NERVOUS SYSTEMOverview of structures and functions:Central Nervous SystemBrainSpinal CordPeripheral Nervous SystemCranial NervesSpinal NervesAutonomic Nervous SystemSympathetic nervous systemParasympathetic nervous system

Sympathetic Nervous System(ADRENERGIC)

Parasympathetic Nervous System(CHOLINERGIC, VAGAL, SYMPATHOLYTIC)

-nvolved in fight or aggression response.- Release of Norepinephrine (cathecolamines)from

adrenal glandsand causesvasoconstriction.- Increase all bodily activity except GIT

EFFECTS OF SNS- Dilation of pupils(mydriasis) in order to be aware.- Dry mouth (thickened saliva).- Increase BP and Heart Rate.- Bronchodilation, Increase RR- Constipation.- Urinary Retention.- Increase blood supply tobrain,heart and skeletalmuscles- SNS

.1 Adrenergic Agents- Give

Epinephrine.Signs and Symptoms:- SNSContraindication:- Contraindicated to patients suffering from COPD(Broncholitis, Bronchoectasis, Emphysema, Asthma).II. Beta-adrenergic Blocking Agents- Also calledBeta-blockers.- All ending with “lol”-Propranolol ,Atenelol ,Metoprolol.  Effects of Beta-blockersB – roncho spasmE– licits a decrease in myocardial contraction.T– reats hypertension.

A-V conduction slows down.-Should be given to patients withAngina Pectoris,

-Involved in fight or withdrawal response.- Release of Acetylcholine.- Decreases all bodily activities except GIT.EFFECTS OF PNS- Constriction of pupils (meiosis).- Increase salivation.- Decrease BP and Heart Rate.- Bronchoconstriction, Decrease RR.- Diarrhea- Urinary frequency.

I. Cholinergic Agents-Mestinon , Neostigmine.

Side Effects- PNSII. Anti-cholinergic Agents-To counter cholinergic agents.- Atropine SulfateSide Effects- SNS

Myocardial Infarction,Hypertension.ANTI- HYPERTENSIVE AGENTS1. Beta-blockers – “lol”2. Ace Inhibitors – Angiotensin, “pril” (Captopril,Enalapril)3. Calcium Antagonist – Nifedipine (Calcibloc)-In chronic cases of arrhythmia giveLidocaine (Xylocaine)

CENTRAL NERVOUS SYSTEM-Brain and Spinal Cord.

I. CELLSA. NEURONS- Basic cells for nerve impulse and conduction.

PROPERTIESExcitability– 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.

TYPES1. Astrocytes -maintains blood brain barrier semi-permeable.-Majority of brain tumors (90%) arises from calledastrocytoma.

2. Oligodendria3. Microglia4. EpindymalSUBSTANCES THAT CAN PASS THE BLOOD-BRAIN BARRIER

1. Ammonia

-Cerebral toxin-Hepatic Encephalopathy (Liver Cirrhosis)-Ascites-Esophageal Varices

Early Signs of Hepatic Encephalopathy-asterixis (flapping hand tremors).

Late Signs of Hepatic Encephalopathy-Headache

-Dizziness-Confusion-Fetor hepaticus (ammonia like breath)-Decrease LOC

PATHOGNOMONIC SIGNS1. PTB –low-grade afternoon fever.2. PNEUMONIA –rusty sputum.3. ASTHMA –wheezing on expiration.4. EMPHYSEMA – barrel chest.5. KAWASAKI SYNDROME –strawberry tongue.6. PERNICIOUS ANEMIA –red beefy tongue.7. DOWN SYNDROME –protruding tongue.8. CHOLERA –rice watery stool.9. MALARIA –stepladder like fever with chills.10. TYPHOID –rose spots in abdomen.11. DIPTHERIA –pseudo membrane formation12. MEASLES –koplik’s spots.13. SLE –butterfly rashes.14. LIVER CIRRHOSIS –spider like varices.15. LEPROSY –lioning face.16. BULIMIA –chipmunk face.17. APPENDICITIS –rebound tenderness.18. DENGUE –petechiae or (+) Herman’s sign.19. MENINGITIS –Kernig’s sign (leg pain), Brudzinski sign (neck pain).20. TETANY –HYPOCALCEMIA (+)Trousseau’s sign/carpopedal spasm; Chvostek sign(facial spasm).21. TETANUS –risus sardonicus.22. PANCREATITIS –Cullen’s sign (ecchymosis of umbilicus); (+) Grey turners spots.23. PYLORIC STENOSIS –olive like mass.24. PDA –machine like murmur.25. ADDISON’S DISEASE –bronze like skin pigmentation.26. CUSHING’S SYNDROME –moon face appearance and buffalo hump.27. HYPERTHYROIDISM/GRAVE’S DISEASE –exopthalmus.28. INTUSSUSCEPTION – sausage shaped mass

2. Carbon Monoxide and Lead Poisoning-Can lead to-Parkinson’s Disease.-Epilepsy

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

- Act as insulator and facilitates rapid nerve impulse transmission.

1. ALZHEIMER’S DISEASE-Atrophy of brain tissues.

Sign and Symptoms4 A’s of Alzheimer a.Amnesia– loss of memory.b.Agnosia – no recognition of inanimate objects.c.Apraxia – no recognition of objects function.d.Aphasia – no speech (nodding).*Expressive aphasia- “motor speech center”-Broca’s Aphasia*Receptive aphasia-inability to understand spoken words.-Wernicke’s Aphasia-General Knowing Gnostic Area or General Interpretative Area.DRUG OF CHOICE: ARICEPT ( taken at bedtime) and COGNEX.2. MULTIPLE SCLEROSIS-Chronic intermittent disorder of CNS characterized by white patches of demyelination in brain andspinal 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-GBSIg G – only antibody that pass placental circulation causingpassive 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 Symptoms1. Visual disturbances-blurring of vision (primary)-diplopia (double vision)scotomas(blind spots)

2. Impaired sensation-to touch, pain, pressure, heat and cold.-tingling sensation-paresthesia-numbness

3. Mood swings-euphoria (sense of well being) 4. Impaired motor function-weakness-spasticity-paralysis5. Impaired cerebral function-scanning speech

TRIAD SIGNS OF MS Ataxia(Unsteady gait, (+) Romberg’s test )

Intentional tremors Nystagmus6. Urinary retention/incontinence7. Constipation8. Decrease sexual capacity

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

NURSING MANAGEMENT1.Administer medications as ordereda.ACTH (Adreno Corticotropic Hormone)/ Steroids -for acute exacerbation to reduce edema at siteof demyelination to prevent paralysis.

b.Baclofen (Dioresal)/ Dantrolene Sodium (Dantrene)  – muscle relaxants.

c.Interferons – alter immune response.d.Immunosupresants2.Maintain side rails to prevent injury related to falls.3.Institute stress management techniques.a.Deep breathing exercisesb. Yoga4.Increase fluid intake and increase fiber to prevent constipation.5.Catheterization to prevent retention.a.Diureticsb.Bethanicol Chloride (Urecholine)Nursing Management-Only given subcutaneous.-Monitor side effects bronchospasm and wheezing.-Monitor breath sounds 1 hour after subcutaneous administration.c.For Urinary IncontinenceAnti spasmodic agent

a.Prophantheline Bromide (Promanthene)-Acid ash diet like cranberry juice, plums, prunes, pineapple, vitamin C and orange.-To acidify urine and prevent bacterial multiplication.

