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Members of the BOARD OF NURSING and their SPECIALIZATIONS: Chairman Carmencita Abaquin, UP: MS neuro, sensory, endocrine, BURNS, ONCOLOGY, elderly care, RESEARCH Hon. Marco Sto. Tomas, St. Joseph College of Nursing: Funda, MCN, IMCI Hon. Leonila Faire, UP: renal transplant, RENAL DISORDERS, ENT, ophtha (cataract), OR Hon. Betty Meritt, UP: Psych: Child psychology, stress management Hon. Perla Po, UP: Psych: Therapeutic comm., psych drugs, nursing theories Hon. Amelia Rosales, Ortaez College of Nursing: MS Hon. Yolanda Arugay, PWU: CHN
ALPHABET OF PAIN:
Crushing pain = MI Pounding occipital headache = HPNsive crisis in MAOI + Tyramine Knife like = Ectopic pregnancy, Pleurisy Gnawing = Gastric Ulcer
Radiating Pain:
Chest to arm = ANGINA Chest to back = MI Epigastrium to Right Scapula = CHOLECYSTITIS Epigastrium to Left Scapula = RENAL COLIC LUQ to Left shoulder = PANCREATITIS Labor = back pain to abdomen = TRUE LABOR
McCafferey = Subjective definition Gate control theory Patient Controlled Analgesia (PCA) = ability to self dose TENS = nonnarcotic,noninvasive, inhibits transmission
Pain Medications:
OPIOIDS
Morphine Sulfate DOC (severe) Meperidine Fentanyl RR check Respiratory depression, hPN, urinary retention SE: elderly = constipation NALOXONE @ bedside Detoxification = Methadone
NON- OPIOIDS NSAIDS = inhibits prostaglandin synthesis Cox 1 and 2 inhibitors ADJUVANT MEDICATIONS Antidepressants, Anticonvulsants = DOC neuropathic pain
PERIOPERATIVE NURSING
Preoperative Intraoperative Postoperative Members of the surgical team: Surgeon Surgical Assistant Anesthesiologist Circulating nurse Scrub nurse
Angina Pectoris
Types Occurrence Severity Relieve by drug and rest Stable Unstable During Unpredictable exertion Unchanging Increases with time Yes No
Manifestations: 1. Diaphoresis 2. Dizziness 3. Chest pain common sign Squeezing (retrosternal) Radiates from chest to jaw and left arm
NTG-vasodilator
Salient points: a. place sublingual (where vessels are visible) b. keep three tablets (note: interval of 5 minutes) c. dont follow with water (it will be deactivated by the GI tract) d. dont smoke after (the nicotine (vasoconstrictor) might antagonize the effect of the drug) e. if unrelieved, refer to physician f. side effect: headache g. it must be stored in a brown bottle container h. monitor heart rate If NTG patch: rotate the site, place in non-hairy part of the body
ASA-anti-platelet aggregation
Salient points: a. avoid green leafy vegetable b. monitor pulse rate c. Laboratory : platelets d. dont give with antihistamine, Heparin and Coumadin e. use soft bristle toothbrush and electric razor f. question if given to small children (associated in Reyes syndrome)
Beta-blockers to decrease BP and HR Laboratory interventions: a. ECG ST depression b. Cardiac catheterization ( note for the presence of atheroma)
Medical Interventions:
a. Coronary arteriogram Note: 1. Allergy to dye must be assessed 2. Artery (Femoral) is commonly used 3. Assess for bleeding after 4. Advise client to place affected leg in extension (usually with sandbag weighing 20 lbs for 8-12 hours)
b. Percutaneous Transluminal Angioplasty (PTCA) A balloon tip catheter will be inserted to crush the atheroma c. Coronary Artery Bypass Graft Saphenous vein is commonly used Assess the donor site (note : it should be warm and non-edematous
Myocardial infarction
Death of myocardial tissue due to abrupt interruption of coronary blood supply Etiologies: CAD, Vasospasm and Occlusion
Manifestations: 1. Dyspnea 2. Diaphoresis 3. Dysarhythmias 4. Chest pain Crushing (Substernal) Radiates from the chest to back
Problem
Pain and radiation
Angina Pectoris
Chest to arm
Myocardial Infarction
Chest to back
Duration
Relieve by rest Description
Laboratory Intervention: a. ECG ST segment elevated b. Cardiac enzymes-elevated CPK-MB and Troponin levels
Note: WBC in some extent is elevated
Nursing Interventions:
Consider: a. Semi-fowlers (promote airway) b. High-fiber, low fat and low Na diet c. Rest d. Drug (MONA)
1. Morphine to decrease oxygen demand Salient points: a. Monitor PR b. Have Narcan (antidote) at hand c. Can cause addiction (Note: consider Methadone) 2. Oxygen 3. Nitrates 4. Aspirin
Note:Clients who are able to climb stairs are usually ready to start sexual activities
CHF can be Left-sided or Right-sided Left-sided CHF can lead to Right-sided CHF, but Right cannot lead to Left Lasix is given to both types of CHF CHF is the inability of the heart to pump blood towards systemic circulation
Left-Sided Heart Failure (LSHF) Can be caused by Rheumatic Heart Disease: Tonsillitis strep bacteria migrate to mitral valve RHEUMATIC HEART DISEASE mitral stenosis LSHF
