decorticate and decerebrate) Signs of meningeal irritation a. Nursing Management for LP Before Lumbar Puncture 1.
Maintain fluid and electrolyte balance. Incidence Rate men are 2-3 times high risk B. 8. Compartment syndrome (compression of arteries and nerves) . If there is bone fracture there is hemorrhage and there would be escape of the fat cells in the circulation.E. 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. Provide client health care and discharge planning concerning: a. input and output and neuro check 6. Prevent complications most feared is hydrocephalus hearing loss/nerve deafness is second complication consult audiologist mental retardation delayed psychomotor development c. Internal Cerebral Artery – the 2 largest artery A. Yellow bone marrow are produced from the medullary cavity of the long bones and produces fat cells. 2 most common cerebral artery affected by stroke a. Maintain good diet of increase CHO. 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. 7. 9. Mid Cerebral Artery b. b. CHON. Institute measures to prevent increase ICP and seizure. Nursing Management 1. Anti pyretics 3. Broad spectrum antibiotics (Penicillin. Mild analgesics c. 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. Monitor strictly V/S. calories with small frequent feedings. Administer medications as ordered a. Tetracycline) b. Enforce complete bed rest 2. Institute strict respiratory isolation 24 hours after initiation of anti biotic therapy 4. Elevate head 30-45o 5.
nausea and vomiting dysphagia (+) Kernig’s sign and Brudzinski sign which may lead to hemorrhagic stroke focal neurological deficits a. deadline driven b. D. usually fells guilty when not doing anything 6. Lifestyle (smoking). Hyperlipidemia more on genetics/genes that binds to cholesterol 5. Related to diet: increase intake of saturated fats like whole milk 7. homonymous hemianopsia (loss of half of visual field) 1. phlegia b. aphasia c. Valvular Cardiac Surgery (mitral valve replacement) 2. Type A personality a. Obesity (increase 20% ideal body weight) 4. Diagnostic Procedure 1. Stroke in evolution 3. CT Scan – reveals brain lesions 2. alexia (difficulty reading) e. Myocardial Infarction. dysarthria (inability to articulate words) d. sedentary lifestyle 3. Hypertension. 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. can do multiple tasks c. Risk Factors 1. Related stress physical and emotional 8. Diabetes Mellitus.C. 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 . Prolong use of oral contraceptives promotes lypolysis (breakdown of lipids) leading to atherosclerosis that will lead to hypertension and eventually CVA. Complete stroke Signs and Symptoms E. Signs and Symptoms Heart Disease. Atherosclerosis. agraphia (difficulty writing) f. TIA Signs and Symptoms 2.
F. I & O and neuro check 5. magic slate 9. avoidance of modifiable risk factors (diet. 6. If positive to hemianopsia approach client on unaffected side 10. Cortecosteroids d. Nursing Management 1. ulcer and unknown cause of headache because it may potentiate bleeding 11. Maintain patent airway and adequate ventilation by: a. Administer medications as ordered a. turn client to side b. dietary modification (decrease salt. prevent complication (subarachnoid hemorrhage is the most feared complication) c. exercise. Provide alternative means of communication a. assist in mechanical ventilation b. saturated fats and caffeine) d. administrate O2 inhalation 2. Mild Analgesics e. Provide client health teachings and discharge planning concerning a. Osmotic Diuretics (Mannitol) b. importance of follow up care . Assist in passive ROM exercise every 4 hours to promote proper bodily alignment and prevent contractures 7. Anti Coagulants Heparin (short acting) check for partial thromboplastin time if prolonged there is a risk for bleeding. Elevate head 30 – 45o 4. Monitor strictly vitals signs. smoking) b. 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. Loop Diuretics (Lasix. Anti Platelet PASA (Aspirin) Contraindicated for dengue. Institute NGT feeding 8. K (Aqua Mephyton) g. Restrict fluids to prevent cerebral edema that might increase ICP 3. provide sand bag or food board. Thrombolytic/Fibrinolytic Agents – dissolves thrombus Streptokinase Side Effect: Allergic Reaction Urokinase Tissue Plasminogen Activating Factor Side Effect: Chest Pain f. non verbal cues b. provide egg crate mattresses or water bed c. Prevent complications of immobility by: a. Furosemide) c.
Maintain patent airway and adequate ventilation by: a. A. Anti Arrythmic Agents Lidocaine. Assist in plasma pharesis (filtering of blood to remove autoimmune anti-bodies) 9. constipation C. assist in mechanical ventilation b. . Antecedent viral infections such as LRT infections B. Zylocaine Bretylium – blocks release of norepinephrine to prevent increase of BP 8. Administer medications as ordered a. increase salivation b. Anti Cholinergic Agents – Atrophine Sulfate c. Ascending muscle weakness leading to paralysis 4. Maintain side rails to prevent injury related to fall 4. Signs and Symptoms 1. Decreased of diminished deep tendon reflex 5. Dysphagia 3. Institute NGT feeding to prevent aspiration 6. Autoimmune 2. Prevent complications a. Diagnostic Procedures 1. Monitor strictly the following a. CSF analysis reveals increase in IgG and protein D.GUILLAIN BARRE SYNDROME a disorder of the CNS characterized by bilateral symmetrical polyneuritis leading to ascending muscle paralysis. ECG 3. Clumsiness (initial sign) 2. neuro check d. intake and output c. Alternate hypotension to hypertension ** ARRYTHMIA (most feared complication) 6. increase sweating c. Autonomic symptoms that includes a. Prevent complications of immobility by turning the client every 2 hours 5. Arrythmia b. Predisposing Factors 1. 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. Assist in passive ROM exercise 7. monitor pulmonary function test 2. vital signs b. Corticosteroids – suppress immune response b. Nursing Management 1.
visual.direct symmetrical extension of extremities Clonic contractions . if left untreated can lead to hyperpyrexia and lead to coma and eventually death.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. Psychomotor Seizure (focal motor seizure) a. Seizure – first convulsive attack Epilepsy – second or series of attacks Febrile seizure – normal in children age below 5 years A. tactile. Physical and emotional stress 7. Partial or Localized Seizure 1. Grand mal Seizure (tonic-clonic seizure) a. Post ictal sleep – unresponsive sleep 2. lead b carbon monoxide 5. EEG – reveals hyper activity of electrical brain waves . loss of consciousness (5 – 10 seconds) II. twitching of mouth d. Drug of choice: Diazepam. Head injury due to birth trauma 2. olfactory. Diagnostic Procedures 1. sensory experience b. Petit mal Seizure – absence of seizure common among pediatric clients characterized by a.contraction of extremities d. Nutritional and Metabolic deficiencies 6. 2. Genetics 3. mild hallucinatory sensory experience III. Valium) B. Signs or aura with auditory. Generalized Seizure 1. Predisposing Factors 1. automatism – stereotype repetitive and non propulsive behavior 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. Valium and Glucose C. Toxicity from a. clouding of consciousness – not in contact with environment c. Signs and Symptoms Dependent on stages of development or types of seizure I. Presence of brain tumor 4. CT Scan – reveals brain lesions 2. blank stare b. Tonic contractions . Sudden withdrawal to anti convulsant drug is predisposing factor for status epilepticus (drug of choice is Diazepam. Epileptic cry – is characterized by fall and loss of consciousness for 3 – 5 minutes c. decrease blinking of eyes c. Status Epilepticus A continuous uninterrupted seizure activity.
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
Blurring or hazy vision 2. Miotics – constricts pupil a. TRABECULECTOMY (Peripheral Indectomy) – drain aqueous humor 2. Signs and Symptoms 1. Carbonic Anhydrase Inhibitors a. Mydriatics (Mydriacyl) – constricts pupils 2. Acetazolamide (Diamox) – promotes increase outflow of aqueous humor or drainage 4. Loss of central vision C. Cyclopegics (Cyclogyl) – paralyses cilliary muscle F. Surgical Procedures 1. Pathognomonic Signs 1. Diagnostic Procedure 1. Surgical Procedure Extra Capsular Cataract Lens Extraction . Decrease perception to colors Complication is blindness D. Epinephrine eyedrops – decrease formation of aqueous humor 3. Diabetes Mellitus 4. Cataract Decrease opacity of lens A. Treatment 1.Total removal of cataract with its surrounding capsules Most feared complication post op is RETINAL DETACHMENT 3. Treatment 1. Aging 65 years and above 2. Retinal Detachment Separation of epithelial surface of retina . Pilocarpine Sodium. Opthalmoscopic exam E.3. Milky white appearance at center of pupils 3.Partial removal Intra Capsular Cataract Lens Extraction . Prolonged exposure to UV rays B. Timoptics (Timolol Maleate) E. Carbachol 2. Predisposing Factor 1. Gonioscopy D. Related to congenital 3.
Floaters C. Scleral Buckling 2.A. VI: OCULOMOTOR. IV. Macular Degeneration Degeneration of the macula lutea (yellowish spot at the center of retina) A. Signs and Symptoms 1. Cryosurgery – cold application 3. TROCHLEAR. Post Lens Extraction 2. Myopia (near sightedness) B. Signs and Symptoms 1. Curtain veil like vision 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. Black Spots CRANIAL NERVE III. Surgical Procedures 1. Diathermy – heat application 4. mandibular . maxillary.
Inner Ear Vestibule: Meinere’s Disease Cochlea Mastoid Cells Endolymph and Perilymph COCHLEA: controls hearing. frown and if results are negative there is facial paralysis or Bell’s Palsy and the primary cause is forcep delivery. CRANIAL NERVE VIII: ACOUSTIC/VESTIBULOCOCHLEAR Controls balance particularly kinesthesia or position sense. X: GLOSOPHARYNGEAL. VAGUS NERVE Glosopharyngeal: controls taste. teeth. Pituitary Gland (Hypophysis Cerebri) . ENDOCRINE SYSTEM Overview of the structures and functions 1. Middle Ear 3. 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. refers to movement and orientation of the body in space. 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. Outer Ear Pinna Eardrum Hammer Anvil Stirrup Malleus Incus Stapes 2. sensory: controls sensation of face. contains the Organ of Corti (the true organ of hearing) Let client repeat words uttered CRANIAL NERVE IX. Parts of the Ear 1. mucous membrane.
