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NERVOUS SYSTEM Overview of structures and functions: Central Nervous System
Brain Spinal Cord Cranial Nerves Spinal Nerves Sympathetic nervous system Parasympathetic nervous system AUTONOMIC NERVOUS SYSTEM
Peripheral Nervous System
Autonomic Nervous System
Sympathetic Nervous System (ADRENERGIC) - Involved in fight or aggression response. - Release of Norepinephrine (cathecolamines) from adrenal glands and causes vasoconstriction. - Increase all bodily activity except GIT EFFECTS OF SNS - Dilation of pupils(mydriasis) in order to be aware. - Dry mouth (thickened saliva). - Increase BP and Heart Rate. - Bronchodilation, Increase RR - Constipation. - Urinary Retention. - Increase blood supply to brain, heart and skeletal muscles. - SNS I. Adrenergic Agents - Give Epinephrine. Signs and Symptoms: - SNS Contraindication: - Contraindicated to patients suffering from COPD (Broncholitis, Bronchoectasis, Emphysema, Asthma). II. Beta-adrenergic Blocking Agents - Also called Beta-blockers. - All ending with “lol” - Propranolol, Atenelol, Metoprolol. Effects of Beta-blockers B – roncho spasm E – licits a decrease in myocardial contraction. T – reats hypertension. A – V conduction slows down. Should be given to patients with Angina Pectoris, Myocardial Infarction, Hypertension. ANTI- HYPERTENSIVE AGENTS 1. Beta-blockers – “lol” 2. Ace Inhibitors – Angiotensin, “pril” (Captopril, Enalapril) 3. Calcium Antagonist – Nifedipine (Calcibloc) In chronic cases of arrhythmia give Lidocaine(Xylocaine)
Parasympathetic Nervous System (CHOLINERGIC, VAGAL, SYMPATHOLYTIC) - Involved in fight or withdrawal response. - Release of Acetylcholine. - Decreases all bodily activities except GIT. EFFECTS OF PNS - Constriction of pupils (meiosis). - Increase salivation. - Decrease BP and Heart Rate. - Bronchoconstriction, Decrease RR. - Diarrhea - Urinary frequency.
I. Cholinergic Agents - Mestinon, Neostigmine. Side Effects - PNS
II. Anti-cholinergic Agents - To counter cholinergic agents. - Atropine Sulfate Side Effects - SNS
CENTRAL NERVOUS SYSTEM
Brain and Spinal Cord.
I. CELLS A. NEURONS
Basic cells for nerve impulse and conduction.
PROPERTIES Excitability – ability of neuron to be affected by changes in external environment. Conductivity – ability of neuron to transmit a wave of excitation from one cell to another. Permanent Cell – once destroyed not capable of regeneration. TYPES OF CELLS BASED ON REGENERATIVE CAPACITY 1. Labile
Capable of regeneration. Epidermal cells, GIT cells, GUT cells, cells of lungs. Capable of regeneration with limited time, survival period. Kidney cells, Liver cells, Salivary cells, pancreas. Not capable of regeneration. Myocardial cells, Neurons, Bone cells, Osteocytes, Retinal Cells.
Support and protection of neurons.
TYPES 1. Astrocytes – maintains blood brain barrier semi-permeable. 2. Oligodendria 3. Microglia 4. Epindymal SUBSTANCES THAT CAN PASS THE BLOOD-BRAIN BARRIER 1. Ammonia
Majority of brain tumors (90%) arises from called astrocytoma.
Cerebral toxin Hepatic Encephalopathy (Liver Cirrhosis) Ascites Esophageal Varices asterixis (flapping hand tremors). Headache Dizziness Confusion Fetor hepaticus (ammonia like breath) Decrease LOC
Early Signs of Hepatic Encephalopathy
Late Signs of Hepatic Encephalopathy
PATHOGNOMONIC SIGNS 1. PTB – low-grade afternoon fever. 2. PNEUMONIA – rusty sputum. 3. ASTHMA – wheezing on expiration. 4. EMPHYSEMA – barrel chest. 5. KAWASAKI SYNDROME – strawberry tongue. 6. PERNICIOUS ANEMIA – red beefy tongue. 7. DOWN SYNDROME – protruding tongue. 8. CHOLERA – rice watery stool. 9. MALARIA – stepladder like fever with chills. 10. TYPHOID – rose spots in abdomen. 11. DIPTHERIA – pseudo membrane formation 12. MEASLES – koplik’s spots. 13. SLE – butterfly rashes. 14. LIVER CIRRHOSIS – spider like varices. 15. LEPROSY – lioning face. 16. BULIMIA – chipmunk face. 17. APPENDICITIS – rebound tenderness. 18. DENGUE – petechiae or (+) Herman’s sign. 19. MENINGITIS – Kernig’s sign (leg pain), Brudzinski sign (neck pain). 20. TETANY – HYPOCALCEMIA (+) Trousseau’s sign/carpopedal spasm; Chvostek sign (facial spasm). 21. TETANUS – risus sardonicus. 22. PANCREATITIS – Cullen’s sign (ecchymosis of umbilicus); (+) Grey turners spots. 23. PYLORIC STENOSIS – olive like mass. 24. PDA – machine like murmur. 25. ADDISON’S DISEASE – bronze like skin pigmentation. 26. CUSHING’S SYNDROME – moon face appearance and buffalo hump. 27. HYPERTHYROIDISM/GRAVE’S DISEASE – exopthalmus. 28. INTUSSUSCEPTION – sausage shaped mass 2. Carbon Monoxide and Lead Poisoning
Can lead to Parkinson’s Disease. Epilepsy Treat with ANTIDOTE: Calcium EDTA. Causes diabetic ketoacidosis. And increases breakdown of fats. And free fatty acids Resulting to cholesterol and (+) to Ketones (CNS depressant). Resulting to acetone breath odor/fruity odor. KUSSMAUL’S respiration, a rapid shallow respiration. Which may lead to diabetic coma. Signs of jaundice (icteric sclerae). Caused by bilirubin (yellow pigment) Increase bilirubin in brain (Kernicterus). Causing irreversible brain damage.
3. Type 1 DM (IDDM)
Maintains integrity of blood brain barrier. Produces myelin sheath in CNS Act as insulator and facilitates rapid nerve impulse transmission.
*Receptive aphasia DRUG OF CHOICE: ARICEPT (taken at bedtime) and COGNEX. Wernicke’s Aphasia General Knowing Gnostic Area or General Interpretative Area. d. heat and cold. b.short term protection. Amnesia – loss of memory. Apraxia – no recognition of objects function. MULTIPLE SCLEROSIS Chronic intermittent disorder of CNS characterized by white patches of demyelination in brain and spinal cord. Sign and Symptoms 4 A’s of Alzheimer a. ALZHEIMER’S DISEASE Atrophy of brain tissues. colostrums). Aphasia – no speech (nodding). 2. Characterized by remission and exacerbation. . Agnosia – no recognition of inanimate objects. c. saliva. Ig D – for chronic inflammation. Signs and Symptoms 1. Mood swings . Ig M – acute in inflammation. . *Expressive aphasia “motor speech center” Broca’s Aphasia inability to understand spoken words. 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. * Give palliative or supportive care. tingling sensation paresthesia numbness euphoria (sense of well being) 3.Immediate action. Visual disturbances blurring of vision (primary) diplopia (double vision) scotomas (blind spots) 2. pain.DEMYELINATING DISORDERS 1. Ig E – for allergic reaction. Impaired sensation to touch. pressure. Ig A – present in all bodily secretions (tears.
NURSING MANAGEMENT 1. Urinary retention/incontinence 7. d. Diuretics b. (+) Lhermitte’s sign a continuous and increase contraction of spinal column. Maintain side rails to prevent injury related to falls. . 3. Impaired motor function weakness spasticity paralysis scanning speech TRIAD SIGNS OF MS Ataxia (Unsteady gait. a. prunes. Increase fluid intake and increase fiber to prevent constipation.4. Bethanicol Chloride (Urecholine) Nursing Management Only given subcutaneous. a. Constipation 8. c. Interferons – alter immune response. Deep breathing exercises b. vitamin C and orange. Monitor breath sounds 1 hour after subcutaneous administration. plums. Prophantheline Bromide (Promanthene) Acid ash diet like cranberry juice. Yoga 4. pineapple. Institute stress management techniques. Baclofen (Dioresal)/ Dantrolene Sodium (Dantrene) – muscle relaxants. ACTH (Adreno Corticotropic Hormone)/ Steroids for acute exacerbation to reduce edema at site of demyelination to prevent paralysis. MRI (reveals site and extent of demyelination). Decrease sexual capacity DIAGNOSTIC PROCEDURE Nystagmus CSF analysis (increase in IgG and Protein). c. Impaired cerebral function CHARCOTS TRIAD IAN Intentional tremors 6. 5. Immunosupresants 2. For Urinary Incontinence Anti spasmodic agent a. Administer medications as ordered a. (+) Romberg’s test) 5. Catheterization to prevent retention. Monitor side effects bronchospasm and wheezing. To acidify urine and prevent bacterial multiplication. b.
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. CEREBRUM largest part composed of the Right Cerebral Hemisphere and Left Cerebral Hemisphere enclosed in the Corpus Callosum. Urethra (20 cm. pressure. Parietal 4. heat. 3. Frontal higher cortical thinking controls personality controls motor activity Broca’s Area (motor speech area) when damaged results to garbled speech. Occipital . 80% brain mass 10% blood 10% CSF COMPOSITION OF BRAIN I. pinocytosis (cell drinking). 8 inches) urinate after intercourse Nursing Management Male MICROGLIA stationary cells that carry on phagocytosis (engulfing of bacteria or cellular debris. Temporal hearing short term memory for appreciation discrimination of sensory impulses to pain.COMMON CAUSE OF UTI Female short urethra (3-5 cm. 1-1 ½ inches) poor perineal hygiene vaginal environment is moist avoid bubble bath (can alter Ph of vagina). 2. numbness. Functions of Cerebrum integrative sensory motor Lobes of Cerebrum 1. avoid use of tissue papers avoid using talcum powder and perfume. eating). Brain Mass PARTS OF THE BRAIN 1. cold. touch.
equal size of pupil is isocoria. controls smell and if damaged results to Anosmia (absence of smell). BASAL GAGLIA areas of grey matter located deep within each cerebral hemisphere. size of pupil is 2 – 3 mm. Medulla Oblongata 3. for vision visceral function activities of internal organ like gastric motility. controls temperature (thermoregulatory center). INTERBRAIN/ DIENCEPHALON Parts of Diencephalon A. rhythm and depth of respiration. hiccup. swallowing. BRAIN STEM located at lowest part of brain Parts of Brain Stem 1. vasomotor center (dilation and constriction of bronchioles). heart rate. controls respiration. lesser brain. positive PERRLA 4. Hypothalamus 5. controls libido controls long term memory Insula (Island of Reil) Limbic System (Rhinencephalon) 2. Thalamus acts as relay station for sensation. unequal size of pupil is anisocoria. release dopamine (controls gross voluntary movement. B. 2. DECREASE Myasthenia Gravis Parkinson’s Disease INCREASE Bi-polar Disorder Schizophrenia NEURO TRANSMITTER Acethylcholine Dopamine 3. hearing acuity is 30 – 40 dB. early sign for females telarche and late sign is menarche. . controls pituitary functions androgenic hormones promotes secondary sex characteristics. anxiety and excitement. Pons pneumotaxic center controls the rate. MIDBRAIN/ MESENCEPHALON acts as relay station for sight and hearing. Cerebellum smallest part of the brain. early sign for males are testicular and penile enlargement late sign is deepening of voice. controls blood pressure controls thirst appetite/satiety sleep and wakefulness controls some emotional responses like fear. vomiting.
posture and gait. 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. NEUROLOGIC DISORDERS INCREASE INTRACRANIAL PRESSURE – increase in intra-cranial bulk brought about by an increase in one of the 3 major intra cranial components. . Early closure of posterior fontanels causes posterior enlargement of skull in hydrocephalus. heart rate decrease respiratory rate decrease temperature increase directly proportional to blood pressure. equilibrium. 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). controls balance. Cervical 2 – also known as AXIS. projective vomiting headache papilledema (edema of optic disc) abnormal posturing decorticate posturing (damage to cortex and spinal cord). 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. widening of pulse pressure is neurologic in nature (if narrow cardiac in nature).
Prevent further increase ICP by: a. Limit fluid intake to 1200 – 1500 ml/day (in force fluids 2000 – 3000 ml/day). avoid use of restraints. Elevate bed of client 30 – 35o angle with neck in neutral position unless contraindicated to promote venous drainage. Before and after suctioning hyper oxygenate client 100% and done 10 – 15 seconds only. decerebrate posturing (damage to upper brain stem that includes pons. Late signs of hypoxia HYPERCARBIA b. cerebellum and midbrain). administered via side drip regulated fast drip to prevent crystal formation. 3. Osmotic diuretic (Mannitol) for cerebral diuresis Nursing Management monitor vital signs especially BP (hypotension). Prevent complications of 6. Prevention of hypoxia and hypercarbia Early signs of hypoxia restlessness agitation tachycardia Bradycardia Extreme restlessness Dyspnea Cyanosis Increase CO2 (most powerful respiratory stimulant) retention. unilateral dilation of pupils called uncal herniation bilateral dilation of pupils called tentorial herniation resulting to mild headache possible seizure activity Nursing Management 1. c. provide an comfortable and quite environment. In chronic respiratory distress syndrome decrease O2 stimulates respiration. maintain side rails. 4. Administer medications like: a. b. Nursing Management . Furosemide) Drug of choice for CHF (pulmonary edema) Loop of Henle in kidneys. 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. b. Maintain patent and adequate ventilation by: a. monitor strictly input and output every 1 hour notify physician if output is less 30 cc/hr. c. avoid clustering of nursing activity together. Loop diuretic (Lasix. Monitor strictly input and output and neuro check 5. 7. Assist in mechanical ventilation 2. d.
maximum effect of 6 hours. Phenytoin) c. administered IV push or oral. monitor strictly input and output every 1 hour notify physician if output is less 30 cc/hr. given early morning immediate effect of 10 – 15 minutes. Monitor vital signs especially BP (hypotension). Corticosteroids *CONGESTIVE HEART FAILURE Signs and Symptoms dyspnea orthopnea paroxysmal nocturnal dyspnea productive cough frothy salivation cyanosis rales/crackles bronchial wheezing pulsus alternans anorexia and general body malaise PMI (point of maximum impulse/apical pulse rate) is displaced laterally S3 (ventricular gallop) Predisposing Factors/Mitral Valve RHD Aging TREATMENT Morphine Sulfate Aminophelline Digoxin Diuretics Oxygen Gases. blood monitor RIGHT CONGESTIVE HEART FAILURE (Venous congestion) Signs and Symptoms jugular vein distention (neck) ascites pitting edema weight gain hepatosplenomegaly jaundice pruritus esophageal varices anorexia and general body malaise . Dexamethasone (Decadron) Hydrocortisone Prednisone (to reduce edema that may lead to increase ICP) Mild Analgesics (Codeine Sulfate for respiratory depression) Anti Convulsants (Dilantin.
