MEDICAL-SURGICAL NURSING

NERVOUS SYSTEM
Overview of structures and functions:
Central Nervous System
 Brain
 Spinal Cord
Peripheral Nervous System
 Cranial Nerves
 Spinal Nerves
Autonomic Nervous System
 Sympathetic nervous system
 Parasympathetic 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
Parasympathetic Nervous System
(CHOLINERGIC, VAGAL, SYMPATHOLYTIC)
- Involved in fight or withdrawal response.
- Release of Acetylcholine.
- Decreases all bodily activities except GIT.

EFFECTS OF SNS EFFECTS OF PNS

- Dilation of pupils(mydriasis) in order to be aware. - Constriction of pupils (meiosis).
- Dry mouth (thickened saliva). - Increase salivation.
- Increase BP and Heart Rate. - Decrease BP and Heart Rate.
- Bronchodilation, Increase RR - Bronchoconstriction, Decrease RR.
- Constipation. - Diarrhea
- Urinary Retention. - Urinary frequency.
- Increase blood supply to brain, heart and skeletal
muscles.
- SNS

I. Adrenergic Agents I. Cholinergic Agents

- Give Epinephrine. - Mestinon, Neostigmine.
Signs and Symptoms: Side Effects
- SNS - PNS
Contraindication:
- Contraindicated to patients suffering from COPD
(Broncholitis, Bronchoectasis, Emphysema, Asthma).

II. Beta-adrenergic Blocking Agents II. Anti-cholinergic Agents

- Also called Beta-blockers. - To counter cholinergic agents.
- All ending with “lol” - Atropine Sulfate
- Propranolol, Atenelol, Metoprolol. Side Effects
Effects of Beta-blockers - SNS
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)

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.
2. Stable
 Capable of regeneration with limited time, survival period.
 Kidney cells, Liver cells, Salivary cells, pancreas.
3. Permanent
 Not capable of regeneration.
 Myocardial cells, Neurons, Bone cells, Osteocytes, Retinal Cells.

B. NEUROGLIA
 Support and protection of neurons.
TYPES
1. Astrocytes – maintains blood brain barrier semi-permeable.
 Majority of brain tumors (90%) arises from called astrocytoma.
2. Oligodendria
3. Microglia
4. Epindymal

SUBSTANCES THAT CAN PASS THE BLOOD-BRAIN BARRIER

1. Ammonia
 Cerebral toxin
 Hepatic Encephalopathy (Liver Cirrhosis)
  Ascites
 Esophageal Varices
Early Signs of Hepatic Encephalopathy
 asterixis (flapping hand tremors).
Late Signs of Hepatic Encephalopathy
 Headache
 Dizziness
 Confusion
 Fetor hepaticus (ammonia like breath)
 Decrease LOC

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(DANCE SIGN) empty portion of RLQ

2. Carbon Monoxide and Lead Poisoning

 Can lead to Parkinson’s Disease.
 Epilepsy
 Treat with ANTIDOTE: Calcium EDTA.
3. Type 1 DM (IDDM)
 Causes diabetic ketoacidosis.
 And increases breakdown of fats.
Astrocites
 And free fatty acids
 Resulting to cholesterol and (+) to Ketones (CNS depressant). Maintains integrity of blood
 Resulting to acetone breath odor/fruity odor. brain barrier.
 KUSSMAUL’S respiration, a rapid shallow respiration.
 Which may lead to diabetic coma. Oligodendria
4. Hepatitis  Produces myelin sheath in
 Signs of jaundice (icteric sclerae).
 Caused by bilirubin (yellow pigment) CNS
5. Bilirubin  Act as insulator and
 Increase bilirubin in brain (Kernicterus).
facilitates rapid nerve
 Causing irreversible brain damage.

DEMYELINATING DISORDERS

1. ALZHEIMER’S DISEASE
Sign and Symptoms
4 A’s of Alzheimer
a. Amnesia – loss of memory.
b. Agnosia – no recognition of inanimate objects.
c. Apraxia – no recognition of objects function.
d. Aphasia – no speech (nodding).
*Expressive aphasia
 “motor speech center”
 Broca’s Aphasia
*Receptive aphasia
 inability to understand spoken words.
 Wernicke’s Aphasia
 General Knowing Gnostic Area or General Interpretative Area.
DRUG OF CHOICE: ARICEPT (taken at bedtime) and COGNEX.

2. MULTIPLE SCLEROSIS
 Chronic intermittent disorder of CNS characterized by white patches of demyelination in brain and spinal cord.
 Characterized by remission and exacerbation.
 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.
- short term protection.
- Immediate action.
Ig A – present in all bodily secretions (tears, saliva, colostrums).
Ig M – acute in inflammation.
Ig E – for allergic reaction.
Ig D – for chronic inflammation.
* Give palliative or supportive care.
Signs and Symptoms
1. Visual disturbances
 blurring of vision (primary)
 diplopia (double vision)
 scotomas (blind spots)

2. Impaired sensation
 to touch, pain, pressure, heat and cold.
 tingling sensation
 paresthesia
 numbness
3. Mood swings
 euphoria (sense of well being)
4. Impaired motor function
 weakness
 spasticity
 paralysis
5. Impaired cerebral function
 scanning speech
TRIAD SIGNS OF MS
Ataxia
(Unsteady gait, (+) Romberg’s test)

CHARCOTS
TRIAD
Intentional tremors
IAN Nystagmus

6. Urinary retention/incontinence
7. Constipation
8. Decrease sexual capacity

DIAGNOSTIC PROCEDURE
 CSF analysis (increase in IgG and Protein).
 MRI (reveals site and extent of demyelination).
 (+) Lhermitte’s sign a continuous and increase contraction of spinal column.

NURSING MANAGEMENT
1. Administer medications as ordered
a. ACTH (Adreno Corticotropic Hormone)/ Steroids for acute exacerbation to reduce edema at site
of demyelination to prevent paralysis.
b. Baclofen (Dioresal)/ Dantrolene Sodium (Dantrene) – muscle relaxants.
c. Interferons – alter immune response.
d. Immunosupresants
2. Maintain side rails to prevent injury related to falls.
3. Institute stress management techniques.
a. Deep breathing exercises
b. Yoga
4. Increase fluid intake and increase fiber to prevent constipation.
5. Catheterization to prevent retention.
a. Diuretics
b. Bethanicol Chloride (Urecholine)
Nursing Management
 Only given subcutaneous.
 Monitor side effects bronchospasm and wheezing.
 Monitor breath sounds 1 hour after subcutaneous administration.
c. For Urinary Incontinence
Anti spasmodic agent
a. Prophantheline Bromide (Promanthene)
 Acid ash diet like cranberry juice, plums, prunes, pineapple, vitamin C and orange.
 To acidify urine and prevent bacterial multiplication.

COMMON CAUSE OF UTI

Female
 short urethra (3-5 cm, 1-1 ½ inches)
 poor perineal hygiene
 vaginal environment is moist MACROPHAGE ORGAN
Nursing Management Microglia Brain
 avoid bubble bath (can alter Ph of vagina). Monocytes Blood
 avoid use of tissue papers Kupffers cells Kidney
 avoid using talcum powder and perfume. Histiocytes Skin
Male Alveolar Macrophage Lung
 Urethra (20 cm, 8 inches)
 urinate after intercourse

MICROGLIA
 stationary cells that carry on phagocytosis (engulfing of bacteria or cellular debris, eating), pinocytosis
(cell drinking).

EPINDYMAL CELLS
 Secretes a glue called chemo attractants that concentrate the bacteria.
COMPOSITION OF BRAIN
 80% brain mass
 10% blood
 10% CSF
I. Brain Mass
PARTS OF THE BRAIN
1. CEREBRUM
 largest part
 composed of the Right Cerebral Hemisphere and Left Cerebral Hemisphere enclosed in the Corpus
Callosum.
Functions of Cerebrum
 integrative
 sensory
 motor

Lobes of Cerebrum  controls blood pressure

1. Frontal  controls thirst
 higher cortical thinking  appetite/satiety
 controls personality  sleep and wakefulness
 controls motor activity  controls some emotional responses
 Broca’s Area (motor speech area) like fear, anxiety and excitement.
when damaged results to garbled  controls pituitary functions
speech.  androgenic hormones promotes
secondary sex characteristics.
2. Temporal  early sign for males are testicular and
 hearing penile enlargement
 short term memory  late sign is deepening of voice.
3. Parietal  early sign for females telarche and
 for appreciation late sign is menarche.
 discrimination of sensory impulses to
pain, touch, pressure, heat, cold, 5. BRAIN STEM
numbness.  located at lowest part of brain
4. Occipital Parts of Brain Stem
 for vision 1. Pons
Insula (Island of Reil)  pneumotaxic center controls the rate,
 visceral function activities of internal rhythm and depth of respiration.
organ like gastric motility. 2. Medulla Oblongata
Limbic System (Rhinencephalon)
 controls smell and if damaged results  controls respiration, heart rate,
to Anosmia (absence of smell). swallowing, vomiting, hiccup,
 controls libido vasomotor center (dilation
 controls long term memory 3. Cerebellum
 smallest part of the brain.
2. BASAL GAGLIA  lesser brain.
 areas of grey matter located deep  controls balance, equilibrium, posture
within each cerebral hemisphere. and gait.
 release dopamine (controls gross
voluntary movement. INTRA CRANIAL PRESSURE

NEURO DECREASE INCREASE Increase intra-cranial pressure

TRANSMITTER (normal ICP is 0 – 15 mmHg)
Acethylcholine Myasthenia Bi-polar
Gravis Disorder Cervical 1 – also known as ATLAS.
Dopamine Parkinson’s Schizophrenia Cervical 2 – also known as AXIS.
Disease

3. MIDBRAIN/ MESENCEPHALON * Alternate hot and cold compress to prevent

HEMATOMA
 acts as relay station for sight and
hearing.
CSF cushions brain (shock absorber)
 size of pupil is 2 – 3 mm.
Obstruction of flow of CSF will lead to enlargement of
 equal size of pupil is isocoria.
skull posteriorly called hydrocephalus.
 unequal size of pupil is anisocoria.
Early closure of posterior fontanels causes posterior
 hearing acuity is 30 – 40 dB.
enlargement of skull in hydrocephalus.
 positive PERRLA
NEUROLOGIC DISORDERS
4. INTERBRAIN/ DIENCEPHALON
Parts of Diencephalon
A. Thalamus INCREASE INTRACRANIAL PRESSURE – increase in
intra-cranial bulk brought about by an increase in one of
 acts as relay station for sensation.
the 3 major intra cranial components.
B. Hypothalamus
Signs and Symptoms (Early)
 controls temperature
(thermoregulatory center).
 decrease LOC lethargy/stupor
 restlessness/agitation coma
 irritability
Signs and Symptoms (Late) Early signs of hypoxia
 blood pressure (systolic blood  restlessness
pressure increases but diastolic  agitation
remains the same).  tachycardia
 widening of pulse pressure is Late signs of hypoxia
neurologic in nature (if narrow cardiac  Bradycardia
in nature).  Extreme restlessness
 heart rate decrease  Dyspnea
 respiratory rate decrease  Cyanosis
 temperature increase directly HYPERCARBIA
proportional to blood pressure.  Increase CO2 (most powerful
 projective vomiting respiratory stimulant) retention.
 headache  In chronic respiratory distress
 papilledema (edema of optic disc) syndrome decrease O2 stimulates
 decorticate posturing (damage to respiration.
cortex and spinal cord). b. Before and after suctioning hyper
 decerebrate posturing (damage to oxygenate client 100% and done 10 – 15 seconds
upper brain stem that includes pons, only.
cerebellum and midbrain). c. Assist in mechanical ventilation
 unilateral dilation of pupils called 2. Elevate bed of client 30 – 35o angle with neck in
uncal herniation neutral position unless contraindicated to promote
 bilateral dilation of pupils called venous drainage.
tentorial herniation 3. Limit fluid intake to 1200 – 1500 ml/day (in force
Nursing Management fluids 2000 – 3000 ml/day).
1. Maintain patent and adequate ventilation by: 4. Monitor strictly input and output and neuro check
a. Prevention of hypoxia and hypercarbia 5. Administer medications like:
 a. Osmotic diuretic (Mannitol) (+) Trousseau’s sign/ Carpopedal
for cerebral diuresis spasm
Nursing Management (+) Chvostek’s sign
monitor vital signs especially BP (hypotension). Complications
monitor strictly input and output every 1 hour notify Arrhythmia
physician if output is less 30 cc/hr. Seizures
administered via side drip
regulated fast drip to prevent crystal formation. Nursing Management
b. Loop diuretic (Lasix, Furosemide) Calcium Gluconate per IV slowly as ordered
 Drug of choice for CHF * Calcium Gluconate toxicity – results to SEIZURE
(pulmonary edema)
 Loop of Henle in kidneys. Magnesium Sulfate
Nursing Management
 Monitor vital signs especially BP Magnesium Sulfate toxicity
(hypotension). S/S
 monitor strictly input and output BP
every 1 hour notify physician if output Urine output DECREASE
is less 30 cc/hr. Respiratory rate
Patellar relfex absent
 administered IV push or oral.
 given early morning
3. Hyponatremia
 immediate effect of 10 – 15
 decrease sodium level
minutes.
 normal value is 135 – 145 meq/L
 maximum effect of 6 hours.
Signs and Symptoms
c. Corticosteroids
hypotension
 Dexamethasone (Decadron)
dehydration signs (Initial sign in adult is THIRST, in
 Hydrocortisone Multiple loss
infant TACHYCARDIA)
 Prednisone (to reduce edema that causes
agitation
may lead to increase ICP) suicide
dry mucous membrane
 Mild Analgesics (Codeine Sulfate for
poor skin turgor
respiratory depression)
weakness and fatigue
 Anti Convulsants (Dilantin, Phenytoin)
Nursing Management
*CONGESTIVE HEART FAILURE
Signs and Symptoms force fluids
 dyspnea administer isotonic fluid solution as ordered
 orthopnea
4. Hyperglycemia
 paroxysmal nocturnal dyspnea
 normal FBS is 80 – 100 mg/dl
 productive cough
Signs and Symptoms
 frothy salivation
 polyuria
 cyanosis
 polydypsia
 rales/crackles
 polyphagia
 bronchial wheezing Nursing Management
 pulsus alternans  monitor FBS
 anorexia and general body malaise 5. Hyperuricemia
 PMI (point of maximum impulse/apical  increase uric acid (purine metabolism)
pulse rate) is displaced laterally  foods high in uric acid (sardines,
 S3 (ventricular gallop) organ meats and anchovies)
 Predisposing Factors/Mitral Valve  *Increase in tophi deposit leads
 RHD to Gouty arthritis.
 Aging 
TREATMENT Signs and Symptoms
Morphine Sulfate  joint pain (great toes)
Aminophelline  swelling
Digoxin Nursing Management
Diuretics
 force fluids
Oxygen
 administer medications as ordered
Gases, blood monitor
a. Allopurinol (Zyloprim)
Signs and Symptoms of Lasix in terms of  Drug of choice for gout.
electrolyte imbalances  Mechanism of action: inhibits
1. Hypokalemia synthesis of uric acid.
 decrease potassium level b. Colchecine
 normal value is 3.4 – 5.5 meq/L Acute gout
Sign and Symptoms Mechanism of action:
 weakness and fatigue promotes excretion of uric acid.
* KIDNEY STONES
 constipation
Signs and Symptoms
 positive U wave on ECG tracing
 renal colic
Nursing Management
 Cool moist skin
 administer potassium supplements as ordered (Kalium
Nursing Management
Durule, Oral Potassium Chloride)
 force fluids
 increase intake of foods rich in potassium
 administer medications as ordered
a. Narcotic Analgesic
FRUITS VEGETABLES  Morphine Sulfate
Apple Asparagus  ANTIDOTE: Naloxone
Banana Brocolli (Narcan) toxicity leads to
Cantalope Carrots tremors.
Oranges Spinach b. Allopurinol (Zyloprim)
2. Hypocalcemia/ Tetany Side Effects
 decrease calcium level  Respiratory depression (check for RR)
 normal value is 8.5 – 11 mg/100
ml PARKINSON’S DISEASE/ PARKINSONISM
Signs and Symptoms  Chronic progressive disorder of CNS
 tingling sensation characterized by degeneration of
 paresthesia dopamine producing cells in the
SUBSTANCIA NIGRA of the
 numbness
midbrain and basal ganglia.
Predisposing Factors
1. Poisoning (lead and carbon monoxide)
2. Arteriosclerosis
3. Hypoxia
4. Encephalitis
5. Increase dosage of the following drugs: Aloneness