Poor Skin turgor d. Force fluids 2. Prevent complilcations – HYPOVOLEMIC SHOCK is the most feared complication Normal value: 1.015 – 1. Predisposing Factor o o o o 1. Weakness and fatigue 4. Monitor strictly vital signs and intake and output 3. 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. Nursing Management . Urine Specific Gravity o o o 1. Posterior Pituitary Gland 2. Diagnostic Procedures 1. Pitressin (Vasopresin Tannate) – administered IM Z-tract 4. 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. Serum Sodium D. If left untreated results to hypovolemic shock (sign is anuria) C. Anterior Pituitary Gland o o o hemorrhage o o administrate oxytocin immediately after delivery to prevent uterine atony. Administer medications as ordered a. Hypotension 5. Adult: thirst b. Agitation c. Signs of dehydration a. Dry mucous membrane 3. Signs and Symptoms 2. Polyuria 2. Weight loss 6.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 1.030 Ph 4 – 8 Increase resulting to hypernatremia Related to pituitary surgery Trauma Inflammation Presence of tumor B.
Serum Sodium is decreased D. Melanocyte Stimulating hormone o o o for skin pigmentation Hyposecretion of MSH results to Albinism Most feared complications of albinism a. Weight gain 2. Predisposing Factors 1. Related to presence of bronchogenic cancer o o gland. 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. Loop diuretics (Lasix) b.SIADH o hypersecretion of anti diuretic hormone A. Head injury 2. Signs and Symptoms 1. Provide meticulous skin care 6. Prone to skin cancer o Hypersecretion of MSH results to Vitiligo 3. B. Lead to blindness due to severe photophobia b. Edema c. Adrenochorticotropic hormone (ACTH) o promotes development of adrenal cortex . Hypertension b. Urine specific gravity is increased 2. Osmotic diuretics (Mannitol) 3. Weigh patient daily and assess for pitting edema 5. Administer medications as ordered a. Diagnostic Procedure 1. Fluid retention a. Related to hyperplasia (increase size of organ brought about by increase of number of cells) of pituitary 2. Water intoxication may lead to cerebral edema and lead to increase ICP – may lead to seizure activity C. Monitor strictly vital signs. 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. intake and output and neuro check 4. Restrict fluid 2. Nursing Management 1.
sweet potato. T4 (tetra iodothyronine. Increase intake of goitrogenic foods o o o contains pro-goitrin an anti thyroid agent that has no iodine. radish. 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 1.3 molecules of iodine (more potent) 2. Goiter belt area a. Predisposing Factors 1. Thyroxine) o o T3 and T4 are metabolic or calorigenic hormone promotes cerebration (thinking) 3. 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. Thyrocalcitonin – antagonizes the effects of parathormone to promote calcium resorption. strawberry. Leutinizing hormone 6. all nuts soil erosion washes away iodine . T3 (Tri iodothyronine) . turnips. cabbage. carrots.4. broccoli. Mountainous regions 2. places far from sea b. 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.
Enlarged thyroid gland 2. Phenylbutazones (NSAIDs) .o goitrogenic drugs a. Tetracycline. Nursing Management 1. Related to atrophy of thyroid gland due to trauma. Anti Thyroid Agent – Prophylthiuracil (PTU) b. Instruct client to take in the morning to prevent insomnia 2. 4 Medications to be taken via straw: Lugol’s. Signs and Symptoms 1. Administer medications as ordered a. Predisposing Factors 1.if goiter is caused by B. Serum Thyroid Stimulating Hormone (TSH) – is increased (confirmatory diagnostic test) D. Thyroid Hormones o o o Levothyroxine (Synthroid) Liothyronine (Cytomel) Thyroid Extracts Nursing Management when giving Thyroid Hormones 1. Nitrofurantoin (drug of choice for pyelonephritis) b. Lugol’s Solution/SSKI ( Saturated Solution of Potassium Iodine) o o color purple or violet and administered via straw to prevent staining of teeth. clams and lobster but not shrimps because it contains lesser amount of iodine. Iron. Thyroid Scan – reveals enlarged thyroid gland. Enforce complete bed rest 2. presence of tumor. Cobalt e. Monitor side effects o o o o o o o insomnia tachycardia and palpitations hypertension heat intolerance seaweeds seafood’s like oyster. Mild restlessness C. Lithium Carbonate c. PASA (Aspirin) d. Increase dietary intake of foods rich in iodine A. Mild dysphagia 3. inflammation . 3. 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. Diagnostic Procedures 1. iodized salt. Iatrogenic Cause – disease caused by medical intervention such as surgery 2. best taken raw because it it is easily destroyed by heat 5. Serum T3 and T4 – reveals normal or below normal 2. crabs. Monitor vital signs especially heart rate because drug causes tachycardia and palpitations 3.
RAIU (Radio Active Iodine Uptake) is decreased D. 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. Provide client health teaching and discharge planning concerning a. Cold intolerance 5. Iodine deficiency 4. hypoventilation. Avoid precipitating factors leading to myxedema coma o o stress infection Assist in mechanical ventilation Administer thyroid hormones as ordered Force fluids . Decrease in all vital signs – hypotension. CNS changes o o o o lethargy memory impairment psychosis menorrhagia C. Administer medications as ordered Thyroid Hormones a. Administer isotonic fluid solution as ordered 4. Autoimmune (Hashimotos Disease) B.3. Non pitting edema (Myxedema) 3. bradypnea. Constipation (Late Signs) 1. Force fluids 3. Nursing Management 1. bradycardia. hypothermia leading to pregressive stupor and coma. Provide dietary intake that is low in calories 6. Nursing Management for Myxedema Coma 2. hypothermia 6. Serum Cholesterol is increased 3. hypoglycemia. Weakness and fatigue 2. Loss of appetite but with weight gain which promotes lipolysis leading to atherosclerosis and MI 3. Decrease libido 5. Dry skin 4. Levothyroxine b. hyponatremia. Thyroid Extracts 5. Hoarseness of voice 4. Brittleness of hair and nails 2. bradycardia. bradypnea. Diagnostic Procedures 1. Leothyronine c. Provide meticulous skin care 8. Signs and Symptoms (Early Signs) 1. Serum T3 and T4 is decreased 2. Provide comfortable and warm environment 7.
CNS involvement a. narcotics. Diagnostic Procedures 1. Maintain side rails . Provide meticulous skin care 5. Restlessness c. Provide dietary intake that is increased in calories. Increase appetite (hyperphagia) but there is weight loss 2. Amenorrhea C. Serum T3 and T4 is increased 2. Monitor strictly vital signs and intake and output 2. All vital signs are increased 6. 4. RAIU (Radio Active Iodine Uptake) is increased 3. 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. Administer medications as ordered Anti Thyroid Agent a. Diarrhea 5. 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. Signs and Symptoms 1.reveals an enlarged thyroid gland D. Tremors d. Irritability and agitation b. Related to hyperplasia (increase size) B. Thyroid Scan. Prophythioracill (PTU) b. Goiter 8. Autoimmune – it involves release of long acting thyroid stimulator causing exopthalmus (protrusion of eyeballs) enopthalmus (late sign of dehydration among infants) 2. Comfortable and cold environment 6. Heat intolerance 4. Insomnia e. Excessive iodine intake 3. Predisposing Factors 1. Hallucinations 7. and sedatives prevent complications (myxedema coma.o o o o o o o o cold intolerance use of anesthetics. Exopthalmus 9. Moist skin 3. Nursing Management 1.
seizure give Calcium Gluconate IV slowly as ordered 3. 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. 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 . input and output and neuro check.7. Beta-blockers o o o monitor strictly vital signs. Provide bilateral eye patch to prevent drying of the eyes. 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. 8. 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. 1. Hormonal replacement therapy for lifetime 6. Watch out for signs of thyroid storm/ thyrotoxicosis Agitation TRIAD SIGNS Hyperthermia o administer medications as ordered a. 5. 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. Anti Pyretics b. POST OPERATIVELY.
5 – 11 mg/100 ml) 2.C MAD . Predisposing Factors 1. trauma B. Administer medications as ordered such as: a. dysphagia e. tingling sensation b. nausea and vomiting d. inflammation b. Acute tetany a.5 – 4. laryngospasm/broncospasm h. Serum Calcium is decreased (normal value: 8. Chronic tetany a. CT Scan – reveals degeneration of basal ganglia D. Signs and Symptoms 1. Following subtotal thyroidectomy 2. seizure i. Diagnostic Procedures 1. tumor c. anorexia. Chronic Tetany Oral Calcium supplements Calcium Gluconate Calcium Lactate Calcium Carbonate c. positive trousseu’s sign/carpopedal spasm f. Phosphate binder Aluminum Hydroxide Gel (Ampogel) Side effect: constipation ANTACID A.A. Nursing Management 1. loss of tooth enamel c. Vitamin D (Cholecalciferol) for absorption of calcium CHOLECALCIFEROL ARE DERIVED FROM Drug Diet (Calcidiol) Sunlight (Calcitriol) feared complications d. numbness d. photophobia and cataract formation b. X-ray of long bones reveals a decrease in bone density 4. arrhythmia 2. Atrophy of parathyroid gland due to: a. agitation and memory impairment C.A. Serum Phosphate is decreased (normal value: 2. Acute Tetany Calcium Gluconate IV slowly b.5 mg/100 ml) 3. paresthesia c. positive chvostek sign g.
