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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.
tingling sensation paresthesia numbness euphoria (sense of well being) 3. Amnesia – loss of memory. ALZHEIMER’S DISEASE Atrophy of brain tissues. .DEMYELINATING DISORDERS 1. 2. *Receptive aphasia DRUG OF CHOICE: ARICEPT (taken at bedtime) and COGNEX. pressure. heat and cold. Visual disturbances blurring of vision (primary) diplopia (double vision) scotomas (blind spots) 2. Mood swings . Aphasia – no speech (nodding). pain. d. saliva. MULTIPLE SCLEROSIS Chronic intermittent disorder of CNS characterized by white patches of demyelination in brain and spinal cord. Wernicke’s Aphasia General Knowing Gnostic Area or General Interpretative Area. b.short term protection. * Give palliative or supportive care. Ig E – for allergic reaction. Ig D – for chronic inflammation. Apraxia – no recognition of objects function. colostrums). Signs and Symptoms 1. Impaired sensation to touch. Ig M – acute in inflammation. c. Sign and Symptoms 4 A’s of Alzheimer a. *Expressive aphasia “motor speech center” Broca’s Aphasia inability to understand spoken words. Ig A – present in all bodily secretions (tears. 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.Immediate action. Agnosia – no recognition of inanimate objects. . Characterized by remission and exacerbation.
Yoga 4. Monitor side effects bronchospasm and wheezing. Institute stress management techniques.4. a. (+) Lhermitte’s sign a continuous and increase contraction of spinal column. d. Catheterization to prevent retention. Impaired motor function weakness spasticity paralysis scanning speech TRIAD SIGNS OF MS Ataxia (Unsteady gait. c. . c. Bethanicol Chloride (Urecholine) Nursing Management Only given subcutaneous. Administer medications as ordered a. plums. Interferons – alter immune response. Decrease sexual capacity DIAGNOSTIC PROCEDURE Nystagmus CSF analysis (increase in IgG and Protein). Maintain side rails to prevent injury related to falls. NURSING MANAGEMENT 1. To acidify urine and prevent bacterial multiplication. Immunosupresants 2. Diuretics b. Deep breathing exercises b. (+) Romberg’s test) 5. ACTH (Adreno Corticotropic Hormone)/ Steroids for acute exacerbation to reduce edema at site of demyelination to prevent paralysis. 5. prunes. For Urinary Incontinence Anti spasmodic agent a. Urinary retention/incontinence 7. a. Constipation 8. Increase fluid intake and increase fiber to prevent constipation. 3. Prophantheline Bromide (Promanthene) Acid ash diet like cranberry juice. b. vitamin C and orange. Baclofen (Dioresal)/ Dantrolene Sodium (Dantrene) – muscle relaxants. Impaired cerebral function CHARCOTS TRIAD IAN Intentional tremors 6. MRI (reveals site and extent of demyelination). pineapple. Monitor breath sounds 1 hour after subcutaneous administration.
Temporal hearing short term memory for appreciation discrimination of sensory impulses to pain. heat. CEREBRUM largest part composed of the Right Cerebral Hemisphere and Left Cerebral Hemisphere enclosed in the Corpus Callosum. pressure. 2. Functions of Cerebrum integrative sensory motor Lobes of Cerebrum 1. pinocytosis (cell drinking). avoid use of tissue papers avoid using talcum powder and perfume. Parietal 4. touch. numbness. 80% brain mass 10% blood 10% CSF COMPOSITION OF BRAIN I. Brain Mass PARTS OF THE BRAIN 1. Occipital . 3. 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. eating). 1-1 ½ inches) poor perineal hygiene vaginal environment is moist avoid bubble bath (can alter Ph of vagina). Urethra (20 cm.COMMON CAUSE OF UTI Female short urethra (3-5 cm. cold. Frontal higher cortical thinking controls personality controls motor activity Broca’s Area (motor speech area) when damaged results to garbled speech. 8 inches) urinate after intercourse Nursing Management Male MICROGLIA stationary cells that carry on phagocytosis (engulfing of bacteria or cellular debris.
controls blood pressure controls thirst appetite/satiety sleep and wakefulness controls some emotional responses like fear. positive PERRLA 4. controls smell and if damaged results to Anosmia (absence of smell). . MIDBRAIN/ MESENCEPHALON acts as relay station for sight and hearing. Hypothalamus 5. heart rate. release dopamine (controls gross voluntary movement. DECREASE Myasthenia Gravis Parkinson’s Disease INCREASE Bi-polar Disorder Schizophrenia NEURO TRANSMITTER Acethylcholine Dopamine 3. vasomotor center (dilation and constriction of bronchioles). Medulla Oblongata 3. vomiting. early sign for males are testicular and penile enlargement late sign is deepening of voice. controls respiration. rhythm and depth of respiration. lesser brain. controls temperature (thermoregulatory center). hiccup. 2. B. hearing acuity is 30 – 40 dB. equal size of pupil is isocoria. unequal size of pupil is anisocoria. BASAL GAGLIA areas of grey matter located deep within each cerebral hemisphere. swallowing. early sign for females telarche and late sign is menarche. for vision visceral function activities of internal organ like gastric motility. INTERBRAIN/ DIENCEPHALON Parts of Diencephalon A. BRAIN STEM located at lowest part of brain Parts of Brain Stem 1. controls pituitary functions androgenic hormones promotes secondary sex characteristics. Cerebellum smallest part of the brain. Thalamus acts as relay station for sensation. Pons pneumotaxic center controls the rate. anxiety and excitement. controls libido controls long term memory Insula (Island of Reil) Limbic System (Rhinencephalon) 2. size of pupil is 2 – 3 mm.
. 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. Early closure of posterior fontanels causes posterior enlargement of skull in hydrocephalus. controls balance. 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. NEUROLOGIC DISORDERS INCREASE INTRACRANIAL PRESSURE – increase in intra-cranial bulk brought about by an increase in one of the 3 major intra cranial components. heart rate decrease respiratory rate decrease temperature increase directly proportional to blood pressure. equilibrium. posture and gait. Cervical 2 – also known as AXIS. 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). projective vomiting headache papilledema (edema of optic disc) abnormal posturing decorticate posturing (damage to cortex and spinal cord). widening of pulse pressure is neurologic in nature (if narrow cardiac in nature).
b. Limit fluid intake to 1200 – 1500 ml/day (in force fluids 2000 – 3000 ml/day). Nursing Management . Monitor strictly input and output and neuro check 5. 3. Osmotic diuretic (Mannitol) for cerebral diuresis Nursing Management monitor vital signs especially BP (hypotension). Assist in mechanical ventilation 2. 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. monitor strictly input and output every 1 hour notify physician if output is less 30 cc/hr. maintain side rails. administered via side drip regulated fast drip to prevent crystal formation. avoid use of restraints. Prevent further increase ICP by: a. Prevention of hypoxia and hypercarbia Early signs of hypoxia restlessness agitation tachycardia Bradycardia Extreme restlessness Dyspnea Cyanosis Increase CO2 (most powerful respiratory stimulant) retention. provide an comfortable and quite environment. d. c. avoid clustering of nursing activity together. Elevate bed of client 30 – 35o angle with neck in neutral position unless contraindicated to promote venous drainage. Administer medications like: a. Before and after suctioning hyper oxygenate client 100% and done 10 – 15 seconds only. cerebellum and midbrain). unilateral dilation of pupils called uncal herniation bilateral dilation of pupils called tentorial herniation resulting to mild headache possible seizure activity Nursing Management 1. Prevent complications of 6. c. Maintain patent and adequate ventilation by: a. b. 7. Late signs of hypoxia HYPERCARBIA b. In chronic respiratory distress syndrome decrease O2 stimulates respiration. decerebrate posturing (damage to upper brain stem that includes pons. Furosemide) Drug of choice for CHF (pulmonary edema) Loop of Henle in kidneys. Loop diuretic (Lasix. 4.
Monitor vital signs especially BP (hypotension). Phenytoin) c. maximum effect of 6 hours. Dexamethasone (Decadron) Hydrocortisone Prednisone (to reduce edema that may lead to increase ICP) Mild Analgesics (Codeine Sulfate for respiratory depression) Anti Convulsants (Dilantin. administered IV push or oral. given early morning immediate effect of 10 – 15 minutes. monitor strictly input and output every 1 hour notify physician if output is less 30 cc/hr. 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 . 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.
Hypocalcemia/ Tetany VEGETABLES Asparagus Brocolli Carrots Spinach decrease calcium level normal value is 8.4 – 5. Hyponatremia DECREASE decrease sodium level normal value is 135 – 145 meq/L Signs and Symptoms hypotension dehydration signs (Initial sign in adult is THIRST.5 – 11 mg/100 ml Signs and Symptoms tingling sensation paresthesia numbness (+) Trousseau’s sign/ Carpopedal spasm (+) Chvostek’s sign Complications Arrhythmia Seizures Nursing Management Calcium Gluconate per IV slowly as ordered * Calcium Gluconate toxicity – results to SEIZURE Magnesium Sulfate Magnesium Sulfate toxicity S/S BP Urine output Respiratory rate Patellar relfex absent 3. in infant TACHYCARDIA) agitation dry mucous membrane poor skin turgor weakness and fatigue .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.Signs and Symptoms of Lasix in terms of electrolyte imbalances 1. Hypokalemia decrease potassium level normal value is 3. Oral Potassium Chloride) increase intake of foods rich in potassium FRUITS Apple Banana Cantalop e Oranges 2.
Hyperglycemia normal FBS is 80 – 100 mg/dl polyuria polydypsia polyphagia monitor FBS Signs and Symptoms Nursing Management 5. Mechanism of action: inhibits synthesis of uric acid. organ meats and anchovies) *Increase in tophi deposit leads to Gouty arthritis. joint pain (great toes) swelling force fluids administer medications as ordered Drug of choice for gout. Colchecine * KIDNEY STONES Signs and Symptoms renal colic Cool moist skin force fluids administer medications as ordered Morphine Sulfate ANTIDOTE: Naloxone (Narcan) toxicity leads to tremors. Nursing Management a. Narcotic Analgesic b. Hyperuricemia increase uric acid (purine metabolism) foods high in uric acid (sardines.Nursing Management force fluids administer isotonic fluid solution as ordered 4. Allopurinol (Zyloprim) b. Signs and Symptoms Nursing Management a. Acute gout Mechanism of action: promotes excretion of uric acid. Allopurinol (Zyloprim) Side Effects Respiratory depression (check for RR) .
seborrhea d. 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. constipation e. difficulty rising from sitting position. Monotone type speech mood lability (in state of depression) increase salivation (drooling type) autonomic changes a. Increase dosage of the following drugs: a.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. 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. increase sweating b. Reserpine(Serpasil) b. Hypoxia 4. decrease sexual capacity Nursing Management 1. Arteriosclerosis 3. Administer medications as ordered Anti Parkinsonian agents Levodopa (L-dopa) short acting Amantadine Hydrochloride (Symmetrel) Carbidopa (Sinemet) . Haloperidol(Haldol) d. Predisposing Factors 1. increase lacrimation c. Encephalitis 5. Poisoning (lead and carbon monoxide) 2. Methyldopa(Aldomet) c.