COMMON CAUSE OF UTIFemaleshort urethra (3-5 cm, 1-1 ½ inches)poor perineal hygienevaginal environment is moist

Nursing Managementavoid bubble bath (can alter Ph of vagina).avoid use of tissue papersavoid using talcum powder and perfume.

MaleUrethra (20 cm, 8 inches)urinate after intercourse

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

M A C R O P H A G E O R G A NMicrogliaMonocytesKupffers cellsHistiocytesAlveolar Macrophage

BrainBloodKidneySkinLung

EPINDYMAL CELLSSecretes a glue called chemo attractants that concentrate the bacteria.

COMPOSITION OF BRAIN

80% brain mass10% blood10% CSF

I. Brain MassPARTS OF THE BRAIN1. CEREBRUMlargest partcomposed of the Right Cerebral Hemisphere and Left Cerebral Hemisphere enclosed in

theCorpus Callosum.Functions of Cerebrum

integrativesensorymotor  

Lobes of Cerebrum1. Frontalhigher cortical thinkingcontrols personalitycontrols motor activityBroca’s Area (motor speech area)  when damaged results to garbled speech.

2. Temporalhearingshort term memory

3. Parietalfor appreciationdiscrimination of sensory impulses to pain, touch,  pressure, heat, cold, numbness.

4. Occipitacontrols balance, equilibrium, posture and gait.

INTRA CRANIAL PRESSUREMonroe 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 DISORDERSINCREASE INTRACRANIAL PRESSURE– increase in intra-cranial bulk brought about by an increase in oneof the 3 major intra cranial components.Causes:

head trauma/injurylocalized abscesscerebral edemahemorrhageinflammatory condition (stroke)hydrocephalustumor (rarely)

Signs and Symptoms (Early)decrease LOCrestlessness/agitation

irritabilitylethargy/stupor  coma

Signs and Symptoms (Late)changes in vital signsblood 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 decreaserespiratory rate decreasetemperature increase directly proportional to blood pressure.projective vomitingheadache

papilledema (edema of optic disc)abnormal posturing

decorticate posturing (damage to cortex and spinal cord). decerebrate posturing (damage to upper brain stem that includes pons, cerebellum andmidbrain).unilateral dilation of pupils calleduncal herniation

bilateral dilation of pupils called tentorial herniationresulting to mild headachepossible seizure activity

Nursing Management1. Maintain patent and adequate ventilation by:a. Prevention of hypoxia and hypercarbiaEarly signs of hypoxia

restlessnessagitationtachycardia

Late signs of hypoxiaBradycardiaExtreme restlessnessDyspneaCyanosisHYPERCARBIA

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 venousdrainage.3. Limit fluid intake to 1200 – 1500 ml/day (in force fluids 2000 – 3000 ml/day).4. Monitor strictly input and output and neuro check5. 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 stoolexcessive vomiting (use anti emetics)excessive coughing (use anti  tussive like dextromethorphan)avoid stooping/bendingavoid lifting heavy objectse. avoid clustering of nursing  activity together.

7. Administer medications like:a.Osmotic diuretic (Mannitol)

for cerebral diuresisNursing 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 dripregulated 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.

c.CorticosteroidsDexamethasone (Decadron)HydrocortisonePrednisone (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

dyspneaorthopneaparoxysmal nocturnal dyspneaproductive coughfrothy salivationcyanosisrales/cracklesbronchial wheezing

pulsus alternansanorexia and general body malaisePMI (point of maximum impulse/apical pulse rate) is  displaced laterallyS3 (ventricular gallop)Predisposing Factors/Mitral  ValveRHDAging

TREATMENTMorphine SulfateAminophellineDigoxinDiureticsOxygenGases, blood monitor RIGHT CONGESTIVE HEART FAILURE (Venous congestion)Signs and Symptoms jugular vein distention (neck)

ascitespitting edemaweight gainhepatosplenomegaly

 jaundicepruritusesophageal varicesanorexia and general body malaise

Signs and Symptoms of Lasix in terms of electrolyte imbalances1. Hypokalemia

decrease potassium levelnormal valueis3.4 – 5.5 meq/LSign and Symptoms

weakness and fatigueconstipationpositive U wave on  ECG tracing

Nursing Management administer potassium supplements as ordered ( Kalium Durule, Oral Potassium Chloride)increase intake of foods rich in potassiumF R U I T S VEGETABLESAppleBananaCantalopeOranges

AsparagusBrocolliCarrotsSpinach

2. Hypocalcemia/ Tetanydecrease calcium level

normal valueis 8.5 – 11 mg/100 mlSigns and Symptomstingling sensationparesthesianumbness

(+) Trousseau’s sign/ Carpopedal spasm(+) Chvostek’s signComplications

ArrhythmiaSeizures

Nursing ManagementCalcium Gluconate per IV slowly as ordered

* Calcium Gluconate toxicity – results to SEIZURE

Magnesium Sulfate

Magnesium Sulfate toxicityS/S BPUrine output DECREASERespiratory ratePatellar relfex absent3. Hyponatremia

decrease sodium levelnormal value is135 – 145 meq/LSigns and Symptoms

hypotensiondehydration signs (Initial sign in adult is THIRST, in infant TACHYCARDIA)agitationdry mucous membranepoor skin turgor  weakness and fatigue

Nursing Managementforce fluidsadminister  isotonic fluid solutionas ordered

4. Hyperglycemianormal FBS is 80 – 100 mg/dlSigns and Symptoms

polyuriapolydypsiapolyphagia

Nursing Managementmonitor FBS

5. Hyperuricemiaincrease 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)

swellingNursing Management

force fluidsadminister medications as ordered

a. Allopurinol (Zyloprim)Drug of choice for gout.Mechanism of action : inhibits synthesis of uric acid.b. Colchecine

Acute goutMechanism of action:promotes excretion of uric acid.* KIDNEY STONESSigns and Symptoms

renal colicCool moist skin

Nursing Managementforce fluidsadminister medications as ordereda. Narcotic AnalgesicMorphine Sulfate

