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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.
Immediate action. Ig D – for chronic inflammation. Apraxia – no recognition of objects function. 2. *Receptive aphasia DRUG OF CHOICE: ARICEPT (taken at bedtime) and COGNEX. . pressure. d. Mood swings . . pain. * Give palliative or supportive care. Sign and Symptoms 4 A’s of Alzheimer a. colostrums). Aphasia – no speech (nodding). tingling sensation paresthesia numbness euphoria (sense of well being) 3. Ig E – for allergic reaction. Ig M – acute in inflammation. c. ALZHEIMER’S DISEASE Atrophy of brain tissues. Wernicke’s Aphasia General Knowing Gnostic Area or General Interpretative Area. Signs and Symptoms 1. MULTIPLE SCLEROSIS Chronic intermittent disorder of CNS characterized by white patches of demyelination in brain and spinal cord. Amnesia – loss of memory. Visual disturbances blurring of vision (primary) diplopia (double vision) scotomas (blind spots) 2. saliva.DEMYELINATING DISORDERS 1. Agnosia – no recognition of inanimate objects. Women ages 15-35 are prone Unknown Cause Slow growing virus Autoimmune disorders Pernicious anemia Myasthenia gravis Lupus Hypothyroidism GBS Ig G – only antibody that pass placental circulation causing passive immunity. b. Characterized by remission and exacerbation. Impaired sensation to touch.short term protection. Ig A – present in all bodily secretions (tears. heat and cold. *Expressive aphasia “motor speech center” Broca’s Aphasia inability to understand spoken words.
Diuretics b. Yoga 4. Immunosupresants 2. Decrease sexual capacity DIAGNOSTIC PROCEDURE Nystagmus CSF analysis (increase in IgG and Protein). . (+) Lhermitte’s sign a continuous and increase contraction of spinal column. a. c. Catheterization to prevent retention. Increase fluid intake and increase fiber to prevent constipation. Deep breathing exercises b. Institute stress management techniques. For Urinary Incontinence Anti spasmodic agent a. d. pineapple. 5. Impaired motor function weakness spasticity paralysis scanning speech TRIAD SIGNS OF MS Ataxia (Unsteady gait. Constipation 8. prunes. Monitor side effects bronchospasm and wheezing. 3. plums. Administer medications as ordered a.4. Bethanicol Chloride (Urecholine) Nursing Management Only given subcutaneous. Maintain side rails to prevent injury related to falls. To acidify urine and prevent bacterial multiplication. b. Monitor breath sounds 1 hour after subcutaneous administration. c. 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). Interferons – alter immune response. vitamin C and orange. Impaired cerebral function CHARCOTS TRIAD IAN Intentional tremors 6. (+) Romberg’s test) 5. a. Urinary retention/incontinence 7. Baclofen (Dioresal)/ Dantrolene Sodium (Dantrene) – muscle relaxants. Prophantheline Bromide (Promanthene) Acid ash diet like cranberry juice. NURSING MANAGEMENT 1.
Brain Mass PARTS OF THE BRAIN 1. 80% brain mass 10% blood 10% CSF COMPOSITION OF BRAIN I. CEREBRUM largest part composed of the Right Cerebral Hemisphere and Left Cerebral Hemisphere enclosed in the Corpus Callosum. 8 inches) urinate after intercourse Nursing Management Male MICROGLIA stationary cells that carry on phagocytosis (engulfing of bacteria or cellular debris. Occipital . pressure. Parietal 4.COMMON CAUSE OF UTI Female short urethra (3-5 cm. numbness. avoid use of tissue papers avoid using talcum powder and perfume. ORGAN Brain Blood Kidney Skin Lung MACROPHAGE Microglia Monocytes Kupffers cells Histiocytes Alveolar Macrophage EPINDYMAL CELLS Secretes a glue called chemo attractants that concentrate the bacteria. eating). Frontal higher cortical thinking controls personality controls motor activity Broca’s Area (motor speech area) when damaged results to garbled speech. Functions of Cerebrum integrative sensory motor Lobes of Cerebrum 1. 2. cold. pinocytosis (cell drinking). 1-1 ½ inches) poor perineal hygiene vaginal environment is moist avoid bubble bath (can alter Ph of vagina). heat. 3. Urethra (20 cm. touch. Temporal hearing short term memory for appreciation discrimination of sensory impulses to pain.
Thalamus acts as relay station for sensation. controls smell and if damaged results to Anosmia (absence of smell). release dopamine (controls gross voluntary movement. 2. positive PERRLA 4. rhythm and depth of respiration. swallowing. B. . heart rate. unequal size of pupil is anisocoria. MIDBRAIN/ MESENCEPHALON acts as relay station for sight and hearing. vomiting. lesser brain. controls respiration. Hypothalamus 5. early sign for females telarche and late sign is menarche. controls libido controls long term memory Insula (Island of Reil) Limbic System (Rhinencephalon) 2. controls blood pressure controls thirst appetite/satiety sleep and wakefulness controls some emotional responses like fear. anxiety and excitement. controls temperature (thermoregulatory center). BASAL GAGLIA areas of grey matter located deep within each cerebral hemisphere. Cerebellum smallest part of the brain. controls pituitary functions androgenic hormones promotes secondary sex characteristics. early sign for males are testicular and penile enlargement late sign is deepening of voice. size of pupil is 2 – 3 mm. hiccup. for vision visceral function activities of internal organ like gastric motility. equal size of pupil is isocoria. vasomotor center (dilation and constriction of bronchioles). BRAIN STEM located at lowest part of brain Parts of Brain Stem 1. hearing acuity is 30 – 40 dB. DECREASE Myasthenia Gravis Parkinson’s Disease INCREASE Bi-polar Disorder Schizophrenia NEURO TRANSMITTER Acethylcholine Dopamine 3. INTERBRAIN/ DIENCEPHALON Parts of Diencephalon A. Pons pneumotaxic center controls the rate. Medulla Oblongata 3.
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). 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. posture and gait. widening of pulse pressure is neurologic in nature (if narrow cardiac in nature). 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. projective vomiting headache papilledema (edema of optic disc) abnormal posturing decorticate posturing (damage to cortex and spinal cord). Cervical 2 – also known as AXIS. . equilibrium. NEUROLOGIC DISORDERS INCREASE INTRACRANIAL PRESSURE – increase in intra-cranial bulk brought about by an increase in one of the 3 major intra cranial components. heart rate decrease respiratory rate decrease temperature increase directly proportional to blood pressure. Early closure of posterior fontanels causes posterior enlargement of skull in hydrocephalus. controls balance.
In chronic respiratory distress syndrome decrease O2 stimulates respiration. Furosemide) Drug of choice for CHF (pulmonary edema) Loop of Henle in kidneys. 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. Monitor strictly input and output and neuro check 5. b. monitor strictly input and output every 1 hour notify physician if output is less 30 cc/hr. maintain side rails. Administer medications like: a. 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. Late signs of hypoxia HYPERCARBIA b. Assist in mechanical ventilation 2. 3. avoid clustering of nursing activity together. decerebrate posturing (damage to upper brain stem that includes pons. avoid use of restraints. Prevent further increase ICP by: a. Nursing Management . Before and after suctioning hyper oxygenate client 100% and done 10 – 15 seconds only. Elevate bed of client 30 – 35o angle with neck in neutral position unless contraindicated to promote venous drainage. 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. c. 4. b. cerebellum and midbrain). 7. d. Maintain patent and adequate ventilation by: a. Limit fluid intake to 1200 – 1500 ml/day (in force fluids 2000 – 3000 ml/day). administered via side drip regulated fast drip to prevent crystal formation. provide an comfortable and quite environment. Osmotic diuretic (Mannitol) for cerebral diuresis Nursing Management monitor vital signs especially BP (hypotension). Loop diuretic (Lasix.
Dexamethasone (Decadron) Hydrocortisone Prednisone (to reduce edema that may lead to increase ICP) Mild Analgesics (Codeine Sulfate for respiratory depression) Anti Convulsants (Dilantin. maximum effect of 6 hours. Monitor vital signs especially BP (hypotension). monitor strictly input and output every 1 hour notify physician if output is less 30 cc/hr. 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. Phenytoin) c. 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 . administered IV push or oral. given early morning immediate effect of 10 – 15 minutes.
Hypokalemia decrease potassium level normal value is 3.4 – 5.Signs and Symptoms of Lasix in terms of electrolyte imbalances 1. 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. Oral Potassium Chloride) increase intake of foods rich in potassium FRUITS Apple Banana Cantalop e Oranges 2.5 meq/L weakness and fatigue constipation positive U wave on ECG tracing Sign and Symptoms Nursing Management administer potassium supplements as ordered (Kalium Durule.5 – 11 mg/100 ml Signs and Symptoms tingling sensation paresthesia numbness (+) Trousseau’s sign/ Carpopedal spasm (+) Chvostek’s sign Complications Arrhythmia Seizures Nursing Management Calcium Gluconate per IV slowly as ordered * Calcium Gluconate toxicity – results to SEIZURE Magnesium Sulfate Magnesium Sulfate toxicity S/S BP Urine output Respiratory rate Patellar relfex absent 3. in infant TACHYCARDIA) agitation dry mucous membrane poor skin turgor weakness and fatigue .
Colchecine * KIDNEY STONES Signs and Symptoms renal colic Cool moist skin force fluids administer medications as ordered Morphine Sulfate ANTIDOTE: Naloxone (Narcan) toxicity leads to tremors. Allopurinol (Zyloprim) Side Effects Respiratory depression (check for RR) . Mechanism of action: inhibits synthesis of uric acid. Hyperuricemia increase uric acid (purine metabolism) foods high in uric acid (sardines. Nursing Management a.Nursing Management force fluids administer isotonic fluid solution as ordered 4. Acute gout Mechanism of action: promotes excretion of uric acid. Allopurinol (Zyloprim) b. Hyperglycemia normal FBS is 80 – 100 mg/dl polyuria polydypsia polyphagia monitor FBS Signs and Symptoms Nursing Management 5. organ meats and anchovies) *Increase in tophi deposit leads to Gouty arthritis. Narcotic Analgesic b. joint pain (great toes) swelling force fluids administer medications as ordered Drug of choice for gout. Signs and Symptoms Nursing Management a.
Haloperidol(Haldol) d. Encephalitis 5. Administer medications as ordered Anti Parkinsonian agents Levodopa (L-dopa) short acting Amantadine Hydrochloride (Symmetrel) Carbidopa (Sinemet) . increase lacrimation c. Arteriosclerosis 3. decrease sexual capacity Nursing Management 1. Reserpine(Serpasil) b. Increase dosage of the following drugs: a.PARKINSON’S DISEASE/ PARKINSONISM Chronic progressive disorder of CNS characterized by degeneration of dopamine producing cells in the SUBSTANCIA NIGRA of the midbrain and basal ganglia. difficulty rising from sitting position. Monotone type speech mood lability (in state of depression) increase salivation (drooling type) autonomic changes a. Predisposing Factors 1. increase sweating b. Poisoning (lead and carbon monoxide) 2. bradykinesia (slowness of movement) rigidity (cogwheel type) stooped posture shuffling and propulsive gait over fatigue mask like facial expression with decrease blinking of the eyes. Phenothiazine AntipsychoticS AntihypertensiveS SIDE EFFECTS RESERPINE Major depression leading to suicide Aloneness Multiple loss causes suicide Loss of spouse direct approach towards the client close surveillance is a nursing priority Loss of Job time to commit suicide is on weekends early morning Signs and Symptoms for Parkinson’s pill rolling tremors of extremities especially the hands. seborrhea d. Hypoxia 4. constipation e. Methyldopa(Aldomet) c.
Encourage increase fluid intake and fiber. Assist in Stereotaxic Thalamotomy MAGIC 2’s IN DRUG MONITORING DRUG Digoxin/ Lanoxin (Increase force of cardiac output) Lithium/ Lithane (Decrease level of Ach/NE/Serotonin) Aminophylline (Dilates bronchial tree) Dilantin/ Phenytoin Acetaminophen/Tylenol NORMAL RANGE .2 meq/L 10 – 19 mg/100 ml 10 – 19 mg/100 ml 10 – 30 mg/100 ml TOXICITY LEVEL 2 2 20 20 200 INDICATION CHF Bipolar COPD Seizures Osteo Arthritis CLASSIFICATION Cardiac Glycoside Anti-Manic Agents Bronchodilators Anti-Convulsant Non-narcotic Analgesic . Assist/supervise in ambulation 7.6 – 1.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).relieves tremor rigidity Bromocriptene Hydrochloride (Parlodel) Side Effects Respiratory depression 2. Isonicotinic Acid Hydrazide Anti Cholinergic Agents (ARTANE and COGENTIN) .5 meq/L . Dopamine Agonist . 6. Prevent complications of immobility 4. Maintain side rails to prevent injury 3. Decrease protein in morning and increase protein in afternoon to induce sleep 5.5 – 1.to relieve tremors Mechanism of Action inhibits action of acethylcholine SNS Side Effects Anti Histamine (Dipenhydramine Hydrochloride) Side Effects Adult: drowsiness Children: CNS excitement (hyperactivity) because blood brain barrier is not yet fully developed.