6 – 1. 6. Prevent complications of immobility 4.5 meq/L .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 . Isonicotinic Acid Hydrazide Anti Cholinergic Agents (ARTANE and COGENTIN) . 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 . Assist/supervise in ambulation 7.5 – 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.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). Encourage increase fluid intake and fiber.relieves tremor rigidity Bromocriptene Hydrochloride (Parlodel) Side Effects Respiratory depression 2. Dopamine Agonist . Maintain side rails to prevent injury 3.
tachycardia Irritability Restlessness Extreme fatigue Diaphoresis. depression Antidote: Acetylcisteine (mucomyst) prepare suction apparatus as bedside. 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 3.1. agitation and restlessness) only mixed with plain NSS or 0. Dilantin Toxicity Signs and Symptoms gingival hyperplasia (swollen gums) hairy tongue ataxia nystagmus provide oral care massage gums Nursing Management 5. irritability.9 NaCl to prevent development of crystals or precipitate.8 – 1) hypoglycemia Tremors. . Digitalis Toxicity Signs and Symptoms nausea and vomiting diarrhea confusion photophobia changes in color perception (yellowish spots) Antidote: Digibind 2. Aminophylline Toxicity Signs and Symptoms tachycardia palpitations CNS excitement (tremors. Acetaminophen Toxicity Signs and Symptoms hepatotoxicity (monitor for liver enzymes) SGPT/ALT (Serum Glutamic Pyruvate Transaminace) SGOT/AST (Serum Glutamic Oxalo-Acetil Transaminace) nephrotoxicity monitor BUN (10 – 20) and Creatinine (. administered sandwich method avoid taking alcohol because it can lead to severe CNS depression avoid caffeine Nursing Management 4.
under medication .administer cholinergic agents as ordered 7. Prevent complications . airway 2. 8. administer medications as ordered a.infection Signs and Symptoms . Incidence rate: women 20 – 40 years old Predisposing factors unknown autoimmune: it involves release of cholinesterase an enzyme that destroys Ach. swallow.The client is unable to see. maintain side rails to prevent injury related to falls 5.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. speak. Assist in plasma paresis and removing auto immune anti bodies 9. Assist in surgical procedure known as thymectomy because it is believed that the thymus gland is responsible for M.G. aspiration 3. institute NGT feeding 6. input and output and neuro check * monitor strength or motor grading scale 4.Administer anti cholinergic agents (Atropine Sulfate) Side Effects MYASTHENIC CRISIS Causes: . 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: . mmobility * assist in mechanical ventilation and monitor pulmonary function test * monitor strictly vital signs.over medication Signs and Symptoms . breathe Treatment .stress .G. initial sign is ptosis a clinical parameter to determine ptosis is palpebral fissure. if there is no effect there is damage to occipital lobe and midbrain and is negative for Signs and Symptoms Diagnostic Procedure M. 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. Cholinergic (Mestinon) b.PNS Treatment . Nursing Management 1.
Signs and Symptoms headache photophobia projectile vomiting fever. Nursing Management for LP Before Lumbar Puncture 1. anorexia. Increase CHON and WBC 2. 2. A. Pneumococcus 3. Increase CSF opening pressure (normal pressure is 50 – 100 mmHg) 4. Post Lumbar Puncture 1.causes adult meningitis 4. Dura matter – outer layer 2. for support and protection for nourishment blood supply LAYERS OF THE MENINGES 1. Etiology 1. chills. CSF analysis reveals 1. CSF aspiration is done. Decrease glucose 3. 3. Meningococcus – most dangerous 2. Hemophilus Influenzae – causes pediatric meningitis B. Nuchal rigidity or stiff neck b. Check punctured site for any discoloration. Opisthotonus (arching of back) c. Secure informed consent and explain procedure. Arachnoid – middle layer 3. Diagnostic Procedures Lumbar puncture: a hollow spinal needle is inserted in the subarachnoid space between the L3 – L4 to L5. drainage and leakage to tissues.INFLAMMATORY CONDITIONS OF THE BRAIN MENINGITIS Meninges 3 fold membrane that covers brain and spinal cord. (+) Kernig’s sign (leg pain) d. Place flat on bed 12 – 24 o 2. Empty bladder and bowel to promote comfort. Increase wbc . Force fluids 3. Streptococcus . general body malaise and weight loss Possible increase in ICP and seizure activity Abnormal posturing (decorticate and decerebrate) Signs of meningeal irritation a. (+) Brudzinski sign (neck pain) D. (+) cultured microorganism (confirms meningitis) CBC reveals 1. Mode of transmission airborne transmission (droplet nuclei) C. Assess for movement and sensation of extremities. 4. Encourage to arch back to clearly visualize L3-L4. Pia matter – inner layer subdural space between the dura and arachnoid subarachnoid space between the arachnoid and pia.
input and output and neuro check 6. Provide a comfortable and darkened environment. Anti pyretics 3. b. calories with small frequent feedings. Yellow bone marrow are produced from the medullary cavity of the long bones and produces fat cells. Elevate head 30-45o 5. Rehabilitation for neurological deficit CVA (STROKE/BRAIN ATTACK/ ADOPLEXY/ CEREBRAL THROMBOSIS) a partial or complete disruption in the brains blood supply.E. Enforce complete bed rest 2. Administer medications as ordered a. Maintain good diet of increase CHO. Prevent complications most feared is hydrocephalus hearing loss/nerve deafness is second complication consult audiologist mental retardation delayed psychomotor development c. Institute measures to prevent increase ICP and seizure. Compartment syndrome (compression of arteries and nerves) . 8. Monitor strictly V/S. If there is bone fracture there is hemorrhage and there would be escape of the fat cells in the circulation. 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. Nursing Management 1. Tetracycline) b. Mid Cerebral Artery b. 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. CHON. Institute strict respiratory isolation 24 hours after initiation of anti biotic therapy 4. Internal Cerebral Artery – the 2 largest artery A. Maintain fluid and electrolyte balance. 9. Broad spectrum antibiotics (Penicillin. Mild analgesics c. Provide client health care and discharge planning concerning: a. 7. Incidence Rate men are 2-3 times high risk B. 2 most common cerebral artery affected by stroke a.
nausea and vomiting dysphagia (+) Kernig’s sign and Brudzinski sign which may lead to hemorrhagic stroke focal neurological deficits a. Type A personality a. Atherosclerosis. Signs and Symptoms Heart Disease. Stroke in evolution 3. Valvular Cardiac Surgery (mitral valve replacement) 2. Hypertension. can do multiple tasks c. Diabetes Mellitus. 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. CT Scan – reveals brain lesions 2. Related stress physical and emotional 8. usually fells guilty when not doing anything 6. deadline driven b.C. Diagnostic Procedure 1. aphasia c. homonymous hemianopsia (loss of half of visual field) 1. Myocardial Infarction. Hyperlipidemia more on genetics/genes that binds to cholesterol 5. D. alexia (difficulty reading) e. Complete stroke Signs and Symptoms E. Lifestyle (smoking). Obesity (increase 20% ideal body weight) 4. 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 . Related to diet: increase intake of saturated fats like whole milk 7. Risk Factors 1. agraphia (difficulty writing) f. phlegia b. sedentary lifestyle 3. dysarthria (inability to articulate words) d. TIA Signs and Symptoms 2. Prolong use of oral contraceptives promotes lypolysis (breakdown of lipids) leading to atherosclerosis that will lead to hypertension and eventually CVA.
Cortecosteroids d. Anti Platelet PASA (Aspirin) Contraindicated for dengue. provide sand bag or food board. Provide alternative means of communication a. 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. Elevate head 30 – 45o 4. Osmotic Diuretics (Mannitol) b. magic slate 9. Assist in passive ROM exercise every 4 hours to promote proper bodily alignment and prevent contractures 7. Institute NGT feeding 8. non verbal cues b. Administer medications as ordered a. Maintain patent airway and adequate ventilation by: a. ulcer and unknown cause of headache because it may potentiate bleeding 11. Restrict fluids to prevent cerebral edema that might increase ICP 3. prevent complication (subarachnoid hemorrhage is the most feared complication) c. K (Aqua Mephyton) g. dietary modification (decrease salt. Loop Diuretics (Lasix. Monitor strictly vitals signs. avoidance of modifiable risk factors (diet. Mild Analgesics e. Furosemide) c. Nursing Management 1. assist in mechanical ventilation b. importance of follow up care . saturated fats and caffeine) d. administrate O2 inhalation 2. I & O and neuro check 5. Thrombolytic/Fibrinolytic Agents – dissolves thrombus Streptokinase Side Effect: Allergic Reaction Urokinase Tissue Plasminogen Activating Factor Side Effect: Chest Pain f. turn client to side b. exercise. If positive to hemianopsia approach client on unaffected side 10. smoking) b.F. Anti Coagulants Heparin (short acting) check for partial thromboplastin time if prolonged there is a risk for bleeding. Provide client health teachings and discharge planning concerning a. provide egg crate mattresses or water bed c. Prevent complications of immobility by: a. 6.
Monitor strictly the following a. constipation C. Zylocaine Bretylium – blocks release of norepinephrine to prevent increase of BP 8. Maintain side rails to prevent injury related to fall 4. Maintain patent airway and adequate ventilation by: a. Dysphagia 3. Ascending muscle weakness leading to paralysis 4. Prevent complications a. vital signs b. Institute NGT feeding to prevent aspiration 6. Nursing Management 1. assist in mechanical ventilation b. Administer medications as ordered a. Prevent complications of immobility by turning the client every 2 hours 5. A. Autonomic symptoms that includes a. 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. Arrythmia b. Predisposing Factors 1. Anti Arrythmic Agents Lidocaine. Decreased of diminished deep tendon reflex 5. ECG 3. neuro check d. Corticosteroids – suppress immune response b. CSF analysis reveals increase in IgG and protein D. Alternate hypotension to hypertension ** ARRYTHMIA (most feared complication) 6. Diagnostic Procedures 1. . Assist in passive ROM exercise 7. Signs and Symptoms 1. Assist in plasma pharesis (filtering of blood to remove autoimmune anti-bodies) 9. intake and output c. monitor pulmonary function test 2.GUILLAIN BARRE SYNDROME a disorder of the CNS characterized by bilateral symmetrical polyneuritis leading to ascending muscle paralysis. increase salivation b. increase sweating c. Clumsiness (initial sign) 2. Autoimmune 2. Anti Cholinergic Agents – Atrophine Sulfate c. Antecedent viral infections such as LRT infections B.
Signs or aura with auditory. Grand mal Seizure (tonic-clonic seizure) a. clouding of consciousness – not in contact with environment c.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. Seizure – first convulsive attack Epilepsy – second or series of attacks Febrile seizure – normal in children age below 5 years A. Physical and emotional stress 7. visual. EEG – reveals hyper activity of electrical brain waves . 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. Post ictal sleep – unresponsive sleep 2. Diagnostic Procedures 1. Nutritional and Metabolic deficiencies 6. Sudden withdrawal to anti convulsant drug is predisposing factor for status epilepticus (drug of choice is Diazepam. decrease blinking of eyes c. tactile.direct symmetrical extension of extremities Clonic contractions . Toxicity from a. Petit mal Seizure – absence of seizure common among pediatric clients characterized by a. automatism – stereotype repetitive and non propulsive behavior b. Valium and Glucose C. Status Epilepticus A continuous uninterrupted seizure activity. Partial or Localized Seizure 1. Valium) B. twitching of mouth d. lead b carbon monoxide 5. Generalized Seizure 1. Epileptic cry – is characterized by fall and loss of consciousness for 3 – 5 minutes c. blank stare b. mild hallucinatory sensory experience III. Predisposing Factors 1. Genetics 3. loss of consciousness (5 – 10 seconds) II. Tonic contractions . CT Scan – reveals brain lesions 2. olfactory. Head injury due to birth trauma 2. 2. Psychomotor Seizure (focal motor seizure) a. Presence of brain tumor 4. Drug of choice: Diazepam.contraction of extremities d. sensory experience b. if left untreated can lead to hyperpyrexia and lead to coma and eventually death. Signs and Symptoms Dependent on stages of development or types of seizure I.
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
Signs and Symptoms 1. TRABECULECTOMY (Peripheral Indectomy) – drain aqueous humor 2. Carbachol 2. Surgical Procedures 1. Loss of central vision C. Surgical Procedure Extra Capsular Cataract Lens Extraction . Predisposing Factor 1. Diagnostic Procedure 1. Related to congenital 3. Prolonged exposure to UV rays B. Aging 65 years and above 2. Epinephrine eyedrops – decrease formation of aqueous humor 3. Treatment 1. Cyclopegics (Cyclogyl) – paralyses cilliary muscle F. Cataract Decrease opacity of lens A.3. Milky white appearance at center of pupils 3. Mydriatics (Mydriacyl) – constricts pupils 2. Pathognomonic Signs 1. Retinal Detachment Separation of epithelial surface of retina . Opthalmoscopic exam E. Timoptics (Timolol Maleate) E.Partial removal Intra Capsular Cataract Lens Extraction .Total removal of cataract with its surrounding capsules Most feared complication post op is RETINAL DETACHMENT 3. Diabetes Mellitus 4. Acetazolamide (Diamox) – promotes increase outflow of aqueous humor or drainage 4. Miotics – constricts pupil a. Treatment 1. Gonioscopy D. Blurring or hazy vision 2. Pilocarpine Sodium. Decrease perception to colors Complication is blindness D. Carbonic Anhydrase Inhibitors a.