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. Oral Potassium Chloride) increase intake of foods rich in potassium FRUITS Apple Banana Cantalop e Oranges 2.5 – 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.Signs and Symptoms of Lasix in terms of electrolyte imbalances 1. in infant TACHYCARDIA) agitation dry mucous membrane poor skin turgor weakness and fatigue . Hypocalcemia/ Tetany VEGETABLES Asparagus Brocolli Carrots Spinach decrease calcium level normal value is 8. Hyponatremia DECREASE decrease sodium level normal value is 135 – 145 meq/L Signs and Symptoms hypotension dehydration signs (Initial sign in adult is THIRST.4 – 5. Hypokalemia decrease potassium level normal value is 3.
Mechanism of action: inhibits synthesis of uric acid.Nursing Management force fluids administer isotonic fluid solution as ordered 4. Signs and Symptoms Nursing Management a. Colchecine * KIDNEY STONES Signs and Symptoms renal colic Cool moist skin force fluids administer medications as ordered Morphine Sulfate ANTIDOTE: Naloxone (Narcan) toxicity leads to tremors. Nursing Management a. Hyperglycemia normal FBS is 80 – 100 mg/dl polyuria polydypsia polyphagia monitor FBS Signs and Symptoms Nursing Management 5. Acute gout Mechanism of action: promotes excretion of uric acid. Hyperuricemia increase uric acid (purine metabolism) foods high in uric acid (sardines. Narcotic Analgesic b. Allopurinol (Zyloprim) b. organ meats and anchovies) *Increase in tophi deposit leads to Gouty arthritis. Allopurinol (Zyloprim) Side Effects Respiratory depression (check for RR) . joint pain (great toes) swelling force fluids administer medications as ordered Drug of choice for gout.
Hypoxia 4. constipation e. Haloperidol(Haldol) d. Arteriosclerosis 3. 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. Predisposing Factors 1. Increase dosage of the following drugs: a. Monotone type speech mood lability (in state of depression) increase salivation (drooling type) autonomic changes a.PARKINSON’S DISEASE/ PARKINSONISM Chronic progressive disorder of CNS characterized by degeneration of dopamine producing cells in the SUBSTANCIA NIGRA of the midbrain and basal ganglia. 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. Methyldopa(Aldomet) c. seborrhea d. increase sweating b. increase lacrimation c. difficulty rising from sitting position. Administer medications as ordered Anti Parkinsonian agents Levodopa (L-dopa) short acting Amantadine Hydrochloride (Symmetrel) Carbidopa (Sinemet) . Reserpine(Serpasil) b. Encephalitis 5. decrease sexual capacity Nursing Management 1. Poisoning (lead and carbon monoxide) 2.
6.6 – 1. Isonicotinic Acid Hydrazide Anti Cholinergic Agents (ARTANE and COGENTIN) .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. Encourage increase fluid intake and fiber.relieves tremor rigidity Bromocriptene Hydrochloride (Parlodel) Side Effects Respiratory depression 2.5 meq/L . Maintain side rails to prevent injury 3. Prevent complications of immobility 4.5 – 1. 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 .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). Decrease protein in morning and increase protein in afternoon to induce sleep 5. Assist/supervise in ambulation 7.2 meq/L 10 – 19 mg/100 ml 10 – 19 mg/100 ml 10 – 30 mg/100 ml TOXICITY LEVEL 2 2 20 20 200 INDICATION CHF Bipolar COPD Seizures Osteo Arthritis CLASSIFICATION Cardiac Glycoside Anti-Manic Agents Bronchodilators Anti-Convulsant Non-narcotic Analgesic . Dopamine Agonist .
8 – 1) hypoglycemia Tremors. administered sandwich method avoid taking alcohol because it can lead to severe CNS depression avoid caffeine Nursing Management 4. depression Antidote: Acetylcisteine (mucomyst) prepare suction apparatus as bedside.1. Aminophylline Toxicity Signs and Symptoms tachycardia palpitations CNS excitement (tremors. Lithium Toxicity Signs and Symptoms anorexia nausea and vomiting diarrhea dehydration causing fine tremors hypothyroidism force fluids increase sodium intake to 4 – 10 g% daily Nursing Management 3. 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.9 NaCl to prevent development of crystals or precipitate. Acetaminophen Toxicity Signs and Symptoms hepatotoxicity (monitor for liver enzymes) SGPT/ALT (Serum Glutamic Pyruvate Transaminace) SGOT/AST (Serum Glutamic Oxalo-Acetil Transaminace) nephrotoxicity monitor BUN (10 – 20) and Creatinine (. Digitalis Toxicity Signs and Symptoms nausea and vomiting diarrhea confusion photophobia changes in color perception (yellowish spots) Antidote: Digibind 2. . agitation and restlessness) only mixed with plain NSS or 0. irritability.
Cholinergic (Mestinon) b.Administer anti cholinergic agents (Atropine Sulfate) Side Effects MYASTHENIC CRISIS Causes: . swallow. initial sign is ptosis a clinical parameter to determine ptosis is palpebral fissure.G. Assist in surgical procedure known as thymectomy because it is believed that the thymus gland is responsible for M. airway 2. maintain side rails to prevent injury related to falls 5. speak.stress . Prevent complications . institute NGT feeding 6. input and output and neuro check * monitor strength or motor grading scale 4.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.PNS Treatment . Assist in plasma paresis and removing auto immune anti bodies 9.administer cholinergic agents as ordered 7. mmobility * assist in mechanical ventilation and monitor pulmonary function test * monitor strictly vital signs.The client is unable to see.over medication Signs and Symptoms . administer medications as ordered a. Anti Cholenisterase (Neostegmin) Mechanism of Action maintain patent airway and adequate ventilation increase level of Ach PNS Cortocosteroids suppress immune response monitor for 2 types of crisis: CHOLINERGIC CRISIS Cause: . Nursing Management 1. Incidence rate: women 20 – 40 years old Predisposing factors unknown autoimmune: it involves release of cholinesterase an enzyme that destroys Ach. aspiration 3. 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. if there is no effect there is damage to occipital lobe and midbrain and is negative for Signs and Symptoms Diagnostic Procedure M.infection Signs and Symptoms . 8.under medication .G. breathe Treatment .
CSF analysis reveals 1. (+) Brudzinski sign (neck pain) D. Encourage to arch back to clearly visualize L3-L4. Meningococcus – most dangerous 2. for support and protection for nourishment blood supply LAYERS OF THE MENINGES 1. general body malaise and weight loss Possible increase in ICP and seizure activity Abnormal posturing (decorticate and decerebrate) Signs of meningeal irritation a. Increase CSF opening pressure (normal pressure is 50 – 100 mmHg) 4. Diagnostic Procedures Lumbar puncture: a hollow spinal needle is inserted in the subarachnoid space between the L3 – L4 to L5. Place flat on bed 12 – 24 o 2. Opisthotonus (arching of back) c. Empty bladder and bowel to promote comfort. Assess for movement and sensation of extremities. Nursing Management for LP Before Lumbar Puncture 1. Secure informed consent and explain procedure. (+) Kernig’s sign (leg pain) d. Force fluids 3.causes adult meningitis 4. Pneumococcus 3. Dura matter – outer layer 2. Hemophilus Influenzae – causes pediatric meningitis B. Post Lumbar Puncture 1. Streptococcus . Increase CHON and WBC 2. 4. Decrease glucose 3. drainage and leakage to tissues. chills. (+) cultured microorganism (confirms meningitis) CBC reveals 1. A. 3. 2. Nuchal rigidity or stiff neck b. Check punctured site for any discoloration. Arachnoid – middle layer 3. Pia matter – inner layer subdural space between the dura and arachnoid subarachnoid space between the arachnoid and pia. Mode of transmission airborne transmission (droplet nuclei) C. CSF aspiration is done. Etiology 1.INFLAMMATORY CONDITIONS OF THE BRAIN MENINGITIS Meninges 3 fold membrane that covers brain and spinal cord. Increase wbc . Signs and Symptoms headache photophobia projectile vomiting fever. anorexia.
Prevent complications most feared is hydrocephalus hearing loss/nerve deafness is second complication consult audiologist mental retardation delayed psychomotor development c. input and output and neuro check 6. Institute strict respiratory isolation 24 hours after initiation of anti biotic therapy 4. 7. Rehabilitation for neurological deficit CVA (STROKE/BRAIN ATTACK/ ADOPLEXY/ CEREBRAL THROMBOSIS) a partial or complete disruption in the brains blood supply. Broad spectrum antibiotics (Penicillin. Mild analgesics c. Elevate head 30-45o 5. If there is bone fracture there is hemorrhage and there would be escape of the fat cells in the circulation. Administer medications as ordered a. Provide a comfortable and darkened environment. Yellow bone marrow are produced from the medullary cavity of the long bones and produces fat cells. 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. 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. Mid Cerebral Artery b. 9. Provide client health care and discharge planning concerning: a. calories with small frequent feedings. b. Monitor strictly V/S. Anti pyretics 3. Internal Cerebral Artery – the 2 largest artery A. 2 most common cerebral artery affected by stroke a. Incidence Rate men are 2-3 times high risk B. Compartment syndrome (compression of arteries and nerves) . Nursing Management 1. Tetracycline) b. Institute measures to prevent increase ICP and seizure. Enforce complete bed rest 2. CHON. Maintain good diet of increase CHO. 8. Maintain fluid and electrolyte balance.E.
aphasia c. TIA Signs and Symptoms 2. Diagnostic Procedure 1. Lifestyle (smoking). Diabetes Mellitus. can do multiple tasks c. Prolong use of oral contraceptives promotes lypolysis (breakdown of lipids) leading to atherosclerosis that will lead to hypertension and eventually CVA. Risk Factors 1. homonymous hemianopsia (loss of half of visual field) 1. Related to diet: increase intake of saturated fats like whole milk 7. Obesity (increase 20% ideal body weight) 4. CT Scan – reveals brain lesions 2. agraphia (difficulty writing) f. Related stress physical and emotional 8. Valvular Cardiac Surgery (mitral valve replacement) 2. Hyperlipidemia more on genetics/genes that binds to cholesterol 5. D. usually fells guilty when not doing anything 6. dysarthria (inability to articulate words) d. alexia (difficulty reading) e. Atherosclerosis. sedentary lifestyle 3. deadline driven b. phlegia b. Hypertension. Type A personality a. Complete stroke Signs and Symptoms E. 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. Stroke in evolution 3. nausea and vomiting dysphagia (+) Kernig’s sign and Brudzinski sign which may lead to hemorrhagic stroke focal neurological deficits a. Cerebral Arteriography reveals the site and extent of malocclusion uses dye for visualization most of dye are iodine based check for shellfish allergy after diagnostic exam force fluids to release dye because it is nephro toxic check for distal pulse (femoral) check for hematoma formation . Myocardial Infarction.C. Signs and Symptoms Heart Disease.
exercise. Monitor strictly vitals signs. Provide alternative means of communication a. magic slate 9. Loop Diuretics (Lasix. provide egg crate mattresses or water bed c. Furosemide) c. Restrict fluids to prevent cerebral edema that might increase ICP 3. Osmotic Diuretics (Mannitol) b. If positive to hemianopsia approach client on unaffected side 10. administrate O2 inhalation 2. Cortecosteroids d. smoking) b. I & O and neuro check 5. avoidance of modifiable risk factors (diet. Maintain patent airway and adequate ventilation by: a. Provide client health teachings and discharge planning concerning a. give Protamine Sulfate Comadin/ Warfarin (long acting) give simultaneously because Coumadin will take effect after 3 days check for prothrombin time if prolonged there is a risk for bleeding give Vit. Mild Analgesics e. Anti Coagulants Heparin (short acting) check for partial thromboplastin time if prolonged there is a risk for bleeding. Nursing Management 1. Institute NGT feeding 8. K (Aqua Mephyton) g. Elevate head 30 – 45o 4. importance of follow up care . saturated fats and caffeine) d. Assist in passive ROM exercise every 4 hours to promote proper bodily alignment and prevent contractures 7. Thrombolytic/Fibrinolytic Agents – dissolves thrombus Streptokinase Side Effect: Allergic Reaction Urokinase Tissue Plasminogen Activating Factor Side Effect: Chest Pain f.F. Anti Platelet PASA (Aspirin) Contraindicated for dengue. dietary modification (decrease salt. turn client to side b. non verbal cues b. assist in mechanical ventilation b. prevent complication (subarachnoid hemorrhage is the most feared complication) c. provide sand bag or food board. 6. ulcer and unknown cause of headache because it may potentiate bleeding 11. Prevent complications of immobility by: a. Administer medications as ordered a.
