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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.
Wernicke’s Aphasia General Knowing Gnostic Area or General Interpretative Area. colostrums). Characterized by remission and exacerbation. d. *Receptive aphasia DRUG OF CHOICE: ARICEPT (taken at bedtime) and COGNEX. Amnesia – loss of memory. 2. Signs and Symptoms 1. pain. MULTIPLE SCLEROSIS Chronic intermittent disorder of CNS characterized by white patches of demyelination in brain and spinal cord. pressure.DEMYELINATING DISORDERS 1. Impaired sensation to touch.Immediate action. *Expressive aphasia “motor speech center” Broca’s Aphasia inability to understand spoken words.short term protection. b. Agnosia – no recognition of inanimate objects. Sign and Symptoms 4 A’s of Alzheimer a. Ig A – present in all bodily secretions (tears. . Visual disturbances blurring of vision (primary) diplopia (double vision) scotomas (blind spots) 2. saliva. 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. c. Ig D – for chronic inflammation. Aphasia – no speech (nodding). Ig M – acute in inflammation. Mood swings . ALZHEIMER’S DISEASE Atrophy of brain tissues. Ig E – for allergic reaction. * Give palliative or supportive care. . Apraxia – no recognition of objects function. heat and cold. tingling sensation paresthesia numbness euphoria (sense of well being) 3.
Catheterization to prevent retention. Yoga 4. Impaired motor function weakness spasticity paralysis scanning speech TRIAD SIGNS OF MS Ataxia (Unsteady gait. Urinary retention/incontinence 7. Interferons – alter immune response. Baclofen (Dioresal)/ Dantrolene Sodium (Dantrene) – muscle relaxants. a. Immunosupresants 2. prunes. Institute stress management techniques. 3. . Impaired cerebral function CHARCOTS TRIAD IAN Intentional tremors 6.4. For Urinary Incontinence Anti spasmodic agent a. vitamin C and orange. Constipation 8. 5. c. d. Decrease sexual capacity DIAGNOSTIC PROCEDURE Nystagmus CSF analysis (increase in IgG and Protein). Monitor breath sounds 1 hour after subcutaneous administration. To acidify urine and prevent bacterial multiplication. plums. NURSING MANAGEMENT 1. c. b. pineapple. (+) Romberg’s test) 5. Increase fluid intake and increase fiber to prevent constipation. a. Deep breathing exercises b. ACTH (Adreno Corticotropic Hormone)/ Steroids for acute exacerbation to reduce edema at site of demyelination to prevent paralysis. MRI (reveals site and extent of demyelination). Monitor side effects bronchospasm and wheezing. Diuretics b. (+) Lhermitte’s sign a continuous and increase contraction of spinal column. Bethanicol Chloride (Urecholine) Nursing Management Only given subcutaneous. Maintain side rails to prevent injury related to falls. Administer medications as ordered a. Prophantheline Bromide (Promanthene) Acid ash diet like cranberry juice.
Occipital . cold. avoid use of tissue papers avoid using talcum powder and perfume. Urethra (20 cm. touch.COMMON CAUSE OF UTI Female short urethra (3-5 cm. Brain Mass PARTS OF THE BRAIN 1. Temporal hearing short term memory for appreciation discrimination of sensory impulses to pain. Parietal 4. 8 inches) urinate after intercourse Nursing Management Male MICROGLIA stationary cells that carry on phagocytosis (engulfing of bacteria or cellular debris. Frontal higher cortical thinking controls personality controls motor activity Broca’s Area (motor speech area) when damaged results to garbled speech. CEREBRUM largest part composed of the Right Cerebral Hemisphere and Left Cerebral Hemisphere enclosed in the Corpus Callosum. heat. 3. eating). 2. pressure. 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. numbness. 80% brain mass 10% blood 10% CSF COMPOSITION OF BRAIN I. pinocytosis (cell drinking). Functions of Cerebrum integrative sensory motor Lobes of Cerebrum 1. 1-1 ½ inches) poor perineal hygiene vaginal environment is moist avoid bubble bath (can alter Ph of vagina).
Medulla Oblongata 3. controls temperature (thermoregulatory center). hiccup. early sign for females telarche and late sign is menarche. controls smell and if damaged results to Anosmia (absence of smell). release dopamine (controls gross voluntary movement. 2. controls libido controls long term memory Insula (Island of Reil) Limbic System (Rhinencephalon) 2. heart rate. DECREASE Myasthenia Gravis Parkinson’s Disease INCREASE Bi-polar Disorder Schizophrenia NEURO TRANSMITTER Acethylcholine Dopamine 3. B. . unequal size of pupil is anisocoria. rhythm and depth of respiration. for vision visceral function activities of internal organ like gastric motility. controls pituitary functions androgenic hormones promotes secondary sex characteristics. Pons pneumotaxic center controls the rate. MIDBRAIN/ MESENCEPHALON acts as relay station for sight and hearing. BRAIN STEM located at lowest part of brain Parts of Brain Stem 1. early sign for males are testicular and penile enlargement late sign is deepening of voice. BASAL GAGLIA areas of grey matter located deep within each cerebral hemisphere. positive PERRLA 4. Cerebellum smallest part of the brain. vomiting. anxiety and excitement. vasomotor center (dilation and constriction of bronchioles). Thalamus acts as relay station for sensation. controls blood pressure controls thirst appetite/satiety sleep and wakefulness controls some emotional responses like fear. hearing acuity is 30 – 40 dB. swallowing. lesser brain. Hypothalamus 5. controls respiration. equal size of pupil is isocoria. INTERBRAIN/ DIENCEPHALON Parts of Diencephalon A. size of pupil is 2 – 3 mm.
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. Cervical 2 – also known as AXIS. 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. 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. controls balance. projective vomiting headache papilledema (edema of optic disc) abnormal posturing decorticate posturing (damage to cortex and spinal cord). equilibrium. Early closure of posterior fontanels causes posterior enlargement of skull in hydrocephalus. widening of pulse pressure is neurologic in nature (if narrow cardiac in nature). 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.
Elevate bed of client 30 – 35o angle with neck in neutral position unless contraindicated to promote venous drainage. 7. Late signs of hypoxia HYPERCARBIA 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. b. c. cerebellum and midbrain). c. monitor strictly input and output every 1 hour notify physician if output is less 30 cc/hr. Prevent further increase ICP by: a. Administer medications like: a. maintain side rails. Osmotic diuretic (Mannitol) for cerebral diuresis Nursing Management monitor vital signs especially BP (hypotension). 3. b. Monitor strictly input and output and neuro check 5. avoid clustering of nursing activity together. d. Limit fluid intake to 1200 – 1500 ml/day (in force fluids 2000 – 3000 ml/day). 4. Maintain patent and adequate ventilation by: a. Furosemide) Drug of choice for CHF (pulmonary edema) Loop of Henle in kidneys. Assist in mechanical ventilation 2. Loop diuretic (Lasix. decerebrate posturing (damage to upper brain stem that includes pons. administered via side drip regulated fast drip to prevent crystal formation. Prevent complications of 6. Nursing Management . provide an comfortable and quite environment. unilateral dilation of pupils called uncal herniation bilateral dilation of pupils called tentorial herniation resulting to mild headache possible seizure activity Nursing Management 1. In chronic respiratory distress syndrome decrease O2 stimulates respiration. 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. Before and after suctioning hyper oxygenate client 100% and done 10 – 15 seconds only. avoid use of restraints.
Dexamethasone (Decadron) Hydrocortisone Prednisone (to reduce edema that may lead to increase ICP) Mild Analgesics (Codeine Sulfate for respiratory depression) Anti Convulsants (Dilantin. Phenytoin) c. administered IV push or oral. 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 . maximum effect of 6 hours. Monitor vital signs especially BP (hypotension). given early morning immediate effect of 10 – 15 minutes. monitor strictly input and output every 1 hour notify physician if output is less 30 cc/hr.
Signs and Symptoms of Lasix in terms of electrolyte imbalances 1.5 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. in infant TACHYCARDIA) agitation dry mucous membrane poor skin turgor weakness and fatigue . Hypocalcemia/ Tetany VEGETABLES Asparagus Brocolli Carrots Spinach decrease calcium level normal value is 8. Hypokalemia decrease potassium level normal value is 3.5 – 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. Oral Potassium Chloride) increase intake of foods rich in potassium FRUITS Apple Banana Cantalop e Oranges 2. Hyponatremia DECREASE decrease sodium level normal value is 135 – 145 meq/L Signs and Symptoms hypotension dehydration signs (Initial sign in adult is THIRST.
Hyperglycemia normal FBS is 80 – 100 mg/dl polyuria polydypsia polyphagia monitor FBS Signs and Symptoms Nursing Management 5.Nursing Management force fluids administer isotonic fluid solution as ordered 4. Allopurinol (Zyloprim) Side Effects Respiratory depression (check for RR) . Signs and Symptoms Nursing Management a. Nursing Management a. Hyperuricemia increase uric acid (purine metabolism) foods high in uric acid (sardines. Allopurinol (Zyloprim) b. joint pain (great toes) swelling force fluids administer medications as ordered Drug of choice for gout. Mechanism of action: inhibits synthesis of uric acid. Acute gout Mechanism of action: promotes excretion of uric acid. Narcotic Analgesic b. organ meats and anchovies) *Increase in tophi deposit leads to Gouty arthritis. 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.
increase sweating b. Methyldopa(Aldomet) c. Encephalitis 5. Monotone type speech mood lability (in state of depression) increase salivation (drooling type) autonomic changes a. Arteriosclerosis 3. difficulty rising from sitting position. increase lacrimation c. Administer medications as ordered Anti Parkinsonian agents Levodopa (L-dopa) short acting Amantadine Hydrochloride (Symmetrel) Carbidopa (Sinemet) .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. Predisposing Factors 1. seborrhea d. decrease sexual capacity Nursing Management 1. Haloperidol(Haldol) d. 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. Poisoning (lead and carbon monoxide) 2. Reserpine(Serpasil) b. Hypoxia 4. 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. Increase dosage of the following drugs: a. constipation e.
Isonicotinic Acid Hydrazide Anti Cholinergic Agents (ARTANE and COGENTIN) .5 – 1.to relieve tremors Mechanism of Action inhibits action of acethylcholine SNS Side Effects Anti Histamine (Dipenhydramine Hydrochloride) Side Effects Adult: drowsiness Children: CNS excitement (hyperactivity) because blood brain barrier is not yet fully developed. Dopamine Agonist . Maintain side rails to prevent injury 3.relieves tremor rigidity Bromocriptene Hydrochloride (Parlodel) Side Effects Respiratory depression 2. 6.6 – 1. Encourage increase fluid intake and fiber. Decrease protein in morning and increase protein in afternoon to induce sleep 5. Assist in Stereotaxic Thalamotomy MAGIC 2’s IN DRUG MONITORING DRUG Digoxin/ Lanoxin (Increase force of cardiac output) Lithium/ Lithane (Decrease level of Ach/NE/Serotonin) Aminophylline (Dilates bronchial tree) Dilantin/ Phenytoin Acetaminophen/Tylenol NORMAL RANGE . Prevent complications of immobility 4.5 meq/L . Assist/supervise in ambulation 7.2 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).
9 NaCl to prevent development of crystals or precipitate. depression Antidote: Acetylcisteine (mucomyst) prepare suction apparatus as bedside. Dilantin Toxicity Signs and Symptoms gingival hyperplasia (swollen gums) hairy tongue ataxia nystagmus provide oral care massage gums Nursing Management 5.1. Aminophylline Toxicity Signs and Symptoms tachycardia palpitations CNS excitement (tremors. administered sandwich method avoid taking alcohol because it can lead to severe CNS depression avoid caffeine Nursing Management 4. 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 (. Digitalis Toxicity Signs and Symptoms nausea and vomiting diarrhea confusion photophobia changes in color perception (yellowish spots) Antidote: Digibind 2.8 – 1) hypoglycemia Tremors. 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. tachycardia Irritability Restlessness Extreme fatigue Diaphoresis. agitation and restlessness) only mixed with plain NSS or 0. irritability. .