SSx of LSHF:
Most of the symptoms of LSHF are RESPIRATORY: Pulmonary edema and congestion Dyspnea: Paroxysmal nocturnal dyspnea difficulty of breathing at nighttime Nursing intervention: give patient 2 to 3 pillows Orthopnea difficulty of breathing while lying down Nursing intervention: Position patient HighFowlers or Orthopneic position Productive cough, blood-tinged sputum Frothy salivation alveolar fluid in the mouth Abnormal breath sounds: Rales (crackles) and bronchial wheezing
Cardiovascular symptoms:
Pulsus alternans weak pulse followed by strong bounding pulse Can lead to arrhythmia Point of Maximal Impulse (PMI) is displaced laterally Fluid in the lungs pushes heart to one side Check apical pulse to determine the location of PMI Normal PMI is at the left midclavicular line between the 4th and 5th intercostals space (below the nipple). Note: if the PMI is displaced vertically (lower than normal) then the patient has cardiomegaly. S3 extra heart sound (Ventricular gallop) Note: S4 sound occurs in myocardial infarction
Venous congestion blood goes back to superior & inferior vena cava Jugular vein distention Pitting edema Ascites fluid in the peritoneal cavity Weight gain Hepatosplenomegaly Jaundice Pruritus and urticaria Esophageal varices Generalized body malaise and anorexia
DIGOXIN
Indicated for Congestive Heart Failure Mechanism of digoxin: increases force of myocardial contractions, thereby increasing cardiac output The normal cardiac output is 3 to 6 L/min. Nursing Management when administering Digoxin: Check apical pulse rate: if below 60, withhold drug and notify the physician.
SSx of Dig toxicity: GI DISTURBANCES (Early Sign): Anorexia (loss of appetite is the most evident sign), nausea and vomiting, diarrhea Visual disturbances: photophobia, XANTOPSIA (seeing yellow spots), diplopia Confusion The antidote for dig toxicity is DIGIBIND
CARDIAC TAMPONADE HEART UNABLE TO PUMP BLOOD DUE TO ACCUMULATION OF FLUID (50 ML) IN THE PERICRADIAL SAC = restricts ventricular filling = LOW ventricular output Jugular vein distention hPN Muffled heart sound Increased CVP Pulsus paradoxus
HPN = above 140/90 ( 2 consecutive readings) Types: Essential = most common Secondary = due to Pheochromocytoma, SIADH Predisposing Factors: Smoking, DM, 60 years old and above Int.: 5 Ls = lose weight, low fat and low Na diet, limit alcohol, lifestyle modification, lipid, BUN, crea and ECG monitoring
SINUS TACHYCARDIA = cause: alcohol and caffeine; Tx: Beta blockers and digitalis SINUS BRADYCARDIA =Tx: Atropine sulfate ATRIAL FIBRILLATION = Bed rest, Cardioversion, Digitalis VFIB = Unconscious, NO CO = Code, CPR, Epinephrine
AV BLOCK = Cause: Digitalis toxicity, electrolyte imbalance, Tx: ECG PVC = Tx: Lidocaine, Oxygen VTACH = life threatening, cause: hypokalemia, Tx: Lidocaine
4 Types of COPD
Bronchitis bluebloater cyanosis with edema Asthma Bronchiectasis Emphysema pink-puffer acyanotic with compensatory purse-lip breathing
PSSx: Barrel-chest
Bronchitis
Asthma
Bronchiectasis
Emphysema
Can lead to pneumothorax (air in pleural space),
Hereditary
For all types of COPD: #1 cause is smoking Expect doctor to prescribe bronchodilators LOW-FLOW OXYGEN only so as not so suppress the respiratory drive
Aminophylline
Indicated for Chronic Obstructive Pulmonary Disease (COPD) Bronchodilators dilate the bronchial tree, thereby allowing more air to enter the lungs SSx of aminophylline toxicity: Tachycardia, hPN Palpitations CNS excitability: irritability, agitation, restlessness and tremors Nursing management for aminophylline: AVOID COFFEE will aggravate CNS excitability
PULMONARY EMBOLISM
Cause: Fat embolism ( long bone fracture) Initial sign: Restlessness chest pain of a "pleuritic" nature Cyanosis Tachycardia Diaphoresis Dysrythmias Chest pain (stabbing)
Edema excess accumulation of fluid in the interstitial space Localized edema result of traumatic injury from accidents, surgery, local inflammation, burns Anasarca generalized edema cardiac, renal or liver failure
Infants and older adult are at higher risk for fluid related problems than younger adults; children have a greater proportion of body water than adults and the older adult has the least proportion of body water
HYPOKALEMIA
HYPERKALEMIA
Potassium less than 3.5 mEq/L Potassium greater than SSx of hypokalemia: 5 mEq/L Weakness, fatigue SSx of hyperkalemia: Decreased GI motility: constipation Irritability, Positive U Wave on ECG can lead to excitement arrhythmias Increased GI Metabolic alkalosis motility: diarrhea, Bradycardia (HR 60 to 100 bpm) abdominal cramps Rx for hypokalemia Peaked T wave K supplements: Oral KCl, Kalium durule can also lead to Foods rich in K: arrhythmia Fruits: Apple, Banana, Cantaloupe Metabolic acidosis Note: Green bananas have more K Vegetables: Asparagus, Broccoli, Carrots Also rich in K: orange, spinach, apricot
