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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.
colostrums). Ig M – acute in inflammation. Wernicke’s Aphasia General Knowing Gnostic Area or General Interpretative Area. d. . Characterized by remission and exacerbation. pain. c. Sign and Symptoms 4 A’s of Alzheimer a. 2. saliva. pressure. Signs and Symptoms 1.short term protection. Ig D – for chronic inflammation. *Expressive aphasia “motor speech center” Broca’s Aphasia inability to understand spoken words. MULTIPLE SCLEROSIS Chronic intermittent disorder of CNS characterized by white patches of demyelination in brain and spinal cord. Apraxia – no recognition of objects function. * Give palliative or supportive care. ALZHEIMER’S DISEASE Atrophy of brain tissues. Visual disturbances blurring of vision (primary) diplopia (double vision) scotomas (blind spots) 2. Aphasia – no speech (nodding).DEMYELINATING DISORDERS 1.Immediate action. 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. *Receptive aphasia DRUG OF CHOICE: ARICEPT (taken at bedtime) and COGNEX. Ig E – for allergic reaction. tingling sensation paresthesia numbness euphoria (sense of well being) 3. Mood swings . Impaired sensation to touch. . Amnesia – loss of memory. Ig A – present in all bodily secretions (tears. Agnosia – no recognition of inanimate objects. b. heat and cold.
(+) Romberg’s test) 5. d. c. Maintain side rails to prevent injury related to falls. 5. vitamin C and orange. Monitor side effects bronchospasm and wheezing. Yoga 4. MRI (reveals site and extent of demyelination). Urinary retention/incontinence 7. Impaired motor function weakness spasticity paralysis scanning speech TRIAD SIGNS OF MS Ataxia (Unsteady gait. plums. (+) Lhermitte’s sign a continuous and increase contraction of spinal column. pineapple. Immunosupresants 2. . Institute stress management techniques. Interferons – alter immune response. Administer medications as ordered a. Prophantheline Bromide (Promanthene) Acid ash diet like cranberry juice. Monitor breath sounds 1 hour after subcutaneous administration. NURSING MANAGEMENT 1. To acidify urine and prevent bacterial multiplication. Decrease sexual capacity DIAGNOSTIC PROCEDURE Nystagmus CSF analysis (increase in IgG and Protein). a. a. ACTH (Adreno Corticotropic Hormone)/ Steroids for acute exacerbation to reduce edema at site of demyelination to prevent paralysis. Catheterization to prevent retention. Deep breathing exercises b. Baclofen (Dioresal)/ Dantrolene Sodium (Dantrene) – muscle relaxants. For Urinary Incontinence Anti spasmodic agent a. Increase fluid intake and increase fiber to prevent constipation.4. 3. Diuretics b. Constipation 8. prunes. c. b. Bethanicol Chloride (Urecholine) Nursing Management Only given subcutaneous. Impaired cerebral function CHARCOTS TRIAD IAN Intentional tremors 6.
1-1 ½ inches) poor perineal hygiene vaginal environment is moist avoid bubble bath (can alter Ph of vagina). avoid use of tissue papers avoid using talcum powder and perfume. Parietal 4. pinocytosis (cell drinking). numbness. 3. CEREBRUM largest part composed of the Right Cerebral Hemisphere and Left Cerebral Hemisphere enclosed in the Corpus Callosum. 8 inches) urinate after intercourse Nursing Management Male MICROGLIA stationary cells that carry on phagocytosis (engulfing of bacteria or cellular debris. Occipital . Urethra (20 cm. 2. 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. heat. Functions of Cerebrum integrative sensory motor Lobes of Cerebrum 1. pressure. Brain Mass PARTS OF THE BRAIN 1. cold. touch. Frontal higher cortical thinking controls personality controls motor activity Broca’s Area (motor speech area) when damaged results to garbled speech. eating). 80% brain mass 10% blood 10% CSF COMPOSITION OF BRAIN I.COMMON CAUSE OF UTI Female short urethra (3-5 cm. Temporal hearing short term memory for appreciation discrimination of sensory impulses to pain.
2. Medulla Oblongata 3. controls temperature (thermoregulatory center). early sign for females telarche and late sign is menarche. Pons pneumotaxic center controls the rate. swallowing. hearing acuity is 30 – 40 dB. heart rate. early sign for males are testicular and penile enlargement late sign is deepening of voice. Thalamus acts as relay station for sensation. . anxiety and excitement. controls libido controls long term memory Insula (Island of Reil) Limbic System (Rhinencephalon) 2. B. unequal size of pupil is anisocoria. lesser brain. controls pituitary functions androgenic hormones promotes secondary sex characteristics. Cerebellum smallest part of the brain. vomiting. equal size of pupil is isocoria. controls respiration. size of pupil is 2 – 3 mm. BRAIN STEM located at lowest part of brain Parts of Brain Stem 1. Hypothalamus 5. DECREASE Myasthenia Gravis Parkinson’s Disease INCREASE Bi-polar Disorder Schizophrenia NEURO TRANSMITTER Acethylcholine Dopamine 3. controls blood pressure controls thirst appetite/satiety sleep and wakefulness controls some emotional responses like fear. vasomotor center (dilation and constriction of bronchioles). INTERBRAIN/ DIENCEPHALON Parts of Diencephalon A. for vision visceral function activities of internal organ like gastric motility. release dopamine (controls gross voluntary movement. BASAL GAGLIA areas of grey matter located deep within each cerebral hemisphere. controls smell and if damaged results to Anosmia (absence of smell). rhythm and depth of respiration. MIDBRAIN/ MESENCEPHALON acts as relay station for sight and hearing. positive PERRLA 4. hiccup.
Foramen Magnum Medulla Oblongata Brain Herniation Increase intra cranial pressure * Alternate hot and cold compress to prevent HEMATOMA CSF cushions brain (shock absorber) Obstruction of flow of CSF will lead to enlargement of skull posteriorly called hydrocephalus. widening of pulse pressure is neurologic in nature (if narrow cardiac in nature). projective vomiting headache papilledema (edema of optic disc) abnormal posturing decorticate posturing (damage to cortex and spinal cord). NEUROLOGIC DISORDERS INCREASE INTRACRANIAL PRESSURE – increase in intra-cranial bulk brought about by an increase in one of the 3 major intra cranial components. posture and gait. INTRA CRANIAL PRESSURE Monroe Kellie Hypothesis Skull is a closed container Any alteration or increase in one of the intracranial components Increase intra-cranial pressure (normal ICP is 0 – 15 mmHg) Cervical 1 – also known as ATLAS. 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). equilibrium. controls balance. heart rate decrease respiratory rate decrease temperature increase directly proportional to blood pressure. Early closure of posterior fontanels causes posterior enlargement of skull in hydrocephalus. Cervical 2 – also known as AXIS. .
provide an comfortable and quite environment. 3. administered via side drip regulated fast drip to prevent crystal formation. b. avoid use of restraints. monitor strictly input and output every 1 hour notify physician if output is less 30 cc/hr. Prevent further increase ICP by: a. Loop diuretic (Lasix. 4. cerebellum and midbrain). Monitor strictly input and output and neuro check 5. Assist in mechanical ventilation 2. Limit fluid intake to 1200 – 1500 ml/day (in force fluids 2000 – 3000 ml/day). Prevent complications of 6. In chronic respiratory distress syndrome decrease O2 stimulates respiration. unilateral dilation of pupils called uncal herniation bilateral dilation of pupils called tentorial herniation resulting to mild headache possible seizure activity Nursing Management 1. 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. Osmotic diuretic (Mannitol) for cerebral diuresis Nursing Management monitor vital signs especially BP (hypotension). Elevate bed of client 30 – 35o angle with neck in neutral position unless contraindicated to promote venous drainage. 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. c. decerebrate posturing (damage to upper brain stem that includes pons. d. 7. Administer medications like: a. Late signs of hypoxia HYPERCARBIA b. Nursing Management . maintain side rails. avoid clustering of nursing activity together. Maintain patent and adequate ventilation by: a. c. Before and after suctioning hyper oxygenate client 100% and done 10 – 15 seconds only. b.
maximum effect of 6 hours. given early morning immediate effect of 10 – 15 minutes. monitor strictly input and output every 1 hour notify physician if output is less 30 cc/hr. Dexamethasone (Decadron) Hydrocortisone Prednisone (to reduce edema that may lead to increase ICP) Mild Analgesics (Codeine Sulfate for respiratory depression) Anti Convulsants (Dilantin. administered IV push or oral. Monitor vital signs especially BP (hypotension). Phenytoin) c. blood monitor RIGHT CONGESTIVE HEART FAILURE (Venous congestion) Signs and Symptoms jugular vein distention (neck) ascites pitting edema weight gain hepatosplenomegaly jaundice pruritus esophageal varices anorexia and general body malaise . 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.
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. Hyponatremia DECREASE decrease sodium level normal value is 135 – 145 meq/L Signs and Symptoms hypotension dehydration signs (Initial sign in adult is THIRST. Oral Potassium Chloride) increase intake of foods rich in potassium FRUITS Apple Banana Cantalop e Oranges 2. in infant TACHYCARDIA) agitation dry mucous membrane poor skin turgor weakness and fatigue .4 – 5. Hypocalcemia/ Tetany VEGETABLES Asparagus Brocolli Carrots Spinach decrease calcium level normal value is 8.5 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.Signs and Symptoms of Lasix in terms of electrolyte imbalances 1.
Allopurinol (Zyloprim) b. Signs and Symptoms Nursing Management a. Colchecine * KIDNEY STONES Signs and Symptoms renal colic Cool moist skin force fluids administer medications as ordered Morphine Sulfate ANTIDOTE: Naloxone (Narcan) toxicity leads to tremors. organ meats and anchovies) *Increase in tophi deposit leads to Gouty arthritis.Nursing Management force fluids administer isotonic fluid solution as ordered 4. Hyperglycemia normal FBS is 80 – 100 mg/dl polyuria polydypsia polyphagia monitor FBS Signs and Symptoms Nursing Management 5. Narcotic Analgesic b. Mechanism of action: inhibits synthesis of uric acid. Acute gout Mechanism of action: promotes excretion of uric acid. Allopurinol (Zyloprim) Side Effects Respiratory depression (check for RR) . Hyperuricemia increase uric acid (purine metabolism) foods high in uric acid (sardines. joint pain (great toes) swelling force fluids administer medications as ordered Drug of choice for gout. Nursing Management a.
Administer medications as ordered Anti Parkinsonian agents Levodopa (L-dopa) short acting Amantadine Hydrochloride (Symmetrel) Carbidopa (Sinemet) . increase sweating b. Haloperidol(Haldol) d. Reserpine(Serpasil) b. Monotone type speech mood lability (in state of depression) increase salivation (drooling type) autonomic changes a. Increase dosage of the following drugs: a. Arteriosclerosis 3. increase lacrimation c. Methyldopa(Aldomet) c.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. seborrhea d. Poisoning (lead and carbon monoxide) 2. Encephalitis 5. decrease sexual capacity Nursing Management 1. bradykinesia (slowness of movement) rigidity (cogwheel type) stooped posture shuffling and propulsive gait over fatigue mask like facial expression with decrease blinking of the eyes. difficulty rising from sitting position. Predisposing Factors 1. Hypoxia 4. constipation e. 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.
Prevent complications of immobility 4.to relieve tremors Mechanism of Action inhibits action of acethylcholine SNS Side Effects Anti Histamine (Dipenhydramine Hydrochloride) Side Effects Adult: drowsiness Children: CNS excitement (hyperactivity) because blood brain barrier is not yet fully developed.6 – 1.5 – 1. Maintain side rails to prevent injury 3. Decrease protein in morning and increase protein in afternoon to induce sleep 5.relieves tremor rigidity Bromocriptene Hydrochloride (Parlodel) Side Effects Respiratory depression 2. Assist/supervise in ambulation 7. Isonicotinic Acid Hydrazide Anti Cholinergic Agents (ARTANE and COGENTIN) .5 meq/L . 6. 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 . 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).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 .