Dilantin Toxicity Signs and Symptoms gingival hyperplasia (swollen gums) hairy tongue ataxia nystagmus provide oral care massage gums Nursing Management 5. depression Antidote: Acetylcisteine (mucomyst) prepare suction apparatus as bedside. administered sandwich method avoid taking alcohol because it can lead to severe CNS depression avoid caffeine Nursing Management 4. agitation and restlessness) only mixed with plain NSS or 0. tachycardia Irritability Restlessness Extreme fatigue Diaphoresis. 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 3.8 – 1) hypoglycemia Tremors. irritability.1. 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 2.9 NaCl to prevent development of crystals or precipitate. . Aminophylline Toxicity Signs and Symptoms tachycardia palpitations CNS excitement (tremors.
speak.PNS Treatment .Administer anti cholinergic agents (Atropine Sulfate) Side Effects MYASTHENIC CRISIS Causes: . initial sign is ptosis a clinical parameter to determine ptosis is palpebral fissure. Incidence rate: women 20 – 40 years old Predisposing factors unknown autoimmune: it involves release of cholinesterase an enzyme that destroys Ach. if there is no effect there is damage to occipital lobe and midbrain and is negative for Signs and Symptoms Diagnostic Procedure M. mmobility * assist in mechanical ventilation and monitor pulmonary function test * monitor strictly vital signs.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. swallow. aspiration 3. Prevent complications . Nursing Management 1.over medication Signs and Symptoms .stress .infection Signs and Symptoms . 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. Assist in surgical procedure known as thymectomy because it is believed that the thymus gland is responsible for M. administer medications as ordered a.under medication . input and output and neuro check * monitor strength or motor grading scale 4.administer cholinergic agents as ordered 7.G.The client is unable to see. Cholinergic (Mestinon) b. maintain side rails to prevent injury related to falls 5. Assist in plasma paresis and removing auto immune anti bodies 9. breathe Treatment . 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: .G. airway 2. 8. institute NGT feeding 6.
Decrease glucose 3. (+) Kernig’s sign (leg pain) d. Nursing Management for LP Before Lumbar Puncture 1. Assess for movement and sensation of extremities. (+) cultured microorganism (confirms meningitis) CBC reveals 1. Increase CSF opening pressure (normal pressure is 50 – 100 mmHg) 4. anorexia. (+) Brudzinski sign (neck pain) D. chills. Pia matter – inner layer subdural space between the dura and arachnoid subarachnoid space between the arachnoid and pia. Arachnoid – middle layer 3. general body malaise and weight loss Possible increase in ICP and seizure activity Abnormal posturing (decorticate and decerebrate) Signs of meningeal irritation a. Signs and Symptoms headache photophobia projectile vomiting fever. Empty bladder and bowel to promote comfort. Secure informed consent and explain procedure. Encourage to arch back to clearly visualize L3-L4. Increase wbc . 3. Nuchal rigidity or stiff neck b.INFLAMMATORY CONDITIONS OF THE BRAIN MENINGITIS Meninges 3 fold membrane that covers brain and spinal cord. Streptococcus . Post Lumbar Puncture 1. Meningococcus – most dangerous 2. CSF aspiration is done. Opisthotonus (arching of back) c. Check punctured site for any discoloration. Diagnostic Procedures Lumbar puncture: a hollow spinal needle is inserted in the subarachnoid space between the L3 – L4 to L5. A. Mode of transmission airborne transmission (droplet nuclei) C. Force fluids 3. 4. 2. Place flat on bed 12 – 24 o 2. Pneumococcus 3. Etiology 1.causes adult meningitis 4. drainage and leakage to tissues. CSF analysis reveals 1. Hemophilus Influenzae – causes pediatric meningitis B. for support and protection for nourishment blood supply LAYERS OF THE MENINGES 1. Increase CHON and WBC 2. Dura matter – outer layer 2.
Predisposing Factors thrombus (attached) embolus (detached and most dangerous because it can go to the lungs and cause pulmonary embolism or the brain and cause cerebral embolism. Maintain fluid and electrolyte balance. Internal Cerebral Artery – the 2 largest artery A. Nursing Management 1. Enforce complete bed rest 2. Prevent complications most feared is hydrocephalus hearing loss/nerve deafness is second complication consult audiologist mental retardation delayed psychomotor development c. 8. Rehabilitation for neurological deficit CVA (STROKE/BRAIN ATTACK/ ADOPLEXY/ CEREBRAL THROMBOSIS) a partial or complete disruption in the brains blood supply. Mild analgesics c.E. Provide client health care and discharge planning concerning: a. Compartment syndrome (compression of arteries and nerves) . Maintain good diet of increase CHO. 2 most common cerebral artery affected by stroke a. Mid Cerebral Artery b. Incidence Rate men are 2-3 times high risk B. Yellow bone marrow are produced from the medullary cavity of the long bones and produces fat cells. Monitor strictly V/S. 7. Tetracycline) b. Elevate head 30-45o 5. calories with small frequent feedings. 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. If there is bone fracture there is hemorrhage and there would be escape of the fat cells in the circulation. Broad spectrum antibiotics (Penicillin. Institute measures to prevent increase ICP and seizure. 9. Institute strict respiratory isolation 24 hours after initiation of anti biotic therapy 4. Provide a comfortable and darkened environment. input and output and neuro check 6. CHON. b. Anti pyretics 3. Administer medications as ordered a.
C. Type A personality 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 . dysarthria (inability to articulate words) d. usually fells guilty when not doing anything 6. Hyperlipidemia more on genetics/genes that binds to cholesterol 5. 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. Atherosclerosis. Hypertension. Myocardial Infarction. Obesity (increase 20% ideal body weight) 4. alexia (difficulty reading) e. sedentary lifestyle 3. can do multiple tasks c. aphasia c. Risk Factors 1. Valvular Cardiac Surgery (mitral valve replacement) 2. Lifestyle (smoking). Prolong use of oral contraceptives promotes lypolysis (breakdown of lipids) leading to atherosclerosis that will lead to hypertension and eventually CVA. homonymous hemianopsia (loss of half of visual field) 1. Diabetes Mellitus. TIA Signs and Symptoms 2. Diagnostic Procedure 1. agraphia (difficulty writing) f. D. phlegia b. Signs and Symptoms Heart Disease. Related to diet: increase intake of saturated fats like whole milk 7. Complete stroke Signs and Symptoms E. Related stress physical and emotional 8. CT Scan – reveals brain lesions 2. nausea and vomiting dysphagia (+) Kernig’s sign and Brudzinski sign which may lead to hemorrhagic stroke focal neurological deficits a. Stroke in evolution 3. deadline driven b.
Prevent complications of immobility by: a. Institute NGT feeding 8. Administer medications as ordered a. saturated fats and caffeine) d. Loop Diuretics (Lasix. dietary modification (decrease salt. provide sand bag or food board. turn client to side b. Thrombolytic/Fibrinolytic Agents – dissolves thrombus Streptokinase Side Effect: Allergic Reaction Urokinase Tissue Plasminogen Activating Factor Side Effect: Chest Pain f. provide egg crate mattresses or water bed c. Cortecosteroids d. administrate O2 inhalation 2. Anti Platelet PASA (Aspirin) Contraindicated for dengue. avoidance of modifiable risk factors (diet. Furosemide) c. smoking) b. exercise. Assist in passive ROM exercise every 4 hours to promote proper bodily alignment and prevent contractures 7. K (Aqua Mephyton) g. Maintain patent airway and adequate ventilation by: a. Restrict fluids to prevent cerebral edema that might increase ICP 3. Provide alternative means of communication a. Elevate head 30 – 45o 4. ulcer and unknown cause of headache because it may potentiate bleeding 11. Provide client health teachings and discharge planning concerning a. 6. prevent complication (subarachnoid hemorrhage is the most feared complication) c. Anti Coagulants Heparin (short acting) check for partial thromboplastin time if prolonged there is a risk for bleeding. non verbal cues b. Nursing Management 1.F. Monitor strictly vitals signs. Osmotic Diuretics (Mannitol) b. magic slate 9. If positive to hemianopsia approach client on unaffected side 10. Mild Analgesics e. 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. assist in mechanical ventilation b. I & O and neuro check 5. importance of follow up care .
Corticosteroids – suppress immune response b. Maintain side rails to prevent injury related to fall 4. assist in mechanical ventilation b. ECG 3. Antecedent viral infections such as LRT infections B. Nursing Management 1. Decreased of diminished deep tendon reflex 5. increase salivation b. Prevent complications of immobility by turning the client every 2 hours 5. Dysphagia 3. Autoimmune 2. Signs and Symptoms 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. . Clumsiness (initial sign) 2. Anti Cholinergic Agents – Atrophine Sulfate c. Assist in passive ROM exercise 7. Institute NGT feeding to prevent aspiration 6. Monitor strictly the following a. Diagnostic Procedures 1. constipation C. Maintain patent airway and adequate ventilation by: a. monitor pulmonary function test 2. Alternate hypotension to hypertension ** ARRYTHMIA (most feared complication) 6. Prevent complications a. CSF analysis reveals increase in IgG and protein D. vital signs b.GUILLAIN BARRE SYNDROME a disorder of the CNS characterized by bilateral symmetrical polyneuritis leading to ascending muscle paralysis. Zylocaine Bretylium – blocks release of norepinephrine to prevent increase of BP 8. neuro check d. Predisposing Factors 1. Assist in plasma pharesis (filtering of blood to remove autoimmune anti-bodies) 9. A. Anti Arrythmic Agents Lidocaine. intake and output c. Arrythmia b. increase sweating c. Administer medications as ordered a. Ascending muscle weakness leading to paralysis 4. Autonomic symptoms that includes a.
Signs and Symptoms Dependent on stages of development or types of seizure I. Toxicity from a. EEG – reveals hyper activity of electrical brain waves . Valium and Glucose C. Valium) B. Partial or Localized Seizure 1. Post ictal sleep – unresponsive sleep 2. Sudden withdrawal to anti convulsant drug is predisposing factor for status epilepticus (drug of choice is Diazepam. Nutritional and Metabolic deficiencies 6. CT Scan – reveals brain lesions 2. Predisposing Factors 1. 2. Drug of choice: Diazepam. Psychomotor Seizure (focal motor seizure) a. loss of consciousness (5 – 10 seconds) II. Physical and emotional stress 7. blank stare b. Generalized Seizure 1. automatism – stereotype repetitive and non propulsive behavior b. decrease blinking of eyes c. mild hallucinatory sensory experience III. tactile. lead b carbon monoxide 5. Seizure – first convulsive attack Epilepsy – second or series of attacks Febrile seizure – normal in children age below 5 years A. Signs or aura with auditory. Epileptic cry – is characterized by fall and loss of consciousness for 3 – 5 minutes c.direct symmetrical extension of extremities Clonic contractions . if left untreated can lead to hyperpyrexia and lead to coma and eventually death. twitching of mouth d. Diagnostic Procedures 1. Petit mal Seizure – absence of seizure common among pediatric clients characterized by a. olfactory. visual. Head injury due to birth trauma 2. Tonic contractions . Status Epilepticus A continuous uninterrupted seizure activity. Genetics 3.contraction of extremities d. Presence of brain tumor 4. sensory experience b. 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. Grand mal Seizure (tonic-clonic seizure) a. clouding of consciousness – not in contact with environment c.CONVULSIVE DISORDER/ CONVULSION disorder of CNS characterized by paroxysmal seizure with or without loss of consciousness abnormal motor activity alternation in sensation and perception and changes in behavior.
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
Diagnostic Procedure 1. Predisposing Factor 1. Carbachol 2. Gonioscopy D.3. Treatment 1. Retinal Detachment Separation of epithelial surface of retina . Epinephrine eyedrops – decrease formation of aqueous humor 3. Loss of central vision C. Decrease perception to colors Complication is blindness D. Miotics – constricts pupil a. Surgical Procedures 1. Mydriatics (Mydriacyl) – constricts pupils 2. Pathognomonic Signs 1. Timoptics (Timolol Maleate) E. Surgical Procedure Extra Capsular Cataract Lens Extraction . Blurring or hazy vision 2. Pilocarpine Sodium. Prolonged exposure to UV rays B. Treatment 1. Cataract Decrease opacity of lens A. Related to congenital 3.Partial removal Intra Capsular Cataract Lens Extraction . Signs and Symptoms 1. Diabetes Mellitus 4.Total removal of cataract with its surrounding capsules Most feared complication post op is RETINAL DETACHMENT 3. TRABECULECTOMY (Peripheral Indectomy) – drain aqueous humor 2. Aging 65 years and above 2. Opthalmoscopic exam E. Acetazolamide (Diamox) – promotes increase outflow of aqueous humor or drainage 4. Milky white appearance at center of pupils 3. Cyclopegics (Cyclogyl) – paralyses cilliary muscle F. Carbonic Anhydrase Inhibitors a.