Morphine Sulfate (Demerol) 5. Bone pain especially at back (bone fracture) 2. Anorexia. Maintain side rails . Strain all the urine using gauze pad for stone analysis 3. Institute seizure and safety precaution 5. Agitation and memory impairment C. 6. Nursing Management 1. renal cholic b. salmon c. Provide warm sitz bath 4. 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. Serum Calcium is increased 2. Avoid precipitating stimulus such as glaring lights and noise 3. Assist/supervise in ambulation 8. Signs and Symptoms 1. Hyperplasia of parathyroid gland 2. anchovies b. Children: Ricketts b. Encourage client to breathe using paper bag to produce mild respiratory acidosis result. Administer medications as ordered a. X-ray of long bones reveals bone demineralization D. Kidney stones a. cool moist skin 3. nausea and vomiting 4. Over compensation of parathyroid gland due to vitamin D deficiency a. Hormonal replacement therapy for lifetime 9. Diagnostic Procedures 1. green turnips 4. Encourage increase intake of foods rich in phosphate but decrease in calcium 6. Predisposing Factors 1. Encourage increase intake of foods rich in calcium a. Prevent complications 8.▼ Aluminum Containing Antacids ▼ Aluminum Hydroxide Gel ▼ Side Effect: Constipation ▼ Magnesium Containing Antacids ▼ Side Effect: Diarrhea 2. Force fluids to prevent kidney stones 2. Adults: Osteomalacia B. Importance of follow up care. Serum Phosphate is decreased 3. Provide acid ash in the diet to acidify urine and prevent bacterial growth 7. Prepare trache set at bedside for presence of laryngo spasm 7.
deficiency of neuromuscular function – Salt/Sex A.Salt ADDISON’S DISEASE o Hyposecretion of adreno cortical hormone leading to a. Fungal infections B. Adrenal Cortex – outermost b.signs of dehydration . Zona Glumerulosa . Hyponatremia . metabolic disturbance – Sugar b.Sex 3.9. Zona Fasciculata . Importance of follow up care ADRENAL GLAND o o Located atop of each kidney 2 layers of adrenal gland a. fluid and electrolyte imbalance – Salt c.secretes mineralocorticoids (aldosterone) .function: controls glucose metabolism . Assist in surgical procedure known as parathyroidectomy 11. Hypoglycemia – TIRED 2. Prevent complications (seizure and arrhythmia) 10.weight loss .Sugar 2. Predisposing Factors 1.function: promotes sodium and water reabsorption and excretion of potassium . Decrease tolerance to stress 3.secretes traces of glucocorticoids and androgenic hormones .hypotension .secretes glucocortocoids (cortisol) . 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. Related to atrophy of adrenal glands 2. Zona Reticularis .function: promotes secondary sex characteristics . Signs and Symptoms 1. Hormonal replacement therapy for lifetime 12.
Nursing Management 1.arrhythmia 5.addisonian crisis . Prednisone c. edema c. Dexamethasone (Decadrone) b. Bronze like skin pigmentation C. Loss of pubic and axillary hair 7. Plasma Cortisol is decreased 3. Hydrocortisone (Cortison) Nursing Management when giving steroids 1. Monitor side effects a. increase susceptibility to infection e.sudden withdrawal to steroids b. avoid precipitating factor leading to addisonian crisis leading to .agitation . .diarrhea . carbohydrates.stress . Hyperkalemia . Instruct client to take 2/3 dose in the morning and 1/3 dose in the afternoon to mimic the normal diurnal rhythm 2.infection .force fluids 2.administer steroids as ordered . severe hypotension b. Administer isotonic fluid solution as ordered 3. Administer medications as ordered Corticosteroids a. hypertension b. Serum Sodium is decrease (normal value: 135 – 145 meq/L) 4. 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.5 – 4. Provide dietary intake.hypovolemic shock . hypovolemic shock c. Provide meticulous skin care 7. Monitor strictly vital signs. prevent complications . Serum Potassium is increased (normal value: 3. protein but decrease in potassium 6.5 meq/L) D. hirsutism d. Decrease libido 6. Provide client health teaching and discharge planning a. Force fluids 4. FBS is decreased (normal value: 80 – 100 mg/dl) 2. Diagnostic Procedures 1. increase calories. Assist in mechanical ventilation.4. moon face appearance 4. Taper dose (withdraw gradually from drug) 3. hyponatremia leading to progressive stupor and coma Nursing Management for Addisonian Crisis 1. Mineralocorticoids (Flourocortisone) 5.
Serum Sodium is increased 4. Hirsutism 6. Prevent complications (DM) 8. U wave upon ECG (T wave hyperkalemia) 5. Diagnostic Procedures 1. thin extremities 4. Predisposing Factors 1 Related to hyperplasia of adrenal gland 2. Hypokalemia a.Mixed gland (exocrine and endocrine) . weight gain d. constipation c. obese trunk f. importance of follow up care CUSHING SYNDROME o Hypersecretion of adenocortical hormones A. hormonal replacement for lifetime d. Provide meticulous skin care 6. pendulous abdomen g. Hormonal replacement for lifetime 10. Spinarolactone – potassium sparring diuretics 7. Assist in surgical procedure (bilateral adrenoraphy) 9. Administer medications as ordered a. Plasma Cortisol is increased 3. weakness and fatigue b. hypertension b.c. Measure abdominal girth daily and notify physician 4. Monitor strictly vital signs and intake and output 2. Increase susceptibility to infections 3. Importance of follow up care PANCREAS .Located behind the stomach . Restrict sodium intake 5. Hypernatremia a. Increase masculinity among females B. Nursing Management 1. Weigh patient daily and assess for pitting edema 3. moon face appearance and buffalo hump e. Easy bruising 8. FBS is increased 2. edema c. Serum Potassium is decreased C. Acne and striae 7.
Glucosuria 6.90% of general population has type 2 DM B.Has alpha cells that secretes glucagons (function: hyperglycemia) .Juvenile onset type . Related to carbon tetrachloride toxicity C. Polyuria 3. Lasix b.Delta cells secretes somatostatin (function: antagonizes the effects of growth hormones) 3 Main Disorders of Pancreas 1. Incidence Rate .Brittle disease A. Predisposing Factors 1.metabolic disorder characterized by non utilization of carbohydrates. Hyper 2. Polydypsia 4. Obesity – because obese persons lack insulin receptor binding sites .10% general population has type 1 DM B. Drugs a. Non 4. Polydypsia 3. Signs and Symptoms 1.Maturity onset type . Usually asymptomatic 2. Related to viruses 3. Blurring of vision 8. Polyuria 2. Diet 3. Ketotic 5.Obese over 40 years old A. Polyphagia 5. Polyphagia 4. Complication 1. Osmolar 3. Weight loss 6. Diabetes Mellitus 3. Diabetic Ketoacidosis D. Signs and Symptoms 1.Consist of islets of langerhans .Adult onset . Increase susceptibility to infection 9. protein and fat metabolism CLASSIFICATION OF DM Type 1 (IDDM) . Weight gain Type 2 (NIDDM) . Diet 3. Complications 1. Glucosuria 5. nausea and vomiting 7. Pancreatic Tumor/Cancer 2. Insulin therapy 2.Beta cells secretes insulin (function: hypoglycemia) . Delayed/poor wound healing D. Oral Hypoglycemic agents 2. Hereditary (total destruction of pancreatic cells) 2. Treatment 1.Consist of acinar cells which secretes pancreatic juices that aids in digestion thus it is an exocrine gland . Coma C. Pancreatitis DIABETES MELLITUS . Predisposing Factors 1. Incidence Rate . Exercise E. Treatment 1. Steroids 4.. Anorexia. Exercise E.
MAIN FOODSTUFF 1. Carbohydrates 2.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 . Fats ANABOLISM CATABOLISM Glucose Amino Acids Fatty Acids Glycogen Nitrogen Free Fatty Acids .Cholesterol . Protein 3.
BUN (normal value: 10 – 20) 3. nausea and vomiting 7. Administer medications as ordered a. Weight loss 6. Administer 0.45 NaCl (hypotonic solutions) to counteract dehydration and shock 3. Acetone breath odor 9. Nursing Management 1.8 – 1) 4.DIABETIC KETOACIDOSIS . Polydypsia 3. male 42 – 48) due to severe dehydration D.Non ketotic: absence of lypolysis (no ketones) A. Creatinine (normal value: .Hyperosmolar: increase osmolarity (severe dehydration) . Hct (normal value: female 36 – 42. Signs and Symptoms 1. Restlessness 3. Predisposing Factors 1. Signs and Symptoms 1. Glucosuria 5. Polyuria 2. Sodium Bicarbonate to counteract acidosis c. Hyperglycemia 2. Polyphagia 4. Assist in mechanical ventilation 2. Antibiotics to prevent infection HYPER OSMOLAR NON KETOTIC COMA . Seizure activity 4. Insulin therapy (regular acting insulin/rapid acting insulin peak action of 2 – 4 hours) b. Stress – number one precipitating factor 3.9 NaCl followed by . intake and output and blood sugar levels 4.Acute complication of type 1 DM due to severe hyperglycemia leading to severe CNS depression A. FBS is increased 2. Diagnostic Procedures 1. Kussmaul’s Respiration (rapid shallow breathing) 10 CNS depression leading to coma C. Monitor strictly vital signs. Decrease LOC – diabetic coma . Headache and dizziness 2. Infection B. Anorexia. Blurring of vision 8.