Anti Cholinergic Agents – Atrophine Sulfate c. intake and output c. constipation C. monitor pulmonary function test 2. neuro check d. Decreased of diminished deep tendon reflex 5. Arrythmia b. Zylocaine Bretylium – blocks release of norepinephrine to prevent increase of BP 8. increase sweating c. Dysphagia 3. . ECG 3. Diagnostic Procedures 1. vital signs b. Alternate hypotension to hypertension ** ARRYTHMIA (most feared complication) 6.GUILLAIN BARRE SYNDROME a disorder of the CNS characterized by bilateral symmetrical polyneuritis leading to ascending muscle paralysis. Anti Arrythmic Agents Lidocaine. Ascending muscle weakness leading to paralysis 4. Clumsiness (initial sign) 2. Institute NGT feeding to prevent aspiration 6. Maintain side rails to prevent injury related to fall 4. Corticosteroids – suppress immune response b. Antecedent viral infections such as LRT infections B. Predisposing Factors 1. assist in mechanical ventilation b. Prevent complications a. Prevent complications of immobility by turning the client every 2 hours 5. increase salivation b. Monitor strictly the following a. Autoimmune 2. Assist in plasma pharesis (filtering of blood to remove autoimmune anti-bodies) 9. Maintain patent airway and adequate ventilation by: a. Signs and Symptoms 1. Administer medications as ordered a. A. Assist in passive ROM exercise 7. Nursing Management 1. Paralysis or respiratory muscles/Respiratory arrest * Sengstaken Blakemore Tube for liver cirrhosis to decompress bleeding esophageal verices (prepare scissor to cut tube incase of difficulty in breathing to release air in the balloon for hemodialysis prepare bulldog clips to prevent air embolism. Autonomic symptoms that includes a. CSF analysis reveals increase in IgG and protein D.
Generalized Seizure 1. visual. Signs and Symptoms Dependent on stages of development or types of seizure I. Predisposing Factors 1.contraction of extremities d. Toxicity from a. Post ictal sleep – unresponsive sleep 2. Partial or Localized Seizure 1. Valium and Glucose C. Petit mal Seizure – absence of seizure common among pediatric clients characterized by a. Diagnostic Procedures 1.direct symmetrical extension of extremities Clonic contractions . sensory experience b. lead b carbon monoxide 5. EEG – reveals hyper activity of electrical brain waves . Nutritional and Metabolic deficiencies 6. tactile. mild hallucinatory sensory experience III. clouding of consciousness – not in contact with environment c. Presence of brain tumor 4. 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. Psychomotor Seizure (focal motor seizure) a. twitching of mouth d. Grand mal Seizure (tonic-clonic seizure) a. Genetics 3.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. Valium) B. olfactory. if left untreated can lead to hyperpyrexia and lead to coma and eventually death. Tonic contractions . Drug of choice: Diazepam. loss of consciousness (5 – 10 seconds) II. blank stare b. 2. Sudden withdrawal to anti convulsant drug is predisposing factor for status epilepticus (drug of choice is Diazepam. Status Epilepticus A continuous uninterrupted seizure activity. Head injury due to birth trauma 2. Seizure – first convulsive attack Epilepsy – second or series of attacks Febrile seizure – normal in children age below 5 years A. automatism – stereotype repetitive and non propulsive behavior b. CT Scan – reveals brain lesions 2. Physical and emotional stress 7. decrease blinking of eyes c. Epileptic cry – is characterized by fall and loss of consciousness for 3 – 5 minutes c. Signs or aura with auditory.
D. Nursing Management 1. Maintain patent airway and promote safety before seizure activity a. clear the site of blunt or sharp objects b. loosen clothing of client c. maintain side rails d. avoid use of restrains e. turn clients head to side to prevent aspiration f. place mouth piece of tongue guard to prevent biting or tongue 2. Avoid precipitating stimulus such as bright/glaring lights and noise 3. Administer medications as ordered a. Anti convulsants (Dilantin, Phenytoin) b. Diazepam, Valium c. Carbamazepine (Tegretol) – Trigeminal neuralgia d. Phenobarbital, Luminal 4. Institute seizure and safety precaution post seizure attack a. administer O2 inhalation b. provide suction apparatus 5. Document and monitor the following a. onset and duration b. types of seizures c. duration of post ictal sleep may lead to status epilepticus d. assist in surgical procedure cortical resection COMPREHENSIVE NEURO EXAM GLASGOW COMA SCALE
objective measurement of LOC sometimes called as the quick neuro check
Components 1. Motor response 2. Verbal response 3. Eye opening Conscious Lethargy Stupor Coma Deep Coma 15 – 14 13 – 11 10 – 8 7 3
Survey of mental status and speech a. LOC b. Test of memory Levels of orientation Cranial nerve assessment Sensory nerve assessment Motor nerve assessment Deep tendon reflex Autonimics Cerebellar test a, Romberg’s test – 2 nurses, positive for ataxia b. Finger to nose test – positive result mean dimetria (inability of body to stop movement at desired point) c. Alternate supination and pronation – positive result mean dimetria
I. LEVEL OF CONSCIOUSNESS 1. Conscious - awake 2. Lethargy – lethargic (drowsy, sleepy, obtunded) 3. Stupor
stuporous (awakened by vigorous stimulation) generalized body weakness decrease body reflex comatose light coma (positive to all forms of painful stimulus) deep coma (negative to all forms of painful stimulus)
DIFFERENT PAINFUL STIMULATION 1. Deep sternal stimulation/ deep sternal pressure 2. Orbital pressure 3. Pressure on great toes 4. Corneal or blinking reflex Conscious client use a wisp of cotton Unconscious client place 1 drop of saline solution II. TEST OF MEMORY 1. Short term memory
ask most recent activity positive result mean anterograde amnesia and damage to temporal lobe ask for birthday and validate on profile sheet positive result mean retrograde amnesia and damage to limbic system consider educational background
2. Long term memory
III. LEVELS OF ORIENTATION 1. Time – first asked 2. Person – second asked 3. Place – third asked CRANIAL NERVES CRANIAL NERVES I. OLFACTORY II. OPTIC III OCCULOMOTOR IV. TROCHLEAR V. TRIGEMINAL VI. ABDUCENSE VII. FACIAL VIII. ACOUSTIC IX. GLOSSOPHARYNGEAL X. VAGUS FUNCTION S S M M (Smallest) B (Largest) M B S B B
(Longest) XI. SPINAL ACCESSORY M XII. HYPOGLOSSAL M CRANIAL NERVE I: OLFACTORY
sensory function for smell
don’t use alcohol, ammonia, perfume because it is irritating and highly diffusible. use coffee granules, vinegar, bar of soap, cigarette test each nostril by occluding each nostril
Abnormal Findings 1. Hyposnia – decrease sensitivity to smell 2. Dysosmia – distorted sense of smell 3. Anosmia – absence of smell Indicative of 1. head injury damaging the cribriform plate of ethmoid bone where olfactory cells are located 2. may indicate inflammatory conditions (sinusitis) CRANIAL NERVE II: OPTIC
sensory function for vision or sight
Functions 1. Test visual acuity or central vision or distance
use Snellen’s Chart Snellen’s Alphabet chart: for literate clients Snellen’s E chart: for illiterate clients Snellen’s Animal chart: for pediatric clients normal visual acuity 20/20 numerator is constant, it is the distance of person from the chart (6 – 7 m, 20 feet) denominator changes, indicates distance by which the person normally can see letter in the chart. - 20/200 indicates blindness 20/20 visual acuity if client is able to read letters above the red line. a. Superiorly b. Bitemporaly c. Nasally d. Inferiorly
2. Test of visual field or peripheral vision
COMMON VISUAL DISORDERS 1. Glaucoma
increase IOP normal IOP is 12 – 21 mmHg preventable but not curable Common among 40 years old and above Hereditary Hypertension Obesity
A. Predisposing Factors
B. Signs and Symptoms 1. Loss of peripheral vision
pathognomonic sign is tunnel vision steamy cornea may lead to blindness
2. Headache, nausea, vomiting, eye pain (halos around light)
C. Diagnostic Procedures 1. Tonometry 2. Perimetry
Signs and Symptoms 1. Treatment 1. Treatment 1. Gonioscopy D. Mydriatics (Mydriacyl) – constricts pupils 2. Diagnostic Procedure 1. Prolonged exposure to UV rays B. Miotics – constricts pupil a. Blurring or hazy vision 2. Decrease perception to colors Complication is blindness D. Carbachol 2.3. Pilocarpine Sodium. Retinal Detachment Separation of epithelial surface of retina . Surgical Procedures 1. TRABECULECTOMY (Peripheral Indectomy) – drain aqueous humor 2. Loss of central vision C. Epinephrine eyedrops – decrease formation of aqueous humor 3. Milky white appearance at center of pupils 3. Opthalmoscopic exam E. Acetazolamide (Diamox) – promotes increase outflow of aqueous humor or drainage 4. Surgical Procedure Extra Capsular Cataract Lens Extraction .Total removal of cataract with its surrounding capsules Most feared complication post op is RETINAL DETACHMENT 3. Timoptics (Timolol Maleate) E. Predisposing Factor 1. Cyclopegics (Cyclogyl) – paralyses cilliary muscle F. Diabetes Mellitus 4. Carbonic Anhydrase Inhibitors a. Related to congenital 3.Partial removal Intra Capsular Cataract Lens Extraction . Cataract Decrease opacity of lens A. Aging 65 years and above 2. Pathognomonic Signs 1.
Scleral Buckling 2. Macular Degeneration Degeneration of the macula lutea (yellowish spot at the center of retina) A.A. Diathermy – heat application 4. Signs and Symptoms 1. mandibular . VI: OCULOMOTOR. IV. Myopia (near sightedness) B. Surgical Procedures 1. Predisposing Factors 1. Black Spots CRANIAL NERVE III. Post Lens Extraction 2. Floaters C. maxillary. Signs and Symptoms 1. 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. Cryosurgery – cold application 3. TROCHLEAR. Curtain veil like vision 2.
mucous membrane. VAGUS NERVE Glosopharyngeal: controls taste. Parts of the Ear 1. teeth. X: GLOSOPHARYNGEAL. contains the Organ of Corti (the true organ of hearing) Let client repeat words uttered CRANIAL NERVE IX. anterior 2/3 of tongue pinch of sugar and cotton applicator placed on tip of tongue Motor: controls muscle of facial expression instruct client to smile. ENDOCRINE SYSTEM Overview of the structures and functions 1. frown and if results are negative there is facial paralysis or Bell’s Palsy and the primary cause is forcep delivery. soft palate and corneal reflex) motor: controls the muscle of mastication or chewing damage to CN V leads to trigeminal neuralgia/thickdolorum medication: Carbamezapine(Tegretol) CRANIAL NERVE VII: FACIAL Sensory: controls taste. refers to movement and orientation of the body in space. 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. Middle Ear 3. Inner Ear Vestibule: Meinere’s Disease Cochlea Mastoid Cells Endolymph and Perilymph COCHLEA: controls hearing. sensory: controls sensation of face. Pituitary Gland (Hypophysis Cerebri) . CRANIAL NERVE VIII: ACOUSTIC/VESTIBULOCOCHLEAR Controls balance particularly kinesthesia or position sense. Outer Ear Pinna Eardrum Hammer Anvil Stirrup Malleus Incus Stapes 2.
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. Prevent complilcations – HYPOVOLEMIC SHOCK is the most feared complication Normal value: 1. Weakness and fatigue 4. Polyuria 2. Force fluids 2. Serum Sodium D. Monitor strictly vital signs and intake and output 3. Anterior Pituitary Gland o o o hemorrhage o o administrate oxytocin immediately after delivery to prevent uterine atony.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. Nursing Management . Agitation c. Signs and Symptoms 2. Adult: thirst b. If left untreated results to hypovolemic shock (sign is anuria) C.015 – 1. Hypotension 5.030 Ph 4 – 8 Increase resulting to hypernatremia Related to pituitary surgery Trauma Inflammation Presence of tumor B. Urine Specific Gravity 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. Signs of dehydration a. Dry mucous membrane 3. Administer medications as ordered a. Weight loss 6. Posterior Pituitary Gland 2. Predisposing Factor o o o o 1. Poor Skin turgor d. Pitressin (Vasopresin Tannate) – administered IM Z-tract 4.
Related to hyperplasia (increase size of organ brought about by increase of number of cells) of pituitary 2. Related to presence of bronchogenic cancer o o gland. Lead to blindness due to severe photophobia b. Osmotic diuretics (Mannitol) 3. Weight gain 2. B. Growth hormones (somatotropic hormone) o o o o o initial sign of lung cancer is non productive cough non invasive procedure is chest x-ray 3. Loop diuretics (Lasix) b.SIADH o hypersecretion of anti diuretic hormone A. Predisposing Factors 1. Provide meticulous skin care 6. Weigh patient daily and assess for pitting edema 5. Urine specific gravity is increased 2. Fluid retention a. Signs and Symptoms 1. Prone to skin cancer o Hypersecretion of MSH results to Vitiligo 3. Melanocyte Stimulating hormone o o o for skin pigmentation Hyposecretion of MSH results to Albinism Most feared complications of albinism a. Hypertension b. Administer medications as ordered a. Restrict fluid 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. Monitor strictly vital signs. Nursing Management 1. Head injury 2. Edema c. Water intoxication may lead to cerebral edema and lead to increase ICP – may lead to seizure activity C. Serum Sodium is decreased D. intake and output and neuro check 4. Diagnostic Procedure 1. Adrenochorticotropic hormone (ACTH) o promotes development of adrenal cortex .