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: . Nursing Management 1. swallow. 8.administer cholinergic agents as ordered 7.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.The client is unable to see. Cholinergic (Mestinon) b.stress . institute NGT feeding 6.G.infection Signs and Symptoms . mmobility * assist in mechanical ventilation and monitor pulmonary function test * monitor strictly vital signs. initial sign is ptosis a clinical parameter to determine ptosis is palpebral fissure.over medication Signs and Symptoms . Assist in surgical procedure known as thymectomy because it is believed that the thymus gland is responsible for M.Administer anti cholinergic agents (Atropine Sulfate) Side Effects MYASTHENIC CRISIS Causes: . Incidence rate: women 20 – 40 years old Predisposing factors unknown autoimmune: it involves release of cholinesterase an enzyme that destroys Ach. breathe Treatment . 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. Prevent complications . if there is no effect there is damage to occipital lobe and midbrain and is negative for Signs and Symptoms Diagnostic Procedure M. aspiration 3.PNS Treatment . input and output and neuro check * monitor strength or motor grading scale 4.G. Assist in plasma paresis and removing auto immune anti bodies 9. maintain side rails to prevent injury related to falls 5. speak.under medication . airway 2. administer medications as ordered a.
Streptococcus . chills. Signs and Symptoms headache photophobia projectile vomiting fever. 2. Diagnostic Procedures Lumbar puncture: a hollow spinal needle is inserted in the subarachnoid space between the L3 – L4 to L5. Nursing Management for LP Before Lumbar Puncture 1. Meningococcus – most dangerous 2. anorexia. 4. Mode of transmission airborne transmission (droplet nuclei) C. Assess for movement and sensation of extremities. Decrease glucose 3.causes adult meningitis 4. Pia matter – inner layer subdural space between the dura and arachnoid subarachnoid space between the arachnoid and pia. Secure informed consent and explain procedure. drainage and leakage to tissues. 3. Encourage to arch back to clearly visualize L3-L4. Check punctured site for any discoloration. Increase CSF opening pressure (normal pressure is 50 – 100 mmHg) 4. Dura matter – outer layer 2. CSF aspiration is done. A. Pneumococcus 3. Force fluids 3. Arachnoid – middle layer 3. (+) cultured microorganism (confirms meningitis) CBC reveals 1.INFLAMMATORY CONDITIONS OF THE BRAIN MENINGITIS Meninges 3 fold membrane that covers brain and spinal cord. Increase CHON and WBC 2. Empty bladder and bowel to promote comfort. (+) Brudzinski sign (neck pain) D. Place flat on bed 12 – 24 o 2. Increase wbc . Hemophilus Influenzae – causes pediatric meningitis B. Opisthotonus (arching of back) c. Etiology 1. (+) Kernig’s sign (leg pain) d. for support and protection for nourishment blood supply LAYERS OF THE MENINGES 1. general body malaise and weight loss Possible increase in ICP and seizure activity Abnormal posturing (decorticate and decerebrate) Signs of meningeal irritation a. Post Lumbar Puncture 1. Nuchal rigidity or stiff neck b. CSF analysis reveals 1.
Monitor strictly V/S. Anti pyretics 3. Elevate head 30-45o 5. Institute measures to prevent increase ICP and seizure. b. Yellow bone marrow are produced from the medullary cavity of the long bones and produces fat cells. Institute strict respiratory isolation 24 hours after initiation of anti biotic therapy 4. 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. 9. Incidence Rate men are 2-3 times high risk B. Compartment syndrome (compression of arteries and nerves) . CHON. 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. Broad spectrum antibiotics (Penicillin. Maintain good diet of increase CHO. Mid Cerebral Artery b. Provide a comfortable and darkened environment. input and output and neuro check 6. 2 most common cerebral artery affected by stroke a. Mild analgesics c. Maintain fluid and electrolyte balance. 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. 7. Administer medications as ordered a. Enforce complete bed rest 2. Provide client health care and discharge planning concerning: a. Rehabilitation for neurological deficit CVA (STROKE/BRAIN ATTACK/ ADOPLEXY/ CEREBRAL THROMBOSIS) a partial or complete disruption in the brains blood supply. 8. Nursing Management 1.E. calories with small frequent feedings. Tetracycline) b. If there is bone fracture there is hemorrhage and there would be escape of the fat cells in the circulation.
Related stress physical and emotional 8. Hyperlipidemia more on genetics/genes that binds to cholesterol 5. homonymous hemianopsia (loss of half of visual field) 1. usually fells guilty when not doing anything 6. Valvular Cardiac Surgery (mitral valve replacement) 2. D.C. Stroke in evolution 3. Risk Factors 1. sedentary lifestyle 3. agraphia (difficulty writing) f. deadline driven b. Prolong use of oral contraceptives promotes lypolysis (breakdown of lipids) leading to atherosclerosis that will lead to hypertension and eventually CVA. Diagnostic Procedure 1. CT Scan – reveals brain lesions 2. aphasia c. can do multiple tasks c. TIA Signs and Symptoms 2. Obesity (increase 20% ideal body weight) 4. Related to diet: increase intake of saturated fats like whole milk 7. Complete stroke Signs and Symptoms E. Lifestyle (smoking). Myocardial Infarction. Atherosclerosis. Hypertension. Type A personality a. nausea and vomiting dysphagia (+) Kernig’s sign and Brudzinski sign which may lead to hemorrhagic stroke focal neurological deficits a. 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 . Signs and Symptoms Heart Disease. phlegia b. Diabetes Mellitus. dysarthria (inability to articulate words) d. Post dependent on stages of development Initial sign of stroke or warning sign headache and dizziness tinnitus visual and speech disturbances paresis (plegia) possible increase ICP progression of signs and symptoms of stroke resolution phase characterized by: headache and dizziness Cheyne Stokes Respiration anorexia. alexia (difficulty reading) e.
administrate O2 inhalation 2. Cortecosteroids d. Provide alternative means of communication a. Mild Analgesics e. Loop Diuretics (Lasix. ulcer and unknown cause of headache because it may potentiate bleeding 11. exercise. K (Aqua Mephyton) g. Institute NGT feeding 8. 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. smoking) b. non verbal cues b. Thrombolytic/Fibrinolytic Agents – dissolves thrombus Streptokinase Side Effect: Allergic Reaction Urokinase Tissue Plasminogen Activating Factor Side Effect: Chest Pain f. If positive to hemianopsia approach client on unaffected side 10. provide egg crate mattresses or water bed c. I & O and neuro check 5. Elevate head 30 – 45o 4. saturated fats and caffeine) d. Osmotic Diuretics (Mannitol) b. turn client to side b. provide sand bag or food board. Anti Coagulants Heparin (short acting) check for partial thromboplastin time if prolonged there is a risk for bleeding. dietary modification (decrease salt. Prevent complications of immobility by: a. Assist in passive ROM exercise every 4 hours to promote proper bodily alignment and prevent contractures 7. Administer medications as ordered a. 6. Provide client health teachings and discharge planning concerning a. magic slate 9. Maintain patent airway and adequate ventilation by: a. Monitor strictly vitals signs. Anti Platelet PASA (Aspirin) Contraindicated for dengue. Restrict fluids to prevent cerebral edema that might increase ICP 3. prevent complication (subarachnoid hemorrhage is the most feared complication) c.F. assist in mechanical ventilation b. Nursing Management 1. importance of follow up care . avoidance of modifiable risk factors (diet. Furosemide) c.
intake and output c. Dysphagia 3. monitor pulmonary function test 2. Zylocaine Bretylium – blocks release of norepinephrine to prevent increase of BP 8. Monitor strictly the following a. Prevent complications of immobility by turning the client every 2 hours 5. assist in mechanical ventilation b.GUILLAIN BARRE SYNDROME a disorder of the CNS characterized by bilateral symmetrical polyneuritis leading to ascending muscle paralysis. Decreased of diminished deep tendon reflex 5. Institute NGT feeding to prevent aspiration 6. Diagnostic Procedures 1. vital signs b. Anti Cholinergic Agents – Atrophine Sulfate c. constipation C. 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. Prevent complications a. Ascending muscle weakness leading to paralysis 4. Antecedent viral infections such as LRT infections B. Autoimmune 2. Maintain side rails to prevent injury related to fall 4. CSF analysis reveals increase in IgG and protein D. Administer medications as ordered a. Signs and Symptoms 1. Anti Arrythmic Agents Lidocaine. increase salivation b. Alternate hypotension to hypertension ** ARRYTHMIA (most feared complication) 6. Predisposing Factors 1. Corticosteroids – suppress immune response b. . Arrythmia b. Autonomic symptoms that includes a. Maintain patent airway and adequate ventilation by: a. Assist in plasma pharesis (filtering of blood to remove autoimmune anti-bodies) 9. increase sweating c. Clumsiness (initial sign) 2. A. Assist in passive ROM exercise 7. neuro check d. Nursing Management 1. ECG 3.
Predisposing Factors 1. Signs and Symptoms Dependent on stages of development or types of seizure I. 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. Petit mal Seizure – absence of seizure common among pediatric clients characterized by a. clouding of consciousness – not in contact with environment c. Status Epilepticus A continuous uninterrupted seizure activity. twitching of mouth d. Physical and emotional stress 7. Diagnostic Procedures 1. 2. Generalized Seizure 1. Seizure – first convulsive attack Epilepsy – second or series of attacks Febrile seizure – normal in children age below 5 years A. Partial or Localized Seizure 1. EEG – reveals hyper activity of electrical brain waves . Signs or aura with auditory.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. sensory experience b. Tonic contractions . Post ictal sleep – unresponsive sleep 2. Psychomotor Seizure (focal motor seizure) a. blank stare b. decrease blinking of eyes c. Epileptic cry – is characterized by fall and loss of consciousness for 3 – 5 minutes c. Grand mal Seizure (tonic-clonic seizure) a. automatism – stereotype repetitive and non propulsive behavior b. Presence of brain tumor 4. Genetics 3. Nutritional and Metabolic deficiencies 6. tactile. loss of consciousness (5 – 10 seconds) II.contraction of extremities d. Valium) B. lead b carbon monoxide 5. CT Scan – reveals brain lesions 2. Head injury due to birth trauma 2. Drug of choice: Diazepam. Sudden withdrawal to anti convulsant drug is predisposing factor for status epilepticus (drug of choice is Diazepam. Valium and Glucose C. if left untreated can lead to hyperpyrexia and lead to coma and eventually death. mild hallucinatory sensory experience III. olfactory. Toxicity from a.direct symmetrical extension of extremities Clonic contractions . visual.
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
Timoptics (Timolol Maleate) E. Milky white appearance at center of pupils 3. Cataract Decrease opacity of lens A. Treatment 1. Decrease perception to colors Complication is blindness D. Treatment 1. TRABECULECTOMY (Peripheral Indectomy) – drain aqueous humor 2. Pathognomonic Signs 1. Diabetes Mellitus 4. Diagnostic Procedure 1. Aging 65 years and above 2. Surgical Procedure Extra Capsular Cataract Lens Extraction . Retinal Detachment Separation of epithelial surface of retina .3. Pilocarpine Sodium. Cyclopegics (Cyclogyl) – paralyses cilliary muscle F. Surgical Procedures 1. Epinephrine eyedrops – decrease formation of aqueous humor 3.Total removal of cataract with its surrounding capsules Most feared complication post op is RETINAL DETACHMENT 3. Carbonic Anhydrase Inhibitors a. Gonioscopy D. Miotics – constricts pupil a. Signs and Symptoms 1. Carbachol 2. Loss of central vision C. Prolonged exposure to UV rays B. Opthalmoscopic exam E. Mydriatics (Mydriacyl) – constricts pupils 2. Blurring or hazy vision 2. Related to congenital 3. Acetazolamide (Diamox) – promotes increase outflow of aqueous humor or drainage 4.Partial removal Intra Capsular Cataract Lens Extraction . Predisposing Factor 1.
