DEMYELLENATING DSE

1.)ALZHEIMERS DISEASE atrophy of brain tissue due to a deficiency of acetylcholine.

S&Sx:
A amnesia loss of memory
A apraxia unable to determine function & purpose of object
A agnosia unable to recognize familiar object
A aphasia
- Expressive broccas aphasia unable to speak
- Receptive wernickes aphasia unable to understand spoken words
Common to Alzheimer receptive aphasia
Drug of choice ARICEPT (taken at bedtime) & COGNEX.
Mgt: Supportive & palliative.
Microglia stationary cells, engulfs bacteria, engulfs cellular debris.
II. Compositions of Cord & Spinal cord
80% - brain mass
10% - CSF
10% - blood
MONROE KELLY HYPOTHESIS: The skull is a closed vault. Any increase in one component will increase ICP.
Normal ICP: 0-15mmHg
Brain mass
1. Cerebrum largest -

Connects R & L cerebral hemisphere

- Corpus collusum
Rt cerebral hemisphere, Lt cerebral hemisphere
Function:
1. Sensory
2. Motor
3. Integrative
Lobes
1.) Frontal
a. Controls motor activity
b. Controls personality development
c. Where primitive reflexes are inhibited
d. Site of development of sense of umor
e. Broccas area speech center
Damage - expressive aphasia
2.) Temporal
a. Hearing
b. Short term memory
c. Wernickes area gen interpretative or knowing Gnostic area
Damage receptive aphasia
3.) Parietal lobe appreciation & discrimation of sensory imp
- Pain, touch, pressure, heat & cold
4.) Occipital - vision
5.) Insula/island of reil/ Central lobe- controls visceral fx
Function: - activities of internal organ
6.) Rhinencephalon/ Limbec
- Smell, libido, long-term memory
Basal Ganglia areas of gray matte located deep within a cerebral hemisphere
Extra pyramidal tract
Releases dopamineControls gross voluntary unit
Decrease dopamine (Parkinsons) pin rolling of extremities & Huntingtons Dse.
Decrease acetylcholine Myasthenia Gravis & Alzheimers
Increased neurotransmitter = psychiatric disorder
Increase dopamine schizo
Increase acetylcholine bipolar
MID BRAIN relay station for sight & hearing
Controls size & reaction of pupil 2 3 mm
Controls hearing acuity
CN 3 4
Isocoria normal size (equal)
Anisocoria uneven size damage to mid brain
PERRLA normal reaction

DIENCEPHALON- between brain

Thalamus acts as a relay station for sensation
Hypothalamus (thermoregulating center of temp, sleep & wakefulness, thirst, appetite/ satiety center, emotional responses,
controls pituitary function.
BRAIN STEM- a. Pons or pneumotaxic center controls respiration
Cranial 5 8 CNS
MEDULLA OBLONGATA- controls heart rate, respiratory rate, swallowing, vomiting, hiccups/ singutus
Vasomotor center, spinal decuissation termination, CN 9, 10, 11, 12
CEREBELLUM lesser brain
- Controls posture, gait, balance, equilibrium
Cerebellar Tests:
a.) R Rombergs test- needs 2 RNs to assist
- Normal anatomical position 5 10 min
(+) Rombergs test (+) ataxia or unsteady gait or drunken like movement with loss of balance.
b.) Finger to nose test
(+) To FTNT dymetria inability to stop a movement at a desired point
c.) Alternate pronation & supination
Palm up & down . (+) To alternate pronation & supination or damage to cerebellum dymentrium
Composition of brain - based on Monroe Kellie Hypothesis
Skull is a closed container. Any alteration in 1 of 3 intracranial components = increase in ICP
Normal ICP 0 15 mmHg
Foramen Magnum
C1 atlas
C2 axis
(+) Projectile vomiting = increase ICP
Observe for 24 - 48 hrs
CSF cushions the brain, shock absorber
Obstruction of flow of CSF = increase ICP
Hydrocephalus posteriorly due to closure of posterior fontanel
CVA partial/ total obstruction of blood supply
INCREASED ICP increase ICP is due to increase in 1 of the Intra Cranial components.
Predisposing factors:
1.) Head injury
2.) Tumor
3.) Localized abscess
4.) Hemorrhage (stroke)
5.) Cerebral edema
6.) Hydrocephalus
7.) Inflammatory conditions - Meningitis, encephalitis
B. S&Sx
change in VS = always late symptoms
Earliest Sx:
a.) Change or decrease LOC Restlessness to confusion
Wide pulse pressure: Increased ICP
- Disorientation to lethargy
Narrow pp: Cardiac disorder, shock
- Stupor to coma
Late sign change in V/S
1. BP increase (systolic increase, diastole- same)
2. Widening pulse pressure
Normal adult BP 120/80 120 80 = 40 (normal pulse pressure)
Increase ICP = BP 140/80 = 140 80= 60 PP (wide)
3. RR is decreased (Cheyne-Stokes = bet period of apnea or hyperpnea with periods of apnea)
4. Temp increase
Increased ICP: Increase BP
Shock decrease BP
Decrease HR
Increase HR
CUSHINGS EFFECT
Decrease RR
Increase RR
Increase Temp
Decrease temp
b.) Headache
Projectile vomiting
Papilledima (edema of optic disk outer surface of retina)
Decorticate (abnormal flexion) = Damage to cortico spinal tract /
Decerebrate (abnormal extension) = Damage to upper brain stem-pons/
c.) Uncal herniation unilateral dilation of pupil.

(Bilateral dilation of pupil tentorial herniation.)

d.) Possible seizure.

Nursing priority:
1.) Maintain patent a/w & adequate ventilation
a. Prevention of hypoxia (decrease tissue oxygenation) & hypercarbia (increase in CO2 retention).
Hypoxia cerebral edema - increase ICP
Hypoxia inadequate tissue oxygenation
Late symptoms of hypoxia B bradycardia
E extreme restlessness
D dyspnea
C cyanosis
Early symptoms R restlessness
A agitation
T tachycardia
Increase CO2 retention/ hypercarbia cerebral vasodilatation = increase ICP
Most powerful respiratory stimulant increase in CO2
Hyperventilate decrease CO2 excrete CO2
Respiratory Distress Syndrome (RDS) decrease Oxygen
Suctioning 10-15 seconds, max 15 seconds. Suction upon removal of suction cap.
Ambu bag pump upon inspiration
c. Assist in mechanical ventilation
1. Maintain patent a/w
2. Monitor VS & I&O
3. Elevate head of bed 30 45 degrees angle neck in neutral position unless contra indicated to promote venous drainage
4. Limit fluid intake 1,200 1,500 ml/day
(FORCE FLUID means:Increase fluid intake/day 2,000 3,000 ml/day)- not for inc ICP.
5. Prevent complications of immobility
6. Prevent increase ICP by:
a. Maintain quiet & comfy environment
b. Avoid use of restraints lead to fractures
c. Siderails up
d. Instruct patient to avoid the ff:
-Valsalva maneuver or bearing down, avoid straining of stool
(give laxatives/ stool softener Dulcolax/ Duphalac)
- Excessive cough antitussive
Dextrometorpham
-Excessive vomiting anti emetic (Plasil Phil only)/ Phenergan
- Lifting of heavy objects
- Bending & stooping
e. Avoid clustering of nursing activities
7. Administer meds as ordered:
1.) Osmotic diuretic Mannitol./Osmitrol promotes cerebral diuresis by decompressing brain tissue
1.
2.
3.
4.

Nursing considerations: Mannitol

Monitor BP SE of hypotension
Monitor I&O every hr. report if < 30cc out put
Administer via side drip
Regulate fast drip to prevent formation of crystals or precipitate

2.) Loop diuretic - Lasix (Furosemide)

Nursing Mgt: Lasix
Same as Mannitol except
- Lasix is given via IV push (expect urine after 10-15mins) should be in the morning. If
given at 7am. Pt will urinate at 7:15
Immediate effect of Lasix within 15 minutes. Max effect 6 hrs due (7am 1pm)
S/E of Lasix
Hypokalemia (normal K-3.5 5.5 meg/L)
S&Sx
1. Weakness & fatigue
2. Constipation
3. (+) U wave in ECG tracing
Nursing Mgt:
1.) Administer K supplements ex Kalium Durule, K chloride
Potassium Rich food:
ABCs of K
Vegetables
Fruits

A - asparagus
B broccoli (highest)
C carrots

A apple
B banana green
C cantalope/ melon
O orange (highest) for digitalis toxicity also.
Vit A squash, carrots yellow vegetables & fruits, spinach, chesa
Iron raisins,
Food appropriate for toddler spaghetti! Not milk increase bronchial secretions
Dont give grapes may choke
S/E of Lasix:
1.) Hypokalemia
2.) Hypocalcemia (Normal level Ca = 8.5 11mg/100ml) or Tetany:
S&Sx
weakness
Paresthesia
(+) Trousseau sign pathognomonic or carpopedal spasm. Put bp cuff on arm=hand spasm.
(+) Chevosteks sign
Arrhythmia
Laryngospasm
Administer Ca gluconate IV slowly
Ca gluconate toxicity: Sx seizure administer Mg SO4
Mg SO4 toxcicity administer Ca gluconate
B BP decrease
U urine output decrease
R RR decrease
P patellar reflexes absent
3.) Hyponatremia Normal Na level = 135 145 meg/L
S/Sx
Hypotension
Signs of Dehydration: dry skin, poor skin turgor, gen body malaise.
Early signs Adult: thirst and agitation / Child: tachycardia
Mgt: force fluid
Administer isotonic fluid sol
4.) Hyperglycemia increase blood sugar level
P polyuria
P polyphagia
P polydipsia
Nsg Mgt:
a. Monitor FBS (N=80 120 mg/dl)
5.) Hyperurecemia increase serum uric acid. Tophi- urate crystals in joint.
Gouty arthritis

kidney stones- renal colic (pain)

Cool moist skin
Sx joint pain & swelling usually at great toe.
Nsg Mgt of Gouty Arthritis
a.) Cheese (not sardines, anchovies, organ meat)
(Not good if pt taking MAO)
b.) Force fluid
c.) Administer meds Allopurinol/ Zyloprim inhibits synthesis of uric acid drug of choice for gout
Colchicene excretes uric acid. Acute gout drug of choice.
Kidney stones renal colic (pain). Cool moist skin
Mgt:
1.) Force fluid
2.) Meds narcotic analgesic
Morphine SO4
SE of Morphine SO4 toxicity
Respiratory depression (check RR 1st)
Antidote for morphine SO4 toxicity Narcan (NALOXONE)
Naloxone toxicity tremors
Increase ICP meds:
3.) Corticosteroids - Dexamethsone decrease cerebral edema (Decadrone)
4.) Mild analgesic codeine SO4. For headache.
5.) Anti consultants Dilantin (Phenytoin)
Question: Increase ICP what is the immediate nsg action?
a. Administer Mannitol as ordered

b.
c.
d.

Elevate head 30 45 degrees

Restrict fluid
Avoid use of restraints

Nsg Priority ABC & safety

Pt suffering from epiglotitis. What is nsg priority?
a. Administer steroids least priority
b. Assist in ET temp, a/w
c. Assist in tracheotomy permanent (Answer)
d. Apply warm moist pack? Least priority
Rationale: Wont need to pass larynx due to larynx is inflamed. ET cant pass. Need tracheostomy onlyMagic 2s of drug monitoring
Drug
N range
D digoxin
.5 1.5 meq/L
L - lithium
.6 1.2 meq/L
A aminophylline10 19 mg/100ml
D Dilantin
10 -19 mg/100 ml
A acetaminophen
10 30 mg/100ml

Toxicity
2
2
20

20
200

Classification
cardiac glycosides
antimanic
bronchodilator
anticonvulsant
narcotic analgesic

Indication
CHF
bipolar
COPD

seizures
osteoarthritis

Digitalis increase cardiac contraction = increase CO

Nursing Mgt
1. Check PR, HR (if HR below 60bpm, dont giveDigoxin)
Digitalis toxicity antidote - Digivine
a. Anorexia
-initial sx.
b. n/v
GIT
c. Diarrhea
d. Confusion
e. Photophobia
f.
Changes in color perception yellow spots
(Ok to give to pts with renal failure. Digoxin is metabolized in liver not in kidney.)
L lithium (lithane) decrease levels of norepinephrine, serotonine, acetylcholine
Antimanic agent
Lithium toxicity
S/Sx a.) Anorexia
b.) n/s
c.) Diarrhea
d.) Dehydration force fluid, maintain Na intake 4 10g daily
e.) Hypothyroidism
(CRETINISM the only endocrine disorder that can lead to mental retardation)
A aminophyline (theophylline) dilates bronchioles.
Take bp before giving aminophylline.
S/Sx : Aminophylline toxicity:
1. Tachycardia
2. Hyperactivity restlessness, agitation, tremors
a.
b.
c.
d.

Question: Avoid giving food with Aminophylline

Cheese/butter
food rich in tyramine, avoided only if pt is given MAOI
Beer/ wine Hot chocolate & tea caffeine CNS stimulant tachycardia
Organ meat/ box cereals anti parkinsonian

MAOI antidepressant
m AR plan
n AR dil
can lead to CVA or hypertensive crisis
p AR nate
3 4 weeks - before MAOI will take effect
Anti Parkinsonian agents Vit B6 Pyridoxine reverses effect of Levodopa
D dilatin (Phenytoin) anti convulsant/seizure
Nursing Mgt:
1. Mixed with plain NSS or .9 NaCl to prevent formation of crystals or precipitate
Do sandwich method
Give NSS then Dilantin, then NSS!
2. Instruct the pt to avoid alcohol bec alcohol + dilantin can lead to severe CNS depression

Dilantin toxicity:
S/Sx:
G gingival hyperplasia swollen gums
i. Oral hygiene soft toothbrush
ii. Massage gums
H hairy tongue
A - ataxia
N nystagmus abnormal movement of eyeballs
A acetaminophen/ Tylenol non-opoid analgesic & antipyretic febrile pts
Acetaminophen toxicity :
1. Hepato toxicity
2. Monitor liver enzymes
SGPT (ALT) Serum Glutamic Piruvate Tyranase
SGOT- Serum Glutamic Acetate Tyranase
3. Monitor BUN (10 20)
Crea (.8-1)
Acetaminophen toxicity can lead to hypoglycemia
T tremors, Tachycardia
I irritability
R restlessness
E extreme fatigue
D depression (nightmares) , Diaphoresis
Antidote for acetaminophen toxicity Acetylcesteine = causes outporing of secretions. Suction.
Prepare suctioning apparatus.
Question: The following are symptoms of hypoglycemia except:
a. Nightmares
b. Extreme thirst hyperglycemia symptoms
c. Weakness
d. Diaphoresis
PARKINSONS DSE (parkinsonism) - chronic, progressive disease of CNS char by degeneration of dopamine producing cells in substancia
nigra at mid brain & basal ganglia
Palliative, Supportive
Function of dopamine: controls gross voluntary motors.
Predisposing Factors:
1. Poisoning (lead & carbon monoxide). Antidote for lead = Calcium EDTA
2. Hypoxia
3. Arteriosclerosis
4. Encephalitis
High doses of the ff:
a. Reserpine (serpasil)
anti HPN, SE 1.) depression - suicidal 2.) breast cancer
b. Methyldopa (aldomet)
- promote safety
c. Haloperidol (Haldol)- anti psychotic
d. Phenothiazide - anti psychotic
SE of anti psychotic drugs Extra Pyramidal Symptom
Over meds of anti psychotic drugs neuroleptic malignant syndrome char by tremors (severe)
S/Sx: Parkinsonism
1. Pill rolling tremors of extremities early sign
2. Bradykinesia slow movement
3. Over fatigue
4. Rigidity (cogwheel type)
a. Stooped posture
b. Shuffling most common
c. Propulsive gait
5. Mask like facial expression with decrease blinking eyes
6. Monotone speech
7. Difficulty rising from sitting position
8. Mood labilety always depressed suicide
Nsg priority: Promote safety
9. Increase salivation drooling type
10. Autonomic signs:
Increase sweating
Increase lacrimation
Seborrhea (increase sebaceous gland)
Constipation
Decrease sexual activity
Nsg Mgt
1.) Anti parkinsonian agents
Levodopa (L-Dopa), Carbidopa (Sinemet), Amantadine Hcl (Symmetrel)
Mechanism of action

Increase levels of dopa relieving tremors & bradykinesia

S/E of anti parkinsonian
Anorexia
n/v
Confusion
Orthostatic hypotension
Hallucination
Arrhythmia
Contraindication:
1. Narrow angled closure glaucoma
2. Pt taking MAOI (Parnate, Marplan, Nardil)
Nsg Mgt when giving anti-parkinsonian
1. Take with meals to decrease GIT irritation
2. Inform pt urine/ stool may be darkened
3. Instruct pt- dont take food Vit B6 (Pyridoxine) cereals, organ meats, green leafy veg
Cause B6 reverses therapeutic effects of levodopa
Give INH (Isoniazide-Isonicotene acid hydrazide.) SE-Peripheral neuritis.
2.) Anti cholinergic agents relieves tremors
Artane
mech inhibits acetylcholine
Cogentin
action , S/E - SNS
3.) Antihistamine Diphenhydramine Hcl (Benadryl) take at bedtime
S/E: adult drowsiness, avoid driving & operating heavy equipt. Take at bedtime.
Child hyperactivity CNS excitement for kids.
4.) Dopamine agonist
Bromotriptine Hcl (Parlodel) respiratory depression. Monitor RR.
Nsg Mgt Parkinson
1.)
Maintain siderails
2.)
Prevent complications of immobility
- Turn pt every 2h
Turn pt every 1 h elderly
3.)
Assist in passive ROM exercises to prevent contractures
4.)
Maintain good nutrition
CHON in am
CHON in pm to induce sleep due Tryptopan Amino Acid
5.)
Increase fluid in take, high fiber diet to prevent constipation
6.)
Assist in surgery Sterotaxic Thalamotomy
Complications in sterotaxic thalmotomy- 1.) Subarachnoid hemorrhage 2.) aneurism 3.) encephalitis
MULTIPLE SCLEROSIS (MS)
Chronic intermittent disorder of CNS white patches of demyelenation in brain & spinal cord.
Remission & exacerbation
Common women, 15 35 yo
cause unknown
Predisposing factor:
1. Slow growing virus
2. Autoimmune (supportive & palliative treatment only)
Normal Resident Antibodies:
Ig G can pass placenta passive immunity. Short acting.
Ig A body secretions saliva, tears, colostrums, sweat
Ig M acute inflammation
Ig E allergic reactions
IgD chronic inflammation
S & Sx of MS: (everything down)
1. Visual disturbances
a. Blurring of vision
b. Diplopia/ double vision
c. Scotomas (blind spots) initial sx
2. Impaired sensation to touch, pain, pressure, heat, cold
a. Numbness
b. Tingling
c. Paresthesia
3. Mood swings euphoria (sense of elation )
4. Impaired motor function:
a. Weakness
b. Spasiticity tigas
c. Paralysis major problem
5. Impaired cerebellar function
Triad Sx of MS
I intentional tremors

N nystagmus abnormal rotation of eyes

A Ataxia
& Scanning speech
6. Urinary retention or incontinence
7. Constipation
8. Decrease sexual ability

Charcots triad

Dx MS

1. CSF analysis thru lumbar puncture

- Reveals increase CHON & IgG
2. MRI reveals site & extent of demyelination
3. Lhermittes response is (+). Introduce electricity at the back. Theres spasm & paralysis at spinal cord.
Nsg Mgt MS
Supportive mgt
1.) Meds
a. Acute exacerbation
ACTH adenocorticotopic
Steroids to reduce edema at the site of demyelination to prevent paralysis
Spinal Cord Injury
Administer drug to prevent paralysis due to edema
a. Give ACTH steroids
b. Baclopen (Lioresol) or Dantrolene Na (Dantrene)
To decrease muscle spasticity
c. Interferone to alter immune response
d. Immunosuppresants
2. Maintain siderails
3. Assist passive ROMexercises promote proper body alignment
4. Prevent complications of immobility
5. Encourage fluid intake & increase fiber diet to prevent constipation
6. Provide catheterization die urinary retention
7. Give diuretics
Urinary incontinence give Prophantheline bromide (probanthene)
Antispasmodic anti cholinergic
8. Give stress reducing activity. Deep breathing exercises, biofeedback, yoga techniques.
9. Provide acid-ash diet to acidify urine & prevent bacteria multiplication
Grape, Cranberry, Orange juice, Vit C
MYASTHENIA GRAVIS (MG) disturbance in transmission of impulses from nerve to muscle cell at neuro muscular
junction.
Common in Women, 20 40 yo, unknown cause or idiopathic
Autoimmune release of cholenesterase enzyme
Cholinesterase destroys ACH (acetylcholine) = Decrease acetylcholine
Descending muscle weakness
(Ascending muscle weakness Guillain Barre Syndrome)
Nsg priority:
1) a/w
2) aspiration
3) immobility
S/ Sx:
1.) Ptosis drooping of upper lid ( initial sign)
Check Palpebral fissure opening of upper & lower lids = to know if (+) of MG.
2.) Diplopia double vision
3.) Mask like facial expression
4.) Dysphagia risk for aspiration!
5.) Weakening of laryngeal muscles hoarseness of voice
6.) Resp muscle weakness lead respiratory arrest. Prepare at bedside tracheostomy set
7.) Extreme muscle weakness during activity especially in the morning.
Dx test
1. Tensilon test (Edrophonium Hcl) temporarily strengthens muscles for 5 10 mins. Short term- cholinergic. PNS effect.
Nsg Mgt
1. Maintain patent a/w & adequate vent by:
a.) Assist in mechanical vent attach to ventilator
b.) Monitor pulmonary function test. Decrease vital lung capacity.
2. Monitor VS, I&O neuro check, muscle strength or motor grading scale (4/5, 5/5, etc)
3. Siderails
4. Prevent complications of immobility. Adult-every 2 hrs. Elderly- every 1 hr.
5. NGT feeding
Administer meds
a.) Cholinergics or anticholinesterase agents
Mestinon (Pyridostigmine)
Neostignine (prostigmin) Long term