a. Reserpine(Serpasil)
1. Administer medications as ordered AntihypertensiveS
b. Methyldopa(Aldomet)
Anti Parkinsonian agents
c. Haloperidol(Haldol) Anti Cholinergic Agents (ARTANE and
 Levodopa (L-dopa) short acting AntipsychoticS
d. Phenothiazine COGENTIN) - to relieve tremors
 Amantadine Hydrochloride Mechanism of Action
(Symmetrel)  inhibits action of acethylcholine
SIDE EFFECTS Carbidopa (Sinemet)
 RESERPINE Side Effects
 Major depression leading to suicide Loss of spouse
Mechanism
Loss of Job of Action  SNS
 increase level of dopamine
Side Effects  direct approach towards the client Anti Histamine (Dipenhydramine Hydrochloride)
 GIT irritation (should be taken with
close surveillance is a nursing priority Side Effects
Adult: drowsiness
 meals
time to commit suicide is on weekends early morning
 orthostatic hypotension Children: CNS excitement (hyperactivity) because blood
brain barrier is not yet fully developed.
 arrhythmia
Signs and Symptoms for Parkinson’s
Dopamine Agonist - relieves tremor rigidity
 hallucinations
Bromocriptene Hydrochloride (Parlodel)
Contraindications
Side Effects
 clients with narrow angle closure
 Respiratory depression
glaucoma
2. Maintain side rails to prevent injury
 clients taking MAOI’s (no foods with 3. Prevent complications of immobility
triptophan and thiamine) 4. Decrease protein in morning and increase
 urine and stool may be darkened protein in afternoon to induce sleep
 no Vitamin B6 (Pyridoxine) reverses 5. Encourage increase fluid intake and fiber.
the therapeutic effects of Levodopa 6. Assist/supervise in ambulation
7. Assist in Stereotaxic Thalamotomy

MAGIC 2’s IN DRUG MONITORING

DRUG NORMAL RANGE TOXICITY INDICATION CLASSIFICATION

LEVEL
Digoxin/ Lanoxin .5 – 1.5 meq/L 2 CHF Cardiac Glycoside
(Increase force of c.o)
Lithium/ Lithane .6 – 1.2 meq/L 2 Bipolar Anti-Manic Agents
(Decrease level of
Ach/NE/Serotonin)
Aminophylline 10 – 19 mg/100 ml 20 COPD Bronchodilators
(Dilates bronchial tree)
Dilantin/ Phenytoin 10 – 19 mg/100 ml 20 Seizures Anti-Convulsant
Acetaminophen/Tylenol 10 – 30 mg/100 ml 200 Osteo Arthritis Non-narcotic Analgesic

1. Aminophylline Toxicity cells at the neuromuscular junction leading to

descending muscle weakness.
Signs and Symptoms
 tachycardia Incidence rate: women 20 – 40 years old
 palpitations Predisposing factors
 CNS excitement (tremors, irritability,  unknown
agitation and restlessness)  autoimmune: it involves release of
Nursing Management cholinesterase an enzyme that
 only mixed with plain NSS or 0.9 NaCl destroys Ach.
to prevent development of crystals or Signs and Symptoms
precipitate.  initial sign is ptosis a clinical
 administered sandwich method parameter to determine ptosis is
 avoid taking alcohol because it can palpebral fissure.
lead to severe CNS depression  diplopia
 avoid caffeine  mask like facial expression
 dysphagia
2. Dilantin Toxicity  hoarseness of voice
 respiratory muscle weakness that
Signs and Symptoms may lead to respiratory arrest
 gingival hyperplasia (swollen gums)  extreme muscle weakness especially
 hairy tongue during exertion and morning
 ataxia Diagnostic Procedure
 nystagmus  Tensilon test (Edrophonium
Nursing Management Hydrochloride) provides temporary
 provide oral care relief of signs and symptoms for
 massage gums about 5 – 10 minutes and a
maximum of 15 minutes.
3. Acetaminophen Toxicity if there is no effect there is
damage to occipital lobe and midbrain and is negative
Signs and Symptoms for M.G.
 hepatotoxicity (monitor for liver Nursing Management
enzymes)
 SGPT/ALT (Serum Glutamic Pyruvate a. Cholinergic (Mestinon)
Transaminace) b. Anti Cholenisterase (Neostegmin)
Mechanism of Action
 SGOT/AST (Serum Glutamic Oxalo-
Acetil Transaminace)  increase level of Ach
Side Effects
 nephrotoxicity monitor BUN (10 – 20)
and Creatinine (.8 – 1)  PNS
 hypoglycemia  Cortocosteroids suppress
immune response

Tremors, tachycardia  monitor for 2 types of crisis:
Irritability MYASTHENIC CRISIS CHOLINERGIC
Restlessness CRISIS
Extreme fatigue Causes: Cause:
Diaphoresis, depression - under medication - over medication
- stress
- infection Signs and
Antidote: Acetylcisteine (mucomyst) prepare suction Signs and Symptoms Symptoms
apparatus as bedside. - The client is unable to see, - PNS
MYASTHENIA GRAVIS swallow, speak, breathe
Neuromuscular disorder characterized by a disturbance Treatment Treatment
in the transmission of impulses from nerve to muscle - administer cholinergic - Administer anti
agents as ordered cholinergic agents
(ATSO4)
  hearing loss/nerve deafness is
second complication
 consult audiologist

INFLAMMATORY CONDITIONS OF THE BRAIN CVA (STROKE/BRAIN ATTACK/ ADOPLEXY/

CEREBRAL THROMBOSIS)
MENINGITIS - partial or complete disruption in the brains blood
Meninges supply.
3 fold membrane that covers brain and spinal cord. -2 most common cerebral artery affected by stroke
 for support and protection a. Mid Cerebral Artery
 for nourishment b. Internal Cerebral Artery – the 2 largest
 blood supply artery
A. Incidence Rate
LAYERS OF THE MENINGES  men are 2-3 times high risk
1. Dura matter – outer layer
2. Arachnoid – middle layer B. Predisposing Factors
3. Pia matter – inner layer  thrombus (attached)
 subdural space between the  embolus (detached and most
dura and arachnoid dangerous because it can go to the
 subarachnoid space between lungs and cause pulmonary
the arachnoid and pia, CSF embolism or the brain and cause
aspiration is done. cerebral embolism.
A. Etiology
1. Meningococcus – most dangerous Signs and Symptoms of Pulmonary Embolism
2. Pneumococcus  Sudden sharp chest pain
3. Streptococcus - causes adult meningitis  Unexplained dyspnea
4. Hemophilus Influenzae – causes pediatric meningitis  Tachycardia
B. Mode of transmission  Palpitations
 airborne transmission (droplet nuclei)  Diaphoresis
C. Signs and Symptoms  Mild restlessness
 headache
 photophobia Signs and Symptoms of Cerebral Embolism
 projectile vomiting  Headache and dizziness
 fever, chills, anorexia, general body  Confusion
malaise and weight loss  Restlessness
 Possible increase in ICP and seizure  Decrease LOC
activity Fat embolism is the most feared complications after
 Abnormal posturing (decorticate and femur fracture.
decerebrate) Yellow bone marrow are produced from the medullary
 Signs of meningeal irritation cavity of the long bones and produces fat cells.
a. Nuchal rigidity or stiff neck If there is bone fracture there is hemorrhage and there
b. Opisthotonus (arching of would be escape of the fat cells in the circulation.
back)
Compartment syndrome (compression of arteries and
c. (+) Kernig’s sign (leg pain)
nerves)
d. (+) Brudzinski sign (neck
C. Risk Factors
pain)
D. Diagnostic Procedures
1. Hypertension, Diabetes Mellitus, Myocardial
 Lumbar puncture: a hollow spinal Infarction, Atherosclerosis, Valvular Heart
needle is inserted in the subarachnoid Disease, Post Cardiac Surgery (mitral valve
space between the L3 – L4 to L5. replacement)
2. Lifestyle (smoking), sedentary lifestyle
Nursing Management for LP 3. Obesity (increase 20% ideal body weight)
4. Hyperlipidemia more on genetics/genes that binds to
Before Lumbar Puncture cholesterol
1. Secure informed consent and explain procedure. 5. Type A personality
2. Empty bladder and bowel to promote comfort. a. deadline driven
3. Encourage to arch back to clearly visualize L3-L4. b. can do multiple tasks
Post Lumbar Puncture c. usually fells guilty when not doing anything
1. Place flat on bed 12 – 24 o 6. Related to diet: increase intake of saturated fats like
2. Force fluids whole milk
3. Check punctured site for any discoloration, drainage 7. Related stress physical and emotional
and leakage to tissues. 8. Prolong use of oral contraceptives promotes lypolysis
(breakdown of lipids) leading to atherosclerosis that will
CSF analysis reveals lead to hypertension and eventually CVA.
1. Increase CHON and WBC
2. Decrease glucose D. Signs and Symptoms
3. Increase CSF opening pressure (normal pressure is  dependent on stages of development
50 – 100 mmHg) 1. TIA
4. (+) cultured microorganism (confirms meningitis)  Initial sign of stroke or warning sign
Signs and Symptoms
CBC reveals
 headache and dizziness
1. Increase wbc
 tinnitus
E. Nursing Management  visual and speech disturbances
1. Enforce complete bed rest  paresis (plegia)
2. Administer medications as ordered  possible increase ICP
a. Broad spectrum antibiotics (Penicillin, 2. Stroke in evolution
Tetracycline)  progression of signs and symptoms of
b. Mild analgesics stroke
c. Anti pyretics 3. Complete stroke
3. Institute strict respiratory isolation 24 hours after  resolution phase characterized by:
initiation of anti biotic therapy Signs and Symptoms
4. Elevate head 30-45o  headache and dizziness
5. Monitor strictly V/S, input and output and neuro  Cheyne Stokes Respiration
check  anorexia, nausea and vomiting
6. Institute measures to prevent increase ICP and  dysphagia
seizure. 
7. Provide a comfortable and darkened environment.
 (+) Kernig’s sign and Brudzinski sign
8. Maintain fluid and electrolyte balance.
which may lead to hemorrhagic stroke
9. Provide client health care and discharge planning
 focal neurological deficits
concerning:
a. phlegia
a. Maintain good diet of increase CHO,
b. aphasia
CHON, calories with small frequent feedings.
c. dysarthria (inability to articulate
b. Prevent complications
words)
 most feared is hydrocephalus
d. alexia (difficulty reading)
e. agraphia (difficulty writing)
 f. homonymous hemianopsia (loss of
half of visual field) C. Diagnostic Procedures
E. Diagnostic Procedure 1. CSF analysis reveals increase in IgG and protein
1. CT Scan – reveals brain lesions
2. Cerebral Arteriography D. Nursing Management
 reveals the site and extent of 1. Maintain patent airway and adequate ventilation by:
malocclusion a. assist in mechanical ventilation
 uses dye for visualization b. monitor pulmonary function test
 most of dye are iodine based 2. Monitor strictly the following
 check for shellfish allergy a. vital signs
b. intake and output
 after diagnostic exam force fluids to
c. neuro check
release dye because it is nephro toxic
d. ECG
 check for distal pulse (femoral)
3. Maintain side rails to prevent injury related to fall
 check for hematoma formation 4. Prevent complications of immobility by turning the
client every 2 hours
F. Nursing Management 5. Institute NGT feeding to prevent aspiration
1. Maintain patent airway and adequate ventilation by: 6. Assist in passive ROM exercise
a. assist in mechanical ventilation 7. Administer medications as ordered
b. administrate O2 inhalation a. Corticosteroids – suppress immune response
2. Restrict fluids to prevent cerebral edema that might b. Anti Cholinergic Agents – Atrophine Sulfate
increase ICP c. Anti Arrythmic Agents
3. Elevate head 30 – 45o
 Lidocaine, Zylocaine
4. Monitor strictly vitals signs, I & O and neuro check
 Bretylium – blocks release of
5. Prevent complications of immobility by:
norepinephrine to prevent increase of
a. turn client to side
BP
b. provide egg crate mattresses or water bed
8. Assist in plasma pharesis (filtering of blood to
c. provide sand bag or food board.
remove autoimmune anti-bodies)
6. Assist in passive ROM exercise every 4 hours to
9. Prevent complications
promote proper bodily alignment and prevent
a. Arrythmia
contractures
b. Paralysis or respiratory muscles/Respiratory
7. Institute NGT feeding
arrest
8. Provide alternative means of communication
a. non verbal cues
* Sengstaken Blakemore Tube
b. magic slate
9. If positive to hemianopsia approach client on  for liver cirrhosis
unaffected side  to decompress bleeding esophageal
10. Administer medications as ordered verices (prepare scissor to cut tube
a. Osmotic Diuretics (Mannitol) incase of difficulty in breathing to
b. Loop Diuretics (Lasix, Furosemide) release air in the balloon
c. Cortecosteroids  for hemodialysis prepare bulldog clips
d. Mild Analgesics to prevent air embolism.
e. Thrombolytic/Fibrinolytic Agents – dissolves
thrombus CONVULSIVE DISORDER/ CONVULSION
 Streptokinase -disorder of CNS characterized by paroxysmal seizure
 Side Effect: Allergic with or without loss of consciousness abnormal motor
Reaction activity alternation in sensation and perception and
changes in behavior.
 Urokinase
 Seizure – first convulsive attack
 Tissue Plasminogen
Activating Factor  Epilepsy – second or series of attacks
 Side Effect:  Febrile seizure – normal in children
Chest Pain age below 5 years
f. Anti Coagulants
A. Predisposing Factors
 Heparin (short acting)
1. Head injury due to birth trauma
 check for partial thromboplastin time if prolonged there
2. Genetics
is a risk for bleeding.
3. Presence of brain tumor
 give Protamine Sulfate 4. Toxicity from
 Comadin/ Warfarin (long a. lead
acting) b carbon monoxide
 give simultaneously because Coumadin will take effect 5. Nutritional and Metabolic deficiencies
after 3 days 6. Physical and emotional stress
 check for prothrombin time if prolonged there is a risk 7. Sudden withdrawal to anti convulsant drug is
for bleeding predisposing factor for status epilepticus (drug of choice
 give Vit. K (Aqua Mephyton) is Diazepam, Valium)
g. Anti Platelet
 PASA (Aspirin) B. Signs and Symptoms
 Contraindicated for dengue,  Dependent on stages of development or types of
ulcer and unknown cause of seizure
headache because it may I. Generalized Seizure
potentiate bleeding 1. Grand mal Seizure (tonic-clonic seizure)
11. Provide client health teachings and discharge a. Signs or aura with auditory, olfactory, visual,
planning concerning tactile, sensory experience
a. avoidance of modifiable risk factors (diet, b. Epileptic cry – is characterized by fall and
exercise, smoking) loss of consciousness for 3 – 5 minutes
b. prevent complication (subarachnoid c. Tonic contractions - direct symmetrical
hemorrhage is the most feared complication) extension of extremities
c. dietary modification (decrease salt, Clonic contractions - contraction of
saturated fats and caffeine) extremities
d. Post ictal sleep – unresponsive sleep
GUILLAIN BARRE SYNDROME 2. Petit mal Seizure – absence of seizure common
a disorder of the CNS characterized by bilateral among pediatric clients characterized by
symmetrical polyneuritis leading to ascending muscle a. blank stare
paralysis. b. decrease blinking of eyes
c. twitching of mouth
A. Predisposing Factors d. loss of consciousness (5 – 10 seconds)
1. Autoimmune II. Partial or Localized Seizure
2. Antecedent viral infections such as LRT infections 1. Jacksonian Seizure (focal seizure)
B. Signs and Symptoms  Characterized by tingling and jerky
1. Clumsiness (initial sign) movement of index finger and thumb that
2. Dysphagia spreads to the shoulder and other side of the
3. Ascending muscle weakness leading to paralysis body.
4. Decreased of diminished deep tendon reflex 2. Psychomotor Seizure (focal motor seizure)
5. Alternate hypotension to hypertension a. automatism – stereotype repetitive and non
** ARRYTHMIA (most feared complication) propulsive behavior
6. Autonomic symptoms that includes b. clouding of consciousness – not in contact
a. increase salivation with environment
b. increase sweating c. mild hallucinatory sensory experience
c. constipation
III. Status Epilepticus Unconscious
 A continuous uninterrupted seizure client place 1 drop of saline solution
activity, if left untreated can lead to
hyperpyrexia and lead to coma and II. TEST OF MEMORY
eventually death. 1. Short term memory
 Drug of choice: Diazepam, Valium  ask most recent activity
and Glucose  positive result mean anterograde
C. Diagnostic Procedures amnesia and damage to temporal
1. CT Scan – reveals brain lesions lobe
2. EEG – reveals hyper activity of electrical brain waves 2. Long term memory
D. Nursing Management  ask for birthday and validate on
1. Maintain patent airway and promote safety before profile sheet
seizure activity  positive result mean retrograde
a. clear the site of blunt or sharp objects amnesia and damage to limbic
b. loosen clothing of client system
c. maintain side rails  consider educational background
d. avoid use of restrains
e. turn clients head to side to prevent III. LEVELS OF ORIENTATION
aspiration 1. Time – first asked
f. place mouth piece of tongue guard to 2. Person – second asked
prevent biting or tongue 3. Place – third asked
2. Avoid precipitating stimulus such as bright/glaring
lights and noise CRANIAL NERVES
3. Administer medications as ordered
a. Anti convulsants (Dilantin, Phenytoin) CRANIAL NERVES FUNCTION
b. Diazepam, Valium
c. Carbamazepine (Tegretol) – Trigeminal I. OLFACTORY S
neuralgia II. OPTIC S
d. Phenobarbital, Luminal III OCCULOMOTOR M
4. Institute seizure and safety precaution post seizure IV. TROCHLEAR M
attack (Smallest)
a. administer O2 inhalation V. TRIGEMINAL B (Largest)
b. provide suction apparatus VI. ABDUCENSE M
5. Document and monitor the following VII. FACIAL B
a. onset and duration VIII. ACOUSTIC S
b. types of seizures IX. GLOSSOPHARYNGEAL B
c. duration of post ictal sleep may lead to X. VAGUS B (Longest)
status epilepticus XI. SPINAL ACCESSORY M
d. assist in surgical procedure cortical XII. HYPOGLOSSAL M
resection