HYPOTHYROIDISM o o o o o o all are decrease except weight and menstruation memory impairment there is loss of appetite but there is weight gain menorrhagia cold intolerance constipation Signs and Symptoms HYPERTHYROIDISM o o o o all are increase except weight and menstruation increase appetite but there is weight loss amenorrhea exophthalmos Signs and Symptoms THYROID DISORDERS SIMPLE GOITER o enlargement of thyroid gland due to iodine deficiency A. T3 (Tri iodothyronine) . strawberry. all nuts soil erosion washes away iodine . sweet potato. broccoli. Predisposing Factors 1. Increase intake of goitrogenic foods o o o contains pro-goitrin an anti thyroid agent that has no iodine. turnips.3 molecules of iodine (more potent) 2.4. Thyroxine) o o T3 and T4 are metabolic or calorigenic hormone promotes cerebration (thinking) 3. Thyrocalcitonin – antagonizes the effects of parathormone to promote calcium resorption. Goiter belt area a. places far from sea b. cabbage. Lactogenic homone (Prolactin) o o o o promotes development of mammary gland with help of oxytocin it initiates milk let down reflex secretes estrogen secretes progesterone 5. T4 (tetra iodothyronine. 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. Leutinizing hormone 6. carrots. Mountainous regions 2. radish.
Phenylbutazones (NSAIDs) . Tetracycline. presence of tumor. Nursing Management 1. 4 Medications to be taken via straw: Lugol’s. crabs. Instruct client to take in the morning to prevent insomnia 2. Cobalt e. 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. Predisposing Factors 1. Iron.if goiter is caused by B. Monitor side effects o o o o o o o insomnia tachycardia and palpitations hypertension heat intolerance seaweeds seafood’s like oyster. Mild dysphagia 3. Signs and Symptoms 1. Enlarged thyroid gland 2. Mild restlessness C. Diagnostic Procedures 1. best taken raw because it it is easily destroyed by heat 5. Administer medications as ordered a. Anti Thyroid Agent – Prophylthiuracil (PTU) b. Thyroid Scan – reveals enlarged thyroid gland. Iatrogenic Cause – disease caused by medical intervention such as surgery 2. clams and lobster but not shrimps because it contains lesser amount of iodine. 3. Serum T3 and T4 – reveals normal or below normal 2. inflammation . Thyroid Hormones o o o Levothyroxine (Synthroid) Liothyronine (Cytomel) Thyroid Extracts Nursing Management when giving Thyroid Hormones 1. Enforce complete bed rest 2. Nitrofurantoin (drug of choice for pyelonephritis) b.o goitrogenic drugs a. Monitor vital signs especially heart rate because drug causes tachycardia and palpitations 3. Serum Thyroid Stimulating Hormone (TSH) – is increased (confirmatory diagnostic test) D. PASA (Aspirin) d. Increase dietary intake of foods rich in iodine A. Related to atrophy of thyroid gland due to trauma. Lithium Carbonate c. Lugol’s Solution/SSKI ( Saturated Solution of Potassium Iodine) o o color purple or violet and administered via straw to prevent staining of teeth. iodized salt.
Weakness and fatigue 2. Avoid precipitating factors leading to myxedema coma o o stress infection Assist in mechanical ventilation Administer thyroid hormones as ordered Force fluids . Autoimmune (Hashimotos Disease) B.3. Leothyronine c. Signs and Symptoms (Early Signs) 1. Hoarseness of voice 4. hypothermia 6. bradypnea. CNS changes o o o o lethargy memory impairment psychosis menorrhagia C. hypothermia leading to pregressive stupor and coma. Administer isotonic fluid solution as ordered 4. Loss of appetite but with weight gain which promotes lipolysis leading to atherosclerosis and MI 3. hypoglycemia. bradycardia. hyponatremia. bradypnea. Constipation (Late Signs) 1. Force fluids 3. Serum Cholesterol is increased 3. hypoventilation. Decrease in all vital signs – hypotension. Thyroid Extracts 5. Provide meticulous skin care 8. bradycardia. Diagnostic Procedures 1. Decrease libido 5. Levothyroxine b. Dry skin 4. Iodine deficiency 4. Cold intolerance 5. Provide client health teaching and discharge planning concerning a. Non pitting edema (Myxedema) 3. 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. Administer medications as ordered Thyroid Hormones a. Nursing Management for Myxedema Coma 2. Serum T3 and T4 is decreased 2. Provide dietary intake that is low in calories 6. RAIU (Radio Active Iodine Uptake) is decreased D. Nursing Management 1. Brittleness of hair and nails 2. Provide comfortable and warm environment 7.
Heat intolerance 4. 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. Administer medications as ordered Anti Thyroid Agent a. and sedatives prevent complications (myxedema coma. 4. Diagnostic Procedures 1. Moist skin 3.o o o o o o o o cold intolerance use of anesthetics. Restlessness c. Exopthalmus 9. Amenorrhea C. Increase appetite (hyperphagia) but there is weight loss 2. Excessive iodine intake 3. All vital signs are increased 6. Provide meticulous skin care 5. Predisposing Factors 1. Thyroid Scan. Maintain side rails . Goiter 8. Provide dietary intake that is increased in calories. Prophythioracill (PTU) b. Monitor strictly vital signs and intake and output 2. RAIU (Radio Active Iodine Uptake) is increased 3. Serum T3 and T4 is increased 2. CNS involvement a. Irritability and agitation b. Tremors d. Diarrhea 5. Signs and Symptoms 1. Comfortable and cold environment 6. narcotics. Nursing Management 1.reveals an enlarged thyroid gland D. hypovolemic shock hormonal replacement therapy for lifetime importance of follow up care increase in T3 and T4 Grave’s Disease or Thyrotoxicosis developed by Robert Grave HYPERTHYROIDISM A. Hallucinations 7. Related to hyperplasia (increase size) B. Insomnia e. Autoimmune – it involves release of long acting thyroid stimulator causing exopthalmus (protrusion of eyeballs) enopthalmus (late sign of dehydration among infants) 2.
maintain side rails offer TSB Tachycardia 2.7. Watch out for signs of thyroid storm/ thyrotoxicosis Agitation TRIAD SIGNS Hyperthermia o administer medications as ordered a. 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 . POST OPERATIVELY. input and output and neuro check. Beta-blockers o o o monitor strictly vital signs. Signs of bleeding (feeling of fullness at incisional site) Nursing Management o Check the soiled dressings at the back or nape area. seizure give Calcium Gluconate IV slowly as ordered 3. 1. 5. Provide bilateral eye patch to prevent drying of the eyes. Assist in surgical procedures known as subtotal thyroidectomy ** Before thyroidectomy administer Lugol’s Solution (SSKI) to decrease vascularity of the thyroid gland to prevent bleeding and hemorrhage. 8. Anti Pyretics b. 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. Hormonal replacement therapy for lifetime 6. 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.
Administer medications as ordered such as: a.A. loss of tooth enamel c. photophobia and cataract formation b. dysphagia e.C MAD . Signs and Symptoms 1. nausea and vomiting d. Acute Tetany Calcium Gluconate IV slowly b. Vitamin D (Cholecalciferol) for absorption of calcium CHOLECALCIFEROL ARE DERIVED FROM Drug Diet (Calcidiol) Sunlight (Calcitriol) feared complications d. Following subtotal thyroidectomy 2.5 mg/100 ml) 3. trauma B. seizure i. tumor c.A. Atrophy of parathyroid gland due to: a. anorexia. Chronic Tetany Oral Calcium supplements Calcium Gluconate Calcium Lactate Calcium Carbonate c. numbness d. inflammation b. arrhythmia 2. Acute tetany a. Chronic tetany a. positive chvostek sign g. Phosphate binder Aluminum Hydroxide Gel (Ampogel) Side effect: constipation ANTACID A. Diagnostic Procedures 1. CT Scan – reveals degeneration of basal ganglia D.5 – 11 mg/100 ml) 2. X-ray of long bones reveals a decrease in bone density 4. Predisposing Factors 1. Nursing Management 1.5 – 4. laryngospasm/broncospasm h. agitation and memory impairment C. positive trousseu’s sign/carpopedal spasm f. paresthesia c. Serum Phosphate is decreased (normal value: 2. Serum Calcium is decreased (normal value: 8. tingling sensation b.
X-ray of long bones reveals bone demineralization D. anchovies b. Diagnostic Procedures 1. Morphine Sulfate (Demerol) 5. salmon c. Importance of follow up care. 6. Prepare trache set at bedside for presence of laryngo spasm 7. green turnips 4. Force fluids to prevent kidney stones 2. Nursing Management 1. Serum Phosphate is decreased 3. Signs and Symptoms 1. Encourage client to breathe using paper bag to produce mild respiratory acidosis result. Agitation and memory impairment C. Institute seizure and safety precaution 5. Administer medications as ordered a.▼ Aluminum Containing Antacids ▼ Aluminum Hydroxide Gel ▼ Side Effect: Constipation ▼ Magnesium Containing Antacids ▼ Side Effect: Diarrhea 2. Encourage increase intake of foods rich in phosphate but decrease in calcium 6. Assist/supervise in ambulation 8. Hyperplasia of parathyroid gland 2. Over compensation of parathyroid gland due to vitamin D deficiency a. Hormonal replacement therapy for lifetime 9. Prevent complications 8. Encourage increase intake of foods rich in calcium a. Children: Ricketts b. 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. Anorexia. Serum Calcium is increased 2. renal cholic b. Maintain side rails . Bone pain especially at back (bone fracture) 2. Strain all the urine using gauze pad for stone analysis 3. Kidney stones a. nausea and vomiting 4. Avoid precipitating stimulus such as glaring lights and noise 3. Provide acid ash in the diet to acidify urine and prevent bacterial growth 7. cool moist skin 3. Predisposing Factors 1. Provide warm sitz bath 4. Adults: Osteomalacia B.
secretes traces of glucocorticoids and androgenic hormones . Hormonal replacement therapy for lifetime 12.function: controls glucose metabolism .secretes mineralocorticoids (aldosterone) . deficiency of neuromuscular function – Salt/Sex A. fluid and electrolyte imbalance – Salt c. Hypoglycemia – TIRED 2. Fungal infections B. Predisposing Factors 1. Zona Reticularis . Zona Glumerulosa .signs of dehydration . Assist in surgical procedure known as parathyroidectomy 11.weight loss .function: promotes secondary sex characteristics .Salt ADDISON’S DISEASE o Hyposecretion of adreno cortical hormone leading to a. Adrenal Cortex – outermost b. Zona Fasciculata . Prevent complications (seizure and arrhythmia) 10.Sugar 2.hypotension .secretes glucocortocoids (cortisol) . Importance of follow up care ADRENAL GLAND o o Located atop of each kidney 2 layers of adrenal gland a.function: promotes sodium and water reabsorption and excretion of potassium . Related to atrophy of adrenal glands 2. Decrease tolerance to stress 3.Sex 3. Signs and Symptoms 1.9. 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. Hyponatremia . metabolic disturbance – Sugar b.
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. Monitor strictly vital signs.infection . Administer isotonic fluid solution as ordered 3. Provide dietary intake. hypertension b. Serum Potassium is increased (normal value: 3.administer steroids as ordered . Diagnostic Procedures 1.arrhythmia 5. moon face appearance 4.5 – 4. Serum Sodium is decrease (normal value: 135 – 145 meq/L) 4.force fluids 2. Hyperkalemia .sudden withdrawal to steroids b. Force fluids 4. Decrease libido 6. severe hypotension b. increase susceptibility to infection e. Nursing Management 1. Plasma Cortisol is decreased 3. FBS is decreased (normal value: 80 – 100 mg/dl) 2.hypovolemic shock . Provide client health teaching and discharge planning a.diarrhea . increase calories.agitation . Provide meticulous skin care 7.addisonian crisis . edema c. Assist in mechanical ventilation. Dexamethasone (Decadrone) b. Bronze like skin pigmentation C. protein but decrease in potassium 6. Monitor side effects a. Instruct client to take 2/3 dose in the morning and 1/3 dose in the afternoon to mimic the normal diurnal rhythm 2. Prednisone c. Hydrocortisone (Cortison) Nursing Management when giving steroids 1. hypovolemic shock c. . avoid precipitating factor leading to addisonian crisis leading to . Administer medications as ordered Corticosteroids a. prevent complications .4.stress . Mineralocorticoids (Flourocortisone) 5.5 meq/L) D. Taper dose (withdraw gradually from drug) 3. hirsutism d. carbohydrates. hyponatremia leading to progressive stupor and coma Nursing Management for Addisonian Crisis 1. Loss of pubic and axillary hair 7.
FBS is increased 2. Easy bruising 8. Serum Sodium is increased 4. Restrict sodium intake 5. thin extremities 4. Administer medications as ordered a. Weigh patient daily and assess for pitting edema 3. Importance of follow up care PANCREAS . Hypernatremia a. Serum Potassium is decreased C. pendulous abdomen g.Mixed gland (exocrine and endocrine) . Increase masculinity among females B. Measure abdominal girth daily and notify physician 4. Acne and striae 7. weight gain d. hypertension b. moon face appearance and buffalo hump e. Diagnostic Procedures 1. Hirsutism 6. importance of follow up care CUSHING SYNDROME o Hypersecretion of adenocortical hormones A.c. Prevent complications (DM) 8. Plasma Cortisol is increased 3. Hypokalemia a. edema c. Provide meticulous skin care 6. Spinarolactone – potassium sparring diuretics 7. Monitor strictly vital signs and intake and output 2. weakness and fatigue b. hormonal replacement for lifetime d. constipation c. Hormonal replacement for lifetime 10. obese trunk f.Located behind the stomach . U wave upon ECG (T wave hyperkalemia) 5. Nursing Management 1. Predisposing Factors 1 Related to hyperplasia of adrenal gland 2. Assist in surgical procedure (bilateral adrenoraphy) 9. Increase susceptibility to infections 3.
