1

MEDICAL-SURGICAL NURSING By: Anthony T. Villegas R.N. • Overview of structures and functions: NERVOUS SYSTEM • • • The functional unit of the nervous system is the nerve cells or neurons The nervous system is composed of the ff: B. NEUROGLIA • Support and protection of neurons. 3. • • • Capable of regeneration with limited time, survival period. Kidney cells, Liver cells, Salivary cells, pancreas.

Permanent Not capable of regeneration. Myocardial cells, Neurons, Bone cells, Osteocytes, Retinal Cells.

Central Nervous System Brain Spinal Cord – serves as a connecting link between the brain & the periphery. Peripheral Nervous System

TYPES 1. Astrocytes • maintains blood brain barrier semi-permiable. majority of brain tumors (90%) arises from called astrocytoma. • 2. integrity of blood brain barrier.

• •

Cranial Nerves –12 pairs; carry impulses to & from the brain. Spinal Nerves – 31 pairs; carry impulses to & from spinal cord.

Autonomic Nervous System subdivision of the PNS that automatically controls body function such as breathing & heart beat. Special senses of vision and hearing are also covered in this section

Oligodendria


• 3.

produces myelin sheath in CNS. act as insulator and facilitates rapid nerve impulse transmission.

• •

Sympathetic nervous system – generally accelerate some body functions in response to stress. Parasympathetic nervous system – controls normal body functioning.

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

4. CELLS A. NEURONS • • • Primary component of nervous system Composed of cell body (gray matter), axon, and dendrites Basic cells for nerve impulse and conduction.

Epindymal

secretes a glue called chemo attractants that concentrate the bacteria.

MACROPHAGE Microglia Monocytes Kupffers Histiocytes Alveolar Macrophage

ORGAN Brain Blood Kidney Skin Lung

Axon • Elongated process or fiber extending from the cell body Transmits impulses (messages) away from the cell body to dendrites or directly to the cell bodies of other neurons • • • • Neurons usually has only one axon

Central Nervous System Composition Of Brain • • • Brain Mass Parts Of The Brain 1. Cerebrum • largest part of the brain outermost area (cerebral cortex) is gray matter deeper area is composed of white matter function of cerebrum: integration, sensory, motor composed of two hemisphere the Right Cerebral Hemisphere and Left Cerebral Hemisphere enclosed in the Corpus Callosum. • Each hemisphere divided into four lobes; many of the functional areas of the cerebrum have been located in these lobes: 80% brain mass 10% blood 10% CSF

Dendrites Short, blanching fibers that receives impulses and conducts them toward the nerve cell body. Neurons may have many dendrites.

Synapse Junction between neurons where an impulse is transmitted

Neurotransmitter

Chemical agent (ex. Acetylcholine, norepinephrine) involved in the transmission of impulse across synapse.

Myelin Sheath


A wrapping of myelin (whitish, fatty material) that protects and insulates nerve fibers and enhances the speed of impulse conduction.

• •

o o

Both axons and dendrites may or may not have a myelin sheath (myelinated/unmyelinated) Most axons leaving the CNS are heavily myelinated by schwann cells

Functional Classification 1. Afferent (sensory) neurons • 2. • 3. • Transmit impulses from peripheral receptors to the CNS Lobes of Cerebrum 1. Frontal Lobe • • controls personality, behavior higher cortical thinking, intellectual functioning precentral gyrus: controls motor function Broca’s Area: specialized motor speech area - when damaged results to garbled speech. 2. Temporal Lobe • • hearing, taste, smell short term memory Wernicke’s area: sensory speech area (understanding/formulation of language) 3. Pareital Lobe • • • for appreciation integrates sensory information discrimination of sensory impulses to pain, touch, pressure, heat, cold, numbness.

Efferent (motor) neurons Conduct impulses from CNS to muscle and glands

Internuncial neurons (interneurons) Connecting links between afferent and efferent neurons

• •

Properties

1. Excitability – ability of neuron to be affected by changes in
external environment.

2. Conductility – ability of neuron to transmit a wave of
excitetation from one cell to another.

3. Permanent Cell – once destroyed not capable of
regeneration. TYPES OF CELLS BASED ON REGENERATIVE CAPACITY 1. Labile • • 2. Capable of regeneration. Epidermal cells, GIT cells, GUT cells, cells of lungs.

Stable

1

2 •
4. • controls respiration, heart rate, swallowing, vomiting, hiccup, vasomotor center (dilation and constriction of bronchioles). 5. Insula (Island of Reil) • visceral function activities of internal organ like gastric motility. Limbic System (Rhinencephalon) • Spinal Cord • • serves as a connecting link between the brain and periphery extends from foramen magnum to second lumbar vertebra Cerebellum • • smallest part of the brain, lesser brain. coordinates muscle tone and movements and maintains position in space (equilibrium) controls balance, equilibrium, posture and gait.

Postcentral gyrus: registered general sensation (ex. Touch, pressure)

Occipital Lobe • for vision


• •

controls smell - if damaged results to anosmia (absence of smell). controls libido controls long term memory

Corpus Callosum

large fiber tract that connects the two cerebral hemisphere

H-shaped gray matter in the center (cell bodies) surrounded by white matter (nerve tract and fibers)

Basal Ganglia • • • • island of gray matter within white matter of cerebrum regulate & integrate motor activity originating in the cerebral cortex part of extrapyramidal system area of gray matter located deep within each cerebral hemisphere. 2.

Gray Matter 1. Anterior Horns

Contains cell bodies giving rise to efferent (motor) fibers

Posterior Horns


2.

release dopamine (controls gross voluntary movement). 3.

Contains cell bodies connecting with afferent (sensory) fibers from dorsal root ganglion

Diencephalon/interbrain • Connecting part of the brain, between the cerebrum & the brain stem

Lateral Horns • In thoracic region, contain cells giving rise to autonomic fibers of sympathetic nervous system

Contains several small structures: the thalamus & hypothalamus are most important

White Matter

Thalamus

1. Ascending Tracts (sensory pathways)
a. Posterior Column • b. Carry impulses concerned with touch, pressure, vibration, & position sense Spinocerebellar • Carry impulses concerned with muscle tension & position sense to cerebellum c. Lateral Spinothalamic • d. Carry impulses resulting in pain & temperature sensations Anterior Spinothlamic • Carry impulses concerned with crude touch & pressure

• •

acts as relay station for discrimination of sensory signals (ex. Pain, temperature, touch) controls primitive emotional responses (ex. Rage, fear)

Hypothalamus found immediately beneath the thalamus plays a major role in regulation/controls of vital function: blood pressure, thirst, appetite, sleep & wakefulness, temperature (thermoregulatory center) • • acts as controls center for pituitary gland and affects both divisions of the autonomic nervous system. controls some emotional responses like fear, anxiety and excitement.


• • • 3.

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 telarch and late sign is menarch.

2. Descending Tracts (motor pathways) a. Corticospinal (pyramidal, upper motor neurons)
• Conduct motor impulses from motor cortex to anterior horn cells (cross in the medulla) b. Extrapyramidal • Help to maintain muscle tone & to control body movement, especially gross automatic movements such as walking Reflex Arc

Mesencephalon/Midbrain • 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.

• •

Reflex consists of an involuntary response to a stimulus occurring over a neural pathway called a reflex arc. Not relayed to & from brain: take place at cord levels

Brain Stem • • • • located at lowest part of brain. contains midbrain, pons, medulla oblongata. extends from the cerebral hemispheres to the foramen magnum at the base of the skull. contains nuclei of the cranial nerves and the long ascending and descending tracts connecting the cerebrum and the spinal cord. • contains vital center of respiratory, vasomotor, and cardiac functions. Pons • pneumotaxic center controls the rate, rhythm and depth of respiration. Medulla Oblongata

Components a. Sensory Receptors • b. • c. Receives/reacts to stimulus

Afferent Pathways Transmits impulses to spinal cord

Interneurons


d. • e. •

Synapses with a motor neuron (anterior horn cell)

Efferent Pathways Transmits impulses from motor neuron to effector

Effectors Muscle or organ that responds to stimulus

Supporting Structures 1. Skull • Rigid; numerous bones fused together

2

3
• 2. • • 3. • • • Protects & support the brain


Resulting to cholesterol and positive to ketones (CNS depressant). Resulting to acetone breath odor/fruity odor. And kusshmauls respiration a rapid shallow respiration. Which may lead to diabetic coma.

Spinal Column Consists of 7 cervical, 12 thoracic, & 5 lumbar vertebrae as well as sacrum & coccyx Supports the head & protect the spinal cord 4.


Meninges Membranes between the skull & brain & the vertebral column & spinal cord 3 fold membrane that covers brain and spinal cord. For support and protection; for nourishment; blood supply

Hepatitis


• 5.

Signs of jaundice (icteric sclerae). Caused by bilirubin (yellow pigment)

Bilirubin


Increase bilirubin in brain (kernicterus). Causing irreversible brain damage.

• •

Area between arachnoid & pia mater is called subarachnoid space: CSF aspiration is done Subdural space between the dura and arachnoid Layers: Dura Mater • • • outermost layer, tough, leathery

Peripheral Nervous System Spinal Nerves 31 pairs: carry impulses to & from spinal cord Each segment of the spinal cord contains a pair of spinal nerves (one of each side of the body) Each nerve is attached to the spinal by two roots:

Arachnoid Mater middle layer, weblike

Pia Mater innermost layer, delicate, clings to surface of brain

4.

Ventricles • • Four fluid-filled cavities connecting with one another & spinal canal Produce & circulate cerebrospinal fluid

1. Dorsal (posterior) roots •
contains afferent (sensory) nerve whose cell body is in the dorsal roots ganglion

5. Cerebrospinal Fluid (CSF)
• Surrounds brain & spinal cord Offer protection by functioning as a shock absorber Allows fluid shifts from the cranial cavity to the spinal cavity • Carries nutrient to & waste product away from nerve cells

2. Ventral (anterior) roots •
Contains efferent (motor) nerve whose nerve fibers originate in the anterior horn cell of the spinal cord (lower motor neuron) Cranial Nerves 12 pairs: carry impulses to & from the brain. May have sensory, motor, or mixed functions. Name & Number Olfactory sense of smell. Optic Oculomotor : CN II : CN III Sensory: carries impulses for vision. Motor: muscles for papillary 4 out of 6 extraocular movement. Trochlear Trigeminal : CN IV : CN V Motor: muscles for downward, Mixed: impulses from face, surface Controlling mastication. Abducens of eye Facial : CN VII Mixed: impulses for taste from Movement. Acoustic : CN VIII Sensory: impulses for Division). Glossopharyngeal : CN IX Mixed: impulses for For movement of pharynx (elevation) & swallowing. Vagus : CN X Mixed: impulses for sensation to Movement of soft palate, pharynx, & larynx. Spinal Accessory : CN XI Motor: movement of Muscles. Hypoglossal : CN XII Motor: movement of tongue. sternomastoid muscles & upper part of trapezius lower pharynx & larynx; muscle for sensation to posterior tongue & pharynx; muscle hearing (cochlear division) & balance (vestibular anterior tongue; muscles for facial : CN VI Motor: muscles for lateral deviation inward, movement of the eye of eyes (corneal reflex); muscle : CN I Function Sensory: carries impulses for

• •


6. • •

Component of CSF: CHON, WBC, Glucose

Vascular Supply Two internal carotid arteries anteriorly Two vertebral arteries leading to basilar artery posteriorly

• •

These arteries communicate at the base of the brain through the circle of willis Anterior, middle, & posterior cerebral arteries are the main arteries for distributing blood to each hemisphere of the brain

constriction, elevation of upper eyelid;

• •

Brain stem & cerebellum are supplied by branches of the vertebral & basilar arteries Venous blood drains into dural sinuses & then into jugular veins

7. Blood-Brain-Barrier (BBB) •
Protective barrier preventing harmful agents from entering the capillaries of the CNS; protect brain & spinal cord Substance That Can Pass Blood-Brain Barrier 1. Amonia • Cerebral toxin Hepatic Encephalopathy (Liver Cirrhosis) Ascites Esophageal Varices


• •

Early Signs of Hepatic Encephalopathy


• • •

Asterexis (flapping hand tremors).

Late Signs of Hepatic Encephalopathy Headache Dizziness Confusion Fetor hepaticus (amonia like breath) decrease LOC


• 2.

Carbon Monoxide and Lead Poisoning

Autonomic Nervous System Part of the peripheral nervous system Include those peripheral nerves (both cranial & spinal) that regulates smooth muscles, cardiac muscles, & glands. Component: 1. Sympathetic Nervous System Generally 2. accelerates some body function in response to stress. Parasympathetic Nervous System


Can lead to Parkinson’s Disease. Epilepsy Treated with calcium EDTA.


3. • • •

Type 1 DM (IDDM) Causes diabetic ketoacidosis. And increases breakdown of fats. And free fatty acids

3

4
Blood Vessel constrict smooth muscles of the skin, Abdominal blood vessels, and Cutaneous blood vessels Sympathetic Nervous System (Adrenergic) Effect - Involved in fight or aggression response. - Release of Norepinephrine (cathecolamines) from adrenal glands and causes vasoconstriction. - Increase all bodily activity except GIT EFFECTS OF SNS - Dilation of pupils (mydriasis) in order to be aware. - Dry mouth (thickened saliva). - Increase BP and Heart Rate. - Bronchodilation, Increase RR - Constipation. - Urinary Retention. - Increase blood supply to brain, heart and skeletal muscles. - SNS I. Adrenergic Agents - Give Epinephrine. SE: - SNS effect Contraindication: - Contraindicated to patients suffering from COPD (Broncholitis, Bronchoectasis, Emphysema, Asthma). II. Beta-adrenergic Blocking Agents - Also called Beta-blockers. - all ending with “lol” - Propranolol, Atenelol, Metoprolol. Effect of Beta-blockers B – broncho spasm E – elicits a decrease in myocardial contraction. T – treats hypertension. A – AV conduction slows down. - Should be given to patients with Angina, 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 Lidocane, Xylocane. Effectors Sympathetic (Adrenergic) Effect Components 1. Eye pupil (miosis) Gland of Head Lacrimal Salivary no effect scanty thick, viscous secretions Dry mouth Heart increase rate & force of contraction decrease rate 3. stimulate secretions copious thin, watery secretions dilate pupil (mydriasis) constrict 2. 3. Eye opening Verbal response Motor response 2. II. Anti-cholinergic Agents - To counter cholinergic agents. - Atrophine Sulfate SE: - SNS effect I. Cholinergic Agents - Mestinon, Neostignin. SE: - PNS effect Urinary Tract EFFECTS OF PNS - Constriction of pupils (miosis). - Increase salivation. - Decrease BP and Heart Rate. - Bronchoconstriction, Decrease RR. - Diarrhea - Urinary frequency. Parasympathetic Nervous System (Cholinergic) Effect, Vagal, Sympatholytic - Involved in flight or withdrawal response. - Release of Acetylcholine. - Decreases all bodily activities except GIT. GI Tract decrease motility increase motility Constrict sphincters sphincters Possibly inhibits secretions stimulate secretions Inhibits activity of gallbladder & ducts stimulate activity of gallbladder & ducts Inhibits glycogenolysis in liver Adrenal Gland stimulates secretion of epinephrine & Norepinephrine relaxes detrusor muscles Contract trigone sphincter (prevent voiding) relaxes trigone sphincter (allows voiding) NEURO TRANSMITTER Acethylcholine Dopamine Physical Examination Comprehensive Neuro Exam Neuro Check Decrease Myesthenia Gravis Parkinson’s Disease Increase Bi-polar Disorder Schizophrenia no effect relaxed Dilates smooth muscles of bronchioles, Blood vessels of the heart & skeletal muscles Lungs bronchodilation bronchoconstriction no effect

Controls normal body functioning

contract detrusor muscles

1. Level of Consciousness (LOC)
a. Orientation to time, place, person

b. Speech: clear, garbled, rambling
c. Ability to follow command stimulus (ex. Pressure on the nailbeds, squeeze

d. If does not respond to verbal stimuli, apply a painful
trapezius muscle); note response to pain Appropriate: withdrawal, moaning Inappropriate: non-purposeful

e. Abnormal posturing (may occur spontaneously or in
response to stimulus) Decorticate Posturing: extension of leg, internal rotation & abduction of arms with flexion of elbows, wrist, & finger: (damage to corticospinal tract; cerebral hemisphere) Decerebrate Posturing: back arched, rigid extension of all four extremities with hyperpronation of arms & plantar flexion of feet: (damage to upper brain stem, midbrain, or pons) Glasgow Coma Scale Objective measurement of LOC sometimes called as the quick neuro check Objective evaluation of LOC, motor / verbal response A standardized system for assessing the degree of neurologic impairment in critically ill client

Parasympathetic (Cholinergic) Effect

GCS Grading / Scoring 1. 2. 3. 4. 5. Conscious Lethargy Stupor Coma Deep Coma 15 – 14 13 – 11 10 – 8 7 3

Pupillary Reaction & Eye Movement

a. Observe size, shape, & equality of pupil (note size in
millimeter)

b. Reaction to light: pupillary constriction

4

5 c. Corneal reflex: blink reflex in response to light stroking
of cornea 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 Level of Orientation

d. Oculocephalic reflex (doll’s eyes): present in
unconscious client with intact brainstem 4. Motor Function

a. Movement of extremities (paralysis)
b. Muscle strength

5. Vital Signs: respiratory patterns (may help localize possible
lesion)

1. Time: first asked 2. Person: second asked 3. Place: third asked
Cranial Nerves 1. 2. 3. 4. 5. 6. 7. 8. 9. Cranial Nerves Olfactory Optic Oculomotor Trochlear Trigeminal Abducens Facial Acoustic Glossophareng Function S S M M (smallest) B (largest) M B S B B (longest) M M

a. Cheyne-Stokes Respiration: regular rhythmic alternating
between hyperventilation & apnea; may be caused by structural cerebral dysfunction or by metabolic problems such as diabetic coma

b. Central Neurogenic Hyperventilation: sustained, rapid,
regular respiration (rate of 25/min) with normal O2 level; usually due to brainstem dysfunction

c. Apneustic Breathing: prolonged inspiratory phase,
followed by a 2-to-3 sec pause; usually indicates dysfunction respiratory center in pons

d. Cluster Breathing: cluster of irregular breathing,
irregularly followed by periods of apnea; usually caused by a lesion in upper medulla & lower pons

eal 10. Vagus 11. Spinal Accessory 12. Hypoglossal

e. Ataxic Breathing: breathing pattern completely irregular;
indicates damage to respiratory center of the medulla Neurologic Exam

CRANIAL NERVE I: OLFACTORY Sensory function for smell Material Used Don’t use alcohol, ammonia, perfume because it is irritating (recent & remote), and highly diffusible. Use coffee granules, vinegar, bar of soap, cigarette Procedure Test each nostril by occluding each nostril Abnormal Findings

1. Mental status and speech (Cerebral Function)
a. b. General appearance & behavior LOC attention span, cognitive skills d. e. f. 2. Emotional status Thought content Language / speech

c. Intellectual Function: memory

Cranial nerve assessment

1. Hyposnia: decrease sensitivity to smell 2. Dysosmia: distorted sense of smell 3. Anosmia: absence of smell
Either of the 3 may indicate head injury damaging the cribriform plate of ethmoid bone where olfactory cells are located may indicate inflammatory conditions (sinusitis) CRANIAL NERVE II: OPTIC Sensory function for vision or sight Functions 1. Test visual acuity or central vision or distance Use Snellen’s Chart Snellen’s Alphabet chart: for literate client Snellen’s E chart: for illiterate client Snellen’s Animal chart: for pediatric client 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. b. c. d. Superiorly Bitemporaly Nasally Inferiorly

3. Cerebellar Function: posture, gait, balance, coordination a. Romberg’s Test: 2 nurses, positive for ataxia b. Finger to Nose Test: positive result mean dimetria
(inability of body to stop movement at desired point)

4. Sensory Function: light touch, superficial pain, temperature,
vibration & position sense

5. Motor Function: muscle size, tone, strength; abnormal or
involuntary movements 6. Reflexes

a. Deep tendon reflex: grade from 0 (no response); to 4
(hyperactive); 2 (normal) b. Superficial with fanning of toes): indicates damage to corticospinal tracts Level Of Consciouness (LOC)

c. Pathologic: babinski reflex (dorsiflexion of the great toe

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. 2. 3. 4. Deep sternal stimulation / deep sternal pressure Orbital pressure Pressure on great toes Corneal or blinking reflex Conscious Client: use a wisp of cotton Unconscious Client: place 1 drop of saline solution Test of Memory 1. Short term memory Ask most recent activity Positive result mean anterograde amnesia and damage to temporal lobe

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 Rectus

Medial

5

6 20. TETANY – hypocalcemia (+) trousseu’s sign or carpopedal
Inferior Oblique 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 / Tic Douloureux 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 Bell’s 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. CRANIAL NERVE IX, X: GLOSOPHARENGEAL, VAGUS Glosopharenageal: 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. Pathognomonic Signs: Multiple Sclerosis (MS) Chronic intermittently progressive disorder of CNS characterized by scattered white patches of demyelination in brain and spinal cord. Characterized by remission and exacerbation. S/sx are varied & multiple, reflecting the location of demyelination within the CNS. Cause unknown: maybe a slow growing virus or possibly autoimmune disorders. Incident: Affects women more than men ages 20-40 are prone & more frequent in cool or temperate climate. Management 1. Palliative & supportive *Expressive aphasia “motor speech center” unable to speak Broca’s Aphasia *Receptive aphasia inability to understand spoken words. Common to Alzheimer’s Wernike’s Aphasia General Knowing Gnostic Area or General Interpretative Area. DOC Aricept (taken at bedtime) Cognex S/sx 4 A’s of Alzheimer DEMYELINATING DISORDERS Alzheimer’s disease Atrophy of brain tissue due to deficiency of acetylcholine. Inferior spasm/ (+) chvostek sign (facial spasm).

21. TETANUS – risus sardonicus 22. PANCREATITIS – cullen’s sign (echymosis of umbilicus) / (+)
grey turners spots.

23. PYLORIC STENOSIS – olive like mass. 24. PDA – machine like murmur 25. ADDISON’S DISEASE – bronze like skin pigmentation. 26. CUSHING’S SYNDROME – moon face appearance and buffalo
hump.

27. HYPERTHYROIDSM/GRAVES DISEASE – exopthalmus.

a. Amnesia – loss of memory. b. Agnosia – unable to recognized inanimate/familiar
objects.

c. Apraxia – unable to determine purpose/ function of
objects.

d. Aphasia – no speech (nodding).

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 – step ladder like fever with chills. 10. TYPHOID – rose spots in abdomen. 11. DIPTHERIA – pseudo membrane. 12. MEASLES – koplick’s spots 13. SLE – butterfly rashes. 14. LIVER CIRRHOSIS – spider like varices 15. LEPROSY – lioning face 16. BOLIMIA – chipmunk face. 17. APPENDICITIS – rebound tenderness 18. DENGUE – petichae or positive herman’s sign. 19. MENINGITIS – kernig’s sign (leg pain), brudzinski sign (neck
pain). 2. 1. S/sx

Ig G - only antibody that pass placental circulation causing passive immunity, short term protection 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.

Visual disturbances blurring of vision (primary) diplopia (double vision) scotomas (blind spots) Impaired sensation

6

7

touch, pain, pressure, temperature, or position sense paresthesia such as tingling sensation, numbness 2.

monitor breath sounds 1 hour after subcutaneous administration. Urinary Incontinence a. Establish voiding schedule banthine) if ordered 3. Force fluid to 3000 ml/day. prunes, pineapple, vitamin C and orange: to acidify urine and prevent bacterial multiplication. 11. Prevent injury related to sensory problems. a. b. c. d. Test bath water with thermometer. Avoid heating pads, hot water bottles. Inspect body parts frequently for injury. Make frequent position changes.

3. Mood swings or euphoria (sense of elation)
4. Impaired motor function weakness spasticity paralysis 5. Impaired cerebral function scanning speech ataxic gait nystagmus dysarthria intentional tremor 6. 7. 8. Bladder Urinary retention or incontinence Constipation Sexual impotence in male / decrease sexual capacity TRIAD SIGNS OF MS

b. Anti spasmodic agent Prophantheline Bromide (Pro-

4. Promote use of acid ash diet like cranberry juice, plums,

12. Prepare client for plasma exchange if indicated: to remove
antibodies 13. Provide psychologic support to client/significant others. a. b. Ataxia (unsteady gait, c. d. a. Encourage positive attitude & assist client in setting realistic goals. Provide compassion in helping client adapt to changes in body image & self-concept. Do not encourage false hope during remission. Refer to MS societies & community agencies. General measures to ensure optimum health. Balance between activity & rest Regular exercise such as walking, swimming, biking in mild case. Use energy conservation techniques

positive romberg’s test)

14. Provide client teaching & discharge planning concerning:

CHARCOTS TRIAD

Intentional tremors Nystagmus Dx

Well-balance diet Fresh air & sunshine Avoiding fatigue, overheating or chilling, stress, infection. b. c. Use of medication & side effects. Alternative methods for sexual counseling if indicated.

1. CSF Analysis: increase in IgG and Protein. 2. MRI: reveals site and extent of demyelination. 3. CT Scan: increase density of white matter. 4. Visual Evoked Response (VER) determine by EEG: maybe
delayed

COMMON CAUSE OF UTI Female - short urethra (3-5 cm, 1-1 ½ inches) - poor perineal hygiene - vaginal environment is moist Nursing Management - avoid bubble bath (can alter Ph of vagina). - avoid use of tissue papers - avoid using talcum powder and perfume. Male - urethra (20 cm, 8 inches) - do not urinate after intercourse INTRACRANIAL PRESSURE ICP Monroe Kelly Hypothesis Skull is a closed container Any alteration or increase in one of the intracranial components Increase intracranial 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 Nursing Intervention 1. alternate hot and cold compress to prevent hematoma

5. Positive Lhermittes Sign: a continuous and increase
contraction of spinal column. Nursing Intervention 1. 2. Assess the client for specific deficit related to location of demyelination Promote optimum mobility a. Muscles stretching & strengthening exercises

b. Walking exercises to improve gait: use wide-base gait c. Assistive devices: canes, walker, rails, wheelchair as
necessary 3. Administer medications as ordered

a. ACTH (adreno chorticotropic hormone), Corticosteroids
(prednisone) for acute exacerbations: to reduce edema at site of demyelination to prevent paralysis.

b. Baclofen (Lioresal), Dantrolene (Dantrium), Diazepam
(Valium) - muscle relaxants: for spacity

c. Beta Interferons - Immunosuppresants: alter immune
response. 4. 5. 6. 7. Encourage independence in self-care activities Prevent complications of immobility Institute bowel program Maintain side rails to prevent injury related to falls.

8. Institute stress management techniques.
a. b. 9. Deep breathing exercises Yoga fluid intake and increase fiber to prevent

Increase

constipation. 10. Maintain urinary elimination 1. Urinary Retention a. b. perform intermittent catheterization as ordered: to prevent retention. Bethanecol Chloride (Urecholine) as ordered Nursing Management only given subcutaneous. monitor side effects bronchospasm and wheezing. CSF cushions brain (shock absorber) Obstruction of flow of CSF will lead to enlargement of skull posteriorly called hydrocephalus.

7

8

Early closure of posterior fontanels causes posterior enlargement of skull in hydrocephalus. DISORDERS Increase Intracranial Pressure (IICP) Increase in intracranial bulk brought due to an increase in any of the 3 major intracranial components: Brain Tissue, CSF, Blood. Untreated increase ICP can lead to displacement of brain tissue (herniation). Present life threatening situation because of pressure on vital structures in the brain stem, nerve tracts & cranial nerve. Increase ICP may be caused: head trauma/injury localized abscess cerebral edema hemorrhage inflammatory condition (stroke) hydrocephalus tumor (rarely) S/sx (Early signs) 1. 2. 3. Decrease LOC Irritability / agitation Progresses from restlessness to confusion & disorientation to lethargy & coma (Late signs) 5. b.

Cyanosis Hypercarbia may cause cerebral vasodilation which increase ICP Hypercabia Increase CO2 (most powerful respiratory stimulant) retention. In chronic respiratory distress syndrome decrease O2 stimulates respiration. Before and after suctioning hyperventilate the client with resuscitator bag connected to 100% O2 & limit suctioning to 10 – 15 seconds only.

c. Assist with mechanical hyperventilation as
indicated: produces hypocarbia (decease CO2) causing cerebral constriction & decrease ICP.

2. Monitor V/S, input and output & neuro check frequently to
detect increase in ICP

3. Maintain fluid balance: fluid restriction to 1200-1500 ml/day
may be ordered

4. Position the client with head of bed elevated to 30-45o angle
with neck in neutral position unless contraindicated to improve venous drainage from brain. Prevent further increase ICP by: a. b. c. d. Provide comfortable and quite environment. Avoid use of restraints. Maintain side rails. Instruct client to avoid forms of valsalva maneuver like: Straining stool: administer stool softener & mild laxatives as ordered (Dulcolax, Duphalac) Excessive vomiting: administer anti-emetics as ordered (Plasil - Phil only, Phenergan) Excessive coughing: administer anti-tussive (dextromethorphan) Avoid stooping/bending Avoid lifting heavy objects e. 6. 7. Avoid clustering of nursing care activity together. Prevent complications of immobility. Administer medications as ordered:

1. Changes in Vital Signs (may be a late signs) a. Systolic blood pressure increases while diastolic
pressure remains the same (widening pulse pressure) b. Pulse rate decrease respiration) d. 2. temperature increase directly proportional to blood pressure. Pupillary Changes

c. Abnormal respiratory patterns (cheyne-stokes

a. Hyperosmotic agent / Osmotic Diuretic [Mannitol
(Osmitrol)]: to reduce cerebral edema Nursing Management Monitor V/S especially BP: SE hypotension. Monitor strictly input and output every hour: (output should increase): notify physician if output is less 30 cc/hr. Administered via side drip Regulate fast drip to prevent crystal formation.

a. Ipsilateral (same side) dilatation of pupil with
sluggish reaction to light from compression of cranial nerve III

b. unilateral dilation of pupils called uncal
herniation

c. bilateral dilation of pupils called tentorial
herniation d. 3. Pupil eventually becomes fixed & dilated Motor Abnormalities

b. Loop Diuretics [Furosemide, (Lasix)]: to reduce cerebral
edema drug of choice for CHF (pulmonary edema) loop of henle in kidneys. Nursing Management Monitor V/S especially BP: SE hypotension. Monitor strictly input and output every hour: (output should increase): 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.

a. Contralateral (opposite side) hemiparesis from
compression of corticospinal tract b. abnormal posturing spinal cord).

c. decorticate posturing (damage to cortex and d. decerebrate posturing (damage to upper brain
stem that includes pons, cerebellum and midbrain). 4. 5. Headache Projective Vomiting

6. Papilledema (edema of optic disc)
7. Possible seizure activity Nursing Intervention 1. Maintain patent airway and adequate ventilation by:

c. Corticosteroids [Dexamethasone (Decadron)]: antiinflammatory effect reduces cerebral edema

d. Analgesics for headache as needed:
Small dose of Codein SO4 and Strong opiates may be contraindicated since they potentiate respiratory depression, alter LOC, & cause papillary changes. of hypoxia (decrease O2)

a. Prevention

hypercarbia (increase CO2) important: Hypoxia may cause brain swelling which increase ICP Early signs of hypoxia: Restlessness Tachycardia Agitation Late signs of hypoxia: Extreme restlessness Bradycardia Dyspnea b. 8. a.

e. Anti-convulsants [Phenytoin (Dilantin)]: to prevent
seizures. Assist with ICP monitoring when indicated: ICP monitoring records the pressure exerted within the cranial cavity by the brain, cerebral blood, & CSF Types of monitoring devices: Intraventricular Catheter: inserted in lateral ventricle to give direct measurement of ICP; also allows for drainage of CSF if needed.