A. Black Spots CRANIAL NERVE III. Diathermy – heat application 4. Signs and Symptoms 1. Predisposing Factors 1. VI: OCULOMOTOR. Macular Degeneration Degeneration of the macula lutea (yellowish spot at the center of retina) A. Floaters C. Myopia (near sightedness) B. maxillary. Surgical Procedures 1. IV. Cryosurgery – cold application 3. ABDUCENS Controls or innervates the movement of extrinsic ocular muscle (EOM) 6 muscles Superior Rectus Superior Oblique Lateral Rectus Medial Rectus Inferior Oblique Inferior Rectus trochlear controls superior oblique abducens controls lateral rectus oculomotor controls the 4 remaining EOM Oculomotor controls the size and response of pupil normal pupil size is 2 – 3 mm equal size of pupil: Isocoria Unequal size of pupil: Anisocoria Normal response: positive PERRLA CRANIAL NERVE V: TRIGEMINAL largest cranial nerve consists of ophthalmic. Curtain veil like vision 2. TROCHLEAR. Signs and Symptoms 1. Post Lens Extraction 2. Scleral Buckling 2. mandibular .
Parts of the Ear 1. CRANIAL NERVE VIII: ACOUSTIC/VESTIBULOCOCHLEAR Controls balance particularly kinesthesia or position sense. Inner Ear Vestibule: Meinere’s Disease Cochlea Mastoid Cells Endolymph and Perilymph COCHLEA: controls hearing. teeth. X: GLOSOPHARYNGEAL. contains the Organ of Corti (the true organ of hearing) Let client repeat words uttered CRANIAL NERVE IX. Middle Ear 3. Outer Ear Pinna Eardrum Hammer Anvil Stirrup Malleus Incus Stapes 2. sensory: controls sensation of face. frown and if results are negative there is facial paralysis or Bell’s Palsy and the primary cause is forcep delivery. Pituitary Gland (Hypophysis Cerebri) . 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. refers to movement and orientation of the body in space. ENDOCRINE SYSTEM Overview of the structures and functions 1. 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. mucous membrane. 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. VAGUS NERVE Glosopharyngeal: controls taste.
Administer medications as ordered a. Serum Sodium D. Prevent complilcations – HYPOVOLEMIC SHOCK is the most feared complication Normal value: 1. Poor Skin turgor d. If left untreated results to hypovolemic shock (sign is anuria) C. Posterior Pituitary Gland 2. Hypotension 5. Pitressin (Vasopresin Tannate) – administered IM Z-tract 4. initiates milk let down reflex with help of hormone prolactin called as adenohypophysis called as neurohypophysis secretes hormones oxytocin -promotes uterine contractions preventing bleeding/ 2.015 – 1. Weight loss 6. Polyuria 2. Urine Specific Gravity o o o 1. Diagnostic Procedures 1. Weakness and fatigue 4. Anterior Pituitary Gland o o o hemorrhage o o administrate oxytocin immediately after delivery to prevent uterine atony. Nursing Management . Monitor strictly vital signs and intake and output 3. Agitation c. Signs of dehydration a.o o o Located at base of brain particularly at sella turcica Master gland or master clock Controls all metabolic function of body PARTS OF THE PITUITARY GLAND 1. Antidiuretic Hormone o o o Pitressin (Vasopressin) Function: prevents urination thereby conserving water Diabetes Insipidus/ Syndrome of Inappropriate Anti Diuretic Hormone DIABETES INSIPIDUS o Decrease production of anti diuretic hormone A. Force fluids 2. Dry mucous membrane 3. Predisposing Factor o o o o 1. Adult: thirst b. Signs and Symptoms 2.030 Ph 4 – 8 Increase resulting to hypernatremia Related to pituitary surgery Trauma Inflammation Presence of tumor B.
B. Nursing Management 1. Loop diuretics (Lasix) b. Related to presence of bronchogenic cancer o o gland. Lead to blindness due to severe photophobia b. Fluid retention a. Provide meticulous skin care 6. Monitor strictly vital signs. Diagnostic Procedure 1. Administer medications as ordered a. Predisposing Factors 1. Related to hyperplasia (increase size of organ brought about by increase of number of cells) of pituitary 2. Head injury 2.SIADH o hypersecretion of anti diuretic hormone A. Restrict fluid 2. Signs and Symptoms 1. Weight gain 2. Osmotic diuretics (Mannitol) 3. Serum Sodium is decreased D. Melanocyte Stimulating hormone o o o for skin pigmentation Hyposecretion of MSH results to Albinism Most feared complications of albinism a. Hypertension b. Prone to skin cancer o Hypersecretion of MSH results to Vitiligo 3. intake and output and neuro check 4. Weigh patient daily and assess for pitting edema 5. Edema c. Urine specific gravity is increased 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. Water intoxication may lead to cerebral edema and lead to increase ICP – may lead to seizure activity C. Growth hormones (somatotropic hormone) o o o o o initial sign of lung cancer is non productive cough non invasive procedure is chest x-ray 3. Adrenochorticotropic hormone (ACTH) o promotes development of adrenal cortex .
places far from sea b. Increase intake of goitrogenic foods o o o contains pro-goitrin an anti thyroid agent that has no iodine. Goiter belt area a. sweet potato. Predisposing Factors 1. 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 5.3 molecules of iodine (more potent) 2. all nuts soil erosion washes away iodine . strawberry. T4 (tetra iodothyronine. Thyrocalcitonin – antagonizes the effects of parathormone to promote calcium resorption. turnips. broccoli. Follicle stimulating hormone PINEAL GLAND o o o secretes melatonin inhibits LH secretion it controls/regulates circadian rhythm (body clock) THYROID GLAND o located anterior to the neck 3 Hormones secreted 1. Mountainous regions 2. HYPOTHYROIDISM o o o o o o all are decrease except weight and menstruation memory impairment there is loss of appetite but there is weight gain menorrhagia cold intolerance constipation Signs and Symptoms HYPERTHYROIDISM o o o o all are increase except weight and menstruation increase appetite but there is weight loss amenorrhea exophthalmos Signs and Symptoms THYROID DISORDERS SIMPLE GOITER o enlargement of thyroid gland due to iodine deficiency A. Thyroxine) o o T3 and T4 are metabolic or calorigenic hormone promotes cerebration (thinking) 3. cabbage.4. carrots. radish. Leutinizing hormone 6. T3 (Tri iodothyronine) .
Phenylbutazones (NSAIDs) . Enlarged thyroid gland 2. Assist in surgical procedure of subtotal thyroidectomy HYPOTHYROIDISM o o o hyposecretion of thyroid hormone adults: MYXEDEMA non pitting edema children: CRETINISM the only endocrine disorder that can lead to mental retardation 4. Increase dietary intake of foods rich in iodine A. Enforce complete bed rest 2.if goiter is caused by B. Thyroid Hormones o o o Levothyroxine (Synthroid) Liothyronine (Cytomel) Thyroid Extracts Nursing Management when giving Thyroid Hormones 1. Monitor side effects o o o o o o o insomnia tachycardia and palpitations hypertension heat intolerance seaweeds seafood’s like oyster. Predisposing Factors 1. iodized salt. Lithium Carbonate c. 3. Mild restlessness C. Anti Thyroid Agent – Prophylthiuracil (PTU) b. Nursing Management 1. presence of tumor. Iron. best taken raw because it it is easily destroyed by heat 5. Instruct client to take in the morning to prevent insomnia 2. Diagnostic Procedures 1. Iatrogenic Cause – disease caused by medical intervention such as surgery 2. Thyroid Scan – reveals enlarged thyroid gland. PASA (Aspirin) d. Serum T3 and T4 – reveals normal or below normal 2. Mild dysphagia 3. Administer medications as ordered a. inflammation . clams and lobster but not shrimps because it contains lesser amount of iodine. Monitor vital signs especially heart rate because drug causes tachycardia and palpitations 3. 4 Medications to be taken via straw: Lugol’s. crabs. Tetracycline. Serum Thyroid Stimulating Hormone (TSH) – is increased (confirmatory diagnostic test) D. Nitrofurantoin (drug of choice for pyelonephritis) b.o goitrogenic drugs a. Lugol’s Solution/SSKI ( Saturated Solution of Potassium Iodine) o o color purple or violet and administered via straw to prevent staining of teeth. Related to atrophy of thyroid gland due to trauma. Signs and Symptoms 1. Cobalt e.
Dry skin 4. hyponatremia. Provide comfortable and warm environment 7. Administer isotonic fluid solution as ordered 4. Brittleness of hair and nails 2. Loss of appetite but with weight gain which promotes lipolysis leading to atherosclerosis and MI 3. Avoid precipitating factors leading to myxedema coma o o stress infection Assist in mechanical ventilation Administer thyroid hormones as ordered Force fluids . hypothermia leading to pregressive stupor and coma. Nursing Management 1. CNS changes o o o o lethargy memory impairment psychosis menorrhagia C. Thyroid Extracts 5. Provide client health teaching and discharge planning concerning a. Force fluids 3. bradycardia. hypothermia 6. Decrease in all vital signs – hypotension. Levothyroxine b. Non pitting edema (Myxedema) 3. Decrease libido 5. bradypnea. hypoglycemia. hypoventilation. bradycardia.3. Constipation (Late Signs) 1. Provide dietary intake that is low in calories 6. Iodine deficiency 4. Administer medications as ordered Thyroid Hormones a. Provide meticulous skin care 8. Weakness and fatigue 2. Hoarseness of voice 4. Leothyronine c. bradypnea. Diagnostic Procedures 1. Serum Cholesterol is increased 3. Cold intolerance 5. Serum T3 and T4 is decreased 2. RAIU (Radio Active Iodine Uptake) is decreased D. 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. Signs and Symptoms (Early Signs) 1. Autoimmune (Hashimotos Disease) B. Nursing Management for Myxedema Coma 2.
Comfortable and cold environment 6. Moist skin 3. Nursing Management 1. Hallucinations 7. Diarrhea 5. Diagnostic Procedures 1. Restlessness c. Prophythioracill (PTU) b.o o o o o o o o cold intolerance use of anesthetics. 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. Provide dietary intake that is increased in calories. RAIU (Radio Active Iodine Uptake) is increased 3. Thyroid Scan. Predisposing Factors 1. Autoimmune – it involves release of long acting thyroid stimulator causing exopthalmus (protrusion of eyeballs) enopthalmus (late sign of dehydration among infants) 2. Exopthalmus 9. All vital signs are increased 6. and sedatives prevent complications (myxedema coma.reveals an enlarged thyroid gland D. narcotics. Excessive iodine intake 3. Increase appetite (hyperphagia) but there is weight loss 2. Serum T3 and T4 is increased 2. Tremors d. Monitor strictly vital signs and intake and output 2. Related to hyperplasia (increase size) B. CNS involvement a. Administer medications as ordered Anti Thyroid Agent a. 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. Maintain side rails . Provide meticulous skin care 5. Goiter 8. 4. Signs and Symptoms 1. Amenorrhea C. Insomnia e. Irritability and agitation b. Heat intolerance 4.
