Medical-Surgical Nursing: Nervous System

MEDICAL-SURGICAL NURSING
NERVOUS SYSTEM
Overview of structures and functions:
Central Nervous System
Brain
Spinal Cord
Peripheral Nervous System
Cranial Nerves
Spinal Nerves
Autonomic Nervous System
Sympathetic nervous system
Parasympathetic nervous system
AUTONOMIC NERVOUS SYSTEM

Sympathetic Nervous System Parasympathetic Nervous System
(ADRENERGIC) (CHOLINERGIC, VAGAL, SYMPATHOLYTIC)
- Involved in fight or aggression response. - Involved in fight or withdrawal response.
- Release of Norepinephrine (cathecolamines) - Release of Acetylcholine.
from adrenal glands and causes
vasoconstriction.
- Increase all bodily activity except GIT - Decreases all bodily activities except GIT.
EFFECTS OF SNS EFFECTS OF PNS

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

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

- Also called Beta-blockers. - To counter cholinergic agents.
- All ending with lol - Atropine Sulfate
- Propranolol, Atenelol, Metoprolol. Side Effects
Effects of Beta-blockers - SNS
B roncho spasm
E licits a decrease in myocardial contraction.
T reats hypertension.
A V conduction slows down.
Should be given to patients with Angina
Pectoris, Myocardial Infarction, Hypertension.
ANTI- HYPERTENSIVE AGENTS

1. Beta-blockers lol
2. Ace Inhibitors Angiotensin, pril (Captopril,
Enalapril)
3. Calcium Antagonist Nifedipine (Calcibloc)
In chronic cases of arrhythmia give
Lidocaine(Xylocaine)
CENTRAL NERVOUS SYSTEM
Brain and Spinal Cord.
I. CELLS
A. NEURONS
Basic cells for nerve impulse and conduction.
PROPERTIES
Excitability ability of neuron to be affected by changes in external environment.
Conductivity ability of neuron to transmit a wave of excitation from one cell to another.
Permanent Cell once destroyed not capable of regeneration.
TYPES OF CELLS BASED ON REGENERATIVE CAPACITY

1. Labile
Capable of regeneration.
Epidermal cells, GIT cells, GUT cells, cells of lungs.
2. Stable
Capable of regeneration with limited time, survival period.
Kidney cells, Liver cells, Salivary cells, pancreas.
3. Permanent
Not capable of regeneration.
Myocardial cells, Neurons, Bone cells, Osteocytes, Retinal Cells.
B. NEUROGLIA
Support and protection of neurons.
TYPES
1. Astrocytes maintains blood brain barrier semi-permeable.
Majority of brain tumors (90%) arises from called astrocytoma.
2. Oligodendria
3. Microglia
4. Epindymal
SUBSTANCES THAT CAN PASS THE BLOOD-BRAIN BARRIER

1. Ammonia
Cerebral toxin
Hepatic Encephalopathy (Liver Cirrhosis)
Ascites
Esophageal Varices
Early Signs of Hepatic Encephalopathy
asterixis (flapping hand tremors).
Late Signs of Hepatic Encephalopathy
Headache
Dizziness
Confusion
Fetor hepaticus (ammonia like breath)
Decrease LOC
PATHOGNOMONIC SIGNS
1. PTB low-grade afternoon fever.
2. PNEUMONIA rusty sputum.
3. ASTHMA wheezing on expiration.
4. EMPHYSEMA barrel chest.
5. KAWASAKI SYNDROME strawberry tongue.
6. PERNICIOUS ANEMIA red beefy tongue.
7. DOWN SYNDROME protruding tongue.
8. CHOLERA rice watery stool.
9. MALARIA stepladder like fever with chills.
10. TYPHOID rose spots in abdomen.
11. DIPTHERIA pseudo membrane formation
12. MEASLES kopliks 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 (+) Hermans sign.
19. MENINGITIS Kernigs sign (leg pain), Brudzinski sign (neck pain).
20. TETANY HYPOCALCEMIA (+) Trousseaus sign/carpopedal spasm; Chvostek sign (facial spasm).
21. TETANUS risus sardonicus.
22. PANCREATITIS Cullens sign (ecchymosis of umbilicus); (+) Grey turners spots.
23. PYLORIC STENOSIS olive like mass.
24. PDA machine like murmur.
25. ADDISONS DISEASE bronze like skin pigmentation.
26. CUSHINGS SYNDROME moon face appearance and buffalo hump.
27. HYPERTHYROIDISM/GRAVES DISEASE exopthalmus.
28. INTUSSUSCEPTION sausage shaped mass
2. Carbon Monoxide and Lead Poisoning

