medical-surgical nursing with mnemonics[1]

FOCUS! AND AIM HIGH WITH GOD

Graphics & Edited By:

J. F. ADORABLE, RN.

Text from Pentagon Review Center

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)

Parasympathetic Nervous System (CHOLINERGIC, VAGAL, SYMPATHOLYTIC)

- Involved in fight or aggression response. - Release of Norepinephrine (cathecolamines) from adrenal glands and causes vasoconstriction. - Increase all bodily activity except GIT EFFECTS OF SNS - Dilation of pupils(mydriasis) in order to be aware. - Dry mouth (thickened saliva). - Increase BP and Heart Rate. - Bronchodilation, Increase RR - Constipation. - Urinary Retention. FLUID VOLUME EXCESS - Increase blood supply to brain, heart and skeletal muscles. - SNS I. Adrenergic Agents - Give Epinephrine. [ADRENALIN] Signs and Symptoms: - SNS Contraindication: - Contraindicated to patients suffering from COPD (Broncholitis, Bronchoectasis, Emphysema, Asthma). II. Anti-cholinergic Agents - To counter cholinergic agents. - Atropine Sulfate – decreased mucus production Side Effects - SNS

Antipsychotics: Haloperidol [Haldol], chlorpromazine Thorazine, etc.

Side effect of THORAZINE: atopic dermatitis and foul smelling odor.

Side effect of all antipsychotic: signs of PARKINSON‘S DISEASE, therefore antipsychotic are given together with antiparkinson drugs

Anti-parkinson drugs: C.A.P.A.B.L.E.S

- Involved in fight or withdrawal response. - Release of Acetylcholine. - vasodilation bronchoconstriction - Decreases all bodily activities except GIT. EFFECTS OF PNS - Constriction of pupils (meiosis). - Increase salivation. - Decrease BP and Heart Rate. - Bronchoconstriction, Decrease RR. - Diarrhea - Urinary frequency. FLUID VOLUME DEF. - antihypertension I. Cholinergic Agents - Mestinon, Neostigmine. Side Effects - PNS II. Beta-adrenergic Blocking Agents - Also called Beta-blockers. - All ending with ―lol‖ - Propranolol [Inderal], Atenelol, Metoprolol. Effects of Beta-blockers B – roncho spasm E – licits a decrease in myocardial contraction. T – reats hypertension. A – V conduction slows down. Should be given to patients with Angina

Pectoris, Myocardial Infarction, and 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.

[Spinal cord terminates at L1 to L2 therefore a LUMBAR TAP is performed at L3 , L4 or L5 no risk for

spinal cord damage]

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 Produces myelin sheath in CNS. Act as insulator and facilitates rapid nerve impulse transmission

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 [hepatic coma]

[AIRWAY FOR HEPATIC COMA]

2. Carbon Monoxide and Lead Poisoning

Can lead to Parkinson’s disease.

[PILL ROLLING TREMORS]

Epilepsy

Treat with ANTIDOTE: Calcium EDTA

For Lead poisoning

Hyperbaric oxygenation (100% O2)

For carbon monoxide poisoning

PATHOGNOMONIC SIGNS

1. PTB - Low-grade afternoon fever.

2. PNEUMONIA - Rusty sputum.

3. ASTHMA - Wheezing on expiration.

4. EMPHYSEMA - Barrel chest.

5. KAWASAKI DISEASE - Strawberry tongue.

6. PERNICIOUS ANEMIA - Red beefy tongue.

7. DOWN SYNDROME - Protruding tongue / semian crease on palm

8. CHOLERA - Rice watery stool.

9. MALARIA - Stepladder like fever and chills.

10. TYPHOID - Rose spots in abdomen.

11. DIPTHERIA - pseudo membrane formation (pharynx, tonsils, nasal)

12. MEASLES - Koplik’s spots.

13. SLE - Butterfly rashes.

14. LIVER CIRRHOSIS - spider angioma, due to esophageal varices

15. LEPROSY - lioning face

16. BULIMIA NERVOSA - Chipmunk face. Parotid gland swelling

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 SHAPE mass on the abdomen

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

29. PARKINSON’S DISEASE - Pill rolling tremors

30. HEPATITIS - Jaundice

31. THROMBOPHEBITIS - Homan’s sign

32. CATARACT - Hazy vision / loss of central vision

33. GLAUCOMA - Tunnel vision / loss of peripheral vision

34. RETINAL DETACHMENT - Curtain veil-like vision / flashes and floaters

35. CHOLECYSTITIS - Murphy’s sign (pain on deep inspiration, a inflammation of the gallbladder

36. ANGINA PECTORIS - Levine’s sign [hand clutching in the chest]

37. MYASTHENIA GRAVIS - Ptosis [drooping of the upper eyelid]

38. TETRALOGY OF FALLOT - Clubbing of fingers

3. Type 1 DM (IDDM) [KETONES]

Causes diabetic ketoacidosis.

And increases breakdown of fats.

And free fatty acids

Resulting to cholesterol and (+) to Ketones (CNS depressant).

Resulting to acetone breath odor/fruity odor.

KUSSMAUL’S respiration, a rapid shallow respiration.

This may lead to diabetic coma.

4. Hepatitis

Signs of jaundice (icteric sclerae).

Caused by bilirubin (yellow pigment)

5. Bilirubin

Increase bilirubin in brain (Kernicterus).

Causing irreversible brain damage.

DEMYELINATING DISORDERS

1. ALZHEIMER’S DISEASE

Atrophy of brain tissues. Progressive, irreversible, degenerative neurologic disease characterized by

gradual losses of cognitive fx. And disturbances in behavior and affect.

Sign and Symptoms

4 A’s of Alzheimer

a. Amnesia – partial or total loss of memory.

b. Agnosia – no recognition of inanimate objects.

c. Apraxia – no recognition of objects function.

d. Aphasia – no speech (nodding).

*Expressive aphasia (Broca‘s Aphasia) frontal lobe

―motor speech center‖

Nursing mgt. provide PICTURE BOARD

*Receptive aphasia (Wernicke‘s Aphasia) temporal lobe

Inability to understand spoken words.

Irrational thoughts/illogical

General Knowing Gnostic Area or General Interpretative Area.

DRUG OF CHOICE: ARICEPT (taken at bedtime) and COGNEX. [increasing acetylcholine]

2. MULTIPLE SCLEROSIS [Autoimmune process]

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

Pain, pressure, heat and cold. [do not give hot packs b‘coz of dec. sensation to heat which can lead to burns.]

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)

Intentional tremors 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/cord following laminotomy.

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. [Best given in Morning to mimic body normal rhythm]

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) – treat urinary retention

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 (Probanthine) – antispasmodic drug to treat urinary incontinence

Acid ash diet like cranberry juice, plums, prunes, pineapple, vitamin C and orange.

To acidify urine and prevent bacterial multiplication.

CHARCOTS TRIAD ANI

COMMON CAUSE OF UTI

Female

short urethra (3-5 cm, 1-1 ½ inches)

poor perineal hygiene

vaginal environment is moist

Nursing Management

avoid bubble bath (can alter Ph of vagina).

avoid use of tissue papers

avoid using talcum powder and perfume.

Male

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).

MACROPHAGE ORGAN

Microglia

Monocytes

Kupffers cells

Histiocytes

Alveolar

Macrophage

Brain

Blood

Kidney

Skin

Lung

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

1. Frontal

higher cortical thinking

controls personality

controls motor activity

Broca‘s Area (motor speech area) when damaged results to garbled speech.

2. Temporal

hearing

short term memory

3. Parietal

for appreciation

Discrimination of sensory impulses to pain, touch, pressure, heat, cold, numbness.

4. Occipital

for vision

Insula (Island of Reil)

Visceral function activities of internal organ like gastric motility.

Limbic System (Rhinencephalon)

controls smell and if damaged results to Anosmia (absence of smell).

controls libido [the true sense of sexual arousal is when you smelled the fumes of the natural body]

controls long term memory

2. BASAL GAGLIA

areas of grey matter located deep within each cerebral hemisphere.

release dopamine (controls gross voluntary movement.)

NEURO TRANSMITTER DECREASE INCREASE

Acethylcholine Myasthenia Gravis Bi-polar Disorder

Dopamine Parkinson’s Disease Schizophrenia

3. MIDBRAIN/ MESENCEPHALON

acts as relay station for sight and hearing.

size of pupil is 2 – 3 mm.

equal size of pupil is isocoria.

unequal size of pupil is anisocoria.

hearing acuity is 30 – 40 dB.

positive PERRLA [Pupils equal, round, reactive to light and accommodation]

4. INTERBRAIN/ DIENCEPHALON

Parts of Diencephalon

A. Thalamus

Acts as relay station for sensation.

B. Hypothalamus

Controls temperature (thermoregulatory center).

controls blood pressure

controls thirst

appetite/satiety

sleep and wakefulness

Controls some emotional responses like fear, anxiety and excitement.

controls pituitary functions

Androgenic hormones promote secondary sex characteristics.

early sign for males are testicular and penile enlargement

late sign is deepening of voice.

early sign for females telarche and late sign is menarche.

5. BRAIN STEM

located at lowest part of brain

Parts of Brain Stem

1. Pons

pneumotaxic center controls the rate, rhythm and depth of respiration.

2. Medulla Oblongata

Controls respiration, heart rate, and swallowing, vomiting, hiccup, vasomotor center (dilation and

constriction of bronchioles).

[damage to medulla is most life threatening]

3. Cerebellum

Smallest part of the brain.

Lesser brain.

Controls balance, equilibrium, posture and gait.

INTRA CRANIAL PRESSURE

Monroe Kellie Hypothesis

Skull is a closed container

Any alteration or increase in one of the intracranial components

Increase intra-cranial pressure

(normal ICP is 0 – 15 mmHg)

Cervical 1 – also known as ATLAS.

Cervical 2 – also known as AXIS.

Foramen Magnum

Medulla Oblongata

Brain Herniation

Increase intra cranial pressure

* Alternate hot and cold compress to prevent HEMATOMA

CSF cushions brain (shock absorber)

Obstruction of flow of CSF will lead to enlargement of skull posteriorly called hydrocephalus.

Early closure of posterior fontanels causes posterior enlargement of skull in hydrocephalus.

NEUROLOGIC DISORDERS

INCREASE INTRACRANIAL PRESSURE – increase in intra-cranial bulk brought about by an increase in one of the 3

major intra cranial components. NORMAL ICP: 0-15 mmhg

Causes:

head trauma/injury

localized abscess

cerebral edema

hemorrhage

inflammatory condition (stroke)

hydrocephalus

tumor (rarely)

Signs and Symptoms (Early)

decrease LOC

restlessness/agitation

irritability

lethargy/stupor

coma

Signs and Symptoms (Late)

changes in vital signs

Blood pressure (systolic blood pressure increases but diastolic remains the same).

Widening of pulse pressure is neurologic in nature (if narrow cardiac in nature).

heart rate decrease

respiratory rate decrease

Temperature increase directly proportional to blood pressure.

projective vomiting

headache

papilledema (edema of optic disc)

abnormal posturing, [may positive to babinski reflex]

Decorticate posturing (damage to cortex and spinal cord).

decerebrate posturing (damage to upper brain stem

that includes pons, cerebellum and midbrain).

unilateral dilation of pupils called uncal herniation

bilateral dilation of pupils called tentorial herniation

resulting to mild headache

possible seizure activity

Nursing Management

1. Maintain patent and adequate ventilation by:

a. Prevention of hypoxia and hypercarbia

Early signs of hypoxia

Restlessness

Agitation

Tachycardia

Late signs of hypoxia

Bradycardia

Extreme restlessness

Dyspnea

Cyanosis

HYPERCARBIA

Increase CO2 (most powerful respiratory stimulant) retention.

In chronic respiratory distress syndrome decrease O2 stimulates respiration.

b. Before and after suctioning hyper oxygenate client 100% and done 10 – 15 seconds only.

c. Assist in mechanical ventilation

2. Elevate bed of client 30 – 35o angle with neck in neutral position unless contraindicated to promote venous drainage.

3. Limit fluid intake to 1200 – 1500 ml/day (in force fluids 2000 – 3000 ml/day).

4. Monitor strictly input and output and neuro check

5. Prevent complications of

6. Prevent further increase ICP by:

a. provide an comfortable and quite environment.

b. avoid use of restraints.

c. maintain side rails.

d. instruct client to avoid forms of valsalva maneuver like:

straining stool

excessive vomiting (use anti emetics)

excessive coughing (use anti tussive like dextromethorphan)

avoid stooping/bending

avoid lifting heavy objects

e. avoid clustering of nursing activity together.

7. Administer medications like:

a. Osmotic diuretic (Mannitol)

for cerebral diuresis

Nursing Management

monitor vital signs especially BP (hypotension).

monitor strictly input and output every 1 hour notify physician if output is less 30 cc/hr.

administered via side drip

Regulated fast drip to prevent crystal formation.

b. Loop diuretic (Lasix, Furosemide)

Drug of choice for CHF (pulmonary edema)

Loop of Henle in kidneys.

Nursing Management

Monitor vital signs especially BP (hypotension).

monitor strictly input and output every 1 hour notify physician if output is less 30 cc/hr.

Administered IV push or oral.

given early morning

Immediate effect of 10 – 15 minutes.

maximum effect of 6 hours. [monitor for potassium depletion]

c. Corticosteroids

Dexamethasone (Decadron)

Hydrocortisone

Prednisone (to reduce edema that may lead to increase ICP)

Mild Analgesics (Codeine Sulfate for respiratory depression)

Anti Convulsants (Dilantin, Phenytoin)

*CONGESTIVE HEART FAILURE

Signs and Symptoms

dyspnea

orthopnea

paroxysmal nocturnal dyspnea

productive cough

frothy salivation

cyanosis

rales/crackles

bronchial wheezing

pulsus alternans

anorexia and general body malaise

PMI (point of maximum impulse/apical pulse rate) is displaced laterally

S3 (ventricular gallop)

Predisposing Factors/Mitral Valve

RHD

Aging

TREATMENT

Morphine Sulfate

Aminophelline

Digoxin

Diuretics

Oxygen

Gases, blood monitor

RIGHT CONGESTIVE HEART FAILURE (Venous congestion)

Signs and Symptoms

jugular vein distention (neck)

ascites

pitting edema

weight gain

hepatosplenomegaly

jaundice

pruritus

esophageal varices

anorexia and general body malaise

Signs and Symptoms of Lasix in terms of electrolyte imbalances

1. Hypokalemia

decrease potassium level

normal value is 3.4 – 5.5 meq/L

Sign and Symptoms

weakness and fatigue

constipation

positive U wave on ECG tracing

Nursing Management

administer potassium supplements as ordered (Kalium Durule, Oral Potassium Chloride)

increase intake of foods rich in potassium

FRUITS VEGETABLES

Apple

Banana

Cantalope

Oranges

Asparagus

Brocolli

Carrots

Spinach

2. Hypocalcemia/ Tetany

decrease calcium level

normal value is 8.5 – 10.5 mg/100 ml

Signs and Symptoms

tingling sensation

paresthesia

numbness

(+) Trousseau’s sign/ Carpopedal spasm

(+) Chvostek’s sign

Complications

Arrhythmia

Seizures

Nursing Management

Calcium Gluconate per IV slowly as ordered

* Calcium Gluconate toxicity – results to SEIZURE

Magnesium Sulfate

Magnesium Sulfate toxicity [B.U.R.P]

S/S

BP

Urine output DECREASE

Respiratory rate

Patellar relfex absent

3. Hyponatremia

decrease sodium level

normal value is 135 – 145 meq/L

Signs and Symptoms

hypotension

dehydration signs (Initial sign in adult is THIRST, in infant TACHYCARDIA)

agitation

dry mucous membrane

poor skin turgor

weakness and fatigue

Nursing Management

force fluids

administer isotonic fluid solution as ordered

4. Hyperglycemia

normal FBS is 80 – 100 mg/dl

Signs and Symptoms - 3 P’s

polyuria

polydypsia

polyphagia

Nursing Management

monitor FBS

5. Hyperuricemia

increase uric acid (purine metabolism)

foods high in uric acid (sardines, organ meats and anchovies)

*Increase in tophi deposit leads to Gouty arthritis.

Signs and Symptoms

joint pain (great toes)

swelling

Nursing Management

force fluids

administer medications as ordered

a. Allopurinol (Zyloprim)

Drug of choice for gout.

Mechanism of action: inhibits synthesis of uric acid.

b. Colchecine

Acute gout

Mechanism of action: promotes excretion of uric acid.

KIDNEY STONES

Signs and Symptoms

renal colic

Cool moist skin

Nursing Management

force fluids

administer medications as ordered

a. Narcotic Analgesic

Morphine Sulfate

ANTIDOTE: Naloxone (Narcan)

toxicity leads to tremors.

b. Allopurinol (Zyloprim)

Side Effects

Respiratory depression (check for RR)

PARKINSON’S DISEASE/ PARKINSONISM

Chronic progressive disorder of CNS

characterized by degeneration of dopamine producing cells in the

SUBSTANCIA NIGRA of the midbrain and basal ganglia.

Predisposing Factors

1. Poisoning (lead and carbon monoxide)

2. Arteriosclerosis

3. Hypoxia

4. Encephalitis

5. Increase dosage of the following drugs:

a. Reserpine(Serpasil)

b. Methyldopa(Aldomet) AntihypertensiveS

c. Haloperidol(Haldol)

d. Phenothiazine AntipsychoticS

Multiple loss causes suicide

SIDE EFFECTS RESERPINE Major depression leading to suicide

Aloneness

Loss of spouse Loss of Job

direct approach towards the client

close surveillance is a nursing priority

time to commit suicide is on weekends early morning

Signs and Symptoms for Parkinson’s

pill rolling tremors of extremities especially the hands.

bradykinesia (slowness of movement)

rigidity (cogwheel type)

stooped posture

shuffling and propulsive gait

over fatigue

mask like facial expression with decrease blinking of the eyes.

difficulty rising from sitting position.

Dysphonia – soft slurred Monotone type speech

mood lability (in state of depression)

Micrographia-shrinking slow handwriting

increase salivation (drooling type)

autonomic changes

a. increase sweating

b. increase lacrimation

c. seborrhea

d. constipation

e. decrease sexual capacity

Nursing Management


Anti Parkinsonian agents

Levodopa (L-dopa) short acting

Amantadine Hydrochloride (Symmetrel)

Carbidopa (Sinemet)

Mechanism of Action

increase level of dopamine

Side Effects

GIT irritation (should be taken with meals

orthostatic hypotension (CBQ)

arrhythmia

hallucinations

Contraindications

clients with narrow angle closure glaucoma

clients taking MAOI‘s (no foods with tryptophan and thiamine: cheese, beer, avocado, wine)

urine and stool may be darkened

no Vitamin B6 (Pyridoxine) reverses the therapeutic effects of Levodopa

* Increase Vitamin B when taking INH (Isoniazid), Isonicotinic Acid Hydrazide

Anti Cholinergic Agents (ARTANE and COGENTIN) - to relieve tremors

Mechanism of Action

inhibits action of acethylcholine

Side Effects

SNS

Anti Histamine (Dipenhydramine Hydrochloride)

Side Effects

Adult: drowsiness

Children: CNS excitement (hyperactivity) because blood brain barrier is not yet fully developed.

Dopamine Agonist - relieves tremor rigidity

Bromocriptene Hydrochloride (Parlodel)

Side Effects

Respiratory depression

2. Maintain side rails to prevent injury

3. Prevent complications of immobility

4. Decrease protein in morning and increase protein in afternoon to induce sleep

5. Encourage increase fluid intake and fiber.

6. Assist/supervise in ambulation

7. Assist in Stereotaxic Thalamotomy –a portion of thalamus is destroyed to reduce tremors

MAGIC 2’s IN DRUG MONITORING [D.L.A.D.A]

DRUG NORMAL RANGE TOXICITY

LEVEL INDICATION CLASSIFICATION

Digoxin/ Lanoxin (Increase force of cardiac output)

.5 – 1.5 meq/L 2 CHF Cardiac Glycoside

Lithium/ Lithane (Decrease level of Ach/NE/Serotonin)

.6 – 1.2 meq/L 2 Bipolar Anti-Manic Agents

Aminophylline (Dilates bronchial tree)

10 – 19 mg/100 ml 20 COPD Bronchodilators

Dilantin/ Phenytoin 10 – 19 mg/100 ml 20 Seizures Anti-Convulsant

Acetaminophen/Tylenol 10 – 30 mg/100 ml 200 Osteoarthritis Non-narcotic

Analgesic

1. Digitalis Toxicity

Signs and Symptoms

nausea and vomiting / anorexia

diarrhea

confusion / fatigue / depression / malaise

photophobia

changes in color perception (yellowish or green halo around lights or ―snowy‖ vision)

Antidote: Digibind – digoxin immune FAB

2. Lithium Toxicity – anti-manic agent/ mood stabilizing agent

Signs and Symptoms

anorexia

nausea and vomiting

diarrhea

dehydration causing fine tremors

hypothyroidism (cretinism – the only endocrine disorder that can lead to mental retardation)

Nursing Management

force fluids

increase sodium intake to 4 – 10 g% daily

3. Aminophylline Toxicity

Signs and Symptoms

tachycardia

palpitations

CNS excitement (tremors, irritability, agitation and restlessness)

Nursing Management

Only mixed with plain NSS or 0.9 NaCl to prevent development of crystals or precipitate.

administered sandwich method

avoid taking alcohol because it can lead to severe CNS depression

avoid caffeine

4. Dilantin phenytoin Toxicity

Signs and Symptoms

gingival hyperplasia (swollen & tender gums)

hairy tongue

ataxia

nystagmus

Nursing Management

provide oral care

massage gums

5. Acetaminophen Toxicity

Signs and Symptoms

hepatotoxicity (monitor for liver enzymes)

SGPT/ALT (Serum Glutamic Pyruvate Transaminace)

SGOT/AST (Serum Glutamic Oxalo-Acetil Transaminace)

nephrotoxicity monitor BUN (10 – 20) and Creatinine (.8 – 1)

hypoglycemia

Tremors, tachycardia

Irritability

Restlessness

Extreme fatigue

Diaphoresis, depression

Antidote: Acetylcisteine (mucomyst) prepare suction apparatus at bedside.

MYASTHENIA GRAVIS

Neuromuscular disorder characterized by a disturbance in the transmission of impulses from nerve to

muscle cells at the neuromuscular junction leading to descending muscle weakness.