Anti Pyretics b. Signs of bleeding (feeling of fullness at incisional site) Nursing Management o Check the soiled dressings at the back or nape area. Watch out for signs of thyroid storm/ thyrotoxicosis Agitation TRIAD SIGNS Hyperthermia o administer medications as ordered a. POST OPERATIVELY. 5. 8. 1. 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. seizure give Calcium Gluconate IV slowly as ordered 3. Importance of follow up care PARATHYROID GLAND o o o o o A pair of small nodules behind the thyroid gland Secretes parathormone Promotes calcium reabsorption Hypoparathyroidism Hyperparathyroidism HYPOPARATHYROIDISM o o Decrease secretion of parathormone leading to hypocalcemia Resulting to hyperphospatemia . Assist in surgical procedures known as subtotal thyroidectomy ** Before thyroidectomy administer Lugol’s Solution (SSKI) to decrease vascularity of the thyroid gland to prevent bleeding and hemorrhage. Beta-blockers o o o monitor strictly vital signs. Hormonal replacement therapy for lifetime 6.7. input and output and neuro check. maintain side rails offer TSB Tachycardia 2. Watch out for accidental removal of parathyroid gland that may lead to Hypocalcemia (tetany) Signs and Symptoms o o o (+) trousseau’s sign (+) chvostek sign Watch out for arrhythmia. Provide bilateral eye patch to prevent drying of the eyes.
seizure i. Nursing Management 1. Signs and Symptoms 1. Predisposing Factors 1. CT Scan – reveals degeneration of basal ganglia D. Diagnostic Procedures 1.5 – 11 mg/100 ml) 2. Chronic Tetany Oral Calcium supplements Calcium Gluconate Calcium Lactate Calcium Carbonate c. agitation and memory impairment C. Serum Phosphate is decreased (normal value: 2. dysphagia e.A. X-ray of long bones reveals a decrease in bone density 4. photophobia and cataract formation b. anorexia. nausea and vomiting d. Administer medications as ordered such as: a.C MAD . Phosphate binder Aluminum Hydroxide Gel (Ampogel) Side effect: constipation ANTACID A. tingling sensation b. positive trousseu’s sign/carpopedal spasm f. loss of tooth enamel c. positive chvostek sign g. Following subtotal thyroidectomy 2. laryngospasm/broncospasm h. numbness d. Atrophy of parathyroid gland due to: a. Acute tetany a. Acute Tetany Calcium Gluconate IV slowly b. paresthesia c.5 – 4. inflammation b. tumor c. Vitamin D (Cholecalciferol) for absorption of calcium CHOLECALCIFEROL ARE DERIVED FROM Drug Diet (Calcidiol) Sunlight (Calcitriol) feared complications d. arrhythmia 2. Chronic tetany a. trauma B.5 mg/100 ml) 3. Serum Calcium is decreased (normal value: 8.A.
Maintain side rails . Morphine Sulfate (Demerol) 5. Institute seizure and safety precaution 5. Nursing Management 1. Provide acid ash in the diet to acidify urine and prevent bacterial growth 7. X-ray of long bones reveals bone demineralization D. Diagnostic Procedures 1. salmon c. Agitation and memory impairment C. Hormonal replacement therapy for lifetime 9. Importance of follow up care. Prepare trache set at bedside for presence of laryngo spasm 7. Encourage increase intake of foods rich in calcium a. Children: Ricketts b. Serum Calcium is increased 2. renal cholic b. cool moist skin 3. Prevent complications 8. Assist/supervise in ambulation 8. Encourage increase intake of foods rich in phosphate but decrease in calcium 6. Hyperplasia of parathyroid gland 2. Bone pain especially at back (bone fracture) 2. Predisposing Factors 1. HYPERTHYROIDISM o o o Decrease parathormone Hypercalcemia: bone demineralization leading to bone fracture (calcium is stored 99% in bone and 1% blood) Kidney stones A. Anorexia. Over compensation of parathyroid gland due to vitamin D deficiency a. Provide warm sitz bath 4. Signs and Symptoms 1. Kidney stones a. Adults: Osteomalacia B. anchovies b. Administer medications as ordered a.▼ Aluminum Containing Antacids ▼ Aluminum Hydroxide Gel ▼ Side Effect: Constipation ▼ Magnesium Containing Antacids ▼ Side Effect: Diarrhea 2. 6. Serum Phosphate is decreased 3. Strain all the urine using gauze pad for stone analysis 3. Avoid precipitating stimulus such as glaring lights and noise 3. green turnips 4. nausea and vomiting 4. Encourage client to breathe using paper bag to produce mild respiratory acidosis result. Force fluids to prevent kidney stones 2.
Related to atrophy of adrenal glands 2.function: controls glucose metabolism . Decrease tolerance to stress 3.secretes traces of glucocorticoids and androgenic hormones . Predisposing Factors 1.Sugar 2. fluid and electrolyte imbalance – Salt c. Signs and Symptoms 1. Assist in surgical procedure known as parathyroidectomy 11.weight loss . Zona Fasciculata .9. metabolic disturbance – Sugar b.Sex 3.function: promotes secondary sex characteristics . Fungal infections B.secretes glucocortocoids (cortisol) .signs of dehydration . Hormonal replacement therapy for lifetime 12. Adrenal Cortex – outermost b. deficiency of neuromuscular function – Salt/Sex A. Hyponatremia . Zona Glumerulosa . 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. Zona Reticularis . Prevent complications (seizure and arrhythmia) 10.function: promotes sodium and water reabsorption and excretion of potassium .hypotension . Importance of follow up care ADRENAL GLAND o o Located atop of each kidney 2 layers of adrenal gland a.secretes mineralocorticoids (aldosterone) . Hypoglycemia – TIRED 2.Salt ADDISON’S DISEASE o Hyposecretion of adreno cortical hormone leading to a.
Monitor side effects a. avoid precipitating factor leading to addisonian crisis leading to . Bronze like skin pigmentation C. Monitor strictly vital signs. severe hypotension b. edema c.sudden withdrawal to steroids b. Taper dose (withdraw gradually from drug) 3. 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. moon face appearance 4. Plasma Cortisol is decreased 3.arrhythmia 5. hypertension b. Prednisone c. Provide client health teaching and discharge planning a. Assist in mechanical ventilation. Mineralocorticoids (Flourocortisone) 5. Provide meticulous skin care 7.diarrhea . Hyperkalemia .stress . hypovolemic shock c.agitation . hirsutism d.5 meq/L) D. prevent complications . Administer isotonic fluid solution as ordered 3.force fluids 2. Nursing Management 1.hypovolemic shock .infection . Loss of pubic and axillary hair 7. Provide dietary intake.addisonian crisis . hyponatremia leading to progressive stupor and coma Nursing Management for Addisonian Crisis 1. Dexamethasone (Decadrone) b.administer steroids as ordered . Force fluids 4. FBS is decreased (normal value: 80 – 100 mg/dl) 2.5 – 4. Instruct client to take 2/3 dose in the morning and 1/3 dose in the afternoon to mimic the normal diurnal rhythm 2. Administer medications as ordered Corticosteroids a. Serum Potassium is increased (normal value: 3. protein but decrease in potassium 6. carbohydrates. Hydrocortisone (Cortison) Nursing Management when giving steroids 1. . Decrease libido 6. increase susceptibility to infection e. Diagnostic Procedures 1. increase calories. Serum Sodium is decrease (normal value: 135 – 145 meq/L) 4.4.
Serum Sodium is increased 4. Prevent complications (DM) 8. Nursing Management 1. Hypokalemia a.Mixed gland (exocrine and endocrine) . Spinarolactone – potassium sparring diuretics 7. Easy bruising 8. Plasma Cortisol is increased 3. Diagnostic Procedures 1. thin extremities 4.Located behind the stomach . hormonal replacement for lifetime d.c. Hypernatremia a. Predisposing Factors 1 Related to hyperplasia of adrenal gland 2. Monitor strictly vital signs and intake and output 2. Acne and striae 7. hypertension b. Importance of follow up care PANCREAS . Hirsutism 6. Provide meticulous skin care 6. obese trunk f. Serum Potassium is decreased C. Administer medications as ordered a. Assist in surgical procedure (bilateral adrenoraphy) 9. FBS is increased 2. importance of follow up care CUSHING SYNDROME o Hypersecretion of adenocortical hormones A. Increase susceptibility to infections 3. Restrict sodium intake 5. U wave upon ECG (T wave hyperkalemia) 5. weight gain d. edema c. constipation c. weakness and fatigue b. Increase masculinity among females B. moon face appearance and buffalo hump e. Hormonal replacement for lifetime 10. Measure abdominal girth daily and notify physician 4. pendulous abdomen g. Weigh patient daily and assess for pitting edema 3.
Brittle disease A. Delayed/poor wound healing D.Delta cells secretes somatostatin (function: antagonizes the effects of growth hormones) 3 Main Disorders of Pancreas 1. Hereditary (total destruction of pancreatic cells) 2. Treatment 1. Incidence Rate . Polyuria 2. Signs and Symptoms 1. Usually asymptomatic 2. Signs and Symptoms 1.Has alpha cells that secretes glucagons (function: hyperglycemia) . Pancreatic Tumor/Cancer 2. Oral Hypoglycemic agents 2. Complication 1. Polydypsia 3. Diet 3. Weight gain Type 2 (NIDDM) . Glucosuria 6.90% of general population has type 2 DM B. Predisposing Factors 1.Beta cells secretes insulin (function: hypoglycemia) . Complications 1.Adult onset . Predisposing Factors 1. Lasix b. Related to viruses 3. Exercise E.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 . Diet 3. Blurring of vision 8. Treatment 1..Juvenile onset type . Exercise E. Insulin therapy 2. protein and fat metabolism CLASSIFICATION OF DM Type 1 (IDDM) . Steroids 4. Weight loss 6. Drugs a. Osmolar 3. Ketotic 5.Obese over 40 years old A. Diabetic Ketoacidosis D. Non 4. Obesity – because obese persons lack insulin receptor binding sites . Diabetes Mellitus 3. Anorexia. Coma C. Glucosuria 5.Consist of islets of langerhans . Hyper 2. Pancreatitis DIABETES MELLITUS . Polyuria 3. Polyphagia 5. Polydypsia 4. Incidence Rate .Maturity onset type .metabolic disorder characterized by non utilization of carbohydrates. Related to carbon tetrachloride toxicity C. nausea and vomiting 7. Polyphagia 4. Increase susceptibility to infection 9.
MAIN FOODSTUFF 1.Cholesterol . Protein 3.Ketones HYPERGLYCEMIA Increase osmotic diuresis Glycosuria Cellular starvation – weight loss Stimulates the appetite/satiety center (Hypothalamus) Polyphagia Polyuria Cellular dehydration Stimulates the thirst center (Hypothalamus) Polydypsia * Liver has glycogen that undergo glycogenesis/ glycogenolysis GLUCONEOGENESIS Formation of glucose from non-CHO sources Increase protein formation ▼ Negative Nitrogen balance ▼ Tissue wasting (Cachexia) ▼ INCREASE FAT CATABOLISM ▼ Free fatty acids Cholesterol ▼ Atherosclerosis ▼ Hypertension MI CVA Ketones ▼ Diabetic Keto Acidosis Acetone Breath odor Kussmaul’s Respiration Death Diabetic Coma . Fats ANABOLISM CATABOLISM Glucose Amino Acids Fatty Acids Glycogen Nitrogen Free Fatty Acids . Carbohydrates 2.
Anorexia. FBS is increased 2. Monitor strictly vital signs. Antibiotics to prevent infection HYPER OSMOLAR NON KETOTIC COMA . Headache and dizziness 2. Nursing Management 1. Administer 0. BUN (normal value: 10 – 20) 3.Acute complication of type 1 DM due to severe hyperglycemia leading to severe CNS depression A.Hyperosmolar: increase osmolarity (severe dehydration) . Assist in mechanical ventilation 2. Infection B. intake and output and blood sugar levels 4. Kussmaul’s Respiration (rapid shallow breathing) 10 CNS depression leading to coma C. Insulin therapy (regular acting insulin/rapid acting insulin peak action of 2 – 4 hours) b. Creatinine (normal value: . Hyperglycemia 2.9 NaCl followed by . Signs and Symptoms 1. male 42 – 48) due to severe dehydration D. Glucosuria 5. Polydypsia 3. Restlessness 3. Administer medications as ordered a.Non ketotic: absence of lypolysis (no ketones) A. Decrease LOC – diabetic coma .DIABETIC KETOACIDOSIS . Blurring of vision 8. Signs and Symptoms 1. Predisposing Factors 1. Sodium Bicarbonate to counteract acidosis c. Polyphagia 4. Polyuria 2. Weight loss 6. Hct (normal value: female 36 – 42.45 NaCl (hypotonic solutions) to counteract dehydration and shock 3. Seizure activity 4. Stress – number one precipitating factor 3. Diagnostic Procedures 1. Acetone breath odor 9.8 – 1) 4. nausea and vomiting 7.