- Increase acetylcholine
s/e PNS
b.) Corticosteroids to suppress immune resp
Decadron (dexamethasone)
Monitor for 2 types of Crisis:
Myastinic crisis
A cause 1. Under medication
2. Stress
3. Infection
B S&Sx 1. Unable to see Ptosis & diplopia
2. Dysphagia- unable to swallow.
3. Unable to breath
C Mgt adm cholinergic agents

Cholinergic crisis
Cause: 1 over meds
S/Sx - PNS

Mgt. adm anti-cholinergic

Atropine SO4
SNS dry mouth
7. Assist in surgical proc thymectomy. Removal of thymus gland. Thymus secretes auto immune antibody.
8. Assist in plasmaparesis filter blood
9. Prevent complication respiratory arrest
Prepare tracheostomy set at bedside.
GBS Guillain Barre Syndrome
Disorder of CNS
Bilateral symmetrical polyneuritis
Ascending paralysis
Cause unknown, idiopathic
Auto immune
r/t antecedent viral infection
Immunizations
S&Sx
Initial :
1. Clumsiness
2. Ascending muscle weakness lead to paralysis
3. Dysphagia
4. Decrease or diminished DTR (deep tendon reflexes)
Paralysis
5. Alternate HPN to hypotension lead to arrhythmia - complication
6. Autonomic changes
increase sweating, increase salivation.
Increase lacrimation
Constipation
Dx most important: CSF analysis thru lumbar puncture reveals increase in : IgG & CHON (same with MS)
Nsg Mgt

1. Maintain patent a/w & adequate vent

a. Assist in mechanical vent
b. Monitor pulmonary function test
2. Monitor vs., I&O neuro check, ECG tracing due to arrhythmia
3. Siderails
4. Prevent compl immobility
5. Assist in passive ROM exercises
6. Institute NGT feeding due dysphagia
7. Adm meds (GBS) as ordered: 1. Anti cholinergic atropine SO4
2. Corticosteroids to suppress immune response
3. Anti arrhythmic agents
a.) Lidocaine /Xylocaine SE confusion = VTach
b.) Bretyllium
c.) Quinines/Quinidine anti malarial agent. Give with meals.
- Toxic effect cinchonism
Quinidine toxicity
S/E anorexia, n/v, headache, vertigo, visual disturbances
8.
Assist in plasmaparesis (MG. GBS)
9.
Prevent comp arrhythmias, respiratory arrest
Prepare tracheostomy set at bedside.

INFL CONDITONS OF BRAIN

Meninges 3-fold membrane cover brain & spinal cord
Fx:
Protection & support
Nourishment

Blood supply
3 layers
1. Duramater
2. Arachmoid matter
3. Pia matter

sub dural space

sub arachnoid space

where CSF flows L3 & L4. Site for lumbar puncture.

MENINGITIS inflammation of meningitis & spinal cord

Etiology Meningococcus
Pneumococcus
Hemophilous influenza child
Streptococcus adult meningitis
MOT direct transmission via droplet nuclei
S&Sx
Sx

Stiff neck or nuchal rigidity (initial sign)

Headache
Projectile vomiting due to increase ICP
Photophobia
Fever chills, anorexia
Gen body malaise
Wt loss
Decorticate/decerebration abnormal posturing
Possible seizure
of meningeal irritation nuchal rigidity or stiffness
Opisthotonus- rigid arching of back

Pathognomonic sign (+) Kernigs & Brudzinski sign

Leg pain

neck pain

Dx:
1. Lumbar puncture lumbar/ spinal tap use of hallow spinal needle sub arachnoid space L3 & L4 or L4 & L5
Aspirate CSF for lumbar puncture.
Nsg Mgt for lumbar puncture invasive
1. Consent / explain procedure to pt
RN dx procedure (lab)
MD operation procedure
2. Empty bladder, bowel promote comfort
3. Arch back to clearly visualize L3, L4
Nsg Ngt
1.
2.
3.
4.

post lumbar
Flat on bed 12 24 h to prevent spinal headache & leak of CSF
Force fluid
Check punctured site for drainage, discoloration & leakage to tissue
Assess for movement & sensation of extremeties

Result
1. CSF analysis:

a. increase CHON & WBC

Content of CSF: Chon, wbc, glucose
b. Decrease glucose
Confirms meningitis c. increase CSF opening pressure
N 50 160 mmHg
d. (+) Culture microorganism
2. Complete blood count CBC reveals increase WBC
Mgt:
1. Adm meds
a.) Broad-spectrum antibiotic penicillin
S/E
1. GIT irritation take with food
2. Hepatotoxicity, nephrotoxcicity
3. Allergic reaction
4. Super infection alteration in normal bacterial flora
N flora throat streptococcus
N flora intestine e coli
Sx of superinfection of penicillin = diarrhea
b.) Antipyretic
c.) Mild analgesic
2. Strict resp isolation 24h after start of antibiotic therapy
A Cushings synd reverse isolation - due to increased corticosteroid in body.
B Aplastic anemia reverse isolation - due to bone marrow depression.
C Cancer anytype reverse isolation immunocompromised.
D Post liver transplant reverse isolation takes steroids lifetime.
E Prolonged use steroids reverse isolation

10

F Meningitis strict respiratory isolation safe after 24h of antibiotic therapy

G Asthma not to be isolated
3.
4.
5.
6.
7.

Comfy & dark room due to photophobia & seizure

Prevent complications of immobility
Maintain F & E balance
Monitor vs, I&O , neuro check
Provide client health teaching & discharge plan
a. Nutrition increase cal & CHO, CHON-for tissue repair. Small freq feeding
b. Prevent complication hydrocephalus, hearing loss or nerve deafness.
8. Prevent seizure.
Where to bring 2 yo post meningitis
Audiologist due to damage to hearing- post repair myelomeningocele
Urologist -Damage to sacral area spina bifida controls urination
9. Rehab for neurological deficit. Can lead to mental retardation or a delay in psychomotor development.
CEREBRO VASCULAR ACCIDENT stroke, brain attack or cerebral thrombosis, apoplexy
Partial or complete disruption in the brains blood supply
2 largest & common artery in stroke
Middle cerebral artery
Internal carotid artery
Common to male 2 3x high risk
Predisposing factor:
1. Thrombosis clot (attached)
2. Embolism dislodged clot pulmo embolism
S/Sx: pulmo embolism
Sudden sharp chest pain
Unexplained dyspnea, SOB
Tachycardia, palpitations, diaphoresis & mild restlessness
S/Sx: cerebral embolism
Headache, disorientation, confusion & decrease in LOC
Femur fracture complications: fat embolism most feared complication w/in 24hrs
Yellow bone marrow produces fat cells at meduallary cavity of long bone
Red bone marrow provides WBC, platelets, RBC found at epiphisis

2.) Hemorrhage
3.) Compartment syndrome compression of nerves/ arteries

Risk factors of CVA: HPN, DM, MI, artherosclerosis, valvular heart dse - Post heart surgery mitral valve replacement
Lifestyle:

1.
2.
3.
4.

5.

6.
7.
8.

Smoking nicotine potent vasoconstrictor

Sedentary lifestyle
Hyperlipidemia genetic
Prolonged use of oral contraceptives
- Macro pill has large amt estrogen
- Mini pill has large amt of progestin
- Promote lipolysis (breakdown of lipids/fats) artherosclerosis HPN - stroke
Type A personality
a. Deadline driven person
b. 2 5 things at the same time
c. Guilty when not dong anything
Diet increase saturated fats
Emotional & physical stress
Obesity

S & Sx
1. TIA- warning signs of impending stroke attacks
Headache (initial sx), dizziness/ vertigo, numbness, tinnitus, visual & speech disturbances, paresis or plegia (monoplegia 1
extreme)
Increase ICP
2. Stroke in evolution progression of S & Sx of stroke
3. Complete stroke resolution of stroke
a.) Headache
b.) Cheyne-Stokes Resp
c.) Anorexia, n/v
d.) Dysphagia
e.) Increase BP
f.) (+) Kernigs & Brudzinski sx of hemorrhagic stroke
g.) Focal & neurological deficit
1. Phlegia
2. Dysarthria inability to vocalize, articulate words
3. Aphasia

11

4. Agraphia diff writing

5. Alesia diff reading
6. Homoninous hemianopsia loss of half of field of vision
Left sided hemianopsia approach Right side of pt the unaffected side
Dx
1. CT Scan reveals brain lesion
2. Cerebral arteriography site & extent of mal occlusion
Invasive procedure due to inject dye
Allergy test
All graphy invasive due to iodine dye
Post
1.) Force fluid to excrete dye is nephrotoxic
2.) Check peripheral pulses - distal
Nsg Mgt
1. Maintain patent a/w & adequate vent
- Assist mechanical ventilation
- Administer O2
2. Restrict fluids prevent cerebral edema
3. Elevate head of bed 30-45 degrees angle. Avoid valsalva maneuver.
4. Monitor vs., I&O, neuro check
5. Prevent compl of immobility by:
a. Turn client q2h
Elderly q1h
To prevent decubitus ulcer
To prevent hypostatic pneumonia after prolonged immobility.
b. Egg crate mattress or H2O bed
c. Sand bag or foot board- prevent foot drop
6. NGT feeding if pt cant swallow
7. Passive ROM exercise q4h
8. Alternative means of communication
- Non-verbal cues
- Magic slate. Not paper and pen. Tiring for pt.
- (+) To hemianopsia approach on unaffected side
9. Meds
Osmotic diuretics Mannitol
Loop diuretics Lasix/ Furosemide
Corticosteroids dextamethazone
Mild analgesic
Thrombolytic/ fibrolitic agents tunaw clot. SE-Urticaria, pruritus-caused by foreign subs.
Streptokinase
Urokinase
Tissue plasminogen activating
Monitor bleeding time
Anticoagulants Heparin & Coumadin sabay
Coumadin will take effect after 3 days
Heparin monitor PTT partial thromboplastin time if prolonged bleeding give Protamine SO4- antidote.
Coumadin Long term. monitor PT prothrombin time if prolonged- bleeding give Vit K Aquamephyton- antidote.
Antiplatelet PASA aspirin paraanemo aspirin, dont give to dengue, ulcer, and unknown headache.
Health Teaching
1. Avoidance modifiable lifestyle
- Diet, smoking
2. Dietary modification
- Avoid caffeine, decrease Na & saturated fats
Complications:
Subarachnoid hemorrhage
Rehab for focal neurological deficit physical therapy
1. Mental retardation
2. Delay in psychomotor development
CONVULSIVE Disorder (CONVULSIONS)- disorder of the CNS char. by paroxysmal seizures with or without loss of consciousness,
abnormal motor activity, alteration in sensation & perception & change in behavior.
Can you outgrow febrile seizure?
Febrile seizure Normal if < 5 yo
Pathologic if > 5 yo

Difference between:

Seizure- 1st convulsive attack

Epilepsy 2nd and with history of seizure

Predisposing Factor
Head injury due birth trauma
Toxicity of carbon monoxide

12

Brain tumor
Genetics
Nutritional & metabolic deficit
Physical stress
Sudden withdrawal to anticonvulsants will bring about status epilepticus
Status epilepticus drug of choice: Diazepam & glucose
S & Sx
I. Generalized Seizure
a.) Grand mal / tonic clonic seizures
With or without aura warning symptoms of impending seizure attack- Epigastric pain- associated with olfactory,
tactile, visual, auditory sensory experience
Epileptic cry fall
Loss of consciousness 3 5 min
Tonic clonic contractions
Direct symmetrical extension of extremities-TONIC. Contractions-CLONIC
Post ictal sleep -state of lethargy or drowsiness - unresponding sleep after tonic clonic
b.) Petimal seizure (same as daydreaming!) or absent seizure.
- Blank stare
- Decrease blinking eye
- Twitching of mouth
- Loss of consciousness 5 10 secs (quick & short)
II. Localized/partial seizure
a.) Jacksonian seizure or focal seizure tingling/jerky movement of index finger/thumb & spreads to shoulder &
sideof the body with janksonian march
b.) Psychomotor/ focal motor - seizure
-Automatism stereotype repetitive & non-purposive behavior
- Clouding of consciousness not in control with environment
- Mild hallucinatory sensory experience
1.
2.
3.

HALLUCINATIONS
Auditory schitzo paranoid type
Visual korsakoffs psychosis chronic alcoholism
Tactile addict substance abuse

III. Status epilecticus continuous, uninterrupted seizure activity, if untreated, lead to hyperprexia coma death
Seizure: inc electrical firing in brain=increased metabolic activity in brain=brain using glucose and O2=dec glucose, dec O2.
Tx:Diazepam (drug of choice), glucose
Dx-Convulsion- get health history!
1. CT scan brain lesion
2. EEG electroencephalography
Hyperactivity brain waves
Nsg Mgt
Priority Airway & safety
1. Maintain patent a/w & promote safety
Before seizure:
1. Remove blunt/sharp objects
2. Loosen clothing
3. Avoid restraints
4. Maintain siderails
5. Turn head to side to prevent aspiration
6. Tongue guard or mouth piece to prevent biting of tongue-BEFORE SEIZURE ONLY! Can use spoon at home.
7. Avoid precipitating stimulus bright glaring lights & noises
8. Administer meds
a. Dilantin (Phenytoin) ( toxicity level 20 )
SE Ginguial hyperplasia
H-hairy tongue
A-ataxia
N-nystagmus
A-acetaminophen- febrile pt
Mix with NSS
- Dont give alcohol lead to CNS depression
b. (Tegretol) Carbamasene- given also to Trigeminal Neuralgia. SE: arrythmia
c. Phenobarbital (Luminal)- SE: hallucinations
2. Institute seizure & safety precaution. Post seizure: Administer O2. Suction apparatus ready at bedside
3. Monitor onset & duration
- Type of seizure
- Duration of post ictal sleep. The longer the duration of post ictal sleep, the higher chance of having status epilepticus!
4. Assist in surgical procedure. Cortical resection

13

5. Complications: Subarachnoid hemorrhage and encephalitis

Question: 1 yo grand mal immediate nursing action = a/w & safety
a. Mouthpiece 1 yr old little teeth only
b. Adm o2 inhalation post!
c. Give pillow safety (answer)
d. Prepare suction
Neurological assessment:
1. Comprehensive neuro exam
2. GCS - Glasgow coma scale obj measurement of LOC or quick neuro check
3 components of ECS
M motor
6
V verbal resp 5
E eye opening 4
15
15 14 conscious
13 11 lethargy
10 8 stupor
7 coma
3 deep coma lowest score
Survey of mental
1.)
2.)
3.)
4.)
5.)
6.)
7.)
8.)

status & speech (Comprehensice Neuro Exam)

LOC & test of memory
Levels of orientation
CN assessment
Motor assessment
Sensory assessment
Cerebral test Romhberg, finger to nose
DTR
Autonomics

Levels of consciousness (LOC)

1. Conscious (conscious) awake levels of wakefulness
2. Lethargy (lethargic) drowsy, sleepy, obtunded
3. Stupor (stuporous) awakened by vigorous stimulation
Pt has gen body weakness, decrease body reflex
4. Coma (Comatose) light (+) all forms of painful stimulations
Deep (-) to painful stimulation
Question: Describe a conscious pt ?
a. Alert not all pt are alert & oriented to time & place
b. Coherent
c. Awake- answer
d. Aware
Different types of pain stimulation
Dont prick
1. Deep sternal stimulation/ pressure 3x fist knuckle
With response light coma
Without response deep coma
2. Pressure on great toe 3x
3. Orbital pressure pressure on orbits only below eye
4. Corneal reflex/ blinking reflex
Wisp of cotton used to illicit blinking reflex among conscious patients
Instill 1-drop saline solution unconscious pt if (-) response pt is in deep coma
5. Test of memory considered educational background
a.) Short term memory
What did you eat for breakfast?
Damage to temporal lobe (+) antero grade amnesia
b.) Long term memory
(+) Retrograde amnesia damage to limbic system
6. Levels of orientation
Time
Place
Person
Graphesthesia- can identify numbers or letters written on palm with a blunt object.
Agraphesthesia cant identify numbers or letters written on palm with a blunt object.
CN assessment:
I
Olfactory
II
Optic
III
Oculomotor
IV
Trocheal

s
s
m
m

smallest CN

14

V
VI
VII
VIII
IX
X
XI
XII

Trigeminal
Abducens
Facial
Acustic/auditory
Glassopharyngeal
Vagus
Spinal accessory
Hypoglossal

b
m
b
s
b
b
m
m

largest CN

longest CN

I. Olfactory dont use ammonia, alcohol, cologne irritating to mucosa use coffee, bar soap, vinegar, cigarette tar
- Hyposmia decrease sensitivity to smell
- Diposmia distorted sense of smell
- Anosmia absence of sense of smell
Either of 3 might indicate head injury damage to cribriform plate of ethmoid bone where olfactory cells are located or
indicate inflammation condition sinusitis
II optic- test of visual acuity Snellens chart central or distance vision
Snellens E chart used for illiterate chart
N 20/20 vision distance by w/c person can see letters- 20 ft
Numerator distance to snellens chart
Denominator distance the person can see the letters
OD Rt eye
20/20
20/200 blindness cant read E biggest
OS left eye
20/20
OU both eye
20/20
2.
a.
b.
c.
d.

Test of peripheral vision/ visual field

Superiority
Bitemporally
Inferiorly
Nasally

Common Disorders see page 85-87 for more info on glaucoma, etc.
1. Glaucoma Normal 12 21 mmHg pressure
- Increase IOP - Loss of peripheral vision tunnel vision
2. Cataract opacity of lens - Loss of central vision, Blurring or hazy vision
3. Retinal detachment curtain veil like vision & floaters
4. Macular degeneration black spots
III, IV, VI tested simultaneously
Innervates the movementt of extrinsic ocular muscle
6 cardinal gaze EOM
IO

Rt eye

LR

SO
MR

N
O
S
E

left eye

SR
3 4 EOM
IV sup oblique
VI lateral rectus
Normal response PERRLA (isocoria equal pupil)
Anisocoria unequal pupil
Oculomotor
1. Raising of eyelid Ptosis
2. Controls pupil size 2 -3 cm or 1.5 2 mm
V Trigeminal Largest consists of - ophthalmic, maxillary, mandibular
Sensory controls sensation of the face, mucus membrane; teeth & cornea reflex
Unconscious instill drop of saline solution
Motor controls muscles of chewing/ muscles of mastication
Trigeminal neuralgia diff chewing & swallowing extreme food temp is not recommended
Question: Trigeminal neuralgia, RN should give
a. Hot milk, butter, raisins
b. Cereals
c. Gelatin, toast, potato all correct but
d. Potato, salad, gelatin salad easier to chew

15

VI Facial: Sensory controls taste ant 2/3 of tongue test cotton applicator put sugar.
-Put applicator with sugar to tip to tongue.
-Start of taste insensitivity: Age group 40 yrs old
Motor- controls muscles of facial expression, smile frown, raise eyebrow
Damage Bells palsy facial paralysis
Cause bells palsy pedia R/T forcep delivery
Temporary only
Most evident clinical sign of facial symmetry: Nasolabial folds
VIII Acoustic/ vestibule cochlear (controls hearing) controls balance (kenesthesia or position sense)
Movement & orientation of body in space
Organ of Corti for hearing true sense organ of hearing

Outer tympanic membrane, pinna, oricle (impacted cerumen), cerumen

Middle hammer, anvil, stirrup or melleus, incus, staples. Mid otitis media
Eustachean ear
Inner ear- meniere dse, sensory hearing loss (research parts! & dse)
Remove vestibule menieres dse disease inner ear

Archimedes law buoyancy (pregnancy fetus)

Daltons law partial pressure of gases
Inertia law of motion (dizziness, vertigo)
1.) Pt with multiple stab wound - chest
- Movement of air in & out of lungs is carried by what principle?
- Diffusion Daltons law
2.) Pregnant check up ultrasound reveals fetus is carried by amniotic fluid
- Archimedes
3.) Severe vertigo due- Inertia
Test for acoustic nerve:
Repeat words uttered
IX Glossopharyngeal controls taste posterior 1/3 of tongue
X Vagus controls gag reflex
Test 9 10
Pt say ah check uvula should be midline
Damage cerebral hemisphere is L or R
Gag reflex place tongue depression post part of tongue

Dont touch uvula

XI Spinal Accessory - controls sternocleidomastoid (neck) & trapezius (shoulders and back)
Shrug shoulders, put pressure. Pt should resist pressure. Paresis or phlegia
XII Hypoglossal controls movement of tongue say ah. Assess tongue position=midline
L or R deviation
- Push tongue against cheek
- Short frenulum lingue
Tongue tied bulol
ENDOCRINE
Fx of endocrine ductless gland
Main gland Pituitary gland located at base of brain of Stella Turcica
Master gland of body
Master clock of body
Anterior pituitary gland adenohypophysis
Posterior pituitary gland neurohypophysis
Posterior pituitary:
1.) Oxytocin a.) Promotes uterine contraction preventing bleeding/ hemorrhage.
- Give after placental delivery to prevent uterine atony.
b.) Milk letdown reflex with help of prolactin.
2.) ADH antidiuretic hormone (vasopressin) -Prevents urination conserve H2O
A. DIABETIS INSIPIDUS (DI- dalas ihi) hyposecretion of ADH
Cause: idiopathic/ unknown
Predisposing factor:
1. Pituitary surgery
2. Trauma/ head injury
3. Tumor

16

4.