ANTIDOTE: Naloxone (Narcan)toxicity leads to tremors.b. Allopurinol (Zyloprim)

Side EffectsRespiratory depression (check for RR)

PARKINSON’S DISEASE/ PARKINSONISMChronic progressive disorder of CNS characterized by degeneration of  dopamine

producingcells in the SUBSTANCIA NIGRA of the midbrain and basal ganglia.Predisposing Factors1. Poisoning (lead and carbon monoxide)2. Arteriosclerosis3. Hypoxia4. Encephalitis5. Increase dosage of the following drugs:a. Reserpine(Serpasil)b. Methyldopa(Aldomet) AntihypertensiveSc. Haloperidol(Haldol)d. Phenothiazine AntipsychoticSSIDE EFFECTS RESERPINE

Major depression leading to suicide- Alones- Loss of spouse- Loss of job

direct approach towards the clientclose surveillance is a nursing  prioritytime to commit suicide is on weekends early morning

Signs and Symptoms for Parkinson’spill rolling tremors of extremities especially the hands.bradykinesia (slowness of movement)rigidity (cogwheel type)stooped postureshuffling and propulsive gaitover fatigue

mask like facial expression with decrease blinking of the eyes.difficulty rising from sitting position.

Monotone type speechmood lability (in state of  depression)increase salivation ( drooling type)autonomic changesa. increase sweatingb. increase lacrimationc. seborrhead.

constipatione. decrease sexual capacityNursing Management

1. Administer medications as ordered

Anti Parkinsonian agentsLevodopa (L-dopa) short actingAmantadine Hydrochloride (Symmetrel)Carbidopa (Sinemet)

Mechanism of Actionincrease level of dopamine

Side EffectsGIT irritation (should be taken with mealsorthostatic hypotensionarrhythmiahallucinations

Contraindicationsclients with narrow angle closure glaucomaclients taking MAOI’s (no foods with triptophan and  thiamine)urine and stool may be darkenedno Vitamin B6 (Pyridoxine) reverses the therapeutic effects of Levodopa

* Increase Vitamin B when taking INH (Isoniazid), Isonicotinic Acid HydrazideAnti Cholinergic Agents (ARTANE and COGENTIN)-to relieve tremorsMechanism of Action

inhibits action of acethylcholine

Side EffectsSNS

Anti Histamine (Dipenhydramine Hydrochloride)Side EffectsAdult: drowsinessChildren: CNS excitement (hyperactivity) because blood brain barrier is not yet fully developed.Dopamine Agonist - relieves tremor rigidityBromocriptene Hydrochloride (Parlodel)Side Effects

Respiratory depression2. Maintain side rails to prevent injury3. Prevent complications of immobility4. Decrease protein in morning and increase protein in afternoon to induce sleep5. Encourage increase fluid intake and fiber.6. Assist/supervise in ambulation7. Assist in Stereotaxic ThalamotomyDRUG Normal range Toxicity Level Indication ClassificationDigoxin/ Lanoxin (Increase force of cardiac output)

Lithium/ Lithane (Decrease level of Ach/NE/Serotonin)Aminophylline(Dilates bronchial tree)

Dilantin/ Phenytoin

Acetaminophen/tylenol

.5 -1.5 meq

.5 -1.5 meq

10- 19mg /100 ml

10- 19mg /100 ml

10- 30mg /100 ml

2

2

20

20

200

CHF

Bipolar

COPD

Seizures

Osteoarthritis

Cardiac glycoside

Anti – Manic agent

Bronchodilator

Anti –convulsant

Non –Narcotic/ Analgesic

1. Digitalis ToxicitySigns and Symptoms-nausea and vomiting

diarrheaconfusionphotophobiachanges in color perception (yellowish spots)

Antidote: Digibind2. Lithium ToxicitySigns and Symptoms

anorexianausea and vomitingdiarrheadehydration causing fine tremorshypothyroidism

Nursing Managementforce fluidsincrease sodium intake to 4 – 10 g%  daily

3. Aminophylline ToxicitySigns and SymptomstachycardiapalpitationsCNS excitement (tremors, irritability, agitation and restlessness)

Nursing Managementonly mixed with plain NSS or  0.9 NaCl to prevent development of crystals or precipitate.administered sandwich methodavoid taking alcohol because it can lead to severe CNS depressionavoid caffeine

4. Dilantin ToxicitySigns and Symptomsgingival hyperplasia (swollen gums)hairy tongue

ataxianystagmusNursing Management

provide oral caremassage gums

5. Acetaminophen ToxicitySigns and Symptomshepatotoxicity (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, tachycardiaIrritabilityRestlessnessExtreme fatigueDiaphoresis, depressionAntidote:Acetylcisteine (mucomyst) prepare suction apparatus as bedside MYASTHENIA GRAVIS

neuromuscular disorder characterized by a disturbance in the transmission of impulses fromnerve to muscle cells at the neuromuscular junction leading to descending muscle weakness.Incidence rate:women 20 – 40 years oldPredisposing factors

unknownautoimmune: it involves release of cholinesterase an  enzyme that destroys Ach.

Signs and Symptomsinitial sign is

Ptosis a clinical parameter to determine ptosis is palpebral fissure.diplipiamask like facial expressiondysphagiahoarseness of voicerespiratory muscle weakness that may lead  to respiratory arrestextreme muscle weakness especially during exertion and  morning

Diagnostic ProcedureTensilon test(Edrophonium Hydrochloride) provides temporary relief of signs and symptomsfor about5 – 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 Management1. airway2. aspiration maintain patent airway and adequate ventilation3. mmobility* assist in mechanical ventilation and monitor pulmonary function test* monitor strictly vital signs, input and output and neuro check* monitor strength or motor grading scale4. maintain side rails to prevent injury related to falls5. institute NGT feeding6. administer medications as ordereda. Cholinergic (Mestinon)b. Anti Cholenisterase (Neostegmin)Mechanism of Action

increase level of AchSide Effects

PNSCortocosteroidssuppress immune response

monitor for 2 types of crisis:Myasthenic crisis Cholinergic crisis

Causes:- under medication- stress- infectionSigns and Symptoms- The client is unable to see, swallow, speak,breatheTreatment- administer cholinergic agents as ordered

Cause:- over medicationSigns and Symptoms- PNSTreatment- Administer anti cholinergic agents(Atropine Sulfate)

7 . Ass i s t   i n   su rg i ca l   p rocedure  known  as   thymec tomy because   i t   i s   be l i eved   tha t   the thymus  g land   i s responsible for M.G.