B. Place in refrigerator once opened 3. Intermediate Acting Insulin (cloudy) . Long Acting Insulin (cloudy) .Derived from beef and pork 2. Administer insulin either 45o – 90o depending on amount of clients tissue deposit 6. Animal sources . Administer 0.9 NaCl followed by .for DKA use rapid acting insulin b. Insulin therapy (regular acting insulin peak action of 2 – 4 hours) . Avoid shaking insulin vial vigorously instead gently roll vial between palm to prevent formation of bubbles 4. Allergic reactions b. Chlorpropamide (Diabenase) b.Peak action is 2 – 4 hours 2. Sources of Insulin 1.Non Protamine Hagedorn Insulin (NPH) .Stimulates the pancreas to secrete insulin A. Artificially Compound Insulin B. Classsification 1. Tolbutamide (Orinase) . Monitor strictly vital signs. Nursing Management for Insulin Injections 1.Rarely used because it can cause severe allergic reaction . intake and output and blood sugar levels 4.45 NaCl (hypotonic solutions) to counteract dehydration and shock 3. First Generation Sulfonylureas a. 10.Peak action is 8 – 16 hours 3. Monitor for signs of local complications such as a. hypertrophy of subcutaneous tissues) 2. Assist in mechanical ventilation 2. Use gauge 25 – 26 needle 5.Ultra Lente . Nursing Management 1. Somogyis Phenomenon – rebound effect of insulin characterized by hypoglycemia to hyperglycemia ORAL HYPOGLYCEMIC AGENTS . Administer at room temperature to prevent development of lipodystrophy (atrophy. Rotate insulin injection sites to prevent development of lipodystrophy 8. Antibiotics to prevent infection INSULIN THERAPY A. When mixing 2 types of insulin aspirate first the clear insulin before cloudy to prevent contaminating the clear insulin and promote proper calibration.Regular acting insulin (IV only) . Human Sources . Administer medications as ordered a.Frequently used type because it has less antigenicity property thus less allergic reaction 3. Rapid Acting Insulin (clear) .Peak action is 16 – 24 hours C. Types of Insulin 1. Lipodystrophy c. Most accessible route is abdomen 9. No need to aspirate upon injection 7.
Monitor for signs of DKA and HONKC 11. assist in surgical wound debriment (give analgesics 15 – 30 mins prior) 9. Nursing Management 1.sexual impotence 8. CVA) b. Provide nutritional intake of diabetic diet that includes: carbohydrates 50%.administer simple sugars . Monitor for peak action of insulin and OHA and notify physician 2. HPN and DM major cause of renal failure d. instruct client to cut toenails straight c. Instruct the client to avoid taking alcohol because it can lead to severe hypoglycemia reaction or Disulfiram (Antabuse) toxicity symptoms B. instruct client to avoid wearing constrictive garments d. Administer insulin and OHA therapy as ordered 3. Second Generation Sulfonylureas a. MI. Instruct the client to take it with meals to lessen GIT irritation and prevent hypoglycemia 2. Diagnostic Procedures 1.Blindness KIDNEY -RECURRENT PYELONEPHRITIS . Atherosclerosis (HPN. Monitor for signs of hypoglycemia and hyperglycemia . Institute foot care management a. Gangrene formation e. Blood Forming Organs . Alpha Glycosylated Hemoglobin is increased C. Instruct client to exercise best after meals when blood glucose is rising 7.peripheral neuropathy . Glipzide (Glucotrol) b. Monitor strictly vital signs. protein 30% and fats 20% or offer alternative food substitutes 6.diarrhea/constipation . polyphagia and glucosuria confirmatory for DM) 2.for hypoglycemia (cold and clammy skin) give simple sugars . encourage client to apply lanolin lotion to prevent skin breakdown e. Microangiopathy (affects small minute blood vessels of eyes and kidneys) EYES -PREMATURE CATARACT . Random Blood Sugar is increased 3.c. Assist in surgical procedure HEMATOLOGICAL SYSTEM I.Renal failure c. FBS is increased (3 consecutive times with signs or polyuria. instruct client to avoid walking barefooted b. Shock due to dehydration . Blood II. Monitor signs for complications a.for hyperglycemia (dry and warm skin) 5. Diabeta (Micronase) Nursing Management when giving OHA 1. Oral glucose tolerance test is increased – most sensitive test 4. intake and output and blood sugar levels 4. polydypsia. Instruct client to have an annual eye and kidney exam 10. Tolamazide (Tolinase) 2. Blood Vessels III.
RBC (ERYTHROCYTES) .hemoglobin: normal value female 12 – 14 gms% male 14 – 16 gms% . Polymorphonuclear Basophils . Monocytes .largest WBC . Albumin 2. Spleen 4.Largest and numerous plasma CHON .for allergic reaction B.biconcave discs .consist of molecules of hgb (red pigment) bilirubin (yellow pigment) biliverdin (green pigment) hemosiderin (golden brown pigment) .transport steroids.Normal life span of RBC is 80 – 120 days and is killed in red pulp of spleen 2.macrophage in blood . vitamin c d. Liver 3. Lymphoid Organ 5.hematocrit red cell percentage in wholeblood . Arteries 2. Polymorpho Neutrophils . iron c. Bone Marrow ALBUMIN . bilirubin and hormones . folic acid b.Beta globulins – iron and copper .for parasite infections .only unnucleated cell . Non Granulocytes 1.transports and carries oxygen to tissues . Polymorphonuclear Eosinophils . WBC (LEUKOCYTES) . vitamin b6 (pyridoxine) f. Globulins 3. intrinsic factor .normal value: female 36 – 42% male 42 – 48% . vitamin b12 (cyanocobalamin) e. anti-bodies and immunoglobulins b.Alpha globulins .60 – 70% of WBC .Maintains osmotic pressure preventing edema GLOBULINS .responsible for the release of chemical mediation for inflammation 3. Veins Plasma CHON (formed in liver) 1.substances needed for maturation of RBC a. Prothrombin and Fibrinogen 1. prothrombin and fibrinogen clotting factors FORMED ELEMENTS 1.normal value: 4 – 6 million/mm3 . Lymph Nodes 6.Gamma globulins a.55% Plasma Serum 45% Formed 1.involved in short term phagocytosis for acute inflammation 2.normal value: 5000 – 10000/mm3 A. Granulocytes 1.
Heavy menstruation b. Common among women 15 – 35 years old 4. Related to improper cooking of foods C. Predisposing Factors 1. Headache and dizziness .thymus for immunity Natural killer cell . Oozing of blood from venipunctured site BLOOD DISORDERS Iron Deficiency Anemia . Chronic blood loss due to trauma a.Promotes hemostasis (prevention of blood loss) . Pneumocystis Carinii Pneumonia 3. High cereal intake with low animal protein digestion d. Echhymosis 3. Related to GIT bleeding resulting to hematemesis and melena (sign for upper GIT bleeding) c.6 months – 5 years incubation period .Normal life span of platelet is 9 – 12 days Signs of Platelet Dysfunction 1. Signs and Symptoms 1.western blot opportunistic .A chronic microcytic anemia resulting from inadequate absorption of iron leading to hypoxemic tissue injury A. Chronic diarrhea b. Petechiae 2.Normal value: 150. Weakness and fatigue (initial signs) 3.anti viral and anti tumor property HIV .Consist of immature or baby platelets or megakaryocytes which is the target of dengue virus . Kaposi’s Sarcoma 2.bone marrow . Incidence Rate 1. fresh blood per rectum is called hematochezia 2.ELISA .6 months window period . Related to poor nutrition B.000 – 450.involved in long term phagocytosis for chronic inflammation 2. Common among tropical zones 3.000/mm3 . Lymphocytes B-cell T-cell . Subtotal gastrectomy 4.drug of choice AZT (Zidon Retrovir) 2 Common fungal opportunistic infection in AIDS 1.. Usually asymptomatic 2. Inadequate intake of iron due to a. Related to malabsorption syndrome c. Platelets (THROMBOCYTES) . Common among developed countries 2.
Nausea and vomiting c. Brittleness of hair and spoon shape nails (koilonychias) 8. Diarrhea/constipation e. Instruct the client to avoid taking tea and coffee because it contains tannates which impairs iron absorption 5. Melena 5. Monitor and inform client of side effects a. Reticulocyte is decreased 6. Anorexia b. Sweet potatoes e. Administer Z tract technique to prevent discomfort. Hct is deceased 4.Dysphagia 9. IV) b. Dried fruits f. Palpitations 7. stool and GIT 2. Instruct client to take foods rich in iron a.Tetracycline .Iron . Instruct client to take with meals to lessen GIT irritation 2. Avoid massaging the injection site instead encourage to ambulate to facilitate absorption 3. Ferrous Fumarate c. Ferrous Gluconate .4. Nuts 4. Ferritin is decreased E. Enforce CBR so as not to over tire client 3. Iron Dextran (IM. When diluting it in liquid iron preparations administer with straw to prevent staining of teeth Medications administered via straw . Hgb is decreased 3. Legumes g. Pain at injection site PLUMBER VINSON’S SYNDROME . Abdominal pain d. Raisin d. Organ meat b. Iron is decreased 5. Administer with Vitamin C or orange juice for absorption 4. Dyspnea 6. Pallor and cold sensitivity 5. Atropic Glossitis (inflammation of tongue) .Nitrofurantoin (Macrodentin) 3.Lugol’s solution . PICA (abnormal appetite or craving for non edible foods D. Monitor for signs of bleeding of all hema test including urinw. Sorbitex (IM) Nursing Management when giving parenteral iron preparations 1.300 mg/day Nursing Management when taking oral iron preparations 1. If client cant tolerate/no compliance administer parenteral iron preparation a. Nursing Management 1. Egg (yolk) c. Administer medications as ordered Oral Iron Preparations a. RBC is decreased 2.Stomatitis . Diagnostic Procedures 1. Ferrous Sulfate b. discoloration and leakage to tissues 2. Monitor side effects a.
GIT changes that includes a. mouth sore b. Enforce CBR 2. Strictly vegetarian diet STOMACH ▼ Pareital cells/ Argentaffin or Oxyntic cells Produces intrinsic factors ▼ Promotes reabsorption of Vit B12 ▼ Promotes maturation of RBC B. Pallor and cold sensitivity 4.Chronic anemia characterized by a deficiency of intrinsic factor leading to hypochlorhydria (decrease hydrochloric acid secretion) A.Never given orally because there is possibility of developing tolerance Secretes hydrochloric acid ▼ Aids in digestion . Localized abscess c.b. Lymphadenopathy d. numbness c. Hypotension (anaphylactic shock) PERNICIOUS ANEMIA . Dyspnea and palpitations as part of compensation 5. Fever and chills e. Subtotal gastrectomy 2. Inflammatory disorders of the ileum 4. indigestion/dyspepsia d. Pruritus/orticaria g. Nursing Management 1. CNS changes a. paresthesia d. jaundice 6. Diagnostic Procedure Schilling’s Test – reveals inadequate/decrease absorption of Vitamin B12 D. red beefy tongue c. Hereditary factors 3. Autoimmune 5. positive to Romberg’s test – damage to cerebellum resulting to ataxia e. weight loss e. Predisposing Factors 1. Signs and Symptoms 1. tingling sensation b. result to psychosis C. Skin rashes f. Administer Vitamin B12 injections at monthly intervals for lifetime as ordered . Headache and dizziness 3. Weakness and fatigue 2.