Scleral Buckling 2. Floaters C. Macular Degeneration Degeneration of the macula lutea (yellowish spot at the center of retina) A. TROCHLEAR. Signs and Symptoms 1. mandibular . VI: OCULOMOTOR. Cryosurgery – cold application 3. Predisposing Factors 1. Signs and Symptoms 1. Myopia (near sightedness) B. Post Lens Extraction 2. Black Spots CRANIAL NERVE III. Surgical Procedures 1. IV. maxillary. Diathermy – heat application 4.A. 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. Curtain veil like vision 2.
contains the Organ of Corti (the true organ of hearing) Let client repeat words uttered CRANIAL NERVE IX. Pituitary Gland (Hypophysis Cerebri) . mucous membrane. 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. Parts of the Ear 1. refers to movement and orientation of the body in space. X: GLOSOPHARYNGEAL. 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. sensory: controls sensation of face. Middle Ear 3. Inner Ear Vestibule: Meinere’s Disease Cochlea Mastoid Cells Endolymph and Perilymph COCHLEA: controls hearing. 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. CRANIAL NERVE VIII: ACOUSTIC/VESTIBULOCOCHLEAR Controls balance particularly kinesthesia or position sense. Outer Ear Pinna Eardrum Hammer Anvil Stirrup Malleus Incus Stapes 2. ENDOCRINE SYSTEM Overview of the structures and functions 1. VAGUS NERVE Glosopharyngeal: controls taste. teeth. frown and if results are negative there is facial paralysis or Bell’s Palsy and the primary cause is forcep delivery.
Signs and Symptoms 2. Agitation c. Anterior Pituitary Gland o o o hemorrhage o o administrate oxytocin immediately after delivery to prevent uterine atony. Weakness and fatigue 4.015 – 1. Hypotension 5. Poor Skin turgor d. Nursing Management . If left untreated results to hypovolemic shock (sign is anuria) C. Predisposing Factor o o o o 1. Signs of dehydration a.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. 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. Monitor strictly vital signs and intake and output 3. Administer medications as ordered a. Adult: thirst b. Diagnostic Procedures 1. Pitressin (Vasopresin Tannate) – administered IM Z-tract 4. Serum Sodium D. Dry mucous membrane 3. Polyuria 2. Prevent complilcations – HYPOVOLEMIC SHOCK is the most feared complication Normal value: 1. Force fluids 2. Urine Specific Gravity o o o 1. Weight loss 6.030 Ph 4 – 8 Increase resulting to hypernatremia Related to pituitary surgery Trauma Inflammation Presence of tumor B. Posterior Pituitary Gland 2. 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.
Restrict fluid 2. Predisposing Factors 1. Water intoxication may lead to cerebral edema and lead to increase ICP – may lead to seizure activity C. Melanocyte Stimulating hormone o o o for skin pigmentation Hyposecretion of MSH results to Albinism Most feared complications of albinism a. Serum Sodium is decreased D. B. Fluid retention a. Related to hyperplasia (increase size of organ brought about by increase of number of cells) of pituitary 2. Diagnostic Procedure 1. Urine specific gravity is increased 2. Adrenochorticotropic hormone (ACTH) o promotes development of adrenal cortex . Lead to blindness due to severe photophobia b. intake and output and neuro check 4.SIADH o hypersecretion of anti diuretic hormone A. 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. Weight gain 2. Monitor strictly vital signs. Related to presence of bronchogenic cancer o o gland. Weigh patient daily and assess for pitting edema 5. Hypertension b. Loop diuretics (Lasix) b. Head injury 2. Provide meticulous skin care 6. 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. Prone to skin cancer o Hypersecretion of MSH results to Vitiligo 3. Administer medications as ordered a. Signs and Symptoms 1. Osmotic diuretics (Mannitol) 3. Nursing Management 1. Edema c.
Goiter belt area a. carrots. Lactogenic homone (Prolactin) o o o o promotes development of mammary gland with help of oxytocin it initiates milk let down reflex secretes estrogen secretes progesterone 5. T4 (tetra iodothyronine. cabbage. turnips. Predisposing Factors 1. Mountainous regions 2. sweet potato. all nuts soil erosion washes away iodine . radish.4. strawberry. Leutinizing hormone 6. Thyrocalcitonin – antagonizes the effects of parathormone to promote calcium resorption. Thyroxine) o o T3 and T4 are metabolic or calorigenic hormone promotes cerebration (thinking) 3. broccoli. 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. places far from sea b.3 molecules of iodine (more potent) 2. 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. T3 (Tri iodothyronine) . Increase intake of goitrogenic foods o o o contains pro-goitrin an anti thyroid agent that has no iodine.
Monitor side effects o o o o o o o insomnia tachycardia and palpitations hypertension heat intolerance seaweeds seafood’s like oyster. PASA (Aspirin) d. Lithium Carbonate c. presence of tumor. Iatrogenic Cause – disease caused by medical intervention such as surgery 2. Increase dietary intake of foods rich in iodine A. 3. best taken raw because it it is easily destroyed by heat 5. Tetracycline. Enforce complete bed rest 2. Enlarged thyroid gland 2.o goitrogenic drugs a. Signs and Symptoms 1. Diagnostic Procedures 1. Serum Thyroid Stimulating Hormone (TSH) – is increased (confirmatory diagnostic test) D. Instruct client to take in the morning to prevent insomnia 2. 4 Medications to be taken via straw: Lugol’s. Mild dysphagia 3. Phenylbutazones (NSAIDs) . Iron. crabs. clams and lobster but not shrimps because it contains lesser amount of iodine. Mild restlessness C. Nitrofurantoin (drug of choice for pyelonephritis) b. Administer medications as ordered a. Anti Thyroid Agent – Prophylthiuracil (PTU) b. Thyroid Hormones o o o Levothyroxine (Synthroid) Liothyronine (Cytomel) Thyroid Extracts Nursing Management when giving Thyroid Hormones 1. 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.if goiter is caused by B. inflammation . Lugol’s Solution/SSKI ( Saturated Solution of Potassium Iodine) o o color purple or violet and administered via straw to prevent staining of teeth. iodized salt. Nursing Management 1. Monitor vital signs especially heart rate because drug causes tachycardia and palpitations 3. Serum T3 and T4 – reveals normal or below normal 2. Predisposing Factors 1. Related to atrophy of thyroid gland due to trauma. Thyroid Scan – reveals enlarged thyroid gland. Cobalt e.
bradypnea.3. Brittleness of hair and nails 2. bradypnea. Serum Cholesterol is increased 3. Leothyronine c. Constipation (Late Signs) 1. Hoarseness of voice 4. Levothyroxine b. Nursing Management 1. Administer isotonic fluid solution as ordered 4. hypoventilation. hyponatremia. RAIU (Radio Active Iodine Uptake) is decreased D. bradycardia. Provide client health teaching and discharge planning concerning a. Avoid precipitating factors leading to myxedema coma o o stress infection Assist in mechanical ventilation Administer thyroid hormones as ordered Force fluids . Dry skin 4. Signs and Symptoms (Early Signs) 1. 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. Diagnostic Procedures 1. Provide meticulous skin care 8. hypothermia leading to pregressive stupor and coma. hypothermia 6. hypoglycemia. Nursing Management for Myxedema Coma 2. bradycardia. Weakness and fatigue 2. Provide dietary intake that is low in calories 6. Autoimmune (Hashimotos Disease) B. Thyroid Extracts 5. Provide comfortable and warm environment 7. Cold intolerance 5. Non pitting edema (Myxedema) 3. Force fluids 3. CNS changes o o o o lethargy memory impairment psychosis menorrhagia C. Decrease in all vital signs – hypotension. Decrease libido 5. Serum T3 and T4 is decreased 2. Loss of appetite but with weight gain which promotes lipolysis leading to atherosclerosis and MI 3. Administer medications as ordered Thyroid Hormones a. Iodine deficiency 4.
All vital signs are increased 6. Thyroid Scan. Signs and Symptoms 1. Serum T3 and T4 is increased 2. Amenorrhea C. Administer medications as ordered Anti Thyroid Agent a. Increase appetite (hyperphagia) but there is weight loss 2. Irritability and agitation b. Tremors d.reveals an enlarged thyroid gland D. CNS involvement a. 4. Comfortable and cold environment 6. Maintain side rails . RAIU (Radio Active Iodine Uptake) is increased 3. Provide dietary intake that is increased in calories.o o o o o o o o cold intolerance use of anesthetics. Prophythioracill (PTU) b. Monitor strictly vital signs and intake and output 2. and sedatives prevent complications (myxedema coma. Autoimmune – it involves release of long acting thyroid stimulator causing exopthalmus (protrusion of eyeballs) enopthalmus (late sign of dehydration among infants) 2. Moist skin 3. Hallucinations 7. Provide meticulous skin care 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. Nursing Management 1. Diarrhea 5. Excessive iodine intake 3. Exopthalmus 9. Restlessness c. narcotics. Predisposing Factors 1. Related to hyperplasia (increase size) B. Heat intolerance 4. 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. Insomnia e. Diagnostic Procedures 1. Goiter 8.
Anti Pyretics b. 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.7. maintain side rails offer TSB Tachycardia 2. 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. input and output and neuro check. seizure give Calcium Gluconate IV slowly as ordered 3. Hormonal replacement therapy for lifetime 6. Watch out for signs of thyroid storm/ thyrotoxicosis Agitation TRIAD SIGNS Hyperthermia o administer medications as ordered a. Beta-blockers o o o monitor strictly vital signs. Provide bilateral eye patch to prevent drying of the eyes. 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 . 5. 8. POST OPERATIVELY. 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. Signs of bleeding (feeling of fullness at incisional site) Nursing Management o Check the soiled dressings at the back or nape area. 1.
C MAD .5 mg/100 ml) 3. arrhythmia 2.A. Acute Tetany Calcium Gluconate IV slowly b. agitation and memory impairment C. Administer medications as ordered such as: a. Predisposing Factors 1.A. Nursing Management 1. Phosphate binder Aluminum Hydroxide Gel (Ampogel) Side effect: constipation ANTACID A. Signs and Symptoms 1. Following subtotal thyroidectomy 2. anorexia.5 – 4. Serum Calcium is decreased (normal value: 8. nausea and vomiting d. tingling sensation b. X-ray of long bones reveals a decrease in bone density 4. positive chvostek sign g. trauma B. loss of tooth enamel c. Acute tetany a. Serum Phosphate is decreased (normal value: 2. Chronic tetany a. CT Scan – reveals degeneration of basal ganglia D. positive trousseu’s sign/carpopedal spasm f. photophobia and cataract formation b. seizure i. inflammation b. Vitamin D (Cholecalciferol) for absorption of calcium CHOLECALCIFEROL ARE DERIVED FROM Drug Diet (Calcidiol) Sunlight (Calcitriol) feared complications d.5 – 11 mg/100 ml) 2. laryngospasm/broncospasm h. Diagnostic Procedures 1. Chronic Tetany Oral Calcium supplements Calcium Gluconate Calcium Lactate Calcium Carbonate c. dysphagia e. Atrophy of parathyroid gland due to: a. numbness d. tumor c. paresthesia c.