8. Assist in plasma paresis and removing auto immune anti bodies9. Prevent complications

INFLAMMATORY CONDITIONS OF THE BRAIN

MENINGITISMeninges

3 fold membrane that covers brain and spinal cord.for support and protectionfor nourishmentblood supply

LAYERS OF THE MENINGES1.Dura matter – outer layer 2.Arachnoid – middle layer 3.Pia matter  – inner layer 

subdural space between the dura and arachnoidsubarachnoid space between the arachnoid and pia, CSF aspiration is done.

A. Etiology1. Meningococcus – most dangerous2. Pneumococcus3. Streptococcus - causes adult meningitis4. Hemophilus Influenzae – causes pediatric meningitisB. Mode of transmission

airborne transmission (droplet nuclei)C. Signs and Symptoms

headachephotophobiaprojectile vomitingfever, chills, anorexia, general body malaise and weight lossPossible increase in ICP and seizure activityAbnormal posturing (decorticate and decerebrate)Signs of meningeal  irritation

a. Nuchal rigidity or stiff neckb. 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 theL3 – L4 to L5.Nursing Management for LPBefore Lumbar Puncture1. Secure informed consent and explain procedure2. Empty bladder and bowel to promote comfort3. Encourage to arch back to clearly visualize L3-L4. Post Lumbar Puncture1. Place flat on bed 12 – 24 o2. Force fluids3. Check punctured site for any discoloration, drainage and leakage to tissues.4. Assess for movement and sensation of extremities.CSF analysis reveals1. Increase CHON and WBC2. Decrease glucose3. Increase CSF opening pressure (normal pressure is 50 – 100 mmHg)4. (+) cultured microorganism (confirms meningitis)CBC reveals1. Increase wbc

E. Nursing Management1. Enforce complete bed rest2. Administer medications as ordereda. Broad spectrum antibiotics (Penicillin, Tetracycline)

b. Mild analgesicsc. Anti pyretics3. Institute strict respiratory isolation 24 hours after initiation of anti biotic therapy4. Elevate head 30-45o5. Monitor strictly V/S, input and output and neuro check6. 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 hydrocephalushearing loss/nerve deafness is second complication

consult audiologistc. Rehabilitation for neurological deficit

mental retardationdelayed psychomotor development

CVA (STROKE/BRAIN ATTACK/ ADOPLEXY/ CEREBRAL THROMBOSIS)a partial or complete disruption in  the brains blood supply.2 most common cerebral  artery affected by strokea. Mid Cerebral Arteryb. Internal

Cerebral Artery – the 2 largest arteryA. Incidence Rate

men are 2-3 times high riskB. Predisposing Factors

thrombus (attached)e m b o l u s   ( d e t a c h e d   a n d   m o s t   d a n g e r o u s   b e c a u s e   i t   c a n   g o   t o  t h e lungs and   causepulmonary embolism or the brain and cause cerebral embolism.Signs and Symptoms of Pulmonary Embolism

Sudden sharp chest painUnexplained dyspnea

TachycardiaPalpitationsDiaphoresisMild restlessness

Signs and Symptoms of Cerebral EmbolismHeadache and dizzinessConfusionRestlessnessDecrease LOCFat 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)

C. Risk Factors1. Hypertension, Diabetes Mellitus, Myocardial Infarction, Atherosclerosis, Valvular Heart Disease, PostCardiac Surgery (mitral valve replacement)2. Lifestyle (smoking), sedentary lifestyle3. Obesity (increase 20% ideal body weight)4. Hyperlipidemia more on genetics/genes that binds to cholesterol5. Type A personalitya. deadline drivenb. can do multiple tasksc. usually fells guilty when not doing anything6. Related to diet: increase intake of saturated fats like whole milk7. Related stress physical and emotional8. Prolong use of oral contraceptives promotes lypolysis (breakdown of lipids) leading to atherosclerosis thatwill lead to hypertension and eventually CVA.D. Signs and Symptoms

dependent on stages of development1. TIA

Initial sign of stroke or warning signSigns and Symptoms

headache and dizziness

tinnitusvisual and speech disturbancesparesis (plegia)possible increase ICP

2. Stroke in evolutionprogression of signs and symptoms of stroke

3. Complete strokeresolution phase characterized by:

Signs and Symptomsheadache and dizziness

Cheyne Stokes Respirationanorexia, nausea and vomitingdysphagia(+) Kernig’s sign and Brudzinski sign  which may lead to hemorrhagic strokefocal neurological deficitsa. phlegiab. aphasiac. dysarthria (inability to articulate words)d.

alexia (difficulty reading)e. agraphia (difficulty writing)f. homonymous hemianopsia (loss of half of visual field)E. Diagnostic Procedure1.CT Scan – reveals brain lesions2.Cerebral Arteriography

reveals the site and extent of malocclusionuses dye for visualizationmost of dye are iodine basedcheck for shellfish allergyafter diagnostic exam force fluids to release dye because it is nephro toxiccheck for distal pulse  (femoral)check for hematoma formation

F. Nursing Management1. Maintain patent airway and adequate ventilation by:a. assist in mechanical ventilationb. administrate O2 inhalation2. Restrict fluids to prevent cerebral edema that might increase ICP3. Elevate head 30 – 45 o4. Monitor strictly vitals signs, I & O and neuro check5. Prevent complications of immobility by:a. turn client to sideb. provide egg crate mattresses or water bedc. provide sand bag or food board.6. Assist in passive ROM exercise every 4 hours to promote proper bodily alignment and prevent contractures7. Institute NGT feeding8. Provide alternative means of communicationa. non verbal cuesb. magic slate9. If positive to hemianopsia approach client on unaffected side10. Administer medications as ordered a. Osmotic Diuretics (Mannitol)b. Loop Diuretics (Lasix, Furosemide)c. Cortecosteroidsd. Mild Analgesicse. Thrombolytic/Fibrinolytic Agents – dissolves thrombusStreptokinase

Side Effect: Allergic ReactionUrokinaseTissue Plasminogen Activating Factor Side Effect: Chest Painf. Anti CoagulantsHeparin (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  dayscheck for prothrombin time if prolonged there is a risk for bleedinggive Vit. K (Aqua Mephyton)g. Anti Platelet

PASA (Aspirin)Contraindicated for dengue, ulcer and unknown cause of headache because it maypotentiate bleeding11. Provide client health teachings and discharge planning concerninga. 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 careGUILLAIN BARRE SYNDROME

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

A. Predisposing Factors1. Autoimmune2. Antecedent viral infections such as LRT infectionsB. Signs and Symptoms1.Clumsiness (initial sign)2. Dysphagia3. Ascending muscle weakness leading to paralysis4. Decreased of diminished deep tendon reflex5. Alternate hypotension to hypertension** ARRYTHMIA (most feared complication)6. Autonomic symptoms that includesa. increase salivationb. increase sweatingc. constipationC. Diagnostic Procedures1. CSF analysis reveals increase in IgG and proteinD. Nursing Management1. Maintain patent airway and adequate ventilation by:a. assist in mechanical ventilationb. monitor pulmonary function test2. Monitor strictly the followinga. vital signsb. intake and outputc. neuro checkd. ECG3. Maintain side rails to prevent injury related to fall4. Prevent complications of immobility by turning the client every 2 hours5. Institute NGT feeding to prevent aspiration6. Assist in passive ROM exercise7. Administer medications as ordereda. Corticosteroids – suppress immune responseb. Anti Cholinergic Agents – Atrophine Sulfatec. Anti Arrythmic Agents