COMPREHENSIVE NEURO EXAM

CRANIAL NERVE I: OLFACTORY
 sensory function for smell
GLASGOW COMA SCALE
Material Used
 objective measurement of LOC
 don’t use alcohol, ammonia, perfume
sometimes called as the quick neuro
because it is irritating and highly
check
diffusible.
Components  use coffee granules, vinegar, bar of
1. Motor response soap, cigarette
Conscious 15 –
2. Verbal response Procedure
14
3. Eye opening Lethargy 13 –  test each nostril by occluding each
11 nostril
Stupor 10 – Abnormal Findings
1. Hyposnia – decrease sensitivity to smell
 Survey of mental status and speech 2. Dysosmia – distorted sense of smell
a. LOC 3. Anosmia – absence of smell
b. Test of memory Indicative of
1. head injury damaging the cribriform plate of
 Levels of orientation
ethmoid bone where olfactory cells are located
 Cranial nerve assessment
2. may indicate inflammatory conditions (sinusitis)
 Sensory nerve assessment
 Motor nerve assessment CRANIAL NERVE II: OPTIC
 Deep tendon reflex  sensory function for vision or sight
 Autonimics Functions
 Cerebellar test 1. Test visual acuity or central vision or distance
a, Romberg’s test – 2 nurses, positive for  use Snellen’s Chart
ataxia  Snellen’s Alphabet chart: for literate
b. Finger to nose test – positive result mean clients
dimetria  Snellen’s E chart: for illiterate clients
(inability of body to stop
 Snellen’s Animal chart: for pediatric
movement at desired point)
clients
c. Alternate supination and pronation – positive
 normal visual acuity 20/20
result mean dimetria
 numerator is constant, it is the
I. LEVEL OF CONSCIOUSNESS distance of person from the chart (6 –
1. Conscious - awake 7 m, 20 feet)
2. Lethargy – lethargic (drowsy, sleepy, obtunded)  denominator changes, indicates
3. Stupor distance by which the person
 stuporous (awakened by vigorous normally can see letter in the chart.
stimulation)  - 20/200 indicates blindness
 generalized body weakness  20/20 visual acuity if client is able to
 decrease body reflex read letters above the red line.
4. Coma 2. Test of visual field or peripheral vision
a. Superiorly
 comatose
b. Bitemporaly
 light coma (positive to all forms of
c. Nasally
painful stimulus)
d. Inferiorly
 deep coma (negative to all forms of
painful stimulus) COMMON VISUAL DISORDERS
DIFFERENT PAINFUL STIMULATION 1. Glaucoma
1. Deep sternal stimulation/ deep sternal pressure
 increase IOP
2. Orbital pressure
 normal IOP is 12 – 21 mmHg
3. Pressure on great toes
4. Corneal or blinking reflex  preventable but not curable
A. Predisposing Factors
Conscious
client use a wisp of cotton  Common among 40 years old and
above
  Hereditary C. Pathognomonic Signs
 Hypertension 1. Blurring or hazy vision
 Obesity 2. Milky white appearance at center of pupils
B. Signs and Symptoms 3. Decrease perception to colors
1. Loss of peripheral vision Complication is blindness
 pathognomonic sign is tunnel vision
2. Headache, nausea, vomiting, eye pain (halos D. Diagnostic Procedure
around light) 1. Opthalmoscopic exam
 steamy cornea
E. Treatment
C. Diagnostic Procedures 1. Mydriatics (Mydriacyl) – constricts pupils
1. Tonometry 2. Cyclopegics (Cyclogyl) – paralyses cilliary muscle
2. Perimetry
3. Gonioscopy F. Surgical Procedure
Extra Intra
D. Treatment Capsular Capsular
1. Miotics – constricts pupil Cataract Cataract
a. Pilocarpine Sodium, Carbachol Lens Lens
2. Epinephrine eyedrops – decrease formation of Extraction Extraction
aqueous humor - Partial removal - Total removal of cataract
3. Carbonic Anhydrase Inhibitors with its surrounding capsules
a. Acetazolamide (Diamox) – promotes Most feared complication post op is RETINAL
increase outflow of aqueous humor or drainage DETACHMENT
4. Timoptics (Timolol Maleate)
3. Retinal Detachment
E. Surgical Procedures  Separation of epithelial surface of
retina
1. TRABECULECTOMY (Peripheral Indectomy) – drain
aqueous humor A. Predisposing Factors
2. Cataract 1. Post Lens Extraction
 Decrease opacity of lens 2. Myopia (near sightedness)
A. Predisposing Factor
1. Aging 65 years and above B. Signs and Symptoms
2. Related to congenital 1. Curtain veil like vision
3. Diabetes Mellitus 2. Floaters
4. Prolonged exposure to UV rays
C. Surgical Procedures
B. Signs and Symptoms 1. Scleral Buckling
1. Loss of central vision 2. Cryosurgery – cold application
3. Diathermy – heat application

4. Macular Degeneration
 Degeneration of the macula lutea (yellowish spot at the center of retina)

A. Signs and Symptoms

1. Black Spots

CRANIAL NERVE III, IV, VI: OCULOMOTOR, TROCHLEAR, 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 CRANIAL NERVE VIII:
pupil ACOUSTIC/VESTIBULOCOCHLEAR
 normal pupil size is 2 – 3 mm  Controls balance particularly
 equal size of pupil: Isocoria kinesthesia or position sense, refers
 Unequal size of pupil: Anisocoria to movement and orientation of the
 Normal response: positive PERRLA body in space.
Parts of the Ear
CRANIAL NERVE V: TRIGEMINAL 1. Outer Ear
 largest cranial nerve  Pinna
 consists of ophthalmic, maxillary,  Eardrum
mandibular 2. Middle Ear
 sensory: controls sensation of face,  HammerMalleus
mucous membrane, teeth, soft palate  Anvil Incus
and corneal reflex)  Stirrup Stapes
 motor: controls the muscle of 3. Inner Ear
mastication or chewing  Vestibule: Meinere’s Disease
 damage to CN V leads to trigeminal  Cochlea
neuralgia/thickdolorum  Mastoid Cells
 medication: Carbamezapine(Tegretol)  Endolymph and Perilymph
COCHLEA: controls hearing, contains the Organ of
CRANIAL NERVE VII: FACIAL Corti (the true organ of hearing)
 Sensory: controls taste, anterior 2/3 of Let client repeat words uttered
tongue
 pinch of sugar and cotton applicator CRANIAL NERVE IX, X: GLOSOPHARYNGEAL,
placed on tip of tongue VAGUS NERVE
 Motor: controls muscle of facial  Glosopharyngeal: controls taste,
expression posterior 1/3 of tongue
 instruct client to smile, frown and if  Vagus: controls gag reflex
results are negative there is facial  Uvula should be midline and if not
paralysis or Bell’s Palsy and the indicative of damage to cerebral
primary cause is forcep delivery. hemisphere
CRANIAL NERVE XI: SPINAL ACCESSORY
 Innervates with sternocleidomastoid
(neck) and trapezius (shoulder)
CRANIAL NERVE XII: HYPOGLOSSAL
 Controls the movement of tongue
 Let client protrude tongue and it
should be midline and if unable to do
indicative of damage to cerebral
hemisphere and/or has short
frenulum.
ENDOCRINE SYSTEM
1. Pituitary Gland (Hypophysis Cerebri)
o Located at base of brain particularly
at sella turcica
o Master gland or master clock
o Controls all metabolic function of
body
PARTS OF THE PITUITARY GLAND
1. Anterior Pituitary Gland
o called as adenohypophysis
2. Posterior Pituitary Gland
o called as neurohypophysis
o secretes hormones oxytocin
-promotes uterine contractions preventing
bleeding/ hemorrhage
o administrate oxytocin
immediately after delivery to prevent
uterine atony.
o initiates milk let down reflex
with help of hormone prolactin
2. Antidiuretic Hormone
o Pitressin (Vasopressin)
o Function: prevents urination thereby
conserving water
o Diabetes Insipidus/ Syndrome of
Inappropriate Anti Diuretic Hormone
DIABETES INSIPIDUS
Decrease production of anti diuretic hormone
A. Predisposing Factor
o Related to pituitary surgery
o Trauma
o Inflammation
o Presence of tumor
B. Signs and Symptoms
1. Polyuria
2. Signs of dehydration
a. Adult: thirst
b. Agitation
c. Poor Skin turgor
d. Dry mucous membrane
3. Weakness and fatigue
4. Hypotension
5. Weight loss
6. If left untreated results to hypovolemic shock (sign is
anuria)
2. Water intoxication may lead to cerebral edema and
lead to increase ICP – may lead to seizure activity
C. Diagnostic Procedure
1. Urine specific gravity is increased
2. Serum Sodium is decreased
D. Nursing Management
1. Restrict fluid
2. Administer medications as ordered
a. Loop diuretics (Lasix)
b. Osmotic diuretics (Mannitol)
3. Monitor strictly vital signs, intake and output and
neuro check
4. Weigh patient daily and assess for pitting edema
5. Provide meticulous skin care
6. Prevent complications
ANTERIOR PITUITARY GLAND
o also called ADENOHYPOPHYSIS secretes
1. Growth hormones (somatotropic hormone)
o Promotes elongation of long bones
o Hyposecretion of GH among
children results to Dwarfism
o Hypersecretion of GH results to
Gigantism
o Hypersecretion of GH among adults
results to Acromegaly (square face)
o Drug of choice: Ocreotide
(Sandostatin)
2. Melanocyte Stimulating hormone
o for skin pigmentation
o Hyposecretion of MSH results to
Albinism
o Most feared complications of albinism
a. Lead to blindness due to severe
photophobia
b. Prone to skin cancer
o Hypersecretion of MSH results to
Vitiligo
3. Adrenochorticotropic hormone (ACTH)
o promotes development of adrenal
cortex
4. Lactogenic homone (Prolactin)
o promotes development of mammary
gland
o with help of oxytocin it initiates milk
let down reflex
5. Leutinizing hormone
o secretes estrogen
6. Follicle stimulating hormone
o secretes progesterone
PINEAL GLAND
o secretes melatonin
o inhibits LH secretion
o it controls/regulates circadian rhythm
(body clock)