Can lead to Parkinsons Disease.
Epilepsy
Treat with ANTIDOTE: 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.
KUSSMAULS 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.
DEMYELINATING DISORDERS
1. ALZHEIMERS DISEASE
Atrophy of brain tissues.
Sign and Symptoms
4 As 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
Brocas Aphasia
*Receptive aphasia
inability to understand spoken words.
Wernickes Aphasia
General Knowing Gnostic Area or General Interpretative Area.
DRUG OF CHOICE: ARICEPT (taken at bedtime) and COGNEX.
2. MULTIPLE SCLEROSIS
Chronic intermittent disorder of CNS characterized by white patches of demyelination in brain and
spinal cord.
Characterized by remission and exacerbation.
Women ages 15-35 are prone
Unknown Cause
Slow growing virus
Autoimmune disorders
Pernicious anemia
Myasthenia gravis
Lupus
Hypothyroidism
GBS
Ig G only antibody that pass placental circulation causing passive immunity.

- short term protection.
- Immediate action.
Ig A present in all bodily secretions (tears, saliva, colostrums).
Ig M acute in inflammation.
Ig E for allergic reaction.
Ig D for chronic inflammation.
* Give palliative or supportive care.
Signs and Symptoms
1. Visual disturbances
blurring of vision (primary)
diplopia (double vision)
scotomas (blind spots)
2. Impaired sensation
to touch, pain, pressure, heat and cold.
tingling sensation
paresthesia
numbness
3. Mood swings
euphoria (sense of well being)
4. Impaired motor function
weakness
spasticity
paralysis
5. Impaired cerebral function
scanning speech
TRIAD SIGNS OF MS
Ataxia
(Unsteady gait, (+) Rombergs test)
CHARCOTS
TRIAD
IAN
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).
(+) Lhermittes sign a continuous and increase contraction of spinal column.
NURSING MANAGEMENT
1. Administer medications as ordered
a. ACTH (Adreno Corticotropic Hormone)/ Steroids for acute exacerbation to reduce edema at site
of demyelination to prevent paralysis.
b. Baclofen (Dioresal)/ Dantrolene Sodium (Dantrene) muscle relaxants.
c. Interferons alter immune response.
d. Immunosupresants
2. Maintain side rails to prevent injury related to falls.
3. Institute stress management techniques.
a. Deep breathing exercises
b. Yoga
4. Increase fluid intake and increase fiber to prevent constipation.
5. Catheterization to prevent retention.
a. Diuretics
b. Bethanicol Chloride (Urecholine)
Nursing Management
Only given subcutaneous.
Monitor side effects bronchospasm and wheezing.
Monitor breath sounds 1 hour after subcutaneous administration.
c. For Urinary Incontinence
Anti spasmodic agent
a. Prophantheline Bromide (Promanthene)
Acid ash diet like cranberry juice, plums, prunes, pineapple, vitamin C and orange.
To acidify urine and prevent bacterial multiplication.
COMMON CAUSE OF UTI
Female
short urethra (3-5 cm, 1-1 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 Brain
Monocytes Blood
Kupffers cells Kidney
Histiocytes Skin
Alveolar Lung
Macrophage
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
Brocas 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
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 Parkinsons 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
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 promotes 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, swallowing, vomiting, hiccup, vasomotor center (dilation and
constriction of bronchioles).
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.
Causes:
head trauma/injury inflammatory condition (stroke)
localized abscess hydrocephalus
cerebral edema tumor (rarely)
hemorrhage
Signs and Symptoms (Early)
decrease LOC lethargy/stupor
restlessness/agitation coma
irritability
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
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.
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 Asparagus
Banana Brocolli
Cantalop Carrots
e Spinach
Oranges
2. Hypocalcemia/ Tetany
decrease calcium level
normal value is 8.5 11 mg/100 ml
Signs and Symptoms
tingling sensation
paresthesia
numbness
(+) Trousseaus sign/ Carpopedal spasm
(+) Chvosteks sign
Complications
Arrhythmia
Seizures
Nursing Management
Calcium Gluconate per IV slowly as ordered
* Calcium Gluconate toxicity results to SEIZURE
Magnesium Sulfate
Magnesium Sulfate toxicity

