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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.
Ig E – for allergic reaction. 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. Aphasia – no speech (nodding). d. saliva.Immediate action. Wernicke’s Aphasia General Knowing Gnostic Area or General Interpretative Area.short term protection. pressure. Apraxia – no recognition of objects function. Sign and Symptoms 4 A’s of Alzheimer a. b. *Receptive aphasia DRUG OF CHOICE: ARICEPT (taken at bedtime) and COGNEX.DEMYELINATING DISORDERS 1. Impaired sensation to touch. Amnesia – loss of memory. colostrums). ALZHEIMER’S DISEASE Atrophy of brain tissues. Ig A – present in all bodily secretions (tears. . *Expressive aphasia “motor speech center” Broca’s Aphasia inability to understand spoken words. MULTIPLE SCLEROSIS Chronic intermittent disorder of CNS characterized by white patches of demyelination in brain and spinal cord. . tingling sensation paresthesia numbness euphoria (sense of well being) 3. Ig M – acute in inflammation. Characterized by remission and exacerbation. Mood swings . 2. pain. c. Signs and Symptoms 1. Ig D – for chronic inflammation. * Give palliative or supportive care. Visual disturbances blurring of vision (primary) diplopia (double vision) scotomas (blind spots) 2. Agnosia – no recognition of inanimate objects. heat and cold.
(+) Lhermitte’s sign a continuous and increase contraction of spinal column. 5. ACTH (Adreno Corticotropic Hormone)/ Steroids for acute exacerbation to reduce edema at site of demyelination to prevent paralysis. Impaired cerebral function CHARCOTS TRIAD IAN Intentional tremors 6. Monitor breath sounds 1 hour after subcutaneous administration. d. Constipation 8. Maintain side rails to prevent injury related to falls. vitamin C and orange. Bethanicol Chloride (Urecholine) Nursing Management Only given subcutaneous. . b. Prophantheline Bromide (Promanthene) Acid ash diet like cranberry juice. prunes. 3. Immunosupresants 2. For Urinary Incontinence Anti spasmodic agent a. Deep breathing exercises b. Increase fluid intake and increase fiber to prevent constipation. Impaired motor function weakness spasticity paralysis scanning speech TRIAD SIGNS OF MS Ataxia (Unsteady gait. c. NURSING MANAGEMENT 1. To acidify urine and prevent bacterial multiplication. a. MRI (reveals site and extent of demyelination). Yoga 4. Institute stress management techniques. Administer medications as ordered a. a. Diuretics b.4. (+) Romberg’s test) 5. Interferons – alter immune response. Urinary retention/incontinence 7. Baclofen (Dioresal)/ Dantrolene Sodium (Dantrene) – muscle relaxants. Monitor side effects bronchospasm and wheezing. plums. Catheterization to prevent retention. c. Decrease sexual capacity DIAGNOSTIC PROCEDURE Nystagmus CSF analysis (increase in IgG and Protein). pineapple.
Occipital . Temporal hearing short term memory for appreciation discrimination of sensory impulses to pain. Frontal higher cortical thinking controls personality controls motor activity Broca’s Area (motor speech area) when damaged results to garbled speech. numbness. heat. pressure. 2. 80% brain mass 10% blood 10% CSF COMPOSITION OF BRAIN I. Functions of Cerebrum integrative sensory motor Lobes of Cerebrum 1. 3. cold. 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. avoid use of tissue papers avoid using talcum powder and perfume. Brain Mass PARTS OF THE BRAIN 1. eating). 8 inches) urinate after intercourse Nursing Management Male MICROGLIA stationary cells that carry on phagocytosis (engulfing of bacteria or cellular debris.COMMON CAUSE OF UTI Female short urethra (3-5 cm. CEREBRUM largest part composed of the Right Cerebral Hemisphere and Left Cerebral Hemisphere enclosed in the Corpus Callosum. Urethra (20 cm. touch. 1-1 ½ inches) poor perineal hygiene vaginal environment is moist avoid bubble bath (can alter Ph of vagina). pinocytosis (cell drinking). Parietal 4.
B. vasomotor center (dilation and constriction of bronchioles). controls pituitary functions androgenic hormones promotes secondary sex characteristics. controls libido controls long term memory Insula (Island of Reil) Limbic System (Rhinencephalon) 2. vomiting. . Cerebellum smallest part of the brain. INTERBRAIN/ DIENCEPHALON Parts of Diencephalon A. early sign for females telarche and late sign is menarche. Hypothalamus 5. controls blood pressure controls thirst appetite/satiety sleep and wakefulness controls some emotional responses like fear. hearing acuity is 30 – 40 dB. Medulla Oblongata 3. heart rate. early sign for males are testicular and penile enlargement late sign is deepening of voice. for vision visceral function activities of internal organ like gastric motility. unequal size of pupil is anisocoria. hiccup. controls temperature (thermoregulatory center). Thalamus acts as relay station for sensation. 2. Pons pneumotaxic center controls the rate. MIDBRAIN/ MESENCEPHALON acts as relay station for sight and hearing. DECREASE Myasthenia Gravis Parkinson’s Disease INCREASE Bi-polar Disorder Schizophrenia NEURO TRANSMITTER Acethylcholine Dopamine 3. BASAL GAGLIA areas of grey matter located deep within each cerebral hemisphere. controls respiration. lesser brain. positive PERRLA 4. release dopamine (controls gross voluntary movement. anxiety and excitement. size of pupil is 2 – 3 mm. controls smell and if damaged results to Anosmia (absence of smell). swallowing. BRAIN STEM located at lowest part of brain Parts of Brain Stem 1. rhythm and depth of respiration. equal size of pupil is isocoria.
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. Cervical 2 – also known as AXIS. controls balance. Early closure of posterior fontanels causes posterior enlargement of skull in hydrocephalus. . 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). posture and gait. INTRA CRANIAL PRESSURE Monroe Kellie Hypothesis Skull is a closed container Any alteration or increase in one of the intracranial components Increase intra-cranial pressure (normal ICP is 0 – 15 mmHg) Cervical 1 – also known as ATLAS. widening of pulse pressure is neurologic in nature (if narrow cardiac in nature). 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. projective vomiting headache papilledema (edema of optic disc) abnormal posturing decorticate posturing (damage to cortex and spinal cord). heart rate decrease respiratory rate decrease temperature increase directly proportional to blood pressure.
unilateral dilation of pupils called uncal herniation bilateral dilation of pupils called tentorial herniation resulting to mild headache possible seizure activity Nursing Management 1. Late signs of hypoxia HYPERCARBIA b. Prevent complications of 6. Limit fluid intake to 1200 – 1500 ml/day (in force fluids 2000 – 3000 ml/day). Prevention of hypoxia and hypercarbia Early signs of hypoxia restlessness agitation tachycardia Bradycardia Extreme restlessness Dyspnea Cyanosis Increase CO2 (most powerful respiratory stimulant) retention. In chronic respiratory distress syndrome decrease O2 stimulates respiration. b. c. c. instruct client to avoid forms of valsalva maneuver like: straining stool excessive vomiting (use anti emetics) excessive coughing (use anti tussive like dextromethorphan) avoid stooping/bending avoid lifting heavy objects e. b. cerebellum and midbrain). Administer medications like: a. Monitor strictly input and output and neuro check 5. avoid use of restraints. provide an comfortable and quite environment. administered via side drip regulated fast drip to prevent crystal formation. 7. Before and after suctioning hyper oxygenate client 100% and done 10 – 15 seconds only. Maintain patent and adequate ventilation by: a. monitor strictly input and output every 1 hour notify physician if output is less 30 cc/hr. Prevent further increase ICP by: a. avoid clustering of nursing activity together. Assist in mechanical ventilation 2. d. decerebrate posturing (damage to upper brain stem that includes pons. 4. Nursing Management . Loop diuretic (Lasix. 3. maintain side rails. Elevate bed of client 30 – 35o angle with neck in neutral position unless contraindicated to promote venous drainage. Osmotic diuretic (Mannitol) for cerebral diuresis Nursing Management monitor vital signs especially BP (hypotension). Furosemide) Drug of choice for CHF (pulmonary edema) Loop of Henle in kidneys.
Phenytoin) c. given early morning immediate effect of 10 – 15 minutes. monitor strictly input and output every 1 hour notify physician if output is less 30 cc/hr. administered IV push or oral. Dexamethasone (Decadron) Hydrocortisone Prednisone (to reduce edema that may lead to increase ICP) Mild Analgesics (Codeine Sulfate for respiratory depression) Anti Convulsants (Dilantin. Monitor vital signs especially BP (hypotension). blood monitor RIGHT CONGESTIVE HEART FAILURE (Venous congestion) Signs and Symptoms jugular vein distention (neck) ascites pitting edema weight gain hepatosplenomegaly jaundice pruritus esophageal varices anorexia and general body malaise . maximum effect of 6 hours. 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.
Hyponatremia DECREASE decrease sodium level normal value is 135 – 145 meq/L Signs and Symptoms hypotension dehydration signs (Initial sign in adult is THIRST. Hypokalemia decrease potassium level normal value is 3. Hypocalcemia/ Tetany VEGETABLES Asparagus Brocolli Carrots Spinach decrease calcium level normal value is 8.4 – 5. in infant TACHYCARDIA) agitation dry mucous membrane poor skin turgor weakness and fatigue .5 – 11 mg/100 ml Signs and Symptoms tingling sensation paresthesia numbness (+) Trousseau’s sign/ Carpopedal spasm (+) Chvostek’s sign Complications Arrhythmia Seizures Nursing Management Calcium Gluconate per IV slowly as ordered * Calcium Gluconate toxicity – results to SEIZURE Magnesium Sulfate Magnesium Sulfate toxicity S/S BP Urine output Respiratory rate Patellar relfex absent 3.Signs and Symptoms of Lasix in terms of electrolyte imbalances 1. 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.
Hyperuricemia increase uric acid (purine metabolism) foods high in uric acid (sardines. Narcotic Analgesic b. organ meats and anchovies) *Increase in tophi deposit leads to Gouty arthritis.Nursing Management force fluids administer isotonic fluid solution as ordered 4. 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. joint pain (great toes) swelling force fluids administer medications as ordered Drug of choice for gout. Nursing Management a. Mechanism of action: inhibits synthesis of uric acid. Hyperglycemia normal FBS is 80 – 100 mg/dl polyuria polydypsia polyphagia monitor FBS Signs and Symptoms Nursing Management 5. Allopurinol (Zyloprim) b. Allopurinol (Zyloprim) Side Effects Respiratory depression (check for RR) . Signs and Symptoms Nursing Management a. Acute gout Mechanism of action: promotes excretion of uric acid.
Encephalitis 5. increase lacrimation c. decrease sexual capacity Nursing Management 1. Reserpine(Serpasil) b. Administer medications as ordered Anti Parkinsonian agents Levodopa (L-dopa) short acting Amantadine Hydrochloride (Symmetrel) Carbidopa (Sinemet) . 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. Hypoxia 4. increase sweating b. Methyldopa(Aldomet) c. seborrhea d. Arteriosclerosis 3. 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. difficulty rising from sitting position. Predisposing Factors 1. Monotone type speech mood lability (in state of depression) increase salivation (drooling type) autonomic changes a. 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. Haloperidol(Haldol) d. Poisoning (lead and carbon monoxide) 2. constipation e.
Decrease protein in morning and increase protein in afternoon to induce sleep 5. Maintain side rails to prevent injury 3.relieves tremor rigidity Bromocriptene Hydrochloride (Parlodel) Side Effects Respiratory depression 2. 6. Prevent complications of immobility 4.5 meq/L . Assist in Stereotaxic Thalamotomy MAGIC 2’s IN DRUG MONITORING DRUG Digoxin/ Lanoxin (Increase force of cardiac output) Lithium/ Lithane (Decrease level of Ach/NE/Serotonin) Aminophylline (Dilates bronchial tree) Dilantin/ Phenytoin Acetaminophen/Tylenol NORMAL RANGE . Encourage increase fluid intake and fiber. Dopamine Agonist . Assist/supervise in ambulation 7. Isonicotinic Acid Hydrazide Anti Cholinergic Agents (ARTANE and COGENTIN) .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 .6 – 1.to relieve tremors Mechanism of Action inhibits action of acethylcholine SNS Side Effects Anti Histamine (Dipenhydramine Hydrochloride) Side Effects Adult: drowsiness Children: CNS excitement (hyperactivity) because blood brain barrier is not yet fully developed.Mechanism of Action increase level of dopamine GIT irritation (should be taken with meals orthostatic hypotension arrhythmia hallucinations clients with narrow angle closure glaucoma clients taking MAOI’s (no foods with triptophan and thiamine) urine and stool may be darkened no Vitamin B6 (Pyridoxine) reverses the therapeutic effects of Levodopa Side Effects Contraindications * Increase Vitamin B when taking INH (Isoniazid).5 – 1.