THYROID GLAND
C. Diagnostic Procedures o located anterior to the neck
1. Urine Specific Gravity 3 Hormones secreted
o Normal value: 1.015 – 1.030 1. T3 (Tri iodothyronine) - 3 molecules of
o Ph 4 – 8 iodine (more potent)
2. Serum Sodium 2. T4 (tetra iodothyronine, Thyroxine)
o Increase resulting to hypernatremia o T3 and T4 are metabolic or calorigenic
D. Nursing Management hormone
1. Force fluids o promotes cerebration (thinking)
2. Monitor strictly vital signs and intake and output 3. Thyrocalcitonin – antagonizes the effects
3. Administer medications as ordered of parathormone to promote calcium resorption.
a. Pitressin (Vasopresin Tannate) –
administered IM Z-tract HYPOTHYROIDISM
4. Prevent complilcations – HYPOVOLEMIC SHOCK is the o all are decrease except weight and
most feared complication menstruation
o memory impairment
SIADH Signs and Symptoms
hypersecretion of anti diuretic hormone o there is loss of appetite but there is
weight gain
A. Predisposing Factors o menorrhagia
1. Head injury o cold intolerance
2. Related to presence of bronchogenic cancer o constipation
o initial sign of lung cancer is non
productive cough HYPERTHYROIDISM
o non invasive procedure is chest x-ray
3. Related to hyperplasia (increase size of organ
brought about by increase of number of cells) of oall are increase except weight and
pituitary gland. menstruation
Signs and Symptoms
B. Signs and Symptoms o increase appetite but there is weight
1. Fluid retention loss
a. Hypertension o amenorrhea
b. Edema o exophthalmos
c. Weight gain
THYROID DISORDERS
 a. Anti Thyroid Agent –
SIMPLE GOITER Prophylthiuracil (PTU)
o enlargement of thyroid gland due to b. Lithium Carbonate
iodine deficiency c. PASA (Aspirin)
d. Cobalt
A. Predisposing Factors e. Phenylbutazones (NSAIDs)
1. Goiter belt area - if goiter is caused
a. places far from sea by
b. Mountainous regions
2. Increase intake of goitrogenic foods B. Signs and Symptoms
o contains pro-goitrin an anti thyroid 1. Enlarged thyroid gland
agent that has no iodine. 2. Mild dysphagia
o cabbage, turnips, radish, strawberry, 3. Mild restlessness
carrots, sweet potato, broccoli, all
nuts C. Diagnostic Procedures
o soil erosion washes away iodine 1. Serum T3 and T4 – reveals normal or below normal
o goitrogenic drugs 2. Thyroid Scan – reveals enlarged thyroid gland.
3. Serum Thyroid Stimulating Hormone (TSH) – is
increased (confirmatory diagnostic test)

D. Nursing Management
1. Enforce complete bed rest
2. Administer medications as ordered

a. Lugol’s Solution/SSKI ( Saturated Solution of 2. Monitor vital signs especially heart rate
Potassium Iodine) because drug causes tachycardia and
o color purple or violet and palpitations
administered via straw to prevent 3. Monitor side effects
staining of teeth. o Insomnia, hpn
o 4 Medications to be taken via straw: o tachycardia and palpitations
Lugol’s, Iron, Tetracycline, o heat intolerance
Nitrofurantoin (drug of choice for 4. Increase dietary intake of foods rich in
pyelonephritis) iodine
b. Thyroid Hormones o seaweeds
o Levothyroxine (Synthroid) o seafood’s like oyster, crabs, clams
o Liothyronine (Cytomel) and lobster but not shrimps because
o Thyroid Extracts it contains lesser amount of iodine.
Nursing Management when giving o iodized salt, best taken raw because it
Thyroid Hormones it is easily destroyed by heat
1. Instruct client to take in the morning to 5. Assist in surgical procedure of subtotal
prevent insomnia thyroidectomy

HYPOTHYROIDISM

o hyposecretion of thyroid hormone

o adults: MYXEDEMA non pitting edema
o children: CRETINISM the only endocrine disorder that can lead to mental retardation

A. Predisposing Factors
1. Iatrogenic Cause – disease caused by
medical intervention such as surgery
2. Related to atrophy of thyroid gland due to C. Diagnostic Procedures
trauma, presence of tumor, inflammation 1. Serum T3 and T4 is decreased
3. Iodine deficiency 2. Serum Cholesterol is increased
4. Autoimmune (Hashimotos Disease) 3. RAIU (Radio Active Iodine Uptake) is
decreased
B. Signs and Symptoms
(Early Signs) D. Nursing Management (Myxedema Coma)
1. Weakness and fatigue 3. Administer isotonic fluid solution as ordered
2. Loss of appetite but with weight gain which 4. Administer medications as ordered
promotes lipolysis leading to atherosclerosis Thyroid Hormones
and MI a. Levothyroxine
3. Dry skin b. Leothyronine
4. Cold intolerance c. Thyroid Extracts
5. Constipation 5. Provide dietary intake that is low in calories
(Late Signs) 6. Provide comfortable and warm environment
1. Brittleness of hair and nails 7. Provide meticulous skin care
2. Non pitting edema (Myxedema) 8. Provide client health teaching and discharge
3. Hoarseness of voice planning concerning
4. Decrease libido a. Avoid precipitating factors leading to
5. Decrease in all vital signs – hypotension, myxedema coma
bradycardia, bradypnea, hypothermia o Stress, infection
6. CNS changes o cold intolerance
o lethargy o use of anesthetics, narcotics, and
o memory impairment sedatives
o psychosis o prevent complications (myxedema
o menorrhagia coma, hypovolemic shock
o hormonal replacement therapy for
lifetime

HYPERTHYROIDISM

o increase in T3 and T4 1. Increase appetite (hyperphagia) but there is

o Grave’s Disease or Thyrotoxicosis weight loss
o developed by Robert Grave 2. Moist skin
3. Heat intolerance
4. Diarrhea
A. Predisposing Factors
5. All vital signs are increased
1. Autoimmune – it involves release of long
6. CNS involvement
acting thyroid stimulator causing
a. Irritability and agitation
exopthalmus (protrusion of eyeballs)
b. Restlessness
enopthalmus (late sign of dehydration among
c. Tremors
infants)
d. Insomnia
2. Excessive iodine intake
e. Hallucinations
3. Related to hyperplasia (increase size)
7. Goiter
8. Exopthalmus
B. Signs and Symptoms
9. Amenorrhea
 4. Signs of bleeding (feeling of fullness at
C. Diagnostic Procedures incisional site)
1. Serum T3 and T4 is increased Nursing Management
2. RAIU (Radio Active Iodine Uptake) is o Check the soiled dressings at the back or nape
increased area.
3. Thyroid Scan- reveals an enlarged thyroid 5. Hormonal replacement therapy for
gland lifetime
6. Importance of follow up care
D. Nursing Management
1. Monitor strictly vital signs and intake and PARATHYROID GLAND
output o A pair of small nodules behind the thyroid
2. Administer medications as ordered gland
Anti Thyroid Agent o Secretes parathormone
a. Prophythioracill (PTU) o Promotes calcium reabsorption
b. Methymazole (Tapazole) o Hypoparathyroidism
Side Effects of Agranulocytosis o Hyperparathyroidism
o increase
lymphocytes and HYPOPARATHYROIDISM
monocytes o Decrease secretion of parathormone leading to
o fever and chills
hypocalcemia
o sore throat (throat
o Resulting to hyperphospatemia
swab/culture)
o leukocytosis (CBC)
A. Predisposing Factors
3. Provide dietary intake that is increased in 1. Following subtotal thyroidectomy
calories. 2. Atrophy of parathyroid gland due to:
4. Provide meticulous skin care a. inflammation
5. Comfortable and cold environment b. tumor
6. Maintain side rails c. trauma
7. Provide bilateral eye patch to prevent drying B. Signs and Symptoms
of the eyes. 1. Acute tetany
8. Assist in surgical procedures known as a. tingling sensation
subtotal thyroidectomy b. paresthesia
** Before thyroidectomy administer c. numbness
Lugol’s Solution (SSKI) to decrease d. dysphagia
vascularity of the thyroid e. positive trousseu’s sign/carpopedal spasm
gland to prevent bleeding and f. positive chvostek sign
hemorrhage. g. laryngospasm/broncospasm
h. seizure feared complications
POST OPERATIVELY, i. arrhythmia
1. Watch out for signs of thyroid storm/ 2. Chronic tetany
thyrotoxicosis a. photophobia and cataract formation
o administer medications as ordered b. loss of tooth enamel
a. Anti Pyretics c. anorexia, nausea and vomiting
b. Beta-blockers d. agitation and memory impairment
o monitor strictly vital signs, input and
output and neuro check. C. Diagnostic Procedures
o maintain side rails 1. Serum Calcium is decreased (normal value: 8.5 – 11
o offer TSB mg/100 ml)
2. Serum Phosphate is decreased (normal value: 2.5 –
2. Watch out for accidental removal of 4.5 mg/100 ml)
parathyroid gland that may lead to 3. X-ray of long bones reveals a decrease in bone
Hypocalcemia (tetany) density
4. CT Scan – reveals degeneration of basal ganglia
Signs and Symptoms
o (+) trousseau’s sign D. Nursing Management
o (+) chvostek sign 1. Administer medications as ordered such as:
o Watch out for arrhythmia, seizure give Calcium a. Acute Tetany
Gluconate IV slowly as ordered  Calcium Gluconate IV slowly
b. Chronic Tetany
3. Watch out for accidental Laryngeal  Oral Calcium supplements
damage which may lead to hoarseness of voice  Calcium Gluconate
Nursing Management  Calcium Lactate
o encourage client to talk/speak immediately  Calcium Carbonate
after operation and notify physician c. Vitamin D (Cholecalciferol) for absorption of
calcium

CHOLECALCIFEROL ARE DERIVED FROM

Drug Diet (Calcidiol) Sunlight

(Calcitriol)

d. Phosphate binder
 Aluminum Hydroxide Gel (Ampogel)
 Side effect: constipation

ANTACID

A.A.C MAD
▼ ▼
Aluminum Containing Magnesium Containing
Antacids Antacids
▼ ▼
Aluminum
Hydroxide
Gel
▼
Side Effect: Constipation Side Effect: Diarrhea

2. Avoid precipitating stimulus such as glaring lights and noise

3. Encourage increase intake of foods rich in calcium
a. anchovies
b. salmon
c. green turnips
4. Institute seizure and safety precaution
5. Encourage client to breathe using paper bag to produce mild respiratory acidosis result.
6. Prepare trache set at bedside for presence of laryngo spasm
7. Prevent complications
8. Hormonal replacement therapy for lifetime
9. Importance of follow up care.

HYPERTHYROIDISM - signs of dehydration

Decrease parathormone - weight loss
Hypercalcemia: bone demineralization leading to bone
fracture (calcium is stored 99% in bone and 1% blood)
Kidney stones 4. Hyperkalemia
- agitation
A. Predisposing Factors - diarrhea
1. Hyperplasia of parathyroid gland - arrhythmia
2. Over compensation of parathyroid gland due to 5. Decrease libido
vitamin D deficiency 6. Loss of pubic and axillary hair
a. Children: Ricketts 7. Bronze like skin pigmentation
b. Adults: Osteomalacia
B. Signs and Symptoms C. Diagnostic Procedures
1. Bone pain especially at back (bone fracture) 1. FBS is decreased (normal value: 80 – 100 mg/dl)
2. Kidney stones 2. Plasma Cortisol is decreased
a. renal cholic 3. Serum Sodium is decrease (normal value: 135 – 145
b. cool moist skin meq/L)
3. Anorexia, nausea and vomiting 4. Serum Potassium is increased (normal value: 3.5 –
4. Agitation and memory impairment 4.5 meq/L)