Lithium Toxicity Signs and Symptoms anorexia nausea and vomiting diarrhea dehydration causing fine tremors hypothyroidism force fluids increase sodium intake to 4 – 10 g% daily Nursing Management 3. irritability. Dilantin Toxicity Signs and Symptoms gingival hyperplasia (swollen gums) hairy tongue ataxia nystagmus provide oral care massage gums Nursing Management 5. agitation and restlessness) only mixed with plain NSS or 0. Digitalis Toxicity Signs and Symptoms nausea and vomiting diarrhea confusion photophobia changes in color perception (yellowish spots) Antidote: Digibind 2. administered sandwich method avoid taking alcohol because it can lead to severe CNS depression avoid caffeine Nursing Management 4. tachycardia Irritability Restlessness Extreme fatigue Diaphoresis. depression Antidote: Acetylcisteine (mucomyst) prepare suction apparatus as bedside.1. .9 NaCl to prevent development of crystals or precipitate.8 – 1) hypoglycemia Tremors. Aminophylline Toxicity Signs and Symptoms tachycardia palpitations CNS excitement (tremors. Acetaminophen Toxicity Signs and Symptoms hepatotoxicity (monitor for liver enzymes) SGPT/ALT (Serum Glutamic Pyruvate Transaminace) SGOT/AST (Serum Glutamic Oxalo-Acetil Transaminace) nephrotoxicity monitor BUN (10 – 20) and Creatinine (.
institute NGT feeding 6. Anti Cholenisterase (Neostegmin) Mechanism of Action maintain patent airway and adequate ventilation increase level of Ach PNS Cortocosteroids suppress immune response monitor for 2 types of crisis: CHOLINERGIC CRISIS Cause: . Assist in plasma paresis and removing auto immune anti bodies 9.over medication Signs and Symptoms .administer cholinergic agents as ordered 7. input and output and neuro check * monitor strength or motor grading scale 4. Assist in surgical procedure known as thymectomy because it is believed that the thymus gland is responsible for M.G. Cholinergic (Mestinon) b.PNS Treatment .Administer anti cholinergic agents (Atropine Sulfate) Side Effects MYASTHENIC CRISIS Causes: . initial sign is ptosis a clinical parameter to determine ptosis is palpebral fissure.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. airway 2. Nursing Management 1. Prevent complications . speak. administer medications as ordered a. if there is no effect there is damage to occipital lobe and midbrain and is negative for Signs and Symptoms Diagnostic Procedure M. aspiration 3. swallow.under medication .stress . Incidence rate: women 20 – 40 years old Predisposing factors unknown autoimmune: it involves release of cholinesterase an enzyme that destroys Ach. 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. maintain side rails to prevent injury related to falls 5. 8.infection Signs and Symptoms .G. mmobility * assist in mechanical ventilation and monitor pulmonary function test * monitor strictly vital signs.The client is unable to see. breathe Treatment .
Etiology 1. Decrease glucose 3.INFLAMMATORY CONDITIONS OF THE BRAIN MENINGITIS Meninges 3 fold membrane that covers brain and spinal cord. Check punctured site for any discoloration. (+) cultured microorganism (confirms meningitis) CBC reveals 1. drainage and leakage to tissues. Pneumococcus 3. Post Lumbar Puncture 1. Encourage to arch back to clearly visualize L3-L4. A. Hemophilus Influenzae – causes pediatric meningitis B. Signs and Symptoms headache photophobia projectile vomiting fever. Assess for movement and sensation of extremities. (+) Kernig’s sign (leg pain) d. for support and protection for nourishment blood supply LAYERS OF THE MENINGES 1. Increase CSF opening pressure (normal pressure is 50 – 100 mmHg) 4. Opisthotonus (arching of back) c. Dura matter – outer layer 2. Pia matter – inner layer subdural space between the dura and arachnoid subarachnoid space between the arachnoid and pia. general body malaise and weight loss Possible increase in ICP and seizure activity Abnormal posturing (decorticate and decerebrate) Signs of meningeal irritation a. Arachnoid – middle layer 3.causes adult meningitis 4. Empty bladder and bowel to promote comfort. Place flat on bed 12 – 24 o 2. 4. Increase CHON and WBC 2. Force fluids 3. Streptococcus . 3. Secure informed consent and explain procedure. CSF aspiration is done. Meningococcus – most dangerous 2. Nursing Management for LP Before Lumbar Puncture 1. chills. CSF analysis reveals 1. Increase wbc . Nuchal rigidity or stiff neck b. (+) Brudzinski sign (neck pain) D. anorexia. Diagnostic Procedures Lumbar puncture: a hollow spinal needle is inserted in the subarachnoid space between the L3 – L4 to L5. 2. Mode of transmission airborne transmission (droplet nuclei) C.
Enforce complete bed rest 2. Maintain fluid and electrolyte balance. 7. 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. Elevate head 30-45o 5. Monitor strictly V/S. If there is bone fracture there is hemorrhage and there would be escape of the fat cells in the circulation. Mild analgesics c. Mid Cerebral Artery b.E. b. Institute strict respiratory isolation 24 hours after initiation of anti biotic therapy 4. input and output and neuro check 6. Rehabilitation for neurological deficit CVA (STROKE/BRAIN ATTACK/ ADOPLEXY/ CEREBRAL THROMBOSIS) a partial or complete disruption in the brains blood supply. Nursing Management 1. Provide client health care and discharge planning concerning: a. Maintain good diet of increase CHO. 8. Tetracycline) b. Incidence Rate men are 2-3 times high risk B. 2 most common cerebral artery affected by stroke a. Administer medications as ordered a. CHON. Provide a comfortable and darkened environment. Anti pyretics 3. 9. Institute measures to prevent increase ICP and seizure. Prevent complications most feared is hydrocephalus hearing loss/nerve deafness is second complication consult audiologist mental retardation delayed psychomotor development c. calories with small frequent feedings. Internal Cerebral Artery – the 2 largest artery A. 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. Yellow bone marrow are produced from the medullary cavity of the long bones and produces fat cells. Broad spectrum antibiotics (Penicillin. Compartment syndrome (compression of arteries and nerves) .
C. aphasia c. D. phlegia b. dysarthria (inability to articulate words) d. homonymous hemianopsia (loss of half of visual field) 1. alexia (difficulty reading) e. agraphia (difficulty writing) f. Related to diet: increase intake of saturated fats like whole milk 7. usually fells guilty when not doing anything 6. Diabetes Mellitus. Related stress physical and emotional 8. deadline driven b. Lifestyle (smoking). nausea and vomiting dysphagia (+) Kernig’s sign and Brudzinski sign which may lead to hemorrhagic stroke focal neurological deficits a. TIA Signs and Symptoms 2. Hypertension. 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 . Diagnostic Procedure 1. Atherosclerosis. Hyperlipidemia more on genetics/genes that binds to cholesterol 5. Valvular Cardiac Surgery (mitral valve replacement) 2. can do multiple tasks c. Signs and Symptoms Heart Disease. Obesity (increase 20% ideal body weight) 4. Myocardial Infarction. 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. Risk Factors 1. CT Scan – reveals brain lesions 2. Prolong use of oral contraceptives promotes lypolysis (breakdown of lipids) leading to atherosclerosis that will lead to hypertension and eventually CVA. sedentary lifestyle 3. Type A personality a. Complete stroke Signs and Symptoms E. Stroke in evolution 3.
magic slate 9. Maintain patent airway and adequate ventilation by: a. Furosemide) c. I & O and neuro check 5. K (Aqua Mephyton) g. Elevate head 30 – 45o 4. Anti Coagulants Heparin (short acting) check for partial thromboplastin time if prolonged there is a risk for bleeding. dietary modification (decrease salt. turn client to side b. If positive to hemianopsia approach client on unaffected side 10. Nursing Management 1. Administer medications as ordered a. Loop Diuretics (Lasix. Restrict fluids to prevent cerebral edema that might increase ICP 3. importance of follow up care . ulcer and unknown cause of headache because it may potentiate bleeding 11. provide egg crate mattresses or water bed c. avoidance of modifiable risk factors (diet. non verbal cues b. Institute NGT feeding 8. Provide alternative means of communication a. Cortecosteroids d. Mild Analgesics e. prevent complication (subarachnoid hemorrhage is the most feared complication) c. administrate O2 inhalation 2. assist in mechanical ventilation b. Assist in passive ROM exercise every 4 hours to promote proper bodily alignment and prevent contractures 7. Monitor strictly vitals signs. 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. Anti Platelet PASA (Aspirin) Contraindicated for dengue. saturated fats and caffeine) d.F. provide sand bag or food board. Prevent complications of immobility by: a. smoking) b. 6. Provide client health teachings and discharge planning concerning a. Osmotic Diuretics (Mannitol) b. Thrombolytic/Fibrinolytic Agents – dissolves thrombus Streptokinase Side Effect: Allergic Reaction Urokinase Tissue Plasminogen Activating Factor Side Effect: Chest Pain f. exercise.
Decreased of diminished deep tendon reflex 5. Ascending muscle weakness leading to paralysis 4. . monitor pulmonary function test 2. Diagnostic Procedures 1. Clumsiness (initial sign) 2. Antecedent viral infections such as LRT infections B. Prevent complications of immobility by turning the client every 2 hours 5. Alternate hypotension to hypertension ** ARRYTHMIA (most feared complication) 6. neuro check d. Anti Arrythmic Agents Lidocaine. Anti Cholinergic Agents – Atrophine Sulfate c. Predisposing Factors 1. A. intake and output c. Assist in plasma pharesis (filtering of blood to remove autoimmune anti-bodies) 9. CSF analysis reveals increase in IgG and protein D. constipation C.GUILLAIN BARRE SYNDROME a disorder of the CNS characterized by bilateral symmetrical polyneuritis leading to ascending muscle paralysis. Signs and Symptoms 1. Institute NGT feeding to prevent aspiration 6. assist in mechanical ventilation b. Corticosteroids – suppress immune response b. ECG 3. Zylocaine Bretylium – blocks release of norepinephrine to prevent increase of BP 8. increase sweating c. Prevent complications a. Assist in passive ROM exercise 7. Nursing Management 1. vital signs b. Monitor strictly the following a. Autoimmune 2. Dysphagia 3. Administer medications as ordered a. Autonomic symptoms that includes a. increase salivation b. Arrythmia b. Maintain patent airway and adequate ventilation by: a. Paralysis or respiratory muscles/Respiratory arrest * Sengstaken Blakemore Tube for liver cirrhosis to decompress bleeding esophageal verices (prepare scissor to cut tube incase of difficulty in breathing to release air in the balloon for hemodialysis prepare bulldog clips to prevent air embolism. Maintain side rails to prevent injury related to fall 4.
Generalized Seizure 1. Toxicity from a. Valium) B. visual. lead b carbon monoxide 5. Petit mal Seizure – absence of seizure common among pediatric clients characterized by a. Seizure – first convulsive attack Epilepsy – second or series of attacks Febrile seizure – normal in children age below 5 years A. Predisposing Factors 1. clouding of consciousness – not in contact with environment c. Jacksonian Seizure (focal seizure) Characterized by tingling and jerky movement of index finger and thumb that spreads to the shoulder and other side of the body. EEG – reveals hyper activity of electrical brain waves . Tonic contractions .direct symmetrical extension of extremities Clonic contractions . Sudden withdrawal to anti convulsant drug is predisposing factor for status epilepticus (drug of choice is Diazepam. CT Scan – reveals brain lesions 2. sensory experience b. Status Epilepticus A continuous uninterrupted seizure activity. loss of consciousness (5 – 10 seconds) II. Nutritional and Metabolic deficiencies 6. Epileptic cry – is characterized by fall and loss of consciousness for 3 – 5 minutes c. automatism – stereotype repetitive and non propulsive behavior b.contraction of extremities d. olfactory. twitching of mouth d.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. mild hallucinatory sensory experience III. decrease blinking of eyes c. Drug of choice: Diazepam. Presence of brain tumor 4. Signs and Symptoms Dependent on stages of development or types of seizure I. 2. Head injury due to birth trauma 2. if left untreated can lead to hyperpyrexia and lead to coma and eventually death. Diagnostic Procedures 1. Genetics 3. Valium and Glucose C. Psychomotor Seizure (focal motor seizure) a. Post ictal sleep – unresponsive sleep 2. blank stare b. Physical and emotional stress 7. Partial or Localized Seizure 1. tactile. Grand mal Seizure (tonic-clonic seizure) a. Signs or aura with auditory.