Avoid precipitating stimulus such as glaring lights and noise 3. Provide acid ash in the diet to acidify urine and prevent bacterial growth 7. green turnips 4. renal cholic b. anchovies b. Morphine Sulfate (Demerol) 5. Serum Phosphate is decreased 3. Prevent complications 8. Adults: Osteomalacia B. Bone pain especially at back (bone fracture) 2. Assist/supervise in ambulation 8. Diagnostic Procedures 1. Over compensation of parathyroid gland due to vitamin D deficiency a. Hormonal replacement therapy for lifetime 9. Maintain side rails .▼ Aluminum Containing Antacids ▼ Aluminum Hydroxide Gel ▼ Side Effect: Constipation ▼ Magnesium Containing Antacids ▼ Side Effect: Diarrhea 2. Hyperplasia of parathyroid gland 2. Prepare trache set at bedside for presence of laryngo spasm 7. 6. salmon c. Importance of follow up care. 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. nausea and vomiting 4. cool moist skin 3. Force fluids to prevent kidney stones 2. Kidney stones a. Anorexia. Agitation and memory impairment C. Encourage client to breathe using paper bag to produce mild respiratory acidosis result. Administer medications as ordered a. Signs and Symptoms 1. Encourage increase intake of foods rich in phosphate but decrease in calcium 6. Encourage increase intake of foods rich in calcium a. Predisposing Factors 1. X-ray of long bones reveals bone demineralization D. Strain all the urine using gauze pad for stone analysis 3. Provide warm sitz bath 4. Nursing Management 1. Children: Ricketts b. Institute seizure and safety precaution 5. Serum Calcium is increased 2.
weight loss . Hyponatremia .secretes traces of glucocorticoids and androgenic hormones . Decrease tolerance to stress 3. Related to atrophy of adrenal glands 2. Fungal infections B.secretes mineralocorticoids (aldosterone) . Zona Reticularis . Adrenal Cortex – outermost b.Sex 3. Assist in surgical procedure known as parathyroidectomy 11.9. Zona Glumerulosa .Salt ADDISON’S DISEASE o Hyposecretion of adreno cortical hormone leading to a. Hormonal replacement therapy for lifetime 12.secretes glucocortocoids (cortisol) . Signs and Symptoms 1.Sugar 2. fluid and electrolyte imbalance – Salt c. Predisposing Factors 1. 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.hypotension .signs of dehydration .function: promotes sodium and water reabsorption and excretion of potassium . Hypoglycemia – TIRED 2. deficiency of neuromuscular function – Salt/Sex A. metabolic disturbance – Sugar b.function: controls glucose metabolism . Zona Fasciculata . Prevent complications (seizure and arrhythmia) 10.function: promotes secondary sex characteristics . Importance of follow up care ADRENAL GLAND o o Located atop of each kidney 2 layers of adrenal gland a.
Serum Sodium is decrease (normal value: 135 – 145 meq/L) 4. Taper dose (withdraw gradually from drug) 3. hypovolemic shock c. Monitor strictly vital signs. Force fluids 4.agitation . Dexamethasone (Decadrone) b. Nursing Management 1. Diagnostic Procedures 1. Mineralocorticoids (Flourocortisone) 5. Instruct client to take 2/3 dose in the morning and 1/3 dose in the afternoon to mimic the normal diurnal rhythm 2. Provide client health teaching and discharge planning a. Serum Potassium is increased (normal value: 3.sudden withdrawal to steroids b.stress . Provide dietary intake. protein but decrease in potassium 6. Provide meticulous skin care 7. Loss of pubic and axillary hair 7. hirsutism d. carbohydrates.5 – 4. Bronze like skin pigmentation C. Monitor side effects a.administer steroids as ordered . avoid precipitating factor leading to addisonian crisis leading to .hypovolemic shock . Decrease libido 6. 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. severe hypotension b. hypertension b. .infection . Prednisone c.force fluids 2. Plasma Cortisol is decreased 3. Hyperkalemia . Administer isotonic fluid solution as ordered 3. Hydrocortisone (Cortison) Nursing Management when giving steroids 1.addisonian crisis . increase calories. edema c. moon face appearance 4.5 meq/L) D.4. hyponatremia leading to progressive stupor and coma Nursing Management for Addisonian Crisis 1. Administer medications as ordered Corticosteroids a. prevent complications . Assist in mechanical ventilation. FBS is decreased (normal value: 80 – 100 mg/dl) 2.arrhythmia 5. increase susceptibility to infection e.diarrhea .
Increase masculinity among females B. obese trunk f. Administer medications as ordered a. pendulous abdomen g. U wave upon ECG (T wave hyperkalemia) 5. hormonal replacement for lifetime d. Easy bruising 8. Predisposing Factors 1 Related to hyperplasia of adrenal gland 2. Hypernatremia a. importance of follow up care CUSHING SYNDROME o Hypersecretion of adenocortical hormones A. Hormonal replacement for lifetime 10. Restrict sodium intake 5. weakness and fatigue b. Prevent complications (DM) 8. Weigh patient daily and assess for pitting edema 3. Importance of follow up care PANCREAS . Diagnostic Procedures 1.Mixed gland (exocrine and endocrine) . constipation c. Spinarolactone – potassium sparring diuretics 7. Plasma Cortisol is increased 3. Hirsutism 6. Monitor strictly vital signs and intake and output 2. Serum Sodium is increased 4. Serum Potassium is decreased C.c. Provide meticulous skin care 6. thin extremities 4. hypertension b. Measure abdominal girth daily and notify physician 4.Located behind the stomach . Acne and striae 7. Assist in surgical procedure (bilateral adrenoraphy) 9. Nursing Management 1. FBS is increased 2. Increase susceptibility to infections 3. weight gain d. Hypokalemia a. edema c. moon face appearance and buffalo hump e.
Brittle disease A. Signs and Symptoms 1. Related to viruses 3. Polyuria 3. Polyphagia 5. Delayed/poor wound healing D. Insulin therapy 2. Signs and Symptoms 1. Polyuria 2. Polydypsia 3. Osmolar 3.. Polydypsia 4.Delta cells secretes somatostatin (function: antagonizes the effects of growth hormones) 3 Main Disorders of Pancreas 1. Oral Hypoglycemic agents 2.metabolic disorder characterized by non utilization of carbohydrates. Steroids 4. Polyphagia 4. Lasix b. Ketotic 5. Treatment 1. Increase susceptibility to infection 9. Non 4. Anorexia. Coma C. Predisposing Factors 1. Incidence Rate . Exercise E. Incidence Rate .Maturity onset type . Treatment 1. Diabetic Ketoacidosis D. Usually asymptomatic 2.Juvenile onset type . Pancreatic Tumor/Cancer 2.Consist of acinar cells which secretes pancreatic juices that aids in digestion thus it is an exocrine gland . Drugs a. Weight loss 6. Obesity – because obese persons lack insulin receptor binding sites . Diet 3. Glucosuria 5. Glucosuria 6. Diabetes Mellitus 3. Blurring of vision 8. Predisposing Factors 1. Weight gain Type 2 (NIDDM) .Consist of islets of langerhans . Hereditary (total destruction of pancreatic cells) 2. nausea and vomiting 7.Beta cells secretes insulin (function: hypoglycemia) . Complication 1.Adult onset . Hyper 2.Has alpha cells that secretes glucagons (function: hyperglycemia) . Related to carbon tetrachloride toxicity C. Complications 1.10% general population has type 1 DM B.Obese over 40 years old A. Pancreatitis DIABETES MELLITUS . protein and fat metabolism CLASSIFICATION OF DM Type 1 (IDDM) .90% of general population has type 2 DM B. Diet 3. Exercise E.
Cholesterol . 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 . Protein 3. Fats ANABOLISM CATABOLISM Glucose Amino Acids Fatty Acids Glycogen Nitrogen Free Fatty Acids .MAIN FOODSTUFF 1.
intake and output and blood sugar levels 4.9 NaCl followed by . Hct (normal value: female 36 – 42.8 – 1) 4. Hyperglycemia 2.Hyperosmolar: increase osmolarity (severe dehydration) . Polyphagia 4. Nursing Management 1. Polydypsia 3. Polyuria 2. nausea and vomiting 7. Creatinine (normal value: . Predisposing Factors 1. Assist in mechanical ventilation 2. Blurring of vision 8.Non ketotic: absence of lypolysis (no ketones) A. Restlessness 3. Glucosuria 5. Anorexia. Administer medications as ordered a. Decrease LOC – diabetic coma . Diagnostic Procedures 1. Weight loss 6. Signs and Symptoms 1. FBS is increased 2.DIABETIC KETOACIDOSIS .45 NaCl (hypotonic solutions) to counteract dehydration and shock 3. male 42 – 48) due to severe dehydration D. Monitor strictly vital signs. Seizure activity 4. Acetone breath odor 9. Antibiotics to prevent infection HYPER OSMOLAR NON KETOTIC COMA . Insulin therapy (regular acting insulin/rapid acting insulin peak action of 2 – 4 hours) b. Kussmaul’s Respiration (rapid shallow breathing) 10 CNS depression leading to coma C. Sodium Bicarbonate to counteract acidosis c. Stress – number one precipitating factor 3. BUN (normal value: 10 – 20) 3. Signs and Symptoms 1.Acute complication of type 1 DM due to severe hyperglycemia leading to severe CNS depression A. Headache and dizziness 2. Administer 0. Infection B.
Insulin therapy (regular acting insulin peak action of 2 – 4 hours) . Most accessible route is abdomen 9.Rarely used because it can cause severe allergic reaction . Nursing Management 1.Ultra Lente .Frequently used type because it has less antigenicity property thus less allergic reaction 3.Regular acting insulin (IV only) . Tolbutamide (Orinase) . No need to aspirate upon injection 7. Nursing Management for Insulin Injections 1.for DKA use rapid acting insulin b.Derived from beef and pork 2. Human Sources .Non Protamine Hagedorn Insulin (NPH) . Lipodystrophy c. Administer at room temperature to prevent development of lipodystrophy (atrophy.9 NaCl followed by . Rapid Acting Insulin (clear) .45 NaCl (hypotonic solutions) to counteract dehydration and shock 3. Administer 0. Intermediate Acting Insulin (cloudy) . First Generation Sulfonylureas a.Peak action is 8 – 16 hours 3. Monitor for signs of local complications such as a. Rotate insulin injection sites to prevent development of lipodystrophy 8. Avoid shaking insulin vial vigorously instead gently roll vial between palm to prevent formation of bubbles 4. Long Acting Insulin (cloudy) . Sources of Insulin 1. Administer insulin either 45o – 90o depending on amount of clients tissue deposit 6.Stimulates the pancreas to secrete insulin A. Antibiotics to prevent infection INSULIN THERAPY A. hypertrophy of subcutaneous tissues) 2. Chlorpropamide (Diabenase) b. Assist in mechanical ventilation 2. Artificially Compound Insulin B. 10.B. Classsification 1. When mixing 2 types of insulin aspirate first the clear insulin before cloudy to prevent contaminating the clear insulin and promote proper calibration. Administer medications as ordered a. intake and output and blood sugar levels 4. Somogyis Phenomenon – rebound effect of insulin characterized by hypoglycemia to hyperglycemia ORAL HYPOGLYCEMIC AGENTS . Place in refrigerator once opened 3. Monitor strictly vital signs. Types of Insulin 1. Use gauge 25 – 26 needle 5.Peak action is 16 – 24 hours C. Animal sources . Allergic reactions b.Peak action is 2 – 4 hours 2.