Juvenile onset type . nausea and vomiting 7.Adult onset . Polyphagia 5. Hereditary (total destruction of pancreatic cells) 2. Diet 3. Polydypsia 3. Insulin therapy 2. Polyphagia 4. Hyper 2. Oral Hypoglycemic agents 2. Related to viruses 3. Weight loss 6. Polydypsia 4.Brittle disease A. Anorexia. Osmolar 3.metabolic disorder characterized by non utilization of carbohydrates. Diet 3. Lasix b.Beta cells secretes insulin (function: hypoglycemia) . Signs and Symptoms 1. Treatment 1. Steroids 4. Incidence Rate . Non 4.Maturity onset type . Coma C. protein and fat metabolism CLASSIFICATION OF DM Type 1 (IDDM) . Complication 1. Pancreatitis DIABETES MELLITUS .. Increase susceptibility to infection 9.10% general population has type 1 DM B.Consist of acinar cells which secretes pancreatic juices that aids in digestion thus it is an exocrine gland . Complications 1. Weight gain Type 2 (NIDDM) . Related to carbon tetrachloride toxicity C. Predisposing Factors 1. Usually asymptomatic 2. Glucosuria 6.Consist of islets of langerhans . Exercise E. Predisposing Factors 1. Blurring of vision 8.Delta cells secretes somatostatin (function: antagonizes the effects of growth hormones) 3 Main Disorders of Pancreas 1. Treatment 1. Polyuria 3.90% of general population has type 2 DM B.Has alpha cells that secretes glucagons (function: hyperglycemia) . Diabetic Ketoacidosis D. Obesity – because obese persons lack insulin receptor binding sites . Polyuria 2. Drugs a. Incidence Rate . Ketotic 5. Exercise E.Obese over 40 years old A. Pancreatic Tumor/Cancer 2. Diabetes Mellitus 3. Glucosuria 5. Signs and Symptoms 1. Delayed/poor wound healing D.
Carbohydrates 2. Protein 3. Fats ANABOLISM CATABOLISM Glucose Amino Acids Fatty Acids Glycogen Nitrogen Free Fatty Acids .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 .
Acute complication of type 1 DM due to severe hyperglycemia leading to severe CNS depression A. Diagnostic Procedures 1. male 42 – 48) due to severe dehydration D. intake and output and blood sugar levels 4. Acetone breath odor 9. Stress – number one precipitating factor 3. Weight loss 6. Signs and Symptoms 1. Headache and dizziness 2.DIABETIC KETOACIDOSIS . Blurring of vision 8.45 NaCl (hypotonic solutions) to counteract dehydration and shock 3. BUN (normal value: 10 – 20) 3. Infection B. Nursing Management 1. Glucosuria 5.9 NaCl followed by . Polyphagia 4. Monitor strictly vital signs. Antibiotics to prevent infection HYPER OSMOLAR NON KETOTIC COMA .Hyperosmolar: increase osmolarity (severe dehydration) . FBS is increased 2. Kussmaul’s Respiration (rapid shallow breathing) 10 CNS depression leading to coma C. Administer 0. Creatinine (normal value: . Hyperglycemia 2. Signs and Symptoms 1. Anorexia. Seizure activity 4. Hct (normal value: female 36 – 42. Insulin therapy (regular acting insulin/rapid acting insulin peak action of 2 – 4 hours) b. Predisposing Factors 1.8 – 1) 4. Sodium Bicarbonate to counteract acidosis c. Assist in mechanical ventilation 2. Polydypsia 3. Polyuria 2. Restlessness 3.Non ketotic: absence of lypolysis (no ketones) A. Administer medications as ordered a. Decrease LOC – diabetic coma . nausea and vomiting 7.
Non Protamine Hagedorn Insulin (NPH) .45 NaCl (hypotonic solutions) to counteract dehydration and shock 3. Insulin therapy (regular acting insulin peak action of 2 – 4 hours) . Administer medications as ordered a. Allergic reactions b. Administer 0. Rapid Acting Insulin (clear) . Lipodystrophy c. Use gauge 25 – 26 needle 5. Antibiotics to prevent infection INSULIN THERAPY A. Rotate insulin injection sites to prevent development of lipodystrophy 8.for DKA use rapid acting insulin b.Ultra Lente . hypertrophy of subcutaneous tissues) 2. No need to aspirate upon injection 7.Rarely used because it can cause severe allergic reaction . Assist in mechanical ventilation 2. intake and output and blood sugar levels 4.Frequently used type because it has less antigenicity property thus less allergic reaction 3. Animal sources . Long Acting Insulin (cloudy) . Nursing Management 1.B. Avoid shaking insulin vial vigorously instead gently roll vial between palm to prevent formation of bubbles 4.Peak action is 2 – 4 hours 2. Monitor for signs of local complications such as a. 10. Administer at room temperature to prevent development of lipodystrophy (atrophy.Derived from beef and pork 2. Classsification 1.Peak action is 8 – 16 hours 3. Somogyis Phenomenon – rebound effect of insulin characterized by hypoglycemia to hyperglycemia ORAL HYPOGLYCEMIC AGENTS . When mixing 2 types of insulin aspirate first the clear insulin before cloudy to prevent contaminating the clear insulin and promote proper calibration. Monitor strictly vital signs. Sources of Insulin 1. Human Sources . Chlorpropamide (Diabenase) b. First Generation Sulfonylureas a. Place in refrigerator once opened 3. Tolbutamide (Orinase) .Stimulates the pancreas to secrete insulin A.Regular acting insulin (IV only) . Artificially Compound Insulin B.Peak action is 16 – 24 hours C. Most accessible route is abdomen 9. Intermediate Acting Insulin (cloudy) . Nursing Management for Insulin Injections 1. Types of Insulin 1.9 NaCl followed by . Administer insulin either 45o – 90o depending on amount of clients tissue deposit 6.
Monitor for peak action of insulin and OHA and notify physician 2. Blood II. intake and output and blood sugar levels 4. instruct client to avoid wearing constrictive garments d. Microangiopathy (affects small minute blood vessels of eyes and kidneys) EYES -PREMATURE CATARACT . Gangrene formation e. assist in surgical wound debriment (give analgesics 15 – 30 mins prior) 9.sexual impotence 8. Nursing Management 1. Alpha Glycosylated Hemoglobin is increased C. protein 30% and fats 20% or offer alternative food substitutes 6. polyphagia and glucosuria confirmatory for DM) 2. Second Generation Sulfonylureas a. Oral glucose tolerance test is increased – most sensitive test 4.Blindness KIDNEY -RECURRENT PYELONEPHRITIS . Shock due to dehydration . CVA) b. Atherosclerosis (HPN.for hypoglycemia (cold and clammy skin) give simple sugars . MI. Administer insulin and OHA therapy as ordered 3. Institute foot care management a. Monitor for signs of hypoglycemia and hyperglycemia . Provide nutritional intake of diabetic diet that includes: carbohydrates 50%.c.peripheral neuropathy .diarrhea/constipation . Assist in surgical procedure HEMATOLOGICAL SYSTEM I. FBS is increased (3 consecutive times with signs or polyuria. instruct client to avoid walking barefooted b. Diagnostic Procedures 1. encourage client to apply lanolin lotion to prevent skin breakdown e. polydypsia. instruct client to cut toenails straight c. Instruct client to exercise best after meals when blood glucose is rising 7. HPN and DM major cause of renal failure d. Monitor for signs of DKA and HONKC 11. Monitor signs for complications a. Instruct the client to take it with meals to lessen GIT irritation and prevent hypoglycemia 2. Tolamazide (Tolinase) 2.Renal failure c. Blood Forming Organs .for hyperglycemia (dry and warm skin) 5. Instruct client to have an annual eye and kidney exam 10. Monitor strictly vital signs. Diabeta (Micronase) Nursing Management when giving OHA 1. Blood Vessels III. Instruct the client to avoid taking alcohol because it can lead to severe hypoglycemia reaction or Disulfiram (Antabuse) toxicity symptoms B. Glipzide (Glucotrol) b.administer simple sugars . Random Blood Sugar is increased 3.
Alpha globulins . Albumin 2. Non Granulocytes 1. vitamin b6 (pyridoxine) f.Gamma globulins a. Globulins 3. Arteries 2. vitamin c d. Lymphoid Organ 5.normal value: female 36 – 42% male 42 – 48% .normal value: 4 – 6 million/mm3 .consist of molecules of hgb (red pigment) bilirubin (yellow pigment) biliverdin (green pigment) hemosiderin (golden brown pigment) .substances needed for maturation of RBC a.macrophage in blood . RBC (ERYTHROCYTES) . vitamin b12 (cyanocobalamin) e. prothrombin and fibrinogen clotting factors FORMED ELEMENTS 1.transport steroids. Polymorphonuclear Basophils . Liver 3.Maintains osmotic pressure preventing edema GLOBULINS .only unnucleated cell .biconcave discs . Spleen 4. Bone Marrow ALBUMIN . folic acid b.55% Plasma Serum 45% Formed 1. intrinsic factor . anti-bodies and immunoglobulins b.normal value: 5000 – 10000/mm3 A. Monocytes . iron c.Largest and numerous plasma CHON .hemoglobin: normal value female 12 – 14 gms% male 14 – 16 gms% . Polymorpho Neutrophils .hematocrit red cell percentage in wholeblood . Prothrombin and Fibrinogen 1. Granulocytes 1.Normal life span of RBC is 80 – 120 days and is killed in red pulp of spleen 2.Beta globulins – iron and copper . bilirubin and hormones .involved in short term phagocytosis for acute inflammation 2. Lymph Nodes 6. Polymorphonuclear Eosinophils . WBC (LEUKOCYTES) .largest WBC .60 – 70% of WBC .for allergic reaction B.responsible for the release of chemical mediation for inflammation 3.transports and carries oxygen to tissues .for parasite infections . Veins Plasma CHON (formed in liver) 1.
thymus for immunity Natural killer cell .drug of choice AZT (Zidon Retrovir) 2 Common fungal opportunistic infection in AIDS 1.involved in long term phagocytosis for chronic inflammation 2. fresh blood per rectum is called hematochezia 2. Usually asymptomatic 2. Headache and dizziness . Platelets (THROMBOCYTES) .western blot opportunistic . Related to malabsorption syndrome c. Lymphocytes B-cell T-cell .6 months – 5 years incubation period . Common among tropical zones 3. Related to GIT bleeding resulting to hematemesis and melena (sign for upper GIT bleeding) c.bone marrow . Signs and Symptoms 1. Subtotal gastrectomy 4. Chronic blood loss due to trauma a.ELISA . Oozing of blood from venipunctured site BLOOD DISORDERS Iron Deficiency Anemia . Pneumocystis Carinii Pneumonia 3.. Chronic diarrhea b. Weakness and fatigue (initial signs) 3. Petechiae 2. Echhymosis 3. Inadequate intake of iron due to a.A chronic microcytic anemia resulting from inadequate absorption of iron leading to hypoxemic tissue injury A. Incidence Rate 1.6 months window period .000 – 450. High cereal intake with low animal protein digestion d.Normal value: 150.Consist of immature or baby platelets or megakaryocytes which is the target of dengue virus . Kaposi’s Sarcoma 2.Normal life span of platelet is 9 – 12 days Signs of Platelet Dysfunction 1. Common among developed countries 2.Promotes hemostasis (prevention of blood loss) . Related to poor nutrition B.000/mm3 . Heavy menstruation b. Predisposing Factors 1. Common among women 15 – 35 years old 4. Related to improper cooking of foods C.anti viral and anti tumor property HIV .
Tetracycline . If client cant tolerate/no compliance administer parenteral iron preparation a. Administer Z tract technique to prevent discomfort. Ferrous Fumarate c.Nitrofurantoin (Macrodentin) 3. Ferritin is decreased E. Nursing Management 1. PICA (abnormal appetite or craving for non edible foods D. Atropic Glossitis (inflammation of tongue) .Dysphagia 9. Abdominal pain d. When diluting it in liquid iron preparations administer with straw to prevent staining of teeth Medications administered via straw . Diagnostic Procedures 1. Organ meat b. Anorexia b. Nuts 4. Diarrhea/constipation e. Nausea and vomiting c. Hct is deceased 4. Monitor side effects a. Avoid massaging the injection site instead encourage to ambulate to facilitate absorption 3.Lugol’s solution . Iron Dextran (IM. Instruct client to take foods rich in iron a. Hgb is decreased 3. Sorbitex (IM) Nursing Management when giving parenteral iron preparations 1. Administer with Vitamin C or orange juice for absorption 4. Brittleness of hair and spoon shape nails (koilonychias) 8.Stomatitis . Enforce CBR so as not to over tire client 3. Raisin d. Ferrous Gluconate . Melena 5. Pallor and cold sensitivity 5.4. Reticulocyte is decreased 6. Palpitations 7. Administer medications as ordered Oral Iron Preparations a.Iron . Instruct the client to avoid taking tea and coffee because it contains tannates which impairs iron absorption 5. Monitor for signs of bleeding of all hema test including urinw. Legumes g. stool and GIT 2.300 mg/day Nursing Management when taking oral iron preparations 1. Monitor and inform client of side effects a. Ferrous Sulfate b. Egg (yolk) c. Instruct client to take with meals to lessen GIT irritation 2. RBC is decreased 2. discoloration and leakage to tissues 2. IV) b. Dried fruits f. Iron is decreased 5. Pain at injection site PLUMBER VINSON’S SYNDROME . Dyspnea 6. Sweet potatoes e.