Chlorpropamide (Diabenase) b. Types of Insulin 1. No need to aspirate upon injection 7. Somogyis Phenomenon – rebound effect of insulin characterized by hypoglycemia to hyperglycemia ORAL HYPOGLYCEMIC AGENTS . Monitor for signs of local complications such as a.Ultra Lente . Sources of Insulin 1. Animal sources . First Generation Sulfonylureas a. Nursing Management 1. Use gauge 25 – 26 needle 5. Human Sources . Classsification 1. Insulin therapy (regular acting insulin peak action of 2 – 4 hours) .Regular acting insulin (IV only) .for DKA use rapid acting insulin b.Rarely used because it can cause severe allergic reaction .Non Protamine Hagedorn Insulin (NPH) .Peak action is 2 – 4 hours 2. Administer at room temperature to prevent development of lipodystrophy (atrophy. Assist in mechanical ventilation 2. 10. Administer 0. Artificially Compound Insulin B. hypertrophy of subcutaneous tissues) 2. When mixing 2 types of insulin aspirate first the clear insulin before cloudy to prevent contaminating the clear insulin and promote proper calibration.B. intake and output and blood sugar levels 4.Frequently used type because it has less antigenicity property thus less allergic reaction 3. Antibiotics to prevent infection INSULIN THERAPY A. Lipodystrophy c. Place in refrigerator once opened 3. Avoid shaking insulin vial vigorously instead gently roll vial between palm to prevent formation of bubbles 4.45 NaCl (hypotonic solutions) to counteract dehydration and shock 3.Derived from beef and pork 2. Long Acting Insulin (cloudy) .Peak action is 8 – 16 hours 3. Most accessible route is abdomen 9. Monitor strictly vital signs.9 NaCl followed by . Rotate insulin injection sites to prevent development of lipodystrophy 8. Administer insulin either 45o – 90o depending on amount of clients tissue deposit 6. Nursing Management for Insulin Injections 1. Intermediate Acting Insulin (cloudy) . Administer medications as ordered a. Rapid Acting Insulin (clear) . Allergic reactions b. Tolbutamide (Orinase) .Stimulates the pancreas to secrete insulin A.Peak action is 16 – 24 hours C.
instruct client to cut toenails straight c. Provide nutritional intake of diabetic diet that includes: carbohydrates 50%.Renal failure c. polyphagia and glucosuria confirmatory for DM) 2. Shock due to dehydration . Gangrene formation e. Institute foot care management a. CVA) b. assist in surgical wound debriment (give analgesics 15 – 30 mins prior) 9.for hypoglycemia (cold and clammy skin) give simple sugars .sexual impotence 8. Blood Vessels III. Administer insulin and OHA therapy as ordered 3. Alpha Glycosylated Hemoglobin is increased C.peripheral neuropathy . Monitor for peak action of insulin and OHA and notify physician 2. Atherosclerosis (HPN. Random Blood Sugar is increased 3. HPN and DM major cause of renal failure d. Instruct client to exercise best after meals when blood glucose is rising 7. Blood Forming Organs . instruct client to avoid walking barefooted b. intake and output and blood sugar levels 4. Oral glucose tolerance test is increased – most sensitive test 4. encourage client to apply lanolin lotion to prevent skin breakdown e. Blood II. Instruct the client to take it with meals to lessen GIT irritation and prevent hypoglycemia 2. Instruct client to have an annual eye and kidney exam 10. Nursing Management 1. Monitor signs for complications a.diarrhea/constipation .c. polydypsia. FBS is increased (3 consecutive times with signs or polyuria. Second Generation Sulfonylureas a. Diabeta (Micronase) Nursing Management when giving OHA 1.Blindness KIDNEY -RECURRENT PYELONEPHRITIS . Monitor for signs of DKA and HONKC 11. Glipzide (Glucotrol) b. Microangiopathy (affects small minute blood vessels of eyes and kidneys) EYES -PREMATURE CATARACT . instruct client to avoid wearing constrictive garments d. Monitor for signs of hypoglycemia and hyperglycemia . protein 30% and fats 20% or offer alternative food substitutes 6. MI. Assist in surgical procedure HEMATOLOGICAL SYSTEM I. Tolamazide (Tolinase) 2.for hyperglycemia (dry and warm skin) 5.administer simple sugars . Diagnostic Procedures 1. Instruct the client to avoid taking alcohol because it can lead to severe hypoglycemia reaction or Disulfiram (Antabuse) toxicity symptoms B. Monitor strictly vital signs.
Polymorphonuclear Eosinophils .largest WBC . anti-bodies and immunoglobulins b. bilirubin and hormones . vitamin b12 (cyanocobalamin) e.hemoglobin: normal value female 12 – 14 gms% male 14 – 16 gms% . Arteries 2.normal value: 5000 – 10000/mm3 A.normal value: 4 – 6 million/mm3 . Prothrombin and Fibrinogen 1. Polymorphonuclear Basophils .involved in short term phagocytosis for acute inflammation 2.60 – 70% of WBC .for parasite infections . Veins Plasma CHON (formed in liver) 1. iron c. prothrombin and fibrinogen clotting factors FORMED ELEMENTS 1. folic acid b.for allergic reaction B. Polymorpho Neutrophils . Lymphoid Organ 5. vitamin b6 (pyridoxine) f.55% Plasma Serum 45% Formed 1. WBC (LEUKOCYTES) . Lymph Nodes 6.substances needed for maturation of RBC a.only unnucleated cell . intrinsic factor .transport steroids. Liver 3. vitamin c d. Non Granulocytes 1. Globulins 3.macrophage in blood .hematocrit red cell percentage in wholeblood .biconcave discs .Gamma globulins a. RBC (ERYTHROCYTES) .Normal life span of RBC is 80 – 120 days and is killed in red pulp of spleen 2.transports and carries oxygen to tissues .Beta globulins – iron and copper .Alpha globulins . Spleen 4.Largest and numerous plasma CHON .Maintains osmotic pressure preventing edema GLOBULINS . Bone Marrow ALBUMIN . Monocytes .responsible for the release of chemical mediation for inflammation 3.consist of molecules of hgb (red pigment) bilirubin (yellow pigment) biliverdin (green pigment) hemosiderin (golden brown pigment) .normal value: female 36 – 42% male 42 – 48% . Albumin 2. Granulocytes 1.
6 months window period .drug of choice AZT (Zidon Retrovir) 2 Common fungal opportunistic infection in AIDS 1. Weakness and fatigue (initial signs) 3. Related to GIT bleeding resulting to hematemesis and melena (sign for upper GIT bleeding) c. Signs and Symptoms 1. Platelets (THROMBOCYTES) . Related to malabsorption syndrome c. Related to improper cooking of foods C. Common among developed countries 2..Normal value: 150. Usually asymptomatic 2. Inadequate intake of iron due to a.000/mm3 . Incidence Rate 1. Echhymosis 3. Pneumocystis Carinii Pneumonia 3.Promotes hemostasis (prevention of blood loss) . Common among women 15 – 35 years old 4.bone marrow .6 months – 5 years incubation period .A chronic microcytic anemia resulting from inadequate absorption of iron leading to hypoxemic tissue injury A. Lymphocytes B-cell T-cell .ELISA .Normal life span of platelet is 9 – 12 days Signs of Platelet Dysfunction 1. High cereal intake with low animal protein digestion d. Kaposi’s Sarcoma 2. fresh blood per rectum is called hematochezia 2.thymus for immunity Natural killer cell . Chronic blood loss due to trauma a.involved in long term phagocytosis for chronic inflammation 2. Headache and dizziness . Heavy menstruation b. Petechiae 2. Oozing of blood from venipunctured site BLOOD DISORDERS Iron Deficiency Anemia . Subtotal gastrectomy 4.anti viral and anti tumor property HIV . Predisposing Factors 1. Related to poor nutrition B. Chronic diarrhea b.Consist of immature or baby platelets or megakaryocytes which is the target of dengue virus .000 – 450. Common among tropical zones 3.western blot opportunistic .
Diagnostic Procedures 1. Melena 5. Hct is deceased 4. discoloration and leakage to tissues 2. PICA (abnormal appetite or craving for non edible foods D. Avoid massaging the injection site instead encourage to ambulate to facilitate absorption 3. Nausea and vomiting c. Pain at injection site PLUMBER VINSON’S SYNDROME . Ferrous Sulfate b. Dried fruits f. Anorexia b. Iron is decreased 5. Administer medications as ordered Oral Iron Preparations a. RBC is decreased 2. Sorbitex (IM) Nursing Management when giving parenteral iron preparations 1. Ferrous Gluconate . Ferrous Fumarate c.Tetracycline . Legumes g. Instruct client to take with meals to lessen GIT irritation 2. IV) b. Instruct client to take foods rich in iron a. Egg (yolk) c. If client cant tolerate/no compliance administer parenteral iron preparation a. Instruct the client to avoid taking tea and coffee because it contains tannates which impairs iron absorption 5. When diluting it in liquid iron preparations administer with straw to prevent staining of teeth Medications administered via straw .Stomatitis . Dyspnea 6. Atropic Glossitis (inflammation of tongue) . Administer with Vitamin C or orange juice for absorption 4. Brittleness of hair and spoon shape nails (koilonychias) 8. Enforce CBR so as not to over tire client 3.Iron . Monitor and inform client of side effects a. Nursing Management 1. Monitor for signs of bleeding of all hema test including urinw. stool and GIT 2. Sweet potatoes e. Monitor side effects a. Hgb is decreased 3. Ferritin is decreased E. Organ meat b. Pallor and cold sensitivity 5. Iron Dextran (IM.Dysphagia 9. Administer Z tract technique to prevent discomfort.300 mg/day Nursing Management when taking oral iron preparations 1.Nitrofurantoin (Macrodentin) 3. Raisin d. Diarrhea/constipation e.4. Palpitations 7. Nuts 4.Lugol’s solution . Abdominal pain d. Reticulocyte is decreased 6.
Chronic anemia characterized by a deficiency of intrinsic factor leading to hypochlorhydria (decrease hydrochloric acid secretion) A. tingling sensation b. Diagnostic Procedure Schilling’s Test – reveals inadequate/decrease absorption of Vitamin B12 D. indigestion/dyspepsia d.Never given orally because there is possibility of developing tolerance Secretes hydrochloric acid ▼ Aids in digestion . positive to Romberg’s test – damage to cerebellum resulting to ataxia e. Weakness and fatigue 2. Fever and chills e. Lymphadenopathy d. jaundice 6. Enforce CBR 2. Subtotal gastrectomy 2. Hereditary factors 3. Predisposing Factors 1.b. weight loss e. CNS changes a. Hypotension (anaphylactic shock) PERNICIOUS ANEMIA . red beefy tongue c. GIT changes that includes a. Signs and Symptoms 1. Nursing Management 1. Headache and dizziness 3. Strictly vegetarian diet STOMACH ▼ Pareital cells/ Argentaffin or Oxyntic cells Produces intrinsic factors ▼ Promotes reabsorption of Vit B12 ▼ Promotes maturation of RBC B. Administer Vitamin B12 injections at monthly intervals for lifetime as ordered . numbness c. result to psychosis C. Inflammatory disorders of the ileum 4. mouth sore b. paresthesia d. Pruritus/orticaria g. Pallor and cold sensitivity 4. Skin rashes f. Dyspnea and palpitations as part of compensation 5. Autoimmune 5. Localized abscess c.
Dyspnea and palpitations 2. Signs and Symptoms 1. Pallor and cold sensitivity d.. Bone marrow biopsy/aspiration (site is the posterior iliac crest) – reveals fat necrosis in bone marrow D. Institute reverse isolation 6. Oozing of blood from venipunctured sites C. vitamin c and iron 4. Methotrexate (Alkylating Agent) b.Stem cell disorder leading to bone marrow depression leading to pancytopenia PANCYTOPENIA Decrease RBC (anemia) A. Headache and dizziness c.No side effects 3. Related to irradiation/exposure to x-ray 3. Chemicals (Benzine and its derivatives) 2. Administer oxygen inhalation 4. Monitor for signs of infection a. Anemia a. Removal of underlying cause 2.Site of injection for Vitamin B12 is dorsogluteal and ventrogluteal . Increase susceptibility to infection 3. Leukopenia a. Weakness and fatigue b. Provide a dietary intake that is high in carbohydrates. Avoid heat application to prevent burns APLASTIC ANEMIA . Enforce CBR 5. Thrombocytopenia a. Drugs Broad Spectrum Antibiotics a. fever Decrease WBC (leucopenia) Decrease Platelet (thrombocytopenia) . Nursing Management 1. protein. Diagnostic Procedures 1. Immunologic injury 4. Chloramphenicol (Sulfonamides) Chemotherapeutic Agents a. Instruct client to avoid irritating mouth washes instead use soft bristled toothbrush 5. Ecchymosis c. CBC reveals pancytopenia 2. Nitrogen Mustard (Antimetabolite) Phenylbutazones (NSAIDS) B. Vincristine (Plant Alkaloid) c. Institute BT as ordered 3. Predisposing Factors 1. Petechiae (multiple petechiae is called purpura) b.