HYPERNATREMIA more
Manifestations
Burns, SIADH, diuretic Diarrhea and IVF therapy and plain water use use N/V and Seizure Dry tongue, thirst Low sodium Fluid Volume Deficit Hypotension The initial sign of dehydration is THIRST (adults) or TACHYCARDIA (infants) Nursing Management: Force fluids (2 to 3 L/day), administer isotonic IV
HYPERCALCEMIA more
Etiologies
Manifestation
Test
ECG
DOC
Prolonged QT interval
Ca gluconate (PC)
Shortened QT interval
Calcitonin
HYPOCALCEMIA
Tetany involuntary muscle contraction SSx of hypocalcemia: Trousseau sign carpal spasm when BP cuff is inflated 150 to 160 mmHg Chvostek sign facial twitch when facial nerve is tapped at the angle of the jaw Complications of hypocalcemia: Arrhythmia and Seizure (Calcium deficiency is life-threatening!)
Nursing management for hypocalcemia: Administer Ca Gluconate IV Must be administered slowly to prevent cardiac arrest Excess Ca Gluconate Ca Gluconate toxicity seizure Antidote for Ca excess: Magnesium Sulfate Monitor for signs of MgSO4 toxicity (BURP): BP low Urine output low RR low PATELLAR REFLEX ABSENT important! earliest sign of MgSO4 toxicity
Hypocalcemia: prolonged ST interval, prolonged QT interval Hypercalcemia: shortened ST segment, widened T wave Hypokalemia: ST depression, shallow, flat, or inverted T wave, prominent U wave Hyperkalemia: Tall peaked T waves, flat P waves, widened QRS complex, prolonged PR interval Hypomagnesemia: Tall T waves, depressed ST segment Hypermagnesemia: prolonged PR interval, widened QRS complex
Client at risk for Potassium deficit? Client on nasogastric (NG) suction Food item contains the least amount of magnesium? Processed drinking water Foods with least amount of Potassium? APPLE (3 mEq of potassium per serving) Lettuce (less than 100 mg)
Risk for Hyperkalemia? trauma, burns, sepsis, or with metabolic or respiratory acidosis early stages of massive cell destruction cellular shifting K+ Sodium polystyrene sulfonate (Kayexalate) cation exchange resin, treats hyperkalemia Releases sodium ions in exchange for primarily potassium ions therapeutic effect 2 to 12 hours after oral administration and longer after rectal administration
HYPONATREMIA - Syndrome of inappropriate secretion of antidiuretic hormone (SIADH) Postural blood pressure changes, rapid thready pulse, dry mucous membranes and intense thirst Diabetes Insipidus HYPERNATREMIA Avoid foods: high in sodium Processed oat cereals
Condition causing low serum calcium level? IMMOBILITY prolonged bed rest (long term effect) Indication of HYPERCALCEMIA? Generalized muscle weakness
Hyperparathyroidism client with 13 mg/dl Ca give Calcitonin(Calcimar) inhibits bone resorption AVOID: high doses of VITAMIN D (causative factor of Hypercalcemia) HYPOLCALCEMIA? + Trosseauss sign, + Chvosteks sign, hyperactive bowel sounds Calcium gluconate and calcium chloride treats tetany from acute hypocalcemia
Least amount of Calcium? BUTTER Hypomagnesemia indication? Loss of deep tendon reflexes Least amount of Phosphorous? ORANGE
Client with a nasogastric (NG) tube with irrigations Q shift. Laboratory Test Results: Potassium level of 4.5 mEq/L, Sodium level of 132 mEq/L Most appropriate solution to use for? NORMAL SALINE
pH
pCO2
HCO3
Normal
7.35 7.45
35 - 45
22 - 26
Respiratory Acidosis
N N
RESPIRATORY ACIDOSIS Causes COPD, Respiratory failure, Overdose, Atelectasis, Pulmonary edema, aspiration Manifestation Weakness, tachycardia, decreased LOC, headache Management Assess VS, Monitor ABG, CPT, TCDB
METABOLIC ACIDOSIS Causes DKA, DIARRHEA, DM, ASA poisoning, renal failure Manifestation Headache, N/V, Kussmauls respiration, dysrythmias Management Administer Na bicarb, monitor I/O, Use seizure precautions
METABOLIC ALKALOSIS Vomiting, NGT, Diuretics and antacids Tingling, Dizziness, Bradypnea
Hypertonic 3% saline (3% NS) 5% saline 10% dextrose in water (D10W) 5% dextrose in 0.9% saline 5% dextrose in 0.45% saline 5% dextrose in LR Colloid Dextran Albumin
Peripheral venous sites to avoid: Edematous extremity, arm that is weak, traumatized or paralyzed, arm on same side with mastectomy, arm with AV shunt or fistula for dialysis, infected skin tissue
HYPERURICEMIA
Uric acid is a by-product of purine metabolism Foods high in uric acid: Organ meats, sardines, anchovies, legumes, nuts Tophi uric acid crystals Gout uric acid deposit in joints leading to joint pain & swelling, particularly affecting the great toes.