Surgical Procedures 1. Myopia (near sightedness) B. TROCHLEAR. Floaters C. Post Lens Extraction 2.A. Diathermy – heat application 4. Predisposing Factors 1. Black Spots CRANIAL NERVE III. IV. Scleral Buckling 2. Macular Degeneration Degeneration of the macula lutea (yellowish spot at the center of retina) A. mandibular . maxillary. 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. Cryosurgery – cold application 3. Signs and Symptoms 1. Signs and Symptoms 1. VI: OCULOMOTOR.
teeth. X: GLOSOPHARYNGEAL. refers to movement and orientation of the body in space. 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. ENDOCRINE SYSTEM Overview of the structures and functions 1. Middle Ear 3. posterior 1/3 of tongue Vagus: controls gag reflex Uvula should be midline and if not indicative of damage to cerebral hemisphere Effects of vagal stimulation is PNS CRANIAL NERVE XI: SPINAL ACCESSORY Innervates with sternocleidomastoid (neck) and trapezius (shoulder) CRANIAL NERVE XII: HYPOGLOSSAL Controls the movement of tongue Let client protrude tongue and it should be midline and if unable to do indicative of damage to cerebral hemisphere and/or has short frenulum. Parts of the Ear 1. VAGUS NERVE Glosopharyngeal: controls taste. Outer Ear Pinna Eardrum Hammer Anvil Stirrup Malleus Incus Stapes 2. CRANIAL NERVE VIII: ACOUSTIC/VESTIBULOCOCHLEAR Controls balance particularly kinesthesia or position sense. sensory: controls sensation of face. frown and if results are negative there is facial paralysis or Bell’s Palsy and the primary cause is forcep delivery. 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. contains the Organ of Corti (the true organ of hearing) Let client repeat words uttered CRANIAL NERVE IX. Pituitary Gland (Hypophysis Cerebri) . mucous membrane. Inner Ear Vestibule: Meinere’s Disease Cochlea Mastoid Cells Endolymph and Perilymph COCHLEA: controls hearing.
Agitation c.030 Ph 4 – 8 Increase resulting to hypernatremia Related to pituitary surgery Trauma Inflammation Presence of tumor B. Pitressin (Vasopresin Tannate) – administered IM Z-tract 4. 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. Dry mucous membrane 3. Polyuria 2. Hypotension 5. Adult: thirst b. Weight loss 6. Posterior Pituitary Gland 2. Monitor strictly vital signs and intake and output 3. 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. Signs of dehydration a. Predisposing Factor o o o o 1. If left untreated results to hypovolemic shock (sign is anuria) C. Administer medications as ordered a. Signs and Symptoms 2. Serum Sodium D. Nursing Management . Urine Specific Gravity o o o 1. Anterior Pituitary Gland o o o hemorrhage o o administrate oxytocin immediately after delivery to prevent uterine atony. Weakness and fatigue 4. Diagnostic Procedures 1.o o o Located at base of brain particularly at sella turcica Master gland or master clock Controls all metabolic function of body PARTS OF THE PITUITARY GLAND 1. Poor Skin turgor d. Force fluids 2.015 – 1. Prevent complilcations – HYPOVOLEMIC SHOCK is the most feared complication Normal value: 1.
Monitor strictly vital signs. Related to presence of bronchogenic cancer o o gland. intake and output and neuro check 4. Diagnostic Procedure 1. Osmotic diuretics (Mannitol) 3. Head injury 2. Hypertension b. 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. Related to hyperplasia (increase size of organ brought about by increase of number of cells) of pituitary 2. Prone to skin cancer o Hypersecretion of MSH results to Vitiligo 3. B. Lead to blindness due to severe photophobia b. Weigh patient daily and assess for pitting edema 5. Loop diuretics (Lasix) b. Urine specific gravity is increased 2. Melanocyte Stimulating hormone o o o for skin pigmentation Hyposecretion of MSH results to Albinism Most feared complications of albinism a. Adrenochorticotropic hormone (ACTH) o promotes development of adrenal cortex . Provide meticulous skin care 6.SIADH o hypersecretion of anti diuretic hormone A. Administer medications as ordered a. Serum Sodium is decreased D. Weight gain 2. Predisposing Factors 1. Signs and Symptoms 1. Fluid retention a. Nursing Management 1. Edema c. Restrict fluid 2. Water intoxication may lead to cerebral edema and lead to increase ICP – may lead to seizure activity C. 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.
Thyroxine) o o T3 and T4 are metabolic or calorigenic hormone promotes cerebration (thinking) 3. cabbage. 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. radish. strawberry. broccoli. Increase intake of goitrogenic foods o o o contains pro-goitrin an anti thyroid agent that has no iodine. 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. sweet potato. T4 (tetra iodothyronine. carrots. Leutinizing hormone 6. Thyrocalcitonin – antagonizes the effects of parathormone to promote calcium resorption. Predisposing Factors 1. Goiter belt area a. places far from sea b. turnips. 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 5.4. T3 (Tri iodothyronine) . Mountainous regions 2.3 molecules of iodine (more potent) 2. all nuts soil erosion washes away iodine .
4 Medications to be taken via straw: Lugol’s. Serum Thyroid Stimulating Hormone (TSH) – is increased (confirmatory diagnostic test) D. iodized salt. Increase dietary intake of foods rich in iodine A. Enforce complete bed rest 2. 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. Monitor vital signs especially heart rate because drug causes tachycardia and palpitations 3. Diagnostic Procedures 1. Serum T3 and T4 – reveals normal or below normal 2. Thyroid Scan – reveals enlarged thyroid gland.o goitrogenic drugs a. Iron. Thyroid Hormones o o o Levothyroxine (Synthroid) Liothyronine (Cytomel) Thyroid Extracts Nursing Management when giving Thyroid Hormones 1. Signs and Symptoms 1. Anti Thyroid Agent – Prophylthiuracil (PTU) b. Nitrofurantoin (drug of choice for pyelonephritis) b. Instruct client to take in the morning to prevent insomnia 2. presence of tumor. Cobalt e. 3. PASA (Aspirin) d. Mild restlessness C. Predisposing Factors 1. Monitor side effects o o o o o o o insomnia tachycardia and palpitations hypertension heat intolerance seaweeds seafood’s like oyster. Phenylbutazones (NSAIDs) . Mild dysphagia 3. Nursing Management 1.if goiter is caused by B. inflammation . Lithium Carbonate c. Administer medications as ordered a. clams and lobster but not shrimps because it contains lesser amount of iodine. crabs. Related to atrophy of thyroid gland due to trauma. Lugol’s Solution/SSKI ( Saturated Solution of Potassium Iodine) o o color purple or violet and administered via straw to prevent staining of teeth. Tetracycline. Enlarged thyroid gland 2. Iatrogenic Cause – disease caused by medical intervention such as surgery 2. best taken raw because it it is easily destroyed by heat 5.
Serum T3 and T4 is decreased 2. Signs and Symptoms (Early Signs) 1. Provide meticulous skin care 8. hypoventilation. Administer medications as ordered Thyroid Hormones a. Non pitting edema (Myxedema) 3. Provide client health teaching and discharge planning concerning a. bradypnea. Hoarseness of voice 4. Force fluids 3.3. Avoid precipitating factors leading to myxedema coma o o stress infection Assist in mechanical ventilation Administer thyroid hormones as ordered Force fluids . Administer isotonic fluid solution as ordered 4. Decrease libido 5. Nursing Management for Myxedema Coma 2. Provide dietary intake that is low in calories 6. Thyroid Extracts 5. Serum Cholesterol is increased 3. hyponatremia. Dry skin 4. Provide comfortable and warm environment 7. Cold intolerance 5. Brittleness of hair and nails 2. Leothyronine c. 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. bradycardia. Levothyroxine b. Autoimmune (Hashimotos Disease) B. hypothermia leading to pregressive stupor and coma. bradypnea. Constipation (Late Signs) 1. Weakness and fatigue 2. Nursing Management 1. Loss of appetite but with weight gain which promotes lipolysis leading to atherosclerosis and MI 3. hypoglycemia. Diagnostic Procedures 1. RAIU (Radio Active Iodine Uptake) is decreased D. CNS changes o o o o lethargy memory impairment psychosis menorrhagia C. bradycardia. hypothermia 6. Iodine deficiency 4. Decrease in all vital signs – hypotension.
Diarrhea 5. Administer medications as ordered Anti Thyroid Agent a. narcotics. Heat intolerance 4. Prophythioracill (PTU) b. and sedatives prevent complications (myxedema coma. Comfortable and cold environment 6. Thyroid Scan. Monitor strictly vital signs and intake and output 2. Hallucinations 7.o o o o o o o o cold intolerance use of anesthetics. Signs and Symptoms 1. Serum T3 and T4 is increased 2. Tremors d. Excessive iodine intake 3. 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. Diagnostic Procedures 1.reveals an enlarged thyroid gland D. 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. Autoimmune – it involves release of long acting thyroid stimulator causing exopthalmus (protrusion of eyeballs) enopthalmus (late sign of dehydration among infants) 2. RAIU (Radio Active Iodine Uptake) is increased 3. Predisposing Factors 1. Related to hyperplasia (increase size) B. Exopthalmus 9. Moist skin 3. CNS involvement a. Maintain side rails . Nursing Management 1. Provide meticulous skin care 5. Provide dietary intake that is increased in calories. All vital signs are increased 6. Amenorrhea C. Restlessness c. Increase appetite (hyperphagia) but there is weight loss 2. Goiter 8. 4. Insomnia e. Irritability and agitation b.
Signs of bleeding (feeling of fullness at incisional site) Nursing Management o Check the soiled dressings at the back or nape area. 1. maintain side rails offer TSB Tachycardia 2. seizure give Calcium Gluconate IV slowly as ordered 3. Provide bilateral eye patch to prevent drying of the eyes. Assist in surgical procedures known as subtotal thyroidectomy ** Before thyroidectomy administer Lugol’s Solution (SSKI) to decrease vascularity of the thyroid gland to prevent bleeding and hemorrhage. input and output and neuro check. Hormonal replacement therapy for lifetime 6. 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. 8. 5. Beta-blockers o o o monitor strictly vital signs. POST OPERATIVELY. Watch out for accidental removal of parathyroid gland that may lead to Hypocalcemia (tetany) Signs and Symptoms o o o (+) trousseau’s sign (+) chvostek sign Watch out for arrhythmia. Anti Pyretics b. 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 . Watch out for signs of thyroid storm/ thyrotoxicosis Agitation TRIAD SIGNS Hyperthermia o administer medications as ordered a.7.
arrhythmia 2. Serum Calcium is decreased (normal value: 8. Signs and Symptoms 1. Serum Phosphate is decreased (normal value: 2. laryngospasm/broncospasm h. nausea and vomiting d.A. agitation and memory impairment C. tingling sensation b. Diagnostic Procedures 1. anorexia. paresthesia c.A. CT Scan – reveals degeneration of basal ganglia D. Administer medications as ordered such as: a.C MAD .5 mg/100 ml) 3.5 – 11 mg/100 ml) 2. inflammation b. trauma B. Chronic Tetany Oral Calcium supplements Calcium Gluconate Calcium Lactate Calcium Carbonate c. positive chvostek sign g. positive trousseu’s sign/carpopedal spasm f.5 – 4. loss of tooth enamel c. photophobia and cataract formation b. Vitamin D (Cholecalciferol) for absorption of calcium CHOLECALCIFEROL ARE DERIVED FROM Drug Diet (Calcidiol) Sunlight (Calcitriol) feared complications d. Atrophy of parathyroid gland due to: a. dysphagia e. Nursing Management 1. X-ray of long bones reveals a decrease in bone density 4. tumor c. Following subtotal thyroidectomy 2. Chronic tetany a. Acute Tetany Calcium Gluconate IV slowly b. seizure i. Acute tetany a. Phosphate binder Aluminum Hydroxide Gel (Ampogel) Side effect: constipation ANTACID A. Predisposing Factors 1. numbness d.