Incidence rate: women 20 – 40 years old

Predisposing factors

unknown

Autoimmune: it involves release of cholinesterase an enzyme that destroys Acetylcholine

Signs and Symptoms

initial sign is ptosis a clinical parameter to determine ptosis is palpebral fissure. (drooping of eyelid)

diplipia

mask like facial expression

dysphagia

hoarseness of voice [dysphonia-voice impairment]

respiratory muscle weakness that may lead to respiratory arrest (tracheostomy at bed side)

extreme muscle weakness especially during activity or exertion

Diagnostic Procedure

Tensilon test (Edrophonium Hydrochloride) provides temporary relief of signs and symptoms for about 5

– 10 minutes and a maximum of 15 minutes.

if there is no effect there is damage to occipital lobe and midbrain and is negative for M.G.

Nursing Management

1. Airway

2. Aspiration maintain patent airway and adequate ventilation

3. Immobility

* assist in mechanical ventilation and monitor pulmonary function test

* monitor strictly vital signs, input and output and neuro check

* monitor strength or motor grading scale

4. Maintain side rails to prevent injury related to falls

5. Institute NGT feeding


a. Cholinergic (Mestinon) – pyridostigmine bromide

b. Anti Cholenisterase (Prostigmin) – neostigmine bromide

Mechanism of Action

increase level of Ach

Side Effects

PNS

Cortocosteroids suppress immune response

monitor for 2 types of crisis:

MYASTHENIC CRISIS CHOLINERGIC CRISIS

Causes: under medication stress (disease exacerbation, high temp.) infection

Signs and Symptoms The client is unable to see, swallow, speak,

breathe Treatment

administer cholinergic agents as ordered

Cause: over medication

Signs and Symptoms PNS Tensilon test doesn‘t improve MG

Treatment

Administer anti cholinergic agents (Atropine Sulfate)

7. Assist in surgical procedure known as thymectomy because it is believed that the thymus gland is responsible for M.G.

8. Assist in plasma paresis and removing auto immune anti bodies

9. Prevent complications

INFLAMMATORY CONDITIONS OF THE BRAIN

MENINGITIS

Meninges

3 fold membrane that covers brain and spinal cord.

for support and protection

for nourishment

blood supply

LAYERS OF THE MENINGES

1. Dura matter – outer layer

2. Arachnoid – middle layer

3. Pia matter – inner layer

subdural space between the dura and arachnoid

Subarachnoid space between the arachnoid and pia, CSF aspiration is done.

A. Etiology

1. Meningococcus – most dangerous

2. Pneumococcus

3. Streptococcus - causes adult meningitis

4. Hemophilus Influenzae – causes pediatric meningitis

B. Mode of transmission

airborne transmission (droplet nuclei)

C. Signs and Symptoms

headache

photophobia

projectile vomiting

fever & chills, anorexia, generalized body malaise and weight loss

Possible increase in ICP and seizure activity

Abnormal posturing (decorticate and decerebrate)

Signs of meningeal irritation

a. Nuchal rigidity or stiff neck

b. Opisthotonus (arching of back)

c. (+) Kernig’s sign (leg pain)

d. (+) Brudzinski sign (neck pain)

D. Diagnostic Procedures

Lumbar puncture: a hollow spinal needle is inserted in the subarachnoid space between the L3 – L4 to

L5.

Nursing Management for LP

Before Lumbar Puncture. [note all surgery procedure explain by the doctor, diagnostic procedure is by the nurse] 1. Secure informed consent and explain procedure. 2. Empty bladder and bowel to promote comfort. 3. Encourage to arch back to clearly visualize L3-L4. (fetal position)

Post Lumbar Puncture 1. Place flat on bed 12 – 24

o

2. Force fluids 3. Check punctured site for any discoloration, drainage and leakage to tissues. 4. Assess for movement and sensation of extremities.

CSF analysis reveals 1. Increase CHON and WBC 2. Decrease glucose 3. Increase CSF opening pressure (normal pressure is 50 – 100 mmHg) 4. (+) cultured microorganism (confirms meningitis)

CBC reveals notes on hematology:

1. Increase wbc

E. Nursing Management

1. Enforce complete bed rest


a. Broad spectrum antibiotics (Penicillin, Tetracycline)

b. Mild analgesics

c. Anti pyretics

3. Institute strict respiratory isolation 24 hours after initiation of anti biotic therapy

4. Elevate head 30-45o

5. Monitor strictly V/S, input and output and neuro check

6. Institute measures to prevent increase ICP and seizure.

7. Provide a comfortable and darkened environment.

8. Maintain fluid and electrolyte balance.

9. Provide client health care and discharge planning concerning:

a. Maintain good diet of increase CHO, CHON, calories with small frequent feedings.

b. Prevent complications

most feared is hydrocephalus

hearing loss/nerve deafness is second complication

consult audiologist

c. Rehabilitation for neurological deficit

mental retardation

delayed psychomotor development

INCREASED DECREASED

RBC Polycythemia Anemia

WBC Leukocytosis Leukopenia

PLATELETS Thrombocytosis Thrombocytopenia

CVA (STROKE/BRAIN ATTACK/ ADOPLEXY/ CEREBRAL THROMBOSIS)

a partial or complete disruption in the brains blood supply.

2 most common cerebral artery affected by stroke

a. Mid Cerebral Artery

b. Internal Cerebral Artery – the 2 largest artery

A. Incidence Rate

men are 2-3 times high risk

B. Predisposing Factors

thrombus (attached)

embolus (detached and most dangerous because it can go to the lungs and cause pulmonary

embolism or the brain and cause cerebral embolism.

Signs and Symptoms of Pulmonary Embolism

Sudden sharp chest pain

Unexplained dyspnea

Tachycardia

Palpitations

Diaphoresis

Mild restlessness

Signs and Symptoms of Cerebral Embolism

Headache and dizziness

Confusion

Restlessness

Decrease LOC

Fat embolism is the most feared complications after femur fracture.

Yellow bone marrow are produced from the medullary cavity of the long bones and produces fat cells.

If there is bone fracture there is hemorrhage and there would be escape of the fat cells in the circulation.

Compartment syndrome (compression of arteries and nerves)

Notes: “Plegia” – paralysis Ex: Hemiplegia – paralysis of one side of the body. “Paresis” – weakness Ex: Hemiparesis - weakness of one side

of the body.

C. Risk Factors

1. Hypertension, Diabetes Mellitus, Myocardial Infarction, Atherosclerosis, Valvular Heart Disease, Post Cardiac Surgery

(mitral valve replacement)

2. Lifestyle (smoking), sedentary lifestyle

3. Obesity (increase 20% ideal body weight)

4. Hyperlipidemia more on genetics/genes that binds to cholesterol

5. Type A personality

a. deadline driven

b. can do multiple tasks

c. usually fells guilty when not doing anything

6. Related to diet: increase intake of saturated fats like whole milk

7. Related stress physical and emotional

8. Prolong use of oral contraceptives promotes lypolysis (breakdown of lipids) leading to atherosclerosis that will lead to

hypertension and eventually CVA.

D. Signs and Symptoms

dependent on stages of development

1. TIA

Initial sign of stroke or warning sign

Signs and Symptoms

headache and dizziness

tinnitus

visual and speech disturbances

paresis to plegia

possible increase ICP

2. Stroke in evolution

-progression of signs and symptoms of stroke

3. Complete stroke

resolution phase characterized by:

Signs and Symptoms

headache and dizziness

Cheyne Stokes Respiration

anorexia, nausea and vomiting

dysphagia

(+) Kernig’s sign and Brudzinski sign

which may lead to hemorrhagic stroke

focal neurological deficits

a. phlegia

b. aphasia

c. dysarthria (inability to articulate words)

d. alexia (difficulty reading)

e. agraphia (difficulty writing)

f. homonymous hemianopsia (loss of half of visual field)

E. Diagnostic Procedure

1. CT Scan – reveals brain lesions

2. Cerebral Arteriography

reveals the site and extent of malocclusion

uses dye for visualization

most of dye are iodine based

check for shellfish allergy

after diagnostic exam force fluids to release dye because it is nephro toxic

check for distal pulse (femoral)

check for hematoma formation

F. Nursing Management

1. Maintain patent airway and adequate ventilation by:

a. assist in mechanical ventilation

b. administrate O2 inhalation

2. Restrict fluids to prevent cerebral edema that might increase ICP

3. Elevate head 30 – 45o

4. Monitor strictly vitals signs, I & O and neuro check

5. Prevent complications of immobility by:

a. turn client to side

b. provide egg crate mattresses or water bed

c. provide sand bag or foot board.

6. Assist in passive ROM exercise every 4 hours to promote proper bodily alignment and prevent contractures

7. Institute NGT feeding

8. Provide alternative means of communication

a. non verbal cues

b. magic slate

9. If positive to hemianopsia approach client on unaffected side


a. Osmotic Diuretics (Mannitol)

b. Loop Diuretics (Lasix, Furosemide)

c. Cortecosteroids

d. Mild Analgesics

e. Thrombolytic/Fibrinolytic Agents – dissolves thrombus

Streptokinase

Side Effect: Allergic Reaction

Urokinase

Tissue Plasminogen Activating Factor

Side Effect: Chest Pain

f. Anti Coagulants

Heparin (short acting)

check for partial thromboplastin time if prolonged there is a risk for bleeding.

give Protamine Sulfate

Comadin/ Warfarin (long acting)

give simultaneously because Coumadin will take effect after 3 days

check for prothrombin time if prolonged there is a risk for bleeding

give Vit. K (Aqua Mephyton)

g. Anti Platelet

PASA (Aspirin)

Contraindicated for dengue, ulcer and unknown cause of headache because it may potentiate

bleeding

11. Provide client health teachings and discharge planning concerning

a. avoidance of modifiable risk factors (diet, exercise, smoking)

b. prevent complication (subarachnoid hemorrhage is the most feared complication)

c. dietary modification (decrease salt, saturated fats and caffeine)

d. importance of follow up care

GUILLAIN BARRE SYNDROME (Acute Ediopathic Polyneuropathy)

a disorder of the CNS characterized by bilateral symmetrical polyneuritis leading to ascending muscle

paralysis/weakness.

A. Predisposing Factors

1. Autoimmune

2. Antecedent viral infections such as LRT infections

B. Signs and Symptoms

1. Clumsiness (initial sign)

2. Dysphagia

3. Ascending muscle weakness leading to paralysis

4. Decreased of diminished deep tendon reflex

5. Alternate hypotension to hypertension

** ARRYTHMIA (most feared complication)

6. Autonomic symptoms that includes

a. increase salivation

b. increase sweating

c. constipation

C. Diagnostic Procedures

1. CSF analysis reveals increase in IgG and protein

D. Nursing Management

1. Maintain patent airway and adequate ventilation by:

a. assist in mechanical ventilation

b. monitor pulmonary function test

2. Monitor strictly the following

a. vital signs

b. intake and output

c. neuro check

d. ECG

3. Maintain side rails to prevent injury related to fall

4. Prevent complications of immobility by turning the client every 2 hours

5. Institute NGT feeding to prevent aspiration

6. Assist in passive ROM exercise


a. Corticosteroids – suppress immune response

b. Anti Cholinergic Agents – Atrophine Sulfate

c. Anti Arrythmic Agents

Lidocaine, Zylocaine

Bretylium – blocks release of norepinephrine to prevent increase of BP

8. Assist in plasma pharesis (filtering of blood to remove autoimmune anti-bodies)


a. Arrythmia

b. Paralysis or respiratory muscles / Respiratory arrest

* Sengstaken Blakemore Tube

for liver cirrhosis

to decompress bleeding esophageal verices (prepare scissor to cut tube incase of difficulty in breathing

to release air in the balloon

for hemodialysis prepare bulldog clips to prevent air embolism.

CONVULSIVE DISORDER/ CONVULSION

Disorder of CNS characterized by paroxysmal seizure with or without loss of consciousness abnormal

motor activity alternation in sensation and perception and changes in behavior.

Seizure – first convulsive attack

Epilepsy – second or series of attacks

Febrile seizure – normal in children age below 5 years


1. Head injury due to birth trauma

2. Genetics

3. Presence of brain tumor

4. Toxicity from

a. lead

b carbon monoxide

5. Nutritional and Metabolic deficiencies

6. Physical and emotional stress

7. Sudden withdrawal to anti convulsant drug is predisposing factor for status epilepticus (drug of choice is Diazepam,

Valium)


Dependent on stages of development or types of seizure

I. Generalized Seizure

1. Grand mal Seizure (tonic-clonic seizure)

a. Signs or aura with auditory, olfactory, visual, tactile, sensory experience

b. Epileptic cry – is characterized by fall and loss of consciousness for 3 – 5 minutes

c. Tonic contractions - direct symmetrical extension of extremities

Clonic contractions - contraction of extremities

d. Post ictal sleep – unresponsive sleep

2. Petit mal Seizure – absence of seizure common among pediatric clients characterized by

a. blank stare

b. decrease blinking of eyes

c. twitching of mouth

d. loss of consciousness (5 – 10 seconds)

II. Partial or Localized Seizure

1. Jacksonian Seizure (focal seizure)

Characterized by tingling and jerky movement of index finger and thumb that spreads to the shoulder and other side

of the body.

2. Psychomotor Seizure (focal motor seizure)

a. automatism – stereotype repetitive and non propulsive behavior

b. clouding of consciousness – not in contact with environment

c. mild hallucinatory sensory experience

III. Status Epilepticus

A continuous uninterrupted seizure activity, if left untreated can lead to hyperpyrexia and lead to coma

and eventually death.

Drug of choice: Diazepam, Valium and Glucose


1. CT Scan – reveals brain lesions

2. EEG – reveals hyper activity of electrical brain waves


1. Maintain patent airway and promote safety before seizure activity

a. clear the site of blunt or sharp objects

b. loosen clothing of client

c. maintain side rails

d. avoid use of restrains

e. turn clients head to side to prevent aspiration

f. place mouth piece of tongue guard to prevent biting or tongue

2. Avoid precipitating stimulus such as bright/glaring lights and noise


a. Anti convulsants (Dilantin, Phenytoin)

b. Diazepam, Valium

c. Carbamazepine (Tegretol) – Trigeminal neuralgia

d. Phenobarbital, Luminal

4. Institute seizure and safety precaution post seizure attack

a. administer O2 inhalation

b. provide suction apparatus

5. Document and monitor the following

a. onset and duration

b. types of seizures

c. duration of post ictal sleep may lead to status epilepticus

d. assist in surgical procedure cortical resection

COMPREHENSIVE NEURO EXAM

GLASGOW COMA SCALE

objective measurement of LOC sometimes called as the quick neuro check

Components

1. Motor response

2. Verbal response

3. Eye opening

Survey of mental status and speech

a. LOC

b. Test of memory

Levels of orientation

Cranial nerve assessment

Sensory nerve assessment

Motor nerve assessment

Deep tendon reflex

Autonimics

Cerebellar test

a, Romberg‘s test – 2 nurses, positive for ataxia

b. Finger to nose test – positive result mean dimetria

(inability of body to stop movement at desired point)

c. Alternate supination and pronation – positive result mean dimetria

I. LEVEL OF CONSCIOUSNESS

1. Conscious - awake

2. Lethargy – lethargic (drowsy, sleepy, obtunded)

3. Stupor

stuporous (awakened by vigorous stimulation)

generalized body weakness

decrease body reflex

4. Coma

comatose

light coma (positive to all forms of painful stimulus)

deep coma (negative to all forms of painful stimulus)

Conscious 15 – 14

Lethargy 13 – 11

Stupor 10 – 8

Coma 7

Deep Coma 3

DIFFERENT PAINFUL STIMULATION

1. Deep sternal stimulation/ deep sternal pressure

2. Orbital pressure

3. Pressure on great toes

4. Corneal or blinking reflex

Conscious client use a wisp of cotton

Unconscious client place 1 drop of saline solution

II. TEST OF MEMORY

1. Short term memory

ask most recent activity

positive result mean anterograde amnesia and damage to temporal lobe

2. Long term memory

ask for birthday and validate on profile sheet

positive result mean retrograde amnesia and damage to limbic system

consider educational background

III. LEVELS OF ORIENTATION

1. Time – first asked

2. Person – second asked

3. Place – third asked

CRANIAL NERVES

CRANIAL NERVE I: OLFACTORY

sensory function for smell

Material Used

don‘t use alcohol, ammonia, perfume because it is irritating

and highly diffusible.

use coffee granules, vinegar, bar of soap, cigarette

Procedure

test each nostril by occluding each nostril

Abnormal Findings

1. Hyposnia – decrease sensitivity to smell

2. Dysosmia – distorted sense of smell

3. Anosmia – absence of smell

Indicative of

1. head injury damaging the cribriform plate of ethmoid bone where olfactory cells are located

2. may indicate inflammatory conditions (sinusitis)

CRANIAL NERVE II: OPTIC

sensory function for vision or sight

Functions

1. Test visual acuity or central vision or distance

use Snellen’s Chart

Snellen‘s Alphabet chart: for literate clients

Snellen‘s E chart: for illiterate clients

Snellen‘s Animal chart: for pediatric clients

normal visual acuity 20/20

numerator is constant, it is the distance of person from the chart (6 – 7 m, 20 feet)

denominator changes, indicates distance by which the person normally can see letter in the chart.

- 20/200 indicates blindness

20/20 visual acuity if client is able to read letters above the red line.

2. Test of visual field or peripheral vision

CRANIAL NERVES

FUNCTION

I. OLFACTORY

S

II. OPTIC S

III OCCULOMOTOR M

IV. TROCHLEAR M

(Smallest)

V. TRIGEMINAL B

(Largest)

VI. ABDUCENSE M

VII. FACIAL B

VIII. ACOUSTIC S

IX. GLOSSOPHARYNGEAL B

X. VAGUS B

(Longest)

XI. SPINAL ACCESSORY M

XII. HYPOGLOSSAL M

a. Superiorly

b. Bitemporaly

c. Nasally

d. Inferiorly

COMMON VISUAL DISORDERS

1. Glaucoma

increase IOP

normal IOP is 12 – 21 mmHg

preventable but not curable


Common among 40 years old and above

Hereditary

Hypertension

Obesity


1. Loss of peripheral vision

pathognomonic sign is tunnel vision

2. Headache, nausea, vomiting, eye pain (halos around light)

steamy cornea

may lead to blindness


1. Tonometry

2. Perimetry

3. Gonioscopy

D. Treatment

1. Miotics – constricts pupil

a. Pilocarpine Sodium, Carbachol

2. Epinephrine eyedrops – decrease formation of aqueous humor

3. Carbonic Anhydrase Inhibitors

a. Acetazolamide (Diamox) – promotes increase outflow of aqueous humor or drainage

4. Timoptics (Timolol Maleate)

E. Surgical Procedures

1. TRABECULECTOMY (Peripheral Indectomy) – drain aqueous humor

2. CATARACT

Decrease opacity of lens

A. Predisposing Factor

1. Aging 65 years and above

2. Related to congenital

3. Diabetes Mellitus

4. Prolonged exposure to UV rays


1. Loss of central vision

C. Pathognomonic Signs

1. Blurring or hazy vision

2. Milky white appearance at center of pupils

3. Decrease perception to colors

Complication is blindness

D. Diagnostic Procedure

1. Opthalmoscopic exam

E. Treatment

1. Mydriatics (Mydriacyl) – dilating pupils

2. Cyclopegics (Cyclogyl) – paralyses cilliary muscle

F. Surgical Procedure

Extra Intra

Capsular Capsular

Cataract Cataract

Lens Lens

Extraction Extraction

- Partial removal - Total removal of cataract with its surrounding capsules

Most feared complication post op is RETINAL DETACHMENT

3. Retinal Detachment

Separation of epithelial surface of retina


1. Post Lens Extraction

2. Myopia (near sightedness)


1. Curtain veil like vision

2. Floaters

C. Surgical Procedures

1. Scleral Buckling

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

A. normal retina B. ―wet‖ macular degeneration c. ―dry‖ macular degeneration

trochlear controls superior oblique

abducens controls lateral rectus

oculomotor controls the 4 remaining EOM

Oculomotor

controls the size and response of pupil

normal pupil size is 2 – 3 mm

equal size of pupil: Isocoria

Unequal size of pupil: Anisocoria

Normal response: positive PERRLA

CRANIAL NERVE V: TRIGEMINAL

largest cranial nerve

consists of ophthalmic, maxillary, mandibular

sensory: controls sensation of face, mucous membrane, teeth, soft palate and corneal reflex)

motor: controls the muscle of mastication or chewing

damage to CN V leads to trigeminal neuralgia/tic douloureux (nerve pain)

medication: Carbamezapine(Tegretol) - anticonvulsant

CRANIAL NERVE VII: FACIAL

Sensory: controls taste, anterior 2/3 of tongue

pinch of sugar and cotton applicator placed on tip of tongue

Motor: controls muscle of facial expression

Instruct client to smile, frown and if results are negative there is facial paralysis or Bell‘s palsy and the

primary cause is forceps delivery.

CRANIAL NERVE VIII: ACOUSTIC/VESTIBULOCOCHLEAR

Controls balance particularly kinesthesia or position sense, refers to movement and orientation of the

body in space.

Parts of the Ear

1. Outer Ear

Pinna

Eardrum

2. Middle Ear

Hammer Malleus

Anvil Incus

Stirrup Stapes

3. Inner Ear

Vestibule: Meinere’s Disease

Cochlea

Mastoid Cells

Endolymph and Perilymph

COCHLEA: controls hearing, contains the Organ of Corti (the true organ of hearing)

Let client repeat words uttered

CRANIAL NERVE IX, X: GLOSOPHARYNGEAL, VAGUS NERVE

Glosopharyngeal: controls taste, posterior 1/3 of tongue

Vagus: controls gag reflex

Uvula should be midline and if not indicative of damage to cerebral hemisphere

Effects of vagal stimulation is PNS

CRANIAL NERVE XI: SPINAL ACCESSORY

Innervates with sternocleidomastoid (neck) and trapezius (shoulder)

CRANIAL NERVE XII: HYPOGLOSSAL

Controls the movement of tongue

Let client protrude tongue and it should be midline and if unable to do indicative of damage to cerebral

hemisphere and/or has short frenulum.