D. Nursing Management 1. Maintain patent airway and promote safety before seizure activity a. clear the site of blunt or sharp objects b. loosen clothing of client c. maintain side rails d. avoid use of restrains e. turn clients head to side to prevent aspiration f. place mouth piece of tongue guard to prevent biting or tongue 2. Avoid precipitating stimulus such as bright/glaring lights and noise 3. Administer medications as ordered a. Anti convulsants (Dilantin, Phenytoin) b. Diazepam, Valium c. Carbamazepine (Tegretol) – Trigeminal neuralgia d. Phenobarbital, Luminal 4. Institute seizure and safety precaution post seizure attack a. administer O2 inhalation b. provide suction apparatus 5. Document and monitor the following a. onset and duration b. types of seizures c. duration of post ictal sleep may lead to status epilepticus d. assist in surgical procedure cortical resection COMPREHENSIVE NEURO EXAM GLASGOW COMA SCALE
objective measurement of LOC sometimes called as the quick neuro check
Components 1. Motor response 2. Verbal response 3. Eye opening Conscious Lethargy Stupor Coma Deep Coma 15 – 14 13 – 11 10 – 8 7 3
Survey of mental status and speech a. LOC b. Test of memory Levels of orientation Cranial nerve assessment Sensory nerve assessment Motor nerve assessment Deep tendon reflex Autonimics Cerebellar test a, Romberg’s test – 2 nurses, positive for ataxia b. Finger to nose test – positive result mean dimetria (inability of body to stop movement at desired point) c. Alternate supination and pronation – positive result mean dimetria
I. LEVEL OF CONSCIOUSNESS 1. Conscious - awake 2. Lethargy – lethargic (drowsy, sleepy, obtunded) 3. Stupor
stuporous (awakened by vigorous stimulation) generalized body weakness decrease body reflex comatose light coma (positive to all forms of painful stimulus) deep coma (negative to all forms of painful stimulus)
DIFFERENT PAINFUL STIMULATION 1. Deep sternal stimulation/ deep sternal pressure 2. Orbital pressure 3. Pressure on great toes 4. Corneal or blinking reflex Conscious client use a wisp of cotton Unconscious client place 1 drop of saline solution II. TEST OF MEMORY 1. Short term memory
ask most recent activity positive result mean anterograde amnesia and damage to temporal lobe ask for birthday and validate on profile sheet positive result mean retrograde amnesia and damage to limbic system consider educational background
2. Long term memory
III. LEVELS OF ORIENTATION 1. Time – first asked 2. Person – second asked 3. Place – third asked CRANIAL NERVES CRANIAL NERVES I. OLFACTORY II. OPTIC III OCCULOMOTOR IV. TROCHLEAR V. TRIGEMINAL VI. ABDUCENSE VII. FACIAL VIII. ACOUSTIC IX. GLOSSOPHARYNGEAL X. VAGUS FUNCTION S S M M (Smallest) B (Largest) M B S B B
(Longest) XI. SPINAL ACCESSORY M XII. HYPOGLOSSAL M CRANIAL NERVE I: OLFACTORY
sensory function for smell
don’t use alcohol, ammonia, perfume because it is irritating and highly diffusible. use coffee granules, vinegar, bar of soap, cigarette test each nostril by occluding each nostril
Abnormal Findings 1. Hyposnia – decrease sensitivity to smell 2. Dysosmia – distorted sense of smell 3. Anosmia – absence of smell Indicative of 1. head injury damaging the cribriform plate of ethmoid bone where olfactory cells are located 2. may indicate inflammatory conditions (sinusitis) CRANIAL NERVE II: OPTIC
sensory function for vision or sight
Functions 1. Test visual acuity or central vision or distance
use Snellen’s Chart Snellen’s Alphabet chart: for literate clients Snellen’s E chart: for illiterate clients Snellen’s Animal chart: for pediatric clients normal visual acuity 20/20 numerator is constant, it is the distance of person from the chart (6 – 7 m, 20 feet) denominator changes, indicates distance by which the person normally can see letter in the chart. - 20/200 indicates blindness 20/20 visual acuity if client is able to read letters above the red line. a. Superiorly b. Bitemporaly c. Nasally d. Inferiorly
2. Test of visual field or peripheral vision
COMMON VISUAL DISORDERS 1. Glaucoma
increase IOP normal IOP is 12 – 21 mmHg preventable but not curable Common among 40 years old and above Hereditary Hypertension Obesity
A. Predisposing Factors
B. Signs and Symptoms 1. Loss of peripheral vision
pathognomonic sign is tunnel vision steamy cornea may lead to blindness
2. Headache, nausea, vomiting, eye pain (halos around light)
C. Diagnostic Procedures 1. Tonometry 2. Perimetry
Carbachol 2. Related to congenital 3. Cataract Decrease opacity of lens A. Loss of central vision C. Gonioscopy D. Timoptics (Timolol Maleate) E. Diabetes Mellitus 4. Milky white appearance at center of pupils 3. Prolonged exposure to UV rays B. Surgical Procedures 1. Surgical Procedure Extra Capsular Cataract Lens Extraction . Carbonic Anhydrase Inhibitors a.Total removal of cataract with its surrounding capsules Most feared complication post op is RETINAL DETACHMENT 3. Diagnostic Procedure 1. Blurring or hazy vision 2. Treatment 1.Partial removal Intra Capsular Cataract Lens Extraction . Predisposing Factor 1. Decrease perception to colors Complication is blindness D. Opthalmoscopic exam E. Treatment 1.3. Signs and Symptoms 1. Pathognomonic Signs 1. Acetazolamide (Diamox) – promotes increase outflow of aqueous humor or drainage 4. Aging 65 years and above 2. Miotics – constricts pupil a. TRABECULECTOMY (Peripheral Indectomy) – drain aqueous humor 2. Retinal Detachment Separation of epithelial surface of retina . Epinephrine eyedrops – decrease formation of aqueous humor 3. Mydriatics (Mydriacyl) – constricts pupils 2. Pilocarpine Sodium. Cyclopegics (Cyclogyl) – paralyses cilliary muscle F.
Predisposing Factors 1. ABDUCENS Controls or innervates the movement of extrinsic ocular muscle (EOM) 6 muscles Superior Rectus Superior Oblique Lateral Rectus Medial Rectus Inferior Oblique Inferior Rectus trochlear controls superior oblique abducens controls lateral rectus oculomotor controls the 4 remaining EOM Oculomotor controls the size and response of pupil normal pupil size is 2 – 3 mm equal size of pupil: Isocoria Unequal size of pupil: Anisocoria Normal response: positive PERRLA CRANIAL NERVE V: TRIGEMINAL largest cranial nerve consists of ophthalmic. Myopia (near sightedness) B. Macular Degeneration Degeneration of the macula lutea (yellowish spot at the center of retina) A. Scleral Buckling 2. Curtain veil like vision 2.A. Post Lens Extraction 2. Floaters C. Cryosurgery – cold application 3. Surgical Procedures 1. VI: OCULOMOTOR. Diathermy – heat application 4. Signs and Symptoms 1. Black Spots CRANIAL NERVE III. IV. TROCHLEAR. Signs and Symptoms 1. mandibular . maxillary.
Inner Ear Vestibule: Meinere’s Disease Cochlea Mastoid Cells Endolymph and Perilymph COCHLEA: controls hearing. contains the Organ of Corti (the true organ of hearing) Let client repeat words uttered CRANIAL NERVE IX. Outer Ear Pinna Eardrum Hammer Anvil Stirrup Malleus Incus Stapes 2. refers to movement and orientation of the body in space. VAGUS NERVE Glosopharyngeal: controls taste. CRANIAL NERVE VIII: ACOUSTIC/VESTIBULOCOCHLEAR Controls balance particularly kinesthesia or position sense. frown and if results are negative there is facial paralysis or Bell’s Palsy and the primary cause is forcep delivery. X: GLOSOPHARYNGEAL. ENDOCRINE SYSTEM Overview of the structures and functions 1. anterior 2/3 of tongue pinch of sugar and cotton applicator placed on tip of tongue Motor: controls muscle of facial expression instruct client to smile. teeth. sensory: controls sensation of face. Middle Ear 3. mucous membrane. 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. Parts of the Ear 1. Pituitary Gland (Hypophysis Cerebri) . 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.
Administer medications as ordered a. Agitation c. Polyuria 2. Posterior Pituitary Gland 2. Hypotension 5. Poor Skin turgor d. Weakness and fatigue 4. Predisposing Factor o o o o 1. Dry mucous membrane 3. Urine Specific Gravity o o o 1.015 – 1. Pitressin (Vasopresin Tannate) – administered IM Z-tract 4. Prevent complilcations – HYPOVOLEMIC SHOCK is the most feared complication Normal value: 1. If left untreated results to hypovolemic shock (sign is anuria) C. Monitor strictly vital signs and intake and output 3. 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. Diagnostic Procedures 1. Signs and Symptoms 2.o o o Located at base of brain particularly at sella turcica Master gland or master clock Controls all metabolic function of body PARTS OF THE PITUITARY GLAND 1. Nursing Management . Adult: thirst b. Signs of dehydration a. Anterior Pituitary Gland o o o hemorrhage o o administrate oxytocin immediately after delivery to prevent uterine atony. Weight loss 6. Serum Sodium D. Force fluids 2.030 Ph 4 – 8 Increase resulting to hypernatremia Related to pituitary surgery Trauma Inflammation Presence of tumor B. 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.
intake and output and neuro check 4. B. Loop diuretics (Lasix) b. Lead to blindness due to severe photophobia b. Weight gain 2. Restrict fluid 2. Serum Sodium is decreased D. Monitor strictly vital signs. Fluid retention a. Signs and Symptoms 1. Related to hyperplasia (increase size of organ brought about by increase of number of cells) of pituitary 2. Provide meticulous skin care 6. 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. 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. Administer medications as ordered a. Adrenochorticotropic hormone (ACTH) o promotes development of adrenal cortex . Water intoxication may lead to cerebral edema and lead to increase ICP – may lead to seizure activity C. Urine specific gravity is increased 2. Nursing Management 1. Diagnostic Procedure 1. Prone to skin cancer o Hypersecretion of MSH results to Vitiligo 3. Weigh patient daily and assess for pitting edema 5. Edema c. Hypertension b.SIADH o hypersecretion of anti diuretic hormone A. Head injury 2. Predisposing Factors 1. 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.
T3 (Tri iodothyronine) . cabbage. strawberry. 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.4. all nuts soil erosion washes away iodine . Thyrocalcitonin – antagonizes the effects of parathormone to promote calcium resorption. turnips. 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. Increase intake of goitrogenic foods o o o contains pro-goitrin an anti thyroid agent that has no iodine. radish. Mountainous regions 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. sweet potato. Predisposing Factors 1.3 molecules of iodine (more potent) 2. T4 (tetra iodothyronine. Leutinizing hormone 6. carrots. Goiter belt area a. broccoli. Thyroxine) o o T3 and T4 are metabolic or calorigenic hormone promotes cerebration (thinking) 3. places far from sea b.
Signs and Symptoms 1.o goitrogenic drugs a. clams and lobster but not shrimps because it contains lesser amount of iodine. Anti Thyroid Agent – Prophylthiuracil (PTU) b. Lugol’s Solution/SSKI ( Saturated Solution of Potassium Iodine) o o color purple or violet and administered via straw to prevent staining of teeth. Nitrofurantoin (drug of choice for pyelonephritis) b. Related to atrophy of thyroid gland due to trauma. Tetracycline. crabs. Instruct client to take in the morning to prevent insomnia 2. Assist in surgical procedure of subtotal thyroidectomy HYPOTHYROIDISM o o o hyposecretion of thyroid hormone adults: MYXEDEMA non pitting edema children: CRETINISM the only endocrine disorder that can lead to mental retardation 4. Lithium Carbonate c. Enlarged thyroid gland 2. Administer medications as ordered a. iodized salt. Mild restlessness C. Monitor side effects o o o o o o o insomnia tachycardia and palpitations hypertension heat intolerance seaweeds seafood’s like oyster. Thyroid Hormones o o o Levothyroxine (Synthroid) Liothyronine (Cytomel) Thyroid Extracts Nursing Management when giving Thyroid Hormones 1. Thyroid Scan – reveals enlarged thyroid gland. Increase dietary intake of foods rich in iodine A. Iron. inflammation . Phenylbutazones (NSAIDs) . Enforce complete bed rest 2. PASA (Aspirin) d. Nursing Management 1. presence of tumor. Mild dysphagia 3. Serum Thyroid Stimulating Hormone (TSH) – is increased (confirmatory diagnostic test) D. Iatrogenic Cause – disease caused by medical intervention such as surgery 2. Monitor vital signs especially heart rate because drug causes tachycardia and palpitations 3. 3. 4 Medications to be taken via straw: Lugol’s.if goiter is caused by B. Serum T3 and T4 – reveals normal or below normal 2. Diagnostic Procedures 1. Cobalt e. Predisposing Factors 1. best taken raw because it it is easily destroyed by heat 5.
bradycardia. Provide client health teaching and discharge planning concerning a. Constipation (Late Signs) 1. CNS changes o o o o lethargy memory impairment psychosis menorrhagia C. Diagnostic Procedures 1. Decrease in all vital signs – hypotension. Brittleness of hair and nails 2. Avoid precipitating factors leading to myxedema coma o o stress infection Assist in mechanical ventilation Administer thyroid hormones as ordered Force fluids . hypoventilation. Levothyroxine b. Force fluids 3. Autoimmune (Hashimotos Disease) B. Cold intolerance 5. bradypnea. Serum Cholesterol is increased 3. Dry skin 4. Nursing Management 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. Nursing Management for Myxedema Coma 2. Weakness and fatigue 2. hypoglycemia. Provide comfortable and warm environment 7. hypothermia 6. Serum T3 and T4 is decreased 2. RAIU (Radio Active Iodine Uptake) is decreased D. Leothyronine c. Loss of appetite but with weight gain which promotes lipolysis leading to atherosclerosis and MI 3. Hoarseness of voice 4. Thyroid Extracts 5. Non pitting edema (Myxedema) 3. Decrease libido 5. bradycardia. hypothermia leading to pregressive stupor and coma. bradypnea. Administer medications as ordered Thyroid Hormones a. Provide meticulous skin care 8. Iodine deficiency 4.3. Provide dietary intake that is low in calories 6. Administer isotonic fluid solution as ordered 4. Signs and Symptoms (Early Signs) 1. hyponatremia.