8

9

Subarachnoid screw (bolt): inserted through the skull & dura matter into subarachnoid space. Epidural Sensor: least invasive method; placed in space between skull & dura matter for indirect measurement of ICP.

c. Monitor ICP pressure readings frequently & prevent
complications: Normal ICP reading is 0-15 mmHg; a sustained increase above 15 mmHg is considered abnormal. Use strict aseptic technique when handling any part of the monitoring system. Check insertion site for signs of infection; monitor temperature. Assess system for CSF leakage, loose connections, air bubbles in he line, & occluded tubing. 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

9. Provide intensive nursing care for clients treated with
barbiturates therapy or administration of paralyzing agents.

a. Intravenous administration of barbiturates may be
ordered: to induce coma artificially in the client who has not responded to conventional treatment.

b. Paralytic agents such as [vercuronium bromide
(Norcuron)]: may be administered to paralyzed the client c. d. e. f. Reduces metabolic demand that may protect the brain from further injury. Constant monitoring of the client’s ICP, arterial blood gas, serum barbiturates level, & ECG is necessary. EEG monitoring as necessary Provide appropriate nursing care for the client on a ventilator

FRUITS Apple Banana Cantalop e Oranges

VEGETABLE S Asparagus Brocolli Carrots Spinach

10. Observe for hyperthermia secondary to hypothalamus
damage.

2. Hypocalcemia/Tetany - decrease calcium level - normal value is 8.5 – 11 mg/100 ml *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 o o 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 RHD Aging Signs and Symptoms - tingling sensation - paresthesia - numbness - (+) Trousseus sign/Carpopedal spasm - (+) Chvostek’s sign Complications - arrythmia - seizures Nursing Management - Calcium Glutamate per IV slowly as ordered * Calcium Glutamate toxicity – results to seizure Magnesium Sulfate Magnesium Sulfate toxicity S/S BP Urine output 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 DECREASE

9

10
- polyphagia Nursing Management - monitor FBS 5. Hyperuricemia - increase uric acid (purine metabolism) - foods high in uric acid (sardines, organ meats and anchovies) S/sx *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 (Zylopril) - drug of choice for gout. - mechanism of action: inhibits synthesis of uric acid. b. Colchesine - acute gout - mechanism of action: promotes excretion of uric acid. * Kidney stones Signs and Symptoms - renal cholic - 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 (Zylopril) Side Effects - respiratory depression (check for RR) Parkinson’s Disease/ Parkinsonism Chronic progressive disorder of CNS characterized by degeneration of dopamine producing cells in the substantia nigra of the midbrain and basal ganglia. Progressive disorder with degeneration of the nerve cell in the basal ganglia resulting in generalized decline in muscular function Disorder of the extrapyramidal system Usually occurs in the older population Cause Unknown: predominantly idiopathic, but sometimes disorder is postencephalitic, toxic, arteriosclerotic, traumatic, or drug induced (reserpine, methyldopa (aldomet) haloperidol (haldol), phenothiazines). Pathophysiology Disorder causes degeneration of dopamine producing neurons in the substantia nigra in the midbrain Dopamine: influences purposeful movement Depletion of dopamine results in degeneration of the basal ganglia Predisposing Factors 1. 2. 3. 4. 5. Poisoning (lead and carbon monoxide) Arteriosclerosis Hypoxia Encephalitis Increase dosage of the following drugs: a. Reserpine (Serpasil) b. Methyldopa (Aldomet) c. Haloperidol (Haldol) Antihypertensive _______ Anti-Cholinergic Drug a. b. c. Benztropine Mesylate (Cogentin) Procyclidine (Kemadrine) Trihexyphenidyl (Artane) MOA: inhinit the action of acetylcholine; used in mild cases or in combination with L-dopa; relived tremors & rigidity SE: dry mouth; blurred vision; constipation; urinary retention; confusion; hallucination; tachycardia Anti-Histamines Drug a. Diphenhydramine (benadryl) MOA: decrease tremors & anxiety SE: Adult: drowsiness Children: CNS excitement Side Effects Reserpine: Major depression lead to suicide Aloneness b. (hyperactivity) because blood brain barrier is not yet fully developed. Bromocriptine (Parlodel) MOA:
Multiple loss causes suicide

Loss of spouse of Job Nursing Intervention for Suicide direct approach towards the client close surveillance is a nursing priority time to commit suicide is on weekends early morning

Loss

1. Tremor: mainly of the upper limbs “pill rolling tremors” of
extremities especially the hands; resting tremor: most common initial symptoms 2. 3. Bradykinesia: slowness of movement Rigidity: cogwheel type

4. Stooped posture: shuffling, propulsive gait
5. Fatigue eyes. 7. Difficulty rising from sitting position.

6. Mask like facial expression with decrease blinking of the

8. Quite, monotone speech 9. Emotional lability: state of depression 10. Increase salivation: drooling type
11. Cramped, small handwriting 12. Autonomic Symptoms a. b. c. d. e. excessive sweating increase lacrimation seborrhea constipation decrease sexual capacity

Nursing Intervention 1. Administer medications as ordered Anti-Parkinson Drug

a. Levodopa (L-dopa) short acting
MOA: Increase level of dopamine in the brain; relieves tremors; rigidity; bradykinesia SE: GIT irritation (should be taken with meal); anorexia; N/V; postural hypotension; mental changes: confusion, agitation, hallucination; cardiac arrhythmias; dyskinesias. CI: narrow-angled glaucoma; client taking MAOI inhibitor; reserpine; guanethidine; methyldopa; antipsychotic; acute psychoses Avoid multi-vitamins preparation containing vitamin B6 & food rich in vitamin B6 (Pyridoxine): reverses the therapeutic effects of Levodopa Urine and stool may be darkened Be aware of any worsening of symptoms with prolonged high-dose therapy: “on-off” syndrome.

b. Carbidopa-levodopa (Sinemet)
Prevents breakdown of dopamine in the periphery & causes fewer side effects. c. Amantadine Hydrochloride (Symmetrel) Used in mild cases or in combination with L-dopa to reduce rigidity, tremors, & bradykinesia

d. Phenothiazine ___________________ Antipsychotic

stimulate

release

of

dopamine

in

the

substantia nigra Often employed when L-dopa loses effectiveness MAOI Inhibitor

10

11
a. Eldepryl (Selegilene) MOA: inhibit dopamine breakdown & slow progression of disease Anti-Depressant Drug a. Tricyclic MOA: given to treat depression commonly seen in Parkinson’s disease 2. Provide safe environment Side rails on bed Rails & handlebars in the toilet, bathtub, & hallways No scattered rugs Hard-back or spring-loaded chair to make getting up easier 3. Provide measures to increase mobility Physical Therapy: active & passive ROM exercise; stretching exercise; warm baths Assistive devices If client “freezes” suggest thinking of something to walk over 4. Encourage independence in self-care activities: alter clothing for ease in dressing use assistive device do not rush the client 5. Improve communication abilities: Instruct the client to practice reading a loud Listen to own voice & enunciate each syllable clearly 6. 7. Refer for speech therapy when indicated. Maintain adequate nutrition. Cut food into bite-size pieces Provide small frequent feeding Allow sufficient time for meals, use warming tray 8. 9. Avoid constipation & maintain adequate bowel elimination Provide significant support to client/ significant others: Depression is common due to changes in body image & self-concept 10. Provide client teaching & discharge planning concerning: a. b. c. Nature of the disease Use prescribed medications & side effects Importance of daily exercise as tolerated: balanced activity & rest walking swimming gardening d. Activities/ methods to limit postural deformities: Firm mattress with small pillow Keep head & neck as erected as possible Use broad-based gait Raise feet while walking e. Hydrazide * Dopamine Agonist relieves tremor rigidity MAGIC 2’s IN DRUG MONITORING DRUG Digoxin/Lanoxin (increase force of cardiac output) Lithium/Lithane (decrease level of Ach/NE/Serotonin) Aminophelline (dilates bronchial tree) Dilantin/Phenytoin Acetaminophen/Tylen ol 1. Digitalis Toxicity Signs and Symptoms - nausea and vomiting - diarrhea - confusion - photophobia - changes in color perception (yellowish spots) Antidote: Digibind 2. Lithium Toxicity 2. 3. S/sx 10 – 19 mg/100 ml 10 – 19 mg/100 ml 10 – 30 mg/100 ml 20 20 200 COPD Seizures Osteo Arthritis .6 – 1.2 meq/L 2 Bipolar NORMAL RANGE .5 – 1.5 meq/L TOXICITY LEVEL 2 INDICATION CHF Promotion of active participation in self-care activities. * Increase Vitamin B when taking INH (Isoniazid), Isonicotinic Acid Nursing Management - force fluids - increase sodium intake to 4 – 10 g% daily 3. Aminophelline 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 of 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: Acetylceisteine (mucomyst) prepare suction apparatus as bedside. MYASTHENIA GRAVIS (MG) 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: highest between 15 & 35 years old for women, over 40 for men. Affects women more than men Cause: Unknown/ idiopathic Thought to be autoimmune disorder whereby antibodies destroy acetylcholine receptor sites on the postsynaptic membrane of the neuromuscular junction. Voluntary muscles are affected, especially those muscles innervated by the cranial nerve. Pathophysiology Autoimmune = Release of Cholinesterase Enzymes = Cholinesterase destroy Acetylcholine (ACH) = Decrease of Acetylcholine (ACH) Acetylcholine: activate muscle contraction Autoimmune: it involves release of cholinesterase an enzyme that destroys Ach Cholinesterase: an enzyme that destroys ACH Signs and Symptoms - anorexia - nausea and vomiting - diarrhea - dehydration causing fine tremors - hypothyroidism

1. Initial sign is ptosis a clinical parameter to determine ptosis
is palpebral fissure: cracked or cleft in the lining or membrane of the eyelids Diplopia Dysphagia

11

12
4. 5. Mask like facial expression Hoarseness of voice, weakness of voice arrest

physical or emotional stress infection Signs and Symptoms the client is unable to see, swallow, speak, breathe Treatment administer cholinergic agents as ordered

over medication with the chol drugs (anti-cholinesterase) Signs and Symptoms PNS Treatment

6. Respiratory muscle weakness that may lead to respiratory 7. Extreme muscle weakness especially during exertion and
morning; increase activity & reduced with rest. Dx

administer anti-cholinergic ag (Atrophine Sulfate) Nursing Care in Crisis: a. b. Maintain tracheostomy set or endotracheal tube with mechanical ventilation as indicated. Monitor ABG & Vital Capacity

1. Tensilon Test (Edrophonium Hydrochloride): IV injection of
tensilon provides temporary relief of S/sx for about 5-10 minutes and a maximum of 15 minutes. If there is no effect there is no damage to occipital lobe and midbrain and is negative for M.G.

2. Electromyography (EMG): amplitudes of evoked potentials
decrease rapidly.

c. Administer medication as ordered:
Myasthenic Crisis: increase doses of anticholinesterase drug as ordered. Cholinergic Crisis: discontinue anticholinesterase drugs as ordered until the client recovers. d. e. 6. Established method of communication Provide support & reassurance.

3. Presence of anti-acetlycholine receptors antibodies in the
serum. Medical Management 1. Drug Therapy

a. Anti-cholinesterase Drugs: [Ambenonium (Mytelase),
Neostigmine (Prostigmin), Pyridostigmine (Mestinon)] MOA: block the action of cholinesterase & increase the level of acetylcholine at the neuromuscular junction. SE: excessive salivation & sweating, abdominal cramps, N/V, diarrhea, fasciculations (muscle twitching).

Provide nursing care for the client with thymectomy.

7. Provide client teaching & discharge planning concerning:
a. b. c. d. e. f. g. h. Nature of the disease Use of prescribe medications their side effects & sign of toxicity Importance of checking with physician before taking any new medication including OTC drugs Importance of planning activities to take advantage of energy peaks & of scheduling frequent rest period Need o avoid fatigue, stress, people with upper respiratory infection Use of eye patch for diplopia (alternate eyes) Need to wear medic-alert bracelet Myasthenia Gravis foundation & other community agencies Guillain-Barre Syndrome a disorder of the CNS characterized by bilateral, symmetrical, peripheral polyneuritis characterized by ascending muscle paralysis. Can occur at any age; affects women and men equally Progression of disease is highly individual; 90% of clients stop progression in 4 weeks; recovery is usually from 3-6 months; may have residual deficits. Causes: 1. 2. Unknown / idiopathic May be autoimmune process Predisposing Factors 1. 2. Immunization Antecedent viral infections such as LRT infections S/sx

b. Corticosteroids: Prednisone
MOA: suppress autoimmune response Used if other drugs are not effective

2. Surgery (Thymectomy) a. Surgical removal of thymus gland: thought to be involve
in the production of acetylcholine receptor antibodies. b. May cause remission in some clients especially if performed early in the disease.

3. Plasma Exchange (Plasmapheresis)
a. b. Removes circulating acetylcholine receptor antibodies. Use in clients who do not respond to other types of therapy. Nursing Interventions

1. Administer anti-cholinesterase drugs as ordered:
a. b. Give medication exactly on time. Give with milk & crackers to decrease GI upset & vital capacity before & after medication. d. Avoid use of the ff drugs: Morphine SO4 & Strong Sedatives: respiratory depressant effects Quinine, Curare, Procainamide, Neomycin, Streptomycine, Kanamycine & other aminoglycosides: skeletal muscle blocking effect e. Observe for side effects

c. Monitor effectiveness of drugs: assess muscle strength

2. Promote optimal nutrition: a. Mealtime should coincide with the peak effect of the
drugs: give medication 30 minutes before meals.

1. Mild Sensory Changes: in some clients severe
misinterpretation of sensory stimuli resulting to extreme discomfort

b. Check gag reflex & swallowing ability before feeding.
c. Provide mechanical soft diet. not leave alone at mealtime; keep emergency airway & suctioning equipment nearby.

2. Clumsiness (initial sign) 3. Progressive motor weakness in more than one limb
(classically is ascending & symmetrical)

d. If the client has difficulty in chewing & swallowing, do

4. Dysphagia: cranial nerve involvement 5. Ascending muscle weakness leading to paralysis 6. Ventilatory insufficiency if paralysis ascends to respiratory
muscles 7. 8. Absence or decreased deep tendon reflex Alternate hypotension to hypertension

3. Monitor respiratory status frequently: Rate, Depth, Vital
Capacity; ability to deep breathe & cough

4. Assess muscle strength frequently; plan activity to take
advantage of energy peaks & provide frequent rest periods.

5. Observe for signs of myasthenic or cholinergic crisis.
MYASTHENIC CRISIS Abrupt onset of severe, generalized muscle weakness with inability to swallow, speak, or maintain respirations. Symptoms will improve temporarily with tensilon test.

CHOLINERGIC CRISIS 9. Arrythmia (most feared complication) Symptoms similar to myasthenic crisis & 10. Autonomic disfunction: symptoms that includes in addition the side effect of antia. increase salivation cholinesterase drugs (excessive b. increase sweating salivation & sweating, abdominal carmp, c. constipation N/V, diarrhea, fasciculation) Symptoms worsen with tensilon test: Dx keep Atropine Sulfate & emergency 1. CSF analysis: reveals increased in IgG and protein equipment on hand. 2. EMG: slowed nerve conduction

Causes: under medication Cause:

12

13
Medical Management

1. Mechanical Ventilation: if respiratory problems present 2. Plasmapheresis: to reduce circulating antibodies 3. Continuous ECG monitoring to detect alteration in heart rate
& rhythm 2.

Mode of transmission

1. Airborne transmission (droplet nuclei)
Via blood, CSF, lymph sinuses, mastoid bone, ear, skull fracture) 4. By oral or nasopharyngeal route Signs and Symptoms 2. Headache, photophobia, general body malaise, irritability,

3. By direct extension from adjacent cranial structures (nasal,

4. Propranolol: to prevent tachycardia 5. Atropine SO4: may be given to prevent episodes of
bradycardia during endotracheal suctioning & physical therapy Nursing Intervention 1. Maintain patent airway & adequate ventilation: a. b. c. d. 2. 3. Monitor rate & depth of respiration; serial vital capacity Observe for ventilatory insufficiency Maintain mechanical ventilation as needed Keep airway free of secretions & prevent pneumonia

3. Projectile vomiting: due to increase ICP
4. 5. 6. Fever & chills Anorexia & weight loss Possible seizure activity & decrease LOC

7. Abnormal posturing: (decorticate and decerebrate)
8. Signs of Meningeal Irritation:

Check individual muscle groups every 2 hrs in acute phase to check progression of muscle weakness Assess cranial nerve function: a. b. c. d. Check gag reflex Swallowing ability Ability to handle secretion Voice Vital signs Input and output Neuro check

a. Nuchal rigidity or stiff neck: initial sign b. Opisthotonos (arching of back): head & heels bent
backward & body arched forward

c. PS: Kernig’s sign (leg pain): contraction or pain in the
hamstring muscles when attempting to extend the leg when the hip is flexed

d. PS: Brudzinski sign (neck pain): flexion at the hip & knee
in response to forward flexion of the neck

4.

Monitor strictly the following: a. b. c.

Dx

d. ECG: due to arrhythmia e. Observe signs of autonomic dysfunction: acute period of
hypertension fluctuating with hypotension f. g. 5. Tachycardia Arrhythmias

1. Lumbar Puncture:
Measurement & analysis of CSF shows increased pressure, elevated WBC & CHON, decrease glucose & culture positive for specific M.O. A hollow spinal needle is inserted in the subarachnoid space between the L3-L4 or L4-L5. Nursing Management Before Lumbar Puncture 1. 2. 3. Secure informed consent and explain procedure. Empty bladder and bowel to promote comfort. Encourage to arch back to clearly visualize L3-L4. Nursing Management Post Lumbar Puncture

Maintain side rails to prevent injury related to fall 2 hrs

6. Prevent complications of immobility: turning the client every
7. Assist in passive ROM exercise changes): a. b. c. d. Foot cradle Sheepskin Guided imagery Relaxation techniques

8. Promote comfort (especially in clients with sensory

1. Place flat on bed 12 – 24 o
2. 3. 4. Force fluids Check punctured site for any discoloration, drainage and leakage to tissues. Assess for movement and sensation of extremities. CSF analysis reveals 1. 2. Increase CHON and WBC Decrease glucose 100 mmHg)

9. Promote optimum nutrition:
a. b. Check gag reflex before feeding Start with pureed food prevent aspiration 10. Administer medications as ordered

c. Assess need for NGT feeding: if unable to swallow; to

a. Corticosteroids: suppress immune response b. Anti Cholinergic Agents:
Atrophine Sulfate

3. Increase CSF opening pressure (normal pressure is 50 – 4. (+) cultured microorganism (confirms meningitis)
CBC reveals 1. Increase WBC

c. Anti Arrythmic Agents:
Lidocaine (Xylocaine) Bretylium: blocks release of norepinephrine; to prevent increase of BP

11. Assist in plasmapheresis (filtering of blood to remove
autoimmune anti-bodies)

Nursing Management 1. Administer large doses of antibiotic IV as ordered:

12. Prevent complications:
a. b. Arrythmia Paralysis of respiratory muscles / respiratory arrest

a. Broad spectrum antibiotics (Penicillin, Tetracycline) b. Mild analgesics: for headaches c. Antipyretics: for fever 2. Enforced strict respiratory isolation 24 hours after initiation
of anti biotic therapy (for some type of meningitis) 3. 4. 5. Provide nursing care for increase ICP, seizure & hyperthermia if they occur

13. Provide psychologic support & encouragement to client / significant others 14. Refer for rehabilitation to regain strength & treat any residual deficits. INFLAMMATORY CONDITIONS OF THE BRAIN Meningitis Inflammation of the meninges of the brain & spinal cord. Cause by bacteria, viruses, & other M.O. 7. Etiology / Most Common M.O. 8. 9.

Provide nursing care for delirious or unconscious client as needed Enforce complete bed rest photophobia Monitor strictly V/S, I & O & neuro check Maintain fluid & electrolyte balance Prevent complication of immobility

6. Keep room quiet & dark: if the client has headache &

1. Meningococcus: most dangerous
2. Pneumococcus

10. Provide client teaching & discharge planning concerning:

3. Streptococcus: cause of adult meningitis 4. Hemophilus Influenzae: cause of pediatric meningitis

a. Importance of good diet: high CHON, high calories with
small frequent feedings. b. Rehabilitation program for residual deficit

13

14 8. Prolong use of oral contraceptives: promotes lypolysis
(breakdown of lipids) leading to atherosclerosis that will lead to hypertension & eventually CVA. Pathophysiology

mental retardation delayed psychomotor development c. Prevent complications most feared is hydrocephalus hearing loss/nerve deafness is second complication consult audiologist Cerebrovascular Accident (CVA) (Stroke/Brain Attack/Apoplexy/Cerebral Thrombosis) Destruction (infarction) of brain cells caused by a reduction in cerebral blood flow and oxygen A partial or complete disruption in the brains blood supply. 2 largest & most common cerebral artery affected by stroke: a. b. Mid Cerebral Artery Internal Cerebral Artery

1. Interruption of cerebral blood flow for 5 min or more causes
death of neurons in affected area with irreversible loss of function. 2. Modifying Factors: a. Cerebral Edema: Develops around affected area causing further impairment b. Vasospasm: Constriction of cerebral blood vessel may occur, causing further decrease in blood flow c. Collateral Circulation: May help to maintain cerebral blood flow when there is compromise of main blood supply Stages of Development

Incidence Rate: a. Affects men more than women; Men are 2-3 times high risk; Incidence increase with age Causes:

1. Transient Ischemic Attack (TIA)
a. b. Initial / warning signs of impending CVA / stroke Brief period of neurologic deficit: Visual loss / Visual disturbance Hemiparesis Slurred Speech / Speech disturbance Vertigo Aphasia Headache: initial sign Dizziness Tinnitus Possible Increase ICP c. 2. May last less than 30 sec, but no more than 24 hrs with complete resolution of symptoms Stroke in Evolution Progressive development of stroke symptoms over a period of hours to days S/sx of Cerebral Embolism 3. Complete Stroke Neurologic deficit remains unchanged for 2-3-days period S/sx 1. S/sx Compartment syndrome 2. Headache Generalized Signs: Vomiting Seizure Confusion Disorientation Decrease LOC Nuchal Rigidity Fever Hypertension Slow Bounding Pulse Cheyne-Strokes Respiration (+) Kernig’s & Brudzinski sign: may lead to hemorrhagic stroke

a. Thrombosis (attached) b. Embolism (detached): most dangerous because it can
go to the lungs & cause pulmonary embolism or the brain & cause cerebral embolism. c. Hemorrhage arteries S/sx Pulmonary Embolism 1. 2. 3. 4. 5. 6. 7. Sudden sharp chest pain Unexplained dyspnea SOB Tachycardia Palpitations Diaphoresis Mild restlessness

d. Compartment Syndrome: compression of nerves &

1. 2. 3. 4.

Headache disorientation Confusion Decrease LOC

1. Fat embolism is the most feared complications w/in
24 hrs after a 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. Risk Factors Disease: 1. 2. 3. 4. 5. 6. 7. 8. Hypertension Diabetes Mellitus Atherosclerosis / Arteriosclerosis Myocardial Infarction Mitral valve replacement Valvular Disease / replacement Chronic atrial Fibrillation Post Cardiac Surgery Lifestyle: 1. 2. 3. 4. 5. Smoking Sedentary lifestyle Obesity (increase 20% ideal body weight) Hyperlipidemia more on genetics/genes that binds to cholesterol Type A personality a. b. c. Deadline driven Can do multiple tasks Usually fells guilty when not doing anything

3. Focal Signs (related to site of infarction):
Hemiplegia Homonymous hemianopsia: loss of half of visual field Sensory loss Aphasia Dysarthia: inability to articulate words Alexia: difficulty reading Agraphia: difficulty writing Dx

1. CT & Brain Scan: reveals brain lesions 2. EEG: abnormal changes 3. Cerebral Arteriography: invasive procedure due to injection
of dye (iodine based); Uses dye for visualization May show occlusion or malformation of blood vessels Reveals the site and extent of malocclusion Nursing Management Post Cerebral Arteriography Allergy Test (shellfish)

6. Related to diet: increase intake of saturated fats like whole
milk 7. Related stress physical and emotional

14

15 b. Prevent complication (subarachnoid hemorrhage is
the most feared complication)

Force fluids to release dye because it is nephro toxic Check for peripheral pulse: distal (femoral) Check for hematoma formation Nursing Intervention: Acute Stage 1. Maintain patent airway and adequate ventilation by: a. b. 2. 3. 4. Assist in mechanical ventilation Administer O2 inhalation

c. Dietary modification (decrease salt, saturated fats
and caffeine) d. Importance of follow up care

Nursing Intervention: Rehabiltation

1. Hemiplegia: results from injury to cell in the cerebral motor
cortex or to corticospinal tract (causes contralateral hemiplegia since tracts crosses medulla)

Monitor strictly V/S, I & O, neuro check & observe signs of increase ICP, shock, hyperthermia, & seizure Provide CBR as ordered Maintain fluid & electrolyte balance & ensure adequate nutrition: a. b. IV therapy for the first few days NGT for feeding the client who is unable to swallow & might also increase ICP

a. Turn every 2 hrs (20 min only on affected side) b. Use proper positioning & repositioning to prevent
deformities (foot drop, external rotation of hips, flexion of fingers, wrist drop, abduction of shoulder & arms)

c. Support paralyzed arm on pillow or use sling while out of
bed to prevent subluxation of shoulders

c. Fluid restriction as ordered: to decrease cerebral edema
5. Maintain proper positioning & body alignment: a. b. Elevate head 30-45 degree to decrease ICP Turn & reposition every 2 hrs (20 min only on the affected side) 2. e. a. b. c.

d. Elevate extremities to prevent dependent edema
Provide active & passive ROM exercises every 4 hrs Keep side rails up at all times Institute safety measures Inspect body parts frequently for signs of injury Susceptibility to hazard

c. Passive ROM exercise every 4 hrs: prevent contractures;
promote body alignment

3. Dysphagia: difficulty of swallowing
a. b. c. d. e. f. Check for gag reflex before feeding client Maintain a calm, unhurried approach Place client in upright position Place food in unaffected side of the mouth Offer soft foods Give mouth care before & after meals

6. Promote optimum skin integrity: turn client & apply lotion
every 2 hrs 7. Prevent complications of immobility by: a. b. c. 8. Turn client to side Provide egg crate mattresses or water bed Provide sand bag or food board.

Maintain adequate elimination:

4. Homonymous Hemianopsia: loss of right or left half of each
visual field a. b. Approach the client on unaffected side Place personal belongings, food etc., on unaffected side (ex. Turning the head to see things on affected side)

a. Offer bed pan or urinal every 2 hrs; catheterized only if
necessary

b. Administer stool softener & suppositories as ordered: to
prevent constipation & fecal impaction 9. Provide quiet, restful environment

c. Gradually teach the client to compensate by scanning 5. Emotional Lability: mood swings, frustrations
a. b. c. Create a quiet, restful environment with a reduction in excessive sensory stimuli Maintain a calm, non-threatening manner Explain to family that client’s behavior is not purposeful

10. Provide alternative means of communication to the client:
a. Non verbal cues

b. Magic slate: not paper & pen tiring for client c. If positive to hemianopsia: approach client on
unaffected side 11. Administer medications as ordered:

6. Aphasia: most common in right hemiplegics; may be
receptive / expressive a. Receptive Aphasia Give simple, slow directions Give one command at a time; gradually shift topics Use non-verbal techniques of communication (ex. Pantomime, demonstration) b. Expressive Aphasia Listen & watch very carefully when the client attempts to speak Anticipate client’s needs to decrease frustrations & feeling of helplessness Allow sufficient time for client to answer

a. Hyperosmotic agent: to decrease cerebral edema
Osmotic Diuretics (Mannitol) Loop Diuretics Furosemide (Lasix) Corticosteroids (Dexamethazone)

b. Anti-convulsants: to prevent or treat seizures c. Thrombolytic / Fibrinolytic Agents: given to dissolve clot
(hemorrhage must be ruled out) Tissue Plasminogen Activating Factor (tPA, Alteplase): SE: allergic Reaction Streptokinase, Urokinase: SE: chest pain

d. Anticoagulants: for stroke in evolution or embolic stroke
(hemorrhage must be ruled out) Heparin: short acting Check for Partial Thromboplastin Time (PTT): if prolonged there is a risk for bleeding Antidote: Protamine SO4 Warfarin (Comadin): long acting / long term therapy Give simultaneously with Heparin cause Warfarin (Coumadin) will take effect after 3 days Check for Prothrombin Time (PT): if prolonged there is a risk for bleeding Antidote: Vitamin K (Aqua Mephyton) Anti Platelet: to inhibit platelet aggregation in treating TIA’s PASA (Aspirin) Contraindicated for dengue, ulcer and unknown cause of headache because it may potentiate bleeding b.

7. Sensory / Perceptual Deficit: more common in left
hemiplegics; characterized by impulsiveness unawareness of disabilities, visual neglect (neglect of affected side & visual space on affected side) a. b. c. d. Assist with self-care Provide safety measures Initially arrange objects in environment on unaffected side Gradually teach client to take care of the affected & turn frequently & look at affected side

8. Apraxia: loss of ability to perform purposeful, skilled acts a. Guide client through intended movement (ex. Take
object such as wash cloth & guide client through movement of washing) Keep repeating the movement

9. Generalizations about the clients with left hemiplegia vs.
right hemiplegia & nursing care a. Left Hemiplegia Perceptual, sensory deficits: quick & impulsive behavior Use safety measures, verbal cues, simplicity in all area of care b. Right Hemiplegia Speech-language deficits: slow & cautious behavior

e. Antihypertensive: if indicated for elevated BP f.
Mild Analgesics: for pain 12. Provide client health teachings and discharge planning concerning

a. Avoid

modifiable

risk

factors

(diet,

exercise,

smoking)

15

16

Use pantomime & demonstration 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 Predisposing Factors 1. 2. 3. 4. Head injury due to birth trauma Genetics Presence of brain tumor Toxicity from the ff: a. b. 5. 6. Lead Carbon monoxide 3.

Aura is present: daydreaming like Automatism: stereotype repetitive and non propulsive behavior Clouding of consciousness: not in contact with environment Mild hallucinatory sensory experience Status Epilepticus Usually refers to generalized grand mal seizure Seizure is prolong (or there are repeated seizures without regaining consciousness) & unresponsive to treatment Can result in decrease in O2 supply & possible cardiac arrest A continuous uninterrupted seizure activity If left untreated can lead to hyperpyrexia and lead to coma and eventually death. DOC: Diazepam (Valium) & Glucose C. Diagnostic Procedures 1. CT Scan – reveals brain lesions 2. EEG – reveals hyper activity of electrical brain waves D. Nursing Management

Nutritional and Metabolic deficiencies Physical and emotional stress factor for status epilepticus: DOC: Diazepam (Valium) & Glucose S/sx Dependent on stages of development or types of seizure

7. Sudden withdrawal to anti-convulsant drug: is predisposing

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 3. Administer medications as ordered a. Anti convulsants (Dilantin, Phenytoin) b. Diazepam, Valium c. Carbamazepine (Tegnetol) – 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 Overview Anatomy & Physiology of the Eye External Structure of Eye

1.

Generalized Seizure Initial onset in both hemisphere, usually involves loss of consciousness & bilateral motor activity.

a. Major Motor Seizure (Grand mal Seizure): tonic-clonic
seizure Signs or aura with auditory, olfactory, visual, tactile, sensory experience Epileptic cry: is characterized by fall and loss of consciousness for 3-5 minutes Tonic Phase: Limbs contract or stiffens Pupils dilated & eye roll up to one side Glottis closes: causing noise on exhalation May be incontinent Occurs at same time as loss of consciousness last 20-40 sec Tonic contractions: direct symmetrical extension of extremities Clonic Phase: repetitive movement increase mucus production slowly tapers Clonic contractions: contraction of extremities Postictal sleep: unresponsive sleep Seizure ends with postictal period of confusion, drowsiness

a. Eyelids (Palpebrae) & Eyelashes: protect the eye from
foreign particles

b. Absence Seizure (Petit mal Seizure):
Usually non-organic brain damage present Must be differentiated from daydreaming Sudden onset with twitching & rolling of eyes that last 20-40 sec Common among pediatric clients characterized by: Blank stare Decrease blinking of eyes Twitching of mouth Loss of consciousness (5 – 10 seconds) 2. Partial or Localized Seizure Begins in focal area of brain & symptoms are related to a dysfunction of that area May progress into a generalized seizure

b. Conjunctiva:
Palpebral Conjunctiva: pink; lines inner surface of eyelids Bulbar Conjunctiva: white with small blood vessels, covers anterior sclera

c. Lacrimal Apparatus (lacrimal gland & its ducts & passage):
produces tears to lubricate the eye & moisten the cornea; tears drain into the nasolacrimal duct, which empties into nasal cavity

d. The movement of the eye is controlled by 6 extraocular
muscles (EOM) Internal Structure of Eye A. 3 layers of the eyeball 1. Outer Layer

a. Sclera: tough, white connective tissue (“white of the
eye”); located anteriorly & posteriorly

a. 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.

b. Cornea: transparent tissue through which light
enters the eye; located anteriorly Middle Layer

b. Psychomotor Seizure (focal motor seizure)
May follow trauma, hypoxia, drug use Purposeful but inappropriate repetitive motor acts

a. Choroid: highly vascular layer, nourishes retina;
located posteriorly

b. Ciliary Body: anterior to choroid, secrets aqueous
humor; muscle change shape of lens

16

17 c. Iris: pigmented membrane behind cornea, gives
color to eye; located anteriorly

4. Amblyopia: prolong squinting
Common Visual Disorder Glaucoma Characterized by increase intraocular pressure resulting in progressive loss of vision May cause blindness if not recognized & treated Early detection is very important preventable but not curable Regular eye exam including tonometry for person over age 40 is recommended Predisposing Factors 1. 2. 3. 4. 5. Common among 40 years old and above Hereditary Hypertension Obesity History of previous eye surgery, trauma, inflammation

d. Pupil: is circular opening in the middle of the iris that
constrict or dilates to regulate amount of light entering the eye 3. Inner Layer

a. Light-sensitive layer composed of rods & cones
(visual cell) Cones: specialized for fine discrimination & color vision; (daylight / colored vision) Rods: more sensitive to light than cones, aid in peripheral vision; (night twilight vision)

b. Optic Disk: area in retina for entrance of optic nerve,
has no photoreceptors

B. Lens: transparent body that focuses image on retina
C. Fluid of the eye

1. Aqueous Humor: clear, watery fluid in anterior &
posterior chambers in anterior part of eye; serves as refracting medium & provides nutrients to lens & cornea; contribute to maintenance of intraocular pressure

Types of Glaucoma:

1. Chronic (open-angle) Glaucoma:
Most common form Due to obstruction of the outflow of aqueous humor, in trabecular meshwork or canal of schlemm

2. Vitreous Humor: clear, gelatinous material that fills
posterior cavity of eye; maintains transparency & form of eye Visual Pathways

2. Acute (close-angle) Glaucoma:
Due to forward displacement of the iris against the cornea, obstructing the outflow of the aqueous humor Occurs suddenly & is an emergency situation If untreated it will result to blindness

a. Retina (rods & cones) translates light waves into neural
impulses that travel over the optic nerves b. Optic nerves for each eye meet at the optic chiasm Fibers from median halves of the retinas cross here & travel to the opposite side of the brain Fibers from lateral halves of retinas remain uncrossed

3. Chronic (close-angle) Glaucoma:
similar to acute (close-angle) glaucoma, with the potential for an acute attack S/sx

c. Optic nerves continue from optic chiasm as optic tracts &
travels to the cerebrum (occipital lobe) where visual impulses are perceived & interpreted

1. Chronic (open-angle) Glaucoma: symptoms develops slowly
Impaired peripheral vision (PS: tunnel vision) Halos around light

Canal of schlemm: site of aqueous humor drainage Meibomian gland: secrets a lubricating fluid inside the eyelid Maculla lutea: yellow spot center of retina Fovea centralis: area with highest visual acuity or acute vision 2 muscles of iris: Circular smooth muscle fiber: Constricts the pupil Radial smooth muscle fiber: Dilates the pupil Physiology of vision 4 Physiological processes for vision to occur:

Mild discomfort in the eye Loss of central vision if unarrested

2. Acute (close-angle) Glaucoma
Severe eye pain Blurred cloudy vision Halos around light N/V Steamy cornea Moderate pupillary dilation

3. Chronic (close-angle) Glaucoma
Transient blurred vision Slight eye pain Halos around lights Dx

1. Refraction of light rays: bending of light rays
2. 3. 4. Accommodation of lens Constriction & dilation of pupils Convergence of eyes

Unit of measurements of refraction: diopters Normal eye refraction: emmetropia Normal IOP: 12-21 mmHg Error of Refraction

1. Visual Acuity: reduced 2. Tonometry: reading of 24-32 mmHg suggest glaucoma; may
be 50 mmHg of more in acute (close-angle) glaucoma

3. Ophthalmoscopic exam: reveals narrowing of small vessels
of optic disk, cupping of optic disk

1. Myopia: nearsightedness: Treatment: biconcave lens 2. Hyperopia: farsightedness: Treatment: biconvex lens 3. Astigmatisim: distorted vision: Treatment: cylindrical 4. Presbyopia: “old sight” inelasticity of lens due to aging:
Treatment: bifocal lens or double vista Accommodation of lenses: based on thelmholtz theory of accommodation Near Vision: Ciliary muscle contracts: Lens bulges Far Vision: ciliary muscle dilates / relaxes: lens is flat

4. Perimetry: reveals defects in visual field 5. Gonioscopy: examine angle of anterior chamber
Medical Management

1. Chronic (open-angle) Glaucoma a. Drug Therapy: one or a combination of the following
Miotics eye drops (Pilocarpine): to increase outflow of aqueous humor Epinephrine eye drops: to decrease aqueous humor production & increase outflow Carbonic Anhydrase Inhibitor: Acetazolamide Convergence of the eye: Error: (Diamox): to decrease aqueous humor production Timolol Maleate (Timoptic): topical beta-adrenergic blocker: to decrease intraocular pressure (IOP) corrected by

1. Exotropia:1 eye normal 2. Esophoria:
corrective eye surgery

b. Surgery (if no improvement with drug)

3. Strabismus: squint eye

17

18
b. c. d. Surgery performed on one eye at a time; usually in a same day surgery unit Local anesthesia & intravenous sedation usually used Types of cataract surgery: Extracapsular Extraction: lens capsule is excised & the lens is expressed; posterior capsule is left in place (may be used to support new artificial lens implant); partial removal of lens Phacoemulsification: type of extracapsular extraction; a hollow needle capable of ultrasonic vibration is inserted into lens, vibrations emulsify the lens, which is aspirated Intracapsular Extraction: lens is totally removed within its capsules, may be delivered from eye by cryoextraction (lens is frozen with metal probe & removed); total removal of lens & surrounding capsules

Filtering procedure (Trabeculectomy / Trephining): to create artificial openings for the outflow of aqueous humor Laser Trabeculoplasty: non-invasive procedure performed with argon laser that can be done on an out-client basis; procedure similar result as trabeculectomy

2. Acute (close-angle) Glaucoma a. Drug Therapy: before surgery
Miotics eye drops (Pilocarpine): to cause pupil to contract & draw iris away from cornea Osmotic Agent (Glycerin oral, Mannitol IV): to decrease intraocular pressure (IOP) Narcotic Analgesic: for pain b. Surgery Peripheral Iridectomy: portion of the iris is excised to facilitate outflow of aqueous humor Argon Laser Beam Surgery: non-invasive procedure using laser produces same effect as iridectomy; done in out-client basis Iridectomy: usually performed on second eye later since a large number of client have an acute acute attack in the other eye 2.

e. Peripheral Iridectomy: may be performed at the time of
surgery; small hole cut in iris to prevent development of secondary glaucoma

f.