Nursing Management for Gout: Force fluids (2 to 3 L/day) Rx: Allopurinol [Zyloprim] drug of choice for gout Most common side effect: allergic reaction (maculopapular rash) Rx: Colchicine drug of choice for acute gout
PEPTIC ULCER
Gastric Ulcer Gnawing epigastric pain occurring 30 minutes to 1 hour after meals Aggravated by eating (because acid secretion increase at meal time) leads to weight loss Relieved by vomiting (because acid is expelled out) No pain at hours of sleep (HCl production decreases at hours of sleep) More common in persons older than age 50
Duodenal Ulcer Gnawing epigastric pain occurring 2-3 hours after meals Relieved by food (because the pyloric sphincter, at the junction of stomach and duodenum, closes upon eating to concentrate food in the stomach) causes weight gain Not relieved Pain at hours of sleep (because gastric emptying continuous at hours of sleep) More common between ages 25 and 50
Esophageal varices = secondary to portal HPN Dx test: Upper GI Series or Barium swallow Sengstaken Blakemore tube AVOID: ASA Worst complication: Bleeding
HIATAL HERNIA Heartburn Regurgitation Dysphagia Small frequent feedings Fowlers after eating for 1 H
GERD Gastro-Esophageal Reflux Disease Common cause: Pyloric stenosis Manifestations: Heartburn, N/V (Note: Metabolic alkalosis) Nursing intervention:
Avoid SPICES, COFFEE, Nicotine, cola Barium swallow Consider liquid diet Elevate head of the bed
DUMPING SYNDROME
Rapid emptying of the stomach Commonly occurs 5- 30 minutes after meals (early), 2- 3 H (late) Manifestations: Diaphoresis, drowsiness, dizziness, diarrhea Diet: HIGH FAT, HIGH CHON, LOW CHO Small frequent feedings Lie down after eating
Cause
Age
Bleeding Not common; stool Severe: stool with with pus and mucus blood, pus, mucus Fistulas Common Rare
CROHNS (REGIONAL ENTERITIS) Perianal involvement Diarrhea Abdominal pain Weight loss Severe
5 6 stools/day
20 30 watery stools/day
Severe + +
APPENDICITIS RLQ pain Appendectomy Pain monitoring AVOID: hot compress, enema Sign of Peritonitis: Rigid boardlike abdomen
DIVERTICULITIS = LLQ pain, rectal mass, rectal bleeding LIVER CIRRHOSIS = RUQ abdominal pain, jaundice, note: ASTEREXIS, Rx: LACTULOSE CHOLECYSTITIS = Murphys sign, Low fat diet, steatorrhea PANCREATITIS = Cullens sign and Turners sign, Lab: Amylase and Lipase
HYPOTHYROIDISM All body systems are DECREASED except WEIGHT and MENSTRUATION! decreased CNS: drowsiness, memory problems (forgetfulness) decreased v/s: hypotension, bradycardia, bradypnea, low body temp decreased GI motility: constipation
HPYERTHYROIDISM All body systems are INCREASED except WEIGHT and MENSTRUATION! increased CNS: tremors, insomnia increased v/s: hypertension, tachycardia, tachypnea, fever increased GI motility: diarrhea
HYPOTHYROIDISM decreased appetite (anorexia) but with WEIGHT GAIN [low metabolism causes decreased burning of fats and carbs] This leads to increased serum cholesterol atherosclerosis (hardening of arteries due to cholesterol deposits) Because of increased cholesterol, hypothyroid patients are prone to hypertension, myocardial infarction, CHF and stroke
HPYERTHYROIDISM increased appetite (hyperphagia) but with WEIGHT LOSS [high metabolism causes increased burning of fats and carbs]
HYPOTHYROIDISM
HPYERTHYROIDISM
decreased metabolism causes decreased perspiration DRY SKIN and COLD INTOLERANCE
Menorrhagia (excessive bleeding during menstruation) Nursing Management for hypothyroidism: Low calorie diet Warm environment
increased metabolism causes increased perspiration MOIST SKIN and HEAT INTOLERANCE
Amenorrhea (absence of menstruation) Pathognomic sign: EXOPHTHALMOS Nursing Management for hyperthyroidism: High calorie diet Cool environment
Type I DM Insulin-dependent Juvenile onset type (common among children) Non-obese Brittle disease
Type II DM Non Insulin-dependent Adult/Maturity onset type (common among 40 y.o. & above) Obese Non-brittle disease
Etiology: Obesity Asymptomatic Characterized by Weight Gain Treatment: Oral Hypoglycemic Agents (OHA) Complications: Hyper-Osmolar NonKetotic Coma (HONCK) Non-ketotic, so no lipolysis
Can also lead to coma Can lead to seizure
HYPERGLYCEMIA
SSx: 3Ps (Polyuria, Polydipsia, Polyphagia) Nursing Management: Monitor Fasting Blood Sugar (Normal FBS is 80 to 100 mg/dL)
Decreased tolerance to stress due to decreased steroids can lead to ADDISIONIAN CRISIS