Stool occult blood positive 3. Massive trauma 4. Oliguria (late sign) C. Institute NGT decompression by performing gastric lavage by using ice or cold saline solution of 500 – 1000 ml 8. lungs and lower extremities 2. Nursing Management 1. Septecemia 6. CBC reveals decreased platelets 2. subcutaneous. Neoplasia (new growth of tissue) 7. cough 7. Anaphylaxis 5. Corticosteroids – caused by immunologic injury b. Pregnancy B. Diagnostic Procedures 1. Related to rapid blood transfusion 2. Administer medications as ordered a. ABG analysis reveals metabolic acidosis 4. Provide heparin lock 7. Administer medications as ordered a.b. Monitor NGT output 9. Instruct client to use electric razor when shaving 10. Heparin/Coumadin is ineffective 6. Pitressin/ Vasopresin to conserve fluids c. Force fluids 5. venipunctured sites 8 Instead provide heparin lock 9. Oozing of blood from punctured sites 4. Signs and Symptoms 1. Hemoptysis 6. Administer isotonic fluid solution as ordered 3. Petechiae (widespread and systemic) eye. Ecchymosis 3. Prevent complication . Avoid IM. Administer oxygen inhalation 4. Predisposing Factors 1. Vitamin K b. Massive burns 3. Opthamoscopic exam reveals sub retinal hemorrhages D. 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. Monitor for signs of bleeding of all hema test including stool and GIT 2.
Hyperkalemia (caused by expired blood) . Gauge 18 – 19 needle c. Serial number 5. Pyrogenic reaction d. Aseptically assemble all materials needed for BT a. 85% of population is RH positive 3. Filter set b. 6. Replace circulating blood volume 2. Type AB – universal recipient c. Check the blood unit for bubbles cloudiness. Expiration date d. Hypovolemic shock b. Circulatory overload e. Blood typing and cross matching c. Thrombocytopenia g.a. Proper typing and cross matching a. Client name b. Anuria – late sign BLOOD TRANSFUSION Goals/Objectives 1.Expiration of packed RBC is 3 – 6 days . Instruct another RN to re check the following a. BT should be completed less than 4 hours because blood that is exposed at room temperature more than 2 hours causes blood deterioration that can lead to BACTERIAL CONTAMINATION 7. Monitor strictly vital signs before. Avoid mixing or administering drugs at BT line to prevent HEMOLYSIS 8. Prevent bleeding if there is platelet deficiency Principles of blood transfusion 1.Emergency rapid BT is given after 30 minutes and let natural room temperature warm the blood. Increase the oxygen carrying capacity of blood 3. . Hemolytic reaction b.9 NaCl/plain NSS) to prevent hemolysis 4.Expiration of platelet is 3 – 5 days 2. Prevent infection in there is a decrease in WBC 4. Air embolism f. Isotonic solution (0. during and after BT especially every 15 minutes for first hour because majority of transfusion reaction occurs during this period a.Never warm blood as it may destroy vital factors in blood. Allergic reaction c. Cytrate intoxication h. Type O – universal donor b. sediments and darkness in color because it indicates bacterial contamination .Warming is only done during emergency situation and if you have the warming device . Regulate BT 10 – 15 gtts/min or KVO rate or equivalent to 100 cc/hr to prevent circulatory overload 9. Proper refrigeration .
anaphylactic shock treat with Epinephrine 5.Signs and Symptoms of Hemolytic reaction 1. Stop BT 2. Send the blood unit to blood bank for re examination 6. Hypotension 5. Dyspnea 3. Send the blood unit to blood bank for re examination 6. Skin rashes 5. Urticaria 6. Headache and dizziness 2. Stop BT 2. Administer isotonic fluid solution to prevent shock and acute tubular necrosis 5. Stop BT 2. Notify physician 3. Flushed skin 6. Diarrhea/Constipation 4. Fever and chills 2. Fever 2. Monitor vital signs and intake and output SIGNS AND SYMPTOMS OF ALLERGIC REACTION 1. Administer medications as ordered a. Urine is color red/ portwine urine Nursing Management 1. Dyspnea 3. Diaphoresis 6. Obtain urine and blood sample and send to laboratory for re examination 7. Tachycardia 4. Notify physician 3. Anti Histamine (Benadryl) . Flush with plain NSS 4. Lumbasternal/ Flank pain 7. Laryngospasm and Broncospasm Nursing Management 1. Monitor vital signs and intake and output SIGNS AND SYMPTOMS PYROGENIC REACTIONS 1. Headache 3. Dyspnea Nursing Management 1. Flush with plain NSS 4. Flush with plain NSS . Obtain urine and blood sample and send to laboratory for re examination 7. Palpitations 5. Broncial wheezing 4.if positive to hypotension. Notify physician 3.
Right atrium has decreased pressure which is 60 – 80 mmHg C.4.Resemble like a close fist . tricuspid valve . Upper Chamber (connecting or receiving) a. Antipyretic b. Rales/Crackles upon auscultation 4. Myocardium – middle layer 3. Dyspnea 3. Visceral – inner layer . Administer medications as ordered a. Atria 2. . Valves .Left ventricle has increased pressure which is 120 – 180 mmHg . Parietal – outer layer b. Administer medications as ordered a. Cardiac tamponade A. Atrioventricular Valves – guards opening between a.Covered by a serous membrane called the pericardium 2 layers of pericardium a. Ventricles . Layers of Heart 1.Muscular pumping organ of the body. Render TSB SIGNS AND SYMPTOMS OF CIRCULATORY REACTION 1. Notify physician 3. Epicardium – outer layer 2.Located on the left mediastinum . Endocardium – inner layer . Chambers of the Heart 1. Monitor vital signs and intake and output 8. pericarditis. Stop BT 2. Antibiotic 5. Lower Chamber (contracting or pumping) a.Myocarditis can lead to cardiogenic shock and rheumatic heart disease B. Obtain urine and blood sample and send to laboratory for re examination 7. Send the blood unit to blood bank for re examination 6. Loop diuretic (Lasix) CARDIOVASCULAR SYSTEM OVERVIEW OF THE STRUCTURE AND FUNCTIONS OF THE HEART HEART . Exertional discomfort Nursing Management 1. Orthopnea 2.Common among MI.Prevent pericardial friction rub .Weighs approximately 300 – 400 grams .In order to propel blood to the systemic circulation .In between is the pericardial fluid which is 10 – 20 cc .To promote unidimensional flow or prevent backflow 1.
Closure of SV valve give rise to second heart sound (S2 “dub”) Extra Heart Sounds 1.Closure of AV valves give rise to first heart sound (S1 “lub”) 2.Arises from base of the aorta Types of Coronary Arteries 1. Cardiac Conduction System 1.T WAVE (ventricular repolarization) .Delay of electrical impulse for about . mitral valve . Semi – lunar Valves a.Right Main Bundle of His .Located at the inter atrial septum . Atrio – Ventricular Node (AV or Tawara Node) .Located at the junction of superior vena cava and right atrium . Bundle of His . Sino – Atrial Node (SA or Keith Flack Node) .Left Main Bundle of His .P WAVE (atrial depolarization) contraction .Located at the walls of the ventricles for ventricular contraction SA NODE AV NODE BUNDLE OF HIS JLJLJLJJLJLJL PURKINJE FIBERS .Initiates electrical impulse of 60 – 100 bpm 2.QRS WAVE (ventricular depolarization) . Right Main Coronary Artery 2.08 milliseconds to allow ventricular filling 3.Located at the interventricular septum 4. Purkinje Fibers .Supplies the myocardium E. S4 – atrial gallop usually seen in Myocardial Infarction and Hypertension D. Left Main Coronary Artery . Coronary Arteries . S3 – ventricular gallop usually seen in Left Congestive Heart Failure 2.Acts as primary pacemaker of the heart . pulmonic b. aortic .b.
Myocardial Injury . Revascularize myocardium 2. Increase survival rate ARTERIOSCLEROSIS . Type A personality B.hardening of artery . Treatment Percutaneous Transluminal Coronary Angioplasty Objectives of PTCA 1.Atherosclerosis 2.narrowing of artery . Diabetes Mellitus 8.calcium and protein deposits . Hyperlipidemia 6.tunica media . Peak T wave – Hyperkalemia 3. Palpitations 5. Signs and Symptoms 1. Dyspnea 3. Insert pacemaker if there is complete heart block Most common pacemaker is the metal pacemaker and lasts up to 2 – 5 years ABNORMAL ECG TRACING 1.tunica intima A. Chest pain 2. ST segment elevation – Myocardial Infarction 5. Positive U wave . To prevent angina 3. Myocardial Ischemia – Angina Pectoris 3. T wave inversion – Myocardial Infarction 6. Smoking 4. Hypothyroidism 9. Tachycardia 4. Obesity 5. Duaphoresis C. Sex – male 2. Widening of QRS complexes – Arrythmia CARDIAC DISORDERS Coronary Arterial Disease/ Ischemic Heart Disease Stages of Development of Coronary Artery Disease 1. Race – black 3. ST segment depression – Angina Pectoris 4. Predisposing Factors 1.Hypokalemia 2. Myocardial Necrosis – Myocardial Infarction ATHEROSCLEROSIS ATHEROSCLEROSIS . Diet – increased saturated fats 10.lipid or fat deposits . sedentary lifestyle 7.
Shock 3. Nursing Management 1.Give second dose of NTG if pain persist after giving first dose with interval of 3 . Thrombophlebitis ANGINA PECTORIS (SYNDROME) Clinical syndrome characterized by paroxysmal chest pain that is usually relieved by rest or nitroglycerine due to temporary myocardial ischemia A. reveal abnormal ECG 4. sedentary lifestyle 7. Administer medications as ordered a. Predisposing Factors 1. shoulder.Give first dose of NTG (sublingual) 3 – 5 minutes . Chest pain characterized by sharp stabbing pain located at sub sterna usually radiates from back.If there is 2 or more occluded blood vessels CABG is done Coronary Arterial Bypass And Graft Surgery 3 Complications of CABG 1. Levine’s Sign – initial sign that shows the hand clutching the chest 2. Excessive physical exertion – heavy exercises 2.5 minutes . Hypothyroidism 9. Palpitations 6. Diet – increased saturated fats 10. Enforce complete bed rest 2. Race – black 3. Tachycardia 5. anxiety. Hyperlipidemia 6. Type A personality B. axilla and jaw muscles. Diagnostic Procedure 1. Diaphoresis D. Serum cholesterol and uric acid is increased E. Diabetes Mellitus 8. Extreme emotional response – fear. coughing exercise and use of incentive spirometer 2. Stress test – treadmill test. Dyspnea 4. Excessive intake of foods rich in saturated fats – skimmed milk C. Nitroglycerine (NTG) – when given in small doses will act as venodilator. Pneumonia – encourage to perform deep breathing. Exposure to cold environment 3. Precipitating Factors 4 E’s of Angina Pectoris 1. ECG tracing reveals ST segment depression 3. arms. Obesity 5. excitement 4. Signs and Symptoms 1. Smoking 4. History taking and physical exam 2.. Sex – male 2. but in large doses will act as vasodilator .Done to single occluded vessels . usually relieved by rest or taking nitroglycerine 3.
Place client on semi fowlers position 5. necrosis and scarring. Race – black 3. The importance of follow up care MYOCARDIAL INFARCTION Heart attack Terminal stage of coronary artery disease characterized by malocclusion.Not given to COPD cases because it causes bronchospasm c. Provide client health teachings and discharge planning a. Administer oxygen inhalation 4. Hyperlipidemia . Monitor strictly vital signs. A. Types 1. Subendocardial Myocardial Infarction – characterized by occlusion of either right or left coronary artery B. Smoking 4. Obesity 5. Prevent complication (myocardial infarction) c.NIfedipine 3. Transmural Myocardial Infarction – most dangerous type characterized by occlusion of both right and left coronary artery 2. Sex – male 2.side effects PNS .. Instruct client to take medication before indulging into physical exertion to achieve the maximum therapeutic effect of drug d. Calcium Antagonist . Beta-blockers .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. Provide decrease saturated fats sodium and caffeine 7. ACE Inhibitors . 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. intake and output and ECG tracing 6.Enalapril d.Propanolol . Avoidance of 4 E’s b. 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. Predisposing Factors 1.
SGPT – Serum glutamic pyruvate transaminase is increased d. Ashen skin 6.6. Place client on semi fowlers position . viselike pain located at substernal and rarely in precordial . ST segment elevation b. CBC – increased WBC F. ECG tracing reveals a.Excruciating visceral. T wave inversion c. shoulder. Pericardial friction rub b. Nursing Management Goal: Decrease myocardial oxygen demand 1. S4 or atrial gallop E. Rales/Crackles upon auscultation d.Usually radiates from back.Side Effects of Naloxone Toxicity is tremors 2. Serum Cholesterol and uric acid are both increased 5. sedentary lifestyle 7. Widening of QRS complexes indicates that there is arrhythmia in MI 4. Enforce CBR without bathroom privileges a. CPK – MB . Diagnostic Procedure 1. Troponin Test – is increased 3. Occasional findings a. 12 – 24 hours b. Signs and Symptoms 1.Antidote: Narcan/Naloxone . Decrease myocardial workload (rest heart) .Creatinine phosphokinase is increased . Type A personality D. Cardiac Enzymes a.Administer narcotic analgesic/morphine sulfate . Split S1 and S2 c. Mild restlessness and apprehension 7. SGOT – Serum glutamic oxal-acetic transaminase is increased 2. axilla. Administer oxygen low inflow to prevent respiratory arrest at 2 – 3 L/min 3. jaw and abdominal muscles (abdominal ischemia) . Chest pain . Instruct client to avoid forms of valsalva maneuver 5. Using bedside commode 4.Not usually relieved by rest or by nitroglycerine 2.Side Effects: respiratory depression . Hyperthermia 5.Heart only. Increase in blood pressure (initial sign) 4. Diabetes Mellitus 8. Diet – increased saturated fats 10. arms. Dyspnea 3. LDH – Lactic acid dehydroginase is increased c. Hypothyroidism 9.