polyphagia and glucosuria confirmatory for DM) 2. Random Blood Sugar is increased 3.administer simple sugars . Monitor for peak action of insulin and OHA and notify physician 2. Shock due to dehydration .Blindness KIDNEY -RECURRENT PYELONEPHRITIS . encourage client to apply lanolin lotion to prevent skin breakdown e. Gangrene formation e. instruct client to avoid wearing constrictive garments d. Administer insulin and OHA therapy as ordered 3. HPN and DM major cause of renal failure d. Blood II.diarrhea/constipation . Monitor for signs of hypoglycemia and hyperglycemia . polydypsia. Instruct client to have an annual eye and kidney exam 10. Second Generation Sulfonylureas a. protein 30% and fats 20% or offer alternative food substitutes 6. Instruct the client to take it with meals to lessen GIT irritation and prevent hypoglycemia 2. Monitor for signs of DKA and HONKC 11. Alpha Glycosylated Hemoglobin is increased C. Atherosclerosis (HPN. Monitor strictly vital signs.for hypoglycemia (cold and clammy skin) give simple sugars . instruct client to avoid walking barefooted b. CVA) b. Assist in surgical procedure HEMATOLOGICAL SYSTEM I. intake and output and blood sugar levels 4.peripheral neuropathy . Diagnostic Procedures 1. Tolamazide (Tolinase) 2.for hyperglycemia (dry and warm skin) 5. Blood Vessels III. Oral glucose tolerance test is increased – most sensitive test 4. Diabeta (Micronase) Nursing Management when giving OHA 1. MI. Nursing Management 1. Instruct the client to avoid taking alcohol because it can lead to severe hypoglycemia reaction or Disulfiram (Antabuse) toxicity symptoms B.Renal failure c. Institute foot care management a.c. assist in surgical wound debriment (give analgesics 15 – 30 mins prior) 9. instruct client to cut toenails straight c. Blood Forming Organs .sexual impotence 8. Monitor signs for complications a. Glipzide (Glucotrol) b. FBS is increased (3 consecutive times with signs or polyuria. Provide nutritional intake of diabetic diet that includes: carbohydrates 50%. Microangiopathy (affects small minute blood vessels of eyes and kidneys) EYES -PREMATURE CATARACT . Instruct client to exercise best after meals when blood glucose is rising 7.
responsible for the release of chemical mediation for inflammation 3.60 – 70% of WBC . Spleen 4. vitamin b6 (pyridoxine) f. prothrombin and fibrinogen clotting factors FORMED ELEMENTS 1. vitamin b12 (cyanocobalamin) e. Polymorphonuclear Basophils . RBC (ERYTHROCYTES) .hematocrit red cell percentage in wholeblood .Gamma globulins a.for allergic reaction B. WBC (LEUKOCYTES) .consist of molecules of hgb (red pigment) bilirubin (yellow pigment) biliverdin (green pigment) hemosiderin (golden brown pigment) .involved in short term phagocytosis for acute inflammation 2. bilirubin and hormones .largest WBC .Maintains osmotic pressure preventing edema GLOBULINS . Non Granulocytes 1. folic acid b. Globulins 3.normal value: female 36 – 42% male 42 – 48% .transport steroids.Largest and numerous plasma CHON . anti-bodies and immunoglobulins b. intrinsic factor . Liver 3. Granulocytes 1.macrophage in blood .substances needed for maturation of RBC a.hemoglobin: normal value female 12 – 14 gms% male 14 – 16 gms% . Monocytes .only unnucleated cell .biconcave discs . Bone Marrow ALBUMIN .for parasite infections . Prothrombin and Fibrinogen 1. iron c.Alpha globulins .normal value: 5000 – 10000/mm3 A. Lymph Nodes 6. Veins Plasma CHON (formed in liver) 1.transports and carries oxygen to tissues . vitamin c d. Polymorphonuclear Eosinophils . Polymorpho Neutrophils .Beta globulins – iron and copper . Arteries 2.Normal life span of RBC is 80 – 120 days and is killed in red pulp of spleen 2.55% Plasma Serum 45% Formed 1. Albumin 2. Lymphoid Organ 5.normal value: 4 – 6 million/mm3 .
Normal value: 150.thymus for immunity Natural killer cell . Kaposi’s Sarcoma 2. Oozing of blood from venipunctured site BLOOD DISORDERS Iron Deficiency Anemia .western blot opportunistic . Petechiae 2. Echhymosis 3.bone marrow . Incidence Rate 1. Inadequate intake of iron due to a. Related to improper cooking of foods C. Common among women 15 – 35 years old 4. Heavy menstruation b.000/mm3 . Platelets (THROMBOCYTES) . Chronic blood loss due to trauma a.. Common among tropical zones 3.Normal life span of platelet is 9 – 12 days Signs of Platelet Dysfunction 1.6 months – 5 years incubation period . Pneumocystis Carinii Pneumonia 3. Related to poor nutrition B. Chronic diarrhea b. Lymphocytes B-cell T-cell .Consist of immature or baby platelets or megakaryocytes which is the target of dengue virus . Predisposing Factors 1.drug of choice AZT (Zidon Retrovir) 2 Common fungal opportunistic infection in AIDS 1.Promotes hemostasis (prevention of blood loss) .000 – 450.anti viral and anti tumor property HIV . Related to GIT bleeding resulting to hematemesis and melena (sign for upper GIT bleeding) c. High cereal intake with low animal protein digestion d.A chronic microcytic anemia resulting from inadequate absorption of iron leading to hypoxemic tissue injury A.6 months window period .ELISA . Related to malabsorption syndrome c. Signs and Symptoms 1.involved in long term phagocytosis for chronic inflammation 2. Subtotal gastrectomy 4. Headache and dizziness . Usually asymptomatic 2. Common among developed countries 2. Weakness and fatigue (initial signs) 3. fresh blood per rectum is called hematochezia 2.
Administer medications as ordered Oral Iron Preparations a. Pain at injection site PLUMBER VINSON’S SYNDROME . Dyspnea 6. Ferrous Sulfate b.Nitrofurantoin (Macrodentin) 3. Monitor and inform client of side effects a. Ferrous Fumarate c. Brittleness of hair and spoon shape nails (koilonychias) 8. Egg (yolk) c. Ferrous Gluconate . Enforce CBR so as not to over tire client 3. If client cant tolerate/no compliance administer parenteral iron preparation a. Administer with Vitamin C or orange juice for absorption 4. Nuts 4. Iron is decreased 5. Atropic Glossitis (inflammation of tongue) . Raisin d. When diluting it in liquid iron preparations administer with straw to prevent staining of teeth Medications administered via straw . Ferritin is decreased E.Lugol’s solution . Hct is deceased 4. Dried fruits f. Diarrhea/constipation e. RBC is decreased 2. Monitor side effects a. Organ meat b. Sorbitex (IM) Nursing Management when giving parenteral iron preparations 1. Diagnostic Procedures 1. Instruct the client to avoid taking tea and coffee because it contains tannates which impairs iron absorption 5. Instruct client to take foods rich in iron a. Anorexia b. Instruct client to take with meals to lessen GIT irritation 2. Monitor for signs of bleeding of all hema test including urinw. Abdominal pain d. Pallor and cold sensitivity 5.4. Sweet potatoes e.Stomatitis . discoloration and leakage to tissues 2. Iron Dextran (IM.Iron . Nursing Management 1. Reticulocyte is decreased 6. PICA (abnormal appetite or craving for non edible foods D. Avoid massaging the injection site instead encourage to ambulate to facilitate absorption 3. IV) b.Dysphagia 9. stool and GIT 2. Legumes g. Palpitations 7. Nausea and vomiting c. Hgb is decreased 3. Administer Z tract technique to prevent discomfort. Melena 5.Tetracycline .300 mg/day Nursing Management when taking oral iron preparations 1.
Nursing Management 1. Signs and Symptoms 1. Subtotal gastrectomy 2. Pallor and cold sensitivity 4. Diagnostic Procedure Schilling’s Test – reveals inadequate/decrease absorption of Vitamin B12 D. Localized abscess c. red beefy tongue c. Administer Vitamin B12 injections at monthly intervals for lifetime as ordered . Dyspnea and palpitations as part of compensation 5. Predisposing Factors 1. Hypotension (anaphylactic shock) PERNICIOUS ANEMIA .b. Skin rashes f. numbness c.Never given orally because there is possibility of developing tolerance Secretes hydrochloric acid ▼ Aids in digestion . Strictly vegetarian diet STOMACH ▼ Pareital cells/ Argentaffin or Oxyntic cells Produces intrinsic factors ▼ Promotes reabsorption of Vit B12 ▼ Promotes maturation of RBC B. Lymphadenopathy d. indigestion/dyspepsia d. Inflammatory disorders of the ileum 4. paresthesia d. weight loss e. jaundice 6.Chronic anemia characterized by a deficiency of intrinsic factor leading to hypochlorhydria (decrease hydrochloric acid secretion) A. Autoimmune 5. Pruritus/orticaria g. positive to Romberg’s test – damage to cerebellum resulting to ataxia e. Enforce CBR 2. Hereditary factors 3. Fever and chills e. result to psychosis C. GIT changes that includes a. mouth sore b. Weakness and fatigue 2. Headache and dizziness 3. tingling sensation b. CNS changes a.
Oozing of blood from venipunctured sites C. Leukopenia a. Headache and dizziness c. Monitor for signs of infection a. Vincristine (Plant Alkaloid) c. Predisposing Factors 1. Methotrexate (Alkylating Agent) b. Bone marrow biopsy/aspiration (site is the posterior iliac crest) – reveals fat necrosis in bone marrow D. Ecchymosis c. Nitrogen Mustard (Antimetabolite) Phenylbutazones (NSAIDS) B. Related to irradiation/exposure to x-ray 3. Chloramphenicol (Sulfonamides) Chemotherapeutic Agents a.Site of injection for Vitamin B12 is dorsogluteal and ventrogluteal . Anemia a. Thrombocytopenia a. Signs and Symptoms 1. Dyspnea and palpitations 2. Instruct client to avoid irritating mouth washes instead use soft bristled toothbrush 5. Institute reverse isolation 6. CBC reveals pancytopenia 2. Nursing Management 1. vitamin c and iron 4. Increase susceptibility to infection 3.. Diagnostic Procedures 1. Administer oxygen inhalation 4.Stem cell disorder leading to bone marrow depression leading to pancytopenia PANCYTOPENIA Decrease RBC (anemia) A. Immunologic injury 4. Enforce CBR 5. Provide a dietary intake that is high in carbohydrates. Petechiae (multiple petechiae is called purpura) b. Institute BT as ordered 3. Drugs Broad Spectrum Antibiotics a. Pallor and cold sensitivity d. protein. Removal of underlying cause 2. Weakness and fatigue b. Chemicals (Benzine and its derivatives) 2. Avoid heat application to prevent burns APLASTIC ANEMIA .No side effects 3. fever Decrease WBC (leucopenia) Decrease Platelet (thrombocytopenia) .
Avoid IM. Force fluids 5. Massive trauma 4. Pregnancy B. ABG analysis reveals metabolic acidosis 4.b. Pitressin/ Vasopresin to conserve fluids c. subcutaneous. Predisposing Factors 1. Nursing Management 1. 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. Opthamoscopic exam reveals sub retinal hemorrhages D. Signs and Symptoms 1. Corticosteroids – caused by immunologic injury b. Massive burns 3. Neoplasia (new growth of tissue) 7. Hemoptysis 6. Anaphylaxis 5. venipunctured sites 8 Instead provide heparin lock 9. Diagnostic Procedures 1. Provide heparin lock 7. Administer oxygen inhalation 4. Stool occult blood positive 3. Septecemia 6. CBC reveals decreased platelets 2. Petechiae (widespread and systemic) eye. Oliguria (late sign) C. lungs and lower extremities 2. Ecchymosis 3. Prevent complication . Administer isotonic fluid solution as ordered 3. Heparin/Coumadin is ineffective 6. Vitamin K b. Related to rapid blood transfusion 2. Oozing of blood from punctured sites 4. Administer medications as ordered a. Instruct client to use electric razor when shaving 10. Institute NGT decompression by performing gastric lavage by using ice or cold saline solution of 500 – 1000 ml 8. Monitor NGT output 9. cough 7. Administer medications as ordered a. Monitor for signs of bleeding of all hema test including stool and GIT 2.
