MEDICAL-SURGICAL NURSING

NERVOUS SYSTEM Overview of structures and functions: Central Nervous System
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Brain Spinal Cord Cranial Nerves Spinal Nerves Sympathetic nervous system Parasympathetic nervous system AUTONOMIC NERVOUS SYSTEM

Peripheral Nervous System
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Autonomic Nervous System
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Sympathetic Nervous System (ADRENERGIC) - Involved in fight or aggression response. - Release of Norepinephrine (cathecolamines) from adrenal glands and causes vasoconstriction. - Increase all bodily activity except GIT EFFECTS OF SNS - Dilation of pupils(mydriasis) in order to be aware. - Dry mouth (thickened saliva). - Increase BP and Heart Rate. - Bronchodilation, Increase RR - Constipation. - Urinary Retention. - Increase blood supply to brain, heart and skeletal muscles. - SNS I. Adrenergic Agents - Give Epinephrine. Signs and Symptoms: - SNS Contraindication: - Contraindicated to patients suffering from COPD (Broncholitis, Bronchoectasis, Emphysema, Asthma). II. Beta-adrenergic Blocking Agents - Also called Beta-blockers. - All ending with “lol” - Propranolol, Atenelol, Metoprolol. Effects of Beta-blockers B – roncho spasm E – licits a decrease in myocardial contraction. T – reats hypertension. A – V conduction slows down.  Should be given to patients with Angina Pectoris, Myocardial Infarction, Hypertension. ANTI- HYPERTENSIVE AGENTS 1. Beta-blockers – “lol” 2. Ace Inhibitors – Angiotensin, “pril” (Captopril, Enalapril) 3. Calcium Antagonist – Nifedipine (Calcibloc)  In chronic cases of arrhythmia give Lidocaine(Xylocaine)

Parasympathetic Nervous System (CHOLINERGIC, VAGAL, SYMPATHOLYTIC) - Involved in fight or withdrawal response. - Release of Acetylcholine. - Decreases all bodily activities except GIT. EFFECTS OF PNS - Constriction of pupils (meiosis). - Increase salivation. - Decrease BP and Heart Rate. - Bronchoconstriction, Decrease RR. - Diarrhea - Urinary frequency.

I. Cholinergic Agents - Mestinon, Neostigmine. Side Effects - PNS

II. Anti-cholinergic Agents - To counter cholinergic agents. - Atropine Sulfate Side Effects - SNS

CENTRAL NERVOUS SYSTEM

Brain and Spinal Cord.

I. CELLS A. NEURONS

Basic cells for nerve impulse and conduction.

PROPERTIES Excitability – ability of neuron to be affected by changes in external environment. Conductivity – ability of neuron to transmit a wave of excitation from one cell to another. Permanent Cell – once destroyed not capable of regeneration. TYPES OF CELLS BASED ON REGENERATIVE CAPACITY 1. Labile
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Capable of regeneration. Epidermal cells, GIT cells, GUT cells, cells of lungs. Capable of regeneration with limited time, survival period. Kidney cells, Liver cells, Salivary cells, pancreas. Not capable of regeneration. Myocardial cells, Neurons, Bone cells, Osteocytes, Retinal Cells.

2. Stable
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3. Permanent
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B. NEUROGLIA

Support and protection of neurons.

TYPES 1. Astrocytes – maintains blood brain barrier semi-permeable.  2. Oligodendria 3. Microglia 4. Epindymal SUBSTANCES THAT CAN PASS THE BLOOD-BRAIN BARRIER 1. Ammonia
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Majority of brain tumors (90%) arises from called astrocytoma.

Cerebral toxin Hepatic Encephalopathy (Liver Cirrhosis) Ascites Esophageal Varices asterixis (flapping hand tremors). Headache Dizziness Confusion Fetor hepaticus (ammonia like breath) Decrease LOC

Early Signs of Hepatic Encephalopathy

Late Signs of Hepatic Encephalopathy
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PATHOGNOMONIC SIGNS 1. PTB – low-grade afternoon fever. 2. PNEUMONIA – rusty sputum. 3. ASTHMA – wheezing on expiration. 4. EMPHYSEMA – barrel chest. 5. KAWASAKI SYNDROME – strawberry tongue. 6. PERNICIOUS ANEMIA – red beefy tongue. 7. DOWN SYNDROME – protruding tongue. 8. CHOLERA – rice watery stool. 9. MALARIA – stepladder like fever with chills. 10. TYPHOID – rose spots in abdomen. 11. DIPTHERIA – pseudo membrane formation 12. MEASLES – koplik’s spots. 13. SLE – butterfly rashes. 14. LIVER CIRRHOSIS – spider like varices. 15. LEPROSY – lioning face. 16. BULIMIA – chipmunk face. 17. APPENDICITIS – rebound tenderness. 18. DENGUE – petechiae or (+) Herman’s sign. 19. MENINGITIS – Kernig’s sign (leg pain), Brudzinski sign (neck pain). 20. TETANY – HYPOCALCEMIA (+) Trousseau’s sign/carpopedal spasm; Chvostek sign (facial spasm). 21. TETANUS – risus sardonicus. 22. PANCREATITIS – Cullen’s sign (ecchymosis of umbilicus); (+) Grey turners spots. 23. PYLORIC STENOSIS – olive like mass. 24. PDA – machine like murmur. 25. ADDISON’S DISEASE – bronze like skin pigmentation. 26. CUSHING’S SYNDROME – moon face appearance and buffalo hump. 27. HYPERTHYROIDISM/GRAVE’S DISEASE – exopthalmus. 28. INTUSSUSCEPTION – sausage shaped mass 2. Carbon Monoxide and Lead Poisoning
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Can lead to Parkinson’s Disease. Epilepsy Treat with ANTIDOTE: Calcium EDTA. Causes diabetic ketoacidosis. And increases breakdown of fats. And free fatty acids Resulting to cholesterol and (+) to Ketones (CNS depressant). Resulting to acetone breath odor/fruity odor. KUSSMAUL’S respiration, a rapid shallow respiration. Which may lead to diabetic coma. Signs of jaundice (icteric sclerae). Caused by bilirubin (yellow pigment) Increase bilirubin in brain (Kernicterus). Causing irreversible brain damage.

3. Type 1 DM (IDDM)
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4. Hepatitis
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5. Bilirubin
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Astrocites

Maintains integrity of blood brain barrier. Produces myelin sheath in CNS Act as insulator and facilitates rapid nerve impulse transmission.

Oligodendria
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2.DEMYELINATING DISORDERS 1. * Give palliative or supportive care. . Ig A – present in all bodily secretions (tears. Amnesia – loss of memory. Apraxia – no recognition of objects function.short term protection. tingling sensation paresthesia numbness euphoria (sense of well being) 3. Ig E – for allergic reaction. heat and cold. Agnosia – no recognition of inanimate objects. c. saliva. ALZHEIMER’S DISEASE  Atrophy of brain tissues. Ig D – for chronic inflammation.Immediate action. Aphasia – no speech (nodding). d. Wernicke’s Aphasia General Knowing Gnostic Area or General Interpretative Area. pressure. Impaired sensation     to touch. *Expressive aphasia   “motor speech center” Broca’s Aphasia inability to understand spoken words. colostrums). Women ages 15-35 are prone Unknown Cause Slow growing virus Autoimmune disorders Pernicious anemia Myasthenia gravis Lupus Hypothyroidism GBS           Ig G – only antibody that pass placental circulation causing passive immunity. b. *Receptive aphasia    DRUG OF CHOICE: ARICEPT (taken at bedtime) and COGNEX. MULTIPLE SCLEROSIS  Chronic intermittent disorder of CNS characterized by white patches of demyelination in brain and spinal cord. Mood swings  . Signs and Symptoms 1. Characterized by remission and exacerbation. Ig M – acute in inflammation. . Sign and Symptoms 4 A’s of Alzheimer a. pain. Visual disturbances    blurring of vision (primary) diplopia (double vision) scotomas (blind spots) 2.

Maintain side rails to prevent injury related to falls. pineapple. . Prophantheline Bromide (Promanthene)   Acid ash diet like cranberry juice. Impaired cerebral function  CHARCOTS TRIAD IAN Intentional tremors 6. vitamin C and orange. Catheterization to prevent retention. MRI (reveals site and extent of demyelination).4. Monitor side effects bronchospasm and wheezing. Interferons – alter immune response. plums. Immunosupresants 2. Deep breathing exercises b. Monitor breath sounds 1 hour after subcutaneous administration. Bethanicol Chloride (Urecholine) Nursing Management    Only given subcutaneous. d. 5. b. c. Urinary retention/incontinence 7. Institute stress management techniques. Diuretics b. ACTH (Adreno Corticotropic Hormone)/ Steroids for acute exacerbation to reduce edema at site of demyelination to prevent paralysis. c. prunes. (+) Lhermitte’s sign a continuous and increase contraction of spinal column. Decrease sexual capacity DIAGNOSTIC PROCEDURE    Nystagmus CSF analysis (increase in IgG and Protein). (+) Romberg’s test) 5. Yoga 4. 3. Administer medications as ordered a. To acidify urine and prevent bacterial multiplication. Increase fluid intake and increase fiber to prevent constipation. a. Baclofen (Dioresal)/ Dantrolene Sodium (Dantrene) – muscle relaxants. Impaired motor function    weakness spasticity paralysis scanning speech TRIAD SIGNS OF MS Ataxia (Unsteady gait. NURSING MANAGEMENT 1. a. For Urinary Incontinence Anti spasmodic agent a. Constipation 8.

Temporal   hearing short term memory for appreciation discrimination of sensory impulses to pain. pressure.COMMON CAUSE OF UTI Female    short urethra (3-5 cm. touch. Frontal     higher cortical thinking controls personality controls motor activity Broca’s Area (motor speech area) when damaged results to garbled speech. pinocytosis (cell drinking). Brain Mass PARTS OF THE BRAIN 1. 2. heat. eating). avoid use of tissue papers avoid using talcum powder and perfume. Occipital . Urethra (20 cm. ORGAN Brain Blood Kidney Skin Lung MACROPHAGE Microglia Monocytes Kupffers cells Histiocytes Alveolar Macrophage EPINDYMAL CELLS  Secretes a glue called chemo attractants that concentrate the bacteria. 3. 1-1 ½ inches) poor perineal hygiene vaginal environment is moist avoid bubble bath (can alter Ph of vagina). cold. Functions of Cerebrum    integrative sensory motor Lobes of Cerebrum 1. CEREBRUM   largest part composed of the Right Cerebral Hemisphere and Left Cerebral Hemisphere enclosed in the Corpus Callosum. Parietal   4. 8 inches) urinate after intercourse Nursing Management    Male   MICROGLIA  stationary cells that carry on phagocytosis (engulfing of bacteria or cellular debris. 80% brain mass 10% blood 10% CSF COMPOSITION OF BRAIN    I. numbness.

controls pituitary functions androgenic hormones promotes secondary sex characteristics. controls libido controls long term memory Insula (Island of Reil)  Limbic System (Rhinencephalon)    2. controls blood pressure controls thirst appetite/satiety sleep and wakefulness controls some emotional responses like fear. MIDBRAIN/ MESENCEPHALON       acts as relay station for sight and hearing. size of pupil is 2 – 3 mm. vomiting. lesser brain. equal size of pupil is isocoria. . rhythm and depth of respiration. swallowing. controls respiration. Medulla Oblongata  3. Pons  pneumotaxic center controls the rate. for vision visceral function activities of internal organ like gastric motility. Cerebellum   smallest part of the brain. Hypothalamus            5. unequal size of pupil is anisocoria. controls smell and if damaged results to Anosmia (absence of smell). early sign for females telarche and late sign is menarche. 2. B. vasomotor center (dilation and constriction of bronchioles). release dopamine (controls gross voluntary movement. early sign for males are testicular and penile enlargement late sign is deepening of voice. BRAIN STEM  located at lowest part of brain Parts of Brain Stem 1. hiccup. heart rate. INTERBRAIN/ DIENCEPHALON Parts of Diencephalon A. BASAL GAGLIA   areas of grey matter located deep within each cerebral hemisphere. positive PERRLA 4. DECREASE Myasthenia Gravis Parkinson’s Disease INCREASE Bi-polar Disorder Schizophrenia NEURO TRANSMITTER Acethylcholine Dopamine 3. controls temperature (thermoregulatory center). Thalamus  acts as relay station for sensation. hearing acuity is 30 – 40 dB. anxiety and excitement.

heart rate decrease respiratory rate decrease temperature increase directly proportional to blood pressure. INTRA CRANIAL PRESSURE Monroe Kellie Hypothesis Skull is a closed container Any alteration or increase in one of the intracranial components Increase intra-cranial pressure (normal ICP is 0 – 15 mmHg) Cervical 1 – also known as ATLAS. Causes:     head trauma/injury localized abscess cerebral edema hemorrhage decrease LOC restlessness/agitation irritability inflammatory condition (stroke) hydrocephalus tumor (rarely) Signs and Symptoms (Early)    lethargy/stupor coma Signs and Symptoms (Late)            changes in vital signs blood pressure (systolic blood pressure increases but diastolic remains the same). widening of pulse pressure is neurologic in nature (if narrow cardiac in nature). projective vomiting headache papilledema (edema of optic disc) abnormal posturing decorticate posturing (damage to cortex and spinal cord). Cervical 2 – also known as AXIS.    NEUROLOGIC DISORDERS INCREASE INTRACRANIAL PRESSURE – increase in intra-cranial bulk brought about by an increase in one of the 3 major intra cranial components. Foramen Magnum Medulla Oblongata Brain Herniation Increase intra cranial pressure * Alternate hot and cold compress to prevent HEMATOMA CSF cushions brain (shock absorber) Obstruction of flow of CSF will lead to enlargement of skull posteriorly called hydrocephalus. Early closure of posterior fontanels causes posterior enlargement of skull in hydrocephalus. posture and gait. controls balance. . equilibrium.

Prevent complications of 6. 7. Nursing Management . Elevate bed of client 30 – 35o angle with neck in neutral position unless contraindicated to promote venous drainage. unilateral dilation of pupils called uncal herniation bilateral dilation of pupils called tentorial herniation resulting to mild headache possible seizure activity     Nursing Management 1. b. b. instruct client to avoid forms of valsalva maneuver like:      straining stool excessive vomiting (use anti emetics) excessive coughing (use anti tussive like dextromethorphan) avoid stooping/bending avoid lifting heavy objects e. In chronic respiratory distress syndrome decrease O2 stimulates respiration. c. d. maintain side rails. Prevention of hypoxia and hypercarbia Early signs of hypoxia    restlessness agitation tachycardia Bradycardia Extreme restlessness Dyspnea Cyanosis Increase CO2 (most powerful respiratory stimulant) retention. avoid clustering of nursing activity together. Maintain patent and adequate ventilation by: a. Osmotic diuretic (Mannitol) for cerebral diuresis Nursing Management monitor vital signs especially BP (hypotension). avoid use of restraints. Loop diuretic (Lasix. Administer medications like: a. provide an comfortable and quite environment. Before and after suctioning hyper oxygenate client 100% and done 10 – 15 seconds only. c. 4. Late signs of hypoxia     HYPERCARBIA   b. administered via side drip regulated fast drip to prevent crystal formation. Prevent further increase ICP by: a. Limit fluid intake to 1200 – 1500 ml/day (in force fluids 2000 – 3000 ml/day). monitor strictly input and output every 1 hour notify physician if output is less 30 cc/hr. Furosemide)   Drug of choice for CHF (pulmonary edema) Loop of Henle in kidneys. 3. Monitor strictly input and output and neuro check 5. cerebellum and midbrain). Assist in mechanical ventilation 2. decerebrate posturing (damage to upper brain stem that includes pons.