S/S
BP
Urine output 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
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)
PARKINSONS 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
SIDE EFFECTS RESERPINE Major depression leading to suicide
Aloneness
Multiple loss
causes
suicide
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 Parkinsons

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.
Monotone type speech
mood lability (in state of depression)
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
arrhythmia
hallucinations
Contraindications
clients with narrow angle closure glaucoma
clients taking MAOIs (no foods with triptophan and thiamine)
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
MAGIC 2s IN DRUG MONITORING

DRUG NORMAL RANGE TOXICITY INDICATION CLASSIFICATION
LEVEL
Digoxin/ Lanoxin .5 1.5 meq/L 2 CHF Cardiac Glycoside
(Increase force of
cardiac output)
Lithium/ Lithane .6 1.2 meq/L 2 Bipolar Anti-Manic Agents
(Decrease level of
Ach/NE/Serotonin)
Aminophylline 10 19 mg/100 ml 20 COPD Bronchodilators
(Dilates bronchial tree)
Dilantin/ Phenytoin 10 19 mg/100 ml 20 Seizures Anti-Convulsant
Acetaminophen/Tylenol 10 30 mg/100 ml 200 Osteo Non-narcotic
Arthritis Analgesic
1. Digitalis Toxicity
Signs and Symptoms
nausea and vomiting
diarrhea
confusion
photophobia
changes in color perception (yellowish spots)
Antidote: Digibind
2. Lithium Toxicity
Signs and Symptoms
anorexia
nausea and vomiting
diarrhea
dehydration causing fine tremors
hypothyroidism
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 Toxicity
Signs and Symptoms
gingival hyperplasia (swollen 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 as 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 Ach.
Signs and Symptoms
initial sign is ptosis a clinical parameter to determine ptosis is palpebral fissure.
diplipia
mask like facial expression
dysphagia
hoarseness of voice
respiratory muscle weakness that may lead to respiratory arrest
extreme muscle weakness especially during exertion and morning
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. 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 scale
4. maintain side rails to prevent injury related to falls
5. institute NGT feeding
6. administer medications as ordered
a. Cholinergic (Mestinon)
b. Anti Cholenisterase (Neostegmin)
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: Cause:
- under medication - over medication
- stress
- infection
Signs and Symptoms Signs and Symptoms
- The client is unable to see, swallow, speak, - PNS
breathe
Treatment Treatment
- administer cholinergic agents as ordered - 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, general 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. (+) Kernigs 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
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.
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
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
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)
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 (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
(+) Kernigs 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 food 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
a disorder of the CNS characterized by bilateral symmetrical polyneuritis leading to ascending muscle
paralysis.
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
Conscious 15 14
Lethargy 13 11
Stupor 10 8
Coma 7
Deep Coma 3
Survey of mental status and speech