1. depression Antidote: Acetylcisteine (mucomyst) prepare suction apparatus as bedside. irritability. Aminophylline Toxicity Signs and Symptoms tachycardia palpitations CNS excitement (tremors. Acetaminophen Toxicity Signs and Symptoms hepatotoxicity (monitor for liver enzymes) SGPT/ALT (Serum Glutamic Pyruvate Transaminace) SGOT/AST (Serum Glutamic Oxalo-Acetil Transaminace) nephrotoxicity monitor BUN (10 – 20) and Creatinine (. Dilantin Toxicity Signs and Symptoms gingival hyperplasia (swollen gums) hairy tongue ataxia nystagmus provide oral care massage gums Nursing Management 5. 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 3.9 NaCl to prevent development of crystals or precipitate. Digitalis Toxicity Signs and Symptoms nausea and vomiting diarrhea confusion photophobia changes in color perception (yellowish spots) Antidote: Digibind 2. agitation and restlessness) only mixed with plain NSS or 0. administered sandwich method avoid taking alcohol because it can lead to severe CNS depression avoid caffeine Nursing Management 4.8 – 1) hypoglycemia Tremors. tachycardia Irritability Restlessness Extreme fatigue Diaphoresis. .
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.PNS Treatment . Assist in plasma paresis and removing auto immune anti bodies 9. Nursing Management 1. Cholinergic (Mestinon) b. aspiration 3.G.infection Signs and Symptoms . if there is no effect there is damage to occipital lobe and midbrain and is negative for Signs and Symptoms Diagnostic Procedure M.The client is unable to see. input and output and neuro check * monitor strength or motor grading scale 4. swallow. maintain side rails to prevent injury related to falls 5. Prevent complications .stress . speak.under medication . airway 2. 8. administer medications as ordered a.Administer anti cholinergic agents (Atropine Sulfate) Side Effects MYASTHENIC CRISIS Causes: . Incidence rate: women 20 – 40 years old Predisposing factors unknown autoimmune: it involves release of cholinesterase an enzyme that destroys Ach. mmobility * assist in mechanical ventilation and monitor pulmonary function test * monitor strictly vital signs. institute NGT feeding 6.over medication Signs and Symptoms . breathe Treatment .administer cholinergic agents as ordered 7. 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: . Assist in surgical procedure known as thymectomy because it is believed that the thymus gland is responsible for M. initial sign is ptosis a clinical parameter to determine ptosis is palpebral fissure.G.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.
Etiology 1. Nursing Management for LP Before Lumbar Puncture 1.causes adult meningitis 4. drainage and leakage to tissues. Assess for movement and sensation of extremities. (+) Brudzinski sign (neck pain) D. 3. Check punctured site for any discoloration. general body malaise and weight loss Possible increase in ICP and seizure activity Abnormal posturing (decorticate and decerebrate) Signs of meningeal irritation a. Empty bladder and bowel to promote comfort. (+) cultured microorganism (confirms meningitis) CBC reveals 1. (+) Kernig’s sign (leg pain) d. Meningococcus – most dangerous 2. anorexia. 4. Streptococcus . Signs and Symptoms headache photophobia projectile vomiting fever. Dura matter – outer layer 2. Arachnoid – middle layer 3. A. Force fluids 3. Pneumococcus 3. Nuchal rigidity or stiff neck b. Secure informed consent and explain procedure. Encourage to arch back to clearly visualize L3-L4. Diagnostic Procedures Lumbar puncture: a hollow spinal needle is inserted in the subarachnoid space between the L3 – L4 to L5. Place flat on bed 12 – 24 o 2. Mode of transmission airborne transmission (droplet nuclei) C. chills. Increase CHON and WBC 2. Decrease glucose 3. Increase wbc . CSF aspiration is done. Pia matter – inner layer subdural space between the dura and arachnoid subarachnoid space between the arachnoid and pia. Post Lumbar Puncture 1. CSF analysis reveals 1. Opisthotonus (arching of back) c. for support and protection for nourishment blood supply LAYERS OF THE MENINGES 1. 2.INFLAMMATORY CONDITIONS OF THE BRAIN MENINGITIS Meninges 3 fold membrane that covers brain and spinal cord. Increase CSF opening pressure (normal pressure is 50 – 100 mmHg) 4. Hemophilus Influenzae – causes pediatric meningitis B.
8. Maintain good diet of increase CHO. b. Institute measures to prevent increase ICP and seizure. Provide a comfortable and darkened environment. Broad spectrum antibiotics (Penicillin. Incidence Rate men are 2-3 times high risk B. Maintain fluid and electrolyte balance. calories with small frequent feedings. Administer medications as ordered a. CHON. Compartment syndrome (compression of arteries and nerves) . 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. Monitor strictly V/S. Tetracycline) b. Provide client health care and discharge planning concerning: a. 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. Yellow bone marrow are produced from the medullary cavity of the long bones and produces fat cells. Prevent complications most feared is hydrocephalus hearing loss/nerve deafness is second complication consult audiologist mental retardation delayed psychomotor development c. 2 most common cerebral artery affected by stroke a. If there is bone fracture there is hemorrhage and there would be escape of the fat cells in the circulation. Mild analgesics c. Institute strict respiratory isolation 24 hours after initiation of anti biotic therapy 4. 9. Rehabilitation for neurological deficit CVA (STROKE/BRAIN ATTACK/ ADOPLEXY/ CEREBRAL THROMBOSIS) a partial or complete disruption in the brains blood supply. Nursing Management 1. 7.E. Internal Cerebral Artery – the 2 largest artery A. input and output and neuro check 6. Elevate head 30-45o 5. Mid Cerebral Artery b. Enforce complete bed rest 2. Anti pyretics 3.
Diagnostic Procedure 1. Signs and Symptoms Heart Disease. Stroke in evolution 3. 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. D. alexia (difficulty reading) e. Obesity (increase 20% ideal body weight) 4. Cerebral Arteriography reveals the site and extent of malocclusion uses dye for visualization most of dye are iodine based check for shellfish allergy after diagnostic exam force fluids to release dye because it is nephro toxic check for distal pulse (femoral) check for hematoma formation . Hypertension. Complete stroke Signs and Symptoms E. Atherosclerosis. Type A personality a. Related to diet: increase intake of saturated fats like whole milk 7. phlegia b. aphasia c. Prolong use of oral contraceptives promotes lypolysis (breakdown of lipids) leading to atherosclerosis that will lead to hypertension and eventually CVA. CT Scan – reveals brain lesions 2.C. TIA Signs and Symptoms 2. usually fells guilty when not doing anything 6. homonymous hemianopsia (loss of half of visual field) 1. dysarthria (inability to articulate words) d. Risk Factors 1. nausea and vomiting dysphagia (+) Kernig’s sign and Brudzinski sign which may lead to hemorrhagic stroke focal neurological deficits a. Valvular Cardiac Surgery (mitral valve replacement) 2. agraphia (difficulty writing) f. Myocardial Infarction. Lifestyle (smoking). can do multiple tasks c. Diabetes Mellitus. sedentary lifestyle 3. Related stress physical and emotional 8. Hyperlipidemia more on genetics/genes that binds to cholesterol 5. deadline driven b.
Anti Platelet PASA (Aspirin) Contraindicated for dengue. avoidance of modifiable risk factors (diet. Anti Coagulants Heparin (short acting) check for partial thromboplastin time if prolonged there is a risk for bleeding. ulcer and unknown cause of headache because it may potentiate bleeding 11. K (Aqua Mephyton) g. Cortecosteroids d. importance of follow up care . Nursing Management 1. Osmotic Diuretics (Mannitol) b. Thrombolytic/Fibrinolytic Agents – dissolves thrombus Streptokinase Side Effect: Allergic Reaction Urokinase Tissue Plasminogen Activating Factor Side Effect: Chest Pain f. Assist in passive ROM exercise every 4 hours to promote proper bodily alignment and prevent contractures 7. Institute NGT feeding 8. provide sand bag or food board. Elevate head 30 – 45o 4. 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.F. Maintain patent airway and adequate ventilation by: a. Monitor strictly vitals signs. Provide client health teachings and discharge planning concerning a. Provide alternative means of communication a. Restrict fluids to prevent cerebral edema that might increase ICP 3. non verbal cues b. magic slate 9. smoking) b. administrate O2 inhalation 2. I & O and neuro check 5. provide egg crate mattresses or water bed c. Administer medications as ordered a. Furosemide) c. dietary modification (decrease salt. prevent complication (subarachnoid hemorrhage is the most feared complication) c. turn client to side b. Mild Analgesics e. saturated fats and caffeine) d. assist in mechanical ventilation b. 6. exercise. Prevent complications of immobility by: a. If positive to hemianopsia approach client on unaffected side 10. Loop Diuretics (Lasix.
Antecedent viral infections such as LRT infections B. Predisposing Factors 1. increase salivation b. constipation C. Corticosteroids – suppress immune response b. neuro check d. Clumsiness (initial sign) 2. Institute NGT feeding to prevent aspiration 6. ECG 3. Ascending muscle weakness leading to paralysis 4. Prevent complications of immobility by turning the client every 2 hours 5.GUILLAIN BARRE SYNDROME a disorder of the CNS characterized by bilateral symmetrical polyneuritis leading to ascending muscle paralysis. Diagnostic Procedures 1. Dysphagia 3. Anti Cholinergic Agents – Atrophine Sulfate c. Assist in plasma pharesis (filtering of blood to remove autoimmune anti-bodies) 9. intake and output c. monitor pulmonary function test 2. CSF analysis reveals increase in IgG and protein D. Alternate hypotension to hypertension ** ARRYTHMIA (most feared complication) 6. Maintain side rails to prevent injury related to fall 4. vital signs b. Signs and Symptoms 1. Assist in passive ROM exercise 7. increase sweating c. Maintain patent airway and adequate ventilation by: a. Autoimmune 2. Anti Arrythmic Agents Lidocaine. Arrythmia b. Administer medications as ordered a. Paralysis or respiratory muscles/Respiratory arrest * Sengstaken Blakemore Tube for liver cirrhosis to decompress bleeding esophageal verices (prepare scissor to cut tube incase of difficulty in breathing to release air in the balloon for hemodialysis prepare bulldog clips to prevent air embolism. Monitor strictly the following a. Nursing Management 1. Decreased of diminished deep tendon reflex 5. assist in mechanical ventilation b. A. Prevent complications a. Zylocaine Bretylium – blocks release of norepinephrine to prevent increase of BP 8. . Autonomic symptoms that includes a.
Predisposing Factors 1. Generalized Seizure 1. clouding of consciousness – not in contact with environment c. EEG – reveals hyper activity of electrical brain waves . olfactory. Partial or Localized Seizure 1. Valium) B. Status Epilepticus A continuous uninterrupted seizure activity. Presence of brain tumor 4. if left untreated can lead to hyperpyrexia and lead to coma and eventually death. Psychomotor Seizure (focal motor seizure) a. Genetics 3.direct symmetrical extension of extremities Clonic contractions . Signs and Symptoms Dependent on stages of development or types of seizure I. Nutritional and Metabolic deficiencies 6. twitching of mouth d. Drug of choice: Diazepam. loss of consciousness (5 – 10 seconds) II. Post ictal sleep – unresponsive sleep 2. Signs or aura with auditory. automatism – stereotype repetitive and non propulsive behavior b. Tonic contractions . 2. blank stare b. Diagnostic Procedures 1. visual. CT Scan – reveals brain lesions 2. Seizure – first convulsive attack Epilepsy – second or series of attacks Febrile seizure – normal in children age below 5 years A. Head injury due to birth trauma 2.contraction of extremities d. Toxicity from a. mild hallucinatory sensory experience III. Grand mal Seizure (tonic-clonic seizure) a. tactile. Petit mal Seizure – absence of seizure common among pediatric clients characterized by a. Physical and emotional stress 7. Sudden withdrawal to anti convulsant drug is predisposing factor for status epilepticus (drug of choice is Diazepam. sensory experience b. Valium and Glucose 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. decrease blinking of eyes c. 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. lead b carbon monoxide 5. Epileptic cry – is characterized by fall and loss of consciousness for 3 – 5 minutes c.