      Monitor vital signs especially BP (hypotension). blood monitor RIGHT CONGESTIVE HEART FAILURE (Venous congestion) Signs and Symptoms          jugular vein distention (neck) ascites pitting edema weight gain hepatosplenomegaly jaundice pruritus esophageal varices anorexia and general body malaise . Phenytoin) c. given early morning immediate effect of 10 – 15 minutes. Corticosteroids      *CONGESTIVE HEART FAILURE Signs and Symptoms              dyspnea orthopnea paroxysmal nocturnal dyspnea productive cough frothy salivation cyanosis rales/crackles bronchial wheezing pulsus alternans anorexia and general body malaise PMI (point of maximum impulse/apical pulse rate) is displaced laterally S3 (ventricular gallop) Predisposing Factors/Mitral Valve  RHD  Aging TREATMENT Morphine Sulfate Aminophelline Digoxin Diuretics Oxygen Gases. monitor strictly input and output every 1 hour notify physician if output is less 30 cc/hr. maximum effect of 6 hours. Dexamethasone (Decadron) Hydrocortisone Prednisone (to reduce edema that may lead to increase ICP) Mild Analgesics (Codeine Sulfate for respiratory depression) Anti Convulsants (Dilantin. administered IV push or oral.

Oral Potassium Chloride) increase intake of foods rich in potassium FRUITS Apple Banana Cantalop e Oranges 2. Hyponatremia        DECREASE decrease sodium level normal value is 135 – 145 meq/L Signs and Symptoms       hypotension dehydration signs (Initial sign in adult is THIRST. Hypokalemia   decrease potassium level normal value is 3.5 meq/L weakness and fatigue constipation positive U wave on ECG tracing Sign and Symptoms    Nursing Management   administer potassium supplements as ordered (Kalium Durule.Signs and Symptoms of Lasix in terms of electrolyte imbalances 1.4 – 5. Hypocalcemia/ Tetany VEGETABLES Asparagus Brocolli Carrots Spinach   decrease calcium level normal value is 8. in infant TACHYCARDIA) agitation dry mucous membrane poor skin turgor weakness and fatigue .5 – 11 mg/100 ml Signs and Symptoms tingling sensation paresthesia numbness (+) Trousseau’s sign/ Carpopedal spasm (+) Chvostek’s sign Complications Arrhythmia Seizures Nursing Management Calcium Gluconate per IV slowly as ordered * Calcium Gluconate toxicity – results to SEIZURE Magnesium Sulfate Magnesium Sulfate toxicity S/S BP Urine output Respiratory rate Patellar relfex absent 3.

Hyperglycemia  normal FBS is 80 – 100 mg/dl polyuria polydypsia polyphagia monitor FBS Signs and Symptoms    Nursing Management  5. Hyperuricemia    increase uric acid (purine metabolism) foods high in uric acid (sardines. Nursing Management   a. organ meats and anchovies) *Increase in tophi deposit leads to Gouty arthritis. Acute gout Mechanism of action: promotes excretion of uric acid. Signs and Symptoms   Nursing Management   a. joint pain (great toes) swelling force fluids administer medications as ordered Drug of choice for gout. Allopurinol (Zyloprim) Side Effects  Respiratory depression (check for RR) . Narcotic Analgesic   b. Mechanism of action: inhibits synthesis of uric acid. Colchecine   * KIDNEY STONES Signs and Symptoms   renal colic Cool moist skin force fluids administer medications as ordered Morphine Sulfate ANTIDOTE: Naloxone (Narcan) toxicity leads to tremors. Allopurinol (Zyloprim)   b.Nursing Management   force fluids administer isotonic fluid solution as ordered 4.

increase lacrimation c. Predisposing Factors 1. Reserpine(Serpasil) b. Monotone type speech mood lability (in state of depression) increase salivation (drooling type) autonomic changes a. bradykinesia (slowness of movement) rigidity (cogwheel type) stooped posture shuffling and propulsive gait over fatigue mask like facial expression with decrease blinking of the eyes. Phenothiazine AntipsychoticS AntihypertensiveS SIDE EFFECTS RESERPINE  Major depression leading to suicide Aloneness Multiple loss causes suicide Loss of spouse direct approach towards the client close surveillance is a nursing priority Loss of Job    time to commit suicide is on weekends early morning Signs and Symptoms for Parkinson’s             pill rolling tremors of extremities especially the hands.PARKINSON’S DISEASE/ PARKINSONISM  Chronic progressive disorder of CNS characterized by degeneration of dopamine producing cells in the SUBSTANCIA NIGRA of the midbrain and basal ganglia. Administer medications as ordered Anti Parkinsonian agents    Levodopa (L-dopa) short acting Amantadine Hydrochloride (Symmetrel) Carbidopa (Sinemet) . constipation e. seborrhea d. difficulty rising from sitting position. Haloperidol(Haldol) d. decrease sexual capacity Nursing Management 1. Poisoning (lead and carbon monoxide) 2. Encephalitis 5. Arteriosclerosis 3. Methyldopa(Aldomet) c. increase sweating b. Increase dosage of the following drugs: a. Hypoxia 4.

to relieve tremors Mechanism of Action  inhibits action of acethylcholine SNS Side Effects  Anti Histamine (Dipenhydramine Hydrochloride) Side Effects Adult: drowsiness Children: CNS excitement (hyperactivity) because blood brain barrier is not yet fully developed.5 meq/L . Assist in Stereotaxic Thalamotomy MAGIC 2’s IN DRUG MONITORING DRUG Digoxin/ Lanoxin (Increase force of cardiac output) Lithium/ Lithane (Decrease level of Ach/NE/Serotonin) Aminophylline (Dilates bronchial tree) Dilantin/ Phenytoin Acetaminophen/Tylenol NORMAL RANGE .2 meq/L 10 – 19 mg/100 ml 10 – 19 mg/100 ml 10 – 30 mg/100 ml TOXICITY LEVEL 2 2 20 20 200 INDICATION CHF Bipolar COPD Seizures Osteo Arthritis CLASSIFICATION Cardiac Glycoside Anti-Manic Agents Bronchodilators Anti-Convulsant Non-narcotic Analgesic . Maintain side rails to prevent injury 3.Mechanism of Action  increase level of dopamine GIT irritation (should be taken with meals orthostatic hypotension arrhythmia hallucinations clients with narrow angle closure glaucoma clients taking MAOI’s (no foods with triptophan and thiamine) urine and stool may be darkened no Vitamin B6 (Pyridoxine) reverses the therapeutic effects of Levodopa Side Effects     Contraindications     * Increase Vitamin B when taking INH (Isoniazid). 6. Prevent complications of immobility 4. Assist/supervise in ambulation 7.6 – 1.5 – 1.relieves tremor rigidity Bromocriptene Hydrochloride (Parlodel) Side Effects  Respiratory depression 2. Dopamine Agonist . Isonicotinic Acid Hydrazide Anti Cholinergic Agents (ARTANE and COGENTIN) . Encourage increase fluid intake and fiber. Decrease protein in morning and increase protein in afternoon to induce sleep 5.

Aminophylline Toxicity Signs and Symptoms    tachycardia palpitations CNS excitement (tremors. Digitalis Toxicity Signs and Symptoms      nausea and vomiting diarrhea confusion photophobia changes in color perception (yellowish spots) Antidote: Digibind 2. Acetaminophen Toxicity Signs and Symptoms      hepatotoxicity (monitor for liver enzymes) SGPT/ALT (Serum Glutamic Pyruvate Transaminace) SGOT/AST (Serum Glutamic Oxalo-Acetil Transaminace) nephrotoxicity monitor BUN (10 – 20) and Creatinine (.1. Dilantin Toxicity Signs and Symptoms     gingival hyperplasia (swollen gums) hairy tongue ataxia nystagmus provide oral care massage gums Nursing Management   5. tachycardia Irritability Restlessness Extreme fatigue Diaphoresis. agitation and restlessness) only mixed with plain NSS or 0.9 NaCl to prevent development of crystals or precipitate. administered sandwich method avoid taking alcohol because it can lead to severe CNS depression avoid caffeine Nursing Management     4. Lithium Toxicity Signs and Symptoms      anorexia nausea and vomiting diarrhea dehydration causing fine tremors hypothyroidism force fluids increase sodium intake to 4 – 10 g% daily Nursing Management   3. irritability. depression Antidote: Acetylcisteine (mucomyst) prepare suction apparatus as bedside. .8 – 1) hypoglycemia Tremors.

Nursing Management 1. Incidence rate: women 20 – 40 years old Predisposing factors   unknown autoimmune: it involves release of cholinesterase an enzyme that destroys Ach.G.infection Signs and Symptoms . breathe Treatment .administer cholinergic agents as ordered 7. input and output and neuro check * monitor strength or motor grading scale 4. aspiration 3. initial sign is ptosis a clinical parameter to determine ptosis is palpebral fissure. Assist in plasma paresis and removing auto immune anti bodies 9. maintain side rails to prevent injury related to falls 5. Prevent complications . speak. mmobility * assist in mechanical ventilation and monitor pulmonary function test * monitor strictly vital signs.The client is unable to see. Anti Cholenisterase (Neostegmin) Mechanism of Action  maintain patent airway and adequate ventilation increase level of Ach PNS Cortocosteroids suppress immune response monitor for 2 types of crisis: CHOLINERGIC CRISIS Cause: . if there is no effect there is damage to occipital lobe and midbrain and is negative for Signs and Symptoms        Diagnostic Procedure   M. administer medications as ordered a.PNS Treatment . swallow.MYASTHENIA GRAVIS  neuromuscular disorder characterized by a disturbance in the transmission of impulses from nerve to muscle cells at the neuromuscular junction leading to descending muscle weakness. Assist in surgical procedure known as thymectomy because it is believed that the thymus gland is responsible for M. 8.over medication Signs and Symptoms . Cholinergic (Mestinon) b. diplipia mask like facial expression dysphagia hoarseness of voice respiratory muscle weakness that may lead to respiratory arrest extreme muscle weakness especially during exertion and morning Tensilon test (Edrophonium Hydrochloride) provides temporary relief of signs and symptoms for about 5 – 10 minutes and a maximum of 15 minutes.under medication . institute NGT feeding 6.G. airway 2.stress .Administer anti cholinergic agents (Atropine Sulfate) Side Effects    MYASTHENIC CRISIS Causes: .

Pia matter – inner layer   subdural space between the dura and arachnoid subarachnoid space between the arachnoid and pia. Place flat on bed 12 – 24 o 2. chills.INFLAMMATORY CONDITIONS OF THE BRAIN MENINGITIS Meninges     3 fold membrane that covers brain and spinal cord. (+) Kernig’s sign (leg pain) d. Pneumococcus 3. CSF analysis reveals 1. Force fluids 3. Diagnostic Procedures  Lumbar puncture: a hollow spinal needle is inserted in the subarachnoid space between the L3 – L4 to L5. Signs and Symptoms        headache photophobia projectile vomiting fever. Nuchal rigidity or stiff neck b. Hemophilus Influenzae – causes pediatric meningitis B. Mode of transmission  airborne transmission (droplet nuclei) C. Etiology 1. Post Lumbar Puncture 1. general body malaise and weight loss Possible increase in ICP and seizure activity Abnormal posturing (decorticate and decerebrate) Signs of meningeal irritation a. for support and protection for nourishment blood supply LAYERS OF THE MENINGES 1. (+) Brudzinski sign (neck pain) D. Decrease glucose 3. CSF aspiration is done. Secure informed consent and explain procedure. Check punctured site for any discoloration. Encourage to arch back to clearly visualize L3-L4. 4. Empty bladder and bowel to promote comfort. Increase CSF opening pressure (normal pressure is 50 – 100 mmHg) 4. Nursing Management for LP Before Lumbar Puncture 1. drainage and leakage to tissues. Dura matter – outer layer 2. Assess for movement and sensation of extremities. 2. Increase wbc . Streptococcus . anorexia.causes adult meningitis 4. Meningococcus – most dangerous 2. Opisthotonus (arching of back) c. Arachnoid – middle layer 3. 3. A. (+) cultured microorganism (confirms meningitis) CBC reveals 1. Increase CHON and WBC 2.

Incidence Rate  men are 2-3 times high risk B. 2 most common cerebral artery affected by stroke a. input and output and neuro check 6. Mid Cerebral Artery b. calories with small frequent feedings. Anti pyretics 3. Internal Cerebral Artery – the 2 largest artery A. 8. CHON. Rehabilitation for neurological deficit   CVA (STROKE/BRAIN ATTACK/ ADOPLEXY/ CEREBRAL THROMBOSIS)   a partial or complete disruption in the brains blood supply. Monitor strictly V/S.E. If there is bone fracture there is hemorrhage and there would be escape of the fat cells in the circulation. Enforce complete bed rest 2. Provide client health care and discharge planning concerning: a. Mild analgesics c. Nursing Management 1. b. Elevate head 30-45o 5. Tetracycline) b. Signs and Symptoms of Pulmonary Embolism       Sudden sharp chest pain Unexplained dyspnea Tachycardia Palpitations Diaphoresis Mild restlessness Headache and dizziness Confusion Restlessness Decrease LOC Signs and Symptoms of Cerebral Embolism     Fat embolism is the most feared complications after femur fracture. 7. Compartment syndrome (compression of arteries and nerves) . Administer medications as ordered a. Yellow bone marrow are produced from the medullary cavity of the long bones and produces fat cells. Institute measures to prevent increase ICP and seizure. Broad spectrum antibiotics (Penicillin. Institute strict respiratory isolation 24 hours after initiation of anti biotic therapy 4. Prevent complications    most feared is hydrocephalus hearing loss/nerve deafness is second complication consult audiologist mental retardation delayed psychomotor development c. Maintain fluid and electrolyte balance. Predisposing Factors   thrombus (attached) embolus (detached and most dangerous because it can go to the lungs and cause pulmonary embolism or the brain and cause cerebral embolism. Maintain good diet of increase CHO. Provide a comfortable and darkened environment. 9.

homonymous hemianopsia (loss of half of visual field) 1. D. phlegia b. Obesity (increase 20% ideal body weight) 4. TIA  Signs and Symptoms      2. Myocardial Infarction. Type A personality a. Risk Factors 1. Signs and Symptoms  Heart Disease. nausea and vomiting dysphagia (+) Kernig’s sign and Brudzinski sign which may lead to hemorrhagic stroke focal neurological deficits a. Hypertension. alexia (difficulty reading) e. Atherosclerosis. CT Scan – reveals brain lesions 2. dysarthria (inability to articulate words) d. Related stress physical and emotional 8. Lifestyle (smoking). deadline driven b. usually fells guilty when not doing anything 6. agraphia (difficulty writing) f. Valvular Cardiac Surgery (mitral valve replacement) 2. Prolong use of oral contraceptives promotes lypolysis (breakdown of lipids) leading to atherosclerosis that will lead to hypertension and eventually CVA. Post dependent on stages of development Initial sign of stroke or warning sign headache and dizziness tinnitus visual and speech disturbances paresis (plegia) possible increase ICP progression of signs and symptoms of stroke resolution phase characterized by: headache and dizziness Cheyne Stokes Respiration anorexia. Cerebral Arteriography        reveals the site and extent of malocclusion uses dye for visualization most of dye are iodine based check for shellfish allergy after diagnostic exam force fluids to release dye because it is nephro toxic check for distal pulse (femoral) check for hematoma formation . Stroke in evolution  3. Related to diet: increase intake of saturated fats like whole milk 7. Complete stroke  Signs and Symptoms       E. Diabetes Mellitus.C. aphasia c. sedentary lifestyle 3. can do multiple tasks c. Hyperlipidemia more on genetics/genes that binds to cholesterol 5. Diagnostic Procedure 1.

