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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.
saliva. Wernicke’s Aphasia General Knowing Gnostic Area or General Interpretative Area. Apraxia – no recognition of objects function. c. tingling sensation paresthesia numbness euphoria (sense of well being) 3. pressure.DEMYELINATING DISORDERS 1. *Receptive aphasia DRUG OF CHOICE: ARICEPT (taken at bedtime) and COGNEX. Ig D – for chronic inflammation. . colostrums). Sign and Symptoms 4 A’s of Alzheimer a.short term protection. ALZHEIMER’S DISEASE Atrophy of brain tissues. 2. *Expressive aphasia “motor speech center” Broca’s Aphasia inability to understand spoken words. Impaired sensation to touch. . 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. Mood swings . MULTIPLE SCLEROSIS Chronic intermittent disorder of CNS characterized by white patches of demyelination in brain and spinal cord. Visual disturbances blurring of vision (primary) diplopia (double vision) scotomas (blind spots) 2. heat and cold. Ig A – present in all bodily secretions (tears. Aphasia – no speech (nodding). d. Ig M – acute in inflammation. Characterized by remission and exacerbation. * Give palliative or supportive care.Immediate action. pain. Agnosia – no recognition of inanimate objects. Signs and Symptoms 1. b. Amnesia – loss of memory.
Monitor breath sounds 1 hour after subcutaneous administration. vitamin C and orange. Baclofen (Dioresal)/ Dantrolene Sodium (Dantrene) – muscle relaxants. 3. Constipation 8. c. Immunosupresants 2. plums. Impaired motor function weakness spasticity paralysis scanning speech TRIAD SIGNS OF MS Ataxia (Unsteady gait. Institute stress management techniques. Diuretics b. 5. Urinary retention/incontinence 7. Increase fluid intake and increase fiber to prevent constipation. (+) Romberg’s test) 5. Deep breathing exercises b. Bethanicol Chloride (Urecholine) Nursing Management Only given subcutaneous. a. prunes. Decrease sexual capacity DIAGNOSTIC PROCEDURE Nystagmus CSF analysis (increase in IgG and Protein). (+) Lhermitte’s sign a continuous and increase contraction of spinal column. Yoga 4. Catheterization to prevent retention. Administer medications as ordered a. . b. For Urinary Incontinence Anti spasmodic agent a. Interferons – alter immune response. c. Impaired cerebral function CHARCOTS TRIAD IAN Intentional tremors 6. Maintain side rails to prevent injury related to falls. d. To acidify urine and prevent bacterial multiplication. ACTH (Adreno Corticotropic Hormone)/ Steroids for acute exacerbation to reduce edema at site of demyelination to prevent paralysis.4. MRI (reveals site and extent of demyelination). Prophantheline Bromide (Promanthene) Acid ash diet like cranberry juice. pineapple. Monitor side effects bronchospasm and wheezing. NURSING MANAGEMENT 1. a.
CEREBRUM largest part composed of the Right Cerebral Hemisphere and Left Cerebral Hemisphere enclosed in the Corpus Callosum. heat.COMMON CAUSE OF UTI Female short urethra (3-5 cm. ORGAN Brain Blood Kidney Skin Lung MACROPHAGE Microglia Monocytes Kupffers cells Histiocytes Alveolar Macrophage EPINDYMAL CELLS Secretes a glue called chemo attractants that concentrate the bacteria. Occipital . touch. 8 inches) urinate after intercourse Nursing Management Male MICROGLIA stationary cells that carry on phagocytosis (engulfing of bacteria or cellular debris. Frontal higher cortical thinking controls personality controls motor activity Broca’s Area (motor speech area) when damaged results to garbled speech. 1-1 ½ inches) poor perineal hygiene vaginal environment is moist avoid bubble bath (can alter Ph of vagina). 2. Parietal 4. Temporal hearing short term memory for appreciation discrimination of sensory impulses to pain. 80% brain mass 10% blood 10% CSF COMPOSITION OF BRAIN I. Functions of Cerebrum integrative sensory motor Lobes of Cerebrum 1. numbness. eating). avoid use of tissue papers avoid using talcum powder and perfume. pinocytosis (cell drinking). pressure. 3. Urethra (20 cm. cold. Brain Mass PARTS OF THE BRAIN 1.
controls blood pressure controls thirst appetite/satiety sleep and wakefulness controls some emotional responses like fear. BRAIN STEM located at lowest part of brain Parts of Brain Stem 1. Hypothalamus 5. hearing acuity is 30 – 40 dB. anxiety and excitement. Medulla Oblongata 3. Cerebellum smallest part of the brain. lesser brain. vomiting. BASAL GAGLIA areas of grey matter located deep within each cerebral hemisphere. controls respiration. Thalamus acts as relay station for sensation. early sign for males are testicular and penile enlargement late sign is deepening of voice. hiccup. 2. controls pituitary functions androgenic hormones promotes secondary sex characteristics. for vision visceral function activities of internal organ like gastric motility. . early sign for females telarche and late sign is menarche. unequal size of pupil is anisocoria. MIDBRAIN/ MESENCEPHALON acts as relay station for sight and hearing. positive PERRLA 4. heart rate. release dopamine (controls gross voluntary movement. controls libido controls long term memory Insula (Island of Reil) Limbic System (Rhinencephalon) 2. Pons pneumotaxic center controls the rate. vasomotor center (dilation and constriction of bronchioles). controls smell and if damaged results to Anosmia (absence of smell). swallowing. controls temperature (thermoregulatory center). size of pupil is 2 – 3 mm. equal size of pupil is isocoria. DECREASE Myasthenia Gravis Parkinson’s Disease INCREASE Bi-polar Disorder Schizophrenia NEURO TRANSMITTER Acethylcholine Dopamine 3. rhythm and depth of respiration. B. INTERBRAIN/ DIENCEPHALON Parts of Diencephalon A.
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. equilibrium. Causes: head trauma/injury localized abscess cerebral edema hemorrhage decrease LOC restlessness/agitation irritability inflammatory condition (stroke) hydrocephalus tumor (rarely) Signs and Symptoms (Early) lethargy/stupor coma Signs and Symptoms (Late) changes in vital signs blood pressure (systolic blood pressure increases but diastolic remains the same). 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. Cervical 2 – also known as AXIS. NEUROLOGIC DISORDERS INCREASE INTRACRANIAL PRESSURE – increase in intra-cranial bulk brought about by an increase in one of the 3 major intra cranial components. heart rate decrease respiratory rate decrease temperature increase directly proportional to blood pressure. . posture and gait. projective vomiting headache papilledema (edema of optic disc) abnormal posturing decorticate posturing (damage to cortex and spinal cord). widening of pulse pressure is neurologic in nature (if narrow cardiac in nature). controls balance. Early closure of posterior fontanels causes posterior enlargement of skull in hydrocephalus.
provide an comfortable and quite environment. Osmotic diuretic (Mannitol) for cerebral diuresis Nursing Management monitor vital signs especially BP (hypotension). Nursing Management . 7. unilateral dilation of pupils called uncal herniation bilateral dilation of pupils called tentorial herniation resulting to mild headache possible seizure activity Nursing Management 1. Maintain patent and adequate ventilation by: a. Elevate bed of client 30 – 35o angle with neck in neutral position unless contraindicated to promote venous drainage. c. Late signs of hypoxia HYPERCARBIA b. c. monitor strictly input and output every 1 hour notify physician if output is less 30 cc/hr. cerebellum and midbrain). d. b. maintain side rails. Monitor strictly input and output and neuro check 5. 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. Administer medications like: a. 3. In chronic respiratory distress syndrome decrease O2 stimulates respiration. 4. Furosemide) Drug of choice for CHF (pulmonary edema) Loop of Henle in kidneys. Prevention of hypoxia and hypercarbia Early signs of hypoxia restlessness agitation tachycardia Bradycardia Extreme restlessness Dyspnea Cyanosis Increase CO2 (most powerful respiratory stimulant) retention. Prevent further increase ICP by: a. Loop diuretic (Lasix. b. avoid clustering of nursing activity together. Limit fluid intake to 1200 – 1500 ml/day (in force fluids 2000 – 3000 ml/day). avoid use of restraints. Before and after suctioning hyper oxygenate client 100% and done 10 – 15 seconds only. decerebrate posturing (damage to upper brain stem that includes pons. Prevent complications of 6. administered via side drip regulated fast drip to prevent crystal formation. Assist in mechanical ventilation 2.
monitor strictly input and output every 1 hour notify physician if output is less 30 cc/hr. 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). administered IV push or oral. Corticosteroids *CONGESTIVE HEART FAILURE Signs and Symptoms dyspnea orthopnea paroxysmal nocturnal dyspnea productive cough frothy salivation cyanosis rales/crackles bronchial wheezing pulsus alternans anorexia and general body malaise PMI (point of maximum impulse/apical pulse rate) is displaced laterally S3 (ventricular gallop) Predisposing Factors/Mitral Valve RHD Aging TREATMENT Morphine Sulfate Aminophelline Digoxin Diuretics Oxygen Gases. blood monitor RIGHT CONGESTIVE HEART FAILURE (Venous congestion) Signs and Symptoms jugular vein distention (neck) ascites pitting edema weight gain hepatosplenomegaly jaundice pruritus esophageal varices anorexia and general body malaise . Phenytoin) c. maximum effect of 6 hours. given early morning immediate effect of 10 – 15 minutes.
Signs and Symptoms of Lasix in terms of electrolyte imbalances 1. Hypocalcemia/ Tetany VEGETABLES Asparagus Brocolli Carrots Spinach decrease calcium level normal value is 8.5 – 11 mg/100 ml Signs and Symptoms tingling sensation paresthesia numbness (+) Trousseau’s sign/ Carpopedal spasm (+) Chvostek’s sign Complications Arrhythmia Seizures Nursing Management Calcium Gluconate per IV slowly as ordered * Calcium Gluconate toxicity – results to SEIZURE Magnesium Sulfate Magnesium Sulfate toxicity S/S BP Urine output Respiratory rate Patellar relfex absent 3. in infant TACHYCARDIA) agitation dry mucous membrane poor skin turgor weakness and fatigue .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. Hypokalemia decrease potassium level normal value is 3. Oral Potassium Chloride) increase intake of foods rich in potassium FRUITS Apple Banana Cantalop e Oranges 2.4 – 5. Hyponatremia DECREASE decrease sodium level normal value is 135 – 145 meq/L Signs and Symptoms hypotension dehydration signs (Initial sign in adult is THIRST.
Acute gout Mechanism of action: promotes excretion of uric acid. Allopurinol (Zyloprim) Side Effects Respiratory depression (check for RR) . Nursing Management a. Mechanism of action: inhibits synthesis of uric acid. Allopurinol (Zyloprim) b. Signs and Symptoms Nursing Management a. Hyperglycemia normal FBS is 80 – 100 mg/dl polyuria polydypsia polyphagia monitor FBS Signs and Symptoms Nursing Management 5.Nursing Management force fluids administer isotonic fluid solution as ordered 4. joint pain (great toes) swelling force fluids administer medications as ordered Drug of choice for gout. organ meats and anchovies) *Increase in tophi deposit leads to Gouty arthritis. 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. Narcotic Analgesic b. Hyperuricemia increase uric acid (purine metabolism) foods high in uric acid (sardines.
decrease sexual capacity Nursing Management 1. seborrhea d. Poisoning (lead and carbon monoxide) 2. Increase dosage of the following drugs: a. difficulty rising from sitting position. Arteriosclerosis 3. Haloperidol(Haldol) d.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. Monotone type speech mood lability (in state of depression) increase salivation (drooling type) autonomic changes a. Administer medications as ordered Anti Parkinsonian agents Levodopa (L-dopa) short acting Amantadine Hydrochloride (Symmetrel) Carbidopa (Sinemet) . constipation e. Methyldopa(Aldomet) c. bradykinesia (slowness of movement) rigidity (cogwheel type) stooped posture shuffling and propulsive gait over fatigue mask like facial expression with decrease blinking of the eyes. Phenothiazine AntipsychoticS AntihypertensiveS SIDE EFFECTS RESERPINE Major depression leading to suicide Aloneness Multiple loss causes suicide Loss of spouse direct approach towards the client close surveillance is a nursing priority Loss of Job time to commit suicide is on weekends early morning Signs and Symptoms for Parkinson’s pill rolling tremors of extremities especially the hands. Predisposing Factors 1. increase sweating b. Hypoxia 4. Reserpine(Serpasil) b. Encephalitis 5. increase lacrimation c.
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.relieves tremor rigidity Bromocriptene Hydrochloride (Parlodel) Side Effects Respiratory depression 2. Prevent complications of immobility 4. Maintain side rails to prevent injury 3.2 meq/L 10 – 19 mg/100 ml 10 – 19 mg/100 ml 10 – 30 mg/100 ml TOXICITY LEVEL 2 2 20 20 200 INDICATION CHF Bipolar COPD Seizures Osteo Arthritis CLASSIFICATION Cardiac Glycoside Anti-Manic Agents Bronchodilators Anti-Convulsant Non-narcotic Analgesic . Assist/supervise in ambulation 7. Isonicotinic Acid Hydrazide Anti Cholinergic Agents (ARTANE and COGENTIN) . 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 . Dopamine Agonist .5 meq/L . Encourage increase fluid intake and fiber.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. Decrease protein in morning and increase protein in afternoon to induce sleep 5.6 – 1. 6.