a. LOC
b. Test of memory
Levels of orientation
Cranial nerve assessment
Sensory nerve assessment
Motor nerve assessment
Deep tendon reflex
Autonimics
Cerebellar test
a, Rombergs 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)
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 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
CRANIAL NERVE I: OLFACTORY
sensory function for smell
Material Used
dont 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 Snellens Chart
Snellens Alphabet chart: for literate clients
Snellens E chart: for illiterate clients
Snellens 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
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) constricts 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
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/thickdolorum
medication: Carbamezapine(Tegretol)
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 Bells Palsy
and the primary cause is forcep 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: Meineres 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
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
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
SIADH
o hypersecretion of anti diuretic 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
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
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
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
o cold intolerance
o constipation
HYPERTHYROIDISM
o all are increase except weight and menstruation
Signs and Symptoms
o increase appetite but there is weight loss
o amenorrhea
o exophthalmos
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
o soil erosion washes away iodine
o goitrogenic drugs
a. Anti Thyroid Agent Prophylthiuracil (PTU)
b. Lithium Carbonate
c. PASA (Aspirin)
d. Cobalt
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. Lugols 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: Lugols, 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 seafoods 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
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
o 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
6. Provide comfortable and warm environment
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
o increase in T3 and T4
o Graves Disease or Thyrotoxicosis
o developed by Robert Grave
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 (increase size)

1. Increase appetite (hyperphagia) but there is weight loss
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
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
Anti Thyroid Agent
a. Prophythioracill (PTU)
b. Methymazole (Tapazole)
Side Effects of Agranulocytosis
o increase lymphocytes and monocytes
o fever and chills
o sore throat (throat swab/culture)
o leukocytosis (CBC)
3. Provide dietary intake that is increased in calories.
5. Comfortable and cold environment
6. Maintain side rails
7. Provide bilateral eye patch to prevent drying of the eyes.
8. Assist in surgical procedures known as subtotal thyroidectomy
** Before thyroidectomy administer Lugols Solution (SSKI) to decrease vascularity of the thyroid
gland to prevent bleeding and hemorrhage.
POST OPERATIVELY,
1. Watch out for signs of thyroid storm/ thyrotoxicosis
Agitation
TRIAD SIGNS
Hyperthermia Tachycardia
o administer medications as ordered
a. Anti Pyretics
b. Beta-blockers
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 that may lead to
Hypocalcemia (tetany)
Signs and Symptoms
o (+) trousseaus sign
o (+) chvostek sign
o Watch out for arrhythmia, seizure give Calcium Gluconate IV slowly as ordered
3. Watch out for accidental Laryngeal damage which may lead to hoarseness of voice
Nursing Management
o encourage client to talk/speak immediately after operation and notify physician
4. 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 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 Hypoparathyroidism
o Hyperparathyroidism
HYPOPARATHYROIDISM
o Decrease secretion of parathormone leading to hypocalcemia
o Resulting to hyperphospatemia
1. Following subtotal thyroidectomy
2. Atrophy of parathyroid gland due to:
a. inflammation
b. tumor
c. trauma
1. Acute tetany
a. tingling sensation
b. paresthesia
c. numbness
d. dysphagia
e. positive trousseus sign/carpopedal spasm
f. positive chvostek sign
g. laryngospasm/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
1. 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 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
CHOLECALCIFEROL ARE DERIVED FROM
Drug Diet (Calcidiol) Sunlight (Calcitriol)
d. Phosphate binder
Aluminum Hydroxide Gel (Ampogel)
Side effect: constipation
ANTACID
A.A.C MAD

Aluminum Containing Magnesium Containing
Antacids Antacids

Aluminum
Hydroxide
Gel

Side Effect: Constipation Side Effect: Diarrhea
2. Avoid precipitating stimulus such as glaring lights and noise