Anti Platelet   PASA (Aspirin) Contraindicated for dengue. avoidance of modifiable risk factors (diet. magic slate 9. ulcer and unknown cause of headache because it may potentiate bleeding 11. prevent complication (subarachnoid hemorrhage is the most feared complication) c. Mild Analgesics e. exercise. Anti Coagulants  Heparin (short acting)   check for partial thromboplastin time if prolonged there is a risk for bleeding. provide sand bag or food board. Nursing Management 1. saturated fats and caffeine) d. Elevate head 30 – 45o 4. smoking) b. Restrict fluids to prevent cerebral edema that might increase ICP 3. If positive to hemianopsia approach client on unaffected side 10. Maintain patent airway and adequate ventilation by: a. I & O and neuro check 5. importance of follow up care . Assist in passive ROM exercise every 4 hours to promote proper bodily alignment and prevent contractures 7. provide egg crate mattresses or water bed c. assist in mechanical ventilation b. Provide alternative means of communication a. dietary modification (decrease salt. turn client to side b. Cortecosteroids d. K (Aqua Mephyton) g. Administer medications as ordered a. administrate O2 inhalation 2. non verbal cues b. Provide client health teachings and discharge planning concerning a. 6. give Protamine Sulfate  Comadin/ Warfarin (long acting)    give simultaneously because Coumadin will take effect after 3 days check for prothrombin time if prolonged there is a risk for bleeding give Vit. Monitor strictly vitals signs. Thrombolytic/Fibrinolytic Agents – dissolves thrombus  Streptokinase  Side Effect: Allergic Reaction Urokinase Tissue Plasminogen Activating Factor  Side Effect: Chest Pain   f. Osmotic Diuretics (Mannitol) b. Institute NGT feeding 8. Furosemide) c.F. Prevent complications of immobility by: a. Loop Diuretics (Lasix.

Arrythmia b.  . Dysphagia 3. Antecedent viral infections such as LRT infections B. Ascending muscle weakness leading to paralysis 4. Nursing Management 1. Maintain patent airway and adequate ventilation by: a.GUILLAIN BARRE SYNDROME  a disorder of the CNS characterized by bilateral symmetrical polyneuritis leading to ascending muscle paralysis. Anti Arrythmic Agents   Lidocaine. Assist in plasma pharesis (filtering of blood to remove autoimmune anti-bodies) 9. Signs and Symptoms 1. assist in mechanical ventilation b. vital signs b. A. Maintain side rails to prevent injury related to fall 4. constipation C. intake and output c. Administer medications as ordered a. Diagnostic Procedures 1. Zylocaine Bretylium – blocks release of norepinephrine to prevent increase of BP 8. Anti Cholinergic Agents – Atrophine Sulfate c. monitor pulmonary function test 2. Autonomic symptoms that includes a. neuro check d. Alternate hypotension to hypertension ** ARRYTHMIA (most feared complication) 6. Prevent complications a. Prevent complications of immobility by turning the client every 2 hours 5. increase sweating c. increase salivation b. Monitor strictly the following a. Decreased of diminished deep tendon reflex 5. Corticosteroids – suppress immune response b. Paralysis or respiratory muscles/Respiratory arrest * Sengstaken Blakemore Tube   for liver cirrhosis to decompress bleeding esophageal verices (prepare scissor to cut tube incase of difficulty in breathing to release air in the balloon for hemodialysis prepare bulldog clips to prevent air embolism. Predisposing Factors 1. ECG 3. Autoimmune 2. CSF analysis reveals increase in IgG and protein D. Clumsiness (initial sign) 2. Institute NGT feeding to prevent aspiration 6. Assist in passive ROM exercise 7.

tactile.contraction of extremities d. Genetics 3. automatism – stereotype repetitive and non propulsive behavior b. clouding of consciousness – not in contact with environment c. Head injury due to birth trauma 2. Presence of brain tumor 4. Predisposing Factors 1. visual. Nutritional and Metabolic deficiencies 6. Drug of choice: Diazepam. Signs and Symptoms  Dependent on stages of development or types of seizure I. loss of consciousness (5 – 10 seconds) II.CONVULSIVE DISORDER/ CONVULSION  disorder of CNS characterized by paroxysmal seizure with or without loss of consciousness abnormal motor activity alternation in sensation and perception and changes in behavior. CT Scan – reveals brain lesions 2. Post ictal sleep – unresponsive sleep 2. Seizure – first convulsive attack Epilepsy – second or series of attacks Febrile seizure – normal in children age below 5 years    A. Status Epilepticus  A continuous uninterrupted seizure activity. Partial or Localized Seizure 1. olfactory. if left untreated can lead to hyperpyrexia and lead to coma and eventually death. Petit mal Seizure – absence of seizure common among pediatric clients characterized by a. blank stare b. decrease blinking of eyes c. Valium and Glucose  C. Psychomotor Seizure (focal motor seizure) a. Toxicity from a. mild hallucinatory sensory experience III.direct symmetrical extension of extremities Clonic contractions . Signs or aura with auditory. Epileptic cry – is characterized by fall and loss of consciousness for 3 – 5 minutes c. 2. twitching of mouth d. EEG – reveals hyper activity of electrical brain waves . Sudden withdrawal to anti convulsant drug is predisposing factor for status epilepticus (drug of choice is Diazepam. Diagnostic Procedures 1. Grand mal Seizure (tonic-clonic seizure) a. Valium) B. sensory experience b. lead b carbon monoxide 5. Physical and emotional stress 7. Generalized Seizure 1. Jacksonian Seizure (focal seizure)  Characterized by tingling and jerky movement of index finger and thumb that spreads to the shoulder and other side of the body. Tonic contractions .

D. Nursing Management 1. Maintain patent airway and promote safety before seizure activity a. clear the site of blunt or sharp objects b. loosen clothing of client c. maintain side rails d. avoid use of restrains e. turn clients head to side to prevent aspiration f. place mouth piece of tongue guard to prevent biting or tongue 2. Avoid precipitating stimulus such as bright/glaring lights and noise 3. Administer medications as ordered a. Anti convulsants (Dilantin, Phenytoin) b. Diazepam, Valium c. Carbamazepine (Tegretol) – Trigeminal neuralgia d. Phenobarbital, Luminal 4. Institute seizure and safety precaution post seizure attack a. administer O2 inhalation b. provide suction apparatus 5. Document and monitor the following a. onset and duration b. types of seizures c. duration of post ictal sleep may lead to status epilepticus d. assist in surgical procedure cortical resection COMPREHENSIVE NEURO EXAM GLASGOW COMA SCALE

objective measurement of LOC sometimes called as the quick neuro check

Components 1. Motor response 2. Verbal response 3. Eye opening Conscious Lethargy Stupor Coma Deep Coma 15 – 14 13 – 11 10 – 8 7 3

Survey of mental status and speech a. LOC b. Test of memory Levels of orientation Cranial nerve assessment Sensory nerve assessment Motor nerve assessment Deep tendon reflex Autonimics Cerebellar test a, Romberg’s test – 2 nurses, positive for ataxia b. Finger to nose test – positive result mean dimetria (inability of body to stop movement at desired point) c. Alternate supination and pronation – positive result mean dimetria

      

I. LEVEL OF CONSCIOUSNESS 1. Conscious - awake 2. Lethargy – lethargic (drowsy, sleepy, obtunded) 3. Stupor
  

stuporous (awakened by vigorous stimulation) generalized body weakness decrease body reflex comatose light coma (positive to all forms of painful stimulus) deep coma (negative to all forms of painful stimulus)

4. Coma
  

DIFFERENT PAINFUL STIMULATION 1. Deep sternal stimulation/ deep sternal pressure 2. Orbital pressure 3. Pressure on great toes 4. Corneal or blinking reflex Conscious client use a wisp of cotton Unconscious client place 1 drop of saline solution II. TEST OF MEMORY 1. Short term memory
 

ask most recent activity positive result mean anterograde amnesia and damage to temporal lobe ask for birthday and validate on profile sheet positive result mean retrograde amnesia and damage to limbic system consider educational background

2. Long term memory
  

III. LEVELS OF ORIENTATION 1. Time – first asked 2. Person – second asked 3. Place – third asked CRANIAL NERVES CRANIAL NERVES I. OLFACTORY II. OPTIC III OCCULOMOTOR IV. TROCHLEAR V. TRIGEMINAL VI. ABDUCENSE VII. FACIAL VIII. ACOUSTIC IX. GLOSSOPHARYNGEAL X. VAGUS FUNCTION S S M M (Smallest) B (Largest) M B S B B

(Longest) XI. SPINAL ACCESSORY M XII. HYPOGLOSSAL M CRANIAL NERVE I: OLFACTORY

sensory function for smell

Material Used

 

don’t use alcohol, ammonia, perfume because it is irritating and highly diffusible. use coffee granules, vinegar, bar of soap, cigarette test each nostril by occluding each nostril

Procedure

Abnormal Findings 1. Hyposnia – decrease sensitivity to smell 2. Dysosmia – distorted sense of smell 3. Anosmia – absence of smell Indicative of 1. head injury damaging the cribriform plate of ethmoid bone where olfactory cells are located 2. may indicate inflammatory conditions (sinusitis) CRANIAL NERVE II: OPTIC

sensory function for vision or sight

Functions 1. Test visual acuity or central vision or distance
      

use Snellen’s Chart Snellen’s Alphabet chart: for literate clients Snellen’s E chart: for illiterate clients Snellen’s Animal chart: for pediatric clients normal visual acuity 20/20 numerator is constant, it is the distance of person from the chart (6 – 7 m, 20 feet) denominator changes, indicates distance by which the person normally can see letter in the chart. - 20/200 indicates blindness 20/20 visual acuity if client is able to read letters above the red line. a. Superiorly b. Bitemporaly c. Nasally d. Inferiorly

 

2. Test of visual field or peripheral vision

COMMON VISUAL DISORDERS 1. Glaucoma
  

increase IOP normal IOP is 12 – 21 mmHg preventable but not curable Common among 40 years old and above Hereditary Hypertension Obesity

A. Predisposing Factors
   

B. Signs and Symptoms 1. Loss of peripheral vision

pathognomonic sign is tunnel vision steamy cornea may lead to blindness

2. Headache, nausea, vomiting, eye pain (halos around light)
 

C. Diagnostic Procedures 1. Tonometry 2. Perimetry

Cyclopegics (Cyclogyl) – paralyses cilliary muscle F. Epinephrine eyedrops – decrease formation of aqueous humor 3. Gonioscopy D. Aging 65 years and above 2. Blurring or hazy vision 2. Opthalmoscopic exam E. Treatment 1. Pilocarpine Sodium. Milky white appearance at center of pupils 3. Carbonic Anhydrase Inhibitors a.Total removal of cataract with its surrounding capsules  Most feared complication post op is RETINAL DETACHMENT 3. Diabetes Mellitus 4. Decrease perception to colors  Complication is blindness D. Diagnostic Procedure 1. Signs and Symptoms 1. Prolonged exposure to UV rays B. Timoptics (Timolol Maleate) E. Loss of central vision C. Acetazolamide (Diamox) – promotes increase outflow of aqueous humor or drainage 4. Surgical Procedures 1. Retinal Detachment  Separation of epithelial surface of retina . Treatment 1.3. Mydriatics (Mydriacyl) – constricts pupils 2. Pathognomonic Signs 1. TRABECULECTOMY (Peripheral Indectomy) – drain aqueous humor 2. Miotics – constricts pupil a. Related to congenital 3. Cataract  Decrease opacity of lens A.Partial removal Intra Capsular Cataract Lens Extraction . Predisposing Factor 1. Carbachol 2. Surgical Procedure Extra Capsular Cataract Lens Extraction .

Myopia (near sightedness) B. Predisposing Factors 1. Signs and Symptoms 1. TROCHLEAR. Scleral Buckling 2.A. maxillary. ABDUCENS   Controls or innervates the movement of extrinsic ocular muscle (EOM) 6 muscles Superior Rectus Superior Oblique Lateral Rectus Medial Rectus Inferior Oblique Inferior Rectus    trochlear controls superior oblique abducens controls lateral rectus oculomotor controls the 4 remaining EOM Oculomotor      controls the size and response of pupil normal pupil size is 2 – 3 mm equal size of pupil: Isocoria Unequal size of pupil: Anisocoria Normal response: positive PERRLA CRANIAL NERVE V: TRIGEMINAL   largest cranial nerve consists of ophthalmic. Diathermy – heat application 4. Post Lens Extraction 2. VI: OCULOMOTOR. Black Spots CRANIAL NERVE III. mandibular . Signs and Symptoms 1. IV. Curtain veil like vision 2. Macular Degeneration  Degeneration of the macula lutea (yellowish spot at the center of retina) A. Surgical Procedures 1. Cryosurgery – cold application 3. Floaters C.

posterior 1/3 of tongue Vagus: controls gag reflex Uvula should be midline and if not indicative of damage to cerebral hemisphere Effects of vagal stimulation is PNS CRANIAL NERVE XI: SPINAL ACCESSORY  Innervates with sternocleidomastoid (neck) and trapezius (shoulder) CRANIAL NERVE XII: HYPOGLOSSAL   Controls the movement of tongue Let client protrude tongue and it should be midline and if unable to do indicative of damage to cerebral hemisphere and/or has short frenulum.    sensory: controls sensation of face. anterior 2/3 of tongue pinch of sugar and cotton applicator placed on tip of tongue Motor: controls muscle of facial expression instruct client to smile. Inner Ear     Vestibule: Meinere’s Disease Cochlea Mastoid Cells Endolymph and Perilymph COCHLEA: controls hearing. refers to movement and orientation of the body in space. frown and if results are negative there is facial paralysis or Bell’s Palsy and the primary cause is forcep delivery. VAGUS NERVE     Glosopharyngeal: controls taste. Outer Ear   Pinna Eardrum Hammer Anvil Stirrup Malleus Incus Stapes 2. Pituitary Gland (Hypophysis Cerebri) . Middle Ear    3. Parts of the Ear 1. teeth. ENDOCRINE SYSTEM Overview of the structures and functions 1. mucous membrane. soft palate and corneal reflex) motor: controls the muscle of mastication or chewing damage to CN V leads to trigeminal neuralgia/thickdolorum medication: Carbamezapine(Tegretol) CRANIAL NERVE VII: FACIAL     Sensory: controls taste. contains the Organ of Corti (the true organ of hearing) Let client repeat words uttered CRANIAL NERVE IX. X: GLOSOPHARYNGEAL. CRANIAL NERVE VIII: ACOUSTIC/VESTIBULOCOCHLEAR  Controls balance particularly kinesthesia or position sense.

