RESPIRATORY SYSTEM Normal Value of Atmospheric Pressure (PA) 760 mm Hg 14.

4.7 psi (pounds per square inch) Important Concepts!!! Principle of air flow is from areas of higher pressure to areas of lower pressure For exchange of gases to occur, NORMALLY (N), there must be a pressure gradient of PLUS AND MINUS SIX (+/-) 6 mm Hg Pressure must be positive (+) (or greater outside) to enter the lung
RESPIRATORY MECHANISM Respiratory Muscles 1. Diaphragm 2.Pectoral Muscle 3. Intercostal Muscles Lung Size Thorax Size Intrapulmonic Pressure Intrathoracic Pressure INSPIRATION EXPIRATION

Larynx Trachea Bronchi Lungs

Lowers and contracts Contracts Moves inward and contracts Increases Increases Decreases (less than atmospheric pressure) Decreases (less than atmospheric pressure)

Rises and relaxes Relaxes Moves outward and contracts Decreases Decreases Increases (greater than atmospheric pressure) Increases (greater than atmospheric pressure)

Important Concepts!!! Hilus o Hilar Mass Pleurisy o Pleural Effusion Intrapulmonic Space o Space inside the lung Intrathoracic Space o Space between the lungs and the bony thorax Normal Respiratory Rate o Twelve (12) cycles per minute o Also known as Eupnea Tachypnea o Respiratory Rate above the normal rate Bradypnea o Respiratory Rate below the normal rate Apnea o Absence of Respiration jor absence of breathing Types of Respiration Reference is the cell Internal or Cellular Respiration External Respiration Important Concepts!!! Hyperpnea o Deep Breathing Hypopnea o Shallow Breathing Kussmauls Breathing o Deep, rapid breaths Factors Affecting the Rate and Depth of Respiration

Important Concepts!!! Upper Respiratory Tract Composed of: Nose Pharynx Associated Structures Lower Respiratory Tract: Composed of: 1

Neurological Medulla Center of Respiration Pons Affects the rhythm Expansion of the lungs Herring Brewer Prevents over distension of the lungs Clinical Arterial Blood Gas Artery o Complete presence of oxygen and carbon dioxide Parameters: o pH 7.35 to 7.45 o pHCO3 22 to 26 meq / Liter o PCO2 35 to 45 mm Hg o PO2 80 to 100 mm Hg (for adults) 40 to 60 mm Hg (for infants) If increased or greater than 60% in infants, it leads to RETROLENTAL FIBROPLASIA Important Concepts!!! Acidosis or alkalosis is detected by the pH Control: Respiratory / metabolic Bicarbonate o Buffer / neutralizer o Must be > 26 meq / L to counteract acidosis Kidney o Base factor

Determination of Lung function o PCO2 Hypoxic Drive o Stimulant is CO2 Hyperventilation o Prone to Alkalosis o Patient gets a lot of O2 o Decreases amount of CO2 o Therefore, breathe inside a bag o Do paper bag breathing o Do cupped hand breathing Respiratory Acidosis o Do pursed lip breathing o You want to retain positive (+) pressure on the lung o Takes effect on CO2 utilization o To remove CO2 Expiration is prolonged (longer than inspiration) by pursed lip breathing ASSESSMENT TO RULE OUT RESPIRATORY DISORDER 1. Cough Important Concept!!! Three (3) types of cough medications: Antitussives o Suppresses the cough reflex Expectorant o Clears the airway Mucolytic o Lyses, breaks down, liquefies the phlegm Types of Cough 1.1) Non-productive Cough With presence of phlegm With copious amounts of phlegm 2

 Phlegm is retained and is not expelled from the body Medication is a MUCOLYTIC o It lyses, breaks down and liquefies the phlegm 1.2) Productive Cough With presence of phlegm With copious amounts of phlegm Phlegm is being expelled from the body Medication is an EXPECTORANT o To clear airway 1.3) Dry Cough No phlegm Cough needs to be suppressed Medication is an ANTITUSSIVE o With sedating effect Important Concept! o No antitussive is given when there is phlegm o Suppression of cough will not allow the phlegm to be expelled from the body 2. Sputum and Phlegm 2.1 Color Important Concepts!!! Saliva o Normal color is clear Phlegm o Red With blood Hemoptysis Spitting of blood Hematamesis Upper GI bleeding