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
Epinephrine eyedrops – decrease formation of aqueous humor 3. TRABECULECTOMY (Peripheral Indectomy) – drain aqueous humor 2. Aging 65 years and above 2. Pathognomonic Signs 1. Diagnostic Procedure 1.Total removal of cataract with its surrounding capsules Most feared complication post op is RETINAL DETACHMENT 3.Partial removal Intra Capsular Cataract Lens Extraction . Opthalmoscopic exam E. Cataract Decrease opacity of lens A. Diabetes Mellitus 4. Predisposing Factor 1. Decrease perception to colors Complication is blindness D. Loss of central vision C. Prolonged exposure to UV rays B. Gonioscopy D. Surgical Procedure Extra Capsular Cataract Lens Extraction . Carbachol 2. Cyclopegics (Cyclogyl) – paralyses cilliary muscle F. Signs and Symptoms 1. Surgical Procedures 1. Pilocarpine Sodium. Carbonic Anhydrase Inhibitors a.3. Timoptics (Timolol Maleate) E. Related to congenital 3. Miotics – constricts pupil a. Blurring or hazy vision 2. Treatment 1. Mydriatics (Mydriacyl) – constricts pupils 2. Acetazolamide (Diamox) – promotes increase outflow of aqueous humor or drainage 4. Treatment 1. Milky white appearance at center of pupils 3. Retinal Detachment Separation of epithelial surface of retina .
Signs and Symptoms 1. VI: OCULOMOTOR. Scleral Buckling 2. mandibular . Black Spots CRANIAL NERVE III. Predisposing Factors 1. Post Lens Extraction 2. Cryosurgery – cold application 3. Myopia (near sightedness) B. Diathermy – heat application 4. Curtain veil like vision 2.A. 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. TROCHLEAR. IV. Macular Degeneration Degeneration of the macula lutea (yellowish spot at the center of retina) A. Signs and Symptoms 1. Surgical Procedures 1. Floaters C. maxillary.
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. VAGUS NERVE Glosopharyngeal: controls taste. contains the Organ of Corti (the true organ of hearing) Let client repeat words uttered CRANIAL NERVE IX. sensory: controls sensation of face. X: GLOSOPHARYNGEAL. teeth. CRANIAL NERVE VIII: ACOUSTIC/VESTIBULOCOCHLEAR Controls balance particularly kinesthesia or position sense. 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. Outer Ear Pinna Eardrum Hammer Anvil Stirrup Malleus Incus Stapes 2. Inner Ear Vestibule: Meinere’s Disease Cochlea Mastoid Cells Endolymph and Perilymph COCHLEA: controls hearing. Pituitary Gland (Hypophysis Cerebri) . ENDOCRINE SYSTEM Overview of the structures and functions 1. 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. refers to movement and orientation of the body in space. frown and if results are negative there is facial paralysis or Bell’s Palsy and the primary cause is forcep delivery. mucous membrane. Middle Ear 3. Parts of the Ear 1.
Posterior Pituitary Gland 2. Adult: thirst b.015 – 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. Polyuria 2. Administer medications as ordered a. Prevent complilcations – HYPOVOLEMIC SHOCK is the most feared complication Normal value: 1. Force fluids 2. Diagnostic Procedures 1. Monitor strictly vital signs and intake and output 3. Signs of dehydration a. Pitressin (Vasopresin Tannate) – administered IM Z-tract 4.030 Ph 4 – 8 Increase resulting to hypernatremia Related to pituitary surgery Trauma Inflammation Presence of tumor B. Weight loss 6. If left untreated results to hypovolemic shock (sign is anuria) C. Anterior Pituitary Gland o o o hemorrhage o o administrate oxytocin immediately after delivery to prevent uterine atony. Serum Sodium D. 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. Poor Skin turgor d.o o o Located at base of brain particularly at sella turcica Master gland or master clock Controls all metabolic function of body PARTS OF THE PITUITARY GLAND 1. Weakness and fatigue 4. Signs and Symptoms 2. Dry mucous membrane 3. Predisposing Factor o o o o 1. Urine Specific Gravity o o o 1. Nursing Management . Agitation c. Hypotension 5.
Loop diuretics (Lasix) b. Weigh patient daily and assess for pitting edema 5. 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. Osmotic diuretics (Mannitol) 3. Signs and Symptoms 1. Edema c. Head injury 2. Melanocyte Stimulating hormone o o o for skin pigmentation Hyposecretion of MSH results to Albinism Most feared complications of albinism a. Nursing Management 1. Adrenochorticotropic hormone (ACTH) o promotes development of adrenal cortex . intake and output and neuro check 4. Weight gain 2. Diagnostic Procedure 1. B. 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. Lead to blindness due to severe photophobia b. Hypertension b. Fluid retention a. Predisposing Factors 1. Related to hyperplasia (increase size of organ brought about by increase of number of cells) of pituitary 2. Restrict fluid 2. Related to presence of bronchogenic cancer o o gland. Monitor strictly vital signs. Prone to skin cancer o Hypersecretion of MSH results to Vitiligo 3. Administer medications as ordered a. Urine specific gravity is increased 2.SIADH o hypersecretion of anti diuretic hormone A. Provide meticulous skin care 6. Serum Sodium is decreased D.
turnips. all nuts soil erosion washes away iodine . radish. Follicle stimulating hormone PINEAL GLAND o o o secretes melatonin inhibits LH secretion it controls/regulates circadian rhythm (body clock) THYROID GLAND o located anterior to the neck 3 Hormones secreted 1.4. 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. Mountainous regions 2. cabbage. Leutinizing hormone 6. sweet potato.3 molecules of iodine (more potent) 2. T4 (tetra iodothyronine. carrots. broccoli. 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. Thyrocalcitonin – antagonizes the effects of parathormone to promote calcium resorption. Thyroxine) o o T3 and T4 are metabolic or calorigenic hormone promotes cerebration (thinking) 3. strawberry. places far from sea b. Increase intake of goitrogenic foods o o o contains pro-goitrin an anti thyroid agent that has no iodine. T3 (Tri iodothyronine) . Goiter belt area a.
Iron. Mild dysphagia 3. 3. clams and lobster but not shrimps because it contains lesser amount of iodine. Increase dietary intake of foods rich in iodine A. Phenylbutazones (NSAIDs) . Instruct client to take in the morning to prevent insomnia 2. Anti Thyroid Agent – Prophylthiuracil (PTU) b. Thyroid Scan – reveals enlarged thyroid gland. Related to atrophy of thyroid gland due to trauma. Enforce complete bed rest 2. Serum Thyroid Stimulating Hormone (TSH) – is increased (confirmatory diagnostic test) D. Thyroid Hormones o o o Levothyroxine (Synthroid) Liothyronine (Cytomel) Thyroid Extracts Nursing Management when giving Thyroid Hormones 1. best taken raw because it it is easily destroyed by heat 5. Assist in surgical procedure of subtotal thyroidectomy HYPOTHYROIDISM o o o hyposecretion of thyroid hormone adults: MYXEDEMA non pitting edema children: CRETINISM the only endocrine disorder that can lead to mental retardation 4.if goiter is caused by B. Signs and Symptoms 1. Iatrogenic Cause – disease caused by medical intervention such as surgery 2. Nursing Management 1. Diagnostic Procedures 1. Administer medications as ordered a. Monitor side effects o o o o o o o insomnia tachycardia and palpitations hypertension heat intolerance seaweeds seafood’s like oyster. iodized salt.o goitrogenic drugs a. inflammation . presence of tumor. Serum T3 and T4 – reveals normal or below normal 2. Lugol’s Solution/SSKI ( Saturated Solution of Potassium Iodine) o o color purple or violet and administered via straw to prevent staining of teeth. Nitrofurantoin (drug of choice for pyelonephritis) b. Tetracycline. Enlarged thyroid gland 2. 4 Medications to be taken via straw: Lugol’s. Cobalt e. Monitor vital signs especially heart rate because drug causes tachycardia and palpitations 3. crabs. Mild restlessness C. PASA (Aspirin) d. Lithium Carbonate c. Predisposing Factors 1.
Avoid precipitating factors leading to myxedema coma o o stress infection Assist in mechanical ventilation Administer thyroid hormones as ordered Force fluids . RAIU (Radio Active Iodine Uptake) is decreased D. Diagnostic Procedures 1. hyponatremia. Levothyroxine b. CNS changes o o o o lethargy memory impairment psychosis menorrhagia C. Provide comfortable and warm environment 7. hypoventilation. Nursing Management 1. Force fluids 3. bradypnea. Serum T3 and T4 is decreased 2. Dry skin 4. Cold intolerance 5. hypothermia leading to pregressive stupor and coma. Decrease libido 5. Provide dietary intake that is low in calories 6. bradycardia. Provide meticulous skin care 8. Signs and Symptoms (Early Signs) 1. Non pitting edema (Myxedema) 3. Constipation (Late Signs) 1. Decrease in all vital signs – hypotension. Weakness and fatigue 2.3. Leothyronine c. Nursing Management for Myxedema Coma 2. Serum Cholesterol is increased 3. Thyroid Extracts 5. Administer isotonic fluid solution as ordered 4. Hoarseness of voice 4. Provide client health teaching and discharge planning concerning a. hypothermia 6. 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. Loss of appetite but with weight gain which promotes lipolysis leading to atherosclerosis and MI 3. Autoimmune (Hashimotos Disease) B. hypoglycemia. Administer medications as ordered Thyroid Hormones a. bradypnea. bradycardia. Iodine deficiency 4. Brittleness of hair and nails 2.
Nursing Management 1. Diarrhea 5. Insomnia e. Heat intolerance 4. Tremors d. Irritability and agitation b. Thyroid Scan. narcotics. Maintain side rails . Provide dietary intake that is increased in calories. Autoimmune – it involves release of long acting thyroid stimulator causing exopthalmus (protrusion of eyeballs) enopthalmus (late sign of dehydration among infants) 2. All vital signs are increased 6. 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. Signs and Symptoms 1. 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. Increase appetite (hyperphagia) but there is weight loss 2. Restlessness c. Related to hyperplasia (increase size) B. Goiter 8. Exopthalmus 9.reveals an enlarged thyroid gland D. 4.o o o o o o o o cold intolerance use of anesthetics. RAIU (Radio Active Iodine Uptake) is increased 3. and sedatives prevent complications (myxedema coma. Prophythioracill (PTU) b. Amenorrhea C. Excessive iodine intake 3. Administer medications as ordered Anti Thyroid Agent a. Predisposing Factors 1. Serum T3 and T4 is increased 2. Diagnostic Procedures 1. Comfortable and cold environment 6. Provide meticulous skin care 5. Hallucinations 7. Monitor strictly vital signs and intake and output 2. CNS involvement a. Moist skin 3.
maintain side rails offer TSB Tachycardia 2. 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. 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 . Hormonal replacement therapy for lifetime 6. Anti Pyretics b. Beta-blockers o o o monitor strictly vital signs. seizure give Calcium Gluconate IV slowly as ordered 3. Watch out for signs of thyroid storm/ thyrotoxicosis Agitation TRIAD SIGNS Hyperthermia o administer medications as ordered a. 8. Signs of bleeding (feeling of fullness at incisional site) Nursing Management o Check the soiled dressings at the back or nape area. 5. Watch out for accidental 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. 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. POST OPERATIVELY.7. Provide bilateral eye patch to prevent drying of the eyes. input and output and neuro check.
dysphagia e. arrhythmia 2. laryngospasm/broncospasm h. numbness d. tumor c. Acute tetany a. agitation and memory impairment C. Chronic Tetany Oral Calcium supplements Calcium Gluconate Calcium Lactate Calcium Carbonate c.5 – 11 mg/100 ml) 2. Signs and Symptoms 1.A. inflammation b. Predisposing Factors 1.C MAD . photophobia and cataract formation b. X-ray of long bones reveals a decrease in bone density 4. tingling sensation b.5 – 4. loss of tooth enamel c. Vitamin D (Cholecalciferol) for absorption of calcium CHOLECALCIFEROL ARE DERIVED FROM Drug Diet (Calcidiol) Sunlight (Calcitriol) feared complications d. trauma B. Administer medications as ordered such as: a.5 mg/100 ml) 3. Chronic tetany a. Atrophy of parathyroid gland due to: a. CT Scan – reveals degeneration of basal ganglia D. Diagnostic Procedures 1. Phosphate binder Aluminum Hydroxide Gel (Ampogel) Side effect: constipation ANTACID A. Following subtotal thyroidectomy 2. Serum Phosphate is decreased (normal value: 2. positive chvostek sign g. Serum Calcium is decreased (normal value: 8. Acute Tetany Calcium Gluconate IV slowly b. anorexia. nausea and vomiting d.A. seizure i. paresthesia c. Nursing Management 1. positive trousseu’s sign/carpopedal spasm f.