Intraocular Lens Implant: often performed at the time of surgery

Nursing Intervention Pre-op a. Assess vision in the unaffected eye since the affected eye will be patched post-op

3. Chronic (close-angle) Glaucoma a. Drug Therapy:
miotics (pilocarpine) b. Surgery: bilateral peripheral iridectomy: to prevent acute attacks Nursing Intervention 1. 2. 3. 4. 5. 6. Administer medication as ordered Provide quite, dark environment Maintain accurate I & O with the use of osmotic agent Prepare client for surgery if indicated Provide post-op care Provide client teaching & discharge planning a. Self-administration of eye drops emotional upsets, excessive fluid intake, constrictive clothing around the neck 3. c.

b. Provide pre-op teaching regarding measures to prevent
intraocular pressure (IOP) post-op Administer medication as ordered: Topical Mydriatics (Mydriacyl) & Cyclopegics (Cyclogyl): to dilate the pupil Topical antibiotics: to prevent infection Acetazolamide (Diamox) & osmotic agent (Oral Glycerin or Mannitol IV): to decrease intraocular pressure to provide soft eyeball for surgery Nursing Intervention Post-op a. b. Reorient the client to surroundings Provide safety measures: Elevate side rails Provide call bells Assist with ambulation when fully recovered from anesthesia c. Prevent intraocular pressure & stress on the suture line: Elevate head of the bed 30-40 degree Have the client lie on back or unaffected side Avoid having the client cough, sneeze, bend over, or move head too rapidly Treat nausea with anti-emetics as ordered: to

b. Need to avoid stooping, heavy lifting or pushing,

c. Need to avoid the use antihistamines or
sympathomimetic drugs (found in cold preparation) in close-angle glaucoma since they may cause mydriasis d. e. Cataract Decrease opacity of ocular lens Incidence increases with age Predisposing Factor 1. Aging 65 years and above cataract) 3. Related to congenital certain drugs (corticosteroids) 5. 6. Diabetes Mellitus Prolonged exposure to UV rays S/sx 1. 2. 3. 4. 5. 6. Loss of central vision Blurring or hazy vision Progressive decrease of vision Glare in bright lights Milky white appearance at center of pupils Decrease perception to colors Diagnostic Procedure 6. 5. 4. Importance of follow-up care Need to wear medic-alert tag

prevent vomiting Give stool softener as ordered: to prevent straining Observe for & report signs of intraocular pressure (IOP): Severe eye pain Restlessness Increased pulse Protect eye from injury: a. b. c. Dressing usually removed the day after the surgery Eyeglasses or eye shield used during the day Always use eye shield during the night

2. May caused by changes associated with aging (“senile”

4. May develop secondary to trauma, radiation, infection,

Administer medication as ordered:

a. Topical mydriatics & cycloplegic: to decrease spasm of
ciliary body & relieve pain b. c. a. b. c. d. Topical antibiotics & corticosteroids Mild analgesic as needed Technique of eyedrop administration Use of eye shield at night No bending, stooping, or lifting Report signs & symptoms of complication immediately to physician: Severe eye pain Decrease vision Excessive drainage

Provide client teaching & discharge planning concerning:

1. Ophthalmoscopic exam: confirms presence of cataract
Nursing Intervention 1. Prepare client for cataract surgery: a. Performed when client can no longer remain independent because of reduced vision e.

Swelling of eyelid Cataract glasses / contact lenses If a lens implant has not been performed the client will need glasses or contact lenses

18

19 g. Need to report complications such as recurrence of
detachment Overview of Anatomy & Physiology Of Ear (Hearing) External Ear

Temporary glasses are worn for 1-4 weeks then permanent glasses fitted Cataract glasses magnify object by 1/3 & distortion peripheral vision Have the client practice manual coordination with assistance until new spatial relationship becomes familiar Have client practice walking, using stairs, reaching for articles Contact lenses cause less distortion of vision; prescribe at one month Retinal Detachment Separation of epithelial surface of retina Detachment or the sensory retina from the pigment epithelium of the retina Predisposing Factors 1. 2. 3. 4. Trauma Aging process Severe diabetic retinopathy Post-cataract extraction

1. Auricle (Pinna): outer projection of ear composed of
cartilage & covered by skin; collects sound waves

2. External Auditory Canal: lined with skin; glands secretes
cerumen (wax), providing protection; transmits sound waves to tympanic membrane

3. Tympanic Membrane (Eardrum): at end of external canal;
vibrates in response to sound & transmits vibrations to middle ear Middle Ear 1. Ossicles

a. 3 small bones: malleus (Hammer) attached to
tympanic membrane, incus (anvil), stapes (stirrup) b. Ossicles are set in motion by sound waves from tympanic membrane

c. Sound waves are conducted by vibration to the
footplate of the stapes in the oval widow (an opening between the middle ear & the inner ear)

5. Severe myopia (near sightedness)
Pathophysiology Tear in the retina allows vitreous humor to seep behind the sensory retina & separate it from the pigment epithelium Inner Ear S/sx 1. 2. 3. 4. 5. Curtain veil like vision coming across field of vision Flashes of light Visual field loss Floaters Gradual decrease of central vision Dx 1.

2. Eustachian Tube: connects nasopharynx & middle ear;
bring air into middle ear, thus equalizing pressure on both sides of eardrum

Cochlea Controls hearing Contains Organ of Corti (the true organ of hearing): the receptor end-organ for hearing Transmit sound waves from the oval window & initiates nerve impulses carried by cranial nerve VIII (acoustic branch) to the brain (temporal lobe of cerebrum)

1. Ophthalmoscopic exam: confirms diagnosis
Medical Management

2.

Vestibular Apparatus Organ of balance Composed of three semicircular canals & the utricle

1. Bed rest with eye patched & detached areas dependent to
prevent further detachment

3. 4.

Endolymph & Perilymph For static equilibrium Mastoid air cells Air filled spaces in temporal bone in skull

2. Surgery: necessary to repair detachment a. Photocoagulation: light beam (argon laser) through
dilated pupil creates an inflammatory reaction & scarring to heal the area

Disorder of the Ear Otosclerosis Formation of new spongy bone in the labyrinth of the ear causing fixation of the stapes in the oval window This prevent transmission of auditory vibration to the inner ear Predisposing Factor 1. Found more often in women Cause 1. 2. 3. Unknown / idiopathic There is familial tendency Ear trauma & surgery S/sx 1. 2. Progressive hearing loss Tinnitus Dx

b. Cryosurgery or diathermy: application of extreme cold or
heat to external globe; inflammatory reaction causes scarring & healing of area

c. Scleral buckling: shortening of sclera to force pigment
epithelium close to retina Nursing Intervention Pre-op 1. Maintain bed rest as ordered with head of bed flat & detached area in a dependent position

2. Use bilateral eye patches as ordered; elevate side rails to
prevent injury 3. 4. Identify yourself when entering the room Orient the client frequently to time of date & surroundings; explain procedures

5. Provide diversional activities to provide sensory stimulation
Nursing Intervention Post-op 1. Check orders for positioning & activity level: a. b. 2. May be on bed rest for 1-2 days May need to position client so that detached area is in dependent position Administer medication as ordered: a. b. 3. a. b. c. d. e. f. Topical mydriatics Analgesic as needed

1. Audiometry: reveals conductive hearing loss 2. Weber’s & Rinne’s Test: show bone conduction is greater
than air conduction Medical Management

Provide client teaching & discharge planning concerning: Techniques of eyedrop administration Use eye shield at night No bending from waist; no heavy work or lifting for 6 weeks Restriction of reading for 3 weeks or more May watch TV Need to check to physician regarding combing & shampooing hair & shaving

1. Stapedectomy: procedure of choice
Removal of diseased portion of stapes & replacement with prosthesis to conduct vibrations from the middle ear to inner ear Usually performed under local anesthesia Used to treat otoscrlerosis Nursing Intervention Pre-op

19

20
1. Provide general pre-op nursing care, including an explanation of post-op expectation

Atropine (decreases autonomic nervous system activity) Diazepam (Valium) Fentanyl & Droperidol (Innovar) 2. Chronic:

2. Explain to the client that hearing may improve during
surgery & then decrease due to edema & packing Nursing Intervention Post-op

1. Position the client according to the surgeon’s orders
(possibly with operative ear uppermost to prevent displacement of the graft)

a. Drug Therapy:
Vasodilators (nicotinic Acid) Diuretics Mild sedative or tranquilizers: Diazepam (Valium) Antihistamines: Diphenhydramine (Benadryl) Meclizine (antivert) b. Diet: Low sodium diet Restricted fluid intake Restrict caffeine & nicotine 3. Surgery:

2. Have the client deep breathe every 2 hours while in bed,
but no coughing

3. Elevate side rails; assist the client with ambulation &
move slowly: may have some vertigo

4. Administer medication as ordered:
Analgesic Antibiotics Anti-emetics Anti-motion sickness drug: Meclesine Hcl (Bonamine) 5. Check for dressing frequently for excessive drainage or bleeding

a. Surgical destruction of labyrinth causing loss of
vestibular & cochlear function (if disease is unilateral) b. Intracranial division of vestibular portion of cranial nerve VIII

6. Assess facial nerve function: Ask the client to do the ff:
Wrinkle forehead Close eyelids Puff out checks for any asymmetry

c. Endolymphatic sac decompression or shunt to
equalize pressure in endolymphatic space Nursing Intervention 1. Maintain bed rest in a quiet, darkened room in position of choice; elevate side rails as needed

7. Question the client about the ff: report existence to
physicians Pain Headaches Vertigo Unusual sensations in the ear 8. Provide client teaching & discharge planning concerning:

2. Only move the client for essential care (bath may not be
essential)

3. Provide emesis basin for vomiting
4. 5. 6. Monitor IV Therapy; maintain accurate I&O Assist in ambulation when the attack is over Administer medication as ordered includes using above measures)

a. Warning against blowing nose or coughing; sneeze
with mouth open

b. Need to keep ear dry in the shower; no shampooing
until allowed

7. Prepare client for surgery as indicated (pot-op care 8. Provide client care & discharge planning concerning:
a. b. c. Use of medication & side effects Low sodium diet & decrease fluid intake Importance of eliminating smoking

c. No flying for 6 mos. Especially if upper respiratory
tract infection is present

d. Placement of cotton balls in auditory meatus after
packing is removed; change twice daily

Overview of Anatomy & Physiology of Endocrine System Meniere’s Disease Disease of the inner ear resulting from dilatation of the endolymphatic system & increase volume of endolymph Characterized by recurrent & usually progressive triad of symptoms: vertigo, tinnitus, hearing loss Predisposing Factor 1. Incidence highest between ages 30 & 60 Cause 2. 3. Unknown / idiopathic Theories include the ff: a. b. c. d. e. f. Allergy Toxicity Localized ischemia Hemorrhage Viral infection Edema Endocrine System Is composed of an interrelated complex of glands (Pituitary G, Adrenal G, Thyroid G, Parathyroid G, Islets of langerhans of the pancreas, Ovaries & Testes) that secretes a variety of hormones directly into the bloodstream. Its major function, together with the nervous system: is to regulate body function Hormones Regulation

1. Hormones: chemical substance that acts s messenger to
specific cells & organs (target organs), stimulating & inhibiting various processes Two Major Categories

a. Local: hormones with specific effect in the area of
secretion (ex. Secretin, cholecystokinin, panceozymin [CCK-PZ])

b. General: hormones transported in the blood to distant
sites where they exert their effects (ex. Cortisol)

S/sx 1. 2. 3. 4. 5. Sudden attacks of vertigo lasting hours or days; attacks occurs several times a year N/V Tinnitus Progressive hearing loss Nystagmus Dx

2. Negative Feedback Mechanisms: major means of regulating
hormone levels a. Decreased concentration of a circulating hormones triggers production of a stimulating hormones from pituitary gland; this hormones in turn stimulates its target organ to produce hormones b. Increased concentration of a hormones inhibits production of the stimulating hormone, resulting in decreased secretion of the target organ hormone

1. Audiometry: reveals sensorineural hearing loss 2. Vestibular Test: reveals decrease function
Medical Management 1. Acute:

3. Some hormones are controlled by changing blood levels of
specific substances (ex. Calcium, glucose)

4. Certain hormones (ex. Cortisol or female reproductive
hormones) follow rhythmic patterns of secretion

5. Autonomic & CNS control (pituitary-hypothalamic axis):
hypothalamus controls release of the hormones of the

20

21
anterior pituitary gland through releasing & inhibiting factors that stimulate or inhibits hormone secretions Hormone Function Endocrine G Pituitary G Anterior lobe : ACTH : TSH : stimulate : stimulate adrenal cortex to produce & release adrenocoticoids : FSH, LH maturation, & function of primary & secondary sex organ : GH, Somatotropin body tissues & bones : Prolactin or LTH development of mammary gland & Lactation Posterior lobe : ADH : regulates H2O Pituitary Gland (Hypophysis) Or in response to an increase in plasma osmolality To stimulate reabsorption of H2O & decrease urine Output : Oxytocin contractions during delivery & the Release of milk in lactation Intermediate lobe pigmentation Adrenal G Adrenal Cortex : Mineralocorticoid (ex. Aldosterone) : regulate fluid & reabsoption potassium excretion : Glucocorticoids blood glucose level by increasing rate of (ex. Cortisol, increase CHON catabolism; increase corticosterone) acid; promote sodium & H2O retention; anti-inflammatory effect; aid body in coping with stress : Sex Hormones development of secondary sex (androgens, estrogens characeristics progesterones) Adrenal Medulla : Epinephrine, Norepinephrine : function in acute bronchioles; Needed by the muscles for energy Thyroid G : T3, T4 : regulate metabolic Metabolism; regulating physical & mental Growth development : Thyrocalcitonin serum calcium & phosphate levels Parathyroid G : PTH : regulates serum : lowers & aid in : influence c. mobilization of fatty glyconeogenesis; : increase : MSH : affects skin : stimulate uterine Located in sella turcica at the base of brain “Master Gland” or master clock Controls all metabolic function of body 3 Lobes of Pituitary Gland the sex organs, sexual functioning : stimulate : stimulate growth of pregnancy Testes : Testosterone : development of secondary sex characteristics in the Male maturation of of sex organ, sexual functioning Maintenance of : stimulate growth, Ovaries : Estrogen, Progesterone Female, : maturation Hormone Functions Alpha Cells : Glucagon

Beta Cells

: Insulin

: allows glucose to Converts glucose to glycogen : increase blood & glycogenolysis in the liver; secreted in response to low blood sugar

diffuse across cell membrane;

glucose by causing glyconeogenisis

thyroid G to release thyroid hormones

development of secondary sex characteristics in the

metabolism; release during stress

1. Anterior Lobe PG (Adenohypophysis) a. Secretes tropic hormones (hormones that stimulate
target glands to produce their hormones): adrenocorticotropic H (ACTH), thyroid-stimulating H (TSH), follicle-stimulating H (FSH), luteinizing H (LH) ACTH: promotes development of adrenal cortex LH: secretes estrogen FSH: secretes progesterone

b. Also secretes hormones that have direct effects on
tissues: somatotropic or growth H, prolactin Somatotropic / GH: promotes elongation of long bones Hyposecretion of GH: among children results to dwarfism Hypersecretion of GH: among children results to gigantism Hypersecretion of GH: among adults results to acromegaly (square face) DOC: Ocreotide (Sandostatin) Prolactin: promotes development of mammary gland; with help of oxytocin it initiates milk let down reflex Regulated by hypothalamic releasing & inhibiting factors & by negative feedback system

electrolyte balance; stimulate of sodium, chloride, & H2O; stimulate

2. Posterior Lobe PG (Neurohypophysis)
Does not produce hormones Store & release anti-diuretic hormones (ADH) & oxytocin produced by hypothalamus Secretes hormones oxytocin (promotes uterine contractions preventing bleeding or hemorrhage) Administer oxytocin immediately after delivery to prevent uterine atony. Initiates milk let down reflex with help of hormone prolactin 3. Intermediate Lobe PG Secretes melanocytes stimulating H (MSH) MSH: for skin pigmentation Hyposecretion of MSH: results to albinism Hypersecretion of MSH: results to vitiligo 2 feared complications of albinism: 1. 2. Adrenal Glands Lead to blindness due to severe photophobia Prone to skin cancer

stress; increase HR, BP; dilates convert glycogen to glucose when

rate; CHO, fats, & CHON

calcium & phosphate levels Pancreas (islets of Langerhans)

Two small glands, one above each kidney; Located at top of each kidney

21

22
2 Sections of Adrenal Glands

1. Adrenal Cortex (outer portion): produces mineralocorticoids,
glucocorticoids, sex hormones 3 Zones/Layers Zona Fasciculata: secretes glucocortocoids (cortisol): controls glucose metabolism: Sugar Zona Reticularis: secretes traces of glucocorticoids & androgenic hormones: promotes secondary sex characteristics: Sex Zona Glumerulosa: secretes mineralocorticoids (aldosterone): promotes sodium and water reabsorption and excretion of potassium: Salt 1. 2. 3. 4. Predisposing Factor Related to pituitary surgery Trauma Inflammation Presence of tumor S/sx 1. Severe polyuria with low specific gravity Anti-diuretic Hormone: Pitressin (Vasopressin) Function: prevents urination thereby conserving water Note: Alcohol inhibits release of ADH

2. Adrenal Medulla (inner portion): produces epinephrine,
norepinephrine (secretes catecholamines a power hormone): vasoconstrictor 2 Types of Catecholamines: Epinephrine (vasoconstrictor) Norepinephrine (vasoconstrictor)

2. Polydipsia (excessive thirst)
3. 4. 5. 6. 7. 8. Fatigue Muscle weakness Irritability Weight loss Hypotension Signs of dehydration

o

Pheochromocytoma (adrenal medulla): Increase secretion of norepinephrine: Leading to hypertension which is resistant to pharmacological agents leading to CVA: Use beta-blockers

a. Adult: thirst; Children: tachycardia
b. c. d. Agitation Poor Skin turgor Dry mucous membrane

Thyroid Gland Located in anterior portion of the neck Consist of 2 lobes connected by a narrow isthmus Produces thyroxine (T4), triiodothyronine (T3), thyrocalcitonin 3 Hormones Secreted: T3: 3 molecules of iodine (more potent) T4: 4 molecule of iodine T3 and T4 are metabolic hormone: increase brain activity; promotes cerebration (thinking); increase V/S Thyrocalcitonin: antagonizes the effects of parathormone to promote calcium reabsorption. Parathyroid Gland 4 small glands located in pairs behind the thyroid gland Produce parathormone (PTH) Promotes calcium reabsorption Pancreas Located behind the stomach Has both endocrine & exocrine function (mixed gland) Consist of Acinar Cells (exocrine gland): which secretes pancreatic juices: that aids in digestion Islets of langerhans (alpha & beta cells) involved in endocrine function: Alpha Cell: produce glucagons: (function: hyperglycemia) Beta Cell: produce insulin: (function: hypoglycemia) Delta Cells: produce somatostatin: (function: antagonizes the effects of growth hormones) Gonads Ovaries: located in pelvic cavity; produce estrogen & progesterone Testes: located in scrotum; produces testosterone Pineal Gland Secretes melatonin Inhibits LH secretion It controls & regulates circadian rhythm (body clock)

9. Tachycardia, eventually shock if fluids is not replaced 10. If left untreated results to hypovolemic shock (late sign
anuria) Dx

1. Urine Specific Gravity (NV: 1.015 – 1.030): less than 1.004 2. Serum Na: increase resulting to hypernatremia 3. H2O deprivation test: reveals inability to concentrate urine
Nursing Intervention 1. Maintain F&E balance / Force fluids 2000-3000 ml/day a. b. c. 2. Keep accurate I&O Weigh daily Administer IV/oral fluids as ordered to replace fluid loss

Monitor strictly V/S & observe for signs of dehydration & hypovolemia

3. Administer hormone replacement as ordered: a. Vasopressin (Pitressin) & Vasopressin Tannate (Pitressin
Tannate Oil): administered by IM injection Warm to body temperature before giving Shake tannate suspension to ensure uniform dispersion

b. Lypressin (Diapid): nasal spray 4. Prevent complications: hypovolemic shock is the most
feared complication 5. Provide client teaching & discharge planning concerning:

a. Lifelong hormone replacement: Lypressin (Diapid) as
needed to control polyuria & polydipsia b. Need to wear medic-alert bracelet

Syndrome of Inappropriate Anti-diuretic Hormone Secretion (SIADH) Hypersecretion of anti-diuretic hormone (ADH) from the PPG even when the client has abnormal serum osmolality Predisposing Factors 1. 2. Head injury Related to presence of bronchogenic cancer Initial sign of lung cancer is non productive cough Non invasive procedure is chest x-ray

3. Related to hyperplasia of pituitary gland (increase size of
organ brought about by increase of number of cells) S/sx 1. Person with SIADH cannot excrete a dilute urine Fluid retention & Na deficiency a. b. c. Hypertension Edema Weight gain 2.

Diabetes Incipidus (DI) DI: dalas-ihi Decrease of anti-diuretic hormone (ADH) Hyposecretion of ADH Hypofunction of the posterior pituitary gland (PPG) resulting in deficiency of ADH Characterized by excessive thirst & urination

3. Water intoxication: may lead to cerebral edema: lead to
increase ICP; may lead to seizure activity Dx

22

23 1. Urine specific gravity: is increase 2. Serum Sodium: is decreased
Medical Management 1. 2. Treat underlying cause if possible Diuretics & fluid restriction Nursing Intervention Dx 2. 3. 4. Dysphagia Respiratory distress Mild restlessness

1. Serum T4: reveals normal or below normal 2. Thyroid Scan: reveals enlarged thyroid gland. 3. Serum Thyroid Stimulating Hormone (TSH): is increased
(confirmatory diagnostic test)

1. Restrict fluid: to promote fluid loss & gradual increase in
serum Na

4. RAIU (Radio Active Iodine Uptake): normal or increased
Medical Management 1. Drug Therapy: Hormone replacement with levothyroxine (Synthroid) (T4), dessicated thyroid, or liothyronine (Cytomel) (T3) Small dose of iodine (Lugol’s or potassium iodide solution): for goiter resulting from iodine deficiency 2. 3. Avoidance of goitrogenic food or drugs in sporadic goiter Surgery: Subtotal thyroidectomy: (if goiter is large) to relieve pressure symptoms & for cosmetic reasons

2. Administer medications as ordered: a. Loop diuretics (Lasix) b. Osmotic diuretics (Mannitol)
3. 4. 5. 6. 7. Monitor strictly V/S, I&O & neuro check Weigh patient daily and assess for pitting edema Monitor serum electrolytes & blood chemistries carefully Provide meticulous skin care Prevent complications

HYPOTHYROIDISM - all are decrease except weight and menstruation - memory impairment Signs and Symptoms - there is loss of appetite but there is weight gain - menorrhagia - cold intolerance - constipation HYPERTHYROIDISM - all are increase except weight and menstruation Signs and Symptoms - increase appetite but there is weight loss - amenorrhea - exophthalmos Thyroid Disorder Simple Goiter Enlargement of thyroid gland due to iodine deficiency Enlargement of the thyroid gland not caused by inflammation of neoplasm Low level of thyroid hormones stimulate increased secretion of TSH by pituitary; under TSH stimulation the thyroid increases in size to compensate & produce more thyroid hormone Predisposing Factors 1.

Nursing Intervention Administer Replacement therapy as ordered:

a. Lugol’s Solution / SSKI (Saturated Solution of Potassium
Iodine) Color purple or violet and administered via straw to prevent staining of teeth. 4 Medications to be taken via straw: Lugol’s, Iron, Tetracycline, Nitrofurantoin (DOC: for pyelonephritis) b. Thyroid Hormones: Levothyroxine (Synthroid) Liothyronine (Cytomel) Thyroid Extracts Nursing Intervention 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: Insomnia Tachycardia and palpitations Hypertension Heat intolerance

2. Increase dietary intake of foods rich in iodine:
Seaweeds Seafood’s like oyster, crabs, clams and lobster but not shrimps because it contains lesser amount of iodine. Iodized salt: best taken raw because it is easily destroyed by heat 3. 4. Assist in surgical procedure of subtotal thyroidectomy Provide client teaching & discharge planning concerning: Used of iodized salt in preventing & treating endemic goiter Thyroid hormone replacement Hypothyroidism (Myxedema) Slowing of metabolic processes caused by hypofunction of the thyroid gland with decreased thyroid hormone secretion Hyposecretion of thyroid hormone Decrease in all V/S except wt & menses Adults: myxedema non pitting edema Children: cretinism the only endocrine disorder that can lead to mental retardation In severe or untreated cases myxedema coma may occur: Characterized by intensification of S/sx of hypothyroidism & neurologic impairment leading to coma Mortality rate high; prompt recognition & treatment essential Precipitating factors: failure to take prescribed

1. Endemic: caused by nutritional iodine deficiency, most
common in the “goiter belt” area, areas where soil & H2O are deficient in iodine; occurs most frequently during adolescence & pregnancy Goiter belt area: a. b. c. Midwest, northwest & great lakes region Places far from sea Mountainous regions

2. Sporadic: caused by
Increase intake of goitrogenic foods (contains agent that decrease the thyroxine production: pro-goitrin an antithyroid agent that has no iodine). Ex. cabbage, turnips, radish, strawberry, carrots, sweet potato, rutabagas, peaches, peas, spinach, broccoli, all nuts Soil erosion washes away iodine Goitrogenic drugs:

a. Anti-Thyroid Agent: Propylthiouracil (PTU)
b. c. d. e. Large doses of iodine Phenylbutazone Para-amino salicylic acid Lithium Carbonate PASA (Aspirin) Cobalt

f.
g. 3.

Genetic defects that prevents synthesis of thyroid hormones S/sx

medications; infection; trauma; exposure to cold; use of sedatives, narcotics or anesthetics

1.

Enlarged thyroid gland

23

24 3. Provide comfortable and warm environment: due to cold
Predisposing Factors intolerance 4. 5. Provide a low calorie diet Avoid the use of sedatives; reduce the dose of any sedatives, narcotics, or anesthetic agent by half as ordered

1. Primary hypothyroidism: atrophy of the gland possibly
caused by an autoimmune process

2. Secondary hypothyroidism: caused by decreased
stimulation from pituitary TSH

3. Iatrogenic: surgical removal of the gland or over
treatment of hyperthyroidism with drugs or radioactive iodine; disease caused by medical intervention such as surgery

6.

Provide meticulous skin care: to prevent skin breakdown

7. Increase fluid & food high in fiber: to prevent
constipation; administer stool softener as ordered

4. Related to atrophy of thyroid gland due to trauma,
presence of tumor, inflammation 5. Iodine deficiency

8. Observe for signs of myxedema coma; provide
appropriate nursing care a. Administer medication as ordered

6. Autoimmune (Hashimotos Disease)
7. Occurs more often to women ages 30 & 60 S/sx

b. Maintain vital functions:
Correct hypothermia Maintain adequate ventilation

9. Myxedema coma:
A complication of hypothyroidism & an emergency case A severe form of hypothyroidism is characterized by: Severe hypotension Bradycardia Bradypnea Hypoventilation Hyponatremia Hypoglycemia Hypothermia Leading to progressive stupor and coma Nursing Management for Myxedema Coma 1. 2. 3. Assist in mechanical ventilation Administer thyroid hormones as ordered Administer IVF replacement isotonic fluid solution as ordered / Force fluids 10. Provide client health teaching and discharge planning concerning: a. b. c. d. e. f. g. Thyroid hormone replacement Importance of regular follow-up care Need in additional protection in cold weather Measures to prevent constipation Avoid precipitating factors leading to myxedema coma & hypovolemic shock Stress & infection Use of anesthetics, narcotics, and sedatives

1. Loss of appetite: but there is wt gain
2. Anorexia atherosclerosis and MI 4. 5. 6. 7. 8. Constipation Cold intolerance Dry scaly skin Spares hair Brittleness of nails

3. Weight gain: which promotes lipolysis leading to

9. Decrease in all V/S: except wt gain & menses
a. b. c. d. Hypotension Bradycardia Bradypnea Hypothermia

10. Weakness and fatigue 11. Slowed mental processes 12. Dull look 13. Slow clumsy movement 14. Lethargy

15. Generalized interstitial non-pitting edema (Myxedema)
16. Hoarseness of voice 17. Decrease libido 18. Memory impairment 19. Psychosis 20. Menorrhagia Dx

1. Serum T3 and T4: is decreased 2. Serum Cholesterol: is increased 3. RAIU (Radio Active Iodine Uptake): is decreased
Medical Management

Hyperthyroidism Secretion of excessive amounts of thyroid hormone in the blood causes an increase in metabolic process Increase in T3 and T4 Grave’s Disease or Thyrotoxicosis Increase in all V/S except wt & menses Predisposing Factors 1. More often seen in women between ages 30 & 50 stimulator causing exopthalmus (protrusion of eyeballs) enopthalmus (late sign of dehydration among infants) 3. Excessive iodine intake

1. Drug Therapy:
Levothyroxine (Synthroid) Thyroglobulin (Proloid) Dessicated thyroid Liothyronine (Cytomel) 2. Myxedema coma is a medical emergency: IV thyroid hormones Correction of hypothermina Maintenance of vital function Treatment of precipitating cause Nursing Intervention

2. Autoimmune: involves release of long acting thyroid

4. Related to hyperplasia (increase size of TG) 1. Monitor strictly V/S & I&O, daily weights; observe for
edema & signs of cardiovascular complication & to determine presence of myxedema coma 2. 3. S/sx

1. Increase appetite (hyperphagia): but there is weight loss
Heat intolerance Weight loss

2. Administer thyroid hormone replacement therapy as
ordered & monitor effects:

4. Diarrhea: increase motility 5. Increased in all V/S: except wt & menses
a. b. c. 6. 7. 8. 9. Tachycardia Increase systolic BP Palpitation

a. Observe signs of thyrotoxicosis:
Tachycardia & palpitation N/V Diarrhea Sweating Tremors Agitation Dyspnea b. Increase dosage gradually, especially in clients with cardiac complication

Warm smooth skin Fine soft hair Pliable nails CNS involvement a. b. c. Irritability & agitation Restlessness Tremors

24

25
d. e. f. g. Insomnia Hallucinations Sweating Hyperactive movement 1. 2. 3. Dx Nursing Intervention Maintain patent airway & adequate ventilation; administer O2 as ordered Administer IV therapy as ordered Administer medication as ordered: a. b. c. d. Thyroidectomy Partial or total removal of thyroid gland Indication: Subtotal Thyroidectomy: hyperthyroidism Total Thyroidectomy: thyroid cancer Nursing Intervention Pre-op 1. Ensure that the client is adequately prepared for surgery a. b. 2. Cardiac status is normal Weight & nutritional status is normal Anti-thyroid drugs Corticosteroids Sedatives Cardiac Drugs 7. 8. Delirium Coma

10. Goiter

11. PS: Exopthalmus (protrusion of eyeballs)
12. Amenorrhea

1. Serum T3 and T4: is increased 2. RAIU (Radio Active Iodine Uptake): is increased 3. Thyroid Scan: reveals an enlarged thyroid gland
Medical Management 1. Drug Therap:

a. Anti-thyroid drugs: Propylthiouracil (PTU) &
methimazole (Tapazole): blocke synthesis of thyroid hormone; toxic effect include agranulocytosis

b. Adrenergic Blocking Agent: Propranolol (Inderal):
used to decrease sympathetic activity & alleviate symptoms such as tachycardia 2. Radioactive Iodine Therapy

a. Radioactive isotope of iodine (ex. 131I): given to
destroy the thyroid gland, thereby decreasing production of thyroid hormone b. c. Used in middle-aged or older clients who are resistant to, or develop toxicity from drug therapy Hypothyroidism is a potential complication 3.

Administer anti-thyroid drugs as ordered: to suppressed the production of thyroid hormone & to prevent thyroid storm Administer iodine preparation Lugol’s Solution (SSKI) or Potassium Iodide Solution: to decrease vascularity of the thyroid gland & to prevent hemorrhage. Nursing Intervention Post-Op

3. Surgery: Thyroidectomy performed in younger client for
whom drug therapy has not been effective Nursing Intervention 1. 2. Monitor strictly V/s & I&O, daily weight Administer anti-thyroid medications as ordered: 1.

Monitor V/S & I&O wetness behind the neck

2. Check dressing for signs of hemorrhage: check for
3. Place client in semi-fowlers position & support head with pillow

a. Propylthiouracil (PTU) b. Methimazole (Tapazole)
3. Provide for period of uninterrupted rest: a. b. 4. 5. 6. Assign a private room away from excessive activity Administer medication to promote sleep as ordered

4. Observe for respiratory distress secondary to
hemorrhage, edema of glottis, laryngeal nerve damage, or tetany: keep tracheostomy set, O2 & suction nearby

Provide comfortable and cold environment Minimized stress in the environment Encourage quiet, relaxing diversional activities calories, vitamin & minerals with supplemental feeding between meals & at bedtime; omit stimulant

5. Assess for signs of tetany: due to hypocalcemia: due to
secondary accidental removal of parathyroid glands: keep Calcium Gluconate available: Watch out for accidental removal of parathyroid which may lead to hypocalcemia (tetany) Classic S/sx of Tetany Positive trousseu’s sign Positive chvostek sign Observe for arrhythmia, seizure: give Calcium Gluconate IV slowly as ordered 6. Ecourage clients voice to rest: a. b. Some hoarseness is common Check every 30-60 min for extreme hoarseness or any accompanying respiratory distress

7. Provide dietary intake that is high in CHO, CHON,

8.

Observe for & prevent complication

a. Exophthalmos: protects eyes with dark glasses &
artificial tears as ordered b. 9. Thyroid Storm Provide meticulous skin care

10. Maintain side rails 11. Provide bilateral eye patch to prevent drying of the eyes

12. Assist in surgical procedures subtotal Thyroidectomy:
13. Provide client teaching & discharge planning concerning:

7. Observe for signs of thyroid storm / thyrotoxicosis: due
to release of excessive amount of thyroid hormone during surgery Agitation

a. Need to recognized & report S/sx of agranulocytosis
(fever, sore throat, skin rash): if taking anti-thyroid drugs b. Thyroid Storm Uncontrolled & potentially life-threatening hyperthyroidism caused by sudden & excessive release of thyroid hormone into the bloodstream Precipitating Factors 1. 2. 3. Stress Infection unprepared thyroid surgery S/sx 1. 2. Apprehension Restlessness S/sx of hyperthyroidism & hypothyroidism

TRIAD SIGNS

Hyperthermia Tachycardia Administer medications as ordered: Anti Pyretics Beta-blockers Monitor strictly vital signs, input and output and neuro check. Maintain side rails Offer TSB

3. Extremely high temp (up to 106 F / 40.7 C)
4. 5. 6. Tahchycardia HF Respiratory Distress

8. Administer IV fluids as ordered: until the client is
tolerating fluids by mouth

9. Administer analgesics as ordered: for incisional pain

25

26
10. Relieve discomfort from sore throat: a. b. Cool mist humidifier to thin secretions Administer analgesic throat lozenges before meals prn as ordered 11. Encourage coughing & deep breathing every hour Nursing Management

1. Administer medications as ordered such as: a. Acute Tetany: Calcium Gluconate slow IV drip as
ordered

12. Assist the client with ambulation: instruct the client to
place the hands behind the neck: to decrease stress on suture line if added support is necessary 13. Hormonal replacement therapy for lifetime

b. Chronic Tetany:
Oral calcium preparation: Calcium Gluconate, Calcium Lactate, Calcium Carbonate (Os-Cal) Large dose of vitamin D (Calciferol): to help absorption of calcium CHOLECALCIFEROL ARE DERIVED FROM Drug Sunlight (Calcitriol) Diet (Calcidiol)

14. Watch out for accidental laryngeal damage which may
lead to hoarseness of voice: encourage client to talk/speak immediately after operation and notify physician

15. Provide client teaching& discharge planning concerning:
a. b. c. d. e. S/sx of hyperthyroidism & hypothyroidism Self administration of thyroid hormone: if total thyroidectomy is performed Application of lubricant to the incision once suture is removed Perform ROM neck exercise 3-4 times a day Importance of follow up care with periodic serum calcium level

Phosphate Binder: Aluminum Hydroxide Gel (Amphogel) or aluminum carbonate gel, basic (basaljel): to decrease phosphate levels ANTACID A.A.C MAD

Hypoparathyroidism Disorder characterized by hypocalcemia resulting from a deficiency of parathormone (PTH) production Decrease secretion of parathormone: leading to hypocalcemia: resulting to hyperphospatemia If calcium decreases phosphate increases Predisposing Factors 1. 2. 3. May be hereditary Idiopathic Caused by accidental damage to or removal of parathyroid gland during thyroidectomy surgery

Aluminum Magnesium Containing Containing Antacids Antacids

Aluminum Hydroxide Gel Side Effect: Constipation Side Effect: Diarrhea 2. Institute seizure & safety precaution Provide quite environment free from excessive stimuli Avoid precipitating stimulus such as glaring lights and noise 5. Monitor signs of hoarseness or stridor; check for signs for Chvostek’s & Trousseau’s sign 3. 4.