Increased steroids cause decreased WBC (Leukopenia) IMMUNODEFICIENCY Note: Steroids takers (athletes,body builders) experience ssx of Cushings Hypernatremia with Fluid Volume Excess Hypertension Edema Weight Gain Pathognomonic Sx of Cushings: Moon-face Buffalo hump Obese trunks Pendulous Abdomen Thin extremeties
Hypokalemia Weakness, fatigue Constipation Prominent U wave can also lead to arrhythmia Hirsutism, acne and striae due to increased sex hormones Other signs: Depression Easy bruising Increased masculinity in women
Decreased sexual urge and loss of pubic and axillary hair Pathognomonic sx: Bronze-like skin Decreased cortisol causes pituitary gland to secrete Melanocytestimulating hormone
Management: Management: Steroids (2/3 dose in AM and 1/3 dose in Potassium-sparing diuretics: Aldactone PM) [Spironolactone] promotes excretion of sodium while retaining potassium DO NOT GIVE LASIX Limit fluids Increase potassium in the diet
Icteric skin and sclerae is termed Jaundice = a sign of HEPATITIS Note: Icteric skin with normal sclerae is termed Carotinemia = a sign of PITUITARY GLAND TUMOR, not hepatitis Kernicterus (Hyperbilirubinemia) can lead to irreversible brain damage
Ammonia is a by-product of protein metabolism; toxic substance metabolized by the liver into a non-toxic substance (urea), which is then excreted by the kidneys Increase in serum ammonia can cause HEPATIC ENCEPHALOPATHY (Liver cirrhosis) Normal liver is scarlet brown; liver with cirrhosis is covered by fat deposits (fatty liver) The primary cause of hepatic encephalopathy is MALNUTRITION The major cause of hepatic encephalopathy is ALCOHOLISM Alcoholism causes Thiamine (B1) deficiency (Alcoholic beriberi) Ammonia is a cerebral toxin.
Early sign of Hepatic Encephalopathy: ASTERIXIS flapping hand tremors. This is the EARLIEST SIGN OF HEPATIC ENCEPHALOPATHY.
Late Signs of Hepatic Encephalopathy: Headache Restlessness Fetor hepaticus (ammonia-like breath) Decreased level of consciousness HEPATIC COMA Note: The primary Nursing Intervention in hepatic coma is AIRWAY [Assist in mechanical ventilation]
Arterial Occlusion
Color Edema Nails Pain Pulse
Temperature
Venous Occlusion
Ruddy Severe Normal Homans sign Normal
Ulcer
Cold Dry
Warm Wet
BUERGERS DISEASE OR THROMBOANGITIS OBLITERANS Inflammation of arteries thrombus formation occlusion of vessel Unknown, RF: Smoking Men
RAYNAUDS DISEASE
Constriction of arteries Coldness, pain and pallor of the fingertips or toes Unknown Women
18 - 40 Raynauds phenomenon Tingling sensation Burning pain on the hands and feet UTZ Avoid COLD temp. and nicotine AVOID SHARPS
STRAIN VS. SPRAIN STRAIN = overstretching MUSCLE or TENDON SPRAIN = overstretching LIGAMENTS
OSTEOPOROSIS
Primary - menopause Secondary steroids RF: Age Alcohol and caffeine Asian and Caucasian Absence of mobility High Ca and Vit D, Calcium supplement
OSTEOARTHRITIS RF: obesity, repetitive use of joints with previous damage Joint pain and stiffness Affects: WEIGHT BEARING JOINTS Heberdens nodes - DIP Bouchards nodes - PIP
RHEUMATOID ARTHRITIS Pain usually in the morning Joint involvement: SYMMETRICAL Starts in the hands, wrist and feet = deformities: spindle-shaped Dx test: Arthrocentesis (+) = cloudy, dark yellow
GOUTY ARTHRITIS
Gout or podagra Deposition of uric acid crystals in the joint = Poor metabolism of purine TOPHI Rx: Allopurinol, Colchicine, Probenecid Diet: low purine, increase fluids
Nonurgent (Green) Priority 3: local injuries, no immediate complications, can wait for hours for treatment, evaluation every 1-2 H thereafter Minor lacerations, sprain or cold symptoms Expectant (Black)
ABCD of Basic Life Support for the Health Care Provider: Airway Breathing Circulation Defibrillation or definitive treatment
When to stop CPR: STOP ONLY IF Pulse and respiration returns Emergency medical help arrives Admnistration of automated external defibrillator A physician declares victim dead/deceased Non-health care setting: if rescuer is exhausted and physically unable to do CPR
Sympathetic Nervous Parasympathetic System (SNS) Nervous System (PNS) Fight or aggression Flight or withdrawal response response Also termed adrenergic or Also termed cholinergic or parasympatholytic sympatholytic response response The neurotransmitter for The neurotransmitter for the SNS is norepinephrine the PNS is acetylcholine (Ach) All body activities are All body activities are DECREASED except INCREASED except GIT! GIT!