Irritability and agitation b. narcotics.reveals an enlarged thyroid gland D. Provide meticulous skin care 5. and sedatives prevent complications (myxedema coma. Nursing Management 1. Monitor strictly vital signs and intake and output 2. Comfortable and cold environment 6. Excessive iodine intake 3. Amenorrhea C. RAIU (Radio Active Iodine Uptake) is increased 3. Increase appetite (hyperphagia) but there is weight loss 2. Predisposing Factors 1. Goiter 8. Provide dietary intake that is increased in calories. Maintain side rails . 4. Tremors d. Related to hyperplasia (increase size) B. Prophythioracill (PTU) b. CNS involvement a. Administer medications as ordered Anti Thyroid Agent a. All vital signs are increased 6. Restlessness c. Serum T3 and T4 is increased 2. Diarrhea 5. Insomnia e. 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. 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. Moist skin 3. Exopthalmus 9. Hallucinations 7.o o o o o o o o cold intolerance use of anesthetics. Diagnostic Procedures 1. Thyroid Scan. Heat intolerance 4. Signs and Symptoms 1. Autoimmune – it involves release of long acting thyroid stimulator causing exopthalmus (protrusion of eyeballs) enopthalmus (late sign of dehydration among infants) 2.
8. 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. 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. Beta-blockers o o o monitor strictly vital signs. Watch out for signs of thyroid storm/ thyrotoxicosis Agitation TRIAD SIGNS Hyperthermia o administer medications as ordered a. 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. Signs of bleeding (feeling of fullness at incisional site) Nursing Management o Check the soiled dressings at the back or nape area. Hormonal replacement therapy for lifetime 6. Anti Pyretics b.7. maintain side rails offer TSB Tachycardia 2. seizure give Calcium Gluconate IV slowly as ordered 3. 1. 5. input and output and neuro check. POST OPERATIVELY. 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 . Provide bilateral eye patch to prevent drying of the eyes.
anorexia. paresthesia c. Serum Phosphate is decreased (normal value: 2. Acute tetany a. Acute Tetany Calcium Gluconate IV slowly b. arrhythmia 2. Administer medications as ordered such as: a. photophobia and cataract formation b. CT Scan – reveals degeneration of basal ganglia D.A.C MAD . nausea and vomiting d.5 – 11 mg/100 ml) 2. Atrophy of parathyroid gland due to: a. Chronic Tetany Oral Calcium supplements Calcium Gluconate Calcium Lactate Calcium Carbonate c. seizure i. tumor c. Diagnostic Procedures 1. Following subtotal thyroidectomy 2. positive chvostek sign g. X-ray of long bones reveals a decrease in bone density 4. Vitamin D (Cholecalciferol) for absorption of calcium CHOLECALCIFEROL ARE DERIVED FROM Drug Diet (Calcidiol) Sunlight (Calcitriol) feared complications d. Serum Calcium is decreased (normal value: 8. Predisposing Factors 1. trauma B. numbness d. Signs and Symptoms 1.5 mg/100 ml) 3. laryngospasm/broncospasm h. positive trousseu’s sign/carpopedal spasm f. agitation and memory impairment C. Phosphate binder Aluminum Hydroxide Gel (Ampogel) Side effect: constipation ANTACID A.A. inflammation b. Nursing Management 1. tingling sensation b.5 – 4. Chronic tetany a. loss of tooth enamel c. dysphagia e.
Hormonal replacement therapy for lifetime 9. Kidney stones a. Maintain side rails . Bone pain especially at back (bone fracture) 2.▼ Aluminum Containing Antacids ▼ Aluminum Hydroxide Gel ▼ Side Effect: Constipation ▼ Magnesium Containing Antacids ▼ Side Effect: Diarrhea 2. Strain all the urine using gauze pad for stone analysis 3. Encourage client to breathe using paper bag to produce mild respiratory acidosis result. Prevent complications 8. Agitation and memory impairment C. Adults: Osteomalacia B. Over compensation of parathyroid gland due to vitamin D deficiency a. Force fluids to prevent kidney stones 2. Institute seizure and safety precaution 5. Signs and Symptoms 1. Administer medications as ordered a. Morphine Sulfate (Demerol) 5. Nursing Management 1. Provide acid ash in the diet to acidify urine and prevent bacterial growth 7. Assist/supervise in ambulation 8. Children: Ricketts b. X-ray of long bones reveals bone demineralization D. Predisposing Factors 1. salmon c. Encourage increase intake of foods rich in calcium a. 6. green turnips 4. Encourage increase intake of foods rich in phosphate but decrease in calcium 6. Serum Calcium is increased 2. Serum Phosphate is decreased 3. renal cholic b. Provide warm sitz bath 4. cool moist skin 3. HYPERTHYROIDISM o o o Decrease parathormone Hypercalcemia: bone demineralization leading to bone fracture (calcium is stored 99% in bone and 1% blood) Kidney stones A. Importance of follow up care. Avoid precipitating stimulus such as glaring lights and noise 3. nausea and vomiting 4. anchovies b. Prepare trache set at bedside for presence of laryngo spasm 7. Hyperplasia of parathyroid gland 2. Anorexia. Diagnostic Procedures 1.
Sex 3. Adrenal Cortex – outermost b. Decrease tolerance to stress 3.function: promotes sodium and water reabsorption and excretion of potassium . Prevent complications (seizure and arrhythmia) 10. Zona Reticularis .Sugar 2.weight loss . Hormonal replacement therapy for lifetime 12.hypotension . Related to atrophy of adrenal glands 2. metabolic disturbance – Sugar b. Signs and Symptoms 1.secretes glucocortocoids (cortisol) .signs of dehydration . Zona Fasciculata .9.secretes traces of glucocorticoids and androgenic hormones . deficiency of neuromuscular function – Salt/Sex A.Salt ADDISON’S DISEASE o Hyposecretion of adreno cortical hormone leading to a. Fungal infections B. fluid and electrolyte imbalance – Salt c. Hypoglycemia – TIRED 2. Assist in surgical procedure known as parathyroidectomy 11. Adrenal Medulla – innermost (secretes catecholamines a power hormone) 2 Types of Catecholamines o o o o o Epinephrine and Norepinephrine (vasoconstrictor) Pheochromocytoma (adrenal medulla) Increase secretion of norepinephrine Leading to hypertension which is resistant to pharmacological agents leading to CVA Use beta-blockers ADRENAL CORTEX 3 Zones/Layers 1. Zona Glumerulosa .function: promotes secondary sex characteristics . Importance of follow up care ADRENAL GLAND o o Located atop of each kidney 2 layers of adrenal gland a. Predisposing Factors 1.secretes mineralocorticoids (aldosterone) .function: controls glucose metabolism . Hyponatremia .
hyponatremia leading to progressive stupor and coma Nursing Management for Addisonian Crisis 1. Loss of pubic and axillary hair 7.force fluids 2. Assist in mechanical ventilation. Hydrocortisone (Cortison) Nursing Management when giving steroids 1. prevent complications . Dexamethasone (Decadrone) b.diarrhea . Decrease libido 6. Administer medications as ordered Corticosteroids a. Hyperkalemia . hypovolemic shock c. Provide client health teaching and discharge planning a. increase calories. severe hypotension b. Taper dose (withdraw gradually from drug) 3. Instruct client to take 2/3 dose in the morning and 1/3 dose in the afternoon to mimic the normal diurnal rhythm 2. input and output to determine presence of Addisonian crisis (complication of addison’s disease) o Addisonian crisis results from acute exacerbation of addison’s disease characterized by a.sudden withdrawal to steroids b. Serum Potassium is increased (normal value: 3. Bronze like skin pigmentation C. Serum Sodium is decrease (normal value: 135 – 145 meq/L) 4. Administer isotonic fluid solution as ordered 3. Provide meticulous skin care 7. Prednisone c. Mineralocorticoids (Flourocortisone) 5. Monitor side effects a.infection . carbohydrates. Nursing Management 1.4. Provide dietary intake. hirsutism d.5 meq/L) D.5 – 4. Diagnostic Procedures 1.administer steroids as ordered . FBS is decreased (normal value: 80 – 100 mg/dl) 2. hypertension b. Monitor strictly vital signs. protein but decrease in potassium 6.arrhythmia 5. Plasma Cortisol is decreased 3.agitation . Force fluids 4.hypovolemic shock . avoid precipitating factor leading to addisonian crisis leading to .addisonian crisis . increase susceptibility to infection e. . moon face appearance 4. edema c.stress .
c. obese trunk f. Easy bruising 8.Mixed gland (exocrine and endocrine) . moon face appearance and buffalo hump e. Increase susceptibility to infections 3. Provide meticulous skin care 6. Weigh patient daily and assess for pitting edema 3. constipation c. Monitor strictly vital signs and intake and output 2. Plasma Cortisol is increased 3. hormonal replacement for lifetime d. FBS is increased 2. Assist in surgical procedure (bilateral adrenoraphy) 9. Hypernatremia a. hypertension b. Measure abdominal girth daily and notify physician 4.Located behind the stomach . Restrict sodium intake 5. Spinarolactone – potassium sparring diuretics 7. Administer medications as ordered a. thin extremities 4. weight gain d. Hirsutism 6. Nursing Management 1. Acne and striae 7. Predisposing Factors 1 Related to hyperplasia of adrenal gland 2. importance of follow up care CUSHING SYNDROME o Hypersecretion of adenocortical hormones A. Diagnostic Procedures 1. edema c. Hypokalemia a. Serum Sodium is increased 4. Serum Potassium is decreased C. Hormonal replacement for lifetime 10. Prevent complications (DM) 8. pendulous abdomen g. weakness and fatigue b. Increase masculinity among females B. Importance of follow up care PANCREAS . U wave upon ECG (T wave hyperkalemia) 5.
Anorexia. Predisposing Factors 1.Delta cells secretes somatostatin (function: antagonizes the effects of growth hormones) 3 Main Disorders of Pancreas 1. Diet 3.Consist of islets of langerhans . Complication 1.Maturity onset type . Blurring of vision 8.Beta cells secretes insulin (function: hypoglycemia) .. Incidence Rate . Diet 3.90% of general population has type 2 DM B. Polyuria 2. Polydypsia 4. nausea and vomiting 7. Exercise E. Pancreatitis DIABETES MELLITUS .Adult onset .Juvenile onset type . Ketotic 5.Has alpha cells that secretes glucagons (function: hyperglycemia) . Signs and Symptoms 1.Brittle disease A. Drugs a. Related to carbon tetrachloride toxicity C. Coma C. Hyper 2. Pancreatic Tumor/Cancer 2. Osmolar 3. Hereditary (total destruction of pancreatic cells) 2.Consist of acinar cells which secretes pancreatic juices that aids in digestion thus it is an exocrine gland . Increase susceptibility to infection 9. Polyuria 3. Polyphagia 4. Weight gain Type 2 (NIDDM) . Oral Hypoglycemic agents 2.Obese over 40 years old A. Predisposing Factors 1. protein and fat metabolism CLASSIFICATION OF DM Type 1 (IDDM) . Lasix b. Incidence Rate . Weight loss 6. Insulin therapy 2. Polydypsia 3. Non 4.metabolic disorder characterized by non utilization of carbohydrates. Related to viruses 3. Delayed/poor wound healing D. Complications 1. Glucosuria 5. Diabetic Ketoacidosis D. Signs and Symptoms 1. Polyphagia 5. Obesity – because obese persons lack insulin receptor binding sites . Exercise E. Usually asymptomatic 2. Treatment 1.10% general population has type 1 DM B. Treatment 1. Steroids 4. Glucosuria 6. Diabetes Mellitus 3.
Fats ANABOLISM CATABOLISM Glucose Amino Acids Fatty Acids Glycogen Nitrogen Free Fatty Acids . Carbohydrates 2.Cholesterol .MAIN FOODSTUFF 1.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 . Protein 3.