Agitation c. Pitressin (Vasopresin Tannate) – administered IM Z-tract 4. Administer medications as ordered a. Adult: thirst b. Prevent complilcations – HYPOVOLEMIC SHOCK is the most feared complication Normal value: 1. Posterior Pituitary Gland 2. Signs and Symptoms 2. Force fluids 2. Dry mucous membrane 3. Weakness and fatigue 4. Serum Sodium D. Monitor strictly vital signs and intake and output 3. Diagnostic Procedures 1. Antidiuretic Hormone o o o Pitressin (Vasopressin) Function: prevents urination thereby conserving water Diabetes Insipidus/ Syndrome of Inappropriate Anti Diuretic Hormone DIABETES INSIPIDUS o Decrease production of anti diuretic hormone A. Urine Specific Gravity o o o 1. Polyuria 2. Poor Skin turgor d.o o o Located at base of brain particularly at sella turcica Master gland or master clock Controls all metabolic function of body PARTS OF THE PITUITARY GLAND 1.015 – 1. Predisposing Factor o o o o 1. initiates milk let down reflex with help of hormone prolactin called as adenohypophysis called as neurohypophysis secretes hormones oxytocin -promotes uterine contractions preventing bleeding/ 2. Anterior Pituitary Gland o o o hemorrhage o o administrate oxytocin immediately after delivery to prevent uterine atony. Signs of dehydration a. Hypotension 5. Weight loss 6. If left untreated results to hypovolemic shock (sign is anuria) C.030 Ph 4 – 8 Increase resulting to hypernatremia Related to pituitary surgery Trauma Inflammation Presence of tumor B. Nursing Management .

Prone to skin cancer o Hypersecretion of MSH results to Vitiligo 3. Water intoxication may lead to cerebral edema and lead to increase ICP – may lead to seizure activity C.SIADH o hypersecretion of anti diuretic hormone A. Restrict fluid 2. Predisposing Factors 1. Head injury 2. Prevent complications ANTERIOR PITUITARY GLAND o also called ADENOHYPOPHYSIS secretes Promotes elongation of long bones Hyposecretion of GH among children results to Dwarfism Hypersecretion of GH results to Gigantism Hypersecretion of GH among adults results to Acromegaly (square face) Drug of choice: Ocreotide (Sandostatin) 1. Serum Sodium is decreased D. Osmotic diuretics (Mannitol) 3. Fluid retention a. Lead to blindness due to severe photophobia b. Melanocyte Stimulating hormone o o o for skin pigmentation Hyposecretion of MSH results to Albinism Most feared complications of albinism a. Adrenochorticotropic hormone (ACTH) o promotes development of adrenal cortex . Provide meticulous skin care 6. Administer medications as ordered a. Urine specific gravity is increased 2. Weight gain 2. Hypertension b. intake and output and neuro check 4. Related to hyperplasia (increase size of organ brought about by increase of number of cells) of pituitary 2. Monitor strictly vital signs. Loop diuretics (Lasix) b. B. Weigh patient daily and assess for pitting edema 5. Growth hormones (somatotropic hormone) o o o o o initial sign of lung cancer is non productive cough non invasive procedure is chest x-ray 3. Edema c. Signs and Symptoms 1. Diagnostic Procedure 1. Related to presence of bronchogenic cancer o o gland. Nursing Management 1.

T3 (Tri iodothyronine) . Thyroxine) o o T3 and T4 are metabolic or calorigenic hormone promotes cerebration (thinking) 3. carrots. Mountainous regions 2. Thyrocalcitonin – antagonizes the effects of parathormone to promote calcium resorption. Leutinizing hormone 6.3 molecules of iodine (more potent) 2. strawberry. Increase intake of goitrogenic foods o o o contains pro-goitrin an anti thyroid agent that has no iodine.4. T4 (tetra iodothyronine. HYPOTHYROIDISM o o o o o o all are decrease except weight and menstruation memory impairment there is loss of appetite but there is weight gain menorrhagia cold intolerance constipation Signs and Symptoms HYPERTHYROIDISM o o o o all are increase except weight and menstruation increase appetite but there is weight loss amenorrhea exophthalmos Signs and Symptoms THYROID DISORDERS SIMPLE GOITER o enlargement of thyroid gland due to iodine deficiency A. Predisposing Factors 1. radish. Follicle stimulating hormone PINEAL GLAND o o o secretes melatonin inhibits LH secretion it controls/regulates circadian rhythm (body clock) THYROID GLAND o located anterior to the neck 3 Hormones secreted 1. broccoli. Lactogenic homone (Prolactin) o o o o promotes development of mammary gland with help of oxytocin it initiates milk let down reflex secretes estrogen secretes progesterone 5. places far from sea b. sweet potato. Goiter belt area a. all nuts soil erosion washes away iodine . turnips. cabbage.

Mild restlessness C. Monitor vital signs especially heart rate because drug causes tachycardia and palpitations 3. Monitor side effects o o o o o o o insomnia tachycardia and palpitations hypertension heat intolerance seaweeds seafood’s like oyster. Lithium Carbonate c. Iatrogenic Cause – disease caused by medical intervention such as surgery 2. Administer medications as ordered a. crabs. Related to atrophy of thyroid gland due to trauma. Tetracycline. Iron. Nursing Management 1. Instruct client to take in the morning to prevent insomnia 2. 3. Assist in surgical procedure of subtotal thyroidectomy HYPOTHYROIDISM o o o hyposecretion of thyroid hormone adults: MYXEDEMA non pitting edema children: CRETINISM the only endocrine disorder that can lead to mental retardation 4.if goiter is caused by B. Thyroid Scan – reveals enlarged thyroid gland.o goitrogenic drugs a. clams and lobster but not shrimps because it contains lesser amount of iodine. Nitrofurantoin (drug of choice for pyelonephritis) b. Signs and Symptoms 1. Enforce complete bed rest 2. Diagnostic Procedures 1. Serum T3 and T4 – reveals normal or below normal 2. Mild dysphagia 3. inflammation . Lugol’s Solution/SSKI ( Saturated Solution of Potassium Iodine) o o color purple or violet and administered via straw to prevent staining of teeth. Thyroid Hormones o o o Levothyroxine (Synthroid) Liothyronine (Cytomel) Thyroid Extracts Nursing Management when giving Thyroid Hormones 1. Predisposing Factors 1. best taken raw because it it is easily destroyed by heat 5. Phenylbutazones (NSAIDs) . presence of tumor. Enlarged thyroid gland 2. iodized salt. Cobalt e. Increase dietary intake of foods rich in iodine A. PASA (Aspirin) d. Anti Thyroid Agent – Prophylthiuracil (PTU) b. Serum Thyroid Stimulating Hormone (TSH) – is increased (confirmatory diagnostic test) D. 4 Medications to be taken via straw: Lugol’s.

Weakness and fatigue 2. Decrease libido 5.3. hyponatremia. Autoimmune (Hashimotos Disease) B. Provide client health teaching and discharge planning concerning a. Administer medications as ordered Thyroid Hormones a. Serum T3 and T4 is decreased 2. Levothyroxine b. Administer isotonic fluid solution as ordered 4. Decrease in all vital signs – hypotension. Nursing Management 1. bradypnea. RAIU (Radio Active Iodine Uptake) is decreased D. Iodine deficiency 4. Force fluids 3. Provide comfortable and warm environment 7. Non pitting edema (Myxedema) 3. Provide dietary intake that is low in calories 6. Thyroid Extracts 5. Constipation (Late Signs) 1. hypothermia leading to pregressive stupor and coma. Monitor strictly vital signs and intake and output to determine presence of o o Myxedema coma is a complication of hypothyroidism and an emergency case a severe form of hypothyroidism is characterized by severe hypotension. Serum Cholesterol is increased 3. Provide meticulous skin care 8. Leothyronine c. Loss of appetite but with weight gain which promotes lipolysis leading to atherosclerosis and MI 3. Nursing Management for Myxedema Coma    2. bradypnea. Diagnostic Procedures 1. Dry skin 4. CNS changes o o o o lethargy memory impairment psychosis menorrhagia C. Cold intolerance 5. hypothermia 6. Hoarseness of voice 4. Avoid precipitating factors leading to myxedema coma o o stress infection Assist in mechanical ventilation Administer thyroid hormones as ordered Force fluids . Signs and Symptoms (Early Signs) 1. Brittleness of hair and nails 2. hypoventilation. hypoglycemia. bradycardia. bradycardia.

Tremors d. CNS involvement a. Diagnostic Procedures 1. Increase appetite (hyperphagia) but there is weight loss 2. Methymazole (Tapazole) Side Effects of Agranulocytosis o o o o increase lymphocytes and monocytes fever and chills sore throat (throat swab/culture) leukocytosis (CBC) 3.o o o o o o o o cold intolerance use of anesthetics. Restlessness c. Irritability and agitation b. Administer medications as ordered Anti Thyroid Agent a. Amenorrhea C. Moist skin 3. hypovolemic shock hormonal replacement therapy for lifetime importance of follow up care increase in T3 and T4 Grave’s Disease or Thyrotoxicosis developed by Robert Grave HYPERTHYROIDISM A. Nursing Management 1. Provide dietary intake that is increased in calories. Exopthalmus 9. Insomnia e. Excessive iodine intake 3. Comfortable and cold environment 6. Autoimmune – it involves release of long acting thyroid stimulator causing exopthalmus (protrusion of eyeballs) enopthalmus (late sign of dehydration among infants) 2. All vital signs are increased 6. Thyroid Scan. Signs and Symptoms 1. Diarrhea 5. Monitor strictly vital signs and intake and output 2. Related to hyperplasia (increase size) B. Goiter 8. RAIU (Radio Active Iodine Uptake) is increased 3. Predisposing Factors 1.reveals an enlarged thyroid gland D. Hallucinations 7. narcotics. Provide meticulous skin care 5. and sedatives prevent complications (myxedema coma. Serum T3 and T4 is increased 2. Prophythioracill (PTU) b. 4. Maintain side rails . Heat intolerance 4.

Provide bilateral eye patch to prevent drying of the eyes. Watch out for accidental removal of parathyroid gland that may lead to Hypocalcemia (tetany) Signs and Symptoms o o o (+) trousseau’s sign (+) chvostek sign Watch out for arrhythmia. 8. maintain side rails offer TSB Tachycardia 2. Hormonal replacement therapy for lifetime 6. 1.7. Importance of follow up care PARATHYROID GLAND o o o o o A pair of small nodules behind the thyroid gland Secretes parathormone Promotes calcium reabsorption Hypoparathyroidism Hyperparathyroidism HYPOPARATHYROIDISM o o Decrease secretion of parathormone leading to hypocalcemia Resulting to hyperphospatemia . Assist in surgical procedures known as subtotal thyroidectomy ** Before thyroidectomy administer Lugol’s Solution (SSKI) to decrease vascularity of the thyroid gland to prevent bleeding and hemorrhage. Watch out for signs of thyroid storm/ thyrotoxicosis Agitation TRIAD SIGNS Hyperthermia o administer medications as ordered a. seizure give Calcium Gluconate IV slowly as ordered 3. Beta-blockers o o o monitor strictly vital signs. Anti Pyretics b. input and output and neuro check. POST OPERATIVELY. Signs of bleeding (feeling of fullness at incisional site) Nursing Management o Check the soiled dressings at the back or nape area. 5. Watch out for accidental Laryngeal damage which may lead to hoarseness of voice Nursing Management o encourage client to talk/speak immediately after operation and notify physician 4.

5 – 11 mg/100 ml) 2. Serum Calcium is decreased (normal value: 8. numbness d. Administer medications as ordered such as: a. Chronic Tetany  Oral Calcium supplements  Calcium Gluconate  Calcium Lactate  Calcium Carbonate c. positive trousseu’s sign/carpopedal spasm f. dysphagia e. X-ray of long bones reveals a decrease in bone density 4. Acute Tetany  Calcium Gluconate IV slowly b. Acute tetany a. inflammation b. arrhythmia 2. agitation and memory impairment C. Predisposing Factors 1.5 – 4. Vitamin D (Cholecalciferol) for absorption of calcium CHOLECALCIFEROL ARE DERIVED FROM Drug Diet (Calcidiol) Sunlight (Calcitriol) feared complications d. CT Scan – reveals degeneration of basal ganglia D.C MAD .A. positive chvostek sign g. Following subtotal thyroidectomy 2. loss of tooth enamel c. laryngospasm/broncospasm h. tingling sensation b. seizure i. Atrophy of parathyroid gland due to: a. Nursing Management 1.A. photophobia and cataract formation b. Chronic tetany a. Diagnostic Procedures 1. Signs and Symptoms 1. Phosphate binder   Aluminum Hydroxide Gel (Ampogel) Side effect: constipation ANTACID A. trauma B. anorexia. tumor c. paresthesia c.5 mg/100 ml) 3. Serum Phosphate is decreased (normal value: 2. nausea and vomiting d.

Encourage client to breathe using paper bag to produce mild respiratory acidosis result. cool moist skin 3. Bone pain especially at back (bone fracture) 2. salmon c. Serum Phosphate is decreased 3. Prevent complications 8. Hormonal replacement therapy for lifetime 9. HYPERTHYROIDISM o o o Decrease parathormone Hypercalcemia: bone demineralization leading to bone fracture (calcium is stored 99% in bone and 1% blood) Kidney stones A. Force fluids to prevent kidney stones 2. Administer medications as ordered a. Strain all the urine using gauze pad for stone analysis 3.▼ Aluminum Containing Antacids ▼ Aluminum Hydroxide Gel ▼ Side Effect: Constipation ▼ Magnesium Containing Antacids ▼ Side Effect: Diarrhea 2. Nursing Management 1. Avoid precipitating stimulus such as glaring lights and noise 3. Hyperplasia of parathyroid gland 2. Agitation and memory impairment C. Maintain side rails . Institute seizure and safety precaution 5. X-ray of long bones reveals bone demineralization D. Encourage increase intake of foods rich in phosphate but decrease in calcium 6. green turnips 4. Provide warm sitz bath 4. renal cholic b. Importance of follow up care. Signs and Symptoms 1. Diagnostic Procedures 1. Morphine Sulfate (Demerol) 5. nausea and vomiting 4. Encourage increase intake of foods rich in calcium a. anchovies b. Children: Ricketts b. Predisposing Factors 1. 6. Over compensation of parathyroid gland due to vitamin D deficiency a. Assist/supervise in ambulation 8. Adults: Osteomalacia B. Prepare trache set at bedside for presence of laryngo spasm 7. Kidney stones a. Provide acid ash in the diet to acidify urine and prevent bacterial growth 7. Anorexia. Serum Calcium is increased 2.

Zona Glumerulosa . Signs and Symptoms 1.secretes mineralocorticoids (aldosterone) . Related to atrophy of adrenal glands 2.function: promotes sodium and water reabsorption and excretion of potassium . Zona Fasciculata . Hormonal replacement therapy for lifetime 12. Hypoglycemia – TIRED 2. Zona Reticularis . Assist in surgical procedure known as parathyroidectomy 11. Prevent complications (seizure and arrhythmia) 10.Sex 3. metabolic disturbance – Sugar b. Predisposing Factors 1.signs of dehydration . Importance of follow up care ADRENAL GLAND o o Located atop of each kidney 2 layers of adrenal gland a. Adrenal Medulla – innermost (secretes catecholamines a power hormone) 2 Types of Catecholamines o o o o o Epinephrine and Norepinephrine (vasoconstrictor) Pheochromocytoma (adrenal medulla) Increase secretion of norepinephrine Leading to hypertension which is resistant to pharmacological agents leading to CVA Use beta-blockers ADRENAL CORTEX 3 Zones/Layers 1. deficiency of neuromuscular function – Salt/Sex A.secretes traces of glucocorticoids and androgenic hormones .weight loss .function: promotes secondary sex characteristics .function: controls glucose metabolism .Sugar 2.9. Hyponatremia .secretes glucocortocoids (cortisol) .Salt ADDISON’S DISEASE o Hyposecretion of adreno cortical hormone leading to a.hypotension . Fungal infections B. Decrease tolerance to stress 3. fluid and electrolyte imbalance – Salt c. Adrenal Cortex – outermost b.