Inflammation

* alcohol inhibits release of ADH

S & Sx:

1. Polyuria
2. Sx of dehydration
- Excessive thirst (adult)
- Agitation
- Poor skin turgor
- Dry mucus membrane
3. Weakness & fatigue
4. Hypotension if left untreated 5. Hypovolemic shock
Anuria late sign hypovolemic shock

(1st sx of dehydration in children-tachycardia)

Dx Proc:
1. Decrease urine specific gravity- concentrated urine
N= 1.015 1.035
2. Serum Na = increase (N=135 -145 meq/L) Hypernatremia
Mgt:
1.
2.
3.
4.
5.

Force fluid 2,000 3,000ml/day

Administer IV fluid replacement as ordered
Monitor VS, I&O
Administer meds as ordered
a.) Pitresin (vasopressin) IM
Prevent complications
Most feared complication Hypovolemic shock

B.) SIADH - Syndrome of Inappropriate Anti-Diuretic Hormone

- Increase ADH
- Idiopathic/ unknown
Predisposing factor
1. Head injury
2. Related to Bronchogenic cancer or lung canerEarly Sign of Lung Ca - Cough 1. non productive 2. productive
3. Hyperplasia of Pit gland
Increase size of organ
S&Sx
1.
2.
3.
4.
5.

Fluid retention
Increase BP HPN
Edema
Wt gain
Danger of H2O intoxication Complications: 1. cerebral edema increase ICP 2. seizure

Dx Proc:
1. Urine specific gravity increase diluted urine
2. Hyponatremia Decreased Na
Nsg Mgt:
1. Restrict fluid
2. Administer meds as ordered eg. Diuretics: Loop and Osmotic
3. Monitorstrictly V/S, I&O, neuro check increase ICP
4. Weigh daily
5. Assess for presence edema
6. Provide meticulous skin care
7. Prevent complications increase ICP & seizures activity
Anterior Pituitary Gland adeno
1. Growth hormone (GH) (Somatotropic hormone)
Fx: Elongation of long bones
Decrease GH dwarfism
children
Increase GH gigantism
Increase GH acromegaly adult
Puberty 9 yo 21 yo
Epiphyseal plate closes at 21 yo
Square face
Square jaw

17

Drug of choice in acromegaly: Ocreotide (Sandostatin) SE dizziness

Somatostatin Hormone antagonizes the release of of GH
Melanocytes stimulating hormone - MSH
Skin pigmentation
Prolactin/luteotrpic hormone/ lactogenic hormone - Promotes development of mammary gland
(Oxytocin-Initiates milk letdown reflex)
4. Adrenocorticotropic hormone ACTH - Development & maturation of adrenal cortex
5. Luteinizing hormone produces progesterone.
6. FSH- produces estrogen
2.
3.

PINEAL GLAND
1. Secretes Melatonin inhibits lutenizing hormone (LH) secretion
THYROID GLAND (TG)
Question: Normal physical finding on TG:
a. With tenderness thyroid never tender
b. With nodular consistency- answer
c. Marked asymmetry only 1 TG
d. Palpable upon swallowing - Normal TG never palpable unless with goiter
TG hormones:
T3
- Triodothyronine

T4
-Tetraiodothyronine/ Tyroxine

- 3 molecules of iodine

- 4 molecules of iodine

Thyrocalcitonin
FX antagonizes effects of parathormone

Metabolic hormone
Increase metabolism brain inc cerebration, inc v/s all v/s down, constipation
Hypo T3 T4 - lethargy & memory impairment
Hyper T3 T4 - agitation, restlessness, and hallucination
7. Increase VS, increase motility
HYPOTHYROIDISM all decreased except wt & menstruation, loss of appetite but with wt gain
menorrhagia increase in mens
HYPERTHYROIDISM - Increase appetite wt loss, amenorrhea
SIMPLE GOITER enlarged thyroid gland - iodine deficiency
Predisposing factors
1. Goiter belt area - Place far from sea no iodine. Seafoods rich in iodine
2. Mountainous area increase intake of goitrogenic foods (US: Midwest, NE, Salt Lake)
Cabbage has progoitrin an anti thyroid agent with no iodine
Example: Turnips (singkamas), radish, peas, strawberries, potato, beans, kamote, cassava (root crops), all nuts.
3.
Goitrogenic drugs:
Anti thyroid agents :(PTU) prephyl thiupil
Lithium carbonate, Aspirin PASA
Cobalt, Phenyl butasone
Endemic goiter cause # 1
Sporadic goiter caused by #2 & 3
S & Sx enlarged TG
Mild restlessness
Mild dysphagia
Dx Proc.
1. Thyroid scan reveals enlarged TG
2. Serum TSH increase (confirmatory)
3. Serum T3, T4 N or below N
Nsg Mgt:
1. Administer meds
a.) Iodine solution Logols solution or saturated sol of K iodide SSKI
Nsg Mgt Lugols sol violet color
1. use straw prevent staining teeth
2. Prophylaxis 2 -3 drops Treatment 5 to 6 drops
Use straw to prevernt staining of teeth

18

1. Lugols sol., 2. tetracycline 3. nitrofurantin (macrodantin)-urinary anticeptic-pyelonephritis. 4. Iron solution.

B. Thyroid h / Agents
1. Levothyroxine (Synthroid)
2. Liothyronine (cytomel)
3. Thyroid extract
Nsg Mgt: for TH/agents
1. Monitor vs. HR due tachycardia & palpitation
2. Take it early AM SE insomnia
3. Monitor s/e
Tachycardia, palpitations
Signs of
insomnia
Hyperthyroidism restlessness agitation
Heat intolerance
HPN
3.

Encourage increase intake iodine iodine is extracted from seaweeds (!)

Seafood- highest iodine content oysters, clams, crabs, lobster
Lowest iodine shrimps
Iodized salt easily destroyed by heat take it raw not cooked

4.

Assist surgery- Sub total thyroidectomyComplication: 1. Tetany 2. laryngeal nerve damage 3.Hemorrhage-feeling of fullness at incision site.Check nape for wet
blood. 4.Laryngeal spasm DOB, SOB trache set ready at bedside.

2.) HYPOTHYROIDISM decrease secretion of T3, T4 can lead to MI / Atherosclerosis

Adult myxedema
Child- cretinism only endocrine dis lead to mental retardation
Predisposing factor:
1. `Iatrogenic causes caused by surgery
2. Atrophy of TG due to:
a. Irradiation
b. Trauma
c. Tumor, inflammation
3. Iodine def
4. Autoimmune Hashimoto disease
S&Sx everything decreased except wt gain & mens increase)
Early signs weakness and fatigue
Loss of appetite increased lypolysis breakdown of fats causing atherosclerosis = MI
Wt gain
Cold intolerance myxedema - coma
Constipation
Late Sx brittle hair/ nails
Non pitting edema due increase accumulation of mucopolysacharide in SQ tissue -Myxedema
Horseness voice
Decrease libido
Decrease VS hypotension bradycardia, bradypnea, and hypothermia
Lethargy
Memory impairment leading to psychosis-forgetfulness
Menorrhagia
Dx:

1.
2.
3.

Serum T3 T4 decrease
Serum cholesterol increase can lead to MI
RA IU radio iodine uptake decrease

Nsg Mgt:
1. Monitor strictly V/S. I&O to determine presence of myxedema coma!
Myxedema Coma - Severe form of hypothyroidism
Hypotension, hypoventilation, bradycardia, bradypnea, hyponatremia, hypoglycemia, hypothermia
Might lead to progressive stupor & coma
Impt mgt for Myxedema coma
1. Assist mech vent priority a/w
2. Adm thyroid hormone
3. Adm IVF replacement force fluid
Mgt myxedema coma
1. Monitor VS, I&O
2. Provide dietary intake low in calories due to wt gain
3. Skin care due to dry skin

19

4.
5.
6.
7.

8.

Comfortable & warm environment due to cold intolerance

Administer IVF replacements
Force fluid
Administer meds take AM SE insomia. Monitor HR.
Thyroid hormones
Levothyroxine(Synthroid), Liothyronine (cytomel)
Thyroid extracts
Health teaching & discharge plan
a. Avoidance precipitating factors leading to myxedema coma:
1. Exposure to cold environment
2. Stress 3. Infection
4. Use of sedative, narcotics, anesthetics not allowed CNS depressants V/S already down

Complications:
9. Hypovolemic shock, myxedema coma
10. Hormonal replacement therapy - lifetime
11. Importance of follow up care
HYPERTHYROIDISM - Graves dse or thyrotoxicosis ( everything up except wt and mens)
-Increased T3 & T4
Predisposing factors:
1. Autoimmune disease release of long acting thyroid stimulator (LATS)
Exopthalmos
Enopthalmos severe dehydration depressed eye
2. Excessive iodine intake
3. Hyperplasia of TG
S&Sx:
1.
2.
3.
4.
5.
6.
8.
7.
8.
9.

Increase in appetite hyperphagia wt loss due to increase metabolism

Skin is moist - perspiration
Heat intolerance
Diarrhea increase motility
All VS increase = HPN, tachycardia, tachypnea, hyperthermia
CNS changes
Irritability & agitation, restlessness, tremors, insomnia, hallucinations
Goiter
Exopthalmos pathognomonic sx
Amenorrhea

Dx:
1.
2.
3.

Serum T3 & T4 - increased

Radio iodine uptake increase
Thyroid scan reveals enlarged TG

Nsg Mgt:
1. Monitor VS & I & O determine presence of thyroid storm or most feared complication: Thyrotoxicosis
2. Administer meds
a. Antithyroid agents
1. Prophylthiuracil (PTU)
2. Methymazole (Tapazole)
Most toxic s/e agranulocytosis- fever, sore throat, leukocytosis=inc wbc: check cbc and throat swab culture
Most feared complication : Thrombosis stroke CVS
3.
4.
5.
6.
7.
8.

Diet increase calorie to correct wt loss

Skin care
Comfy & cool environment
Maintain siderails- due agitation/restlessness
Provide bilateral eye patch to prevent drying of eyes- exopthalmos
Assist in surgery subtotal thyroidectomy

Nsg Mgt: pre-op

Adm Lugols solution (SSKI) K iodide
9. To decrease vascularity of TG
10. To prevent bleeding & hemorrhage
Mgt post op:
Complication: 1. Watch out for signs of thyroid storm or thyrotoxicosis
Triad signs of thyroidstorm;
a. Tachycardia /palpitation
b. Hyperthermia
c. Agitation
1.

Nsg Mgt Thyroid Storm:

Monitor VS & neuro check

20

2.
3.

Agitated might decrease LOC

Antipyretic fever
Tachycardia - blockers (-lol)
Siderails agitated

Comp 2. Watch for inadvertent (accidental) removal of parathyroid gland

Secretes Para hormone
If removed, hypocalcemia - classic sign tetany 1. .(+) Trousseau sign/ 2. Chvostecks sign
Nsg Mgt:
Adm calcium gluconate slowly to prevent arrhythmia
Ca gluconate toxicity antidote MgSO4
3.Laryngeal (voice box) nerve damage (accidental)
Sx: hoarseness of voice
***Encourage pt to talk or speak post operatively asap to determine laryngeal nerve damage
Notify physician!
4. Signs of bleeding post subtotal thyroidectomy
- Feeling of fullness at incision site
Nsg mgt:
Check soiled dressing at nape area
5. Signs of laryngeal spasm
a. DOB
b. SOB
Prepare at bedside tracheostomy
6. Hormonal replacement therapy - lifetime
7. Importance of follow up care

(Liver cirrhosis bedside scissor if pt complaints of DOB)

(Cut cystachean tube to deflate balloon)

Parathyroid gland pair of small nodules located behind the TG

11. Secrets parathyroid hormone promotes Ca reabsorption
Thyrocalcitonin antagonises secretion of parathyroid hormone
1.
2.

Hypoparthroidism decrease of parathyroid hormone

Hyperparathroidsm

HYPOPARATHYROIDISM decreased parathormone

Hypocalcemia
(Or tetany)

Hyperphosphatemia

[If Ca decreases, phosphate increases]

A. Predisposing, factors:
1. Following subtotal thyroidectomy
2. Atrophy of parathyroid gland due to
a. Irradiation
b. Trauma
S&Sx:
1.

Acute tetany
a. Tingling sensation
b. Paresthesia
c. Dysphagia
d. Laryngospasm
e. Bronchospasm
Pathognomonic Sign of tetany:
a. (+) Trousseaus or carpopedial spasm
b. (+) Chvostecks sign
f. Seizure
g. Arrhythmia

most feared complication

21

Dx:

2.

Chronic
a.
b.
c.
d.

tetany
Loss of tooth enamel
Photophobia & cataract formation
GIT changes anorexia, n/v, general body malaise
CNS changes memory impairment, irritability

1.
2.
3.
4.

Serum calcium decrease (N 8.5 11 mg/100ml)

Serum phosphate increase (N 2.5 4.5 mg/100ml)
X-ray of long bone decrease bone density
CT Scan reveals degeneration of basal ganglia

Nsg Mgt:
1. Administration of meds:
a.) Acute tetany
Ca gluconate IV, slowly
b.) Chronic tetany
1. Oral Ca supplements
Ex. Ca gluconate
Ca carbonate
Ca lactate
Vit D (Cholecalceferol)
Drug
Cholecalceferol

diet

sunlight

calcidiol

calcitriol

2. Phosphate binder
Alumminum DH gel (ampho gel)
SE constipation
Antacid
AAC
MAD
Aluminum containing acids
Aluminum OH gel

Diarrhea

7am 9am

Mg containing antacids
Ex. Milk or magnesia

Constipation
Maalox magnesium & aluminum - Less s/e
2. Avoid precipitating stimulus such as bright lights & noise: photophobia leading to seizure
3. Diet increase Ca & decrease phosphorus
- Dont give milk due to increase phosphorus
Good = anchovies increase Ca, decrease phosphorus + inc uric acid. Tuna & green turnips- Inc Ca.
4. Bedside tracheostomy set due to laryngospasm
5. Encourage to breath with paper bag in order to produce mild respiratory acidosis to promote increase ionized Ca levels
6. Most feared complication : Seizure & arrhythmia
7. Hormonal replacement therapy - lifetime
8. Important fallow up care
HYPERPARATHYROIDISM - increase parathormone. Complication: Renal failure
Hypercalcemia can lead to Hypophosphatemia
Bone dse Mineralization

kidney stones

Leading to bone fracture

Ca 99% bones
1% serum blood
Predisposing Factors:
1. Hyperplasia parathyroid gland (PTG)
2. Over compensation of PTG due to Vit D deficiency
Children Rickets
Vit D
Adults Osteomalacia
deficiency
Sippys diet Vit D diet not good for pt with ulcer
2 -4 cups of milk & butter
Karrels diet Vit D diet not good for pt with ulcer
6 cups of milk & whole cream

22

Food rich in CHON eggnog combination of egg & milk

S/Sx:
Bone fracture
1. Bone pain (especially at back), bone fracture
2. Kidney stone
a. Renal colic
b. Cool moist skin
3. GIT changes anorexia, n/v, ulcerations
4. CNS involvement irritability, memory impairment
Dx Proc:
1. Serum Ca increase
2. Serum phosphorus decreases
3. X-ray long bones reveals bone demineralization
Nsg Mgt: Kidney Stone
1.
2.
3.
4.
5.
6.

7.
8.
9.
10.
11.
12.
13.

Force fluids 2,000 3,000/day or 2-3L/day

Isotonic solution
Warm sitz bath for comfort
Strain all urine with gauze pad
Acid ash diet cranberry, plum, grapefruit, vit C, calamansi to acidify urine
Adm meds
a. Narcotic analgesic Morphine SO4, Demerol (Meperidine Hcl)
S/E resp depression. Monitor RR)
Narcan/ Naloxone antidote
Naloxone toxicity tremors
Siderails
Assist in ambulation
Diet low in Ca, increase phosphorus lean meat
Prevent complication
Most feared renal failure
Assist surgical procedure parathyroidectomy
Impt ff up care
Hormonal replacement- lifetime

ADRENAL GLAND
12. Atop of @ kidney
13. 2 parts
Adrenal cortex outermost layer
Adrenal medulla - innermost layer
14. Secrets cathecolamines
a.) Epinephrine / Norephinephrine potent vasoconstrictor adrenaline=Increase BP
Adrenal Medullas only disease:
PHEOCHROMOCYTOMA- presence of tumor at adrenal medulla
-increase nor/epinephrine
-with HPN and resistant to drugs
-drug of choice: beta blockers
-complication: HPN crisis = lead to stroke
-no valsalva maneuver
Adrenal Cortex
1. Zona fasiculata secrets glucocorticoids
Ex. Cortisol - Controls glucose metabolism (SUGAR)
2. Zona reticularis secrets traces of glucocorticoids & androgenic hormones
M testosterone
F estrogen & progesterone
Fx promotes development of secondary sexual characteristics
3. Zona glomerulosa - secretes mineralcortisone
Ex. Aldosterone
Fx: promotes Na & H2O reabsorption & excretion of potassium (SALT)
ADDISONS DISEASE Steroids-lifetime
Decreased adrenocortical hormones leading to:
a.) Metabolic disturbances (sugar)
b.) F&E imbalances- Na, H2O, K
c.) Deficiency of neuromuscular function (salt & sex)
Predisposing Factors:

23

1.
2.
3.
S/Sx:
1.

Atrophy of adrenal gland

Fungal infections
Tubercular infections
Decrease sugar Hypoglycemia Decreased glucocorticoids - cortisol

T tremors, tachycardia
I - irritability
R - restlessness
E extreme fatigue
D diaphoresis, depression
2.

Decrease plasma cortisol

Decrease tolerance to stress lead to Addisonians crisis

3. Decrease salt Hyponatermia Decreased mineralocorticoids - Aldosterone

Hypovolemia
a.) Hypotension
b.) Signs of dehydration extreme thirst, agitation
c.) Wt loss
4. Hyperkalemia
a.) Irritability
b.) Diarrhea
c.) Arrhythmia
5. Decrease sexual urge or libido- Decreased Androgen
6. Loss of pubic and axillary hair
To Prevent STD
7.

Local practice monogamous relationship

CGFNS/NCLEX condom
Pathognomonic sign bronze like skin pigmentation due to decrease cortisol will stimulate pituitary gland to release melanocyte
stimulating hormone.

Dx Proc:
1. FBS decrease FBS (N 80 120 mg/dL)
2. Plasma cortisol decreased
Serum Na decreased (N 135 145 meg/L)
3. Serum K increased (N 3.5 5.5 meg/L)
Nsg Mgt:
1. Monitor VS, I&O to determine presence of Addisonian crisis
15. Complication of Addisons dse : Addisonian crisis
16. Results the acute exacerbation of Addisons dse characterized by :
Hypotension, hypovolemia, hyponatremia, wt loss, arrhythmia
17. Lead to progressive stupor & coma
1.
2.
3.
2.

Nsg Mgt Addisonian Crisis (Coma)

Assist in mechanical ventilation
Adm steroids
Force fluids

Administer meds
a.) Corticosteroids - (Decadron) or Dexamethazone
- Hydrocortisone (cortisone)- Prednisone
Nsg
1.
2.
3.
a.)
b.)
c.)
d.)
e.)

Mgt with Steroids

Adm 2/3 dose in AM & 1/3 dose in PM in order to mimic the normal diurnal rhythm.
Taper the dose (w/draw, gradually from drug) sudden withdrawal can lead to addisonian crisis
Monitor S/E (Cushings syndrome S/Sx)
HPN
Hirsutism
Edema
Moon face & buffalo hump
Increase susceptibility to infection sue to steroids- reverse isolation

b.) Mineralocorticoids ex. Flourocortisone

3.
4.
5.
6.
7.