Morphine Sulfate (Demerol) 5. X-ray of long bones reveals bone demineralization D. Provide acid ash in the diet to acidify urine and prevent bacterial growth 7. Nursing Management 1. Prepare trache set at bedside for presence of laryngo spasm 7. Strain all the urine using gauze pad for stone analysis 3. Administer medications as ordered a. Anorexia. Hyperplasia of parathyroid gland 2. salmon c. Institute seizure and safety precaution 5. Adults: Osteomalacia B. Importance of follow up care. renal cholic b. Serum Phosphate is decreased 3. Diagnostic Procedures 1. Hormonal replacement therapy for lifetime 9. Encourage increase intake of foods rich in calcium a. Predisposing Factors 1. HYPERTHYROIDISM o o o Decrease parathormone Hypercalcemia: bone demineralization leading to bone fracture (calcium is stored 99% in bone and 1% blood) Kidney stones A. Serum Calcium is increased 2. anchovies b. green turnips 4. cool moist skin 3. Children: Ricketts b. Bone pain especially at back (bone fracture) 2. Maintain side rails . nausea and vomiting 4. Over compensation of parathyroid gland due to vitamin D deficiency a. Encourage increase intake of foods rich in phosphate but decrease in calcium 6. Provide warm sitz bath 4. Kidney stones a.▼ Aluminum Containing Antacids ▼ Aluminum Hydroxide Gel ▼ Side Effect: Constipation ▼ Magnesium Containing Antacids ▼ Side Effect: Diarrhea 2. Signs and Symptoms 1. Prevent complications 8. Avoid precipitating stimulus such as glaring lights and noise 3. Force fluids to prevent kidney stones 2. Encourage client to breathe using paper bag to produce mild respiratory acidosis result. Assist/supervise in ambulation 8. Agitation and memory impairment C. 6.
Related to atrophy of adrenal glands 2.Sugar 2. 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. deficiency of neuromuscular function – Salt/Sex A. Zona Fasciculata .secretes traces of glucocorticoids and androgenic hormones . Decrease tolerance to stress 3.function: promotes sodium and water reabsorption and excretion of potassium . Assist in surgical procedure known as parathyroidectomy 11. fluid and electrolyte imbalance – Salt c.secretes mineralocorticoids (aldosterone) . Hyponatremia . Zona Glumerulosa . Hypoglycemia – TIRED 2.weight loss . Adrenal Cortex – outermost b.function: controls glucose metabolism .secretes glucocortocoids (cortisol) . Predisposing Factors 1. Zona Reticularis .9. 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.Salt ADDISON’S DISEASE o Hyposecretion of adreno cortical hormone leading to a.Sex 3.hypotension . Hormonal replacement therapy for lifetime 12. Fungal infections B. metabolic disturbance – Sugar b.signs of dehydration . Signs and Symptoms 1.
input and output to determine presence of Addisonian crisis (complication of addison’s disease) o Addisonian crisis results from acute exacerbation of addison’s disease characterized by a. severe hypotension b. increase susceptibility to infection e.agitation . Dexamethasone (Decadrone) b. Serum Potassium is increased (normal value: 3.stress .diarrhea . Assist in mechanical ventilation.force fluids 2. Taper dose (withdraw gradually from drug) 3.5 – 4. edema c. Force fluids 4.arrhythmia 5. Prednisone c. Administer isotonic fluid solution as ordered 3.hypovolemic shock .infection .5 meq/L) D. Provide client health teaching and discharge planning a. hypertension b. Loss of pubic and axillary hair 7. Nursing Management 1. hirsutism d. hyponatremia leading to progressive stupor and coma Nursing Management for Addisonian Crisis 1.sudden withdrawal to steroids b. Hyperkalemia . Serum Sodium is decrease (normal value: 135 – 145 meq/L) 4. increase calories. hypovolemic shock c. Monitor strictly vital signs. avoid precipitating factor leading to addisonian crisis leading to . Plasma Cortisol is decreased 3. Bronze like skin pigmentation C. Administer medications as ordered Corticosteroids a. carbohydrates. protein but decrease in potassium 6. 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. Hydrocortisone (Cortison) Nursing Management when giving steroids 1. Provide dietary intake. Diagnostic Procedures 1. FBS is decreased (normal value: 80 – 100 mg/dl) 2. prevent complications . moon face appearance 4. . Decrease libido 6.4. Monitor side effects a. Provide meticulous skin care 7.addisonian crisis .administer steroids as ordered .
Increase masculinity among females B.Mixed gland (exocrine and endocrine) . hypertension b. U wave upon ECG (T wave hyperkalemia) 5. Serum Potassium is decreased C. edema c. Administer medications as ordered a. Assist in surgical procedure (bilateral adrenoraphy) 9. Diagnostic Procedures 1. Serum Sodium is increased 4. Easy bruising 8. Provide meticulous skin care 6. obese trunk f. weight gain d. Hirsutism 6. Weigh patient daily and assess for pitting edema 3. Increase susceptibility to infections 3. Hormonal replacement for lifetime 10. weakness and fatigue b. hormonal replacement for lifetime d. constipation c. Hypokalemia a. Restrict sodium intake 5. moon face appearance and buffalo hump e. thin extremities 4. FBS is increased 2. Plasma Cortisol is increased 3. Spinarolactone – potassium sparring diuretics 7.Located behind the stomach . Acne and striae 7. importance of follow up care CUSHING SYNDROME o Hypersecretion of adenocortical hormones A. Predisposing Factors 1 Related to hyperplasia of adrenal gland 2. Monitor strictly vital signs and intake and output 2. Measure abdominal girth daily and notify physician 4. Hypernatremia a.c. Nursing Management 1. Prevent complications (DM) 8. Importance of follow up care PANCREAS . pendulous abdomen g.
Weight gain Type 2 (NIDDM) .Consist of islets of langerhans . Exercise E. Osmolar 3. Steroids 4. Polyuria 2. Delayed/poor wound healing D. Pancreatitis DIABETES MELLITUS .. Hyper 2. Pancreatic Tumor/Cancer 2. Glucosuria 5. Signs and Symptoms 1. Polyphagia 4. Treatment 1. Non 4. Diet 3. Incidence Rate . Diet 3. Anorexia.Maturity onset type . Diabetes Mellitus 3. Exercise E. Predisposing Factors 1. Weight loss 6. Polydypsia 3. Lasix b. Oral Hypoglycemic agents 2.Adult onset . Glucosuria 6.10% general population has type 1 DM B. Ketotic 5. Signs and Symptoms 1. Insulin therapy 2. Polyuria 3. Polyphagia 5.Brittle disease A. Hereditary (total destruction of pancreatic cells) 2. Treatment 1. Complications 1. Obesity – because obese persons lack insulin receptor binding sites . nausea and vomiting 7.90% of general population has type 2 DM B.Beta cells secretes insulin (function: hypoglycemia) .Obese over 40 years old A. Incidence Rate .Delta cells secretes somatostatin (function: antagonizes the effects of growth hormones) 3 Main Disorders of Pancreas 1. Coma C. Increase susceptibility to infection 9. Complication 1. protein and fat metabolism CLASSIFICATION OF DM Type 1 (IDDM) .Juvenile onset type . Blurring of vision 8. Drugs a.metabolic disorder characterized by non utilization of carbohydrates. Usually asymptomatic 2. Polydypsia 4. Related to carbon tetrachloride toxicity C. Predisposing Factors 1.Has alpha cells that secretes glucagons (function: hyperglycemia) . Related to viruses 3.Consist of acinar cells which secretes pancreatic juices that aids in digestion thus it is an exocrine gland . Diabetic Ketoacidosis D.
MAIN FOODSTUFF 1.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. Carbohydrates 2.Cholesterol . Fats ANABOLISM CATABOLISM Glucose Amino Acids Fatty Acids Glycogen Nitrogen Free Fatty Acids .
Hct (normal value: female 36 – 42. Polyphagia 4. Antibiotics to prevent infection HYPER OSMOLAR NON KETOTIC COMA . Stress – number one precipitating factor 3. Infection B.Non ketotic: absence of lypolysis (no ketones) A.45 NaCl (hypotonic solutions) to counteract dehydration and shock 3. Monitor strictly vital signs. Glucosuria 5. Signs and Symptoms 1. Hyperglycemia 2.Acute complication of type 1 DM due to severe hyperglycemia leading to severe CNS depression A. male 42 – 48) due to severe dehydration D. Blurring of vision 8. Creatinine (normal value: . Acetone breath odor 9. Restlessness 3.Hyperosmolar: increase osmolarity (severe dehydration) . Assist in mechanical ventilation 2. Nursing Management 1.9 NaCl followed by . Diagnostic Procedures 1. Polyuria 2. Anorexia. BUN (normal value: 10 – 20) 3. intake and output and blood sugar levels 4. Weight loss 6. Headache and dizziness 2.8 – 1) 4. Seizure activity 4. nausea and vomiting 7. Decrease LOC – diabetic coma . Signs and Symptoms 1.DIABETIC KETOACIDOSIS . Polydypsia 3. Administer medications as ordered a. FBS is increased 2. Predisposing Factors 1. Kussmaul’s Respiration (rapid shallow breathing) 10 CNS depression leading to coma C. Insulin therapy (regular acting insulin/rapid acting insulin peak action of 2 – 4 hours) b. Administer 0. Sodium Bicarbonate to counteract acidosis c.
Derived from beef and pork 2.Regular acting insulin (IV only) . hypertrophy of subcutaneous tissues) 2. Sources of Insulin 1. Use gauge 25 – 26 needle 5. Tolbutamide (Orinase) . Human Sources . Administer medications as ordered a.Frequently used type because it has less antigenicity property thus less allergic reaction 3.Peak action is 2 – 4 hours 2. Allergic reactions b. Administer insulin either 45o – 90o depending on amount of clients tissue deposit 6. Monitor for signs of local complications such as a. Insulin therapy (regular acting insulin peak action of 2 – 4 hours) . Animal sources .Stimulates the pancreas to secrete insulin 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. Nursing Management 1. Most accessible route is abdomen 9.Ultra Lente .9 NaCl followed by . When mixing 2 types of insulin aspirate first the clear insulin before cloudy to prevent contaminating the clear insulin and promote proper calibration.B. No need to aspirate upon injection 7.for DKA use rapid acting insulin b. Administer 0. Somogyis Phenomenon – rebound effect of insulin characterized by hypoglycemia to hyperglycemia ORAL HYPOGLYCEMIC AGENTS . intake and output and blood sugar levels 4.Rarely used because it can cause severe allergic reaction . Antibiotics to prevent infection INSULIN THERAPY A. Types of Insulin 1. Assist in mechanical ventilation 2. Chlorpropamide (Diabenase) b.45 NaCl (hypotonic solutions) to counteract dehydration and shock 3.Peak action is 8 – 16 hours 3. Classsification 1. Lipodystrophy c. Intermediate Acting Insulin (cloudy) . Artificially Compound Insulin B. Monitor strictly vital signs. Long Acting Insulin (cloudy) .Non Protamine Hagedorn Insulin (NPH) .Peak action is 16 – 24 hours C. Administer at room temperature to prevent development of lipodystrophy (atrophy. Place in refrigerator once opened 3. Nursing Management for Insulin Injections 1. 10. First Generation Sulfonylureas a. Rapid Acting Insulin (clear) .