Diagnostic Procedures 1. FBS is decreased (normal value: 80 – 100 mg/dl) 2. Taper dose (withdraw gradually from drug) 3. Serum Potassium is increased (normal value: 3. edema c. avoid precipitating factor leading to addisonian crisis leading to . Administer medications as ordered Corticosteroids a. hypovolemic shock c. Mineralocorticoids (Flourocortisone) 5. Administer isotonic fluid solution as ordered 3.infection .stress . .addisonian crisis . moon face appearance 4. protein but decrease in potassium 6. Decrease libido 6.5 meq/L) D.hypovolemic shock . Force fluids 4.diarrhea . Assist in mechanical ventilation. Loss of pubic and axillary hair 7.agitation . carbohydrates.sudden withdrawal to steroids b. hypertension b.force fluids 2.administer steroids as ordered . hyponatremia leading to progressive stupor and coma Nursing Management for Addisonian Crisis 1. Instruct client to take 2/3 dose in the morning and 1/3 dose in the afternoon to mimic the normal diurnal rhythm 2.arrhythmia 5. severe hypotension b. Plasma Cortisol is decreased 3. Prednisone c. prevent complications . Serum Sodium is decrease (normal value: 135 – 145 meq/L) 4. increase susceptibility to infection e. Provide meticulous skin care 7. Provide dietary intake. Hydrocortisone (Cortison) Nursing Management when giving steroids 1. increase calories. Nursing Management 1. hirsutism d. Bronze like skin pigmentation C. Monitor strictly vital signs. Monitor side effects a.5 – 4. input and output to determine presence of Addisonian crisis (complication of addison’s disease) o Addisonian crisis results from acute exacerbation of addison’s disease characterized by a. Dexamethasone (Decadrone) b.4. Hyperkalemia . Provide client health teaching and discharge planning a.

Diagnostic Procedures 1. Provide meticulous skin care 6. Measure abdominal girth daily and notify physician 4. Hypernatremia a. Acne and striae 7. obese trunk f. Importance of follow up care PANCREAS . importance of follow up care CUSHING SYNDROME o Hypersecretion of adenocortical hormones A. hypertension b. Plasma Cortisol is increased 3. Assist in surgical procedure (bilateral adrenoraphy) 9. Serum Potassium is decreased C. Restrict sodium intake 5. Prevent complications (DM) 8.Located behind the stomach . weakness and fatigue b. thin extremities 4. Nursing Management 1. edema c. Weigh patient daily and assess for pitting edema 3.c. constipation c. Monitor strictly vital signs and intake and output 2. Hirsutism 6. hormonal replacement for lifetime d. Hormonal replacement for lifetime 10. U wave upon ECG (T wave hyperkalemia) 5. pendulous abdomen g. Administer medications as ordered a. Spinarolactone – potassium sparring diuretics 7. FBS is increased 2. Increase masculinity among females B. moon face appearance and buffalo hump e. Easy bruising 8. Increase susceptibility to infections 3. Serum Sodium is increased 4.Mixed gland (exocrine and endocrine) . Hypokalemia a. Predisposing Factors 1 Related to hyperplasia of adrenal gland 2. weight gain d.

Polyphagia 5. Steroids 4. Complication 1. Polyuria 2. Incidence Rate . Coma C.10% general population has type 1 DM B. Predisposing Factors 1. Weight gain Type 2 (NIDDM) . Drugs a. Hereditary (total destruction of pancreatic cells) 2. Predisposing Factors 1.90% of general population has type 2 DM B. Complications 1. Blurring of vision 8. Anorexia. Treatment 1. Incidence Rate . protein and fat metabolism CLASSIFICATION OF DM Type 1 (IDDM) .Brittle disease A. Ketotic 5. Delayed/poor wound healing D. Exercise E. Diabetic Ketoacidosis D..metabolic disorder characterized by non utilization of carbohydrates. Signs and Symptoms 1. Polyuria 3. Osmolar 3. Treatment 1. Non 4. Related to carbon tetrachloride toxicity C.Delta cells secretes somatostatin (function: antagonizes the effects of growth hormones) 3 Main Disorders of Pancreas 1. Obesity – because obese persons lack insulin receptor binding sites .Maturity onset type . Diabetes Mellitus 3.Adult onset . Polyphagia 4. Increase susceptibility to infection 9. Lasix b. Glucosuria 6. Diet 3.Beta cells secretes insulin (function: hypoglycemia) .Consist of acinar cells which secretes pancreatic juices that aids in digestion thus it is an exocrine gland . Usually asymptomatic 2. Polydypsia 4. Polydypsia 3. Exercise E. Pancreatitis DIABETES MELLITUS . nausea and vomiting 7. Oral Hypoglycemic agents 2. Insulin therapy 2. Signs and Symptoms 1. Glucosuria 5.Obese over 40 years old A. Diet 3. Related to viruses 3. Hyper 2.Has alpha cells that secretes glucagons (function: hyperglycemia) .Juvenile onset type . Pancreatic Tumor/Cancer 2. Weight loss 6.Consist of islets of langerhans .

Carbohydrates 2. Protein 3.MAIN FOODSTUFF 1.Cholesterol .Ketones HYPERGLYCEMIA Increase osmotic diuresis Glycosuria Cellular starvation – weight loss Stimulates the appetite/satiety center (Hypothalamus) Polyphagia Polyuria Cellular dehydration Stimulates the thirst center (Hypothalamus) Polydypsia * Liver has glycogen that undergo glycogenesis/ glycogenolysis GLUCONEOGENESIS Formation of glucose from non-CHO sources Increase protein formation ▼ Negative Nitrogen balance ▼ Tissue wasting (Cachexia) ▼ INCREASE FAT CATABOLISM ▼ Free fatty acids Cholesterol ▼ Atherosclerosis ▼ Hypertension MI CVA Ketones ▼ Diabetic Keto Acidosis Acetone Breath odor Kussmaul’s Respiration Death Diabetic Coma . Fats ANABOLISM CATABOLISM Glucose Amino Acids Fatty Acids Glycogen Nitrogen Free Fatty Acids .

Hyperosmolar: increase osmolarity (severe dehydration) . Decrease LOC – diabetic coma . Polyphagia 4. Antibiotics to prevent infection HYPER OSMOLAR NON KETOTIC COMA .9 NaCl followed by . Seizure activity 4. Creatinine (normal value: .45 NaCl (hypotonic solutions) to counteract dehydration and shock 3. Restlessness 3. Signs and Symptoms 1. intake and output and blood sugar levels 4. FBS is increased 2. Nursing Management 1.Acute complication of type 1 DM due to severe hyperglycemia leading to severe CNS depression A. Predisposing Factors 1. nausea and vomiting 7. Insulin therapy (regular acting insulin/rapid acting insulin peak action of 2 – 4 hours) b. Administer medications as ordered a. Blurring of vision 8. Headache and dizziness 2. Glucosuria 5.Non ketotic: absence of lypolysis (no ketones) A. Anorexia. Infection B. Hyperglycemia 2. Weight loss 6. Polydypsia 3. Monitor strictly vital signs. Hct (normal value: female 36 – 42. BUN (normal value: 10 – 20) 3. male 42 – 48) due to severe dehydration D. Acetone breath odor 9. Assist in mechanical ventilation 2.DIABETIC KETOACIDOSIS . Administer 0.8 – 1) 4. Diagnostic Procedures 1. Polyuria 2. Signs and Symptoms 1. Stress – number one precipitating factor 3. Sodium Bicarbonate to counteract acidosis c. Kussmaul’s Respiration (rapid shallow breathing) 10 CNS depression leading to coma C.

Tolbutamide (Orinase) . Monitor for signs of local complications such as a.Derived from beef and pork 2.Peak action is 8 – 16 hours 3. Rapid Acting Insulin (clear) . Administer at room temperature to prevent development of lipodystrophy (atrophy. 10. Animal sources .Frequently used type because it has less antigenicity property thus less allergic reaction 3. Somogyis Phenomenon – rebound effect of insulin characterized by hypoglycemia to hyperglycemia ORAL HYPOGLYCEMIC AGENTS .9 NaCl followed by . Sources of Insulin 1. Assist in mechanical ventilation 2. Use gauge 25 – 26 needle 5. Long Acting Insulin (cloudy) .Peak action is 16 – 24 hours C. Avoid shaking insulin vial vigorously instead gently roll vial between palm to prevent formation of bubbles 4.for DKA use rapid acting insulin b. Human Sources . First Generation Sulfonylureas a. Nursing Management 1. Chlorpropamide (Diabenase) b.Non Protamine Hagedorn Insulin (NPH) . intake and output and blood sugar levels 4.B. Administer insulin either 45o – 90o depending on amount of clients tissue deposit 6.Peak action is 2 – 4 hours 2. Administer 0. Artificially Compound Insulin B. Rotate insulin injection sites to prevent development of lipodystrophy 8. Monitor strictly vital signs.Rarely used because it can cause severe allergic reaction . hypertrophy of subcutaneous tissues) 2. Allergic reactions b. When mixing 2 types of insulin aspirate first the clear insulin before cloudy to prevent contaminating the clear insulin and promote proper calibration. Types of Insulin 1.Stimulates the pancreas to secrete insulin A. Nursing Management for Insulin Injections 1. Intermediate Acting Insulin (cloudy) . Classsification 1. Lipodystrophy c.45 NaCl (hypotonic solutions) to counteract dehydration and shock 3. Administer medications as ordered a. Most accessible route is abdomen 9. Place in refrigerator once opened 3. Insulin therapy (regular acting insulin peak action of 2 – 4 hours) .Regular acting insulin (IV only) . Antibiotics to prevent infection INSULIN THERAPY A.Ultra Lente . No need to aspirate upon injection 7.

Monitor signs for complications a. Monitor strictly vital signs.for hyperglycemia (dry and warm skin) 5. instruct client to avoid wearing constrictive garments d. Tolamazide (Tolinase) 2.Blindness KIDNEY -RECURRENT PYELONEPHRITIS . Microangiopathy (affects small minute blood vessels of eyes and kidneys) EYES -PREMATURE CATARACT .sexual impotence 8. Instruct the client to take it with meals to lessen GIT irritation and prevent hypoglycemia 2. polydypsia. Blood Vessels III. CVA) b. Administer insulin and OHA therapy as ordered 3. Assist in surgical procedure HEMATOLOGICAL SYSTEM I. Diagnostic Procedures 1. Diabeta (Micronase) Nursing Management when giving OHA 1. Instruct client to have an annual eye and kidney exam 10.peripheral neuropathy .Renal failure c. instruct client to avoid walking barefooted b. MI. Monitor for signs of hypoglycemia and hyperglycemia . FBS is increased (3 consecutive times with signs or polyuria. assist in surgical wound debriment (give analgesics 15 – 30 mins prior) 9. Glipzide (Glucotrol) b. Atherosclerosis (HPN. Monitor for peak action of insulin and OHA and notify physician 2.for hypoglycemia (cold and clammy skin) give simple sugars . Blood II. Instruct the client to avoid taking alcohol because it can lead to severe hypoglycemia reaction or Disulfiram (Antabuse) toxicity symptoms B. Alpha Glycosylated Hemoglobin is increased C. Gangrene formation e. Shock due to dehydration . Blood Forming Organs . Monitor for signs of DKA and HONKC 11. instruct client to cut toenails straight c. HPN and DM major cause of renal failure d. Random Blood Sugar is increased 3. Institute foot care management a. encourage client to apply lanolin lotion to prevent skin breakdown e. Oral glucose tolerance test is increased – most sensitive test 4.c.diarrhea/constipation . Instruct client to exercise best after meals when blood glucose is rising 7. protein 30% and fats 20% or offer alternative food substitutes 6. Second Generation Sulfonylureas a.administer simple sugars . polyphagia and glucosuria confirmatory for DM) 2. intake and output and blood sugar levels 4. Nursing Management 1. Provide nutritional intake of diabetic diet that includes: carbohydrates 50%.

normal value: female 36 – 42% male 42 – 48% . Polymorpho Neutrophils .for parasite infections . RBC (ERYTHROCYTES) . Albumin 2.involved in short term phagocytosis for acute inflammation 2. Lymphoid Organ 5.60 – 70% of WBC .largest WBC . WBC (LEUKOCYTES) . Monocytes .Beta globulins – iron and copper . Lymph Nodes 6. vitamin b6 (pyridoxine) f.normal value: 4 – 6 million/mm3 .macrophage in blood . Arteries 2.consist of molecules of hgb (red pigment) bilirubin (yellow pigment) biliverdin (green pigment) hemosiderin (golden brown pigment) . Veins Plasma CHON (formed in liver) 1.Largest and numerous plasma CHON .hematocrit red cell percentage in wholeblood . folic acid b. Non Granulocytes 1. prothrombin and fibrinogen clotting factors FORMED ELEMENTS 1.normal value: 5000 – 10000/mm3 A.substances needed for maturation of RBC a. vitamin c d.only unnucleated cell . Liver 3. Polymorphonuclear Eosinophils . Granulocytes 1.Maintains osmotic pressure preventing edema GLOBULINS .for allergic reaction B. Polymorphonuclear Basophils .transport steroids. anti-bodies and immunoglobulins b.Normal life span of RBC is 80 – 120 days and is killed in red pulp of spleen 2.Alpha globulins . intrinsic factor . Globulins 3.biconcave discs .Gamma globulins a. bilirubin and hormones .responsible for the release of chemical mediation for inflammation 3. Spleen 4. Prothrombin and Fibrinogen 1. iron c.55% Plasma Serum 45% Formed 1. Bone Marrow ALBUMIN .hemoglobin: normal value female 12 – 14 gms% male 14 – 16 gms% . vitamin b12 (cyanocobalamin) e.transports and carries oxygen to tissues .

Platelets (THROMBOCYTES) . Headache and dizziness . Kaposi’s Sarcoma 2.A chronic microcytic anemia resulting from inadequate absorption of iron leading to hypoxemic tissue injury A. Pneumocystis Carinii Pneumonia 3. Inadequate intake of iron due to a. Chronic diarrhea b. Petechiae 2. Related to improper cooking of foods C. Heavy menstruation b.6 months – 5 years incubation period . High cereal intake with low animal protein digestion d. fresh blood per rectum is called hematochezia 2.bone marrow . Weakness and fatigue (initial signs) 3.000/mm3 . Oozing of blood from venipunctured site BLOOD DISORDERS Iron Deficiency Anemia .anti viral and anti tumor property HIV . Incidence Rate 1.000 – 450.thymus for immunity Natural killer cell . Common among developed countries 2.involved in long term phagocytosis for chronic inflammation 2.6 months window period . Common among women 15 – 35 years old 4. Common among tropical zones 3. Usually asymptomatic 2. Predisposing Factors 1.drug of choice AZT (Zidon Retrovir) 2 Common fungal opportunistic infection in AIDS 1.Promotes hemostasis (prevention of blood loss) . Echhymosis 3.. Lymphocytes B-cell T-cell . Related to malabsorption syndrome c.Normal value: 150.Normal life span of platelet is 9 – 12 days Signs of Platelet Dysfunction 1.ELISA . Signs and Symptoms 1. Related to poor nutrition B.western blot opportunistic . Related to GIT bleeding resulting to hematemesis and melena (sign for upper GIT bleeding) c.Consist of immature or baby platelets or megakaryocytes which is the target of dengue virus . Chronic blood loss due to trauma a. Subtotal gastrectomy 4.