3. Encourage increase intake of foods rich in calcium
a. anchovies
b. salmon
c. green turnips
4. Institute seizure and safety precaution
5. Encourage client to breathe using paper bag to produce mild respiratory acidosis result.
6. Prepare trache set at bedside for presence of laryngo spasm
9. Importance of follow up care.
HYPERTHYROIDISM
o Decrease parathormone
o Hypercalcemia: bone demineralization leading to bone fracture (calcium is stored 99% in bone and 1%
blood)
o Kidney stones
1. Hyperplasia of parathyroid gland
2. Over compensation of parathyroid gland due to vitamin D deficiency
a. Children: Ricketts
b. Adults: Osteomalacia
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)
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 catecholamines a power hormone)
2 Types of Catecholamines
o Epinephrine and Norepinephrine (vasoconstrictor)
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
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
ADDISONS DISEASE
o Hyposecretion of adreno cortical hormone leading to
a. metabolic disturbance Sugar
b. fluid and electrolyte imbalance Salt
c. deficiency of neuromuscular function Salt/Sex
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
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
addisons disease)
o Addisonian crisis results from acute exacerbation of addisons 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
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
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
3. Serum Sodium is increased
4. Serum Potassium is decreased
C. Nursing Management
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
- 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
CLASSIFICATION OF DM
Type 1 (IDDM) Type 2 (NIDDM)
- Juvenile onset type - Adult onset
- Brittle disease - Maturity onset type
- Obese over 40 years old
A. Incidence Rate A. Incidence Rate
- 10% general population has type 1 DM - 90% of general population has type 2 DM
B. Predisposing Factors B. Predisposing Factors
1. Hereditary (total destruction of pancreatic cells) 1. Obesity because obese persons lack insulin
2. Related to viruses receptor binding sites
3. Drugs
a. Lasix
b. Steroids
4. Related to carbon tetrachloride toxicity
C. Signs and Symptoms C. Signs and Symptoms

1. Polyuria 1. Usually asymptomatic
2. Polydypsia 2. Polyuria
3. Polyphagia 3. Polydypsia
4. Glucosuria 4. Polyphagia
5. Weight loss 5. Glucosuria
6. Anorexia, nausea and vomiting 6. Weight gain
7. Blurring of vision
8. Increase susceptibility to infection
9. Delayed/poor wound healing
D. Treatment D. Treatment
1. Insulin therapy 1. Oral Hypoglycemic agents
2. Diet 2. Diet
3. Exercise 3. Exercise
E. Complication E. Complications
1. Diabetic Ketoacidosis 1. Hyper
2. Osmolar
3. Non
4. Ketotic
5. Coma
MAIN ANABOLISM CATABOLISM
FOODSTUFF
1. Carbohydrates Glucose Glycogen

2. Protein Amino Acids Nitrogen
3. Fats Fatty Acids Free Fatty Acids
- Cholesterol
- Ketones
HYPERGLYCEMIA
Increase osmotic diuresis
Glycosuria Polyuria
Cellular starvation weight loss Cellular dehydration
Stimulates the appetite/satiety center Stimulates the thirst center

(Hypothalamus) (Hypothalamus)
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 Kussmauls 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
6. Anorexia, nausea and vomiting
7. Blurring of vision
8. Acetone breath odor
9. Kussmauls 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 palm to prevent formation of bubbles
4. Use gauge 25 26 needle
5. Administer insulin either 45o 90o 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. Somogyis Phenomenon rebound effect of insulin characterized by hypoglycemia to
hyperglycemia
ORAL HYPOGLYCEMIC AGENTS

- 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
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)
EYES KIDNEY
-PREMATURE CATARACT -RECURRENT PYELONEPHRITIS
- Blindness - Renal failure
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
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. Kaposis 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
B. Predisposing Factors
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 VINSONS 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 urinw, 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
- Lugols 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 Rombergs test damage to cerebellum resulting to ataxia
e. result to psychosis
Schillings 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
7. Avoid IM, subcutaneous, venipunctured sites
8 Instead provide heparin lock
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. Septecemia
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. Lumbasternal/ 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

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 fluid which is 10 20 cc
- Prevent pericardial friction rub
- 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
2. S4 atrial gallop usually seen in Myocardial Infarction and Hypertension
D. Coronary Arteries
- Arises from base of the aorta
Types of Coronary Arteries
1. Right Main Coronary Artery
2. Left Main Coronary Artery
- 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
- Located at the walls of the ventricles for ventricular contraction
SA NODE
AV NODE
BUNDLE OF HIS
JLJLJLJJLJLJL
PURKINJE FIBERS
- 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
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 Arrythmia
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 - hardening of artery
- lipid or fat deposits - calcium and protein deposits
- tunica intima - 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. Duaphoresis
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 Es 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. Levines 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
- 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 persist 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
o Orthostatic hypotension
o 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 duting defibrillation as it may lead to burns (most
important thing to remember)
b. Beta-blockers
- Propanolol - side effects PNS
- Not given to COPD cases because it causes bronchospasm
c. ACE Inhibitors
- Enalapril
d. Calcium Antagonist
- NIfedipine