9 NaCl to prevent development of crystals or precipitate.8 – 1) hypoglycemia Tremors. irritability. Dilantin Toxicity Signs and Symptoms gingival hyperplasia (swollen gums) hairy tongue ataxia nystagmus provide oral care massage gums Nursing Management 5. administered sandwich method avoid taking alcohol because it can lead to severe CNS depression avoid caffeine Nursing Management 4. Digitalis Toxicity Signs and Symptoms nausea and vomiting diarrhea confusion photophobia changes in color perception (yellowish spots) Antidote: Digibind 2. Acetaminophen Toxicity Signs and Symptoms hepatotoxicity (monitor for liver enzymes) SGPT/ALT (Serum Glutamic Pyruvate Transaminace) SGOT/AST (Serum Glutamic Oxalo-Acetil Transaminace) nephrotoxicity monitor BUN (10 – 20) and Creatinine (. 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. .1. depression Antidote: Acetylcisteine (mucomyst) prepare suction apparatus as bedside. Aminophylline Toxicity Signs and Symptoms tachycardia palpitations CNS excitement (tremors. tachycardia Irritability Restlessness Extreme fatigue Diaphoresis. agitation and restlessness) only mixed with plain NSS or 0.
The client is unable to see. 8. institute NGT feeding 6.over medication Signs and Symptoms . administer medications as ordered a. initial sign is ptosis a clinical parameter to determine ptosis is palpebral fissure.infection Signs and Symptoms .stress .G. breathe Treatment . maintain side rails to prevent injury related to falls 5. 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: .PNS Treatment . Cholinergic (Mestinon) b. mmobility * assist in mechanical ventilation and monitor pulmonary function test * monitor strictly vital signs.G. speak.under medication . Incidence rate: women 20 – 40 years old Predisposing factors unknown autoimmune: it involves release of cholinesterase an enzyme that destroys Ach. Assist in plasma paresis and removing auto immune anti bodies 9. input and output and neuro check * monitor strength or motor grading scale 4. aspiration 3. diplipia mask like facial expression dysphagia hoarseness of voice respiratory muscle weakness that may lead to respiratory arrest extreme muscle weakness especially during exertion and morning Tensilon test (Edrophonium Hydrochloride) provides temporary relief of signs and symptoms for about 5 – 10 minutes and a maximum of 15 minutes. Prevent complications .administer cholinergic agents as ordered 7.Administer anti cholinergic agents (Atropine Sulfate) Side Effects MYASTHENIC CRISIS Causes: . Assist in surgical procedure known as thymectomy because it is believed that the thymus gland is responsible for M. Nursing Management 1.MYASTHENIA GRAVIS neuromuscular disorder characterized by a disturbance in the transmission of impulses from nerve to muscle cells at the neuromuscular junction leading to descending muscle weakness. swallow. if there is no effect there is damage to occipital lobe and midbrain and is negative for Signs and Symptoms Diagnostic Procedure M. airway 2.
Increase wbc . A. Opisthotonus (arching of back) c. drainage and leakage to tissues. Pia matter – inner layer subdural space between the dura and arachnoid subarachnoid space between the arachnoid and pia. Pneumococcus 3. chills.INFLAMMATORY CONDITIONS OF THE BRAIN MENINGITIS Meninges 3 fold membrane that covers brain and spinal cord. Secure informed consent and explain procedure. CSF aspiration is done. Streptococcus . (+) cultured microorganism (confirms meningitis) CBC reveals 1. Hemophilus Influenzae – causes pediatric meningitis B. Arachnoid – middle layer 3. anorexia. (+) Brudzinski sign (neck pain) D. Assess for movement and sensation of extremities. general body malaise and weight loss Possible increase in ICP and seizure activity Abnormal posturing (decorticate and decerebrate) Signs of meningeal irritation a. Meningococcus – most dangerous 2. Empty bladder and bowel to promote comfort. for support and protection for nourishment blood supply LAYERS OF THE MENINGES 1. 3. 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. 2. Post Lumbar Puncture 1. Check punctured site for any discoloration. (+) Kernig’s sign (leg pain) d. Signs and Symptoms headache photophobia projectile vomiting fever. Force fluids 3. Decrease glucose 3. Dura matter – outer layer 2. Nursing Management for LP Before Lumbar Puncture 1. CSF analysis reveals 1.causes adult meningitis 4. 4. Increase CSF opening pressure (normal pressure is 50 – 100 mmHg) 4. Nuchal rigidity or stiff neck b. Encourage to arch back to clearly visualize L3-L4. Mode of transmission airborne transmission (droplet nuclei) C. Increase CHON and WBC 2. Etiology 1.
Elevate head 30-45o 5. CHON. 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. input and output and neuro check 6. 9. Anti pyretics 3. Compartment syndrome (compression of arteries and nerves) . Prevent complications most feared is hydrocephalus hearing loss/nerve deafness is second complication consult audiologist mental retardation delayed psychomotor development c. Tetracycline) b. Enforce complete bed rest 2. Maintain good diet of increase CHO. Institute strict respiratory isolation 24 hours after initiation of anti biotic therapy 4. Maintain fluid and electrolyte balance. Monitor strictly V/S. 8. 2 most common cerebral artery affected by stroke a. 7. Yellow bone marrow are produced from the medullary cavity of the long bones and produces fat cells. Provide a comfortable and darkened environment. Internal Cerebral Artery – the 2 largest artery A. Mid Cerebral Artery b. Institute measures to prevent increase ICP and seizure. Incidence Rate men are 2-3 times high risk B. b. calories with small frequent feedings. Signs and Symptoms of Pulmonary Embolism Sudden sharp chest pain Unexplained dyspnea Tachycardia Palpitations Diaphoresis Mild restlessness Headache and dizziness Confusion Restlessness Decrease LOC Signs and Symptoms of Cerebral Embolism Fat embolism is the most feared complications after femur fracture. Provide client health care and discharge planning concerning: a. If there is bone fracture there is hemorrhage and there would be escape of the fat cells in the circulation. Rehabilitation for neurological deficit CVA (STROKE/BRAIN ATTACK/ ADOPLEXY/ CEREBRAL THROMBOSIS) a partial or complete disruption in the brains blood supply. Broad spectrum antibiotics (Penicillin. Mild analgesics c. Administer medications as ordered a. Nursing Management 1.E.
CT Scan – reveals brain lesions 2. Lifestyle (smoking). Atherosclerosis. Obesity (increase 20% ideal body weight) 4. Related to diet: increase intake of saturated fats like whole milk 7. sedentary lifestyle 3. aphasia c. Prolong use of oral contraceptives promotes lypolysis (breakdown of lipids) leading to atherosclerosis that will lead to hypertension and eventually CVA. TIA Signs and Symptoms 2. D. 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. Type A personality a. usually fells guilty when not doing anything 6. Risk Factors 1. deadline driven b. Related stress physical and emotional 8. Hyperlipidemia more on genetics/genes that binds to cholesterol 5.C. alexia (difficulty reading) e. Complete stroke Signs and Symptoms E. can do multiple tasks c. Signs and Symptoms Heart Disease. Diagnostic Procedure 1. Valvular Cardiac Surgery (mitral valve replacement) 2. homonymous hemianopsia (loss of half of visual field) 1. phlegia b. dysarthria (inability to articulate words) d. Diabetes Mellitus. nausea and vomiting dysphagia (+) Kernig’s sign and Brudzinski sign which may lead to hemorrhagic stroke focal neurological deficits a. Myocardial Infarction. Stroke in evolution 3. 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. agraphia (difficulty writing) f.
smoking) b. provide egg crate mattresses or water bed c. Institute NGT feeding 8. Restrict fluids to prevent cerebral edema that might increase ICP 3. Anti Platelet PASA (Aspirin) Contraindicated for dengue. Provide client health teachings and discharge planning concerning a. I & O and neuro check 5. prevent complication (subarachnoid hemorrhage is the most feared complication) c. Administer medications as ordered a. K (Aqua Mephyton) g. ulcer and unknown cause of headache because it may potentiate bleeding 11. avoidance of modifiable risk factors (diet. Maintain patent airway and adequate ventilation by: a. non verbal cues b. Prevent complications of immobility by: a. Nursing Management 1. Monitor strictly vitals signs. Furosemide) c. If positive to hemianopsia approach client on unaffected side 10. Provide alternative means of communication a. Loop Diuretics (Lasix. turn client to side b. Cortecosteroids d. 6. saturated fats and caffeine) d. assist in mechanical ventilation b. administrate O2 inhalation 2. magic slate 9. Assist in passive ROM exercise every 4 hours to promote proper bodily alignment and prevent contractures 7. dietary modification (decrease salt. Osmotic Diuretics (Mannitol) b. exercise.F. Thrombolytic/Fibrinolytic Agents – dissolves thrombus Streptokinase Side Effect: Allergic Reaction Urokinase Tissue Plasminogen Activating Factor Side Effect: Chest Pain f. Anti Coagulants Heparin (short acting) check for partial thromboplastin time if prolonged there is a risk for bleeding. provide sand bag or food board. importance of follow up care . Mild Analgesics e. 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.
Ascending muscle weakness leading to paralysis 4. intake and output c. Prevent complications of immobility by turning the client every 2 hours 5. Predisposing Factors 1. Autoimmune 2. monitor pulmonary function test 2. Monitor strictly the following a. increase sweating c. . vital signs b. ECG 3. Assist in passive ROM exercise 7. Arrythmia b. Signs and Symptoms 1. Administer medications as ordered a. Diagnostic Procedures 1. Prevent complications a. increase salivation b. Paralysis or respiratory muscles/Respiratory arrest * Sengstaken Blakemore Tube for liver cirrhosis to decompress bleeding esophageal verices (prepare scissor to cut tube incase of difficulty in breathing to release air in the balloon for hemodialysis prepare bulldog clips to prevent air embolism. Assist in plasma pharesis (filtering of blood to remove autoimmune anti-bodies) 9. Antecedent viral infections such as LRT infections B. Maintain side rails to prevent injury related to fall 4. neuro check d. Clumsiness (initial sign) 2.GUILLAIN BARRE SYNDROME a disorder of the CNS characterized by bilateral symmetrical polyneuritis leading to ascending muscle paralysis. Institute NGT feeding to prevent aspiration 6. constipation C. Alternate hypotension to hypertension ** ARRYTHMIA (most feared complication) 6. Maintain patent airway and adequate ventilation by: a. Zylocaine Bretylium – blocks release of norepinephrine to prevent increase of BP 8. Autonomic symptoms that includes a. A. assist in mechanical ventilation b. Decreased of diminished deep tendon reflex 5. Dysphagia 3. Corticosteroids – suppress immune response b. Anti Cholinergic Agents – Atrophine Sulfate c. CSF analysis reveals increase in IgG and protein D. Anti Arrythmic Agents Lidocaine. Nursing Management 1.
if left untreated can lead to hyperpyrexia and lead to coma and eventually death.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. Head injury due to birth trauma 2. EEG – reveals hyper activity of electrical brain waves . 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. Signs or aura with auditory. 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. Nutritional and Metabolic deficiencies 6. Epileptic cry – is characterized by fall and loss of consciousness for 3 – 5 minutes c. tactile. Sudden withdrawal to anti convulsant drug is predisposing factor for status epilepticus (drug of choice is Diazepam. clouding of consciousness – not in contact with environment c. Grand mal Seizure (tonic-clonic seizure) a. loss of consciousness (5 – 10 seconds) II. Genetics 3. Partial or Localized Seizure 1. Post ictal sleep – unresponsive sleep 2. Valium) B. visual. blank stare b. Generalized Seizure 1. sensory experience b. Tonic contractions . Psychomotor Seizure (focal motor seizure) a. Valium and Glucose C. automatism – stereotype repetitive and non propulsive behavior b. decrease blinking of eyes c. Drug of choice: Diazepam. olfactory. Petit mal Seizure – absence of seizure common among pediatric clients characterized by a. Signs and Symptoms Dependent on stages of development or types of seizure I.contraction of extremities d. lead b carbon monoxide 5. Diagnostic Procedures 1. Toxicity from a.direct symmetrical extension of extremities Clonic contractions . twitching of mouth d. Status Epilepticus A continuous uninterrupted seizure activity. Predisposing Factors 1. mild hallucinatory sensory experience III. Presence of brain tumor 4. 2. Physical and emotional stress 7.