Hct is deceased 4. Administer with Vitamin C or orange juice for absorption 4. Monitor side effects a. Palpitations 7. Ferrous Gluconate . Melena 5. Administer Z tract technique to prevent discomfort. Monitor for signs of bleeding of all hema test including urinw. Diagnostic Procedures 1. Nuts 4. Enforce CBR so as not to over tire client 3. Sweet potatoes e. Administer medications as ordered Oral Iron Preparations a.Lugol’s solution . Ferrous Fumarate c. Dyspnea 6.300 mg/day Nursing Management when taking oral iron preparations 1. Nursing Management 1.Nitrofurantoin (Macrodentin) 3. Brittleness of hair and spoon shape nails (koilonychias) 8. Instruct client to take with meals to lessen GIT irritation 2. Organ meat b. Ferritin is decreased E. Abdominal pain d. Diarrhea/constipation e. Iron Dextran (IM.Tetracycline . Dried fruits f.4. Reticulocyte is decreased 6. Pallor and cold sensitivity 5.Stomatitis . Ferrous Sulfate b. When diluting it in liquid iron preparations administer with straw to prevent staining of teeth Medications administered via straw . stool and GIT 2. Monitor and inform client of side effects a. Anorexia b. RBC is decreased 2. Sorbitex (IM) Nursing Management when giving parenteral iron preparations 1. Raisin d. Nausea and vomiting c. Legumes g. Pain at injection site PLUMBER VINSON’S SYNDROME . Hgb is decreased 3. Iron is decreased 5. If client cant tolerate/no compliance administer parenteral iron preparation a. Instruct client to take foods rich in iron a.Dysphagia 9. IV) b. Egg (yolk) c. Atropic Glossitis (inflammation of tongue) . PICA (abnormal appetite or craving for non edible foods D. Instruct the client to avoid taking tea and coffee because it contains tannates which impairs iron absorption 5. Avoid massaging the injection site instead encourage to ambulate to facilitate absorption 3.Iron . discoloration and leakage to tissues 2.

Predisposing Factors 1. Weakness and fatigue 2. Strictly vegetarian diet STOMACH ▼ Pareital cells/ Argentaffin or Oxyntic cells Produces intrinsic factors ▼ Promotes reabsorption of Vit B12 ▼ Promotes maturation of RBC B. Nursing Management 1. Signs and Symptoms 1. Subtotal gastrectomy 2. jaundice 6. Enforce CBR 2. Skin rashes f. result to psychosis C. numbness c. GIT changes that includes a. Dyspnea and palpitations as part of compensation 5. tingling sensation b.b. Localized abscess c. Administer Vitamin B12 injections at monthly intervals for lifetime as ordered . indigestion/dyspepsia d. Lymphadenopathy d. Headache and dizziness 3. Hypotension (anaphylactic shock) PERNICIOUS ANEMIA . positive to Romberg’s test – damage to cerebellum resulting to ataxia e. paresthesia d. Autoimmune 5. Hereditary factors 3. Diagnostic Procedure Schilling’s Test – reveals inadequate/decrease absorption of Vitamin B12 D. CNS changes a.Chronic anemia characterized by a deficiency of intrinsic factor leading to hypochlorhydria (decrease hydrochloric acid secretion) A. Inflammatory disorders of the ileum 4. mouth sore b. Fever and chills e. red beefy tongue c.Never given orally because there is possibility of developing tolerance Secretes hydrochloric acid ▼ Aids in digestion . Pruritus/orticaria g. Pallor and cold sensitivity 4. weight loss e.

No side effects 3. Avoid heat application to prevent burns APLASTIC ANEMIA . Signs and Symptoms 1. Chloramphenicol (Sulfonamides) Chemotherapeutic Agents a. vitamin c and iron 4. Chemicals (Benzine and its derivatives) 2. Nitrogen Mustard (Antimetabolite) Phenylbutazones (NSAIDS) B. Petechiae (multiple petechiae is called purpura) b. Drugs Broad Spectrum Antibiotics a. Institute reverse isolation 6. Administer oxygen inhalation 4. Enforce CBR 5. Nursing Management 1. fever Decrease WBC (leucopenia) Decrease Platelet (thrombocytopenia) . Predisposing Factors 1. Removal of underlying cause 2. Increase susceptibility to infection 3. CBC reveals pancytopenia 2. Provide a dietary intake that is high in carbohydrates. Leukopenia a. Vincristine (Plant Alkaloid) c. Pallor and cold sensitivity d. Bone marrow biopsy/aspiration (site is the posterior iliac crest) – reveals fat necrosis in bone marrow D. Monitor for signs of infection a. Weakness and fatigue b.Site of injection for Vitamin B12 is dorsogluteal and ventrogluteal . Headache and dizziness c. Oozing of blood from venipunctured sites C. Immunologic injury 4. Related to irradiation/exposure to x-ray 3. Thrombocytopenia a. Dyspnea and palpitations 2. Methotrexate (Alkylating Agent) b. Diagnostic Procedures 1.Stem cell disorder leading to bone marrow depression leading to pancytopenia PANCYTOPENIA Decrease RBC (anemia) A. Anemia a. protein. Institute BT as ordered 3.. Ecchymosis c. Instruct client to avoid irritating mouth washes instead use soft bristled toothbrush 5.

Related to rapid blood transfusion 2. Administer medications as ordered a. Septecemia 6. Monitor for signs of bleeding of all hema test including stool and GIT 2. Opthamoscopic exam reveals sub retinal hemorrhages D. Institute NGT decompression by performing gastric lavage by using ice or cold saline solution of 500 – 1000 ml 8. Signs and Symptoms 1. Vitamin K b. Massive trauma 4.b. Avoid IM. lungs and lower extremities 2. Corticosteroids – caused by immunologic injury b. Administer medications as ordered a. Neoplasia (new growth of tissue) 7. Diagnostic Procedures 1. Oliguria (late sign) C. Administer oxygen inhalation 4. Stool occult blood positive 3. Pregnancy B. Nursing Management 1. Anaphylaxis 5. subcutaneous. CBC reveals decreased platelets 2. Predisposing Factors 1. Ecchymosis 3. Petechiae (widespread and systemic) eye. Heparin/Coumadin is ineffective 6. Oozing of blood from punctured sites 4. Administer isotonic fluid solution as ordered 3. venipunctured sites 8 Instead provide heparin lock 9. Force fluids 5. Prevent complication . Monitor NGT output 9. Instruct client to use electric razor when shaving 10. Hemoptysis 6. Immunosuppressants Anti Lymphocyte Globulin ▼ Given via central venous catheter ▼ Given 6 days to 3 weeks to achieve Maximum therapeutic effect of drug DISSEMINATED INTRAVASCULAR COAGULATION Acute hemorrhagic syndrome characterized by wide spread bleeding and thrombosis due to a deficiency of prothrombin and fibrinogen A. Pitressin/ Vasopresin to conserve fluids c. cough 7. ABG analysis reveals metabolic acidosis 4. Provide heparin lock 7. Massive burns 3.

Cytrate intoxication h. Regulate BT 10 – 15 gtts/min or KVO rate or equivalent to 100 cc/hr to prevent circulatory overload 9.a. Filter set b. Pyrogenic reaction d. Prevent infection in there is a decrease in WBC 4. Replace circulating blood volume 2. BT should be completed less than 4 hours because blood that is exposed at room temperature more than 2 hours causes blood deterioration that can lead to BACTERIAL CONTAMINATION 7. Proper refrigeration . Instruct another RN to re check the following a. Monitor strictly vital signs before. Type O – universal donor b. Circulatory overload e. Prevent bleeding if there is platelet deficiency Principles of blood transfusion 1. 6. Hemolytic reaction b. sediments and darkness in color because it indicates bacterial contamination .Warming is only done during emergency situation and if you have the warming device .Emergency rapid BT is given after 30 minutes and let natural room temperature warm the blood. Serial number 5. Air embolism f. Blood typing and cross matching c. Proper typing and cross matching a. Isotonic solution (0. during and after BT especially every 15 minutes for first hour because majority of transfusion reaction occurs during this period a. Aseptically assemble all materials needed for BT a. Client name b. Hypovolemic shock b.Expiration of platelet is 3 – 5 days 2. Allergic reaction c. Thrombocytopenia g.Expiration of packed RBC is 3 – 6 days . . Hyperkalemia (caused by expired blood) . Avoid mixing or administering drugs at BT line to prevent HEMOLYSIS 8. Gauge 18 – 19 needle c.9 NaCl/plain NSS) to prevent hemolysis 4. Increase the oxygen carrying capacity of blood 3. Anuria – late sign BLOOD TRANSFUSION Goals/Objectives 1. Check the blood unit for bubbles cloudiness.Never warm blood as it may destroy vital factors in blood. 85% of population is RH positive 3. Expiration date d. Type AB – universal recipient c.

Headache and dizziness 2. Notify physician 3. Diaphoresis 6. Anti Histamine (Benadryl) . Obtain urine and blood sample and send to laboratory for re examination 7. Dyspnea Nursing Management 1. Stop BT 2. Broncial wheezing 4. Monitor vital signs and intake and output SIGNS AND SYMPTOMS OF ALLERGIC REACTION 1. Laryngospasm and Broncospasm Nursing Management 1.Signs and Symptoms of Hemolytic reaction 1. Lumbasternal/ Flank pain 7. Hypotension 5. Dyspnea 3. Diarrhea/Constipation 4. Notify physician 3. anaphylactic shock treat with Epinephrine 5. Send the blood unit to blood bank for re examination 6. Urticaria 6. Dyspnea 3. Stop BT 2. Flush with plain NSS 4. Administer isotonic fluid solution to prevent shock and acute tubular necrosis 5. Fever and chills 2. Urine is color red/ portwine urine Nursing Management 1.if positive to hypotension. Skin rashes 5. Obtain urine and blood sample and send to laboratory for re examination 7. Flushed skin 6. Flush with plain NSS 4. Headache 3. Palpitations 5. Administer medications as ordered a. Flush with plain NSS . Send the blood unit to blood bank for re examination 6. Tachycardia 4. Fever 2. Monitor vital signs and intake and output SIGNS AND SYMPTOMS PYROGENIC REACTIONS 1. Notify physician 3. Stop BT 2.

Covered by a serous membrane called the pericardium 2 layers of pericardium a. Exertional discomfort Nursing Management 1. Lower Chamber (contracting or pumping) a. Administer medications as ordered a. Loop diuretic (Lasix) CARDIOVASCULAR SYSTEM OVERVIEW OF THE STRUCTURE AND FUNCTIONS OF THE HEART HEART . Obtain urine and blood sample and send to laboratory for re examination 7.Resemble like a close fist . Ventricles .To promote unidimensional flow or prevent backflow 1.Located on the left mediastinum . Orthopnea 2. Atria 2. Valves . pericarditis. Myocardium – middle layer 3.Muscular pumping organ of the body.Myocarditis can lead to cardiogenic shock and rheumatic heart disease B. Stop BT 2.Common among MI. Send the blood unit to blood bank for re examination 6.Right atrium has decreased pressure which is 60 – 80 mmHg C. Antipyretic b. Endocardium – inner layer .Weighs approximately 300 – 400 grams . Chambers of the Heart 1.In between is the pericardial fluid which is 10 – 20 cc . Visceral – inner layer . Layers of Heart 1. Render TSB SIGNS AND SYMPTOMS OF CIRCULATORY REACTION 1. Administer medications as ordered a. Atrioventricular Valves – guards opening between a. Antibiotic 5. Monitor vital signs and intake and output 8.Prevent pericardial friction rub . Notify physician 3. Upper Chamber (connecting or receiving) a. Parietal – outer layer b. Epicardium – outer layer 2. tricuspid valve .4.In order to propel blood to the systemic circulation . Cardiac tamponade A.Left ventricle has increased pressure which is 120 – 180 mmHg . Dyspnea 3. Rales/Crackles upon auscultation 4. .

S4 – atrial gallop usually seen in Myocardial Infarction and Hypertension D.Closure of AV valves give rise to first heart sound (S1 “lub”) 2.Supplies the myocardium E.Acts as primary pacemaker of the heart . Atrio – Ventricular Node (AV or Tawara Node) . Right Main Coronary Artery 2.Arises from base of the aorta Types of Coronary Arteries 1. S3 – ventricular gallop usually seen in Left Congestive Heart Failure 2.b.QRS WAVE (ventricular depolarization) .T WAVE (ventricular repolarization) .Right Main Bundle of His .Located at the interventricular septum 4. Purkinje Fibers . pulmonic b. mitral valve .Left Main Bundle of His .Located at the junction of superior vena cava and right atrium .Delay of electrical impulse for about .P WAVE (atrial depolarization) contraction . Bundle of His . Cardiac Conduction System 1.Located at the walls of the ventricles for ventricular contraction SA NODE AV NODE BUNDLE OF HIS JLJLJLJJLJLJL PURKINJE FIBERS . Sino – Atrial Node (SA or Keith Flack Node) . aortic .Initiates electrical impulse of 60 – 100 bpm 2. Semi – lunar Valves a. Coronary Arteries . Left Main Coronary Artery .Closure of SV valve give rise to second heart sound (S2 “dub”) Extra Heart Sounds 1.08 milliseconds to allow ventricular filling 3.Located at the inter atrial septum .

Obesity 5. sedentary lifestyle 7. Chest pain 2.Hypokalemia 2.tunica intima A. Peak T wave – Hyperkalemia 3. Dyspnea 3. Duaphoresis C. Widening of QRS complexes – Arrythmia CARDIAC DISORDERS Coronary Arterial Disease/ Ischemic Heart Disease Stages of Development of Coronary Artery Disease 1. Type A personality B. Sex – male 2. Positive U wave .tunica media .calcium and protein deposits . ST segment depression – Angina Pectoris 4. Hypothyroidism 9.narrowing of artery . Myocardial Necrosis – Myocardial Infarction ATHEROSCLEROSIS ATHEROSCLEROSIS .lipid or fat deposits . Myocardial Ischemia – Angina Pectoris 3.hardening of artery . Increase survival rate ARTERIOSCLEROSIS . Myocardial Injury . Smoking 4. Race – black 3. Insert pacemaker if there is complete heart block  Most common pacemaker is the metal pacemaker and lasts up to 2 – 5 years ABNORMAL ECG TRACING 1. Signs and Symptoms 1. Diet – increased saturated fats 10. Diabetes Mellitus 8. To prevent angina 3.Atherosclerosis 2. Treatment Percutaneous Transluminal Coronary Angioplasty Objectives of PTCA 1. T wave inversion – Myocardial Infarction 6. ST segment elevation – Myocardial Infarction 5. Palpitations 5. Revascularize myocardium 2. Predisposing Factors 1. Hyperlipidemia 6. Tachycardia 4.