Vomiting of bright red blood

o Yellow Green Signifies infection o Greenish Depends on type of infecting microbe o Rusty Brown Blood is brownish due to extravasation Pneumonia Due to blood (old blood) Viral or bacterial With consolidation (hardening or naninigas) o Two Types of Consolidation Lobar Occurs at the lobes Bronchial Occurs in the bronchi Occurs in bronchopneumonia More common Interjected Concept! Pulmonary Tuberculosis o Bacterial o Mode of Transmission Droplet nuclei o Route Airborne o It is appropriate to wear MASK o It is inappropriate to wear GOWN

o With CAVITIES Other Interjected Concepts! Black and tarry stool o Indicates dead blood Melena indicates upper GI bleeding 2.2) Viscosity and Tenacity Mucin o Makes saliva slippery Phlegm o Irritated saliva o Thick and tenacious saliva Hypermucous Production o Leads to phlegm Important Interjected Concepts!!! Rhinitis o Nasal cavity inflammation Colds o Viral in nature Coryza o Viral in nature Glossitis o Inflammation of the tongue Glottitis o Inflammation of the glottis Tracheitis o Inflammation of the trachea Bronchiolitis o Inflammation of the bronchioles Pneumonitis o Inflammation of the alveoli Gastritis o Inflammation of the stomach Stomatitis o Inflammation of the oral cavity

Important Interjected Concepts! Signs of Inflammation Rubor o Redness Calor o Heat Tumor o Swelling Dolor o Pain Functiolaesa o Loss of Function Viscosity and Tenacity of Sputum (continued. . .) 2.2.1) Frothy Sputum Air is present but is due to PULMONARY EDEMA Pneumothorax o Air at intrapleural space 2.2.2) Stringy and Thready (thinner) Sputum Due to BRONCHIAL ASTHMA Masyadong malagkit Caused by allergen o Dust o Pollen o All dust particles Interjected Concept Clear and stretchy vaginal mucus or discharge indicates fertility 3. Assess for Cyanosis Bluish color due to lack of oxygen 3.1) Central Cyanosis Bluish coloration of the: Face Chest

3.2) Peripheral Cyanosis Bluish coloration of the extremities 3.3) Differential Cyanosis Acrocyanosis Use Apgar scoring o Within one (1) minute o After five (5) minutes APGAR also stands for: o A for Appearance o P for Pulse Heart Rate determines if the baby is alive o G for Grimace To rule out neurological problems or problems with the nervous system Important Concept!! In newborns, eyeblinking before crying is Normal If there is NO BLINKING, this indicates A SIGN OF MYASTHENIA GRAVIS of the newborn This indicates that there is NO INNERVA-TION o A for Activity Muscle Tonicity o R for Respiration Changes in respiration requires immediate intervention and action First thing to do to newborn: 5

Suction

4. Abnormal Breath Sounds Also called Adventitious Breath Sounds 4.1) Rales Two (2) types: Fine Rales Coarse Rales 4.1.1) Fine Rales Sound similar to when you rub your hair Also called Friction Rub 4.1.2) Coarse Rales Sound similar to crumpling of paper 4.2) Ronchi Sound similar to bubbling water 4.3) Wheezing Musical sound Whistling sound Occurs more on or during expiratory phase Important Concept! Abnormal breath sounds are due to: o Obstruction o Phlegm 5. Abnormal Respiration Pattern of breathing or sequence of breathing 5.1) Biots Respiration Initially NORMAL Followed by APNEA Then NORMAL Then APNEA

 Pattern is NANA normal, apnea, normal, apnea, etc. 5.2) Cheyne Stokes Initially NORMAL Followed by HYPERPNEA (deep breathing) Then APNEA Pattern is NHA normal, hyperpnea, apnea 5.3) Kussmauls Respiration Hyperpnic with tachypnea Malalim na, mabilis pa Asthmatic and labored breathing Common Signs and Symptoms of Respiratory Diseases 1. Dyspnea Also called Difficulty of Breathing o Management Positioning HighFowlers Interjected Concept!! In reverse trendelenberg, only the head part is elevated This is indicated for arterial occlusion 2. Cough 3. Anorexia o Loss of appetite o Management Provide small frequent feedings Patient chooses his own food Nurse assists in the selection of the food Good oral hygiene triggers appetite 4. Weight Loss 6