D. Nursing Management 1. Maintain patent airway and promote safety before seizure activity a. clear the site of blunt or sharp objects b. loosen clothing of client c. maintain side rails d. avoid use of restrains e. turn clients head to side to prevent aspiration f. place mouth piece of tongue guard to prevent biting or tongue 2. Avoid precipitating stimulus such as bright/glaring lights and noise 3. Administer medications as ordered a. Anti convulsants (Dilantin, Phenytoin) b. Diazepam, Valium c. Carbamazepine (Tegretol) – Trigeminal neuralgia d. Phenobarbital, Luminal 4. Institute seizure and safety precaution post seizure attack a. administer O2 inhalation b. provide suction apparatus 5. Document and monitor the following a. onset and duration b. types of seizures c. duration of post ictal sleep may lead to status epilepticus d. assist in surgical procedure cortical resection COMPREHENSIVE NEURO EXAM GLASGOW COMA SCALE
objective measurement of LOC sometimes called as the quick neuro check
Components 1. Motor response 2. Verbal response 3. Eye opening Conscious Lethargy Stupor Coma Deep Coma 15 – 14 13 – 11 10 – 8 7 3
Survey of mental status and speech a. LOC b. Test of memory Levels of orientation Cranial nerve assessment Sensory nerve assessment Motor nerve assessment Deep tendon reflex Autonimics Cerebellar test a, Romberg’s test – 2 nurses, positive for ataxia b. Finger to nose test – positive result mean dimetria (inability of body to stop movement at desired point) c. Alternate supination and pronation – positive result mean dimetria
I. LEVEL OF CONSCIOUSNESS 1. Conscious - awake 2. Lethargy – lethargic (drowsy, sleepy, obtunded) 3. Stupor
stuporous (awakened by vigorous stimulation) generalized body weakness decrease body reflex comatose light coma (positive to all forms of painful stimulus) deep coma (negative to all forms of painful stimulus)
DIFFERENT PAINFUL STIMULATION 1. Deep sternal stimulation/ deep sternal pressure 2. Orbital pressure 3. Pressure on great toes 4. Corneal or blinking reflex Conscious client use a wisp of cotton Unconscious client place 1 drop of saline solution II. TEST OF MEMORY 1. Short term memory
ask most recent activity positive result mean anterograde amnesia and damage to temporal lobe ask for birthday and validate on profile sheet positive result mean retrograde amnesia and damage to limbic system consider educational background
2. Long term memory
III. LEVELS OF ORIENTATION 1. Time – first asked 2. Person – second asked 3. Place – third asked CRANIAL NERVES CRANIAL NERVES I. OLFACTORY II. OPTIC III OCCULOMOTOR IV. TROCHLEAR V. TRIGEMINAL VI. ABDUCENSE VII. FACIAL VIII. ACOUSTIC IX. GLOSSOPHARYNGEAL X. VAGUS FUNCTION S S M M (Smallest) B (Largest) M B S B B
(Longest) XI. SPINAL ACCESSORY M XII. HYPOGLOSSAL M CRANIAL NERVE I: OLFACTORY
sensory function for smell
don’t use alcohol, ammonia, perfume because it is irritating and highly diffusible. use coffee granules, vinegar, bar of soap, cigarette test each nostril by occluding each nostril
Abnormal Findings 1. Hyposnia – decrease sensitivity to smell 2. Dysosmia – distorted sense of smell 3. Anosmia – absence of smell Indicative of 1. head injury damaging the cribriform plate of ethmoid bone where olfactory cells are located 2. may indicate inflammatory conditions (sinusitis) CRANIAL NERVE II: OPTIC
sensory function for vision or sight
Functions 1. Test visual acuity or central vision or distance
use Snellen’s Chart Snellen’s Alphabet chart: for literate clients Snellen’s E chart: for illiterate clients Snellen’s Animal chart: for pediatric clients normal visual acuity 20/20 numerator is constant, it is the distance of person from the chart (6 – 7 m, 20 feet) denominator changes, indicates distance by which the person normally can see letter in the chart. - 20/200 indicates blindness 20/20 visual acuity if client is able to read letters above the red line. a. Superiorly b. Bitemporaly c. Nasally d. Inferiorly
2. Test of visual field or peripheral vision
COMMON VISUAL DISORDERS 1. Glaucoma
increase IOP normal IOP is 12 – 21 mmHg preventable but not curable Common among 40 years old and above Hereditary Hypertension Obesity
A. Predisposing Factors
B. Signs and Symptoms 1. Loss of peripheral vision
pathognomonic sign is tunnel vision steamy cornea may lead to blindness
2. Headache, nausea, vomiting, eye pain (halos around light)
C. Diagnostic Procedures 1. Tonometry 2. Perimetry
Diagnostic Procedure 1. Blurring or hazy vision 2.Partial removal Intra Capsular Cataract Lens Extraction . Opthalmoscopic exam E. Timoptics (Timolol Maleate) E. Surgical Procedures 1. Carbachol 2. Diabetes Mellitus 4.3. Predisposing Factor 1. Loss of central vision C. Cataract Decrease opacity of lens A. Carbonic Anhydrase Inhibitors a. Pathognomonic Signs 1. Cyclopegics (Cyclogyl) – paralyses cilliary muscle F. Acetazolamide (Diamox) – promotes increase outflow of aqueous humor or drainage 4. TRABECULECTOMY (Peripheral Indectomy) – drain aqueous humor 2. Surgical Procedure Extra Capsular Cataract Lens Extraction . Aging 65 years and above 2. Milky white appearance at center of pupils 3. Mydriatics (Mydriacyl) – constricts pupils 2. Treatment 1. Pilocarpine Sodium. Epinephrine eyedrops – decrease formation of aqueous humor 3. Signs and Symptoms 1.Total removal of cataract with its surrounding capsules Most feared complication post op is RETINAL DETACHMENT 3. Treatment 1. Related to congenital 3. Prolonged exposure to UV rays B. Miotics – constricts pupil a. Decrease perception to colors Complication is blindness D. Retinal Detachment Separation of epithelial surface of retina . Gonioscopy D.
mandibular . IV. Cryosurgery – cold application 3. Macular Degeneration Degeneration of the macula lutea (yellowish spot at the center of retina) A. TROCHLEAR. Surgical Procedures 1. Scleral Buckling 2. Curtain veil like vision 2. Floaters C. VI: OCULOMOTOR. Black Spots CRANIAL NERVE III.A. Signs and Symptoms 1. Post Lens Extraction 2. Predisposing Factors 1. Signs and Symptoms 1. Diathermy – heat application 4. maxillary. ABDUCENS Controls or innervates the movement of extrinsic ocular muscle (EOM) 6 muscles Superior Rectus Superior Oblique Lateral Rectus Medial Rectus Inferior Oblique Inferior Rectus trochlear controls superior oblique abducens controls lateral rectus oculomotor controls the 4 remaining EOM Oculomotor controls the size and response of pupil normal pupil size is 2 – 3 mm equal size of pupil: Isocoria Unequal size of pupil: Anisocoria Normal response: positive PERRLA CRANIAL NERVE V: TRIGEMINAL largest cranial nerve consists of ophthalmic. Myopia (near sightedness) B.
X: GLOSOPHARYNGEAL. CRANIAL NERVE VIII: ACOUSTIC/VESTIBULOCOCHLEAR Controls balance particularly kinesthesia or position sense. Parts of the Ear 1. refers to movement and orientation of the body in space. 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. 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. ENDOCRINE SYSTEM Overview of the structures and functions 1. teeth. 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. frown and if results are negative there is facial paralysis or Bell’s Palsy and the primary cause is forcep delivery. mucous membrane. Inner Ear Vestibule: Meinere’s Disease Cochlea Mastoid Cells Endolymph and Perilymph COCHLEA: controls hearing. Outer Ear Pinna Eardrum Hammer Anvil Stirrup Malleus Incus Stapes 2. sensory: controls sensation of face. Pituitary Gland (Hypophysis Cerebri) . Middle Ear 3.
Signs and Symptoms 2. Predisposing Factor o o o o 1. Nursing Management . Weight loss 6.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. Dry mucous membrane 3. Administer medications as ordered a. Serum Sodium D. Antidiuretic Hormone o o o Pitressin (Vasopressin) Function: prevents urination thereby conserving water Diabetes Insipidus/ Syndrome of Inappropriate Anti Diuretic Hormone DIABETES INSIPIDUS o Decrease production of anti diuretic hormone A. Urine Specific Gravity o o o 1. Weakness and fatigue 4. Adult: thirst b. Anterior Pituitary Gland o o o hemorrhage o o administrate oxytocin immediately after delivery to prevent uterine atony. Prevent complilcations – HYPOVOLEMIC SHOCK is the most feared complication Normal value: 1. Posterior Pituitary Gland 2. Force fluids 2.030 Ph 4 – 8 Increase resulting to hypernatremia Related to pituitary surgery Trauma Inflammation Presence of tumor B. Poor Skin turgor 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. Agitation c. If left untreated results to hypovolemic shock (sign is anuria) C. Hypotension 5. Polyuria 2. Signs of dehydration a. Diagnostic Procedures 1. Pitressin (Vasopresin Tannate) – administered IM Z-tract 4. Monitor strictly vital signs and intake and output 3.015 – 1.
Signs and Symptoms 1. Prone to skin cancer o Hypersecretion of MSH results to Vitiligo 3. Serum Sodium is decreased D. Loop diuretics (Lasix) b. Diagnostic Procedure 1. Restrict fluid 2. Monitor strictly vital signs. Related to hyperplasia (increase size of organ brought about by increase of number of cells) of pituitary 2. Weight gain 2. Weigh patient daily and assess for pitting edema 5. Lead to blindness due to severe photophobia b. Provide meticulous skin care 6. Head injury 2. Prevent complications ANTERIOR PITUITARY GLAND o also called ADENOHYPOPHYSIS secretes Promotes elongation of long bones Hyposecretion of GH among children results to Dwarfism Hypersecretion of GH results to Gigantism Hypersecretion of GH among adults results to Acromegaly (square face) Drug of choice: Ocreotide (Sandostatin) 1. Urine specific gravity is increased 2. B. Related to presence of bronchogenic cancer o o gland. Melanocyte Stimulating hormone o o o for skin pigmentation Hyposecretion of MSH results to Albinism Most feared complications of albinism a. intake and output and neuro check 4. Hypertension b. Adrenochorticotropic hormone (ACTH) o promotes development of adrenal cortex . Nursing Management 1. Edema c. Predisposing Factors 1.SIADH o hypersecretion of anti diuretic hormone A. 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. Osmotic diuretics (Mannitol) 3. Water intoxication may lead to cerebral edema and lead to increase ICP – may lead to seizure activity C. Fluid retention a. Administer medications as ordered a.
Leutinizing hormone 6. Mountainous regions 2. T3 (Tri iodothyronine) . turnips. Thyroxine) o o T3 and T4 are metabolic or calorigenic hormone promotes cerebration (thinking) 3. strawberry. T4 (tetra iodothyronine. 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. broccoli. Thyrocalcitonin – antagonizes the effects of parathormone to promote calcium resorption. sweet potato.3 molecules of iodine (more potent) 2. 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. places far from sea b.4. radish. all nuts soil erosion washes away iodine . carrots. Goiter belt area a. 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. Increase intake of goitrogenic foods o o o contains pro-goitrin an anti thyroid agent that has no iodine. Predisposing Factors 1. cabbage.
Iatrogenic Cause – disease caused by medical intervention such as surgery 2. Enlarged thyroid gland 2. PASA (Aspirin) d. Lugol’s Solution/SSKI ( Saturated Solution of Potassium Iodine) o o color purple or violet and administered via straw to prevent staining of teeth. Administer medications as ordered a.if goiter is caused by B. best taken raw because it it is easily destroyed by heat 5. Thyroid Scan – reveals enlarged thyroid gland. Iron. Related to atrophy of thyroid gland due to trauma. Signs and Symptoms 1. Enforce complete bed rest 2. iodized salt. 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. Serum T3 and T4 – reveals normal or below normal 2. clams and lobster but not shrimps because it contains lesser amount of iodine. Lithium Carbonate c. Serum Thyroid Stimulating Hormone (TSH) – is increased (confirmatory diagnostic test) D. Diagnostic Procedures 1. Monitor vital signs especially heart rate because drug causes tachycardia and palpitations 3. inflammation . Tetracycline. Monitor side effects o o o o o o o insomnia tachycardia and palpitations hypertension heat intolerance seaweeds seafood’s like oyster. Instruct client to take in the morning to prevent insomnia 2. Anti Thyroid Agent – Prophylthiuracil (PTU) b. 3. Mild dysphagia 3. Cobalt e. presence of tumor.o goitrogenic drugs a. Mild restlessness C. Nursing Management 1. crabs. 4 Medications to be taken via straw: Lugol’s. Thyroid Hormones o o o Levothyroxine (Synthroid) Liothyronine (Cytomel) Thyroid Extracts Nursing Management when giving Thyroid Hormones 1. Increase dietary intake of foods rich in iodine A. Predisposing Factors 1. Nitrofurantoin (drug of choice for pyelonephritis) b. Phenylbutazones (NSAIDs) .
hypothermia leading to pregressive stupor and coma. Serum Cholesterol is increased 3. Brittleness of hair and nails 2. Provide dietary intake that is low in calories 6. Provide client health teaching and discharge planning concerning a. hyponatremia. Decrease libido 5. Signs and Symptoms (Early Signs) 1. Administer isotonic fluid solution as ordered 4. Thyroid Extracts 5. Constipation (Late Signs) 1. RAIU (Radio Active Iodine Uptake) is decreased D. Dry skin 4. bradypnea. bradycardia. Administer medications as ordered Thyroid Hormones a. Loss of appetite but with weight gain which promotes lipolysis leading to atherosclerosis and MI 3. Serum T3 and T4 is decreased 2. Leothyronine c. hypoglycemia. Provide meticulous skin care 8. Provide comfortable and warm environment 7. bradypnea. Nursing Management 1. Weakness and fatigue 2. CNS changes o o o o lethargy memory impairment psychosis menorrhagia C. hypoventilation. Diagnostic Procedures 1. 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. Cold intolerance 5. Levothyroxine b. hypothermia 6. Avoid precipitating factors leading to myxedema coma o o stress infection Assist in mechanical ventilation Administer thyroid hormones as ordered Force fluids .3. Decrease in all vital signs – hypotension. Autoimmune (Hashimotos Disease) B. Iodine deficiency 4. Nursing Management for Myxedema Coma 2. bradycardia. Non pitting edema (Myxedema) 3. Force fluids 3. Hoarseness of voice 4.