Check the blood unit for bubbles cloudiness. Increase the oxygen carrying capacity of blood 3.Expiration of packed RBC is 3 – 6 days .Warming is only done during emergency situation and if you have the warming device . 6. Instruct another RN to re check the following a. sediments and darkness in color because it indicates bacterial contamination . Proper typing and cross matching a. Hypovolemic shock b. Hemolytic reaction b. Cytrate intoxication h. 85% of population is RH positive 3. Aseptically assemble all materials needed for BT a.Never warm blood as it may destroy vital factors in blood. Monitor strictly vital signs before. Expiration date d. Pyrogenic reaction d. Regulate BT 10 – 15 gtts/min or KVO rate or equivalent to 100 cc/hr to prevent circulatory overload 9. Avoid mixing or administering drugs at BT line to prevent HEMOLYSIS 8. Prevent bleeding if there is platelet deficiency Principles of blood transfusion 1. Type AB – universal recipient c. Proper refrigeration . Serial number 5. Air embolism f. Replace circulating blood volume 2.Emergency rapid BT is given after 30 minutes and let natural room temperature warm the blood. Prevent infection in there is a decrease in WBC 4. Circulatory overload e. Client name b. Thrombocytopenia g. 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. during and after BT especially every 15 minutes for first hour because majority of transfusion reaction occurs during this period a. Gauge 18 – 19 needle c. Anuria – late sign BLOOD TRANSFUSION Goals/Objectives 1. Filter set b. Hyperkalemia (caused by expired blood) . .a. Allergic reaction c. Blood typing and cross matching c. Type O – universal donor b.Expiration of platelet is 3 – 5 days 2. Isotonic solution (0.9 NaCl/plain NSS) to prevent hemolysis 4.
anaphylactic shock treat with Epinephrine 5. Flush with plain NSS 4. Notify physician 3. Stop BT 2. Anti Histamine (Benadryl) . Dyspnea 3.Signs and Symptoms of Hemolytic reaction 1. Hypotension 5. Administer medications as ordered a. Stop BT 2. Dyspnea Nursing Management 1. Notify physician 3. Laryngospasm and Broncospasm Nursing Management 1. Flush with plain NSS 4. Headache 3. Flush with plain NSS . Send the blood unit to blood bank for re examination 6. Monitor vital signs and intake and output SIGNS AND SYMPTOMS PYROGENIC REACTIONS 1. Headache and dizziness 2. Obtain urine and blood sample and send to laboratory for re examination 7. Send the blood unit to blood bank for re examination 6. Administer isotonic fluid solution to prevent shock and acute tubular necrosis 5. Monitor vital signs and intake and output SIGNS AND SYMPTOMS OF ALLERGIC REACTION 1. Palpitations 5. Obtain urine and blood sample and send to laboratory for re examination 7. Fever and chills 2. Dyspnea 3. Broncial wheezing 4. Skin rashes 5. Lumbasternal/ Flank pain 7. Urticaria 6. Diaphoresis 6. Diarrhea/Constipation 4. Notify physician 3. Fever 2. Stop BT 2. Flushed skin 6. Urine is color red/ portwine urine Nursing Management 1.if positive to hypotension. Tachycardia 4.
tricuspid valve . Loop diuretic (Lasix) CARDIOVASCULAR SYSTEM OVERVIEW OF THE STRUCTURE AND FUNCTIONS OF THE HEART HEART . Administer medications as ordered a. Render TSB SIGNS AND SYMPTOMS OF CIRCULATORY REACTION 1. Administer medications as ordered a. Stop BT 2. Visceral – inner layer .Weighs approximately 300 – 400 grams . pericarditis.Common among MI. Obtain urine and blood sample and send to laboratory for re examination 7. Chambers of the Heart 1.Right atrium has decreased pressure which is 60 – 80 mmHg C. . Epicardium – outer layer 2. Parietal – outer layer b.In order to propel blood to the systemic circulation .Prevent pericardial friction rub . Rales/Crackles upon auscultation 4.Located on the left mediastinum . Layers of Heart 1. Send the blood unit to blood bank for re examination 6.Left ventricle has increased pressure which is 120 – 180 mmHg . Notify physician 3. Upper Chamber (connecting or receiving) a.Myocarditis can lead to cardiogenic shock and rheumatic heart disease B.To promote unidimensional flow or prevent backflow 1. Dyspnea 3.In between is the pericardial fluid which is 10 – 20 cc . Cardiac tamponade A. Endocardium – inner layer . Monitor vital signs and intake and output 8. Antibiotic 5. Antipyretic b.Muscular pumping organ of the body.4. Atrioventricular Valves – guards opening between a. Atria 2. Exertional discomfort Nursing Management 1. Myocardium – middle layer 3. Lower Chamber (contracting or pumping) a. Ventricles .Covered by a serous membrane called the pericardium 2 layers of pericardium a. Valves . Orthopnea 2.Resemble like a close fist .
b.Closure of AV valves give rise to first heart sound (S1 “lub”) 2. Sino – Atrial Node (SA or Keith Flack Node) .Left Main Bundle of His . Left Main Coronary Artery . Semi – lunar Valves a.Closure of SV valve give rise to second heart sound (S2 “dub”) Extra Heart Sounds 1.Initiates electrical impulse of 60 – 100 bpm 2. Right Main Coronary Artery 2.Acts as primary pacemaker of the heart . Coronary Arteries . Cardiac Conduction System 1. aortic . Atrio – Ventricular Node (AV or Tawara Node) .Delay of electrical impulse for about .P WAVE (atrial depolarization) contraction .Located at the walls of the ventricles for ventricular contraction SA NODE AV NODE BUNDLE OF HIS JLJLJLJJLJLJL PURKINJE FIBERS .Supplies the myocardium E.Located at the interventricular septum 4.Right Main Bundle of His .08 milliseconds to allow ventricular filling 3.T WAVE (ventricular repolarization) .Located at the inter atrial septum . mitral valve . S4 – atrial gallop usually seen in Myocardial Infarction and Hypertension D.QRS WAVE (ventricular depolarization) . Bundle of His . pulmonic b.Arises from base of the aorta Types of Coronary Arteries 1. S3 – ventricular gallop usually seen in Left Congestive Heart Failure 2. Purkinje Fibers .Located at the junction of superior vena cava and right atrium .
Hyperlipidemia 6. Duaphoresis C. Treatment Percutaneous Transluminal Coronary Angioplasty Objectives of PTCA 1. Diet – increased saturated fats 10.Atherosclerosis 2. ST segment depression – Angina Pectoris 4. ST segment elevation – Myocardial Infarction 5.tunica intima A. Smoking 4.lipid or fat deposits .narrowing of artery . Diabetes Mellitus 8. To prevent angina 3.hardening of artery . Obesity 5. Hypothyroidism 9. Increase survival rate ARTERIOSCLEROSIS .Hypokalemia 2. Myocardial Necrosis – Myocardial Infarction ATHEROSCLEROSIS ATHEROSCLEROSIS . T wave inversion – Myocardial Infarction 6. Palpitations 5. Peak T wave – Hyperkalemia 3. Revascularize myocardium 2. Signs and Symptoms 1. Sex – male 2. Chest pain 2. Widening of QRS complexes – Arrythmia CARDIAC DISORDERS Coronary Arterial Disease/ Ischemic Heart Disease Stages of Development of Coronary Artery Disease 1. Myocardial Ischemia – Angina Pectoris 3. Myocardial Injury . Predisposing Factors 1.tunica media . Dyspnea 3. 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. Tachycardia 4. Race – black 3.calcium and protein deposits . Positive U wave . Type A personality B. sedentary lifestyle 7.
Precipitating Factors 4 E’s of Angina Pectoris 1.If there is 2 or more occluded blood vessels CABG is done Coronary Arterial Bypass And Graft Surgery 3 Complications of CABG 1. but in large doses will act as vasodilator . Tachycardia 5. Nitroglycerine (NTG) – when given in small doses will act as venodilator. Race – black 3. 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. Diet – increased saturated fats 10. anxiety. Diaphoresis D. excitement 4. Nursing Management 1. usually relieved by rest or taking nitroglycerine 3. Enforce complete bed rest 2. Extreme emotional response – fear. Stress test – treadmill test. axilla and jaw muscles. Predisposing Factors 1. Excessive intake of foods rich in saturated fats – skimmed milk C. Smoking 4. Serum cholesterol and uric acid is increased E.5 minutes . Sex – male 2. sedentary lifestyle 7. Obesity 5.. Shock 3. Diagnostic Procedure 1. Hypothyroidism 9.Give second dose of NTG if pain persist after giving first dose with interval of 3 . Diabetes Mellitus 8. arms. History taking and physical exam 2. reveal abnormal ECG 4. Exposure to cold environment 3. Chest pain characterized by sharp stabbing pain located at sub sterna usually radiates from back. Signs and Symptoms 1. Palpitations 6. Pneumonia – encourage to perform deep breathing.Done to single occluded vessels . Administer medications as ordered a. Dyspnea 4. ECG tracing reveals ST segment depression 3. Hyperlipidemia 6. Levine’s Sign – initial sign that shows the hand clutching the chest 2.Give first dose of NTG (sublingual) 3 – 5 minutes . shoulder. coughing exercise and use of incentive spirometer 2. Type A personality B. Excessive physical exertion – heavy exercises 2.
Sex – male 2. Beta-blockers . 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. Monitor strictly vital signs. Obesity 5. intake and output and ECG tracing 6. ACE Inhibitors . Predisposing Factors 1. Prevent complication (myocardial infarction) c. Provide decrease saturated fats sodium and caffeine 7.NIfedipine 3. Avoidance of 4 E’s b. Provide client health teachings and discharge planning a. Subendocardial Myocardial Infarction – characterized by occlusion of either right or left coronary artery B. A.Enalapril d. necrosis and scarring. Types 1. Administer oxygen inhalation 4. Calcium Antagonist . 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..side effects PNS . Race – black 3.Not given to COPD cases because it causes bronchospasm c. The importance of follow up care MYOCARDIAL INFARCTION Heart attack Terminal stage of coronary artery disease characterized by malocclusion. 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. Place client on semi fowlers position 5. Hyperlipidemia . Smoking 4.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.Propanolol .
arms. Ashen skin 6. Hypothyroidism 9. Pericardial friction rub b.Side Effects: respiratory depression . Dyspnea 3. Administer oxygen low inflow to prevent respiratory arrest at 2 – 3 L/min 3. Place client on semi fowlers position . ECG tracing reveals a. shoulder.6. T wave inversion c. jaw and abdominal muscles (abdominal ischemia) . LDH – Lactic acid dehydroginase is increased c. CPK – MB . Increase in blood pressure (initial sign) 4. ST segment elevation b. Occasional findings a.Side Effects of Naloxone Toxicity is tremors 2. Cardiac Enzymes a. Troponin Test – is increased 3. Diagnostic Procedure 1. Signs and Symptoms 1. Diabetes Mellitus 8. Widening of QRS complexes indicates that there is arrhythmia in MI 4. Serum Cholesterol and uric acid are both increased 5.Excruciating visceral.Antidote: Narcan/Naloxone . SGOT – Serum glutamic oxal-acetic transaminase is increased 2. viselike pain located at substernal and rarely in precordial . Hyperthermia 5. Instruct client to avoid forms of valsalva maneuver 5. 12 – 24 hours b. axilla. Diet – increased saturated fats 10.Usually radiates from back. Rales/Crackles upon auscultation d. Type A personality D.Creatinine phosphokinase is increased . Decrease myocardial workload (rest heart) .Administer narcotic analgesic/morphine sulfate . Mild restlessness and apprehension 7. S4 or atrial gallop E. SGPT – Serum glutamic pyruvate transaminase is increased d.Not usually relieved by rest or by nitroglycerine 2. Split S1 and S2 c. Nursing Management Goal: Decrease myocardial oxygen demand 1. Using bedside commode 4.Heart only. Enforce CBR without bathroom privileges a. sedentary lifestyle 7. CBC – increased WBC F. Chest pain .