C. Diagnostic Procedures D. Nursing Management

1. Serum Calcium is increased 1. Monitor strictly vital signs, input and output to
2. Serum Phosphate is decreased determine presence of Addisonian crisis
3. X-ray of long bones reveals bone demineralization (complication of addison’s disease)
D. Nursing Management o Addisonian crisis results from acute
1. Force fluids to prevent kidney stones exacerbation of addison’s disease
2. Strain all the urine using gauze pad for stone characterized by
analysis a. severe hypotension
3. Provide warm sitz bath b. hypovolemic shock
4. Administer medications as ordered c. hyponatremia leading to progressive stupor
a. Morphine Sulfate (Demerol) and coma
5. Encourage increase intake of foods rich in phosphate Nursing Management for Addisonian Crisis
but decrease in calcium 1. Assist in mechanical ventilation,
6. Provide acid ash in the diet to acidify urine and - administer steroids as ordered
prevent bacterial growth - force fluids
7. Assist/supervise in ambulation 2. Administer isotonic fluid solution as ordered
8. Maintain side rails 3. Force fluids
9. Prevent complications (seizure and arrhythmia) 4. Administer medications as ordered
10. Assist in surgical procedure known as Corticosteroids
parathyroidectomy a. Dexamethasone (Decadrone)
11. Hormonal replacement therapy for lifetime b. Prednisone
12. Importance of follow up care c. Hydrocortisone (Cortison)
Nursing Management when giving steroids
ADRENAL GLAND 1. Instruct client to take 2/3 dose in the morning and
o Located atop of each kidney 1/3 dose in the afternoon to mimic the normal diurnal
o 2 layers of adrenal gland rhythm
a. Adrenal Cortex – outermost 2. Taper dose (withdraw gradually from drug)
b. Adrenal Medulla – innermost (secretes 3. Monitor side effects
catecholamines a power hormone) a. hypertension
b. edema
2 Types of Catecholamines c. hirsutism
o Epinephrine and Norepinephrine
(vasoconstrictor) d. increase susceptibility to infection
o Pheochromocytoma (adrenal medulla) e. moon face appearance
o Increase secretion of norepinephrine 4. Mineralocorticoids (Flourocortisone)
o Leading to hypertension which is resistant to 5. Provide dietary intake, increase calories,
pharmacological agents leading to CVA carbohydrates, protein but decrease in potassium
o Use beta-blocker 6. Provide meticulous skin care
ADRENAL CORTEX 7. Provide client health teaching and discharge planning
a. avoid precipitating factor leading to
3 Zones/Layers addisonian crisis leading to
1. Zona Fasciculata - stress
- secretes glucocortocoids (cortisol) - infection
- function: controls glucose metabolism - sudden withdrawal to steroids
- Sugar b. prevent complications
2. Zona Reticularis - addisonian crisis
- secretes traces of glucocorticoids and androgenic - hypovolemic shock
hormones c. hormonal replacement for lifetime
- function: promotes secondary sex characteristics d. importance of follow up care
- Sex
3. Zona Glumerulosa
- secretes mineralocorticoids (aldosterone)
- function: promotes sodium and water reabsorption CUSHING SYNDROME
and excretion of potassium Hypersecretion of adenocortical hormones
- Salt
A. Predisposing Factors
ADDISON’S DISEASE 1 Related to hyperplasia of adrenal gland
Hyposecretion of adreno cortical hormone leading to 2. Increase susceptibility to infections
a. metabolic disturbance – Sugar 3. Hypernatremia
b. fluid and electrolyte imbalance – Salt a. hypertension
c. deficiency of neuromuscular function – b. edema
Salt/Sex c. weight gain
d. moon face appearance and buffalo
A. Predisposing Factors hump
1. Related to atrophy of adrenal glands e. obese trunk
2. Fungal infections f. pendulous abdomen
g. thin extremities
B. Signs and Symptoms 4. Hypokalemia
1. Hypoglycemia – TIRED a. weakness and fatigue
2. Decrease tolerance to stress b. constipation
3. Hyponatremia c. U wave upon ECG (T wave hyperkalemia)
- hypotension 5. Hirsutism
6. Acne and striae 9. Hormonal replacement for lifetime
7. Easy bruising 10. Importance of follow up care
8. Increase masculinity among females
PANCREAS
B. Diagnostic Procedures - Located behind the stomach
1. FBS is increased - Mixed gland (exocrine and endocrine)
2. Plasma Cortisol is increased - Consist of acinar cells which secretes pancreatic
3. Serum Sodium is increased juices that aids in digestion thus it is an exocrine gland
4. Serum Potassium is decreased - Consist of islets of langerhans
- Has alpha cells that secretes glucagons (function:
C. Nursing Management hyperglycemia)
1. Monitor strictly vital signs and intake and output - Beta cells secretes insulin (function: hypoglycemia)
2. Weigh patient daily and assess for pitting edema - Delta cells secretes somatostatin (function:
3. Measure abdominal girth daily and notify physician antagonizes the effects of growth hormones)
4. Restrict sodium intake
5. Provide meticulous skin care 3 Main Disorders of Pancreas
6. Administer medications as ordered 1. Pancreatic Tumor/Cancer
a. Spinarolactone – potassium sparring 2. Diabetes Mellitus
diuretics 3. Pancreatitis
7. Prevent complications (DM)
8. Assist in surgical procedure (bilateral adrenoraphy)
DIABETES MELLITUS
- metabolic disorder characterized by non utilization of carbohydrates, protein and fat metabolism

Type 1 (IDDM) Type 2 (NIDDM)

- Juvenile onset type - Adult onset
- Brittle disease - Maturity onset type
- Obese over 40 years old
A. Incidence Rate A. Incidence Rate
- 10% general population has type 1 DM - 90% of general population has type 2 DM
B. Predisposing Factors B. Predisposing Factors
1. Hereditary (total destruction of pancreatic cells) 1. Obesity – because obese persons lack insulin receptor
2. Related to viruses binding sites
3. Drugs: a. Lasix
b. Steroids
4. Related to carbon tetrachloride toxicity
C. Signs and Symptoms
1. Polyuria C. Signs and Symptoms
2. Polydypsia 1. Usually asymptomatic
3. Polyphagia 2. Polyuria
4. Glucosuria 3. Polydypsia
5. Weight loss 4. Polyphagia
6. Anorexia, nausea and vomiting 5. Glucosuria
7. Blurring of vision 6. Weight gain
8. Increase susceptibility to infection
9. Delayed/poor wound healing
D. Treatment
1. Insulin therapy D. Treatment
2. Diet 1. Oral Hypoglycemic agents
3. Exercise 2. Diet
3. Exercise
E. Complication
1. Diabetic Ketoacidosis E. Complications
1. Hyper
2. Osmolar
3. Non
4. Ketotic
5. Coma

MAIN FOODSTUFF ANABOLISM CATABOLISM

1. Carbohydrates Glucose Glycogen

2. Protein Amino Acids Nitrogen
3. Fats Fatty Acids Free Fatty Acids
- Cholesterol
- Ketones

HYPERGLYCEMIA

Increase osmotic diuresis

Glycosuria Polyuria

Cellular starvation – weight loss Cellular dehydration

Stimulates the appetite/satiety center Stimulates the thirst center

(Hypothalamus) (Hypothalamus)

O Polyphagia 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 Ketones
▼ ▼
Atherosclerosis Diabetic Keto Acidosis
▼
Hypertension
Acetone Breath Kussmaul’s Respiration
odor
MI CVA

Death Diabetic Coma

DIABETIC KETOACIDOSIS
- Acute complication of type 1 DM due to severe C. Nursing Management for Insulin Injections
hyperglycemia leading to severe CNS depression 1. Administer at room temperature to prevent
development of lipodystrophy (atrophy, hypertrophy of
A. Predisposing Factors subcutaneous tissues)
1. Hyperglycemia 2. Place in refrigerator once opened
2. Stress – number one precipitating factor 3. Avoid shaking insulin vial vigorously instead gently
3. Infection roll vial between palm to prevent formation of bubbles
4. Use gauge 25 – 26 needle
B. Signs and Symptoms 5. Administer insulin either 45o – 90o depending on
1. Polyuria amount of clients tissue deposit
2. Polydypsia 6. No need to aspirate upon injection
3. Polyphagia 7. Rotate insulin injection sites to prevent development
4. Glucosuria of lipodystrophy
5. Weight loss 8. Most accessible route is abdomen
6. Anorexia, nausea and vomiting 9. When mixing 2 types of insulin aspirate first the clear
7. Blurring of vision insulin before cloudy to prevent contaminating the clear
8. Acetone breath odor insulin and promote proper calibration.
9. Kussmaul’s Respiration (rapid shallow breathing) 10. Monitor for signs of local complications such as
10 CNS depression leading to coma a. Allergic reactions
b. Lipodystrophy
C. Diagnostic Procedures c. Somogyis Phenomenon – rebound effect
1. FBS is increased of insulin characterized by hypoglycemia to
2. BUN (normal value: 10 – 20) hyperglycemia
3. Creatinine (normal value: .8 – 1)
4. Hct (normal value: female 36 – 42, male 42 – 48) due ORAL HYPOGLYCEMIC AGENTS
to severe dehydration - Stimulates the pancreas to secrete insulin
A. Classsification
D. Nursing Management 1. First Generation Sulfonylureas
1. Assist in mechanical ventilation a. Chlorpropamide (Diabenase)
2. Administer 0.9 NaCl followed by .45 NaCl (hypotonic b. Tolbutamide (Orinase)
solutions) to counteract dehydration and shock c. Tolamazide (Tolinase)
3. Monitor strictly vital signs, intake and output and 2. Second Generation Sulfonylureas
blood sugar levels a. Glipzide (Glucotrol)
4. Administer medications as ordered b. Diabeta (Micronase)
a. Insulin therapy (regular acting insulin/rapid Nursing Management when giving OHA
acting insulin peak action of 2 – 4 hours) 1. Instruct the client to take it with meals to lessen GIT
b. Sodium Bicarbonate to counteract acidosis irritation and prevent hypoglycemia
c. Antibiotics to prevent infection 2. Instruct the client to avoid taking alcohol because it
can lead to severe hypoglycemia reaction or Disulfiram
HYPER OSMOLAR NON KETOTIC COMA (Antabuse) toxicity symptoms
- Hyperosmolar: increase osmolarity (severe
dehydration) B. Diagnostic Procedures
- Non ketotic: absence of lypolysis (no ketones) 1. FBS is increased (3 consecutive times with signs or
polyuria, polydypsia, polyphagia and glucosuria
A. Signs and Symptoms confirmatory for DM)
1. Headache and dizziness 2. Random Blood Sugar is increased
2. Restlessness 3. Oral glucose tolerance test is increased – most
3. Seizure activity sensitive test
4. Decrease LOC – diabetic coma 4. Alpha Glycosylated Hemoglobin is increased

B. Nursing Management C. Nursing Management

1. Assist in mechanical ventilation 1. Monitor for peak action of insulin and OHA and notify
2. Administer 0.9 NaCl followed by .45 NaCl (hypotonic physician
solutions) to counteract dehydration and shock 2. Administer insulin and OHA therapy as ordered
3. Monitor strictly vital signs, intake and output and 3. Monitor strictly vital signs, intake and output and
blood sugar levels blood sugar levels
4. Administer medications as ordered 4. Monitor for signs of hypoglycemia and hyperglycemia
a. Insulin therapy (regular acting insulin peak - administer simple sugars
action of 2 – 4 hours) - for hypoglycemia (cold and clammy skin) give simple
- for DKA use rapid acting insulin sugars
b. Antibiotics to prevent infection - for hyperglycemia (dry and warm skin)
5. Provide nutritional intake of diabetic diet that
INSULIN THERAPY includes: carbohydrates 50%, protein 30% and fats 20%
or offer alternative food substitutes
A. Sources of Insulin 6. Instruct client to exercise best after meals when
1. Animal sources blood glucose is rising
- Rarely used because it can cause severe allergic 7. Monitor signs for complications
reaction a. Atherosclerosis (HPN, MI, CVA)
- Derived from beef and pork b. Microangiopathy (affects small minute blood
2. Human Sources vessels of eyes and kidneys)
- Frequently used type because it has less antigenicity
property thus less allergic reaction EYES KIDNEY
3. Artificially Compound Insulin -PREMATURE CATARACT -RECURRENT
- Blindness PYELONEPHRITIS
B. Types of Insulin - Renal failure
1. Rapid Acting Insulin (clear)
- Regular acting insulin (IV only) c. HPN and DM major cause of renal failure
- Peak action is 2 – 4 hours d. Gangrene formation
2. Intermediate Acting Insulin (cloudy) e. Shock due to dehydration
- Non Protamine Hagedorn Insulin (NPH) - peripheral neuropathy
- Peak action is 8 – 16 hours - diarrhea/constipation
3. Long Acting Insulin (cloudy) - sexual impotence
- Ultra Lente 8. Institute foot care management
- Peak action is 16 – 24 hours
 a. instruct client to avoid walking barefooted
b. instruct client to cut toenails straight
c. instruct client to avoid wearing constrictive
garments
d. encourage client to apply lanolin lotion to
prevent skin breakdown
e. assist in surgical wound debriment (give
analgesics 15 – 30 mins prior)
9. Instruct client to have an annual eye and kidney
exam
10. Monitor for signs of DKA and HONKC
11. Assist in surgical procedure

HEMATOLOGICAL SYSTEM

ALBUMIN - Normal life span of RBC is 80 – 120 days and is

- Largest and numerous plasma CHON killed in red pulp of spleen
- Maintains osmotic pressure preventing edema
2. WBC (LEUKOCYTES)
GLOBULINS - normal value: 5000 – 10000/mm3
- Alpha globulins - transport steroids, bilirubin and A. Granulocytes
hormones 1. Polymorpho Neutrophils
- Beta globulins – iron and copper - 60 – 70% of WBC
- Gamma globulins - involved in short term phagocytosis for acute
a. anti-bodies and immunoglobulins inflammation
b. prothrombin and fibrinogen clotting factors 2. Polymorphonuclear Basophils
- for parasite infections
FORMED ELEMENTS - responsible for the release of chemical mediation for
1. RBC (ERYTHROCYTES) inflammation
- normal value: 4 – 6 million/mm3 3. Polymorphonuclear Eosinophils
- only unnucleated cell - for allergic reaction
- biconcave discs B. Non Granulocytes
- consist of molecules of hgb (red pigment) bilirubin 1. Monocytes
(yellow pigment) biliverdin (green pigment) - macrophage in blood
hemosiderin (golden brown pigment) - largest WBC
- transports and carries oxygen to tissues - involved in long term phagocytosis for chronic
- hemoglobin: normal value female 12 – 14 gms% inflammation
male 14 – 16 gms% 2. Lymphocytes
- hematocrit red cell percentage in wholeblood
- normal value: female 36 – 42% male 42 – 48% B-cell T-cell Natural
- substances needed for maturation of RBC killer cell
a. folic acid - bone marrow - thymus - anti viral and anti
b. iron tumor property
c. vitamin c for immunity
d. vitamin b12 (cyanocobalamin)
e. vitamin b6 (pyridoxine)