Methymazole (Tapazole) Side Effects of Agranulocytosis o o o o increase lymphocytes and monocytes fever and chills sore throat (throat swab/culture) leukocytosis (CBC) 3. Insomnia e. and sedatives prevent complications (myxedema coma. Provide dietary intake that is increased in calories.o o o o o o o o cold intolerance use of anesthetics. Administer medications as ordered Anti Thyroid Agent a. Predisposing Factors 1.reveals an enlarged thyroid gland D. Amenorrhea C. Tremors d. Hallucinations 7. Signs and Symptoms 1. Irritability and agitation b. Nursing Management 1. Diagnostic Procedures 1. Exopthalmus 9. narcotics. Increase appetite (hyperphagia) but there is weight loss 2. Heat intolerance 4. Serum T3 and T4 is increased 2. Autoimmune – it involves release of long acting thyroid stimulator causing exopthalmus (protrusion of eyeballs) enopthalmus (late sign of dehydration among infants) 2. Excessive iodine intake 3. Provide meticulous skin care 5. Comfortable and cold environment 6. Restlessness c. Maintain side rails . Goiter 8. Monitor strictly vital signs and intake and output 2. 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. CNS involvement a. All vital signs are increased 6. RAIU (Radio Active Iodine Uptake) is increased 3. 4. Prophythioracill (PTU) b. Thyroid Scan. Moist skin 3. Diarrhea 5. Related to hyperplasia (increase size) B.
Watch out for accidental Laryngeal damage which may lead to hoarseness of voice Nursing Management o encourage client to talk/speak immediately after operation and notify physician 4. Watch out for signs of thyroid storm/ thyrotoxicosis Agitation TRIAD SIGNS Hyperthermia o administer medications as ordered a. 5. Provide bilateral eye patch to prevent drying of the eyes. POST OPERATIVELY.7. Signs of bleeding (feeling of fullness at incisional site) Nursing Management o Check the soiled dressings at the back or nape area. 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 . Anti Pyretics b. Beta-blockers o o o monitor strictly vital signs. Hormonal replacement therapy for lifetime 6. 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. seizure give Calcium Gluconate IV slowly as ordered 3. maintain side rails offer TSB Tachycardia 2. Watch out for accidental removal of parathyroid gland that may lead to Hypocalcemia (tetany) Signs and Symptoms o o o (+) trousseau’s sign (+) chvostek sign Watch out for arrhythmia. 1. 8. input and output and neuro check.
Diagnostic Procedures 1. Signs and Symptoms 1.5 – 4. tumor c. Atrophy of parathyroid gland due to: a. Vitamin D (Cholecalciferol) for absorption of calcium CHOLECALCIFEROL ARE DERIVED FROM Drug Diet (Calcidiol) Sunlight (Calcitriol) feared complications d. Chronic Tetany Oral Calcium supplements Calcium Gluconate Calcium Lactate Calcium Carbonate c. agitation and memory impairment C. Administer medications as ordered such as: a. positive chvostek sign g. numbness d. Following subtotal thyroidectomy 2. positive trousseu’s sign/carpopedal spasm f. trauma B. loss of tooth enamel c. nausea and vomiting d.5 – 11 mg/100 ml) 2. arrhythmia 2. photophobia and cataract formation b. tingling sensation b. dysphagia e. Chronic tetany a.5 mg/100 ml) 3. CT Scan – reveals degeneration of basal ganglia D. Acute Tetany Calcium Gluconate IV slowly b. anorexia. Nursing Management 1. Serum Phosphate is decreased (normal value: 2. laryngospasm/broncospasm h. seizure i.A. Acute tetany a.A. Serum Calcium is decreased (normal value: 8.C MAD . Predisposing Factors 1. X-ray of long bones reveals a decrease in bone density 4. paresthesia c. inflammation b. Phosphate binder Aluminum Hydroxide Gel (Ampogel) Side effect: constipation ANTACID A.
Kidney stones a. Bone pain especially at back (bone fracture) 2. Hormonal replacement therapy for lifetime 9. Avoid precipitating stimulus such as glaring lights and noise 3. renal cholic b. Prepare trache set at bedside for presence of laryngo spasm 7. Provide acid ash in the diet to acidify urine and prevent bacterial growth 7. green turnips 4. Institute seizure and safety precaution 5. Agitation and memory impairment C. Over compensation of parathyroid gland due to vitamin D deficiency a. Encourage increase intake of foods rich in phosphate but decrease in calcium 6. Prevent complications 8. Maintain side rails .▼ Aluminum Containing Antacids ▼ Aluminum Hydroxide Gel ▼ Side Effect: Constipation ▼ Magnesium Containing Antacids ▼ Side Effect: Diarrhea 2. 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. anchovies b. Children: Ricketts b. Assist/supervise in ambulation 8. Encourage client to breathe using paper bag to produce mild respiratory acidosis result. cool moist skin 3. 6. X-ray of long bones reveals bone demineralization D. nausea and vomiting 4. Hyperplasia of parathyroid gland 2. salmon c. Strain all the urine using gauze pad for stone analysis 3. Provide warm sitz bath 4. Serum Calcium is increased 2. Diagnostic Procedures 1. Predisposing Factors 1. Encourage increase intake of foods rich in calcium a. Importance of follow up care. Nursing Management 1. Anorexia. Force fluids to prevent kidney stones 2. Administer medications as ordered a. Adults: Osteomalacia B. Morphine Sulfate (Demerol) 5. Serum Phosphate is decreased 3. Signs and Symptoms 1.
secretes mineralocorticoids (aldosterone) . Importance of follow up care ADRENAL GLAND o o Located atop of each kidney 2 layers of adrenal gland a.function: promotes sodium and water reabsorption and excretion of potassium .function: promotes secondary sex characteristics . Hypoglycemia – TIRED 2. Hyponatremia .weight loss . Zona Glumerulosa .Sex 3.signs of dehydration . Prevent complications (seizure and arrhythmia) 10. metabolic disturbance – Sugar b. deficiency of neuromuscular function – Salt/Sex A. Signs and Symptoms 1. fluid and electrolyte imbalance – Salt c.9.secretes glucocortocoids (cortisol) . Fungal infections B. Zona Fasciculata . Related to atrophy of adrenal glands 2. 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. Hormonal replacement therapy for lifetime 12. Predisposing Factors 1. Decrease tolerance to stress 3.hypotension .function: controls glucose metabolism . Assist in surgical procedure known as parathyroidectomy 11.secretes traces of glucocorticoids and androgenic hormones . Adrenal Cortex – outermost b.Sugar 2.Salt ADDISON’S DISEASE o Hyposecretion of adreno cortical hormone leading to a. Zona Reticularis .
Hyperkalemia .arrhythmia 5. Serum Sodium is decrease (normal value: 135 – 145 meq/L) 4. Diagnostic Procedures 1. severe hypotension b. Provide client health teaching and discharge planning a. hypertension b. Taper dose (withdraw gradually from drug) 3.4. increase susceptibility to infection e. Serum Potassium is increased (normal value: 3. moon face appearance 4. Administer isotonic fluid solution as ordered 3. hirsutism d. Monitor side effects a. Assist in mechanical ventilation. Monitor strictly vital signs. protein but decrease in potassium 6. avoid precipitating factor leading to addisonian crisis leading to .stress . Bronze like skin pigmentation C. Decrease libido 6. Mineralocorticoids (Flourocortisone) 5. prevent complications . Administer medications as ordered Corticosteroids a. Provide meticulous skin care 7.5 – 4. Dexamethasone (Decadrone) b. Hydrocortisone (Cortison) Nursing Management when giving steroids 1. Provide dietary intake. Nursing Management 1. hyponatremia leading to progressive stupor and coma Nursing Management for Addisonian Crisis 1.addisonian crisis . Prednisone c. edema c.sudden withdrawal to steroids b. input and output to determine presence of Addisonian crisis (complication of addison’s disease) o Addisonian crisis results from acute exacerbation of addison’s disease characterized by a. Plasma Cortisol is decreased 3. .hypovolemic shock . Force fluids 4.administer steroids as ordered .diarrhea .agitation .infection . hypovolemic shock c. Instruct client to take 2/3 dose in the morning and 1/3 dose in the afternoon to mimic the normal diurnal rhythm 2.force fluids 2. Loss of pubic and axillary hair 7. carbohydrates.5 meq/L) D. increase calories. FBS is decreased (normal value: 80 – 100 mg/dl) 2.
Administer medications as ordered a. Spinarolactone – potassium sparring diuretics 7. Restrict sodium intake 5. Increase masculinity among females B. hormonal replacement for lifetime d. obese trunk f. Plasma Cortisol is increased 3. weakness and fatigue b.Mixed gland (exocrine and endocrine) . Increase susceptibility to infections 3. Provide meticulous skin care 6. Nursing Management 1. Predisposing Factors 1 Related to hyperplasia of adrenal gland 2. Easy bruising 8. Hirsutism 6. Serum Sodium is increased 4. importance of follow up care CUSHING SYNDROME o Hypersecretion of adenocortical hormones A. Hypokalemia a. Monitor strictly vital signs and intake and output 2. U wave upon ECG (T wave hyperkalemia) 5. Hypernatremia a. pendulous abdomen g. hypertension b. Importance of follow up care PANCREAS . FBS is increased 2. weight gain d. moon face appearance and buffalo hump e. Prevent complications (DM) 8. Acne and striae 7.c. Hormonal replacement for lifetime 10. Serum Potassium is decreased C. edema c. thin extremities 4.Located behind the stomach . constipation c. Measure abdominal girth daily and notify physician 4. Assist in surgical procedure (bilateral adrenoraphy) 9. Diagnostic Procedures 1. Weigh patient daily and assess for pitting edema 3.
Complications 1. Coma C. protein and fat metabolism CLASSIFICATION OF DM Type 1 (IDDM) . Delayed/poor wound healing D.Has alpha cells that secretes glucagons (function: hyperglycemia) . Glucosuria 6. Related to viruses 3. Pancreatic Tumor/Cancer 2.90% of general population has type 2 DM B. Incidence Rate . Exercise E. Treatment 1.Obese over 40 years old A. Weight gain Type 2 (NIDDM) .metabolic disorder characterized by non utilization of carbohydrates. Diabetes Mellitus 3. Predisposing Factors 1. Polydypsia 3.Delta cells secretes somatostatin (function: antagonizes the effects of growth hormones) 3 Main Disorders of Pancreas 1.Brittle disease A. Hereditary (total destruction of pancreatic cells) 2. Obesity – because obese persons lack insulin receptor binding sites .Maturity onset type .10% general population has type 1 DM B. Lasix b. Anorexia. Weight loss 6. Diet 3. Polyphagia 5. Polyuria 3.. Ketotic 5. Exercise E.Consist of islets of langerhans . Steroids 4.Juvenile onset type . Blurring of vision 8.Consist of acinar cells which secretes pancreatic juices that aids in digestion thus it is an exocrine gland . Complication 1. Increase susceptibility to infection 9. Treatment 1. Incidence Rate . Polydypsia 4. Diet 3. nausea and vomiting 7.Adult onset . Polyphagia 4. Non 4. Diabetic Ketoacidosis D. Glucosuria 5. Signs and Symptoms 1. Insulin therapy 2. Drugs a. Usually asymptomatic 2. Hyper 2. Osmolar 3.Beta cells secretes insulin (function: hypoglycemia) . Related to carbon tetrachloride toxicity C. Oral Hypoglycemic agents 2. Polyuria 2. Pancreatitis DIABETES MELLITUS . Predisposing Factors 1. Signs and Symptoms 1.
Protein 3.Ketones HYPERGLYCEMIA Increase osmotic diuresis Glycosuria Cellular starvation – weight loss Stimulates the appetite/satiety center (Hypothalamus) Polyphagia Polyuria Cellular dehydration Stimulates the thirst center (Hypothalamus) Polydypsia * Liver has glycogen that undergo glycogenesis/ glycogenolysis GLUCONEOGENESIS Formation of glucose from non-CHO sources Increase protein formation ▼ Negative Nitrogen balance ▼ Tissue wasting (Cachexia) ▼ INCREASE FAT CATABOLISM ▼ Free fatty acids Cholesterol ▼ Atherosclerosis ▼ Hypertension MI CVA Ketones ▼ Diabetic Keto Acidosis Acetone Breath odor Kussmaul’s Respiration Death Diabetic Coma . Fats ANABOLISM CATABOLISM Glucose Amino Acids Fatty Acids Glycogen Nitrogen Free Fatty Acids .Cholesterol .MAIN FOODSTUFF 1. Carbohydrates 2.