ENDOCRINE SYSTEM

Overview of the structures and functions

1. 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 (Dalas Ihi)

o Decrease production of anti diuretic hormone

A. Predisposing Factor

o Related to pituitary surgery

o Trauma

o Inflammation

o Presence of tumor


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 (payat)

6. If left untreated results to hypovolemic shock (sign is anuria)


1. Urine Specific Gravity

o Normal value: 1.015 – 1.030

o Ph 4 – 8

2. Serum Sodium

o Increase resulting to hypernatremia


1. Force fluids

2. Monitor strictly vital signs and intake and output


a. Pitressin (Vasopresin Tannate) – administered IM Z-tract

4. Prevent complilcations – HYPOVOLEMIC SHOCK is the most feared complication

Anterior pituitary Posterior pituitary

ADH

OXYTOCIN

GH

ACTH

TSH

FSH & LH

PROLACTIN

MSH

SIADH – lunod sa tubig

o hypersecretion of antidiuretic hormone


1. Head injury

2. Related to presence of bronchogenic cancer

o initial sign of lung cancer is non productive cough

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 pituitary gland.


1. Fluid retention

a. Hypertension

b. Edema

c. Weight gain (mataba)

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 (hyponatremia 135 mg/dl)


1. Restrict fluid


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


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

o located anterior to the neck

3 Hormones secreted

1. T3 (Tri iodothyronine) - 3 molecules of iodine (more potent)

2. T4 (tetra iodothyronine, Thyroxine)

o T3 and T4 are metabolic or calorigenic hormone

o promotes cerebration (thinking)

3. Thyrocalcitonin – antagonizes the effects of parathormone to promote calcium resorption.

HYPOTHYROIDISM – thyroid deficiency

o all are decrease except weight and menstruation

o memory impairment

Signs and Symptoms

o there is loss of appetite but there is weight gain

o menorrhagia or amenorrhea

o cold intolerance

o constipation

o can lead to Myxedema

o extreme fatigue

o babagsak sa exam (mental proc. Decreased)

o weight gain

o hypothermic

HYPERTHYROIDISM

o all are increase except weight and menstruation

Signs and Symptoms

o increase appetite but there is weight loss

o amenorrhea

o exophthalmos

o Tachycardia, palpitations

o insomnia

o restlessness agitation

o Heat intolerance

o HPN

THYROID DISORDERS

SIMPLE GOITER

o enlargement of thyroid gland due to iodine deficiency


1. Goiter belt area

a. places far from sea

b. Mountainous regions

2. Increase intake of goitrogenic foods

o contains pro-goitrin an anti thyroid agent that has no iodine.

o cabbage, turnips, radish, strawberry, carrots, sweet potato, broccoli, all nuts

Myxedema coma Severe hypothyroidism

- Increased lethargic

- Hypothermic - Stupor - coma

Pharmacologic therapy for hypothyroidism Synthetic levothyroxine (syndroid or levothroid)

o soil erosion washes away iodine

o goitrogenic drugs

a. Anti Thyroid Agent – Prophylthiuracil (PTU)

b. Lithium Carbonate d. Cobalt

c. PASA (Aspirin) e. Phenylbutazones (NSAIDs) - if goiter is caused by


1. Enlarged thyroid gland

2. Mild dysphagia

3. Mild restlessness


1. Serum T3 and T4 – reveals normal or below normal

2. Thyroid Scan – reveals enlarged thyroid gland.

3. Serum Thyroid Stimulating Hormone (TSH) –

is increased (confirmatory diagnostic test)




a. Lugol’s Solution/SSKI ( Saturated Solution of Potassium Iodine)

o color purple or violet and administered via straw to prevent staining of teeth.

o 4 Medications to be taken via straw: Lugol‘s, Iron, Tetracycline, Nitrofurantoin (drug of choice for

pyelonephritis)

b. Thyroid Hormones

o Levothyroxine (Synthroid)

o Liothyronine (Cytomel)

o Thyroid Extracts

Nursing Management when giving Thyroid Hormones

1. Instruct client to take in the morning to prevent insomnia

2. Monitor vital signs especially heart rate because drug causes tachycardia and palpitations

3. Monitor side effects

o insomnia

o tachycardia and palpitations

o hypertension

o heat intolerance

4. Increase dietary intake of foods rich in iodine

o seaweeds

o seafood‘s like oyster, crabs, clams and lobster but not shrimps because it contains lesser amount of

iodine.

o iodized salt, best taken raw because it it is easily destroyed by heat

5. Assist in surgical procedure of subtotal 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


1. Iatrogenic Cause – disease caused by medical intervention such as surgery

2. Related to atrophy of thyroid gland due to trauma, presence of tumor, inflammation

3. Iodine deficiency

4. Autoimmune (Hashimotos Disease)


(Early Signs)


2. Loss of appetite but with weight gain which promotes lipolysis leading to atherosclerosis and MI

3. Dry skin

4. Cold intolerance

5. Constipation

(Late Signs)

1. Brittleness of hair and nails

2. Non pitting edema (Myxedema)

3. Hoarseness of voice

4. Decrease libido

5. Decrease in all vital signs – hypotension, bradycardia, bradypnea, hypothermia

6. CNS changes

o lethargy

o memory impairment (forgetfulness)

o psychosis

o menorrhagia


1. Serum T3 and T4 is decreased

2. Serum Cholesterol is increased

3. RAIU (Radio Active Iodine Uptake) is decreased


1. Monitor strictly vital signs and intake and output to determine presence of

o Myxedema coma is a complication of hypothyroidism and an emergency case a severe form of

hypothyroidism is characterized by severe hypotension, bradycardia, bradypnea, hypoventilation,

hyponatremia, hypoglycemia, hypothermia leading to pregressive stupor and coma.

Nursing Management for Myxedema Coma

Assist in mechanical ventilation

Administer thyroid hormones as ordered

Force fluids

2. Force fluids

3. Administer isotonic fluid solution as ordered


Thyroid Hormones

a. Levothyroxine

b. Leothyronine

c. Thyroid Extracts

5. Provide dietary intake that is low in calories – due to wt. gain

6. Provide comfortable and warm environment – due to cold intolerance


8. Provide client health teaching and discharge planning concerning

a. Avoid precipitating factors leading to myxedema coma

o stress

o infection

o cold intolerance

o use of anesthetics, narcotics, and sedatives

o prevent complications (myxedema coma, hypovolemic shock

o hormonal replacement therapy for lifetime

o importance of follow up care

HYPERTHYROIDISM – grave‘s disease or thyroid toxicosis (everything is up except wt. and mens.

o increase in T3 and T4

o Grave’s Disease or Thyrotoxicosis

o developed by Robert Graves


1. Autoimmune – it involves release of long acting thyroid stimulator causing exopthalmus (protrusion of

eyeballs) enopthalmus (late sign of dehydration among infants)

2. Excessive iodine intake

3. Related to hyperplasia of TG (increase size)


1. Increase appetite (hyperphagia) but there is weight loss due to increased metabolism

2. Moist skin

3. Heat intolerance

4. Diarrhea

5. All vital signs are increased

6. CNS involvement

a. Irritability and agitation

b. Restlessness

c. Tremors

d. Insomnia

e. Hallucinations

7. Goiter

8. Exopthalmus (Pathognomonic sign)

9. Amenorrhea


1. Serum T3 and T4 is increased

2. RAIU (Radio Active Iodine Uptake) is increased

3. Thyroid Scan- reveals an enlarged thyroid gland


1. Monitor strictly vital signs and intake and output - determine thyroid storm or most feared complication:

Thyrotoxicosis


Anti Thyroid Agent

a. Prophythioracill (PTU)

b. Methymazole (Tapazole)

Most toxic Side Effects Agranulocytosis

o increase lymphocytes and monocytes

o fever and chills

o sore throat (throat swab/culture)

o leukocytosis (CBC)

o Most feared complication : Thrombosis – stroke CVS

3. Provide dietary intake that is increased in calories.


5. Comfortable and cold environment

6. Maintain side rails - due to agitation/restlessness

7. Provide bilateral eye patch to prevent drying of the eyes.

8. Assist in surgical procedures known as subtotal thyroidectomy

* Before thyroidectomy administer Lugol’s Solution (SSKI) to decrease vascularity of the thyroid

gland to prevent bleeding and hemorrhage.

TRIAD SIGNS

POST OPERATIVELY,

1. Watch out for signs of thyroid storm/ thyrotoxicosis

Agitation

Hyperthermia Tachycardia

o administer medications as ordered

a. Anti Pyretics

b. Beta-blockers – tachycardia

o Monitor strictly vital signs, input and output and neuro check.

o maintain side rails

o offer TSB

2. Watch out for accidental removal of parathyroid gland (secretes parathormone) that may lead to

Hypocalcemia (tetany)

Signs and Symptoms

o (+) trousseau‘s sign

o (+) chvostek sign

o Watch out for arrhythmia, seizure give Calcium Gluconate IV slowly as ordered

Ca gluconate toxicity – antidote – MgSO4

3. Watch out for accidental Laryngeal (voice box) damage which may lead to hoarseness of voice

Nursing Management

o encourage client to talk/speak immediately after operation and notify physician

4. Signs of bleeding (feeling of fullness at incisional site)

Nursing Management

o Check the soiled dressings at the back or nape area.

o Sign of laryngeal spasm – DOB, SOB (tracheostomy at bed side)

5. Hormonal replacement therapy for lifetime

6. Importance of follow up care

PARATHYROID GLAND

o A pair of small nodules behind the thyroid gland

o Secretes parathormone

o Promotes calcium reabsorption

o Thyrocalcitonin – antagonises secretion of parathyroid hormone

o Hypoparathyroidism

o Hyperparathyroidism

HYPOPARATHYROIDISM

o Decrease secretion of parathormone leading to hypocalcemia (tetany)

o Resulting to Hyperphosphatemia

[If Ca decreases, phosphate increases]


1. Following subtotal thyroidectomy

2. Atrophy of parathyroid gland due to:

a. inflammation

VIT. D (CHOLECALCEFEROL)

DRUG DIET SUNLIGHT

Cholecalceferol calcidiol calcitriol

7am – 9am

b. tumor

c. trauma


1. Acute tetany

a. tingling sensation

b. paresthesia

c. numbness

d. dysphagia

e. positive trousseau’s sign/carpopedal spasm

f. positive chvostek sign

g. laryngospasms / broncospasm

h. seizure feared complications

i. arrhythmia

2. Chronic tetany

a. photophobia and cataract formation

b. loss of tooth enamel

c. anorexia, nausea and vomiting

d. agitation and memory impairment (irritable)


1. Serum Calcium is decreased (normal value: 8.5 – 10.5 mg/100 ml)

2. Serum Phosphate is increased (normal value: 2.5 – 4.5 mg/100 ml)

3. X-ray of long bones reveals a decrease in bone density

4. CT Scan – reveals degeneration of basal ganglia


1. Administer medications as ordered such as:

a. Acute Tetany

Calcium Gluconate IV slowly

b. Chronic Tetany

Oral Calcium supplements

Calcium Gluconate

Calcium Lactate

Calcium Carbonate

c. Vitamin D (Cholecalciferol) for absorption of calcium

d. Phosphate binder

Aluminum Hydroxide Gel (Ampogel)

Side effect: constipation

ANTACID

A.A.C MAD ▼ ▼

Aluminum Containing Magnesium Containing Antacids Antacids ▼ ▼

Aluminum Ex. Milk of magnesia Hydroxide Gel (Maalox – magnesium & aluminum - Less s/e)

▼ 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 (decreased phosphorus)

a. anchovies - increase Ca, decrease phosphorus + inc uric acid. Tuna & green turnips- Inc Ca.

b. salmon

c. green turnips

Don„t give milk – due to increase phosphorus

4. Institute seizure and safety precaution

5. Encourage client to breathe using paper bag to produce mild respiratory acidosis result.

6. Prepare trachea set at bedside for presence of laryngospasm



9. Importance of follow up care.

HYPERPARATHYROIDISM

o Decrease parathormone

o Hypercalcemia: bone demineralization leading to bone fracture (calcium is stored 99% in bone and 1% blood)

o Kidney stones

(parathormone pullout the Ca in from the bone to the blood)


1. Hyperplasia of parathyroid gland

2. over compensation of parathyroid gland due to vitamin D deficiency

a. Children: Rickets - the bone do not hardened

b. Adults: Osteomalacia - softening of the bone


1. Bone pain especially at back (bone fracture)

2. Kidney stones

a. renal cholic

b. cool moist skin

3. Anorexia, nausea and vomiting

4. Agitation and memory impairment


1. Serum Calcium is increased

2. Serum Phosphate is decreased

3. X-ray of long bones reveals bone demineralization


1. Force fluids to prevent kidney stones

2. Strain all the urine using gauze pad for stone analysis

3. Provide warm sitz bath


a. Morphine Sulfate (Demerol)

5. Encourage increase intake of foods rich in phosphate but decrease in calcium

6. Provide acid ash in the diet to acidify urine and prevent bacterial growth

7. Assist/supervise in ambulation

8. Maintain side rails

9. Prevent complications (seizure and arrhythmia) most feared renal failure

10. Assist in surgical procedure known as parathyroidectomy



ADRENAL GLAND

o Located atop of each kidney

o 2 layers of adrenal gland

a. Adrenal Cortex – outermost

b. Adrenal Medulla – innermost (secretes catecholamine’s a power hormone)

2 Types of Catecholamines

o Epinephrine and Norepinephrine (vasoconstrictor) increased BP

o Pheochromocytoma (adrenal medulla)

o Increase secretion of norepinephrine

o Leading to hypertension which is resistant to pharmacological agents leading to CVA

o Use beta-blockers

PHEOCHROMOCYTOMA- presence of tumor at adrenal medulla

Increase norepinephrine. HPN with pounding headache. with HPN and resistant to drugs drug of choice: beta blockers complication: HPN crisis = lead to stroke no valsalva maneuver. Don‗t smoke. No caffeine.

ADRENAL CORTEX

3 Zones/Layers

1. Zona Fasciculata

- secretes glucocortocoids (cortisol)

- function: controls glucose metabolism

- Sugar

2. Zona Reticularis

- secretes traces of glucocorticoids and androgenic hormones

- function: promotes secondary sex characteristics

- Sex

3. Zona Glumerulosa

- secretes mineralocorticoids (aldosterone)

- function: promotes sodium and water reabsorption and excretion of potassium

- Salt

ADDISON’S DISEASE - payat

o Hyposecretion of adreno cortical hormone leading to

ex – secondary sex disturbances / decreased libido

ugar - metabolic disturbance / hypoglycemia

alt – fluid & electrolytes imbalance


1. Related to atrophy of adrenal glands

2. Fungal infections


1. Hypoglycemia – TIRED

2. Decrease tolerance to stress

3. Hyponatremia

- hypotension

- signs of dehydration

- weight loss

4. Hyperkalemia

- agitation

- diarrhea

- arrhythmia

5. Decrease libido

6. Loss of pubic and axillary hair

7. Bronze like skin pigmentation

s

I love Sex!!!


1. FBS is decreased (normal value: 80 – 100 mg/dl)

2. Plasma Cortisol is decreased

3. Serum Sodium is decrease (normal value: 135 – 145 meq/L)

4. Serum Potassium is increased (normal value: 3.5 – 4.5 meq/L)


1. Monitor strictly vital signs, input and output to determine presence of Addisonian crisis (complication of addison‘s

disease)

o Addisonian crisis results from acute exacerbation of addison‘s disease characterized by

a. severe hypotension

b. hypovolemic shock

c. hyponatremia leading to progressive stupor and coma

Nursing Management for Addisonian Crisis

1. Assist in mechanical ventilation,

- administer steroids as ordered

- force fluids


3. Force fluids


Addisonian crisis: Cyanosis Classic sign of circulatory shock: pallor, apprehension, rapid weak pulse, rapid RR, low BP

Hydrocortisone (Solu-Cortef) admin. IV, followed w/ 5% D5NS.

Corticosteroids

a. Dexamethasone (Decadrone)

b. Prednisone

c. Hydrocortisone (Cortison)

Nursing Management when giving steroids

1. Instruct client to take 2/3 dose in the morning and 1/3 dose in the afternoon to mimic the normal diurnal rhythm

2. Taper dose (withdraw gradually from drug)


a. hypertension

b. edema

c. hirsutism

d. increase susceptibility to infection

e. moon face appearance

4. Mineralocorticoids (Flourocortisone)

5. Provide dietary intake, increase calories, carbohydrates, protein but decrease in potassium


7. Provide client health teaching and discharge planning

a. avoid precipitating factor leading to addisonian crisis leading to

- stress

- infection

- sudden withdrawal to steroids

b. prevent complications

- addisonian crisis

- hypovolemic shock

c. hormonal replacement for lifetime

d. importance of follow up care

CUSHING SYNDROME - mataba

o Hypersecretion of adenocortical hormones


1 Related to hyperplasia of adrenal gland

2. Increase susceptibility to infections

3. Hypernatremia

a. hypertension

b. edema

c. weight gain

d. moon face appearance and buffalo hump

e. obese trunk

f. pendulous abdomen

g. thin extremities

4. Hypokalemia

a. weakness and fatigue

b. constipation

c. U wave upon ECG (T wave hyperkalemia)

5. Hirsutism

6. Acne and striae

7. Easy bruising

8. Increase masculinity among females

B. Diagnostic Procedures

1. FBS is increased

2. Plasma Cortisol is increased

Cushing’s syndrome. A. Client prior to syndrome. B. Client 4 months after diagnosis of syndrome.

3. Serum Sodium is increased

4. Serum Potassium is decreased

5. Dexamethasone suppression test

C. Nursing Management

1. Monitor strictly vital signs and intake and output

2. Weigh patient daily and assess for pitting edema

3. Measure abdominal girth daily and notify physician

4. Restrict sodium intake



a. Spinarolactone – potassium sparring diuretics

7. Prevent complications (DM)

8. Assist in surgical procedure (bilateral adrenoraphy)

9. Hormonal replacement for lifetime


PANCREAS

- Located behind the stomach

- Mixed gland (exocrine and endocrine)

- Consist of acinar cells which secretes pancreatic juices that aids in digestion thus it is an exocrine gland

Type 1 (IDDM) Type 2 (NIDDM)

- Juvenile onset type

- Brittle disease

A. Incidence Rate

- 10% general population has type 1 DM


1. Hereditary (total destruction of pancreatic cells)

2. Related to viruses

3. Drugs

a. Lasix

b. Steroids

4. Related to carbon tetrachloride toxicity


1. Polyuria

2. Polydypsia

3. Polyphagia

4. Glycosuria

5. Weight loss


7. Blurring of vision

8. Increase susceptibility to infection

9. Delayed/poor wound healing

D. Treatment

1. Insulin therapy

2. Diet

3. Exercise

E. Complication

1. Diabetic Ketoacidosis

- Adult onset

- Maturity onset type

- Obese over 40 years old

A. Incidence Rate

- 90% of general population has type 2 DM


1. Obesity – because obese persons lack insulin

receptor binding sites


1. Usually asymptomatic

2. Polyuria

3. Polydypsia

4. Polyphagia

5. Glucosuria

6. Weight gain

D. Treatment

1. Oral Hypoglycemic agents

2. Diet

3. Exercise

E. Complications

1. Hyper

2. Osmolar

3. Non

4. Ketotic

5. Coma

Best example of CUSHING SYNDROME is no other than JOLLIBEE – moon face & big body with thin extremities

- Consist of islets of langerhans

- Has alpha cells that secretes glucagons (function: hyperglycemia)

- Beta cells secretes insulin (function: hypoglycemia)

- Delta cells secretes somatostatin (function: antagonizes the effects of growth hormones)

3 Main Disorders of Pancreas

1. Pancreatic Tumor/Cancer


3. Pancreatitis

DIABETES MELLITUS

- Metabolic disorder characterized by non utilization of carbohydrates, protein and fat metabolism

MAIN

FOODSTUFF ANABOLISM CATABOLISM

1. Carbohydrates

2. Protein

3. Fats

Glucose

Amino Acids

Fatty Acids

Glycogen

Nitrogen

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)

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 hyperglycemia leading to severe CNS depression


1. Hyperglycemia

2. Stress – number one precipitating factor

3. Infection


1. Polyuria

2. Polydypsia

3. Polyphagia

4. Glucosuria

5. Weight loss


7. Blurring of vision

8. Acetone breath odor

9. Kussmaul’s Respiration (rapid shallow breathing)

10 CNS depression leading to coma


1. FBS is increased

2. BUN (normal value: 10 – 20)

3. Creatinine (normal value: .8 – 1)

4. Hct (normal value: female 36 – 42, male 42 – 48) due to severe dehydration


1. Assist in mechanical ventilation

2. Administer 0.9 NaCl followed by .45 NaCl (hypotonic solutions) to counteract dehydration and shock

3. Monitor strictly vital signs, intake and output and blood sugar levels


a. Insulin therapy (regular acting insulin/rapid acting insulin peak action of 2 – 4 hours)

b. Sodium Bicarbonate to counteract acidosis

c. Antibiotics to prevent infection

HYPER OSMOLAR NON KETOTIC COMA

- Hyperosmolar: increase osmolarity (severe dehydration)

- Non ketotic: absence of lypolysis (no ketones)


1. Headache and dizziness

2. Restlessness

3. Seizure activity

4. Decrease LOC – diabetic coma

B. Nursing Management

1. Assist in mechanical ventilation

2. Administer 0.9 NaCl followed by .45 NaCl

(hypotonic solutions) to counteract dehydration and shock



a. Insulin therapy (regular acting insulin peak action of 2 – 4 hours)

- for DKA use rapid acting insulin

b. Antibiotics to prevent infection

INSULIN THERAPY

A. Sources of Insulin

1. Animal sources

- Rarely used because it can cause severe allergic reaction

- Derived from beef and pork

2. Human Sources

- Frequently used type because it has less antigenicity property thus less allergic reaction

3. Artificially Compound Insulin

B. Types of Insulin

1. Rapid Acting Insulin (clear)

- Regular acting insulin (IV only)

- Peak action is 2 – 4 hours

2. Intermediate Acting Insulin (cloudy)

- Non Protamine Hagedorn Insulin (NPH)


3. Long Acting Insulin (cloudy)

- Ultra Lente


C. Nursing Management for Insulin Injections

1. Administer at room temperature to prevent development of lipodystrophy (atrophy, hypertrophy of subcutaneous

tissues)

2. Place in refrigerator once opened

3. Avoid shaking insulin vial vigorously instead gently roll vial between palms to prevent formation of bubbles

4. Use gauge 25 – 26 needle

5. Administer insulin either 45o – 90

o depending on amount of clients tissue deposit

6. No need to aspirate upon injection

7. Rotate insulin injection sites to prevent development of lipodystrophy

8. Most accessible route is abdomen

9. When mixing 2 types of insulin aspirate first the clear insulin before cloudy to prevent contaminating the clear

insulin and promote proper calibration.