Fever and chills e. Hereditary factors 3.Chronic anemia characterized by a deficiency of intrinsic factor leading to hypochlorhydria (decrease hydrochloric acid secretion) A. Headache and dizziness 3. positive to Romberg’s test – damage to cerebellum resulting to ataxia e. Weakness and fatigue 2. mouth sore b. Nursing Management 1. Localized abscess c. red beefy tongue c. tingling sensation b. Pruritus/orticaria g. Skin rashes f. paresthesia d. weight loss e. Inflammatory disorders of the ileum 4.Never given orally because there is possibility of developing tolerance Secretes hydrochloric acid ▼ Aids in digestion . GIT changes that includes a.b. indigestion/dyspepsia d. Administer Vitamin B12 injections at monthly intervals for lifetime as ordered . Lymphadenopathy d. result to psychosis C. Strictly vegetarian diet STOMACH ▼ Pareital cells/ Argentaffin or Oxyntic cells Produces intrinsic factors ▼ Promotes reabsorption of Vit B12 ▼ Promotes maturation of RBC B. Dyspnea and palpitations as part of compensation 5. CNS changes a. Diagnostic Procedure Schilling’s Test – reveals inadequate/decrease absorption of Vitamin B12 D. Signs and Symptoms 1. Predisposing Factors 1. Enforce CBR 2. jaundice 6. Pallor and cold sensitivity 4. numbness c. Autoimmune 5. Hypotension (anaphylactic shock) PERNICIOUS ANEMIA . Subtotal gastrectomy 2.
Monitor for signs of infection a. Related to irradiation/exposure to x-ray 3.No side effects 3. Methotrexate (Alkylating Agent) b. Petechiae (multiple petechiae is called purpura) b. Signs and Symptoms 1. protein. Anemia a. Drugs Broad Spectrum Antibiotics a. Dyspnea and palpitations 2. Pallor and cold sensitivity d. CBC reveals pancytopenia 2.Stem cell disorder leading to bone marrow depression leading to pancytopenia PANCYTOPENIA Decrease RBC (anemia) A. vitamin c and iron 4. Avoid heat application to prevent burns APLASTIC ANEMIA . Ecchymosis c. Enforce CBR 5. Vincristine (Plant Alkaloid) c. Institute BT as ordered 3. Chemicals (Benzine and its derivatives) 2. Diagnostic Procedures 1. Chloramphenicol (Sulfonamides) Chemotherapeutic Agents a. Immunologic injury 4. Thrombocytopenia a. Weakness and fatigue b. Bone marrow biopsy/aspiration (site is the posterior iliac crest) – reveals fat necrosis in bone marrow D. Headache and dizziness c. Instruct client to avoid irritating mouth washes instead use soft bristled toothbrush 5. Nitrogen Mustard (Antimetabolite) Phenylbutazones (NSAIDS) B.Site of injection for Vitamin B12 is dorsogluteal and ventrogluteal . Administer oxygen inhalation 4. Institute reverse isolation 6. Removal of underlying cause 2.. fever Decrease WBC (leucopenia) Decrease Platelet (thrombocytopenia) . Leukopenia a. Increase susceptibility to infection 3. Provide a dietary intake that is high in carbohydrates. Oozing of blood from venipunctured sites C. Nursing Management 1. Predisposing Factors 1.
Diagnostic Procedures 1. Provide heparin lock 7. Nursing Management 1. Administer medications as ordered a. Predisposing Factors 1. venipunctured sites 8 Instead provide heparin lock 9. Stool occult blood positive 3. Immunosuppressants Anti Lymphocyte Globulin ▼ Given via central venous catheter ▼ Given 6 days to 3 weeks to achieve Maximum therapeutic effect of drug DISSEMINATED INTRAVASCULAR COAGULATION Acute hemorrhagic syndrome characterized by wide spread bleeding and thrombosis due to a deficiency of prothrombin and fibrinogen A. Heparin/Coumadin is ineffective 6. Corticosteroids – caused by immunologic injury b. Oozing of blood from punctured sites 4. subcutaneous. Related to rapid blood transfusion 2. Instruct client to use electric razor when shaving 10. Institute NGT decompression by performing gastric lavage by using ice or cold saline solution of 500 – 1000 ml 8. Avoid IM. Septecemia 6. Administer medications as ordered a. Monitor NGT output 9. Oliguria (late sign) C. Vitamin K b. Massive burns 3. cough 7. Signs and Symptoms 1. CBC reveals decreased platelets 2. Pitressin/ Vasopresin to conserve fluids c. Opthamoscopic exam reveals sub retinal hemorrhages D. Ecchymosis 3. Monitor for signs of bleeding of all hema test including stool and GIT 2. Pregnancy B. lungs and lower extremities 2. ABG analysis reveals metabolic acidosis 4. Petechiae (widespread and systemic) eye. Neoplasia (new growth of tissue) 7. Administer oxygen inhalation 4. Hemoptysis 6.b. Anaphylaxis 5. Prevent complication . Massive trauma 4. Administer isotonic fluid solution as ordered 3. Force fluids 5.
Allergic reaction c. 85% of population is RH positive 3. Type AB – universal recipient c. Cytrate intoxication h.Warming is only done during emergency situation and if you have the warming device . during and after BT especially every 15 minutes for first hour because majority of transfusion reaction occurs during this period a. Proper refrigeration .9 NaCl/plain NSS) to prevent hemolysis 4. Increase the oxygen carrying capacity of blood 3. sediments and darkness in color because it indicates bacterial contamination . Proper typing and cross matching a. Hypovolemic shock b. Instruct another RN to re check the following a.Expiration of packed RBC is 3 – 6 days . Anuria – late sign BLOOD TRANSFUSION Goals/Objectives 1.a. Check the blood unit for bubbles cloudiness. Blood typing and cross matching c. Filter set b. Prevent bleeding if there is platelet deficiency Principles of blood transfusion 1. Hemolytic reaction b. Gauge 18 – 19 needle c. Pyrogenic reaction d.Emergency rapid BT is given after 30 minutes and let natural room temperature warm the blood. 6.Never warm blood as it may destroy vital factors in blood. Circulatory overload e. Expiration date d.Expiration of platelet is 3 – 5 days 2. Type O – universal donor b. 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. Hyperkalemia (caused by expired blood) . Aseptically assemble all materials needed for BT a. Avoid mixing or administering drugs at BT line to prevent HEMOLYSIS 8. Client name b. Isotonic solution (0. Air embolism f. Serial number 5. Thrombocytopenia g. Monitor strictly vital signs before. . Prevent infection in there is a decrease in WBC 4. Regulate BT 10 – 15 gtts/min or KVO rate or equivalent to 100 cc/hr to prevent circulatory overload 9. Replace circulating blood volume 2.
Diarrhea/Constipation 4. Flush with plain NSS 4. Flushed skin 6.Signs and Symptoms of Hemolytic reaction 1. Urticaria 6. Hypotension 5. Headache 3. Obtain urine and blood sample and send to laboratory for re examination 7. Send the blood unit to blood bank for re examination 6. Urine is color red/ portwine urine Nursing Management 1. Stop BT 2. Administer medications as ordered a. Dyspnea 3. Flush with plain NSS 4. Notify physician 3. Tachycardia 4. Stop BT 2. Dyspnea Nursing Management 1. Skin rashes 5. Anti Histamine (Benadryl) . Notify physician 3. Laryngospasm and Broncospasm Nursing Management 1. Obtain urine and blood sample and send to laboratory for re examination 7. Stop BT 2. Monitor vital signs and intake and output SIGNS AND SYMPTOMS PYROGENIC REACTIONS 1. Lumbasternal/ Flank pain 7. Monitor vital signs and intake and output SIGNS AND SYMPTOMS OF ALLERGIC REACTION 1. Fever 2. Diaphoresis 6. Broncial wheezing 4. Notify physician 3.if positive to hypotension. Headache and dizziness 2. Flush with plain NSS . Palpitations 5. Dyspnea 3. anaphylactic shock treat with Epinephrine 5. Send the blood unit to blood bank for re examination 6. Fever and chills 2. Administer isotonic fluid solution to prevent shock and acute tubular necrosis 5.
Atria 2. Antipyretic b.Weighs approximately 300 – 400 grams . Layers of Heart 1. Valves .Right atrium has decreased pressure which is 60 – 80 mmHg C. Myocardium – middle layer 3. Visceral – inner layer . Exertional discomfort Nursing Management 1. Dyspnea 3. Ventricles . Upper Chamber (connecting or receiving) a. Antibiotic 5. Chambers of the Heart 1. Parietal – outer layer b. Lower Chamber (contracting or pumping) a. Loop diuretic (Lasix) CARDIOVASCULAR SYSTEM OVERVIEW OF THE STRUCTURE AND FUNCTIONS OF THE HEART HEART . Stop BT 2. pericarditis. tricuspid valve .To promote unidimensional flow or prevent backflow 1. Rales/Crackles upon auscultation 4.Covered by a serous membrane called the pericardium 2 layers of pericardium a.4.In between is the pericardial fluid which is 10 – 20 cc . Cardiac tamponade A. Obtain urine and blood sample and send to laboratory for re examination 7. Epicardium – outer layer 2. Administer medications as ordered a.Left ventricle has increased pressure which is 120 – 180 mmHg . .Common among MI. Monitor vital signs and intake and output 8.In order to propel blood to the systemic circulation . Notify physician 3.Resemble like a close fist .Prevent pericardial friction rub . Send the blood unit to blood bank for re examination 6. Atrioventricular Valves – guards opening between a.Located on the left mediastinum . Render TSB SIGNS AND SYMPTOMS OF CIRCULATORY REACTION 1. Endocardium – inner layer .Myocarditis can lead to cardiogenic shock and rheumatic heart disease B. Orthopnea 2. Administer medications as ordered a.Muscular pumping organ of the body.
Supplies the myocardium E. S4 – atrial gallop usually seen in Myocardial Infarction and Hypertension D. S3 – ventricular gallop usually seen in Left Congestive Heart Failure 2. Bundle of His .Located at the interventricular septum 4.Arises from base of the aorta Types of Coronary Arteries 1. Purkinje Fibers . mitral valve . Left Main Coronary Artery . Atrio – Ventricular Node (AV or Tawara Node) .Located at the inter atrial septum . aortic .b.Closure of SV valve give rise to second heart sound (S2 “dub”) Extra Heart Sounds 1. Sino – Atrial Node (SA or Keith Flack Node) . pulmonic b. Coronary Arteries .T WAVE (ventricular repolarization) .Left Main Bundle of His . Cardiac Conduction System 1.QRS WAVE (ventricular depolarization) .Located at the junction of superior vena cava and right atrium .Acts as primary pacemaker of the heart .Located at the walls of the ventricles for ventricular contraction SA NODE AV NODE BUNDLE OF HIS JLJLJLJJLJLJL PURKINJE FIBERS .Closure of AV valves give rise to first heart sound (S1 “lub”) 2.Initiates electrical impulse of 60 – 100 bpm 2.P WAVE (atrial depolarization) contraction . Right Main Coronary Artery 2.08 milliseconds to allow ventricular filling 3.Delay of electrical impulse for about .Right Main Bundle of His . Semi – lunar Valves a.
hardening of artery . Duaphoresis C. ST segment elevation – Myocardial Infarction 5. Widening of QRS complexes – Arrythmia CARDIAC DISORDERS Coronary Arterial Disease/ Ischemic Heart Disease Stages of Development of Coronary Artery Disease 1.tunica media . Palpitations 5. Hypothyroidism 9. Peak T wave – Hyperkalemia 3.narrowing of artery .Atherosclerosis 2.calcium and protein deposits . Race – black 3.tunica intima A. To prevent angina 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. Smoking 4. Predisposing Factors 1.Hypokalemia 2. Dyspnea 3.lipid or fat deposits . Positive U wave . Chest pain 2. Treatment Percutaneous Transluminal Coronary Angioplasty Objectives of PTCA 1. Myocardial Ischemia – Angina Pectoris 3. Type A personality B. Diabetes Mellitus 8. Hyperlipidemia 6. Diet – increased saturated fats 10. Increase survival rate ARTERIOSCLEROSIS . Myocardial Injury . Signs and Symptoms 1. T wave inversion – Myocardial Infarction 6. ST segment depression – Angina Pectoris 4. Myocardial Necrosis – Myocardial Infarction ATHEROSCLEROSIS ATHEROSCLEROSIS . Revascularize myocardium 2. Sex – male 2. sedentary lifestyle 7. Obesity 5. Tachycardia 4.
anxiety. Serum cholesterol and uric acid is increased E. Precipitating Factors 4 E’s of Angina Pectoris 1. reveal abnormal ECG 4. 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. Chest pain characterized by sharp stabbing pain located at sub sterna usually radiates from back. Pneumonia – encourage to perform deep breathing. Levine’s Sign – initial sign that shows the hand clutching the chest 2. Stress test – treadmill test. Diet – increased saturated fats 10. Administer medications as ordered a. sedentary lifestyle 7. Diagnostic Procedure 1. Enforce complete bed rest 2. 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. Type A personality B. arms. Sex – male 2. shoulder.. Tachycardia 5. ECG tracing reveals ST segment depression 3. Hypothyroidism 9.5 minutes . History taking and physical exam 2. axilla and jaw muscles. Diaphoresis D. Smoking 4. Signs and Symptoms 1. Race – black 3. Extreme emotional response – fear. Obesity 5. Nitroglycerine (NTG) – when given in small doses will act as venodilator.Done to single occluded vessels . Excessive physical exertion – heavy exercises 2. Predisposing Factors 1. Excessive intake of foods rich in saturated fats – skimmed milk C. Nursing Management 1. Diabetes Mellitus 8. Hyperlipidemia 6. Exposure to cold environment 3.Give second dose of NTG if pain persist after giving first dose with interval of 3 .Give first dose of NTG (sublingual) 3 – 5 minutes . but in large doses will act as vasodilator . Shock 3. usually relieved by rest or taking nitroglycerine 3. excitement 4. coughing exercise and use of incentive spirometer 2. Palpitations 6.