Signs and Symptoms 1. Creatinine (normal value: . Headache and dizziness 2. Polydypsia 3. Polyuria 2. Seizure activity 4. Monitor strictly vital signs. Signs and Symptoms 1. BUN (normal value: 10 – 20) 3.Hyperosmolar: increase osmolarity (severe dehydration) . Insulin therapy (regular acting insulin/rapid acting insulin peak action of 2 – 4 hours) b. Kussmaul’s Respiration (rapid shallow breathing) 10 CNS depression leading to coma C. nausea and vomiting 7. Administer 0. FBS is increased 2.8 – 1) 4. Hct (normal value: female 36 – 42. Infection B. Weight loss 6. Assist in mechanical ventilation 2. Polyphagia 4. male 42 – 48) due to severe dehydration D. intake and output and blood sugar levels 4. Diagnostic Procedures 1. Blurring of vision 8.45 NaCl (hypotonic solutions) to counteract dehydration and shock 3. Restlessness 3. Administer medications as ordered a. Antibiotics to prevent infection HYPER OSMOLAR NON KETOTIC COMA . Nursing Management 1.Non ketotic: absence of lypolysis (no ketones) A. Hyperglycemia 2. Anorexia. Decrease LOC – diabetic coma .9 NaCl followed by . Sodium Bicarbonate to counteract acidosis c. Acetone breath odor 9.DIABETIC KETOACIDOSIS . Predisposing Factors 1. Stress – number one precipitating factor 3.Acute complication of type 1 DM due to severe hyperglycemia leading to severe CNS depression A. Glucosuria 5.
Intermediate Acting Insulin (cloudy) . Antibiotics to prevent infection INSULIN THERAPY A. Monitor strictly vital signs. Long Acting Insulin (cloudy) . Nursing Management for Insulin Injections 1. No need to aspirate upon injection 7. Administer 0. Administer insulin either 45o – 90o depending on amount of clients tissue deposit 6. Most accessible route is abdomen 9.9 NaCl followed by .Frequently used type because it has less antigenicity property thus less allergic reaction 3.Derived from beef and pork 2. Avoid shaking insulin vial vigorously instead gently roll vial between palm to prevent formation of bubbles 4. Classsification 1. Administer medications as ordered a.Peak action is 16 – 24 hours C.Stimulates the pancreas to secrete insulin A. Types of Insulin 1. hypertrophy of subcutaneous tissues) 2. Place in refrigerator once opened 3. Animal sources . Use gauge 25 – 26 needle 5. Artificially Compound Insulin B.Peak action is 2 – 4 hours 2. Nursing Management 1.Rarely used because it can cause severe allergic reaction . Assist in mechanical ventilation 2. Somogyis Phenomenon – rebound effect of insulin characterized by hypoglycemia to hyperglycemia ORAL HYPOGLYCEMIC AGENTS . Monitor for signs of local complications such as a. Human Sources . Sources of Insulin 1. When mixing 2 types of insulin aspirate first the clear insulin before cloudy to prevent contaminating the clear insulin and promote proper calibration. Insulin therapy (regular acting insulin peak action of 2 – 4 hours) . Chlorpropamide (Diabenase) b. Allergic reactions b.for DKA use rapid acting insulin b. Rotate insulin injection sites to prevent development of lipodystrophy 8.Peak action is 8 – 16 hours 3. Lipodystrophy c. 10. First Generation Sulfonylureas a. Tolbutamide (Orinase) . Administer at room temperature to prevent development of lipodystrophy (atrophy.B.Ultra Lente .Regular acting insulin (IV only) .Non Protamine Hagedorn Insulin (NPH) .45 NaCl (hypotonic solutions) to counteract dehydration and shock 3. intake and output and blood sugar levels 4. Rapid Acting Insulin (clear) .
Instruct client to have an annual eye and kidney exam 10. Provide nutritional intake of diabetic diet that includes: carbohydrates 50%. HPN and DM major cause of renal failure d.peripheral neuropathy . polydypsia. Alpha Glycosylated Hemoglobin is increased C.sexual impotence 8. Second Generation Sulfonylureas a. polyphagia and glucosuria confirmatory for DM) 2. MI.diarrhea/constipation .Renal failure c. Institute foot care management a. Monitor for peak action of insulin and OHA and notify physician 2. Nursing Management 1. instruct client to cut toenails straight c. Oral glucose tolerance test is increased – most sensitive test 4. Monitor for signs of DKA and HONKC 11.for hyperglycemia (dry and warm skin) 5. assist in surgical wound debriment (give analgesics 15 – 30 mins prior) 9. CVA) b.administer simple sugars . Atherosclerosis (HPN. Shock due to dehydration . protein 30% and fats 20% or offer alternative food substitutes 6. Diabeta (Micronase) Nursing Management when giving OHA 1. instruct client to avoid wearing constrictive garments d. instruct client to avoid walking barefooted b. Administer insulin and OHA therapy as ordered 3.for hypoglycemia (cold and clammy skin) give simple sugars . Monitor strictly vital signs. Blood II. FBS is increased (3 consecutive times with signs or polyuria. Gangrene formation e. Diagnostic Procedures 1. Assist in surgical procedure HEMATOLOGICAL SYSTEM I. Glipzide (Glucotrol) b. intake and output and blood sugar levels 4. Monitor signs for complications a.c. Instruct the client to take it with meals to lessen GIT irritation and prevent hypoglycemia 2. Microangiopathy (affects small minute blood vessels of eyes and kidneys) EYES -PREMATURE CATARACT . Random Blood Sugar is increased 3. Tolamazide (Tolinase) 2. Blood Forming Organs .Blindness KIDNEY -RECURRENT PYELONEPHRITIS . Instruct client to exercise best after meals when blood glucose is rising 7. Instruct the client to avoid taking alcohol because it can lead to severe hypoglycemia reaction or Disulfiram (Antabuse) toxicity symptoms B. Blood Vessels III. encourage client to apply lanolin lotion to prevent skin breakdown e. Monitor for signs of hypoglycemia and hyperglycemia .
Globulins 3.normal value: 4 – 6 million/mm3 . Monocytes .substances needed for maturation of RBC a. Bone Marrow ALBUMIN .hemoglobin: normal value female 12 – 14 gms% male 14 – 16 gms% .consist of molecules of hgb (red pigment) bilirubin (yellow pigment) biliverdin (green pigment) hemosiderin (golden brown pigment) . Polymorpho Neutrophils . Granulocytes 1.Alpha globulins . vitamin b6 (pyridoxine) f.normal value: 5000 – 10000/mm3 A. Spleen 4. bilirubin and hormones .transports and carries oxygen to tissues . Liver 3. folic acid b.Maintains osmotic pressure preventing edema GLOBULINS .involved in short term phagocytosis for acute inflammation 2. anti-bodies and immunoglobulins b. prothrombin and fibrinogen clotting factors FORMED ELEMENTS 1.biconcave discs . vitamin c d.largest WBC . WBC (LEUKOCYTES) . Albumin 2.for parasite infections .Normal life span of RBC is 80 – 120 days and is killed in red pulp of spleen 2.only unnucleated cell .hematocrit red cell percentage in wholeblood .Largest and numerous plasma CHON .55% Plasma Serum 45% Formed 1. Lymphoid Organ 5. Polymorphonuclear Eosinophils . Arteries 2. Polymorphonuclear Basophils .macrophage in blood .normal value: female 36 – 42% male 42 – 48% .60 – 70% of WBC . Non Granulocytes 1. Lymph Nodes 6.responsible for the release of chemical mediation for inflammation 3.for allergic reaction B. RBC (ERYTHROCYTES) . Prothrombin and Fibrinogen 1.Beta globulins – iron and copper . Veins Plasma CHON (formed in liver) 1.transport steroids. iron c. intrinsic factor .Gamma globulins a. vitamin b12 (cyanocobalamin) e.
Oozing of blood from venipunctured site BLOOD DISORDERS Iron Deficiency Anemia . Signs and Symptoms 1. Subtotal gastrectomy 4. fresh blood per rectum is called hematochezia 2. Common among women 15 – 35 years old 4.ELISA . Predisposing Factors 1.anti viral and anti tumor property HIV .6 months window period . Chronic blood loss due to trauma a. Common among tropical zones 3. Related to improper cooking of foods C. Pneumocystis Carinii Pneumonia 3. Lymphocytes B-cell T-cell . Weakness and fatigue (initial signs) 3.6 months – 5 years incubation period .000/mm3 .Promotes hemostasis (prevention of blood loss) . Headache and dizziness .Normal life span of platelet is 9 – 12 days Signs of Platelet Dysfunction 1. Echhymosis 3. Related to GIT bleeding resulting to hematemesis and melena (sign for upper GIT bleeding) c.A chronic microcytic anemia resulting from inadequate absorption of iron leading to hypoxemic tissue injury A. Related to poor nutrition B. Platelets (THROMBOCYTES) . Incidence Rate 1. Heavy menstruation b. Inadequate intake of iron due to a..000 – 450. Related to malabsorption syndrome c. Petechiae 2. Usually asymptomatic 2. Chronic diarrhea b.western blot opportunistic .involved in long term phagocytosis for chronic inflammation 2.Consist of immature or baby platelets or megakaryocytes which is the target of dengue virus .Normal value: 150. High cereal intake with low animal protein digestion d.bone marrow . Kaposi’s Sarcoma 2.thymus for immunity Natural killer cell .drug of choice AZT (Zidon Retrovir) 2 Common fungal opportunistic infection in AIDS 1. Common among developed countries 2.
Nitrofurantoin (Macrodentin) 3. Nursing Management 1. Palpitations 7. Diagnostic Procedures 1. RBC is decreased 2. Ferrous Fumarate c. Instruct the client to avoid taking tea and coffee because it contains tannates which impairs iron absorption 5. Instruct client to take foods rich in iron a. Reticulocyte is decreased 6. Raisin d. Monitor side effects a.Iron .Stomatitis . Diarrhea/constipation e. Legumes g. IV) b. Iron is decreased 5. Ferritin is decreased E.Dysphagia 9. Administer Z tract technique to prevent discomfort. Dried fruits f. Brittleness of hair and spoon shape nails (koilonychias) 8. Enforce CBR so as not to over tire client 3.Lugol’s solution . Hct is deceased 4. Monitor for signs of bleeding of all hema test including urinw.Tetracycline . PICA (abnormal appetite or craving for non edible foods D. Nuts 4. Organ meat b. Sorbitex (IM) Nursing Management when giving parenteral iron preparations 1. Anorexia b. If client cant tolerate/no compliance administer parenteral iron preparation a. Instruct client to take with meals to lessen GIT irritation 2. Ferrous Sulfate b. Abdominal pain d.4. Egg (yolk) c. Atropic Glossitis (inflammation of tongue) . Ferrous Gluconate . Administer medications as ordered Oral Iron Preparations a. Iron Dextran (IM. stool and GIT 2. Administer with Vitamin C or orange juice for absorption 4. Nausea and vomiting c. Hgb is decreased 3. Monitor and inform client of side effects a. Dyspnea 6. Melena 5. Avoid massaging the injection site instead encourage to ambulate to facilitate absorption 3.300 mg/day Nursing Management when taking oral iron preparations 1. Pallor and cold sensitivity 5. discoloration and leakage to tissues 2. Sweet potatoes e. Pain at injection site PLUMBER VINSON’S SYNDROME . When diluting it in liquid iron preparations administer with straw to prevent staining of teeth Medications administered via straw .
Pallor and cold sensitivity 4. Headache and dizziness 3. Nursing Management 1. Dyspnea and palpitations as part of compensation 5.Chronic anemia characterized by a deficiency of intrinsic factor leading to hypochlorhydria (decrease hydrochloric acid secretion) A. numbness c.Never given orally because there is possibility of developing tolerance Secretes hydrochloric acid ▼ Aids in digestion . tingling sensation b. Subtotal gastrectomy 2. Hypotension (anaphylactic shock) PERNICIOUS ANEMIA . Signs and Symptoms 1. Pruritus/orticaria g. red beefy tongue c. Enforce CBR 2. indigestion/dyspepsia d. positive to Romberg’s test – damage to cerebellum resulting to ataxia e. Lymphadenopathy d. Strictly vegetarian diet STOMACH ▼ Pareital cells/ Argentaffin or Oxyntic cells Produces intrinsic factors ▼ Promotes reabsorption of Vit B12 ▼ Promotes maturation of RBC B. GIT changes that includes a. Fever and chills e. Administer Vitamin B12 injections at monthly intervals for lifetime as ordered . Predisposing Factors 1. Autoimmune 5. weight loss e. result to psychosis C. Skin rashes f. paresthesia d.b. Diagnostic Procedure Schilling’s Test – reveals inadequate/decrease absorption of Vitamin B12 D. jaundice 6. Hereditary factors 3. Inflammatory disorders of the ileum 4. CNS changes a. mouth sore b. Weakness and fatigue 2. Localized abscess c.