Diet increase calorie or CHO

Increase Na, Increase CHON, Decrease K
Force fluid
Administer isotonic fluid as ordered
Meticulous skin care due to bronze like
HT & discharge planning

24

a) Avoid precipitating factors leading to Addisonian crisis

1. Sudden withdrawal crisis
2. Stress
3. Infection
b) Prevent complications
Addisonian crisis & Hypovolemic shock
8. Hormonal replacement therapy lifetime
9. Important: follow up care
CUSHINGS SYNDROME increase secretion of adrenocortical hormone
Predisposing Factors:
1. Hyperplasia of adrenal gland
2. Tubercular infection milliary TB
S/Sx
1. Increase sugar Hyperglycemia
3 Ps
1. Polyuria
2. Polydipsia increase thirst
3. Polyphagia increase appetite
Classic Sx of DM 3 Ps & glycosuria + wt loss
2. Increase susceptibility to infection due to increased corticosteroid
3. Hypernatrermia
a. HPN
b. Edema
c. Wt gain
d. Moon face
Buffalo hump
Obese trunk
classic signs
Pendulous abdomen
Thin extremities
4. Hypokalemia
a. Weakness & fatigue
b. Constipation
c. ECG (+) U wave
5. Hirsutism increase sex
6. Acne & striae
7. Increase muscularity of female
Dx:
1. FBS increase (N: 80-120mg/dL)
2. Plasma cortisol increase
3. Na increase (135-145 meq/L)
4. K- decrease (3.5-5.5 meq/L)
Nsg Mgt:
1. Monitor VS, I&O
2. Administer meds
a. K- sparing diuretics (Aldactone) Spironolactone
- promotes excretion of NA while conserving potassium
Not lasix due to S/E hypoK & Hyperglycemia!
3.
4.

Restrict Na
Provide Dietary intake low in CHO, low in Na & fats
High in CHON & K
5. Weigh pt daily & assess presence of edema- measure abdominal girth- notify doc.
6. Reverse isolation
7. Skin care due acne & striae
8. Prevent complication
- Most feared arrhythmia & DM
(Endocrine disorder lead to MI Hypothyroidism & DM)
9. Surgical bilateral Adrenolectomy
10. Hormonal replacement therapy lifetime due to adrenal gland removal- no more corticosteroid!

PANCREAS behind the stomach, mixed gland both endocrine and exocrine gland
Acinar cells (exocrine gland)
Secrete pancreatic juices at pancreatic ducts.
Aids in digestion (in stomach)

Islets of Langerhans (endocrine gland ductless)

cells
secrets glucagon

25

Fxn: hyperglycemia (high glucose)

Cells
Secrets insulin
Fxn: hypoglycemia
Delta Cells
Secrets somatostatin
Fxn: antagonizes growth hormone
3 disorders of the Pancreas
1. DM
2. Pancreatic Cancer
3. Pancreatitis
Overview only:
PANCREATITIS (check page 72) acute inflammation of pancreas leading to pancreatic edema, hemorrhage & necrosis due to
Autodigestion self-digestion
Cause: unknown/idiopathic
18. Or alcoholism
Pathognomonic sign- (+) Cullens sign - Ecchymosis of umbilicus (bluish color)- pasa
(+) Grey turners sign ecchymosis of flank area
Both sx means hemorrhage
CHRONIC HEMORRHAGIC PANCREATITIS- bangugot
Predisposing factors - unknown
Risk factor:
1. History of hepatobiliary disorder
2. Alcohol
3. Drugs thiazide diuretics, oral contraceptives, aspirin, penthan
4. Obesity
5. Hyperlipidemia
6. Hyperthyroidism
7. High intake of fatty food saturated fats
DIABETES MELLITUS - metabolic disorder characterized by non utilization of CHO, CHON,& fat metabolism
Classification:
I.
Type I DM (IDDM) Juvenile onset, common in children, non-obese brittle dse
-Insulin dependent diabetes mellitus
Incidence rate
1.) 10% of population with DM have Type I
Predisposing Factor:
1. 90% hereditary total destruction of pancreatic dells
2. Virus
3. Toxicity to carbon tetrachloride
4. Drugs Steroids
both cause hyperglycemia
Lasix - loop diuretics
S/Sx:
3 PS + G
1.) Polyuria
2.) Poydipsia
3.) Polyphagia
4.) Glycosuria
5.) Weight loss
6.) Anorexia
7.) N/V
8.) Blurring of vision
9.) Increase susceptibility to infection
10.) Delayed/ poor wound healing

26

Mgt:
1.

Insulin Therapy
Diet
Exercise
Complications Diabetic Ketoacidosis (DKA)
Diabetic Ketoacidosis (DKA) due to increase fat catabolism or breakdown of fats
DKA (+) fruity or acetone breath odor
Kassmauls respiration rapid, shallow breathing
Diabetic coma (needs oxygen)

II. Type II DM (NIDDM)

Adult/ maturity onset type age 40 & above, obese
Incidence Rate
1. 90% of pop with DM have Type II
Mid 1980s marked increase in type II because of increase proliferation of fast food chains!
Predisposing Factor:
1. Obesity obese people lack insulin receptors binding site
2. Hereditary
S/Sx:
1.
2.
Tx:

1.
2.
3.

Asymptomatic
3 Ps and 1G
Oral Hypoglycemic Agents (OHA)
Diet
Exercise

Complication: HONKC
H hyper
O osmolar
N non
K ketotic
C coma
III. GESTATIONAL DM occurs during pregnancy & terminates upon delivery of child
Predisposing Factors:
1. Unknown/ idiopathic
2. Influence of maternal hormones
S/Sx :
Same as type II
1. Asymptomatic
2. 3 Ps & 1G
Type of delivery CS due to large baby
Sx of hypoglycemia on infant
1. High pitched shrill cry
2. Poor sucking reflex
IV. DM
a.)
b.)
c.)

ASSOCIATED WITH OTHER DISORDER

Pancreatic tumor
Cancer
Cushings syndrome

3 MAIN FOOD GROUPS

Anabolism
Catabolism
1. CHON glucose
glycogen
2. CHON amino acids
nitrogen
3. Fats
fatty acids
free fatty acids (FFA) Cholesterol & Ketones
Pancreas glucose ATP (Main fuel/energy of cell )
Reserve glucose glycogen
Liver will undergo glucogenesis synthesis of glucagons
& Glycogenolysis breakdown of glucagons
& Gluconeogenesis formation of glucose form CHO sources CHON & fats

27

Hyperglycemia pancreas will not release insulin. Glucose cant go to cell, stays at circulation causing hyperglycemia.
increase osmotic diuresis glycosuria
Lead to cellular starvation
Lead to wt loss

stimulates the appetite/ satiety center

(Hypothalamus)
Polyphagia

polyuria
Cellular dehydration
Stimulates thirst center (hypothalamus)
Polydipsia

Increased CHON catabolism

Lead to (-) nitrogen balance
Tissue wasting (cachexia)
Increase fat catabolism
Free fatty acids
Cholesterol

ketones

Atherosclerosis
HPN
MI

DKA
coma
death

stroke

DIABETIC KETOACIDOSIS (DKA)

Acute complication of Type I DM due to severe hyperglycemia leading to CNS depression & Coma.
Ketones- a CNS depressant
Predisposing factor:
1. Stress between stress and infection, stress causes DKA more.
2. Hyperglycemia
3. Infection
S/Sx:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

3 Ps & 1G
Polyuria
Polydipsia
Polyphagia
Glycosuria
Wt loss
Anorexia, N/V
(+) Acetone breath odor- fruity odor
Kussmaul's resp-rapid shallow respiration
CNS depression
Coma

pathognomonic DKA

Dx Proc:
1. FBS increase, Hct increase (compensate due to dehydration)
N =BUN 10 -20 mg/100ml
--increased due to severe dehydration
Crea - .8 1 mg/100ml
Hct 42% (should be 3x high)-nto hgb
Nsg Mgt:
1. Can lead to coma assist mechanical ventilation
2. Administer .9NaCl isotonic solution
Followed by .45NaCl hypotonic solution
To counteract dehydration.
3. Monitor VS, I&O, blood sugar levels
4. Administer meds as ordered:
a.) Insulin therapy IV push

28

Regular Acting Insulin clear (2-4hrs, peak action)

b.) To counteract acidosis Na HCO3
c.) Antibiotic to prevent infection
Insulin Therapy
A. Sources:
1. Animal source beef/ pork-rarely used. Causes severe allergic reaction.
2. Human has less antigenecity property
Cause less allergic reaction. Humulin
3.
B.

If kid is allergic to chicken dont give measles vaccine due it comes from chicken embryo.
Artificially compound
Types of Insulin
1. Rapid Acting Insulin - Ex. Regular acting I
2. Intermediate acting I - Ex. NPH (non-protamine Hagedorn I)
3. Long acting I - Ex. Ultra lente

Types of Insulin
1. Rapid
2. Intermediate
3. Long acting

color & consistency

clear
cloudy
cloudy

onset
-

peak
duration
2-4h
6-12h
12-24h
-

Ex. 5am Hemoglucose test (HGT)

250 mg/dl
Adm 5 units of RA I
Peak 7-9am monitor hypoglycemic reaction at this time- TIRED
Nsg Mgt: upon injection of insulin:
1.Administer insulin at room temp! To prevent lipodystrophy = atrophy/ hypertrophy of SQ tissues
2. Insulin is only refrigerated once opened!
3. Gently roll vial bet palms. Avoid shaking to prevent formation of bubbles.
4. Use gauge 25 26needle tuberculin syringe
5. Administer insulin at either 45(for skinny pt) or 90 (taba pt)depending on the client tissue deposit.
6. Dont aspirate after injection
7. Rotate injection site to prevent lipodystrophy
8. Most accessible site abdomen
9. When mixing 2 types of insulin, aspirate
1st regular/ clear before cloudy to prevent contaminating clear insulin & to promote accurate calibration.
10. Monitor signs of complications:
a. Allergic reactions lipodystrophy
b. Somogyis phenomenon hypoglycemia followed by periods of hyperglycemia or rebound effect of insulin.
11. 1ml or cc of tuberculin = 100 units of insulin
- - 1 cc = 100 units
- - .5cc

= 50 units

- - .1 cc = 10 units

6 units RA
Most Feared Complication of Type II DM
Hyper
osmolarity = severe dehydration
Osmolar
Non
- absence of lipolysis
Ketotic
- no ketone formation
Coma S/Sx: headache, restlessness, seizure, decrease LOC = coma
Nsg Mgt; - same as DKA except dont give NaHCO3!
1.Can lead to coma assist mechanical ventilation
2. Administer .9NaCl isotonic solution
Followed by .45NaCl hypotonic solution
To counteract dehydration.
3.Monitor VS, I&O, blood sugar levels
4.Administer meds
a.) Insulin therapy IV
b.) Antibiotic to prevent infection
Tx:

29

O ral
H ypoglycemic
A gents
19. Stimulates pancreas to secrete insulin
Classifications of OHA
1. First generation Sulfonylurear
a. Chlorpropamide (diabenase)
b. Tolbutamide (orinase)
c. Tolazamide (tolinase)
2.

2nd generation sulfonylurear

a. Diabeta (Micronase)
b. Glipside (Glucotrol)

Nsg Mgt or OHA

1. Administer with meals to lessen GIT irritation & prevent hypoglycemia
2. Avoid alcohol (alcohol + OHA = severe hypoglycemic reaction=CNS depression=coma) Antabuse-Disufram
Dx for DM
1. FBS N 80 120 mg/dl = Increased for 3 consecutive times
+ 3 Ps & 1G
2. Oral glucose tolerance (OGTT) - Most sensitive test
3. Random blood sugar increased
4. Alpha Glucosylated Hgb elevated

=confirms DM!!

Nsg Mgt;
1. Monitor for PEAK action of OHA & insulin
Notify Doc
2. Monitor VS, I&O, neurocheck, blood sugar levels.
3. Administer insulin & OHA therapy as ordered.
4. Monitor signs of hyper & hypoglycemia.
Pt DM hinimatay
20. You dont know if hypo or hyperglycemia.
Give simple sugar
(Brain can tolerate high sugar, but brain cant tolerate low sugar!)
Cold, clammy skin hypo Orange Juice or simple sugar / warm to touch hyper adm insulin
5. Provide nutritional intake of diabetic diet:
CHO 50%
CHON 30%
Fats 20%
-Or offer alternative food products or beverage.
-Glass of orange juice.
6. Exercise after meals when blood glucose is rising.
7. Monitor complications of DM
a. Atherosclerosis HPN, MI, CVA
b. Microangiopathy small blood vessels
Eyes diabetic retinopathy , premature cataract & blindness
Kidneys recurrent pyelonephritis & Renal Failure
(2 common causes of Renal Failure : DM & HPN)
c. Gangrene formation
d. Peripheral neuropathy
1. Diarrhea/ constipation
2. Sexual impotence
e. Shock due to cellular dehydration
8. Foot care mgt
a. Avoid waking barefooted
b. Cut toe nails straight
c. Apply lanolin lotion prevent skin breakdown
d. Avoid wearing constrictive garments
9. Annual eye & kidney exam
10. Monitor urinalysis for presence of ketones
Blood or serum more accurate
11. Assist in surgical wound debridement
12. Monitor signs or DKA & HONKC
13. Assist surgical procedure
BKA or above knee amputation
Overview: HEMATOLOGICAL SYSTEMS

30

I Blood
II Blood vessels
III Blood forming organs
1. Thymus removed myasthenia gravis
2. Liver largest gland
3. Lymph nodes
4. Lymphoid organs payers patch
5. Bone marrow
6. Spleen destroys RBC
Blood vessels
1. Veins SVC, IVC, Jugular vein blood towards the heart
2. Artery carries blood away from the
21. Aorta, carotid
3. Capillaries
Blood 45% formed elements 55% plasma fluid portion of vlood. Yellow color.
Serum

Plasma CHONs (Produced in Liver)

1. Albumin- largest, most abundant plasma
Maintains osmotic pressure preventing edema
FXN: promotes skin integrity
2. Globulins alpha transports steroids Hormones & bilirubin
- Transports iron & copper
Gamma transport immunoglobulins or antibodies
3. Prothrombin fibrinogen clotting factor to prevent bleeding

Formed Elements:
1. RBC (erythrocytes)
Spleen life span = 120 days
(N) 3 6 M/mm3
- Anucleated
- Biconcave discs
- Has molecules of Hgb (red cell pigment)
Transports & carries O2

SICKLE CELL ANEMIA sickle shaped RBC. Should be round. Impaired circulation of RBC.
-immature cells=hemolysis of RBC=decreased hgb
3 Nsg priority
1. a/w avoid deoxygenating activities
- High altitude is bad
2. Fluid deficit promote hydration
3. Pain & comfort
Hgb ( hemoglobin)
F= 12 14 gms %
M = 14-16 gms %
Hct 3x hgb
(hamatocrit)

12 x 3 = 36
F 36 42%
14 x 3 = 42
M 42 48%
Average 42%
- Red cell percentage in whole red

Substances needed for maturation of RBC

a.) Folic acid
b.) Iron
c.) Vit C
d.) Vit B12 (cyanocobalamin)
e.) Vit B6 (Pyridoxine)
f.) Intrinsic factor
Pregnant:

1st trimester- Folic acid prevent neural tube deficit

3rd tri iron
Life span of rbc 80 120 days. Destroyed at spleen.

WBC leucocytes 5,000 10,000/mm3

GRANULOCYTES
1. Polymorphonuclearneutrophils
Most abundant 60-70% WBC
- fx short term phagocytosis
For acute inflammation

NON-GRANULOCYTES
1. Monocytes (macrophage) - largest WBC
- involved in long term phagocytes
- For chronic inflammation
- Other name macrophage

31

2. PM Basophils
-Involved in Parasitic infection
- Release of chem. Mediator for inflammation
Serotonin, histamine, prostaglandin,
bradykinins
3. PM eosinophils
- Allergic reactions

Macrophage
Macrophage
Macrophage
Macrophage

in
in
in
in

CNS- microglia
skin Histiocytes
lungs alveolar macrophage
Kidneys Kupffer cells

2. Lymphocytes
B Cell L bone marrow or bursa dependent
T cell devt of immunity- target site for HIV
NK cell natural killer cell
Have both antiviral & anti-tumor properties
3.Platelets (thrombocytes)
N- 150,000 450, 000/ mm3
it promotes hemostasis prevention of blood loss by activating clotting
- Consists of immature or baby platelets known as megakaryocytes target of virus
dengue
- Normal lifespan 9 12 days

Drug of choice for HIV Zidovudine (AZT or Retrovir)

Standard precaution for HIV gloves, gown, goggles & mask
Malaria night biting mosquito
Dengue day biting mosquito
Signs of
a.)
b.)
c.)

platelet dis function:

Petecchiae
Ecchemosis/ bruises
Oozing or blood from venipuncture site

ANEMIA
Iron deficiency Anemia chronic normocytic, hypocromic (pale), microcytic anemia due to inadequate absorption of iron leading to
hypoxemic injury.
Incidence rate:
1. Common developed country due to high cereal intake
Due to accidents common on adults
2. Common tropical countries blood sucking parasites
3. Women 15 35yo reproductive yrs
4. Common among the poor poor nutritional intake
Suicide - common in teenager
Poisoning common in children (aspirin)
Aspiration common in infant
Accidents common in adults
Choking common in toddler
SIDS common in infant in US
22. Common in tropical zone Phil due blood sucks
Predisposing factor:
1. Chronic blood loss
a. Trauma
b. Mens
c. GIT bleeding:
i. Hematemesisii. Melena upper GIT duodenal cancer
iii. Hematochezia lower GIT large intestine fresh blood from rectum
2.
Inadequate intake of food rich in iron
3.
Inadequate absorption of iron due to :
a. Chronic diarrhea
b. Malabsorption syndrome celiac disease-gluten free diet. Food for celiac pts- sardines
c. High cereal intake with low animal CHON ingestion
d. Subtotal gastrectomy
4. Improper cooking of food
S/Sx:
1.
2.
3.
4.
5.

Asymptomatic
Headache, dizziness, dyspnea, palpitations, cold sensitivity, gen body malaise, pallor
Brittle hair, spoon shaped nails (KOILONYCHIA)=Dec O2=hypoxia=atrophy of epidermal cells
Atropic glossitis, dysphagia, stomatitis
Pica abnormal craving for non edible food (caused by hypoxia=dec tissue perfusion=psychotic behavior)

Brittle hair, spoon shaped nail atrophy of epidermal cells

N = capillary refill time < 2 secs

32

N = shape nails biconcave shape, 180

Atrophy of cells Plummer Vinsons Syndrome due to cerebral hypoxia
1. Atropic glossiti inflammation of tongue
due to atrophy of pharyngeal and tongue cells
2. Stomatitis mouth sores
3. Dysphagia
Dx Proc:
1. RBC
2. Hgb
3. Reticulocyte
4. Hct
5. Iron
6. Ferritin
Nsg Mgt
1.
2.
3.
23.
4.
5.

Monitor signs of bleeding of all hema test including urine & stool
Complete bed rest dont overtire pt =weakness and fatigue=activity intolerance
Encourage iron rich food
Raisins, legumes, egg yolk
Instruct the pt to avoid taking tea - impairs iron absorption
Administer meds
a.) Oral iron preparation
Ferrous SO4
Fe gluconate
Fe Fumarate
Nsg Mgt oral iron meds:
1. Administer with meals to lessen GIT irritation
2. If diluting in iron liquid prep adm with straw
Straw
1.
2.
3.
4.

Lugols
Tetracycline
Oral iron
Macrodantine
3.
4.
a.
b.
c.
d.
e.

Give Orange juice for iron absorption

Monitor & inform pts S/E
Anorexia
n/v
Abdominal pain
Diarrhea or constipation
Melena

If pt cant tolerate oral iron prep administer parenteral iron prep example:
1. Iron dextran (IV, IM)
2. Sorbitex (IM)
Nsg Mgt
1.
2.
3.

parenteral iron prep

Administer of use Z tract method to prevent discomfort, discoloration leakage to tissues.
Dont massage injection site. Ambulate to facilitate absorption.
Monitor S/E:
a.) Pain at injury site
b.) Localized abscess (nana)
c.) Lymphadenopathy
d.) Fever/ chills
e.) Urticaria itchiness
f.) Hypotension anaphylactic shock

Anaphylactic shock give epinephrine

PERNICIOUS ANEMIA - megaloblastic, chronic anemia due to deficiency of intrinsic factor leading to
Hypochlorhydria decrease Hcl acid secretion. Lifetime B12 injections. With CNS involvement.
Predisposing factor
1. Subtotal gastrectomy removal stomach
2. Hereditary
3. Infl dse of ileum
4. Autoimmune
5. Strict vegetable diet

33

STOMACH
Parietal or ergentaffen Oxyntic cells
Fxn produce intrinsic factor

Fxn secrets Hcl acid

For reabsorption of B12

Fx aids in digestion

For maturation of RBC

Diet high caloric or CHO to correct wt loss
S/Sx:
1.
2.