Predisposing Factors 1. A.Not given to COPD cases because it causes bronchospasm c. Administer oxygen inhalation 4.Propanolol . Monitor strictly vital signs. necrosis and scarring. Race – black 3. Smoking 4. The importance of follow up care MYOCARDIAL INFARCTION Heart attack Terminal stage of coronary artery disease characterized by malocclusion. The Most Critical Period Following Diagnosis of Myocardial Infarction ** 6 – 8 hours because majority of death occurs due to arrhythmia leading to PVC’s C. Prevent complication (myocardial infarction) c. Subendocardial Myocardial Infarction – characterized by occlusion of either right or left coronary artery B. Place client on semi fowlers position 5. Provide client health teachings and discharge planning a. 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. Provide decrease saturated fats sodium and caffeine 7.. ACE Inhibitors .NIfedipine 3. Obesity 5.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. Types 1. Transmural Myocardial Infarction – most dangerous type characterized by occlusion of both right and left coronary artery 2. Instruct client to take medication before indulging into physical exertion to achieve the maximum therapeutic effect of drug d. Calcium Antagonist . Sex – male 2. Hyperlipidemia . Beta-blockers . intake and output and ECG tracing 6. Avoidance of 4 E’s b.side effects PNS .Enalapril d.
arms. Serum Cholesterol and uric acid are both increased 5. Administer oxygen low inflow to prevent respiratory arrest at 2 – 3 L/min 3. LDH – Lactic acid dehydroginase is increased c. Increase in blood pressure (initial sign) 4. ECG tracing reveals a.Creatinine phosphokinase is increased .Side Effects: respiratory depression . Signs and Symptoms 1. Pericardial friction rub b. CPK – MB . Diet – increased saturated fats 10. Nursing Management Goal: Decrease myocardial oxygen demand 1. ST segment elevation b. axilla. Cardiac Enzymes a. Diagnostic Procedure 1. SGOT – Serum glutamic oxal-acetic transaminase is increased 2.Antidote: Narcan/Naloxone .Usually radiates from back. Chest pain . Rales/Crackles upon auscultation d. T wave inversion c. Place client on semi fowlers position .6. CBC – increased WBC F. SGPT – Serum glutamic pyruvate transaminase is increased d. jaw and abdominal muscles (abdominal ischemia) . Hyperthermia 5. Type A personality D. sedentary lifestyle 7. Diabetes Mellitus 8. shoulder.Side Effects of Naloxone Toxicity is tremors 2.Excruciating visceral. 12 – 24 hours b. Occasional findings a.Heart only. S4 or atrial gallop E.Not usually relieved by rest or by nitroglycerine 2. Troponin Test – is increased 3. Instruct client to avoid forms of valsalva maneuver 5. Widening of QRS complexes indicates that there is arrhythmia in MI 4. Enforce CBR without bathroom privileges a. viselike pain located at substernal and rarely in precordial . Mild restlessness and apprehension 7. Using bedside commode 4. Hypothyroidism 9. Split S1 and S2 c. Dyspnea 3. Ashen skin 6. Decrease myocardial workload (rest heart) .Administer narcotic analgesic/morphine sulfate .
arrhythmia (caused by premature ventricular contraction) b.Side Effects: confusion and dizziness . Cardiogenic shock .TIPAF (tissue plasminogen activating factor) .6.Side Effects of Aspirin Tinnitus Heartburn Indigestion/Dyspepsia .Coumadin/ Warfarin Sodium (check for prothrombin time) . Provide client health teaching and discharge planning concerning a.Urokinase .ISD (Isosorbide Dinitrate. Vasodilators . Monitor strictly vital signs.Antidote: protamine sulfate . pruritus .PASA (Aspirin) .Contraindication Dengue Peptic Ulcer Disease Unknown cause of headache 10. Beta-blockers d. Provide a general liquid to soft diet that is low in saturated fats.Side Effects: allergic reaction. Left Congestive Heart Failure d. intake and output and ECG tracing 7.Brutylium c.late sign is oliguria c. Encourage client to take 20 – 30 cc/week of wine. whisky and brandy to induce vasodilation 9. sodium and caffeine 8. Anti Platelet . Avoidance of modifiable risk factors .Lidocaine (Xylocane . Stroke/CVA . Administer medication as ordered a. Calcium Antagonist f. ACE Inhibitors e.homan’s sign e. Thrombolytics/ Fibrinolytic Agents .Anti thrombotic effect .Streptokinase . Anti Arrythmic Agents . Thrombophlebitis . Anti Coagulant .Monitor for bleeding time g.Antidote: Vitamin K h.Nitroglycerine .Side Effects: chest pain . Isodil) sublingual b.Heparin (check for partial thrombin time) .
PCO2 is increased (respiratory acidosis) 2.Aspirin b. Paroxysmal nocturnal dyspnea – client is awakened at night due to difficulty of breathing 3.client can resume sexual intercourse if can climb staircase .client is resistant to pharmacological agents. RHD – inflammation of mitral valve due to invasion of Grp. Chest x-ray – reveals cardiomegaly 2.dietary modification h. Aortic valve stenosis B. 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) 3.000 – 450. Rales/Crackles 8. dependent on extent of heart failure 4. Frothy salivation 6. Orthopnea – use 2 – 3 pillows when sleeping or place in high fowlers 4. post CABG and instruct to . PMI is displaced laterally due to cardiomegaly 11. There is anorexia and generalized body malaise 12. S3 – ventricular gallop C. Hypertension 5.f. 90% is mitral valve stenosis due to a. RIGHT SIDED HEART FAILURE . Aging 2. 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. Ecocardiography – enlarged heart chamber (cardiomyopathy). Cyanosis 7. Dyspnea 2. Signs and Symptoms 1. Productive cough with blood tinged sputum 5.Common among children . Resumption of ADL particularly sexual intercourse is 4 – 6 weeks post cardiac rehab.Penicillin .instruct client to assume a non weight bearing position . Pulsus Alternans – weak pulse followed by strong bounding pulse 10.000 units of streptokinase as ordered g. Predisposing Factors 1.ASO Titer (Anti streptolysin O titer) .make sex as an appetizer rather than dessert . ABG – reveals PO2 is decreased (hypoxemia). administer 150. LEFT SIDED HEART FAILURE A. A beta-hemolytic streptococcus .Formation of aschoff bodies in the mitral valve . Diagnostic Procedure 1. Ischemic heart disease 4. Bronchial wheezing 9. Myocardial Infarction 3.
Loop Diuretics . Vasodilators . Administer oxygen inhalation with high inflow. Ascites 4. Pitting edema 3. Central venous pressure (CVP) .Digoxin (Lanoxin) .If heart rate is decreased do not give b. 3 – 4 L/min.CVP fluid status measure .Administer loop diuretics as ordered . High fowlers position . Ecocardiography – reveals enlarged heart chambers (cardiomyopathy 4.Nitroglycerine f.Do the fluid challenge (increase IV flow rate) .A. Pulmonic valve stenosis 5. Esophageal varices C.Lasix (Furosemide) c. Bronchodilators d. delivered via nasal cannula 4.Increase force of cardiac contraction .When reading CVP patient should be flat on bed . Signs and Symptoms (venous congestion) 1. Related to COPD 4.Morphine Sulfate e. Anorexia 9. Predisposing Factors 1.Lidocaine (Xylocane) 3. Pruritus 8. Nursing Management Goal: increase cardiac contractility thereby increasing cardiac output (3 – 6 L/min) 1.If CVP is less than 4 cm of water hypovolemic shock . Hepatosplenomegaly 6. Jaundice 7. Narcotic analgesics . Enforce CBR 2. Cardiac glycosides . Chest x-ray – reveals cardiomegaly 2.Upon insertion place client in trendelendberg position to promote ventricular filling and prevent pulmonary embolism 3. Left sided heart failure B. Weight gain 5. Tricuspid valve stenosis 2.Measure pressure in right atrium (4 – 10 cm of water) . Diagnostic Procedures 1. Administer medications as ordered a. Anti Arrhythmic . Neck/jugular vein distension 2. Pulmonary embolism 3. Liver enzymes – SGPT and SGOT is increased D.If CVP is more than 10 cm of water hypervolemic shock .
cholesterol and caffeine 8. Nursing Management 1. Provide a dietary intake of low sodium. Angiography – reveals site and extent of malocclusion D.Shock . Trophic changes 5. Administer medications as ordered a. Encourage a slow progressive physical activity a. intake and output and ECG tracing 6. cyanosis then rubor) 3. Varicose Veins 2. Intermittent claudication – leg pain upon walking 2. Gangrene formation C. Diagnostic Procedures 1. High risk groups – men 30 years old and above 2. rotated clockwise every 15 minutes to promote decrease venous return 10. Thrombo Angitis Obliterans Venous Ulcer 1. Doppler UTZ – decrease blood flow to the affected extremity 3. Thrombophlebitis (deep vein thrombosis) THROMBOANGITIS OBLITERANS Acute inflammatory disorder usually affecting the small medium sized arteries and veins of the lower extremities A. Dietary modification c. out of bed 3 – 4 times a day 2. Monitor strictly vital signs.Thrombophlebitis b. Measure abdominal girth daily and notify physician 7. Analgesics Burger’s Disease Reynaud’s Disease .5.Arrythmia . Signs and Symptoms 1. Smoking B.MI . Decreased peripheral pulses 4. Provide client health teaching and discharge planning a. Predisposing Factors 1. Assist in bloodless phlebotomy – rotating tourniquet. Oscillometry – decrease in peripheral pulses 2. Provide meticulous skin care 9. Prevent complications . walking 3 – 4 times a day b. Cold sensitivity and changes in skin color (pallor.Right ventricular hypertrophy . Strict compliance to medications PERIPHERAL VASCULAR DISORDER Arterial Ulcer I. Ulceration 6.
Cold sensitivity and changes in skin color (pallor. Pregnancy . Predisposing Factors 1. Trophic changes 4. Collagen diseases a. Excessive typing c. Doppler UTZ – decrease blood flow to the affected extremity 2. Nursing Management 1. High risk group – female 40 years old and above 2. Thrombophlebitis 4. Operating chainsaw B. 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. Cardiac disorder 5. Administer medications as ordered a. Anti coagulants 3. Piano playing b.b. Assist in surgical procedure – bellow knee amputation REYNAUD’S DISEASE Disorder characterized by acute episodes of arterial spasm involving the fingers or digits of the hands A. Signs and Symptoms 1. cyanosis then rubor) 3. Smoking 3. Congenital weakness of veins 3. Vasodilators c. Encourage to wear gloves 3. Analgesics b. Predisposing Factors 1. Angiography – reveals site and extent of malocclusion D. Rheumatoid Arthritis 4. Vasodilators 2. Ulceration 5. Instruct client to avoid smoking and exposure to cold environment 5. Intermittent claudication – leg pain upon walking 2. Direct hand trauma a. Gangrene formation C. SLE (butterfly rash) b. Hereditary 2. Diagnostic Procedures 1. Institute foot care management 4.
Analgesics 5. Trendelenburg’s Test . Assist in surgical procedure a. Congestive heart failure 8. Dilated tortuous skin veins 3. Positive Hpman’s Signs – pain at the calf or leg muscle upon dorsi flexion of the foot C. Heaviness in legs C. Nursing Management 1. Vein stripping and ligation (most effective) b. Myocardial infarction 9. Pain after prolonged standing 2. Diagnostic Procedure 1. Administer medications as ordered a. Diabetes mellitus 7.6.veins distends quickly in less than 35 seconds D. Venography 2. Smoking 3. Predisposing Factors 1. Warm to touch 4. Venography 2. Measure the circumference of leg muscle to determine if swollen 3. Related to pregnancy 4. Prolong use of oral contraceptives – promotes lipolysis 6. B. Pain at affected extremity 2. 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. Wear anti embolic stockings 4. Signs and Symptoms 1. Nursing Management . Post op complication 10. Obesity 7. Increase in saturated fats in the diet. Elevate legs above heart level to promote increased venous return by placing 2 – 3 pillows under the legs 2. Obesity 2. Chronic anemia 5. Angiography D. Post cannulation – insertion of various cardiac catheter 11. Warm to touch 3. Diagnostic Procedure 1. Prolonged standing or sitting B. Dilated tortuous skin veins 4. Signs and Symptoms 1.
For gas exchange A.Closes to allow passage of food going to the esophagus . Analgesics b.Tachycardia . Monitor for signs of complications Embolism a. Anti Coagulant . Pharynx/Throat .Separated by septum . Nose .Heparin 6.Consist of cartilaginous rings . cholecystitis characterized by pain at the right upper quadrant with tenderness RESPIRATORY SYSTEM OVERVIEW OF THE STRUCTURES AND FUCNTIONS OF THE RESPIRATORY SYSTEM I.Serves as a muscular passageway for both food and air C.Consist of anastomosis of capillaries known as Keissel Rach Plexus (the site of nose bleeding) B.Opens to allow passage of air .1.Serves as passageway of air going to the lungs . Trachea/Windpipe .For cough reflex Glottis . Filtering of air 2. Humidification A.For phonation (voice production) . Lower Respiratory System . Larynx .Diaphoresis . Warming and moistening of air 3.Sudden sharp chest pain .Headache .Left nostril .Restlessness b.Dizziness . Measure circumference of leg muscle to determine if swollen 4.Palpitations . Cerebral .Opening of larynx . Apply warm moist pack – to reduce lymphatic congestion 3. Elevate legs above heart level to promote increase venous return 2.Right nostril .The initial sign of complete airway obstruction is the inability to cough II.Cartillage . Pulmonary . Encourage to wear anti embolic stockings or knee elastic stockings 5. Administer medications as ordered a.Decrease LOC • MURPHY’S SIGN is seen in clients with cholelithiasis.Unexplained dyspnea . Upper Respiratory System 1.