Signs and Symptoms 1. green turnips 4. Serum Phosphate is decreased 3. salmon c. renal cholic b. Strain all the urine using gauze pad for stone analysis 3. Importance of follow up care. cool moist skin 3. Serum Calcium is increased 2. X-ray of long bones reveals bone demineralization D. Predisposing Factors 1. Provide acid ash in the diet to acidify urine and prevent bacterial growth 7. anchovies b. Maintain side rails . Bone pain especially at back (bone fracture) 2. Encourage increase intake of foods rich in calcium a. Administer medications as ordered a. Adults: Osteomalacia B. Force fluids to prevent kidney stones 2. Morphine Sulfate (Demerol) 5. Nursing Management 1. Over compensation of parathyroid gland due to vitamin D deficiency a. Anorexia. Avoid precipitating stimulus such as glaring lights and noise 3. 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. nausea and vomiting 4. Prepare trache set at bedside for presence of laryngo spasm 7. 6. Agitation and memory impairment C. Kidney stones a. Encourage increase intake of foods rich in phosphate but decrease in calcium 6. Institute seizure and safety precaution 5. Prevent complications 8. Hyperplasia of parathyroid gland 2.▼ Aluminum Containing Antacids ▼ Aluminum Hydroxide Gel ▼ Side Effect: Constipation ▼ Magnesium Containing Antacids ▼ Side Effect: Diarrhea 2. Children: Ricketts b. Diagnostic Procedures 1. Assist/supervise in ambulation 8. Hormonal replacement therapy for lifetime 9. Provide warm sitz bath 4. Encourage client to breathe using paper bag to produce mild respiratory acidosis result.
Zona Glumerulosa . Assist in surgical procedure known as parathyroidectomy 11.weight loss . Hormonal replacement therapy for lifetime 12. Decrease tolerance to stress 3. deficiency of neuromuscular function – Salt/Sex A.signs of dehydration . metabolic disturbance – Sugar b. Adrenal Cortex – outermost b. Predisposing Factors 1. Hypoglycemia – TIRED 2.hypotension .secretes traces of glucocorticoids and androgenic hormones . Hyponatremia .secretes glucocortocoids (cortisol) . Prevent complications (seizure and arrhythmia) 10. 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.Sugar 2.9. Fungal infections B. Zona Reticularis . Related to atrophy of adrenal glands 2.secretes mineralocorticoids (aldosterone) . Zona Fasciculata .function: controls glucose metabolism . Signs and Symptoms 1.function: promotes sodium and water reabsorption and excretion of potassium .Sex 3. fluid and electrolyte imbalance – Salt c. Importance of follow up care ADRENAL GLAND o o Located atop of each kidney 2 layers of adrenal gland a.function: promotes secondary sex characteristics .Salt ADDISON’S DISEASE o Hyposecretion of adreno cortical hormone leading to a.
Monitor side effects a. Mineralocorticoids (Flourocortisone) 5.4. Assist in mechanical ventilation. increase susceptibility to infection e. hypovolemic shock c. Loss of pubic and axillary hair 7. Hydrocortisone (Cortison) Nursing Management when giving steroids 1. FBS is decreased (normal value: 80 – 100 mg/dl) 2. hyponatremia leading to progressive stupor and coma Nursing Management for Addisonian Crisis 1. protein but decrease in potassium 6. . 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.sudden withdrawal to steroids b.5 – 4.infection .hypovolemic shock .arrhythmia 5. Force fluids 4. Hyperkalemia . increase calories. edema c. carbohydrates. avoid precipitating factor leading to addisonian crisis leading to .diarrhea . Nursing Management 1.administer steroids as ordered . Serum Potassium is increased (normal value: 3. Provide meticulous skin care 7. hypertension b.force fluids 2. Provide client health teaching and discharge planning a. Prednisone c. severe hypotension b.agitation . moon face appearance 4. Plasma Cortisol is decreased 3. Administer medications as ordered Corticosteroids a. prevent complications .5 meq/L) D. Taper dose (withdraw gradually from drug) 3. Administer isotonic fluid solution as ordered 3. Instruct client to take 2/3 dose in the morning and 1/3 dose in the afternoon to mimic the normal diurnal rhythm 2. Monitor strictly vital signs. Dexamethasone (Decadrone) b. Provide dietary intake.stress . hirsutism d. Bronze like skin pigmentation C. Decrease libido 6. Diagnostic Procedures 1.addisonian crisis . Serum Sodium is decrease (normal value: 135 – 145 meq/L) 4.
hormonal replacement for lifetime d. FBS is increased 2. Spinarolactone – potassium sparring diuretics 7. weight gain d. pendulous abdomen g. obese trunk f. Prevent complications (DM) 8. Assist in surgical procedure (bilateral adrenoraphy) 9. importance of follow up care CUSHING SYNDROME o Hypersecretion of adenocortical hormones A. hypertension b. Nursing Management 1. Serum Sodium is increased 4. Restrict sodium intake 5. constipation c. Importance of follow up care PANCREAS . Monitor strictly vital signs and intake and output 2. Weigh patient daily and assess for pitting edema 3. Hypernatremia a.c. Hypokalemia a. Predisposing Factors 1 Related to hyperplasia of adrenal gland 2. Increase masculinity among females B. Measure abdominal girth daily and notify physician 4. moon face appearance and buffalo hump e. Administer medications as ordered a. Diagnostic Procedures 1. Increase susceptibility to infections 3.Located behind the stomach . thin extremities 4. Serum Potassium is decreased C. Easy bruising 8. Hormonal replacement for lifetime 10. Acne and striae 7. U wave upon ECG (T wave hyperkalemia) 5. Provide meticulous skin care 6. weakness and fatigue b.Mixed gland (exocrine and endocrine) . edema c. Hirsutism 6. Plasma Cortisol is increased 3.
Polydypsia 3. Hyper 2. Polyphagia 5. Drugs a.Obese over 40 years old A. Incidence Rate .metabolic disorder characterized by non utilization of carbohydrates. Oral Hypoglycemic agents 2.Consist of acinar cells which secretes pancreatic juices that aids in digestion thus it is an exocrine gland . Polydypsia 4. Weight gain Type 2 (NIDDM) . nausea and vomiting 7. Glucosuria 6. Related to viruses 3.10% general population has type 1 DM B. Diet 3. Pancreatitis DIABETES MELLITUS . Weight loss 6. Predisposing Factors 1. Polyuria 3. Diet 3.. Complications 1.Adult onset . Predisposing Factors 1. protein and fat metabolism CLASSIFICATION OF DM Type 1 (IDDM) .Delta cells secretes somatostatin (function: antagonizes the effects of growth hormones) 3 Main Disorders of Pancreas 1. Treatment 1. Delayed/poor wound healing D. Pancreatic Tumor/Cancer 2. Polyuria 2. Blurring of vision 8. Anorexia. Non 4. Insulin therapy 2. Complication 1. Hereditary (total destruction of pancreatic cells) 2.Consist of islets of langerhans . Polyphagia 4. Incidence Rate . Related to carbon tetrachloride toxicity C. Diabetic Ketoacidosis D. Obesity – because obese persons lack insulin receptor binding sites .Beta cells secretes insulin (function: hypoglycemia) . Lasix b. Usually asymptomatic 2. Treatment 1. Steroids 4.90% of general population has type 2 DM B.Juvenile onset type . Signs and Symptoms 1. Osmolar 3.Brittle disease A. Exercise E.Maturity onset type . Glucosuria 5. Exercise E. Diabetes Mellitus 3.Has alpha cells that secretes glucagons (function: hyperglycemia) . Coma C. Signs and Symptoms 1. Increase susceptibility to infection 9. Ketotic 5.
Protein 3.Cholesterol . Carbohydrates 2. Fats ANABOLISM CATABOLISM Glucose Amino Acids Fatty Acids Glycogen Nitrogen Free Fatty Acids .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 .MAIN FOODSTUFF 1.
Decrease LOC – diabetic coma . Hct (normal value: female 36 – 42. Sodium Bicarbonate to counteract acidosis c.9 NaCl followed by . FBS is increased 2. Hyperglycemia 2. Assist in mechanical ventilation 2. Creatinine (normal value: . BUN (normal value: 10 – 20) 3. Insulin therapy (regular acting insulin/rapid acting insulin peak action of 2 – 4 hours) b. Monitor strictly vital signs. intake and output and blood sugar levels 4. Blurring of vision 8. Diagnostic Procedures 1. Anorexia. Infection B. Polydypsia 3. Polyuria 2. Seizure activity 4.Acute complication of type 1 DM due to severe hyperglycemia leading to severe CNS depression A. nausea and vomiting 7. Headache and dizziness 2.Non ketotic: absence of lypolysis (no ketones) A. Acetone breath odor 9. Nursing Management 1. Glucosuria 5.45 NaCl (hypotonic solutions) to counteract dehydration and shock 3. Polyphagia 4. Predisposing Factors 1. male 42 – 48) due to severe dehydration D. Kussmaul’s Respiration (rapid shallow breathing) 10 CNS depression leading to coma C. Signs and Symptoms 1.DIABETIC KETOACIDOSIS . Stress – number one precipitating factor 3.Hyperosmolar: increase osmolarity (severe dehydration) . Weight loss 6.8 – 1) 4. Administer medications as ordered a. Antibiotics to prevent infection HYPER OSMOLAR NON KETOTIC COMA . Administer 0. Signs and Symptoms 1. Restlessness 3.
Peak action is 16 – 24 hours C.Derived from beef and pork 2. Rotate insulin injection sites to prevent development of lipodystrophy 8. Intermediate Acting Insulin (cloudy) .Non Protamine Hagedorn Insulin (NPH) . Administer insulin either 45o – 90o depending on amount of clients tissue deposit 6. Types of Insulin 1. Place in refrigerator once opened 3.Frequently used type because it has less antigenicity property thus less allergic reaction 3.B.for DKA use rapid acting insulin b. intake and output and blood sugar levels 4. Rapid Acting Insulin (clear) . Assist in mechanical ventilation 2. Nursing Management 1. Long Acting Insulin (cloudy) . No need to aspirate upon injection 7. Animal sources . Monitor strictly vital signs. Antibiotics to prevent infection INSULIN THERAPY A.Stimulates the pancreas to secrete insulin A. Sources of Insulin 1. Insulin therapy (regular acting insulin peak action of 2 – 4 hours) . Lipodystrophy c. When mixing 2 types of insulin aspirate first the clear insulin before cloudy to prevent contaminating the clear insulin and promote proper calibration. Monitor for signs of local complications such as a. Avoid shaking insulin vial vigorously instead gently roll vial between palm to prevent formation of bubbles 4. Nursing Management for Insulin Injections 1. Administer at room temperature to prevent development of lipodystrophy (atrophy. Most accessible route is abdomen 9. Classsification 1.Regular acting insulin (IV only) . Tolbutamide (Orinase) . First Generation Sulfonylureas a.Peak action is 8 – 16 hours 3. Allergic reactions b.Peak action is 2 – 4 hours 2. 10. Administer medications as ordered a. hypertrophy of subcutaneous tissues) 2. Artificially Compound Insulin B. Chlorpropamide (Diabenase) b.Rarely used because it can cause severe allergic reaction . Somogyis Phenomenon – rebound effect of insulin characterized by hypoglycemia to hyperglycemia ORAL HYPOGLYCEMIC AGENTS .45 NaCl (hypotonic solutions) to counteract dehydration and shock 3.Ultra Lente . Use gauge 25 – 26 needle 5. Administer 0. Human Sources .9 NaCl followed by .