No side effects 3. Instruct client to avoid irritating mouth washes instead use soft bristled toothbrush 5. Predisposing Factors 1. fever Decrease WBC (leucopenia) Decrease Platelet (thrombocytopenia) . Ecchymosis c. vitamin c and iron 4.Stem cell disorder leading to bone marrow depression leading to pancytopenia PANCYTOPENIA Decrease RBC (anemia) A. Increase susceptibility to infection 3. Nitrogen Mustard (Antimetabolite) Phenylbutazones (NSAIDS) B. Drugs Broad Spectrum Antibiotics a.Site of injection for Vitamin B12 is dorsogluteal and ventrogluteal . Dyspnea and palpitations 2. Headache and dizziness c. Vincristine (Plant Alkaloid) c. Institute BT as ordered 3. Removal of underlying cause 2. Provide a dietary intake that is high in carbohydrates.. Monitor for signs of infection a. Thrombocytopenia a. Administer oxygen inhalation 4. Leukopenia a. Chemicals (Benzine and its derivatives) 2. Immunologic injury 4. protein. Signs and Symptoms 1. Chloramphenicol (Sulfonamides) Chemotherapeutic Agents a. Diagnostic Procedures 1. Oozing of blood from venipunctured sites C. Nursing Management 1. Weakness and fatigue b. Enforce CBR 5. Related to irradiation/exposure to x-ray 3. Avoid heat application to prevent burns APLASTIC ANEMIA . CBC reveals pancytopenia 2. Bone marrow biopsy/aspiration (site is the posterior iliac crest) – reveals fat necrosis in bone marrow D. Methotrexate (Alkylating Agent) b. Petechiae (multiple petechiae is called purpura) b. Pallor and cold sensitivity d. Institute reverse isolation 6. Anemia a.
Petechiae (widespread and systemic) eye. Administer medications as ordered a. Provide heparin lock 7. ABG analysis reveals metabolic acidosis 4. 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. Monitor for signs of bleeding of all hema test including stool and GIT 2. Prevent complication . Pregnancy B. Pitressin/ Vasopresin to conserve fluids c. cough 7. Vitamin K b. lungs and lower extremities 2. CBC reveals decreased platelets 2. Ecchymosis 3. Monitor NGT output 9. Neoplasia (new growth of tissue) 7. Institute NGT decompression by performing gastric lavage by using ice or cold saline solution of 500 – 1000 ml 8. Massive trauma 4. Instruct client to use electric razor when shaving 10. Administer isotonic fluid solution as ordered 3. Administer oxygen inhalation 4. Corticosteroids – caused by immunologic injury b. Avoid IM. Stool occult blood positive 3. Massive burns 3. Hemoptysis 6. Oliguria (late sign) C. subcutaneous. Signs and Symptoms 1. Opthamoscopic exam reveals sub retinal hemorrhages D. Related to rapid blood transfusion 2. Force fluids 5. Predisposing Factors 1. venipunctured sites 8 Instead provide heparin lock 9. Heparin/Coumadin is ineffective 6. Administer medications as ordered a.b. Nursing Management 1. Oozing of blood from punctured sites 4. Anaphylaxis 5. Diagnostic Procedures 1. Septecemia 6.
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. Pyrogenic reaction d. Increase the oxygen carrying capacity of blood 3. Filter set b. Allergic reaction c.Expiration of packed RBC is 3 – 6 days . sediments and darkness in color because it indicates bacterial contamination . Hypovolemic shock b. Proper refrigeration .Warming is only done during emergency situation and if you have the warming device . Proper typing and cross matching a. Regulate BT 10 – 15 gtts/min or KVO rate or equivalent to 100 cc/hr to prevent circulatory overload 9. . Circulatory overload e. Serial number 5. Thrombocytopenia g. Isotonic solution (0. Prevent bleeding if there is platelet deficiency Principles of blood transfusion 1. Hemolytic reaction b. 6. Client name b.Expiration of platelet is 3 – 5 days 2. 85% of population is RH positive 3. during and after BT especially every 15 minutes for first hour because majority of transfusion reaction occurs during this period a. Prevent infection in there is a decrease in WBC 4. Instruct another RN to re check the following a. Blood typing and cross matching c. Cytrate intoxication h. Air embolism f.a. Type AB – universal recipient c. Type O – universal donor b. Monitor strictly vital signs before. Replace circulating blood volume 2. Hyperkalemia (caused by expired blood) .Emergency rapid BT is given after 30 minutes and let natural room temperature warm the blood. Aseptically assemble all materials needed for BT a.9 NaCl/plain NSS) to prevent hemolysis 4. Avoid mixing or administering drugs at BT line to prevent HEMOLYSIS 8. Gauge 18 – 19 needle c. Check the blood unit for bubbles cloudiness.Never warm blood as it may destroy vital factors in blood. Expiration date d. Anuria – late sign BLOOD TRANSFUSION Goals/Objectives 1.
Administer medications as ordered a. Stop BT 2. Headache and dizziness 2. Notify physician 3. Obtain urine and blood sample and send to laboratory for re examination 7. Administer isotonic fluid solution to prevent shock and acute tubular necrosis 5. Palpitations 5. Diarrhea/Constipation 4. Notify physician 3. Lumbasternal/ Flank pain 7.Signs and Symptoms of Hemolytic reaction 1. Dyspnea 3. Diaphoresis 6. Dyspnea 3. Monitor vital signs and intake and output SIGNS AND SYMPTOMS OF ALLERGIC REACTION 1. Obtain urine and blood sample and send to laboratory for re examination 7. Laryngospasm and Broncospasm Nursing Management 1. Send the blood unit to blood bank for re examination 6. Fever and chills 2. Flush with plain NSS 4. Notify physician 3. Fever 2. anaphylactic shock treat with Epinephrine 5. Urine is color red/ portwine urine Nursing Management 1. Hypotension 5. Flushed skin 6. Send the blood unit to blood bank for re examination 6. Stop BT 2. Skin rashes 5. Broncial wheezing 4.if positive to hypotension. Monitor vital signs and intake and output SIGNS AND SYMPTOMS PYROGENIC REACTIONS 1. Headache 3. Dyspnea Nursing Management 1. Stop BT 2. Flush with plain NSS . Anti Histamine (Benadryl) . Urticaria 6. Flush with plain NSS 4. Tachycardia 4.
Prevent pericardial friction rub . Orthopnea 2. pericarditis. Administer medications as ordered a. Rales/Crackles upon auscultation 4. Chambers of the Heart 1. Antipyretic b. Atria 2. Send the blood unit to blood bank for re examination 6.4. Notify physician 3. Upper Chamber (connecting or receiving) a. Ventricles . Parietal – outer layer b. Stop BT 2. tricuspid valve .Right atrium has decreased pressure which is 60 – 80 mmHg C.In between is the pericardial fluid which is 10 – 20 cc . Endocardium – inner layer . .Weighs approximately 300 – 400 grams .Covered by a serous membrane called the pericardium 2 layers of pericardium a. Myocardium – middle layer 3. Layers of Heart 1. Obtain urine and blood sample and send to laboratory for re examination 7.In order to propel blood to the systemic circulation . Cardiac tamponade A.Resemble like a close fist . Atrioventricular Valves – guards opening between a. Visceral – inner layer .Common among MI.Myocarditis can lead to cardiogenic shock and rheumatic heart disease B. Lower Chamber (contracting or pumping) a. Antibiotic 5.To promote unidimensional flow or prevent backflow 1. Exertional discomfort Nursing Management 1. Valves . Administer medications as ordered a.Muscular pumping organ of the body. Epicardium – outer layer 2.Left ventricle has increased pressure which is 120 – 180 mmHg . Monitor vital signs and intake and output 8. Loop diuretic (Lasix) CARDIOVASCULAR SYSTEM OVERVIEW OF THE STRUCTURE AND FUNCTIONS OF THE HEART HEART . Render TSB SIGNS AND SYMPTOMS OF CIRCULATORY REACTION 1. Dyspnea 3.Located on the left mediastinum .
b.Closure of AV valves give rise to first heart sound (S1 “lub”) 2.QRS WAVE (ventricular depolarization) .Located at the inter atrial septum .Initiates electrical impulse of 60 – 100 bpm 2.Left Main Bundle of His . Bundle of His .Located at the walls of the ventricles for ventricular contraction SA NODE AV NODE BUNDLE OF HIS JLJLJLJJLJLJL PURKINJE FIBERS . Right Main Coronary Artery 2.Closure of SV valve give rise to second heart sound (S2 “dub”) Extra Heart Sounds 1.Arises from base of the aorta Types of Coronary Arteries 1.T WAVE (ventricular repolarization) . Coronary Arteries .Supplies the myocardium E. pulmonic b. Semi – lunar Valves a. Atrio – Ventricular Node (AV or Tawara Node) . mitral valve .Located at the junction of superior vena cava and right atrium .08 milliseconds to allow ventricular filling 3. S3 – ventricular gallop usually seen in Left Congestive Heart Failure 2. aortic .Right Main Bundle of His . Left Main Coronary Artery . Purkinje Fibers . Sino – Atrial Node (SA or Keith Flack Node) .Located at the interventricular septum 4. Cardiac Conduction System 1.Delay of electrical impulse for about . S4 – atrial gallop usually seen in Myocardial Infarction and Hypertension D.Acts as primary pacemaker of the heart .P WAVE (atrial depolarization) contraction .