Headache dizziness, dyspnea, palpitations, cold sensitivity, gen body malaise, pallor
GIT changes
a. Red beefy tongue PATHOGNOMONIC mouth sores
b. Dyspepsia indigestion
c. Wt loss
d. Jaundice
3. CNS
Most dangerous anemia: pernicious due to neuroglogic involvement.
a. Tingling sensation
b. Paresthesia
c. (+) Rombergs test
Ataxia
d. Psychosis
Dx:- Shillings test
Nsg Mgt Pernicious anemia
1. Enforce CBR
2. Administer B12 injections at monthly intervals for lifetime as ordered. IM- dorsogluteal or ventrogluteal. Not given oral due pt
might have tolerance to drug
3. Diet high calorie or CHO. Increase CHON, iron & Vit C
4. Avoid irritating mouthwashes. Use of soft bristled toothbrush is encouraged.
5. Avoid applying electric heating pads can lead to burns
APLASTIC ANEMIA stem cell disorder due to bone marrow depression leading to pancytopenia all RBC are decreased
Decrease RBC
Anemia

Increase WBC leukocytocys

Increase RBC polycythemia vera complication stroke, CVA, thrombosis

decrease WBC
leukopenia

decrease platelets
thrombocytopenia

Predisposing factors leading to Aplastic Anemia

1. Chemicals Banzene & its derivatives
2. radiation
3. Immunologic injury
4. Drugs cause bone marrow depression
a. Broad spectrum antibiotic - Chlorampenicol
- Sulfonamides bactrim
b. Chemo therapeutic agents
Methotrexate alkylating agents
Nitrogen mustard anti metabolic
Vincristine plant alkaloid
S/Sx:

Dx:

1. Anemia:
a. Weakness & fatigue
b. Headache, dizziness, dyspnea
c. cold sensitivity, pallor
d. palpitations
2. Leucopenia increase susceptibility to infection
3. Thrombocytopenia
Peticchiae
Oozing ofblood from venipuncture site
ecchymosis

1. CBC pancytopenia
2. Bone marrow biopsy/ aspiration at post iliac crest reveals fatty streaks in bone marrow
Nsg Mgt:

34

1.
2.
3.
4.
5.
6.
7.
8.
9.

Removal of underlying cause

Blood transfusion as ordered
Complete bed rest
O2 inhalation
Reverse isolation due leukopenia
Monitor signs of infection
Avoid SQ, IM or any venipuncture site = HEPLOCK
Use electric razor when shaving to prevent bleeding
Administer meds
Immunosuppresants
Anti lymphocyte globulin (Alg) given via central venous catheter, 6 days 3 weeks to achieve max therapeutic effect of drug.

BLOOD TRANSFUSION:
Objectives:
1. To replace circulating blood volume
2. To increase O2 carrying capacity of blood
3. To combat infection if theres decrease WBC
4. To prevent bleeding if theres platelet deficiency
Nsg Mgt & principles in Blood Transfusion
1. Proper refrigeration
2. Proper typing & crossmatching
Type O universal donor
AB universal recipient
85% of people is RH (+)
3. Asceptically assemble all materials needed:
a.) Filter set
b.) Isotonic or PNSS or .9NaCl to prevent Hemolysis
Hypotonic sol swell or burst
Hypertonic sol will shrink or crenate
c.) Needle gauge 18 - 19 or large bore needle to prevent hemolysis.
d.) Instruct another RN to recheck the following .
Pts name, blood typing & cross typing expiration date, serial number.
e.) Check blood unit for presence of bubbles, cloudiness, dark in color & sediments indicates bacterial contamination. Dont
dispose. Return to blood bank.
f.) Never warm blood products may destroy vital factors in blood.
- Warming is done if with warming device only in EMERGENCY! For multiple BT.
- Within 30 mins room temp only!
g.) Blood transfusion should be completed < 4hrs because blood that is exposed at room temp for > 2h causes blood
deterioration.
h.) Avoid mixing or administering drug at BT line leads to hemolysis
i.) Regulate BT 10 15 gtts/min KVO or 100cc/hr to prevent circulatory overload
j.) Monitor VS before, during & after BT especially q15 mins(local board) for 1st hour. NCLEX-q5min for 1 st 15min.
- Majority of BT reaction occurs within 1h.
BT reactions
S/Sx Hemolytic reaction:
H hemolytic Reaction
1. Headache, dizziness, dyspnea, palpitation, lumbar/ sterna/ flank pain,
A allergic Reaction
hypotension, flushed skin , (red) port wine urine.
P pyrogenic Reaction
C circulatory overload
A air embolism
T - thrombocytopenia
C citrate intoxication expired blood =hyperkalemia
H hyperkalemia
Nsg Mgt: Hemolytic
1.
2.
3.
4.
5.
6.
7.

Reaction:
Stop BT
Notify Doc
Flush with plain NSS
Administer isotonic fluid sol to prevent acute tubular necrosis & conteract shock
Send blood unit to blood bank for reexamination
Obtain urine & blood samples of pt & send to lab for reexamination
Monitor VS & Allergic Rxn

Allergic Reaction:
S/Sx
1. Fever/ chills
2. Urticaria/ pruritus
3. Dyspnea
4. Laryngospasm/ bronchospasm
5. Bronchial wheezing

35

Nsg Mgt:
1. Stop BT
2. Notify Doc
3. Flush with PNSS
4. Administer antihistamine diphenhydramine Hcl (Benadryl). Give bedtime.SE-Adult-drowsiness. Child-hyperactive
If (+) Hypotension anaphylactic shock administer epinephrine
5. Send blood unit to blood bank
6. Obtain urine & blood samples send to lab
7. Monitor VS & IO
8. Adm. Antihistamine as ordered for AllergicRxn, if (+) to hypotension indicates anaphylactic shock
24. administer epinephrine
9. Adm antipyretic & antibiotic for pyrogenic Rxn & TSB
Pyrogenic Reaction:
S/Sx
a.) Fever/ chills
b.) Headache
c.) Dyspnea

d. tachycardia
e. palpitations
f. diaphoresis

Nsg Mgt:
1.
2.
3.
4.
5.
6.
7.
8.

Stop BT
Notify Doc
Flush with PNSS
Administer antipyretics, antibiotics
Send blood unit to blood bank
Obtain urine & blood samples send to lab
Monitor VS & IO
Tepid sponge bath offer hypothermic blanket

Circulatory Overload:
Sx
a. Dyspnea
b. Orthopnea
c. Rales or crackles
d. Exertional discomfort
Nsg Mgt:
1. Stop BT
2. Notify Doc. Dont flush due pt has circulatory overload.
3. Administer diuretics
Priority cases:
Hemolytic Rxn 1st due to hypotension 1st priority attend to destruction of Hgb O2 brain damage
Allergic
3rd
Pyrogenic
4th
Circulatory
2nd
Hemolytic
Anaphylitic

2nd
1st priority

DIC DISSEMINATED INTRAVASCULAR COAGULATION

25. Acute hemorrhagic syndrome char by wide spread bleeding & thrombosis due to a def of clotting factors (Prothrombin &
Fibrinogen).
Predisposing factor:
1. Rapid BT
2. Massive trauma
3. Massive burns
4. Septicemia
5. Hemolytic reaction
6. Anaphylaxis
7. Neoplasia growth of new tissue
8. Pregnancy
S/Sx
1.
2.
3.
4.
5.
6.

Petechiae widespread & systemic (lungs, lower & upper trunk)

Ecchymosis widespread
Oozing of blood from venipunctured site
Hemoptysis cough blood
Hemorrhage
Oliguria late sx

36

Dx Proc
1. CBC reveals decrease platelets
2. Stool for occult blood (+)
Specimen stool
3. Opthalmoscopic exam sub retinal hemorrhage
4. ABG analysis metabolic acidosis

pH
pH

HCO3
PCO2

respiratory alkalosis

ph

PCO2

respiratory acidosis

ph

HCO3

metabolic alkalosis

ph

HCO3

metabolic acidosis

Diarrhea met acidosis

Vomitting met alk
Pyloric stenosis met alkalosis vomiting
Ileostomy or intestinal tubing met acidosis
Cushings met alk
DM met acid
Chronic bronchitis resp acid with hypoxemia, cyanosis
Nsg Mgt DIC
1.
2.
3.
4.
a.
b.
5.

Monitor signs of bleeding hema test + urine, stool, GIT

Administer isotonic fluid solution to prevent shock.
Administer O2 inhalation
Administer meds
Vit K aquamephyton
Pitressin or vasopressin to conserve water.
NGT lavage
- Use iced saline lavage
6. Monitor NGT output
7. Provide heplock
8. Prevent complication: hypovolemic shock
Late signs of hypovolemic shock : anuria
Oncologic Nsg:
Oncology study of neoplasia new growth
Benign (tumor)

Malignancy (cancer)

Diff
- well differentiated
Encapulation (+)
Metastasis (-)
Prognosis good
Therapeutic modality surgery

poorly or undifferentiated
(-)
(+)
poor
1. Chemotherapy plenty S/E
2. Radiation
3. Surgery
most preferred treatment
4. Bone marrow transplant - Leukemia only

Predisposing factors: (carcinogenesis)

G genetic factors
I immunologic factors
V viral factors
a. Human papiloma virus causing warts
b. Epstein barr virus
E environmental Factors 90%
a. Physical irradiation, UV rays, nuclear explosion, chronic irritation, direct trauma
b. Chemical factors
- Food additives (nitrates
- Hydrocarbon vesicants, alkalies
- Drugs (stillbestrol)
- Uraehane
- Hormones
- Smoking
Male
3.) Prostate cancer - common 40 & above (middle age & above)
BPH 50 & above
1.) Lung cancer
2.) Liver cancer

37

Female
1. Breast cancer 40 yrs old & up mammography
2. Cervical cancer 90% multi sexual partners
5% early pregnancy
3. Ovarian cancer

15 20 mins (SBE 7 days after mens)

Classes of cancer
Tissue typing
1.
2.
3.

Carcinoma arises from surface epithelium & glandular tissues

Sarcoma- from connective tissue or bones
Multiple myeloma from bone marrow
Pathological fracture of ribs & back pain
4. Lymphoma from lymph glands
5. Leukemia from blood

Warning / Danger Sx of CA
C change in bowel /bladder habits
A a sore that doesnt heal
U unusual bleeding/ Discharge
T thickening of lump breast or elsewhere
I indigestion? Dysphagia
O obvious change in wart/ mole
N nagging cough/ hoarseness
U unexplained anemia
A - anemia
S sudden wt loss
L loss of wt
Therapeutic Modality:
1. Chemotherapy use various chemotherapeutic agents that kills cancer cells & kills normal rapidly producing cells GIT, bone
marrow, and hair follicle.
Classification:
a.) Alkylating agents
b.) Plant alkaloids vincristine
c.) Anti metabolites nitrogen mustard
d.) Hormones DES
Steroids
e.) Antineoplastic antibiotics
S/E & mgt
GIT - -Nausea & vomiting
Nsg Mgt:
1.
Administer anti emetic 4 6h before start of chemo
Plasil
2. Withhold food/ fluid before start of chemo
3. Provide bland diet post chemo
26. Non irritating / non spicy
- Diarrhea
1. Administer anti diarrheal 4 6h before start of chemo
2. Monitor urine, I&O qh
- Stomatitis/ mouth sores
1. Oral care offer ice chips/ popsickles
2. Inform pt hair loss temporary alopecia
Hair will grow back after 4 6 months post chemo.
-Bone marrow depression anemia
1. Enforce CBR
2. O2 inhalation
3. Reverse isolation
4. Monitor signs of bleeding
Repro organ sterility
1. Do sperm banking before start of chemo
Renal system increase uric acid
1. Administer allopurinol/ xyloprin (gout)
27. Inhibits uric acid
28. Acute gout colchicines
29. Increase secretion of uric acid
Neurological changes peristalsis paralytic ileus
Most feared complication ff any abdominal surgery
Vincristine plant alkaloid causes peripheral neuropathy
2. Radiation therapy involves use of ionizing radiation that kills cancer cells & inhibit their growth & kill N rapidly producing cells.

38

Types of
1.
2.
3.

energy emitted
Alpha rays rarely used doesnt penetrate skin tissues
Beta rays internal radiation more penetration
Gamma ray external radiation penetrates deeper underlying tissues

Methods of delivery
1. External radiation- involves electro magnetic waves
Ex. cobalt therapy
2. Internal radiation injection/ implantation of radioisotopes proximal to CA site for a specific period of time.
2 types:
a.) Sealed implant radioisotope with a container & doesnt contaminate body fluid.
b.) Unsealed implant radioisotope without a container & contaminates body fluid.
Ex. Phosphorus 32
3 Factors affecting exposure:
A.) Half life time period required for half of radioisotopes to decay.
- At end of half life less exposure
B.) Distance the farther the distance lesser exposure
C. ) Time the shorter the time, the lesser exposure
D.) Shielding rays can be shielded or blocked by using rubber gloves & gamma use thick lead on concrete.
S/E & Mgt:
a.) Skin errythema, redness, sloughing
1. Assist in battling pt
2. Force fluid 2,000 3,000 ml/day
3. Avoid lotion or talcum powder skin irritation
4. Apply cornstarch or olive oil
b.) GIT nausea / vomiting 1. Administer antiemetic 4 6h before start of chemo - Plasil
2
Withhold food/ fluid before start of chemo
3. Provide bland diet post chemo
Non irritating / non spicy
Dysglusia decrease taste sensitivity
-When atrophy papilla (taste buds) 40 yo
Stomatitis
c.) Bone marrow depression
1. Enforce CBR
2. O2 inhalation
3. Reverse isolation
4. Monitor signs of bleeding
Overview of function & structure of the heart
HEART
Muscular, pumping organ of the body
Left mediastinum
Weigh 300 400 grams
Resembles a closed fist
Covered by serous membrane pericardium
Pericardium
Parietal layer

Pericardial
Fluid prevent
Friction rub

Visceral layer

Layer
1
Epicardium outermost
2
Myocardium inner responsible for pumping action/ most dangerous layer - cardiogenic shock
3
Endocardium innermost layer
Chambers
1
Upper collecting/ receiving chamber - Atria
2
Lower pumping/ contracting chamber - Ventricles
Valves
1
Atrioventricular valves - Tricuspid & mitral valve
Closure of AV valves gives rise to 1st heart sound or S1 or lub
2
Semi lunar valve
a
Pulmonic
b
Aortic
Closure of semilunar valve gives rise to 2nd heart sound or S2 or dub
Extra heart Sound
S3 ventricular Gallop CHF
S4 atrial gallop MI, HPN

39

Heart conduction system

1
Sino atrial node (SA node) (or Keith-Flock node)
Loc junction of SVC & Rt atrium
Fx- primary pace maker of heart
-Initiates electric impulse of 60 100 bpm
2
3
4

Atrioventicular node (AV node or Tawara node)

Loc inter atrial septum
Delay of electric impulse to allow ventricular filling
Bundle of His location interventricular septum
Rt main Bundle Branch
Lt main Bundle Branch
Purkenjie Fiber
Loc- walls of ventricles-- Ventricular contractions
SA node

AV

Purkenjie Fibers
Bundle of His
Complete heart block insertion of pacemaker at Bundle Branch
Metal Pace Maker change q3 5 yo

Prolonged PR atrial fib

ST segment depression angina
ST elev MI

T wave inversion MI
widening QRS arrhythmia

CAD coronary artery dse or Ischemic Heart Dse (IHD)

Atherosclerosis Myocrdial injury
Angina Pectoris Myocardial ischemia
MI- myocardial necrosis

ATHEROSCLEROSIS
- Hardening or artery due to fat/ lipid deposits at tunica intima.

ARTEROSCLEROSIS
- Narrowing or artery due to calcium & CHON deposits at tunica media.

Artery tunica adventitia outer

Tunica intima innermost
Tunica media middle
ATHEROSCLEROSIS
Predisposing Factor
1
Sex male
2
Black race
3
Hyperlipidemia
4
Smoking
5
HPN
6
DM
7
Oral contraceptive- prolonged use
8
Sedentary lifestyle
9
Obesity
10 Hypothyroidism
Signs & Symptoms
1
Chest pain
2
Dyspnea
3
Tachycardia
4
Palpitations
5
Diaphoresis
Treatment
P percutaneous
T tansluminar
C coronary
A angioplasty
Obj:

40

1
2
3.

To revascularize the myocardium

To prevent angina
Increase survival rate

PTCA done to pt with single occluded vessel .

Multiple occluded vessels
C coronary
A arterial
B bypass
A and
G graft surgery
Nsg Mgt
1
2
3

Before CABAG
Deep breathing cough exercises
Use of incentive spirometer
Leg exercises

ANGINA PECTORIS- A clinical syndrome characterized by paroxysmal chest pain usually relieved by REST or NGT nitroglycerin, resulting fr
temp myocardial ischemia.
Predisposing Factor:
1
sex male
2
black raise
3
hyperlipidemia
4
smoking
5
HPN
6
DM
7
oral contraceptive prolonged
8
sedentary lifestyle
9
obesity
10.hypothyroidism
Precipitating factors
4 Es
1
Excessive physical exertion
2
Exposure to cold environment - Vasoconstriction
3
Extreme emotional response
4. Excessive intake of food saturated fats.
Signs & Symptoms
1
Initial symptoms Levines sign hand clutching of chest
2
Chest pain sharp, stabbing excruciating pain. Location substernal
-radiates back, shoulders, axilla, arms & jaw muscles
-relieve by rest or NGT
3
Dyspnea
4
Tachycardia
5
Palpitation
6.diaphoresis
Diagnosis
1.History taking & PE
2. ECG ST segment depression
3. Stress test treadmill = abnormal ECG
4. Serum cholesterol & uric acid - increase.
Nursing Management
1.) Enforce CBR
2.) Administer meds
NTG small doses venodilator
Large dose vasodilator
1st dose NTG give 3 5 min
2nd dose NTG 3 5 min
3rd & last dose 3 5 min
Still painful after 3rd dose notify doc. MI!
55 yrs old with chest pain:
1st question to ask pt: what did you do before you had chest pain.
2nd question: does pain radiate? If radiate heart in nature. If not radiate pulmonary origin
Venodilator veins of lower ext increase venous pooling lead to decrease venous return.
Meds:
A. NTG- Nsg Mgt:
1
Keep in a dry place. Avoid moisture & heat, may inactivate the drug.
2
Monitor S/E:
orthostatic hypotension dec bp
transient headache

41

3
4.
5.

dizziness
Rise slowly from sitting position
Assist in ambulation.
If giving NTG via patch:
i. avoid placing it near hairy areas-will dec drug absorption
ii. avoid rotating transdermal patches- will dec drug absorption
iii. avoid placing near microwave oven or during defibrillation-will burn pt due aluminum foil in patch

B. Beta blockers propanolol

C. ACE inhibitors captopril
D. Ca antagonist - nefedipine
Administer O2 inhalation
Semi-fowler
Diet- Decrease Na and saturated fats
Monitor VS, I&O, ECG
HT: Discharge planning:
a. Avoid precipitating factors 4 Es
b. Prevent complications MI
c. Take meds before physical exertion-to achieve maximum therapeutic effect of drug
d. Importance of follow-up care.

3.)
4.)
5.)
6.)
7.)

MI MYOCARDIAL INFARCTION hear attack terminal stage of CAD

Characterized by necrosis & scarring due to permanent mal-occlusion
Types:
1
2

Trasmural MI most dangerous MI Mal-occlusion of both R&L coronary artery

Sub-endocardial MI mal-occlusion of either R & L coronary artery

Most critical period upon dx of MI 48 to 72h

Majority of pt suffers from PVC premature ventricular contraction.
Predisposing factors
sex male
black raise
hyperlipidemia
smoking
HPN
DM
oral contraceptive
prolonged
sedentary lifestyle
obesity
hypothyroidism

Signs & symptoms

1. chest pain excruciating, vice like, visceral pain located
substernal or precodial area (rare)
- radiates back, arm, shoulders, axilla, jaw & abd muscles.
- not usually relived by rest r NTG
2. dyspnea
3. erthermia
4. initial increase in BP
5. mild restlessness & apprehensions
6. occasional findings
a.) split S1 & S2
b.) pericardial friction rub
c.) rales /crackles
d.) S4 (atrial gallop)

Diagnostic Exam
1. cardiac enzymes
a.) CPK MB Creatinine
Phosphokinase
b.) LDH lactic acid dehydrogenase
c.) SGPT (ALT) Serum Glutanic Pyruvate
Transaminase- increased
d.) SGOT (AST) Serum Glutamic Oxaloacetic - increased
2. Troponin test increase
3. ECG tracing ST segment increase,
widening or QRS complexes means
arrhythmia in MI indicating PVC
4. serum cholesterol & uric acid - increase
5. CBC increase WBC

Nursing Management
1. Narcotic analgesics Morphine SO4 to induce vasodilation & decrease levels of anxiety.
2. Administer O2 inhalation low inflow (CHF-increase inflow)
3. Enforce CBR without BP
a.) Bedside commode
4. Avoid valsalva maneuver
5. Semi fowler
6. General liquid to soft diet decrease Na, saturated fat, caffeine
7. Monitor VS, I&O & ECG tracings
8. Take 20 30 ml/week wine, brandy/whisky to induce vasodilation.
9. Assist in surgical; CABAG
10. Provide pt HT
a.) Avoid modifiable risk factors
b.) Prevent complications:
1. Arrhythmias PVC
2. Shock cardiogenic shock. Late signs of cardiogenic shock in MI oliguria
3. thrombophlebitis - deep vein
4. CHF left sided
5. Dresslers syndrome post MI syndrome
-Resistant to medications
-Administer 150,000 450,000 units of streptokinase
c.) Strict compliance to meds
- Vasodilators

42

1. NTG
2. Isordil
Antiarrythmic
1. Lydocaine
blocks release of norepenephrine
2. Brithylium
Beta-blockers lol
1. Propanolol (inderal)
ACE inhibitors - pril
1. Captopril (enalapril)
Ca antagonist
1. Nifedipine
Thrombolitics or fibrinolytics to dissolve clots/ thrombus

S/E allergic reactions/ uticaria

1. Streptokinase
2. Urokinase
3. Tissue plasminogen adjusting factor
Monitor for bleeding:
- Anticoagulants
1. Heparin

2. Caumadin delayed reaction 2 3 days

PTT

PT

If prolonged bleeding

prolonged bleeding

Antidote
antidote Vit K
Protamine sulfate
- Anti platelet PASA (aspirin)
d.) Resume ADL sex/ activity 4 to 6 weeks
Post-cardiac rehab
1.)Sex as an appetizer rather then dessert
Before meals not after, due after meals increase metabolism heart is pumping hard after meals.
2.) Position non-weight bearing position.
When to resume sex/ act: When pt can already use staircase, then he can resume sex.
e.) Diet decrease Na, Saturated fats, and caffeine
f.) Follow up care.
CHF CONGESTIVE HEART FAILURE - Inability of heart to pump blood towards systemic circulation.
- Backflow
1.) Left sided heart failure:
Predisposing factors:
1.) 90% mitral valve stenosis due RHD, aging
RHD affects mitral valve streptococcal infection
Dx: - Aso titer anti streptolysine O > 300 total units
- Steroids
- Penicillin
- Aspirin
Complication: RS-CHF
Aging degeneration / calcification of mitral valve
Ischemic heart disease
HPN, MI, Aortic stenosis
S/Sx
Pulmonary congestion/ Edema
1
Dyspnea
2
Orthopnea (Diff of breathing sitting pos platypnea)
3
Paroxysmal nocturnal dysnea PNO- nalulunod
4
Productive cough with blood tinged sputum
5
Frothy salivation (from lungs)
6
Cyanosis
7
Rales/ crackles due to fluid
8
Bronchial wheezing
9
PMI displaced lateral due cardiomegaly
10 Pulsus alternons weak-strong pulse
11 Anorexia & general body malaise
12 S3 ventricular gallop
Dx

1
2

CXR cardiomegaly
PAP Pulmonary Arterial Pressure

43

PCWP Pulmonary CapillaryWedge Pressure

PAP measures pressure of R ventricle. Indicates cardiac status.
PCWP measures end systolic/ diastolic pressure
PAP & PCWP:
Swan ganz catheterization cardiac catheterization is done at bedside at ICU
(Trachesostomy bedside) - Done 5 20 mins scalpel & trachesostomy set

3.
4.