f. intrinsic factor
4. Pallor and cold sensitivity
HIV 5. Dyspnea
6. Palpitations
- 6 months – 5 years incubation period 7. Brittleness of hair and spoon shape nails
- 6 months window period (koilonychias)
- western blot opportunistic 8. PLUMBER VINSON’S SYNDROME
- ELISA - Atropic Glossitis (inflammation of tongue)
- drug of choice AZT (Zidon Retrovir) - Stomatitis
- Dysphagia
2 Common fungal opportunistic infection in AIDS 9. PICA (abnormal appetite or craving for non edible
1. Kaposi’s Sarcoma foods
2. Pneumocystis Carinii Pneumonia D. Diagnostic Procedures
1. RBC is decreased
3. Platelets (THROMBOCYTES) 2. Hgb & . Hct is decreased
- Normal value: 150,000 – 450,000/mm3 3. Ferritin is deceased
- Promotes hemostasis (prevention of blood loss) 4. Iron & Reticulocyte is decreased
- Consist of immature or baby platelets or
megakaryocytes which is the target of dengue virus E. Nursing Management
- Normal life span of platelet is 9 – 12 days 1. Monitor for signs of bleeding of all hema test
including urinw, stool and GIT
Signs of Platelet Dysfunction 2. Enforce CBR so as not to over tire client
1. Petechiae 3. Instruct client to take foods rich in iron
2. Echhymosis a. Organ meat
3. Oozing of blood from venipunctured site b. Egg (yolk)
c. Raisin
BLOOD DISORDERS d. Sweet potatoes
e. Dried fruits
IRON DEFFICIENCY ANEMIA f. Legumes
- A chronic microcytic anemia resulting from inadequate g. Nuts
absorption of iron leading to hypoxemic tissue injury 4. Instruct the client to avoid taking tea and coffee
because it contains tannates which impairs iron
A. Incidence Rate absorption
1. Common among developed countries 5. Administer medications as ordered
2. Common among tropical zones Oral Iron Preparations
3. Common among women 15 – 35 years old a. Ferrous Sulfate
4. Related to poor nutrition b. Ferrous Fumarate
B. Predisposing Factors c. Ferrous Gluconate
1. Chronic blood loss due to trauma - 300 mg/day
a. Heavy menstruation Nursing Management when taking oral
b. Related to GIT bleeding resulting to iron preparations
hematemesis and melena (sign for upper GIT 1. Instruct client to take with meals to lessen
bleeding) GIT irritation
c. fresh blood per rectum is called 2. When diluting it in liquid iron preparations
hematochezia administer with straw to prevent staining of teeth
2. Inadequate intake of iron due to Medications administered via straw
a. Chronic diarrhea - Lugol’s solution
b. Related to malabsorption syndrome - Iron
c. High cereal intake with low animal protein - Tetracycline
digestion - Nitrofurantoin (Macrodentin)
d. Subtotal gastrectomy 3. Administer with Vitamin C or orange juice
4. Related to improper cooking of foods for absorption
C. Signs and Symptoms 4. Monitor and inform client of side effects
1. Usually asymptomatic a. Anorexia
2. Weakness and fatigue (initial signs) b. Nausea and vomiting
3. Headache and dizziness c. Abdominal pain
d. Diarrhea/constipation
 e. Melena 2. Headache and dizziness
5. If client cant tolerate/no compliance 3. Pallor and cold sensitivity
administer parenteral iron preparation 4. Dyspnea and palpitations as part of compensation
a. Iron Dextran (IM, IV) 5. GIT changes that includes
b. Sorbitex (IM) a. mouth sore
Nursing Management when giving b. red beefy tongue
parenteral iron preparations c. indigestion/dyspepsia
1. Administer Z tract technique to prevent d. weight loss
discomfort, discoloration and leakage to tissues e. jaundice
2. Avoid massaging the injection site instead 6. CNS changes
encourage to ambulate to facilitate absorption a. tingling sensation
3. Monitor side effects b. numbness
a. Pain at injection site c. paresthesia
b. Localized abscess d. positive to Romberg’s test – damage to
c. Lymphadenopathy cerebellum resulting to ataxia
d. Fever and chills e. result to psychosis
e. Skin rashes
f. Pruritus/orticaria C. Diagnostic Procedure
g. Hypotension (anaphylactic shock) Schilling’s Test – reveals inadequate/decrease
absorption of Vitamin B12
PERNICIOUS ANEMIA
D. Nursing Management
- Chronic anemia characterized by a deficiency of 1. Enforce CBR
intrinsic factor leading to hypochlorhydria (decrease 2. Administer Vitamin B12 injections at monthly intervals
hydrochloric acid secretion) for lifetime as ordered
- Never given orally because there is possibility
A. Predisposing Factors of developing tolerance
1. Subtotal gastrectomy - Site of injection for Vitamin B12 is
2. Hereditary factors dorsogluteal and ventrogluteal
3. Inflammatory disorders of the ileum - No side effects
4. Autoimmune 3. diet intake: high in carbohydrates, protein, vitamin c
5. Strictly vegetarian diet and iron
4. Instruct client to avoid irritating mouth washes
B. Signs and Symptoms instead use soft bristled toothbrush
1. Weakness and fatigue 5. Avoid heat application to prevent burns

APLASTIC ANEMIA
Stem cell disorder leading to bone marrow depression leading to pancytopenia

PANCYTOPENIA

Decrease RBC Decrease WBC Decrease

Platelet
(anemia) (leucopenia) (thrombocytopenia)
A. Predisposing Factors Maximum therapeutic effect of drug
1. Chemicals (Benzine and its derivatives)
2. Related to irradiation/exposure to x-ray DISSEMINATED INTRAVASCULAR COAGULATION
3. Immunologic injury Acute hemorrhagic syndrome characterized by wide
4. Drugs spread bleeding and thrombosis due to a deficiency of
Broad Spectrum Antibiotics prothrombin and fibrinogen
a. Chloramphenicol (Sulfonamides)
Chemotherapeutic Agents A. Predisposing Factors
a. Methotrexate (Alkylating Agent) 1. Related to rapid blood transfusion
b. Vincristine (Plant Alkaloid) 2. Massive burns
c. Nitrogen Mustard (Antimetabolite) 3. Massive trauma
Phenylbutazones (NSAIDS) 4. Anaphylaxis
5. Septecemia
B. Signs and Symptoms 6. Neoplasia (new growth of tissue)
1. Anemia 7. Pregnancy
a. Weakness and fatigue
b. Headache and dizziness B. Signs and Symptoms
c. Pallor and cold sensitivity 1. Petechiae (widespread and systemic) eye, lungs and
d. Dyspnea and palpitations lower extremities
2. Leukopenia 2. Ecchymosis
a. Increase susceptibility to infection 3. Oozing of blood from punctured sites
3. Thrombocytopenia 4. Hemoptysis
a. Petechiae (multiple petechiae is called 6. Oliguria (late sign)
purpura)
b. Ecchymosis C. Diagnostic Procedures
c. Oozing of blood from venipunctured sites 1. CBC reveals decreased platelets
2. Stool occult blood positive
C. Diagnostic Procedures 3. ABG analysis reveals metabolic acidosis
1. CBC reveals pancytopenia 4. Opthamoscopic exam reveals sub retinal
2. Bone marrow biopsy/aspiration (site is the posterior hemorrhages
iliac crest) – reveals fat necrosis in bone marrow
D. Nursing Management
D. Nursing Management 1. Monitor for signs of bleeding of all hema test
2. Institute BT as ordered including stool and GIT
3. Administer oxygen inhalation 2. Administer isotonic fluid solution as ordered
4. Enforce CBR 3. Administer oxygen inhalation
5. Institute reverse isolation 4. Force fluids
6. Monitor for signs of infection 5. Administer medications as ordered
a. fever a. Vitamin K
b. cough b. Pitressin/ Vasopresin to conserve fluids
7. Avoid IM, subcutaneous, venipunctured sites c. Heparin/Coumadin is ineffective
8 Instead provide heparin lock 6. Provide heparin lock
9. Instruct client to use electric razor when shaving 7. Institute NGT decompression by performing gastric
10. Administer medications as ordered lavage by using ice or cold saline solution of 500 – 1000
a. Corticosteroids – caused by immunologic injury ml
b. Immunosuppressants 8. Monitor NGT output
9. Prevent complication
Anti Lymphocyte Globulin a. Hypovolemic shock
▼ b. Anuria – late sign
Given via central venous catheter
▼ BLOOD TRANSFUSION
Given 6 days to 3 weeks to achieve
Principles of blood transfusion - Prevent pericardial friction rub
1. Proper refrigeration - Common among MI, pericarditis, Cardiac tamponade
- Expiration of packed RBC is 3 – 6 days
- Expiration of platelet is 3 – 5 days A. Layers of Heart
2. Proper typing and cross matching 1. Epicardium – outer layer
a. Type O – universal donor 2. Myocardium – middle layer
b. Type AB – universal recipient 3. Endocardium – inner layer
c. 85% of population is RH positive - Myocarditis can lead to cardiogenic shock and
3. Aseptically assemble all materials needed for rheumatic heart disease
BT
a. Filter set B. Chambers of the Heart
b. Gauge 18 – 19 needle 1. Upper Chamber (connecting or receiving)
c. Isotonic solution (0.9 NaCl/plain NSS) to a. Atria
prevent hemolysis 2. Lower Chamber (contracting or pumping)
4. Instruct another RN to re check the following a. Ventricles
a. Client name - Left ventricle has increased pressure which is
b. Blood typing and cross matching 120 – 180 mmHg
c. Expiration date - In order to propel blood to the systemic
d. Serial number circulation
5. Check the blood unit for bubbles cloudiness, - Right atrium has decreased pressure which is
sediments and darkness in color because it 60 – 80 mmHg
indicates bacterial contamination
- Never warm blood as it may destroy vital C. Valves
factors in blood. - To promote unidimensional flow or prevent backflow
- Warming is only done during emergency
situation and if you have the warming device 1. Atrioventricular Valves – guards opening between
- Emergency rapid BT is given after 30 minutes a. tricuspid valve
and let natural room temperature warm the blood. b. mitral valve
- Closure of AV valves give rise to first heart
6. BT should be completed less than 4 hours because sound (S1 “lub”)
blood that is exposed at room temperature more
than 2 hours causes blood deterioration that can lead 2. Semi – lunar Valves
to BACTERIAL CONTAMINATION a. pulmonic
b. aortic
7. Avoid mixing or administering drugs at BT line to - Closure of SV valve give rise to second heart
prevent HEMOLYSIS sound (S2 “dub”)

8. Regulate BT 10 – 15 gtts/min or KVO rate or Extra Heart Sounds

equivalent to 100 cc/hr to prevent circulatory overload 1. S3 – ventricular gallop usually seen in Left
Congestive Heart Failure
9. Monitor strictly vital signs before, during and after BT 2. S4 – atrial gallop usually seen in Myocardial
especially every 15 minutes for first hour Infarction and Hypertension
because majority of transfusion reaction occurs
during this period. D. Coronary Arteries
- Arises from base of the aorta
SIGNS AND SYMPTOMS OF HEMOLYTIC REACTION Types of Coronary Arteries
1. Right Main Coronary Artery
1. Headache and dizziness 2. Left Main Coronary Artery
2. Dyspnea - Supplies the myocardium
3. Diarrhea/Constipation E. Cardiac Conduction System
4. Hypotension 1. Sino – Atrial Node (SA or Keith Flack Node)
5. Flushed skin - Located at the junction of superior vena cava and right
6. Lumbasternal/ Flank pain atrium
7. Urine is color red/ portwine urine - Acts as primary pacemaker of the heart
- Initiates electrical impulse of 60 – 100 bpm
Nursing Management
1. Stop BT 2. Atrio – Ventricular Node (AV or Tawara Node)
2. Notify physician - Located at the inter atrial septum
3. Flush with plain NSS - Delay of electrical impulse for about .08 milliseconds
4. Administer isotonic fluid solution to prevent shock to allow ventricular filling
and acute tubular necrosis
5. Send the blood unit to blood bank for re examination 3. Bundle of His
6. Obtain urine and blood sample and send to - Right Main Bundle of His
laboratory for re examination - Left Main Bundle of His
7. Monitor vital signs and intake and output - Located at the interventricular septum

SIGNS AND SYMPTOMS OF ALLERGIC REACTION 4. Purkinje Fibers

SA NODE - Located at the walls of the ventricles for ventricular
1. Fever contraction
2. Dyspnea AV NODE
3. Broncial wheezing
4. Skin rashes
5. Urticaria
6. Laryngospasm and Broncospasm
Nursing Management BUNDLE OF HIS
1. Stop BT
2. Notify physician
3. Flush with plain NSS
4. Administer medications as ordered
a. Anti Histamine (Benadryl) - if positive to
hypotension, anaphylactic shock treat with
Epinephrine JLJLJLJJLJLJL
5. Send the blood unit to blood bank for re examination
6. Obtain urine and blood sample and send to PURKINJE FIBERS
laboratory for re examination

CARDIOVASCULAR SYSTEM - P WAVE (atrial depolarization) contraction

- QRS WAVE (ventricular depolarization)
HEART - T WAVE (ventricular repolarization)
- Muscular pumping organ of the body.  Insert pacemaker if there is complete heart
- Located on the left mediastinum block
- Resemble like a close fist  Most common pacemaker is the metal
- Weighs approximately 300 – 400 grams pacemaker and lasts up to 2 – 5 years
- Covered by a serous membrane called the pericardium
2 layers of pericardium ABNORMAL ECG TRACING
a. Parietal – outer layer 1. Positive U wave - Hypokalemia
b. Visceral – inner layer 2. Peak T wave – Hyperkalemia
- In between is the pericardial fluid which is 10 – 20 3. ST segment depression – Angina Pectoris
cc
4. ST segment elevation – Myocardial Infarction 3. Stress test – treadmill test, reveal abnormal ECG
5. T wave inversion – Myocardial Infarction 4. Serum cholesterol and uric acid is increased
6. Widening of QRS complexes – Arrythmia
E. Nursing Management
CARDIAC DISORDERS 1. Enforce complete bed rest
2. Administer medications as ordered
Coronary Arterial Disease/ Ischemic Heart a. Nitroglycerine (NTG) – when given in
Disease small doses will act as venodilator, but in
Stages of Development of Coronary Artery large doses will act as vasodilator
Disease - Give first dose of NTG (sublingual) 3
1. Myocardial Injury - Atherosclerosis – 5 minutes
2. Myocardial Ischemia – Angina Pectoris - Give second dose of NTG if pain
3. Myocardial Necrosis – Myocardial Infarction persist after giving first dose with interval of 3
- 5 minutes
ATHEROSCLEROSIS - Give third and last dose of NTG if
pain still persist at 3 – 5 minutes interval
ATHEROSCLEROSIS ARTERIOSCLEROSIS Nursing Management when giving NTG
- narrowing of artery - hardening of artery - Keep the drug in a dry place, avoid
- lipid or fat deposits - calcium and protein moisture and exposure to sunlight as it
- tunica intima deposits may inactivate the drug
- tunica media - Monitor side effects
o Orthostatic hypotension
o Transient headache and dizziness
A. Predisposing Factors
- Instruct the client to rise slowly from
1. Sex – male
sitting position
2. Race – black
- Assist or supervise in ambulation
3. Smoking
4. Obesity - When giving nitrol or transdermal
5. Hyperlipidemia patch
6. sedentary lifestyle o Avoid placing near hairy areas as
7. Diabetes Mellitus it may decrease drug absorption
8. Hypothyroidism o Avoid rotating transdermal
9. Diet – increased saturated fats patches as it may decrease drug
10. Type A personality absorption
o Avoid placing near microwave
B. Signs and Symptoms ovens or duting defibrillation as it
1. Chest pain may lead to burns (most
2. Dyspnea important thing to remember)
3. Tachycardia b. Beta-blockers
4. Palpitations - Propanolol - side effects PNS
5. Duaphoresis - Not given to COPD cases because it causes
bronchospasm
C. Treatment
Percutaneous Transluminal Coronary Angioplasty c. ACE Inhibitors
Objectives of PTCA - Enalapril
1. Revascularize myocardium
2. To prevent angina d. Calcium Antagonist
3. Increase survival rate - NIfedipine
- Done to single occluded vessels
- If there is 2 or more occluded blood vessels 3. Administer oxygen inhalation
CABG is done 4. Place client on semi fowlers position
Coronary Arterial Bypass And Graft Surgery 5. Monitor strictly vital signs, intake and output and
3 Complications of CABG ECG tracing
1. Pneumonia – encourage to perform deep breathing, 6. Provide decrease saturated fats sodium and caffeine
coughing exercise and use of incentive spirometer 7. Provide client health teachings and discharge
2. Shock planning
3. Thrombophlebitis a. Avoidance of 4 E’s
b. Prevent complication (myocardial infarction)
ANGINA PECTORIS (SYNDROME) c. Instruct client to take medication before
Clinical syndrome characterized by paroxysmal chest indulging into physical exertion to achieve the
pain that is usually relieved by rest or nitroglycerine maximum therapeutic effect of drug
due to temporary myocardial ischemia
MYOCARDIAL INFARCTION
A. Predisposing Factors Heart attack
1. Sex – male Terminal stage of coronary artery disease characterized
2. Race – black by malocclusion, necrosis and scarring.
3. Smoking
4. Obesity A. Types
5. Hyperlipidemia 1. Transmural Myocardial Infarction – most
6. sedentary lifestyle dangerous type characterized by occlusion of both right
7. Diabetes Mellitus and left coronary artery
8. Hypothyroidism 2. Subendocardial Myocardial Infarction –
9. Diet – increased saturated fats characterized by occlusion of either right or left
10. Type A personality coronary artery