Done to single occluded vessels . Tachycardia 5.. reveal abnormal ECG 4. History taking and physical exam 2. Stress test – treadmill test. Extreme emotional response – fear. Excessive intake of foods rich in saturated fats – skimmed milk C.5 minutes . Obesity 5. sedentary lifestyle 7. Dyspnea 4.If there is 2 or more occluded blood vessels CABG is done Coronary Arterial Bypass And Graft Surgery 3 Complications of CABG 1. Signs and Symptoms 1. Chest pain characterized by sharp stabbing pain located at sub sterna usually radiates from back. Hypothyroidism 9. Excessive physical exertion – heavy exercises 2. Administer medications as ordered a. Enforce complete bed rest 2. Diaphoresis D. but in large doses will act as vasodilator . Hyperlipidemia 6.Give first dose of NTG (sublingual) 3 – 5 minutes . Race – black 3. ECG tracing reveals ST segment depression 3. Diabetes Mellitus 8. shoulder. Precipitating Factors 4 E’s of Angina Pectoris 1. coughing exercise and use of incentive spirometer 2. Exposure to cold environment 3. Diet – increased saturated fats 10. anxiety. Diagnostic Procedure 1. Sex – male 2. axilla and jaw muscles. excitement 4. usually relieved by rest or taking nitroglycerine 3. Smoking 4. Thrombophlebitis ANGINA PECTORIS (SYNDROME) Clinical syndrome characterized by paroxysmal chest pain that is usually relieved by rest or nitroglycerine due to temporary myocardial ischemia A. Serum cholesterol and uric acid is increased E. Predisposing Factors 1. Nursing Management 1. Type A personality B. Palpitations 6. Shock 3. Nitroglycerine (NTG) – when given in small doses will act as venodilator. Levine’s Sign – initial sign that shows the hand clutching the chest 2. Pneumonia – encourage to perform deep breathing.Give second dose of NTG if pain persist after giving first dose with interval of 3 . arms.

Give third and last dose of NTG if pain still persist at 3 – 5 minutes interval Nursing Management when giving NTG Keep the drug in a dry place. Sex – male 2. necrosis and scarring. avoid moisture and exposure to sunlight as it may inactivate the drug Monitor side effects o o Orthostatic hypotension Transient headache and dizziness Instruct the client to rise slowly from sitting position Assist or supervise in ambulation When giving nitrol or transdermal patch o o o Avoid placing near hairy areas as it may decrease drug absorption Avoid rotating transdermal patches as it may decrease drug absorption Avoid placing near microwave ovens or duting defibrillation as it may lead to burns (most important thing to remember) b. ACE Inhibitors . Predisposing Factors 1. Types 1.. intake and output and ECG tracing 6. Hyperlipidemia . Obesity 5. Calcium Antagonist . Smoking 4. Place client on semi fowlers position 5.Not given to COPD cases because it causes bronchospasm c.NIfedipine 3. Provide decrease saturated fats sodium and caffeine 7. Prevent complication (myocardial infarction) c. Race – black 3. Instruct client to take medication before indulging into physical exertion to achieve the maximum therapeutic effect of drug d. Administer oxygen inhalation 4.Enalapril d. Beta-blockers . The Most Critical Period Following Diagnosis of Myocardial Infarction ** 6 – 8 hours because majority of death occurs due to arrhythmia leading to PVC’s C. The importance of follow up care MYOCARDIAL INFARCTION Heart attack Terminal stage of coronary artery disease characterized by malocclusion. A.Propanolol .side effects PNS . Avoidance of 4 E’s b. Subendocardial Myocardial Infarction – characterized by occlusion of either right or left coronary artery B. Monitor strictly vital signs. Provide client health teachings and discharge planning a. Transmural Myocardial Infarction – most dangerous type characterized by occlusion of both right and left coronary artery 2.

S4 or atrial gallop E. 12 – 24 hours b.Antidote: Narcan/Naloxone . Troponin Test – is increased 3. Place client on semi fowlers position . Administer oxygen low inflow to prevent respiratory arrest at 2 – 3 L/min 3. Decrease myocardial workload (rest heart) .Not usually relieved by rest or by nitroglycerine 2. Signs and Symptoms 1. Nursing Management Goal: Decrease myocardial oxygen demand 1. T wave inversion c. arms. SGOT – Serum glutamic oxal-acetic transaminase is increased 2. Pericardial friction rub b.Side Effects: respiratory depression . axilla. Mild restlessness and apprehension 7. Using bedside commode 4.Usually radiates from back. shoulder. viselike pain located at substernal and rarely in precordial .Creatinine phosphokinase is increased . Diagnostic Procedure 1.Heart only. Widening of QRS complexes indicates that there is arrhythmia in MI 4. Hyperthermia 5. Enforce CBR without bathroom privileges a. Hypothyroidism 9.Administer narcotic analgesic/morphine sulfate .Side Effects of Naloxone Toxicity is tremors 2.Excruciating visceral. sedentary lifestyle 7. Ashen skin 6. ECG tracing reveals a. Split S1 and S2 c. CPK – MB . Dyspnea 3. Chest pain . LDH – Lactic acid dehydroginase is increased c. Type A personality D. Diabetes Mellitus 8. ST segment elevation b. Increase in blood pressure (initial sign) 4.6. Rales/Crackles upon auscultation d. CBC – increased WBC F. Diet – increased saturated fats 10. Cardiac Enzymes a. SGPT – Serum glutamic pyruvate transaminase is increased d. jaw and abdominal muscles (abdominal ischemia) . Instruct client to avoid forms of valsalva maneuver 5. Serum Cholesterol and uric acid are both increased 5. Occasional findings a.

Calcium Antagonist f. Encourage client to take 20 – 30 cc/week of wine.homan’s sign e.Side Effects of Aspirin  Tinnitus  Heartburn  Indigestion/Dyspepsia . Avoidance of modifiable risk factors .Side Effects: allergic reaction. Beta-blockers d.Antidote: protamine sulfate . whisky and brandy to induce vasodilation 9. Provide a general liquid to soft diet that is low in saturated fats.Contraindication  Dengue  Peptic Ulcer Disease  Unknown cause of headache 10. ACE Inhibitors e. Vasodilators . Thrombolytics/ Fibrinolytic Agents .Heparin (check for partial thrombin time) .late sign is oliguria c.PASA (Aspirin) .6. Thrombophlebitis . Anti Coagulant . Isodil) sublingual b. sodium and caffeine 8. Stroke/CVA .Monitor for bleeding time g.arrhythmia (caused by premature ventricular contraction) b. Administer medication as ordered a.Urokinase .Side Effects: chest pain .Anti thrombotic effect .Antidote: Vitamin K h.Lidocaine (Xylocane .Side Effects: confusion and dizziness . Provide client health teaching and discharge planning concerning a. Monitor strictly vital signs.Streptokinase . Left Congestive Heart Failure d. intake and output and ECG tracing 7.Coumadin/ Warfarin Sodium (check for prothrombin time) . Cardiogenic shock .ISD (Isosorbide Dinitrate.TIPAF (tissue plasminogen activating factor) . Anti Platelet .Brutylium c. pruritus . Anti Arrythmic Agents .Nitroglycerine .

Ischemic heart disease 4. Productive cough with blood tinged sputum 5. Post MI Syndrome/Dressler’s Syndrome . Strict compliance to mediation and importance of follow up care CONGESTIVE HEART FAILURE Inability of the heart to pump blood towards systemic circulation Types of Heart Failure 1. Signs and Symptoms 1. Paroxysmal nocturnal dyspnea – client is awakened at night due to difficulty of breathing 3.000 – 450. post CABG and instruct to . 90% is mitral valve stenosis due to a. Resumption of ADL particularly sexual intercourse is 4 – 6 weeks post cardiac rehab.f. ABG – reveals PO2 is decreased (hypoxemia). Aging 2.client is resistant to pharmacological agents. Predisposing Factors 1.make sex as an appetizer rather than dessert .Formation of aschoff bodies in the mitral valve . There is anorexia and generalized body malaise 12. Diagnostic Procedure 1. Cyanosis 7.000 units of streptokinase as ordered g. RIGHT SIDED HEART FAILURE .ASO Titer (Anti streptolysin O titer) . Orthopnea – use 2 – 3 pillows when sleeping or place in high fowlers 4. Ecocardiography – enlarged heart chamber (cardiomyopathy). S3 – ventricular gallop C. Bronchial wheezing 9. Dyspnea 2. PMI is displaced laterally due to cardiomegaly 11. PCO2 is increased (respiratory acidosis) 2. RHD – inflammation of mitral valve due to invasion of Grp. Frothy salivation 6. PAP (pulmonary arterial pressure) – measures pressure in right ventricle or cardiac status PCWP (pulmonary capillary wedge pressure) – measures end systolic and dyastolic pressure both are increased done by cardiac catheterization (insertion of swan ganz catheter) 3.Penicillin .instruct client to assume a non weight bearing position .Aspirin b. Aortic valve stenosis B. Myocardial Infarction 3. administer 150. LEFT SIDED HEART FAILURE A. Chest x-ray – reveals cardiomegaly 2.Common among children . dependent on extent of heart failure 4. A beta-hemolytic streptococcus . Rales/Crackles 8.dietary modification h. Hypertension 5. Pulsus Alternans – weak pulse followed by strong bounding pulse 10.client can resume sexual intercourse if can climb staircase .

Anti Arrhythmic . 3 – 4 L/min. Bronchodilators d.Morphine Sulfate e. Weight gain 5.Digoxin (Lanoxin) . Nursing Management Goal: increase cardiac contractility thereby increasing cardiac output (3 – 6 L/min) 1. Left sided heart failure B. Loop Diuretics .Measure pressure in right atrium (4 – 10 cm of water) . Administer medications as ordered a.Nitroglycerine f. Pulmonary embolism 3. Tricuspid valve stenosis 2. delivered via nasal cannula 4. Hepatosplenomegaly 6. Related to COPD 4. Chest x-ray – reveals cardiomegaly 2.When reading CVP patient should be flat on bed . Ascites 4. Esophageal varices C. Administer oxygen inhalation with high inflow.Administer loop diuretics as ordered .CVP fluid status measure .Increase force of cardiac contraction . Pruritus 8. Vasodilators .Lasix (Furosemide) c. Diagnostic Procedures 1. Liver enzymes – SGPT and SGOT is increased D.Upon insertion place client in trendelendberg position to promote ventricular filling and prevent pulmonary embolism 3.Lidocaine (Xylocane) 3. Predisposing Factors 1. Anorexia 9. Ecocardiography – reveals enlarged heart chambers (cardiomyopathy 4. Enforce CBR 2.If CVP is less than 4 cm of water hypovolemic shock . Central venous pressure (CVP) . Signs and Symptoms (venous congestion) 1. Narcotic analgesics .If CVP is more than 10 cm of water hypervolemic shock . Cardiac glycosides .A. Neck/jugular vein distension 2.Do the fluid challenge (increase IV flow rate) .If heart rate is decreased do not give b. Jaundice 7. Pulmonic valve stenosis 5. Pitting edema 3. High fowlers position .

Dietary modification c.5. walking 3 – 4 times a day b. High risk groups – men 30 years old and above 2. Cold sensitivity and changes in skin color (pallor. Provide a dietary intake of low sodium.Thrombophlebitis b. Gangrene formation C. Predisposing Factors 1. Thrombo Angitis Obliterans   Venous Ulcer 1.Arrythmia . Thrombophlebitis (deep vein thrombosis) THROMBOANGITIS OBLITERANS Acute inflammatory disorder usually affecting the small medium sized arteries and veins of the lower extremities A. Monitor strictly vital signs. Signs and Symptoms 1. cyanosis then rubor) 3. cholesterol and caffeine 8. intake and output and ECG tracing 6. Measure abdominal girth daily and notify physician 7. Analgesics Burger’s Disease Reynaud’s Disease . Encourage a slow progressive physical activity a. Provide client health teaching and discharge planning a. rotated clockwise every 15 minutes to promote decrease venous return 10. Provide meticulous skin care 9. Strict compliance to medications PERIPHERAL VASCULAR DISORDER Arterial Ulcer I. Intermittent claudication – leg pain upon walking 2. Prevent complications .MI .Right ventricular hypertrophy . Nursing Management 1. out of bed 3 – 4 times a day 2. Administer medications as ordered a. Trophic changes 5. Smoking B. Oscillometry – decrease in peripheral pulses 2. Varicose Veins 2. Assist in bloodless phlebotomy – rotating tourniquet. Decreased peripheral pulses 4. Doppler UTZ – decrease blood flow to the affected extremity 3. Ulceration 6.Shock . Angiography – reveals site and extent of malocclusion D. Diagnostic Procedures 1.

Ulceration 5. Analgesics b. Administer medications as ordered a. Hereditary 2. Direct hand trauma a. Vasodilators 2. Collagen diseases a. Predisposing Factors 1. Congenital weakness of veins 3. Instruct client on importance of cessation of smoking and exposure to cold environment VARICOSITIES Abnormal dilation of veins of lower extremities and trunks due to Incompetent valve resulting to Increased venous pooling resulting to Venous stasis causing Decrease venous return A. Signs and Symptoms 1. Operating chainsaw B. Rheumatoid Arthritis 4. Instruct client to avoid smoking and exposure to cold environment 5. Doppler UTZ – decrease blood flow to the affected extremity 2. Thrombophlebitis 4. High risk group – female 40 years old and above 2. Assist in surgical procedure – bellow knee amputation REYNAUD’S DISEASE Disorder characterized by acute episodes of arterial spasm involving the fingers or digits of the hands A. Institute foot care management 4. Piano playing b. Vasodilators c. Intermittent claudication – leg pain upon walking 2. Encourage to wear gloves 3. Cardiac disorder 5. cyanosis then rubor) 3.b. Anti coagulants 3. Pregnancy . Angiography – reveals site and extent of malocclusion D. SLE (butterfly rash) b. Excessive typing c. Gangrene formation C. Cold sensitivity and changes in skin color (pallor. Diagnostic Procedures 1. Predisposing Factors 1. Smoking 3. Nursing Management 1. Trophic changes 4.

Obesity 2. Nursing Management . Positive Hpman’s Signs – pain at the calf or leg muscle upon dorsi flexion of the foot C. Warm to touch 4. Venography 2. Obesity 7. Nursing Management 1. Heaviness in legs C. Wear anti embolic stockings 4. Assist in surgical procedure a. Dilated tortuous skin veins 3.veins distends quickly in less than 35 seconds D. Predisposing Factors 1. Increase in saturated fats in the diet. Prolonged standing or sitting B. Angiography D. Measure the circumference of leg muscle to determine if swollen 3. Analgesics 5. Post op complication 10.6. Diagnostic Procedure 1. Post cannulation – insertion of various cardiac catheter 11. Warm to touch 3. Smoking 3. Myocardial infarction 9. Sclerotherapy – can recur and only done in spider web varicosities and danger of thrombosis (2 – 3 years for embolism) THROMBOPHLEBITIS Deep vein thrombosis Inflammation of the veins with thrombus formation A. Pain at affected extremity 2. B. Administer medications as ordered a. Chronic anemia 5. Diabetes mellitus 7. Signs and Symptoms 1. Prolong use of oral contraceptives – promotes lipolysis 6. Pain after prolonged standing 2. Diagnostic Procedure 1. Congestive heart failure 8. Dilated tortuous skin veins 4. Elevate legs above heart level to promote increased venous return by placing 2 – 3 pillows under the legs 2. Related to pregnancy 4. Venography 2. Trendelenburg’s Test . Vein stripping and ligation (most effective) b. Signs and Symptoms 1.