Anorexia.Acute complication of type 1 DM due to severe hyperglycemia leading to severe CNS depression A. Decrease LOC – diabetic coma . Signs and Symptoms 1. Hyperglycemia 2. nausea and vomiting 7. Weight loss 6. Acetone breath odor 9.Non ketotic: absence of lypolysis (no ketones) A. Monitor strictly vital signs.DIABETIC KETOACIDOSIS . Stress – number one precipitating factor 3. Polyphagia 4. Signs and Symptoms 1. Polydypsia 3.8 – 1) 4. Glucosuria 5. FBS is increased 2. Hct (normal value: female 36 – 42. Infection B.9 NaCl followed by . Diagnostic Procedures 1. Insulin therapy (regular acting insulin/rapid acting insulin peak action of 2 – 4 hours) b. BUN (normal value: 10 – 20) 3. Nursing Management 1. Restlessness 3. Creatinine (normal value: . Administer 0.Hyperosmolar: increase osmolarity (severe dehydration) . male 42 – 48) due to severe dehydration D. Antibiotics to prevent infection HYPER OSMOLAR NON KETOTIC COMA . Administer medications as ordered a. Assist in mechanical ventilation 2.45 NaCl (hypotonic solutions) to counteract dehydration and shock 3. Polyuria 2. Headache and dizziness 2. Seizure activity 4. intake and output and blood sugar levels 4. Blurring of vision 8. Sodium Bicarbonate to counteract acidosis c. Kussmaul’s Respiration (rapid shallow breathing) 10 CNS depression leading to coma C. Predisposing Factors 1.
No need to aspirate upon injection 7. Tolbutamide (Orinase) . Somogyis Phenomenon – rebound effect of insulin characterized by hypoglycemia to hyperglycemia ORAL HYPOGLYCEMIC AGENTS .Peak action is 16 – 24 hours C.9 NaCl followed by .Regular acting insulin (IV only) . Assist in mechanical ventilation 2. Nursing Management 1.Derived from beef and pork 2.for DKA use rapid acting insulin b. Types of Insulin 1. Place in refrigerator once opened 3. Rotate insulin injection sites to prevent development of lipodystrophy 8.Ultra Lente .Non Protamine Hagedorn Insulin (NPH) . Antibiotics to prevent infection INSULIN THERAPY A.Frequently used type because it has less antigenicity property thus less allergic reaction 3. Nursing Management for Insulin Injections 1. First Generation Sulfonylureas a. Administer 0.Peak action is 2 – 4 hours 2. Administer medications as ordered a. intake and output and blood sugar levels 4. Avoid shaking insulin vial vigorously instead gently roll vial between palm to prevent formation of bubbles 4. Classsification 1. Use gauge 25 – 26 needle 5. Insulin therapy (regular acting insulin peak action of 2 – 4 hours) . Monitor strictly vital signs. Intermediate Acting Insulin (cloudy) . Rapid Acting Insulin (clear) . Sources of Insulin 1. hypertrophy of subcutaneous tissues) 2. When mixing 2 types of insulin aspirate first the clear insulin before cloudy to prevent contaminating the clear insulin and promote proper calibration. Animal sources . Artificially Compound Insulin B. Most accessible route is abdomen 9. Monitor for signs of local complications such as a. Long Acting Insulin (cloudy) .45 NaCl (hypotonic solutions) to counteract dehydration and shock 3. 10. Allergic reactions b. Human Sources . Chlorpropamide (Diabenase) b.B. Administer at room temperature to prevent development of lipodystrophy (atrophy.Rarely used because it can cause severe allergic reaction . Administer insulin either 45o – 90o depending on amount of clients tissue deposit 6.Peak action is 8 – 16 hours 3.Stimulates the pancreas to secrete insulin A. Lipodystrophy c.
instruct client to cut toenails straight c. instruct client to avoid wearing constrictive garments d.c. polyphagia and glucosuria confirmatory for DM) 2. Shock due to dehydration . Monitor strictly vital signs. MI.diarrhea/constipation .Renal failure c. FBS is increased (3 consecutive times with signs or polyuria.administer simple sugars . assist in surgical wound debriment (give analgesics 15 – 30 mins prior) 9. Diagnostic Procedures 1. encourage client to apply lanolin lotion to prevent skin breakdown e. Blood Vessels III. Nursing Management 1.Blindness KIDNEY -RECURRENT PYELONEPHRITIS . Instruct the client to take it with meals to lessen GIT irritation and prevent hypoglycemia 2. protein 30% and fats 20% or offer alternative food substitutes 6. Assist in surgical procedure HEMATOLOGICAL SYSTEM I. Institute foot care management a. Provide nutritional intake of diabetic diet that includes: carbohydrates 50%.sexual impotence 8. intake and output and blood sugar levels 4. Alpha Glycosylated Hemoglobin is increased C. 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. Monitor signs for complications a. HPN and DM major cause of renal failure d. polydypsia. Second Generation Sulfonylureas a. Blood Forming Organs . instruct client to avoid walking barefooted b.for hypoglycemia (cold and clammy skin) give simple sugars . Monitor for signs of hypoglycemia and hyperglycemia . Random Blood Sugar is increased 3.for hyperglycemia (dry and warm skin) 5. Gangrene formation e. Microangiopathy (affects small minute blood vessels of eyes and kidneys) EYES -PREMATURE CATARACT . CVA) b. Tolamazide (Tolinase) 2. Monitor for signs of DKA and HONKC 11. Glipzide (Glucotrol) b. Monitor for peak action of insulin and OHA and notify physician 2.peripheral neuropathy . Oral glucose tolerance test is increased – most sensitive test 4. Atherosclerosis (HPN. Instruct client to have an annual eye and kidney exam 10. Blood II. Diabeta (Micronase) Nursing Management when giving OHA 1. Administer insulin and OHA therapy as ordered 3.
Arteries 2.for allergic reaction B. Polymorphonuclear Eosinophils .transport steroids. RBC (ERYTHROCYTES) . vitamin b6 (pyridoxine) f.normal value: 5000 – 10000/mm3 A.largest WBC . Polymorpho Neutrophils .Beta globulins – iron and copper . vitamin b12 (cyanocobalamin) e. Globulins 3.substances needed for maturation of RBC a. Lymph Nodes 6.only unnucleated cell .normal value: female 36 – 42% male 42 – 48% .55% Plasma Serum 45% Formed 1.60 – 70% of WBC .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) . Albumin 2. Non Granulocytes 1.Maintains osmotic pressure preventing edema GLOBULINS .Gamma globulins a. prothrombin and fibrinogen clotting factors FORMED ELEMENTS 1. Lymphoid Organ 5.Largest and numerous plasma CHON . anti-bodies and immunoglobulins b.macrophage in blood .normal value: 4 – 6 million/mm3 . Granulocytes 1. WBC (LEUKOCYTES) . vitamin c d. Monocytes .responsible for the release of chemical mediation for inflammation 3.hematocrit red cell percentage in wholeblood . intrinsic factor .transports and carries oxygen to tissues .biconcave discs .Alpha globulins . Spleen 4. iron c. Liver 3. Prothrombin and Fibrinogen 1. Bone Marrow ALBUMIN . folic acid b.for parasite infections .involved in short term phagocytosis for acute inflammation 2.Normal life span of RBC is 80 – 120 days and is killed in red pulp of spleen 2. bilirubin and hormones . Veins Plasma CHON (formed in liver) 1. Polymorphonuclear Basophils .
fresh blood per rectum is called hematochezia 2. Headache and dizziness .6 months – 5 years incubation period .ELISA . Petechiae 2.. Oozing of blood from venipunctured site BLOOD DISORDERS Iron Deficiency Anemia . Usually asymptomatic 2.involved in long term phagocytosis for chronic inflammation 2.bone marrow .000 – 450. Predisposing Factors 1. Chronic blood loss due to trauma a.Consist of immature or baby platelets or megakaryocytes which is the target of dengue virus .000/mm3 . High cereal intake with low animal protein digestion d. Common among developed countries 2. Inadequate intake of iron due to a.thymus for immunity Natural killer cell . Signs and Symptoms 1. Common among women 15 – 35 years old 4. Incidence Rate 1. Platelets (THROMBOCYTES) .drug of choice AZT (Zidon Retrovir) 2 Common fungal opportunistic infection in AIDS 1.western blot opportunistic .anti viral and anti tumor property HIV .Promotes hemostasis (prevention of blood loss) . Related to malabsorption syndrome c.Normal life span of platelet is 9 – 12 days Signs of Platelet Dysfunction 1. Echhymosis 3.6 months window period . Weakness and fatigue (initial signs) 3. Related to GIT bleeding resulting to hematemesis and melena (sign for upper GIT bleeding) c. Subtotal gastrectomy 4. Heavy menstruation b. Related to improper cooking of foods C. Related to poor nutrition B. Lymphocytes B-cell T-cell . Kaposi’s Sarcoma 2.A chronic microcytic anemia resulting from inadequate absorption of iron leading to hypoxemic tissue injury A. Common among tropical zones 3. Chronic diarrhea b. Pneumocystis Carinii Pneumonia 3.Normal value: 150.
Hct is deceased 4.4. Ferrous Sulfate b. Monitor and inform client of side effects a. stool and GIT 2. Avoid massaging the injection site instead encourage to ambulate to facilitate absorption 3. Egg (yolk) c. Ferrous Gluconate .300 mg/day Nursing Management when taking oral iron preparations 1. PICA (abnormal appetite or craving for non edible foods D. Diarrhea/constipation e.Iron . Sweet potatoes e. Ferritin is decreased E.Dysphagia 9. Administer with Vitamin C or orange juice for absorption 4. Instruct client to take with meals to lessen GIT irritation 2. Sorbitex (IM) Nursing Management when giving parenteral iron preparations 1. Abdominal pain d. Palpitations 7. Raisin d. Monitor for signs of bleeding of all hema test including urinw. Administer medications as ordered Oral Iron Preparations a. Dyspnea 6. Nursing Management 1.Nitrofurantoin (Macrodentin) 3. discoloration and leakage to tissues 2. Legumes g. Nuts 4. Iron Dextran (IM. Reticulocyte is decreased 6. Organ meat b. Melena 5. Anorexia b. RBC is decreased 2. 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 . IV) b. Diagnostic Procedures 1. Pallor and cold sensitivity 5. Brittleness of hair and spoon shape nails (koilonychias) 8. Atropic Glossitis (inflammation of tongue) . Dried fruits f. Monitor side effects a.Lugol’s solution . Enforce CBR so as not to over tire client 3.Stomatitis . Iron is decreased 5. 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. Ferrous Fumarate c. Hgb is decreased 3. If client cant tolerate/no compliance administer parenteral iron preparation a. Administer Z tract technique to prevent discomfort.Tetracycline . Nausea and vomiting c.
Lymphadenopathy d. Pallor and cold sensitivity 4.b. Skin rashes f.Never given orally because there is possibility of developing tolerance Secretes hydrochloric acid ▼ Aids in digestion . mouth sore b. Localized abscess c. CNS changes a. Enforce CBR 2. Hereditary factors 3. Strictly vegetarian diet STOMACH ▼ Pareital cells/ Argentaffin or Oxyntic cells Produces intrinsic factors ▼ Promotes reabsorption of Vit B12 ▼ Promotes maturation of RBC B. Autoimmune 5. Hypotension (anaphylactic shock) PERNICIOUS ANEMIA . Dyspnea and palpitations as part of compensation 5. Inflammatory disorders of the ileum 4.Chronic anemia characterized by a deficiency of intrinsic factor leading to hypochlorhydria (decrease hydrochloric acid secretion) A. weight loss e. paresthesia d. Pruritus/orticaria g. red beefy tongue c. Administer Vitamin B12 injections at monthly intervals for lifetime as ordered . Signs and Symptoms 1. Diagnostic Procedure Schilling’s Test – reveals inadequate/decrease absorption of Vitamin B12 D. Headache and dizziness 3. GIT changes that includes a. positive to Romberg’s test – damage to cerebellum resulting to ataxia e. tingling sensation b. jaundice 6. result to psychosis C. Fever and chills e. numbness c. Subtotal gastrectomy 2. Predisposing Factors 1. Nursing Management 1. indigestion/dyspepsia d. Weakness and fatigue 2.
vitamin c and iron 4. Oozing of blood from venipunctured sites C. Bone marrow biopsy/aspiration (site is the posterior iliac crest) – reveals fat necrosis in bone marrow D. Provide a dietary intake that is high in carbohydrates. Chemicals (Benzine and its derivatives) 2.. Dyspnea and palpitations 2. Increase susceptibility to infection 3. Ecchymosis c.Stem cell disorder leading to bone marrow depression leading to pancytopenia PANCYTOPENIA Decrease RBC (anemia) A. Leukopenia a. Chloramphenicol (Sulfonamides) Chemotherapeutic Agents a. Petechiae (multiple petechiae is called purpura) b. Pallor and cold sensitivity d. Institute BT as ordered 3. Diagnostic Procedures 1. Signs and Symptoms 1. Institute reverse isolation 6. protein. Nursing Management 1. Drugs Broad Spectrum Antibiotics a.Site of injection for Vitamin B12 is dorsogluteal and ventrogluteal . Methotrexate (Alkylating Agent) b. Related to irradiation/exposure to x-ray 3. Immunologic injury 4. Anemia a. Instruct client to avoid irritating mouth washes instead use soft bristled toothbrush 5. CBC reveals pancytopenia 2. Weakness and fatigue b.No side effects 3. Predisposing Factors 1. Nitrogen Mustard (Antimetabolite) Phenylbutazones (NSAIDS) B. fever Decrease WBC (leucopenia) Decrease Platelet (thrombocytopenia) . Removal of underlying cause 2. Headache and dizziness c. Monitor for signs of infection a. Vincristine (Plant Alkaloid) c. Administer oxygen inhalation 4. Avoid heat application to prevent burns APLASTIC ANEMIA . Thrombocytopenia a. Enforce CBR 5.