Glipzide (Glucotrol) b. Oral glucose tolerance test is increased – most sensitive test 4. intake and output and blood sugar levels 4. Instruct client to have an annual eye and kidney exam 10. Blood Forming Organs . Monitor for signs of DKA and HONKC 11. CVA) b. Instruct the client to take it with meals to lessen GIT irritation and prevent hypoglycemia 2. Second Generation Sulfonylureas a. Blood II. HPN and DM major cause of renal failure d. Random Blood Sugar is increased 3.for hypoglycemia (cold and clammy skin) give simple sugars .c. Monitor for peak action of insulin and OHA and notify physician 2. Nursing Management 1. Atherosclerosis (HPN. Monitor strictly vital signs. instruct client to avoid wearing constrictive garments d. Provide nutritional intake of diabetic diet that includes: carbohydrates 50%.Renal failure c. Monitor signs for complications a. Blood Vessels III. Diagnostic Procedures 1. protein 30% and fats 20% or offer alternative food substitutes 6. Instruct the client to avoid taking alcohol because it can lead to severe hypoglycemia reaction or Disulfiram (Antabuse) toxicity symptoms B. Microangiopathy (affects small minute blood vessels of eyes and kidneys) EYES -PREMATURE CATARACT . encourage client to apply lanolin lotion to prevent skin breakdown e. Institute foot care management a. Gangrene formation e.for hyperglycemia (dry and warm skin) 5. Alpha Glycosylated Hemoglobin is increased C. polydypsia. Tolamazide (Tolinase) 2.sexual impotence 8. Assist in surgical procedure HEMATOLOGICAL SYSTEM I. instruct client to cut toenails straight c. polyphagia and glucosuria confirmatory for DM) 2.administer simple sugars . Diabeta (Micronase) Nursing Management when giving OHA 1. Administer insulin and OHA therapy as ordered 3. Monitor for signs of hypoglycemia and hyperglycemia . MI. assist in surgical wound debriment (give analgesics 15 – 30 mins prior) 9. Shock due to dehydration . Instruct client to exercise best after meals when blood glucose is rising 7.Blindness KIDNEY -RECURRENT PYELONEPHRITIS .peripheral neuropathy .diarrhea/constipation . instruct client to avoid walking barefooted b. FBS is increased (3 consecutive times with signs or polyuria.
Albumin 2.hemoglobin: normal value female 12 – 14 gms% male 14 – 16 gms% .for parasite infections .only unnucleated cell . Globulins 3. Prothrombin and Fibrinogen 1.normal value: female 36 – 42% male 42 – 48% .hematocrit red cell percentage in wholeblood . intrinsic factor .Maintains osmotic pressure preventing edema GLOBULINS . vitamin c d. Lymphoid Organ 5.60 – 70% of WBC .substances needed for maturation of RBC a.largest WBC . bilirubin and hormones . vitamin b6 (pyridoxine) f.55% Plasma Serum 45% Formed 1. Spleen 4.macrophage in blood . Lymph Nodes 6. Non Granulocytes 1. prothrombin and fibrinogen clotting factors FORMED ELEMENTS 1. Veins Plasma CHON (formed in liver) 1.involved in short term phagocytosis for acute inflammation 2.Beta globulins – iron and copper .Largest and numerous plasma CHON . vitamin b12 (cyanocobalamin) e.Alpha globulins . Arteries 2. folic acid b.consist of molecules of hgb (red pigment) bilirubin (yellow pigment) biliverdin (green pigment) hemosiderin (golden brown pigment) . WBC (LEUKOCYTES) . RBC (ERYTHROCYTES) . Bone Marrow ALBUMIN . Polymorpho Neutrophils .normal value: 5000 – 10000/mm3 A. Monocytes . iron c.transport steroids.responsible for the release of chemical mediation for inflammation 3.transports and carries oxygen to tissues . Polymorphonuclear Basophils .Normal life span of RBC is 80 – 120 days and is killed in red pulp of spleen 2. Polymorphonuclear Eosinophils .Gamma globulins a.for allergic reaction B.normal value: 4 – 6 million/mm3 . anti-bodies and immunoglobulins b.biconcave discs . Granulocytes 1. Liver 3.
Lymphocytes B-cell T-cell .Normal life span of platelet is 9 – 12 days Signs of Platelet Dysfunction 1.ELISA . Heavy menstruation b. Common among women 15 – 35 years old 4.. Inadequate intake of iron due to a. Signs and Symptoms 1. Related to GIT bleeding resulting to hematemesis and melena (sign for upper GIT bleeding) c.drug of choice AZT (Zidon Retrovir) 2 Common fungal opportunistic infection in AIDS 1.involved in long term phagocytosis for chronic inflammation 2. Platelets (THROMBOCYTES) . Petechiae 2. Usually asymptomatic 2. Weakness and fatigue (initial signs) 3. Incidence Rate 1. Predisposing Factors 1.A chronic microcytic anemia resulting from inadequate absorption of iron leading to hypoxemic tissue injury A. Related to malabsorption syndrome c. Chronic diarrhea b. High cereal intake with low animal protein digestion d. Pneumocystis Carinii Pneumonia 3.Consist of immature or baby platelets or megakaryocytes which is the target of dengue virus .bone marrow . Common among developed countries 2. fresh blood per rectum is called hematochezia 2. Chronic blood loss due to trauma a. Related to improper cooking of foods C.Normal value: 150.000/mm3 .Promotes hemostasis (prevention of blood loss) . Related to poor nutrition B. Common among tropical zones 3. Kaposi’s Sarcoma 2.6 months window period .6 months – 5 years incubation period . Subtotal gastrectomy 4. Echhymosis 3.000 – 450.thymus for immunity Natural killer cell .western blot opportunistic .anti viral and anti tumor property HIV . Oozing of blood from venipunctured site BLOOD DISORDERS Iron Deficiency Anemia . Headache and dizziness .
Palpitations 7. Dyspnea 6. Sweet potatoes e. Nursing Management 1. Sorbitex (IM) Nursing Management when giving parenteral iron preparations 1. Pallor and cold sensitivity 5.Nitrofurantoin (Macrodentin) 3.4. Reticulocyte is decreased 6. RBC is decreased 2. Anorexia b.300 mg/day Nursing Management when taking oral iron preparations 1. Dried fruits f. Diagnostic Procedures 1. Nausea and vomiting c. Hct is deceased 4. Instruct client to take foods rich in iron a. Brittleness of hair and spoon shape nails (koilonychias) 8. Hgb is decreased 3. Iron is decreased 5. Legumes g. When diluting it in liquid iron preparations administer with straw to prevent staining of teeth Medications administered via straw . Monitor for signs of bleeding of all hema test including urinw. Nuts 4. Monitor side effects a. Melena 5.Dysphagia 9. PICA (abnormal appetite or craving for non edible foods D. Administer with Vitamin C or orange juice for absorption 4.Iron . Ferrous Fumarate c. Diarrhea/constipation e. Monitor and inform client of side effects a. Instruct client to take with meals to lessen GIT irritation 2. Enforce CBR so as not to over tire client 3. Atropic Glossitis (inflammation of tongue) . stool and GIT 2. Iron Dextran (IM.Stomatitis . Pain at injection site PLUMBER VINSON’S SYNDROME . Administer Z tract technique to prevent discomfort. Ferritin is decreased E. If client cant tolerate/no compliance administer parenteral iron preparation a. discoloration and leakage to tissues 2. Organ meat b. Avoid massaging the injection site instead encourage to ambulate to facilitate absorption 3. Egg (yolk) c. IV) b. Ferrous Gluconate . Abdominal pain d. Administer medications as ordered Oral Iron Preparations a.Lugol’s solution . Raisin d.Tetracycline . Instruct the client to avoid taking tea and coffee because it contains tannates which impairs iron absorption 5. Ferrous Sulfate b.
Never given orally because there is possibility of developing tolerance Secretes hydrochloric acid ▼ Aids in digestion . Diagnostic Procedure Schilling’s Test – reveals inadequate/decrease absorption of Vitamin B12 D. Localized abscess c. numbness c. tingling sensation b. GIT changes that includes a. weight loss e.Chronic anemia characterized by a deficiency of intrinsic factor leading to hypochlorhydria (decrease hydrochloric acid secretion) A. paresthesia d. mouth sore b. Headache and dizziness 3. CNS changes a.b. Dyspnea and palpitations as part of compensation 5. indigestion/dyspepsia d. positive to Romberg’s test – damage to cerebellum resulting to ataxia e. jaundice 6. result to psychosis C. Predisposing Factors 1. Pruritus/orticaria g. Nursing Management 1. Hypotension (anaphylactic shock) PERNICIOUS ANEMIA . Autoimmune 5. Administer Vitamin B12 injections at monthly intervals for lifetime as ordered . Inflammatory disorders of the ileum 4. red beefy tongue c. Weakness and fatigue 2. Skin rashes f. Lymphadenopathy d. Subtotal gastrectomy 2. Pallor and cold sensitivity 4. Fever and chills e. Strictly vegetarian diet STOMACH ▼ Pareital cells/ Argentaffin or Oxyntic cells Produces intrinsic factors ▼ Promotes reabsorption of Vit B12 ▼ Promotes maturation of RBC B. Signs and Symptoms 1. Enforce CBR 2. Hereditary factors 3.
fever Decrease WBC (leucopenia) Decrease Platelet (thrombocytopenia) . Nursing Management 1. CBC reveals pancytopenia 2. Vincristine (Plant Alkaloid) c. Chemicals (Benzine and its derivatives) 2. Thrombocytopenia a.Site of injection for Vitamin B12 is dorsogluteal and ventrogluteal . Headache and dizziness c. Enforce CBR 5.Stem cell disorder leading to bone marrow depression leading to pancytopenia PANCYTOPENIA Decrease RBC (anemia) A. Anemia a. Chloramphenicol (Sulfonamides) Chemotherapeutic Agents a. Immunologic injury 4. Diagnostic Procedures 1. Pallor and cold sensitivity d. Oozing of blood from venipunctured sites C.. Predisposing Factors 1. Ecchymosis c. Administer oxygen inhalation 4. Signs and Symptoms 1. Leukopenia a. Petechiae (multiple petechiae is called purpura) b. Increase susceptibility to infection 3.No side effects 3. Avoid heat application to prevent burns APLASTIC ANEMIA . Drugs Broad Spectrum Antibiotics a. vitamin c and iron 4. Dyspnea and palpitations 2. Institute reverse isolation 6. Monitor for signs of infection a. Related to irradiation/exposure to x-ray 3. protein. Bone marrow biopsy/aspiration (site is the posterior iliac crest) – reveals fat necrosis in bone marrow D. Instruct client to avoid irritating mouth washes instead use soft bristled toothbrush 5. Removal of underlying cause 2. Nitrogen Mustard (Antimetabolite) Phenylbutazones (NSAIDS) B. Methotrexate (Alkylating Agent) b. Weakness and fatigue b. Institute BT as ordered 3. Provide a dietary intake that is high in carbohydrates.
Septecemia 6. subcutaneous. Provide heparin lock 7. Force fluids 5. ABG analysis reveals metabolic acidosis 4. Administer medications as ordered a.b. Massive burns 3. Neoplasia (new growth of tissue) 7. Monitor NGT output 9. Stool occult blood positive 3. Anaphylaxis 5. Administer isotonic fluid solution as ordered 3. Predisposing Factors 1. Oozing of blood from punctured sites 4. Related to rapid blood transfusion 2. Massive trauma 4. Prevent complication . Administer oxygen inhalation 4. Vitamin K b. Nursing Management 1. Immunosuppressants Anti Lymphocyte Globulin ▼ Given via central venous catheter ▼ Given 6 days to 3 weeks to achieve Maximum therapeutic effect of drug DISSEMINATED INTRAVASCULAR COAGULATION Acute hemorrhagic syndrome characterized by wide spread bleeding and thrombosis due to a deficiency of prothrombin and fibrinogen A. Corticosteroids – caused by immunologic injury b. Heparin/Coumadin is ineffective 6. Opthamoscopic exam reveals sub retinal hemorrhages D. Avoid IM. Pitressin/ Vasopresin to conserve fluids c. Diagnostic Procedures 1. venipunctured sites 8 Instead provide heparin lock 9. Institute NGT decompression by performing gastric lavage by using ice or cold saline solution of 500 – 1000 ml 8. Oliguria (late sign) C. Instruct client to use electric razor when shaving 10. lungs and lower extremities 2. Petechiae (widespread and systemic) eye. cough 7. Hemoptysis 6. Administer medications as ordered a. CBC reveals decreased platelets 2. Monitor for signs of bleeding of all hema test including stool and GIT 2. Pregnancy B. Ecchymosis 3. Signs and Symptoms 1.