Administer insulin and OHA therapy as ordered 3.sexual impotence 8. Random Blood Sugar is increased 3. Alpha Glycosylated Hemoglobin is increased C. Gangrene formation e. Nursing Management 1. Instruct client to exercise best after meals when blood glucose is rising 7. Monitor for signs of DKA and HONKC 11.Blindness KIDNEY -RECURRENT PYELONEPHRITIS . Monitor signs for complications a. Monitor strictly vital signs. Microangiopathy (affects small minute blood vessels of eyes and kidneys) EYES -PREMATURE CATARACT . Tolamazide (Tolinase) 2. polydypsia. Assist in surgical procedure HEMATOLOGICAL SYSTEM I. instruct client to cut toenails straight c.Renal failure c. Instruct the client to avoid taking alcohol because it can lead to severe hypoglycemia reaction or Disulfiram (Antabuse) toxicity symptoms B.diarrhea/constipation . Glipzide (Glucotrol) b. Monitor for peak action of insulin and OHA and notify physician 2. Provide nutritional intake of diabetic diet that includes: carbohydrates 50%. Instruct the client to take it with meals to lessen GIT irritation and prevent hypoglycemia 2. Diagnostic Procedures 1. Oral glucose tolerance test is increased – most sensitive test 4.c.administer simple sugars . instruct client to avoid walking barefooted b.for hyperglycemia (dry and warm skin) 5. Shock due to dehydration . Monitor for signs of hypoglycemia and hyperglycemia . encourage client to apply lanolin lotion to prevent skin breakdown e. FBS is increased (3 consecutive times with signs or polyuria.for hypoglycemia (cold and clammy skin) give simple sugars . Blood Forming Organs . CVA) b. Second Generation Sulfonylureas a. Diabeta (Micronase) Nursing Management when giving OHA 1. assist in surgical wound debriment (give analgesics 15 – 30 mins prior) 9. intake and output and blood sugar levels 4. polyphagia and glucosuria confirmatory for DM) 2.peripheral neuropathy . Blood II. Institute foot care management a. instruct client to avoid wearing constrictive garments d. protein 30% and fats 20% or offer alternative food substitutes 6. Blood Vessels III. HPN and DM major cause of renal failure d. MI. Instruct client to have an annual eye and kidney exam 10. Atherosclerosis (HPN.
Monocytes .responsible for the release of chemical mediation for inflammation 3. Globulins 3.consist of molecules of hgb (red pigment) bilirubin (yellow pigment) biliverdin (green pigment) hemosiderin (golden brown pigment) . iron c. Veins Plasma CHON (formed in liver) 1.only unnucleated cell . Lymph Nodes 6. WBC (LEUKOCYTES) .normal value: female 36 – 42% male 42 – 48% .hemoglobin: normal value female 12 – 14 gms% male 14 – 16 gms% . Arteries 2.transports and carries oxygen to tissues . Liver 3.transport steroids. Granulocytes 1. vitamin b6 (pyridoxine) f.biconcave discs .Gamma globulins a.60 – 70% of WBC . Prothrombin and Fibrinogen 1. Polymorpho Neutrophils .hematocrit red cell percentage in wholeblood .Alpha globulins .normal value: 5000 – 10000/mm3 A. RBC (ERYTHROCYTES) . Non Granulocytes 1.macrophage in blood . Bone Marrow ALBUMIN . Albumin 2. Polymorphonuclear Eosinophils .Normal life span of RBC is 80 – 120 days and is killed in red pulp of spleen 2. intrinsic factor . Spleen 4. vitamin c d.normal value: 4 – 6 million/mm3 .involved in short term phagocytosis for acute inflammation 2.Maintains osmotic pressure preventing edema GLOBULINS . anti-bodies and immunoglobulins b. bilirubin and hormones . folic acid b.55% Plasma Serum 45% Formed 1. Polymorphonuclear Basophils .Largest and numerous plasma CHON .substances needed for maturation of RBC a.largest WBC .for allergic reaction B. prothrombin and fibrinogen clotting factors FORMED ELEMENTS 1.Beta globulins – iron and copper .for parasite infections . Lymphoid Organ 5. vitamin b12 (cyanocobalamin) e.
involved in long term phagocytosis for chronic inflammation 2. Usually asymptomatic 2. Related to malabsorption syndrome c.000 – 450. Subtotal gastrectomy 4. Common among women 15 – 35 years old 4. Oozing of blood from venipunctured site BLOOD DISORDERS Iron Deficiency Anemia . Platelets (THROMBOCYTES) ..Consist of immature or baby platelets or megakaryocytes which is the target of dengue virus . Heavy menstruation b. fresh blood per rectum is called hematochezia 2. Petechiae 2. Chronic blood loss due to trauma a.A chronic microcytic anemia resulting from inadequate absorption of iron leading to hypoxemic tissue injury A. Lymphocytes B-cell T-cell .6 months – 5 years incubation period . Related to improper cooking of foods C. Predisposing Factors 1. Common among tropical zones 3.Normal value: 150. Incidence Rate 1. Headache and dizziness .Normal life span of platelet is 9 – 12 days Signs of Platelet Dysfunction 1.ELISA . Common among developed countries 2. Related to GIT bleeding resulting to hematemesis and melena (sign for upper GIT bleeding) c. Signs and Symptoms 1.drug of choice AZT (Zidon Retrovir) 2 Common fungal opportunistic infection in AIDS 1. Chronic diarrhea b. Echhymosis 3. Kaposi’s Sarcoma 2.6 months window period .anti viral and anti tumor property HIV . High cereal intake with low animal protein digestion d.000/mm3 . Weakness and fatigue (initial signs) 3. Related to poor nutrition B. Pneumocystis Carinii Pneumonia 3. Inadequate intake of iron due to a.thymus for immunity Natural killer cell .western blot opportunistic .Promotes hemostasis (prevention of blood loss) .bone marrow .
Instruct the client to avoid taking tea and coffee because it contains tannates which impairs iron absorption 5. Egg (yolk) c. stool and GIT 2.Dysphagia 9. Nuts 4. Monitor and inform client of side effects a. Diagnostic Procedures 1. If client cant tolerate/no compliance administer parenteral iron preparation a. Monitor side effects a. Administer with Vitamin C or orange juice for absorption 4. Brittleness of hair and spoon shape nails (koilonychias) 8. Hct is deceased 4. Pain at injection site PLUMBER VINSON’S SYNDROME . Monitor for signs of bleeding of all hema test including urinw.Stomatitis . Ferrous Fumarate c. Sorbitex (IM) Nursing Management when giving parenteral iron preparations 1. Reticulocyte is decreased 6.4. Nursing Management 1.Lugol’s solution . Dyspnea 6. Enforce CBR so as not to over tire client 3.Iron . Iron is decreased 5. IV) b. PICA (abnormal appetite or craving for non edible foods D.Nitrofurantoin (Macrodentin) 3. Palpitations 7. Nausea and vomiting c. Ferritin is decreased E. Instruct client to take foods rich in iron a. Organ meat b. Melena 5. Abdominal pain d. Legumes g. Sweet potatoes e. Atropic Glossitis (inflammation of tongue) . Hgb is decreased 3. RBC is decreased 2. Pallor and cold sensitivity 5. discoloration and leakage to tissues 2. Avoid massaging the injection site instead encourage to ambulate to facilitate absorption 3.300 mg/day Nursing Management when taking oral iron preparations 1. Instruct client to take with meals to lessen GIT irritation 2. Iron Dextran (IM. Raisin d.Tetracycline . Diarrhea/constipation e. Administer medications as ordered Oral Iron Preparations a. When diluting it in liquid iron preparations administer with straw to prevent staining of teeth Medications administered via straw . Ferrous Gluconate . Ferrous Sulfate b. Dried fruits f. Anorexia b. Administer Z tract technique to prevent discomfort.
Headache and dizziness 3. red beefy tongue c. Signs and Symptoms 1. Pruritus/orticaria g. Hereditary factors 3. Skin rashes f. Autoimmune 5. weight loss e. jaundice 6. result to psychosis C. Pallor and cold sensitivity 4. Subtotal gastrectomy 2. Enforce CBR 2. CNS changes a. numbness c. Dyspnea and palpitations as part of compensation 5. mouth sore b. Lymphadenopathy d. Administer Vitamin B12 injections at monthly intervals for lifetime as ordered .b. Weakness and fatigue 2. Fever and chills e. Predisposing Factors 1. positive to Romberg’s test – damage to cerebellum resulting to ataxia e. Inflammatory disorders of the ileum 4.Never given orally because there is possibility of developing tolerance Secretes hydrochloric acid ▼ Aids in digestion . Nursing Management 1. Strictly vegetarian diet STOMACH ▼ Pareital cells/ Argentaffin or Oxyntic cells Produces intrinsic factors ▼ Promotes reabsorption of Vit B12 ▼ Promotes maturation of RBC B. tingling sensation b. Diagnostic Procedure Schilling’s Test – reveals inadequate/decrease absorption of Vitamin B12 D. Localized abscess c. Hypotension (anaphylactic shock) PERNICIOUS ANEMIA . GIT changes that includes a. indigestion/dyspepsia d. paresthesia d.Chronic anemia characterized by a deficiency of intrinsic factor leading to hypochlorhydria (decrease hydrochloric acid secretion) A.
Nitrogen Mustard (Antimetabolite) Phenylbutazones (NSAIDS) B. Institute BT as ordered 3. Dyspnea and palpitations 2. Petechiae (multiple petechiae is called purpura) b. Anemia a. Predisposing Factors 1. Immunologic injury 4. Thrombocytopenia a. Signs and Symptoms 1.No side effects 3. Instruct client to avoid irritating mouth washes instead use soft bristled toothbrush 5. Institute reverse isolation 6. protein. vitamin c and iron 4. Vincristine (Plant Alkaloid) c. Pallor and cold sensitivity d. Increase susceptibility to infection 3. fever Decrease WBC (leucopenia) Decrease Platelet (thrombocytopenia) . Methotrexate (Alkylating Agent) b. Administer oxygen inhalation 4. Oozing of blood from venipunctured sites C. Related to irradiation/exposure to x-ray 3.Stem cell disorder leading to bone marrow depression leading to pancytopenia PANCYTOPENIA Decrease RBC (anemia) A. Drugs Broad Spectrum Antibiotics a. Ecchymosis c. Leukopenia a. Provide a dietary intake that is high in carbohydrates. Chloramphenicol (Sulfonamides) Chemotherapeutic Agents a. Weakness and fatigue b. CBC reveals pancytopenia 2. Monitor for signs of infection a.Site of injection for Vitamin B12 is dorsogluteal and ventrogluteal . Nursing Management 1. Removal of underlying cause 2. Enforce CBR 5. Diagnostic Procedures 1. Headache and dizziness c. Chemicals (Benzine and its derivatives) 2. Bone marrow biopsy/aspiration (site is the posterior iliac crest) – reveals fat necrosis in bone marrow D.. Avoid heat application to prevent burns APLASTIC ANEMIA .
ABG analysis reveals metabolic acidosis 4. CBC reveals decreased platelets 2. Massive burns 3. Petechiae (widespread and systemic) eye. Instruct client to use electric razor when shaving 10. Predisposing Factors 1. Force fluids 5. Nursing Management 1. subcutaneous. Hemoptysis 6. Massive trauma 4. Diagnostic Procedures 1. Institute NGT decompression by performing gastric lavage by using ice or cold saline solution of 500 – 1000 ml 8. Monitor NGT output 9. Signs and Symptoms 1. Provide heparin lock 7.b. Pregnancy B. Related to rapid blood transfusion 2. cough 7. Oliguria (late sign) C. venipunctured sites 8 Instead provide heparin lock 9. Ecchymosis 3. Neoplasia (new growth of tissue) 7. Administer medications as ordered a. Administer medications as ordered a. Monitor for signs of bleeding of all hema test including stool and GIT 2. Prevent complication . Oozing of blood from punctured sites 4. Avoid IM. Stool occult blood positive 3. Pitressin/ Vasopresin to conserve fluids c. Septecemia 6. Administer isotonic fluid solution as ordered 3. 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. Corticosteroids – caused by immunologic injury b. Administer oxygen inhalation 4. Heparin/Coumadin is ineffective 6. Opthamoscopic exam reveals sub retinal hemorrhages D. Vitamin K b. lungs and lower extremities 2. Anaphylaxis 5.
a. 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. Allergic reaction c. Proper refrigeration . Hyperkalemia (caused by expired blood) . Prevent infection in there is a decrease in WBC 4. Instruct another RN to re check the following a. Pyrogenic reaction d. Hemolytic reaction b. Blood typing and cross matching c. Client name b. Anuria – late sign BLOOD TRANSFUSION Goals/Objectives 1. Gauge 18 – 19 needle c.Expiration of platelet is 3 – 5 days 2.9 NaCl/plain NSS) to prevent hemolysis 4. Regulate BT 10 – 15 gtts/min or KVO rate or equivalent to 100 cc/hr to prevent circulatory overload 9. Expiration date d. Monitor strictly vital signs before. Increase the oxygen carrying capacity of blood 3. Proper typing and cross matching a. Hypovolemic shock b. Cytrate intoxication h. Circulatory overload e. Air embolism f. Replace circulating blood volume 2. Aseptically assemble all materials needed for BT a. during and after BT especially every 15 minutes for first hour because majority of transfusion reaction occurs during this period a.Emergency rapid BT is given after 30 minutes and let natural room temperature warm the blood. Thrombocytopenia g. Prevent bleeding if there is platelet deficiency Principles of blood transfusion 1.Never warm blood as it may destroy vital factors in blood.Warming is only done during emergency situation and if you have the warming device . .Expiration of packed RBC is 3 – 6 days . Check the blood unit for bubbles cloudiness. 6. Serial number 5. Filter set b. Avoid mixing or administering drugs at BT line to prevent HEMOLYSIS 8. Isotonic solution (0. 85% of population is RH positive 3. sediments and darkness in color because it indicates bacterial contamination . Type O – universal donor b. Type AB – universal recipient c.