CVP indicates fluid or hydration status

Increase CVP decrease flow rate of IV
Decrease CVP increase flow rate of IV
Echocardiography reveals enlarged heart chamber or cardiomayopathy
ABG PCO2 increase, PO2 decrease = = hypoxemia = resp acidosis

2.) Right sided HF

Predisposing factor
1
90% - tricuspid stenosis
2
COPD
3
Pulmonary embolism
4
Pulmonic stenosis
5
Left sided heart failure
S/Sx
Venous
-

congestion
Neck or jugular vein distension
Pitting edema
Ascites
Wt gain
Hepatomegalo/ splenomegaly
Jaundice
Pruritus
Esophageal varies
Anorexia, gen body malaise

Diagnosis:
1
2

CXR cardiomegaly
CVP measures the pressure at R atrium
Normal: 4 to 10 cm of water
Increase CVP > 10 hypervolemia
Decrease CVP < 4 hypovolemia
Flat on bed post of pt when giving CVP
Position during CVP insertion Trendelenburg to prevent pulmonary embolism & promote ventricular filling.

3. Echocardiography enlarged heart chamber / cardiomyopathy

4.Liver enzyme
SGPT ( ALT)
SGOT AST
Nsg mgt: Increase force of myocardial contraction = increase CO
3 6L of CO
1. Administer meds:
Tx for LSHF: M morphine SO4 to induce vasodilatation
A aminophylline & decrease anxiety
D digitalis (digoxin)
D - diuretics
O - oxygen
G - gases
a.) Cardiac glycosides
Increase myocardial
= increase CO
Digoxin (Lanoxin). Antidote: digivine
Digitoxin: metabolizes in liver not in kidneys not given if with kidney failure.
b.) Loop diuretics: Lasix effect with in 10-15 min. Max = 6 hrs
c.) Bronchodilators: Aminophillin (Theophyllin). Avoid giving caffeine
d.) Narcotic analgesic: Morphine SO4 - induce vasodilaton & decrease anxiety
e.) Vasodilators NTG
f.) Anti-arrythmics Lidocaine
2. Administer O2 inhalation high! @ 3 -4L/min via nasal cannula
3. High fowlers

44

4. Restrict Na!
5. Provide meticulous skin care
6. Weigh pt daily. Assess for pitting edema.
Measure abdominal girth daily & notify MD
7. Monitor V/S, I&O, breath sounds
8. Institute bloodless phlebotomy. Rotating tourniquet or BP cuff rotated clockwise q 15 mins = to promote decrease venous return
9. Diet decrease salt, fats & caffeine
10. HT:
a) Complications :shock
Arrhythmia
Thrombophlebitis
MI
Cor Pulmonale RT ventricular hypertrophy
b.) Dietary modifications
c.) Adherence to meds
PERIPHERAL MUSCULAR DISEASE
Arterial ulcers
1. Thromboangiitis Obliterans male/ feet
2. Reynauds female/ hands

venous ulcer
1. Varicose veins
2. Thrombophlebitis

1.) Thromboangiitis obliterates/ BUERGER DISEASE- Acute inflammatory disorder affecting small to medium sized arteries & veins of
lower extremities. Male/ feet
Predisposing factors:
Male
Smokers
S/Sx
1. Intermittent claudication leg pain upon walking - Relieved by rest
2. Cold sensitivity & skin color changes

3.
4.
5.
6.

White

bluish

red

Pallor

cyanosis

rubor

Decrease or diminished peripheral pulses - Post tibial, Dorsalis pedis

Tropic changes
Ulcerations
Gangrene formation

Dx:

1
2
3
5

Oscillometry decrease peripheral pulse volume.

Doppler UTZ decrease blood flow to affected extremities.
Angiography reveals site & extent of mal-occulsion.

Nsg Mgt:
1
Encourage a slow progression of physical activity
a
Walk 3 -4 x / day
b
Out of bed 2 3 x a / day
2
Meds
a
Analgesic
b
Vasodilator
c
Anticoagulant
3
Foot care mgt like DM
a
Avoid walking barefoot
b
Cut toe nails straight
c
Apply lanolin lotion prevent skin breakdown
d
Avoid wearing constrictive garments
4
Avoid smoking & exposure to cold environment
5
Surgery: BKA (Below the knee amputation)
2.)REYNAUDS PHENOMENON acute episodes of arterial spasm affecting digits of hands & fingers
Predisposing factors:
1
2
3

Female, 40 yrs
Smoking
Collagen dse
a
SLE pathognomonic sign butterfly rash on face

45

Chipmunk face bulimia nervosa

Cherry red skin carbon monoxide poisoning
Spider angioma liver cirrhosis
Caput medusae leg & trunk umbilicus- Liver cirrhosis
Lion face leprosy
4
S/Sx:

b
Rheumatoid arthritis
Direct hand trauma piano playing, excessive typing, operating chainsaw
1
2

Intermittent claudication - leg pain upon walking - Relieved by rest

Cold sensitivity

Nsg Mgt:
a
Analgesics
b
Vasodilators
c
Encourage to wear gloves especially when opening a refrigerator.
d
Avoid smoking & exposure to cold environment
VENOUS ULCERS
1. VARICOSITIES / Varicose veins - Abnormal dilation of veins lower ext & trunk
- Due to:
a.) Incompetent valves leading to
b.) Increase venous pooling & stasis leading to
c.) Decrease venous return
Predisposing factors:
a
Hereditary
b
Congenital weakness of veins
c
Thrombophlebitis
d
Heart dse
e
Pregnancy
f
Obesity
g
Prolonged immobility - Prolonged standing
S/Sx:
1
Pain especially after prolonged standing
2
Dilated tortuous skin veins
3
Warm to touch
4
Heaviness in legs
Dx:

1
2

Venography
Trendelenbergs test vein distend quickly < 35 secs

Nsg Mgt:
1
Elevate legs above heart level to promote venous return 1 to 2 pillows
2
Measure circumference of leg muscles to determine if swollen.
3
Wear anti embolic or knee high stockings. Women panty hose
4
Meds: Analgesics
5
Surgery: vein sweeping & ligation
Sclerotherapy spider web varicosities
S/E thrombosis
THROMBOPHLEBITIS (deep vein thrombosis) - Inflammation of veins with thrombus formation
Predisposing factors:
1
Smoking
2. Obesity
3
Hyperlipedemia
4. Prolonged use of oral contraceptives
5
Chronic anemia
6
DM
7
MI
8
CHF
9
Postop complications
10 Post cannulation insertion of various cardiac catheters
S/Sx:
1
2
3
Dx:

Pain at affected extremities

Cyanosis
(+) Homans sign - Pain at leg muscles upon dorsiflexion of foot.
1

Angiography

46

2
Doppler UTZ
Nsg Mgt:
1
Elevate legs above heart level.
2
Apply warm, moist packs to decrease lymphatic congestion.
3
Measure circumference of leg muscles to detect if swollen.
4
Use anti embolic stockings.
5
Meds: Analgesics.
Anticoagulant: Heparin
6
Complication:
Pulmonary Embolism:
- Sudden sharp chest pain
- Dyspnea
- Tachycardia
- Palpitation
- Diaphoresis
- Mild restlessness
OVERVIEW OF RESPIRATORY SYSTEM:
I. Upper respiratory tract:
Fx:
1
Filtering of air
2
Warming & moistening
3
Humidification
a
Nose cartilage
- Parts:
Rt nostril
separated by septum
Lt nostril
Consists of anastomosis of capillaries
Kessel Bach Plexus site of epistaxis
Pharynx (throat) muscular passageway for air& food
Branches:
1
Oropharynx
2
Nasopharynx
3
Layngopharynx

b.

c. Larynx voice box

Fx:

1
2

For phonation
Cough reflex

Glottis opening
Opens to allow passage of air
Closes to allow passage of food
II. Lower Rt Fx for gas exchange
a
Trachea windpipe
- has cartillagenous rings
- site for permanent/ artificial a/w tracheostomy
b. Bronchus R & L main bronchus
c. Lungs R 3 lobes = 10 segments
L 2 lobes 8 segments
Post pneumonectomy - position affected side to promote expansion of lungs
Post segmental lobectomy position unaffected side to promote drainage
Lungs covered by pleural cavity, parietal lobe & visceral lobe
Alveoli acinar cells
site of gas exchange (O2 & CO2)
diffusion: Daltons law of partial pressure of gases
Ventilation movement of air in & out of lungs
Respiration movement of air into cells
Type II cells of alveoli secrets surfactant
Surfactant - decrease surface tension of alveoli
Lecithin & spinogometer
L/S ratio 2:1 indicator of lung maturity
If 1:2 adm O2 - < 40% Concentration to prevent atelectasis & retinopathy or blindness.
I. PNEUMONIA inflammation of lung parenchyma leading to pulmonary consolidation as alveoli is filled with exudates.

47

Etiologic
1
2
3
4
5

agents:
Streptococcus pneumoniae (pnemococcal pneumonia)
Hemophilus pneumoniae(Bronchopneumonia)
Escherichia coli
Klebsiella P.
Diplococcus P.

High risk elderly & children below 5 yo

Predisposing factors:
1
Smoking
2
Air pollution
3
Immuno-compromised
a
AIDS PLP
b
Bronchogenic CA - Non-productive to productive cough
4. Prolonged immobility CVA- hypostatic pneumonia
5. Aspiration of food
6. Over fatigue
S/Sx:
1
2
3
4
5
6
7
8

Productive cough pathognomonic: greenish to rusty sputum

Dyspnea with prolonged respiratory grunt
Fever, chills, anorexia, gen body malaise
Wt loss
Pleuritic friction rub
Rales/ crackles
Cyanosis
Abdominal distension leading to paralytic ileus

Sputum exam could confirm presence of TB & pneumonia

Dx:

1
Sputum GSCS- gram staining & culture sensitivity - Reveals (+) cultured microorganism.
2
CXR pulmo consolidation
3
CBC increase WBC
Erythrocyte sedimentation rate
4
ABG PO2 decrease

Nsg Mgt:
1
2
3

Enforce CBR
Strict respiratory isolation
Meds:
a
Broad spectrum antibiotics
Penicillin or tetracycline
Macrolides ex azythromycin (zythromax)
b
Anti pyretics
c
Mucolytics or expectorants
4
Force fluids 2 to 3 L/day
5
Institute pulmonary toileta
Deep breathing exercise
b
Coughing exercise
c
Chest physiotherapy cupping
d
Turning & reposition - Promote expectoration of secretions
6. Semi-fowler
7. Nebulize & suction
8. Comfy & humid environment
9. Diet: increase CHO or calories, CHON & vit C
10. Postural drainage - To drain secretions using gravity
Mgt for postural drainage:
a
Best done before meals or 2 4 hrs after meals to prevent Gastroesophageal Reflux
b
Monitor VS & breath sounds
Normal breath sound bronchovesicular
c.) Deep breathing exercises
d.) Adm bronchodilators 15 30 min before procedure
e.) Stop if pt cant tolerate procedure
f.) Provide oral care it may alter taste sensation
g.) C/I pt with unstable VS & hemoptysis, increase ICP, increase IOP (glaucoma)
Normal IOP 12 21 mmHg
11. HT:
a.) Avoidance of precipitating factors
b.) Complication: Atelectacies & meningitis

48

c.) Compliance to meds

PULMONARY TUBERCULOSIS (KOCH DSE) - Inflammation of lung tissue caused by invasion of mycobacterium TB or tubercle bacilli or
acid fast bacilli gram (+) aerobic, motile & easily destroyed by heat or sunlight.
Predisposing factors:
1. Malnutrition
2. Overcrowding
3. Alcoholism
4. Ingestion of infected cattle (mycobacterium BOVIS)
5. Virulence
6
Over fatigue
S/Sx:
1
2
3
4
5
6
7

Productive cough yellowish

Low fever
Night sweats
Dyspnea
Anorexia, general body malaise, wt loss
Chest/ back pain
Hempotysis

Diagnosis:
1
Skin test mantoux test infection of Purified CHON Derivative PPD
DOH 8-10 mm induration
WHO 10-14 mm induration
Result within 48 72h
(+) Mantoux test previous exposure to tubercle bacilli
Mode of
2
3
4

transmission droplet infection

Sputum AFB (+) to cultured microorganism
CXR pulmonary infiltrate
caseosis necrosis
CBC increase WBC

Nursing
1
2
3
4
5
6
7
8
9
10

Mgt:
CBR
Strict resp isolation
O2 inhalation
Semi fowler
Force fluid to liquefy secretions
DBCE
Nebulize & suction
Comfy & humid environment
Diet increase CHO & calories, CHON, Vit, minerals
Short course chemotherapy

Intensive phase
INH isoniazide
Rifampicin

- give before meals for absorption

- given within 4 months, given simultaneously to prevent resistance
-S/E: peripheral neutitis vit B6
Rifampicin -All body secretions turn to red orange color urine, stool, saliva, sweat & tears.

PZA Pyrazinamide given 2 mos/ after meals. S/E: allergic rxn, nephrotoxicity & hepatoxicity

HT:

Standard regimen
1
Injection of streptomycin aminoglycoside
Ex. Kanamycin, gentamycin, neomycin
S/E:
a
Ototoxicity damage CN # 8 tinnitus hearing loss
b
Nephrotoxicicity monitor BUN & Crea
a
b

Avoid pred factors

Complications:
1
Atelectasis
2
Miliary TB spread of Tb to other system
c
Compliance to meds
- Religiously take meds
HISTOPLASMOSIS- acute fungal infection caused by inhalation of contaminated dust with histoplasma capsulatum transmitted to birds
manure.
S/Sx: Same as pneumonia & PTB like
1
Productive cough

49

Dx:

2
3
4
5
6

Dyspnea
Chest & joint pains
Cyanosis
Anorexia, gen body malaise, wt loss
Hemoptysis

1
2

Histoplasmin skin test = (+)

ABG pO2 decrease

Nsg Mgt:
1
CBR
2
Meds:
a

Anti fungal agents

Amphotericin B (Fungizone)
S/E :
a
Nephrotoxcicity check BUN
b
Hypokalemia
b.)Corticosteroids
c.) Mucolytic/ or expectorants
3. O2 force fluids
4. Nebulize, suction
5. Complications:
a.) Atelectasis
b.) Bronchiectasis COPD
6. Prevent spread of histoplasmosis:
a.) Spray breading places or kill the bird.

COPD Chronic Obstructive Pulmonary Disease

1
Chronic bronchitis
2
Bronchial asthma
3
Bronchiectasis
4
Pulmonary emphysema terminal stage
CHRONIC BRONCHITIS - called BLUE BLOATERS inflammation of bronchus due to hypertrophy or hyperplasia of goblet mucus producing
cells leading to narrowing of smaller airways.
Predisposing factors:
1
Smoking all COPD types
2
Air pollution
S/Sx:
1
Prod cough
2
Dyspnea on exertion
3
Prolonged expiratory grunt
4
Scattered rales/ rhonchi
5
Cyanosis
6
Pulmo HPN a.)Leading to peripheral edema
b.) Cor pulmonary respiratory in origin
7. Anorexia, gen body malaise
Dx:

ABG
PO2

PCO2

Resp acidosis

Hypoxemia causing cyanosis

Nsg Mgt:
(Same as emphysema)
2.) BRONCHIAL ASTHMA- reversible inflammation lung condition due to hyerpsensitivity leading to narrowing of smaller airway.
Predisposing factor:
1
Extrinsic Asthma called Atropic/ allergic asthma
a
Pallor
b
Dust
c
Gases
d
Smoke
e
Dander
f
Lints
2
Intrinsic AsthmaCause:
Herediatary
Drugs aspirin, penicillin, blockers
Food additives nitrites

50

3
S/Sx:
1
2
3
4
5
6
7
Dx:
1
2

Foods seafood, chicken, eggs, chocolates, milk

Physical/ emotional stress
Sudden change of temp, humidity &air pressure
mixed type: combi of both ext & intr. Asthma
90% cause of asthma
C cough non productive to productive
D dyspnea
W wheezing on expiration
Cyanosis
Mild apprehension & restlessness
Tachycardia & palpitation
Diaphoresis
Pulmo function test decrease lung capacity
ABG PO2 decrease

Nsg Mgt:
1
CBR all COPD
2
Medsa
Bronchodilator through inhalation or metered dose inhaled / pump. Give 1st before corticosteroids
b
Corticosteroids due inflammatory. Given 10 min after adm bronchodilator
c.) Mucolytic/ expectorant
d.) Mucomist at bedside put suction machine.
e.) Antihistamine
3
Force fluid
4
O2 all COPD low inflow to prevent resp distress
5
Nebulize & suction
6
Semifowler all COPD except emphysema due late stage
7
HT
a
Avoid pred factors
b
Complications:
Status astmaticus- give epinephrine & bronchodilators
Emphysema
c
Adherence to med
BRONCHIECTASIS abnormal permanent dilation of bronchus resulting to destruction of muscular & elastic tissues of alveoli.
Predisposing factors:
1
Recurrent upper & lower RI
2
Congenital anomalies
3
Tumors
4
Trauma
S/Sx:
1
Productive cough
2
Dyspnea
3
Anorexia, gen body malaise- all energy are used to increase respiration.
4
Cyanosis
5
Hemoptisis
Dx:
1
2

ABG PO2 decrease

Bronchoscopy direct visualization of bronchus using fiberscope.
Nsg Mgt: before bronchoscopy
1
Consent, explain procedure MD/ lab explain RN
2
NPO
3
Monitor VS

Nsg Mgt after bronchoscopy

1
Feeding after return of gag reflex
2
Instruct client to avoid talking, smoking or coughing
3
Monitor signs of frank or gross bleeding
4
Monitor of laryngeal spasm
DOB
Prepare at bedside tracheostomy set
Mgt: same as emphysema except Surgery
Pneumonectomy removal of affected lung
Segmental lobectomy position of pt unaffected side
PULMONARY EMPHYSEMA irreversible terminal stage of COPD
Characterized by inelasticity of alveolar wall leading to air trapping, leading to maldistribution of gases.