85% of population is RH positive 3. 6. Aseptically assemble all materials needed for BT a. Prevent infection in there is a decrease in WBC 4.Emergency rapid BT is given after 30 minutes and let natural room temperature warm the blood. Increase the oxygen carrying capacity of blood 3. Hypovolemic shock b. Check the blood unit for bubbles cloudiness. Cytrate intoxication h.Expiration of platelet is 3 – 5 days 2. Type O – universal donor b. Blood typing and cross matching c. Isotonic solution (0.Expiration of packed RBC is 3 – 6 days .Never warm blood as it may destroy vital factors in blood. Client name b. Filter set b.9 NaCl/plain NSS) to prevent hemolysis 4.Warming is only done during emergency situation and if you have the warming device . Prevent bleeding if there is platelet deficiency Principles of blood transfusion 1. Hemolytic reaction b. Hyperkalemia (caused by expired blood) . Pyrogenic reaction d. 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. Instruct another RN to re check the following a. Monitor strictly vital signs before. Thrombocytopenia g. Serial number 5. sediments and darkness in color because it indicates bacterial contamination . Regulate BT 10 – 15 gtts/min or KVO rate or equivalent to 100 cc/hr to prevent circulatory overload 9. Air embolism f. Avoid mixing or administering drugs at BT line to prevent HEMOLYSIS 8. Gauge 18 – 19 needle c. Proper typing and cross matching a. . Replace circulating blood volume 2. Circulatory overload e. Proper refrigeration . Type AB – universal recipient c. Expiration date d. during and after BT especially every 15 minutes for first hour because majority of transfusion reaction occurs during this period a. Anuria – late sign BLOOD TRANSFUSION Goals/Objectives 1. Allergic reaction c.a.
Dyspnea 3. Send the blood unit to blood bank for re examination 6. Palpitations 5. Tachycardia 4. Hypotension 5. Diarrhea/Constipation 4. Monitor vital signs and intake and output SIGNS AND SYMPTOMS OF ALLERGIC REACTION 1. Headache 3. Stop BT 2. Notify physician 3. Stop BT 2. Fever and chills 2. Notify physician 3. Administer medications as ordered a.Signs and Symptoms of Hemolytic reaction 1. Stop BT 2. Urine is color red/ portwine urine Nursing Management 1. Dyspnea 3. Send the blood unit to blood bank for re examination 6. Flush with plain NSS 4. Flush with plain NSS . Headache and dizziness 2. Obtain urine and blood sample and send to laboratory for re examination 7. Laryngospasm and Broncospasm Nursing Management 1. Urticaria 6. Lumbasternal/ Flank pain 7. Flushed skin 6. Obtain urine and blood sample and send to laboratory for re examination 7. Notify physician 3. Dyspnea Nursing Management 1. Monitor vital signs and intake and output SIGNS AND SYMPTOMS PYROGENIC REACTIONS 1. Diaphoresis 6. Flush with plain NSS 4. anaphylactic shock treat with Epinephrine 5. Skin rashes 5. Broncial wheezing 4. Anti Histamine (Benadryl) . Fever 2.if positive to hypotension. Administer isotonic fluid solution to prevent shock and acute tubular necrosis 5.
Visceral – inner layer .Located on the left mediastinum . Ventricles . Myocardium – middle layer 3.Resemble like a close fist .In order to propel blood to the systemic circulation . Obtain urine and blood sample and send to laboratory for re examination 7.Muscular pumping organ of the body. Administer medications as ordered a. Cardiac tamponade A. Antipyretic b. Upper Chamber (connecting or receiving) a.Right atrium has decreased pressure which is 60 – 80 mmHg C. Dyspnea 3.Left ventricle has increased pressure which is 120 – 180 mmHg . Parietal – outer layer b. Valves . Administer medications as ordered a.Covered by a serous membrane called the pericardium 2 layers of pericardium a.Common among MI. Monitor vital signs and intake and output 8. Antibiotic 5.Prevent pericardial friction rub . Chambers of the Heart 1.4. Send the blood unit to blood bank for re examination 6. Render TSB SIGNS AND SYMPTOMS OF CIRCULATORY REACTION 1. . Orthopnea 2.In between is the pericardial fluid which is 10 – 20 cc .To promote unidimensional flow or prevent backflow 1. Rales/Crackles upon auscultation 4. Stop BT 2. Exertional discomfort Nursing Management 1. Loop diuretic (Lasix) CARDIOVASCULAR SYSTEM OVERVIEW OF THE STRUCTURE AND FUNCTIONS OF THE HEART HEART . Layers of Heart 1. Lower Chamber (contracting or pumping) a. Atrioventricular Valves – guards opening between a. Epicardium – outer layer 2. Endocardium – inner layer .Myocarditis can lead to cardiogenic shock and rheumatic heart disease B. pericarditis. Notify physician 3.Weighs approximately 300 – 400 grams . Atria 2. tricuspid valve .
Atrio – Ventricular Node (AV or Tawara Node) . Cardiac Conduction System 1.Located at the inter atrial septum .Closure of SV valve give rise to second heart sound (S2 “dub”) Extra Heart Sounds 1.T WAVE (ventricular repolarization) .b. Bundle of His .Arises from base of the aorta Types of Coronary Arteries 1.Located at the walls of the ventricles for ventricular contraction SA NODE AV NODE BUNDLE OF HIS JLJLJLJJLJLJL PURKINJE FIBERS . Sino – Atrial Node (SA or Keith Flack Node) . Purkinje Fibers .Located at the interventricular septum 4.Left Main Bundle of His .Closure of AV valves give rise to first heart sound (S1 “lub”) 2. Right Main Coronary Artery 2.P WAVE (atrial depolarization) contraction . aortic . Coronary Arteries .Delay of electrical impulse for about . S4 – atrial gallop usually seen in Myocardial Infarction and Hypertension D.Initiates electrical impulse of 60 – 100 bpm 2.08 milliseconds to allow ventricular filling 3. Left Main Coronary Artery .Supplies the myocardium E. pulmonic b. S3 – ventricular gallop usually seen in Left Congestive Heart Failure 2.Right Main Bundle of His .Acts as primary pacemaker of the heart . mitral valve .QRS WAVE (ventricular depolarization) . Semi – lunar Valves a.Located at the junction of superior vena cava and right atrium .
Obesity 5. Diabetes Mellitus 8. Predisposing Factors 1. Positive U wave . Dyspnea 3. Chest pain 2. Type A personality B. Sex – male 2.tunica intima A. Race – black 3. T wave inversion – Myocardial Infarction 6. ST segment depression – Angina Pectoris 4.tunica media .Atherosclerosis 2.lipid or fat deposits . sedentary lifestyle 7. Hypothyroidism 9. Widening of QRS complexes – Arrythmia CARDIAC DISORDERS Coronary Arterial Disease/ Ischemic Heart Disease Stages of Development of Coronary Artery Disease 1. 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. Tachycardia 4. To prevent angina 3. Myocardial Necrosis – Myocardial Infarction ATHEROSCLEROSIS ATHEROSCLEROSIS . Myocardial Injury .Hypokalemia 2. Myocardial Ischemia – Angina Pectoris 3. Increase survival rate ARTERIOSCLEROSIS . Treatment Percutaneous Transluminal Coronary Angioplasty Objectives of PTCA 1. Diet – increased saturated fats 10. Hyperlipidemia 6. Duaphoresis C. ST segment elevation – Myocardial Infarction 5.narrowing of artery . Peak T wave – Hyperkalemia 3.calcium and protein deposits .hardening of artery . Signs and Symptoms 1. Palpitations 5. Smoking 4. Revascularize myocardium 2.
Race – black 3. Precipitating Factors 4 E’s of Angina Pectoris 1.If there is 2 or more occluded blood vessels CABG is done Coronary Arterial Bypass And Graft Surgery 3 Complications of CABG 1. Type A personality B. arms. Diagnostic Procedure 1. Hyperlipidemia 6.Give first dose of NTG (sublingual) 3 – 5 minutes . Shock 3. Smoking 4. Excessive intake of foods rich in saturated fats – skimmed milk C. Diet – increased saturated fats 10. excitement 4. but in large doses will act as vasodilator . anxiety.5 minutes . usually relieved by rest or taking nitroglycerine 3. Palpitations 6. Tachycardia 5. Diabetes Mellitus 8. reveal abnormal ECG 4. Serum cholesterol and uric acid is increased E. Diaphoresis D. axilla and jaw muscles. Hypothyroidism 9.. Excessive physical exertion – heavy exercises 2. shoulder. Sex – male 2. Extreme emotional response – fear. Nursing Management 1. Pneumonia – encourage to perform deep breathing. Nitroglycerine (NTG) – when given in small doses will act as venodilator. Predisposing Factors 1. Dyspnea 4. Levine’s Sign – initial sign that shows the hand clutching the chest 2.Done to single occluded vessels . 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. Stress test – treadmill test. History taking and physical exam 2. coughing exercise and use of incentive spirometer 2. Enforce complete bed rest 2. Administer medications as ordered a.Give second dose of NTG if pain persist after giving first dose with interval of 3 . ECG tracing reveals ST segment depression 3. Obesity 5. Chest pain characterized by sharp stabbing pain located at sub sterna usually radiates from back. sedentary lifestyle 7. Signs and Symptoms 1. Exposure to cold environment 3.
Place client on semi fowlers position 5.Not given to COPD cases because it causes bronchospasm c. 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. Transmural Myocardial Infarction – most dangerous type characterized by occlusion of both right and left coronary artery 2. Smoking 4. Instruct client to take medication before indulging into physical exertion to achieve the maximum therapeutic effect of drug d. Types 1. Race – black 3. Beta-blockers . Sex – male 2.NIfedipine 3. Prevent complication (myocardial infarction) c. Provide decrease saturated fats sodium and caffeine 7. The importance of follow up care MYOCARDIAL INFARCTION Heart attack Terminal stage of coronary artery disease characterized by malocclusion. ACE Inhibitors .side effects PNS . intake and output and ECG tracing 6. 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. Calcium Antagonist . necrosis and scarring. Monitor strictly vital signs. Avoidance of 4 E’s b. Provide client health teachings and discharge planning a..Propanolol . Hyperlipidemia .Enalapril d. A.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. Subendocardial Myocardial Infarction – characterized by occlusion of either right or left coronary artery B. Obesity 5. Administer oxygen inhalation 4. Predisposing Factors 1.