Peak T wave – Hyperkalemia 3. Increase survival rate ARTERIOSCLEROSIS . T wave inversion – Myocardial Infarction 6. Palpitations 5.lipid or fat deposits . To prevent angina 3. Treatment Percutaneous Transluminal Coronary Angioplasty Objectives of PTCA 1. Myocardial Necrosis – Myocardial Infarction ATHEROSCLEROSIS ATHEROSCLEROSIS . Signs and Symptoms 1.Atherosclerosis 2. sedentary lifestyle 7. Type A personality B.calcium and protein deposits . ST segment elevation – Myocardial Infarction 5. ST segment depression – Angina Pectoris 4. Hypothyroidism 9. Diabetes Mellitus 8. Duaphoresis C. 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.Hypokalemia 2. Race – black 3. Obesity 5.tunica intima A. Widening of QRS complexes – Arrythmia CARDIAC DISORDERS Coronary Arterial Disease/ Ischemic Heart Disease Stages of Development of Coronary Artery Disease 1. Chest pain 2. Smoking 4. Myocardial Ischemia – Angina Pectoris 3. Revascularize myocardium 2. Hyperlipidemia 6. Positive U wave .hardening of artery . Dyspnea 3.narrowing of artery .tunica media . Myocardial Injury . Tachycardia 4. Sex – male 2. Diet – increased saturated fats 10. Predisposing Factors 1.
Pneumonia – encourage to perform deep breathing. Palpitations 6. Type A personality B. Diabetes Mellitus 8. reveal abnormal ECG 4. Smoking 4. arms.If there is 2 or more occluded blood vessels CABG is done Coronary Arterial Bypass And Graft Surgery 3 Complications of CABG 1. Diet – increased saturated fats 10. History taking and physical exam 2. Stress test – treadmill test. sedentary lifestyle 7.Give second dose of NTG if pain persist after giving first dose with interval of 3 . shoulder. Sex – male 2. Levine’s Sign – initial sign that shows the hand clutching the chest 2. Extreme emotional response – fear. 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. Dyspnea 4. Nitroglycerine (NTG) – when given in small doses will act as venodilator. Nursing Management 1. ECG tracing reveals ST segment depression 3.Give first dose of NTG (sublingual) 3 – 5 minutes . Excessive intake of foods rich in saturated fats – skimmed milk C. Shock 3. Administer medications as ordered a. Precipitating Factors 4 E’s of Angina Pectoris 1. excitement 4. Serum cholesterol and uric acid is increased E. Diaphoresis D. Race – black 3. Predisposing Factors 1. usually relieved by rest or taking nitroglycerine 3. Signs and Symptoms 1. Hyperlipidemia 6. Chest pain characterized by sharp stabbing pain located at sub sterna usually radiates from back. Diagnostic Procedure 1. Tachycardia 5.Done to single occluded vessels . Obesity 5. but in large doses will act as vasodilator . Hypothyroidism 9..5 minutes . Exposure to cold environment 3. Enforce complete bed rest 2. Excessive physical exertion – heavy exercises 2. coughing exercise and use of incentive spirometer 2. axilla and jaw muscles. anxiety.
Place client on semi fowlers position 5. A.NIfedipine 3. Instruct client to take medication before indulging into physical exertion to achieve the maximum therapeutic effect of drug d. Transmural Myocardial Infarction – most dangerous type characterized by occlusion of both right and left coronary artery 2. Types 1. Subendocardial Myocardial Infarction – characterized by occlusion of either right or left coronary artery B. Smoking 4. ACE Inhibitors . Predisposing Factors 1. Provide client health teachings and discharge planning a. intake and output and ECG tracing 6.Enalapril d. Hyperlipidemia . Calcium Antagonist . The importance of follow up care MYOCARDIAL INFARCTION Heart attack Terminal stage of coronary artery disease characterized by malocclusion. Monitor strictly vital signs.Not given to COPD cases because it causes bronchospasm c. Administer oxygen inhalation 4. Beta-blockers . Race – black 3. Provide decrease saturated fats sodium and caffeine 7. necrosis and scarring. Obesity 5.side effects PNS .. Sex – male 2. 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.Propanolol .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. Prevent complication (myocardial infarction) c. Avoidance of 4 E’s b. 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.
Heart only.Excruciating visceral.Administer narcotic analgesic/morphine sulfate . Instruct client to avoid forms of valsalva maneuver 5. Mild restlessness and apprehension 7. SGOT – Serum glutamic oxal-acetic transaminase is increased 2. sedentary lifestyle 7. CBC – increased WBC F. SGPT – Serum glutamic pyruvate transaminase is increased d. Type A personality D. Widening of QRS complexes indicates that there is arrhythmia in MI 4. Dyspnea 3. Administer oxygen low inflow to prevent respiratory arrest at 2 – 3 L/min 3. viselike pain located at substernal and rarely in precordial . Enforce CBR without bathroom privileges a. Signs and Symptoms 1. Split S1 and S2 c. Occasional findings a. LDH – Lactic acid dehydroginase is increased c. Ashen skin 6. arms. Diet – increased saturated fats 10. Hypothyroidism 9. Rales/Crackles upon auscultation d. Place client on semi fowlers position .Side Effects: respiratory depression .Side Effects of Naloxone Toxicity is tremors 2. Hyperthermia 5. Nursing Management Goal: Decrease myocardial oxygen demand 1.Usually radiates from back. T wave inversion c. Pericardial friction rub b. S4 or atrial gallop E.Antidote: Narcan/Naloxone . ECG tracing reveals a. Troponin Test – is increased 3. shoulder. Diagnostic Procedure 1. Using bedside commode 4.Creatinine phosphokinase is increased . Increase in blood pressure (initial sign) 4.6. 12 – 24 hours b. Decrease myocardial workload (rest heart) . axilla. jaw and abdominal muscles (abdominal ischemia) . Cardiac Enzymes a.Not usually relieved by rest or by nitroglycerine 2. Serum Cholesterol and uric acid are both increased 5. Chest pain . ST segment elevation b. Diabetes Mellitus 8. CPK – MB .
Anti Coagulant .6. ACE Inhibitors e.Anti thrombotic effect .TIPAF (tissue plasminogen activating factor) . Encourage client to take 20 – 30 cc/week of wine. Beta-blockers d. intake and output and ECG tracing 7. Provide client health teaching and discharge planning concerning a. Avoidance of modifiable risk factors .arrhythmia (caused by premature ventricular contraction) b.Monitor for bleeding time g.Nitroglycerine .Brutylium c.Side Effects: allergic reaction.Streptokinase .Antidote: protamine sulfate .Urokinase .Side Effects: chest pain .Side Effects: confusion and dizziness .Antidote: Vitamin K h.Heparin (check for partial thrombin time) .PASA (Aspirin) . Cardiogenic shock . pruritus . Provide a general liquid to soft diet that is low in saturated fats. Anti Platelet . Isodil) sublingual b.late sign is oliguria c. Stroke/CVA . Left Congestive Heart Failure d.ISD (Isosorbide Dinitrate. Thrombolytics/ Fibrinolytic Agents .Side Effects of Aspirin Tinnitus Heartburn Indigestion/Dyspepsia . sodium and caffeine 8.homan’s sign e. Calcium Antagonist f.Coumadin/ Warfarin Sodium (check for prothrombin time) . Vasodilators . Thrombophlebitis . Monitor strictly vital signs. Administer medication as ordered a. whisky and brandy to induce vasodilation 9. Anti Arrythmic Agents .Contraindication Dengue Peptic Ulcer Disease Unknown cause of headache 10.Lidocaine (Xylocane .
000 units of streptokinase as ordered g. Paroxysmal nocturnal dyspnea – client is awakened at night due to difficulty of breathing 3. Ischemic heart disease 4. 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. RHD – inflammation of mitral valve due to invasion of Grp.f. There is anorexia and generalized body malaise 12. Hypertension 5. post CABG and instruct to . Aortic valve stenosis B. Rales/Crackles 8. 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. Bronchial wheezing 9.client can resume sexual intercourse if can climb staircase . dependent on extent of heart failure 4. ABG – reveals PO2 is decreased (hypoxemia).instruct client to assume a non weight bearing position .client is resistant to pharmacological agents. RIGHT SIDED HEART FAILURE . Resumption of ADL particularly sexual intercourse is 4 – 6 weeks post cardiac rehab.make sex as an appetizer rather than dessert . Frothy salivation 6. 90% is mitral valve stenosis due to a. Cyanosis 7. S3 – ventricular gallop C. Diagnostic Procedure 1. administer 150.Common among children . Ecocardiography – enlarged heart chamber (cardiomyopathy).Aspirin b. Aging 2. Pulsus Alternans – weak pulse followed by strong bounding pulse 10. A beta-hemolytic streptococcus . LEFT SIDED HEART FAILURE A.000 – 450. Predisposing Factors 1. PCO2 is increased (respiratory acidosis) 2. Productive cough with blood tinged sputum 5. Orthopnea – use 2 – 3 pillows when sleeping or place in high fowlers 4.Penicillin .dietary modification h. PMI is displaced laterally due to cardiomegaly 11. Post MI Syndrome/Dressler’s Syndrome .Formation of aschoff bodies in the mitral valve . Myocardial Infarction 3. Chest x-ray – reveals cardiomegaly 2. Signs and Symptoms 1.ASO Titer (Anti streptolysin O titer) . Dyspnea 2.
Enforce CBR 2.Digoxin (Lanoxin) . Weight gain 5.CVP fluid status measure .If CVP is more than 10 cm of water hypervolemic shock . Liver enzymes – SGPT and SGOT is increased D. Vasodilators .Lidocaine (Xylocane) 3. Signs and Symptoms (venous congestion) 1. Diagnostic Procedures 1. Predisposing Factors 1. Ascites 4. Hepatosplenomegaly 6.When reading CVP patient should be flat on bed .Upon insertion place client in trendelendberg position to promote ventricular filling and prevent pulmonary embolism 3. Loop Diuretics . Related to COPD 4. Anorexia 9.Do the fluid challenge (increase IV flow rate) . Chest x-ray – reveals cardiomegaly 2.Increase force of cardiac contraction . Pulmonic valve stenosis 5. Central venous pressure (CVP) . Nursing Management Goal: increase cardiac contractility thereby increasing cardiac output (3 – 6 L/min) 1.Measure pressure in right atrium (4 – 10 cm of water) .If CVP is less than 4 cm of water hypovolemic shock . Anti Arrhythmic . Ecocardiography – reveals enlarged heart chambers (cardiomyopathy 4. Left sided heart failure B. High fowlers position . Administer oxygen inhalation with high inflow. Pitting edema 3. Tricuspid valve stenosis 2. delivered via nasal cannula 4.If heart rate is decreased do not give b.Lasix (Furosemide) c. Esophageal varices C. Neck/jugular vein distension 2. Cardiac glycosides . Pulmonary embolism 3. Administer medications as ordered a. Bronchodilators d.Nitroglycerine f. Jaundice 7. 3 – 4 L/min. Pruritus 8.A.Morphine Sulfate e.Administer loop diuretics as ordered . Narcotic analgesics .