Lidocaine, ZylocaineBretylium – blocks release of norepinephrine  to prevent increase of BP

8. Assist in plasma pharesis(filtering of blood to remove autoimmune anti-bodies)9. Prevent complicationsa. Arrythmiab. Paralysis or respiratory muscles/Respiratory arrest* Sengstaken Blakemore Tube

for liver cirrhosisto decompress bleeding esophageal verices (prepare scissor to cut tube incase of difficulty

inbreathing to release air in the balloonfor hemodialysis prepare bulldog clips to  prevent air embolism

CONVULSIVE DISORDER/ CONVULSIONdisorder of CNS characterized by paroxysmal seizure with or without loss of

consciousnessabnormal motor activity alternation in sensation and perception and changes in behavior.Seizure – first convulsive attackEpilepsy – second or series of attacksFebrile seizure– normal in children age below 5 yearsA. Predisposing Factors1. Head injury due to birth trauma2. Genetics3. Presence of brain tumor 4. Toxicity froma. leadb carbon monoxide5. Nutritional and Metabolic deficiencies6. Physical and emotional stress7. Sudden withdrawal to anti convulsant drug is predisposing factor for status epilepticus (drug of choice isDiazepam, Valium)B. Signs and Symptoms

Dependent on stages of development or types of seizureI. Generalized Seizure1.Grand mal Seizure(tonic-clonic seizure)a. Signs or aura with auditory, olfactory, visual, tactile, sensory experienceb. Epileptic cry – is characterized by fall and loss of consciousness for 3 – 5 minutesc. Tonic contractions - direct symmetrical extension of extremities Clonic contractions - contraction of extremitiesd. Post ictal sleep – unresponsive sleep2.Petit mal Seizure– absence of seizure common among pediatric clients characterized bya. blank stareb. decrease blinking of eyesc. twitching of mouthd. 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 body2.Psychomotor Seizure(focal motor seizure)a. automatism – stereotype repetitive and non propulsive behavior b. clouding of consciousness – not in contact with environmentc. mild hallucinatory sensory experienceIII. Status Epilepticus

A continuous uninterrupted seizure activity, if left untreated can lead to hyperpyrexia and leadto coma and eventually death.Drug of choice : Diazepam, Valium and GlucoseC. Diagnostic Procedures1. CT Scan – reveals brain lesions2. EEG – reveals hyper activity of electrical brain waves

D. Nursing Management1. Maintain patent airway and promote safety before seizure activitya. clear the site of blunt or sharp objectsb. loosen clothing of clientc. maintain side railsd. avoid use of restrainse. turn clients head to side to prevent aspirationf. place mouth piece of tongue guard to prevent biting or tongue2. Avoid precipitating stimulus such as bright/glaring lights and noise3. Administer medications as ordereda. Anti convulsants (Dilantin, Phenytoin)b. Diazepam, Valiumc. Carbamazepine (Tegretol) – Trigeminal neuralgiad. Phenobarbital, Luminal4. Institute seizure and safety precaution post seizure attacka. administer O2 inhalationb. provide suction apparatus5. Document and monitor the followinga. onset and durationb. types of seizuresc. duration of post ictal sleep may lead to status epilepticusd. assist in surgical procedure cortical resectionCOMPREHENSIVE NEURO EXAMGLASGOW COMA SCALE

objective measurement of LOC sometimes called as the quick neuro checkComponents1. Motor response2. Verbal response3. Eye openingConscious 15 – 14Lethargy 13 – 11Stupor 10 – 8Coma 7Deep Coma 3COMPREHENSIVE NEURO EXAMGLASGOW COMA SCALE

objective measurement of LOC sometimes called as the quick neuro checkComponents1. Motor response2. Verbal response3. Eye opening

Survey of mental status and speecha. LOC b. Test of memoryLevels of orientationCranial nerve assessmentSensory nerve assessmentMotor nerve assessmentDeep tendon reflexAutonimicsCerebellar test

a, Romberg’s test – 2 nurses, positive for ataxiab. 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 CONSCIOUSNESS1. Conscious - awake2. Lethargy – lethargic (drowsy, sleepy, obtunded)3. Stupor 

stuporous (awakened by vigorous stimulation)generalized body weaknessdecrease body reflex 4. Comacomatoselight coma (positive to all forms of painful stimulus)deep coma (negative to all forms of painful stimulus)

DIFFERENT PAINFUL STIMULATION1. Deep sternal stimulation/ deep sternal pressure2. Orbital pressure3. Pressure on great toes4. Corneal or blinking reflex

Conscious client use a wisp of cottonUnconscious client place 1 drop of saline solution

II. TEST OF MEMORY1. Short term memory

ask most recent activitypositive result mean anterograde amnesia and damage to temporal lobe2. Long term

memoryask for birthday and validate on profile sheetpositive result mean retrograde amnesia and damage to limbic systemconsider educational background

III. LEVELS OF ORIENTATION1. Time – first asked2. Person – second asked3. Place – third askedCRANIAL NERVES

Cranial nerves Function1.olfactory2.optic3. occulomotor4.tronchlear5.trigeminal6.abducense7.facial 8.acoustic9.glossopharyngeal10.vagus11.spinal accessory12.hypoglossal

SSMM SMALLEST BLARGEST MBSBBLONGEST MM

CRANIAL NERVE I: OLFACTORYsensory function for smell

Material Useddon’t use alcohol, ammonia, perfume because  it is irritating and highly diffusibleuse coffee granules, vinegar, bar of soap, cigarette

Proceduretest each nostril by occluding each nostril

Abnormal Findings1. Hyposnia – decrease sensitivity to smell2. Dysosmia – distorted sense of smell3. Anosmia – absence of smellIndicative of 1. head injury damaging the cribriform plate of ethmoid bone where olfactory cells are located2. may indicate inflammatory conditions (sinusitis)CRANIAL NERVE II: OPTIC

sensory function for vision or sightFunctions1. 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 clientsSnellen’s Animal chart:  for pediatric clientsnormal visual acuity 20/20numerator 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

thechart.20/200 indicates blindness20/20 visual acuity if client is able to read letters above the red  line.