10. Monitor for signs of local complications such as

a. Allergic reactions

b. Lipodystrophy

c. Somogyi Phenomenon – rebound effect of insulin characterized by hypoglycemia to hyperglycemia

ORAL HYPOGLYCEMIC AGENTS - OHA

- Stimulates the pancreas to secrete insulin

A. Classsification

1. First Generation Sulfonylureas

a. Chlorpropamide (Diabenase)

b. Tolbutamide (Orinase)

c. Tolamazide (Tolinase)

2. Second Generation Sulfonylureas

a. Glipzide (Glucotrol)

b. Diabeta (Micronase)

Nursing Management when giving OHA

1. Instruct the client to take it with meals to lessen GIT irritation and prevent hypoglycemia

2. Instruct the client to avoid taking alcohol because it can lead to severe hypoglycemia reaction or Disulfiram (Antabuse)

toxicity symptoms

Types of Insulin Color & consistency Peak

Rapid Clear 2-4

Intermediate Cloudy 6-12

Long acting Cloudy 12-24

B. Diagnostic Procedures for DM

1. FBS is increased (3 consecutive times with signs or

polyuria, polydypsia, polyphagia and glucosuria confirmatory for DM)

2. Random Blood Sugar is increased

3. Oral glucose tolerance test is increased – most sensitive test

4. Alpha Glycosylated Hemoglobin is increased


1. Monitor for peak action of insulin and OHA and notify physician

2. Administer insulin and OHA therapy as ordered


4. Monitor for signs of hypoglycemia and hyperglycemia

- administer simple sugars

- for hypoglycemia (cold and clammy skin) give simple sugars

- for hyperglycemia (dry and warm skin)

5. Provide nutritional intake of diabetic diet that includes: carbohydrates 50%, protein 30% and fats 20% or offer

alternative food substitutes

6. Instruct client to exercise best after meals when blood

glucose is rising

7. Monitor signs for complications

a. Atherosclerosis (HPN, MI, CVA)

b. Microangiopathy (affects small minute blood vessels of eyes and kidneys)

c. HPN and DM major cause of renal failure

d. Gangrene formation

e. Shock due to dehydration

- peripheral neuropathy

- diarrhea/constipation

- sexual impotence

8. Institute foot care management

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

CHRONIC HEMORRHAGIC PANCREATITIS- ―bangugot

Predisposing factors - unknown

Risk factor:

History of hepatobiliary disorder

Alcohol

Drugs – thiazide diuretics, oral contraceptives, aspirin, penthan

Obesity

Hyperlipidemia

Hyperthyroidism

High intake of fatty food – saturated fats

Overview only:

PANCREATITIS - acute inflammation of pancreas leading to pancreatic edema, hemorrhage & necrosis due to

Autodigestion – self-digestion

Cause: unknown/idiopathic

alcoholism

Pathognomonic sign- (+) Cullen‘s sign - Ecchymosis of umbilicus (bluish color)- pasa

(+) Grey turner‗s sign – ecchymosis of flank area

EYES KIDNEY

-PREMATURE CATARACT

- Blindness

-RECURRENT PYELONEPHRITIS

- Renal failure

HEMATOLOGICAL SYSTEM

I. Blood II. Blood Vessels III. Blood Forming Organs 1. Arteries 1. Liver 55% Plasma 45% Formed 2. Veins 3. Spleen 4. Lymphoid Organ Serum Plasma CHON 5. Lymph Nodes (formed in liver) 6. Bone Marrow 1. Albumin 2. Globulins 3. Prothrombin and Fibrinogen ALBUMIN

- Largest and numerous plasma CHON

- Maintains osmotic pressure preventing edema

GLOBULINS

- Alpha globulins - transport steroids, bilirubin and hormones

- Beta globulins – iron and copper

- Gamma globulins

a. anti-bodies and immunoglobulins

b. prothrombin and fibrinogen clotting factors

FORMED ELEMENTS

1. RBC (ERYTHROCYTES)

- normal value: 4 – 6 million/mm3

- only unnucleated cell

- biconcave discs

- consist of molecules of hgb (red pigment) bilirubin (yellow pigment) biliverdin (green pigment) hemosiderin (golden

brown pigment)

- transports and carries oxygen to tissues

- hemoglobin: normal value female 12 – 14 gms% male 14 – 16 gms%

- hematocrit red cell percentage in wholeblood

- normal value: female 36 – 42% male 42 – 48%

- substances needed for maturation of RBC

a. folic acid

b. iron

c. vitamin c

d. vitamin b12 (cyanocobalamin)

e. vitamin b6 (pyridoxine)

f. intrinsic factor

- Normal life span of RBC is 80 – 120 days and is killed in red pulp of spleen

2. WBC (LEUKOCYTES)

- normal value: 5000 – 10000/mm3

A. Granulocytes

1. Polymorpho Neutrophils

- 60 – 70% of WBC

- involved in short term phagocytosis for acute inflammation

2. Polymorphonuclear Basophils

- for parasite infections

- responsible for the release of chemical mediation for inflammation

3. Polymorphonuclear Eosinophils

- for allergic reaction

B. Non Granulocytes

1. Monocytes

- macrophage in blood

- largest WBC

- involved in long term phagocytosis for chronic inflammation

2. Lymphocytes

B-cell T-cell Natural killer cell - bone marrow - thymus - anti viral and anti tumor property

for immunity

HIV

- 6 months – 5 years incubation period

- 6 months window period

- western blot opportunistic

- ELISA

- drug of choice AZT (Zidon Retrovir)

2 Common fungal opportunistic infection in AIDS

1. Kaposi‘s Sarcoma

2. Pneumocystis Carinii Pneumonia

3. Platelets (THROMBOCYTES)

- Normal value: 150,000 – 450,000/mm3

- Promotes hemostasis (prevention of blood loss)

- Consist of immature or baby platelets or megakaryocytes which is the target of dengue virus

- Normal life span of platelet is 9 – 12 days

Signs of Platelet Dysfunction

1. Petechiae

2. Echhymosis

3. Oozing of blood from venipunctured site

BLOOD DISORDERS

Iron Deficiency Anemia

- A chronic microcytic anemia resulting from inadequate absorption of iron leading to hypoxemic tissue injury

A. Incidence Rate

1. Common among developed countries

2. Common among tropical zones

3. Common among women 15 – 35 years old

4. Related to poor nutrition


1. Chronic blood loss due to trauma

a. Heavy menstruation

b. Related to GIT bleeding resulting to hematemesis and melena (sign for upper GIT bleeding)

c. fresh blood per rectum is called hematochezia

2. Inadequate intake of iron due to

a. Chronic diarrhea

b. Related to malabsorption syndrome

c. High cereal intake with low animal protein digestion

d. Subtotal gastrectomy

4. Related to improper cooking of foods


1. Usually asymptomatic

2. Weakness and fatigue (initial signs)


4. Pallor and cold sensitivity

5. Dyspnea

6. Palpitations

7. Brittleness of hair and spoon shape nails (koilonychias)

8. Atropic Glossitis (inflammation of tongue)

- Stomatitis PLUMBER VINSON’S SYNDROME

- Dysphagia

9. PICA (abnormal appetite or craving for non edible foods

D. Diagnostic Procedures

1. RBC is decreased

2. Hgb is decreased

3. Hct is deceased

4. Iron is decreased

5. Reticulocyte is decreased

6. Ferritin is decreased


1. Monitor for signs of bleeding of all hema test including urine, stool and GIT

2. Enforce CBR so as not to over tire client

3. Instruct client to take foods rich in iron

a. Organ meat b. Egg (yolk) c. Raisin d. Sweet potatoes e. Dried fruits f. Legumes g. Nuts 4. Instruct the client to avoid taking tea and coffee because it contains tannates which impairs iron absorption


Oral Iron Preparations

a. Ferrous Sulfate

b. Ferrous Fumarate

c. Ferrous Gluconate

- 300 mg/day

Nursing Management when taking oral iron preparations

1. Instruct client to take with meals to lessen GIT irritation

2. When diluting it in liquid iron preparations administer with straw to prevent staining of teeth

Medications administered via straw

Lugol‘s solution

Iron

Tetracycline

Nitrofurantoin (Macrodentin)

3. Administer with Vitamin C or orange juice for absorption

4. Monitor and inform client of side effects

a. Anorexia

b. Nausea and vomiting

c. Abdominal pain

d. Diarrhea/constipation

e. Melena

5. If client cant tolerate/no compliance administer parenteral iron preparation

a. Iron Dextran (IM, IV)

b. Sorbitex (IM)

Nursing Management when giving parenteral iron preparations

1. Administer Z tract technique to prevent discomfort, discoloration and leakage to tissues

2. Avoid massaging the injection site instead encourage to ambulate to facilitate absorption


a. Pain at injection site

b. Localized abscess

c. Lymphadenopathy

d. Fever and chills

e. Skin rashes

f. Pruritus/orticaria

g. Hypotension (anaphylactic shock)

PERNICIOUS ANEMIA

- Chronic anemia characterized by a deficiency of intrinsic factor leading to hypochlorhydria (decrease hydrochloric

acid secretion)


1. Subtotal gastrectomy

2. Hereditary factors

3. Inflammatory disorders of the ileum

4. Autoimmune

5. Strictly vegetarian diet

STOMACH ▼

Pareital cells/ Argentaffin or Oxyntic cells

Produces intrinsic factors Secretes hydrochloric acid

▼ ▼

Promotes reabsorption of Vit B12 Aids in digestion

▼

Promotes maturation of RBC




3. Pallor and cold sensitivity

4. Dyspnea and palpitations as part of compensation

5. GIT changes that includes

a. mouth sore

b. red beefy tongue

c. indigestion/dyspepsia

d. weight loss

e. jaundice

6. CNS changes

a. tingling sensation

b. numbness

c. paresthesia

d. positive to Romberg’s test – damage to cerebellum resulting to ataxia

e. result to psychosis


Schilling’s Test – reveals inadequate/decrease absorption of Vitamin B12


1. Enforce CBR

2. Administer Vitamin B12 injections at monthly intervals for lifetime as ordered

- Never given orally because there is possibility of developing tolerance

- Site of injection for Vitamin B12 is dorsogluteal and ventrogluteal

- No side effects

3. Provide a dietary intake that is high in carbohydrates, protein, vitamin c and iron

4. Instruct client to avoid irritating mouth washes instead use soft bristled toothbrush

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)


1. Chemicals (Benzine and its derivatives)

2. Related to irradiation/exposure to x-ray

3. Immunologic injury

4. Drugs

Broad Spectrum Antibiotics

a. Chloramphenicol (Sulfonamides)

Chemotherapeutic Agents

a. Methotrexate (Alkylating Agent)

b. Vincristine (Plant Alkaloid)

c. Nitrogen Mustard (Antimetabolite)

Phenylbutazones (NSAIDS)


1. Anemia

a. Weakness and fatigue

b. Headache and dizziness

c. Pallor and cold sensitivity

d. Dyspnea and palpitations

2. Leukopenia

a. Increase susceptibility to infection

3. Thrombocytopenia

a. Petechiae (multiple petechiae is called purpura)

b. Ecchymosis

c. Oozing of blood from venipunctured sites


1. CBC reveals pancytopenia

2. Bone marrow biopsy/aspiration (site is the posterior iliac crest) – reveals fat necrosis in bone marrow


1. Removal of underlying cause

2. Institute BT as ordered

3. Administer oxygen inhalation

4. Enforce CBR

5. Institute reverse isolation

6. Monitor for signs of infection

a. fever

b. cough

When all of the blood elements are depressed, the term ―pancytopenia‖ is used. ―Pan‖ meaning everything.

7. Avoid IM, subcutaneous, venipunctured sites

8 Instead provide Heplock

9. Instruct client to use electric razor when shaving


a. Corticosteroids – caused by immunologic injury

b. Immunosuppressants

Anti Lymphocyte Globulin ▼ Given via central venous catheter

▼ Given 6 days to 3 weeks to achieve

Maximum therapeutic effect of drug

DISSEMINATED INTRAVASCULAR COAGULATION

Acute hemorrhagic syndrome characterized by wide spread bleeding and thrombosis due to a deficiency of prothrombin

and fibrinogen


1. Related to rapid blood transfusion

2. Massive burns

3. Massive trauma

4. Anaphylaxis

5. Septicemia

6. Neoplasia (new growth of tissue)

7. Pregnancy


1. Petechiae (widespread and systemic) eye, lungs and lower extremities

2. Ecchymosis

3. Oozing of blood from punctured sites

4. Hemoptysis

6. Oliguria (late sign)


1. CBC reveals decreased platelets

2. Stool occult blood positive

3. ABG analysis reveals metabolic acidosis

4. Opthamoscopic exam reveals sub retinal hemorrhages


1. Monitor for signs of bleeding of all hema test including stool and GIT



4. Force fluids


a. Vitamin K

b. Pitressin/ Vasopresin to conserve fluids

c. Heparin/Coumadin is ineffective

6. Provide heparin lock

7. Institute NGT decompression by performing gastric lavage by using ice or cold saline solution of 500 – 1000 ml

8. Monitor NGT output

9. Prevent complication

a. Hypovolemic shock

b. Anuria – late sign

BLOOD TRANSFUSION

Goals/Objectives

1. Replace circulating blood volume

2. Increase the oxygen carrying capacity of blood

3. Prevent infection in there is a decrease in WBC

4. Prevent bleeding if there is platelet deficiency

Principles of blood transfusion

1. Proper refrigeration

- Expiration of packed RBC is 3 – 6 days

- Expiration of platelet is 3 – 5 days

2. Proper typing and cross matching

a. Type O – universal donor

b. Type AB – universal recipient

c. 85% of population is RH positive

3. Aseptically assemble all materials needed for BT

a. Filter set

b. Gauge 18 – 19 needle

c. Isotonic solution (0.9 NaCl/plain NSS) to prevent hemolysis

4. Instruct another RN to re check the following

a. Client name

b. Blood typing and cross matching

c. Expiration date

d. Serial number

5. Check the blood unit for bubbles cloudiness, sediments and darkness in color because it indicates bacterial

contamination

- Never warm blood as it may destroy vital factors in blood.

- Warming is only done during emergency situation and if you have the warming device

- Emergency rapid BT is given after 30 minutes and let natural room temperature warm the blood.

6. BT should be completed less than 4 hours because blood that is exposed at room temperature more

than 2 hours causes blood deterioration that can lead to BACTERIAL CONTAMINATION

7. Avoid mixing or administering drugs at BT line to prevent HEMOLYSIS

8. Regulate BT 10 – 15 gtts/min or KVO rate or equivalent to 100 cc/hr to prevent circulatory overload

9. Monitor strictly vital signs before, during and after BT especially every 15 minutes for first hour

because majority of transfusion reaction occurs during this period

a. Hemolytic reaction

b. Allergic reaction

c. Pyrogenic reaction

d. Circulatory overload

e. Air embolism

f. Thrombocytopenia

g. Cytrate intoxication

h. Hyperkalemia (caused by expired blood)

Signs and Symptoms of Hemolytic reaction


2. Dyspnea

3. Diarrhea/Constipation

4. Hypotension

5. Flushed skin

6. Lumbar/sternal/ Flank pain

7. Urine is color red/ portwine urine

Nursing Management

1. Stop BT

2. Notify physician

3. Flush with plain NSS

4. Administer isotonic fluid solution to prevent shock and acute tubular necrosis

5. Send the blood unit to blood bank for re examination

6. Obtain urine and blood sample and send to laboratory for re examination

7. Monitor vital signs and intake and output

SIGNS AND SYMPTOMS OF ALLERGIC REACTION

1. Fever

2. Dyspnea

3. Broncial wheezing

4. Skin rashes

5. Urticaria

6. Laryngospasm and Broncospasm

Nursing Management

1. Stop BT

2. Notify physician



a. Anti Histamine (Benadryl) - if positive to hypotension, anaphylactic shock treat with Epinephrine




SIGNS AND SYMPTOMS PYROGENIC REACTIONS (FEVER)

1. Fever and chills

2. Headache

3. Tachycardia

4. Palpitations

5. Diaphoresis

6. Dyspnea

Nursing Management

1. Stop BT

2. Notify physician



a. Antipyretic

b. Antibiotic




8. Render TSB

SIGNS AND SYMPTOMS OF CIRCULATORY REACTION

1. Orthopnea

2. Dyspnea

3. Rales/Crackles upon auscultation

4. Exertional discomfort

Nursing Management

1. Stop BT

2. Notify physician


a. Loop diuretic (Lasix

CARDIOVASCULAR SYSTEM

OVERVIEW OF THE STRUCTURE AND FUNCTIONS OF THE HEART

HEART

- Muscular pumping organ of the body.

- Located on the left mediastinum

- Resemble like a close fist

- Weighs approximately 300 – 400 grams

- Covered by a serous membrane called the pericardium

2 layers of pericardium

a. Parietal – outer layer

b. Visceral – inner layer

- In between is the pericardial space filled w/ fluid

which is 10 – 30 cc lubricates the surface to reduces

friction during systole.

- Common among MI, pericarditis, Cardiac tamponade

A. Layers of Heart

1. Epicardium – outer layer

2. Myocardium – middle layer

3. Endocardium – inner layer

- Myocarditis can lead to cardiogenic shock and rheumatic heart disease

B. Chambers of the Heart

1. Upper Chamber (connecting or receiving)

a. Atria

2. Lower Chamber (contracting or pumping)

a. Ventricles

- Left ventricle has increased pressure which is 120 – 180 mmHg

- In order to propel blood to the systemic circulation

- Right atrium has decreased pressure which is 60 – 80 mmHg

C. Valves

- To promote unidimensional flow or prevent backflow

1. Atrioventricular Valves – guards opening between

a. tricuspid valve

b. mitral valve

- Closure of AV valves give rise to first heart sound (S1 “lub”)

2. Semi – lunar Valves

a. pulmonic

b. aortic

- Closure of SV valve give rise to second heart sound (S2 “dub”)

Extra Heart Sounds

1. S3 – ventricular gallop usually seen in Left Congestive Heart Failure sound occurring during rapid ventricular filling

2. S4 – atrial gallop usually seen in Myocardial Infarction and Hypertension sound head during atrial contraction (often

heard when the ventricle is enlarged or hypertrophied

D. Coronary Arteries

- Arises from base of the aorta

Types of Coronary Arteries

1. Right Main Coronary Artery

2. Left Main Coronary Arterying

- Supplies the myocardium

E. Cardiac Conduction System

1. Sino – Atrial Node (SA or Keith Flack Node)

- Located at the junction of superior vena cava and right atrium

- Acts as primary pacemaker of the heart

- Initiates electrical impulse of 60 – 100 bpm

2. Atrio – Ventricular Node (AV or Tawara Node)

- Located at the inter atrial septum

- Delay of electrical impulse for about .08 milliseconds to allow ventricular filling

3. Bundle of His

- Right Main Bundle of His

- Left Main Bundle of His

- Located at the interventricular septum

4. Purkinje Fibers terminal point in the conduction system

(point which the myocardial cells are stimulated causing ventricular contraction)

- Located at the walls of the ventricles for ventricular contraction

- P WAVE (atrial depolarization) contraction

- QRS WAVE (ventricular depolarization)

- T WAVE (ventricular repolarization)

Insert pacemaker if there is complete heart block

Most common pacemaker is the metal pacemaker and lasts up to 2 – 5 years

Cardiac electrical activity is the result of the movement of ions (charged particles such as SODIUM, POTASSIUM,

AND CALCIUM) across the cell membrane.

ABNORMAL ECG TRACING

1. Positive U wave - Hypokalemia

2. Peak T wave – Hyperkalemia

3. ST segment depression – Angina Pectoris

4. ST segment elevation – Myocardial Infarction

5. T wave inversion – Myocardial Infarction

6. Widening of QRS complexes – Arrhythmias

CARDIAC DISORDERS

Coronary Arterial Disease/ Ischemic Heart Disease

Stages of Development of Coronary Artery Disease

1. Myocardial Injury - Atherosclerosis

2. Myocardial Ischemia – Angina Pectoris

3. Myocardial Necrosis – Myocardial Infarction

ATHEROSCLEROSIS

ATHEROSCLEROSIS ARTERIOSCLEROSIS

- narrowing of artery

- lipid or fat deposits (plaques)

- tunica intima

- hardening of artery, thicken

- calcium and protein deposits

- tunica media


1. Sex – male

2. Race – black

3. Smoking

4. Obesity

5. Hyperlipidemia

6. Sedentary lifestyle


8. Hypothyroidism

9. Diet – increased saturated fats



1. Chest pain

2. Dyspnea

3. Tachycardia

4. Palpitations

5. Diaphoresis

C. Treatment

Percutaneous Transluminal Coronary Angioplasty

Objectives of PTCA

1. Revascularize myocardium 2. To prevent angina 3. Increase survival rate

- Done to single occluded vessels

- If there is 2 or more occluded blood vessels CABG is done

Coronary Arterial Bypass And Graft Surgery

3 Complications of CABG

1. Pneumonia – encourage to perform deep breathing, coughing exercise and use of incentive spirometer

2. Shock

3. Thrombophlebitis

ANGINA PECTORIS (SYNDROME)

Clinical syndrome characterized by paroxysmal chest pain that is usually relieved by rest or nitroglycerine due to

temporary myocardial ischemia


1. Sex – male

2. Race – black

3. Smoking

4. Obesity

5. Hyperlipidemia



8. Hypothyroidism



B. Precipitating Factors

4 E’s of Angina Pectoris

1. Excessive physical exertion – heavy exercises

2. Exposure to cold environment

3. Extreme emotional response – fear, anxiety, excitement

4. Excessive intake of foods rich in saturated fats – skimmed milk


1. Levine’s Sign – initial sign that shows the hand clutching the chest

2. Chest pain characterized by sharp stabbing pain located at sub sterna usually radiates from back, shoulder, arms, axilla

and jaw muscles, usually relieved by rest or taking nitroglycerine

3. Dyspnea

4. Tachycardia

5. Palpitations

6. Diaphoresis


1. History taking and physical exam

2. ECG tracing reveals ST segment depression

3. Stress test – treadmill test, reveal abnormal ECG

4. Serum cholesterol and uric acid is increased




a. Nitroglycerine (NTG) – when given in small doses will act as venodilator, but in large doses will act as

vasodilator

- Give first dose of NTG (sublingual) 3 – 5 minutes

Angina is usually caused by

ATHEROSCLEROTIC Disease.