Doppler UTZ – decrease blood flow to the affected extremity 3. intake and output and ECG tracing 6.5. Predisposing Factors 1. Gangrene formation C. Thrombo Angitis Obliterans Venous Ulcer 1. Trophic changes 5. Ulceration 6. Provide client health teaching and discharge planning a. Angiography – reveals site and extent of malocclusion D. Varicose Veins 2. cholesterol and caffeine 8. Prevent complications . Provide meticulous skin care 9. Intermittent claudication – leg pain upon walking 2.Right ventricular hypertrophy . walking 3 – 4 times a day b. Diagnostic Procedures 1. Oscillometry – decrease in peripheral pulses 2. Administer medications as ordered a. Provide a dietary intake of low sodium. Smoking B. Nursing Management 1.Thrombophlebitis b. Encourage a slow progressive physical activity a. Thrombophlebitis (deep vein thrombosis) THROMBOANGITIS OBLITERANS Acute inflammatory disorder usually affecting the small medium sized arteries and veins of the lower extremities A. out of bed 3 – 4 times a day 2. rotated clockwise every 15 minutes to promote decrease venous return 10. cyanosis then rubor) 3. High risk groups – men 30 years old and above 2. Measure abdominal girth daily and notify physician 7.MI . Signs and Symptoms 1. Dietary modification c. Analgesics Burger’s Disease Reynaud’s Disease . Decreased peripheral pulses 4. Monitor strictly vital signs.Arrythmia . Assist in bloodless phlebotomy – rotating tourniquet. Strict compliance to medications PERIPHERAL VASCULAR DISORDER Arterial Ulcer I.Shock . Cold sensitivity and changes in skin color (pallor.
Gangrene formation C. Rheumatoid Arthritis 4. Anti coagulants 3. Piano playing b. Doppler UTZ – decrease blood flow to the affected extremity 2. 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. Pregnancy . Predisposing Factors 1. Trophic changes 4. Cardiac disorder 5. Administer medications as ordered a. SLE (butterfly rash) b.b. Collagen diseases a. Smoking 3. Instruct client to avoid smoking and exposure to cold environment 5. Vasodilators 2. Encourage to wear gloves 3. Congenital weakness of veins 3. Nursing Management 1. Direct hand trauma a. Institute foot care management 4. cyanosis then rubor) 3. Operating chainsaw B. Diagnostic Procedures 1. Cold sensitivity and changes in skin color (pallor. Intermittent claudication – leg pain upon walking 2. Ulceration 5. Vasodilators c. Hereditary 2. Angiography – reveals site and extent of malocclusion D. Signs and Symptoms 1. Thrombophlebitis 4. High risk group – female 40 years old and above 2. Predisposing Factors 1. 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. Excessive typing c. Analgesics b.
Obesity 2. Post op complication 10. Nursing Management . Pain at affected extremity 2. Wear anti embolic stockings 4. Congestive heart failure 8. Post cannulation – insertion of various cardiac catheter 11. Administer medications as ordered a. Dilated tortuous skin veins 3. Pain after prolonged standing 2. Positive Hpman’s Signs – pain at the calf or leg muscle upon dorsi flexion of the foot C. Elevate legs above heart level to promote increased venous return by placing 2 – 3 pillows under the legs 2. B. Myocardial infarction 9. Warm to touch 4. Venography 2. Nursing Management 1. Prolong use of oral contraceptives – promotes lipolysis 6. Dilated tortuous skin veins 4. Heaviness in legs C. Diagnostic Procedure 1. Warm to touch 3. Venography 2. Signs and Symptoms 1. Signs and Symptoms 1. Obesity 7.6. Vein stripping and ligation (most effective) b. Increase in saturated fats in the diet. Angiography D.veins distends quickly in less than 35 seconds D. Diabetes mellitus 7. Related to pregnancy 4. Chronic anemia 5. Predisposing Factors 1. Assist in surgical procedure a. Prolonged standing or sitting B. Diagnostic Procedure 1. Analgesics 5. Measure the circumference of leg muscle to determine if swollen 3. Smoking 3. Trendelenburg’s Test . 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.
Cartillage . Upper Respiratory System 1. Nose .The initial sign of complete airway obstruction is the inability to cough II.Serves as passageway of air going to the lungs . Administer medications as ordered a. Elevate legs above heart level to promote increase venous return 2. Larynx . Apply warm moist pack – to reduce lymphatic congestion 3.Tachycardia .1.Decrease LOC • MURPHY’S SIGN is seen in clients with cholelithiasis.Closes to allow passage of food going to the esophagus . Analgesics b.Unexplained dyspnea . Anti Coagulant .Left nostril .Separated by septum .Dizziness .Consist of cartilaginous rings . Filtering of air 2.For cough reflex Glottis . Pulmonary . Monitor for signs of complications Embolism a. Humidification A.Opening of larynx .Heparin 6.Sudden sharp chest pain .For gas exchange A. Encourage to wear anti embolic stockings or knee elastic stockings 5. Warming and moistening of air 3. Pharynx/Throat . cholecystitis characterized by pain at the right upper quadrant with tenderness RESPIRATORY SYSTEM OVERVIEW OF THE STRUCTURES AND FUCNTIONS OF THE RESPIRATORY SYSTEM I. Cerebral .Serves as a muscular passageway for both food and air C. Lower Respiratory System .For phonation (voice production) .Diaphoresis .Consist of anastomosis of capillaries known as Keissel Rach Plexus (the site of nose bleeding) B.Right nostril .Palpitations .Opens to allow passage of air . Trachea/Windpipe .Headache .Restlessness b. Measure circumference of leg muscle to determine if swollen 4.
Lungs . Ingestion of an infected cattle with mycobacterium bovis 6. Virulence (degree of pathogenecity) of microorganism B.Site of gas exchange (CO2 and O2) . Bronchus .Decrease surface tension .Site of tracheostomy B. Over fatigue 5.Composed of lecithin and spingomyelin ..retinopathy/blindness in prematurity Disorders of Respiratory System 1.Decrease oxygen stimulates breathing .Normal L/S ratio is 2:1 .Prevent collapse of alveoli .Right main bronchus . Pareital b. Overcrowded places 3. night sweats 2.Increase carbon dioxide is a powerful stimulant for breathing Type II Cells of Alveoli . aerobic and easily destroyed by heat or sunlight A. Signs and Symptoms 1.L/S ratio to determine lung maturity . Precipitating Factors 1. 8 segments) .Serous membranes Pleural Cavity a.Infection of lung tissue caused by invasion of mycobacterium tuberculosis or tubercle bacilli .Secretes surfactant . Airborne transmission via droplet nuclei C. Pleural effusion c. Malnutrition 2.Right lung (consist of 3 lobes. Mode of Transmission 1. Pleural fluid c.Give oxygen of less 40% in premature to prevent atelectasis and retrolental fibroplasias . Pneumonia b.An acid fast. gram negative. Productive cough (yellowish sputum) .Left lung (consist of 2 lobes. Hydrothorax (air and blood in pleural space Alveoli .Left main bronchus C. PTB/Pulmonary Tuberculosis (Koch’s Disease) . Alcoholism 4. Visceral With Pleuritic Friction Rub a. 10 segments) .Diffusion (Dalton’s law of partial pressure of gases) Respiratory Distress Syndrome . Low grade afternoon fever.In premature infants 1:2 .
Positive to cultured microorganism 3. Anorexia. generalized body malaise 4. Comfortable and humid environment 9.Side Effect Ethambutol: optic neuritis b.3. CBC .DOH 8 – 10 mm induration. Chest pain 7. taken after meals to facilitate absorption .Reveals pulmonary infiltrates 4.PZA is given for 2 months. Hemoptysis (chronic) D.Amikacin .Side Effect Rifampicin: all bodily secretions turn to red orange color . Nebulize and suction when needed 8. Institute strict respiratory isolation 3.Gentamycin . 48 – 72 hours . taken before meals to facilitate absorption .INH and Rifampicin is given for 4 months.Rifampicin (Rifampin) .PZA can be replaced by Ethambutol . 48 – 72 hours .Injection of streptomycin (aminoglycoside) . Diagnostic Procedure 1. Mantoux Test (skin test) . Administer oxygen inhalation 4.Given everyday simultaneously to prevent resistance .WHO 10 – 14 mm induration. Dyspnea 6. Chest X-ray .INH (Isonicotinic Acid Hydrazide) .Side Effect PZA: allergic reaction. Encourage deep breathing and coughing exercise 7. Enforce CBR 2. nephrotoxicity . hepatotoxicity. Place client on semi fowlers position to promote expansion of lungs 6.Reveals increase WBC E.Purified protein derivative . Force fluids to liquefy secretions 5. Institute short course chemotherapy a.Kanamycin . Nursing Management 1.Positive Mantoux test (previous exposure to tubercle bacilli but without active TB) 2.PZA (Pyrazinamide) . Weight loss 5. Intensive phase . Standard phase .Side Effect INH: peripheral neuritis/neuropathy (increase intake of Vitamin B6/Pyridoxine) .Neomycin . Sputum Acid Fast Bacillus .