Brutylium c.Antidote: protamine sulfate . Isodil) sublingual b.Side Effects of Aspirin Tinnitus Heartburn Indigestion/Dyspepsia . ACE Inhibitors e.6. pruritus . Anti Coagulant . Beta-blockers d.Urokinase .Antidote: Vitamin K h.arrhythmia (caused by premature ventricular contraction) b.Side Effects: allergic reaction.Contraindication Dengue Peptic Ulcer Disease Unknown cause of headache 10.Monitor for bleeding time g. sodium and caffeine 8.Nitroglycerine . Anti Arrythmic Agents . Monitor strictly vital signs.Coumadin/ Warfarin Sodium (check for prothrombin time) . Thrombolytics/ Fibrinolytic Agents . Cardiogenic shock .Anti thrombotic effect . Thrombophlebitis . Anti Platelet . Left Congestive Heart Failure d.PASA (Aspirin) . Avoidance of modifiable risk factors .late sign is oliguria c.Heparin (check for partial thrombin time) .homan’s sign e. Calcium Antagonist f. Administer medication as ordered a.Side Effects: confusion and dizziness . Provide client health teaching and discharge planning concerning a. Stroke/CVA . Vasodilators . Provide a general liquid to soft diet that is low in saturated fats. whisky and brandy to induce vasodilation 9.TIPAF (tissue plasminogen activating factor) . intake and output and ECG tracing 7.ISD (Isosorbide Dinitrate.Streptokinase .Lidocaine (Xylocane .Side Effects: chest pain . Encourage client to take 20 – 30 cc/week of wine.
Penicillin . 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.dietary modification h. RIGHT SIDED HEART FAILURE . Bronchial wheezing 9.Formation of aschoff bodies in the mitral valve . administer 150.000 – 450.client can resume sexual intercourse if can climb staircase .f. RHD – inflammation of mitral valve due to invasion of Grp. Predisposing Factors 1. Frothy salivation 6. Cyanosis 7.client is resistant to pharmacological agents. ABG – reveals PO2 is decreased (hypoxemia). Ischemic heart disease 4. Strict compliance to mediation and importance of follow up care CONGESTIVE HEART FAILURE Inability of the heart to pump blood towards systemic circulation Types of Heart Failure 1. Signs and Symptoms 1.make sex as an appetizer rather than dessert . Hypertension 5.ASO Titer (Anti streptolysin O titer) . Resumption of ADL particularly sexual intercourse is 4 – 6 weeks post cardiac rehab.Aspirin b. Rales/Crackles 8. There is anorexia and generalized body malaise 12. post CABG and instruct to .Common among children .instruct client to assume a non weight bearing position . Chest x-ray – reveals cardiomegaly 2. Orthopnea – use 2 – 3 pillows when sleeping or place in high fowlers 4. 90% is mitral valve stenosis due to a. Dyspnea 2. Myocardial Infarction 3. Diagnostic Procedure 1. dependent on extent of heart failure 4. Ecocardiography – enlarged heart chamber (cardiomyopathy). Paroxysmal nocturnal dyspnea – client is awakened at night due to difficulty of breathing 3. Productive cough with blood tinged sputum 5. LEFT SIDED HEART FAILURE A. Aortic valve stenosis B. Aging 2. S3 – ventricular gallop C. PCO2 is increased (respiratory acidosis) 2. PMI is displaced laterally due to cardiomegaly 11. A beta-hemolytic streptococcus . Post MI Syndrome/Dressler’s Syndrome . Pulsus Alternans – weak pulse followed by strong bounding pulse 10.000 units of streptokinase as ordered g.
Ecocardiography – reveals enlarged heart chambers (cardiomyopathy 4.If CVP is less than 4 cm of water hypovolemic shock . Enforce CBR 2. Anti Arrhythmic . 3 – 4 L/min. Diagnostic Procedures 1.CVP fluid status measure . Chest x-ray – reveals cardiomegaly 2. Narcotic analgesics . Left sided heart failure B. Liver enzymes – SGPT and SGOT is increased D.Lidocaine (Xylocane) 3. Signs and Symptoms (venous congestion) 1. Ascites 4. Hepatosplenomegaly 6. Cardiac glycosides .If CVP is more than 10 cm of water hypervolemic shock . Nursing Management Goal: increase cardiac contractility thereby increasing cardiac output (3 – 6 L/min) 1. High fowlers position . Central venous pressure (CVP) . Esophageal varices C.Do the fluid challenge (increase IV flow rate) .Lasix (Furosemide) c. Pruritus 8.Administer loop diuretics as ordered . Administer oxygen inhalation with high inflow. Tricuspid valve stenosis 2. Related to COPD 4.Digoxin (Lanoxin) . Anorexia 9. Weight gain 5.Measure pressure in right atrium (4 – 10 cm of water) . Pulmonic valve stenosis 5. Vasodilators .Increase force of cardiac contraction .A. delivered via nasal cannula 4.If heart rate is decreased do not give b.When reading CVP patient should be flat on bed . Pitting edema 3. Loop Diuretics .Morphine Sulfate e.Nitroglycerine f. Neck/jugular vein distension 2. Jaundice 7. Predisposing Factors 1.Upon insertion place client in trendelendberg position to promote ventricular filling and prevent pulmonary embolism 3. Bronchodilators d. Pulmonary embolism 3. Administer medications as ordered a.
Trophic changes 5. Provide a dietary intake of low sodium. Strict compliance to medications PERIPHERAL VASCULAR DISORDER Arterial Ulcer I.Arrythmia .Right ventricular hypertrophy . Measure abdominal girth daily and notify physician 7. Decreased peripheral pulses 4. Angiography – reveals site and extent of malocclusion D.MI . cholesterol and caffeine 8. Administer medications as ordered a. cyanosis then rubor) 3. Assist in bloodless phlebotomy – rotating tourniquet. Analgesics Burger’s Disease Reynaud’s Disease . Diagnostic Procedures 1. Dietary modification c.5. Provide meticulous skin care 9. Predisposing Factors 1. rotated clockwise every 15 minutes to promote decrease venous return 10. Doppler UTZ – decrease blood flow to the affected extremity 3. Intermittent claudication – leg pain upon walking 2.Shock . Encourage a slow progressive physical activity a. Nursing Management 1. walking 3 – 4 times a day b. Ulceration 6. out of bed 3 – 4 times a day 2. Prevent complications . Thrombo Angitis Obliterans Venous Ulcer 1. Gangrene formation C. Signs and Symptoms 1.Thrombophlebitis b. Monitor strictly vital signs. Provide client health teaching and discharge planning a. Smoking B. Oscillometry – decrease in peripheral pulses 2. High risk groups – men 30 years old and above 2. intake and output and ECG tracing 6. Varicose Veins 2. Thrombophlebitis (deep vein thrombosis) THROMBOANGITIS OBLITERANS Acute inflammatory disorder usually affecting the small medium sized arteries and veins of the lower extremities A. Cold sensitivity and changes in skin color (pallor.
Cardiac disorder 5. SLE (butterfly rash) b. Hereditary 2. cyanosis then rubor) 3. Instruct client on importance of cessation of smoking and exposure to cold environment VARICOSITIES Abnormal dilation of veins of lower extremities and trunks due to Incompetent valve resulting to Increased venous pooling resulting to Venous stasis causing Decrease venous return A. Trophic changes 4. Vasodilators 2. Thrombophlebitis 4. Operating chainsaw B. Institute foot care management 4. Rheumatoid Arthritis 4. High risk group – female 40 years old and above 2. Cold sensitivity and changes in skin color (pallor. 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. Nursing Management 1. Anti coagulants 3. Excessive typing c. Piano playing b. Gangrene formation C.b. Intermittent claudication – leg pain upon walking 2. Vasodilators c. Congenital weakness of veins 3. Encourage to wear gloves 3. Angiography – reveals site and extent of malocclusion D. Instruct client to avoid smoking and exposure to cold environment 5. Doppler UTZ – decrease blood flow to the affected extremity 2. Collagen diseases a. Smoking 3. Diagnostic Procedures 1. Direct hand trauma a. Ulceration 5. Predisposing Factors 1. Analgesics b. Pregnancy . Administer medications as ordered a. Predisposing Factors 1. Signs and Symptoms 1.
Smoking 3. Nursing Management 1. B. Warm to touch 4. Congestive heart failure 8. Obesity 7. Increase in saturated fats in the diet. Diabetes mellitus 7. Prolonged standing or sitting B. Signs and Symptoms 1. Trendelenburg’s Test . Myocardial infarction 9. Signs and Symptoms 1. Elevate legs above heart level to promote increased venous return by placing 2 – 3 pillows under the legs 2. Warm to touch 3. Nursing Management . Angiography D. Vein stripping and ligation (most effective) b. Related to pregnancy 4. Measure the circumference of leg muscle to determine if swollen 3. Venography 2. Chronic anemia 5. Diagnostic Procedure 1.6. Assist in surgical procedure a. Post op complication 10. 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. Heaviness in legs C. Predisposing Factors 1. Prolong use of oral contraceptives – promotes lipolysis 6. Pain at affected extremity 2. Positive Hpman’s Signs – pain at the calf or leg muscle upon dorsi flexion of the foot C. Obesity 2.veins distends quickly in less than 35 seconds D. Wear anti embolic stockings 4. Dilated tortuous skin veins 4. Dilated tortuous skin veins 3. Post cannulation – insertion of various cardiac catheter 11. Analgesics 5. Pain after prolonged standing 2. Diagnostic Procedure 1. Venography 2. Administer medications as ordered a.
Consist of anastomosis of capillaries known as Keissel Rach Plexus (the site of nose bleeding) B.Opening of larynx . Upper Respiratory System 1.Restlessness b.The initial sign of complete airway obstruction is the inability to cough II. Pulmonary .Left nostril . Apply warm moist pack – to reduce lymphatic congestion 3. Larynx . Filtering of air 2.Cartillage . Encourage to wear anti embolic stockings or knee elastic stockings 5. Humidification A.Decrease LOC • MURPHY’S SIGN is seen in clients with cholelithiasis.Serves as passageway of air going to the lungs .Separated by septum .Tachycardia .Diaphoresis . Measure circumference of leg muscle to determine if swollen 4.For phonation (voice production) .Serves as a muscular passageway for both food and air C.Palpitations . Analgesics b.Unexplained dyspnea .Headache .Heparin 6. Nose . Administer medications as ordered a.Opens to allow passage of air .1. Pharynx/Throat .Consist of cartilaginous rings .Closes to allow passage of food going to the esophagus .For gas exchange A. Anti Coagulant . cholecystitis characterized by pain at the right upper quadrant with tenderness RESPIRATORY SYSTEM OVERVIEW OF THE STRUCTURES AND FUCNTIONS OF THE RESPIRATORY SYSTEM I.Dizziness . Elevate legs above heart level to promote increase venous return 2.Right nostril .For cough reflex Glottis . Trachea/Windpipe .Sudden sharp chest pain . Lower Respiratory System . Warming and moistening of air 3. Monitor for signs of complications Embolism a. Cerebral .
Secretes surfactant . 10 segments) . Visceral With Pleuritic Friction Rub a.Right lung (consist of 3 lobes. Alcoholism 4.Decrease surface tension . Lungs . Over fatigue 5.An acid fast. gram negative.Right main bronchus .retinopathy/blindness in prematurity Disorders of Respiratory System 1.Serous membranes Pleural Cavity a. Overcrowded places 3. Pneumonia b. aerobic and easily destroyed by heat or sunlight A.Give oxygen of less 40% in premature to prevent atelectasis and retrolental fibroplasias .Site of gas exchange (CO2 and O2) . Pareital b. Virulence (degree of pathogenecity) of microorganism B. 8 segments) . night sweats 2. Low grade afternoon fever. Malnutrition 2.In premature infants 1:2 . Mode of Transmission 1.Normal L/S ratio is 2:1 .Left lung (consist of 2 lobes. Pleural effusion c. Pleural fluid c. Hydrothorax (air and blood in pleural space Alveoli . Ingestion of an infected cattle with mycobacterium bovis 6.Increase carbon dioxide is a powerful stimulant for breathing Type II Cells of Alveoli . Precipitating Factors 1.L/S ratio to determine lung maturity .Decrease oxygen stimulates breathing . PTB/Pulmonary Tuberculosis (Koch’s Disease) . Bronchus .. Airborne transmission via droplet nuclei C.Diffusion (Dalton’s law of partial pressure of gases) Respiratory Distress Syndrome .Prevent collapse of alveoli .Left main bronchus C.Site of tracheostomy B. Productive cough (yellowish sputum) .Composed of lecithin and spingomyelin . Signs and Symptoms 1.Infection of lung tissue caused by invasion of mycobacterium tuberculosis or tubercle bacilli .