S4 or atrial gallop E. Type A personality D.Not usually relieved by rest or by nitroglycerine 2. Serum Cholesterol and uric acid are both increased 5. Enforce CBR without bathroom privileges a. axilla. Increase in blood pressure (initial sign) 4. Rales/Crackles upon auscultation d. 12 – 24 hours b. Troponin Test – is increased 3. Place client on semi fowlers position . Mild restlessness and apprehension 7. Using bedside commode 4. LDH – Lactic acid dehydroginase is increased c. Pericardial friction rub b. Hyperthermia 5.Heart only. Split S1 and S2 c. Decrease myocardial workload (rest heart) .Antidote: Narcan/Naloxone . CBC – increased WBC F.Usually radiates from back. viselike pain located at substernal and rarely in precordial . shoulder.6.Creatinine phosphokinase is increased . CPK – MB . Ashen skin 6. Signs and Symptoms 1. Diagnostic Procedure 1. Administer oxygen low inflow to prevent respiratory arrest at 2 – 3 L/min 3. T wave inversion c. Chest pain . jaw and abdominal muscles (abdominal ischemia) .Administer narcotic analgesic/morphine sulfate . SGPT – Serum glutamic pyruvate transaminase is increased d.Excruciating visceral. Hypothyroidism 9. Widening of QRS complexes indicates that there is arrhythmia in MI 4. Occasional findings a. SGOT – Serum glutamic oxal-acetic transaminase is increased 2. Diabetes Mellitus 8.Side Effects: respiratory depression . arms. Cardiac Enzymes a. ECG tracing reveals a.Side Effects of Naloxone Toxicity is tremors 2. Nursing Management Goal: Decrease myocardial oxygen demand 1. Diet – increased saturated fats 10. sedentary lifestyle 7. ST segment elevation b. Dyspnea 3. Instruct client to avoid forms of valsalva maneuver 5.
late sign is oliguria c. pruritus . Encourage client to take 20 – 30 cc/week of wine. Cardiogenic shock .Contraindication Dengue Peptic Ulcer Disease Unknown cause of headache 10. Thrombophlebitis .ISD (Isosorbide Dinitrate.TIPAF (tissue plasminogen activating factor) . Anti Arrythmic Agents . Thrombolytics/ Fibrinolytic Agents . Provide a general liquid to soft diet that is low in saturated fats. Stroke/CVA . Provide client health teaching and discharge planning concerning a. Administer medication as ordered a. Avoidance of modifiable risk factors .Monitor for bleeding time g.Nitroglycerine . Vasodilators . Anti Coagulant .Streptokinase . sodium and caffeine 8. Monitor strictly vital signs. whisky and brandy to induce vasodilation 9. Beta-blockers d.Lidocaine (Xylocane .Side Effects: chest pain . intake and output and ECG tracing 7.Side Effects of Aspirin Tinnitus Heartburn Indigestion/Dyspepsia . ACE Inhibitors e.6.Antidote: Vitamin K h. Left Congestive Heart Failure d.arrhythmia (caused by premature ventricular contraction) b. Isodil) sublingual b.Brutylium c.Coumadin/ Warfarin Sodium (check for prothrombin time) .Urokinase .PASA (Aspirin) .homan’s sign e. Calcium Antagonist f.Antidote: protamine sulfate . Anti Platelet .Side Effects: confusion and dizziness .Side Effects: allergic reaction.Heparin (check for partial thrombin time) .Anti thrombotic effect .
A beta-hemolytic streptococcus . There is anorexia and generalized body malaise 12. Predisposing Factors 1. Aging 2. Productive cough with blood tinged sputum 5. Diagnostic Procedure 1.Aspirin b. Signs and Symptoms 1.Formation of aschoff bodies in the mitral valve . Bronchial wheezing 9. administer 150. RHD – inflammation of mitral valve due to invasion of Grp. Aortic valve stenosis B. Cyanosis 7. 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. Pulsus Alternans – weak pulse followed by strong bounding pulse 10. Frothy salivation 6. Rales/Crackles 8. PCO2 is increased (respiratory acidosis) 2.f.Common among children .instruct client to assume a non weight bearing position .client can resume sexual intercourse if can climb staircase . PMI is displaced laterally due to cardiomegaly 11. Ecocardiography – enlarged heart chamber (cardiomyopathy). dependent on extent of heart failure 4. S3 – ventricular gallop C. Paroxysmal nocturnal dyspnea – client is awakened at night due to difficulty of breathing 3.make sex as an appetizer rather than dessert . post CABG and instruct to . Hypertension 5.000 – 450.client is resistant to pharmacological agents. Resumption of ADL particularly sexual intercourse is 4 – 6 weeks post cardiac rehab. Orthopnea – use 2 – 3 pillows when sleeping or place in high fowlers 4. RIGHT SIDED HEART FAILURE . Post MI Syndrome/Dressler’s Syndrome .000 units of streptokinase as ordered g. 90% is mitral valve stenosis due to a. 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. ABG – reveals PO2 is decreased (hypoxemia). Dyspnea 2.ASO Titer (Anti streptolysin O titer) . LEFT SIDED HEART FAILURE A.dietary modification h. Myocardial Infarction 3.Penicillin . Ischemic heart disease 4. Chest x-ray – reveals cardiomegaly 2.
Pitting edema 3. Chest x-ray – reveals cardiomegaly 2. Related to COPD 4. Ecocardiography – reveals enlarged heart chambers (cardiomyopathy 4.Morphine Sulfate e. 3 – 4 L/min.CVP fluid status measure . Ascites 4.Do the fluid challenge (increase IV flow rate) . Pruritus 8. Nursing Management Goal: increase cardiac contractility thereby increasing cardiac output (3 – 6 L/min) 1.When reading CVP patient should be flat on bed .Administer loop diuretics as ordered . Anorexia 9. Weight gain 5. Signs and Symptoms (venous congestion) 1. Neck/jugular vein distension 2.A. Cardiac glycosides .Lasix (Furosemide) c. Pulmonary embolism 3.Measure pressure in right atrium (4 – 10 cm of water) . Pulmonic valve stenosis 5.If CVP is more than 10 cm of water hypervolemic shock .Increase force of cardiac contraction . Jaundice 7. Esophageal varices C. High fowlers position . Enforce CBR 2. delivered via nasal cannula 4. Liver enzymes – SGPT and SGOT is increased D. Predisposing Factors 1.Digoxin (Lanoxin) . Central venous pressure (CVP) . Tricuspid valve stenosis 2. Loop Diuretics . Hepatosplenomegaly 6.Lidocaine (Xylocane) 3.Nitroglycerine f. Vasodilators . Diagnostic Procedures 1. Administer oxygen inhalation with high inflow. Narcotic analgesics .Upon insertion place client in trendelendberg position to promote ventricular filling and prevent pulmonary embolism 3. Administer medications as ordered a. Anti Arrhythmic .If CVP is less than 4 cm of water hypovolemic shock .If heart rate is decreased do not give b. Bronchodilators d. Left sided heart failure B.
Oscillometry – decrease in peripheral pulses 2. Doppler UTZ – decrease blood flow to the affected extremity 3. Predisposing Factors 1. out of bed 3 – 4 times a day 2. Smoking B. Strict compliance to medications PERIPHERAL VASCULAR DISORDER Arterial Ulcer I. walking 3 – 4 times a day b.Thrombophlebitis b. Nursing Management 1. cyanosis then rubor) 3. Thrombo Angitis Obliterans Venous Ulcer 1.5. Dietary modification c. Varicose Veins 2. Analgesics Burger’s Disease Reynaud’s Disease . Prevent complications . Trophic changes 5. Signs and Symptoms 1.MI . Encourage a slow progressive physical activity a. Ulceration 6. High risk groups – men 30 years old and above 2. intake and output and ECG tracing 6. Monitor strictly vital signs. Provide a dietary intake of low sodium. Measure abdominal girth daily and notify physician 7. Gangrene formation C. Assist in bloodless phlebotomy – rotating tourniquet. Administer medications as ordered a. Diagnostic Procedures 1.Arrythmia . rotated clockwise every 15 minutes to promote decrease venous return 10. Angiography – reveals site and extent of malocclusion D. Provide meticulous skin care 9. Thrombophlebitis (deep vein thrombosis) THROMBOANGITIS OBLITERANS Acute inflammatory disorder usually affecting the small medium sized arteries and veins of the lower extremities A. Decreased peripheral pulses 4. Intermittent claudication – leg pain upon walking 2.Shock . cholesterol and caffeine 8. Provide client health teaching and discharge planning a. Cold sensitivity and changes in skin color (pallor.Right ventricular hypertrophy .
Ulceration 5. Hereditary 2. Doppler UTZ – decrease blood flow to the affected extremity 2. Cold sensitivity and changes in skin color (pallor. Direct hand trauma a. Anti coagulants 3. Vasodilators c. Vasodilators 2. Predisposing Factors 1. Congenital weakness of veins 3. Rheumatoid Arthritis 4. Predisposing Factors 1. 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. Operating chainsaw B. Thrombophlebitis 4. Gangrene formation C. Signs and Symptoms 1. Piano playing b. Excessive typing c. Collagen diseases a. Institute foot care management 4. Diagnostic Procedures 1. Intermittent claudication – leg pain upon walking 2. cyanosis then rubor) 3.b. Trophic changes 4. Encourage to wear gloves 3. Instruct client to avoid smoking and exposure to cold environment 5. Cardiac disorder 5. Pregnancy . Smoking 3. Angiography – reveals site and extent of malocclusion D. Administer medications as ordered a. 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. SLE (butterfly rash) b. Analgesics b. High risk group – female 40 years old and above 2. Nursing Management 1.
Heaviness in legs C. Assist in surgical procedure a. Diagnostic Procedure 1. Warm to touch 4. Trendelenburg’s Test . Nursing Management . Warm to touch 3. Dilated tortuous skin veins 3. Pain after prolonged standing 2. Signs and Symptoms 1. Smoking 3. Predisposing Factors 1. Obesity 7. Venography 2. Post cannulation – insertion of various cardiac catheter 11. Pain at affected extremity 2. Measure the circumference of leg muscle to determine if swollen 3. Congestive heart failure 8. Analgesics 5. Venography 2. Chronic anemia 5. Prolonged standing or sitting B. Signs and Symptoms 1. Myocardial infarction 9.6. Elevate legs above heart level to promote increased venous return by placing 2 – 3 pillows under the legs 2. Dilated tortuous skin veins 4. Diabetes mellitus 7. B. Vein stripping and ligation (most effective) b.veins distends quickly in less than 35 seconds D. Post op complication 10. Prolong use of oral contraceptives – promotes lipolysis 6. Obesity 2. Angiography D. Nursing Management 1. Positive Hpman’s Signs – pain at the calf or leg muscle upon dorsi flexion of the foot C. Related to pregnancy 4. Increase in saturated fats in the diet. Sclerotherapy – can recur and only done in spider web varicosities and danger of thrombosis (2 – 3 years for embolism) THROMBOPHLEBITIS Deep vein thrombosis Inflammation of the veins with thrombus formation A. Wear anti embolic stockings 4. Diagnostic Procedure 1. Administer medications as ordered a.
Encourage to wear anti embolic stockings or knee elastic stockings 5.Decrease LOC • MURPHY’S SIGN is seen in clients with cholelithiasis. Elevate legs above heart level to promote increase venous return 2.Dizziness .Diaphoresis .Opening of larynx .Opens to allow passage of air . Monitor for signs of complications Embolism a. Analgesics b.For cough reflex Glottis .Sudden sharp chest pain .Cartillage .Consist of anastomosis of capillaries known as Keissel Rach Plexus (the site of nose bleeding) B.For phonation (voice production) .Serves as passageway of air going to the lungs .Headache .Right nostril . Anti Coagulant .Unexplained dyspnea .Restlessness b. Filtering of air 2. Administer medications as ordered a. Warming and moistening of air 3. cholecystitis characterized by pain at the right upper quadrant with tenderness RESPIRATORY SYSTEM OVERVIEW OF THE STRUCTURES AND FUCNTIONS OF THE RESPIRATORY SYSTEM I.Left nostril .Tachycardia .Serves as a muscular passageway for both food and air C. Upper Respiratory System 1.For gas exchange A. Trachea/Windpipe . Apply warm moist pack – to reduce lymphatic congestion 3. Cerebral .Separated by septum . Larynx .Heparin 6. Nose .The initial sign of complete airway obstruction is the inability to cough II. Humidification A.Palpitations . Pulmonary . Pharynx/Throat . Lower Respiratory System . Measure circumference of leg muscle to determine if swollen 4.Closes to allow passage of food going to the esophagus .Consist of cartilaginous rings .1.