- lipid or fat deposits

- tunica intima

- Give second dose of NTG if pain persist after giving first dose with interval of 3 - 5 minutes

- Give third and last dose of NTG if pain still persists at 3 – 5 minutes interval

Nursing Management when giving NTG

- Keep the drug in a dry place, avoid moisture and exposure to sunlight as it may inactivate the drug

- Monitor side effects

Orthostatic hypotension

Transient headache and dizziness

- Instruct the client to rise slowly from sitting position

- Assist or supervise in ambulation

- When giving nitrol or transdermal patch

o Avoid placing near hairy areas as it may decrease drug absorption

o Avoid rotating transdermal patches as it may decrease drug absorption

o Avoid placing near microwave ovens or during defibrillation as it may lead to burns (most important

thing to remember)

b. Beta-blockers

- (lol)

- Propanolol - side effects PNS - broncho constriction, vasodilation

- Not given to COPD cases because it causes Bronchospasm

c. ACE Inhibitors

- (pril)

- Enalapril, captopril, april jane dolo

d. Calcium Antagonist

- calciblock

- Nifedipine, diltiazem


4. Place client on semi fowler‘s position

5. Monitor strictly vital signs, intake and output and ECG tracing

6. Provide decrease saturated fats sodium and caffeine

7. Provide client health teachings and discharge planning

a. Avoidance of 4 E‘s

b. Prevent complication (myocardial infarction)

c. Instruct client to take medication before indulging into physical exertion to achieve the maximum therapeutic

effect of drug

d. The importance of follow up care

MYOCARDIAL INFARCTION – areas in myocardial cells in the heart are permanently destroyed.

Heart attack

Terminal stage of coronary artery disease characterized by malocclusion, necrosis and scarring.

A. Types

1. Transmural Myocardial Infarction – most dangerous type characterized by occlusion of both right and left coronary

artery

2. Subendocardial Myocardial Infarction – characterized by occlusion of either right or left coronary artery

B. The Most Critical Period Following Diagnosis of Myocardial Infarction

** 6 – 8 hours because majority of death occurs due to arrhythmia leading to PVC’s

C. Predisposing Factors

1. Sex – male

2. Race – black

3. Smoking

4. Obesity

5. Hyperlipidemia



8. Hypothyroidism




1. Chest pain

- Excruciating visceral, viselike pain located at substernal and rarely in precordial

- Usually radiates from back, shoulder, arms, axilla, jaw and abdominal muscles (abdominal ischemia) and hands

- Not usually relieved by rest or by nitroglycerine

2. Dyspnea

3. Increase in blood pressure (initial sign)

4. Hyperthermia

5. Ashen skin (pale), cool, clammy, diaphoretic

6. Mild restlessness and apprehension, anxiety

7. Occasional findings

a. Pericardial friction rub

b. Split S1 and S2

c. Rales/Crackles upon auscultation

d. S4 or atrial gallop


1. Cardiac Enzymes

a. CPK – MB

- Creatinine phosphokinase is increased

- Heart only, 12 – 24 hours

b. LDH – Lactic dehydroginase is increased

c. SGPT – Serum glutamic pyruvate transaminase is increased

d. SGOT – Serum glutamic oxal-acetic transaminase is increased

2. Troponin Test – is increased (protein in myocardial)

3. ECG tracing reveals

a. ST segment elevation

b. T wave inversion

c. Widening of QRS complexes indicates that there is arrhythmia in MI

4. Serum Cholesterol and uric acid are both increased

5. CBC – increased WBC


Goal: Decrease myocardial oxygen demand

1. Decrease myocardial workload (rest heart)

- Administer narcotic analgesic/morphine sulfate

- Side Effects: respiratory depression

- Antidote: Narcan/Naloxone

- Side Effects of Naloxone Toxicity is tremors

2. Administer oxygen low inflow to prevent respiratory arrest at 2 – 3 L/min

3. Enforce CBR without bathroom privileges

a. Using bedside commode

4. Instruct client to avoid forms of valsalva maneuver

5. Place client on semi fowler‘s position


7. Provide a general liquid to soft diet that is low in saturated fats, sodium and caffeine

8. Encourage client to take 20 – 30 cc/week of wine, whisky and brandy to induce vasodilation

9. Administer medication as ordered :

a. Vasodilators

- Nitroglycerine

- ISD (Isosorbide Dinitrate, Isordil) sublingual

b. Anti Arrythmic Agents

- Lidocaine (Xylocane

- Side Effects: confusion and dizziness

- Brutylium

c. Beta-blockers

- (-lol)

d. ACE Inhibitors

- (-pril)

e. Calcium Antagonist

- amlodipine, verapamil, diltiazem

f. Thrombolytics/ Fibrinolytic Agents

- Streptokinase

- Side Effects: allergic reaction, pruritus

- Urokinase

- TIPAF (tissue plasminogen activating factor)

- Side Effects: chest pain

- Monitor for bleeding time

g. Anti Coagulant

- Heparin (check for partial thrombin time)

- Antidote: protamine sulfate

- Coumadin/ Warfarin Sodium (check for prothrombin time)

- Antidote: Vitamin K

h. Anti Platelet

- PASA (Aspirin)

- Anti thrombotic effect

- Side Effects of Aspirin

Tinnitus

Heartburn

Indigestion/Dyspepsia

- Contraindication

Dengue

Peptic Ulcer Disease

Unknown cause of headache

10. Provide client health teaching and discharge planning concerning

a. Avoidance of modifiable risk factors

- Arrhythmia (caused by premature ventricular contraction)

b. Cardiogenic shock

- late sign is oliguria

c. Left Congestive Heart Failure

d. Thrombophlebitis

- homan’s sign

e. Stroke/CVA

f. Post MI Syndrome/Dressler’s Syndrome

- Client is resistant to pharmacological agents; administer 150,000 – 450,000 units of streptokinase as

ordered

g. Resumption of ADL particularly sexual intercourse is 4 – 6 weeks post cardiac rehab, post CABG and instruct

to

- make sex as an appetizer rather than dessert

- instruct client to assume a non weight bearing position

Client can resume sexual intercourse if can climb staircase

- dietary modification

h. Strict compliance to mediation and importance of follow up care

CONGESTIVE HEART FAILURE

Inability of the heart to pump blood towards systemic circulation

Types of Heart Failure

1. LEFT SIDED HEART FAILURE


1. 90% is mitral valve stenosis due to

a. RHD – inflammation of mitral valve due to invasion of Group A beta-hemolytic streptococcus

- Formation of aschoff bodies in the mitral valve

- Common among children (throat infection)

- ASO Titer (Anti streptolysin O titer)

- Penicillin

- Aspirin

b. Aging

2. Myocardial Infarction

3. Ischemic heart disease

4. Hypertension

5. Aortic valve stenosis


1. Dyspnea

2. Paroxysmal nocturnal dyspnea – client awakened at night due to DOB (sudden attacks of Orthopnea at night)

3. Orthopnea – use 2 – 3 pillows when sleeping or place in high fowlers

4. Productive cough with blood tinged sputum (severe pulmonary edema)

5. Frothy salivation

6. Cyanosis

7. Rales/Crackles (bi-basilar lobes that do not clear w/ coughing)

8. Bronchial wheezing

9. Pulsus Alternans – weak pulse followed by strong bounding pulse

10. PMI is displaced laterally due to cardiomegaly

11. There is anorexia and generalized body malaise

12. S3 – ventricular gallop

13. Oliguria – blood flow to the kidney decreases, causing decreased perfusion and reduce urine output. (Daytime)

14. Nocturia – sleeping cardiac workload decreased, improving renal perfusion, which then leads to frequent urination at

Night.


1. Chest x-ray – reveals cardiomegaly

2. PAP (pulmonary arterial pressure) – measures pressure in right ventricle or cardiac status

PCWP (pulmonary capillary wedge pressure) – measures end systolic and dyastolic pressure

- both are increased

- done by cardiac catheterization (insertion of swan ganz catheter)

3. Echocardiography – enlarged heart chamber (cardiomyopathy), dependent on extent of heart failure

4. ABG – reveals PO2 is decreased (hypoxemia), PCO2 is increased (respiratory acidosis)

2. RIGHT SIDED HEART FAILURE – RIGHT VENT. FAILS.


1. Tricuspid valve stenosis

2. Pulmonary embolism

3. Related to COPD

4. Pulmonic valve stenosis

5. Left sided heart failure

B. Signs and Symptoms (venous congestion)

1. Neck/jugular vein distension

2. Pitting edema (lower extremities)

3. Ascites

4. Weight gain

5. Hepatosplenomegaly

6. Jaundice

7. Pruritus (albumin)

8. Anorexia

9. Esophageal varices


1. Chest x-ray – reveals cardiomegaly

2. Central venous pressure (CVP)

- Measure pressure in right atrium (4 – 10 cm of water)

- CVP fluid status measure

- If CVP is less than 4 cm of water hypovolemic shock

- Do the fluid challenge (increase IV flow rate)

- If CVP is more than 10 cm of water hypervolemic shock

- Administer loop diuretics as ordered

- When reading CVP patient should be flat on bed

- Upon insertion place client in Trendelenburg position to promote ventricular filling and prevent pulmonary

embolism

3. Ecocardiography – reveals enlarged heart chambers (cardiomyopathy)

4. Liver enzymes – SGPT and SGOT is increased B. hypertrophic cardiomyopathy


Goal: increase cardiac contractility thereby increasing cardiac output (3 – 6 L/min)

1. Enforce CBR


a. Cardiac glycosides B. dilated cardiomyopathy

- Digoxin (Lanoxin) (increases cardiac contraction but lowers the pulse rate)

- Increase force of cardiac contraction

- If heart rate is decreased do not give

b. Loop Diuretics

- Lasix (Furosemide) peak 1-2 hrs, duration 6-8 hrs (monitor for hyperkalemia)

c. Bronchodilators aminophylline

d. Narcotic analgesics

- Morphine Sulfate

e. Vasodilators

- Nitroglycerine

f. Anti Arrhythmic

- Lidocaine (Xylocane)

3. Administer oxygen inhalation with high inflow, 3 – 4 L/min, delivered via nasal cannula

4. High fowler‘s position


6. Measure abdominal girth daily and notify physician

7. Provide a dietary intake of low sodium, cholesterol and caffeine


9. Assist in bloodless phlebotomy – rotating tourniquet, rotated clockwise every 15 minutes to promote decrease venous

return


a. Prevent complications

- Arrhythmia

- Shock

- Right ventricular hypertrophy

- MI

- Thrombophlebitis

b. Dietary modification

c. Strict compliance to medications

PERIPHERAL VASCULAR DISORDER

Arterial Ulcer

I. ThromboAngIitis Obliterans (BUERGER’S DISEASE)

Burger’s Disease - male/ feet

Reynaud’s Disease - female/ hands

Venous Ulcer

1. Varicose Veins

2. Thrombophlebitis (deep vein thrombosis)

THROMBOANGIITIS OBLITERANS or BUERGER’S DISEASE (MALE FEET) 20-35 yrs old

Acute inflammatory disorder usually affecting the small medium sized arteries and veins of the lower extremities

(Autoimmune disease)


1. High risk groups – men 30 years old and above

2. Smoking

3. Thrombus formation and occlusion of the vessels

4. Age 20-35 yrs

B. Signs and Symptoms (pain is the outstanding symptom)

1. Intermittent claudication – leg pain upon walking (foot cramps, especially the arch (instep claudication after exercise)

2. Cold sensitivity and changes in skin color rubor (reddish blue discoloration, pallor, and cyanosis)

3. Decreased peripheral pulses

4. Trophic changes

5. Ulceration

6. Gangrene formation

7. Absence of pedal pulse but with normal femoral pulse and popliteal pulses.

8. Radial and ulnar artery pulses are absent or diminished.


1. Oscillometry – decrease in peripheral pulses

2. Doppler UTZ – decrease blood flow to the affected extremity

3. Angiography – reveals site and extent of malocclusion

4. Segmental limb blood pressure (alternation of tourniquet)


1. Encourage a slow progressive physical activity

A. walking 3 – 4 times a day

B. out of bed 3 – 4 times a day


a. Analgesics

b. Vasodilators

c. Anti coagulants

3. Institute foot care management

4. Instruct client to avoid smoking and exposure to cold environment

5. Assist in surgical procedure – bellow knee amputation (elevate the stump for 24 hrs postop to promote venous return

and minimize edema).

6. Pain is relieve by rest

Lower the extremities below the level of the heart – if the

condition is arterial in nature

Elevate the extremities above the heart level – if the condition

is venous in nature

REYNAUD’S DISEASE

Disorder characterized by acute episodes of arterial (small arteries) spasm/vasoconstriction that result in coldness, pain,

and pallor involving the fingers or digits of the hands.


1. High risk group – female 16-40 years old and above

2. Smoking

3. Collagen diseases

a. SLE (butterfly rash)

b. Rheumatoid Arthritis

4. Direct hand trauma

a. Piano playing

b. Excessive typing

c. Operating chainsaw

5. Cold climates and during winter


1. Intermittent claudication – leg pain upon walking

2. Cold sensitivity and changes in skin color (pallor, cyanosis then rubor)

3. Trophic changes

4. Ulceration

5. Gangrene formation

6. Raynaud’s phenomenon – refer to localized, intermittent episodes of vasoconstriction of small arteries of the hands

that causes changes in color and temperature. (as white, blue, and red)


1. Doppler UTZ – decrease blood flow to the affected extremity

2. Angiography – reveals site and extent of malocclusion



a. Analgesics

b. Vasodilators (calcium channel blockers: nifedipine)

2. Encourage to wear gloves

3. Instruct client on importance of cessation of smoking and exposure to cold environment

VARICOSITIES

Dilated, tortuous, superficial veins caused by incompetent venous valves

Abnormal dilation of veins of lower extremities and trunks due to

Incompetent valve resulting to

Increased venous pooling resulting to

Venous stasis causing

Decrease venous return


1. Hereditary

2. Congenital weakness of veins

3. Thrombophlebitis

4. Cardiac disorder

5. Pregnancy

6. Obesity

7. Prolonged standing or sitting

8. Tortuous veins (saphenous veins)


1. Pain after prolonged standing

2. Dilated tortuous skin veins

3. Warm to touch

4. Heaviness in legs


1. Venography

2. Trendelenburg‘s Test - veins distends quickly in less than 35 seconds


1. Elevate legs above heart level to promote increased venous return by placing 2 – 3 pillows under the legs

2. Measure the circumference of leg muscle to determine if swollen

3. Wear anti embolic stockings


a. Analgesics

5. Assist in surgical procedure

a. Vein stripping and ligation (most effective)

b. Sclerotherapy – can recur and only done small/ spider web varicosities and danger of thrombosis (2 – 3 years

for embolism)

- sclerosing agent is injected into the vein, irritating the venous endothelium and producing

localized phlebitis and fibrousis, thereby obliterating the lumen of the vein.

THROMBOPHLEBITIS

Deep vein thrombosis

Inflammation of the veins with thrombus formation

3 factors known as VIRCHOW’S TRIAD believe to play a significant role in its development:

Stasis of the blood (venous stasis)

Vessel wall injury

Altered blood coagulation


1. Obesity

2. Smoking

3. Related to pregnancy

4. Chronic anemia

5. Prolong use of oral contraceptives – promotes lipolysis

6. Diabetes mellitus

7. Congestive heart failure

8. Myocardial infarction

9. Post op complication

10. Post cannulation – insertion of various cardiac catheter.

11. Increase in saturated fats in the diet.


1. Pain at affected extremity

2. Warm to touch

3. Dilated tortuous skin veins

4. Positive Homan‘s Signs – pain at the calf or leg muscle upon dorsiflexion of the foot


1. Venography

2. Angiography


1. Elevate legs above heart level to promote increase venous return

2. Apply warm moist pack – to reduce lymphatic congestion

3. Measure circumference of leg muscle to determine if swollen

4. Encourage to wear anti embolic stockings or knee elastic stockings


a. Analgesics

b. Anti Coagulant – take at the same time each day, usually bet. 8-9 am

- Heparin

Note: if any of the ff. sign are appear, report them immediately

Faintness, dizziness, or increased weakness

Severe headaches or abdominal pain

Reddish or brownish urine

Any bleeding – nose bleeding, cuts, and unusual

Red black bowel movements

Rash

6. Monitor for signs of complications

Embolism

a. Pulmonary

- Sudden sharp chest pain

- Unexplained dyspnea

- Tachycardia

- Palpitations

- Diaphoresis

- Restlessness

b. Cerebral

- Headache

- Dizziness

- Decrease LOC

MURPHY’S SIGN is seen in clients with cholelithiasis, cholecystitis characterized by pain at the right upper

quadrant with tenderness (inflammation of the gall bladder)

RESPIRATORY SYSTEM

OVERVIEW OF THE STRUCTURES AND FUCNTIONS OF THE RESPIRATORY SYSTEM

I. Upper Respiratory System

1. Filtering of air

2. Warming and moistening of air

3. Humidification

A. Nose

- Cartillage

- Right nostril

- Left nostril

- Separated by septum

- Consist of anastomosis of capillaries known as Kesselbach’s Plexus (the site of nose bleeding)

B. Pharynx/Throat

- Serves as a muscular passageway for both food and air

C. Larynx

- For phonation (voice production)

- For cough reflex

Glottis

- Opening of larynx

- Opens to allow passage of air

- Closes to allow passage of food going to the esophagus

- The initial sign of complete airway obstruction is the inability to cough

II. Lower Respiratory System

- For gas exchange

A. Trachea/Windpipe

- Consist of cartilaginous rings

- Serves as passageway of air going to the lungs

- Site of tracheostomy

B. Bronchus

- Right main bronchus

- Left main bronchus

C. Lungs

- Right lung (consist of 3 lobes, 10 segments)

- Left lung (consist of 2 lobes, 8 segments)

- Serous membranes

Pleural Cavity

a. Pareital

b. Pleural fluid

c. Visceral

With Pleuritic Friction Rub

a. Pneumonia

b. Pleural effusion

c. Hydrothorax (air and blood in pleural space

Alveoli – acinar cells

- Site of gas exchange (CO2 and O2)

- Diffusion (Dalton‘s law of partial pressure of gases)

Respiratory Distress Syndrome

- Decrease oxygen stimulates breathing

- Increase carbon dioxide is a powerful stimulant for breathing

Ventilation – movement of air in & out of lungs Respiration – movement of air into cells

Type II Cells of Alveoli

- Secretes surfactant

- Decrease surface tension

- Prevent collapse of alveoli

- Composed of lecithin and spingomyelin

- L/S ratio to determine lung maturity

- Normal L/S ratio is 2:1

- In premature infants 1:2

- Give oxygen of less 40% in premature to prevent atelectasis and retrolental fibroplasias

- retinopathy/blindness in prematurity

Disorders of Respiratory System

1. PTB/Pulmonary Tuberculosis (Koch’s Disease)

- Infection of lung tissue caused by invasion of mycobacterium tuberculosis or tubercle bacilli

- An acid fast, gram negative, aerobic and easily destroyed by heat or sunlight

A. Precipitating Factors

1. Malnutrition

2. Overcrowded places

3. Alcoholism

4. Over fatigue

5. Ingestion of infected cattle with mycobacterium bovis

6. Virulence (degree of pathogenecity) of microorganism

B. Mode of Transmission

1. Airborne transmission via droplet nuclei


1. Low grade afternoon fever, night sweats

2. Productive cough (yellowish sputum)

3. Anorexia, generalized body malaise

4. Weight loss

5. Dyspnea

6. Chest pain

7. Hemoptysis (chronic)


1. Mantoux Test (skin test)

- Purified protein derivative

- DOH 8 – 10 mm induration, 48 – 72 hours

- WHO 10 – 14 mm induration, 48 – 72 hours

- Positive Mantoux test (previous exposure to tubercle bacilli but without active TB)

2. Sputum Acid Fast Bacillus

- Positive to cultured microorganism

3. Chest X-ray

- Reveals pulmonary infiltrates (chalk thorax)

4. CBC

- Reveals increase WBC


1. Enforce CBR

2. Institute strict respiratory isolation


4. Force fluids to liquefy secretions

5. Place client on semi fowler‘s position to promote

expansion of lungs

6. Encourage deep breathing and coughing exercise

7. Nebulize and suction when needed

8. Comfortable and humid environment

9. Institute short course chemotherapy

a. Intensive phase

- INH (Isonicotinic Acid Hydrazide)

- Rifampicin (Rifampin)

- PZA (Pyrazinamide)

- Given everyday simultaneously to prevent resistance

- INH and Rifampicin is given for 4 months, taken before meals to facilitate absorption

- PZA is given for 2 months, taken after meals to facilitate absorption

- Side Effect INH: peripheral neuritis/neuropathy (increase intake of Vitamin B6/Pyridoxine)

- Side Effect Rifampicin: all bodily secretions turn to red orange color

- Side Effect PZA: allergic reaction, hepatotoxicity, nephrotoxicity

- PZA can be replaced by Ethambutol

- Side Effect Ethambutol: optic neuritis

b. Standard phase

- Injection of streptomycin (aminoglycoside)

- Kanamycin

- Amikacin

- Neomycin

- Gentamycin

- Side Effect:

- Ototoxicity damage to the 8th cranial nerve resulting to tinnitus leading to hearing loss

- Nephrotoxicity check for BUN and Creatinine

- Give aspirin if there is fever

- Side Effect: tinnitus, dyspepsia, heartburn

10. Provide increase carbohydrates, protein, vitamin C and calories


a. Avoidance of precipitating factors

b. Prevent complications (Atelectasis, military tuberculosis)

PTB

- Bones (potts)

- Meninges

- Eyes

- Skin

- Adrenal gland

c. Strict compliance to medications

d. Importance of follow up care

PNEUMONIA

Inflammation of the lung parenchyma leading to pulmonary consolidation as the alveoli is filled with exudates