4. Place client on semi fowlers 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 Es
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
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 PVCs
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)
- Not usually relieved by rest or by nitroglycerine
2. Dyspnea
3. Increase in blood pressure (initial sign)
4. Hyperthermia
5. Ashen skin
6. Mild restlessness and apprehension
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 acid 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
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 fowlers 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, Isodil) sublingual
b. Anti Arrythmic Agents

- Lidocaine (Xylocane
- Side Effects: confusion and dizziness
- Brutylium
c. Beta-blockers
d. ACE Inhibitors
e. Calcium Antagonist
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
- homans sign
e. Stroke/CVA
f. Post MI Syndrome/Dresslers 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 Grp. A beta-hemolytic streptococcus
- Formation of aschoff bodies in the mitral valve
- Common among children
- 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 is awakened at night due to difficulty of breathing
3. Orthopnea use 2 3 pillows when sleeping or place in high fowlers
4. Productive cough with blood tinged sputum
5. Frothy salivation
6. Cyanosis
7. Rales/Crackles
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
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. Ecocardiography 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

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
3. Ascites
4. Weight gain
5. Hepatosplenomegaly
6. Jaundice
7. Pruritus
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 trendelendberg position to promote ventricular filling and prevent
pulmonary embolism
3. Ecocardiography reveals enlarged heart chambers (cardiomyopathy
4. Liver enzymes SGPT and SGOT is increased
Goal: increase cardiac contractility thereby increasing cardiac output (3 6 L/min)
1. Enforce CBR
a. Cardiac glycosides
- Digoxin (Lanoxin)
- Increase force of cardiac contraction
- If heart rate is decreased do not give
b. Loop Diuretics
- Lasix (Furosemide)
c. Bronchodilators
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 fowlers 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
- Arrythmia
- Shock
- Right ventricular hypertrophy
- MI
- Thrombophlebitis
b. Dietary modification
c. Strict compliance to medications
PERIPHERAL VASCULAR DISORDER

Arterial Ulcer
I. Thrombo Angitis Obliterans
Burgers Disease
Reynauds Disease
Venous Ulcer
1. Varicose Veins
2. Thrombophlebitis (deep vein thrombosis)
THROMBOANGITIS OBLITERANS
Acute inflammatory disorder usually affecting the small medium sized arteries and veins of the lower
extremities
1. High risk groups men 30 years old and above
2. Smoking

1. Intermittent claudication leg pain upon walking
2. Cold sensitivity and changes in skin color (pallor, cyanosis then rubor)
3. Decreased peripheral pulses
4. Trophic changes
5. Ulceration
6. Gangrene formation
1. Oscillometry decrease in peripheral pulses
2. Doppler UTZ decrease blood flow to the affected extremity
3. Angiography reveals site and extent of malocclusion
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
REYNAUDS DISEASE
Disorder characterized by acute episodes of arterial spasm involving the fingers or digits of the hands
1. High risk group female 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

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
1. Doppler UTZ decrease blood flow to the affected extremity
2. Angiography reveals site and extent of malocclusion
a. Analgesics
b. Vasodilators
2. Encourage to wear gloves
3. Instruct client on importance of cessation of smoking and exposure to cold environment
VARICOSITIES
Abnormal dilation of veins of lower extremities and trunks due to
Incompetent valve resulting to
Increased venous pooling resulting to
Venous stasis causing
Decrease venous return
1. Hereditary
2. Congenital weakness of veins
3. Thrombophlebitis
4. Cardiac disorder
5. Pregnancy
6. Obesity
7. Prolonged standing or sitting