increased blood flow to brain, heart and skeletal muscles increased BP, heart rate bronchodilation and increased RR: increase oxygen intake urinary retention FLUID VOLUME EXCESS Fluids are withheld by the body to maintain circulating volume
decreased GIT activity: Increased GIT: CONSTIPATION and DRY DIARRHEA and MOUTH: INCREASED SALIVATION Blood flow is decreased in the GIT because it is the least important area in times of stress
Anti-parkinsonians: Cogentin, Artane Pre-operative drug: Atropine Sulfate (AtSO4) given before surgery to decrease salivary and mucus secretions
Calcium channel blockers (Calcium antagonists) Nifedipine [Procardia], Verapamil [Isoptim], Dialtiazem [Cardizem] NURSING ALERT: Anti-hypertensives are not given to patients with CHF or cardiogenic shock (Drug will cause a further decrease in heart rate Death) Rx for Myasthenia Gravis: Pyridostigmine [Mestinon] Neostigmine [Prostigmin]
INCREASED ICP
Predisposing factors: Head injury Tumor Localized abscess (pus) Hydrocephalus Meningitis Cerebral edema Hemorrhage (stroke) Note: For all causes of increased ICP, the patient should be positioned 30 to 45 (Semi-Fowlers)
Early Signs of Increased ICP Change or decreased level of consciousness (restlessness to confusion) Irritability and agitation Disorientation to lethargy to stupor to coma Remember: The 4 levels of consciousness: Conscious Lethargy Stupor Coma
Late Signs of Increased ICP Changes in v/s Increased BP: WIDENING PULSE PRESSURE increased systolic pressure while diastolic pressure remains the same Note: narrowing pulse pressure is seen in SHOCK (inadequate tissue perfusion). Decreased Heart rate (bradycardia) Decreased Respiratory rate (bradypnea) Cheyne-Stokes respiration hyperpnea followed by periods of apnea
Vital signs
BP
Heart Rate Resp Rate Temp
Shock
decreased
increased increased low
Pulse Pressure
widening
narrowing
Headache, papilledema, PROJECTILE VOMITTING Papilledema is edema of the optic disc in the retina, leading to irreversible blindness Projectile vomiting due to compression of the medulla, which is the center for vomiting.
Abnormal Posturing: Decorticate posture abnormal flexion, due to damage to the corticospinal tract (spinal cord & cerebral cortex) Decerebrate posture abnormal extension, due to damage to upper brain Note: Flaccid posture is lost muscle tone, not found in increased ICP (found in poliomyelitis).
Unilateral dilation of pupils Uncal herniation herniation of uncus (in temporal lobe) puts pressure on Cranial Nerve III which controls parasympathetic input to the eye, causing unequal pupillary dilation (ANISOCORIA) Possible seizure
Maintain patent airway and adequate ventilation To prevent hypoxia (inadequate O2 in tissues) and hypercarbia (increased CO2 in blood)
Early Signs of Late Signs of Hypoxia Hypoxia Restlessness Bradycardia Agitation Cyanosis Tachycardia Dyspnea Extreme Restlessness
Assist in mechanical ventilation: Ambubag or Mechanical Ventilator Hyperventilate or hyper-oxygenate client to 100% before and after suctioning Position Semi-Fowlers Elevate head of bed 30 to 45 with neck in neutral position unless contraindicated to promote venous drainage. Monitor v/s, I&O and neurocheck (neurovital signs) Prevent complications of immobility (turn to side) Prevent further increase of ICP
Instruct client to avoid activities leading to Valsalva maneuver (bearing down) Avoid straining of stool: administer laxatives/stool softeners: Bisacodyl [Dulcolax] Avoid excessive coughing: administer antitussives (cough suppresant): Dextromethorphan [Robitussin] Note: common side effect of antitussives is drowsiness, so avoid driving or operating heavy machinery Avoid vomiting: administer anti-emetic: Phenergan [Plasil] Avoid bending, stooping, lifting heavy objects
Osmotic diuretics Mannitol [Osmitrol] Check BP before administering; mannitol can lead to low fluid volume hypotension Monitor strictly I & O and inform physician if output is less than 30 cc per hour Mannitol is given as side-drip (piggy-back) Regulate at FAST-DRIP to prevent crystallization [formation of precipitates in tubing] clogged IV line Note: KVO rate is 10 to 15 gtts per minute Inform client that he will feel a flushing sensation as the drug is introduced.