A. Etiologic Agents

1. Streptococcus Pneumonae – causing pneumococal pneumonia

2. Hemophylus Influenzae – causing broncho pneumonia (children)

3. Diplococcus Pneumoniae

4. Klebsella Pneumoniae

5. Escherichia Pneumoniae

6. Pseudomonas

B. High Risk Groups

1. Children below 5 years old bec. Of low resistance

2. Elderly

C. Predisposing Factors

1. Smoking

2. Air pollution

3. Immuno compromised

a. AIDS

- Pneumocystic carini pneumonia

- Drug of choice is Retrovir

b. Bronchogenic Cancer

- Initial sign is non productive cough to productive cough

- Chest x-ray confirms lung cancer

4. Related to prolonged immobility (CVA clients), causing hypostatic pneumonia

5. Aspiration of food causing aspiration pneumonia


1. Productive cough with greenish to rusty sputum

2. Dyspnea with prolong expiratory grunt

3. Fever, chills, anorexia and general body malaise

4. Weight loss

5. Rales/crackles


7. Cyanosis

8. Pleuritic friction rub

9. Chest pain

10. Abdominal distention leading to paralytic ileus (absence of peristalsis)


1. Sputum Gram Staining and Culture Sensitivity – positive to cultured microorganisms

2. Chest x-ray – reveals pulmonary consolidation

3. ABG analysis – reveals decrease PO2

4. CBC – reveals increase WBC, erythrocyte sedimentation rate is increased


1. Enforce CBR

2. Administer oxygen inhalation low inflow


Broad Spectrum Antibiotic

a. Penicillin

b. Tetracycline

c. Microlides (Zethromax)

- Azethromycin (Side Effect: Ototoxicity)

- Antipyretics

- Mucolytics/Expectorants

- Analgesics

4. Force fluid

5. Place on semi fowler‘s position

6. Institute pulmonary toilet

(tends to promote expectoration)

- Deep breathing exercises

- Coughing exercises

- Chest physiotherapy

- Turning and reposition

7. Nebulize and suction as needed

8. Assist in postural drainage

- Drain uppermost area of lungs

- Placed on various position

Nursing Management for Postural Drainage

a. Best done before meals or 2 – 4 hours after meals to prevent gastro esophageal reflux

b. Monitor vital signs

c. Encourage client deep breathing exercises normal breathe sound bronchovesicular

d. Administer bronchodilators 15 – 30 minutes before procedure

e. Stop if client cannot tolerate procedure

f. Provide oral care after procedure

g. Contraindicated with

- Unstable vital signs

- Hemoptysis

- Clients with increase intra ocular pressure (Normal IOP 12 – 21 mmHg)

- Increase ICP

9. Provide increase carbohydrates, calories, protein and vitamin C

10. Health teaching and discharge planning

a. Avoid smoking


- Atelectasis

- Meningitis (nerve deafness, hydrocephalus)

c. Regular adherence to medications


HISTOPLASMOSIS

Acute fungal infection caused by inhalation of contaminated dust or particles with histoplasma capsulatum derived from

birds manure


PTB or Pneumonia like

1. Productive cough

2. Dyspnea

3. Fever, chills, anorexia, general body malaise

4. Cyanosis

5. Hemoptysis

6. Chest and joint pains

B. Diagnostic Procedures

1. Histoplasmin Skin Test – positive

2. ABG analysis PO2 decrease


1. Enforce CBR



a. Antifungal

- Amphotericin B

- Fungizone (Nephrotoxicity, check for BUN and Creatinine, Hypokalemia)

b. Steroids

c. Mucolytics

d. Antipyretics

4. Force fluids to liquefy secretions

5. Nebulize and suction as needed

6. Prevent complications – bronchiectasis

7. Prevent the spread of infection by spraying of breeding places

COPD (Chronic Obstructive Pulmonary/Lung Disease)

Chronic Bronchitis

Inflammation of bronchus resulting to hypertrophy or hyperplasia of goblet mucous producing cells leading to narrowing of

smaller airways


1. Smoking

2. Air pollution


1. Productive cough (consistent to all COPD)

2. Dyspnea on exertion

3. Prolonged expiratory grunt

4. Anorexia and generalized body malaise

5. Scattered rales/ronchi

6. Cyanosis

7. Pulmonary hypertension

a. Peripheral edema

b. Cor Pulmonale (right ventricular hypertrophy)


ABG analysis – reveals PO2 decrease (hypoxemia), PCO2 increase, and pH decrease (resp. acidosis)

Bronchial Asthma

Reversible inflammatory lung condition due to hypersensitivity to allergens leading to narrowing of smaller airways

A. Predisposing Factors (Depending on Types)

1. Extrinsic Asthma (Atopic/ Allergic)

Causes

a. Pollen

b. Dust

c. Fumes

d. Smoke

e. Gases

f. Danders

g. Furs

h. Lints

2. Intrinsic Asthma (Non atopic/Non allergic)

Causes

a. Hereditary

b. Drugs (aspirin, penicillin, beta blocker)

c. Foods (seafoods, eggs, milk, chocolates, chicken

d. Food additives (nitrates)

e. Sudden change in temperature, air pressure and humidity

f. Physical and emotional stress

3. Mixed Type 90 – 95%


1. Cough that is non productive

2. Dyspnea

3. Wheezing on expiration

4. Cyanosis

5. Mild Stress/apprehension

6. Tachycardia, palpitations

7. Diaphoresis


1. Pulmonary Function Test

- Incentive spirometer reveals decrease vital lung capacity

2. ABG analysis – PO2 decrease

- Before ABG test for positive Allens Test, apply direct

pressure to ulnar and radial artery to determine presence

of collateral circulation


1. Enforce CBR

2. Oxygen inhalation, with low inflow of 2 – 3 L/min


a. Bronchodilators – given via inhalation or metered dose inhalaer or MDI for 5 minutes

b. Steroids – decrease inflammation

c. Mucomysts (acetylceisteine)

d. Mucolytics/expectorants

e. Anti histamine

4. Force fluids

5. Semi fowler‘s position


7. Provide client health teachings and discharge planning concerning

a. Avoidance of precipitating factor


- Emphysema

- Status Asthmaticus (give drug of choice)

- Epinephrine

- Steroids

- Bronchodilators

c. Regular adherence to medications to prevent development of status asthmaticus


BRONCHIECTASIS

Abnormal permanent dilation of bronchus leading to destruction of muscular and elastic tissues of alveoli


1. Recurrent lower respiratory tract infections

2. Chest trauma

3. Congenital defects

4. Related to presence of tumor


1. Productive cough

2. Dyspnea

3. Cyanosis


5. Hemoptysis (only COPD with sign)


1. ABG – PO2 decrease

2. Bronchoscopy – direct visualization of bronchus using fiberscope

Nursing Management PRE Bronchoscopy

1. Secure inform consent and explain procedure to client

2. Maintain NPO 6 – 8 hours prior to procedure

3. Monitor vital signs and breathe sound

POST Bronchoscopy

1. Feeding initiated upon return of gag reflex

2. Avoid talking, coughing and smoking, may cause irritation

3. Monitor for signs of gross

4. Monitor for signs of laryngeal spasm – prepare tracheostomy set

D. Treatment

1. Surgery (pneumonectomy, 1 lung is removed and position on affected side)

2. Segmental Wedge Lobectomy (promote re expansion of lungs)

- Unaffected lobectomy facilitate drainage

EMPHYSEMA

Irreversible terminal stage of COPD characterized by

a. Inelasticity of alveoli

b. Air trapping

c. Maldistribution of gases

d. Over distention of thoracic cavity (barrel chest)


1. Smoking

2. Air pollution

3. Allergy

4. High risk: elderly

5. Hereditary – it involves deficiency of

ALPHA-1 ANTI TRYPSIN

(needed to form Elastase, for recoil of alveoli)


1. Productive cough

2. Dyspnea at rest

3. Prolong expiratory grunt


5. Resonance to hyperresonance

6. Decrease tactile fremitus

7. Decrease or diminished breath sounds

8. Rales or ronchi


10. Barrel chest

11. Flaring of alai nares

12. Purse lip breathing to eliminates excess CO2

(compensatory mechanism)


1. Pulmonary Function Test – reveals decrease vital lung capacity

2. ABG analysis reveals

a. Panlobular/ centrilobular

- Decrease PO2 (hypoxemia leading to chronic bronchitis, ―Blue Bloaters‖)

- Decrease ph

- Increase PCO2

- Respiratory acidosis

b. Panacinar/ centriacinar

- Increase PO2 (hyperaxemia, ―Pink Puffers‖)

- Decrease PCO2

- Increase ph

- Respiratory alkalosis


1. Enforce CBR

2. Administer oxygen inhalation via low inflow


a. Bronchodilators

b. Steroids

c. Antibiotics

d. Mucolytics/expectorants

4. High fowlers position

5. Force fluids

6. Institute pulmonary toilet


8. Institute PEEP (positive end expiratory pressure) in mechanical ventilation promotes maximum alveolar lung expansion

9. Provide comfortable and humid environment

10. Provide high carbohydrates, protein, calories, vitamins and minerals

11. Health teachings and discharge planning concerning

a. Avoid smoking


- Atelectasis

- Cor Pulmonale

- CO2 narcosis may lead to coma

- Pneumothorax

c. Strict compliance to medication


RESTRICTIVE LUNG DISORDER PNEUMOTHORAX – partial / or complete collapse of lungs due to entry or air in pleural space.

Types: 1. Spontaneous pneumothorax – entry of air in pleural space without obvious cause.

eg. Rupture of bleb (alveoli filled sacs) in pt with inflammed lung conditions 2. Open pneumothorax – air enters pleural space through an opening in chest wall

-Stab/ gunshot wound

3. Tension Pneumothorax – air enters plural space with @ inspiration & can‘t escape leading to over distension of thoracic cavity resulting to shifting of mediastinum content to unaffected side.

Eg. Flail chest – ―paradoxical breathing pattern‖

Predisposing factors:

1. Chest trauma 2. Inflammatory lung conditions

3. Tumor S/Sx:

1. Sudden sharp chest pain

2. unexplained Dyspnea or SOB 3. Cyanosis

4. Diminished or decreased breath sound of affected lung

5. Cool moist skin- initial sign of shock 6. Mild restlessness/ apprehension, anxiety

7. Resonance to hyperresonance

8. decreased tactile fremitus Diagnosis:

1. ABG – pO2 decrease – 2. CXR – confirms pneumothorax/collapse of lung

Nursing Mgt:

1. Assist in endotracheal intubation 2. Assist in thoracenthesis

3. Administer meds – Morphine SO4 – due to pain - Anti microbial agents- due to bacteria

4. Assist in test tube thoracotomy attached to H2O sealed drainage system

If client has a tension pneumothorax, the initial treatment of choice is to insert a large-bore needle into the second intercostal space midclavicular line to relieve pressure. Next, a chest tube system is placed into the fourth

intercostal space.

A small chest tube(28 french) is inserted near the second intercostal space; this space is used because it is the

thinnest part of the chest wall, minimizes the danger of contracting the thoracic nerve, and leave small scar. If the patient has also hemothorax, a large-diameter chest tube (32 french) or greater is inserted usually in the 4th

or 5th interscostal space at the midaxillary line.

Purpose of H2O sealed drainage 1. Reestablish (-) pressure in the lungs-lung 6-12mm Hg

2. Promote re-expansion of the lungs 3. Drain fluid, blood and air

4. To prevent reflux of blood fluid and air

Nursing Mgt if pt is on CPT attached to H2O drainage 1. Maintain strict aseptic technique

2. DBE

3. At bedside a.) Petroleum gauze pad if dislodged Hemostat

b.) If with air leakage – clamp c.) Extra bottle

4. Meds – Morphine SO4

Antimicrobial 5. Monitor & assess for oscillation fluctuations or bubbling

a.) If (+) to intermittent bubbling means normal or intact - H2O rises upon inspiration

- H2O goes down upon expiration b.) If (+) to continuous, remittent bubbling

1. Check for air leakage

2. Clamp towards chest tube 3. Notify MD

c.) If (-) to bubbling 1. Check for loop, clots, and kink

2. Milk towards H2O seal

3. Indicates re-expansion of lungs normal 4. Auscultate for breath sounds, Xrays

5. Removal of CTT

When will MD remove chest tube?

1. If (-) fluctuations 2. (+) Breath sounds

3. CXR – full expansion of lungs

Nursing Mgt of removal of chest tube

1. Encourage DBE 2. Instruct to perform Valsalva maneuver for easy removal, to prevent entry of air in pleural space.

3. Apply vaselinated air occlusive dressing and pressure dressing - Maintain dressing dry & intact

4. Prepare: Extra bottle, excellent clamp, petroleum gauze

Gastro Intestinal Tract

I. Upper alimentary canal - function for digestion

a. Mouth b. Pharynx (throat)

c. Esophagus

d. Stomach- site of digestion e. 1st half of duodenum

II. Middle Alimentary canal – Function: for absorption

- Complete absorption – large intestine

a. 2nd half of duodenum for absorption b. Jejunum

c. Ileum d. 1st half of ascending colon

III. Lower Alimentary Canal – Function: elimination

a. 2nd half of ascending colon for elimination

b. Transverse for complete absorption— L I c. Descending colon

d. Sigmoid e. Rectum

IV. Accessory Organ a. Salivary gland

b. Verniform appendix c. Liver

d. Pancreas – auto digestion e. Gallbladder – storage of bile

I. Salivary Glands 1. Parotid – below & front of ear

2. Sublingual 3. Submaxillary

- Produces saliva – for mechanical digestion - 1,200 -1,500 ml/day - saliva produced

Lacrimal gland- depression on the frontal bone Lacrimal duct- outer canthus

PAROTITIS – ―mumps‖ – inflammation of parotid gland

-Paramyxovirus

S/Sx:

1. Fever, chills anorexia, generalized body malaise 2. enlarged parotid gland

3. Swelling of parotid gland 4. Dysphagia

5. Earache – otalgia

Mode of transmission: Direct transmission & droplet nuclei

Incubation period: 14 – 21 days Period of communicability – 1 week before swelling & immediately when swelling begins.

Nursing Mgt:

1. CBR

2. Institute a strict respiratory isolation 3. Meds: analgesic

Antipyretic

Antibiotics – to prevent 2 complications

4. Alternate warm & cold compress at affected part (vinegar promotes cooling)

5. General liquid to soft diet

6. Complications Women – cervicitis, vaginitis, oophoritis

Both sexes – meningitis & encephalitis/ reason why antibiotics is needed Men – orchitis might lead to sterility if it occurs during / after puberty.

VERNIFORM APPENDIX – Rt. iliac or Rt. inguinal area

- Function – lymphatic organ – produces WBC during fetal life - ceases to function upon birth of baby APENDICITIS – inflamation of verniform appendix Predisposing factor:

1. Microbial infection 2. Feacalith – undigested food particles – tomato seeds, guava seeds 3. Intestinal obstruction

S/Sx:

1. Pathognomonic sign: (+) rebound tenderness 2. Low grade fever, anorexia, n/v 3. Diarrhea &/ or constipation 4. Pain at Rt. iliac region-- MCBURNEY‘S point – site of surgical incision 5. Late sign due pain – tachycardia

Rovsing’s sign – elicited by palpating the left lower quadrant; this paradoxically causes pain to be felt in the right lower quadrant.

Diagnosis:

1. CBC – mild leukocytosis – increase WBC 2. PE – (+) rebound tenderness (flex Rt leg, palpate Rt iliac area – rebound) 3. Urinalysis—(+) acetone in urine

Treatment: - appendectomy 24 – 45 Nursing Mgt:

1. Secure consent 2. Routinely nursing measures:

a.) Skin prep b.) NPO c.) Avoid enema/laxatives – lead to rupture of

appendix 3. Meds:

Antipyretic Antibiotics *Don’t give analgesic – pre-diagnosis will mask pain Give analgesic – post diagnosis - Presence of pain means appendix has not ruptured.

4. Avoid heat application – will rupture appendix. 5. Monitor VS, I&O bowel sound 6. Maintain a patent IV line Complications:

Peritonitis Septicemia

Nursing Mgt: post op

1. If (+) to Penrose drain – indicates rupture of appendix Position- affected side to drain

2. Meds: analgesic due post op pain Antibiotics, Antipyretics PRN

3. Monitor VS, I&O, bowel sound- N- borborygmy sound 4. Maintain patent IV line 5. Complications- peritonitis, septicemia

PEPTIC ULCER DISEASE – (PUD) – excoriation / erosion of submucosa & mucosal lining due to:

a.) Hyper secretion of acid – pepsin b.) Decrease resistance to mucosal barrier

Incidence Rate:

1. Men – 40 – 55 yrs old 2. Aggressive persons/ type A personality 3. Hereditary 4. Emotional Stress

Predisposing factors: 1. Hereditary 2. Emotional 3. Smoking – vasoconstriction – GIT ischemia 4. Alcoholism – stimulates release of histamine = Parietal cell release Hcl acid = ulceration 5. Caffeine – tea, soda, chocolate 6. Irregular diet

7. Rapid eating 8. Ulcerogenic drugs – NSAIDS, aspirin, steroids, indomethacin, ibuprofen

Indomethacin - S/E corneal cloudiness. Needs annual eye check up. NSAID and steroids= gastropathy

9. Gastrin producing tumor or gastrinoma – Zollinger Ellisons syndrome 10. Microbial invasion – helicobacter pylori. Metronidazole (Flagyl)

Types of ulcers Ascending to severity

1. Acute – affects submucosal lining 2. Chronic – affects underlying tissues –

heals & forms a scar, deeper According to location

1. Stress ulcer 2. Gastric ulcer 3. Duodenal ulcer – most common

Stress ulcers – common among critically ill clients 2 types 1. Curling’s ulcer – cause: trauma & Burns Hypovolemia GIT schemia Decrease resistance of mucosal barriers to Hcl acid Ulcerations 2. Cushing’s ulcer – cause – stroke/CVA/ head injury

Increase vagal stimulation Hyperacidity Ulcerations

Treatment: Vagotomy - done to prevent hemorrhage and shock prior to surgery on the stomach

GASTRIC ULCER DUODENAL ULCER

SITE Antrum or lesser curvature Duodenal bulb

PAIN - 30 min – 1 hr after eating - epigastrium - gaseous & burning - not usually relieved by food & antacid - Eating leads to pain

- 2-3 hrs after eating - mid epigastrium - cramping & burning pain - usually relieved by food & antacid - 12 MN – 3am pain - Eating lessens pain

HYPERSECRETION Normal gastric acid secretion Increased gastric acid secretion

VOMITING common Not common

HEMORRHAGE hematemesis Melena

WT Wt loss Wt gain

COMPLICATIONS a. stomach cancer b. hemorrhage

a. perforation

HIGH RISK 50 or 60 years old and above 20 years old and above

INCIDENCE Male; female = 1:1 15% of peptic ulcers are gastric

Male: Female = 2-3:1 80% of peptic ulcers are duodenal

90-95% is cases of duodenal ulcers - less bicarbonate ions, decrease so increase incidence Diagnosis:

1. Endoscopic exam 2. Stool from occult blood (+) 3. Gastric analysis – Gastric Ulcer: normal gastric acid secretion

Duodenal: increased gastric acid secretion 4. GI series – confirms presence of ulceration

Nursing Mgt: 1. Diet – bland, non irritating, non spicy 2. Avoid caffeine & milk/ milk products Increase gastric acid secretion 3. Administer meds

a.) Antacids ACA Aluminum containing antacids Magnesium containing antacids

ex. aluminum hydroxide gel ex. milk of magnesia (Amphogel) S/E diarrhea

S/E constipation

Maalox (fever S/E)

b.) H2 receptor antagonist: 1. Ranitidine (Zantac) SE: fever 2. Cimetidine (Tagamet)—hastens the effect of oral anticoagulants 3. Famotidine (Pepcid) SE: fever - Avoid smoking – decrease effectiveness of drug

Nursing Mgt: 1. Administer antacid & H2 receptor antagonist (Cimetidine) – 1hr apart

-Cemetidine decrease antacid absorption & vise versa c.) Cytoprotective agents

Ex 1. Sucralfate (Carafate) - Provides a paste like subs that coats mucosal lining of stomach

2. Misoprostol (Cytotec) –SE: menstrual spotting d.) Sedatives/ Tranquilizers - Valium, lithium e.) Anticholinergics / Antispasmodic

1. Atropine SO4 2. Prophantheline Bromide (Profanthene)

(Pt has history of hpn crisis with peptic ulcer disease. Rn should not administer alka seltzer- has large amount of Na.

3. Surgery: subtotal gastrectomy - Partial removal of stomach

Billroth I (Gastroduodenostomy)

Removal of ½ of stomach & anastomoses of gastric stump to the duodenum.

Billroth II (Gastrojejunostomy)

Removal of ½ -3/4 of stomach & duodenal bulb & anastomostoses of gastric stump to jejunum.