Administer oxygen inhalation 4. ABG analysis reveals metabolic acidosis 4. CBC reveals decreased platelets 2. Instruct client to use electric razor when shaving 10. Neoplasia (new growth of tissue) 7. Monitor for signs of bleeding of all hema test including stool and GIT 2. Predisposing Factors 1. Oozing of blood from punctured sites 4. 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. subcutaneous. Oliguria (late sign) C. Anaphylaxis 5. Petechiae (widespread and systemic) eye. Hemoptysis 6. Heparin/Coumadin is ineffective 6. Institute NGT decompression by performing gastric lavage by using ice or cold saline solution of 500 – 1000 ml 8. Signs and Symptoms 1. Septecemia 6. Stool occult blood positive 3. Vitamin K b. Pregnancy B.b. Monitor NGT output 9. Prevent complication . Provide heparin lock 7. Administer isotonic fluid solution as ordered 3. Opthamoscopic exam reveals sub retinal hemorrhages D. Pitressin/ Vasopresin to conserve fluids c. cough 7. Related to rapid blood transfusion 2. Force fluids 5. Nursing Management 1. Diagnostic Procedures 1. Avoid IM. Massive trauma 4. Massive burns 3. lungs and lower extremities 2. Administer medications as ordered a. Administer medications as ordered a. venipunctured sites 8 Instead provide heparin lock 9. Corticosteroids – caused by immunologic injury b. Ecchymosis 3.
Isotonic solution (0. Client name b. Air embolism f. . sediments and darkness in color because it indicates bacterial contamination . Prevent bleeding if there is platelet deficiency Principles of blood transfusion 1. Anuria – late sign BLOOD TRANSFUSION Goals/Objectives 1.a. Blood typing and cross matching c.Emergency rapid BT is given after 30 minutes and let natural room temperature warm the blood. Replace circulating blood volume 2. 85% of population is RH positive 3. Allergic reaction c. Avoid mixing or administering drugs at BT line to prevent HEMOLYSIS 8. Regulate BT 10 – 15 gtts/min or KVO rate or equivalent to 100 cc/hr to prevent circulatory overload 9. Thrombocytopenia g. Hyperkalemia (caused by expired blood) . Check the blood unit for bubbles cloudiness. 6. Pyrogenic reaction d. during and after BT especially every 15 minutes for first hour because majority of transfusion reaction occurs during this period a. Monitor strictly vital signs before.Never warm blood as it may destroy vital factors in blood.Expiration of packed RBC is 3 – 6 days .Warming is only done during emergency situation and if you have the warming device . Type AB – universal recipient c.9 NaCl/plain NSS) to prevent hemolysis 4.Expiration of platelet is 3 – 5 days 2. Serial number 5. Proper typing and cross matching a. Type O – universal donor b. Expiration date d. Aseptically assemble all materials needed for BT a. Cytrate intoxication h. Hypovolemic shock b. Instruct another RN to re check the following a. Filter set b. Circulatory overload e. 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. Hemolytic reaction b. Gauge 18 – 19 needle c. Prevent infection in there is a decrease in WBC 4. Proper refrigeration .
Laryngospasm and Broncospasm Nursing Management 1.if positive to hypotension. Monitor vital signs and intake and output SIGNS AND SYMPTOMS OF ALLERGIC REACTION 1. Dyspnea 3. Notify physician 3. Send the blood unit to blood bank for re examination 6.Signs and Symptoms of Hemolytic reaction 1. Stop BT 2. Broncial wheezing 4. Notify physician 3. Send the blood unit to blood bank for re examination 6. Dyspnea Nursing Management 1. Anti Histamine (Benadryl) . Urine is color red/ portwine urine Nursing Management 1. Monitor vital signs and intake and output SIGNS AND SYMPTOMS PYROGENIC REACTIONS 1. Palpitations 5. Administer medications as ordered a. Flushed skin 6. Lumbasternal/ Flank pain 7. Flush with plain NSS . Flush with plain NSS 4. Fever 2. Obtain urine and blood sample and send to laboratory for re examination 7. Diaphoresis 6. Tachycardia 4. anaphylactic shock treat with Epinephrine 5. Headache and dizziness 2. Obtain urine and blood sample and send to laboratory for re examination 7. Fever and chills 2. Skin rashes 5. Stop BT 2. Flush with plain NSS 4. Hypotension 5. Urticaria 6. Headache 3. Stop BT 2. Notify physician 3. Dyspnea 3. Administer isotonic fluid solution to prevent shock and acute tubular necrosis 5. Diarrhea/Constipation 4.
Visceral – inner layer . Antibiotic 5. Valves .Located on the left mediastinum . Epicardium – outer layer 2. Layers of Heart 1. Ventricles .In order to propel blood to the systemic circulation . tricuspid valve . Render TSB SIGNS AND SYMPTOMS OF CIRCULATORY REACTION 1.Common among MI. Myocardium – middle layer 3.Prevent pericardial friction rub .Left ventricle has increased pressure which is 120 – 180 mmHg . Send the blood unit to blood bank for re examination 6.Muscular pumping organ of the body. Cardiac tamponade A. Orthopnea 2.Resemble like a close fist . Notify physician 3.Myocarditis can lead to cardiogenic shock and rheumatic heart disease B. Parietal – outer layer b. Loop diuretic (Lasix) CARDIOVASCULAR SYSTEM OVERVIEW OF THE STRUCTURE AND FUNCTIONS OF THE HEART HEART . Stop BT 2. Antipyretic b.Weighs approximately 300 – 400 grams . Administer medications as ordered a.Covered by a serous membrane called the pericardium 2 layers of pericardium a. Rales/Crackles upon auscultation 4. Atria 2. Chambers of the Heart 1. Endocardium – inner layer .In between is the pericardial fluid which is 10 – 20 cc . Upper Chamber (connecting or receiving) a.Right atrium has decreased pressure which is 60 – 80 mmHg C. Lower Chamber (contracting or pumping) a. Atrioventricular Valves – guards opening between a. Dyspnea 3. pericarditis. Administer medications as ordered a.To promote unidimensional flow or prevent backflow 1. Exertional discomfort Nursing Management 1.4. Monitor vital signs and intake and output 8. . Obtain urine and blood sample and send to laboratory for re examination 7.
P WAVE (atrial depolarization) contraction . Atrio – Ventricular Node (AV or Tawara Node) .Acts as primary pacemaker of the heart .Left Main Bundle of His .Arises from base of the aorta Types of Coronary Arteries 1. Coronary Arteries . Left Main Coronary Artery . Cardiac Conduction System 1. aortic .Located at the inter atrial septum . Purkinje Fibers . pulmonic b.T WAVE (ventricular repolarization) . S3 – ventricular gallop usually seen in Left Congestive Heart Failure 2.QRS WAVE (ventricular depolarization) . Sino – Atrial Node (SA or Keith Flack Node) .Supplies the myocardium E. Bundle of His . S4 – atrial gallop usually seen in Myocardial Infarction and Hypertension D.Right Main Bundle of His .08 milliseconds to allow ventricular filling 3. mitral valve .Located at the junction of superior vena cava and right atrium .Initiates electrical impulse of 60 – 100 bpm 2.Located at the walls of the ventricles for ventricular contraction SA NODE AV NODE BUNDLE OF HIS JLJLJLJJLJLJL PURKINJE FIBERS .Closure of SV valve give rise to second heart sound (S2 “dub”) Extra Heart Sounds 1. Semi – lunar Valves a.Closure of AV valves give rise to first heart sound (S1 “lub”) 2.Located at the interventricular septum 4.b. Right Main Coronary Artery 2.Delay of electrical impulse for about .
Diet – increased saturated fats 10. Type A personality B. Obesity 5. Tachycardia 4. Peak T wave – Hyperkalemia 3. Race – black 3. Diabetes Mellitus 8.tunica media . Palpitations 5. Smoking 4. Dyspnea 3. Revascularize myocardium 2. Increase survival rate ARTERIOSCLEROSIS .Atherosclerosis 2. Myocardial Necrosis – Myocardial Infarction ATHEROSCLEROSIS ATHEROSCLEROSIS .lipid or fat deposits . 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. Hyperlipidemia 6. Duaphoresis C. Widening of QRS complexes – Arrythmia CARDIAC DISORDERS Coronary Arterial Disease/ Ischemic Heart Disease Stages of Development of Coronary Artery Disease 1.hardening of artery . sedentary lifestyle 7. Signs and Symptoms 1. Hypothyroidism 9. ST segment elevation – Myocardial Infarction 5.narrowing of artery . Myocardial Ischemia – Angina Pectoris 3.calcium and protein deposits . Sex – male 2. Chest pain 2.Hypokalemia 2. Treatment Percutaneous Transluminal Coronary Angioplasty Objectives of PTCA 1.tunica intima A. Predisposing Factors 1. Myocardial Injury . To prevent angina 3. T wave inversion – Myocardial Infarction 6. Positive U wave . ST segment depression – Angina Pectoris 4.
Smoking 4. Administer medications as ordered a. anxiety. Extreme emotional response – fear. Excessive intake of foods rich in saturated fats – skimmed milk C.Give second dose of NTG if pain persist after giving first dose with interval of 3 . Levine’s Sign – initial sign that shows the hand clutching the chest 2.If there is 2 or more occluded blood vessels CABG is done Coronary Arterial Bypass And Graft Surgery 3 Complications of CABG 1. Shock 3. Diaphoresis D. Sex – male 2. Nitroglycerine (NTG) – when given in small doses will act as venodilator. Enforce complete bed rest 2. Signs and Symptoms 1. excitement 4. Thrombophlebitis ANGINA PECTORIS (SYNDROME) Clinical syndrome characterized by paroxysmal chest pain that is usually relieved by rest or nitroglycerine due to temporary myocardial ischemia A. Diagnostic Procedure 1. Stress test – treadmill test. shoulder. Race – black 3. axilla and jaw muscles. Hyperlipidemia 6. History taking and physical exam 2. Precipitating Factors 4 E’s of Angina Pectoris 1. Predisposing Factors 1.. but in large doses will act as vasodilator . Obesity 5. Tachycardia 5. Hypothyroidism 9. Dyspnea 4. Chest pain characterized by sharp stabbing pain located at sub sterna usually radiates from back. sedentary lifestyle 7. Palpitations 6. coughing exercise and use of incentive spirometer 2. Diabetes Mellitus 8.Done to single occluded vessels .5 minutes . Serum cholesterol and uric acid is increased E. Excessive physical exertion – heavy exercises 2.Give first dose of NTG (sublingual) 3 – 5 minutes . ECG tracing reveals ST segment depression 3. Type A personality B. Diet – increased saturated fats 10. arms. Exposure to cold environment 3. Pneumonia – encourage to perform deep breathing. usually relieved by rest or taking nitroglycerine 3. reveal abnormal ECG 4. Nursing Management 1.
Calcium Antagonist . A. Types 1..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.NIfedipine 3. Provide client health teachings and discharge planning a. Subendocardial Myocardial Infarction – characterized by occlusion of either right or left coronary artery B.Not given to COPD cases because it causes bronchospasm c. The importance of follow up care MYOCARDIAL INFARCTION Heart attack Terminal stage of coronary artery disease characterized by malocclusion. Provide decrease saturated fats sodium and caffeine 7. Smoking 4. Instruct client to take medication before indulging into physical exertion to achieve the maximum therapeutic effect of drug d. 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.Propanolol .Enalapril d. Administer oxygen inhalation 4. Place client on semi fowlers position 5. Predisposing Factors 1. Sex – male 2. necrosis and scarring. Prevent complication (myocardial infarction) c. Monitor strictly vital signs. Avoidance of 4 E’s b. Transmural Myocardial Infarction – most dangerous type characterized by occlusion of both right and left coronary artery 2. Beta-blockers . Race – black 3. Obesity 5. ACE Inhibitors . 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. intake and output and ECG tracing 6.side effects PNS . Hyperlipidemia .