Provide a general liquid to soft diet that is low in saturated fats. Vasodilators .arrhythmia (caused by premature ventricular contraction) b.Anti thrombotic effect . Anti Platelet . Anti Arrythmic Agents . Beta-blockers d.Streptokinase .late sign is oliguria c.Monitor for bleeding time g.Lidocaine (Xylocane . Cardiogenic shock . Calcium Antagonist f. ACE Inhibitors e.Heparin (check for partial thrombin time) .Nitroglycerine . Isodil) sublingual b. Monitor strictly vital signs.Coumadin/ Warfarin Sodium (check for prothrombin time) .Side Effects: confusion and dizziness .6.Urokinase . Anti Coagulant . Thrombolytics/ Fibrinolytic Agents . pruritus .TIPAF (tissue plasminogen activating factor) . Administer medication as ordered a.homan’s sign e.Side Effects of Aspirin Tinnitus Heartburn Indigestion/Dyspepsia . Stroke/CVA .Side Effects: allergic reaction.Brutylium c.Contraindication Dengue Peptic Ulcer Disease Unknown cause of headache 10. Encourage client to take 20 – 30 cc/week of wine. Avoidance of modifiable risk factors . Provide client health teaching and discharge planning concerning a. whisky and brandy to induce vasodilation 9. Left Congestive Heart Failure d. Thrombophlebitis .PASA (Aspirin) .Antidote: protamine sulfate .Antidote: Vitamin K h. intake and output and ECG tracing 7.Side Effects: chest pain . sodium and caffeine 8.ISD (Isosorbide Dinitrate.
Ischemic heart disease 4.000 units of streptokinase as ordered g.Penicillin . Cyanosis 7. Dyspnea 2. Diagnostic Procedure 1.make sex as an appetizer rather than dessert . Myocardial Infarction 3. PMI is displaced laterally due to cardiomegaly 11. Orthopnea – use 2 – 3 pillows when sleeping or place in high fowlers 4. Productive cough with blood tinged sputum 5. There is anorexia and generalized body malaise 12. Paroxysmal nocturnal dyspnea – client is awakened at night due to difficulty of breathing 3.Common among children . Frothy salivation 6.ASO Titer (Anti streptolysin O titer) . Rales/Crackles 8. 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. Predisposing Factors 1. RHD – inflammation of mitral valve due to invasion of Grp. LEFT SIDED HEART FAILURE A. PCO2 is increased (respiratory acidosis) 2.000 – 450.Formation of aschoff bodies in the mitral valve . post CABG and instruct to .client can resume sexual intercourse if can climb staircase . Hypertension 5. 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. Post MI Syndrome/Dressler’s Syndrome . dependent on extent of heart failure 4. ABG – reveals PO2 is decreased (hypoxemia). Signs and Symptoms 1. Aging 2.Aspirin b. A beta-hemolytic streptococcus .client is resistant to pharmacological agents. RIGHT SIDED HEART FAILURE . S3 – ventricular gallop C. Chest x-ray – reveals cardiomegaly 2. Pulsus Alternans – weak pulse followed by strong bounding pulse 10. administer 150.f. Resumption of ADL particularly sexual intercourse is 4 – 6 weeks post cardiac rehab.dietary modification h.instruct client to assume a non weight bearing position . 90% is mitral valve stenosis due to a. Aortic valve stenosis B. Ecocardiography – enlarged heart chamber (cardiomyopathy).
CVP fluid status measure . Narcotic analgesics . Hepatosplenomegaly 6.Upon insertion place client in trendelendberg position to promote ventricular filling and prevent pulmonary embolism 3. Liver enzymes – SGPT and SGOT is increased D.When reading CVP patient should be flat on bed . Administer medications as ordered a. Predisposing Factors 1. Pulmonary embolism 3. Tricuspid valve stenosis 2. Enforce CBR 2. Ecocardiography – reveals enlarged heart chambers (cardiomyopathy 4.Morphine Sulfate e. Vasodilators . Anti Arrhythmic . Related to COPD 4. Cardiac glycosides . Administer oxygen inhalation with high inflow. Signs and Symptoms (venous congestion) 1.Increase force of cardiac contraction . Pitting edema 3. Chest x-ray – reveals cardiomegaly 2. Loop Diuretics . Esophageal varices C. Ascites 4.If CVP is more than 10 cm of water hypervolemic shock . High fowlers position .A.Measure pressure in right atrium (4 – 10 cm of water) .Administer loop diuretics as ordered . Pulmonic valve stenosis 5.Nitroglycerine f. delivered via nasal cannula 4. Nursing Management Goal: increase cardiac contractility thereby increasing cardiac output (3 – 6 L/min) 1.Lasix (Furosemide) c. Diagnostic Procedures 1.Lidocaine (Xylocane) 3. Central venous pressure (CVP) . Weight gain 5. Jaundice 7. Anorexia 9. Pruritus 8.Digoxin (Lanoxin) . Bronchodilators d. Left sided heart failure B. Neck/jugular vein distension 2.Do the fluid challenge (increase IV flow rate) .If CVP is less than 4 cm of water hypovolemic shock . 3 – 4 L/min.If heart rate is decreased do not give b.
Right ventricular hypertrophy . Predisposing Factors 1. Diagnostic Procedures 1. cyanosis then rubor) 3. Analgesics Burger’s Disease Reynaud’s Disease .5. High risk groups – men 30 years old and above 2. Provide meticulous skin care 9. Prevent complications . Assist in bloodless phlebotomy – rotating tourniquet. Ulceration 6. Intermittent claudication – leg pain upon walking 2. Strict compliance to medications PERIPHERAL VASCULAR DISORDER Arterial Ulcer I. walking 3 – 4 times a day b. out of bed 3 – 4 times a day 2. Administer medications as ordered a.MI . Thrombophlebitis (deep vein thrombosis) THROMBOANGITIS OBLITERANS Acute inflammatory disorder usually affecting the small medium sized arteries and veins of the lower extremities A. Measure abdominal girth daily and notify physician 7. Signs and Symptoms 1. Provide a dietary intake of low sodium. Dietary modification c. rotated clockwise every 15 minutes to promote decrease venous return 10. Provide client health teaching and discharge planning a. Doppler UTZ – decrease blood flow to the affected extremity 3.Thrombophlebitis b. Cold sensitivity and changes in skin color (pallor. Oscillometry – decrease in peripheral pulses 2. Varicose Veins 2. Monitor strictly vital signs. Nursing Management 1. cholesterol and caffeine 8. intake and output and ECG tracing 6. Encourage a slow progressive physical activity a. Gangrene formation C.Shock . Trophic changes 5. Smoking B. Angiography – reveals site and extent of malocclusion D.Arrythmia . Decreased peripheral pulses 4. Thrombo Angitis Obliterans Venous Ulcer 1.
Pregnancy . Rheumatoid Arthritis 4. Cardiac disorder 5. Ulceration 5. Vasodilators 2. Anti coagulants 3. Predisposing Factors 1. Direct hand trauma a. Analgesics b. High risk group – female 40 years old and above 2. Gangrene formation C. Intermittent claudication – leg pain upon walking 2. Angiography – reveals site and extent of malocclusion D. Trophic changes 4.b. Predisposing Factors 1. Signs and Symptoms 1. SLE (butterfly rash) b. Piano playing b. Hereditary 2. Excessive typing c. Encourage to wear gloves 3. Instruct client to avoid smoking and exposure to cold environment 5. 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. Administer medications as ordered a. Nursing Management 1. cyanosis then rubor) 3. Vasodilators c. Diagnostic Procedures 1. Cold sensitivity and changes in skin color (pallor. Collagen diseases a. Institute foot care management 4. 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. Smoking 3. Congenital weakness of veins 3. Operating chainsaw B. Thrombophlebitis 4. Doppler UTZ – decrease blood flow to the affected extremity 2.
Pain after prolonged standing 2. Congestive heart failure 8.6. Diagnostic Procedure 1.veins distends quickly in less than 35 seconds D. Smoking 3. Obesity 2. Venography 2. Wear anti embolic stockings 4. Heaviness in legs C. Dilated tortuous skin veins 4. Vein stripping and ligation (most effective) b. Post cannulation – insertion of various cardiac catheter 11. Warm to touch 4. Related to pregnancy 4. Assist in surgical procedure a. 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. B. Dilated tortuous skin veins 3. Chronic anemia 5. Positive Hpman’s Signs – pain at the calf or leg muscle upon dorsi flexion of the foot C. Administer medications as ordered a. Signs and Symptoms 1. Analgesics 5. Diagnostic Procedure 1. Prolonged standing or sitting B. Post op complication 10. Increase in saturated fats in the diet. Venography 2. Angiography D. Warm to touch 3. Pain at affected extremity 2. Elevate legs above heart level to promote increased venous return by placing 2 – 3 pillows under the legs 2. Myocardial infarction 9. Nursing Management . Nursing Management 1. Measure the circumference of leg muscle to determine if swollen 3. Predisposing Factors 1. Trendelenburg’s Test . Prolong use of oral contraceptives – promotes lipolysis 6. Obesity 7. Diabetes mellitus 7. Signs and Symptoms 1.
Filtering of air 2.The initial sign of complete airway obstruction is the inability to cough II.For cough reflex Glottis . cholecystitis characterized by pain at the right upper quadrant with tenderness RESPIRATORY SYSTEM OVERVIEW OF THE STRUCTURES AND FUCNTIONS OF THE RESPIRATORY SYSTEM I. Encourage to wear anti embolic stockings or knee elastic stockings 5. Larynx . Administer medications as ordered a. Monitor for signs of complications Embolism a.Diaphoresis . Pharynx/Throat . Elevate legs above heart level to promote increase venous return 2.Unexplained dyspnea .Dizziness .Left nostril . Apply warm moist pack – to reduce lymphatic congestion 3.For phonation (voice production) .Opening of larynx .Opens to allow passage of air .Decrease LOC • MURPHY’S SIGN is seen in clients with cholelithiasis. Anti Coagulant .Right nostril . Pulmonary . Analgesics b.Restlessness b.Tachycardia .Separated by septum .Palpitations . Lower Respiratory System . Measure circumference of leg muscle to determine if swollen 4.Heparin 6. Humidification A.Sudden sharp chest pain .1.Serves as passageway of air going to the lungs .Consist of cartilaginous rings .For gas exchange A. Trachea/Windpipe .Consist of anastomosis of capillaries known as Keissel Rach Plexus (the site of nose bleeding) B. Upper Respiratory System 1. Warming and moistening of air 3.Closes to allow passage of food going to the esophagus .Cartillage .Headache .Serves as a muscular passageway for both food and air C. Cerebral . Nose .
Decrease oxygen stimulates breathing .In premature infants 1:2 .Give oxygen of less 40% in premature to prevent atelectasis and retrolental fibroplasias .Secretes surfactant ..Left main bronchus C. Bronchus . PTB/Pulmonary Tuberculosis (Koch’s Disease) . Mode of Transmission 1. Precipitating Factors 1. Over fatigue 5. Pneumonia b.Increase carbon dioxide is a powerful stimulant for breathing Type II Cells of Alveoli . Lungs . night sweats 2. Productive cough (yellowish sputum) . Pleural fluid c.L/S ratio to determine lung maturity . Hydrothorax (air and blood in pleural space Alveoli .retinopathy/blindness in prematurity Disorders of Respiratory System 1. Low grade afternoon fever.Diffusion (Dalton’s law of partial pressure of gases) Respiratory Distress Syndrome .Composed of lecithin and spingomyelin .Infection of lung tissue caused by invasion of mycobacterium tuberculosis or tubercle bacilli . Overcrowded places 3.Normal L/S ratio is 2:1 . Pareital b. aerobic and easily destroyed by heat or sunlight A. Alcoholism 4.Decrease surface tension .Left lung (consist of 2 lobes.An acid fast.Site of gas exchange (CO2 and O2) . Ingestion of an infected cattle with mycobacterium bovis 6. Visceral With Pleuritic Friction Rub a. Airborne transmission via droplet nuclei C.Right lung (consist of 3 lobes.Serous membranes Pleural Cavity a. 10 segments) . Virulence (degree of pathogenecity) of microorganism B.Right main bronchus . Signs and Symptoms 1.Site of tracheostomy B. Malnutrition 2. gram negative.Prevent collapse of alveoli . 8 segments) . Pleural effusion c.