51

Body will compensate over distension of thoracic cavity

Barrel chest
Predisposing factor:
1
Smoking
2
Allergy
3
Air pollution
4
High risk elderly
5
Hereditary - 1 anti trypsin to release elastase for recoil of alveoli.
S/Sx:
1
2
3
4
5
6
7
8
9
10
11

Productive cough
Dyspnea at rest due terminal
Anorexia & gen body malaise
Rales/ rhonchi
Bronchial wheezing
Decrease tactile fremitus (should have vibration) palpation 99. Decreased - with air or fluid
Resonance to hyperresonance percussion
Decreased or diminished breath sounds
Pathognomonic: barrel chest increase post/ anterior diameter of chest
Purse lip breathing to eliminated PCO2
Flaring of alai nares

Diagnosis:

1. Pulmonary function test decrease vital lung capacity

2. ABG
a
Panlobular / centrolobular emphysema
pCO2 increase
pO2 decrease hypoxema
resp acidosis
Blue bloaters
b
Panacinar/ Centracinar
pCO2 decrease
pO2 increase hyperaxemia
resp alkalosis
Pink puffers

Nursing Mgt:
1
CBR
2
Meds
a
Bronchodilators
b
Corticosteroids
c
Antimicrobial agents
d
Mucolytics/ expectorants
3
O2 Low inflow
4
Force fluids
5
High fowlers
6
Neb & suction
7
Institute
P posture
E end
E expiratory
to prevent collapse of alveoli
P pressure
8
HT
a
Avoid smoking
b
Prevent complications
1
Cor pulmonary R ventricular hypertrophy
2
CO2 narcosis lead to coma
3
Atelectasis
4
Pneumothorax air in pleural space
9
Adherence to meds

RESTRICTIVE LUNG DISORDER

PNEUMOTHORAX partial / or complete collapse of lungs due to entry or air in pleural space.
Types:
1
Spontaneous pneumothorax entry of air in pleural space without obvious cause.
Eg. rupture of bleb (alveoli filled sacs) in pt with inflammed lung conditions
Eg. open pneumothorax air enters pleural space through an opening in chest wall
-Stab/ gun shot wound
2
Tension Pneumothorax air enters plural space with @ inspiration & cant escape leading to over distension of thoracic cavity
resulting to shifting of mediastinum content to unaffected side.
Eg. flail chest paradoxical breathing
Predisposing factors:
1.Chest trauma
2.Inflammatory lung conditions
3.Tumor
S/Sx:
1
Sudden sharp chest pain

52

2
3
4
5
6
7

Dyspnea
Cyanosis
Diminished breath sound of affected lung
Cool moist skin
Mild restlessness/ apprehension
Resonance to hyper resonance

Diagnosis:
1
ABG pO2 decrease
2
CXR confirms pneumothorax
Nursing
1
2
3
4

Mgt:
Endotracheal intubation
Thoracenthesis
Meds Morphine SO4
Anti microbial agents
Assist in test tube thoracotomy

Nursing Mgt if pt
1
2
3

When
1
2
3

is on CPT attached to H2O drainage

Maintain strict aseptic technique
DBE
At bedside
a
Petroleum gauze pad if dislodged Hemostan
b
If with air leakage clamp
c
Extra bottle
4
Meds Morphine SO4
Antimicrobial
5
Monitor & assess for oscillation fluctuations or bubbling
a
If (+) to intermittent bubbling means normal or intact
- H2O rises upon inspiration
- H2o goes down upon expiration
b.) If (+) to continuous, remittent bubbling
1. Check for air leakage
2. Clamp towards chest tube
3. Notify MD
c.) If (-) to bubbling
1. Check for loop, clots, and kink
2. Milk towards H2O seal
3. Indicates re-expansion of lungs
will MD remove chest tube:
If (-) fluctuations
(+) Breath sounds
CXR full expansion of lungs

Nursing
1
2
3
-

Mgt of removal of chest tube

DBE
Instruct to perform Valsalva maneuver for easy removal, to prevent entry of air in pleural space.
Apply vaselinated air occlusive dressing
Maintain dressing dry & intact

GIT
I. Upper alimentary canal - function for digestion
a
Mouth
b
Pharynx (throat)
c
Esophagus
d
Stomach
e
1st half of duodenum
II. Middle Alimentary canal Function: for absorption
- Complete absorption large intestine
a
2nd half of duodenum
b
Jejunum
c
Ileum
d
1st half of ascending colon
III. Lower Alimentary Canal Function: elimination
a
2nd half of ascending colon
b
Transverse
c
Descending colon
d
Sigmoid
e
Rectum
IV. Accessory Organ
a
Salivary gland
b
Verniform appendix
c
Liver

53

d
e

Pancreas auto digestion

Gallbladder storage of bile

I. Salivary Glands
1. Parotid below & front of ear
2. Sublingual
3. Submaxillary
-

Produces saliva for mechanical digestion

1200 -1500 ml/day - saliva produced

PAROTITIS mumps inflammation of parotid gland

-Paramyxo virus
S/Sx:

1
2
3
4

Fever, chills anorexia, gen body malaise

Swelling of parotid gland
Dysphagia
Ear ache otalgia

Mode of transmission: Direct transmission & droplet nuclei

Incubation period: 14 21 days
Period of communicability 1 week before swelling & immediately when swelling begins.
Nursing
1
2
3

4
5
6

Mgt:
CBR
Strict isolation
Meds: analgesic
Antipyretic
Antibiotics to prevent 2 complications
Alternate warm & cold compress at affected part
Gen liquid to soft diet
Complications
Women cervicitis, vaginitis, oophoritis
Both sexes meningitis & encephalitis/ reason why antibiotics is needed
Men orchitis might lead to sterility if it occur during / after puberty.

VERNIFORM APPENDIX Rt iliac or Rt inguinal area

Function lymphatic organ produces WBC during fetal life - ceases to function upon birth of baby
APENDICITIS inflamation of verniform appendix
Predisposing factor:
1
Microbial infection
2
Feacalith undigested food particles tomato seeds, guava seeds
3
Intestinal obstruction
S/Sx:
1
2
3
4
5

Pathognomonic sign: (+) rebound tenderness

Low grade fever, anorexia, n/v
Diarrhea / & or constipation
Pain at Rt iliac region
Late sign due pain tachycardia

Diagnosis:
1
CBC mild leukocytosis increase WBC
2
PE (+) rebound tenderness (flex Rt leg, palpate Rt iliac area rebound)
3
Urinalysis
Treatment: - appendectomy 24 45
Nursing Mgt:
1
Consent
2
Routinary nursing measures:
a
Skin prep
b
NPO
c
Avoid enema lead to rupture of appendix
3
Meds:
Antipyretic
Antibiotics
*Dont give analgesic will mask pain
- Presence of pain means appendix has not ruptured.
4. Avoid heat application will rupture appendix.
5. Monitor VS, I&O bowel sound

54

Nursing Mgt: post op

1
If (+) to Pendrose drain indicates rupture of appendix
Position- affected side to drain
2
Meds: analgesic due post op pain
Antibiotics, Antipyretics PRN
3
Monitor VS, I&O, bowel sound
4
Maintain patent IV line
5
Complications- peritonitis, septicemia
Liver largest gland
Occupies most of right hypochondriac region
Color: scarlet red
Covered by a fibrous capsule Glissons capsule
Functional unit liver lobules
Function:
1

2
3

Produces bile
Bile emulsifies fats
- Composed of H2O & bile salts
-Gives color to urine urobilin
Stool stircobilin
Detoxifies drugs
Promotes synthesis of vit A, D, E, K - fat soluble vitamins

Hypevitaminosis vit D & K

Vit A retinol
Def Vit A night blindness
Vit D cholecalciferon
Helps calcium
Rickets, osteoarthritis
4. It destroys excess estrogen hormone
5. For metabolism
A. CHO
1. Glycogenesis synthesis of glycogens
2. Glycogenolysis breakdown of glycogen
3. Gluconeogenesis formation of glucose from CHO sources
B. CHON1. Promotes synthesis of albumin & globulin
Cirrhosis decrease albumin
Albumin maintains osmotic pressure, prevents edema
2. Promotes synthesis of prothrombin & fibrinogen
3. Promotes conversion of ammonia to urea.
Ammonia like breath fetor hepaticus
C. FATS promotes synthesis of cholesterol to neutral fats called triglycerides
LIVER CIRRHOSIS - lost of architectural design of liver leading to fat necrosis & scarring
Early sign hepatic encephalopathy
1. Asterixis flapping hand tremors
Late signs headache, restlessness, disorientation, decrease LOC hepatic coma.
Nursing priority assist in mechanical ventilation
Predisposing factor:
Decrease Laennacs cirrhosis caused by alcoholism
1
Chronic alcoholism
2
Malnutrition decreaseVit B, thiamin - main cause
3
Virus
4
Toxicity- eg. Carbon tetrachloride
5
Use of hepatotoxic agents
S/Sx:
Early signs:
a
Weakness, fatigue
b
Anorexia, n/v
c
Stomatitis
d
Urine tea color
Stool clay color
e
Amenorrhea
f
Decrease sexual urge
g
Loss of pubic, axilla hair
h
Hepatomegaly
i
Jaundice
j
Pruritus or urticaria

55

2. Late signs
a.) Hematological changes all blood cells decrease
Leukopenia- decrease
Thrombocytopenia- decrease
Anemia- decrease
b.) Endocrine changes
Spider angiomas, Gynecomastia
Caput medusate, Palmar errythema
c.) GIT changes
Ascitis, bleeding esophageal varices due to portal HPN
d.) Neurological changes:
Hepatic encephalopathy - ammonia (cerebral toxin)
Late signs:
Early signs:
Headache
asterexis
Fetor hepaticus
(flapping hand tremors)
Confusion
Restlessness
Decrease LOC
Hepatic coma
Diagnosis:
Liver enzymes- increase
SGPT (ALT)
SGOT (AST)
Serum cholesterol & ammonia increase
Indirect bilirubin increase
CBC - pancytopenia
PTT prolonged
Hepatic ultrasonogram fat necrosis of liver lobules
Nursing
1
2
3
4
5
6
7
8

Mgt
CBR
Restrict Na!
Monitor VS, I&O
With pt daily & assess pitting edema
Measure abdominal girth daily notify MD
Meticulous skin care
Diet increase CHO, vit & minerals. Moderate fats. Decrease CHON
Well balanced diet
Complications:
a
Ascites fluid in peritoneal cavity
Nursing Mgt:
1
Meds: Loop diuretics 10 15 min effect
2
Assist in abdominal paracentesis - aspiration of fluid
- Void before paracentesis to prevent accidental puncture of bladder as trochar is inserted
b
Bleeding esophageal varices
- Dilation of esophageal veins
1. Meds: Vit K
Pitrisin or Vasopresin (IM)
2. NGT decompression- lavage
- Give before lavage ice or cold saline solution
- Monitor NGT output
3. Assist in mechanical decompression
- Insertion of sengstaken-blackemore tube
- 3 lumen typed catheter
- Scissors at bedside to deflate balloon.
c
Hepatic encephalopathy
1
Assist in mechanical ventilation due coma
2
Monitor VS, neuro check
3
Siderails due restless
4
Meds Laxatives to excrete ammonia

HEPATITIS- jaundice (icteric sclera)

Bilirubin
Kernicterus/ hyperbilirubinia

56

Irreversible brain damage

Pancreas mixed gland (exocrine & endocrine gland)
PANCREATITIS acute or chronic inflammation of pancreas leading to pancreatic edema, hemorrhage & necrosis due to auto digestion.
Bleeding of pancreas - Cullens sign at umbilicus
Predisposing factors:
1
Chronic alcoholism
2
Hepatobilary disease
3
Obesity
4
Hyperlipidemia
5
Hyperparathyroidism
6
Drugs Thiazide diuretics, pills Pentamidine HCL (Pentam)
7
Diet increase saturated fats
S/Sx:
1
Severe Lt epigastric pain radiates from back &flank area
Aggravated by eating, with DOB
2
N/V
3
Tachycardia
4
Palpitation due to pain
5
Dyspepsia indigestion
6
Decrease bowel sounds
7
(+) Cullens sign - ecchymosis of umbilicus
hemorrhage
8
(+) Grey Turners spots ecchymosis of flank area
9
Hypocalcemia
Diagnosis:
1
Serum amylase & lipase increase
2
Urine lipase increase
3
Serum Ca decrease
Nursing Mgt:
1. Meds
a.) Narcotic analgesic - Meperidine Hcl (Demerol)
Dont give Morphine SO4 will cause spasm of sphincter.
b.) Smooth muscle relaxant/ anti cholinergic
- Ex.
Papavarine Hcl
Prophantheline Bromide (Profanthene)
c.) Vasodilator NTG
d.) Antacid Maalox
e.) H2 receptor antagonist - Ranitidin (Zantac)
to decrease pancreatic stimulation
f.) Ca gluconate
2. Withold food & fluid aggravates pain
3. Assist in Total Parenteral Nutrition (TPN) or hyperalimentation
Complications of TPN
1
Infection
2
Embolism
3
Hyperglycemia
4. Institute stress mgt tech
a.) DBE
b.) Biofeedback
5. Comfy position - Knee chest or fetal like position
6. If pt can tolerate food, give increase CHO, decrease fats, and increase CHON
7. Complications: Chronic hemorrhagic pancreatitis
GALLBLADDER storage of bile made up of cholesterol.
CHOLECYSTITIS/ CHOLELITHIASIS inflammation of gallbladder with gallstone formation.
Predisposing factor:
1
High risk women 40 years old
2
Post menopausal women undergoing estrogen therapy
3
Obesity
4
Sedentary lifestyle
5
Hyperlipidemia
6
Neoplasm
S/Sx:
1
Severe Right abdominal pain (after eating fatty food). Occurring especially at night
2
Fatty intolerance
3
Anorexia, n/v
4
Jaundice
5
Pruritus
6
Easy bruising
7
Tea colored urine

57

Steatorrhea

Diagnosis:
1
Oral cholecystogram (or gallbladder series)- confirms presence of stones
Nursing Mgt:
1
Meds a.) Narcotic analgesic - Meperdipine Hcl Demerol
b.) Anti cholinergic - Atropine SO4
c.) Anti emetic
Phenergan Phenothiazide with anti emetic properties
2
Diet increase CHO, moderate CHON, decrease fats
3
Meticulous skin care
4
Surgery:Cholecystectomy
Nursing Mgt post cholecystectomy
-Maintain patency of T-tube intact & prevent infection
Stomach widest section of alimentary canal
J shaped structures
1
Anthrum
2
Pylorus
3
Fundus
Valves
1
1.cardiac sphincter
2
Pyloric sphincter
Cells
1

Chief/ Zymogenic cells secrets

a
Gastric amylase - digest CHO
b
Gastric lipase digest fats
c
Pepsin CHON
d
Rennin digests milk products
Parietal / Argentaffin / oxyntic cells
Function:
a
Produces intrinsic factor promotes reabsorption of vit B12 cyanocobalamin promotes maturation of RBC
b
Secrets Hcl acid aids in digestion
Endocrine cells - Secrets gastrin increase Hcl acid secretion

Function of the stomach

1.Mechanical
2.Chem.
Digestion
3.Storage of food
-CHO, CHON- stored 1 -2 hrs. Fats stored 2 3 hrs
PEPTIC ULCER DISEASE (PUD) excoriation / erosion of submucosa & mucosal lining due to:
a
Hypercecretion of acid pepsin
b
Decrease resistance to mucosal barrier
Incidence Rate:
1
Men 40 55 yrs old
2
Aggressive persons
Predisposing factors:
1
Hereditary
2
Emotional
3
Smoking vasoconstriction GIT ischemia
4
Alcoholism stimulates release of histamine = Parietal cell release Hcl acid = ulceration
5
Caffeine tea, soda, chocolate
6
Irregular diet
7
Rapid eating
8
Ulcerogenic drugs NSAIDS, aspirin, steroids, indomethacin, ibuprofen
Indomethacin - S/E corneal cloudiness. Needs annual eye check up.
9
Gastrin producing tumor or gastrinoma Zollinger Ellisons sign
10 Microbial invasion helicobacter pylori. Metromidazole (Flagyl)
Types of ulcers
Ascending to severity
1
Acute affects submucosal lining
2
Chronic affects underlying tissue heals & forms a scar
According to location
1
Stress ulcer
2
Gastric ulcer

58

Duodenal ulcer most common

Stress ulcers common among eritically ill clients

2 types
1.Curings ulcer cause: trauma & birth
hypovolemia
GIT schemia
Decrease resistance of mucosal barriers to Hcl acid
Ulcerations
2.Cushings ulcer cause stroke/CVA/ head injury
Increase vagal stimulation
Hyperacidity
Ulcerations

GASTRIC ULCER
DUODENAL ULCER
Intrum or lesser curvature
-30 min 1 hr after eating
- epigastrium
- gaseous & burning
- not usually relieved by food & antacid

SITE
PAIN

HYPERSECRETION
VOMITING
HEMORRHAGE
WT
COMPLICATIONS

Normal gastric acid secretion

common
hematemeis
Wt loss
a. stomach cause
b. hemorrhage
60 years old

HIGH RISK
Diagnosis:
1
Endoscopic exam
2
Stool from occult blood
3
Gastric analysis N gastric
Increase duodenal
4
GI series confirms presence of ulceration

Duodenal bulb
-2-3 hrs after eating
- mid epigastrium
- cramping & burning
- usually relieved by food & antacid
- 12 MN 3am pain
Increased gastric acid secretion
Not common
Melena
Wt gain
a. perforation
20 years old

Nursing Mgt:
1
Diet bland, non irritating, non spicy
2
Avoid caffeine & milk/ milk products
3
a

Administer meds
Antacids

Increase gastric acid secretion

AAC
Aluminum containing antacids
Ex. aluminum OH gel
(Ampho-gel)
S/E constipation

Magnesium containing antacids

ex. milk of magnesia
S/E diarrhea

Maalox (fever S/E)

b

H2 receptor antagonist
Ex
1
Ranitidine (Zantac)
2
Cimetidine (Tagamet)
3
Tamotidine (Pepcid)
Avoid smoking decrease effectiveness of drug

Nursing Mgt:

59

Administer antacid & H2 receptor antagonist 1hr apart

-Cemetidine decrease antacid absorption & vise versa
c
Cytoprotective agents
Ex
1. Sucralfate (Carafate) - Provides a paste like subs that coats mucosal lining of stomach
2. Cytotec
d.) Sedatives/ Tranquilizers - Valium, lithium
e.)Anticholinergics
1
Atropine SO4
2
Prophantheline Bromide (Profanthene)
(Pt has history of hpn crisis With peptic ulcer disease. Rn should not administer alka seltzer- has large amount of Na.
4. Surgery: subtotal gastrectomy - Partial removal of stomach
Billroth I (Gastroduodenostomy)
Billroth II (Gastrojejunostomy)
-Removal of of stomach & anastomoses of gastric stump
- removal of -3/4 of stomach & duodenal bulb & anastomostoses of
to the duodenum.
gastric stump to jejunum.
Before surgery for BI or BII - Do vagotomy (severing of vagus nerve) & pyloroplasty (drainage) first.
Nursing Mgt:
1
Monitor NGT output
a
Immediately post op should be bright red
b
Within 36- 42h output is yellow green
c
After 42h output is dark red
2
Administer meds:
a
Analgesic
b
Antibiotic
c
Antiemetics
3
Maintain patent IV line
4
VS, I&O & bowel sounds
5
Complications:
a
Hemorrhage hypovolemic shock
Late signs anuria
b
Peritonitis
c
Paralytic ileus most feared
d
Hypokalemia
e
Thromobphlebitis
f
Pernicious anemia
7.)Dumping syndrome common complication rapid gastric emptying of hypertonic food solutions CHYME leading to hypovolemia.
Sx of Dumping syndrome:
1
Dizziness
2
Diaphoresis
3
Diarrhea
4
Palpitations
Nursing
1
2
3
4

mgt:
Avoid fluids in chilled solutions
Small frequent feeding s-6 equally divided feedings
Diet decrease CHO, moderate fats & CHON
Flat on bed 15 -30 minutes after q feeding

BURNS direct tissue injury caused by thermal, electric, chemical & smoke inhaled (TECS)
Nursing Priority infection (all kinds of burns)
Head burn-priority- a/w
2nd priority for 1st & 2nd - pain
2nd priority for 3rd - F&E
Thermal- direct contact flames, hot grease, sunburn.
Electric, wires
Chem. direct contact corrosive materials acids
Smoke gas / fume inhalation
Stages:
1
Emergent phase Removal of pt from cause of burn. Determine source or loc or burn
2
Shock phase 48 - 72. Characterized by shifting of fluids from intravascular to interstitial space
=Hypovolemia
S/Sx:
-

BP
decrease
Urine output
HR
increase

60

Hct
increase
Serum Na
decrease
Serum K
increase
Met acidosis

3. Diuretic/ Fluid remobilization phase - 3 to 5 days. Return of fluid from interstitial to intravascular space
4. Recovery/ convalescent phase complete diuresis. Wound healing starts immediately after tissue injury.
Class:
I. Partial Burn
1. 1st degree superficial burns
- Affects epidermis
- Cause: thermal burn
- Painful
- Redness (erythema) & blanching upon pressure with no fluid filled vesicles
2. 2nd degree deep burns
- Affects epidermis & dermis
- Cause chem. burns
- very painful
- Erythema & fluid filled vesicles (blisters)
II Full thickness Burns
1. Third & 4th degrees burn
- Affects all layers of skin, muscles, bones
- Cause electrical
- Less painful
- Dry, thick, leathery wound surface known as ESCHAR devitalized or necrotic tissue.
Assessment findings
Rule of nines
Head & neck = 9%
Ant chest =
18%
Post chest =
18%
@ Arm 9+9 = 18%
@ leg 18+18 = 18%
Genitalia/ perineum= 1%
Total
100%
Nursing Mgt
1. Meds
a.) Tetanus toxoid- burn surface area is source of anaerobic growth Claustridium tetany
Tetany
Tetanolysin

tetanospasmin

Hemolysis

muscle spasm

b.) Morphine SO4

c.) Systemic antibiotics
1. Ampicillin
2. Cephalosporin
3. Tetracyclin
4. Topical antibiotic :
1. Silver Sulfadiazene (silvadene)
2. Sulfamylon
3. Silver nitrate
4. Povidone iodine (betadine)
2. Administer isotonic fluid sol & CHON replacements
3. Strict aseptic technique
4. Diet increase CHO, increase CHON, increase Vit C, and increase K- orange
5. If (+) to burns on head, neck, face - Assist in intubation
6. Assist in hydrotherapy
7. Assist in surgical wound debridement. Administer analgesic 15 30 minutes before debridement
8. Complications:
a.) Infection
b.) Shock
c.) Paralytic ileus - due to hypovolemia & hypokalemia
d.) Curlings ulcer H2 receptor antagonist
e.) Septicemia blood poisoning
f.) Surgery: skin grafting