4. Atrophy of parathyroid gland due to: inflammation,
tumor, trauma S/sx

1. Acute hypocalcemia (tetany) a. Paresthesia: tingling sensation of finger & around lip
b. c. d. Muscle spasm laryngospasm/broncospasm Dysphagia

6. Keep emergency equipment (tracheostomy set,
injectable Calcium Gluconate) at bedside: for presence of laryngospasm

e. Seizure: feared complications f.
g. Cardiac arrhythmia: feared complications Numbness

7. For tetany or generalized muscle cramp: may use
rebreathing bag or paper bag to produce mild respiratory acidosis: to promote increase ionized Ca levels 8. 9. Monitor serum calcium & phosphate level Provide high-calcium & low-phosphorus diet concerning: a. b. c. d. e. Medication regimen: oral calcium preparation & vit D to be taken with meal to increase absorption Need to recognized & report S/sx of hypo/hypercalcemia Importance of follow-up care with periodic serum calcium level Prevent complications Hormonal replacement therapy for lifetime

h. Positive trousseu’s sign: carpopedal spasm
i. Positive chvostek sign

2. Chronic hypocalcemia (tetany)
a. b. c. d. e. f. g. h. i. j. k. l. n. o. p. Fatigue Weakness Muscle cramps Personality changes Irritability Memory impairment Agitation Dry scaly skin Hair loss Loss of tooth enamel Tremors Cardiac arrhythmias

10. Provide client teaching & discharge planning

m. Cataract formation Photophobia Anorexia N/V Diagnostic Procedures

Hyperparathyroidism Increase secretion of PTH that results in an altered state of calcium, phosphate & bone metabolism Decrease parathormone Hypercalcemia: bone demineralization leading to bone fracture (calcium is stored 99% in bone and 1% blood) Kidney stones Predisposing Factors 1. Most commonly affects women between ages 35 & 65 hyperplasia of parathyroid gland

1. Serum Calcium level: decreased (normal value: 8.5 – 11
mg/100 ml)

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

3. Skeletal X-ray of long bones: reveals a increased in bone
density

2. Primary Hyperparathyroidism: caused by tumor &

4. CT Scan: reveals degeneration of basal ganglia

26

27 3. Secondary Hyperparathyroidism: cause by
compensatory over secretion of PTH in response to hypocalcemia from: 5.

4. Hyponatremia: hypotension, signs of dehydration,
weight loss, weak pulse Decrease tolerance to stress

a. Children: Ricketts b. Adults: Osteomalacia
c. d. Chronic renal disease Malabsorption syndrome S/sx 1. 2. 3. 4. 5. 6. Bone pain (especially at back); Bone demineralization; Pathologic fracture Kidney stones; Renal colic; Polyuria; Polydipsia; Cool moist skin Anorexia; N/V; Gastric Ulcer; Constipation Muscle weakness; Fatigue Irritability / Agitation; Personality changes; Depression; Memory impairment Cardiac arrhythmias; HPN Dx

6. Hyperkalemia: agitation, diarrhea, arrhythmia
7. 8. 9. Decrease libido Loss of pubic and axillary hair Bronze like skin pigmentation Dx

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) Nursing Intervention

1. Administer hormone replacement therapy as ordered: a. Glucocorticoids: stimulate diurnal rhythm of cortisol
release, give 2/3 of dose in early morning & 1/3 of dose in afternoon Corticosteroids: Dexamethasone (Decadrone) Hydrocortisone: Cortisone (Prednisone)

1. Serum Calcium: is increased 2. Serum Phosphate: is decreased 3. Skeletal X-ray of long bones: reveals bone
demineralization Nursing Intervention 1. 2. Administer IV infusions of normal saline solution & give diuretics as ordered: Monitor I&O & observe fluid overload & electrolytes imbalance 1.

b. Mineralocorticoids:
Fludrocortisone Acetate (Florinef) Nursing Management when giving steroids Instruct client to take 2/3 dose in the morning and 1/3 dose in the afternoon to mimic the normal diurnal rhythm

3. Assist client with self care: Provide careful handling,
Moving, Ambulation: to prevent pathologic fracture

2. Taper dose (withdraw gradually from drug)
3. Monitor side effects: Hypertension Edema Hirsutism Increase susceptibility to infection Moon face appearance 2. 3. 4. Monitor V/S Decrease stress in the environment Prevent exposure to infection

4. Monitor V/S: report irregularities 5. Force fluids 2000-3000 L/day: to prevent kidney stones 6. Provide acid-ash juices (ex. Cranberry, orange juice): to
acidify urine & prevent bacterial growth

7. Strain urine: using gauze pad: for stone analysis
8. Provide low-calcium & high-phosphorus diet

9. Provide warm sitz bath: for comfort 10. Administer medications as ordered: Morphine Sulfate
(Demerol) 11. Maintain side rails

5. Provide rest period: prevent fatigue
6. Weight daily increase cal, CHO, CHON, Na: to prevent hypoglycemia, & hyponatremia & provide proper nutrition

12. Assist in surgical procedure: Parathyroidectomy 13. Provide client teaching & discharge planning
concerning: a. b. Need to engage in progressive ambulatory activities Increase fluid intake calcium diet following a parathyroidectomy

7. Provide small frequent feeding of diet: decrease in K,

8. Monitor I&O: to determine presence of addisonian crisis
(complication of addison’s disease) 9. Provide meticulous skin care client teaching & discharge planning concerning: 10. Provide

c. Use of calcium preparation & importance of highd. Prevent complications: renal failure
e. f. Hormonal replacement therapy for lifetime Importance of follow up care

a. Disease process: signs of adrenal insufficiency b. Use of prescribe medication for lifelong replacement
therapy: never omit medication

Addison’s Disease Primary adrenocortical insufficiency; hypofunction of the adrenal cortex causes decrease secretion of the mineralcorticoids, glucocorticoids, & sex hormones Hyposecretion of adrenocortical hormone leading to: Metabolic disturbance: Sugar Fluid and electrolyte imbalance: Na, H2O, K Deficiency of neuromascular function: Salt, Sex g. Predisposing Factors d. e.

c. Need to avoid stress, trauma & infection: notify the
physician if these occurs as medication dosage may need to be adjusted Stress management technique Diet modification Use of salt tablet (if prescribe) or ingestion of salty foods (potato chips): if experiencing increase sweating Importance of alternating regular exercise with rest periods h. Avoidance of strenuous exercise especially in hot weather Avoid precipitating factor: leading to addisonian crisis: stress, infection, sudden withdrawal to steroids

f.

1. Relatively rare disease caused by:
Idiopathic atrophy of the adrenal cortex: due to an autoimmune process Destruction of the gland secondary to TB or fungal infections

i.

j.
S/sx 1. 2. Fatigue, Muscle weakness Anorexia, N/V, abdominal pain, weight loss tremors, tachycardia, irritability, restlessness, extreme fatigue, diaphoresis, depression k.

Prevent complications: addisonian crisis, hypovolemic shock Importance of follow up care

3. History of hypoglycemic reaction / Hypoglycemia:

Addisonian Crisis

27

28
4. Force fluids antibiotics as ordered Predisposing Factors 1. 2. 3. 4. 5. Strenuous activity Stress Trauma Infection Failure to take prescribe medicine 7. 8. 6. Maintain strict bed rest & eliminate all forms of stressful stimuli Monitor V/S, I&O & daily weight Protect client from infection concerning: same as addison’s disease Cushing Syndrome Condition resulting from excessive secretion of corticosteroids, particularly glucocorticoid cortisol Hypersecretion of adrenocortical hormones Predisposing Factors

Severe exacerbation of addison’s diseasecaused by acute adrenal insufficiency

5. If crisis precipitate by infection: administer

9. Provide client teaching & discharge planning

6. Iatrogenic:
Surgery of pituitary gland or adrenal gland Rapid withdrawal of exogenous steroids in a client on long-term steroid therapy S/sx 1. 2. Generalized muscle weakness Severe hypotension

1. Primary Cushing’s Syndrome: caused by adrenocortical
tumors or hyperplasia

3. Hypovolemic shock: vascular collapse 4. Hyponatremia: leading to progressive stupor and
coma Nursing Intervention 1. Assist in mechanical ventilation as ordered: to treat vascular collapse

2. Secondary Cushing’s Syndrome (also called Cushing’s
disease): caused by functioning pituitary or nonpituitary neoplasm secreting ACTH, causing increase secretion of glucocorticoids

3. Iatrogenic: cause by prolonged use of corticosteroids
4. 5. Related to hyperplasia of adrenal gland Increase susceptibility to infections S/sx

2. Administer IV fluids (5% dextrose in saline, plasma) 3. Administer IV glucocorticoids: Hydrocortisone (SoluCortef) & vasopressors as ordered 1. 2. 3. 4. 5. 6. 7. 8. 9. Muscle weakness Fatigue Obese trunk with thin arms & legs Muscle wasting Irritability Depression Frequent mood swings Moon face Buffalo hump

14. Signs of masculinization in women: menstrual
dysfunction, decrease libido 15. Osteoporosis 16. Decrease resistance to infection 17. Hypertension 18. Edema 19. Hypernatremia 20. Weight gain 21. Hypokalemia 22. Constipation

10. Pendulous abdomen 11. Purple striae on trunk 12. Acne 13. Thin skin

23. U wave upon ECG (T wave hyperkalemia)
24. Hirsutis 25. Easy bruising c. Need to avoid stress & infection therapy or reduce dosage): if caused of condition is prolonged corticosteroid therapy

Dx

d. Change in medication regimen (alternate day

1. FBS: is increased 2. Plasma Cortisol: is increased 3. Serum Sodium: is increased 4. Serum Potassium: is decreased
Nursing Intervention 1. Maintain muscle tone a. b. 2. 3. 4. Provide ROM exercise Assist in ambulation

e. Prevent complications (DM) f.
g. Hormonal replacement for lifetime: lifetime due to adrenal gland removal: no more corticosteroid! Importance of follow up care

Diabetes Mellitus (DM) Represent a heterogenous group of chronic disorders characterized by hyperglycemia Hyperglycemia: due to total or partial insulin deficiency or insensitivity of the cells to insulin Characterized by disorder in the metabolism of CHO, fats, CHON, as well as changes in the structure & function of blood vessels Metabolic disorder characterized by non utilization of carbohydrates, protein and fat metabolism Pathophysiology Lack of insulin causes hyperglycemia (insulin is necessary for the transport of glucose across the cell membrane) = Hyperglycemia leads to osmitic diuresis as large amounts of glucose pass through the kidney result polyuria & glycosuria = Diuresis leads to cellular dehydration & F & E depletion causing polydipsia (excessive thirst) = Polyphagia (hunger & increase appetite) result from cellular starvation = The body turns to fat & CHON for energy but in the absence of glucose in the cell fat cannot be completely metabolized & ketones (intermediate products of fat metabolism) are produced = This leads to ketonemia, ketonuria (contributes to osmotic diuresis) & metabolic acidosis (ketones are acid bodies) = Ketone sacts as CNS depressants & can cause coma = Excess loss of F & E leads to hypovolemia, hypotension, renal failure & decease blood flow to the brain resulting in coma & death unless treated. MAIN FOODSTUFF ANABOLISM CATABOLISM

Prevent accidents fall & provide adequate rest Protect client from exposure to infection Maintain skin integrity a. Provide meticulous skin care necessary

b. Prevent tearing of the skin: use paper tape if
5. Minimize stress in the environment

6. Monitor V/S: observe for hypertension & edema 7. Monitor I&O & daily weight: assess for pitting edema:
Measure abdominal girth: notify physician 8. Provide diet low in Calorie & Na & high in CHON, K, Ca, Vitamin D

9. Monitor urine: for glucose & acetone; administer insulin
as ordered 10. Provide psychological support & acceptance

11. Prepare client for hypophysectomy or radiation: if
condition is caused by a pituitary tumor

12. Prepare client for Adrenalectomy: if condition is caused
by an adrenal tumor or hyperplasia 13. Restrict sodium intake

14. Administer medications as ordered: Spironolactone
(Aldactone): potassium sparring diuretics 15. Provide client teaching & discharge planning concerning: a. b. Diet modification Importance of adequate rest

28

29
1. CHO 2. CHON 3. Fats Glucose Amino Acids Fatty Acids Glycogen Nitrogen Free Fatty Acids : cholesterol : ketones Keto Acidosis Hypertension HYPERGLYCEMIA Increase osmotic diuresis Glycosuria Polyuria Cellular starvation: weight loss 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 1. Negative Nitrogen balance Tissue wasting (Cachexia) INCREASE FAT CATABOLISM Free fatty acids 1. 2. 3. 4. 5. 6. Polyuria Polydipsia Polyphagia Glucosuria Weight loss Fatigue 7. 8. 9. 1. Cellular Diabetic Coma Death Acetone Kussmaul’s Respiration odor MI CVA Breath Atherosclerosis Diabetic Ketones Cholesterol

Classification Of DM

1. Type I Insulin-dependent Diabetes Mellitus (IDDM)
Secondary to destruction of beta cells in the islets of langerhans in the pancreas resulting in little of no insulin production Non-obese adults Requires insulin injection Juvenile onset type (Brittle disease) Incidence Rate 10% general population has Type I DM Predisposing Factors Autoimmune response cells) 3. Related to viruses

2. Genetics / Hereditary (total destruction of pancreatic

4. Drugs: diuretics (Lasix), Steroids, oral contraceptives
5. Related to carbon tetrachloride toxicity S/sx Anorexia N/V Blurring of vision

10. Increase susceptibility to infection 11. Delayed / poor wound healing

d. Insulin Pumps: externally worn device that closely
Dx 1. FBS: a. b. A level of 140 mg/dl of greater on at two occasions confirms DM May be normal in Type II DM Drug Rapid Acting Insulin Injection Regular Ins All insulin prep Medical Management 1. 2. 3. Insulin therapy Exercise Diet: a. b. 4. a. Consistency is imperative to avoid hypoglycemia High-fiber, low-fat diet also recommended Insulin: Short Acting: used in treating ketoacidosis; during surgery, infection, trauma; management of poorly controlled diabetes; to supplement long-acting insulins Intermediate: used for maintenance therapy Long Acting: used for maintenance therapy in clients who experience hyperglycemia during the night with intermediate-acting insulin Insulin Zinc 24 Suspension semilente prep Long Acting Insulin Zinc 36 suspension, semilente prep extended Ultralente Ins Regular Ins & Cloudy 4-8 16-20 30Intermediate Acting Isophane Ins 24 injection injection Lente Ins Regular Ins & Cloudy 1-1 ½ 8-12 18NPH Ins Regular Ins Cloudy 1-1 ½ 8-12 18Insulin, Zinc 16 suspension, prompt Semilente Ins Lente prep Cloudy ½-1 4-6 12except lente Clear ½-1 2-4 6-8 Characteristics of Insulin Preparation Synonym Duration Appearance Onset Peak Compatible Mixed mimic normal pancreatic functioning

5. Exercise: helpful adjunct to therapy as exercise
decrease the body’s need for insulin

2. Postprandial Blood Sugar: elevated 3. Oral Glucose Tolerance Test (most sensitve test):
elevated

4. Glycosolated Hemoglobin (hemoglobin A1c): elevated

Drug therapy:

b. Insulin preparation can consist of mixture of pure
pork, pure beef, or human insulin. Human insulin is the purest insulin & has the lowest antigenic effect

c. Human Insulin: is recommended for all newly
diagnosed Type I & Type II DM who need short-term insulin therapy; the pregnant client & diabetic client with insulin allergy or severe insulin resistance

29

30

Complication

absorption of glucose & improves insulin sensitivity

1. Diabetic Ketoacidosis (DKA) 2. Type II Non-insulin-dependent Diabetes Mellitus (NIDDM)
May result to partial deficiency of insulin production &/or an insensitivity of the cells to insulin Obese adult over 40 years old Maturity onset type Incidence Rate 1. 90% of general population has Type II DM Predisposing Factors 1. Genetics binding sites S/sx 1. 2. 3. 4. 5. 6. 7. 8. 9. Usually asymptomatic Polyuria Polydypsia Polyphagia Glycosuria Weight gain / Obesity Fatigue Blurred Vision Increase susceptibility to infection Oral Alpha-glucosidose Inhibitor Acarbose (Precose) Unknown 1 Unknown :Delay glucose absorption & digestion of CHO, lowering blood sugar Miglitol (Glyset) Troglitazone (Rezulin) Rapid :Reduce plasma glucose & insulin :Potetiates action of insulin in skeletal muscle & decrease glucose production in liver Complications 2-3 2-3 Unknown

2. Obesity: because obese persons lack insulin receptor

1. Hyper Osmolar Non-Ketotic Coma (HONKC)
Nursing Intervention

10. Delayed / poor wound healing Dx

1. Administer insulin or oral hypoglycemic agent as
ordered: monitor hypoglycemia especially during period of drug peak action

5. FBS:
c. d. A level of 140 mg/dl of greater on at two occasions confirms DM May be normal in Type II DM

2. Provide special diet as ordered:
a. Ensure that the client is eating all meals substitute according to the exchange list or give measured amount of orange juice to substitute for leftover food; provide snack later in the day

6. Postprandial Blood Sugar: elevated 7. Oral Glucose Tolerance Test (most sensitve test):
elevated

b. If all food is not ingested: provide appropriate

8. Glycosolated Hemoglobin (hemoglobin A1c): elevated
Medical Management 1. Ideally manage by diet & exercise & exercise are not effective in controlling hyperglycemia 3. Insulin is needed in acute stress: ex. Surgery, infection

3. Monitor urine sugar & acetone (freshly voided
specimen)

4. Perform finger sticks to monitor blood glucose level as
ordered (more accurate than urine test) 5. 6. 7. Observe signs of hypo/hyperglycemia Provide meticulous skin care & prevent injury Maintain I&O; weight daily change in lifestyle & body image 9. Observe for chronic complications & plan of care accordingly:

2. Oral Hypoglycemic agents or occasionally insulin: if diet

4. Diet: CHO 50%, CHON 30% & Fats 20%
a. b. 5. a. Weight loss is important since it decreases insulin resistance High-fiber, low-fat diet also recommended Occasional use of insulin Drug therapy:

8. Provide emotional support: assist client in adapting

a. Atherosclerosis: leads to CAD, MI, CVA & Peripheral
Vascular Disease

b. Oral hypoglycemic agent:
Used by client who are not controlled by diet & exercise Increase the ability of islet cells of the pancreas to secret insulin; may have some effect on cell receptors to decrease resistance to insulin

b. Microangiopathy: most commonly affects eyes &
kidneys c. Kidney Disease Recurrent Pyelonephritis Diabetic Nephropathy d. Ocular Disorder Premature Cataracts Diabetic Retinopathy e. Peripheral Neuropathy Affects PNS & ANS Cause diarrhea, constipation, neurogenic bladder, impotence, decrease sweating 10. Provide client teaching & discharge planning concerning: a. b. Disease process Diet Client should be able to plan a meal using exchange lists before discharge

6. Exercise: helpful adjunct to therapy as exercise
decrease the body’s need for insulin Oral Hypoglycemic Agent Drug Comments Oral Sulfonylureas Acetohexamide (Dymelor) 24 Chlorpropamide (Diabinase) 1 4-6 2-8 40-60 10-24 Glyburide (Micronase, Diabeta) 15 min- 1 hr Oral Biguanides Metformin (Glucophage) 16 :Decrease glucose 2-2.5 101 4-6 12Onset Peak Duration

Emphasize importance of regularity of meals; never skip meals c. Insulin How to draw up into syringe Use insulin at room temp

production in liver :Decrease intestinal

Gently roll the vial between palms Draw up insulin using sterile technique

30

31

If mixing insulin, draw up clear insulin, before cloudy insulin Injection technique Systematically rotate the site: to prevent lipodystrophy: (hypertrophy or atrophy of tissue) Insert needle at a 45 (skinny clients) or 90 (fat or obese clients) degree angle depending on amount of adipose tissue May store current vial of insulin at room temperature; refrigerate extra supplies Somogyi’s phenomenon: hypoglycemia followed by periods of hyperglycemia or rebound effect of insulin. Provide many opportunities for return demonstration d. Oral hypoglycemic agent Stress importance of taking the drug regularly Avoid alcohol intake while on medication: it can lead to severe hypoglycemia reaction Instruct the client to take it with meals: to lessen GIT irritation & prevent hypoglycemia i. h.

Notify physician Monitor urine or blood glucose level & urine ketones frequently If N/V occurs: sip on clear liquid with simple sugar Foot care Wash foot with mild soap & water & pat dry Apply lanolin lotion to feet: to prevent drying & cracking Cut toenail straight across Avoid constrictive garments such as garters Wear clean, absorbent socks (cotton or wool) Purchase properly fitting shoes & break new shoes in gradually Never go barefoot Inspect foot daily & notify physician: if cut, blister, or break in skin occurs Exercise Undertake regular exercise; avoid sporadic, vigorous exercise Food intake may need to be increased before exercising Exercise is best performed after meals when the blood sugar is rising j. Complication Learn to recognized S/sx of hypo/hyperglycemia: for hypoglycemia (cold and clammy skin), for hyperglycemia (dry and warm skin): administer simple sugars Eat candy or drink orange juice with sugar added for insulin reaction (hypoglycemia) Monitor signs of DKA & HONKC k. Need to wear a Medic-Alert bracelet

e. Urine testing (not very accurate reflection of blood
glucose level) May be satisfactory for Type II diabetics since they are more stable Use clinitest, tes-tape, diastix, for glucose testing Perform test before meals & at bedtime Use freshly voided specimen Be consistent in brand of urine test used Report results in percentage Report result to physician if results are greater that 1%, especially if experiencing symptoms of hyperglycemia Urine testing for ketones should be done by Type I diabetic clients when there is persistent glycosuria, increase blood glucose level or if the client is not feeling well (acetest, ketostix) f. Blood glucose monitoring Use for Type I diabetic client: since it gives exact blood glucose level & also detects hypoglycemia Instruct client in finger stick technique: use of monitor device (if used), & recording & utilization of test results g. General care Perform good oral hygiene & have regular dental exam Have regular eye exam Care for “sick days” (ex. Cold or flu) Do not omit insulin or oral hypoglycemic agent: since infection causes increase blood sugar 1. 2. 3. 4. 5.

Diabetic Ketoacidosis (DKA) Acute complication of DM characterized by hyperglycemia & accumulation of ketones in the body: cause metabolic acidosis Acute complication of Type I DM: due to severe hyperglycemia leading to severe CNS depression Occurs in insulin-dependent diabetic clients Onset slow: maybe hours to days Predisposing Factors Undiagnosed DM Neglect to treatment Infection cardiovascular disorder Hyperglycemia factor S/sx

6. Physical & Emotional Stress: number one precipitating

1. 2. 3. 4. 5. 6. 7. 8. 9.

Polyuria Polydipsia Polyphagia Glucosuria Weight loss Anorexia N/V Abdominal pain Skin warm, dry & flushed

10. Dry mucous membrane; soft eyeballs 11. Blurring of vision

12. PS: Acetone breath odor 13. PS: Kussmaul’s Respiration (rapid shallow breathing) or
tachypnea 14. Alteration in LOC 15. Hypotension 16. Tachycardia 17. CNS depression leading to coma

8. ABG: metabolic acidosis with compensatory respiratory
Dx alkalosis Nursing Intervention 1. 2. Maintain patent airway Assist in mechanical ventilation

1. FBS: is increased 2. Serum glucose & ketones level: elevated 3. BUN (normal value: 10 – 20): elevated: due to
dehydration

4. Creatinine (normal value: .8 – 1): elevated: due to
dehydration

3. Maintain F&E balance: a. Administer IV therapy as ordered:
Normal saline (0.9% NaCl), followed by hypotonic solutions (.45% NaCl) sodium chloride: to counteract dehydration & shock When blood sugar drops to 250 mg/dl: may add 5% dextrose to IV

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

6. Serum Na: decrease 7. Serum K: maybe normal or elevated at first

31

32

Potassium will be added: when the urine output is adequate b. Observe for F&E imbalance, especially fluid overload, hyperkalemia & hypokalemia Hyperglycemic Hyperosmolar Non-Ketotic Coma (HHNKC) Characterized by hyperglycemia & a hyperosmolar state without ketosis Occurs in non-insulin-dependent diabetic or non-diabetic persons (typically elderly clients) Hyperosmolar: increase osmolarity (severe dehydration) Non-ketotic: absence of lypolysis (no ketones) Predisposing Factors 1. 2. 3. 4. 5. 6. 7. Undiagnosed diabetes Infection or other stress Certain medications (ex. dilantin, thiazide, diuretics) Dialysis Hyperalimentation Major burns Pancreatic disease S/sx

4. Administer insulin as ordered: regular acting
insulin/rapid acting insulin

a. Regular insulin IV (drip or push) & / or
subcutaneously (SC)

b. If given IV drip: give small amount of albumin since
insulin adheres to IV tubing c. 5. Monitor blood glucose level frequently Administer medications as ordered:

a. Sodium Bicarbonate: to counteract acidosis b. Antibiotics: to prevent infection
6. 7. 8. 9. Check urine output every hour Monitor V/S, I&O & blood sugar levels Assist client with self-care Provide care for unconscious client if in a coma provide additional diabetic teaching if indicated 1. 2. 3. 4. 5. 6. 7. 8. 9. Polyuria Polydipsia Polyphagia Glucosuria Weight loss Anorexia N/V Abdominal pain Skin warm, dry & flushed

10. Discuss with client the reasons ketosis developed &

10. Dry mucous membrane; soft eyeballs 11. Blurring of vision 12. Hypotension 13. Tachycardia 14. Headache and dizziness 15. Restlessness 16. Seizure activity 17. Alteration / Decrease LOC: diabetic coma The hematologic system also plays an important role in

Dx

hormone transport, the inflammatory & immune responses, temperature regulation, F&E balance & acid-base balance.

1. Blood glucose level: extremely elevated 2. BUN: elevated: due to dehydration 3. Creatinine: elevted: due to dehydration 4. Hct: elevated: due to dehydration 5. Urine: (+) for glucose
Nursing Intervention 1. 2. Maintain patent airway Assist in mechanical ventilation

HEMATOLOGICAL SYSTEM

I. Blood III. Blood Forming Organs Liver 55% Plasma Thymus (Fluid) Spleen Lymphoid Organ Serum Lymph Nodes Bone Marrow

II. Blood Vessels 1. Arteries 1. 2. 3. 4.

45% Formed cellular elements

2. Veins 3. Capillaries

3. Maintain F&E balance: a. Administer IV therapy as ordered:
Normal saline (0.9% NaCl), followed by hypotonic solutions (.45% NaCl) sodium chloride: to counteract dehydration & shock When blood sugar drops to 250 mg/dl: may add 5% dextrose to IV Potassium will be added: when the urine output is adequate b. Observe for F&E imbalance, especially fluid overload, hyperkalemia & hypokalemia

Plasma CHON (formed in liver) 1. Albumin 2. Globulins 3. Prothrombin and Fibrinogen

5. 6.

Bone Marrow Contained inside all bones, occupies interior of spongy bones & center of long bones; collectively one of the largest organs in the body (4-5% of total body weight) Primary function is Hematopoiesis: the formation of blood cells All blood cells start as stem cells in the bone marrow; these mature into different, specific types of cells, collectively referred to as Formed Elements of Blood or Blood Components: 1. 2. 3. Two kinds of Bone Marrow: 1. Red Marrow Carries out hematopoiesis; production site of erythroid, myeloid, & thrombocytic component of blood; one source of lymphocytes & macrophages Found in the ribs, vertebral column, other flat bones Erythrocytes Leukocytes Thrombocytes

4. Administer insulin as ordered: a. Regular insulin IV (drip or push) & / or
subcutaneously (SC)

b. If given IV drip: give small amount of albumin since
insulin adheres to IV tubing c. 5. Monitor blood glucose level frequently Administer medications as ordered:

a. Antibiotics: to prevent infection
6. 7. 8. 9. Check urine output every hour Monitor V/S, I&O & blood sugar levels Assist client with self-care Provide care for unconscious client if in a coma provide additional diabetic teaching if indicated

10. Discuss with client the reasons ketosis developed &

Overview of Anatomy & Physiology of Hematologic System

2.

Yellow Marrow Red marrow that has changed to fats; found in long bone; does not contribute to hematopoiesis

The structure of the hematological of hematopoietic system includes the blood, blood vessels, & blood forming organs (bone marrow, spleen, liver, lymph nodes, & thymus gland). The major function of blood: is to carry necessary materials (O2, nutrients) to cells & remove CO2 & metabolic waste products. Blood

Composed of plasma (55%) & cellular components (45%) Hematocrit 1. Reflects portion of blood composed of red blood cells

32

33
2. Centrifugation of blood results in separation into top layer of plasma, middle layer of leukocytes & platelets, & bottom layer of erythrocytes 3. Majority of formed elements is erythrocytes; volume of leukocytes & platelets is negligible Distribution 1. 1300 ml in pulmonary circulation a. b. c. 2. a. b. c. Plasma Liquid part of the blood; yellow in color because of pigments Consists of serum (liquid portion of plasma) & fibrinogen Contains plasma CHON such as albumin, serum, globulins, fibrinogen, prothrombin, plasminogen 1. Albumin Largest & numerous plasma CHON Involved in regulation of intravascular plasma volume Maintains osmotic pressure: preventing edema 2. Serum Globulins 400 ml arterial 60 ml capillary 840 ml venous 550 ml arterial 300 ml capillary 2150 ml venous i.

g. Hemoglobin: normal value female 12 – 14 gms% male
14 – 16 gms%

h. Hematocrit red cell percentage in wholeblood (normal
value: female 36 – 42% male 42 – 48%) Substances needed for maturation of RBC: a. b. c. Folic acid Iron Vitamin c

d. Vitamin b12 (Cyanocobalamin) e. Vitamin b6 (Pyridoxine)
f. Intrinsic factor

3000 ml in systemic circulation

2. Leukocytes (WBC) a. Normal value: 5000 – 10000/mm3 b. Granulocytes and mononuclear cells: involved in the
protection from bacteria and other foreign substances

c. Granulocytes:
• Polymorphonuclear Neutrophils 60 – 70% of WBC Involved in short term phagocytosis for acute inflammation Mature leukocytes Immature band cells) • Polymorphonuclear Basophils • For parasite infections Responsible Involved in for the release of of chemical in mediation for inflammation prevention clotting microcirculation and allergic reactions Polymorphonuclear Eosinophils Involved in phagocytosis and allergic reaction neutrophils: neutrophils: polymorphonuclear band cells (bacterial

-

infection usually produces increased numbers of

a. Alpha: role in transport steroids, lipids, bilirubin &
hormones

b. Beta: role in transport of iron & copper c. Gamma: role in immune response, function of
antibodies

3. Fibrinogens, Prothrombin, Plasminogens: clotting factors
to prevent bleeding Cellular Components or Formed Elements

1. Erythrocytes (RBC)
a. Normal value: 4 – 6 million/mm3 hemoglobin c. Call membrane is highly diffusible to O2 & CO2 d.

Eosinophils & Basophils: are reservoirs of histamine, serotonin & heparin

Non Granulocytes

b. No nucleus, Biconcave shape discs, Chiefly sac of

Mononuclear cells: large nucleated cells a. Monocytes: Involved in long-term phagocytosis for chronic inflammation Play a role in immune response Macrophage in blood Largest WBC Produced by bone marrow: give rise to histiocytes (kupffer cells of liver), macrophages & other components of reticuloendothelial system

d. Responsible for O2 transport via hemoglobin (Hgb)
Two portion: iron carried on heme portion; second portion is CHON Normal blood contains 12-18 g Hgb/100 ml blood; higher (14-18 g) in men than in women (12-14 g) e. Production Start in bone marrow as stem cells, release as reticulocytes (immature cells), mature into erythrocytes Erythropoietin stimulates differentiation; produced by kidneys & stimulated by hypoxia Iron, vitamin B12, folic acid, pyridoxine vitamin B6, & other factors required for erythropoiesis Lymphocytes

b. Lymphocytes: immune cells; produce
substances against foreign cells; produced primarily in lymph tissue (B cells) & thymus (T cells)

f.

Hemolysis (Destruction) Normal life span of RBC is 80 – 120 days and is killed in red pulp of spleen Immature RBCs destroyed in either bone marrow or other reticuloendothelial organs (blood, connective tissue, spleen, liver, lungs and lymph nodes) Mature cells remove chiefly by liver and spleen Bilirubin (yellow pigment): by product of Hgb (red pigment) released when RBCs destroyed, excreted in bile Biliverdin (green pigment) Hemosiderin (golden brown pigment) Iron: feed from Hgb during bilirubin formation; transported to bone marrow via transferring and and reclaimed for new Hgb production Premature destruction: may be caused by RBC membrane abnormalities, Hgb abnormalities, extrinsic physical factors (such as the enzyme defects found in G6PD) Normal age RBCs may be destroyed by gross damage as in trauma or extravascular hemolysis (in spleen, liver, bone marrow) HIV B-cell T-cell - bone marrow - thymus and anti-tumor property for immunity Natural killer cell anti-viral

c. Thrombocytes (Platelets) •
• • • • • Normal value: 150,000 – 450,000/mm3 Normal life span of platelet is 9 – 12 days Fragments of megakaryocytes formed in bone marrow Production regulated by thrombopoietin Essential factors in coagulation via adhesion, aggregation & plug formation Release substances involved in coagulation Promotes hemostasis (prevention of blood loss) • Consist of immature or baby platelets or megakaryocytes which is the target of dengue virus

33

34
Signs of Platelet Dysfunction 1. 2. 3. Blood Groups Erythrocytes carry antigens, which determine the different blood group Blood-typing system are based on the many possible antigens, but the most important are the antigens of the ABO & Rh blood groups because they are most likely to be involved in transfusion reactions 1. ABO Typing a. b. c. d. Antigens of systems are labeled A & B Absence of both antigens results in type O blood Presence of both antigen is type AB Presence of either type A or B results in type A & type B, respectively Petechiae Echhymosis Oozing of blood from venipunctured site reaction _____________________________________________________________________ __________________ Pyrogenic Recipient possesses flushing, palpitation, tachycardia, occasional lumbar pain antibodies Leukocytes agglutination bacterial Within 15-90 min initiation after of Fever, chills, Stop transfusion. Treat temp. Transfuse with organism transfusion leukocytes-poor blood of washed RBC.

directed against WBC; bacterial contamination; Multitransfused Administer client; antibiotics prn multiparous client

e. Type O: universal donor
f. 2. Antibodies are automatically formed against ABO antigens not on persons own RBC Rh Typing

_____________________________________________________________________ __________________ Circulatory Overload transfusion tachycardia, Client orthopnea, blood. Monitor CVP t hro ug ha separate line. _____________________________________________________________________ after __________________ Air Embolism Blood given under air pressure wheezing, chest pain, decrease BP, blood loss apprehension _____________________________________________________________________ __________________ThromboWhen large of cytopenia bleeding banked blood 24 hr amount of Used of large deteriorate of bleeding. rapidly in stored blood precautions. Use fresh blood. Occurrence S/sx _____________________________________________________________________ __________________ Citrate Large amount Citrate binds After large amount of blood Neuromascular Monitor/treat Intoxication of citrated blood hypocalcemia. banked Avoid large amounts of in client with transfusion Bleeding due to decrease liver decrease calcium function citrated blood. Monitor liver fxn ionic calcium irritability given over Initiate bleeding Platelets amount of blood Abnormal Assess for signs Bolus of air Anytime Dyspnea, Clamp tubing. blocks pulmonary artery outflow left side Too rapid Fluid volume During & after Dyspnea, Slow infusion rate infusion in increase BP, Susceptible instead of whole overload Used packed cells

a. Identifies presence or absence of Rh antigens (Rh + or
Rh -)

b. Anti-Rh antibodies not automatically formed in Rh (-)
persons, but if Rh (+) blood is given, antibody formation starts & second exposure to Rh antigen will trigger a transfusion reaction

c. Important for Rh (-) woman carrying Rh (+) baby; 1st
pregnancy not affected, but subsequent pregnancy with an Rh (+) baby, mother’s antibodies attack baby’s RBC Complication of Blood Transfusion Type Causes Intervention Hemolytic ABO Antibodies in Stop transfusion. first 5 min continue saline IV react w/ antigen sternal pain, send blood unit & of transfusion client blood Agglutinated cell block capillary Delayed: Watch for days to 2 weeks after Treat or prevent shock, DIC, & into plasma & shock, renal renal shutdown urine) shutdown, DIC blood flow to organs. Hemolysis (Hgb dyspnea, signs Acute: Mechanism Occurrence S/sx

cyanosis, anxiety

Headache,

Incompatibility; recipient plasma lumbar or Rh completion

Incompatibility; in donor cells. diarrhea, fever, Use of dextrose solutions; Wide temp restlessness, fluctuation

increase pulse, Turn client on

chills, flushing, sample to lab. heat along vein,

following severe

hemoglobinuria.

anemia, jaundice,

Complication of Blood Transfusion Type Causes Intervention Allergic Transfer of an Uticaria, larygeal antigen & edema, wheezing dyspnea, donor to recipient; headache, anaphylaxis Treat life-threatening Allergic donor Immune sensitivity to Administer antihistamine & CHON Within 30 min start of Mechanism

Stop transfusion.

antibody from foreign serum

bronchospasm, or epinephrine.