Loop Diuretics Furosemide [Lasix] Nursing management for loop diuretics is the same as for Osmotic diuretics Lasix is given IV Push (from ampule) Best given AM to prevent sleep disturbances. Lasix given PM will prevent restful sleep due to frequent urination.
Corticosteroids: Dexamethasone [Decadron] to decrease cerebral edema Side-effect of steroids: respiratory depression Mild analgesics: Codein Sulfate Anticonvulsants: Dilantin [Phenytoin]
ALZHIEMERS DISEASE
A type of dementia (degenerative disorder characterized by atrophy of the brain tissue) Caused by Acetylcholine (Ach) deficiency Irreversible Predisposing factors: Aging Aluminum toxicity Hereditary
Agnosia inability to recognize familiar objects Apraxia inability to perform learned purposeful
movements (using objects [toothbrush] for the wrong purpose)
The drugs of choice for Alzheimers are Donepezil [Aricept] or Tacrine [Cognex] The drugs work by inhibiting cholinesterase (an enzyme that breaks down acetylcholine), thereby increasing the levels of acetylcholine in the brain Best given at bedtime
Chronic intermittent disorder of the CNS characterized by white patches of demyelination in the brain and spinal cord Characterized by remission and exacerbation Common among women 15 to 35 y.o.
Predisposing factors: Idiopathic (unknown) Slow-growing viruses Autoimmune Note: other autoimmune diseases: Systemic Lupus Erythematosus (SLE), hypo & hyperthyroidism, pernicious anemia, myasthenia gravis
BLURRED VISION is the INITIAL SIGN of MULTIPLE SCLEROSIS Diplopia (double vision) Scotoma (blind spot in the visual field)
Impaired sensation to touch, pain, pressure, heat and cold
Mood Swings Patients with MS are in a state of euphoria Impaired motor activity Weakness spasticity paralysis Impaired cerebellar function ATAXIA (unsteady gait) Scanning speech Urinary retention and incontinence Constipation Decrease in sexual capacity CHARCOTS TRIAD: A N I
Diagnostic Procedures for Multiple Sclerosis Cerebral analysis through lumbar puncture reveals increased IgG and protein MRI reveals site and extent of demyelination LHERMITTEs SIGN continuous contraction and pain in spinal cord following laminotomy confirms diagnosis of MS
ACTH (steroids) to reduce swelling and edema prevents paralysis resulting from spinal cord compression
Steroids are best administered AM to mimic the normal diurnal rhythm of the body Give 2/3 of dose in AM, 1/3 of dose in PM ACTH is also administered in Motor Vehicular Accidents leading to spinal injury prevents inflammation that can lead to paralysis
Bethanecol Chloride [Urecholine] cholinergic drug used to treat urinary retention; given subQ Side effects of Bethanecol: Bronchospasm and
Wheezing, so always check breath sounds 1 hour after administration. Normal breath sounds are bronchovesicular.
Provide relaxation techniques Deep breathing, yoga, biofeedback Maintain siderails to prevent injury secondary to falls Prevent complications of immobility Turn to side q 2 h, q 1 h for elderly patients, q 30 minutes on the affected extremity Provide catheterization Avoid heat application To treat constipation: Provide high fiber diet
To treat UTI: Provide ACID-ASH DIET (acidifies urine to prevent bacterial infection)
Acid-ash diet consists of Grape, Cranberry, Plums, Prune Juice, Pineapple Women are more prone to UTI Male UTI is often related to post-coitus
Male must urinate after coitus to prevent urine stagnation
A dislodged thrombus becomes an EMBOLUS (free-floating clot) very dangerous if it goes to the BRAIN, HEART or LUNGS
CVA causes increased ICP.