2. Test of visual field or peripheral visiona. Superiorlyb. Bitemporalyc. Nasallyd. InferiorlyCOMMON VISUAL DISORDERS1. Glaucoma

increase IOPnormal IOP is 12 – 21 mmHgpreventable but not curable

A. Predisposing FactorsCommon among 40 years old and aboveHereditaryHypertension

ObesityB. Signs and Symptoms1. Loss of peripheral vision

pathognomonic sign is tunnel vision2. Headache, nausea, vomiting, eye pain ( halos around light)

steamy corneamay lead to blindness

C. Diagnostic Procedures1. Tonometry2. Perimetry3. GonioscopyD. Treatment1.Miotics – constricts pupila.Pilocarpine Sodium ,Carbachol2.Epinephrine eyedrops– decrease formation of aqueous humor 3.Carbonic Anhydrase Inhibitorsa.Acetazolamide (Diamox)– promotes increase outflow of aqueous humor or drainage4.Timoptics ( Timolol Maleate )

E. Surgical Procedures1.TRABECULECTOMY(Peripheral Indectomy) – drain aqueous humor 2. Cataract

Decrease opacity of lensA. Predisposing Factor 1. Aging 65 years and above2. Related to congenital3. Diabetes Mellitus4. Prolonged exposure to UV raysB. Signs and Symptoms1. Loss of central visionC. Pathognomonic Signs1. Blurring or hazy vision2. Milky white appearance at center of pupils3. Decrease perception to colors

Complication is blindnessD. Diagnostic Procedure1. Opthalmoscopic examE. Treatment1.Mydriatics (Mydriacyl) – constricts pupils2.Cyclopegics (Cyclogyl) – paralyses cilliary muscleF. Surgical ProcedurEExtraIntraCapsular Capsular CataractCataractLensLensExtractionExtraction- P a r t i a l   r e m o v a l -   T o t a l   r e m o v a l   o f  c a t a r a c t   w i t h   i t s   s u r r o u n d i n g   c a p s u l e sMost feared complication post op is RETINAL DETACHMENT3. Retinal Detachment

Separation of epithelial surface of retinaA. Predisposing Factors. Post Lens Extraction2. Myopia (near sightedness)B. Signs and Symptoms1. Curtain veil like vision2. FloatersC. Surgical Procedures1.Scleral Buckling2.Cryosurgery– cold application3.Diathermy – heat application4. Macular Degeneration

Degeneration of the macula lutea (yellowish spot at the center of retina)

A. Signs and Symptoms1. Black SpotsCRANIAL NERVE III, IV, VI: OCULOMOTOR, TROCHLEAR, ABDUCENS

Controls or innervates the movement of  extrinsic ocular muscle (EOM)6muscles S u p e r i o r   R e c t u s S u p e r i o r  

O b l i q u e L a t e r a l   R e c t u s M e di a l   R e c t u s I n f e r i o r   O b li q u e I n f e r i o r   R e c t u s

trochlear controls superior obliqueabducens controls lateral rectusoculomotor controls the 4 remaining EOM

Oculomotor controls the size and response of pupilnormal pupil size is 2 – 3  mmequal size of pupil: IsocoriaUnequal size of  pupil: AnisocoriaNormal response: positive PERRLA

CRANIAL NERVE V: TRIGEMINALlargest cranial nerveconsists of  ophthalmic, maxillary, mandibular sensory: controls sensation of face, mucous  membrane, teeth, soft palate and corneal

reflexmotor: controls the muscle of  mastication or chewingdamage to CN V  leads to trigeminal neuralgia/thickdolorum

medication: Carbamezapine(Tegretol)CRANIAL NERVE VII: FACIAL

Sensory: controls taste, anterior 2/3 of tonguepinch of sugar and cotton applicator placed on tip of  tongueMotor: controls muscle of facial expressioninstruct client to smile, frown and if results are negative there is facial paralysis or Bell’s

Palsyand the primary cause is forcep delivery.CRANIAL NERVE VIII: ACOUSTIC/VESTIBULOCOCHLEARControls balance particularlykinesthesiao r   p o s i t i o n   s e n s e ,   r e f e r s   t o  m o v e m e n t   a n d orientation of the body in space.Parts of the Ear 1.Outer Ear 

PinnaEardrum

2.Middle Ear Hammer MalleusAnvilIncusStirrupStapes3.Inner Ear Vestibule: Meinere’s Disease

CochleaMastoid CellsEndolymph and Perilymph

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

Let client repeat words utteredCRANIAL NERVE IX, X: GLOSOPHARYNGEAL, VAGUS NERVE

Glosopharyngeal: controls taste, posterior 1/3 of tongueVagus: controls  gag reflexUvula should be midline and if not indicative of damage to cerebral hemisphereEffects of vagal stimulation is PNS

CRANIAL NERVE XI: SPINAL ACCESSORYInnervates with sternocleidomastoid (neck) and trapezius (shoulder)

CRANIAL NERVE XII: HYPOGLOSSALControls the movement of tongueLet client protrude tongue and it should be midline and if unable to do indicative of

damage tocerebral hemisphere and/or has short frenulum.ENDOCRINE SYSTEMOverview of the structures and functions1. Pituitary Gland (Hypophysis Cerebri)

oLocated at base of brain particularly at sella turcicaoMaster gland or master clockoControls all metabolic function of bodyPARTS OF THE PITUITARY GLAND1.Anterior Pituitary Glandocalled as adenohypophysis2.Posterior Pituitary Glandocalled as neurohypophysisosecretes hormones oxytocin -promotes uterine contractions preventing bleeding/ hemorrhageoadministrate oxytocin immediately after delivery to prevent uterine atony.oinitiates milk let down reflex with help of hormone prolactin2. Antidiuretic HormoneoPitressin (Vasopressin)oFunction: prevents urination thereby conserving water oDiabetes Insipidus/ Syndrome of Inappropriate Anti Diuretic HormoneDIABETES INSIPIDUSoDecrease production of anti diuretic hormoneA. Predisposing Factor oRelated to pituitary surgeryoTraumaoInflammationoPresence of tumor B. Signs and Symptoms1. Polyuria2. Signs of dehydrationa. Adult: thirstb. Agitationc. Poor Skin turgor d. Dry mucous membrane3. Weakness and fatigue4. Hypotension5. Weight loss6. If left untreated results to hypovolemic shock (sign is anuria)C. Diagnostic Procedures1. Urine Specific GravityoNormal value: 1.015 – 1.030oPh 4 – 82. Serum SodiumoIncrease resulting to hypernatremiaD. Nursing Management1. Force fluids2. Monitor strictly vital signs and intake and output3. Administer medications as ordereda.Pitressin (Vasopresin Tannate) – administered IM Z-tract4. Prevent complilcations – HYPOVOLEMIC SHOCK is the most feared complicationSIADHO hypersecretion of anti diuretic hormoneA. Predisposing Factors1. Head injury2. Related to presence of bronchogenic cancer oinitial sign of lung cancer is non productive coughonon invasive procedure is chest x-ray3. Related to hyperplasia (increase size of organ brought about by increase of number of cells) of pituitarygland.B. Signs and Symptoms1. Fluid retentiona. Hypertensionb. Edemac. Weight gain2. Water intoxication may lead to cerebral edema and lead to increase ICP – may lead to seizure activityC. Diagnostic Procedure1. Urine specific gravity isincreased2. Serum Sodium is decreasedD. Nursing Management1. Restrict fluid2. Administer medications as ordereda. Loop diuretics (Lasix)b. Osmotic diuretics (Mannitol)3. Monitor strictly vital signs, intake and output and neuro check4. Weigh