Purified protein derivative . Mantoux Test (skin test) . Intensive phase . Weight loss 5.Side Effect Ethambutol: optic neuritis b. CBC . nephrotoxicity . Nebulize and suction when needed 8. Force fluids to liquefy secretions 5. Place client on semi fowlers position to promote expansion of lungs 6.Neomycin .Given everyday simultaneously to prevent resistance . Standard phase .INH and Rifampicin is given for 4 months. Administer oxygen inhalation 4. Sputum Acid Fast Bacillus . Enforce CBR 2.Side Effect INH: peripheral neuritis/neuropathy (increase intake of Vitamin B6/Pyridoxine) . generalized body malaise 4.PZA (Pyrazinamide) . Nursing Management 1. Chest pain 7. Anorexia.Side Effect PZA: allergic reaction. Hemoptysis (chronic) D.Reveals increase WBC E.Amikacin . Encourage deep breathing and coughing exercise 7.Gentamycin .Injection of streptomycin (aminoglycoside) . hepatotoxicity. Comfortable and humid environment 9. 48 – 72 hours . taken after meals to facilitate absorption . Diagnostic Procedure 1.WHO 10 – 14 mm induration.Reveals pulmonary infiltrates 4. Institute short course chemotherapy a.Kanamycin .PZA is given for 2 months.INH (Isonicotinic Acid Hydrazide) . Dyspnea 6.Positive to cultured microorganism 3.Rifampicin (Rifampin) .Positive Mantoux test (previous exposure to tubercle bacilli but without active TB) 2.PZA can be replaced by Ethambutol . Institute strict respiratory isolation 3. Chest X-ray . 48 – 72 hours .DOH 8 – 10 mm induration.Side Effect Rifampicin: all bodily secretions turn to red orange color .3. taken before meals to facilitate absorption .
Weight loss 5. Importance of follow up care PNEUMONIA Inflammation of the lung parenchyma leading to pulmonary consolidation as the alveoli is filled with exudates A. dyspepsia..Drug of choice is Retrovir b.Chest x-ray confirms lung cancer 4.Side Effect: . chills. Immuno compromised a. Etiologic Agents 1. Dyspnea with prolong expiratory grunt 3.Give aspirin if there is fever .Nephrotoxicity check for BUN and Creatinine . Children below 5 years old 2. Air pollution 3.Adrenal gland c. Provide increase carbohydrates. Fever. Klebsella Pneumoniae 5. Elderly C. Bronchial wheezing . Provide client health teaching and discharge planning a. Streptococcus Pneumonae – causing pneumococal pneumonia 2. Bronchogenic Cancer .Meninges . Smoking 2. High Risk Groups 1. AIDS . Related to prolonged immobility (CVA clients). Prevent complications (atelectasis. Pseudomonas B. Rales/crackles 6.Pneumocystic carini pneumonia . Diplococcus Pneumoniae 4.Bones (potts) . Avoidance of precipitating factors b. Productive cough with greenish to rusty sputum 2.Ototoxicity damage to the 8th cranial nerve resulting to tinnitus leading to hearing loss . Strict compliance to medications d. Predisposing Factors 1. Aspiration of food causing aspiration pneumonia D.Initial sign is non productive cough . heartburn 10. Signs and Symptoms 1. vitamin C and calories 11. Hemophylus Influenzae – causing broncho pneumonia 3.Skin . anorexia and general body malaise 4. Escherichia Pneumoniae 6.Side Effect: tinnitus. protein.Eyes . causing hypostatic pneumonia 5. military tuberculosis) PTB .
Administer medications as ordered Broad Spectrum Antibiotic a. Institute pulmonary toilet (tends to promote expectoration) . Chest pain 10. erythrocyte sedimentation rate is increased F. Stop if client cannot tolerate procedure f. CBC – reveals increase WBC.Increase ICP 9. Provide increase carbohydrates. protein and vitamin C 10.Drain uppermost area of lungs .Chest physiotherapy . Encourage client deep breathing exercises d. calories. Nursing Management 1. Place on semi fowlers position 6. Nebulize and suction as needed 8. Provide oral care after procedure g. Administer bronchodilators 15 – 30 minutes before procedure e. Cyanosis 8.Unstable vital signs .Placed on various position Nursing Management for Postural Drainage a. Microlides (Zethromax) Azethromycin (Side Effect: Ototoxicity) Antipyretics Mucolytics/Expectorants Analgesics 4.Turning and reposition 7. Abdominal distention leading to paralytic ileus (absence of peristalsis) E. Assist in postural drainage . Penicillin b. Force fluid 5. Chest x-ray – reveals pulmonary consolidation 3.7. Prevent complications .Deep breathing exercises . Pleuritic friction rub 9. Contraindicated with . Monitor vital signs c.Clients with increase intra ocular pressure (Normal IOP 12 – 21 mmHg) . Best done before meals or 2 – 3 hours to prevent gastro esophageal reflux b. Tetracycline c.Coughing exercises . Administer oxygen inhalation low inflow 3. Avoid smoking b. ABG analysis – reveals decrease PO2 4. Sputum Gram Staining and Culture Sensitivity – positive to cultured microorganisms 2. Health teaching and discharge planning a.Hemoptysis . Enforce CBR 2. Diagnostic Procedure 1.
Regular adherence to medications d. check for BUN and Creatinine. Hemoptysis 6. Administer medications as ordered a.Meningitis (nerve deafness. Cyanosis 5. Prevent the spread of infection by spraying of breeding places COPD (Chronic Obstructive Pulmonary/Lung Disease) Chronic Bronchitis Inflammation of bronchus resulting to hypertrophy or hyperplasia of goblet mucous producing cells leading to narrowing of smaller airways A. Force fluids to liquefy secretions 5. Importance of follow up care HISTOPLASMOSIS Acute fungal infection caused by inhalation of contaminated dust or particles with histoplasma capsulatum derived from birds manure A. Prevent complications – bronchiectasis 7. Antipyretics 4. Dyspnea on exertion 3. Air pollution B. anorexia. Productive cough 2. Chest and joint pains B. Smoking 2. general body malaise 4. Predisposing Factors 1. Productive cough (consistent to all COPD) 2. Mucolytics d. Prolonged expiratory grunt 4. Enforce CBR 2. Histoplasmin Skin Test – positive 2. chills. Steroids c.Amphotericin B . Nursing Management 1. hydrocephalus) c. Signs and Symptoms 1. Anorexia and generalized body malaise . Signs and Symptoms PTB or Pneumonia like 1. Fever. Diagnostic Procedures 1. Dyspnea 3. Hypokalemia) b. Nebulize and suction as needed 6.. Antifungal .Fungizone (Nephrotoxicity. Administer oxygen inhalation 3.Atelectasis . ABG analysis PO2 decrease C.
Mixed Type 90 – 95% B. Signs and Symptoms 1. apply direct pressure to ulnar and radial artery to determine presence of collateral circulation D. chicken d. Diagnostic Procedure ABG analysis – reveals PO2 decrease (hypoxemia). Cyanosis 7. Food additives (nitrates) e.5. Diagnostic Procedure 1. Wheezing on expiration 4. Enforce CBR . Tachycardia. Pollen b. Danders g. pH decrease Bronchial Asthma Reversible inflammatory lung condition due to hypersensitivity to allergens leading to narrowing of smaller airways A. Scattered rales/ronchi 6. Drugs (aspirin. Cyanosis 5.Incentive spirometer reveals decrease vital lung capacity 2. Mild Stress/apprehension 6. Gases f. Extrinsic Asthma ( Atopic/ Allergic ) Causes a. Dyspnea 3. Nursing Management 1. Peripheral edema b. Cough that is non productive 2.Before ABG test for positive Allens Test. Pulmonary hypertension a. eggs. beta blocker) c. Cor Pulmonale (right ventricular hypertrophy) C. Hereditary b. Intrinsic Asthma (Non atopic/Non allergic) Causes a. Diaphoresis C. Lints 2. air pressure and humidity f. Predisposing Factors (Depending on Types) 1. Foods (seafoods. Dust c. Pulmonary Function Test . Furs h. ABG analysis – PO2 decrease . Smoke e. chocolates. Physical and emotional stress 3. PCO2 increase. Fumes d. Sudden change in temperature. palpitations 7. penicillin. milk.
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. Anorexia and generalized body malaise 5. Force fluids 5. Diagnostic Procedure 1.Status Asthmaticus (give drug of choice) . Feeding initiated upon return of gag reflex 2. Bronchodilators – given via inhalation or metered dose inhalaer or MDI for 5 minutes b. Avoid talking. Nebulize and suction when needed 7.Emphysema .Epinephrine . Bronchoscopy – direct visualization of bronchus using fiberscope Nursing Management PRE Bronchoscopy 1. Treatment . Maintain NPO 6 – 8 hours prior to procedure 3. Predisposing Factors 1. Monitor for signs of laryngeal spasm – prepare tracheostomy set D.Steroids . Related to presence of tumor B.Bronchodilators c. Steroids – decrease inflammation c. Hemoptysis (only COPD with sign) C. Oxygen inhalation. Dyspnea 3. Productive cough 2. Administer medications as ordered a. with low inflow of 2 – 3 L/min 3. Mucolytics/expectorants e. Recurrent lower respiratory tract infections 2.2. ABG – PO2 decrease 2. Secure inform consent and explain procedure to client 2. Prevent complications . Provide client health teachings and discharge planning concerning a. Monitor for signs of gross 4. Cyanosis 4. Congenital defects 4. Regular adherence to medications to prevent development of status asthmaticus d. coughing and smoking. Signs and Symptoms 1. Avoidance of precipitating factor b. may cause irritation 3. Monitor vital signs and breath sound POST Bronchoscopy 1. Mucomysts (acetylceisteine) d. Chest trauma 3. Semi fowlers position 6.
Panlobular/ centrilobular . Productive cough 2. Predisposing Factors 1. Decrease tactile fremitus 7. “Pink Puffers”) . Smoking 2. Barrel chest 11. Surgery (pneumonectomy . Purse lip breathing to eliminates excess CO2 (compensatory mechanism) C.Unaffected lobectomy facilitate drainage EMPHYSEMA Irreversible terminal stage of COPD characterized by a.Respiratory alkalosis D. for recoil of alveoli) B. Segmental Wedge Lobectomy (promote re expansion of lungs) . Air trapping c. Rales or ronchi 9. 1 lung is removed and position on affected side) 2. Diagnostic Procedure 1. Allergy 4. Decrease or diminished breath sounds 8. Nursing Management 1. Signs and Symptoms 1. Hereditary – it involves deficiency of ALPHA-1 ANTI TRYPSIN (needed to form Elastase. Panacinar/ centriacinar .Decrease PCO2 .Decrease PO2 (hypoxemia leading to chronic bronchitis. Anorexia and generalized body malaise 5.Respiratory acidosis b. Enforce CBR .Decrease ph . Flaring of alai nares 12. Over distention of thoracic cavity (barrel chest) A. ABG analysis reveals a. “Blue Bloaters”) .1.Increase PCO2 . Pulmonary Function Test – reveals decrease vital lung capacity 2. Bronchial wheezing 10. Inelasticity of alveoli b.Increase ph .Increase PO2 (hyperaxemia. Maldistribution of gases d. Prolong expiratory grunt 4. Resonance to hyperresonance 6. High risk: elderly 5. Air pollution 3. Dyspnea at rest 3.
Pneumothorax c. Provide comfortable and humid environment 10. Institute PEEP (positive end expiratory pressure) in mechanical ventilation promotes maximum alveolar lung expansion 9. vitamins and minerals 11.Cor Pulmonale . Bronchodilators b. Health teachings and discharge planning concerning a. protein. Prevent complications . Administer medications as ordered a. Antibiotics d. High fowlers position 5. Force fluids 6. Provide high carbohydrates.CO2 narcosis may lead to coma . Steroids c. Institute pulmonary toilet 7. Avoid smoking b. Mucolytics/expectorants 4.Atelectasis . Strict compliance to medication d.2. Importance of follow up care . Administer oxygen inhalation via low inflow 3. calories. Nebulize and suction when needed 8.