Side Effects: respiratory depression . Diet – increased saturated fats 10. Occasional findings a. LDH – Lactic acid dehydroginase is increased c. S4 or atrial gallop E.Heart only. 12 – 24 hours b. Cardiac Enzymes a. Nursing Management Goal: Decrease myocardial oxygen demand 1. Diagnostic Procedure 1. ECG tracing reveals a.Excruciating visceral. T wave inversion c.Creatinine phosphokinase is increased . Diabetes Mellitus 8. Chest pain . Rales/Crackles upon auscultation d. Place client on semi fowlers position . Pericardial friction rub b. Decrease myocardial workload (rest heart) . Hyperthermia 5.Side Effects of Naloxone Toxicity is tremors 2.Usually radiates from back.6. Mild restlessness and apprehension 7. Hypothyroidism 9. Increase in blood pressure (initial sign) 4. Widening of QRS complexes indicates that there is arrhythmia in MI 4. shoulder. axilla. SGOT – Serum glutamic oxal-acetic transaminase is increased 2. Split S1 and S2 c. Using bedside commode 4. ST segment elevation b. Dyspnea 3. Signs and Symptoms 1. Serum Cholesterol and uric acid are both increased 5. Ashen skin 6.Antidote: Narcan/Naloxone . Enforce CBR without bathroom privileges a. SGPT – Serum glutamic pyruvate transaminase is increased d. arms. CBC – increased WBC F.Not usually relieved by rest or by nitroglycerine 2. Instruct client to avoid forms of valsalva maneuver 5. jaw and abdominal muscles (abdominal ischemia) . sedentary lifestyle 7. Troponin Test – is increased 3.Administer narcotic analgesic/morphine sulfate . CPK – MB . Type A personality D. Administer oxygen low inflow to prevent respiratory arrest at 2 – 3 L/min 3. viselike pain located at substernal and rarely in precordial .
Avoidance of modifiable risk factors . Anti Coagulant .Contraindication Dengue Peptic Ulcer Disease Unknown cause of headache 10.Brutylium c.Heparin (check for partial thrombin time) .Anti thrombotic effect . Vasodilators . intake and output and ECG tracing 7. Anti Platelet . Cardiogenic shock . Thrombophlebitis .Coumadin/ Warfarin Sodium (check for prothrombin time) .Side Effects of Aspirin Tinnitus Heartburn Indigestion/Dyspepsia . whisky and brandy to induce vasodilation 9. pruritus .Side Effects: confusion and dizziness . Provide client health teaching and discharge planning concerning a.Side Effects: allergic reaction.homan’s sign e.TIPAF (tissue plasminogen activating factor) .PASA (Aspirin) . Thrombolytics/ Fibrinolytic Agents .arrhythmia (caused by premature ventricular contraction) b.Urokinase . Isodil) sublingual b. Administer medication as ordered a.Monitor for bleeding time g.Lidocaine (Xylocane . Left Congestive Heart Failure d.Side Effects: chest pain . Stroke/CVA .Antidote: Vitamin K h. Monitor strictly vital signs. sodium and caffeine 8.Nitroglycerine . Beta-blockers d.Streptokinase . ACE Inhibitors e.ISD (Isosorbide Dinitrate. Provide a general liquid to soft diet that is low in saturated fats. Anti Arrythmic Agents . Calcium Antagonist f.late sign is oliguria c. Encourage client to take 20 – 30 cc/week of wine.6.Antidote: protamine sulfate .
Post MI Syndrome/Dressler’s Syndrome . post CABG and instruct to .client is resistant to pharmacological agents. PCO2 is increased (respiratory acidosis) 2. 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. Diagnostic Procedure 1. Aortic valve stenosis B. There is anorexia and generalized body malaise 12. Cyanosis 7. administer 150. Predisposing Factors 1. PMI is displaced laterally due to cardiomegaly 11. ABG – reveals PO2 is decreased (hypoxemia).client can resume sexual intercourse if can climb staircase .ASO Titer (Anti streptolysin O titer) . LEFT SIDED HEART FAILURE A. A beta-hemolytic streptococcus .f. 90% is mitral valve stenosis due to a. Productive cough with blood tinged sputum 5.instruct client to assume a non weight bearing position .make sex as an appetizer rather than dessert .Common among children . Aging 2. Ecocardiography – enlarged heart chamber (cardiomyopathy). S3 – ventricular gallop C. Paroxysmal nocturnal dyspnea – client is awakened at night due to difficulty of breathing 3. Ischemic heart disease 4. Hypertension 5. Chest x-ray – reveals cardiomegaly 2.dietary modification h. Orthopnea – use 2 – 3 pillows when sleeping or place in high fowlers 4. Myocardial Infarction 3. Dyspnea 2. Frothy salivation 6.000 – 450. Signs and Symptoms 1.Formation of aschoff bodies in the mitral valve . Pulsus Alternans – weak pulse followed by strong bounding pulse 10.000 units of streptokinase as ordered g.Aspirin b. Resumption of ADL particularly sexual intercourse is 4 – 6 weeks post cardiac rehab. RHD – inflammation of mitral valve due to invasion of Grp. Rales/Crackles 8. dependent on extent of heart failure 4. RIGHT SIDED HEART FAILURE . Bronchial wheezing 9. 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.Penicillin .
Diagnostic Procedures 1. Pulmonic valve stenosis 5. Chest x-ray – reveals cardiomegaly 2.When reading CVP patient should be flat on bed .Increase force of cardiac contraction .If CVP is less than 4 cm of water hypovolemic shock . delivered via nasal cannula 4. Cardiac glycosides .A.Measure pressure in right atrium (4 – 10 cm of water) . High fowlers position . Liver enzymes – SGPT and SGOT is increased D. Central venous pressure (CVP) . Pitting edema 3.Morphine Sulfate e. Hepatosplenomegaly 6. Anti Arrhythmic .Administer loop diuretics as ordered .Do the fluid challenge (increase IV flow rate) . Esophageal varices C. Administer medications as ordered a. Enforce CBR 2. Left sided heart failure B.If heart rate is decreased do not give b. Pruritus 8.Lidocaine (Xylocane) 3.If CVP is more than 10 cm of water hypervolemic shock . Neck/jugular vein distension 2. Pulmonary embolism 3. Nursing Management Goal: increase cardiac contractility thereby increasing cardiac output (3 – 6 L/min) 1.Nitroglycerine f. Vasodilators . Administer oxygen inhalation with high inflow.Lasix (Furosemide) c.Digoxin (Lanoxin) . 3 – 4 L/min. Anorexia 9. Predisposing Factors 1. Weight gain 5. Jaundice 7. Narcotic analgesics . Tricuspid valve stenosis 2. Bronchodilators d. Related to COPD 4. Ecocardiography – reveals enlarged heart chambers (cardiomyopathy 4. Signs and Symptoms (venous congestion) 1.Upon insertion place client in trendelendberg position to promote ventricular filling and prevent pulmonary embolism 3. Loop Diuretics . Ascites 4.CVP fluid status measure .
Nursing Management 1. Smoking B. Prevent complications . Diagnostic Procedures 1. Monitor strictly vital signs. Strict compliance to medications PERIPHERAL VASCULAR DISORDER Arterial Ulcer I. Provide meticulous skin care 9.5. Provide client health teaching and discharge planning a. cholesterol and caffeine 8. Signs and Symptoms 1. Analgesics Burger’s Disease Reynaud’s Disease . intake and output and ECG tracing 6.Shock . High risk groups – men 30 years old and above 2. rotated clockwise every 15 minutes to promote decrease venous return 10. Intermittent claudication – leg pain upon walking 2.MI . Doppler UTZ – decrease blood flow to the affected extremity 3. Trophic changes 5. out of bed 3 – 4 times a day 2. Measure abdominal girth daily and notify physician 7. Encourage a slow progressive physical activity a. Dietary modification c. Decreased peripheral pulses 4. walking 3 – 4 times a day b.Right ventricular hypertrophy . Provide a dietary intake of low sodium. Predisposing Factors 1. Thrombophlebitis (deep vein thrombosis) THROMBOANGITIS OBLITERANS Acute inflammatory disorder usually affecting the small medium sized arteries and veins of the lower extremities A. Assist in bloodless phlebotomy – rotating tourniquet. Ulceration 6. Administer medications as ordered a. Oscillometry – decrease in peripheral pulses 2. cyanosis then rubor) 3. Gangrene formation C. Cold sensitivity and changes in skin color (pallor. Angiography – reveals site and extent of malocclusion D.Arrythmia . Thrombo Angitis Obliterans Venous Ulcer 1.Thrombophlebitis b. Varicose Veins 2.
Instruct client to avoid smoking and exposure to cold environment 5. Trophic changes 4. SLE (butterfly rash) b. Anti coagulants 3. Smoking 3. Collagen diseases a. Piano playing b. Instruct client on importance of cessation of smoking and exposure to cold environment VARICOSITIES Abnormal dilation of veins of lower extremities and trunks due to Incompetent valve resulting to Increased venous pooling resulting to Venous stasis causing Decrease venous return A. Vasodilators 2. Predisposing Factors 1. Doppler UTZ – decrease blood flow to the affected extremity 2. Intermittent claudication – leg pain upon walking 2. cyanosis then rubor) 3. Congenital weakness of veins 3. Operating chainsaw B. Gangrene formation C. Thrombophlebitis 4. Predisposing Factors 1. Rheumatoid Arthritis 4.b. Administer medications as ordered a. Nursing Management 1. High risk group – female 40 years old and above 2. Cold sensitivity and changes in skin color (pallor. Direct hand trauma a. 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. Ulceration 5. Diagnostic Procedures 1. Pregnancy . Excessive typing c. Encourage to wear gloves 3. Analgesics b. Angiography – reveals site and extent of malocclusion D. Cardiac disorder 5. Institute foot care management 4. Signs and Symptoms 1. Vasodilators c. Hereditary 2.
Chronic anemia 5. Related to pregnancy 4. Sclerotherapy – can recur and only done in spider web varicosities and danger of thrombosis (2 – 3 years for embolism) THROMBOPHLEBITIS Deep vein thrombosis Inflammation of the veins with thrombus formation A. Heaviness in legs C. Signs and Symptoms 1. Dilated tortuous skin veins 3. Prolong use of oral contraceptives – promotes lipolysis 6. Myocardial infarction 9. Dilated tortuous skin veins 4. Nursing Management . Post op complication 10. Assist in surgical procedure a. Diagnostic Procedure 1. Smoking 3. Increase in saturated fats in the diet. Warm to touch 3.6. Nursing Management 1. Measure the circumference of leg muscle to determine if swollen 3. Vein stripping and ligation (most effective) b. Trendelenburg’s Test . Positive Hpman’s Signs – pain at the calf or leg muscle upon dorsi flexion of the foot C. Administer medications as ordered a. Prolonged standing or sitting B. B. Angiography D. Obesity 2. Diagnostic Procedure 1. Elevate legs above heart level to promote increased venous return by placing 2 – 3 pillows under the legs 2. Pain after prolonged standing 2. Congestive heart failure 8.veins distends quickly in less than 35 seconds D. Pain at affected extremity 2. Signs and Symptoms 1. Diabetes mellitus 7. Obesity 7. Warm to touch 4. Post cannulation – insertion of various cardiac catheter 11. Predisposing Factors 1. Analgesics 5. Wear anti embolic stockings 4. Venography 2. Venography 2.
Opening of larynx .Consist of anastomosis of capillaries known as Keissel Rach Plexus (the site of nose bleeding) B. Lower Respiratory System . Anti Coagulant .Heparin 6.Dizziness . Measure circumference of leg muscle to determine if swollen 4. Cerebral . Humidification A.Separated by septum . Filtering of air 2.The initial sign of complete airway obstruction is the inability to cough II. Analgesics b.Serves as a muscular passageway for both food and air C.Consist of cartilaginous rings . Nose . Elevate legs above heart level to promote increase venous return 2.Headache .For cough reflex Glottis .Serves as passageway of air going to the lungs .Cartillage .Decrease LOC • MURPHY’S SIGN is seen in clients with cholelithiasis. Upper Respiratory System 1.1.Tachycardia .Restlessness b.Sudden sharp chest pain . Encourage to wear anti embolic stockings or knee elastic stockings 5.For phonation (voice production) .Closes to allow passage of food going to the esophagus .Right nostril .For gas exchange A. Warming and moistening of air 3. Larynx . Monitor for signs of complications Embolism a. Apply warm moist pack – to reduce lymphatic congestion 3. Trachea/Windpipe .Unexplained dyspnea .Opens to allow passage of air . Pulmonary .Left nostril .Palpitations .Diaphoresis . cholecystitis characterized by pain at the right upper quadrant with tenderness RESPIRATORY SYSTEM OVERVIEW OF THE STRUCTURES AND FUCNTIONS OF THE RESPIRATORY SYSTEM I. Administer medications as ordered a. Pharynx/Throat .