Weakness and fatigue b. fever Decrease WBC (leucopenia) Decrease Platelet (thrombocytopenia) . Ecchymosis c. Avoid heat application to prevent burns APLASTIC ANEMIA .Site of injection for Vitamin B12 is dorsogluteal and ventrogluteal . Methotrexate (Alkylating Agent) b. Anemia a. Drugs Broad Spectrum Antibiotics a. Oozing of blood from venipunctured sites C. Diagnostic Procedures 1. Headache and dizziness c. Immunologic injury 4. Provide a dietary intake that is high in carbohydrates. Instruct client to avoid irritating mouth washes instead use soft bristled toothbrush 5. CBC reveals pancytopenia 2. Nitrogen Mustard (Antimetabolite) Phenylbutazones (NSAIDS) B. Bone marrow biopsy/aspiration (site is the posterior iliac crest) – reveals fat necrosis in bone marrow D. Chemicals (Benzine and its derivatives) 2. Increase susceptibility to infection 3. vitamin c and iron 4. Leukopenia a. Related to irradiation/exposure to x-ray 3. Petechiae (multiple petechiae is called purpura) b. Removal of underlying cause 2. Thrombocytopenia a. Institute BT as ordered 3. Predisposing Factors 1.Stem cell disorder leading to bone marrow depression leading to pancytopenia PANCYTOPENIA Decrease RBC (anemia) A. Vincristine (Plant Alkaloid) c. Nursing Management 1. Institute reverse isolation 6.No side effects 3. Monitor for signs of infection a. Signs and Symptoms 1. Dyspnea and palpitations 2. protein. Administer oxygen inhalation 4. Chloramphenicol (Sulfonamides) Chemotherapeutic Agents a.. Enforce CBR 5. Pallor and cold sensitivity d.
CBC reveals decreased platelets 2. Monitor for signs of bleeding of all hema test including stool and GIT 2. Administer isotonic fluid solution as ordered 3. Ecchymosis 3. Provide heparin lock 7. Diagnostic Procedures 1.b. Corticosteroids – caused by immunologic injury b. Monitor NGT output 9. Vitamin K b. Neoplasia (new growth of tissue) 7. Massive burns 3. lungs and lower extremities 2. Administer oxygen inhalation 4. Predisposing Factors 1. Nursing Management 1. Instruct client to use electric razor when shaving 10. cough 7. Stool occult blood positive 3. venipunctured sites 8 Instead provide heparin lock 9. Anaphylaxis 5. Administer medications as ordered a. Massive trauma 4. Force fluids 5. ABG analysis reveals metabolic acidosis 4. Avoid IM. Institute NGT decompression by performing gastric lavage by using ice or cold saline solution of 500 – 1000 ml 8. Administer medications as ordered a. Pregnancy B. Oliguria (late sign) C. 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. Related to rapid blood transfusion 2. Septecemia 6. Pitressin/ Vasopresin to conserve fluids c. Prevent complication . Opthamoscopic exam reveals sub retinal hemorrhages D. Oozing of blood from punctured sites 4. subcutaneous. Petechiae (widespread and systemic) eye. Hemoptysis 6. Heparin/Coumadin is ineffective 6. Signs and Symptoms 1.
Proper refrigeration . Prevent bleeding if there is platelet deficiency Principles of blood transfusion 1.a. Type AB – universal recipient c. Prevent infection in there is a decrease in WBC 4.Expiration of platelet is 3 – 5 days 2.Emergency rapid BT is given after 30 minutes and let natural room temperature warm the blood. Replace circulating blood volume 2. Serial number 5. Regulate BT 10 – 15 gtts/min or KVO rate or equivalent to 100 cc/hr to prevent circulatory overload 9. Allergic reaction c. Hyperkalemia (caused by expired blood) . Check the blood unit for bubbles cloudiness. 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. Increase the oxygen carrying capacity of blood 3. Client name b. Anuria – late sign BLOOD TRANSFUSION Goals/Objectives 1. Avoid mixing or administering drugs at BT line to prevent HEMOLYSIS 8. during and after BT especially every 15 minutes for first hour because majority of transfusion reaction occurs during this period a. 85% of population is RH positive 3. Thrombocytopenia g. Expiration date d. Isotonic solution (0. Hemolytic reaction b. Gauge 18 – 19 needle c. Blood typing and cross matching c. . sediments and darkness in color because it indicates bacterial contamination . Proper typing and cross matching a. Circulatory overload e.Never warm blood as it may destroy vital factors in blood.Expiration of packed RBC is 3 – 6 days . Instruct another RN to re check the following a. Hypovolemic shock b. Air embolism f. Type O – universal donor b. 6. Cytrate intoxication h. Filter set b.Warming is only done during emergency situation and if you have the warming device . Pyrogenic reaction d. Aseptically assemble all materials needed for BT a.9 NaCl/plain NSS) to prevent hemolysis 4. Monitor strictly vital signs before.
Laryngospasm and Broncospasm Nursing Management 1. Send the blood unit to blood bank for re examination 6. Flush with plain NSS 4. Diarrhea/Constipation 4. Lumbasternal/ Flank pain 7. Monitor vital signs and intake and output SIGNS AND SYMPTOMS PYROGENIC REACTIONS 1. Notify physician 3. Notify physician 3. Notify physician 3. Urticaria 6. Fever and chills 2. Urine is color red/ portwine urine Nursing Management 1.if positive to hypotension. Monitor vital signs and intake and output SIGNS AND SYMPTOMS OF ALLERGIC REACTION 1. Dyspnea 3. Fever 2. Administer medications as ordered a. Palpitations 5. Stop BT 2. Flush with plain NSS 4. Stop BT 2. Hypotension 5. anaphylactic shock treat with Epinephrine 5. Tachycardia 4. Obtain urine and blood sample and send to laboratory for re examination 7. Dyspnea 3. Skin rashes 5. Stop BT 2. Flushed skin 6. Flush with plain NSS . Obtain urine and blood sample and send to laboratory for re examination 7. Broncial wheezing 4. Administer isotonic fluid solution to prevent shock and acute tubular necrosis 5. Headache and dizziness 2. Headache 3. Diaphoresis 6. Anti Histamine (Benadryl) . Dyspnea Nursing Management 1.Signs and Symptoms of Hemolytic reaction 1. Send the blood unit to blood bank for re examination 6.
Orthopnea 2.Resemble like a close fist . Upper Chamber (connecting or receiving) a.Prevent pericardial friction rub . Dyspnea 3.In between is the pericardial fluid which is 10 – 20 cc . Cardiac tamponade A. Obtain urine and blood sample and send to laboratory for re examination 7. Ventricles .Left ventricle has increased pressure which is 120 – 180 mmHg . Antibiotic 5. Administer medications as ordered a. Send the blood unit to blood bank for re examination 6.In order to propel blood to the systemic circulation .Covered by a serous membrane called the pericardium 2 layers of pericardium a.Right atrium has decreased pressure which is 60 – 80 mmHg C. Administer medications as ordered a. Rales/Crackles upon auscultation 4. Layers of Heart 1. Render TSB SIGNS AND SYMPTOMS OF CIRCULATORY REACTION 1. Loop diuretic (Lasix) CARDIOVASCULAR SYSTEM OVERVIEW OF THE STRUCTURE AND FUNCTIONS OF THE HEART HEART .To promote unidimensional flow or prevent backflow 1. pericarditis.Common among MI.Weighs approximately 300 – 400 grams . Antipyretic b.4. Chambers of the Heart 1.Myocarditis can lead to cardiogenic shock and rheumatic heart disease B. Atrioventricular Valves – guards opening between a. Endocardium – inner layer . Visceral – inner layer . Myocardium – middle layer 3. . Lower Chamber (contracting or pumping) a. Atria 2.Located on the left mediastinum . tricuspid valve . Monitor vital signs and intake and output 8. Stop BT 2. Parietal – outer layer b.Muscular pumping organ of the body. Notify physician 3. Valves . Epicardium – outer layer 2. Exertional discomfort Nursing Management 1.
pulmonic b.Delay of electrical impulse for about .Left Main Bundle of His . S4 – atrial gallop usually seen in Myocardial Infarction and Hypertension D.Right Main Bundle of His . Coronary Arteries . Bundle of His .Closure of AV valves give rise to first heart sound (S1 “lub”) 2.08 milliseconds to allow ventricular filling 3.Closure of SV valve give rise to second heart sound (S2 “dub”) Extra Heart Sounds 1.T WAVE (ventricular repolarization) . Right Main Coronary Artery 2.QRS WAVE (ventricular depolarization) . Semi – lunar Valves a.Located at the inter atrial septum . S3 – ventricular gallop usually seen in Left Congestive Heart Failure 2.Located at the interventricular septum 4. Cardiac Conduction System 1.Located at the walls of the ventricles for ventricular contraction SA NODE AV NODE BUNDLE OF HIS JLJLJLJJLJLJL PURKINJE FIBERS . Sino – Atrial Node (SA or Keith Flack Node) . Left Main Coronary Artery . Atrio – Ventricular Node (AV or Tawara Node) . Purkinje Fibers .Initiates electrical impulse of 60 – 100 bpm 2.Supplies the myocardium E. aortic .Located at the junction of superior vena cava and right atrium .b.P WAVE (atrial depolarization) contraction .Arises from base of the aorta Types of Coronary Arteries 1. mitral valve .Acts as primary pacemaker of the heart .
Smoking 4.tunica intima A. Diabetes Mellitus 8. To prevent angina 3. Signs and Symptoms 1.tunica media . Tachycardia 4. Positive U wave . Predisposing Factors 1. Treatment Percutaneous Transluminal Coronary Angioplasty Objectives of PTCA 1. Duaphoresis C. Palpitations 5. Myocardial Injury . Peak T wave – Hyperkalemia 3. Hyperlipidemia 6. Dyspnea 3. Myocardial Necrosis – Myocardial Infarction ATHEROSCLEROSIS ATHEROSCLEROSIS .Atherosclerosis 2. Race – black 3. Chest pain 2. sedentary lifestyle 7.narrowing of artery .calcium and protein deposits .lipid or fat deposits . ST segment depression – Angina Pectoris 4.Hypokalemia 2. Widening of QRS complexes – Arrythmia CARDIAC DISORDERS Coronary Arterial Disease/ Ischemic Heart Disease Stages of Development of Coronary Artery Disease 1.hardening of artery . Increase survival rate ARTERIOSCLEROSIS . Type A personality B. Sex – male 2. Hypothyroidism 9. 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. Diet – increased saturated fats 10. Revascularize myocardium 2. ST segment elevation – Myocardial Infarction 5. Myocardial Ischemia – Angina Pectoris 3. Obesity 5. T wave inversion – Myocardial Infarction 6.
anxiety. Smoking 4. Levine’s Sign – initial sign that shows the hand clutching the chest 2. Hyperlipidemia 6. 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. Diagnostic Procedure 1. Diaphoresis D. sedentary lifestyle 7. Nursing Management 1.5 minutes . Shock 3. Stress test – treadmill test. arms. Excessive intake of foods rich in saturated fats – skimmed milk C. Signs and Symptoms 1. shoulder.Give first dose of NTG (sublingual) 3 – 5 minutes . Serum cholesterol and uric acid is increased E. Dyspnea 4. Administer medications as ordered a. Tachycardia 5.Done to single occluded vessels . Enforce complete bed rest 2. Extreme emotional response – fear. History taking and physical exam 2. Diet – increased saturated fats 10. Race – black 3. usually relieved by rest or taking nitroglycerine 3. Sex – male 2. Predisposing Factors 1. Type A personality B. reveal abnormal ECG 4. Obesity 5.If there is 2 or more occluded blood vessels CABG is done Coronary Arterial Bypass And Graft Surgery 3 Complications of CABG 1. Chest pain characterized by sharp stabbing pain located at sub sterna usually radiates from back.. coughing exercise and use of incentive spirometer 2. Pneumonia – encourage to perform deep breathing. axilla and jaw muscles. but in large doses will act as vasodilator . Excessive physical exertion – heavy exercises 2. Precipitating Factors 4 E’s of Angina Pectoris 1. excitement 4. Nitroglycerine (NTG) – when given in small doses will act as venodilator. Diabetes Mellitus 8. ECG tracing reveals ST segment depression 3. Hypothyroidism 9. Exposure to cold environment 3. Palpitations 6.Give second dose of NTG if pain persist after giving first dose with interval of 3 .
Avoidance of 4 E’s b. The importance of follow up care MYOCARDIAL INFARCTION Heart attack Terminal stage of coronary artery disease characterized by malocclusion. Predisposing Factors 1.. Types 1. intake and output and ECG tracing 6.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. Race – black 3. Monitor strictly vital signs. ACE Inhibitors . Provide client health teachings and discharge planning a. Hyperlipidemia . Obesity 5. Instruct client to take medication before indulging into physical exertion to achieve the maximum therapeutic effect of drug d.side effects PNS .NIfedipine 3. Smoking 4. 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. necrosis and scarring. Provide decrease saturated fats sodium and caffeine 7.Enalapril d.Not given to COPD cases because it causes bronchospasm c. A. Calcium Antagonist . Beta-blockers . Place client on semi fowlers position 5. Administer oxygen inhalation 4. Sex – male 2. Subendocardial Myocardial Infarction – characterized by occlusion of either right or left coronary artery B. Prevent complication (myocardial infarction) 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.Propanolol .