B. Precipitating Factors B. The Most Critical Period Following Diagnosis of

4 E’s of Angina Pectoris Myocardial Infarction
1. Excessive physical exertion – heavy exercises ** 6 – 8 hours because majority of death occurs due to
2. Exposure to cold environment arrhythmia leading to PVC’s
3. Extreme emotional response – fear, anxiety,
excitement C. Predisposing Factors
4. Excessive intake of foods rich in saturated fats – 1. Sex – male
skimmed milk 2. Race – black
3. Smoking
C. Signs and Symptoms 4. Obesity
1. Levine’s Sign – initial sign that shows the hand 5. Hyperlipidemia
clutching the chest 6. sedentary lifestyle
2. Chest pain characterized by sharp stabbing pain 7. Diabetes Mellitus
located at sub sterna usually radiates from back, 8. Hypothyroidism
shoulder, arms, axilla and jaw muscles, usually relieved 9. Diet – increased saturated fats
by rest or taking nitroglycerine 10. Type A personality
3. Dyspnea
4. Tachycardia D. Signs and Symptoms
5. Palpitations 1. Chest pain
6. Diaphoresis - Excruciating visceral, viselike pain located
at substernal and rarely in precordial
D. Diagnostic Procedure - Usually radiates from back, shoulder, arms,
1. History taking and physical exam axilla, jaw and abdominal muscles (abdominal ischemia)
2. ECG tracing reveals ST segment depression
 - Not usually relieved by rest or by 10. Provide client health teaching and discharge
nitroglycerine planning concerning
2. Dyspnea a. Avoidance of modifiable risk factors
3. Increase in blood pressure (initial sign) - arrhythmia (caused by premature
4. Hyperthermia ventricular contraction)
5. Ashen skin b. Cardiogenic shock
6. Mild restlessness and apprehension - late sign is oliguria
7. Occasional findings c. Left Congestive Heart Failure
a. Pericardial friction rub d. Thrombophlebitis
b. Split S1 and S2 - homan’s sign
c. Rales/Crackles upon auscultation e. Stroke/CVA
d. S4 or atrial gallop f. Post MI Syndrome/Dressler’s Syndrome
- client is resistant to pharmacological
E. Diagnostic Procedure agents, administer 150,000 – 450,000 units of
1. Cardiac Enzymes streptokinase as ordered
a. CPK – MB g. Resumption of ADL particularly sexual
- Creatinine phosphokinase is intercourse is 4 – 6 weeks post cardiac rehab,
increased post CABG and instruct to
- Heart only, 12 – 24 hours - make sex as an appetizer rather than dessert
b. LDH – Lactic acid dehydroginase is - instruct client to assume a non
increased weight bearing position
c. SGPT – Serum glutamic pyruvate - client can resume sexual intercourse
transaminase is increased if can climb staircase
d. SGOT – Serum glutamic oxal-acetic - dietary modification
transaminase is increased CONGESTIVE HEART FAILURE
2. Troponin Test – is increased Inability of the heart to pump blood towards systemic
3. ECG tracing reveals circulation
a. ST segment elevation
b. T wave inversion Types of Heart Failure
c. Widening of QRS complexes indicates that
there is arrhythmia in MI 1. LEFT SIDED HEART FAILURE
4. Serum Cholesterol and uric acid are both
increased A. Predisposing Factors
5. CBC – increased WBC 1. 90% is mitral valve stenosis due to
a. RHD – inflammation of mitral valve due to
F. Nursing Management invasion of Grp. A beta-hemolytic
Goal: Decrease myocardial oxygen demand streptococcus
- Formation of aschoff bodies in the mitral
1. Decrease myocardial workload (rest heart) valve
- Administer narcotic analgesic/morphine sulfate - Common among children
- Side Effects: respiratory depression - ASO Titer (Anti streptolysin O titer)
- Antidote: Narcan/Naloxone - Penicillin
- Side Effects of Naloxone Toxicity is tremors - Aspirin
2. Administer oxygen low inflow to prevent respiratory b. Aging
arrest at 2 – 3 L/min 2. Myocardial Infarction
4. Instruct client to avoid forms of valsalva maneuver 3. Ischemic heart disease
5. Place client on semi fowlers position 4. Hypertension
6. Monitor strictly vital signs, intake and output and 5. Aortic valve stenosis
ECG tracing
7. Provide a general liquid to soft diet that is low in B. Signs and Symptoms
saturated fats, sodium and caffeine 1. Dyspnea
8. Encourage client to take 20 – 30 cc/week of wine, 2. Paroxysmal nocturnal dyspnea – client is awakened
whisky and brandy to induce vasodilation at night due to difficulty of breathing
9. Administer medication as ordered 3. Orthopnea – use 2 – 3 pillows when sleeping or place
a. Vasodilators in high fowlers
- Nitroglycerine 4. Productive cough with blood tinged sputum
- ISD (Isosorbide Dinitrate, Isodil) 5. Frothy salivation
sublingual 6. Cyanosis
7. Rales/Crackles
b. Anti Arrythmic Agents 8. Bronchial wheezing
- Lidocaine (Xylocane 9. Pulsus Alternans – weak pulse followed by strong
- Side Effects: confusion and bounding pulse
dizziness 10. PMI is displaced laterally due to cardiomegaly
- Brutylium 11. There is anorexia and generalized body malaise
c. Beta-blockers 12. S3 – ventricular gallop