34

35
_____________________________________________________________________ __________________ Hyperkalemia Potassium level Release of Administer blood potassium into renal less than 5-7 plasma with red cell lysis changes (tall with impaired potassium insufficiency increase in diarrhea, muscle stored blood spasm, ECG In client with Blood Tranfusion Purpose Nausea, colic,

Liver also involved in synthesis of clotting factors, synthesis of antithrombins.

1. RBC: Improve O2 transport 2. Whole Blood, Plasma, Albumin: volume expansion 3. Fresh Frozen Plasma, Albumin, Plasma Protein Fraction:
provision of proteins

days old in client

4. Cryoprecipitate, Fresh Frozen Plasma, Fresh Whole
Blood: provision of coagulation factors

peaked T-waves, short Q-T

5. Platelet Concentration, Fresh Whole Blood: provision of
platelets s egments) Blood & Blood Products

excretion

1. Whole Blood: provides all components a. Large volume can cause difficulty: 12-24 hr for Hgb
& Hct to rise

Blood Coagulation Conversion of fluid blood into a solid clot to reduce blood loss when blood vessels are ruptured System that Initiating Clotting

b. Complications: volume overload, transmission of
hepatitis or AIDS, transfusion reacion, infusion of excess potassium & sodium, infusion of anticoagulant (citrate) used to keep stored blood from clotting, calcium binding & depletion (citrate) in massive transfusion therapy

1. Intrinsic System: initiated by contact activation following
endothelial injury (“intrinsic” to vessel itself)

a. Factor XII: initiate as contact made between damaged
vessel & plasma CHON b. 2. Factors VIII, IX & XI activated Extrinsic System:

2. Red Blood Cell (RBC)
a. b. Provide twice amount of Hgb as an equivalent amount of whole blood Indicate in cases of blood loss, pre-op & post-op client & those with incipient congestive failure

a. Initiated by tissue thromboplastins released from injured
vessels (“extrinsic” to vessel) b. Factor VII activated

c. Complication: transfusion reaction (less common
than with whole blood: due to removal of plasma protein) 3. Fresh Frozen Plasma a. b. Contains all coagulation factors including V & VIII Can be stored frozen for 12 months; takes 20 minutes to thaw

Common Pathways: activated by either intrinsic or extrinsic pathways

1. Platelet factor 3 (PF3) & calcium react with factor X & V
2. 3. 4. Prothrombin converted to thrombin via thromboplastin Thrombin acts on fibrinogens, forming soluble fibrin Soluble fibrin polymerized by factor XIII to produce a stable, insoluble fibrin clot Clot Resolution: takes place via fibrinolytic system by plasmin & proteolytic enzymes; clots dissolves as tissue repairs. 4.

c. Hang immediately upon arrival to unit (loses its
coagulation factor rapidly) Platelets

a. Will raise recipient’s platelet count by 10,000/mm3
b. c. Pooled from 4-8 units of whole blood Single-donor platelet transfusion may be necessary for clients who have developed antibodies; compatibilities testing may be necessary

Spleen Largest Lymphatic Organ: functions as blood filtration system & reservoir Vascular bean shape; lies beneath the diaphragm, behind & to the left of the stomach; composed of fibrous tissue capsule surrounding a network of fiber Contains two types of pulp:

5. Factor VIII Fractions (Cryoprecipitate): contains factor
VIII, fibrinogens & XIII 6. Granulocytes

a. Do not increase WBC: increase marginal pool (at
tissue level) rather than circulating pool b. c. Premedication with steroids, antihistamine & acetaminophen Respiratory distress with shortness of breath, cyanosis & chest pain may occur; requires cessation of transfusion & immediate attention d. Shaking chills or rigors common, require brief cessation of therapy, administration of meperdine IV until rigors are diminished & resumption of transfusion when symptoms relieved

a. Red Pulp: located between the fibrous strands,
composed of RBC, WBC & macrophages

b. White Pulp: scattered throughout the red pulp, produces
lymphocytes & sequesters lymphocytes, macrophages, & antigens 1%-2% of red cell mass or 200 ml blood/minute stored in the spleen; blood comes via splenic artery to the pulp for cleansing, then passes into splenic venules that are lined with phagocytic cells & finally to the splenic vein to the liver. Important hematopoietic site in fetus; postnatally procedures lymphocytes & monocytes Important in phagocytosis; removes misshapen erythrocytes, unwanted parts of erythrocytes Also involved in antibody production by plasma cells & iron metabolism (iron released from Hgb portion of destroyed erythrocytes returned to bone marrow) In the adult functions of the spleen can be taken over by the reticuloendothelial system. Liver Involved in bile production (via erythrocyte destruction & bilirubin production) & erythropoeisis (during fetal life & when bone marrow production is insufficient). Kupffer cells of liver have reticuloendothelial function as histiocytes; phagocytic activity & iron storage. 3. 2. 1. 1.

7. Volume Expander: albumin; percentage concentration
varies (50-100 ml/unit); hyperosmolar solution should not be used in dehydrated clients Goals / Objectives Replace circulating blood volume

2. Increase the O2 carrying capacity of blood 3. Prevent infection: if there is a decrease in WBC 4. Prevent bleeding: if there is platelet deficiency
Principles of blood transfusion Proper refrigeration a. b. Expiration of packed RBC is 3-6 days Expiration of platelet is 3-5 days

Proper typing and cross matching

a. Type O: universal donor b. Type AB: universal recipient
c. 85% of population is RH positive Aseptically assemble all materials needed for BT

35

36
a. b. Filter set Gauge 18-19 needle 1. 2. 3. 4. 5. 6. hemolysis 4. Instruct another RN to re check the following a. b. c. d. 5. Client name Blood typing & cross matching Expiration date Serial number Nursing Management 1. 2. 3. 4. Stop BT Notify physician Flush with plain NSS Administer medications as ordered a. b. 5. 6. 7. 8. Antipyretic Antibiotic S/sx Pyrogenic reactions Fever and chills Headache Tachycardia Palpitations Diaphoresis Dyspnea

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

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

a. Never warm blood: it may destroy vital factors in
blood.

b. Warming is only done: during emergency situation &
if you have the warming device c. Emergency rapid BT is given after 30 minutes & let natural room temperature warm the blood.

Send the blood unit to blood bank for re examination Obtain urine & blood sample & send to laboratory for reexamination Monitor vital signs & I&O Render TSB

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

S/sx of Circulatory reaction 1. 2. 3. 4. Orthopnea Dyspnea Rales / Crackles upon auscultation Exertional discomfort Nursing Management 1. 2. 3. Stop BT Notify physician Administer medications as ordered

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 & after BT especially every 15 minutes for first hour because majority of transfusion reaction occurs during this period a. b. c. d. e. f. g. Hemolytic reaction Allergic reaction Pyrogenic reaction Circulatory overload Air embolism Thrombocytopenia Cytrate intoxication

a. Loop diuretic (Lasix)
Nursing Care 1. 2. 3. Assess client for history of previous blood transfusions & any adverse reaction Ensure that the adult client has an 18-19 gauge IV catheter in place Use 0.9% sodium chloride client & blood numbers & expiration date 5. Take baseline V/S before initiating transfusion

h. Hyperkalemia (caused by expired blood)
S/sx of Hemolytic reaction 1. 2. 3. 4. 5. 6. Headache and dizziness Dyspnea Diarrhea / Constipation Hypotension Flushed skin Lumbasternal / Flank pain

4. At least two nurse should verify the ABO group, RH type,

6. Start transfusion slowly (2 ml/min)
7. 8. Stay with the client during the first 15 min of the transfusion & take V/S frequently Maintain the prescribed transfusion rate:

7. Urine is color red / portwine urine
Nursing Management 1. 2. 3. Stop BT Notify physician Flush with plain NSS acute tubular necrosis 5. 6. 7. Send the blood unit to blood bank for re-examination Obtain urine & blood sample & send to laboratory for reexamination Monitor vital signs & I&O S/sx of Allergic reaction 1. 2. 3. 4. 5. 6. Fever Dyspnea Broncial wheezing Skin rashes Urticaria Laryngospasm & Broncospasm Nursing Management 1. 2. 3. 4. Stop BT Notify physician Flush with plain NSS Administer medications as ordered HIV

a. Whole Blood: approximately 3-4 hr b. RBC: approximately 2-4 hr c. Fresh Frozen Plasma: as quickly as possible d. Platelet: as quickly as possible e. Cryoprecipitate: rapid infusion f.
9. Granulocytes: usually over 2 hr

4. Administer isotonic fluid solution: to prevent shock and

g. Volume Expander: volume-dependent rate
Monitor for adverse reaction 10. Document the following:

a. Blood component unit number (apply sticker if
available) b. c. d. e. Date of infusion starts & end Type of component & amount transfused Client reaction & vital signs Signature of transfusionist

- 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. Pneumocystic Carini Pneumonia Blood Disorder Iron Deficiency Anemia (Anemias)

a. Anti Histamine (Benadryl): if positive to
hypotension, anaphylactic shock: treat with Epinephrine 5. 6. 7. Send the blood unit to blood bank for re examination Obtain urine & blood sample & send to laboratory for reexamination Monitor vital signs and intake and output

36

37 5. Instruct the client to avoid taking tea and coffee:
because it contains tannates which impairs iron absorption 6. Administer iron preparation as ordered: a. Oral Iron Preparations: route of choice Ferrous Sulfate Ferrous Fumarate Ferrous Gluconate Nursing Management when taking oral iron preparations Incidence Rate Instruct client to take with meals: to lessen GIT irritation Dilute in liquid preparations well & administer using a straw: to prevent staining of teeth When possible administer with orange juice as vitamin C (ascorbic acid): to enhance iron absorption Predisposing Factors 1. Chronic blood loss due to: a. b. Trauma Heavy menstruation and melena (sign for upper GIT bleeding) Warn clients that iron preparations will change stool color & consistency (dark & tarry) & may cause constipation Antacid ingestion will decrease oral iron effectiveness

A chronic microcytic anemia resulting from inadequate absorption of iron leading to hypoxemic tissue injury Chronic microcytic, hypochromic anemia caused by either inadequate absorption or excessive loss of iron Acute or chronic bleeding principal cause in adults (chiefly from trauma, dysfunctional uterine bleeding & GI bleeding) May also be caused by inadequate intake of iron-rich foods or by inadequate absorption of iron In iron-deficiency states, iron stores are depleted first, followed by a reduction in Hgb formation

1. Common among developed countries & tropical zones
(blood-sucking parasites) 2. 3. Common among women 15 & 45 years old & children affected more frequently, as are the poor Related to poor nutrition

c. Related to GIT bleeding resulting to hematemasis d. Fresh blood per rectum is called hematochezia
2. Inadequate intake or absorption of iron due to: a. b. c. d. e. 3. Chronic diarrhea Related to malabsorption syndrome High cereal intake with low animal CHON digestion Partial or complete gastrectomy Pica

b. Parenteral: used in clients intolerant to oral
preparations, who are noncompliant with therapy or who have continuing blood losses Nursing Management when giving parenteral iron preparation Use one needle to withdraw & another to administer iron preparation as tissue staining & irritation are a problem Use Z-track injection technique: to prevent leakage into tissue Do not massage injection site but encourage ambulation as this will enhance absorption; advice against vigourous exercise & constricting garments Observe for local signs of complication: Pain at the injection site Development of sterile abscesses Lymphadenitis

Related to improper cooking of foods S/sx

1. Usually asymptomatic (mild cases) 2. Weakness & fatigue (initial signs)
3. 4. 5. 6. Headache & dizziness Pallor & cold sensitivity Dyspnea Palpitations (koilonychias)

7. Brittleness of hair & nails, spoon shape nails 8. Atrophic Glossitis (inflammation of tongue) a. Stomatitis
VINSON’S SYNDROME b. Dysphagia PLUMBER

Fever & chills Headache Urticaria Pruritus Hypotension Skin rashes Anaphylactic shock Medications administered via straw Lugol’s Solution Iron Tetracycline Nitrofurantoin (Macrodentin) 7. 8. Administer with Vitamin C or orange juice for absorption Monitor & inform client of side effects a. b. c. d. e. 9. Anorexia N/V Abdominal pain Diarrhea / constipation Melena

9. PICA: abnormal appetite or craving for non edible foods
Dx

1. RBC: small (microcytic) & pale (hypochromic) 2. RBC: is decreased 3. Hgb: decreased 4. Hct: moderately decreased 5. Serum iron: decreased 6. Reticulocyte count: is decreased 7. Serum ferritin: is decreased 8. Hemosiderin: absent from bone marrow
Nursing Intervention 1. Monitor for s/sx of bleeding through hematest of all elimination including urine, stool & gastrict content

2. Enforce CBR / Provide adequate rest: plan activities so
as not to over tire the client

3. Provide thorough explanation of all diagnostic exam
used to determine sources of possible bleeding: help allay anxiety & ensure cooperation 4. Instruct client to take foods rich in iron a. b. c. d. e. f. g. Organ meat Egg yolk Raisin Sweet potatoes Dried fruits Legumes Nuts

If client can’t tolerate / no compliance administer parenteral iron preparation

a. Iron Dextran (IM, IV) b. Sorbitex (IM)
10. Provide dietary teaching regarding food high in iron

11. Encourage ingestion of roughage & increase fluid intake:
to prevent constipation if oral iron preparation are being taken Pernicious Anemia Chronic progressive, macrocytic anemia caused by a deficiency of intrinsic factor; the result is abnormally large

37

38
erythrocytes & hypochlorhydria (a deficiency of hydrochloric acid in gastric secretion) Chronic anemia characterized by a deficiency of intrinsic factor leading to hypochlorhydria (decrease hydrochloric acid secretion) Characterized by neurologic & GI symptoms; death usually resuls if untreated Lack of intrinsic factor is caused by gastric mucosal atrophy (possibly due to heredity, prolonged iron deficiency, or an autoimmune disorder); can also results in clients who have had a total gastrctomy if vitamin B12 is not administer e. b. c.

a. Measures absorption of radioactive vitamin B12
bothe before & after parenteral administration of intrinsic factor Definitive test for pernicious anemia Used to detect lack of intrinsic factor mouth & non-radioactive vitamin B12 IM to permit some excretion of radioactive vitamin B12 in the urine if it os absorbed 24-48 hour urine collection is obtained: client is encourage to drink fluids If indicated, second stage schilling test performed 1 week after first stage. Fasting client is given radioactive vitamin B12 combined with human intrinsic factor & test is repeated

d. Fasting client is given radioactive vitamin B12 by

f.
Pathophysiology

1. Intrinsic factor is necessary for the absorbtion of vitamin
B12 into small intestines

2. B12 deficiency diminished DNA synthesis, which results
in defective maturation of cell (particularly rapidly dividing cells such as blood cells & GI tract cells)

7. Gastric Analysis: decrease free hydrochloric acid 8. Large number of reticulocytes in the blood following
parenteral vitamin B12 administration Medical Management 1. Drug Therapy:

3. B12 deficiency can alter structure & function of
peripheral nerves, spinal cord, & the brain 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 Predisposing Factors 1. 2. 3. 4. 5. 6. 1. 2. 3. 4. Usually occurs in men & women over age of 50 with an increase in blue-eyed person of Scandinavian decent Subtotal gastrectomy Hereditary factors Inflammatory disorders of the ileum Autoimmune Strictly vegetarian diet S/sx Anemia Weakness & fatigue Headache and dizziness Pallor & cold sensitivity

a. Vitamin B12 injection: monthly maintenance b. Iron preparation: (if Hgb level inadequate to meet
increase numbers of erythrocytes) c. Folic Acid Controversial Reverses anemia & GI symptoms but may intensify neurologic symptoms May be safe if given in small amounts in addition to vitamin B12 2. Transfusion Therapy Nursing Intervention

1. Enforce CBR: necessary if anemia is severe 2. Adminster 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 CHON, vitamin c
and iron (fish, meat, milk / milk product & eggs)

4. Avoid highly seasoned, coursed, or very hot foods: if
client has mouth sore

5. Dyspnea & palpitations: as part of compensation
6. GIT S/sx: a. Mouth sore

5. Provide safety when ambulating (especially when
carrying hot item) 6. 7. 8. Instruct client to avoid irritating mouth washes instead use soft bristled toothbrush Avoid heat application to prevent burns Provide client teaching & discharge planning concerning: a. Dietery instruction

b. PS: Red beefy tongue
c. d. e. f. Indigestion / dyspepsia Weight loss Constipation / diarrhea Jaundice

7. CNS S/sx:
a. b. c. d. e. f. Tingling sensation Numbness Paresthesias of hands & feet Paralysis Depression Psychosis resulting to ataxia Dx

b. Importance of lifelong vitamin B12 therapy
c. Rehabilitation & physical therapy for neurologic deficit, as well as instruction regarding safety Aplastic Anemia Stem cell disorder leading to bone marrow depression leading to pancytopenia Pancytopenia or depression of granulocytes, platelets & erythrocytes production: due to fatty replacement of the bone marrow Bone marrow destruction may be idiopathic or secondary PANCYTOPENIA Decrease RBC Decrease Platelet (anemia) (thrombocytopenia) Predisposing Factors Decrease WBC (leukopenia)

g. Positive to Romberg’s test: damage to cerebellum

1. Erythrocytes count: decrease 2. Blood Smear: oval, macrocytic erythrocytes with a
proportionate amount of Hgb

3. Bilirubin (indirect): elevated unconjugated fraction 4. Serum LDH: elevated
5. Bone Marrow:

a. Increased megaloblasts (abnormal erythrocytes)
b. c. Few normoblasts or maturing erythrocytes Defective leukocytes maturation 2. 3. 4.

1. Chemicals (Benzene and its derivatives)
Related to radiation / exposure to x-ray Immunologic injury Drugs:

6. Positive Schilling’s Test: reveals inadequate / decrease
absorption of Vitamin B12

38

39 a. Broad Spectrum Antibiotics: Chloramphenicol
(Sulfonamides) b. Cytotoxic agent / Chemotherapeutic Agents: Methotrexate (Alkylating Agent) Vincristine (Plant Alkaloid) Nitrogen Mustard (Antimetabolite) Phenylbutazones (NSAIDS) S/sx 1. Anemia a. b. c. d. 2. 3. a. Weakness & fatigue Headache & dizziness Pallor & cold sensitivity Dyspnea & palpitations Increase susceptibility to infection Disseminated Intravascular Coagulation (DIC) Diffuse fibrin deposition within arterioles & capillaries with widespread coagulation all over the body & subsequent depletion of clotting factors Acute hemorrhagic syndrome characterized by wide spread bleeding and thrombosis due to a deficiency of prothrombin and fibrinogen Hemorrhage from kidneys, brain, adrenals, heart & other organs May be linked with entry of thromboplasic substance into the blood Mortality rate is high usually because underlying disease cannot be corrected

b. Identification of offending agent & importance of
avoiding it (if possible) in future

Leukopenia Thrombocytopenia

a. Petechiae (multiple petechiae is called purpura)
b. c. Dx Ecchymosis Oozing of blood from venipunctured sites Pathophysiology

1. Underlying disease (ex. toxemia of pregnancy, cancer)
cause release of thromboplastic substance that promote the deposition of fibrin throughout the microcirculation 2. 3. 4. 5. Microthrombi form in many organs, causing microinfarcts & tissue necrosis RBC are trapped in fibrin strands & are hemolysed Platelets, prothrombin & other clotting factors are destroyed, leading to bleeding Excessive clotting activates the fibrinolytic system, which inhibits platelet function, causing futher bleeding. Predisposing Factors 1. 2. 3. 4. 5. Related to rapid blood transfusion Massive burns Massive trauma Anaphylaxis Septecemia

1. CBC: reveals pancytopenia
2. Normocytic anemia, granulocytopenia, thrombocytopenia

3. Bone marrow biopsy: aspiration (site is the posterior iliac
crest): marrow is fatty & contain very few developing cells; reveals fat necrosis in bone marrow Medical Management

1. Blood transfusion: key to therapy until client’s own
marrow begins to produce blood cells 2. 3. 4. Aggressive treatment of infection Bone marrow transplantation Drug Therapy:

a. Corticosteroids & / or androgens: to stimulate bone
marrow function & to increase capillary resistance (effective in children but usually not in adults)

6. Neoplasia (new growth of tissue)
7. Pregnancy S/sx

b. Estrogen & / or progesterone: to prevent
amenorrhea in female clients 5. Identification & withdrawal of offending agent or drug Nursing Intervention 1. 2. Removal of underlying cause Administer Blood Transfusion as ordered

1. Petechiae & Ecchymosis on the skin, mucous
membrane, heart, eyes, lungs & other organs (widespread and systemic) 2. 3. 4. Prolonged bleeding from breaks in the skin: oozing of blood from punctured sites Severe & uncontrollable hemorrhage during childbirth or surgical procedure Hemoptysis

3. Administer O2 inhalation
4. 5. 6. 7. Enforce CBR Institute reverse isolation Provide nursing care for client with bone marrow transplant Administer medications as ordered:

5. Oliguria & acute renal failure (late sign)
6. Convulsion, coma, death Dx

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 8. Monitor for signs of infection & provide care to minimize risk: a. Monitor neuropenic precautions incidence of infection c. d. e. 9. Provide mouth care before & after meals Fever Cough

1. PT: prolonged 2. PTT: usually prolonged 3. Thrombin Time: usually prolonged 4. Fibrinogen level: usually depressed 5. Fibrin splits products: elevated 6. Protamine Sulfate Test: strongly positive 7. Factor assay (II, V, VII): depressed 8. CBC: reveals decreased platelets 9. Stool occult blood: positive 10. ABG analysis: reveals metabolic acidosis 11. Opthamoscopic exam: reveals sub retinal hemorrhages
Medical Management 1. Identification & control the underlying disease is key platelets, plasma, cryoprecipitites & volume expanders 3. Heparin administration a. b. Somewhat controversial Inhibits thrombin thus preventing further clot formation, allowing coagulation factors to accumulate Nursing Intervention 1. Monitor blood loss & attemp to quantify

b. Encourage high CHON, vitamin diet: to help reduce

Monitor signs of bleeding & provide measures to minimize risk:

a. Use soft toothbrush when brushing teeth & electric
razor when shaving: prevent bleeding

2. Blood Tranfusions: include whole blood, packed RBC,

b. Avoid IM, subcutaneous, venipunctured sites:
Instead provide heparin lock c. d. Hematest urine & stool Observe for oozing from gums, petechiae or ecchymoses 10. Provide client teaching & discharge planning concerning: a. Self-care regimen

39

40
2. 3. 4. Monitor for signs of additional bleeding or thrombus formation Monitor all hema test / laboratory data including stool and GIT Prevent further injury a. b. c. Avoid IM injection Apply pressure to bleeding site Turn & position the client frequently & gently toothbrush or gauze sponge) • 2 chambers, function as receiving chambers, lies above the ventricles

Upper Chamber (connecting or receiving)

Right Atrium: receives systemic venous blood through the superior vena cava, inferior vena cava & coronary sinus


Ventricles •

Left Atrium: receives oxygenated blood returning to the heart from the lungs trough the pulmonary veins

d. Provide frequent nontraumatic mouth care (ex. soft 5. Administer isotonic fluid solution as ordered: to prevent
shock 6. 7. 8. Administer oxygen inhalation Force fluids Administer medications as ordered: a. Vitamin K

2 thick-walled chambers; major responsibility for forcing blood out of the heart; lie below the atria

Lower Chamber (contracting or pumping)

Right Ventricle: contracts & propels deoxygenated blood into pulmonary circulation via the aorta during ventricular systole; Right atrium has decreased pressure which is 60 – 80 mmHg

b. Pitressin / Vasopresin: to conserve fluids
c. 9. Heparin / Comadin is ineffective

Left Ventricle: propels blood into the systemic circulation via aortaduring ventricular systole; Left ventricle has increased pressure which is 120 – 180 mmHg in order to propel blood to the systemic circulation

Provide heparin lock lavage: by using ice or cold saline solution of 500-1000 ml

10. Institute NGT decompression by performing gastric

11. Monitor NGT output 12. Prevent complication

Valves • • To promote unidimensional flow or prevent backflow

a. Hypovolemic shock: Anuria (late sign of
hypovolemic shock) 13. Provide emotional support to client & significant other 14. Teach client the importance of avoiding aspirin or aspirin-containing compounds

Atrioventricular Valve Guards opening between

Mitral Valve: located between the left atrium & left ventricle; contains 2 leaflets attached to the chordae tandinae


Overview of the Structure & Functions of the Heart • Cardiovascular system consists of the heart, arteries, veins & capillaries. The major function are circulation of blood, delivery of O2 & other nutrients to the tissues of the body & removal of CO2 & other cellular products metabolism Heart • • • • • Muscular pumping organ that propel blood into the arerial system & receive blood from the venous system 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 •

Tricuspid Valve: located between the right atrium & right ventricle; contains 3 leaflets attached to the chordae tandinae

Functions • • Permit unidirectional flow of blood from specific atrium to specific ventricle during ventricular diastole Prevent reflux flow during ventricular systole Valve leaflets open during ventricular diastole; Closure of AV valves give rise to first heart sound (S1 “lub”) Semi-lunar Valve

Pulmonary Valve • Located between the left ventricle & pulmonary artery

Aortic Valve • Located between left ventricle & aorta

Heart Wall / Layers of the Heart Pericardium

Function • • Pemit unidirectional flow of the blood from specific ventricle to arterial vessel during ventricular diastole Prevent reflux blood flow during ventricular diastole Valve open when ventricle contract & close during ventricular diastole; Closure of SV valve produces second heart sound (S2 “dub”) Extra Heart Sounds

Composed of fibrous (outermost layer) & serous pericardium (parietal & visceral); a sac that function to protect the heart from friction


In between is the pericardial fluid which is 10 – 20 cc: Prevent pericardial friction rub 2 layers of pericardium

• •
Epicardium • • •

Parietal: outer layer Visceral: inner layer

• •

S3: ventricular gallop usually seen in Left Congestive Heart Failure S4: atrial gallop usually seen in Myocardial Infarction and Hypertension

Covers surface of the heart, becomes continuous with visceral layer of serous pericardium Outer layer

Coronary Circulation Coronary Arteries • • • Branch off at the base of the aorta & supply blood to the myocardium & the conduction system Arises from base of the aorta Types of Coronary Arteries • • • Right Main Coronary Artery Left Main Coronary Artery

Myocardium Middle muscular layer Myocarditis can lead to cardiogenic shock and rheumatic heart disease Endocardium • • • Thin, inner membrabous layer lining the chamber of the heart Inner layer

Papillary Muscle Arise from the endocardial & myocardial surface of the ventricles & attach to the chordae tendinae Chordae Tendinae • Attach to the tricuspid & mitral valves & prevent eversion during systole Chambers of the Heart Atria

Coronary Veins Return blood from the myocardium back to the right atrium via the coronary sinus Conduction System Sinoatrial Node (SA node or Keith Flack Node) • • Located at the junction of superior vena cava and right atrium Acts as primary pacemaker of the heart

40

41
• • Initiates the cardiac impulse which spreads across the atria & into AV node Initiates electrical impulse of 60-100 bpm • • Small arteries that distribute blood to the capillaries & function in controlling systemic vascular resistance & therefore arterial pressure Capilliaries Atrioventricular Node (AV node or Tawara Node) • • • Located at the inter atrial septum Delays the impulse from the atria while the ventricles fill Delay of electrical impulse for about .08 milliseconds to allow ventricular filling Venules Bundle of His • • Arises from the AV node & conduct impulse to the bundle branch system Located at the interventricular septum Veins • Low-pressure vessels with thin small & less muscles than arteries; most contains valves that prevent retrograde blood flow; they carry deoxygenated blood back to the heart. When the skeletal surrounding veins contract, the veins are compressed, promoting movement of blood back to the heart. • Small veins that receive blood from capillaries & function as collecting channels between the capillaries & veins The following exchanges occurs in the capilliaries • • • O2 & CO2 Solutes between the blood & tissue Fluid volume transfer between the plasma & interstitial space

Right Bundle Branch: divided into anterior lateral & posterior; transmits impulses down the right side of the interventricular myocardium

Left Bundle Branch: divided into anterior & posterior

• •

Anterior Portion: transmits impulses to the anterior endocardial surface of the left ventricle Posterior Portion: transmits impulse over the posterior & inferior endocardial surface of the left ventricle

Cardiac Disorders Coronary Arterial Disease / Ischemic Heart Disease Stages of Development of Coronary Artery Disease

Purkinje Fibers • • Transmit impulses to the ventricle & provide for depolarization after ventricular contraction Located at the walls of the ventricles for ventricular contraction

1. Myocardial Injury: Atherosclerosis 2. Myocardial Ischemia: Angina Pectoris 3. Myocardial Necrosis: Myocardial Infarction
ATHEROSCLEROSIS • • •
SA NODE AV NODE

ATHEROSCLEROSIS Narrowing of artery Lipid or fat deposits Tunica intima

• • •

ARTERIOSCLEROSIS Hardening of artery Calcium and protein deposits Tunica media

Predisposing Factors

1. Sex: male
BUNDLE OF HIS

2. Race: black
3. 4. 5. 6. 7. 8. Smoking Obesity Hyperlipidemia Sedentary lifestyle Diabetes Mellitus Hypothyroidism

PURKINJE FIBERS

Electrical activity of heart can be visualize by attaching electrodes to the skin & recording activity by ECG Electrocadiography (ECG) Tracing

9. Diet: increased saturated fats
10. Type A personality S/sx 1. 2. 3. 4. 5. Chest pain Dyspnea Tachycardia Palpitations Diaphoresis

• • •
• •

P wave (atrail 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

Treatment P - Percutaneous T - Transluminal C - Coronary A – Angioplasty C - Coronary A - Arterial B - Bypass A - And G - Graft S - Surgery

• • • • • •

Positive U wave: Hypokalemia Peak T wave: Hyperkalemia ST segment depression: Angina Pectoris ST segment elevation: Myocardial Infarction T wave inversion: Myocardial Infarction Widening of QRS complexes: Arrythmia

Vascular System • Major function of the blood vessels isto supply the tissue with blood, remove wastes, & carry unoxygenated blood back to the heart

Objectives Types of Blood Vessels Arteries • Elastic-walled vessels that can stretch during systole & recoil during diastole; they carry blood away from the heart & distribute oxygenated blood throughout the body Arterioles 3 Complications of CABG 1. 2. 3. 4. 5. Revascularize myocardium To prevent angina Increase survival rate Done to single occluded vessels If there is 2 or more occluded blood vessels CABG is done

41

42 1. Pneumonia: encourage to perform deep breathing, coughing
exercise and use of incentive spirometer 2. 3. Shock Thrombophlebitis

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

• • •

Give 1st dose of NTG: sublingual 3-5 minutes Give 2nd dose of NTG: if pain persist after giving 1st dose with interval of 3-5 minutes Give 3rd & last dose of NTG: if pain still persist at 3-5 minutes interval

Angina Pectoris • Transient paroxysmal chest pain produced by insufficient blood flow to the myocardium resulting to myocardial ischemia • Clinical syndrome characterized by paroxysmal chest pain that is usually relieved by rest or nitroglycerine due to temporary myocardial ischemia Predisposing Factors 1. 2. 3. 4. 5. 6. 7. 8. Sex: male Race: black Smoking Obesity Hyperlipidemia Sedentary lifestyle Diabetes Mellitus Hypertension 2.

Nursing Management when giving NTG

1. NTG Tablets (sublingual)
• Keep the drug in a dry place, avoid moisture and exposure to sunlight as it may inactivate the drug

• •

Relax for 15 minutes after taking a tablet: to prevent dizziness Monitor side effects: • Orthostatic hypotension Transient headache & dizziness: frequent side effect


• • • •

Instruct the client to rise slowly from sitting position Assist or supervise in ambulation

9. CAD: Atherosclerosis
10. Thromboangiitis Obliterans 11. Severe Anemia

NTG Nitrol or Transdermal patch Avoid placing near hairy areas as it may decrease drug absorption Avoid rotating transdermal patches as it may decrease drug absorption

12. Aortic Insufficiency: heart valve that fails to open & close
efficiently 13. Hypothyroidism

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

14. Diet: increased saturated fats
15. Type A personality Precipitating Factors 4 E’s of Angina Pectoris b.

Beta-blockers • Propanolol: side effects PNS Not given to COPD cases: it causes bronchospasm


c. • d. • 4. 5. 6. 7. 8.

1. Excessive physical exertion: heavy exercises, sexual activity 2. Exposure to cold environment: vasoconstriction 3. Extreme emotional response: fear, anxiety, excitement,
strong emotions 4. Excessive intake of foods or heavy meal

ACE Inhibitors Enalapril

Calcium Antagonist Nefedipine

Administer oxygen inhalation Place client on semi-to high fowlers position Monitor strictly V/S, I&O, status of cardiopulmonary fuction & ECG tracing Provide decrease saturated fats sodium and caffeine Provide client health teachings and discharge planning Avoidance of 4 E’s Prevent complication (myocardial infarction) Instruct client to take medication before indulging into physical exertion to achieve the maximum therapeutic effect of drug Reduce stress & anxiety: relaxation techniques & guided imagery Avoid overexertion & smoking Avoid extremes of temperature

S/sx

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

2. Chest pain: characterized by sharp stabbing pain located at
sub sterna usually radiates from neck, back, arms, shoulder and jaw muscles usually relieved by rest or taking nitroglycerine (NTG) 3. 4. 5. 6. Dyspnea Tachycardia Palpitations Diaphoresis

Dx 1. History taking and physical exam inversion during chest pain

Dress warmly in cold weather Participate in regular exercise program Space exercise periods & allow for rest periods The importance of follow up care 9. Instruct the client to notify the physician immediately if pain occurs & persists despite rest & medication administration Myocardial Infarction • Death of myocardial cells from inadequate oxygenation, often caused by sudden complete blockage of a coronary artery

2. ECG: may reveals ST segment depression & T wave 3. Stress test / treadmill test: reveal abnormal ECG during
exercise 4. 5. Increase serum lipid levels Serum cholesterol & uric acid is increased

Medical Management

1. Drug Therapy: if cholesterol is elevated • • • •
2. Nitrates: Nitroglycerine (NTG) Beta-adrenergic blocking agent: Propanolol Calcium-blocking agent: nefedipine Ace Inhibitor: Enapril • •

Characterized by localized formation of necrosis (tissue destruction) with subsequent healing by scar formation & fibrosis Heart attack Terminal stage of coronary artery disease characterized by malocclusion, necrosis & scarring.