patient daily and assess for pitting edema5. Provide meticulous skin care6. Prevent complicationsANTERIOR PITUITARY GLANDoalso calledADENOHYPOPHYSISsecretes1. Growth hormones (somatotropic hormone)oPromotes elongation of long bonesoHyposecretionof GH among children results toDwarfismoHypersecretionof GH results toGigantismoHypersecretionof GH among adults results toAcromegaly(square face)oDrug of choice:Ocreotide (Sandostatin)2. Melanocyte Stimulating hormoneofor skin pigmentationoHyposecretionof MSH results toAlbinismoMost feared complications of albinisma. Lead toblindnessdue to severe photophobiab. Prone toskin cancer oHypersecretionof MSH results toVitiligo3. Adrenochorticotropic hormone (ACTH)opromotes development of adrenal cortex4.Lactogenic homone(Prolactin)opromotes development of mammary gland

with help of oxytocin it initiates milk let down reflex5.Leutinizing hormoneosecretes estrogen6.Follicle stimulating hormoneosecretes progesteronePINEAL GLANDosecretesmelatoninoinhibits LH secretionoit controls/regulates circadian rhythm (body clock)

THYROID GLANDolocated anterior to the neck3 Hormones secreted1.T3(Tri iodothyronine) - 3 molecules of iodine (more potent)2.T4(tetra iodothyronine,Thyroxine)oT3 and T4 are metabolic or calorigenic hormoneopromotes cerebration (thinking)3.Thyrocalcitonin – antagonizes the effects of parathormone to promote calcium resorption.HYPOTHYROIDISMoall aredecreaseexceptweightandmenstruationomemory impairmentSigns and Symptomsothere is loss of appetite but there is weight gainomenorrhagiaocold intoleranceoconstipationHYPERTHYROIDISMoall areincreaseexceptweightandmenstruationSigns and Symptomsoincrease appetite but there is weight lossoamenorrheaoexophthalmosTHYROID DISORDERSSIMPLE GOITER oenlargement of thyroid gland due to iodine deficiencyA. Predisposing Factors1. Goiter belt areaa. places far from seab. Mountainous regions2. Increase intake of goitrogenic foodsocontains pro-goitrin an anti thyroid agent that has no iodine.ocabbage, turnips, radish, strawberry, carrots, sweet potato, broccoli, all nuts

osoil erosion washes away iodineogoitrogenic drugsa. Anti Thyroid Agent – Prophylthiuracil (PTU)b. Lithium Carbonatec. PASA (Aspirin)d. Cobalte. Phenylbutazones (NSAIDs)- if goiter is caused byB. Signs and Symptoms1. Enlarged thyroid gland2. Mild dysphagia3. Mild restlessnessC. Diagnostic Procedures1. Serum T3 and T4 – reveals normal or below normal2. Thyroid Scan – reveals enlarged thyroid gland.3. Serum Thyroid Stimulating Hormone (TSH) – is increased (confirmatory diagnostic test)D. Nursing Management1. Enforce complete bed rest2. Administer medications as ordereda.Lugol’s Solution/SSKI( Saturated Solution of Potassium Iodine)ocolor purple or violet and administered via straw to prevent staining of teeth.o4 Medications to be taken via straw: Lugol’s, Iron, Tetracycline, Nitrofurantoin (drug of choicefor pyelonephritis)b.Thyroid HormonesoLevothyroxine (Synthroid)oLiothyronine (Cytomel)oThyroid ExtractsNursing Management when giving Thyroid Hormones1. Instruct client to take in the morning to prevent insomnia2. Monitor vital signs especially heart rate because drug causes tachycardia and palpitations3. Monitor side effectsoinsomniaotachycardia and palpitationsohypertensionoheat intolerance4. Increase dietary intake of foods rich in iodineoseaweedsoseafood’s like oyster, crabs, clams and lobster but not shrimps because it contains lesser amount of iodine.oiodized salt, best taken raw because it it is easily destroyed by heat5. Assist in surgical procedure of subtotal thyroidectomyHYPOTHYROIDISMohyposecretion of thyroid hormoneoadults:MYXEDEMAnon pitting edemaochildren:CRETINISM the only endocrine disorder that can lead to mental retardationA. Predisposing Factors1.Iatrogenic Cause– disease caused by medical intervention such as surgery2. Related to atrophy of thyroid gland due totrauma

,presence of tumor ,inflammation3. Iodine deficiency4. Autoimmune (Hashimotos Disease)B. Signs and Symptoms(Early Signs)1. Weakness and fatigue2. Loss of appetite but with weight gain which promotes lipolysis leading to atherosclerosis and MI3. Dry skin4. Cold intolerance5. Constipation(Late Signs)1. Brittleness of hair and nails2. Non pitting edema (Myxedema)3. Hoarseness of voice4. Decrease libido5. Decrease in all vital signs – hypotension, bradycardia, bradypnea, hypothermia6. CNS changesolethargyomemory impairmentopsychosisomenorrhagiaC. Diagnostic Procedures1. Serum T3 and T4 is decreased2. Serum Cholesterol is increased3. RAIU (Radio Active Iodine Uptake) is decreasedD. Nursing Management1. Monitor strictly vital signs and intake and output to determine presence of oMyxedema coma is a complication of hypothyroidism and an emergency caseoa   severe   fo rm o f  hypo thy ro id i sm   i s   cha rac te r i zed  by   severe  hypo tens ion ,   b radycard ia , bradypnea, hypoventilation, hyponatremia, hypoglycemia, hypothermia leading to pregressivestupor and coma.Nursing Management for Myxedema ComaAssist in mechanical ventilationAdminister thyroid hormones as orderedForce fluids2. Force fluids3. Administer isotonic fluid solution as ordered4. Administer medications as orderedThyroid Hormonesa. Levothyroxineb. Leothyroninec. Thyroid Extracts5. Provide dietary intake that is low in calories6. Provide comfortable and warm environment7. Provide meticulous skin care8. Provide client health teaching and discharge planning concerninga. Avoid precipitating factors leading to myxedema comaostressoinfectionocold intoleranceouse of anesthetics, narcotics, and sedativesoprevent complications (myxedema coma, hypovolemic shock

 ohormonal replacement therapy for lifetimeoimportance of follow up careHYPERTHYROIDISMoincrease in T3 and T4oGrave’s Diseaseor 