Chest pain . ECG tracing reveals a. ST segment elevation b. Dyspnea 3. Instruct client to avoid forms of valsalva maneuver 5. Place client on semi fowlers position .Excruciating visceral. S4 or atrial gallop E. 12 – 24 hours b. Administer oxygen low inflow to prevent respiratory arrest at 2 – 3 L/min 3. Ashen skin 6. shoulder. Nursing Management Goal: Decrease myocardial oxygen demand 1. CPK – MB . Split S1 and S2 c.Side Effects: respiratory depression .Heart only. Troponin Test – is increased 3.Antidote: Narcan/Naloxone . Type A personality D. Occasional findings a. axilla. Serum Cholesterol and uric acid are both increased 5. T wave inversion c.Not usually relieved by rest or by nitroglycerine 2.6. Decrease myocardial workload (rest heart) . sedentary lifestyle 7. Hypothyroidism 9. SGOT – Serum glutamic oxal-acetic transaminase is increased 2. Increase in blood pressure (initial sign) 4.Administer narcotic analgesic/morphine sulfate . Cardiac Enzymes a. jaw and abdominal muscles (abdominal ischemia) .Creatinine phosphokinase is increased . Pericardial friction rub b. Diet – increased saturated fats 10. CBC – increased WBC F. Signs and Symptoms 1. Enforce CBR without bathroom privileges a. Rales/Crackles upon auscultation d. Diabetes Mellitus 8. Using bedside commode 4. viselike pain located at substernal and rarely in precordial . Mild restlessness and apprehension 7.Usually radiates from back. Diagnostic Procedure 1. Widening of QRS complexes indicates that there is arrhythmia in MI 4. Hyperthermia 5. SGPT – Serum glutamic pyruvate transaminase is increased d. LDH – Lactic acid dehydroginase is increased c. arms.Side Effects of Naloxone Toxicity is tremors 2.
late sign is oliguria c. pruritus . intake and output and ECG tracing 7.Antidote: protamine sulfate . Anti Platelet .arrhythmia (caused by premature ventricular contraction) b. Provide a general liquid to soft diet that is low in saturated fats.Side Effects: allergic reaction.Streptokinase .Side Effects: confusion and dizziness .Side Effects: chest pain . sodium and caffeine 8. Anti Arrythmic Agents .homan’s sign e. ACE Inhibitors e. Thrombolytics/ Fibrinolytic Agents . Stroke/CVA . Encourage client to take 20 – 30 cc/week of wine. Beta-blockers d. Provide client health teaching and discharge planning concerning a. Calcium Antagonist f.Coumadin/ Warfarin Sodium (check for prothrombin time) .ISD (Isosorbide Dinitrate.Lidocaine (Xylocane . Avoidance of modifiable risk factors . Isodil) sublingual b. Thrombophlebitis .Brutylium c.Anti thrombotic effect . whisky and brandy to induce vasodilation 9. Vasodilators . Cardiogenic shock . Administer medication as ordered a.Heparin (check for partial thrombin time) . Left Congestive Heart Failure d. Monitor strictly vital signs.TIPAF (tissue plasminogen activating factor) . Anti Coagulant .Urokinase .Antidote: Vitamin K h.Side Effects of Aspirin Tinnitus Heartburn Indigestion/Dyspepsia .Monitor for bleeding time g.6.Contraindication Dengue Peptic Ulcer Disease Unknown cause of headache 10.PASA (Aspirin) .Nitroglycerine .
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. Aortic valve stenosis B.dietary modification h. administer 150. There is anorexia and generalized body malaise 12. S3 – ventricular gallop C. dependent on extent of heart failure 4.000 units of streptokinase as ordered g. Frothy salivation 6.000 – 450.ASO Titer (Anti streptolysin O titer) . Signs and Symptoms 1. 90% is mitral valve stenosis due to a. Dyspnea 2. Cyanosis 7. Diagnostic Procedure 1. PCO2 is increased (respiratory acidosis) 2. Hypertension 5. post CABG and instruct to .instruct client to assume a non weight bearing position . ABG – reveals PO2 is decreased (hypoxemia). RIGHT SIDED HEART FAILURE . Productive cough with blood tinged sputum 5.Common among children . Resumption of ADL particularly sexual intercourse is 4 – 6 weeks post cardiac rehab. Pulsus Alternans – weak pulse followed by strong bounding pulse 10. Paroxysmal nocturnal dyspnea – client is awakened at night due to difficulty of breathing 3. Chest x-ray – reveals cardiomegaly 2. RHD – inflammation of mitral valve due to invasion of Grp. LEFT SIDED HEART FAILURE A. PMI is displaced laterally due to cardiomegaly 11. Rales/Crackles 8.make sex as an appetizer rather than dessert . Post MI Syndrome/Dressler’s Syndrome . 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. Bronchial wheezing 9.client can resume sexual intercourse if can climb staircase .client is resistant to pharmacological agents.Formation of aschoff bodies in the mitral valve . Predisposing Factors 1. Aging 2.f. Orthopnea – use 2 – 3 pillows when sleeping or place in high fowlers 4. A beta-hemolytic streptococcus .Aspirin b.Penicillin . Ischemic heart disease 4. Myocardial Infarction 3. Ecocardiography – enlarged heart chamber (cardiomyopathy).
Anorexia 9. Liver enzymes – SGPT and SGOT is increased D. 3 – 4 L/min.When reading CVP patient should be flat on bed . Administer oxygen inhalation with high inflow.Increase force of cardiac contraction . Anti Arrhythmic . Loop Diuretics . Pulmonary embolism 3. Hepatosplenomegaly 6. Pulmonic valve stenosis 5. Tricuspid valve stenosis 2. Predisposing Factors 1.CVP fluid status measure . Administer medications as ordered a. Bronchodilators d. Cardiac glycosides . Related to COPD 4. Pitting edema 3. Nursing Management Goal: increase cardiac contractility thereby increasing cardiac output (3 – 6 L/min) 1. Diagnostic Procedures 1. Weight gain 5.Lidocaine (Xylocane) 3. Chest x-ray – reveals cardiomegaly 2.If heart rate is decreased do not give b.If CVP is less than 4 cm of water hypovolemic shock . Vasodilators .Administer loop diuretics as ordered . Esophageal varices C. Jaundice 7.If CVP is more than 10 cm of water hypervolemic shock . Ecocardiography – reveals enlarged heart chambers (cardiomyopathy 4.Digoxin (Lanoxin) .Lasix (Furosemide) c. delivered via nasal cannula 4.Upon insertion place client in trendelendberg position to promote ventricular filling and prevent pulmonary embolism 3. Pruritus 8. Narcotic analgesics . Enforce CBR 2.A. High fowlers position . Neck/jugular vein distension 2.Nitroglycerine f. Signs and Symptoms (venous congestion) 1.Morphine Sulfate e. Ascites 4. Central venous pressure (CVP) .Do the fluid challenge (increase IV flow rate) . Left sided heart failure B.Measure pressure in right atrium (4 – 10 cm of water) .
Shock . Dietary modification c. cyanosis then rubor) 3. Administer medications as ordered a.MI . Assist in bloodless phlebotomy – rotating tourniquet. Doppler UTZ – decrease blood flow to the affected extremity 3. Angiography – reveals site and extent of malocclusion D.Thrombophlebitis b. Decreased peripheral pulses 4. Measure abdominal girth daily and notify physician 7. Trophic changes 5. Prevent complications . Varicose Veins 2. Predisposing Factors 1. Cold sensitivity and changes in skin color (pallor. Oscillometry – decrease in peripheral pulses 2. Thrombo Angitis Obliterans Venous Ulcer 1. Strict compliance to medications PERIPHERAL VASCULAR DISORDER Arterial Ulcer I. Smoking B. Signs and Symptoms 1. Thrombophlebitis (deep vein thrombosis) THROMBOANGITIS OBLITERANS Acute inflammatory disorder usually affecting the small medium sized arteries and veins of the lower extremities A. out of bed 3 – 4 times a day 2. rotated clockwise every 15 minutes to promote decrease venous return 10. Encourage a slow progressive physical activity a. Diagnostic Procedures 1. Provide meticulous skin care 9.Arrythmia . High risk groups – men 30 years old and above 2.5. Provide client health teaching and discharge planning a.Right ventricular hypertrophy . intake and output and ECG tracing 6. Ulceration 6. walking 3 – 4 times a day b. cholesterol and caffeine 8. Analgesics Burger’s Disease Reynaud’s Disease . Nursing Management 1. Provide a dietary intake of low sodium. Gangrene formation C. Intermittent claudication – leg pain upon walking 2. Monitor strictly vital signs.
Administer medications as ordered a. Angiography – reveals site and extent of malocclusion D. Cold sensitivity and changes in skin color (pallor. Anti coagulants 3. Vasodilators 2. cyanosis then rubor) 3. SLE (butterfly rash) b. High risk group – female 40 years old and above 2. Cardiac disorder 5. Nursing Management 1.b. Thrombophlebitis 4. Predisposing Factors 1. Hereditary 2. Doppler UTZ – decrease blood flow to the affected extremity 2. Operating chainsaw B. Institute foot care management 4. Intermittent claudication – leg pain upon walking 2. Vasodilators c. Instruct client to avoid smoking and exposure to cold environment 5. 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. Diagnostic Procedures 1. 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. Direct hand trauma a. Pregnancy . Smoking 3. Ulceration 5. Congenital weakness of veins 3. Excessive typing c. Trophic changes 4. Signs and Symptoms 1. Piano playing b. Rheumatoid Arthritis 4. Predisposing Factors 1. Collagen diseases a. Encourage to wear gloves 3. Gangrene formation C. Analgesics b.
Dilated tortuous skin veins 3. Predisposing Factors 1. Diagnostic Procedure 1. Diabetes mellitus 7. Wear anti embolic stockings 4. Pain after prolonged standing 2. Obesity 2. Measure the circumference of leg muscle to determine if swollen 3. Obesity 7. Signs and Symptoms 1. Pain at affected extremity 2. Trendelenburg’s Test . Venography 2. Increase in saturated fats in the diet. Nursing Management . Vein stripping and ligation (most effective) b. Signs and Symptoms 1. Chronic anemia 5. 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. Congestive heart failure 8.6. Dilated tortuous skin veins 4. Prolonged standing or sitting B. Smoking 3. Prolong use of oral contraceptives – promotes lipolysis 6. Angiography D. Positive Hpman’s Signs – pain at the calf or leg muscle upon dorsi flexion of the foot C. Warm to touch 3. Related to pregnancy 4. Nursing Management 1. Post op complication 10. Venography 2. Post cannulation – insertion of various cardiac catheter 11. Myocardial infarction 9. Heaviness in legs C. Analgesics 5.veins distends quickly in less than 35 seconds D. Diagnostic Procedure 1. Warm to touch 4. Elevate legs above heart level to promote increased venous return by placing 2 – 3 pillows under the legs 2. B. Administer medications as ordered a. Assist in surgical procedure a.
Warming and moistening of air 3.For cough reflex Glottis . Humidification A.Cartillage . Apply warm moist pack – to reduce lymphatic congestion 3.Right nostril .Dizziness .1. Filtering of air 2.Opening of larynx .The initial sign of complete airway obstruction is the inability to cough II.For phonation (voice production) . cholecystitis characterized by pain at the right upper quadrant with tenderness RESPIRATORY SYSTEM OVERVIEW OF THE STRUCTURES AND FUCNTIONS OF THE RESPIRATORY SYSTEM I. Upper Respiratory System 1. Measure circumference of leg muscle to determine if swollen 4. Pulmonary . Pharynx/Throat .Decrease LOC • MURPHY’S SIGN is seen in clients with cholelithiasis.Serves as passageway of air going to the lungs . Monitor for signs of complications Embolism a. Administer medications as ordered a.Left nostril .Opens to allow passage of air . Lower Respiratory System . Analgesics b.Consist of anastomosis of capillaries known as Keissel Rach Plexus (the site of nose bleeding) B.Consist of cartilaginous rings .Closes to allow passage of food going to the esophagus . Anti Coagulant .Headache . Nose .Tachycardia .Palpitations .For gas exchange A.Serves as a muscular passageway for both food and air C.Sudden sharp chest pain .Unexplained dyspnea . Cerebral .Diaphoresis . Trachea/Windpipe .Heparin 6.Separated by septum . Larynx .Restlessness b. Elevate legs above heart level to promote increase venous return 2. Encourage to wear anti embolic stockings or knee elastic stockings 5.