Modification of diet & other risk factors

3. Surgery: Coronary artery bypass surgery 4. Percutaneuos Transluminal Coronary Angioplasty (PTCA)

Types Nursing Intervention 1. 2. Enforce complete bed rest Give prompt pain relievers with nitrates or narcotic analgesic as ordered

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

3. Administer medications as ordered:

42

43 2. Administer oxygen low flow 2-3 L / min: to prevent
The Most Critical Period Following Diagnosis of Myocardial Infarction respiratory arrest or dyspnea & prevent arrhythmias

6-8 hours because majority of death occurs due to arrhythmia leading to premature ventricular contractions (PVC)

3. Enforce CBR in semi-fowlers position without bathroom
privileges (use bedside commode): to decrease cardiac workload 4. Instruct client to avoid forms of valsalva maneuver Place client on semi fowlers position Monitor strictly V/S, I&O, ECG tracing & hemodynamic procedures 7. Perform complete lung / cardiovascular assessment hr: indicates decrease cardiac output 5. 6.

Predisposing Factors

1. Sex: male 2. Race: black
3. 4. Smoking Obesity

8. Monitor urinary output & report output of less than 30 ml / 9. Provide a full liquid diet with gradual increase to soft diet:
low in saturated fats, Na & caffeine 10. Maintain quiet environment

5. CAD: Atherosclerotic
6. 7. 8. 9. Thrombus Formation Genetic Predisposition Hyperlipidemia Sedentary lifestyle

11. Administer stool softeners as ordered: to facilitate bowel
evacuation & prevent straining

10. Diabetes Mellitus 11. Hypothyroidism

12. Relieve anxiety associated with coronary care unit (CCU)
environment

12. Diet: increased saturated fats
13. Type A personality S/sx 1. Chest pain

13. Administer medication as ordered: a. Vasodilators: Nitroglycirine (NTG), Isosorbide Dinitrate,
Isodil (ISD): sublingual

b. Anti Arrythmic Agents: Lidocaine (Xylocane), Brithylium •
Side Effects: confusion and dizziness

• •

Excruciating visceral, viselike pain with sudden onset located at substernal & rarely in precordial Usually radiates from neck, back, shoulder, arms, jaw & abdominal muscles (abdominal ischemia): severe crushing

c. Beta-blockers: Propanolol (Inderal) d. ACE Inhibitors: Captopril (Enalapril) e. Calcium Antagonist: Nefedipine f.
Thrombolytics / Fibrinolytic Agents: Streptokinase, Urokinase, Tissue Plasminogen Activating Factor (TIPAF)

• 2. 3. N/V

Not usually relieved by rest or by nitroglycerine

Dyspnea blood pressure (initial sign) g.

• •

Side Effects: allergic reaction, urticaria, pruritus Nursing Intervention: Monitor for bleeding time

4. Increase in blood pressure & pulse, with gradual drop in 5. Hyperthermia: elevated temp
6. 7. 8. Skin: cool, clammy, ashen Mild restlessness & apprehension Occasional findings: • Pericardial friction rub Split S1 & S2 Rales or Crackles upon auscultation S4 or atrial gallop

Anti Coagulant Heparin

• • •

Antidote: Protamine Sulfate Nursing Intervention: Check for Partial Thrombin Time (PTT)

Caumadin (Warfarin)


• •

Antidote: Vitamin K Nursing Intervention: Check for Prothrombin Time (PT)


Dx 1.

h. Anti Platelet: PASA (Aspirin): Anti thrombotic effect
Cardiac Enzymes

• •

Side Effects: Tinnitus, Heartburn, Indigestion / Dyspepsia Contraindication: Dengue, Peptic Ulcer Disease, Unknown cause of headache

• •

CPK-MB: elevated Creatinine phosphokinase (CPK): elevated Heart only, 12 – 24 hours Lactic acid dehydrogenase (LDH): is increased Serum glutamic pyruvate transaminase (SGPT): is increased

14. Provide client health teaching & discharge planning
concerning: a. b. Effects of MI healing process & treatment regimen Medication regimen including time name purpose, schedule, dosage, side effects

• • •

Serum glutamic oxal-acetic transaminase (SGOT): is increased

c. Dietary restrictions: low Na, low cholesterol, avoidance
of caffeine

2. Troponin Test: is increased
3. ECG tracing reveals • • ST segment elevation T wave inversion Widening of QRS complexes: indicates that there is arrhythmia in MI

d. Encourage client to take 20 – 30 cc/week of wine, whisky
and brandy: to induce vasodilation e. f. Avoidance of modifiable risk factors Prevent Complication

• •

Arrhythmia: caused by premature ventricular contraction Cardiogenic shock: late sign is oliguria Left Congestive Heart Failure Thrombophlebitis: homan’s sign Stroke / CVA Dressler’s Syndrome (Post MI Syndrome): client is resistant to pharmacological agents: administer 150,000-450,000 units of streptokinase as ordered

4. Serum Cholesterol & uric acid: are both increased 5. CBC: increased WBC
Nursing Intervention


Goal: Decrease myocardial oxygen demand

1. Decrease myocardial workload (rest heart)
• Establish a patent IV line Administer narcotic analgesic as ordered: Morphine Sulfate IV: provide pain relief (given IV because after an infarction there is poor peripheral perfusion & because serum enzyme would be affected by IM injection as ordered)

g.

Importance of participation in a progressive activity program

h. Resumption of ADL particularly sexual intercourse: is 4-6
weeks post cardiac rehab, post CABG & instruct to: • • Make sex as an appetizer rather than dessert Instruct client to assume a non weight bearing position

• • •

Side Effects: Respiratory Depression Antidote: Naloxone (Narcan) Side Effects of Naloxone Toxicity: is tremors

Client can resume sexual intercourse: if can climb or use the staircase

43

44
i. Need to report the ff s/sx: • • • • • • j. k. Increased persistent chest pain Dyspnea Weakness Fatigue Persistent palpitation Light headedness Predisposing Factors 1. 2. 3. 4. 5. 6. 7. S/sx 1. 2. 3. 4. Types of Heart Failure 1. 2. 3. Left Sided Heart Failure Right Sided Heart Failure High-Output Failure 5. 6. 7. 8. 9. Left Sided Heart Failure Anorexia Nausea Weight gain Neck / jugular vein distension Pitting edema Bounding pulse Hepatomegaly / Slenomegaly Cool extremities Ascites Right ventricular infarction Atherosclerotic heart disease Tricuspid valve stenosis Pulmonary embolism Related to COPD Pulmonic valve stenosis Left sided heart failure

Weakened right ventricle is unable to pump blood into he pulmonary system: systemic venous congestion occurs as pressure builds up

Enrollment of client in a cardiac rehabilitation program Strict compliance to mediation & importance of follow up care

Congestive Heart Failure • • Inability of the heart to pump an adequate supply of blood to meet the metabolic needs of the body Inability of the heart to pump blood towards systemic circulation

10. Jaundice 11. Pruritus 12. Esophageal varices Dx

Left ventricular damage causes blood to back up through the left atrium & into the pulmonary veins: Increased pressure causes transudation into interstitial tissues of the lungs which result pulmonary congestion.

1. Chest X-ray (CXR): reveals cardiomegaly 2. Central Venous Pressure (CVP): measure fluid status:
elevated

Predisposing Factors

1. 90% is mitral valve stenosis due to RHD: inflammation of
mitral valve due to invasion of Group A beta-hemolytic streptococcus 2. 3. 4. 5. S/sx 1. Dyspnea night due to difficulty of breathing Myocardial Infarction Ischemic heart disease Hypertension Aortic valve stenosis

• • •

Measure pressure in right atrium: 4-10 cm of water If CVP is less than 4 cm of water: Hypovolemic shock: increase IV flow rate If CVP is more than 10 cm of water: Hypervolemic shock: Administer loop diuretics as ordered Nursing Intervention: • When reading CVP patient should be flat on bed Upon insertion place client in trendelendberg position: to promote ventricular filling and prevent pulmonary embolism

2. Paroxysmal nocturnal dyspnea (PND): client is awakened at 3. Orthopnea: use 2-3 pillows when sleeping or place in high
fowlers 4. 5. 6. 7. 8. 9. Tiredness Muscle Weakness Productive cough with blood tinged sputum Tachycardia Frothy salivation Cyanosis

3. Echocardiography: reveals increased size of cardiac
chambers (cardiomyopathy)

4. Liver enzymes: SGPT & SGOT: is increased 5. ABG: decreased pO2
Medical Management 1. Determination & elimination / control of underlying cause

2. Drug therapy: digitalis preparations, diuretics, vasodilators 3. Sodium-restricted diet: to decrease fluid retention 4. If medical therapies unsuccessful: mechanical assist devices
(intra-aortic balloon pump), cardiac transplantation, or mechanical heart may be employed

10. Pallor 11. Rales / Crackles 12. Bronchial wheezing

13. Pulsus Alternans: weak pulse followed by strong bounding
pulse

5. Treatment for Left Sided Heart Failure Only:
M – Morphine SO4 A – Aminophylline D – Digitalis

14. PMI is displaced laterally: due to cardiomegaly 15. Possible S3: ventricular gallop
Dx

D – Diuretics

1. Chest X-ray (CXR): reveals cardiomegaly 2. Pulmonary Arterial Pressure (PAP): measures pressure in
right ventricle or cardiac status: increased

O – O2 G – Gases Nursing Intervention Goal: Increase cardiac contractility thereby increasing cardiac output of 3-6 L / min

3. Pulmonary Capillary Wedge Pressure (PCWP): measures end
systolic and dyastolic pressure: increased

4. Central Venous Pressure (CVP): indicates fluid or hydration
status

• •

Increase CVP: decreased flow rate of IV Decrease CVP: increased flow rate of IV

1. Monitor respiratory status & provide adequate ventilation
(when HF progress to pulmonary edema)

5. Swan-Ganz catheterization: cardiac catheterization 6. Echocardiography: shows increased sized of cardiac
chamber (cardiomyopathy): dependent on extent of heart failure

a. Administer O2 therapy: high inflow 3-4 L / min delivered
via nasal cannula

b. Maintain client in semi or high fowlers position:
maximize oxygenation by promoting lung expansion c. Monitor ABG

7. ABG: reveals PO2 is decreased (hypoxemia), PCO2 is
increased (respiratory acidosis) 2. Right Sided Heart Failure

d. Assess for breath sounds: noting any changes
Provide physical & emotional rest a. b. Constantly assess level of anxiety Maintain bed rest with limited activity

44

45
c. d. 3. a. Maintain quiet & relaxed environment Organized nursing care around rest periods Administer digitalis as ordered & monitor effects S/sx

1. Intermittent claudication: leg pain upon walking 2. Cold sensitivity & changes in skin color 1st white (pallor)
changing to blue (cyanosis) then red (rubor)

Increase cardiac output

• • •
b. c.

Cardiac glycosides: Digoxin (Lanoxin) Action: Increase force of cardiac contraction Contraindication: If heart rate is decreased do not give

3. Decreased or absent peripheral pulses (posterior tibial &
dorsalis pedis) 4. Trophic changes

5. Ulceration & Gangrene formation (advanced)
Dx

Monitor ECG & hemodynamic monitoring Administer vasodilators as ordered


d. 4. a.

Vasodilators: Nitroglycerine (NTG)

1. Oscillometry: may reveal decrease in peripheral pulse
volume

Monitor V/S Administer diuretics as ordered

Reduce / eliminate edema

2. Doppler (UTZ): reveals decrease blood flow to the affected
extremity


b. c. d. e. f. g. h. i.

Loop Diuretics: Lasix (Furosemide)

3. Angiography: reveals location & extent of obstructive
process Medical Management 1. Drug Therapy

Daily weight Maintain accurate I&O Assess for peripheral edema Measure abdominal girth daily Monitor electrolyte levels Monitor CVP & Swan-Ganz reading Provide Na restricted diet as ordered Provide meticulous skin care

a. Vasodilators: to improve arterial circulation
(effectiveness ?) • Papaverine Isoxsuprine HCL (Vasodilan) Nylidrin HCL (Arlidin) Nicotinyl Alcohol (Roniacol) Cyclandelate (Cyclospasmol) Tolazoline HCL (Priscoline)

• • • • •

5. If acute pulmonary edema occurs: For Left Sided Heart
Failure only a. Administer Narcotic Analgesic as ordered

• •
b.

Narcotic analgesic: Morphine SO4 Action: to allay anxiety & reduce preload & afterload

Administer Bronchodilator as ordered

b. Analgesic: to relieve ischemic pain c. Anti-coagulant: to prevent thrombus formation
2. Surgery a. b. c. Bypass Grafting Endarterectomy Balloon Catheter Dilation

• •
c.

Bronchodilators: Aminophylline IV Action: relieve bronchospasm, increase urinary output & increase cardiac output

Administer Anti-arrythmic as ordered

Anti-arrythmic: Lidocaine (Xylocane)

d. Lumbar Sympathectomy: to increase blood flow
e. Amputation: may be necessary

6. Assist in bloodless phlebotomy: rotating tourniquet, rotated
clockwise every 15 minutes: to promote decrease venous return or reducing preload 7. Provide client teaching & discharge planning concerning:

Nursing Intervention 1. Encourage a slow progressive physical activity • • 2. • • • 3. • 4. 5. Walking at least 2 times / day Out of bed at least 3-4 times / day

a. Need to monitor self daily for S/sx of Heart Failure (pedal
edema, weight gain, of 1-2 kg in a 2 day period, dyspnea, loss of appetite, cough)

Administer medications as ordered Analgesics Vasodilators Anti-coagulants

b. Medication regimen including name, purpose, dosage,
frequency & side effects (digitalis, diuretics)

c. Prescribe diet plan (low Na, cholesterol, caffeine: small
frequent meals) d. e. Need to avoid fatigue & plan for rest periods Prevent complications • • • • • f. Arrythmia Shock Right ventricular hypertrophy MI Thrombophlebitis

Foot care management: Need to avoid trauma to the affected extreminty

Importance of stop smoking Need to maintain warmth especially in cold weather

6. Prepare client for surgery: below knee amputation (BKA)
7. Importance of follow-up care

Raynaud’s Phenomenon Intermittent episodes of arterial spasm most frequently involving the fingers or digits of the hands

Importance of follow-up care

Peripheral Vascular Disorder Predisposing Factors Arterial Ulcer

1. High risk group: female between the teenage years & age
40 years old & above 2. 3. Smoking Collagen diseases

1. Thromboangiitis Obliterans (Buerger’s Disease)
2. Raynaud’s Phenomenon

Venous Ulcer 1. Varicose Veins 4.

a. Systemic Lupus Erythematosus (SLE): butterfly rash
b. a. Rheumatoid Arthritis Piano playing Excessive typing Operating chainsaw Direct hand trauma b. c. S/sx 1. 2. 3. Coldness Numbness Tingling in one or more digits upset & Tobacco use

2. Thrombophlebitis (deep vein thrombosis)
Thromboangiitis Obliterans (Buerger’s Disease) • • Acute inflammatory disorder affecting the small / medium sized arteries & veins of the lower extremities Occurs as focal, obstructive, process; result in occlusion of a vessel with a subsequent development of collateral circulation Predisposing Factors 1. 2. High risk groups - men 25-40 years old High incident among smokers

4. Pain: usually precipitated by exposure to cold, Emotional 5. Intermittent color changes: pallor (white), cyanosis (blue),
rubor (red)

45

46 6. Small ulceration & gangrene a tips of digits (advance)
Dx 7. • Assess for increase of bleeding particularly in groin area Provide client teaching & discharge planning

1. Doppler UTZ: decrease blood flow to the affected extremity 2. Angiography: reveals site & extent of malocclusion
Thrombophlebitis (Deep vein thrombosis) Medical Management 1. Administer medications as ordered a. Catecholamine-depliting antihypertinsive drugs: • • b. 1. 2. 3. Reserpine Guanethidine Monosulfate (Ismelin) • • •

Inflammation of the vessel wall with formation of clot (thrombus), may affect superficial or deep veins Inflammation of the veins with thrombus formation Most frequent veins affected are the saphenous, femoral & popliteal Can result in damage to the surrounding tissue, ischemia & necrosis

Vasodilators

Nursing Intervention Importance of stop smoking Need to maintain warmth especially in cold weather Need to wear gloves when handling cold object / opening a freezer or refrigerator door

Predisposing Factors 1. 2. 3. 4. Obesity Smoking Related to pregnancy Severe anemia

5. Prolong use of oral contraceptives: promotes lipolysis
Varicose Veins • Dilated veins that occurs most often in the lower extremities & trunk. As the vessel dilates the valves become stretched & incompetent with result venous pooling / edema 6. 7. 8. 9. Prolonged immobility Trauma Dehydration Sepsis

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

10. Congestive heart failure 11. Myocardial infarction

12. Post-op complication: surgery 13. Venous cannulation: insertion of various cardiac catheter
14. Increase in saturated fats in the diet.

Predisposing Factors 1. 2. 3. 4. 5. 6. 7. S/sx Hereditary Congenital weakness of the veins Thrombophlebitis Cardiac disorder Pregnancy Obesity Prolonged standing or sitting 3. S/sx 1. Pain in the affected extremity course of the vein Deep vein: • • • Swelling Venous distention of limb Tenderness over involved vein Positive homan’s sign: pain at the calf or leg muscle upon dorsi flexion of the foot • Dx Cyanosis

2. Superficial vein: Tenderness, redness induration along

1. Pain after prolonged standing: relieved by elevation
2. 3. 4. Dx 1. Venography seconds Swollen dilated tortuous skin veins Warm to touch Heaviness in legs

1. Venography (Phlebography): increased uptake of radioactive
material

2. Trendelenburg Test: veins distends quickly in less than 35 3. Doppler Ultrasound: decreased or no blood flow heard after
calf or thigh compression Medical Management

2. Doppler ultrasonography: impairment of blood flow ahead of
thrombus

3. Venous pressure measurement: high in affected limb until
collateral circulation is developed Medical Management 1. Anti-coagulant therapy a. Heparin

1. Vein Ligation: involves ligating the saphenous vein where it
joins the femoral vein & stripping the saphenous vein system fro groin to ankles

• •

Action: block conversion of prothrombin to thrombin & reduces formation or extension of thrombus Side effects: • Spontaneous bleeding Injection site reaction Ecchymoses Tissue irritation & sloughing Reversible transient alopecia Cyanosis Pan in the arms or legs Thrombocytopenia

2. Sclerotherapy: can recur & only done in spider web
varicosities & danger of thrombosis (2-3 years for embolism) Nursing Intervention

• • • • • • •

1. Elevate legs above heart level: to promote increased venous
return by placing 2-3 pillows under the legs 2. 3. 4. 5. Measure the circumference of ankle & calf muscle daily: to determine if swollen Apply anti-embolic / knee-length stockings Provide adequate rest Administer medications as ordered

a. Analgesics: for pain 6. Prepare client for vein ligation if necessary
a. Provide routine pre-op care: usually OPD

b. Warfarin (Coumadin) •
• Action: block prothrombin synthesis by interfering with vit. K synthesis Side effects:

b. In addition to routine post-op care: •
• • Keep affected extremity elevated above the level of the heart: to prevent edema Apply elastic bandage & stockings which should be removed every 8 hours for short periods & reapplied Assist out of bed within 24 hours ensuring the elastic stockings is applied

GI: • • • • Anorexia N/V Diarrhea Stomatitis

Hypersensitivity:

46

47
• • • • Dermatitis Urticaria Pruritus Fever • • Swim several times weekly Gradually increased walking distance

g. Importance of weight reduction: if obese
h. Monitor for signs of complications a. Pulmonary Embolism • • • • • • Sudden sharp chest pain Unexplained dyspnea Tachycardia Palpitations Diaphoresis Restlessness

Other: • • • Transient hair loss Burning sensation of feet Bleeding complication

2.

Surgery a. Vein ligation & stripping iliofemoral region

b. Venous thrombectomy: removal of cloth in the c. Plication of the inferior vena cava: insertion of an
umbrella-like prosthesis into the lumen of the vena cava: to filter incoming cloth Nursing Intervention

Overview of Anatomy & Physiology of the Respiratory System Upper Respiratory System Structure of the respiratory system, primarily an air conduction system, include the nose, pharynx & larynx. Air is filtered warmed & humidified in the upper airway before passing to lower airway. Nose

1. Elevate legs above heart level: to promote increase venous
return & decreased edema

2. Apply warm moist pack: to reduce lymphatic congestion
3. Administer anti-coagulant as ordered: a. Heparin

1. External nose is a frame work of bone & cartilage , internally
divided into two passages or nares (nasal cavity) by the septum: air enters the system through the nares


• •

Monitor PTT: dosage should be adjusted to keep PTT between 1.5-2.5 times normal control level Use infusion pump to administer heparin Ensure proper injection technique • Use 26 or 27 gauge syringe with ½-5/8 inch needle, inject into fatty layer of abdomen above iliac crest • Avoid injecting within 2 inches of umbilicus Insert needle at 45-90o to skin Do not withdraw plunger to assess blood return Apply gentle pressure after removal of needle: avoid massage 3.

2. The septum is covered with mucous membrane, where the
olfactory receptors are located. Turbinates, located internally, assist in warming & moistening the air The major function of the nose are warming, moistening & filtering air.

4. Consist of anastomosis of capillaries known as Keissel Rach
Plexus: the site of nose bleeding Pharynx 1. 2. 3. A muscular passageway commonly called the throat Air passes through the nose to the pharynx Serves as a muscular passageway for both food and air


• •

Assess for increased bleeding tendencies (hematuria, hematemesis, bleeding gums, petechiae of soft palate, conjunctiva retina, ecchymoses, epistaxis, bloody spumtum, melena) & instruct the client to observe for & report these

Composed of three section

1. Nasopharynx: located above the soft palate of the mouth,
contains the adenoids & opening to the eustachian tubes


Have antidote (Protamine Sulfate) available Instruct the client to avoid aspirin, antihistamines 7 cough preparations containing glyceryl guaiacolate & obtain MD permission before using other OTC drugs

2. Oropharynx: located directly behind the mouth & tongue,
contains the palatine tonsils; air & food enter the body through oropharynx

3. Laryngopharynx: extends from the epiglotitis to the sixth
cervical level Larynx

b. Warfarin (Coumadin) •
Assess PT daily: dosage should be adjusted to maintain PT at 1.5-2.5 times normal control level; INR of 2

1. Sometimes called “voice Box” connects upper & lower
airways 2. 3. 4. Framework is formed by the hyoid bone, epiglotitis & thyroid, cricoid & arytenoids cartilages Larynx opens to allow respiration & closes to prevent aspiration when food passes through the pharynx Vocal cords of larynx permit speech & are involved in the cough reflex


Obtain careful medication history (there are many drug-drug interaction) Advise client to withhold dose & notify MD immediately if bleeding occur

• •

Have antidote (Vitamin K) available Alert client to factors that may affect the anticoagulant response (high-fat diet or sudden increased in vit. K-rich food)

5. For phonation (voice production)
Glottis 1. 2. 3. 4. 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 Lower Respiratory System Consist of trachea, bronchi & branches, & the lungs & associated structures For gas exchange Trachea AKA “Windpipe” Air move from the pharynx to larynx to trachea (length 1113 cm, diameter 1.5-2.5 cm in adult) Extend from the larynx to the second costal cartilage, where it bifurcates & is supported by 16-20 C-shaped cartilage rings

• 4.

Instruct the client to wear medic-alert bracelet

Assess V/S every 4 hours pulmonary embolism

5. Monitor chest pain or shortness of breath: possible
6. 7. Measure thigh, calves, ankles & instep every morning Provide client teaching & discharge planning a. Need to avoid standing, sitting for long period, constrictive clothing, crossing legs at the knee, smoking, oral contraceptives

b. Importance of adequate hydration: to prevent
hypercoagubility c. d. e. f. Use elastic stockings when ambulatory Importance of planned rest periods with elevation of the feet Drug regimen Plan for exercise / activity • Begin with dorsiflexion of the feet while sitting or lying down

47

48

The area where the trachea divides into two branches is called the carina Consist of cartilaginous rings Serves as passageway of air going to the lungs Site of tracheostomy Bronchi Right main bronchus Larger & straighter than the left Divided into three lobar branches (upper, middle & lower bronchi) to supply the three lobes of right lung Left main bronchus Divides into the upper & lower lobar bronchi to supply the left lobes Bronchioles In the bronchioles, airway patency is primarily dependent upon elastic recoil formed by network of smooth muscles The tracheobronchial tree ends at the terminal bronchials. Distal to the terminal bronchioles the major function is no longer air conduction but gas exchange between blood & alveolar air The respiratory bronchioles serves as the transition to the alveolar epithelium

Form the last part of the airway Functionally the same as the alveolar ducts they are surrounded by alveoli & are responsible for the 65% of the alveolar gas exchange Type II Cells of Alveoli Secretes surfactant Decrease surface tension Prevent collapse of alveoli Composed of lecithin and spingomyelin Lecitin / Spingomyelin ratio: to determine lung maturity Normal Lecitin / Spingomyelin 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 premature Pulmonary Circulation Provides for reoxygenation of blood & release of CO2 Gas transfers occurs in the pulmonary capillary bed Respiratory Distress Syndrome Decrease oxygen stimulates breathing Increase carbon dioxide is a powerful stimulant for breathing Pneumonia

Lungs Right lung (consist of 3 lobes, 10 segments) Left lung (consist of 2 lobes, 8 segments) Main organ of respiration, lie within the thoracic cavity on either side of the heart Broad area of lungs resting on diaphragm is called the base & the narrow superior portion called the apex Pleura Serous membranes covering the lungs, continuous with the parietal pleura that lines the chest wall Parietal Pleura Lines the chest walls & secretes small amounts of lubricating fluid into the intrapleural space (space between the parietal pleura & visceral pleura) this fluid holds the lungs & chest wall together as a single unit while allowing them to move separately Chest Wall Includes the ribs cage, intercostal muscles & diaphragm Chest is a C shaped & supported by 12 pairs of ribs & costal cartilages, the ribs have several attached muscles Contraction of the external intercostal muscles raises the ribs cage during inspiration & helps increase the size of the thoracic cavity The internal intercoastal muscles tends to pull ribs down & in & play a role in forced expiration Diaphragm A major muscle of ventilation (the exchange of air between the atmosphere & the alveoli). Alveoli Are functional cellular unit of the lungs; about half arise directly from alveolar ducts & are responsible for about 35% of alveolar gas exchange Produces surfactants Site of gas exchange (CO2 and O2) Diffusion (Dalton’s law of partial pressure of gases) Surfactant A phospholipids substance found in the fluid lining the alveolar epithelium Reduces surface tension & increase stability of the alveoli & prevents their collapse Dx Alveolar Ducts Arises from the respiratory bronchioles & lead to the alveoli Alveolar Sac

Inflammation of the alveolar spaces of the lungs, resulting in consolidation of lung tissue as the alveoli fill with exudates Inflammation of the lung parenchyma leading to pulmonary consolidation as the alveoli is filled with exudates Etiologic Agents

1. Streptococcus Pneumonae: causing pneumococal
pneumonia

2. Hemophylus Influenzae: causing broncho pneumonia
3. 4. 5. 6. Diplococcus Pneumoniae Klebsella Pneumoniae Escherichia Pneumoniae Pseudomonas

High Risk Groups 1. 2. Children below 5 years old Elderly

Predisposing Factors 1. 2. 3. Smoking Air pollution Immuno compromised hypostatic pneumonia

4. Related to prolonged immobility (CVA clients): causing 5. Aspiration of food: causing aspiration pneumonia
S/sx 1. 2. 3. 4. 5. 6. 7. 8. Productive cough with greenish to rusty sputum Rapid shallow respiration with expiratory grunt Nasal flaring Intercostal rib retraction Use of accessory muscles of respiration Dullness to flatness upon auscultation Possible pleural friction rub High-pitched bronchial breath sound

9. Rales / crackles (early) progressing to coarse (later)
10. Fever 11. Chills 12. Anorexia 13. General body malaise 14. Weight loss 15. Bronchial wheezing 16. Cyanosis 17. Chest pain

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

1. Sputum Gram Staining & Culture Sensitivity: positive to
cultured microorganisms

2. Chest x-ray: reveals pulmonary consolidation over affected
area

48

49 3. ABG analysis: reveals decrease PO2 4. CBC: reveals increase WBC, erythrocyte sedimentation rate
is increased Nursing Intervention 1. Facilitate adequate ventilation Administer O2 as needed & assess its effectiveness: low inflow Place client semi fowlers position Turn & reposition frequently client who are immobilized Administer analgesic as ordered: DOC: codeine: to relieve pain associated with breathing Auscultate breath sound every 2-4 hour Monitor ABG 2. Facilitate removal of secretions General hydration Deep breathing & coughing exercise: tends to promote expectoration Tracheobronchial suctioning as needed Administer Mucolytic or Expectorant as ordered Aerosol treatment via nebulizer Humidification of inhaled air Chest physiotherapy (Postural Drainage): tends to promote expectoration S/sx 1. 2. 3. 4. 5. 6. 7. 8. Dx Similar to PTB or Pneumonia Productive cough Fever, chills, anorexia, general body malaise Chest and joint pains Dyspnea Cyanosis Hemoptysis Sometimes asymptomatic Histoplasmosis Systemic fungal disease caused by inhalation of dust contaminated by histoplasma capsulatum which is transmitted to bird manure Acute fungal infection caused by inhalation of contaminated dust or particles with histoplasma capsulatum derived from birds manure h. f. g.

Chills Increased pain Difficulty in breathing Weight loss Persistent fatigue Avoid smoking Prevent complications Atelectasis Meningitis Importance of follow up care

3. Observe color characteristics of sputum & report any
changes: encourage client to perform good oral hygiene after expectoration 4. Provide adequate rest & relief control of pain Enforce CBR with limited activity Limit visits & minimized conversation Plan for uninterrupted rest periods Maintain pleasant & restful environment 5. Administer antibiotic as ordered: monitor effects & possible toxicity Broad Spectrum Antibiotic Penicillin Tetracycline Microlides (Zethromax) Azethromycin: Side Effect: Ototoxicity

1. Chest X-ray: often appears similar to PTB 2. Histoplasmin Skin Test: positive 3. ABG analysis: PO2 decrease
Medical Management

1. Anti-fungal Agent: Amphotericin B (Fungizone)
Very toxic: toxicity includes anorexia, chills, fever, headaches & renal failure Acetaminophen, Benadryl & Steroids is given with Amphotericin B: to prevent reaction Nursing Intervention 1. 2. 3. 4. Monitor respiratory status Enforce CBR Administer oxygen inhalation Administer medications as ordered

6. Prevent transmission: respiratory isolation client with
staphylococcal pneumonia 7. Control fever & chills: Monitor temperature A Administer antipyretic as ordered Increased fluid intake Provide frequent clothing & linen changing

a. Antifungal: Amphotericin B (Fungizone)
Observe severe side effects: Fever: acetaminophen given prophylactically Anaphylactic reaction: Benadryl & Steroids given

8. Assist in postural drainage: uses gravity & various position
to stimulate the movement of secretions Nursing Management for Postural Drainage

prophylactically Abnormal renal function with hypokalemia & azotemia: Nephrotoxicity, check for BUN and Creatinine, Hypokalemia 5. 6. Force fluids to liquefy secretions Nebulize & suction as needed

a. Best done before meals or 2-3 hours: to prevent gastro
esophageal reflux b. c. d. e. f. g. Monitor vital signs Encourage client deep breathing exercises Administer bronchodilators 20-30 minutes before procedure Stop if client cannot tolerate procedure Provide oral care after procedure Contraindicated with Unstable V/S Hemoptysis Clients with increase intra ocular pressure (Normal IOP 12 – 21 mmHg) Increase ICP 9. Provide increase CHO, calories, CHON & vitamin C a. b. c. d. e. Medication regimen / antibiotic therapy Need for adequate rest, limited activity, good nutrition, with adequate fluid intake & good ventilation Need to continue deep breathing & coughing exercise for at least 6-8 weeks after discharge Availability of vaccines Need to report S/sx of respiratory infection Persistent or recurrent fever Changes in characteristics color of sputum 10. Provide client teaching & discharge planning Chronic Bronchitis

7. Prevent complications: bronchiectasis
8. Prevent the spread of infection by spraying of breeding places Chronic Obstructive Pulmonary Disease (COPD)

Excessive production of mucus in the bronchi with accompanying persistent cough Characteristic include hypertrophy / hyperplasia of the mucus secreting gland in the bronchi, decreased ciliary activity, chronic inflammation & narrowing of the airway Inflammation of bronchus resulting to hypertrophy or hyperplasia of goblet mucous producing cells leading to narrowing of smaller airways AKA “Blue Bloaters” Predisposing Factors 1. 2. Smoking Air pollution

49

50 c. Mucomysts (acetylceisteine): at bed side put suction
S/sx machine d. e. 2. 3. 4. 1. Mucolytics / expectorants Anti histamine Dyspnea on exertion Use of accessory muscle of respiration Scattered rales / rhonchi Feeling of gastric fullness Slight Cyanosis Distended neck veins Ankle edema Prolonged expiratory grunt 3. 4. 5. 6. 7. Dx 1. ABG analysis: reveals PO2 decrease (hypoxemia): causing cyanosis, PCO2 increase Bronchial Asthma Immunologic / allergic reaction results in histamine release which produces three mainairway response: Edema of mucus membrane, Spasm of the smooth muscle of bronchi & bronchioles, Accumulation of tenacious secretions Reversible inflammatory lung condition due to hypersensitivity to allergens leading to narrowing of smaller airways Predisposing Factors (Depending on Types) d.