Before surgery for BI or BII - Do vagotomy (severing of vagus nerve) & pyloroplasty (drainage) first. Nursing Mgt:

1. Monitor NGT output or drainage immediately post op- bright red a.) Immediately post op should be bright red b.) Within 36- 48h – output is yellow green c.) After 48h – output is dark red due to HCl acid

2. Administer meds: a.) Analgesic b.) Antibiotic c.) Antiemetics

3. Maintain patent IV line 4. VS, I&O & bowel sounds 5. Complications:

a.) Hemorrhage – hypovolemic shock Late signs – anuria

b.) Peritonitis c.) Paralytic ileus – most feared d.) Hypokalemia e.) Thrombophlebitis f.) Pernicious anemia g.) Septicemia

7.) Dumping syndrome – common complication – rapid gastric

emptying of hypertonic food solutions – CHYME leading to hypovolemia. Sx of Dumping syndrome:

1. Dizziness 2. Diaphoresis 3. Diarrhea 4. Palpitations

Nursing mgt:

1. Avoid fluids in chilled solutions, sweets (fluids must be taken after meals)

2. Small frequent feedings-6 equally divided feedings 3. Diet – decrease CHO, moderate fats & CHON 4. Flat on bed 15 -30 minutes after q feeding

DIVERTICULITIS/DIVERTICULOSIS

1. Diverticulum- an outpouching of the intestinal mucosa particularly the sigmoid colon 2. Diverticulosis- multiple diverticulum 3. Diverticulitis- inflammation of diverticula A. Predisposing Factors

1. High Risk Groups- men (40-45yo) 2. Congenital weakness of muscle fibers of the intestine. 3. Low roughage and fiber in the diet S/S:

1. Intermittent lower left abdominal quadrant pain, particularly in the rectosigmoid area 2. tenderness 3. alternating bouts of constipation or diarrhea with blood or mucous

Dx: 1. Barium enema—reveals inflammatory process 2. CBC reveals: decreased hematocrit and hemoglobin

Nsg Mgt: 1. Administer meds as ordered:

a. antibiotics b. bulk laxatives c. stool softeners d. anti spasmodic agents

2. Instruct clients to take foods high in fiber if there is diverticulosis 3. Monitor for signs of infection Feared complications: Peritonitis 4. Assists in surgical procedure Resection of the diseased bowel and creation of a colostomy

Liver – largest gland - Occupies most of right hypochondriac region - Color: scarlet red, brown shiny and transparent - Covered by a fibrous capsule – Glisson‘s capsule - Functional unit – liver lobules

Function:

1. Produces bile Bile – emulsifies fats—H2O and bile salts= cholesterol Right sided pain: Cholelithiasis- easy bruising Left sided pain: Pancreatitis

- Composed of H2O & bile salts -Gives color to urine – urobilin Stool color – stechobilin 2. Detoxifies drugs 3. Promotes synthesis of vit A, D, E, K - fat soluble vitamins (needs fat for absorption)

Hypervitaminosis – vit D & K Vit A – retinol (Def Vit A – night blindness) Vit D – cholecalciferon

- Helps calcium - Rickets, osteoarthritis

4. It destroys excess estrogen hormone 5. for metabolism A. CHO – 1. Glycogenesis – synthesis of glycogens 2. Glycogenolysis – breakdown of glycogen 3. Gluconeogenesis – formation of glucose from CHO sources B. CHON- 1. Promotes synthesis of albumin & globulin Liver Cirrhosis – decrease albumin; ascites and edema Albumin – maintains osmotic pressure, prevents edema 2. Promotes synthesis of prothrombin & fibrinogen 3. Promotes conversion of ammonia to urea. Ammonia like breath – fetor hepaticus – a sweet, slightly fecal odor to the breath presumed 2 be intestinal orig. C. FATS – promotes synthesis of cholesterol to neutral fats – called triglycerides

LIVER CIRRHOSIS - lost of architectural design of liver leading to fat necrosis & scarring

Laennac Cirrhosis- loss of architectural design of the liver leading to fat necrosis and scarring Early sign – hepatic encephalopathy – accumulation of ammonia and other toxic substance in the blood

1. Asterixis – flapping hand tremors Late signs – headache, restlessness, disorientation, decrease LOC – hepatic coma. Nursing priority – assist in mechanical ventilation Predisposing factor: Decrease Laennac‘s cirrhosis – caused by alcoholism

1. Chronic alcoholism- major cause 2. Malnutrition – decreaseVit B, thiamin - primary cause 3. Virus – 4. Toxicity- eg. Carbon tetrachloride (CCL4) 5. Use of hepatotoxic agents

S/Sx: 1. Early signs:

a.) Weakness, fatigue b.) Anorexia, n/v c.) Stomatitis d.) Urine – tea color

Stool – clay color e.) Amenorrhea f.) Decrease sexual urge

g.) Loss of pubic, axilla hair h.) Hepatomegaly i.) Jaundice j.) Pruritus or urticaria (palmar erythema) k.) Decrease bowel sounds

2. Late signs a.) Hematological changes – all blood cells decrease Leukopenia- decrease Thrombocytopenia- bleeding tendencies Anemia- decrease b.) Endocrine changes Spider angiomas, Gynecomastia Caput medusae, Palmar erythema, loss of tortousity of the umbilicus c.) GIT changes Ascites, bleeding esophageal varices – due to portal HPN d.) Neurological changes: hepatic encephalopathy

Hepatic encephalopathy - ammonia (cerebral toxin)

Late signs: Early signs: Headache and dizziness asterexis - flapping hand tremors Fetor hepaticus Minor mental changes and motor disturbances Confusion hyperactive deep tendon reflexes Restlessness Hypoactive deep tendon reflexes flaccid Decrease LOC Hepatic coma Diagnosis:

1. Liver enzymes- increase SGPT (ALT) SGOT (AST)

2. Serum cholesterol & ammonia increase 3. Indirect or conjugated bilirubin increase 4. CBC - pancytopenia 5. PTT – prolonged bleeding 6. Hepatic ultrasonogram – fat necrosis of liver globules

Nursing Mgt

1. CBR 2. Restrict Na! 3. Monitor VS, I&O 4. Weigh pt daily & assess pitting edema 5. Measure abdominal girth daily – notify MD 6. Meticulous skin care 7. Diet – increase CHO, vit & minerals. Moderate fats. Decrease CHON

Well balanced diet 8. Complications of liver cirrhosis:

a.) Ascites – fluid in peritoneal cavity Nursing Mgt:

1. Meds: Loop diuretics – 10 – 15 min effect or potassium sparing diuretic 2. Assist in abdominal paracentesis - aspiration of fluid

- Void before paracentesis to prevent accidental puncture of bladder as trochar is inserted

b.) Bleeding esophageal varices - Dilation of esophageal veins

1. Meds: Vit K Pitressin or Vasopressin (IM)

2. NGT decompression- lavage - Give before lavage – ice or cold saline solution - Monitor NGT output

3. Assist in mechanical decompression - Insertion of Sengstaken-Blackemore tube - to decompress veins of esophagus-to prevent esophageal varices - 3 lumen typed catheter - Scissors at bedside to deflate/decompress balloon. Prep scissors when pt complains of DOB

c.) Hepatic encephalopathy – 1. Assist in mechanical ventilation – due coma 2. Monitor VS, neuro check 3. Siderails – due restless 4. Meds – Laxatives – to excrete ammonia (Lactulose)

HEPATITIS - jaundice (icteric sclera)

Bilirubin Kernicterus/ hyperbilirubinia Irreversible brain damage

Hepatitis A

Hepatitis A virus (HAV) is a virus that causes liver disease. Incubation is about 30 days, and the virus is excreted in the stool for about 2 weeks before the illness and about a week after it. The mortality rate is low. Children are typically asymptomatic. Adults generally have a more severe illness. The disease is not chronic and is not ―carried‖: FECAL ORAL TRANSMISSION INFECTION CONTROL

Hand hygiene to prevent the spread of HAV. Vaccine before traveling to places where HAV is endemic. Standard precautions, when caring for this client. Contact precautions, for incontinent clients (cannot control bladder/bowel).

Hepatitis B

Hepatitis B (HBV) is one of the five hepatitis viruses that infect the liver. This virus has a complex structure capable of attacking and destroying liver cells, resulting in illness or disease. Cellular destruction results in architectural changes of the normal structure, of the liver which leads to a disruption in the flow of blood and bile. Illness can range from mild signs and symptoms to chronic disease, such as fatal cirrhosis or liver cancer. BLOOD CARRIER Pancreas – mixed gland (exocrine & endocrine gland); found behind the stomach PANCREATITIS – acute or chronic inflammation of pancreas leading to pancreatic edema, hemorrhage & necrosis due to auto digestion (self-digestion). Bleeding of pancreas - Cullen’s sign on umbilical area Predisposing factors:

1. Chronic alcoholism 2. Hepatobilary disease 3. Obesity 4. Hyperlipidemia

5. Hyperparathyroidism 6. Drugs – Thiazide diuretics,aspirin, pills, Pentamidine HCL (Pentam) for clients with AIDS, 7. Diet – increase saturated fats

S/Sx: 1. Severe Midepigastrium epigastric pain – radiates from back & flank area (left upper quadrant) - 24-48 hrs. Aggravated by heavy meals/eating, accompanied by DOB 2. N/V 3. Tachycardia 4. Palpitation due to pain (abdominal guarding) 5. Dyspepsia /indigestion (rigid board like abdomen) 6. Decrease bowel sounds 7. (+) Cullen’s sign - ecchymosis of umbilicus hemorrhage 8. (+) Grey Turner’s spots – ecchymosis of flank area 9. Hypocalcemia

Diagnosis: 1. Serum amylase & lipase – increase 2. Urine lipase – increase 3. Serum Ca – decrease

Nursing Mgt: 1. Meds a.) Narcotic analgesic - Meperidine Hcl (Demerol) Don‘t give Morphine SO4 –will cause spasm of the sphincter of ODDI.

b.) Smooth muscle relaxant/ anticholinergic - Ex. Papavarine Hcl

Prophantheline Bromide (Profanthene) c.) Vasodilator – NTG d.) Antacid – Maalox e.) H2 receptor antagonist - Ranitidin (Zantac) to decrease pancreatic stimulation f.) Ca – gluconate

2. Withold food & fluid – aggravates pain (total NPO) 3. Assist in Total Parenteral Nutrition (TPN) or hyperalimentation

Complications of TPN 1. Infection—maintain a strict aseptic technique 2. Pulmonary Embolism—check all connection to system 3. Hyperglycemia 4. Hyperkalemia

4. Institute stress mgt tech a.) DBE b.) Biofeedback 5. Comfy position - Knee chest or fetal lie position 6. If pt can tolerate food, give increase CHO, decrease fats, and moderate CHON 7. Complications: Chronic hemorrhagic pancreatitis, Peritonitis, Septicemia, Shock

GALLBLADDER – storage of bile – made up of cholesterol.

CHOLECYSTITIS / CHOLELITHIASIS – inflammation of gallbladder with gallstone formation.

Predisposing factor:

1. High risk – women 40 years old 2. Post menopausal women – undergoing estrogen therapy 3. Obesity 4. Sedentary lifestyle, prolonged immobility 5. Hyperlipidemia 6. Neoplasm 7. Obstruction

S/Sx:

1. Severe Right abdominal pain (after eating fatty food). Occurring especially at night = epigastric or right abdominal quadrant after eating a heavy meal

2. Fat intolerance 3. Anorexia, n/v, feeling of fullness 4. Jaundice 5. Pruritus 6. Easy bruising 7. Tea colored urine 8. Steatorrhea

Diagnosis:

1. Oral cholecystogram (or gallbladder series) - confirms presence of gall stones 2. Increased indirect bilirubin 3. Increased alkaline phosphatase 4. increased serum and amylase

Nursing Mgt: 1. Meds – a.) Narcotic analgesic - Meperdipine Hcl – Demerol

b.) Anti cholinergic/Anti-spasmodic - Atropine SO4 c.) Anti emetic

Phenergan – Phenothiazide with anti emetic properties d) Broad spectrum antibiotics

2. Diet – increase CHO, moderate CHON, decrease fats 3. Meticulous skin care 4. Surgery: Cholecystectomy

Nursing Mgt post cholecystectomy -Maintain patency of T-tube intact & prevent infection

Stomach – widest section of alimentary canal

- J shaped structures 1. Anthrum 2. Pylorus 3. Fundus

Valves – prevent GERD 1. cardiac sphincter valve 2. Pyloric sphincter valve- stomach and first half of duodenum

Cells

1. Chief/ Zymogenic cells – secrets a.) Gastric amylase - digest CHO / sugars b.) Gastric lipase – digest fats c.) Pepsin – CHON d.) Rennin – digests milk products

Definition of terms: Biliary

Cholecystitis Inflammation of the gallbladder

Cholelithiasis The presence of calculi in the gallbladder

Cholecystectomy Removal of the gallbladder

Cholecystostomy Opening and drainage of the gallbladder

Choledochotomy Opening into the common duct

Choledocholithiasis Stones in the common duct

Choledocholitholithotomy Incision of common bile duct for removal of stones

Choledochoduodenostomy Anastomosis of common duct to duodenum

Choledochojejunostomy Anastomosis of common duct to jejunum

Lithotripsy Disintegration of gallstones by shock waves

Laparoscopic cholecystectomy Removal of gallbladder through endoscopic procedure

Laser cholecystectomy Removal of gallbladder using laser rather than scalpel and traditional surgical instruments

2. Parietal / Argentaffin / oxyntic cells Function: a.) Produces intrinsic factor – promotes reabsorption of vit B12 cyanocobalamin – promotes maturation of

RBC b.) Secrets Hcl acid – aids in digestion

3. Endocrine cells - Secretes gastrin – increase Hcl acid secretion Function of the stomach

1. Mechanical digestion 2. Chem. 3. Storage of food

-CHO, CHON- stored 1 -2 hrs. Fats – stored 2 – 3 hrs

BURNS – direct tissue injury caused by thermal, electric, chemical & smoke inhaled (TECS)

Nursing Priority – infection (all kinds of burns) Head burn-priority - Airway

2nd

priority for 1st

& 2nd

burn - pain

2nd

priority for 3rd

burn - Fluid and electrolytes Thermal - direct contact – flames, hot grease, sunburn. Electric, – wires Chemical – direct contact – corrosive materials acids Smoke – gas / fume inhalation Stages:

Emergent phase – Removal of pt from cause of burn. Determine source or location of burn

Shock phase – 48 - 72 . Characterized by shifting of fluids from intravascular to interstitial space (Hypovolemia) S/Sx:

- BP decrease - Urine output - HR increase - Hct. increase - Serum Na decrease - Serum K increase - Met acidosis

Diuretic/ Fluid remobilization phase - 3 to 5 days. Return of fluid from interstitial to intravascular space

Recovery/ convalescent phase – complete diuresis. Wound healing starts immediately after tissue injury.

Class: I. Partial Burn 1. 1

st degree – superficial burns

- Affects epidermis - Cause: thermal burn - Painful - Redness (erythema) & blanching upon pressure with no fluid filled vesicles

2. 2nd

degree – deep burns - Affects epidermis & dermis - Cause –chem. burns - very painful - Erythema & fluid filled vesicles (blisters)

II Full thickness Burns 1. Third & 4

th degrees burn

- Affects all layers of skin, muscles, bones - Cause – electrical - Less painful - Dry, thick, leathery wound surface – known as ESCHAR – devitalized or necrotic tissue.

Assessment findings: Rule of nines Head & neck = 9% Ant chest = 18% Post chest = 18% @ Arm 9+9 = 18% @ leg 18+18 = 18% Genitalia/ perineum = 1% Total 100% Nursing Mgt: 1. Meds

a.) Tetanus toxoid- burn surface area is source of anaerobic growth – Claustridium tetany Tetany

Tetanolysin tetanospasmin Hemolysis muscle spasm b.) Morphine SO4 c.) Systemic antibiotics 1. Ampicillin 2. Cephalosporin 3. Tetracyclin 4. Topical antibiotic: 1. Silver Sulfadiazene (silvadene) 2. Sulfamylon 3. Silver nitrate 4. Povidone iodine (betadine) 2. Administer isotonic fluid sol & CHON replacements 3. Strict aseptic technique 4. Diet – increase CHO, increase CHON, increase Vit C, and increase K- orange 5. If (+) to burns on head, neck, face - Assist in intubation 6. Assist in hydrotherapy 7. Assist in surgical wound debridement. Administer analgesic 15 – 30 minutes before debridement 8. Complications: a.) Infection

b.) Shock c.) Paralytic ileus - due to hypovolemia & hypokalemia

d.) Curling‘s ulcer – H2 receptor antagonist e.) Septicemia blood poisoning f.) Surgery: skin grafting

GUT – genito-urinary tract Function:

1. Promote excretion of nitrogenous waste products 2. Maintain F&E & acid base balance

1. Kidneys – pair of bean shaped organ

- Located retroperitonially (back of peritoneum) on either side of vertebral column. Encased in Bowmans‘s capsule. Parts:

1. Renal pelvis – Pyelonephritis – inflammation of the renal pelvis 2. Cortex 3. Medulla

Nephrons – basic living unit of the kidneys consisting of glomerulus Glomerulus – filters blood going to kidneys

Function of kidneys: 1. Urine formation 2. Regulation of BP

Urine formation – 25% of total CO (Cardiac Output) is received by kidneys (3,000-6,000 ml.) 125ml/ min filtered by the glomerulus > Glomerular filtration rate

1. Filtration 2. Tubular Reabsorption—124ml of ultra filtered are

reabsorbed in the blood 3. Tubular Secretion- 1 ml is excreted in the urine

Filtration – Normal GFR/ min is 125 ml of blood Tubular reabsorption – 124ml of ultra infiltrates (H2O & electrolytes is for reabsorption) Tubular secretion – 1 ml is excreted in urine Causes of CRF:

1. HPN 2. DM

Regulation of BP: Predisposing factor: Ex CS – Hypovolemia – decrease BP going to kidneys

Activation of RAAS

Release of Renin (hydrolytic enzyme) at juxtaglomerular apparatus

Angiotensin I mild vasoconstrictor

Angiotensin II vasoconstrictor Adrenal cortex increase CO increase PR Aldosterone Increase BP Increase Na & H2O reabsorption Hypervolemia Ureters – 25 – 35 cm long, passageway of urine to bladder Bladder – loc behind symphisis pubis. Muscular & elastic tissue that is distensible - Function – reservoir of urine 1200 – 1800 ml – Normal adult can hold 200 – 500 ml – needed to initiate micturition reflex (voiding) Color amber Odor aromatic Consistency clear or slightly turbid pH 4.5 – 8 Specific gravity 1.015 – 1.030 WBC/ RBC (-) Albumin (-) E coli (-) Mucus threads few Amorphous urate (-) Urethra – extends to external surface of body. Passage of urine, seminal & vaginal fluids.

- Women 3 – 5 cm or 1 to 1 ½ ― - Male – 20cm or 8‖

UTI

CYSTITIS – inflammation of bladder


1. Microbial invasion – E. coli 2. High risk – women 3. Obstruction 4. Urinary retention 5. Increase estrogen levels 6. Sexual intercourse

S/Sx: 1. Pain – flank area 2. Urinary frequency & urgency 3. Burning upon urination 4. Dysuria & hematuria 5. Fever, chills, anorexia, gen body malaise 6. Nocturia

Causes of Transient Incontinence: DIAPPERS

Delirium

Infection of urinary tract

Atrophic vaginitis, urethritis

Pharmacologic agents (anticholinergic)

Psychological factors (depression, regression)

Excessive urine production (DI, diabetic keto, inc. intake)

Restricted activity

Stool imfaction

In the older adult, the most common signs & symptoms of cystitis or UTI: 1. Fatigue.

2. Change in cognitive status.

Diagnosis: Urine culture & sensitivity - 80% of the cases are (+) to E. coli Nursing Mgt:

1. Force fluid – 2000 ml= to prevent bacterial multiplication 2. Warm sitz bath – to promote comfort 3. Monitor & assess for gross hematuria 4. Monitor and assess urine for color, odor, and bleeding N pH: 4.8 5. Acid ash diet – cranberry, vit C -OJ to acidify urine & prevent bacterial multiplication 6. Meds: systemic antibiotics

Ampicillin Cephalosporin Sulfonamides – cotrimoxazole (Bactrim) - Gantrism (ganthanol) Aminoglycosides: Gentamycin Urinary antiseptics – Nitrofurantoin (Macrodantin) Urinary analgesic- Pyridum

7. Ht a.) Importance of Hydration b.) Void after sex (male and female) c.) Female – avoids cleaning back & front

Bubble bath, Tissue paper, Powder, perfume d.) Complications: Pyelonephritis

PYELONEPHRITIS – acute/ chronic inflammation of 1 or 2 renal pelvis of kidneys leading to tubular destruction,

interstitial abscess formation. - Lead to Renal Failure


1. Microbial invasion (Bacterial) a.) E. Coli b.) Streptococcus

2. Urinary retention /obstruction 3. Pregnancy 4. DM 5. Exposure to renal toxins or nephrotoxic agents

S/Sx: Acute pyelonephritis

a.) Costovertibral angle pain, tenderness b.) Fever, anorexia, gen body malaise c.) Urinary frequency, urgency d.) Nocturia, dysuria, hematuria e.) Burning upon urination f.) FLANK PAIN g.) Enlarged kidney

Chronic Pyelonephritis a.) Fatigue, wt loss, weakness b.) Polyuria, polydypsia c.) HPN

Diagnosis:

1. Urine culture & sensitivity – (+) E. coli & streptococcus 2. Urinalysis

(+) WBC, (+)RBC, (+) Pus cells 3. Cystoscopic exam – urinary obstruction

Nursing Mgt:

1. Provide CBR – especially during acute phase 2. Force fluid 3. Acid ash diet 4. Provide a warm sitz bath for comfort 5. Meds:

a.) Urinary antiseptic – nitrofurantoin (macrodantin) SE: peripheral neuropathy GI irritation Hemolytic anemia Staining of teeth

b.) Urinary analgesic – Pyridium 6. Complication - Renal Failure

NEPHROLITHIASIS/ UROLITHIASIS- formation of stones at urinary tract

- calcium , oxalate, uric acid

milk cabbage anchovies cranberries organ meat nuts tea nuts chocolates sardines

Predisposing factors: 1. Diet – increase Ca & oxalate 2. Hereditary – gout 3. Obesity 4. Sedentary lifestyle 5. Hyperparathyroidism

S/Sx:

1. Renal colic 2. Cool moist skin (shock) 3. Burning upon urination 4. Hematuria 5. Anorexia, n/v

Diagnosis: 1. IVP – intravenous pyelography. Reveals location of stone 2. KUB – reveals location of stone 3. Cytoscopic exam- urinary obstruction 4. Stone analysis – composition & type of stone 5. Urinalysis – increase EBC, increase CHON 6. X-ray

Nursing Mgt: 1. Force fluid 2. Strain urine using gauze pad 3. Warm sitz bath – for comfort 4. Alternate warm compress at flank area 5. a.) Narcotic analgesic- Morphine SO4

b.) Allopurinol (Zyeoprim) c.) Patent IV line d.) Diet – if + Ca stones – acid ash diet If + oxalate stone – alkaline ash diet - (Ex milk/ milk products) If + uric acid stones – decrease organ meat / anchovies sardines

6. Surgery a.) Nephectomy – removal of affected kidney Litholapoxy – removal of 1/3 of stones- Stones will recur. Not advised for pt with big stones b.) Extracorporeal shock wave lithotripsy

- Non - invasive - Dissolve stones by shock wave

7. Complications: Renal Failure

BENIGN PROSTATIC HYPERTROPHY - enlarged prostate gland leading to

a.) Hydro ureters – dilation of ureters b.) Hydronephrosis – dilation of renal pelvis c.) Kidney stones Stone formation-- Renal failure d.) Renal failure

encircles the neck of the bladder decreased form of urinary stream Cause is unknown


1. High risk – 50 years old & above 60 – 70 – (3 to 4 x at risk) Prostate cancer: 40 years old & above

2. Influence of male hormone S/Sx:

1. Decrease force of and amount of urinary stream 2. Dysuria 3. Hematuria 4. Burning upon urination 5. Terminal dribbling—early sign of BPH 6. Backache 7. Sciatica 8. Hesitancy

Diagnosis: 1. Digital rectal exam – enlarged prostate gland 2. KUB – urinary obstruction 3. Cystoscopic exam – obstruction 4. Urinalysis – increase WBC, CHON, RBC

Nursing Mgt:

1. Prostatic message – promotes evacuation of prostatic fluid 2. Limit fluid intake 3. Provide catheterization 4. Provide a warm sitz bath for comfort 5. Meds:

a. Terazozine (hytrin) - Relaxes bladder sphincter, relaxes the smooth muscle of urinary sphincter S/E: HA, hypotension

b. Fenasteride (Proscar) - Atrophy of Prostate Gland (given after meals) S/E: N&V, Anorexia

5. Surgery: Prostatectomy – TURP- Transurethral resection of Prostate- No incision Without incision: for debilitated clients

-Assist in cystoclysis or continuous bladder irrigation. Complication:

1. Hemorrhage 2. Urinary obstruction 3. Penile dysfunction

Nursing mgt:

c. Monitor signs and symptoms of infection d. Monitor symptoms gross/ frank bleeding. Normal bleeding within 24h. 3. Maintain irrigation or tube patent to flush out clots - to prevent bladder spasm & distention

ACUTE RENAL FAILURE – sudden immobility of kidneys to excrete nitrogenous waste products & maintain F&E balance due to a decrease in GFR. (N 125 ml/min) Predisposing factors: Pre renal cause- decrease blood flow Causes:

1. Septic shock 2. Hypovolemia 3. Hypotension decrease blood flow to the kidneys 4. CHF 5. Hemorrhage 6. Dehydration (chronic diarrhea)

Intra-renal cause – involves renal pathology= kidney problem

1. Acute tubular necrosis 3. HPN 2. Pyelonephritis 4. Acute Glom.

Post renal cause – involves mechanical obstruction Causes:

1. Urinary strictures 2. Urolithiasis 3. BPH 4. Presence of tumors

Stages: Initiation period begins with the initial insult and ends when oliguria develops. I. OLIGURIC STAGE (1-2 weeks)

- involves passage of urine < 400ml/day - S/S:

a. Hyperkalemia- arrhythmia b. Hypernatremia c. Hyperphosphatemia d. Hypocalcemia e. High BUN 10-20 and creatinine .8-1 f. Metabolic acidosis 1-2wks

II. DIURETIC PHASE 2-3 weeks Increased amount of urine a. Hypokalemia b. Hyponatremia c. Metabolic Acidosis d. Increased Creatinine and BUN

III. CONVALESCENT/RECOVERY PHASE—3-12 months

CHRONIC RF – irreversible loss of kidney function

Predisposing factors: 1. DM 2. HPN 3. Recurrent UTI/ nephritis/ pyelonephritis 4. Exposure to renal toxins

Stages of CRF

1. Diminished Reserve Volume – asymptomatic Normal BUN & Crea, GFR < 10 – 30%

2. Renal Insufficiency 3. End Stage Renal disease

Increased serum concentration: Urea Creatinine Uric acid Organic acids

Intra cellular cations Potassium

Magnesium

S/Sx: 1.) Urinary System a.) polyuria b.) nocturia c.) hematuria d.) Dysuria e.) oliguria

2.) Metabolic disturbances a.) azotemia (increase BUN & Crea) b.) hyperglycemia c.) hyperinulinemia

3.) CNS a.) headache b.) lethargy c.) disorientation d.) restlessness e.) memory impairment

4.) GIT a.) n/v b.) stomatitis c.) uremic breath d.) diarrhea/ constipation

5.) Respiratory a.) Kassmaul’s resp b.) decrease cough reflex c.) crackles

6.) hematological a.) Normocytic anemia bleeding tendencies

7.) Fluid & Electrolytes a.) hyperkalemia b.) hypernatermia c.) hypermagnesemia d.) hyperposphatemia e.) hypocalcemia f.) met acidosis

8.) Integumentary a.) itchiness/ pruritus b.) uremic frost 9.) Cardiovascular changes a. HPN b. CHF c. Pericarditis

Nursing Mgt:

1. Enforce CBR, reverse isolation 2. Monitor strictly VS, I&O, neurocheck, monitor for signs of hypocalcemia (increased phosphate) 3. Meticulous skin care. Uremic frost – assist in bathing pt

4. Meds: a.) Na HCO3 – due Hyperkalemia b.) Kayexelate enema c.) Anti HPN – Hydralazine (Apresoline) d.) Vit & minerals (Multivitamins) e.) Phosphate binder (Amphogel) Al OH gel - S/E constipation f.) Decrease Ca – Ca gluconate 5. Assist in hemodialysis

1.) Consent/ explain procedure 2.) Weigh patient 3.) Obtain baseline data & monitor VS before and during q30mins, I&O, wt, blood exam 4.) Encourage patient to void 5.) Strict aseptic technique 6.) Monitor for signs of complications:

B – bleeding (due to heparin) E – embolism D – disequilibrium syndrome S – septicemia S – shock – decrease in tissue perfusion

Disequilibrium syndrome – from rapid removal of urea & nitrogenous waste product leading to:

a.) n/v b.) HPN c.) Leg cramps d.) Disorientation e.) Paresthesia

5. Avoid BP taking, blood extraction, IV, at side of shunt or fistula. Can lead to compression of fistula. 6. Maintain patency of shunt by:

i. Palpate for thrills & auscultate for bruits if (+) patent shunt! ii. Bedside- bulldog clip

If with accidental removal of fistula to prevent embolism. Infersole (diastole) – common dialisate used

7. Complication - Peritonitis (most feared) - Shock Inflow time: 10-20mins Indwelling time: 30-45 mins 8. Assist in surgery:

Renal transplantation: Complication – rejection (feared complication). Reverse isolation Rejection time in acute—6mos to 1 year

Rejection time in chronic—5-10 years

EYES External parts

1. Orbital cavity – made up of connective tissue protects eye form trauma. 2. EOM – extrinsic ocular muscles – involuntary muscles of eye needed for gazing movement. 3. Eyelashes/ eyebrows – esthetic purposes 4. Eyelids – palpebral fissure – opening upper & lower lid. Protects eye from direct sunlight

Meibomean gland – secrets a lubricating fluid inside eyelid

b.) Stye/ sty or Hordeolum- inflamed Meibomean gland 5. Conjunctiva 6. Lacrimal apparatus – tears

Process of grieving

a. Denial b. Anger c. Bargaining d. Depression e. Acceptance

Intrinsic coat I. sclerotic coat – outer most

a.) Sclera – white. Occupies ¾ post of eye. Refracts light rays b.) Canal of schlera – site of aqueous humor drainage c.) Cornea – transparent structure of eye

II. Uveal tract – nutritive care Uveitis – infl of uveal tract Consist of: a.) Iris – colored muscular ring of eye

2 muscles of iris: 1. Circular smooth muscle fiber - Constricts the pupil 2.radial smooth muscle fiber - Dilates the pupil

2 chambers of the eye 1. Anterior a.) Vitreous Humor – maintains spherical shape of the eye b.) Aqueous Humor – maintains intrinsic ocular pressure Normal IOP= 12-21 mmHg II. Retina (innermost layer)

i. Optic discs or blind spot – nerve fibers only

No auto receptors cones (daylight/ colored vision) rods – night twilight vision phototopic vision ―scotopic vision‖ = vit A deficiency – rods insufficient

ii. Maculla lutea – yellow spot center of retina iii. Fovea centralis – area with highest visual acuity or acute vision

Physiology of vision 4 Physiological processes for vision to occur:

1. Refraction of light rays – bending of light rays 2. Accommodation of lens 3. Constriction & dilation of pupils 4. Convergence of eyes Unit of measurements of refraction – diopters Normal eye refraction – emmetropia

ERROR of refraction 1. Myopia – near sightedness – Treatment: biconcave lens 2. Hyperopia/ or farsightedness – Treatment: biconvex lens 3. Astigmatisim – distorted vision – Treatment: cylindrical 4. Presbyopia – ―old slight‖ – inelasticity of lens due to aging – Treatment: bifocal lens or double vista

Accommodation of lenses – based on Helmholtz theory of accommodation Near vision = far vision= Ciliary muscle contracts= ciliary muscle dilates / relaxes= Lens bulges lens is flat Convergence of the eye: Error: 1. Exotropia – 1 eye n. 2. Esophoria – corrected by corrective eye surgery 3. Strabismus- squint 4. Amblyopia – prolong squinting

GLAUCOMA – increase IOP – if untreated, atrophy of optic nerve disc – blindness

Predisposing factors: 1. High risk group – 40 & above (nearsightedness) 2. HPN 3. DM 4. Hereditary 5. Obesity 6. Recent eye trauma, infl, surgery

Type:

1. Chronic – (open angle G.) – most common type Obstruct in flow of aqueous humor at trabecular meshwork of canal of schlema

2. Acute (close angle G.) – Most dangerous type Forward displacement of iris to cornea leading to blindness. 3. Chronic (closed – angle) - Precipitated by acute attack

S/Sx:

1. Loss of peripheral vision – tunnel vision 2. Halos around lights 3. Headache 4. n/v 5. Steamy cornea 6. Eye discomfort 7. If untreated – gradual loss of central vision – blindness

Diagnosis: 1. Tonometry – increase IOP >12- 21 mmHg 2. Perimetry – decrease peripheral vision 3. Gonioscopy – abstruction in anterior chamber Nursing mgt:

1. Enforce CBR 2. Maintain siderails 3. Administer meds

a.) Miotics – lifetime - contracts ciliary muscles & constricts pupil. Ex Pilocarpine Na (Carbachol) b.) Epinephrine eye drops – decrease secretion of aqueous humor c.) Carbonic anhydrase inhibitors. Ex. Acetazolamide (Diamox)

- Promotes increase out flow of aquaeous humor d.) Temoptics (Timolol maleate)- Increase outflow of aquaous humor

4. Surgery: Invasive:

a.) Trabeculectomy – eyetrephining – removal of trabelar meshwork of canal or schlera to drain aqueous humor

b.) Peripheral Iridectomy – portion of iris is excised to drain aqueous humor

Non-invasive: Trabeculoctomy (eye laser surgery)

Nursing Mgt pre op- all types surgery

1. Apply eye patch on unaffected eye to force weaker eye to become stronger. Nursing Mgt post op – all types of surgery

1. Position unaffected/ unoperated side - to prevent tension on suture line. 2. Avoid valsalva maneuver

3. Monitor for symptoms of IOP

a.) Headache b.) n/v c.) Eye discomfort d.) Tachycardia

4. Eye patch – both eyes - post op

CATARACT – partial/ complete opacity of lens

Predisposing factor: 1. 90-95% - aging (degenerative/ senile cataract) 2. Congenital 3. Prolonged exposure to UV rays 4. DM

S/Sx:

1. Loss of central vision - ―Hazy or blurring of vision‖ 2. Painless blurry vision

3. Milky white appearance at center of pupil 4. Decrease perception of colors 5. Diplopia

Diagnosis: Opthalmoscopic exam – (+) opacity of lens Nsg Mgt:

1. Reorient pt to environment – due opacity 2. Side rails 3. Meds: a.) Mydriatics – dilate pupil – not lifetime (SNS)

Ex. Mydriacyl c.) Cyslopegics – paralyzes ciliary muscle. Ex. Cyclogye

4. Surgery E – extra C - capsular C – cataract partial removal of lens L - lens E – extraction I - intra C - capsular C – cataract total removal of lens & surrounding capsules L - lens E – extraction

Nursing Mgt:

1. Position unaffected/ unoperated side - to prevent tension on suture line. 2. Avoid valsalva maneuver

3. Monitor symptoms of IOP

a.) Headache b.) n/v c.) Eye discomfort d.) Tachycardia

4. Eye patch – both eyes - post op

RETINAL DETACHMENT- separation of 2 layers of retina


1. Severe myopia – nearsightedness 2. Diabetic Retinopathy 3. Trauma 4. Following lens extraction 5. HPN

S/Sx:

1. ―Curtain –veil‖ like vision 2. Flashes of lights 3. Floaters 4. Gradual decrease in central vision 5. Headache 6. Cobwebs

Diagnosis: ophthalmoscopic exam Nursing Mgt:

1. Side rails (all visual disease) 2. Surgery:

a.) Cryosurgery – cold application (Diathermy – heat application)

b.) Scleral buckling

EAR 1. Hearing 2. Balance (Kinesthesia or position sense)

Parts:

1. Outer- a.) Pinna / auricle – protects ear from direct trauma b.) Ext. auditory meatus – has ceruminous gland. Cerumen c.) Tympanic membrane – transmits sound waves to middle ear

Disorders of outer ear Entry of insects – put flashlight to give route of exit Foreign objects – beans (bring to MD) H2O - drain 2. Middle ear a.) Ear osssicle

1. Hammer -malleus 2. Anvil -Incus for bone conduction disorder conductive hearing loss 3. Stirrups -stapes

b. Eustachian tube - Opens to allow equalization of pressure on both ears

- Yawn, chew, and swallow Children – straight, wide, short

c.) Otitis media Adult – long, narrow & slanted

c. Muscles 1. Stapedius 2. Tensor tympani 3. Inner ear a. Bony labyrinth – for balance, vestibule Utricle & succule Otolithe or ear stone – has Ca carbonate Movement of head = Righting reflex = Kinesthesia b. Membranous Labyrinth

1. Cochlea – ( function for hearing) has organ of corti 2. Endolymph & perilymph – for static equilibrium 3. Mastoid air cells – air filled spaces in temporal bone in skull

Complications of Mastoditis – meningitis Types of hearing loss:

1. Conductive hearing loss – transmission hearing loss Causes: a.) Impacted cerumen – tinnitus & conduction hearing loss- assist in ear irrigation b.) Immobility of stapes – OTOSCLEROSIS d.) Middle ear disease char by formation of spongy bone in the inner ear causing fixation or immobility of stapes e.) Stapes can‘t transmit sound waves

Surgery Stapedectomy – removal of stapes, spongy bone & implantation of graft/ ear prosthesis Predisposing factor:

1. Familiar tendency 2. Ear trauma & surgery

S/Sx:

1. Tinnitus 2. Conductive hearing loss

Diagnosis: 1. Audiometry – various sound stimulates (+) conductive hearing loss 2. Weber‘s test – Normal AC> BC

result BC > AC Stapedectomy

Nursing Mgt post op 1. Position pt unaffected side 2. DBE

No coughing & blowing of nose - Night lead to removal of graft

3. Meds: a.) Analgesic b.) Antiemetic c.) Antimotion sickness agent. Ex. meclesine Hcl (Bonamine)

4. Assess – motor function – facial nerve - (Smile, frown, raise eyebrow) 5. Avoid shampoo hair for 1 to 2 weeks. Use shower cap

SENSORY NEURAL HEARING LOSS/ NERVE DEAFNESS

Cause: 1. Tumor on cocheal 2. Loud noises (gun shot) 3. Presbycusis – bilateral progressive hearing loss especially at high frequencies – elderly

Face elderly to promote lip reading

4. Meniere’s disease – endolymphatic hydrops

f.) Inner ear disease char by dilation of endolympathic system leading to increase volume of endolin

Predisposing factor of MENIERE’S DISEASE

Smoking Hyperlipidemia 30 years old Obesity – (+) chosesteatoma Allergy Ear trauma & infection

S/Sx:

1. TRIAD symptoms of Meniere’s disease a.) Tinnitus b.) Vertigo c.) Sensory neural hearing loss

2. Nystagmus 3. n/v 4. Mild apprehension, anxiety 5. Tachycardia 6. Palpitations 7. Diaphoresis

Diagnosis:

1. Audiometry – (+) sensory hearing loss Nursing mgt:

1. Comfy & darkened environment 2. Siderails 3. Emetic basin 4. Meds:

a.) Diuretics –to remove endolymph b.) Vasodilator c.) Antihistamine d.) Antiemetic e.) Antimotion sickness agent f.) Sedatives/ tranquilizers

5. Restrict Na 6. Limit fluid intake 7. Avoid smoking 8. Surgery – endolymphatic sac decompression - Shunt

OTITIS MEDIA – Inflammation of the middle ear. (last less than 6 wks)

Sign and symptoms:

Pain Temporary hearing loss Tugging at the affected ear Difficulty sleeping Draining fluid / pus Frequent pulling of the ear (children) Fever

Nursing management:

Usually self limiting and resolved spontaneously Antibiotic Drainage (lean on the affected side to facilitate drainage)

Complication:

Hearing loss Mastoiditis Delayed speech and language development Perforation of the TM

OTHER MNEMONICS

IV NOTES Clindamycin, KCl===NOT for IV push—it may cause arrhythmia Chloramphenicol===NOT for IM Procaine, Penicillin, Benzatine, Pen G, Vancomycin HCl, Acyclovir (Zovirax) ===NOT for IV Opened bottles must be used in 8 hours HepLock- flush with NSS KCl < 80meq/L Epinephrine 1:10,000 Lidocaine- 4 mg /ml (1g/250ml) COMPATIBLE WITH PNSS ONLY

o Phenytoin o Vit K o Vit B6 o Vit C o Hydralazine o Furosemide

COMPATIBLE WITH D5W ONLY

o Epinephrine o Norepinephrine o Ephedrine o Dopamine o Dobutamine o Nitroprusside o NaHCO3

Not to be diluted in LR

Penicillin G Ampicillin Cephalosporin NaHCO3

PRBC—to be infused within 2-4hours FFP—1-1.5 hours Platelet concentrates—infuses immediately and quickly

NEURO TRANSMITTER DECREASE INCREASE

Acethylcholine Myasthenia Gravis /

Alzheimer Bi-polar Disorder

Dopamine Parkinson’s Disease Schizophrenia

Autoimmune diseases

Multiple Sclerosis Hypothyroidism Acute Glomerulonephritis Myasthenia Gravis Hyperthyroidism GBS Pernicious Anemia

Apparatus needed at bedside

Acetaminophen toxicity- Acetylcisteine

Prepare suction apparatus-acetylcysteine causes outpouring of secretions

Myasthenia Gravis tracheostomy set. For respiratory arrest

Hemodyalisis bulldog clip

Senkstaken tube scissors to deflate balloon

Guillain Barre Syndrome tracheostomy set. For respiratory arrest

Convulsion- suction apparatus Increased secretions

Hyperthyroidism tracheostomy set. For laryngeal spasm post subtotal thyroidectomy complication

Goiter tracheostomy set. For laryngeal spasm post subtotal thyroidectomy complication

Hypoparathyroidism tracheostomy set. For laryngeal spasm

Jerome Adorable, RN 2010

PATHOGNOMONIC SIGNS

1. PTB - Low-grade afternoon fever.

2. PNEUMONIA - Rusty sputum.

3. ASTHMA - Wheezing on expiration.

4. EMPHYSEMA - Barrel chest.

5. KAWASAKI DISEASE - Strawberry tongue.

6. PERNICIOUS ANEMIA - Red beefy tongue.

7. DOWN SYNDROME - Protruding tongue / semian crease on palm

8. CHOLERA - Rice watery stool.

9. MALARIA - Stepladder like fever and chills.

10. TYPHOID - Rose spots in abdomen.

11. DIPTHERIA - pseudo membrane formation (pharynx, tonsils, nasal)

12. MEASLES - Koplik’s spots.

13. SLE - Butterfly rashes.

14. LIVER CIRRHOSIS - spider angioma, due to esophageal varices

15. LEPROSY - lioning face

16. BULIMIA NERVOSA - Chipmunk face. Parotid gland swelling

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 SHAPE mass on the abdomen

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

29. PARKINSON’S DISEASE - Pill rolling tremors

30. HEPATITIS - Jaundice

31. THROMBOPHEBITIS - Homan’s sign

32. CATARACT - Hazy vision / loss of central vision

33. GLAUCOMA - Tunnel vision / loss of peripheral vision

34. RETINAL DETACHMENT - Curtain veil-like vision / flashes and floaters

35. CHOLECYSTITIS - Murphy’s sign (pain on deep inspiration, a inflammation of the gallbladder

36. ANGINA PECTORIS - Levine’s sign [hand clutching in the chest]

37. MYASTHENIA GRAVIS - Ptosis [drooping of the upper eyelid]

38. TETRALOGY OF FALLOT - Clubbing of fingers

Jerome Adorable, RN 2010

ATHEROSCLEROSIS ARTERIOSCLEROSIS


- lipid or fat deposits (plaques)

- tunica intima

- hardening of artery, thicken

- calcium and protein deposits

- tunica media

THE 5 MOST COMMON DRUG GIVEN IN BOARD EXAM: D.L.A.D.A MAJIC 2’s

DRUG NORMAL RANGE TOXICITY

LEVEL INDICATION CLASSIFICATION

Digoxin/ Lanoxin (Increase force of cardiac output)

.5 – 1.5 meq/L 2 CHF Cardiac Glycoside

Lithium/ Lithane (Decrease level of Ach/NE/Serotonin)

.6 – 1.2 meq/L 2 Bipolar Anti-Manic Agents

Aminophylline (Dilates bronchial tree)

10 – 19 mg/100 ml 20 COPD Bronchodilators

Dilantin/ Phenytoin 10 – 19 mg/100 ml 20 Seizures Anti-Convulsant

Acetaminophen/Tylenol 10 – 30 mg/100 ml 200 Osteoarthritis Non-narcotic Analgesic

PITUITARY SECRETIONS

Anterior pituitary Posterior pituitary

ADH

OXYTOCIN

GH

ACTH

TSH

FSH & LH

PROLACTIN

MSH

GASTRIC ULCER

DUODENAL ULCER

SITE Antrum or lesser curvature Duodenal bulb

PAIN

- 30 min – 1 hr after eating - epigastrium - gaseous & burning - not usually relieved by food & antacid - Eating leads to pain

- 2-3 hrs after eating - mid epigastrium - cramping & burning pain - usually relieved by food & antacid - 12 MN – 3am pain - Eating lessens pain

HYPERSECRETION Normal gastric acid secretion Increased gastric acid secretion

VOMITING common Not common

HEMORRHAGE hematemesis Melena

WT Wt loss Wt gain

COMPLICATIONS a. stomach cancer b. hemorrhage

a. perforation

HIGH RISK 50 or 60 years old and above 20 years old and above

INCIDENCE Male; female = 1:1 15% of peptic ulcers are gastric

Male: Female = 2-3:1 80% of peptic ulcers are duodenal

Jerome Adorable, RN 2010 CSLRM “Happiness is only real, when it shared”

JESUS

EVERY TIME I SAY JESUS

I wish to offer to GOD the infinite merits of Jesus Christ, His passion and death, with all the masses being said all over the world for:

(a) The glory of GOD, (b) my own intentions, (c) the peace of the World.

medical-surgical nursing with mnemonics[1]

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