Alcoholism 4.Site of tracheostomy B.In premature infants 1:2 . 10 segments) . Low grade afternoon fever. Hydrothorax (air and blood in pleural space Alveoli . Pareital b. Airborne transmission via droplet nuclei C.L/S ratio to determine lung maturity .Left lung (consist of 2 lobes. Pleural fluid c. Malnutrition 2. Virulence (degree of pathogenecity) of microorganism B.Right lung (consist of 3 lobes.Right main bronchus . Over fatigue 5.Composed of lecithin and spingomyelin .Give oxygen of less 40% in premature to prevent atelectasis and retrolental fibroplasias . 8 segments) .. Visceral With Pleuritic Friction Rub a. Bronchus .Site of gas exchange (CO2 and O2) . PTB/Pulmonary Tuberculosis (Koch’s Disease) .Decrease oxygen stimulates breathing . gram negative.Infection of lung tissue caused by invasion of mycobacterium tuberculosis or tubercle bacilli .Left main bronchus C. Pleural effusion c. Productive cough (yellowish sputum) .Serous membranes Pleural Cavity a.An acid fast.Normal L/S ratio is 2:1 . Pneumonia b. Precipitating Factors 1. aerobic and easily destroyed by heat or sunlight A.Secretes surfactant .Diffusion (Dalton’s law of partial pressure of gases) Respiratory Distress Syndrome . Overcrowded places 3. night sweats 2.Increase carbon dioxide is a powerful stimulant for breathing Type II Cells of Alveoli . Lungs .Prevent collapse of alveoli . Signs and Symptoms 1.retinopathy/blindness in prematurity Disorders of Respiratory System 1.Decrease surface tension . Mode of Transmission 1. Ingestion of an infected cattle with mycobacterium bovis 6.
Reveals pulmonary infiltrates 4.Neomycin .Positive Mantoux test (previous exposure to tubercle bacilli but without active TB) 2.Purified protein derivative . Standard phase . Nebulize and suction when needed 8.Kanamycin . 48 – 72 hours . Chest X-ray . Diagnostic Procedure 1. Encourage deep breathing and coughing exercise 7. hepatotoxicity. Hemoptysis (chronic) D. Enforce CBR 2.INH and Rifampicin is given for 4 months.Injection of streptomycin (aminoglycoside) .Gentamycin . Comfortable and humid environment 9. nephrotoxicity .Amikacin .Reveals increase WBC E. Institute short course chemotherapy a. taken after meals to facilitate absorption . Chest pain 7.PZA (Pyrazinamide) . Administer oxygen inhalation 4. Nursing Management 1. Force fluids to liquefy secretions 5.Given everyday simultaneously to prevent resistance . Anorexia.Rifampicin (Rifampin) . generalized body malaise 4.3. Dyspnea 6.Side Effect PZA: allergic reaction. Institute strict respiratory isolation 3.Side Effect Ethambutol: optic neuritis b.DOH 8 – 10 mm induration. Place client on semi fowlers position to promote expansion of lungs 6. 48 – 72 hours .INH (Isonicotinic Acid Hydrazide) . CBC .WHO 10 – 14 mm induration.Side Effect Rifampicin: all bodily secretions turn to red orange color . Weight loss 5. taken before meals to facilitate absorption . Sputum Acid Fast Bacillus .PZA is given for 2 months.Positive to cultured microorganism 3.Side Effect INH: peripheral neuritis/neuropathy (increase intake of Vitamin B6/Pyridoxine) . Mantoux Test (skin test) .PZA can be replaced by Ethambutol . Intensive phase .
Dyspnea with prolong expiratory grunt 3. Productive cough with greenish to rusty sputum 2.Nephrotoxicity check for BUN and Creatinine .Side Effect: tinnitus. Smoking 2.Skin . Fever. Immuno compromised a. High Risk Groups 1. Strict compliance to medications d. Aspiration of food causing aspiration pneumonia D. protein. Pseudomonas B. heartburn 10.Give aspirin if there is fever .Initial sign is non productive cough .Eyes . causing hypostatic pneumonia 5. Air pollution 3. Avoidance of precipitating factors b. Etiologic Agents 1. Escherichia Pneumoniae 6. Signs and Symptoms 1.. Prevent complications (atelectasis.Drug of choice is Retrovir b.Chest x-ray confirms lung cancer 4. Weight loss 5. Klebsella Pneumoniae 5. Elderly C. AIDS . Importance of follow up care PNEUMONIA Inflammation of the lung parenchyma leading to pulmonary consolidation as the alveoli is filled with exudates A.Ototoxicity damage to the 8th cranial nerve resulting to tinnitus leading to hearing loss . Rales/crackles 6. military tuberculosis) PTB . Predisposing Factors 1. Related to prolonged immobility (CVA clients). Children below 5 years old 2. vitamin C and calories 11. Provide client health teaching and discharge planning a. chills.Pneumocystic carini pneumonia . Diplococcus Pneumoniae 4. dyspepsia. Bronchogenic Cancer . anorexia and general body malaise 4. Hemophylus Influenzae – causing broncho pneumonia 3. Provide increase carbohydrates.Bones (potts) . Streptococcus Pneumonae – causing pneumococal pneumonia 2.Adrenal gland c. Bronchial wheezing .Side Effect: .Meninges .
Health teaching and discharge planning a. Enforce CBR 2. Sputum Gram Staining and Culture Sensitivity – positive to cultured microorganisms 2. Avoid smoking b. Provide increase carbohydrates.Coughing exercises . CBC – reveals increase WBC. Assist in postural drainage .Chest physiotherapy . Institute pulmonary toilet (tends to promote expectoration) . erythrocyte sedimentation rate is increased F.Drain uppermost area of lungs . Diagnostic Procedure 1. Tetracycline c. Provide oral care after procedure g. Administer oxygen inhalation low inflow 3. Microlides (Zethromax) Azethromycin (Side Effect: Ototoxicity) Antipyretics Mucolytics/Expectorants Analgesics 4. Chest x-ray – reveals pulmonary consolidation 3. Abdominal distention leading to paralytic ileus (absence of peristalsis) E. Cyanosis 8. protein and vitamin C 10. Nebulize and suction as needed 8. Contraindicated with . Pleuritic friction rub 9.Deep breathing exercises . Encourage client deep breathing exercises d.Hemoptysis . Force fluid 5.Clients with increase intra ocular pressure (Normal IOP 12 – 21 mmHg) . Stop if client cannot tolerate procedure f.Turning and reposition 7. Prevent complications . Administer bronchodilators 15 – 30 minutes before procedure e.7. Place on semi fowlers position 6. Chest pain 10. calories. Monitor vital signs c.Increase ICP 9.Placed on various position Nursing Management for Postural Drainage a. Best done before meals or 2 – 3 hours to prevent gastro esophageal reflux b. Administer medications as ordered Broad Spectrum Antibiotic a. Penicillin b.Unstable vital signs . ABG analysis – reveals decrease PO2 4. Nursing Management 1.
Fungizone (Nephrotoxicity. Productive cough (consistent to all COPD) 2.Atelectasis . ABG analysis PO2 decrease C. anorexia. Cyanosis 5. Diagnostic Procedures 1. Dyspnea 3.. Administer oxygen inhalation 3. Hypokalemia) b. Steroids c. Mucolytics d.Meningitis (nerve deafness. 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. Predisposing Factors 1. Prolonged expiratory grunt 4. Antipyretics 4. Force fluids to liquefy secretions 5. general body malaise 4. Regular adherence to medications d. Chest and joint pains B. Dyspnea on exertion 3. Hemoptysis 6. Anorexia and generalized body malaise . check for BUN and Creatinine. Nursing Management 1. hydrocephalus) c. Smoking 2. Histoplasmin Skin Test – positive 2. Fever. Nebulize and suction as needed 6. Prevent complications – bronchiectasis 7. Importance of follow up care HISTOPLASMOSIS Acute fungal infection caused by inhalation of contaminated dust or particles with histoplasma capsulatum derived from birds manure A. Signs and Symptoms 1. Administer medications as ordered a. Signs and Symptoms PTB or Pneumonia like 1. Enforce CBR 2.Amphotericin B . chills. Antifungal . Productive cough 2. Air pollution B.
Predisposing Factors (Depending on Types) 1. Enforce CBR . Peripheral edema b. Diaphoresis C. Scattered rales/ronchi 6. air pressure and humidity f. Mild Stress/apprehension 6. Extrinsic Asthma ( Atopic/ Allergic ) Causes a.Before ABG test for positive Allens Test. penicillin. Drugs (aspirin. Dyspnea 3. Food additives (nitrates) e. milk. Danders g. ABG analysis – PO2 decrease . Cor Pulmonale (right ventricular hypertrophy) C. Lints 2. Diagnostic Procedure 1. Hereditary b. chicken d. Diagnostic Procedure ABG analysis – reveals PO2 decrease (hypoxemia). Fumes d. Cyanosis 5. apply direct pressure to ulnar and radial artery to determine presence of collateral circulation D. Tachycardia. Pulmonary Function Test . Signs and Symptoms 1. Cyanosis 7. Wheezing on expiration 4. Intrinsic Asthma (Non atopic/Non allergic) Causes a. Cough that is non productive 2. eggs. Pollen b. Pulmonary hypertension a. chocolates. Foods (seafoods. Dust c.5. PCO2 increase. Furs h. Gases f. Physical and emotional stress 3.Incentive spirometer reveals decrease vital lung capacity 2. palpitations 7. beta blocker) c. Mixed Type 90 – 95% B. Smoke e. pH decrease Bronchial Asthma Reversible inflammatory lung condition due to hypersensitivity to allergens leading to narrowing of smaller airways A. Nursing Management 1. Sudden change in temperature.
Feeding initiated upon return of gag reflex 2. Regular adherence to medications to prevent development of status asthmaticus d. Semi fowlers position 6. Predisposing Factors 1. Monitor for signs of gross 4. Signs and Symptoms 1. Administer medications as ordered a.Emphysema . Secure inform consent and explain procedure to client 2. Steroids – decrease inflammation c. Mucomysts (acetylceisteine) d.Steroids . Chest trauma 3. Cyanosis 4. Importance of follow up care BRONCHIECTASIS Abnormal permanent dilation of bronchus leading to destruction of muscular and elastic tissues of alveoli A. Avoidance of precipitating factor b. coughing and smoking. Anti histamine 4. Bronchodilators – given via inhalation or metered dose inhalaer or MDI for 5 minutes b. Avoid talking. Force fluids 5. Monitor for signs of laryngeal spasm – prepare tracheostomy set D. may cause irritation 3. Bronchoscopy – direct visualization of bronchus using fiberscope Nursing Management PRE Bronchoscopy 1. Congenital defects 4.Status Asthmaticus (give drug of choice) . ABG – PO2 decrease 2. Nebulize and suction when needed 7. Oxygen inhalation. Related to presence of tumor B. Anorexia and generalized body malaise 5.2.Epinephrine . Recurrent lower respiratory tract infections 2. Prevent complications . Diagnostic Procedure 1. Treatment . Hemoptysis (only COPD with sign) C. Maintain NPO 6 – 8 hours prior to procedure 3. with low inflow of 2 – 3 L/min 3. Dyspnea 3. Monitor vital signs and breath sound POST Bronchoscopy 1. Mucolytics/expectorants e.Bronchodilators c. Provide client health teachings and discharge planning concerning a. Productive cough 2.
Air pollution 3. Anorexia and generalized body malaise 5. 1 lung is removed and position on affected side) 2. Decrease tactile fremitus 7. Pulmonary Function Test – reveals decrease vital lung capacity 2.Increase ph .Respiratory acidosis b.Decrease ph . Inelasticity of alveoli b. Productive cough 2. Purse lip breathing to eliminates excess CO2 (compensatory mechanism) C. Barrel chest 11.Increase PCO2 . for recoil of alveoli) B. Prolong expiratory grunt 4. Signs and Symptoms 1.Decrease PO2 (hypoxemia leading to chronic bronchitis. Flaring of alai nares 12.Respiratory alkalosis D. “Blue Bloaters”) . Panacinar/ centriacinar . Nursing Management 1. Hereditary – it involves deficiency of ALPHA-1 ANTI TRYPSIN (needed to form Elastase. Dyspnea at rest 3. “Pink Puffers”) . Smoking 2. Air trapping c. Segmental Wedge Lobectomy (promote re expansion of lungs) . Maldistribution of gases d.Decrease PCO2 . Enforce CBR .Unaffected lobectomy facilitate drainage EMPHYSEMA Irreversible terminal stage of COPD characterized by a. ABG analysis reveals a.1. Panlobular/ centrilobular . Bronchial wheezing 10. Diagnostic Procedure 1. Resonance to hyperresonance 6. High risk: elderly 5. Decrease or diminished breath sounds 8. Allergy 4. Over distention of thoracic cavity (barrel chest) A.Increase PO2 (hyperaxemia. Surgery (pneumonectomy . Predisposing Factors 1. Rales or ronchi 9.
Administer medications as ordered a. Antibiotics d. High fowlers position 5. vitamins and minerals 11. protein. Provide high carbohydrates. Nebulize and suction when needed 8. calories. Force fluids 6.Cor Pulmonale . Strict compliance to medication d. Avoid smoking b. Bronchodilators b. Provide comfortable and humid environment 10. Institute pulmonary toilet 7. Institute PEEP (positive end expiratory pressure) in mechanical ventilation promotes maximum alveolar lung expansion 9.2. Health teachings and discharge planning concerning a. Steroids c.Pneumothorax c. Prevent complications . Mucolytics/expectorants 4. Importance of follow up care .Atelectasis . Administer oxygen inhalation via low inflow 3.CO2 narcosis may lead to coma .
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