1. Productive copious cough (consistent to all COPD)
2. 3. 4. 5. 6. 7. 8. 9.

Physical Therapy Hyposensitization Execise Enforce CBR distress Administer medications as ordered Force fluids 2-3 L/day Semi fowlers position: to promote lung expansion Nebulize & suction when needed Provide client health teachings and discharge planning concerning a. b. Avoidance of precipitating factor Prevent complications Emphysema Status Asthmaticus: severe attack of asthma which cause poor controlled asthma DOC: Epinephrine Steroids Bronchodilators

Nursing Intervention

2. O2 inhalation: low flow 2-3 L/min: to prevent respiratory

10. Anorexia and generalized body malaise 11. Pulmonary hypertension a. Leading to peripheral edema

b. Cor Pulmonale (right ventricular hypertrophy)

c. Regular adherence to medications: to prevent
development of status asthmaticus Importance of follow up care

Bronchiectasis Permanent abnormal dilation of the bronchi with destruction of muscular & elastic structure of the bronchial wall Abnormal permanent dilation of bronchus leading to destruction of muscular and elastic tissues of alveoli Predisposing Factors 1. 2. 3. Caused by bacterial infection Recurrent lower respiratory tract infections Chest trauma

1. Extrinsic Asthma (Atopic / Allergic)
Causes Pollen Dust Fumes Smoke Gases Danders Furs Lints

4. Congenital defects (altered bronchial structure) 5. Related to presence of tumor (lung tumor)
6. Sx 1. 2. 3. 4. Productive cough with mucopurulent sputum Dyspnea in exertion Cyanosis Anorexia & generalized body malaise Thick tenacious secretion

2. Intrinsic Asthma (Non atopic / Non allergic)
Causes Hereditary Drugs (aspirin, penicillin, beta blocker) Foods (seafoods, eggs, milk, chocolates, chicken) Food additives (nitrates) Sudden change in temperature, air pressure and humidity Physical and emotional stress

5. Hemoptysis (only COPD with sign)
6. 7. Dx Wheezing Weight loss

3. Mixed Type: 90 – 95%
S/sx 1. 2. 3. 4. 5. 6. 7. Dx 1. Pulmonary Function Test Incentive spirometer: reveals decrease vital lung capacity Cough that is non productive Dyspnea Wheezing on expiration Cyanosis Mild Stress or apprehension Tachycardia, palpitations Diaphoresis

1. CBC: elevation in WBC 2. ABG: PO2 decrease 3. Bronchoscopy: reveals sources & sites of secretion: direct
visualization of bronchus using fiberscope Nursing Management before Bronchoscopy 1. 2. 3. Secure inform consent and explain procedure to client Maintain NPO 6-8 hours prior to procedure Monitor vital signs & breath sound Post Bronchoscopy 1. 2. 3. Feeding initiated upon return of gag reflex Avoid talking, coughing and smoking, may cause irritation Monitor for signs of gross set

2. ABG analysis: PO2 decrease
3. Before ABG test for positive Allens Test, apply direct pressure to ulnar & radial artery to determine presence of collateral circulation Medical Management 1. Drug Therapy

4. Monitor for signs of laryngeal spasm: prepare tracheostomy

Medical Management
1. Surgery Pneumonectomy: 1 lung is removed & position on affected side Segmental Wedge Lobectomy: promote re-expansion of lungs Unaffected lobectomy: facilitate drainage

a. Bronchodilators: given via inhalation or metered dose
inhaler or MDI for 5 minutes

b. Steroids: decrease inflammation: given 10 min after
bronchodilator

50

51 4. Facilitate removal of secretions:
Emphysema Enlargement & destruction of the alveolar, bronchial & bronchiolar tissue with resultant loss of recoil, air tapping, thoracic overdistension, sputum accumulation & loss of diaphragmatic muscle tone These changes cause a state of CO2 retention, hypoxia & respiratory acidosis Irreversible terminal stage of COPD characterized by Inelasticity of alveoli Air trapping Maldistribution of gases Overdistention of thoracic cavity (barrel chest) Predisposing Factors 1. Smoking 7. 8. 9. e. 5. a. b. c. d. a. b. Force fluids at least 3 L/day Provide chest physiotherapy, coughing & deep breathing Nebulize & suction when needed Provide oral hygiene after expectoration of sputum Position client to semi or high fowlers Instruct the client diaphragmatic muscles to breathe abdomen to help produce more expulsive cough)

Improve ventilation

c. Encourage productive cough after all treatment (splint d. Employ pursed-lip breathing techniques (prolonged slow
relaxed expiration against pursed lips) Institute pulmonary toilet

6. Institute PEEP (positive end expiratory pressure) in
mechanical ventilation promotes maximum alveolar lung expansion Provide comfortable & humid environment Provide high carbohydrates, protein, calories, vitamins and minerals Provide client teachings and discharge planning concerning a. Prevention of recurrent infection Avoid crowds & individual with known infection Adhere to high CHON, CHO & increased vit C diet Productive cough Sputum production Anorexia & generalized body malaise Weight loss b. Received immunization for influenza & pneumonia Report changes in characteristic & color of sputum immediately Report of worsening of symptoms (increased tightness of chest, fatigue, increased dyspnea) Control of environment Use home humidifier at 30-50% Wear scarf over nose & mouth in cold weather: to prevent bronchospasm Avoid smoking & contact with environmental smoke Avoid abrupt change in temperature c. Avoidance of inhaled irritants Stay indoor: if pollution level is high Use air conditioner with efficiency particulate air filter: to remove particles from air d. Increase activity tolerance Start with mild exercise: such as walking & gradual increase in amount & duration Used breathing techniques: (pursed lip, diaphragmatic) during activities / exercise: to control Dx breathing

2. Inhaled irritants: air pollution
3. 4. Allergy or allergic factor High risk: elderly release elastase for recoil of alveoli S/sx 1. 2. 3. 4.

5. Hereditary: it involves deficiency of Alpha 1 anti-trypsin: to

5. Flaring of nostrils (alai nares)
6. 7. 8. 9. Use of accessory muscles Dyspnea at rest Increased rate & depth of breathing Decrease respiratory excursion

10. Resonance to hyper resonance 11. Decrease or diminished breath sounds with prolong expiration 12. Decrease tactile fremitus 13. Prolong expiratory grunt 14. Rales or rhonchi 15. Bronchial wheezing 16. Barrel chest

17. Purse lip breathing: to eliminates excess CO2 (compensatory
mechanism)

1. Pulmonary Function Test: reveals decrease vital lung
capacity

Have O2 available as needed to assist with activities Plan activities that require low amount of energy Plan rest period before & after activities e. Prevent complications Atelectasis Cor Pulmonale: R ventricular hypertrophy CO2 narcosis: may lead to coma Pneumothorax: air in the pleural space f. g. Strict compliance to medication Importance of follow up care

2. ABG analysis: reveals
Panlobular/centrilobular Decrease PO2 (hypoxemia leading to chronic bronchitis, “Blue Bloaters”) Decrease ph Increase PCO2 Respiratory acidosis Panacinar/centriacinar Increase PO2 (hyperaxemia, “Pink Puffers”) Decrease PCO2 Increase ph Respiratory alkalosis Nursing Intervention 1. 2. 3. Enforce CBR Administer oxygen inhalation via low inflow Administer medications as ordered

Oncology Nursing Pathophysiology & Etiology of Cancer Evolution of Cancer Cells • All cells constantly change through growth, degeneration, repair, & adaptation. Normal cells must divide & multiply to meet the needs of the organism as a whole, & this cycle of cell growth & destruction is an integral part of life processes. The activities of the normal cell in the human body are all coordinated to meet the needs of the organism as a whole, but when the regulatory control mechanisms of normal fail, & growth continues in excess of the body needs, neoplasia results.

a. Bronchodilators: used to treat bronchospam
Aminophylline Isoproterenol (Isuprel) Terbutalin (Brethine) Metaproterenol (Alupent) Theophylline Isoetharine (Bronkosol) b. Corticosteroids: Prednisone

The term neoplasia refers to both benign & malignant growths, but malignant cells behave very differently from normal cells & have special features characteristics of the cancer process.

Since the growth control mechanism of normal cells is not entirely understood, it is not clear what allows the uncontrolled growth, therefore no definitive cure has been found.

c. Anti-microbial / Antibiotics: to treat bacterial infection
Tetracycline Ampicilline d. Mucolytics / expectorants

51

52
Characteristics of Malignant Cells • Cancer cells are mutated stem cells that have undergone structural changes so that they are unable to perform the normal functions of specialized tissues. • They may function is a disorderly way to crease normal function completely, only functioning for their own survival & growth. • The most undifferentiated cells are also called anaplastic.

• •
• • Client Factors 1.

Probably normal (slight changes) Doubtful (more severe changes) Probably cancer or precancerous Definitely cancer

Seven warning signs of cancer

2. BSE – breast self – examination
3. 4. 5. 6. 7. 8. Importance of retal exam for those over age 40 Hazards of smoking Oral self – examination as well as annual exam of mouth & teeth Hazards of excess sun exposure Importance of pap smear P.E. with lab work – up: every 3 years ages 20-40; yearly for age 40 & over

Rate of Growth • • • Cancer cells have uncontrolled growth or cell division Rate at which a tumor grows involves both increased cell division & increased survival time of cells. Malignant cells do not form orderly layers, but pile on top of each other to eventually form tumors. Pre-disposing Factors

9. TSE – testicular self – examination •
Testicular Cancer i. • Most common cancer in men between the age of 15 & 34 Warning signs that men should look for: i. ii. iii. iv. v. vi. vii. Epstein Barr Virus, Human 7 Warning Signs of Cancer C: change in bowel or bladder habits A: a sore that doesn’t heal U: unusual bleeding or discharge T: thickening of lump in breast or elsewhere I: indigestion or dysphagia O: obvious change in wart or mole N: nagging cough or hoarseness Treatment of Cancer Therapeutic Modality dyes, alkylating stilbestol, Chemotherapy • • Ability of the drug to kill cancer cells; normal cells may also be damaged, producing side effects. Different drug act on tumor cell in different stages of the cell growth cycle. Types of Chemotherapeutic Drugs Painless swelling Feeling of heaviness Hard lump (size of a pea) Sudden collection fluid in the scrotum Dull ache in the lower abdomen or in the groin Pain in the testicle or in the scrotum Enlargement breasts or tenderness of the

G – Genetics • • Some cancers shows familial pattern Maybe caused by inherited genetics defects

I – Immunologic • • Failure of the immune system to respond & eradicate cancer cells Immunosuppressed individuals are more susceptible to cancer

V – Viral o o o Viruses have been shown to be the cause of certain tumors in animals Viruses ( HTLV-I, Papilloma Virus) linked to human tumors Oncovirus (RNA – Type Viruses) thought to be culprit

E – Environmental o o Majority (over 80%) of human cancer related to environmental carcinogens Types: Physical • • Radiation: X – ray, radium, nuclear explosion & waste, UV Trauma or chronic irritation

Chemical • Nitrates, & food additives, polycyclic hydrocarbons, agents • • • Classification of Cancer Tissue Typing: Drugs: urethane Cigarette smoke hormones arsenicals,

Carcinoma – arises from surface, glandular, or parenchymal epithelium

1. Antimetabolites
o 2. 3. Foster cancer cell death by interfering with cellular metabolic process. Alkylating Agent o o o 4. act with DNA to hinder cell growth & division. obtained from periwinkle plant. makes the host’s body a less favorable environment for the growth of cancer cells. Antitumor Antibiotics o 5. affect RNA to make environment less favorable for cancer growth. Steroids & Sex Hormones o alter the endocrine environment to make it less conducive to growth of cancer cells. Major Side Effects & Nursing Intervention A. GI System • Nausea & Vomiting o o o Administer antiemetics routinely q 4-6 hrs as well as prophylactically before chemotherapy is initiated. Withhold food/fluid 4-6 hrs before chemotherapy Provide bland food in small amounts after treatment Plant Alkaloids

1. Squamous Cell Carcinoma – surface epithelium 2. Adenocarcinoma – glandular or parenchymal tissue • • • •
Sarcoma – arises from connective tissue Leukemia – from blood Lymphoma – from lymph glands Multiple Myeloma – from bone marrow

Stages of Tumor Growth A. Staging System:

TNM System: uses letters & numbers to designate the extent of tumors

o o o •

T– stands for primary growth; 1-4 with increasing size; T1S indicates carcinoma in situ N – stands for lymph nodes involvement: 0-4 indicates progressively advancing nodal disease M – stands for metastasis; 0 indicates no distant metastases, 1 indicates presence of metastases

Stages 0 – IV: all cancers divided into five stages incorporating size, nodal involvement & spread

B. Cytologic Diagnosis of Cancer

1. Involves in the study of shed cells (ex. Pap smear)
2. Classified by degree of cellular abnormality • Normal

52

53
• Diarrhea o o o o Administer antidiarrheals. Maintain good perineal care. Give clear liquids as tolerated. Monitor K, Na, Cl levels. Radiation Therapy • • • Uses ionizing radiation to kill or limit the growth of cancer cells, maybe internal or external. It not only injured cell membrane but destroy & alter DNA so that the cell cannot reproduce. Effects cannot be limited to cancer cells only; all exposed cells including normal cells will be injured causing side effects. • • Plant alkaloids (vincristine) cause neurologic damage with repeated doses Peripheral neuropathies, hearing loss, loss of deep tendon reflex, & paralytic ileus may occur.

Stomatitis (mouth sore) o o o Provide & teach the client good oral hygiene, including avoidance of commercial mouthwashes. Rinse with viscous lidocaine before meals to provide analgesic effect. Perform a cleansing rinse with plain H2O or dilute a H2O soluble lubricant such as hydrogen peroxide after meal. o o Apply H2O lubricant such as K-Y jelly to lubricate cracked lips. Advice client to suck on Popsicles or ice chips to provide moisture.

Localized effects are related to the area of the body being treated; generalized effects maybe related to cellular breakdown products.

Types of Energy Emitted


B. Hematologic System • Thrombocytopenia o o o o o o Avoid bumping or bruising the skin. Protect client from physical injury. Avoid aspirin or aspirin products. Avoid giving IM injections. Monitor blood counts carefully. Assess for signs of increase bleeding tendencies (epistaxis, petechiae, ecchymoses)

Alpha – particles cannot passed through skin, rarely used. Beta – particle cannot passed through skin, more

penetrating than alpha, generally emitted from radioactive isotopes, used for internal source.

Gamma – penetrate more deeper areas of the body, most common form of external radiotherapy (ex. Electromagnetic or X-ray)

Methods of Delivery

• •

External Radiation Therapy – beams high energy rays directly to the affected area. Ex. Cobalt therapy Internal Radiation Therapy – radioactive material is injected or implanted in the client’s body for designated period of time.

Leukopenia o o o o Use careful handwashing technique. Maintain reverse isolation if WBC count drops below 1000/mm Assess for signs of respiratory infection Avoid crowds/persons with known infection

o

Sealed Implants – a radioisotope enclosed in a container so it does not circulate in the body; client’s body fluids should not be contaminated.

o

Unsealed source – a radioisotope that is not encased in a container & does circulate in the body & contaminate body fluids.

Anemia o o o o Provide adequate rest period Monitor hemoglobin & hematocrit Protect client from injury Administer O2 if needed

Factors Controlling Exposure

Half-life – time required for half of radioactive atoms to decay. 1. 2. Each radioisotope has different half-life. At the end of half-life the danger from exposure decreases.

C. Integumentary System


• Alopecia o o o Explain that hair loss is not permanent Offer support & encouragement Scalp tourniquets or scalp hypothermia via ice pack may be ordered to minimize hair loss with some agent o Advice client to obtain wig before initiating treatment D. Renal System

Time – the shorter the duration the less the exposure. Distance – the greater the distance from the radiation source the less the exposure.

• •

Shielding – all radiation can be blocked; rubber gloves for alpha & usually beta rays; thick lead or concrete stop gamma rays.

Side Effects of Radiation Therapy & Nursing Intervention A. Skin - itching, redness, burning, oozing, sloughing. • • Keep skin free from foreign substances. Avoid use of medicated solution, ointment, or powders that contain heavy metals such as zinc oxide.

Encourage fluid & frequent voiding to prevent accumulation of metabolites in bladder; R: may cause direct damage to kidney by excretion of metabolites.

• • •
• •

Avoid pressure, trauma, infection to skin; use bed cradle. Wash affected areas with plain H2O & pat dry; avoid soap. Use cornstarch, olive oil for itching; avoid talcum powder. If sloughing occurs, use sterile dressing with micropore tape Avoid exposing skin to heat, cold, or sunlight & avoid constricting irritating clothing.

Increased excretion of uric acid may damage kidney Administer allopurinol (Zyloprim) as ordered; R: to prevent uric acid formation; encourage fluids when administering allopurinol

B. Anorexia, N/V E. Reproductive System • • • Damage may occur to both men & women resulting infertility &/or mutagenic damage to chromosomes Banking sperm often recommended for men before chemotherapy Clients & partners advised to use reliable methods of contraception during chemotherapy F. Neurologic System • • • • • • • • Arrange meal time so they do not directly precede or follow therapy. Encourage bland foods. Provide small attractive meals. Avoid extreme temperature. Administer antiemetics as ordered before meals.

C. Diarrhea Encourage low residue, bland, high CHON food. Administer antidiarrheal as ordered. Provide good perineal care.

53

54
• • • • • • • Monitor electrolytes particularly Na, K, Cl

1. Synarthroses: immovable joints 2. Amphiarthroses: partially movable joints 3. Diarthroses (synovial): freely movable joints •
• • • Muscles Have a joint cavity (synovial cavity) between the articulating bone surfaces Articular cartilage covers the ends of the bones A fibrous capsule encloses the joint Capsule is lined with synovial membrane that secretes synovial fluid to lubricate the joint and reduce friction.

D. Anemia, Leukopenia, Thrombocytopenia Isolate from those with known infection. Provide frequent rest period. Encourage high CHON diet. Avoid injury. Assess for bleeding. Monitor CBC, WBC, & platelets.

Burns • Type: 1. 2. 3. 4. Thermal Smoke Inhalation Chemical Electrical direct tissue injury caused by thermal, electric, chemical & smoke inhaled (TECS)

Functions of Muscles • • • • Provide shape to the body Protect the bones Maintain posture Cause movement of body parts by contraction

Types of Muscles

• • •
1.

Cardiac: involuntary; found only in heart Smooth: involuntary; found in walls of hollow structures (e.g. intestines) Striated (skeletal): voluntary

Classification • Partial Thickness

1. Superficial partial thickness (1st degree)
Depth: epidermis only Causes: sunburn, splashes of hot liquid Sensation: painful Characteristics: erythema, blanching on pressure, no vesicles

Characteristics of skeletal muscles • Muscles are attached to the skeleton at the point of origin and to bones at the point of insertion.

Have properties of contraction and extension, as well as elasticity, to permit isotonic (shortening and thickening of the muscle) and isometric (increased muscle tension) movement.

2. Deep Partial Thickness (2nd degree)
Depth: epidermis & dermis Causes: flash, scalding, or flame burn Sensation: very painful Characteristics: fluid filled vesicles; red, shinny, wet after vesicles ruptures Cartilage • • •

Contraction is innervated by nerve stimulation.

Full Thickness (3rd & 4th degree) 1. 2. 3. 4. Depth: all skin layers & nerve endings; may involve muscles, tendons & bones Causes: flames, chemicals, scalding, electric current Sensation: little or no pain Characteristics: wound is dry, white, leathery, or hard

A form of connective tissue Major functions are to cushion bony prominences and offer protection where resiliency is required

Tendons and Ligaments • • Composed of dense, fibrous connective tissue Functions 1. Ligaments attach bone to bone Tendons attach muscle to bone 2.

Overview Of Anatomy & Physiology Of Musculoskeletal System • • • Bones • Function of Bones • • • Provide support to skeletal framework Assist in movement by acting as levers for muscles Protect vital organ & soft tissue Manufacture RBC in the red bone marrow (hematopoiesis) • 1. • Provide site for storage of calcium & phosphorus Cause 1. 2. 3. Consist of bones, muscles, joints, cartilages, tendons, ligaments, bursae To provide a structural framework for the body To provide a means for movement

Rheumatoid Arthritis (RA) • Chronic systemic disease characterized by inflammatory changes in joints and related structures.

Joint distribution is symmetric (bilateral): most commonly affects smaller peripheral joints of hands & also commonly involves wrists, elbows, shoulders, knees, hips, ankles and jaw.

If unarrested, affected joints progress through four stages of deterioration: synovitis, pannus formation, fibrous ankylosis, and bony ankylosis. Cause unknown or idiopathic Maybe an autoimmune process Genetic factors

Types of Bones Long Bones

4. Play a role in society (work)
Predisposing factors

Central shaft (diaphysis) made of compact bone & two end (epiphyses) composed of cancellous bones (ex. Femur & humerus)

1. Occurs in women more often than men (3:1) between the
ages 35-45. 2. 3. 4. 5. S/sx 1. 2. 3. 4. Fatigue Anorexia & body malaise Weight loss Slight elevation in temperature morning & after a period of inactivity & may show crippling deformity in long-standing disease. 6. Muscle weakness secondary to inactivity History of remissions and exacerbations 7. Fatigue Cold Emotional stress Infection

Short Bones • Cancellous bones covered by thin layer of compact bone (ex. Carpals & tarsals)

Flat Bones


Two layers of compact bone separated by a layer of cancellous bone (ex. Skull & ribs)

Irregular Bones


Joints • •

Sizes and shapes vary (ex. Vertebrae & mandible)

Articulation of bones occurs at joints Movable joints provide stabilization and permit a variety of movements

5. Joints are painful: warm, swollen, limited in motion, stiff in

Classification

54

55 8. Some clients have additional extra-articular manifestations:
subcutaneous nodules; eye, vascular, lung, or cardiac problems. Dx b. c. d. e. f. Maintain proper body alignment. Have client lie prone for ½ hour twice a day. Avoid pillows under knees. Keep joints mainly in extension, not flexion. Prevent complications of immobility.

1. X-rays: shows various stages of joint disease 2. CBC: anemia is common 3. ESR: elevated
4. Rheumatoid factor positive

6. Provide heat treatments: warm bath, shower or whirlpool;
warm, moist compresses; paraffin dips as ordered. a. b. May be more effective in chronic pain. Reduce stiffness, pain & muscle spasm.

5. ANA: may be positive 6. C-reactive protein: elevated
Medical Management 1. Drug therapy

7. Provide cold treatments as ordered: most effective during
acute episodes. 8. 9. Provide psychologic support and encourage client to express feelings. Assists clients in setting realistic goals; focus on client strengths.

a. Aspirin: mainstay of treatment: has both analgesic and
anti-inflammatory effect.

10. Provide client teaching & discharge planning & concerning.
a. b. c. d. e. f. g. h. i. Use of prescribed medications & side effects Self-help devices to assist in ADL and to increase independence Importance of maintaining a balance between activity & rest Energy conservation methods Performance of ROM, isometric & prescribed exercises Maintenance of well-balanced diet Application of resting splints as ordered Avoidance of undue physical or emotional stress Importance of follow-up care

b. Nonsteroidal anti-inflammatory drugs (NSAIDs): relieve
pain and inflammation by inhibiting the synthesis of prostaglandins.

• • • • • • • • •

Ibuprofen (Motrin) Indomethacin (Indocin) Fenoprofen (Nalfon) Mefenamic acid (Ponstel) Phenylbutazone (Butazolidin) Piroxicam (Feldene) Naproxen (Naprosyn) Sulindac (Clinoril)

Osteoarthritis Chronic non-systemic disorder of joints characterized by degeneration of articular cartilage Weight-bearing joints (spine, knees and hips) & terminal interphalangeal joints of fingers most commonly affected Incident Rate 1. 2. Women & men affected equally Incidence increases with age

c. Gold compounds (Chrysotherapy)
Injectable form: given IM once a week; take 3-6 months to become effective

• •

Sodium thiomalate (Myochrysine) Aurothioglucose (Solganal)

SI: monitor blood studies & urinalysis frequently • • • • Proteinuria Mouth ulcers Skin rash Aplastic anemia.

Predisposing Factors

1. Most important factor in development is aging (wear & tear
on joints) 2. 3. S/sx Obesity Joint trauma

Oral form: smaller doses are effective; take 3-6 months to become effective

Auranofin (Ridaura)

SI: blood & urine studies should be monitored. • Diarrhea

1. Pain: (aggravated by use & relieved by rest) & stiffness of
joints

2. Heberden’s nodes: bony overgrowths at terminal
interphalangeal joints

d.

Corticosteroids

• •

Intra-articular injections: temporarily suppress inflammation in specific joints. Systemic administration: used only when client does not respond to less potent anti-inflammatory drugs. Dx

3. Decreased ROM with possible crepitation (grating sound
when moving joints)

e. Methotrexate: given to suppress immune response
• Cytoxan

1. X-rays: show joint deformity as disease progresses 2. ESR: may be slightly elevated when disease is inflammatory
Nursing Interventions 1. 2. Assess joints for pain & ROM. Relieve strain & prevent further trauma to joints. a. b. c. Encourage rest periods throughout day. Use cane or walker when indicated. Ensure proper posture & body mechanics.

SI: bone marrow suppression.

2. Physical therapy: to minimize joint deformities. 3. Surgery: to remove severely damaged joints (e.g. total hip
replacement; knee replacement). Nursing Interventions 1. 2. Assess joints for pain, swelling, tenderness & limitation of motion. Promote maintenance of joint mobility and muscle strength.

d. Promote weight reduction: if obese
e. Avoid excessive weight-bearing activities & continuous standing.

a. Perform ROM exercises several times a day: use of heat
prior to exercise may decrease discomfort; stop exercise at the point of pain. b. Use isometric or other exercise to strengthen muscles.

3. Maintain joint mobility and muscle strength.
a. b. c. 4. a. Provide ROM & isometric exercises. Ensure proper body alignment. Change client’s position frequently. Administer medications as ordered: Aspirin & NSAID: most commonly used Corticosteroids (Intra-articular injections): to relieve pain & improve mobility.

3. Change position frequently: alternate sitting, standing &
lying.

Promote comfort / relief of pain.

4. Promote comfort & relief / control of pain.
a. b. Ensure balance between activity & rest. Provide 1-2 scheduled rest periods throughout day. 2 times/day for gentle ROM exercises. 5. Ensure bed rest if ordered for acute exacerbations. a. Provide firm mattress. 5.

c. Rest & support inflamed joints: if splints used: remove 1-

b. Apply heat or ice as ordered (e.g. warm baths,
compresses, hot packs): to reduce pain. Prepare client for joint replacement surgery if necessary.

55

56
6. Provide client teaching and discharge planning concerning a. b. c. d. e. f. Used of prescribed medications and side effects Importance of rest periods Measures to relieve strain on joints ROM and isometric exercises Maintenance of a well-balanced diet Use of heat/ice as ordered. Pathophysiology 1. Gout A disorder of purine metabolism; causes high levels of uric acid in the blood & the precipitation of urate crystals in the joints Inflammation of the joints caused by deposition of urate crystals in articular tissue S/sx Incident Rate 1. 2. S/sx 1. 2. 3. 4. Joint pain Redness Heat Swelling affected (acute gouty arthritis stage) 6. 7. 8. 9. Headache Malaise Anorexia Tachycardia Occurs most often in males Familial tendency 1. 2. 3. 4. 5. 6. 7. 8. 9. Fatigue Fever Anorexia Weight loss Malaise History of remissions & exacerbations Joint pain Morning stiffness Skin lesions Erythematous rash on face, neck or extremities may occur Butterfly rash over bridge of nose & cheeks Photosensitivity with rash in areas exposed to sun 10. Oral or nasopharyngeal ulcerations 11. Alopecia 12. Renal system involvement Proteinuria Hematuria Dx Renal failure 2. A defect in body’s immunologic mechanisms produces autoantibodies in the serum directed against components of the client’s own cell nuclei. Affects cells throughout the body resulting in involvement of many organs, including joints, skin, kidney, CNS & cardiopulmonary system. Predisposing Factors 1. 2. 3. Cause unknown Immune Genetic & viral factors have all been suggested 1. Occurs most frequently in young women

5. Joints of foot (especially great toe) & ankle most commonly

10. Fever

11. Tophi in outer ear, hands & feet (chronic tophaceous stage)

1. CBC: uric acid elevated
Medical Management 1. Drug therapy a. Acute attack: Colchicine IV or PO: discontinue if diarrhea occurs NSAID: Indomethacin (Indocin) Naproxen (Naprosyn) Phenylbutazone (Butazolidin) b. Prevention of attacks Uricosuric agents: increase renal excretion of uric acid Probenecid (Benemid) Sulfinpyrazone (Anturanel) Allopurinal (Zyloprim): inhibits uric acid formation 2. 3. 4. Low-purine diet may be recommended Joint rest & protection Heat or cold therapy Dx

13. CNS involvement Peripheral neuritis Seizures Organic brain syndrome Psychosis 14. Cardiopulmonary system involvement Pericarditis Pleurisy 15. Increase susceptibility to infection

1. ESR: elevated 2. CBC: RBC anemia, WBC & platelet counts decreased 3. Anti-nuclear antibody test (ANA): positive 4. Lupus Erythematosus (LE prep): positive 5. Anti-DNA: positive
6. Chronic false-positive test for syphilis

Nursing Interventions 1. 2. 3. Assess joints for pain, motion & appearance. Provide bed rest & joint immobilization as ordered. Administer anti-gout medications as ordered.

Medical Management 1. Drug therapy

a. Aspirin & NSAID: to relieve mild symptoms such as fever
& arthritis

4. Administer analgesics as ordered: for pain 5. Increased fluid intake to 2000-3000 ml/day: to prevent
formation of renal calculi.

b. Corticosteroids: to suppress the inflammatory response
in acute exacerbations or severe disease

c. Immunosuppressive agents: to suppress the immune
response when client unresponsive to more conservative therapy Azathioprine (Imuran) Cyclophosphamide (Cytoxan)

6. Apply local heat or cold as ordered: to reduce pain 7. Apply bed cradle: to keep pressure of sheets off joints.
8. Provide client teaching and discharge planning concerning a. Medications & their side effects liver, kidney, brains, sweetbreads, sardines, anchovies c. d. e. f. Limitation of alcohol use Increased in fluid intake Weight reduction if necessary Importance of regular exercise

b. Modifications for low-purine diet: avoidance of shellfish,

2. Plasma exchange: to provide temporary reduction in amount
of circulating antibodies.

3. Supportive therapy: as organ systems become involved.
Nursing Interventions 1. 2. 3. Assess symptoms to determine systems involved. Monitor vital signs, I&O, daily weights. Administer medications as ordered. involvement. 5. Provide psychologic support to client / significant others. Provide client teaching & discharge planning concerning 6.

Systemic Lupus Erythematosus (SLE) Chronic connective tissue disease involving multiple organ systems Incident Rate

4. Institute seizure precautions & safety measures: with CNS

56

57
a. b. c. Disease process & relationship to symptoms Medication regimen & side effects. Importance of adequate rest.

Salivary gland: located in the mouth produce secretion containing pyalin for starch digestion & mucus for lubrication

d. Use of daily heat & exercises as prescribed: for arthritis.
e. f. Need to avoid physical or emotional stress Maintenance of a well-balanced diet other protective clothing h. i. j. Need to avoid exposure to persons with infections Importance of regular medical follow-up Availability of community agencies

Pharynx: aids in swallowing & functions in ingestion by providing a route for food to pass from the mouth to the esophagus

g. Need to avoid direct exposure to sunlight: wear hat &
Esophagus • Muscular tube that receives foods from the pharynx & propels it into the stomach by peristalsis Stomach • Osteomyelitis Infection of the bone and surrounding soft tissues, most commonly caused by S. aureus. Infection may reach bone through open wound (compound fracture or surgery), through the bloodstream, or by direct extension from infected adjacent structures. Infections can be acute or chronic; both cause bone destruction. S/sx 1. 2. 3. 4. 5. 6. Dx Malaise Fever Pain & tenderness of bone Redness & swelling over bone Difficulty with weight-bearing Drainage from wound site may be present. • • • Located on the left side of the abdominal cavity occupying the hypochondriac, epigastric & umbilical regions Stores & mixes food with gastric juices & mucus producing chemical & mechanical changes in the bolus of food

The secretion of digestive juice is stimulated by smelling, tasting & chewing food which is known as cephalic phase of digestion The gastric phase is stimulated by the presence of food in the stomach & regulated by neural stimulation via PNS & hormonal stimulation through secretion of gastrin by the gastric mucosa

After processing in the stomach the food bolus called chyme is released into the small intestine through the duodenum

Two sphincters control the rate of food passage

• •

Cardiac Sphincter: located at the opening between the esophagus & stomach Pyloric Sphincter: located between the stomach & duodenum

1. CBC: WBC elevated 2. Blood cultures: may be positive 3. ESR: may be elevated
Nursing Interventions 1. 2. Administer analgesics & antibiotics as ordered. Use sterile techniques during dressing changes. frequently: to prevent deformities. 4. Provide immobilization of affected part as ordered. (depression may result from prolonged hospitalization) 6. Prepare client for surgery if indicated. Incision & drainage: of bone abscess Sequestrectomy: removal of dead, infected bone & cartilage Bone grafting: after repeated infections Leg amputation 7. Provide client teaching and discharge planning concerning Use of prescribed oral antibiotic therapy & side effects Importance of recognizing & reporting signs & complications (deformity, fracture) or recurrence FRACTURES A. General information 1. B. Medical management C. Assessment findings D. Nursing interventions Overview of Anatomy & Physiology Gastro Intestinal Track System • The primary function of GIT are the movement of food, digestion, absorption, elimination & provision of a continuous supply of the nutrients electrolytes & H2O. • • • • •

Three anatomic division Fundus Body Antrum

Gastric Secretions:

3. Maintain proper body alignment & change position

• • • •

Pepsinogen: secreted by the chief cells located in the fundus aid in CHON digestion Hydrocholoric Acid: secreted by parietal cells, function in CHON digestion & released in response to gastrin Intrinsic Factor: secreted by parietal cell, promotes absorption of Vit B12 Mucoid Secretion: coat stomach wall & prevent auto digestion

5. Provide psychologic support & diversional activities

1st half of duodenum Middle Alimentary canal: Function for absorption; Complete absorption: large intestine Small Intestines • Composed of the duodenum, jejunum & ileum Extends from the pylorus to the ileocecal valve which regulates flow into the large intestines to prevent reflux to the into the small intestine


Major function: digestion & absorption of the end product of digestion Structural Features:

Villi (functional unit of the small intestines): finger like projections located in the mucous membrane; containing goblet cells that secrets mucus & absorptive cells that absorb digested food stuff

• •

Crypts of Lieberkuhn: produce secretions containing digestive enzymes Brunner’s Gland: found in the submucosaof the duodenum, secretes mucus

Upper alimentary canal: function for digestion Mouth • • Consist of lips & oral cavity Provides entrance & initial processing for nutrients & sensory data such as taste, texture & temperature

2nd half of duodenum Jejunum Ileum 1st half of ascending colon Lower Alimentary Canal: Function: elimination Large Intestine • Divided into four parts:

Oral Cavity: contains the teeth used for mastication & the tongue which assists in deglutition & the taste sensation & mastication

Cecum (with appendix)

57

58 •
• • •

Colon (ascending, transverse, descending, sigmoid) Rectum Anus •

• • •

Trypsinogen & Chymotrypsin: for protein digestion Amylase: breakdown starch to disacchardes Lipase: for fat digestion

Serves as a reservoir for fecal material until defecation occurs

Endocrine function related to islets of langerhas

• •

Function: to absorb water & electrolytes MO present in the large intestine: are responsible for small amount of further breakdown & also make some vitamins

Physiology of Digestion & Absorption

Digestion: physical & chemical breakdown of food into absorptive substance • • Initiate in the mouth where the food mixes with saliva & starch is broken down Food then passes into the esophagus where it is propelled into the stomach

• • •

Amino Acids: deaminated by bacteria resulting in ammonia which is converted to urea in the liver Bacteria in the large intestine: aid in the synthesis of vitamin K & some of the vitamin B groups

Feces (solid waste): leave the body via rectum & anus


In the stomach food is processed by gastric secretions into a substance called chyme In the small intestines CHO are hydrolyzed to monosaccharides, fats to glycerol & fatty acid & CHON to amino acid to complete the digestive process

• •

Anus: contains internal sphincter (under involuntary control) & external sphincter (voluntary control) Fecal matter: usually 75% water & 25% solid wastes (roughage, dead bacteria, fats, CHON, inorganic matter)

a. 2nd half of ascending colon
b. c. d. e. Transverse Descending colon Sigmoid Rectum

When chymes enters the duodenum, mucus is secreted to neutralized hydrocholoric acid, in response to release secretin, pancreas releases bicarbonate to neutralized acid chyme

Cholecystokinin & Pancreozymin (CCKPZ) • Are produced by the duodenal mucosa Stimulate contraction of the gallbladder along with relaxation of the sphincter of oddi (to allow bile flow from common bile duct into the duodenum) & stimulate release of the pancreatic enzymes

Accessory Organ Liver

• • •
• •

Largest internal organ: located in the right hypochondriac & epigastric regions of the abdomen Liver Loobules: functional unit of the liver composed of hepatic cells Hepatic Sinusoids (capillaries): are lined with kupffer cells which carry out the process of phagocytosis Portal circulation brings blood to the liver from the stomach, spleen, pancreas & intestines Function: • Metabolism of fats, CHO & CHON: oxidizes these nutrient for energy & produces compounds that can be stored • Production of bile Conjugation & excretion (in the form of glycogen, fatty acids, minerals, fat-soluble & water-soluble vitamins) of bilirubin • • • Storage of vitamins A, D, B12 & iron Synthesis of coagulation factors Detoxification of many drugs & conjugation of sex hormones Salivary Glands

1. Parotid – below & front of ear 2. Sublingual 3. Submaxillary Produces saliva – for mechanical digestion 1200 -1500 ml/day - saliva produced

Disorder of the GIT Peptic Ulcer Disease (PUD) Gastric Ulcer • • • Ulceration of the mucosal lining of the stomach Most commonly found in the antrum Excoriation / erosion of submucosa & mucosal lining due to:


Hypersecretion of acid: pepsin Decrease resistance to mucosal barrier

Caused by bacterial infection: Helicobacter Pylori

Salivary gland Verniform appendix Liver Pancreas: auto digestion Gallbladder: storage of bile

Doudenal Ulcer • • Most commonly found in the first 2 cm of the duodenum Characterized by gastric hyperacidity & a significant rate of gastric emptying Predisposing factor

Biliary System

• •
• •

Smoking: vasoconstriction: effect GIT ischemia Alcohol Abuse: stimulates release of histamine: Parietal cell release Hcl acid = Ulceration Emotional Stress Drugs:

• •

Consist of the gallbladder & associated ductal system (bile ducts) Gallbladder: lies under the surface of the liver

• •

Function: to concentrate & store bile

Ductal System: provides a route for bile to reach the intestines


• • S/sx

Salicylates (Aspirin) Steroids Butazolidin

• • •

Bile: is formed in the liver & excreted into hepatic duct Hepatic Duct: joins with the cystic duct (which drains the gallbladder) to form the common bile duct

If the sphincter of oddi is relaxed: bile enters the duodenum, if contracted: bile is stored in gallbladder Site

Gastric Ulcer Duodenal Ulcer Antrum or lesser • • • • curvature 30 min-1 hr after eating Left epigastrium Gaseous & burning Not usually relieved by • • • Duodenal bulb • 2-3 hrs after eating Mid epigastrium Cramping & burning Usually relieved by

Pancreas • • Positioned transversely in the upper abdominal cavity Consist of head, body & tail along with a pancreatic duct which extends along the gland & enters the duodenum via the common bile duct • Has both exocrine & endocrine function Function in GI system: is exocrine Exocrine cells in the pancreas secretes:

Pain

• •

58

59
food & antacid • • Hypersecreti on • • • • Vomiting Hemorrhage Weight Complication s • Dx High Risk • • • • • • • Normal gastric acid secretion Common Hematemeis Weight loss Stomach cause Hemorrhage 60 years old • 20 years old 2. • • • • • food & antacid 12 MN – 3am pain Increased gastric acid secretion Not common Melena Weight gain Perforation Nursing Intervention Post op 1. Monitor NGT output • Immediately post op should be bright red Within 36-42 hrs: output is yellow green After 42 hrs: output is dark red • •

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

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


• • • • 3. 4. 5.