Thyrotoxicosisodeveloped byRobert GraveA. Predisposing Factors1. Autoimmune – it involves release of long acting thyroid stimulator causingexopthalmus(protrusionof eyeballs)enopthalmus(late sign of dehydration among infants)2. Excessive iodine intake3. Related to hyperplasia (increase size)B. Signs and Symptoms1. Increase appetite (hyperphagia) but there is weight loss2. Moist skin3. Heat intolerance4. Diarrhea5. All vital signs are increased6. CNS involvementa. Irritability and agitationb. Restlessnessc. Tremorsd. Insomniae. Hallucinations7. Goiter 8. Exopthalmus9. AmenorrheaC. Diagnostic Procedures1. Serum T3 and T4 is increased2. RAIU (Radio Active Iodine Uptake) is increased3. Thyroid Scan- reveals an enlarged thyroid glandD. Nursing Management1. Monitor strictly vital signs and intake and output2. Administer medications as orderedAnti Thyroid Agenta. Prophythioracill (PTU)b. Methymazole (Tapazole)Side Effects of Agranulocytosisoincrease lymphocytes and monocytesofever and chillsosore throat (throat swab/culture)oleukocytosis (CBC)3. Provide dietary intake that is increased incalories.4. Provide meticulous skin care5. Comfortable and cold environment6. Maintain side rails7. Provide bilateral eye patch to prevent drying of the eyes.8. Assist in surgical procedures known as subtotal thyroidectomy**Before thyroidectomyadminister Lugol’s Solution (SSKI) to decrease vascularity of the thyroidgland to prevent bleeding and hemorrhage.POST OPERATIVELY,1. Watch out for signs of thyroid storm/ thyrotoxicosis AgitationH y p e r t h e r m ia T a c h y c a r d iaoadminister medications as ordereda. Anti Pyreticsb. Beta-blockersomonitor strictly vital signs, input and output and neuro check.omaintain side railsooffer TSB2. Watch out for accidental removal of parathyroid gland that may lead toHypocalcemia (tetany)Signs and Symptomso(+) trousseau’s signo(+) chvostek signoWatch out for arrhythmia, seizure give Calcium Gluconate IV slowly as ordered3. Watch out for accidental Laryngeal damage which may lead to hoarseness of voiceNursing Management oencourage client to talk/speak immediately after operation and notify physician4. Signs of bleeding (feeling of fullness at incisional site)Nursing Management o

Check the soiled dressings at the back or nape area.5. Hormonal replacement therapy for lifetime6. Importance of follow up carePARATHYROID GLANDoA pair of small nodules behind the thyroid glandoSecretes parathormoneoPromotes calcium reabsorptionoHypoparathyroidismoHyperparathyroidismHYPOPARATHYROIDISMoDecrease secretion of parathormone leading tohypocalcemiaoResulting to hyperphospatemiaA. Predisposing Factors1. Following subtotal thyroidectomy2. Atrophy of parathyroid gland due to: a. inflammationb. tumor c. traumaB. Signs and Symptoms1. Acute tetanya. tingling sensationb. paresthesiac. numbnessd. dysphagiae. positive trousseu’s sign/carpopedal spasmf. positive chvostek signg. laryngospasm/broncospasmh . s e i z u r e f e a r e d c o m p l i c a t i o n s i. arrhythmia2. Chronic tetanya. photophobia and cataract formationb. loss of tooth enamelc. anorexia, nausea and vomitingd. agitation and memory impairmentC. Diagnostic Procedures1. Serum Calcium is decreased (normal value: 8.5 – 11 mg/100 ml)2. Serum Phosphate is decreased (normal value: 2.5 – 4.5 mg/100 ml)3. X-ray of long bones reveals a decrease in bone density4. CT Scan – reveals degeneration of basal gangliaD. Nursing Management1. Administer medications as ordered such as:a.Acute TetanyCalcium Gluconate IV slowlyb.Chronic TetanyOral Calcium supplementsCalcium GluconateCalcium LactateCalcium Carbonatec. Vitamin D (Cholecalciferol) for absorption of calciumCHOLECALCIFEROL ARE DERIVED FROMD r u g  D i e t   (Calcidiol)  S u n l i g h t  (Calcitriol)d. Phosphate binder Aluminum Hydroxide Gel (Ampogel)Side effect: constipationANTACIDA . A .C   M AD  ▼ ▼A l u m i n u m   C o n t a i n i n

g   M a g n e s i u m   C o n t a i n i n g A n ta c i d s   A n t a c i d s  ▼ ▼AluminumHydroxide

 Gel ▼S i d e   E f f e c t :  C o n s t i p a t i o n S i d e   E f f e c t :   D ia r r h e a 2. Avoid precipitating stimulus such as glaring lights and noise3. Encourage increase intake of foods rich in calciuma. anchoviesb. salmonc. green turnips4. Institute seizure and safety precaution5. Encourage client to breathe using paper bag to produce mild respiratory acidosis result.6. Prepare trache set at bedside for presence of laryngo spasm7. Prevent complications8. Hormonal replacement therapy for lifetime9. Importance of follow up care.HYPERTHYROIDISMoDecrease parathormoneoHypercalcemia: bone demineralization leading to bone fracture (calcium is stored 99% in bone and 1%blood)oKidney stonesA. Predisposing Factors1. Hyperplasia of parathyroid gland2. Over compensation of parathyroid gland due to vitamin D deficiencya. Children: Rickettsb. Adults: OsteomalaciaB. Signs and Symptoms1. Bone pain especially at back (bone fracture)2. Kidney stonesa. renal cholicb. cool moist skin3. Anorexia, nausea and vomiting4. Agitation and memory impairmentC. Diagnostic Procedures1. Serum Calcium is increased2. Serum Phosphate is decreased3. X-ray of long bones reveals bone demineralizationD. Nursing Management1. Force fluids to prevent kidney stones2. Strain all the urine using gauze pad for stone analysis3. Provide warm sitz bath4. Administer medications as ordereda. Morphine Sulfate (Demerol)5. Encourage increase intake of foods rich in phosphate but decrease in calcium6. Provide acid ash in the diet to acidify urine and prevent bacterial growth7. Assist/supervise in ambulation8. Maintain side rails9. Prevent complications (seizure and arrhythmia)10. Assist in surgical procedure known asparathyroidectomy11. Hormonal replacement therapy for lifetime12. Importance of follow up care