Force fluids to liquefy secretions 5. Mantoux Test (skin test) .INH (Isonicotinic Acid Hydrazide) . Administer oxygen inhalation 4. taken after meals to facilitate absorption . nephrotoxicity . Dyspnea 6.PZA can be replaced by Ethambutol . Place client on semi fowlers position to promote expansion of lungs 6. CBC . Diagnostic Procedure 1. 48 – 72 hours .Neomycin .INH and Rifampicin is given for 4 months.Side Effect INH: peripheral neuritis/neuropathy (increase intake of Vitamin B6/Pyridoxine) .Injection of streptomycin (aminoglycoside) .Kanamycin . Enforce CBR 2.Side Effect PZA: allergic reaction.DOH 8 – 10 mm induration. Chest pain 7. Nebulize and suction when needed 8.PZA is given for 2 months.Purified protein derivative .Gentamycin .Side Effect Rifampicin: all bodily secretions turn to red orange color . Intensive phase . hepatotoxicity. Anorexia. Institute strict respiratory isolation 3.Amikacin .Reveals pulmonary infiltrates 4.WHO 10 – 14 mm induration.Positive Mantoux test (previous exposure to tubercle bacilli but without active TB) 2. Sputum Acid Fast Bacillus . Standard phase . Comfortable and humid environment 9. Chest X-ray .Given everyday simultaneously to prevent resistance .Positive to cultured microorganism 3. taken before meals to facilitate absorption .PZA (Pyrazinamide) .Side Effect Ethambutol: optic neuritis b. Institute short course chemotherapy a.3. Nursing Management 1.Rifampicin (Rifampin) . Weight loss 5. Encourage deep breathing and coughing exercise 7. 48 – 72 hours . Hemoptysis (chronic) D.Reveals increase WBC E. generalized body malaise 4.
Drug of choice is Retrovir b. dyspepsia. Rales/crackles 6. Bronchial wheezing . Hemophylus Influenzae – causing broncho pneumonia 3. Smoking 2. Pseudomonas B.Meninges .. Avoidance of precipitating factors b. Klebsella Pneumoniae 5. Diplococcus Pneumoniae 4. Related to prolonged immobility (CVA clients). Prevent complications (atelectasis. Etiologic Agents 1. Immuno compromised a. vitamin C and calories 11. protein. military tuberculosis) PTB . Weight loss 5. Strict compliance to medications d. causing hypostatic pneumonia 5. High Risk Groups 1. Aspiration of food causing aspiration pneumonia D. Air pollution 3. Escherichia Pneumoniae 6. Provide client health teaching and discharge planning a. anorexia and general body malaise 4. Predisposing Factors 1.Give aspirin if there is fever .Pneumocystic carini pneumonia .Nephrotoxicity check for BUN and Creatinine . Bronchogenic Cancer .Adrenal gland c.Bones (potts) .Skin . Dyspnea with prolong expiratory grunt 3. Elderly C. heartburn 10. AIDS . Children below 5 years old 2. Productive cough with greenish to rusty sputum 2.Ototoxicity damage to the 8th cranial nerve resulting to tinnitus leading to hearing loss .Side Effect: . Provide increase carbohydrates. Signs and Symptoms 1.Eyes . chills. Streptococcus Pneumonae – causing pneumococal pneumonia 2.Chest x-ray confirms lung cancer 4. Fever. Importance of follow up care PNEUMONIA Inflammation of the lung parenchyma leading to pulmonary consolidation as the alveoli is filled with exudates A.Side Effect: tinnitus.Initial sign is non productive cough .
erythrocyte sedimentation rate is increased F. Diagnostic Procedure 1. Chest pain 10.Hemoptysis . protein and vitamin C 10. Health teaching and discharge planning a.Chest physiotherapy .Deep breathing exercises . ABG analysis – reveals decrease PO2 4.Coughing exercises . Administer bronchodilators 15 – 30 minutes before procedure e. Penicillin b. Stop if client cannot tolerate procedure f. Chest x-ray – reveals pulmonary consolidation 3. Tetracycline c. Administer medications as ordered Broad Spectrum Antibiotic a. Prevent complications . Cyanosis 8. CBC – reveals increase WBC. calories. Assist in postural drainage .Unstable vital signs . Sputum Gram Staining and Culture Sensitivity – positive to cultured microorganisms 2.Turning and reposition 7. Contraindicated with . Provide increase carbohydrates. Microlides (Zethromax) Azethromycin (Side Effect: Ototoxicity) Antipyretics Mucolytics/Expectorants Analgesics 4. Administer oxygen inhalation low inflow 3. Force fluid 5. Nebulize and suction as needed 8. Provide oral care after procedure g. Avoid smoking b. Abdominal distention leading to paralytic ileus (absence of peristalsis) E. Institute pulmonary toilet (tends to promote expectoration) . Enforce CBR 2.Increase ICP 9. Pleuritic friction rub 9.7. Nursing Management 1. Best done before meals or 2 – 3 hours to prevent gastro esophageal reflux b. Place on semi fowlers position 6.Drain uppermost area of lungs . Encourage client deep breathing exercises d.Placed on various position Nursing Management for Postural Drainage a. Monitor vital signs c.Clients with increase intra ocular pressure (Normal IOP 12 – 21 mmHg) .
Administer oxygen inhalation 3. Chest and joint pains B. Signs and Symptoms 1. Signs and Symptoms PTB or Pneumonia like 1. Fever. Mucolytics d. Air pollution B. Diagnostic Procedures 1. Administer medications as ordered a. Productive cough 2.Meningitis (nerve deafness. Productive cough (consistent to all COPD) 2. Enforce CBR 2. Hemoptysis 6. Dyspnea 3. Hypokalemia) b. general body malaise 4.Atelectasis . Antipyretics 4. hydrocephalus) c. Steroids c. Nursing Management 1. Regular adherence to medications d. anorexia. Anorexia and generalized body malaise . Prevent complications – bronchiectasis 7. Histoplasmin Skin Test – positive 2. Dyspnea on exertion 3. Force fluids to liquefy secretions 5.Amphotericin B . Prolonged expiratory grunt 4. Cyanosis 5.. 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. ABG analysis PO2 decrease C. chills. Antifungal . Predisposing Factors 1. 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. check for BUN and Creatinine.Fungizone (Nephrotoxicity. Nebulize and suction as needed 6. Smoking 2.
Hereditary b. palpitations 7. apply direct pressure to ulnar and radial artery to determine presence of collateral circulation D. Danders g. Nursing Management 1. air pressure and humidity f. Cyanosis 5. Pulmonary hypertension a. Smoke e. Mild Stress/apprehension 6. milk. Physical and emotional stress 3.Incentive spirometer reveals decrease vital lung capacity 2. Fumes d. Wheezing on expiration 4. Pulmonary Function Test . Diagnostic Procedure 1. Foods (seafoods. Drugs (aspirin. Extrinsic Asthma ( Atopic/ Allergic ) Causes a. PCO2 increase. chicken d. Peripheral edema b. Scattered rales/ronchi 6. eggs.5. Diaphoresis C. ABG analysis – PO2 decrease . Dust c. pH decrease Bronchial Asthma Reversible inflammatory lung condition due to hypersensitivity to allergens leading to narrowing of smaller airways A. chocolates. Signs and Symptoms 1. beta blocker) c. Enforce CBR . Pollen b. Lints 2. Food additives (nitrates) e. Mixed Type 90 – 95% B. penicillin. Cough that is non productive 2. Cyanosis 7.Before ABG test for positive Allens Test. Tachycardia. Cor Pulmonale (right ventricular hypertrophy) C. Gases f. Predisposing Factors (Depending on Types) 1. Furs h. Intrinsic Asthma (Non atopic/Non allergic) Causes a. Diagnostic Procedure ABG analysis – reveals PO2 decrease (hypoxemia). Sudden change in temperature. Dyspnea 3.
Bronchodilators – given via inhalation or metered dose inhalaer or MDI for 5 minutes b. Avoid talking. Force fluids 5. Recurrent lower respiratory tract infections 2. Congenital defects 4. Treatment . Monitor for signs of gross 4.Steroids . Oxygen inhalation. Mucolytics/expectorants e. Prevent complications . Predisposing Factors 1. Feeding initiated upon return of gag reflex 2. ABG – PO2 decrease 2. Monitor for signs of laryngeal spasm – prepare tracheostomy set D. Related to presence of tumor B. Regular adherence to medications to prevent development of status asthmaticus d. Chest trauma 3. Avoidance of precipitating factor b. Anorexia and generalized body malaise 5. Steroids – decrease inflammation c. Diagnostic Procedure 1. Mucomysts (acetylceisteine) d. Dyspnea 3. Productive cough 2. may cause irritation 3. Signs and Symptoms 1. Cyanosis 4. Nebulize and suction when needed 7. Secure inform consent and explain procedure to client 2. Hemoptysis (only COPD with sign) C. Semi fowlers position 6.Bronchodilators c. Administer medications as ordered a. Bronchoscopy – direct visualization of bronchus using fiberscope Nursing Management PRE Bronchoscopy 1.Epinephrine .Emphysema . Anti histamine 4. with low inflow of 2 – 3 L/min 3. Importance of follow up care BRONCHIECTASIS Abnormal permanent dilation of bronchus leading to destruction of muscular and elastic tissues of alveoli A. Provide client health teachings and discharge planning concerning a.2.Status Asthmaticus (give drug of choice) . Maintain NPO 6 – 8 hours prior to procedure 3. Monitor vital signs and breath sound POST Bronchoscopy 1. coughing and smoking.
1. Inelasticity of alveoli b.Decrease PO2 (hypoxemia leading to chronic bronchitis. Flaring of alai nares 12. Dyspnea at rest 3. Maldistribution of gases d. 1 lung is removed and position on affected side) 2. “Blue Bloaters”) .Increase PCO2 . Rales or ronchi 9. Air trapping c. Prolong expiratory grunt 4.Respiratory acidosis b. Anorexia and generalized body malaise 5. Barrel chest 11. Decrease or diminished breath sounds 8. Bronchial wheezing 10. Smoking 2. High risk: elderly 5. Allergy 4.Respiratory alkalosis D. Nursing Management 1. Enforce CBR . Segmental Wedge Lobectomy (promote re expansion of lungs) . Surgery (pneumonectomy . Over distention of thoracic cavity (barrel chest) A. ABG analysis reveals a.Decrease PCO2 . Diagnostic Procedure 1. Productive cough 2.Increase PO2 (hyperaxemia. Signs and Symptoms 1. Panacinar/ centriacinar . Purse lip breathing to eliminates excess CO2 (compensatory mechanism) C. “Pink Puffers”) .Increase ph . Pulmonary Function Test – reveals decrease vital lung capacity 2.Unaffected lobectomy facilitate drainage EMPHYSEMA Irreversible terminal stage of COPD characterized by a. Air pollution 3. Resonance to hyperresonance 6.Decrease ph . for recoil of alveoli) B. Panlobular/ centrilobular . Hereditary – it involves deficiency of ALPHA-1 ANTI TRYPSIN (needed to form Elastase. Predisposing Factors 1. Decrease tactile fremitus 7.
CO2 narcosis may lead to coma . Nebulize and suction when needed 8.Pneumothorax c. Importance of follow up care . protein.2. Provide high carbohydrates.Cor Pulmonale . Strict compliance to medication d. Administer medications as ordered a. Institute pulmonary toilet 7. Health teachings and discharge planning concerning a. Administer oxygen inhalation via low inflow 3. Avoid smoking b. vitamins and minerals 11. High fowlers position 5. Antibiotics d. Bronchodilators b. Mucolytics/expectorants 4. Steroids c. Provide comfortable and humid environment 10. calories. Institute PEEP (positive end expiratory pressure) in mechanical ventilation promotes maximum alveolar lung expansion 9.Atelectasis . Force fluids 6. Prevent complications .
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