1. Pain after prolonged standing
2. Dilated tortuous skin veins
3. Warm to touch
4. Heaviness in legs
1. Venography
2. Trendelenburgs 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 in spider web varicosities and danger of thrombosis (2 3
years for embolism)
THROMBOPHLEBITIS
Deep vein thrombosis
Inflammation of the veins with thrombus formation
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 Hpmans Signs pain at the calf or leg muscle upon dorsi flexion 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
- Heparin
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
MURPHYS SIGN is seen in clients with cholelithiasis, cholecystitis characterized by pain at the
right upper quadrant with tenderness
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 Keissel Rach 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
- Site of gas exchange (CO2 and O2)
- Diffusion (Daltons law of partial pressure of gases)
Respiratory Distress Syndrome

- Decrease oxygen stimulates breathing
- Increase carbon dioxide is a powerful stimulant for breathing
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 (Kochs 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 an 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
4. CBC
- Reveals increase WBC
1. Enforce CBR
2. Institute strict respiratory isolation
4. Force fluids to liquefy secretions
5. Place client on semi fowlers 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
3. Diplococcus Pneumoniae
4. Klebsella Pneumoniae
5. Escherichia Pneumoniae
6. Pseudomonas
B. High Risk Groups

1. Children below 5 years old
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
- 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 fowlers 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 3 hours to prevent gastro esophageal reflux
b. Monitor vital signs
c. Encourage client deep breathing exercises
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
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, pH decrease
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 fowlers 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 breath 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

Medical-Surgical Nursing: Nervous System

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Medical-Surgical Nursing: Nervous System

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MEDICAL-SURGICAL NURSING

AUTONOMIC NERVOUS SYSTEM

EFFECTS OF SNS EFFECTS OF PNS

I. Adrenergic Agents I. Cholinergic Agents

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

ANTI- HYPERTENSIVE AGENTS

TYPES OF CELLS BASED ON REGENERATIVE CAPACITY

SUBSTANCES THAT CAN PASS THE BLOOD-BRAIN BARRIER

2. Carbon Monoxide and Lead Poisoning

Ig G only antibody that pass placental circulation causing passive immunity.

Intentional tremors Nystagmus

NEURO TRANSMITTER DECREASE INCREASE

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

Cervical 1 also known as ATLAS.

Increase intra cranial pressure

CSF cushions brain (shock absorber)

7. Administer medications like:

*CONGESTIVE HEART FAILURE

RIGHT CONGESTIVE HEART FAILURE (Venous congestion)

Magnesium Sulfate toxicity

SIDE EFFECTS RESERPINE Major depression leading to suicide

Loss of spouse Loss of Job

direct approach towards the client

Signs and Symptoms for Parkinsons

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

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

Anti Histamine (Dipenhydramine Hydrochloride)

MAGIC 2s IN DRUG MONITORING

C. Signs and Symptoms

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

Signs and Symptoms of Pulmonary Embolism

Fat embolism is the most feared complications after femur fracture.

D. Signs and Symptoms

* Sengstaken Blakemore Tube

B. Signs and Symptoms

II. Partial or Localized Seizure

III. Status Epilepticus

COMPREHENSIVE NEURO EXAM

Survey of mental status and speech

DIFFERENT PAINFUL STIMULATION

II. TEST OF MEMORY

III. LEVELS OF ORIENTATION

CRANIAL NERVES FUNCTION

CRANIAL NERVE II: OPTIC

COMMON VISUAL DISORDERS

B. Signs and Symptoms

B. Signs and Symptoms

A. Signs and Symptoms

CRANIAL NERVE III, IV, VI: OCULOMOTOR, TROCHLEAR, ABDUCENS

Superior Rectus Superior Oblique

Lateral Rectus Medial Rectus

Inferior Oblique Inferior Rectus

trochlear controls superior oblique

CRANIAL NERVE V: TRIGEMINAL

CRANIAL NERVE VII: FACIAL

CRANIAL NERVE VIII: ACOUSTIC/VESTIBULOCOCHLEAR

CRANIAL NERVE IX, X: GLOSOPHARYNGEAL, VAGUS NERVE

CRANIAL NERVE XI: SPINAL ACCESSORY

CRANIAL NERVE XII: HYPOGLOSSAL