Site of tracheostomy B. 10 segments) .Right main bronchus .Decrease oxygen stimulates breathing .An acid fast. 8 segments) .Normal L/S ratio is 2:1 . aerobic and easily destroyed by heat or sunlight A. Mode of Transmission 1. Virulence (degree of pathogenecity) of microorganism B.Composed of lecithin and spingomyelin . Pleural fluid c..Give oxygen of less 40% in premature to prevent atelectasis and retrolental fibroplasias . Overcrowded places 3.Left lung (consist of 2 lobes. Low grade afternoon fever.Infection of lung tissue caused by invasion of mycobacterium tuberculosis or tubercle bacilli .Serous membranes Pleural Cavity a. Signs and Symptoms 1. Malnutrition 2. night sweats 2.Decrease surface tension . Over fatigue 5. Pareital b. Bronchus .In premature infants 1:2 . Airborne transmission via droplet nuclei C.Secretes surfactant .retinopathy/blindness in prematurity Disorders of Respiratory System 1. Pleural effusion c. Pneumonia b.Diffusion (Dalton’s law of partial pressure of gases) Respiratory Distress Syndrome .Prevent collapse of alveoli . Hydrothorax (air and blood in pleural space Alveoli . PTB/Pulmonary Tuberculosis (Koch’s Disease) . Ingestion of an infected cattle with mycobacterium bovis 6.Increase carbon dioxide is a powerful stimulant for breathing Type II Cells of Alveoli . Productive cough (yellowish sputum) .L/S ratio to determine lung maturity .Right lung (consist of 3 lobes.Left main bronchus C. Visceral With Pleuritic Friction Rub a. Alcoholism 4. Lungs .Site of gas exchange (CO2 and O2) . gram negative. Precipitating Factors 1.
Gentamycin .Side Effect INH: peripheral neuritis/neuropathy (increase intake of Vitamin B6/Pyridoxine) . Chest X-ray . taken after meals to facilitate absorption . hepatotoxicity. Hemoptysis (chronic) D. Mantoux Test (skin test) . Comfortable and humid environment 9.Purified protein derivative . CBC . Enforce CBR 2. Institute strict respiratory isolation 3.Neomycin .PZA can be replaced by Ethambutol . taken before meals to facilitate absorption .Reveals pulmonary infiltrates 4. Anorexia.INH and Rifampicin is given for 4 months.Positive Mantoux test (previous exposure to tubercle bacilli but without active TB) 2. Sputum Acid Fast Bacillus .3.Given everyday simultaneously to prevent resistance . Weight loss 5.Side Effect Ethambutol: optic neuritis b.INH (Isonicotinic Acid Hydrazide) . Intensive phase .Reveals increase WBC E. Nebulize and suction when needed 8. Force fluids to liquefy secretions 5.Positive to cultured microorganism 3. Dyspnea 6. Chest pain 7.PZA is given for 2 months. generalized body malaise 4. Administer oxygen inhalation 4. Place client on semi fowlers position to promote expansion of lungs 6.Side Effect Rifampicin: all bodily secretions turn to red orange color .Injection of streptomycin (aminoglycoside) . Diagnostic Procedure 1. Standard phase .PZA (Pyrazinamide) . 48 – 72 hours .Amikacin .WHO 10 – 14 mm induration.DOH 8 – 10 mm induration. nephrotoxicity . 48 – 72 hours .Kanamycin . Nursing Management 1.Rifampicin (Rifampin) . Encourage deep breathing and coughing exercise 7. Institute short course chemotherapy a.Side Effect PZA: allergic reaction.
Ototoxicity damage to the 8th cranial nerve resulting to tinnitus leading to hearing loss .Pneumocystic carini pneumonia . Aspiration of food causing aspiration pneumonia D.Skin . Etiologic Agents 1. Escherichia Pneumoniae 6. chills. High Risk Groups 1. vitamin C and calories 11. heartburn 10. AIDS . Strict compliance to medications d.Initial sign is non productive cough . Predisposing Factors 1. Bronchial wheezing . Smoking 2. military tuberculosis) PTB .Meninges . Rales/crackles 6.Adrenal gland c.Side Effect: tinnitus.Give aspirin if there is fever . Klebsella Pneumoniae 5. anorexia and general body malaise 4.Side Effect: . Fever. Bronchogenic Cancer . Elderly C. Signs and Symptoms 1. Weight loss 5. Provide increase carbohydrates.Eyes . Diplococcus Pneumoniae 4. protein. Avoidance of precipitating factors b. Hemophylus Influenzae – causing broncho pneumonia 3. Provide client health teaching and discharge planning a. Air pollution 3. Related to prolonged immobility (CVA clients).Bones (potts) .. causing hypostatic pneumonia 5.Nephrotoxicity check for BUN and Creatinine . Productive cough with greenish to rusty sputum 2. Streptococcus Pneumonae – causing pneumococal pneumonia 2. Children below 5 years old 2. Immuno compromised a.Drug of choice is Retrovir b. dyspepsia. Prevent complications (atelectasis.Chest x-ray confirms lung cancer 4. Importance of follow up care PNEUMONIA Inflammation of the lung parenchyma leading to pulmonary consolidation as the alveoli is filled with exudates A. Pseudomonas B. Dyspnea with prolong expiratory grunt 3.
Place on semi fowlers position 6.Unstable vital signs .Deep breathing exercises .Hemoptysis .Chest physiotherapy . CBC – reveals increase WBC.7. protein and vitamin C 10. Prevent complications .Placed on various position Nursing Management for Postural Drainage a. Nursing Management 1. Tetracycline c. Microlides (Zethromax) Azethromycin (Side Effect: Ototoxicity) Antipyretics Mucolytics/Expectorants Analgesics 4. Assist in postural drainage . erythrocyte sedimentation rate is increased F. Nebulize and suction as needed 8. Administer medications as ordered Broad Spectrum Antibiotic a. calories.Drain uppermost area of lungs . Avoid smoking b. Encourage client deep breathing exercises d.Increase ICP 9. Contraindicated with . ABG analysis – reveals decrease PO2 4. Monitor vital signs c.Coughing exercises . Provide oral care after procedure g. Provide increase carbohydrates. Abdominal distention leading to paralytic ileus (absence of peristalsis) E. Chest pain 10. Stop if client cannot tolerate procedure f. Chest x-ray – reveals pulmonary consolidation 3. Enforce CBR 2. Institute pulmonary toilet (tends to promote expectoration) . Health teaching and discharge planning a. Penicillin b.Clients with increase intra ocular pressure (Normal IOP 12 – 21 mmHg) . Administer oxygen inhalation low inflow 3. Administer bronchodilators 15 – 30 minutes before procedure e. Cyanosis 8.Turning and reposition 7. Pleuritic friction rub 9. Best done before meals or 2 – 3 hours to prevent gastro esophageal reflux b. Force fluid 5. Diagnostic Procedure 1. Sputum Gram Staining and Culture Sensitivity – positive to cultured microorganisms 2.
Diagnostic Procedures 1. Histoplasmin Skin Test – positive 2.Atelectasis . Chest and joint pains B. Nursing Management 1. Hypokalemia) b. Smoking 2. Regular adherence to medications d. Hemoptysis 6. Force fluids to liquefy secretions 5. Signs and Symptoms 1. chills. Cyanosis 5.Fungizone (Nephrotoxicity. Prevent complications – bronchiectasis 7. Dyspnea 3. Air pollution B..Meningitis (nerve deafness. 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. Administer oxygen inhalation 3. ABG analysis PO2 decrease C. hydrocephalus) c. Antifungal . Predisposing Factors 1. anorexia. Nebulize and suction as needed 6. general body malaise 4. Prolonged expiratory grunt 4. Administer medications as ordered a.Amphotericin B . check for BUN and Creatinine. Enforce CBR 2. 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. Productive cough 2. Antipyretics 4. Productive cough (consistent to all COPD) 2. Dyspnea on exertion 3. Signs and Symptoms PTB or Pneumonia like 1. Steroids c. Mucolytics d. Anorexia and generalized body malaise . Fever.
Pollen b. Dyspnea 3. Fumes d. ABG analysis – PO2 decrease . Intrinsic Asthma (Non atopic/Non allergic) Causes a. Furs h. pH decrease Bronchial Asthma Reversible inflammatory lung condition due to hypersensitivity to allergens leading to narrowing of smaller airways A. air pressure and humidity f. Diagnostic Procedure 1.5. beta blocker) c. apply direct pressure to ulnar and radial artery to determine presence of collateral circulation D. Lints 2.Incentive spirometer reveals decrease vital lung capacity 2. Peripheral edema b. Extrinsic Asthma ( Atopic/ Allergic ) Causes a. Tachycardia. Nursing Management 1. Predisposing Factors (Depending on Types) 1. Diaphoresis C. Danders g. milk. Cyanosis 7. Mixed Type 90 – 95% B. chocolates. PCO2 increase. Pulmonary Function Test . Mild Stress/apprehension 6. Diagnostic Procedure ABG analysis – reveals PO2 decrease (hypoxemia). Hereditary b. Cyanosis 5. Physical and emotional stress 3. palpitations 7. Cor Pulmonale (right ventricular hypertrophy) C. Wheezing on expiration 4. Drugs (aspirin. Sudden change in temperature. Enforce CBR . Cough that is non productive 2. Foods (seafoods.Before ABG test for positive Allens Test. Signs and Symptoms 1. Gases f. chicken d. Food additives (nitrates) e. Dust c. Pulmonary hypertension a. Smoke e. penicillin. eggs. Scattered rales/ronchi 6.
Semi fowlers position 6. Recurrent lower respiratory tract infections 2.2. Predisposing Factors 1. Mucomysts (acetylceisteine) d.Steroids .Epinephrine . ABG – PO2 decrease 2. Bronchodilators – given via inhalation or metered dose inhalaer or MDI for 5 minutes b. Provide client health teachings and discharge planning concerning a. Regular adherence to medications to prevent development of status asthmaticus d. Related to presence of tumor B. Avoidance of precipitating factor b. Administer medications as ordered a. Cyanosis 4. Anti histamine 4. may cause irritation 3. coughing and smoking. Treatment . Signs and Symptoms 1. Monitor for signs of laryngeal spasm – prepare tracheostomy set D. Force fluids 5. Dyspnea 3. Anorexia and generalized body malaise 5. Monitor for signs of gross 4. Maintain NPO 6 – 8 hours prior to procedure 3. Oxygen inhalation. Hemoptysis (only COPD with sign) C. Secure inform consent and explain procedure to client 2. Monitor vital signs and breath sound POST Bronchoscopy 1.Bronchodilators c. Chest trauma 3. with low inflow of 2 – 3 L/min 3. Avoid talking. Productive cough 2. Diagnostic Procedure 1.Emphysema . Bronchoscopy – direct visualization of bronchus using fiberscope Nursing Management PRE Bronchoscopy 1. Nebulize and suction when needed 7. Feeding initiated upon return of gag reflex 2. Importance of follow up care BRONCHIECTASIS Abnormal permanent dilation of bronchus leading to destruction of muscular and elastic tissues of alveoli A.Status Asthmaticus (give drug of choice) . Steroids – decrease inflammation c. Prevent complications . Mucolytics/expectorants e. Congenital defects 4.
Decrease ph . Maldistribution of gases d. Panacinar/ centriacinar . Pulmonary Function Test – reveals decrease vital lung capacity 2. Prolong expiratory grunt 4. Segmental Wedge Lobectomy (promote re expansion of lungs) . Signs and Symptoms 1. Nursing Management 1. High risk: elderly 5. Purse lip breathing to eliminates excess CO2 (compensatory mechanism) C. Dyspnea at rest 3. ABG analysis reveals a.Decrease PO2 (hypoxemia leading to chronic bronchitis. Inelasticity of alveoli b.Respiratory alkalosis D.Unaffected lobectomy facilitate drainage EMPHYSEMA Irreversible terminal stage of COPD characterized by a. Air pollution 3. Panlobular/ centrilobular . Decrease or diminished breath sounds 8. for recoil of alveoli) B. Bronchial wheezing 10. Anorexia and generalized body malaise 5. Allergy 4.Increase ph . Surgery (pneumonectomy . Predisposing Factors 1.Increase PCO2 . Decrease tactile fremitus 7. Barrel chest 11. Enforce CBR . Resonance to hyperresonance 6. Over distention of thoracic cavity (barrel chest) A. 1 lung is removed and position on affected side) 2. “Pink Puffers”) .Decrease PCO2 .Respiratory acidosis b. Rales or ronchi 9. Air trapping c.Increase PO2 (hyperaxemia. Diagnostic Procedure 1. Productive cough 2.1. “Blue Bloaters”) . Smoking 2. Flaring of alai nares 12. Hereditary – it involves deficiency of ALPHA-1 ANTI TRYPSIN (needed to form Elastase.
Mucolytics/expectorants 4. Institute PEEP (positive end expiratory pressure) in mechanical ventilation promotes maximum alveolar lung expansion 9. Importance of follow up care . High fowlers position 5. Prevent complications .2. protein. Administer oxygen inhalation via low inflow 3.Pneumothorax c. Avoid smoking b.Atelectasis .CO2 narcosis may lead to coma . Bronchodilators b. Strict compliance to medication d. Force fluids 6. Antibiotics d. Provide comfortable and humid environment 10. Health teachings and discharge planning concerning a. Institute pulmonary toilet 7. calories.Cor Pulmonale . vitamins and minerals 11. Administer medications as ordered a. Nebulize and suction when needed 8. Steroids c. Provide high carbohydrates.
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