Rales/crackles 6. Elderly C.Eyes .. High Risk Groups 1. Dyspnea with prolong expiratory grunt 3. Predisposing Factors 1. anorexia and general body malaise 4. military tuberculosis) PTB . Pseudomonas B. Escherichia Pneumoniae 6. Streptococcus Pneumonae – causing pneumococal pneumonia 2.Pneumocystic carini pneumonia .Side Effect: . Productive cough with greenish to rusty sputum 2. Prevent complications (atelectasis. Etiologic Agents 1. AIDS . Avoidance of precipitating factors b. Fever. Diplococcus Pneumoniae 4. Immuno compromised a. Strict compliance to medications d. vitamin C and calories 11. protein.Adrenal gland c.Chest x-ray confirms lung cancer 4.Side Effect: tinnitus. Aspiration of food causing aspiration pneumonia D. heartburn 10.Bones (potts) . dyspepsia. Related to prolonged immobility (CVA clients).Nephrotoxicity check for BUN and Creatinine .Initial sign is non productive cough . Children below 5 years old 2. Signs and Symptoms 1. Weight loss 5.Meninges . chills.Ototoxicity damage to the 8th cranial nerve resulting to tinnitus leading to hearing loss . Provide increase carbohydrates.Skin . Klebsella Pneumoniae 5. causing hypostatic pneumonia 5. Bronchogenic Cancer . Hemophylus Influenzae – causing broncho pneumonia 3. Bronchial wheezing . Smoking 2. Importance of follow up care PNEUMONIA Inflammation of the lung parenchyma leading to pulmonary consolidation as the alveoli is filled with exudates A. Provide client health teaching and discharge planning a.Drug of choice is Retrovir b. Air pollution 3.Give aspirin if there is fever .
7. Cyanosis 8.Increase ICP 9. Avoid smoking b.Drain uppermost area of lungs . Tetracycline c. protein and vitamin C 10. CBC – reveals increase WBC. Chest x-ray – reveals pulmonary consolidation 3.Clients with increase intra ocular pressure (Normal IOP 12 – 21 mmHg) . Institute pulmonary toilet (tends to promote expectoration) . ABG analysis – reveals decrease PO2 4. Diagnostic Procedure 1. Stop if client cannot tolerate procedure f. Place on semi fowlers position 6. Sputum Gram Staining and Culture Sensitivity – positive to cultured microorganisms 2. Nursing Management 1. Monitor vital signs c. Encourage client deep breathing exercises d. Provide oral care after procedure g.Deep breathing exercises . erythrocyte sedimentation rate is increased F.Unstable vital signs . Assist in postural drainage . Best done before meals or 2 – 3 hours to prevent gastro esophageal reflux b. Microlides (Zethromax) Azethromycin (Side Effect: Ototoxicity) Antipyretics Mucolytics/Expectorants Analgesics 4. Health teaching and discharge planning a. Penicillin b. Administer medications as ordered Broad Spectrum Antibiotic a.Placed on various position Nursing Management for Postural Drainage a. Abdominal distention leading to paralytic ileus (absence of peristalsis) E. Administer bronchodilators 15 – 30 minutes before procedure e. Pleuritic friction rub 9. Chest pain 10.Coughing exercises . Force fluid 5.Hemoptysis .Turning and reposition 7. Contraindicated with . Provide increase carbohydrates. Enforce CBR 2. Nebulize and suction as needed 8. Prevent complications . calories. Administer oxygen inhalation low inflow 3.Chest physiotherapy .
general body malaise 4. Antipyretics 4. anorexia. Dyspnea on exertion 3. Administer oxygen inhalation 3. Smoking 2. Diagnostic Procedures 1. Administer medications as ordered a. Enforce CBR 2.Fungizone (Nephrotoxicity. ABG analysis PO2 decrease C. Air pollution B.. Cyanosis 5. Dyspnea 3. Hypokalemia) b. Chest and joint pains B. Force fluids to liquefy secretions 5. Signs and Symptoms PTB or Pneumonia like 1. Prevent complications – bronchiectasis 7. check for BUN and Creatinine. Regular adherence to medications d. Productive cough (consistent to all COPD) 2. Antifungal .Amphotericin B . Predisposing Factors 1. Fever. hydrocephalus) c. Hemoptysis 6. Productive cough 2. Mucolytics d. Steroids c. 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. Signs and Symptoms 1.Atelectasis . Prolonged expiratory grunt 4. Nebulize and suction as needed 6. 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. chills. Nursing Management 1. Anorexia and generalized body malaise . Histoplasmin Skin Test – positive 2.Meningitis (nerve deafness.
Enforce CBR . Extrinsic Asthma ( Atopic/ Allergic ) Causes a. Cor Pulmonale (right ventricular hypertrophy) C. Food additives (nitrates) e. Cyanosis 5. Cough that is non productive 2. milk.5. pH decrease Bronchial Asthma Reversible inflammatory lung condition due to hypersensitivity to allergens leading to narrowing of smaller airways A. ABG analysis – PO2 decrease . Dust c. Pollen b. Physical and emotional stress 3. Danders g. eggs. Fumes d. Nursing Management 1. Foods (seafoods. Wheezing on expiration 4. Drugs (aspirin. Intrinsic Asthma (Non atopic/Non allergic) Causes a. Mixed Type 90 – 95% B. Signs and Symptoms 1. Furs h. beta blocker) c. chicken d. Pulmonary Function Test . Peripheral edema b.Before ABG test for positive Allens Test. air pressure and humidity f. penicillin. Predisposing Factors (Depending on Types) 1. Scattered rales/ronchi 6. palpitations 7. apply direct pressure to ulnar and radial artery to determine presence of collateral circulation D. Diagnostic Procedure ABG analysis – reveals PO2 decrease (hypoxemia). Diagnostic Procedure 1. Sudden change in temperature. Pulmonary hypertension a. Mild Stress/apprehension 6.Incentive spirometer reveals decrease vital lung capacity 2. Cyanosis 7. Gases f. chocolates. Lints 2. Diaphoresis C. Hereditary b. PCO2 increase. Dyspnea 3. Smoke e. Tachycardia.
Anorexia and generalized body malaise 5. Cyanosis 4. Mucolytics/expectorants e. Anti histamine 4. Semi fowlers position 6. Recurrent lower respiratory tract infections 2. Steroids – decrease inflammation c. Diagnostic Procedure 1. Oxygen inhalation. Nebulize and suction when needed 7. Monitor for signs of laryngeal spasm – prepare tracheostomy set D. Bronchoscopy – direct visualization of bronchus using fiberscope Nursing Management PRE Bronchoscopy 1. ABG – PO2 decrease 2. Avoid talking. Mucomysts (acetylceisteine) d. Productive cough 2. Monitor for signs of gross 4. Avoidance of precipitating factor b. Regular adherence to medications to prevent development of status asthmaticus d. Prevent complications . Importance of follow up care BRONCHIECTASIS Abnormal permanent dilation of bronchus leading to destruction of muscular and elastic tissues of alveoli A. Bronchodilators – given via inhalation or metered dose inhalaer or MDI for 5 minutes b. Monitor vital signs and breath sound POST Bronchoscopy 1.2.Epinephrine . Feeding initiated upon return of gag reflex 2. Predisposing Factors 1.Steroids . with low inflow of 2 – 3 L/min 3. Provide client health teachings and discharge planning concerning a. coughing and smoking. Force fluids 5. Signs and Symptoms 1. Administer medications as ordered a. Related to presence of tumor B. Treatment .Status Asthmaticus (give drug of choice) . Hemoptysis (only COPD with sign) C. Secure inform consent and explain procedure to client 2. Congenital defects 4. may cause irritation 3.Emphysema . Chest trauma 3.Bronchodilators c. Dyspnea 3. Maintain NPO 6 – 8 hours prior to procedure 3.
Increase ph . Enforce CBR .Respiratory acidosis b. Resonance to hyperresonance 6. Productive cough 2.1.Increase PO2 (hyperaxemia.Decrease PO2 (hypoxemia leading to chronic bronchitis. Pulmonary Function Test – reveals decrease vital lung capacity 2. Decrease or diminished breath sounds 8. Predisposing Factors 1. Air pollution 3.Respiratory alkalosis D. Allergy 4.Decrease ph . Diagnostic Procedure 1. Hereditary – it involves deficiency of ALPHA-1 ANTI TRYPSIN (needed to form Elastase. Signs and Symptoms 1. Bronchial wheezing 10. for recoil of alveoli) B. Maldistribution of gases d.Decrease PCO2 . Rales or ronchi 9.Unaffected lobectomy facilitate drainage EMPHYSEMA Irreversible terminal stage of COPD characterized by a. Purse lip breathing to eliminates excess CO2 (compensatory mechanism) C. ABG analysis reveals a. Air trapping c. Surgery (pneumonectomy . Dyspnea at rest 3. Over distention of thoracic cavity (barrel chest) A. Segmental Wedge Lobectomy (promote re expansion of lungs) .Increase PCO2 . Flaring of alai nares 12. Smoking 2. High risk: elderly 5. Nursing Management 1. Panlobular/ centrilobular . “Blue Bloaters”) . Decrease tactile fremitus 7. Prolong expiratory grunt 4. 1 lung is removed and position on affected side) 2. Panacinar/ centriacinar . Anorexia and generalized body malaise 5. Inelasticity of alveoli b. “Pink Puffers”) . Barrel chest 11.
Steroids c.Atelectasis . Force fluids 6. Health teachings and discharge planning concerning a.2. Avoid smoking b. Prevent complications . Bronchodilators b. protein. vitamins and minerals 11. Antibiotics d. calories. Mucolytics/expectorants 4. Strict compliance to medication d. High fowlers position 5. Institute PEEP (positive end expiratory pressure) in mechanical ventilation promotes maximum alveolar lung expansion 9.Cor Pulmonale . Administer oxygen inhalation via low inflow 3. Provide high carbohydrates. Provide comfortable and humid environment 10.Pneumothorax c. Nebulize and suction when needed 8.CO2 narcosis may lead to coma . Importance of follow up care . Administer medications as ordered a. Institute pulmonary toilet 7.
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