61

GUT genito-urinary tract

Function:
1
Promote excretion of nitrogenous waste products
2
Maintain F&E & acid base balance
1. Kidneys pair of bean shaped organ
Retro peritonially (back of peritoneum) on either side of vertebral column. Encased in Bowmanss capsule.
Parts:

1
2
3

Renal pelvis pyenophritis infl

Cortex
Medulla

Nephrones basic living unit

Glomerulus filters blood going to kidneys
Function of kidneys:
1
Urine formation
2
Regulation of BP
Urine formation 25% of total CO (Cardiac Output) is received by kidneys
1
Filtration
2
Tubular Reabsorption
3
Tubular Secretion
Filtration Normal GFR/ min is 125 ml of blood
Tubular reabsorption 124ml of ultra infiltrates (H2O & electrolytes is for reabsorption)
Tubular secretion 1 ml is excreted in urine
Regulation of BP:
Predisposing factor:
Ex CS hypovolemia decrease BP going to kidneys
Activation of RAAS
Release of Renin (hydrolytic enzyme) at juxtaglomerular apparatus
Angiotensin I mild vasoconstrictor
Angiotensin II vasoconstrictor
Adrenal cortex
Aldosterone

increase CO

increase PR

Increase BP

Increase Na &
H2O reabsorption
Hypervolemia
Ureters 25 35 cm long, passageway of urine to bladder
Bladder loc behind symphisis pubis. Muscular & elastic tissue that is distensible
- Function reservoir or urine
1200 1800 ml Normal adult can hold
200 500 ml needed to initiate micturition reflex
Color
Odor
Consistency
pH
Specific gravity
WBC/ RBC
Albumin
E coli
Mucus thread
Amorphous urate

amber
aromatic
clear or slightly turbid
4.5 8
1.015 1.030
(-)
(-)
(-)
few
(-)

Urethra extends to external surface of body. Passage of urine, seminal & vaginal fluids.
Women 3 5 cm or 1 to 1
Male 20cm or 8
UTI

62

CYSTITIS inflammation of bladder

Predisposing factors:
1
Microbial invasion E. coli
2
High risk women
3
Obstruction
4
Urinary retention
5
Increase estrogen levels
6
Sexual intercourse
S/Sx:
1
Pain flank area
2
Urinary frequency & urgency
3
Burning upon urination
4
Dysuria & hematuria
5
Fever, chills, anorexia, gen body malaise
Diagnosis:
1
Urine culture & sensitivity - (+) to E. coli
Nursing Mgt:
1
Force fluid 2000 ml
2
Warm sitz bath to promote comfort
3
Monitor & assess for gross hematuria
4
Acid ash diet cranberry, vit C -OJ to acidify urine & prevent bacterial multiplication
5
Meds: systemic antibiotics
Ampicillin
Cephalosporin
Sulfonamides cotrimaxazole (Bactrim)
- Gantrism (ganthanol)
Urinary antiseptics Mitropurantoin (Macrodantin)
Urinary analgesic- Pyridum
6. Ht
a.) Importance of Hydration
b.) Void after sex
c.) Female avoids cleaning back & front
Bubble bath, Tissue paper, Powder, perfume
d.) Complications:
Pyelonephritis
PYELONEPHRITIS acute/ chronic infl of 1 or 2 renal pelvis of kidneys leading to tubular destruction, interstitial abscess formation.
Lead to Renal Failure
Predisposing factor:
1
Microbial invasion
a
E. Coli
b
Streptococcus
2
Urinary retention /obstruction
3
Pregnancy
4
DM
5
Exposure to renal toxins
S/Sx:
Acute pyelonephritis
a
Costovertibral angle pain, tenderness
b
Fever, anorexia, gen body malaise
c
Urinary frequency, urgency
d
Nocturia, dsyuria, hematuria
e
Burning on urination
Chronic
a
b
c

Pyelonephritis
Fatigue, wt loss
Polyuuria, polydypsia
HPN

Diagnosis:
1
Urine culture & sensitivity (+) E. coli & streptococcus
2
Urinalysis
Increase WBC, CHON & pus cells
3
Cystoscopic exam urinary obstruction
Nursing
1
2
3
4

Mgt:
Provide CBR acute phase
Force fluid
Acid ash diet
Meds:
a
Urinary antiseptic nitrofurantoin (macrodantin)
SE: peripheral neuropathy

63

GI irritation
Hemolytic anemia
Staining of teeth
b
Urinary analgesic Peridium
Complication- Renal Failure

NEPHROLITHIASIS/ UROLITHIASIS- formation of stones at urinary tract

- calcium ,
oxalate,
uric acid
milk

cabbage
cranberries
nuts tea
chocolates

anchovies
organ meat
nuts
sardines

Predisposing factors:
1
Diet increase Ca & oxalate
2
Hereditary gout
3
Obesity
4
Sedentary lifestyle
5
Hyperparathyroidism
S/Sx:
1
Renal colic
2
Cool moist skin (shock)
3
Burning upon urination
4
Hematuria
5
Anorexia, n/v
Diagnosis:
1
IVP intravenous pyelography. Reveals location of stone
2
KUB reveals location of stone
3
Cytoscopic exam- urinary obstruction
4
Stone analysis composition & type of stone
5
Urinalysis increase EBC, increase CHON
Nursing Mgt:
1.Force fluid
2.Strain urine using gauze pad
3.Warm sitz bath for comfort
4.Alternate warm compress at flank area
5. a.) Narcotic analgesic- Morphine SO4
b.) Allopurinol (Zyeoprim)
c.) Patent IV line
d.) Diet if + Ca stones acid ash diet
If + oxalate stone alkaline ash diet - (Ex milk/ milk products)
If + uric acid stones decrease organ meat / anchovies sardines
6
Surgery
a
Nephectomy removal of affected kidney
Litholapoxy removal of 1/3 of stones- Stones will recur. Not advised for pt with big stones
b
Extracorporeal shock wave lithotripsy
- Non - invasive
- Dissolve stones by shock wave
7
Complications: Renal Failure
BENIGN PROSTATIC HYPERTROPHY - enlarged prostate gland leading to
a
Hydro ureters dilation of ureters
b
Hydronephrosis dilation of renal pelvis
c
Kidney stones
d
Renal failure
Predisposing factor:
1
High risk 50 years old & above
60 70 (3 to 4 x at risk)
2
Influence of male hormone
S/Sx:
1.Decrease force of urinary stream
2.Dysuria
3.Hematuria
4.Burning upon urination
5.Terminal bubbling
6.Backache
7.Sciatica
Diagnosis:
1
Digital rectal exam enlarged prostate gland
2
KUB urinary obstruction

64

3
4

Cystoscopic exam obstruction

Urinalysis increase WBC, CHON

Nursing
1
2
3
4

Mgt:
Prostatic message promotes evacuation of prostatic fluid
Limit fluid intake
Provide catheterization
Meds:
a. Terazozine (hytrin) - Relaxes bladder sphincter
b. Fenasteride (Proscar) - Atrophy of Prostate Gland
5. Surgery: Prostatectomy TURP- Transurethral resection of Prostate- No incision
-Assist in cystoclysis or continuous bladder irrigation.
Nursing mgt:
c. Monitor symptoms of infection
d. Monitor symptoms gross/ flank bleeding. Normal bleeding within 24h.
3. Maintain irrigation or tube patent to flush out clots - to prevent bladder spasm & distention
ACUTE RENAL FAILURE sudden immobility of kidneys to excrete nitrogenous waste products & maintain F&E balance due to a decrease
in GFR. (N 125 ml/min)
Predisposing factor:
Pre renal cause- decrease blood flow
Causes:
1
Septic shock
2
Hypovolemia
3
Hypotension
decrease flow to kidneys
4
CHF
5
Hemorrhage
6
Dehydration

Intra-renal cause involves renal pathology= kidney problem

1
Acute tubular necrosis2
Pyelonephritis
3
HPN
4
Acute GN
Post renal cause involves mechanical obstruction
1
Stricture
2
Urolithiasis
3
BPH
CHRONIC RF irreversible loss of kidney function
Predisposing factors:
1
DM
2
HPN
3
Recurrent UTI/ nephritis
4
Exposure to renal toxins
Stages of CRF
1
Diminished Reserve Volume asymptomatic
Normal BUN & Crea, GFR < 10 30%
2. Renal Insufficiency
3. End Stage Renal disease
S/Sx:
1.) Urinary System
a.) polyuria
b.) nocturia
c.) hematuria
d.) Dysuria
e.) oliguria
3.) CNS
a.) headache
b.) lethargy
c.) disorientation
d.) restlessness
e.) memory impairment
5.) Respiratory
a.) Kassmauls resp
b.) decrease cough reflex

2.) Metabolic disturbances

a.) azotemia (increase BUN & Crea)
b.) hyperglycemia
c.) hyperinulinemia
4.) GIT
a.) n/v
b.) stomatitis
c.) uremic breath
d.) diarrhea/ constipation
6.) hematological
a.) Normocytic anemia
bleeding tendencies

65

7.) Fluid & Electrolytes

8.) Integumentary
a.) hyperkalemia
a.) itchiness/ pruritus
b.) hypernatermia
b.) uremic frost
c.) hypermagnesemia
d.) hyperposphatemia
e.) hypocalcemia
f.) met acidosis
Nursing Mgt:
1
Enforce CBR
2
Monitor VS, I&O
3
Meticulous skin care. Uremic frost assist in bathing pt
4. Meds:
a.) Na HCO3 due Hyperkalemia
b.) Kagexelate enema
c.) Anti HPN hydralazine
d.) Vit & minerals
e.) Phosphate binder
(Amphogel) Al OH gel - S/E constipation
f.) Decrease Ca Ca gluconate
5. Assist in hemodialysis
1
Consent/ explain procedure
2
Obtain baseline data & monitor VS, I&O, wt, blood exam
3
Strict aseptic technique
4
Monitor for signs of complications:
B bleeding
E embolism
D disequilibrium syndrome
S septicemia
S shock decrease in tissue perfusion
Disequilibrium syndrome from rapid removal of urea & nitrogenous waste prod leading to:
a
n/v
b
HPN
c
Leg cramps
d
Disorientation
e
Paresthesia
5
6

Avoid BP taking, blood extraction, IV, at side of shunt or fistula. Can lead to compression of fistula.
Maintain patency of shunt by:
i. Palpate for thrills & auscultate for bruits if (+) patent shunt!
ii. Bedside- bulldog clip
- If with accidental removal of fistula to prevent embolism.
- Infersole (diastole) common dialisate used
7. Complication
- Peritonitis
- Shock
8. Assist in surgery:
Renal transplantation : Complication rejection. Reverse isolation

EYES
External
1
2
3
4

parts
Orbital cavity made up of connective tissue protects eye form trauma.
EOM extrinsic ocular muscles involuntary muscles of eye needed for gazing movement.
Eyelashes/ eyebrows esthetic purposes
Eyelids palpebral fissure opening upper & lower lid. Protects eye from direct sunlight

Meibomean gland secrets a lubricating fluid inside eyelid

b.) Stye/ sty or Hordeolum- inflamed Meibomean gland
5
Conjunctiva
6
Lacrimal apparatus tears
Process of grieving
a. Denial
b. Anger
c. Bargaining
d. Depression
e. Acceptance
2
Intrinsic coat
I. sclerotic coat outer most
a.) Sclera white. Occupies post of eye. Refracts light rays
b.) Canal of schlera site of aqueous humor drainage
c.) Cornea transparent structure of eye

66

II/ Uveal tract nutritive care

Uveitis infl of uveal tract
Consist of:
a.) Iris colored muscular ring of eye
2 muscles of iris:
1. Circular smooth muscle fiber - Constricts the pupil
2.radial smooth muscle fiber - Dilates the pupil
2 chambers of the eye
1. Anterior
a.) Vitereous Humor maintains spherical shape of the eye
b.) Aqueous Humor maintains intrinsic ocular pressure
Normal IOP= 12-21 mmHg
II. Retina (innermost layer)
i. Optic discs or blind spot nerve fibers only
No auto receptors
cones (daylight/ colored vision)

rods night twilight vision

phototopic vision

scotopic vision = vit A deficiency rods insufficient

ii.
iii.

Maculla lutea yellow spot center of retina

Fovea centralis area with highest visual acuity oracute vision

Physiology of vision
4 Physiological processes for vision to occur:
1. Refraction of light rays bending of light rays
2. Accommodation of lens
3. Constriction & dilation of pupils
4. Convergence of eyes
Unit of measurements of refraction diopters
Normal eye refraction emmetropia
ERROR of refraction
1
Myopia near sightedness Treatment: biconcave lens
2
Hyperopia/ or farsightedness Treatment: biconvex lens
3
Astigmatisim distorted vision Treatment: cylindrical
4
Prebyopia old slight inelasticity of lens due to aging Treatment: bifocal lens or double vista
Accommodation of lenses based on thelmholtz theory of accommodation
Near vision =
Ciliary muscle contracts=
Lens bulges
Convergence of the eye:
Error:
1
Exotropia 1 eye normal
2
Esophoria
3
Strabismus- squint eye
4
Amblyopia prolong squinting

far vision=
ciliary muscle dilates / relaxes=
lens is flat

corrected by corrective eye surgery

GLAUCOMA increase IOP if untreated, atrophy of optic nerve disc blindness

Predisposing factors:
1
High risk group 40 & above
2
HPN
3
DM
4
Hereditary
5
Obesity
6
Recent eye trauma, infl, surgery
Type:
1
2
3
S/Sx:

Chronic (open angle G.) most common type

Obstruct in flow of aqueous humor at trabecular meshwork of canal of schlema
Acute (close angle G.) Most dangerous type
Forward displacement of iris to cornea leading to blindness.
Chronic (closed angle) - Precipitated by acute attack
1.

Loss of peripheral vision tunnel vision

67

2.
3.
4.
5.
6.
7.

Halos around lights

Headache
n/v
Steamy cornea
Eye discomfort
If untreated gradual loss of central vision blindness

Diagnosis:
1. Tonometry increase IOP >12- 21 mmHg
2. Perimetry decrease peripheral vision
3. Gonioscopy abstruction in anterior chamber
Nursing
1
2
3

mgt:
Enforce CBR
Maintain siderails
Administer meds
a
Miotics lifetime - contracts ciliary muscles & constricts pupil. Ex Pilocarpine Na (Carbachol)
b
Epinephrine eye drops decrease secretion of aqueous humor
c
Carbonic anhydrase inhibitors. Ex. acetapolamide (Diamox)
- Promotes increase out flow of aquaeous humor
d.) Temoptics (Timolol maleate)- Increase outflow of aquaous humor
4
Surgery:
Invasive:
a
Trabeculectomy eyetrephining removal of trabelar meshwork of canal or schlera to drain aqueous humor
b
Peripheral Iridectomy portion of iris is excised to drain aqueous humor
Non-invasive:
Trabeculoctomy (eye laser surgery)

Nursing Mgt pre op- all types surgery

1
Apply eye patch on unaffected eye to force weaker eye to become stronger.
Nursing
1
2
3

Mgt post op all types of surgery

Position unaffected/ unoperated side - to prevent tension on suture line.
Avoid valsalva maneuver
Monitor symptoms of IOP
a
Headache
b
n/v
c
Eye discomfort
d
Tachycardia
Eye patch both eyes - post op

CATARACT partial/ complete opacity of lens

Predisposing factor:
1
90-95% - aging (degenerative/ senile cataract)
2
Congenital
3
Prolonged exposure to UV rays
4
DMS/Sx:
1
2
3
4

Loss of central vision - Hazy or blurring of vision

Painless
Milky white appearance at center of pupil
Decrease perception of colors

Diagnosis:
Opthalmoscopic exam (+) opacity of lens
Nsg Mgt:
1
Reorient pt to environment due opacity
2
Siderails
3
Meds a.) Mydriatics dilate pupil not lifetime
Ex. Mydriacyl
c
Cyslopegics paralyzes ciliary muscle. Ex. Cyclogye
4
Surgery
E extra
C - capsular
C cataract
L - lens
E extraction
I - intra
C - capsular
C cataract

partial removal of lens

total removal of lens & surrounding capsules

68

L - lens
E extraction
Nursing Mgt:
1.Position unaffected/ unoperated side - to prevent tension on suture line.
2.Avoid valsalva maneuver
3.Monitor symptoms of IOP
a
Headache
b
n/v
c
Eye discomfort
d
Tachycardia
4.Eye patch both eyes - post op
RETINAL DETACHMENT- separation of 2 layers of retina
Predisposing factors:
1
2
3
4
5
S/Sx:
1
2
3
4
5

Severe myopia nearsightedness

Diabetic Retinopathy
Trauma
Following lens extraction
HPN

Curtain veil like vision

Flashes of lights
Floaters
Gradual decrease in central vision
Headache

Diagnosis- opthaloscopic exam

Nursing Mgt:
1
Siderails (all visual disease)
2
Surgery:
a
Cryosurgery
b
Scleral buckling
EAR
1
2
Parts:
1

Hearing
Balance (Kinesthesia or position sense)
Outera
b
c

Pinna/ auricle protects ear from direct trauma

Ext. auditory meatus has ceruminous gland. Cerumen
Tympanic membrane transmits sound waves to middle ear

Disorders of outer ear

Entry of insects put flashlight to give route of exit
Foreign objects beans (bring to MD)
H2O - drain
2. Middle ear
a.) Ear osssicle
1. Hammer
2. Anvil
3. Stirrups

-malleus
-Incus
-stapes

for bone conduction

disorder conductive hearing loss

b. Eustachian tube - Opens to allow equalization of pressure on both ears

- Yawn, chew, and swallow
Children straight, wide, short
c.) Otitis media
Adult long, narrow & slanted
c. Muscles
1. Stapedius
2. Tensor tympani
3. Inner ear
a. Bony labyrinth for balance, vestibule
Utricle & succule

69

Otolithe or ear stone has Ca carbonate

Movement of head = Righting reflex = Kinesthesia
b. Membranous Labyrinth
1
Cochlea ( function for hearing) has organ of corti
2
Endolymph & perilymph for static equilibrium
3
Mastoid air cells air filled spaces in temporal bone in skull
Complications of Mastoditis meningitis
Types of hearing loss:
1
Conductive hearing loss transmission hearing loss
Causes:
a
Impacted cerumen tinnitus & conduction hearing loss- assist in ear irrigaton
b
Immobility of stapes OTOSCLEROSIS
d.) Middle ear disease char by formation of spongy bone in the inner ear causing fixation or immobility of stapes
e.) Stapes cant transmit sound waves
Surgery
Stapedectomy removal of stapes, spongy bone & implantation of graft/ ear prosthesis
Predisposing factor:
1
Familiar tendency
2
Ear trauma & surgery
S/Sx:
1
2

Tinnitus
Conductive hearing loss

Diagnosis:
1
Audiometry various sound stimulates (+) conductive hearing loss
2
Webers test Normal AC> BC
result BC > AC

Stapedectomy
Nursing Mgt post op
1
Position pt unaffected side
2
DBE
No coughing & blowing of nose
- Night lead to removal of graft
3
Meds:
a
Analgesic
b
Antiemetic
c
Antimotion sickness agent. Ex. meclesine Hcl (Bonamine)
4
Assess motor function facial nerve - (Smile, frown, raise eyebrow)
5
Avoid shampoo hair for 1 to 2 weeks. Use shower cap
SENSORY NEURAL HEARING LOSS/ NERVE DEAFNESS
Cause:
1
Tumor on cocheal
2
Loud noises (gun shot)
3
Presbycusis bilateral progressive hearing loss especially at high frequencies elderly
Face elderly to promote lip reading
4
Menieres disease endolymphatic hydrops
f.) Inner ear disease char by dilation of endo lympathic system leading to increase volume of endolin
Predisposing factor of MENIERES DISEASE
Smoking
Hyperlipidemia
30 years old
Obesity (+) chosesteatoma
Allergy
Ear trauma & infection
S/Sx:
1

TRIAD symptoms of Menieres disease

a
Tinnitus
b
Vertigo
c
Sensory neural hearing loss
Nystagmus

70

3
4
5
6
7

n/v
Mild apprehension, anxiety
Tachycardia
Palpitations
Diaphoresis

Diagnosis:
1
Audiometry (+) sensory hearing loss
1
2
3
4

5
6
7
8

Nursing mgt:
Comfy & darkened environment
Siderails
Emetic basin
Meds:
a
Diuretics to remove endolymph
b
Vasodilator
c
Antihistamine
d
Antiemetic
e
Antimotion sickness agent
f
Sedatives/ tranquilizers
Restrict Na
Limit fluid intake
Avoid smoking
Surgery endolymphatic sac decompression- Shunt

71