Administer medication Analgesic Antibiotic Antiemetics

• • • •

Hgb & Hct: decrease (if anemic) Endoscopy: reveals ulceration & differentiate ulceration from gastric cancer Gastric Analysis: normal gastric acidity Upper GI series: presence of ulcer confirm

Maintain patent IV line Monitor V/S, I&O & bowel sounds Complications:


Hemorrhage: Hypovolemic shock: Late signs: anuria Peritonitis Paralytic ileus: most feared Hypokalemia Thromobphlebitis Pernicious anemia

Medical Management 1. Supportive: • • • 2. Rest Bland diet Stress management


• • •

Drug Therapy:

Antacids: neutralizes gastric acid

Nursing Intervention 1. Administer medication as ordered

• •

Aluminum hydroxide: binds phosphate in the GIT & neutralized gastric acid & inactivates pepsin Magnesium & aluminum salt: neutralized gastric acid & inactivate pepsin if pH is raised to >=4

2. Diet: bland, non irritating, non spicy 3. Avoid caffeine & milk / milk products: Increase gastric acid
secretion 4. Provide client teaching & discharge planning a. Medical Regimen • • • Take medication at prescribe time Have antacid available at all times Recognized situation that would increase the need for antacids

Aluminum containing Antacids containing Antacids Ex. Aluminum OH gel (Amphojel) SE: Constipation

Magnesium Ex. Milk of Magnesia SE: Diarrhea


• Maalox SE: fever b. • •

Avoid ulcerogenic drugs: salicylates, steroids Know proper dosage, action & SE

Proper Diet Bland diet consist of six meals / day Eat slowly Avoid acid producing substance: caffeine, alcohol, highly seasoned food • • • Avoid stressfull situation at mealtime Plan rest period after meal Avoid late bedtime snacks

Histamines (H2) receptor antagonist: inhibits gastric acid secretion of parietal cells

• • •

Ranitidine (Zantac): has some antibacterial action against H. pylori Cimetidine (Tagamet) Famotidine (Pepcid) c.

Avoidance of stress-producing situation & development of stress production methods • • • Relaxation techniques Exercise Biofeedback

Anticholinergic:

Atropine SO4: inhibit the action of acetylcholine at post ganglionic site (secretory glands) results decreases GI secretions

• •

Propantheline: inhibit muscarinic action of acetylcholine resulting decrease GI secretions Dumping syndrome • • • • • Abrupt emptying of stomach content into the intestine Rapid gastric emptying of hypertonic food solutions Common complication of gastric surgery Appears 15-20 min after meal & last for 20-60 min Associated with hyperosmolar CHYME in the jejunum which draws fluid by osmosis from the extracellular fluid into the bowel. Decreased plasma volume & distension of the bowel stimulates increased intestinal motility S/sx 1. 2. 3. 4. 5. 6. 7. Weakness Faintness Feeling of fullness Dizziness Diaphoresis Diarrhea Palpitations

Proton Pump Inhibitor: inhibit gastric acid secretion regardless of acetylcholine or histamine release

Omeprazole (Prilosec): diminished the accumulation of acid in the gastric lumen & healing of duodenal ulcer

Pepsin Inhibitor: reacts with acid to form a paste that binds to ulcerated tissue to prevent further destruction by digestive enzyme pepsin

• •
3.

Sucralfate (Carafate): provides a paste like subs that coats mucosal lining of stomach

Metronidazole & Amoxacillin: for ulcer caused by Helicobacter Pylori

Surgery: • Gastric Resection Anastomosis: joining of 2 or more hollow organ Subtotal Gastrectomy: Partial removal of stomach • Before surgery for BI or BII

• •

Do Vagotomy (severing or cutting of vagus nerve) & Pyloroplasty (drainage) first

Nursing Intervention 1. Avoid fluids in chilled solutions

2. Small frequent feeding: six equally divided feedings
Billroth I (Gastroduodenostomy) Billroth II (Gastrojejunostomy)

59

60 3. Diet: decrease CHO, moderate fats & CHON
4. Flat on bed 15-30 min after q feeding Predisposing factors: Disorders of the Gallbladder Cholecystitis / Cholelithiasis • Cholecystitis: • • • • • Acute or chronic inflammation of the gallbladder Most commonly associated with gallstones Inflammation occurs within the walls of the gallbladder & creates thickening accompanied by edema Consequently there is impaired circulation, ischemia & eventually necrosis Cholelithiasis: • • Formation of gallstones & cholesterol stones 1. 2. 3. 4. 5. 6. 7. 8. 9. Chronic alcoholism Hepatobilary disease Trauma Viral infection Penetrating duodenal ulcer Abscesses Obesity Hyperlipidemia Hyperparathyroidism

Bleeding of Pancreas: Cullen’s sign at umbilicus

10. Drugs: Thiazide, steroids, diuretics, oral contraceptives
S/Sx:

Inflammation of gallbladder with gallstone formation.

1. Severe left upper epigastric pain radiates from back & flank
area: aggravated by eating with DOB 2. 3. N/V Tachycardia

Predisposing Factor:

1. High risk: women 40 years old 2. Post menopausal women: undergoing estrogen therapy
3. 4. 5. 6. S/sx: Obesity Sedentary lifestyle Hyperlipidemia Neoplasm

4. Palpitation: due to pain 5. Dyspepsia: indigestion
6. Decrease bowel sounds Hemorrhage

7. (+) Cullen’s sign: ecchymosis of umbilicus 8. (+) Grey Turner’s spots: ecchymosis of flank area
9. Dx Hypocalcemia

1. Severe Right abdominal pain (after eating fatty food):
Occurring especially at night 2. 3. 4. 5. 6. 7. 8. 9. Dx Intolerance of fatty food Anorexia N/V Jaundice Pruritus Easy bruising Tea colored urine Steatorrhea

1. Serum amylase & lipase: increase 2. Urinary amylase: increase 3. Blood Sugar: increase 4. Lipids Level: increase 5. Serum Ca: decrease 6. CT Scan: shows enlargement of the pancreas
Medical Management

1. Direct Bilirubin Transaminase: increase 2. Alkaline Phosphatase: increase 3. WBC: increase 4. Amylase: increase 5. Lipase: increase 6. Oral cholecystogram (or gallbladder series): confirms
presence of stones Medical Management 1. 2. 3. Supportive Treatment: NPO with NGT & IV fluids Diet modification with administration of fat soluble vitamins Drug Therapy

1.

Drug Therapy

Narcotic Analgesic: for pain

• • • •

Meperidine Hcl (Demerol) Don’t give Morphine SO4: will cause spasm of Sphincter of Oddi

Smooth muscle relaxant: to relieve pain • Papaverine Hcl

Anticholinergic: to decrease pancreatic stimulation • • Atrophine SO4 Propantheline Bromide (Profanthene)

Narcotic analgesic: DOC: Meperdipine Hcl (Demerol): for pain

• •

Antacids: to decrease pancreatic stimulation • Maalox

• •

(Morpine SO4: is contraindicated because it causes spasm of the Sphincter of Oddi)

H2 Antagonist: to decrease pancreatic stimulation

• •

Ranitidin (Zantac)

Antocholinergic: (Atrophine SO4): for pain

Vasodilators: to decrease pancreatic stimulation

• •

(Anticholinergic: relax smooth muscles & open bile ducts)

• •
2.

Nitroglycerine (NTG)

Antiemetics: Phenothiazide (Phenergan): with anti emetic properties

Ca Gluconate: to decrease pancreatic stimulation

Diet Modification

4. Surgery: Cholecystectomy / Choledochostomy
Nursing Intervention 1. 2. Administer pain medication as ordered & monitor effects Administer IV fluids as ordered

3. NPO (usually)
4. 5. Peritoneal Lavage Dialysis

Nursing Intervention 1. Administer medication as ordered pancreatic stimulation / aggravates pain

3. Diet: increase CHO, moderate CHON, decrease fats 4. Meticulous skin care: to relieved priritus
Disorders of the Pancreas Pancreatitis • An inflammatory process with varying degrees of pancreatic edema, fat necrosis or hemorrhage

2. Withhold food & fluid & eliminate odor: to decrease 3. Assist in Total Parenteral Nutrition (TPN) or
hyperalimentation • Complication of TPN • • • Infection Embolism Hyperglycemia

Proteolytic & lipolytic pancreatic enzymes are activated in the pancreas rather than in the duodenum resulting in tissue damage & auto digestion of pancreas

4. Institute non-pharmacological measures: to decrease pain •
Assist client to comfortable position: Knee chest or fetal like position

Acute or chronic inflammation of pancreas leading to pancreatic edema, hemorrhage & necrosis due to auto digestion

60

61
• 5. Teach relaxation techniques & provide quiet, restful environment Provide client teaching & discharge planning • Dietary regimen when oral intake permitted • • • • • • High CHO, CHON & decrease fats Eat small frequent meal instead of three large ones Avoid caffeine products Eliminate alcohol consumption Maintain relaxed atmosphere after meals Types Laennec’s Cirrhosis: Associated with alcohol abuse & malnutrition Characterized by an accumulation of fat in the liver cell progressing to widespread scar formation Postnecrotic Cirrhosis Result in severe inflammation with massive necrosis as a complication of viral hepatitis Cardiac Cirrhosis Occurs as a consequence of right sided heart failure Manifested by hepatomegaly with some fibrosis Biliary Cirrhosis Associated with biliary obstruction usually in the common bile duct Results in chronic impairment of bile excretion S/sx Fatigue Anorexia N/V Predisposing factor: 1. 2. 3. S/Sx: Microbial infection Feacalith: undigested food particles like tomato seeds, guava seeds etc. Intestinal obstruction Dyspepsia: Indigestion Weight loss Flatulence Change (Irregular) bowel habit Ascites Peripheral edema Hepatomegaly: pain located in the right upper quadrant Atrophy of the liver Fetor hepaticus: fruity, musty odor of chronic liver disease Aterixis: flapping of hands & tremores Hard nodular liver upon palpation Increased abdominal girth Changes in moods Alertness & mental ability Sensory deficits Gynecomastia Decrease of pubic & axilla hair in males Amenorrhea in female Jaundice Pruritus or urticaria Medical Management Easy bruising Spider angiomas on nose, cheeks, upper thorax & shoulder Nursing Intervention 1. 2. Administer antibiotics / antipyretic as ordered Routinary pre-op nursing measures: • • Skin prep NPO Avoid enema, cathartics: lead to rupture of appendix Dx Liver enzymes: increase SGPT (ALT) SGOT (AST) LDH Alkaline Phosphate Serum cholesterol & ammonia: increase Indirect bilirubin: increase CBC: pancytopenia PT: prolonged Nursing Intervention post op Hepatic Ultrasonogram: fat necrosis of liver lobules Nursing Intervention CBR with bathroom privileges Encourage gradual, progressive, increasing activity with planned rest period Institute measure to relieve pruritus Do not use soap & detergent Bathe with tepid water followed by application of emollient lotion Provide cool, light, non-constrictive clothing Keep nail short: to avoid skin excoriation from scratching Apply cool, moist compresses to pruritic area Monitor VS, I & O Palmar erythema Muscle atrophy Liver Cirrhosis Chronic progressive disease characterized by inflammation, fibrosis & degeneration of the liver parenchymal cell Destroyed liver cell are replaced by scar tissue, resulting in architectural changes & malfunction of the liver Lost of architectural design of liver leading to fat necrosis & scarring

Report signs of complication • • • • • Continued N/V Abdominal distension with feeling of fullness Persistent weight loss Severe epigastric or back pain Frothy foul smelling bowel movement Irritability, confusion, persistent elevation of temperature (2 day)

Apendicitis • • • • • Inflammation of the appendix that prevents mucus from passing into the cecum Inflammation of verniform appendix If untreated: ischemia, gangrene, rupture & peritonitis May cause by mechanical obstruction (fecalith, intestinal parasites) or anatomic defect May be related to decrease fiber in the diet

1. Pathognomonic sign: (+) rebound tenderness
2. 3. 4. 5. Low grade fever N/V Decrease bowel sound Diffuse pain at lower Right iliac region

6. Late sign: tachycardia: due to pain
Dx

1. CBC: mild leukocytosis: increase WBC 2. PE: (+) rebound tenderness (flex Right leg, palpate Right
iliac area: rebound)

3. Urinalysis: elevated acetone in urine

Surgery: Appendectomy 24-45 hrs


3. Don’t give analgesic: will mask pain
Presence of pain means appendix has not ruptured

4. Avoid heat application: will rupture appendix
5. Monitor VS, I&O bowel sound

1. If (+) Pendrose drain (rubber drain inserted at surgical
wound for drainage of blood, pus etc): indicates rupture of appendix

2. Position the client semi-fowlers or side lying on right: to
facilitate drainage 3. Administer Meds:

• • •
4. 5.

Analgesic: due post op pain Antibiotics: for infection Antipyretics: for fever (PRN)

Monitor VS, I&O, bowel sound Maintain patent IV line

6. Complications: Peritonitis, Septicemia

61

62
Prevent Infection Prevent skin breakdown: by turning & skin care Provide reverse isolation for client with severe leukopenia: handwashing technique Monitor WBC Diet: Small frequent meals Restrict Na! High calorie, low to moderate CHON, high CHO, low fats with supplemental Vit A, B-complex, C, D, K & folic acid Monitor / prevent bleeding Measure abdominal girth daily: notify MD With pt daily & assess pitting edema Administer diuretics as ordered Provide client teaching & discharge planning Avoidance of hepatotoxicity drug: sedative, opiates or OTC drugs detoxified by liver How to assess weight gain & increase abdominal girth Avoid person with upper respiratory infection Reporting signs of reccuring illness (liver tenderness, increase jaundice, increase fatigue, anorexia) Avoid all alcohol Avoid straining stool vigorous blowing of nose & coughing: to decrease incidence of bleeding Complications: Ascites: accumolation of free fluid in abdominal cavity Nursing Intervention Meds: Loop diuretics: 10-15 min effect Assist in abdominal paracentesis: aspiration of fluid Void before paracentesis: to prevent accidental puncture of bladder as trochar is inserted Bleeding esophageal varices: Dilation of esophageal veins Nursing Intervention Administer meds: Vit K Pitrisin or Vasopresin (IM) NGT decompression: lavage Give before lavage: ice or cold saline solution Monitor NGT output Assist in mechanical decompression Insertion of sengstaken-blackemore tube 3 lumen typed catheter Scissors at bedside to deflate balloon. Hepatic encephalopathy Nursing Intervention Assist in mechanical ventilation: due coma Monitor VS, neuro check Siderails: due restless Administer meds Laxatives: to excrete ammonia Overview of Anatomy & Physiology Of GUT System GUT: Genito-urinary tract GUT includes the kidneys, ureters, urinary bladder, urethra & the male & female genitalia Function: Promote excretion of nitrogenous waste products Maintain F&E & acid base balance Kidneys Two of bean shaped organ that lie in the retroperitonial space on either side of the vertebral column Retroperitonially (back of peritoneum) on either side of vertebral column Adrenal gland is on top of each kidneys Encased in Bowmans’s capsule Renal Parenchyma Cortex Outermost layer Site of glomeruli & proximal & distal tubules of nephron Medulla Middle layer Tubular Function Urine formation: 25 % of total cardiac output is received by kidneys Glomerular Filtration Ultrafiltration of blood by the glomerulus, beginning of urine formation Requires hydrostatic pressure & sufficient circulating volume Pressure in bowman’s capsule opposes hydrostatic pressure & filtration If glomerular pressure insufficient to force substance out of the blood into the tubules filtrate formation stops Glomerular Filtration Rate (GFR) Amount of blood filtered by the glomeruli in a given time Normal: 125 ml / min Filtrate formed has essentially same composition as blood plasma without the CHON; blood cells & CHON are usually too large to pass the glomerular membrane Urethra Small tube that extends from the bladder to the exterior of the body Passage of urine, seminal & vaginal fluids. Females: located behind the symphisis pubis & anterior vagina & approximately 3-5 cm Males: extend the entire length of the penis & approximately 20 cm Function of kidneys Kidneys remove nitrogenous waste & regulates F & E balance & acid base balance Urine is the end product Bladder Located behind the symphisis pubis Composed of muscular elastic tissue that makes it distensible Serve s as reservoir of urine (capable of holding 1000-1800 ml & 500 ml moderately full) Internal & external urethral sphincter controls the flow of urine Urge to void stimulated by passage of urine past the internal sphincter (involuntary) to the upper urethra Relaxation of external sphincter (voluntary) produces emptying of the bladder (voiding) Ureters Two tubes approximately 25-35 cm long Extend from the renal pelvis to the pelvic cavity where they enter the bladder, convey urine from the kidney to the bladder Passageway of urine to bladder Ureterovesical valve: prevent backflow of urine into ureters Renal Corpuscle (vascular system of nephron) Bowman’s Capsule: Portion of the proximal tubule surrounds the glomerulus Glomerulus: Capillary network permeable to water, electrolytes, nutrients & waste Impermeable to large CHON molecules Filters blood going to kidneys Renal Tubule Divided into proximal convoluted tubule, descending loop of Henle, acending loop of Henle, distal convoluted tubule & collecting ducts Nephron Functional unit of the kidney Basic living unit Renal Sinus & Pelvis Papillae Projection of renal tissues located at the tip of the renal pyramids Calices Minor Calyx: collects urine flow from collecting ducts Major Calyx: directs urine from renal sinus to renal pelvis Urine flows from renal pelvis to ureters Formed by collecting tubules & ducts

62

63
Tubules & collecting ducts carry out the function of reabsorption, secretion & excretion Reabsorption of H2O & electrolytes is controlled by anitdiuretics hormones (ADH) released by the pituitary & aldosterone secreted by the adrenal glands Proximal Convoluted Tubule Reabsorb the ff: 80% of F & E H2O Glucose Amino acids Bicarbonate Secretes the ff: Organic substance Waste Loop of Henli Reabsorb the ff: Na & Chloride in the ascending limb H2O in the descending limb Concentrate / dilutes urine Distal Convoluted Tubule Secretes the ff: Potassium Hydrogen ions Ammonia Reabsorb the ff: H2O Bicarbonate Regulate the ff: Ca Phosphate concentration Collecting Ducts Received urine from distal convoluted tubules & reabsorb H2O (regulated by ADH) Dx Normal Adult: produces 1 L /day of urine Regulation of BP Through maintenance of volume (formation / excretion of urine) Rennin-angiotensin system is the kidneys controlled mechanism that can contribute to rise the BP When the BP drops the cells of the glomerulus release rennin which then activates angiotensin to cause vasoconstriction. Urine culture & sensitivity: (+) to E. coli Nursing Intervention Force fluid: 3000 ml Warm sitz bath: to promote comfort Monitor & assess urine for gross odor, hematuria & sediments Acid Ash Diet: cranberry, vit C: OJ: to acidify urine & prevent bacterial multiplication Administer Medication as ordered: Systemic Antibiotics Filtration – Normal GFR/ min is 125 ml of blood Tubular reabsorption – 124ml of ultra infiltrates (H2O & electrolytes is for reabsorption) Tubular secretion – 1 ml is excreted in urine Regulation of BP: Predisposing factor: Ex CS – hypovolemia – decrease BP going to kidneys Activation of RAAS Release of Renin (hydrolytic enzyme) at juxtaglomerular apparatus Angiotensin I mild vasoconstrictor Angiotensin II vasoconstrictor Ampicillin Cephalosporin Aminoglycosides Sulfonamides Co-trimaxazole (Bactrim) Gantrism (Gantanol) Antibacterial Nitrofurantoin (Macrodantin) Methenamine Mandelate (Mandelamine) Nalixidic Acid (NegGram) Urinary Tract Anagesic Urinary antiseptics: Mitropurantoin (Macrodantin) Urinary analgesic: Pyridium Provide client teachings & discharge planning Importance of Hydration Void after sex: to avoid stagnation Female: avoids cleaning back & front (should be front to back) Bubble bath, Tissue paper, Powder, perfume Adrenal cortex Aldosterone Increase BP Increase Na & H2O reabsorption Hypervolemia increase CO increase PR Complications: Pyelonephritis Pyelonephritis Acute / chronic inflammation of 1 or 2 renal pelvis of kidneys leading to tubular destruction & interstitial abscess formation Acute: infection usually ascends from lower urinary tract Chronic: a combination of structural alteration along with infection major cause is ureterovesical reflux with infected urine backing up into ureters & renal pelvis Recurrent infection will lead to renal parenchymal deterioration & Renal Failure Color – amber S/Sx: Pain: flank area Urinary frequency & urgency Burning pain upon urination Dysuria Hematuria Nocturia Fever Chills Anorexia Gen body malaise Predisposing factors: Microbial invasion: E. coli High risk: women Obstruction Urinary retention Increase estrogen levels Sexual intercourse UTI CYSTITIS Inflammation of bladder due to bacterial infection Odor – Consistency – pH – WBC/ RBC – Albumin – E coli – aromatic clear or slightly turbid 4.5 – 8 (-) (-) (-)

Specific gravity – 1.015 – 1.030

Mucus thread – few Amorphous urate (-)

63

64
Predisposing factor: Microbial invasion E. Coli Streptococcus Urinary retention /obstruction Pregnancy DM Exposure to renal toxins S/sx: Acute Pyelonephritis Severe flank pain or dull ache Costovertibral angle pain / tenderness Fever Chills N/V Anorexia Gen body malaise Urinary frequency & urgency Nocturia Dsyuria Hematuria Burning sensation on urination Chronic Pyelonephritis: client usually not aware of disease Bladder irritability Slight dull ache over the kidney Chronic Fatigue Weight loss Polyuria Polydypsia HPN Atrophy of the kidney Medical Management Urinary analgesic: Peridium Acute Antibiotics Antispasmodic Surgery: removal of any obstruction Chronic Antibiotics Urinary Antiseptics Nitrofurantoin (macrodantin) SE: peripheral neuropathy GI irritation Hemolytic anemia Staining of teeth Surgery: correction of structural abnormality if possible Dx Urine culture & sensitivity: (+) E. coli & streptococcus Urinalysis: increase WBC, CHON & pus cells Cystoscopic exam: urinary obstruction Nursing Intervention Provide CBR: acute phase Monitor I & O Force fluid Acid ash diet Administer medication as ordered Chronic: possibility of dialysis & transplant if has renal deterioration Complication: Renal Failure Nephrolithiasis / Urolithiasis Presence of stone anywhere in the urinary tract Formation of stones at urinary tract Frequent composition of stones Calcium Oxalate Uric acid Calcium Milk Oxalate Cabbage Cranberries Nuts tea Nuts Uric Acid Anchovies Organ meat Benign Prostatic Hypertrophy (BPH) Uric Acid Stone Reduce food high in purine (liver, brain, kidney, venison, shellfish, meat soup, gravies, legumes) Maintain alkaline urine Administer Allopurinol (Zyloprim) as ordered: to decrease uric acid production: push fluids when giving allopurinol Provide client teaching & discharge planning Prevention of urinary stasis: increase fluid intake especially during hot weather & illness Mobility Voiding whenever the urge is felt & at least twice during night Adherence to prescribe diet Complications: Renal Failure Nursing Intervention Force fluid: 3000-4000 ml / day Strain urine using gauze pad: to detect stones & crush all cloths Encourage ambulation: to prevent stasis Warm sitz bath: for comfort Administer narcotic analgesic as ordered: Morphine SO4: to relieve pain Application warm compress at flank area: to relieve pain Monitor I & O Provide modified diet depending upon the stone consistency Calcium Stones Limit milk & dairy products Provide acid ash diet (cranberry or prune juice, meat, fish, eggs, poultry, grapes, whole grains): to acidify urine Take vitamin C Oxalate Stone Avoid excess intake of food / fluids high in oxalate (tea, chocolate, rhubarb, spinach) Maintain alkaline-ash diet (milk, vegetable, fruits except cranberry, plums & prune): to alkalinize urine Medical Management Surgery Percutaneous Nephrostomy: Tube is inserted through skin & underlying tissue into renal pelvis to remove calculi Percutaneous Nephrostolithotomy Delivers ultrasound wave through a probe placed on the calculus Extracorporeal Shockwave Lithotripsy: Non-invasive Delivers shockwaves from outside of the body to the stone causing pulverization Pain management & diet modification Dx Intravenous Pyelography (IVP): identifies site of obstruction & presence of non-radiopaque stones KUB: reveals location, number & size of stone Cytoscopic Exam: urinary obstruction Stone Analysis: composition & type of stone Urinalysis: indicates presence of bacteria, increase WBC, RBC & CHON S/sx Abdominal or flank pain Renal colic Cool moist skin (shock) Burning sensation upon urination Hematuria Anorexia N/V Predisposing factors: Diet: increase Ca & oxalate Increase uric acid level Hereditary: gout or calculi Immobility Sedentary lifestyle Hyperparathyroidism Chocolates Sardines

64

65
Mild to moderate glandular enlargement, hyperplsia & over growth of the smooth muscles & connective tissue As the gland enlarges it compresses the urethra: resulting to urinary retention Enlarged prostate gland leading to Hydroureters: dilation of urethers Hydronephrosis: dilation of renal pelvis Kidney stones Renal failure Predisposing factor: High risk: 50 years old & above & 60-70 (3-4x at risk) Influence of male hormone S/sx Urgency, frequency & hesitancy Nocturia Enlargement of prostate gland upon palpation by digital rectal exam Decrease force & amount of urinary stream Dysuria Hematuria Burning sensation upon urination Terminal bubbling Backache Sciatica: severe pain in the lower back & down the back of thigh & leg Dx Digital rectal exam: enlarged prostate gland KUB: urinary obstruction Cystoscopic Exam: reveals enlargement of prostate gland & obstruction of urine flow Urinalysis: alkalinity increase Specific Gravity: normal or elevated BUN & Creatinine: elevated (if longstanding BPH) Prostate-specific Antigen: elevated (normal is < 4 ng /ml) Nursing Intervention Prostate message: promotes evacuation of prostatic fluid Force fluid intake: 2000-3000 ml unless contraindicated Provide catheterization Administer medication as ordered: Terazosine (Hytrin): relaxes bladder sphincter & make it easier to urinate Finasteride (Proscar): shrink enlarge prostate gland Surgery: Prostatectomy Transurethral Resection of Prostate (TURP): insertion of a resectoscope into urethra to excise prostatic tissue Assist in cystoclysis or continuous bladder irrigation. Nursing Intervention Monitor symptoms of infection Monitor symptoms gross / flank bleeding. Normal bleeding within 24h Maintain irrigation or tube patent to flush out clots: to prevent bladder spasm & distention Nursing Intervention Monitor / maintain F&E balance Obtain baseline data on usual appearance & amount of client’s urine Measure I&O every hour: note excessive losses Administer IV F&E supplements as ordered Weight daily Acute Renal Failure Sudden inability of the kidney to regulate fluid & electrolyte balance & remove toxic products from the body Sudden immobility of kidneys to excrete nitrogenous waste products & maintain F&E balance due to a decrease in GFR (N 125 ml/min) Causes Pre-renal cause: interfering with perfusion & resulting in decreased blood flow & glomerular filtrate Inter-renal cause: condiion that cause damage to the nephrons Post-renal cause: mechanical obstruction anywhere from the tubules to the urethra Pre renal cause: decrease blood flow & glomerular filtrate Ischemia & oliguria Cardiogenic shock Acute vasoconstriction Septicemia Monitor lab values: assess / treat F&E & acid base imbalance as needed Monitor alteration in fluid volume Monitor V/S. PAP, PCWP, CVP as needed Monitor I&O strictly Assess every hour fro hypervolemia Maintain ventilation Decrease fluid intake as ordered Administer diuretics, cardiac glycosides & hypertensive agent as ordered Assess every hour for hypovolemia: replace fluid as ordered Monitor ECG Check urine serum osmolality / osmolarity & urine specific gravity as ordered Promote optimal nutrition Administer TPN as ordered Restrict CHON intake Prevent complication from impaired mobility Dx BUN & Creatinine: elevated Recovery or Covalescent Phase: renal function stabilized with gradual improvement over next 3-12 mos Dx BUN & Creatinine: elevated Diuretic Phase: slow gradual increase in daily urine output Diuresis may occur (output 3-5 L / day): due to partially regenerated tubules inability to concentrate urine Duration: 2-3 weeks S/sx Hyponatremia Hypokalemia Hypovolemia S/sx Oliguric Phase: caused by reduction in glomerular filtration rate Urine output less than 400 ml / 24 hrs; duration 1-2 weeks S/sx Hypernatremia Hyperkalemia Hyperphosphotemia Hypermagnesemia Hypocalcemia Metabolic acidosis Post renal cause: involves mechanical obstruction Tumors Stricture Blood cloths Urolithiasis BPH Anatomic malformation Intra-renal cause: involves renal pathology: kidney problem Acute tubular necrosis Endocarditis DM Tumors Pyelonephritis Malignant HPN Acute Glomerulonephritis Blood transfision reaction Hypercalemia Nephrotoxin (certain antibiotics, X-ray, dyes, pesticides, anesthesia) Hypovolemia flow to kidneys Hypotension CHF Hemorrhage Dehydration Decrease

65

66
Pulmonary Embolism Skin breakdown Contractures Atelectesis Prevent infection / fever Assess sign of infection Use strict aseptic technique for wound & catheter care Take temperature via rectal Administer antipyretics as ordered & cooling blankets Support clients / significant others: reduce level of anxiety Provide care for client receiving dialysis Provide client teaching & discharge planning Adherence to prescribed dietary regime S/sx of recurrent renal disease Importance of planned rest period Use of prescribe drugs only S/sx of UTI or respiratory infection: report to MD Chronic Renal Failure Progressive, irreversible destruction of the kidneys that continues until nephrons are replaced by scar tissue Loss of renal function gradual Irreversible loss of kidney function Predisposing factors: DM HPN Recurrent UTI/ nephritis Urinary Tract obstruction Exposure to renal toxins Stages of CRF Diminished Reserve Volume – asymptomatic Normal BUN & Crea, GFR < 10 – 30% 2. Renal Insufficiency 3. End Stage Renal disease Apathy Confusion Elevated BP Edema of face & feet Itchy skin Restlessness Seizures Monitor for changes in mental functioning Orient confused client to time, place, date & person Institute safety measures to protect the client from falling out of bed Monitor serum electrolytes, BUN & creatinine as ordered Promote optimal GI function Provide care for stomatitis Monitor N/V & anorexia: administer antiemetics as ordered Monitor signs of GI bleeding Monitor & prevent alteration in F&E balance S/Sx: N/V Diarrhea / constipation Decreased urinary output Dyspnea Stomatitis Hypotension (early) Hypertension (late) Lethargy Convulsion Memory impairment Pericardial Friction Rub HF Monitor for hyperphosphatemia: administer aluminum hydroxides gel (amphojel, alternagel) as ordered Paresthesias Muscle cramps Seizures Abnormal reflex Maintenance of skin integrity Provide care for pruritus Monitor uremic frost (urea crystallization on the skin): bathe in plain water Monitor for bleeding complication & prevent injury to client Monitor Hgb, Hct, platelets, RBC Hematest all secretions Administer hematinics as ordered Avoid IM injections Urinary System Polyuria Nocturia Hematuria Dysuria Oliguria CNS Headache Lethargy Disorientation Restlessness Memory impairment Respiratory Kassmaul’s resp Decrease cough reflex Fluid & Electrolytes Hyperkalemia Hypernatermia Hypermagnese mia Hyperposphate mia Hypocalcemia Metabolic acidosis GIT N/V Stomatitis Uremic breath Diarrhea / constipation Hematological Normocytic anemia Bleeding tendencies Integumentary Itchiness / pruritus Uremic frost Metabolic Disturbance Azotemia (increase BUN & Creatinine) Hyperglycemia Hyperinsulinemia Maintain maximal cardiovascular function Monitor BP Auscultate for pericardial friction rub Perform circulation check routinely Administer diuretics as ordered & monitor I&O Modify digitalis dose as ordered (digitalis is excreted in kidneys) Provide care for client receiving dialysis Disequilibrium syndrome: from rapid removal of urea & nitrogenous waste prod leading to: N/V HPN Leg cramps Disorientation Paresthes Enforce CBR Monitor VS, I&O Meticulous skin care. Uremic frost – assist in bathing pt 4. Meds: a.) Na HCO3 – due Hyperkalemia b.) Kagexelate enema c.) Anti HPN – hydralazine d.) Vit & minerals e.) Phosphate binder (Amphogel) Al OH gel - S/E constipation Nursing Intervention Prevent neurologic complication Monitor for signs of uremia Fatigue Loss of appetite Decreased urine output Medical Management Diet restriction Multivitamins Hematinics Aluminum Hydroxide Gels Antihypertensive Dx Urinalysis: CHON, Na & WBC: elevated Specific gravity: decrease Platelets: decrease Ca: decrease

66

67
f.) Decrease Ca – Ca gluconate 5. Assist in hemodialysis Consent/ explain procedure Obtain baseline data & monitor VS, I&O, wt, blood exam Strict aseptic technique Monitor for signs of complications: B – bleeding E – embolism D – disequilibrium syndrome S – septicemia S – shock – decrease in tissue perfusion Disequilibrium syndrome – from rapid removal of urea & nitrogenous waste prod leading to: n/v HPN Leg cramps Disorientation Paresthesia Avoid BP taking, blood extraction, IV, at side of shunt or fistula. Can lead to compression of fistula. Maintain patency of shunt by: Palpate for thrills & auscultate for bruits if (+) patent shunt! Bedside- bulldog clip - If with accidental removal of fistula to prevent embolism. - Infersole (diastole) – common dialisate used 7. Complication - Peritonitis - Shock 8. Assist in surgery: Renal transplantation : Complication – rejection. Reverse isolation

67

Sign up to vote on this title
UsefulNot useful

Master Your Semester with Scribd & The New York Times

Special offer: Get 4 months of Scribd and The New York Times for just $1.87 per week!

Master Your Semester with a Special Offer from Scribd & The New York Times