Secretes surfactant . 10 segments) . Mode of Transmission 1.Left main bronchus C.Increase carbon dioxide is a powerful stimulant for breathing Type II Cells of Alveoli . Ingestion of an infected cattle with mycobacterium bovis 6.Prevent collapse of alveoli .Normal L/S ratio is 2:1 . Bronchus . aerobic and easily destroyed by heat or sunlight A.In premature infants 1:2 . Overcrowded places 3. PTB/Pulmonary Tuberculosis (Koch’s Disease) . Precipitating Factors 1.Composed of lecithin and spingomyelin .Right main bronchus .Serous membranes Pleural Cavity a. Pleural effusion c. night sweats 2.Infection of lung tissue caused by invasion of mycobacterium tuberculosis or tubercle bacilli . Hydrothorax (air and blood in pleural space Alveoli . gram negative.Give oxygen of less 40% in premature to prevent atelectasis and retrolental fibroplasias .Left lung (consist of 2 lobes.Decrease oxygen stimulates breathing . Pareital b. Malnutrition 2.retinopathy/blindness in prematurity Disorders of Respiratory System 1. Lungs .Diffusion (Dalton’s law of partial pressure of gases) Respiratory Distress Syndrome . Productive cough (yellowish sputum) .Site of tracheostomy B. Signs and Symptoms 1. Over fatigue 5.Site of gas exchange (CO2 and O2) . Virulence (degree of pathogenecity) of microorganism B. Pneumonia b.L/S ratio to determine lung maturity . Airborne transmission via droplet nuclei C. Alcoholism 4..Decrease surface tension . 8 segments) . Pleural fluid c. Low grade afternoon fever. Visceral With Pleuritic Friction Rub a.An acid fast.Right lung (consist of 3 lobes.
generalized body malaise 4.3. Anorexia. Institute strict respiratory isolation 3. Intensive phase .INH (Isonicotinic Acid Hydrazide) .Amikacin . Institute short course chemotherapy a.PZA is given for 2 months.Side Effect INH: peripheral neuritis/neuropathy (increase intake of Vitamin B6/Pyridoxine) .Kanamycin . Nursing Management 1.PZA (Pyrazinamide) .Reveals increase WBC E.Neomycin . Sputum Acid Fast Bacillus .Side Effect PZA: allergic reaction.Rifampicin (Rifampin) .WHO 10 – 14 mm induration. Mantoux Test (skin test) . Hemoptysis (chronic) D. Administer oxygen inhalation 4. 48 – 72 hours . Encourage deep breathing and coughing exercise 7. Standard phase .Side Effect Rifampicin: all bodily secretions turn to red orange color .Positive Mantoux test (previous exposure to tubercle bacilli but without active TB) 2. Comfortable and humid environment 9. Nebulize and suction when needed 8.DOH 8 – 10 mm induration. Chest X-ray . Diagnostic Procedure 1. CBC .Positive to cultured microorganism 3. Force fluids to liquefy secretions 5.Given everyday simultaneously to prevent resistance . hepatotoxicity.INH and Rifampicin is given for 4 months. nephrotoxicity .Side Effect Ethambutol: optic neuritis b. taken after meals to facilitate absorption .Gentamycin .Reveals pulmonary infiltrates 4. 48 – 72 hours . Enforce CBR 2.Purified protein derivative . taken before meals to facilitate absorption . Weight loss 5.Injection of streptomycin (aminoglycoside) . Dyspnea 6. Chest pain 7. Place client on semi fowlers position to promote expansion of lungs 6.PZA can be replaced by Ethambutol .
Elderly C. Etiologic Agents 1. Strict compliance to medications d.Chest x-ray confirms lung cancer 4. Weight loss 5. Bronchogenic Cancer . Prevent complications (atelectasis. Importance of follow up care PNEUMONIA Inflammation of the lung parenchyma leading to pulmonary consolidation as the alveoli is filled with exudates A.Side Effect: . Air pollution 3. Avoidance of precipitating factors b. Klebsella Pneumoniae 5. Signs and Symptoms 1. Bronchial wheezing . Immuno compromised a. Provide increase carbohydrates.Adrenal gland c. Fever. dyspepsia.Initial sign is non productive cough .Meninges .Ototoxicity damage to the 8th cranial nerve resulting to tinnitus leading to hearing loss . military tuberculosis) PTB . Smoking 2. Streptococcus Pneumonae – causing pneumococal pneumonia 2. Diplococcus Pneumoniae 4. Hemophylus Influenzae – causing broncho pneumonia 3. chills.Nephrotoxicity check for BUN and Creatinine . Provide client health teaching and discharge planning a. Rales/crackles 6. Aspiration of food causing aspiration pneumonia D. Productive cough with greenish to rusty sputum 2. anorexia and general body malaise 4.Side Effect: tinnitus. protein.Drug of choice is Retrovir b.Eyes . Related to prolonged immobility (CVA clients).Skin . High Risk Groups 1. heartburn 10. Children below 5 years old 2.Bones (potts) . Dyspnea with prolong expiratory grunt 3.. Pseudomonas B. causing hypostatic pneumonia 5. Escherichia Pneumoniae 6. Predisposing Factors 1.Give aspirin if there is fever . vitamin C and calories 11. AIDS .Pneumocystic carini pneumonia .
erythrocyte sedimentation rate is increased F. Encourage client deep breathing exercises d. Microlides (Zethromax) Azethromycin (Side Effect: Ototoxicity) Antipyretics Mucolytics/Expectorants Analgesics 4. Provide increase carbohydrates. Sputum Gram Staining and Culture Sensitivity – positive to cultured microorganisms 2. Contraindicated with . Avoid smoking b. Diagnostic Procedure 1.Hemoptysis . Administer bronchodilators 15 – 30 minutes before procedure e. Administer medications as ordered Broad Spectrum Antibiotic a. Pleuritic friction rub 9. Provide oral care after procedure g.Unstable vital signs . Cyanosis 8. Place on semi fowlers position 6. Institute pulmonary toilet (tends to promote expectoration) .Coughing exercises . Prevent complications . Abdominal distention leading to paralytic ileus (absence of peristalsis) E.Increase ICP 9. Chest x-ray – reveals pulmonary consolidation 3. Assist in postural drainage . protein and vitamin C 10.Deep breathing exercises . Health teaching and discharge planning a. Stop if client cannot tolerate procedure f. Enforce CBR 2. Penicillin b.Placed on various position Nursing Management for Postural Drainage a. Tetracycline c.Chest physiotherapy . Nursing Management 1. Nebulize and suction as needed 8. CBC – reveals increase WBC.Clients with increase intra ocular pressure (Normal IOP 12 – 21 mmHg) . Force fluid 5. Monitor vital signs c.Turning and reposition 7. ABG analysis – reveals decrease PO2 4.Drain uppermost area of lungs . calories.7. Chest pain 10. Best done before meals or 2 – 3 hours to prevent gastro esophageal reflux b. Administer oxygen inhalation low inflow 3.
Meningitis (nerve deafness.Fungizone (Nephrotoxicity. general body malaise 4. Steroids c. Enforce CBR 2. Chest and joint pains B. Force fluids to liquefy secretions 5. Dyspnea on exertion 3. Hemoptysis 6. Productive cough 2. chills..Atelectasis . anorexia. Dyspnea 3. hydrocephalus) c. Administer medications as ordered a.Amphotericin B . Signs and Symptoms PTB or Pneumonia like 1. Nursing Management 1. Prevent complications – bronchiectasis 7. check for BUN and Creatinine. Diagnostic Procedures 1. Cyanosis 5. ABG analysis PO2 decrease C. Nebulize and suction as needed 6. Histoplasmin Skin Test – positive 2. Administer oxygen inhalation 3. Importance of follow up care HISTOPLASMOSIS Acute fungal infection caused by inhalation of contaminated dust or particles with histoplasma capsulatum derived from birds manure A. 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. Signs and Symptoms 1. Mucolytics d. Smoking 2. Predisposing Factors 1. Antifungal . Productive cough (consistent to all COPD) 2. Fever. Antipyretics 4. Air pollution B. Prolonged expiratory grunt 4. Anorexia and generalized body malaise . Regular adherence to medications d. Hypokalemia) b.
Gases f. ABG analysis – PO2 decrease . Signs and Symptoms 1. Food additives (nitrates) e. Hereditary b. Smoke e. pH decrease Bronchial Asthma Reversible inflammatory lung condition due to hypersensitivity to allergens leading to narrowing of smaller airways A. Dyspnea 3. Drugs (aspirin. Nursing Management 1. Tachycardia. Foods (seafoods. Wheezing on expiration 4. Pulmonary hypertension a. Pollen b. Cyanosis 7. Cyanosis 5. Sudden change in temperature.5. Physical and emotional stress 3. Diaphoresis C. Furs h.Before ABG test for positive Allens Test. palpitations 7. Lints 2. milk. Cor Pulmonale (right ventricular hypertrophy) C. Enforce CBR . Intrinsic Asthma (Non atopic/Non allergic) Causes a. Pulmonary Function Test . Mild Stress/apprehension 6. chocolates. Mixed Type 90 – 95% B. Extrinsic Asthma ( Atopic/ Allergic ) Causes a. Diagnostic Procedure 1. PCO2 increase. beta blocker) c. Dust c. penicillin. Fumes d. Scattered rales/ronchi 6. air pressure and humidity f. apply direct pressure to ulnar and radial artery to determine presence of collateral circulation D. Danders g. eggs. Peripheral edema b. Diagnostic Procedure ABG analysis – reveals PO2 decrease (hypoxemia). Cough that is non productive 2. chicken d.Incentive spirometer reveals decrease vital lung capacity 2. Predisposing Factors (Depending on Types) 1.
Anorexia and generalized body malaise 5. Feeding initiated upon return of gag reflex 2. Force fluids 5.Steroids . Dyspnea 3.Emphysema . may cause irritation 3. Monitor for signs of gross 4. Chest trauma 3. Mucolytics/expectorants e. Nebulize and suction when needed 7. Diagnostic Procedure 1. Monitor for signs of laryngeal spasm – prepare tracheostomy set D.2. Steroids – decrease inflammation c.Status Asthmaticus (give drug of choice) .Bronchodilators c. Productive cough 2. Congenital defects 4. Bronchoscopy – direct visualization of bronchus using fiberscope Nursing Management PRE Bronchoscopy 1. Semi fowlers position 6. Hemoptysis (only COPD with sign) C. Anti histamine 4. Oxygen inhalation. Bronchodilators – given via inhalation or metered dose inhalaer or MDI for 5 minutes b. Provide client health teachings and discharge planning concerning a. ABG – PO2 decrease 2. coughing and smoking. Treatment . Recurrent lower respiratory tract infections 2. Regular adherence to medications to prevent development of status asthmaticus d. with low inflow of 2 – 3 L/min 3. Avoidance of precipitating factor b. Signs and Symptoms 1. Administer medications as ordered a. Maintain NPO 6 – 8 hours prior to procedure 3. Related to presence of tumor B. Mucomysts (acetylceisteine) d. Cyanosis 4.Epinephrine . Avoid talking. Secure inform consent and explain procedure to client 2. Monitor vital signs and breath sound POST Bronchoscopy 1. Prevent complications . Predisposing Factors 1. Importance of follow up care BRONCHIECTASIS Abnormal permanent dilation of bronchus leading to destruction of muscular and elastic tissues of alveoli A.
1 lung is removed and position on affected side) 2.Increase PO2 (hyperaxemia. Air trapping c. Air pollution 3. Nursing Management 1. Rales or ronchi 9. “Pink Puffers”) . Flaring of alai nares 12.Decrease ph . Hereditary – it involves deficiency of ALPHA-1 ANTI TRYPSIN (needed to form Elastase. Maldistribution of gases d. Diagnostic Procedure 1. High risk: elderly 5. “Blue Bloaters”) .Increase ph .Unaffected lobectomy facilitate drainage EMPHYSEMA Irreversible terminal stage of COPD characterized by a. Allergy 4.Respiratory acidosis b. Surgery (pneumonectomy .Respiratory alkalosis D. Barrel chest 11. Panacinar/ centriacinar . for recoil of alveoli) B. Anorexia and generalized body malaise 5. Over distention of thoracic cavity (barrel chest) A. Panlobular/ centrilobular . Signs and Symptoms 1. Smoking 2.1. Pulmonary Function Test – reveals decrease vital lung capacity 2. Productive cough 2. Prolong expiratory grunt 4. Predisposing Factors 1. Segmental Wedge Lobectomy (promote re expansion of lungs) .Increase PCO2 .Decrease PCO2 . ABG analysis reveals a. Resonance to hyperresonance 6. Purse lip breathing to eliminates excess CO2 (compensatory mechanism) C. Decrease tactile fremitus 7. Enforce CBR .Decrease PO2 (hypoxemia leading to chronic bronchitis. Bronchial wheezing 10. Decrease or diminished breath sounds 8. Inelasticity of alveoli b. Dyspnea at rest 3.
Avoid smoking b.Pneumothorax c. Mucolytics/expectorants 4.Atelectasis . Institute pulmonary toilet 7. Administer medications as ordered a. Institute PEEP (positive end expiratory pressure) in mechanical ventilation promotes maximum alveolar lung expansion 9.CO2 narcosis may lead to coma . protein. Health teachings and discharge planning concerning a. Bronchodilators b. Antibiotics d. Strict compliance to medication d. Provide comfortable and humid environment 10. calories. vitamins and minerals 11. Force fluids 6.Cor Pulmonale . High fowlers position 5. Provide high carbohydrates. Administer oxygen inhalation via low inflow 3. Importance of follow up care .2. Steroids c. Nebulize and suction when needed 8. Prevent complications .
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