10 segments) .Increase carbon dioxide is a powerful stimulant for breathing Type II Cells of Alveoli . 8 segments) . Lungs . aerobic and easily destroyed by heat or sunlight A.. Mode of Transmission 1.Diffusion (Dalton’s law of partial pressure of gases) Respiratory Distress Syndrome . Pneumonia b.In premature infants 1:2 . Pareital b. Visceral With Pleuritic Friction Rub a. Productive cough (yellowish sputum) . Bronchus .Right lung (consist of 3 lobes.Decrease surface tension . Pleural effusion c.Decrease oxygen stimulates breathing . Virulence (degree of pathogenecity) of microorganism B. Airborne transmission via droplet nuclei C.Secretes surfactant .Site of tracheostomy B. Malnutrition 2. Hydrothorax (air and blood in pleural space Alveoli .L/S ratio to determine lung maturity .retinopathy/blindness in prematurity Disorders of Respiratory System 1.Left lung (consist of 2 lobes. Signs and Symptoms 1. Pleural fluid c. Low grade afternoon fever. gram negative.Serous membranes Pleural Cavity a. Over fatigue 5. night sweats 2.Right main bronchus .Prevent collapse of alveoli .Give oxygen of less 40% in premature to prevent atelectasis and retrolental fibroplasias . Alcoholism 4.Infection of lung tissue caused by invasion of mycobacterium tuberculosis or tubercle bacilli .Left main bronchus C.Site of gas exchange (CO2 and O2) .An acid fast. Overcrowded places 3. Ingestion of an infected cattle with mycobacterium bovis 6. PTB/Pulmonary Tuberculosis (Koch’s Disease) .Normal L/S ratio is 2:1 .Composed of lecithin and spingomyelin . Precipitating Factors 1.
PZA (Pyrazinamide) . Enforce CBR 2.Side Effect INH: peripheral neuritis/neuropathy (increase intake of Vitamin B6/Pyridoxine) .Neomycin . Weight loss 5. taken after meals to facilitate absorption .INH and Rifampicin is given for 4 months.PZA can be replaced by Ethambutol . Institute short course chemotherapy a. Hemoptysis (chronic) D. Nursing Management 1. Chest X-ray . hepatotoxicity.Positive to cultured microorganism 3.3. Anorexia.INH (Isonicotinic Acid Hydrazide) . Dyspnea 6.Reveals increase WBC E. Force fluids to liquefy secretions 5. Nebulize and suction when needed 8.PZA is given for 2 months. nephrotoxicity . Place client on semi fowlers position to promote expansion of lungs 6. Encourage deep breathing and coughing exercise 7.Reveals pulmonary infiltrates 4. Comfortable and humid environment 9.Positive Mantoux test (previous exposure to tubercle bacilli but without active TB) 2. 48 – 72 hours . Standard phase .Side Effect PZA: allergic reaction.Purified protein derivative . CBC . Mantoux Test (skin test) .Rifampicin (Rifampin) .WHO 10 – 14 mm induration. Sputum Acid Fast Bacillus . 48 – 72 hours .Side Effect Rifampicin: all bodily secretions turn to red orange color . Administer oxygen inhalation 4.Gentamycin .Amikacin .Kanamycin .Injection of streptomycin (aminoglycoside) .Side Effect Ethambutol: optic neuritis b. taken before meals to facilitate absorption . Chest pain 7. generalized body malaise 4.Given everyday simultaneously to prevent resistance .DOH 8 – 10 mm induration. Diagnostic Procedure 1. Institute strict respiratory isolation 3. Intensive phase .
Bronchial wheezing .. Escherichia Pneumoniae 6. vitamin C and calories 11. causing hypostatic pneumonia 5. dyspepsia. Etiologic Agents 1. Rales/crackles 6. military tuberculosis) PTB . heartburn 10.Give aspirin if there is fever . Productive cough with greenish to rusty sputum 2. protein. Provide client health teaching and discharge planning a. High Risk Groups 1. AIDS .Side Effect: . Klebsella Pneumoniae 5. Bronchogenic Cancer . Predisposing Factors 1. Hemophylus Influenzae – causing broncho pneumonia 3. Provide increase carbohydrates. Dyspnea with prolong expiratory grunt 3. Streptococcus Pneumonae – causing pneumococal pneumonia 2. Smoking 2. Avoidance of precipitating factors b. Fever. Importance of follow up care PNEUMONIA Inflammation of the lung parenchyma leading to pulmonary consolidation as the alveoli is filled with exudates A. Immuno compromised a. Strict compliance to medications d.Skin . anorexia and general body malaise 4. Pseudomonas B. Diplococcus Pneumoniae 4. Aspiration of food causing aspiration pneumonia D.Eyes .Drug of choice is Retrovir b.Side Effect: tinnitus. Children below 5 years old 2.Adrenal gland c.Nephrotoxicity check for BUN and Creatinine .Bones (potts) . Weight loss 5. Signs and Symptoms 1. Related to prolonged immobility (CVA clients). Air pollution 3. chills.Chest x-ray confirms lung cancer 4.Initial sign is non productive cough . Prevent complications (atelectasis.Pneumocystic carini pneumonia .Meninges .Ototoxicity damage to the 8th cranial nerve resulting to tinnitus leading to hearing loss . Elderly C.
Place on semi fowlers position 6. Best done before meals or 2 – 3 hours to prevent gastro esophageal reflux b. Penicillin b. Abdominal distention leading to paralytic ileus (absence of peristalsis) E. Stop if client cannot tolerate procedure f. Prevent complications . Nebulize and suction as needed 8. Encourage client deep breathing exercises d. Administer bronchodilators 15 – 30 minutes before procedure e.Chest physiotherapy .Increase ICP 9.Drain uppermost area of lungs . Tetracycline c. Provide oral care after procedure g.7. ABG analysis – reveals decrease PO2 4. Institute pulmonary toilet (tends to promote expectoration) . Monitor vital signs c. Pleuritic friction rub 9. protein and vitamin C 10. Chest x-ray – reveals pulmonary consolidation 3.Hemoptysis .Unstable vital signs . Provide increase carbohydrates. Enforce CBR 2. calories. Chest pain 10. Administer medications as ordered Broad Spectrum Antibiotic a.Clients with increase intra ocular pressure (Normal IOP 12 – 21 mmHg) . Force fluid 5. Microlides (Zethromax) Azethromycin (Side Effect: Ototoxicity) Antipyretics Mucolytics/Expectorants Analgesics 4. Diagnostic Procedure 1.Placed on various position Nursing Management for Postural Drainage a. Assist in postural drainage .Turning and reposition 7. Contraindicated with . CBC – reveals increase WBC. Nursing Management 1. erythrocyte sedimentation rate is increased F. Health teaching and discharge planning a. Avoid smoking b. Cyanosis 8.Coughing exercises . Sputum Gram Staining and Culture Sensitivity – positive to cultured microorganisms 2.Deep breathing exercises . Administer oxygen inhalation low inflow 3.
Histoplasmin Skin Test – positive 2. chills.. Anorexia and generalized body malaise .Fungizone (Nephrotoxicity. Signs and Symptoms PTB or Pneumonia like 1. Regular adherence to medications d. Administer oxygen inhalation 3. Productive cough (consistent to all COPD) 2. Smoking 2. hydrocephalus) c. Prevent complications – bronchiectasis 7. Force fluids to liquefy secretions 5. Predisposing Factors 1. Administer medications as ordered a. Importance of follow up care HISTOPLASMOSIS Acute fungal infection caused by inhalation of contaminated dust or particles with histoplasma capsulatum derived from birds manure A. Signs and Symptoms 1. Antifungal . Diagnostic Procedures 1. general body malaise 4. 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. Nebulize and suction as needed 6. check for BUN and Creatinine. Antipyretics 4. Hemoptysis 6. Dyspnea on exertion 3. Mucolytics d.Meningitis (nerve deafness. Steroids c.Amphotericin B . Hypokalemia) b. Enforce CBR 2. Chest and joint pains B. Fever. Nursing Management 1.Atelectasis . Air pollution B. Cyanosis 5. ABG analysis PO2 decrease C. Dyspnea 3. anorexia. Prolonged expiratory grunt 4. Productive cough 2.
Fumes d. Hereditary b. chocolates. Peripheral edema b. pH decrease Bronchial Asthma Reversible inflammatory lung condition due to hypersensitivity to allergens leading to narrowing of smaller airways A. palpitations 7.Before ABG test for positive Allens Test. Extrinsic Asthma ( Atopic/ Allergic ) Causes a. Nursing Management 1. Mixed Type 90 – 95% B. Cyanosis 7. Drugs (aspirin. beta blocker) c. Diaphoresis C. Sudden change in temperature. Food additives (nitrates) e. Furs h. Smoke e. Tachycardia. Intrinsic Asthma (Non atopic/Non allergic) Causes a. ABG analysis – PO2 decrease . chicken d. Pollen b. Predisposing Factors (Depending on Types) 1. penicillin. Signs and Symptoms 1. Cor Pulmonale (right ventricular hypertrophy) C. Lints 2. air pressure and humidity f. Foods (seafoods. Mild Stress/apprehension 6. Physical and emotional stress 3.5. PCO2 increase. Pulmonary hypertension a. Scattered rales/ronchi 6. Gases f. Dust c. Pulmonary Function Test . Cough that is non productive 2. Diagnostic Procedure 1. Cyanosis 5. eggs. Enforce CBR . Danders g. milk. Diagnostic Procedure ABG analysis – reveals PO2 decrease (hypoxemia). apply direct pressure to ulnar and radial artery to determine presence of collateral circulation D. Wheezing on expiration 4.Incentive spirometer reveals decrease vital lung capacity 2. Dyspnea 3.
Feeding initiated upon return of gag reflex 2. coughing and smoking. Cyanosis 4. may cause irritation 3.Epinephrine .Bronchodilators c. Monitor for signs of laryngeal spasm – prepare tracheostomy set D. Avoid talking. Hemoptysis (only COPD with sign) C. Semi fowlers position 6.Steroids . Nebulize and suction when needed 7. Mucolytics/expectorants e. ABG – PO2 decrease 2. Prevent complications . Dyspnea 3. Related to presence of tumor B. Provide client health teachings and discharge planning concerning a. Oxygen inhalation. Administer medications as ordered a. Diagnostic Procedure 1. Steroids – decrease inflammation c. with low inflow of 2 – 3 L/min 3. Predisposing Factors 1. Treatment . Mucomysts (acetylceisteine) d. Chest trauma 3. Importance of follow up care BRONCHIECTASIS Abnormal permanent dilation of bronchus leading to destruction of muscular and elastic tissues of alveoli A. Anti histamine 4.2. Recurrent lower respiratory tract infections 2.Emphysema . Force fluids 5. Regular adherence to medications to prevent development of status asthmaticus d. Avoidance of precipitating factor b. Productive cough 2. Signs and Symptoms 1.Status Asthmaticus (give drug of choice) . Congenital defects 4. Anorexia and generalized body malaise 5. Bronchodilators – given via inhalation or metered dose inhalaer or MDI for 5 minutes b. Maintain NPO 6 – 8 hours prior to procedure 3. Secure inform consent and explain procedure to client 2. Bronchoscopy – direct visualization of bronchus using fiberscope Nursing Management PRE Bronchoscopy 1. Monitor for signs of gross 4. Monitor vital signs and breath sound POST Bronchoscopy 1.
Panacinar/ centriacinar . Bronchial wheezing 10. Pulmonary Function Test – reveals decrease vital lung capacity 2.Increase PO2 (hyperaxemia. Hereditary – it involves deficiency of ALPHA-1 ANTI TRYPSIN (needed to form Elastase.Decrease PO2 (hypoxemia leading to chronic bronchitis. Diagnostic Procedure 1.1.Respiratory acidosis b. Over distention of thoracic cavity (barrel chest) A. Segmental Wedge Lobectomy (promote re expansion of lungs) . “Blue Bloaters”) .Decrease PCO2 . Resonance to hyperresonance 6. Purse lip breathing to eliminates excess CO2 (compensatory mechanism) C. Air trapping c. Smoking 2. 1 lung is removed and position on affected side) 2.Increase ph . ABG analysis reveals a. “Pink Puffers”) . High risk: elderly 5. Decrease or diminished breath sounds 8.Increase PCO2 . Flaring of alai nares 12. Inelasticity of alveoli b. Signs and Symptoms 1. Panlobular/ centrilobular . for recoil of alveoli) B. Allergy 4. Productive cough 2. Dyspnea at rest 3.Unaffected lobectomy facilitate drainage EMPHYSEMA Irreversible terminal stage of COPD characterized by a. Surgery (pneumonectomy .Respiratory alkalosis D. Air pollution 3. Barrel chest 11. Enforce CBR . Anorexia and generalized body malaise 5. Prolong expiratory grunt 4. Decrease tactile fremitus 7. Rales or ronchi 9.Decrease ph . Predisposing Factors 1. Nursing Management 1. Maldistribution of gases d.
Atelectasis . Importance of follow up care . Strict compliance to medication d. Avoid smoking b. High fowlers position 5. Prevent complications . Institute PEEP (positive end expiratory pressure) in mechanical ventilation promotes maximum alveolar lung expansion 9.2.CO2 narcosis may lead to coma . Administer oxygen inhalation via low inflow 3. Steroids c.Pneumothorax c. Administer medications as ordered a. protein. Antibiotics d. Force fluids 6. Institute pulmonary toilet 7. Provide high carbohydrates. vitamins and minerals 11. calories. Provide comfortable and humid environment 10.Cor Pulmonale . Bronchodilators b. Health teachings and discharge planning concerning a. Mucolytics/expectorants 4. Nebulize and suction when needed 8.
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