Fever 2. Urticaria 6. Monitor vital signs and intake and output SIGNS AND SYMPTOMS PYROGENIC REACTIONS 1. Headache and dizziness 2. Notify physician 3. Dyspnea 3. anaphylactic shock treat with Epinephrine 5. Headache 3. Urine is color red/ portwine urine Nursing Management 1. Skin rashes 5.Signs and Symptoms of Hemolytic reaction 1. Send the blood unit to blood bank for re examination 6. Notify physician 3. Administer medications as ordered a. Monitor vital signs and intake and output SIGNS AND SYMPTOMS OF ALLERGIC REACTION 1. Flush with plain NSS . Fever and chills 2. Obtain urine and blood sample and send to laboratory for re examination 7. Broncial wheezing 4. Lumbasternal/ Flank pain 7. Stop BT 2. Stop BT 2. Diarrhea/Constipation 4. Flushed skin 6. Flush with plain NSS 4. Stop BT 2. Administer isotonic fluid solution to prevent shock and acute tubular necrosis 5.if positive to hypotension. Anti Histamine (Benadryl) . Palpitations 5. Diaphoresis 6. Tachycardia 4. Send the blood unit to blood bank for re examination 6. Hypotension 5. Laryngospasm and Broncospasm Nursing Management 1. Flush with plain NSS 4. Notify physician 3. Dyspnea Nursing Management 1. Dyspnea 3. Obtain urine and blood sample and send to laboratory for re examination 7.
Prevent pericardial friction rub . Administer medications as ordered a. Upper Chamber (connecting or receiving) a.Located on the left mediastinum . Myocardium – middle layer 3. Valves .Resemble like a close fist .In between is the pericardial fluid which is 10 – 20 cc .4. Monitor vital signs and intake and output 8.In order to propel blood to the systemic circulation . Epicardium – outer layer 2. Parietal – outer layer b. Layers of Heart 1. Cardiac tamponade A. pericarditis. Visceral – inner layer . Orthopnea 2. Rales/Crackles upon auscultation 4. Administer medications as ordered a.Common among MI. Lower Chamber (contracting or pumping) a. Send the blood unit to blood bank for re examination 6. Stop BT 2. Obtain urine and blood sample and send to laboratory for re examination 7. Atrioventricular Valves – guards opening between a. Antibiotic 5.Left ventricle has increased pressure which is 120 – 180 mmHg . Ventricles . .Covered by a serous membrane called the pericardium 2 layers of pericardium a.Myocarditis can lead to cardiogenic shock and rheumatic heart disease B. Exertional discomfort Nursing Management 1. Antipyretic b. tricuspid valve .Right atrium has decreased pressure which is 60 – 80 mmHg C. Chambers of the Heart 1. Dyspnea 3.Muscular pumping organ of the body.Weighs approximately 300 – 400 grams .To promote unidimensional flow or prevent backflow 1. Loop diuretic (Lasix) CARDIOVASCULAR SYSTEM OVERVIEW OF THE STRUCTURE AND FUNCTIONS OF THE HEART HEART . Atria 2. Notify physician 3. Endocardium – inner layer . Render TSB SIGNS AND SYMPTOMS OF CIRCULATORY REACTION 1.
Sino – Atrial Node (SA or Keith Flack Node) .b. Right Main Coronary Artery 2.P WAVE (atrial depolarization) contraction .Closure of AV valves give rise to first heart sound (S1 “lub”) 2.T WAVE (ventricular repolarization) .Supplies the myocardium E.Located at the junction of superior vena cava and right atrium . mitral valve .Left Main Bundle of His .QRS WAVE (ventricular depolarization) . Semi – lunar Valves a.Acts as primary pacemaker of the heart . Coronary Arteries .08 milliseconds to allow ventricular filling 3. Left Main Coronary Artery .Located at the interventricular septum 4.Located at the inter atrial septum .Initiates electrical impulse of 60 – 100 bpm 2.Right Main Bundle of His .Located at the walls of the ventricles for ventricular contraction SA NODE AV NODE BUNDLE OF HIS JLJLJLJJLJLJL PURKINJE FIBERS . pulmonic b. aortic . Purkinje Fibers .Delay of electrical impulse for about .Closure of SV valve give rise to second heart sound (S2 “dub”) Extra Heart Sounds 1. S4 – atrial gallop usually seen in Myocardial Infarction and Hypertension D.Arises from base of the aorta Types of Coronary Arteries 1. Bundle of His . Cardiac Conduction System 1. Atrio – Ventricular Node (AV or Tawara Node) . S3 – ventricular gallop usually seen in Left Congestive Heart Failure 2.
To prevent angina 3. Treatment Percutaneous Transluminal Coronary Angioplasty Objectives of PTCA 1. ST segment elevation – Myocardial Infarction 5.tunica media . Positive U wave . Smoking 4. Diet – increased saturated fats 10. Sex – male 2. Increase survival rate ARTERIOSCLEROSIS . Revascularize myocardium 2. Signs and Symptoms 1. sedentary lifestyle 7.calcium and protein deposits . Myocardial Necrosis – Myocardial Infarction ATHEROSCLEROSIS ATHEROSCLEROSIS .Atherosclerosis 2. Palpitations 5.narrowing of artery . Peak T wave – Hyperkalemia 3. Hyperlipidemia 6. Obesity 5. T wave inversion – Myocardial Infarction 6. Myocardial Ischemia – Angina Pectoris 3. Dyspnea 3. Hypothyroidism 9. 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.lipid or fat deposits .Hypokalemia 2. Predisposing Factors 1. Widening of QRS complexes – Arrythmia CARDIAC DISORDERS Coronary Arterial Disease/ Ischemic Heart Disease Stages of Development of Coronary Artery Disease 1. Type A personality B. Chest pain 2.hardening of artery . Tachycardia 4.tunica intima A. Diabetes Mellitus 8. Myocardial Injury . ST segment depression – Angina Pectoris 4. Duaphoresis C. Race – black 3.
Type A personality B. Nitroglycerine (NTG) – when given in small doses will act as venodilator. Precipitating Factors 4 E’s of Angina Pectoris 1. Diagnostic Procedure 1. Excessive physical exertion – heavy exercises 2. Excessive intake of foods rich in saturated fats – skimmed milk C. Nursing Management 1. excitement 4. Exposure to cold environment 3. coughing exercise and use of incentive spirometer 2. usually relieved by rest or taking nitroglycerine 3. Race – black 3. Palpitations 6.. History taking and physical exam 2. Sex – male 2. Predisposing Factors 1. anxiety.If there is 2 or more occluded blood vessels CABG is done Coronary Arterial Bypass And Graft Surgery 3 Complications of CABG 1. Chest pain characterized by sharp stabbing pain located at sub sterna usually radiates from back. Pneumonia – encourage to perform deep breathing. axilla and jaw muscles. Extreme emotional response – fear. Diet – increased saturated fats 10. sedentary lifestyle 7.Give second dose of NTG if pain persist after giving first dose with interval of 3 . Diabetes Mellitus 8. shoulder. Enforce complete bed rest 2. ECG tracing reveals ST segment depression 3. Administer medications as ordered a. Shock 3. Hyperlipidemia 6. Tachycardia 5. Smoking 4. Hypothyroidism 9. but in large doses will act as vasodilator . arms.Done to single occluded vessels . Signs and Symptoms 1. Levine’s Sign – initial sign that shows the hand clutching the chest 2. Stress test – treadmill test. reveal abnormal ECG 4. Dyspnea 4. Diaphoresis D.Give first dose of NTG (sublingual) 3 – 5 minutes . Serum cholesterol and uric acid is increased E. 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.5 minutes . Obesity 5.
Avoidance of 4 E’s b.NIfedipine 3. necrosis and scarring. Race – black 3.side effects PNS . Calcium Antagonist . intake and output and ECG tracing 6. Transmural Myocardial Infarction – most dangerous type characterized by occlusion of both right and left coronary artery 2. Obesity 5. Administer oxygen inhalation 4. Predisposing Factors 1. Subendocardial Myocardial Infarction – characterized by occlusion of either right or left coronary artery B. Monitor strictly vital signs.Propanolol .. 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. A. Provide decrease saturated fats sodium and caffeine 7.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. Place client on semi fowlers position 5. Instruct client to take medication before indulging into physical exertion to achieve the maximum therapeutic effect of drug d. 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. ACE Inhibitors . Beta-blockers . Hyperlipidemia . Smoking 4.Not given to COPD cases because it causes bronchospasm c. Prevent complication (myocardial infarction) c. Provide client health teachings and discharge planning a. Types 1. Sex – male 2. The importance of follow up care MYOCARDIAL INFARCTION Heart attack Terminal stage of coronary artery disease characterized by malocclusion.Enalapril d.
Heart only. Enforce CBR without bathroom privileges a. LDH – Lactic acid dehydroginase is increased c.Not usually relieved by rest or by nitroglycerine 2. Hyperthermia 5. Type A personality D. jaw and abdominal muscles (abdominal ischemia) . Administer oxygen low inflow to prevent respiratory arrest at 2 – 3 L/min 3. Diabetes Mellitus 8. Place client on semi fowlers position . Split S1 and S2 c. Hypothyroidism 9. Decrease myocardial workload (rest heart) . ST segment elevation b. Using bedside commode 4. shoulder. S4 or atrial gallop E. ECG tracing reveals a. Troponin Test – is increased 3. Ashen skin 6. viselike pain located at substernal and rarely in precordial . Rales/Crackles upon auscultation d.Antidote: Narcan/Naloxone . SGOT – Serum glutamic oxal-acetic transaminase is increased 2.Excruciating visceral.Usually radiates from back.Creatinine phosphokinase is increased . Occasional findings a. axilla. Chest pain . 12 – 24 hours b. Nursing Management Goal: Decrease myocardial oxygen demand 1. sedentary lifestyle 7. Instruct client to avoid forms of valsalva maneuver 5.Side Effects of Naloxone Toxicity is tremors 2. arms. Signs and Symptoms 1. Pericardial friction rub b. Widening of QRS complexes indicates that there is arrhythmia in MI 4. SGPT – Serum glutamic pyruvate transaminase is increased d. Diet – increased saturated fats 10.Side Effects: respiratory depression . Cardiac Enzymes a. CPK – MB . Serum Cholesterol and uric acid are both increased 5. Mild restlessness and apprehension 7. Dyspnea 3.6. Increase in blood pressure (initial sign) 4. CBC – increased WBC F. T wave inversion c.Administer narcotic analgesic/morphine sulfate . Diagnostic Procedure 1.