Parkinsons Disease
A chronic progressive disorder of the CNS characterized by degeneration of DOPAMINE-producing cells in the substancia nigra of the midbrain and basal ganglia. Parkinsons disease is irreversible
Predisposing factors: Lead and carbon monoxide poisoning Arteriosclerosis hardening of an artery Hypoxia Encephalitis
Side effects of Reserpine: DEPRESSION and BREAST CANCER Note: Reserpine is the only antihypertensive with a major side effect of depression patient becomes SUICIDAL Nursing management for suicidal patients: PROMOTE SAFETY (remove equipment that patient can use to harm himself)
Early sign: PILL-ROLLING TREMORS pathognomonic sign of Parkinsons Second sign: BRADYKINESIA (slowness of movement)
cogwheel rigidity intermittent jerking movement Stooped posture Shuffling Gait, Propulsive Gait
Overfatigue Mask-like facial expression Decreased blinking of the eyes Difficulty in arising from sitting position Monotone speech Mood: Lability (depressed) prone to suicide, therefore PROMOTE SAFETY Increased salivation (drooling)
Prepare suction app at bedside
Autonomic changes: Increased sweating and lacrimation Seborrhea (oversecretion of sebaceous gland) Decreased sexual capacity
Rx Anti-Parkinson agents: Levodopa (L-dopa) [Larodopa] short-acting anti-parkinson Mechanism: increases levels of dopamine Side effects: GIT irritation (nausea and vomiting) ORTHOSTATIC HYPOTENSION always asked in the board exam! Arrhythmia Hallucination Confusion
Anti-Parkinsonians
Nursing management for L-dopa Best given with meals to avoid GIT irritation Inform client that his urine and stool may be darkened Instruct client to avoid foods rich in Vit B6 (Pyridoxine): cereals, green leafy vegetables and organ meats Pyridoxine reverses the therapeutic effect of levodopa
Carbidopa [Sinemet] long-acting antiparkinson Mechanism: same as levodopa Side effects: Hypokinesia Hyperkinesias Psychiatric symptoms: EXTRAPYRAMIDAL SYMPTOMS
Amantadine HCl [Symmetrel] Mechanism: same as levodopa Side effects: Tremors Rigidity Bradykinesia
Anticholinergics: [Artane] and [Cogentin] Anticholinergics are given to relieve tremors Mechanism of action: inhibits acetylcholine Side-effects: SNS effects Antihistamines: Diphenhydramine [Benadryl] Antihistamines also relieve tremors Side effect for adults: drowsiness Patient should avoid driving and operating machinery Side effect for children: CNS excitability hyperactivity (paradoxical effect for young children < 2 y.o.)
Dopamine agonists: Bromocriptine [Parlodel] Relieves tremors, rigidity and bradykinesia Side-effect: Respiratory depression, therefore CHECK RR
Maintain siderails, to prevent injury related to falls Prevent complications of immobility: Turn to side q 2, q 1 if elderly Diet should be low-protein in AM, high-protein in PM (give milk before bedtime)
High-protein diet induces sleep (Tryptophan is a precursor to melatonin, the sleep hormone)
Assist in ambulation Safety precautions: Patient should wear flat rubber shoes, and use grab bars
MYASTHENIA GRAVIS
A neurovascular disorder characterized by a disturbance in the transmission of impulse fro nerve to muscle cells at the neuromuscular junction leading to DESCENDING MUSCLE PARALYSIS. More common in women aged 20 to 40.
Etiology: idiopathic, related to autoimmune For unknown reasons, the body is producing cholinesterase which destroys acetylcholine, the neurotransmitter for muscle movement, leading to muscle weakness.
s/Sx:
Initial Sign: PTOSIS (drooping of upper eyelid) Diplopia Masklike facial expression Dysphagia Hoarseness Respiratory muscle weakness respiratory arrest (Prepare tracheostomy set at bedside) Extreme muscle weakness especially during activity or exertion
Dx test:
TENSILON TEST
Tensilon (Edrophonium HCl) is a short acting anticholinesterase Tensilon is administered via IV push If patient has MG, symptoms will be temporarily relieved (for 5 to 10 minutes)
Burning pain on urination Urinary frequency Hematuria Flank pain; costovertebral angle tenderness Mgt: ACID ASH diet, increase fluid intake, perineal care Rx: SULFA DRUGS (trimethoprim, bactrim) AVOID: bubble baths
NEPHROLITHIASIS, UROLITHIASIS
PF: Acid or oxalate stones Renal colic radiating to groin Abdominal or flank pain Hematuria Mgt: Ambulation, increase fluids Removal of stones DOC: Morphine Caused by acid = ALKALINE ASH Caused by uric = PURINE-FREE Caused by oxalate = ACID - ASH
BPH Nocturia and decrease force of urine stream Elevated PSA Recommend: DRE annually Herbal: Saw palmetto TURP: Cystocylsis
GLAUCOMA = Halo vision, headache, loss of peripheral vision Tonometry(IOP) , Perimetry (visual field) DOC: Miotics(TIMOLOL), high fiber diet CATARACT = PAINLESS BLURRY VISION, CLOUDY OPACITY RETINAL DETACHMENT = curtain like vision
OTITIS MEDIA frequent pulling of ear (manifestation), pain, tinnitus, redness Myringotomy MENIERES DISEASE = triad: vertigo, sensorineural hearing loss, nystagmus Priority: safety Caloric test Diamox reduces fluid pressure Diet: Low sodium diet
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