Cerebral .Serves as a muscular passageway for both food and air C.Opening of larynx .The initial sign of complete airway obstruction is the inability to cough II. Administer medications as ordered a.Consist of cartilaginous rings . Apply warm moist pack – to reduce lymphatic congestion 3.Unexplained dyspnea .Cartillage .Sudden sharp chest pain . Analgesics b. Larynx .Diaphoresis .Tachycardia .Decrease LOC • MURPHY’S SIGN is seen in clients with cholelithiasis.Headache .Serves as passageway of air going to the lungs . Filtering of air 2. Elevate legs above heart level to promote increase venous return 2. Measure circumference of leg muscle to determine if swollen 4. Trachea/Windpipe .For cough reflex Glottis .Restlessness b. Warming and moistening of air 3. Upper Respiratory System 1. Monitor for signs of complications Embolism a.Palpitations . Pulmonary .Dizziness .Right nostril . Anti Coagulant .Opens to allow passage of air .1.For phonation (voice production) . cholecystitis characterized by pain at the right upper quadrant with tenderness RESPIRATORY SYSTEM OVERVIEW OF THE STRUCTURES AND FUCNTIONS OF THE RESPIRATORY SYSTEM I.Closes to allow passage of food going to the esophagus .For gas exchange A.Heparin 6. Humidification A.Separated by septum .Left nostril .Consist of anastomosis of capillaries known as Keissel Rach Plexus (the site of nose bleeding) B. Pharynx/Throat . Encourage to wear anti embolic stockings or knee elastic stockings 5. Nose . Lower Respiratory System .

gram negative. Productive cough (yellowish sputum) .Secretes surfactant .retinopathy/blindness in prematurity Disorders of Respiratory System 1.Left lung (consist of 2 lobes. Bronchus . Overcrowded places 3. night sweats 2. Malnutrition 2. 8 segments) . Signs and Symptoms 1.Give oxygen of less 40% in premature to prevent atelectasis and retrolental fibroplasias .In premature infants 1:2 . PTB/Pulmonary Tuberculosis (Koch’s Disease) . 10 segments) . Lungs .Prevent collapse of alveoli . Precipitating Factors 1. Alcoholism 4.Left main bronchus C. Ingestion of an infected cattle with mycobacterium bovis 6. aerobic and easily destroyed by heat or sunlight A. Pleural effusion c. Hydrothorax (air and blood in pleural space Alveoli .Decrease oxygen stimulates breathing . Mode of Transmission 1.Decrease surface tension . Low grade afternoon fever.Right lung (consist of 3 lobes.Increase carbon dioxide is a powerful stimulant for breathing Type II Cells of Alveoli .Right main bronchus . Airborne transmission via droplet nuclei C.Serous membranes Pleural Cavity a.Site of gas exchange (CO2 and O2) .L/S ratio to determine lung maturity . Pneumonia b.Site of tracheostomy B. Pareital b. Virulence (degree of pathogenecity) of microorganism B.Composed of lecithin and spingomyelin .. Pleural fluid c. Visceral With Pleuritic Friction Rub a.Normal L/S ratio is 2:1 .Infection of lung tissue caused by invasion of mycobacterium tuberculosis or tubercle bacilli . Over fatigue 5.Diffusion (Dalton’s law of partial pressure of gases) Respiratory Distress Syndrome .An acid fast.

Side Effect INH: peripheral neuritis/neuropathy (increase intake of Vitamin B6/Pyridoxine) . taken before meals to facilitate absorption . nephrotoxicity .Side Effect PZA: allergic reaction. Institute short course chemotherapy a. taken after meals to facilitate absorption . Comfortable and humid environment 9. CBC . Institute strict respiratory isolation 3.DOH 8 – 10 mm induration. Chest X-ray .PZA can be replaced by Ethambutol .Amikacin .Reveals increase WBC E.Rifampicin (Rifampin) .3.Positive Mantoux test (previous exposure to tubercle bacilli but without active TB) 2. Nursing Management 1.Reveals pulmonary infiltrates 4.Positive to cultured microorganism 3.Side Effect Ethambutol: optic neuritis b. Place client on semi fowlers position to promote expansion of lungs 6.Purified protein derivative . Nebulize and suction when needed 8.WHO 10 – 14 mm induration. Force fluids to liquefy secretions 5. Diagnostic Procedure 1. Dyspnea 6. Enforce CBR 2. Anorexia. generalized body malaise 4. Sputum Acid Fast Bacillus . 48 – 72 hours .Given everyday simultaneously to prevent resistance . Encourage deep breathing and coughing exercise 7.Side Effect Rifampicin: all bodily secretions turn to red orange color . Mantoux Test (skin test) . Administer oxygen inhalation 4.INH (Isonicotinic Acid Hydrazide) .Neomycin .Gentamycin .INH and Rifampicin is given for 4 months. Hemoptysis (chronic) D.Injection of streptomycin (aminoglycoside) . Standard phase . hepatotoxicity. 48 – 72 hours . Intensive phase .PZA (Pyrazinamide) .PZA is given for 2 months. Chest pain 7.Kanamycin . Weight loss 5.

Air pollution 3. Provide increase carbohydrates. heartburn 10. military tuberculosis) PTB . Related to prolonged immobility (CVA clients). Importance of follow up care PNEUMONIA Inflammation of the lung parenchyma leading to pulmonary consolidation as the alveoli is filled with exudates A. Hemophylus Influenzae – causing broncho pneumonia 3.Ototoxicity damage to the 8th cranial nerve resulting to tinnitus leading to hearing loss . Etiologic Agents 1. Provide client health teaching and discharge planning a. Smoking 2. Predisposing Factors 1. Children below 5 years old 2. Diplococcus Pneumoniae 4. anorexia and general body malaise 4.Meninges .Skin . chills. Bronchogenic Cancer .Pneumocystic carini pneumonia .Nephrotoxicity check for BUN and Creatinine . Klebsella Pneumoniae 5. Signs and Symptoms 1. Avoidance of precipitating factors b.Side Effect: tinnitus. Aspiration of food causing aspiration pneumonia D.Drug of choice is Retrovir b.Bones (potts) . Prevent complications (atelectasis. Fever.. Weight loss 5.Give aspirin if there is fever . Rales/crackles 6. Immuno compromised a. Pseudomonas B. AIDS . High Risk Groups 1.Chest x-ray confirms lung cancer 4. Productive cough with greenish to rusty sputum 2. vitamin C and calories 11.Adrenal gland c.Eyes . Streptococcus Pneumonae – causing pneumococal pneumonia 2. protein. Escherichia Pneumoniae 6.Initial sign is non productive cough . Bronchial wheezing . dyspepsia.Side Effect: . Dyspnea with prolong expiratory grunt 3. Strict compliance to medications d. Elderly C. causing hypostatic pneumonia 5.

ABG analysis – reveals decrease PO2 4. calories. Monitor vital signs c. Abdominal distention leading to paralytic ileus (absence of peristalsis) E.Deep breathing exercises . Microlides (Zethromax) Azethromycin (Side Effect: Ototoxicity) Antipyretics Mucolytics/Expectorants Analgesics 4. Best done before meals or 2 – 3 hours to prevent gastro esophageal reflux b. Nursing Management 1.Increase ICP 9. Stop if client cannot tolerate procedure f. Tetracycline c.Unstable vital signs . Institute pulmonary toilet (tends to promote expectoration) . Force fluid 5.Coughing exercises . Nebulize and suction as needed 8. Cyanosis 8.Clients with increase intra ocular pressure (Normal IOP 12 – 21 mmHg) . Prevent complications . Place on semi fowlers position 6. CBC – reveals increase WBC. Assist in postural drainage . Provide increase carbohydrates. Pleuritic friction rub 9.7. Penicillin b.Turning and reposition 7. Administer bronchodilators 15 – 30 minutes before procedure e. Enforce CBR 2. erythrocyte sedimentation rate is increased F. Sputum Gram Staining and Culture Sensitivity – positive to cultured microorganisms 2. Provide oral care after procedure g.Chest physiotherapy . Chest pain 10. Contraindicated with . Administer oxygen inhalation low inflow 3. Chest x-ray – reveals pulmonary consolidation 3. Diagnostic Procedure 1. Avoid smoking b. protein and vitamin C 10. Health teaching and discharge planning a.Hemoptysis . Encourage client deep breathing exercises d. Administer medications as ordered Broad Spectrum Antibiotic a.Drain uppermost area of lungs .Placed on various position Nursing Management for Postural Drainage a.

Air pollution B. hydrocephalus) c. Importance of follow up care HISTOPLASMOSIS Acute fungal infection caused by inhalation of contaminated dust or particles with histoplasma capsulatum derived from birds manure A. Nebulize and suction as needed 6. chills. Steroids c. Prevent the spread of infection by spraying of breeding places COPD (Chronic Obstructive Pulmonary/Lung Disease) Chronic Bronchitis Inflammation of bronchus resulting to hypertrophy or hyperplasia of goblet mucous producing cells leading to narrowing of smaller airways A. Dyspnea 3. Predisposing Factors 1. Productive cough (consistent to all COPD) 2. Fever. Nursing Management 1. Productive cough 2. Prolonged expiratory grunt 4. Diagnostic Procedures 1.Meningitis (nerve deafness.Amphotericin B . general body malaise 4. Hypokalemia) b. Histoplasmin Skin Test – positive 2. Signs and Symptoms 1. Administer oxygen inhalation 3. Hemoptysis 6. Antipyretics 4. Enforce CBR 2. anorexia. Dyspnea on exertion 3.Fungizone (Nephrotoxicity. Prevent complications – bronchiectasis 7. Antifungal . Smoking 2.Atelectasis . Cyanosis 5. Mucolytics d.. check for BUN and Creatinine. Chest and joint pains B. Force fluids to liquefy secretions 5. Regular adherence to medications d. Anorexia and generalized body malaise . ABG analysis PO2 decrease C. Signs and Symptoms PTB or Pneumonia like 1. Administer medications as ordered a.

pH decrease Bronchial Asthma Reversible inflammatory lung condition due to hypersensitivity to allergens leading to narrowing of smaller airways A. Cough that is non productive 2.Incentive spirometer reveals decrease vital lung capacity 2. Diagnostic Procedure 1. Extrinsic Asthma ( Atopic/ Allergic ) Causes a. Cor Pulmonale (right ventricular hypertrophy) C. Gases f. Lints 2. chocolates. Fumes d. Diagnostic Procedure ABG analysis – reveals PO2 decrease (hypoxemia). Pollen b. Cyanosis 7. PCO2 increase. Dust c. Intrinsic Asthma (Non atopic/Non allergic) Causes a. Physical and emotional stress 3. Tachycardia. Food additives (nitrates) e.5. Wheezing on expiration 4. Signs and Symptoms 1. beta blocker) c.Before ABG test for positive Allens Test. Drugs (aspirin. apply direct pressure to ulnar and radial artery to determine presence of collateral circulation D. Diaphoresis C. Sudden change in temperature. Nursing Management 1. Pulmonary Function Test . Enforce CBR . Hereditary b. Dyspnea 3. Scattered rales/ronchi 6. Pulmonary hypertension a. Smoke e. Mixed Type  90 – 95% B. Predisposing Factors (Depending on Types) 1. ABG analysis – PO2 decrease . air pressure and humidity f. Mild Stress/apprehension 6. eggs. Foods (seafoods. Furs h. Cyanosis 5. penicillin. Danders g. chicken d. palpitations 7. Peripheral edema b. milk.

Signs and Symptoms 1. Administer medications as ordered a. Secure inform consent and explain procedure to client 2. Anorexia and generalized body malaise 5. Dyspnea 3. Feeding initiated upon return of gag reflex 2. Avoidance of precipitating factor b. Semi fowlers position 6.2. Oxygen inhalation.Steroids .Status Asthmaticus (give drug of choice) . Chest trauma 3. may cause irritation 3. Steroids – decrease inflammation c. Provide client health teachings and discharge planning concerning a.Emphysema . Bronchodilators – given via inhalation or metered dose inhalaer or MDI for 5 minutes b. Prevent complications . Monitor vital signs and breath sound POST Bronchoscopy 1. Treatment . Predisposing Factors 1. Importance of follow up care BRONCHIECTASIS Abnormal permanent dilation of bronchus leading to destruction of muscular and elastic tissues of alveoli A. Recurrent lower respiratory tract infections 2. Regular adherence to medications to prevent development of status asthmaticus d.Bronchodilators c. Cyanosis 4. Productive cough 2. with low inflow of 2 – 3 L/min 3. Hemoptysis (only COPD with sign) C. Mucolytics/expectorants e. Monitor for signs of gross 4. Monitor for signs of laryngeal spasm – prepare tracheostomy set D. Bronchoscopy – direct visualization of bronchus using fiberscope Nursing Management PRE Bronchoscopy 1. Diagnostic Procedure 1.Epinephrine . Mucomysts (acetylceisteine) d. coughing and smoking. Force fluids 5. Anti histamine 4. Congenital defects 4. Nebulize and suction when needed 7. Maintain NPO 6 – 8 hours prior to procedure 3. Related to presence of tumor B. Avoid talking. ABG – PO2 decrease 2.

“Blue Bloaters”) . Productive cough 2. Bronchial wheezing 10. Over distention of thoracic cavity (barrel chest) A. Hereditary – it involves deficiency of ALPHA-1 ANTI TRYPSIN (needed to form Elastase. Smoking 2.Decrease PO2 (hypoxemia leading to chronic bronchitis. Dyspnea at rest 3. Pulmonary Function Test – reveals decrease vital lung capacity 2.Decrease PCO2 . Surgery (pneumonectomy . Air trapping c.Increase PO2 (hyperaxemia. Allergy 4.1. Decrease tactile fremitus 7.Respiratory acidosis b. Nursing Management 1. ABG analysis reveals a.Increase PCO2 . Barrel chest 11. Panacinar/ centriacinar . Prolong expiratory grunt 4. Decrease or diminished breath sounds 8.Respiratory alkalosis D. 1 lung is removed and position on affected side) 2. Panlobular/ centrilobular . for recoil of alveoli) B. “Pink Puffers”) . High risk: elderly 5. Air pollution 3. Maldistribution of gases d. Inelasticity of alveoli b. Resonance to hyperresonance 6.Increase ph .Decrease ph . Signs and Symptoms 1. Diagnostic Procedure 1. Purse lip breathing to eliminates excess CO2 (compensatory mechanism) C. Segmental Wedge Lobectomy (promote re expansion of lungs) .Unaffected lobectomy facilitate drainage EMPHYSEMA Irreversible terminal stage of COPD characterized by a. Enforce CBR . Predisposing Factors 1. Flaring of alai nares 12. Rales or ronchi 9. Anorexia and generalized body malaise 5.

Force fluids 6. calories. High fowlers position 5. Avoid smoking b. Provide high carbohydrates. Administer oxygen inhalation via low inflow 3. protein. Bronchodilators b. vitamins and minerals 11. Prevent complications .Pneumothorax c. Steroids c. Nebulize and suction when needed 8. Provide comfortable and humid environment 10. Strict compliance to medication d. Health teachings and discharge planning concerning a. Antibiotics d.Atelectasis . Mucolytics/expectorants 4.Cor Pulmonale . Importance of follow up care . Administer medications as ordered a.2. Institute pulmonary toilet 7.CO2 narcosis may lead to coma . Institute PEEP (positive end expiratory pressure) in mechanical ventilation promotes maximum alveolar lung expansion 9.

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