Antidote: protamine sulfate .Nitroglycerine .Antidote: Vitamin K h.Side Effects: allergic reaction. Left Congestive Heart Failure d. Provide a general liquid to soft diet that is low in saturated fats.Heparin (check for partial thrombin time) .Brutylium c.Side Effects of Aspirin Tinnitus Heartburn Indigestion/Dyspepsia . Anti Coagulant . Calcium Antagonist f.late sign is oliguria c.ISD (Isosorbide Dinitrate.Streptokinase .Side Effects: chest pain .arrhythmia (caused by premature ventricular contraction) b. Monitor strictly vital signs. Avoidance of modifiable risk factors . Vasodilators . pruritus . sodium and caffeine 8. Administer medication as ordered a.Urokinase .6. Encourage client to take 20 – 30 cc/week of wine. Anti Arrythmic Agents . whisky and brandy to induce vasodilation 9.Anti thrombotic effect . Cardiogenic shock . Thrombolytics/ Fibrinolytic Agents . Stroke/CVA .Side Effects: confusion and dizziness .PASA (Aspirin) . intake and output and ECG tracing 7. Anti Platelet .Contraindication Dengue Peptic Ulcer Disease Unknown cause of headache 10. Provide client health teaching and discharge planning concerning a.Coumadin/ Warfarin Sodium (check for prothrombin time) .Lidocaine (Xylocane . Isodil) sublingual b.TIPAF (tissue plasminogen activating factor) .homan’s sign e.Monitor for bleeding time g. Thrombophlebitis . ACE Inhibitors e. Beta-blockers d.
Cyanosis 7. Aging 2. PMI is displaced laterally due to cardiomegaly 11.Aspirin b.ASO Titer (Anti streptolysin O titer) . Productive cough with blood tinged sputum 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. Signs and Symptoms 1. PCO2 is increased (respiratory acidosis) 2. A beta-hemolytic streptococcus .dietary modification h. Dyspnea 2. Aortic valve stenosis B. Bronchial wheezing 9. administer 150. Resumption of ADL particularly sexual intercourse is 4 – 6 weeks post cardiac rehab. Orthopnea – use 2 – 3 pillows when sleeping or place in high fowlers 4. Predisposing Factors 1. Hypertension 5. Post MI Syndrome/Dressler’s Syndrome . Diagnostic Procedure 1. 90% is mitral valve stenosis due to a.Formation of aschoff bodies in the mitral valve . Chest x-ray – reveals cardiomegaly 2. Frothy salivation 6.make sex as an appetizer rather than dessert . Ecocardiography – enlarged heart chamber (cardiomyopathy).instruct client to assume a non weight bearing position . There is anorexia and generalized body malaise 12. RHD – inflammation of mitral valve due to invasion of Grp. Myocardial Infarction 3.f. Ischemic heart disease 4. ABG – reveals PO2 is decreased (hypoxemia). 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. S3 – ventricular gallop C.000 – 450. post CABG and instruct to .Penicillin . RIGHT SIDED HEART FAILURE . dependent on extent of heart failure 4.Common among children .client can resume sexual intercourse if can climb staircase . Paroxysmal nocturnal dyspnea – client is awakened at night due to difficulty of breathing 3. Pulsus Alternans – weak pulse followed by strong bounding pulse 10. LEFT SIDED HEART FAILURE A.000 units of streptokinase as ordered g.client is resistant to pharmacological agents. Rales/Crackles 8.
Ascites 4.If heart rate is decreased do not give b. Ecocardiography – reveals enlarged heart chambers (cardiomyopathy 4. Anorexia 9. Administer oxygen inhalation with high inflow. Pitting edema 3.Morphine Sulfate e. Left sided heart failure B. Tricuspid valve stenosis 2.Nitroglycerine f. Narcotic analgesics . Loop Diuretics . Hepatosplenomegaly 6.Upon insertion place client in trendelendberg position to promote ventricular filling and prevent pulmonary embolism 3. Predisposing Factors 1. Enforce CBR 2. Diagnostic Procedures 1. Pulmonic valve stenosis 5. Signs and Symptoms (venous congestion) 1. Related to COPD 4. Cardiac glycosides .Measure pressure in right atrium (4 – 10 cm of water) . Pulmonary embolism 3.Increase force of cardiac contraction .If CVP is more than 10 cm of water hypervolemic shock . Anti Arrhythmic . Jaundice 7. Liver enzymes – SGPT and SGOT is increased D. High fowlers position . Esophageal varices C.Administer loop diuretics as ordered . Pruritus 8.Do the fluid challenge (increase IV flow rate) . Nursing Management Goal: increase cardiac contractility thereby increasing cardiac output (3 – 6 L/min) 1. 3 – 4 L/min. Central venous pressure (CVP) . Administer medications as ordered a. Vasodilators . delivered via nasal cannula 4. Bronchodilators d.Lidocaine (Xylocane) 3.CVP fluid status measure .A. Chest x-ray – reveals cardiomegaly 2.If CVP is less than 4 cm of water hypovolemic shock . Weight gain 5. Neck/jugular vein distension 2.Digoxin (Lanoxin) .When reading CVP patient should be flat on bed .Lasix (Furosemide) c.
Angiography – reveals site and extent of malocclusion D. Oscillometry – decrease in peripheral pulses 2. Doppler UTZ – decrease blood flow to the affected extremity 3. Smoking B.Shock .Thrombophlebitis b. Assist in bloodless phlebotomy – rotating tourniquet. Varicose Veins 2.Arrythmia . cholesterol and caffeine 8. Provide client health teaching and discharge planning a. walking 3 – 4 times a day b. Diagnostic Procedures 1. Cold sensitivity and changes in skin color (pallor. High risk groups – men 30 years old and above 2. Provide a dietary intake of low sodium. Predisposing Factors 1. Strict compliance to medications PERIPHERAL VASCULAR DISORDER Arterial Ulcer I. rotated clockwise every 15 minutes to promote decrease venous return 10. Intermittent claudication – leg pain upon walking 2. Administer medications as ordered a. intake and output and ECG tracing 6. Trophic changes 5. out of bed 3 – 4 times a day 2.Right ventricular hypertrophy . Gangrene formation C. Provide meticulous skin care 9. Signs and Symptoms 1. Encourage a slow progressive physical activity a. Measure abdominal girth daily and notify physician 7.MI . Prevent complications . Decreased peripheral pulses 4. Nursing Management 1. Monitor strictly vital signs. Thrombophlebitis (deep vein thrombosis) THROMBOANGITIS OBLITERANS Acute inflammatory disorder usually affecting the small medium sized arteries and veins of the lower extremities A. cyanosis then rubor) 3. Thrombo Angitis Obliterans Venous Ulcer 1.5. Dietary modification c. Ulceration 6. Analgesics Burger’s Disease Reynaud’s Disease .
Pregnancy . High risk group – female 40 years old and above 2. Signs and Symptoms 1.b. Diagnostic Procedures 1. Collagen diseases a. Congenital weakness of veins 3. Vasodilators 2. Ulceration 5. Thrombophlebitis 4. Encourage to wear gloves 3. Anti coagulants 3. Gangrene formation C. Hereditary 2. Doppler UTZ – decrease blood flow to the affected extremity 2. SLE (butterfly rash) b. Piano playing b. Cold sensitivity and changes in skin color (pallor. Operating chainsaw B. 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. Vasodilators c. Smoking 3. Predisposing Factors 1. Trophic changes 4. Cardiac disorder 5. Analgesics b. Angiography – reveals site and extent of malocclusion D. Institute foot care management 4. Instruct client to avoid smoking and exposure to cold environment 5. Nursing Management 1. Rheumatoid Arthritis 4. Predisposing Factors 1. 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. Direct hand trauma a. cyanosis then rubor) 3. Excessive typing c. Administer medications as ordered a. Intermittent claudication – leg pain upon walking 2.
Nursing Management 1. Obesity 2. Related to pregnancy 4. Venography 2. Prolong use of oral contraceptives – promotes lipolysis 6. Signs and Symptoms 1. Warm to touch 4. Increase in saturated fats in the diet. Prolonged standing or sitting B. Pain after prolonged standing 2. Analgesics 5. Post op complication 10. Warm to touch 3. 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. Venography 2. Pain at affected extremity 2. Administer medications as ordered a. Myocardial infarction 9. Heaviness in legs C. B.6. Predisposing Factors 1. Wear anti embolic stockings 4. Smoking 3. Diagnostic Procedure 1. Positive Hpman’s Signs – pain at the calf or leg muscle upon dorsi flexion of the foot C. Diagnostic Procedure 1. Measure the circumference of leg muscle to determine if swollen 3. Assist in surgical procedure a. Elevate legs above heart level to promote increased venous return by placing 2 – 3 pillows under the legs 2. Angiography D. Dilated tortuous skin veins 3. Vein stripping and ligation (most effective) b. Trendelenburg’s Test . Signs and Symptoms 1. Chronic anemia 5. Post cannulation – insertion of various cardiac catheter 11. Nursing Management . Congestive heart failure 8. Dilated tortuous skin veins 4.veins distends quickly in less than 35 seconds D. Obesity 7. Diabetes mellitus 7.
The initial sign of complete airway obstruction is the inability to cough II.Serves as passageway of air going to the lungs .Serves as a muscular passageway for both food and air C. Encourage to wear anti embolic stockings or knee elastic stockings 5.Closes to allow passage of food going to the esophagus . Larynx . Nose .Dizziness . Cerebral . Measure circumference of leg muscle to determine if swollen 4.Opening of larynx .For gas exchange A.Consist of anastomosis of capillaries known as Keissel Rach Plexus (the site of nose bleeding) B.Restlessness b.Opens to allow passage of air . Anti Coagulant .Heparin 6. Pharynx/Throat . Upper Respiratory System 1. Apply warm moist pack – to reduce lymphatic congestion 3.For cough reflex Glottis .1.Left nostril . Trachea/Windpipe . cholecystitis characterized by pain at the right upper quadrant with tenderness RESPIRATORY SYSTEM OVERVIEW OF THE STRUCTURES AND FUCNTIONS OF THE RESPIRATORY SYSTEM I.For phonation (voice production) .Consist of cartilaginous rings .Separated by septum . Elevate legs above heart level to promote increase venous return 2.Right nostril .Cartillage .Headache .Unexplained dyspnea . Humidification A. Warming and moistening of air 3.Diaphoresis . Analgesics b.Tachycardia . Administer medications as ordered a.Sudden sharp chest pain . Monitor for signs of complications Embolism a.Decrease LOC • MURPHY’S SIGN is seen in clients with cholelithiasis.Palpitations . Lower Respiratory System . Filtering of air 2. Pulmonary .
Signs and Symptoms 1. Over fatigue 5. Airborne transmission via droplet nuclei C. Virulence (degree of pathogenecity) of microorganism B. PTB/Pulmonary Tuberculosis (Koch’s Disease) .Give oxygen of less 40% in premature to prevent atelectasis and retrolental fibroplasias . Low grade afternoon fever.Left lung (consist of 2 lobes.Decrease surface tension .retinopathy/blindness in prematurity Disorders of Respiratory System 1. Pleural effusion c. Visceral With Pleuritic Friction Rub a.Right lung (consist of 3 lobes. Hydrothorax (air and blood in pleural space Alveoli .Secretes surfactant .Left main bronchus C. Lungs . Pareital b. Pleural fluid c.Site of tracheostomy B. aerobic and easily destroyed by heat or sunlight A. 8 segments) .Increase carbon dioxide is a powerful stimulant for breathing Type II Cells of Alveoli .Normal L/S ratio is 2:1 .In premature infants 1:2 . 10 segments) . night sweats 2. Alcoholism 4. Pneumonia b.Decrease oxygen stimulates breathing . Precipitating Factors 1.Site of gas exchange (CO2 and O2) .Right main bronchus .Infection of lung tissue caused by invasion of mycobacterium tuberculosis or tubercle bacilli .Diffusion (Dalton’s law of partial pressure of gases) Respiratory Distress Syndrome . Productive cough (yellowish sputum) .L/S ratio to determine lung maturity .Composed of lecithin and spingomyelin . Bronchus .Prevent collapse of alveoli . Malnutrition 2. Ingestion of an infected cattle with mycobacterium bovis 6.. Overcrowded places 3.Serous membranes Pleural Cavity a.An acid fast. gram negative. Mode of Transmission 1.