d. ACE Inhibitors C. Diagnostic Procedure

1. Chest x-ray – reveals cardiomegaly
e. Calcium Antagonist 2. PAP (pulmonary arterial pressure) – measures
f. Thrombolytics/ Fibrinolytic Agents pressure in right ventricle or cardiac status
- Streptokinase PCWP (pulmonary capillary wedge pressure) –
- Side Effects: allergic reaction, measures end systolic and dyastolic pressure
pruritus - both are increased
- Urokinase
- done by cardiac catheterization (insertion
- TIPAF (tissue plasminogen activating
of swan ganz catheter)
factor)
3. Ecocardiography – enlarged heart chamber
- Side Effects: chest pain
(cardiomyopathy), dependent on extent of heart failure
- Monitor for bleeding time
4. ABG – reveals PO2 is decreased (hypoxemia), PCO2 is
increased (respiratory acidosis)
g. Anti Coagulant
- Heparin (check for partial thrombin
2. RIGHT SIDED HEART FAILURE
time)
A. Predisposing Factors
- Coumadin/ Warfarin Sodium (check
1. Tricuspid valve stenosis
for prothrombin time)
2. Pulmonary embolism
3. Related to COPD
h. Anti Platelet
4. Pulmonic valve stenosis
- PASA (Aspirin)
5. Left sided heart failure
- Anti thrombotic effect
- Side Effects of Aspirin
B. Signs and Symptoms (venous congestion)
 Tinnitus 1. Neck/jugular vein distension
 Heartburn 2. Pitting edema
 Indigestion/Dyspepsia 3. Ascites
- Contraindication 4. Weight gain
 Dengue 5. Hepatosplenomegaly
 Peptic Ulcer Disease 6. Jaundice
 Unknown cause of headache 7. Pruritus
8. Anorexia
9. Esophageal varices
C. Diagnostic Procedures 1. Encourage a slow progressive physical activity
a. walking 3 – 4 times a day
1. Chest x-ray – reveals cardiomegaly b. out of bed 3 – 4 times a day
2. Central venous pressure (CVP) 2. Administer medications as ordered
- Measure pressure in right atrium (4 – 10 cm a. Analgesics
of water) b. Vasodilators
- CVP fluid status measure c. Anti coagulants
- If CVP is less than 4 cm of water hypovolemic 3. Institute foot care management
shock 4. Instruct client to avoid smoking and exposure to
- Do the fluid challenge (increase IV flow rate) cold environment
- If CVP is more than 10 cm of water 5. Assist in surgical procedure – bellow knee amputation
hypervolemic shock
- Administer loop diuretics as ordered REYNAUD’S DISEASE
- When reading CVP patient should be flat on Disorder characterized by acute episodes of arterial
bed spasm involving the fingers or digits of the hands
- Upon insertion place client in trendelendberg
position to promote ventricular filling and A. Predisposing Factors
prevent pulmonary embolism 1. High risk group – female 40 years old and above
3. Ecocardiography – reveals enlarged heart chambers 2. Smoking
(cardiomyopathy 3. Collagen diseases
4. Liver enzymes – SGPT and SGOT is increased a. SLE (butterfly rash)
b. Rheumatoid Arthritis
D. Nursing Management 4. Direct hand trauma
Goal: increase cardiac contractility thereby increasing a. Piano playing
cardiac output (3 – 6 L/min) b. Excessive typing
1. Enforce CBR c. Operating chainsaw
2. Administer medications as ordered
a. Cardiac glycosides B. Signs and Symptoms
- Digoxin (Lanoxin) 1. Intermittent claudication – leg pain upon walking
- Increase force of cardiac contraction 2. Cold sensitivity and changes in skin color (pallor,
- If heart rate is decreased do not give cyanosis then rubor)
b. Loop Diuretics 3. Trophic changes
- Lasix (Furosemide) 4. Ulceration
c. Bronchodilators 5. Gangrene formation
d. Narcotic analgesics
- Morphine Sulfate C. Diagnostic Procedures
e. Vasodilators 1. Doppler UTZ – decrease blood flow to the affected
- Nitroglycerine extremity
f. Anti Arrhythmic 2. Angiography – reveals site and extent of
- Lidocaine (Xylocane) malocclusion
D. Nursing Management
3. Administer oxygen inhalation with high inflow, 3 – 4 1. Administer medications as ordered
L/min, delivered via nasal cannula a. Analgesics
4. High fowlers position b. Vasodilators
6. Measure abdominal girth daily and notify physician 2. Encourage to wear gloves
7. Provide a dietary intake of low sodium, cholesterol 3. Instruct client on importance of cessation of smoking
and caffeine and exposure to cold environment
9. Assist in bloodless phlebotomy – rotating tourniquet,
rotated clockwise every 15 minutes to promote VARICOSITIES
decrease venous return Abnormal dilation of veins of lower extremities and
10. Provide client health teaching and discharge trunks due to
planning Incompetent valve resulting to
a. Prevent complications Increased venous pooling resulting to
- Arrythmia Venous stasis causing
- Shock Decrease venous return
- Right ventricular hypertrophy
- MI A. Predisposing Factors
- Thrombophlebitis 1. Hereditary
b. Dietary modification 2. Congenital weakness of veins
c. Strict compliance to medications 3. Thrombophlebitis
4. Cardiac disorder
PERIPHERAL VASCULAR DISORDER 5. Pregnancy
6. Obesity
Arterial Ulcer 7. Prolonged standing or sitting
I. Thrombo Angitis Obliterans
 Burger’s Disease B. Signs and Symptoms
 Reynaud’s Disease 1. Pain after prolonged standing
2. Dilated tortuous skin veins
Venous Ulcer 3. Warm to touch
1. Varicose Veins 4. Heaviness in legs
2. Thrombophlebitis (deep vein thrombosis) C. Diagnostic Procedure
1. Venography
THROMBOANGITIS OBLITERANS 2. Trendelenburg’s Test - veins distends quickly in less
Acute inflammatory disorder usually affecting the small than 35 seconds
medium sized arteries and veins of the lower
extremities D. Nursing Management
1. Elevate legs above heart level to promote increased
A. Predisposing Factors venous return by placing 2 – 3 pillows under the legs
1. High risk groups – men 30 years old and above 2. Measure the circumference of leg muscle to
2. Smoking determine if swollen
3. Wear anti embolic stockings
B. Signs and Symptoms 5. Assist in surgical procedure
1. Intermittent claudication – leg pain upon walking a. Vein stripping and ligation (most effective)
2. Cold sensitivity and changes in skin color (pallor, b. Sclerotherapy – can recur and only done in
cyanosis then rubor) spider web varicosities and danger of
3. Decreased peripheral pulses thrombosis (2 – 3 years for embolism)
4. Trophic changes
5. Ulceration THROMBOPHLEBITIS
6. Gangrene formation Deep vein thrombosis
Inflammation of the veins with thrombus formation
C. Diagnostic Procedures
1. Oscillometry – decrease in peripheral pulses A. Predisposing Factors
2. Doppler UTZ – decrease blood flow to the affected 1. Obesity
extremity 2. Smoking
3. Angiography – reveals site and extent of 3. Related to pregnancy
malocclusion 4. Chronic anemia
5. Prolong use of oral contraceptives – promotes
D. Nursing Management lipolysis
6. Diabetes mellitus
7. Congestive heart failure Alveoli
8. Myocardial infarction - Site of gas exchange (CO2 and O2)
9. Post op complication - Diffusion (Dalton’s law of partial pressure of gases)
10. Post cannulation – insertion of various cardiac
catheter Respiratory Distress Syndrome
11. Increase in saturated fats in the diet. - Decrease oxygen stimulates breathing
- Increase carbon dioxide is a powerful stimulant for
B. Signs and Symptoms breathing
1. Pain at affected extremity
2. Warm to touch Type II Cells of Alveoli
3. Dilated tortuous skin veins - Secretes surfactant
4. Positive Hpman’s Signs – pain at the calf or leg - Decrease surface tension
muscle upon dorsi flexion of the foot - Prevent collapse of alveoli
- Composed of lecithin and spingomyelin
C. Diagnostic Procedure - L/S ratio to determine lung maturity
1. Venography - Normal L/S ratio is 2:1
2. Angiography - In premature infants 1:2
- Give oxygen of less 40% in premature to prevent
D. Nursing Management atelectasis and retrolental fibroplasias
1. Elevate legs above heart level to promote increase - retinopathy/blindness in prematurity
venous return
2. Apply warm moist pack – to reduce lymphatic Disorders of Respiratory System
congestion
3. Measure circumference of leg muscle to determine if 1. PTB/Pulmonary Tuberculosis (Koch’s Disease)
swollen - Infection of lung tissue caused by invasion of
4. Encourage to wear anti embolic stockings or knee mycobacterium tuberculosis or tubercle bacilli
elastic stockings - An acid fast, gram negative, aerobic and easily
5. Administer medications as ordered destroyed by heat or sunlight
a. Analgesics
b. Anti Coagulant A. Precipitating Factors
- Heparin 1. Malnutrition
6. Monitor for signs of complications 2. Overcrowded places
Embolism 3. Alcoholism
a. Pulmonary 4. Over fatigue
- Sudden sharp chest pain 5. Ingestion of an infected cattle with mycobacterium
- Unexplained dyspnea bovis
- Tachycardia 6. Virulence (degree of pathogenecity) of
- Palpitations microorganism
- Diaphoresis
- Restlessness B. Mode of Transmission
b. Cerebral 1. Airborne transmission via droplet nuclei
- Headache
- Dizziness C. Signs and Symptoms
- Decrease LOC 1. Low grade afternoon fever, night sweats
• MURPHY’S SIGN is seen in clients with 2. Productive cough (yellowish sputum)
cholelithiasis, cholecystitis characterized 3. Anorexia, generalized body malaise
by pain at the right upper quadrant with 4. Weight loss, Hemoptysis (chronic)
tenderness 5. Dyspnea, Chest pain
D. Diagnostic Procedure
RESPIRATORY SYSTEM 1. Mantoux Test (skin test)
- Purified protein derivative
I. Upper Respiratory System - DOH 8 – 10 mm induration, 48 – 72 hours
1. Filtering of air - WHO 10 – 14 mm induration, 48 – 72 hours
2. Warming and moistening of air - Positive Mantoux test (previous exposure to tubercle
3. Humidification bacilli but without active TB)
2. Sputum Acid Fast Bacillus
A. Nose - Positive to cultured microorganism
- Cartillage 3. Chest X-ray
- Right nostril - Reveals pulmonary infiltrates
- Left nostril 4. CBC
- Separated by septum - Reveals increase WBC
- Consist of anastomosis of capillaries known as Keissel
Rach Plexus (the site of nose bleeding) E. Nursing Management
B. Pharynx/Throat 1. Enforce CBR
- Serves as a muscular passageway for both food and 2. Institute strict respiratory isolation
air 3. Administer oxygen inhalation
C. Larynx 4. Force fluids to liquefy secretions
- For phonation (voice production) 5. Place client on semi fowlers position to promote
- For cough reflex expansion of lungs
Glottis 6. Encourage deep breathing and coughing exercise
- Opening of larynx 7. Comfortable and humid environment
- Opens to allow passage of air 8. Institute short course chemotherapy
- Closes to allow passage of food going to the a. Intensive phase
esophagus - INH (Isonicotinic Acid Hydrazide)
- The initial sign of complete airway obstruction is the - Rifampicin (Rifampin)
inability to cough - PZA (Pyrazinamide)
- Given everyday simultaneously to prevent
II. Lower Respiratory System resistance
- For gas exchange - INH and Rifampicin is given for 4 months,
A. Trachea/Windpipe taken before meals to facilitate absorption
- Consist of cartilaginous rings - PZA is given for 2 months, taken after meals
- Serves as passageway of air going to the lungs to facilitate absorption
- Site of tracheostomy - Side Effect INH: peripheral
B. Bronchus neuritis/neuropathy (increase intake of Vitamin
- Right main bronchus B6/Pyridoxine)
- Left main bronchus - Side Effect Rifampicin: all bodily secretions
C. Lungs turn to red orange color
- Right lung (consist of 3 lobes, 10 segments) - Side Effect PZA: allergic reaction,
- Left lung (consist of 2 lobes, 8 segments) hepatotoxicity, nephrotoxicity
- Serous membranes - PZA can be replaced by Ethambutol
Pleural Cavity - Side Effect Ethambutol: optic neuritis
a. Pareital
b. Pleural fluid b. Standard phase
c. Visceral - Injection of streptomycin (aminoglycoside)
With Pleuritic Friction Rub - Kanamycin
a. Pneumonia - Amikacin
b. Pleural effusion - Neomycin
c. Hydrothorax (air and blood in pleural space - Gentamycin
- Side Effect:
 - Ototoxicity damage to the 8th cranial nerve Nursing Management for Postural Drainage
resulting to tinnitus leading to hearing loss
- Nephrotoxicity check for BUN and a. Best done before meals or 2 – 3 hours to
Creatinine prevent gastro esophageal reflux
- Give aspirin if there is fever b. Monitor vital signs
- Side Effect: tinnitus, dyspepsia, heartburn c. Encourage client deep breathing exercises
10. Provide increase carbohydrates, protein, vitamin C d. Administer bronchodilators 15 – 30 minutes
and calories before procedure
11. Provide client health teaching and discharge e. Stop if client cannot tolerate procedure
planning f. Provide oral care after procedure
a. Avoidance of precipitating factors g. Contraindicated with
b. Prevent complications (atelectasis, military - Unstable vital signs
tuberculosis) - Hemoptysis
PTB - Clients with increase intra ocular
- Bones (potts) pressure (Normal IOP 12 – 21 mmHg)
- Meninges - Increase ICP
- Eyes 9. Provide increase carbohydrates, calories, protein and
- Skin vitamin C
- Adrenal gland 10. Health teaching and discharge planning
a. Avoid smoking
PNEUMONIA b. Prevent complications
Inflammation of the lung parenchyma leading to - Atelectasis
pulmonary consolidation as the alveoli is filled with - Meningitis (nerve deafness, hydrocephalus)
exudates c. Regular adherence to medications
d. Importance of follow up care
A. Etiologic Agents
1. Streptococcus Pneumonae – causing pneumococal HISTOPLASMOSIS
pneumonia Acute fungal infection caused by inhalation of
2. Hemophylus Influenzae – causing broncho contaminated dust or particles with histoplasma
pneumonia capsulatum derived from birds manure
3. Diplococcus Pneumoniae
4. Klebsella Pneumoniae A. Signs and Symptoms
5. Escherichia Pneumoniae PTB or Pneumonia like
6. Pseudomonas 1. Productive cough
2. Dyspnea
B. High Risk Groups 3. Fever, chills, anorexia, general body malaise
1. Children below 5 years old 4. Cyanosis
2. Elderly 5. Hemoptysis
6. Chest and joint pains
C. Predisposing Factors
1. Smoking B. Diagnostic Procedures
2. Air pollution 1. Histoplasmin Skin Test – positive
3. Immuno compromised 2. ABG analysis PO2 decrease
a. AIDS
- Pneumocystic carini pneumonia C. Nursing Management
- Drug of choice is Retrovir 2. Administer oxygen inhalation
b. Bronchogenic Cancer 3. Administer medications as ordered
- Initial sign is non productive cough a. Antifungal
- Chest x-ray confirms lung cancer - Amphotericin B
4. Related to prolonged immobility (CVA clients), - Fungizone (Nephrotoxicity, check for BUN and
causing hypostatic pneumonia Creatinine, Hypokalemia)
5. Aspiration of food causing aspiration pneumonia b. Steroids
D. Signs and Symptoms c. Mucolytics
1. Productive cough with greenish to rusty sputum d. Antipyretics
2. Dyspnea with prolong expiratory grunt 4. Force fluids to liquefy secretions
3. Fever, chills, anorexia and general body malaise 5. Nebulize and suction as needed
4. Weight loss 6. Prevent complications – bronchiectasis
5. Rales/crackles 7. Prevent the spread of infection by spraying of
6. Bronchial wheezing breeding places
7. Cyanosis
8. Pleuritic friction rub COPD (Chronic Obstructive Pulmonary/Lung
9. Chest pain Disease)
10. Abdominal distention leading to paralytic ileus Chronic Bronchitis
(absence of peristalsis) Inflammation of bronchus resulting to hypertrophy or
hyperplasia of goblet mucous producing cells leading to
E. Diagnostic Procedure narrowing of smaller airways
1. Sputum Gram Staining and Culture Sensitivity –
positive to cultured microorganisms A. Predisposing Factors
2. Chest x-ray – reveals pulmonary consolidation 1. Smoking
3. ABG analysis – reveals decrease PO2 2. Air pollution
4. CBC – reveals increase WBC, erythrocyte B. Signs and Symptoms
sedimentation rate is increased 1. Productive cough (consistent to all COPD)
2. Dyspnea on exertion
F. Nursing Management 3. Prolonged expiratory grunt
1. Enforce CBR 4. Anorexia and generalized body malaise
2. Administer oxygen inhalation low inflow 5. Scattered rales/ronchi
3. Administer medications as ordered 6. Cyanosis
Broad Spectrum Antibiotic 7. Pulmonary hypertension
a. Penicillin a. Peripheral edema
b. Tetracycline b. Cor Pulmonale (right ventricular
c. Microlides (Zethromax) hypertrophy)
- Azethromycin (Side Effect: Ototoxicity)
- Antipyretics C. Diagnostic Procedure
- Mucolytics/Expectorants ABG analysis – reveals PO2 decrease (hypoxemia),
- Analgesics PCO2 increase, pH decrease
4. Force fluid
5. Place on semi fowlers position BRONCHIAL ASTHMA
6. Institute pulmonary toilet (tends to promote Reversible inflammatory lung condition due to
expectoration) hypersensitivity to allergens leading to narrowing of
- Deep breathing exercises smaller airways
- Coughing exercises
- Chest physiotherapy A. Predisposing Factors (Depending on Types)
- Turning and reposition 1. Extrinsic Asthma ( Atopic/ Allergic )
7. Nebulize and suction as needed Causes
8. Assist in postural drainage a. Pollen
- Drain uppermost area of lungs b. Dust
- Placed on various position c. Fumes
d. Smoke
e. Gases
 2. Maintain NPO 6 – 8 hours prior to procedure
3. Monitor vital signs and breath sound

POST Bronchoscopy
2. Intrinsic Asthma (Non atopic/Non allergic) 1. Feeding initiated upon return of gag reflex
Causes 2. Avoid talking, coughing and smoking, may cause
a. Hereditary irritation
b. Drugs (aspirin, penicillin, beta blocker) 3. Monitor for signs of gross
c. Foods (seafoods, eggs, milk, chocolates, chicken 4. Monitor for signs of laryngeal spasm – prepare
d. Food additives (nitrates) tracheostomy set
e. Sudden change in temperature, air pressure and
humidity D. Treatment
f. Physical and emotional stress 1. Surgery (pneumonectomy , 1 lung is removed and
position on affected side)
3. Mixed Type  90 – 95% 2. Segmental Wedge Lobectomy (promote re expansion
of lungs)
B. Signs and Symptoms - Unaffected lobectomy facilitate drainage
1. Cough that is non productive
2. Dyspnea EMPHYSEMA
3. Wheezing on expiration Irreversible terminal stage of COPD characterized by
4. Cyanosis a. Inelasticity of alveoli
5. Mild Stress/apprehension b. Air trapping
6. Tachycardia, palpitations c. Maldistribution of gases
7. Diaphoresis d. Over distention of thoracic cavity (barrel
chest)
C. Diagnostic Procedure
1. Pulmonary Function Test A. Predisposing Factors
- Incentive spirometer reveals decrease vital lung 1. Smoking
capacity 2. Air pollution
2. ABG analysis – PO2 decrease 3. Allergy
- Before ABG test for positive Allens Test, apply direct 4. High risk: elderly
pressure to ulnar and radial artery to determine 5. Hereditary – it involves deficiency of ALPHA-1 ANTI
presence of collateral circulation TRYPSIN (needed to form Elastase, for recoil of alveoli)

D. Nursing Management B. Signs and Symptoms

1. Enforce CBR 1. Productive cough
2. Oxygen inhalation, with low inflow of 2 – 3 L/min 2. Dyspnea at rest
3. Administer medications as ordered 3. Prolong expiratory grunt
a. Bronchodilators – given via inhalation or 4. Anorexia and generalized body malaise
metered dose inhalaer or MDI for 5 minutes 5. Resonance to hyperresonance
b. Steroids – decrease inflammation 6. Decrease tactile fremitus
c. Mucomysts (acetylceisteine) 7. Decrease or diminished breath sounds
d. Mucolytics/expectorants 8. Rales or ronchi
e. Anti histamine 9. Bronchial wheezing
4. Force fluids 10. Barrel chest
5. Semi fowlers position 11. Flaring of alai nares
6. Nebulize and suction when needed 12. Purse lip breathing to eliminates excess CO2
7. Provide client health teachings and discharge (compensatory mechanism)
planning concerning
a. Avoidance of precipitating factor C. Diagnostic Procedure
b. Prevent complications 1. Pulmonary Function Test – reveals decrease vital lung
- Emphysema capacity
- Status Asthmaticus (give drug of choice) 2. ABG analysis reveals
- Epinephrine a. Panlobular/ centrilobular
- Steroids - Decrease PO2 (hypoxemia leading to chronic
- Bronchodilators bronchitis, “Blue Bloaters”)
c. Regular adherence to medications to - Decrease ph
prevent development of status asthmaticus - Increase PCO2
d. Importance of follow up care - Respiratory acidosis
b. Panacinar/ centriacinar
BRONCHIECTASIS - Increase PO2 (hyperaxemia, “Pink Puffers”)
Abnormal permanent dilation of bronchus leading to - Decrease PCO2
destruction of muscular and elastic tissues of alveoli - Increase ph
- Respiratory alkalosis
A. Predisposing Factors
1. Recurrent lower respiratory tract infections D. Nursing Management
2. Chest trauma
3. Congenital defects 1. Enforce CBR
4. Related to presence of tumor 2. Administer oxygen inhalation via low inflow
3. Administer medications as ordered
B. Signs and Symptoms a. Bronchodilators
1. Productive cough b. Steroids
2. Dyspnea c. Antibiotics
3. Cyanosis d. Mucolytics/expectorants
4. Anorexia and generalized body malaise
5. Hemoptysis (only COPD with sign) 4. High fowlers position
5. Institute PEEP (positive end expiratory pressure)
C. Diagnostic Procedure in mechanical ventilation promotes maximum alveolar
1. ABG – PO2 decrease lung expansion
2. Bronchoscopy – direct visualization of bronchus using 6. Provide comfortable and humid environment
fiberscope 10. Provide high carbohydrates, protein, calories.

Nursing Management PRE Bronchoscopy

1. Secure inform consent and explain procedure to
client

Kathrina D. Dalisay,
R.N.