Enforce CBR 2.Side Effect INH: peripheral neuritis/neuropathy (increase intake of Vitamin B6/Pyridoxine) .Positive Mantoux test (previous exposure to tubercle bacilli but without active TB) 2. Dyspnea 6.Side Effect PZA: allergic reaction. Mantoux Test (skin test) .WHO 10 – 14 mm induration.Kanamycin . Encourage deep breathing and coughing exercise 7. Administer oxygen inhalation 4.Rifampicin (Rifampin) .Amikacin . Intensive phase . Comfortable and humid environment 9. CBC . Hemoptysis (chronic) D. generalized body malaise 4.Purified protein derivative . taken before meals to facilitate absorption . Standard phase .Positive to cultured microorganism 3. 48 – 72 hours . 48 – 72 hours . nephrotoxicity .Gentamycin .DOH 8 – 10 mm induration.Side Effect Rifampicin: all bodily secretions turn to red orange color .Injection of streptomycin (aminoglycoside) . Place client on semi fowlers position to promote expansion of lungs 6.Side Effect Ethambutol: optic neuritis b. Institute strict respiratory isolation 3. Nursing Management 1. hepatotoxicity. Nebulize and suction when needed 8. Sputum Acid Fast Bacillus .PZA can be replaced by Ethambutol . Chest pain 7.Neomycin . Diagnostic Procedure 1.PZA (Pyrazinamide) .3.Reveals increase WBC E. Force fluids to liquefy secretions 5.INH and Rifampicin is given for 4 months. Weight loss 5.Reveals pulmonary infiltrates 4. Chest X-ray . Anorexia.INH (Isonicotinic Acid Hydrazide) .PZA is given for 2 months.Given everyday simultaneously to prevent resistance . taken after meals to facilitate absorption . Institute short course chemotherapy a.
Rales/crackles 6. Importance of follow up care PNEUMONIA Inflammation of the lung parenchyma leading to pulmonary consolidation as the alveoli is filled with exudates A. chills. military tuberculosis) PTB . Bronchial wheezing .Pneumocystic carini pneumonia . Hemophylus Influenzae – causing broncho pneumonia 3. Dyspnea with prolong expiratory grunt 3.Drug of choice is Retrovir b.Meninges . Klebsella Pneumoniae 5. Strict compliance to medications d. Children below 5 years old 2.Nephrotoxicity check for BUN and Creatinine . causing hypostatic pneumonia 5. protein. Productive cough with greenish to rusty sputum 2. dyspepsia. anorexia and general body malaise 4. AIDS .Initial sign is non productive cough . Etiologic Agents 1. Provide client health teaching and discharge planning a.Ototoxicity damage to the 8th cranial nerve resulting to tinnitus leading to hearing loss .Bones (potts) .Side Effect: . Avoidance of precipitating factors b. Weight loss 5. heartburn 10.Skin . Fever. Diplococcus Pneumoniae 4. High Risk Groups 1. Immuno compromised a. Provide increase carbohydrates. Prevent complications (atelectasis. Related to prolonged immobility (CVA clients). Signs and Symptoms 1. Bronchogenic Cancer .Side Effect: tinnitus.Eyes . Pseudomonas B. Predisposing Factors 1. Smoking 2. Streptococcus Pneumonae – causing pneumococal pneumonia 2. vitamin C and calories 11.Adrenal gland c.Chest x-ray confirms lung cancer 4. Elderly C. Aspiration of food causing aspiration pneumonia D. Air pollution 3.Give aspirin if there is fever .. Escherichia Pneumoniae 6.
Prevent complications . Health teaching and discharge planning a.Placed on various position Nursing Management for Postural Drainage a.Chest physiotherapy . Institute pulmonary toilet (tends to promote expectoration) . CBC – reveals increase WBC. Enforce CBR 2. Administer oxygen inhalation low inflow 3. Cyanosis 8. Chest pain 10. protein and vitamin C 10. Provide increase carbohydrates.Clients with increase intra ocular pressure (Normal IOP 12 – 21 mmHg) . Chest x-ray – reveals pulmonary consolidation 3. Best done before meals or 2 – 3 hours to prevent gastro esophageal reflux b. Monitor vital signs c.Drain uppermost area of lungs . Place on semi fowlers position 6.Hemoptysis . Avoid smoking b. Nursing Management 1. Pleuritic friction rub 9.Turning and reposition 7. calories. Microlides (Zethromax) Azethromycin (Side Effect: Ototoxicity) Antipyretics Mucolytics/Expectorants Analgesics 4.Unstable vital signs . Nebulize and suction as needed 8.Coughing exercises . erythrocyte sedimentation rate is increased F.Increase ICP 9. Administer bronchodilators 15 – 30 minutes before procedure e. Abdominal distention leading to paralytic ileus (absence of peristalsis) E. Penicillin b. Administer medications as ordered Broad Spectrum Antibiotic a. Assist in postural drainage . Diagnostic Procedure 1. Encourage client deep breathing exercises d. Tetracycline c. Provide oral care after procedure g. ABG analysis – reveals decrease PO2 4. Sputum Gram Staining and Culture Sensitivity – positive to cultured microorganisms 2.Deep breathing exercises . Force fluid 5. Stop if client cannot tolerate procedure f. Contraindicated with .7.
Amphotericin B . Antipyretics 4.Meningitis (nerve deafness. Administer oxygen inhalation 3. Nebulize and suction as needed 6. Nursing Management 1. Force fluids to liquefy secretions 5. Prevent complications – bronchiectasis 7. Hypokalemia) b. ABG analysis PO2 decrease C. Dyspnea on exertion 3. Steroids c. anorexia. check for BUN and Creatinine. Anorexia and generalized body malaise . Administer medications as ordered a.Fungizone (Nephrotoxicity. general body malaise 4. Productive cough (consistent to all COPD) 2. Cyanosis 5. 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. Productive cough 2. Air pollution B. Regular adherence to medications d. chills. Fever. Mucolytics d. Smoking 2. Diagnostic Procedures 1. Predisposing Factors 1. Prolonged expiratory grunt 4. hydrocephalus) c. Dyspnea 3.. Importance of follow up care HISTOPLASMOSIS Acute fungal infection caused by inhalation of contaminated dust or particles with histoplasma capsulatum derived from birds manure A. Signs and Symptoms PTB or Pneumonia like 1. Antifungal .Atelectasis . Hemoptysis 6. Enforce CBR 2. Signs and Symptoms 1. Histoplasmin Skin Test – positive 2. Chest and joint pains B.
Danders g. Cough that is non productive 2. Peripheral edema b. Pulmonary hypertension a. Pulmonary Function Test . Gases f. Dyspnea 3. Mixed Type 90 – 95% B. palpitations 7. Wheezing on expiration 4.Before ABG test for positive Allens Test. apply direct pressure to ulnar and radial artery to determine presence of collateral circulation D. milk. Predisposing Factors (Depending on Types) 1. Dust c. Lints 2. Cor Pulmonale (right ventricular hypertrophy) C. Diagnostic Procedure 1. air pressure and humidity f. Scattered rales/ronchi 6. Smoke e. Fumes d. chicken d. Foods (seafoods. Extrinsic Asthma ( Atopic/ Allergic ) Causes a. Cyanosis 7. Sudden change in temperature. eggs. Hereditary b. penicillin. Enforce CBR . chocolates. PCO2 increase. Diagnostic Procedure ABG analysis – reveals PO2 decrease (hypoxemia). Intrinsic Asthma (Non atopic/Non allergic) Causes a. Signs and Symptoms 1. pH decrease Bronchial Asthma Reversible inflammatory lung condition due to hypersensitivity to allergens leading to narrowing of smaller airways A. Tachycardia.5. Cyanosis 5. Mild Stress/apprehension 6. Physical and emotional stress 3. Diaphoresis C. Food additives (nitrates) e. beta blocker) c. Furs h. Nursing Management 1. ABG analysis – PO2 decrease .Incentive spirometer reveals decrease vital lung capacity 2. Pollen b. Drugs (aspirin.
Prevent complications .Steroids . Recurrent lower respiratory tract infections 2.Bronchodilators c. coughing and smoking. Bronchoscopy – direct visualization of bronchus using fiberscope Nursing Management PRE Bronchoscopy 1. Maintain NPO 6 – 8 hours prior to procedure 3. Regular adherence to medications to prevent development of status asthmaticus d. Monitor for signs of gross 4. Productive cough 2. Semi fowlers position 6. Signs and Symptoms 1. ABG – PO2 decrease 2. Congenital defects 4. Provide client health teachings and discharge planning concerning a. with low inflow of 2 – 3 L/min 3. Nebulize and suction when needed 7. Force fluids 5. may cause irritation 3. Anti histamine 4. Mucolytics/expectorants e. Treatment . Feeding initiated upon return of gag reflex 2. Monitor vital signs and breath sound POST Bronchoscopy 1. Related to presence of tumor B. Avoid talking.Status Asthmaticus (give drug of choice) . Dyspnea 3. Diagnostic Procedure 1. Mucomysts (acetylceisteine) d. Bronchodilators – given via inhalation or metered dose inhalaer or MDI for 5 minutes b. Avoidance of precipitating factor b. Monitor for signs of laryngeal spasm – prepare tracheostomy set D.Epinephrine . Secure inform consent and explain procedure to client 2. Hemoptysis (only COPD with sign) C. Steroids – decrease inflammation c.2. Anorexia and generalized body malaise 5. Chest trauma 3. Importance of follow up care BRONCHIECTASIS Abnormal permanent dilation of bronchus leading to destruction of muscular and elastic tissues of alveoli A. Oxygen inhalation. Cyanosis 4.Emphysema . Predisposing Factors 1. Administer medications as ordered a.
ABG analysis reveals a. “Blue Bloaters”) . Dyspnea at rest 3. Segmental Wedge Lobectomy (promote re expansion of lungs) . High risk: elderly 5. Prolong expiratory grunt 4. Signs and Symptoms 1. Anorexia and generalized body malaise 5. for recoil of alveoli) B. Diagnostic Procedure 1. Decrease or diminished breath sounds 8. Air pollution 3. Purse lip breathing to eliminates excess CO2 (compensatory mechanism) C. Rales or ronchi 9. Enforce CBR .Decrease PO2 (hypoxemia leading to chronic bronchitis. Bronchial wheezing 10. Barrel chest 11. Resonance to hyperresonance 6.Increase ph . Panacinar/ centriacinar . Air trapping c. Allergy 4. Smoking 2. Over distention of thoracic cavity (barrel chest) A. 1 lung is removed and position on affected side) 2.Decrease PCO2 . Predisposing Factors 1. “Pink Puffers”) .Increase PCO2 .Decrease ph . Surgery (pneumonectomy .1.Unaffected lobectomy facilitate drainage EMPHYSEMA Irreversible terminal stage of COPD characterized by a.Increase PO2 (hyperaxemia.Respiratory acidosis b. Nursing Management 1. Productive cough 2. Decrease tactile fremitus 7. Pulmonary Function Test – reveals decrease vital lung capacity 2.Respiratory alkalosis D. Panlobular/ centrilobular . Maldistribution of gases d. Inelasticity of alveoli b. Hereditary – it involves deficiency of ALPHA-1 ANTI TRYPSIN (needed to form Elastase. Flaring of alai nares 12.
Provide comfortable and humid environment 10. Prevent complications . Steroids c. Bronchodilators b. calories.2. Provide high carbohydrates. vitamins and minerals 11. High fowlers position 5.Cor Pulmonale . Nebulize and suction when needed 8. protein.CO2 narcosis may lead to coma . Health teachings and discharge planning concerning a.Atelectasis . Institute PEEP (positive end expiratory pressure) in mechanical ventilation promotes maximum alveolar lung expansion 9. Mucolytics/expectorants 4. Avoid smoking b. Force fluids 6. Institute pulmonary toilet 7. Administer oxygen inhalation via low inflow 3. Antibiotics d. Administer medications as ordered a. Importance of follow up care . Strict compliance to medication d.Pneumothorax c.
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