5. Malaise o Weakness 6. Easy Fatigability o Management o Provide bed rest 7. General Debilitation o Loss of function o Patient wants to move but is unable to do so o Debilitation Apathetic (schizophrenic) 8. Irritability Interjected Concept!!! Correct technique in cleaning the patient is from A CLEANER AREA to a DIRTIER AREA to avoid conveying infection Chronic Signs and Symptoms of Respiratory Diseases Overdeveloped strap muscles Elevated sternum and shoulder Barrel chest or Pigeon Breast o No elastic recoil o Common in emphysema Stridor o Noisy Respiration Clubbing of Fingers o Caused by hypoxia of the joints Chest Retraction Interjected Concept! The urinary bladder is considered full when it contains a volume of about 450 to 500 ml You cannot stop the urge to void at this level of fullness of the urinary bladder General Management Techniques: To minimize weakness

o Provide bed rest For dyspnea o Proper positioning Provide good nutrition o Proper and balanced nutrition Environmental Sanitation Oxygenation o If patient is dyspneic and not relieved by positioning o Nasal Cannula or nasal prongs o Nasal flow Low flow One (1) to three (3) liters per minute Average of two (2) liters per minute High flow is at six (6) liters per minute Coupette o A plastic bubble Isolette o An incubator Nasal Catheter Tip should be placed posterior to the uvula

reverse isolation because they are prone to infection AIDS patients are on reverse isolation because they are immunocompromised

Important Concepts!!! If the respiratory disease in an infectious disorder, management would include the following: Isolation o Reverse Isolation Patient is being isolated because he could easily be infected by diseases The patient himself is being protected Example: Burn patients are subjected to

o Strict Isolation Patient is being isolated because he can readily spread the disease The people around the patient are being protected Example: PTB patients are subjected to strict isolation Mycobacterium tuberculosis is transmitted through droplet and is airborne Medication o A dependent function o Antibiotics are administered o For allergens Antihistamines are given o Bronchospasm Bronchodilators o Cough Cough medication RESPIRATORY DISORDERS PULMONARY TUBERCULOSIS Causative agent is Mycobacterium tuberculosis

 Acid-fast bacillus Temperature o Coated with wax o Melt this with temperature (an additional factor) Mode of transmission is droplet / airborne Stages of Pulmonary Tuberculosis Stage No. 1 MINIMAL INFILTRATION No cavitaries but with lesion Primary complex in children With chemotherapy or multi-drug therapy Urine becomes BRICK ORANGE o Due to Rifampicin o A normal and expected side effect of Rifampicin use Interjected Concepts!!! In cancer, chemotherapy causes the following: o Alopecia Loss of hair o Keratin Protein in the hair o Collagen Protein in the internal organs o DNA and RNA proliferation is blocked Stage No. 2 MODERATELY ADVANCED With cavitary One-half of lung is affected Lobectomy or removal of one lobe is performed Initially, position the patient at the UNAFFECTED SIDE Then, turn patient on an hourly basis 8

Stage No. 3 FAR ADVANCED With cavitary Whole or entire lungs are affected Pneumonectomy or removal of the entire lungs is performed Position patient at the AFFECTED SIDE Mediastinal Shift is a common complication Turning on an hourly basis is also performed Diagnostic Tests for Pulmonary Tuberculosis Chest X-ray To show where the lesion is located Sputum Examination Culture and Sensitivity To identify the bacteria To know what antibiotic will be used to combat the invading microorganism The doctor and the medical technician would perform this White Blood Cell (WBC) and Erythrocyte Sedimentation Rate (ESR) Test Increased WBC levels indicate: o Bacterial infection o Kochs infection Mantoux Test or Tubercullin Test Utilizes PPD (Purified Protein Derivative) Route is Intradermal Result is read after forty-eight (48) to seventy-two (72) hours Positive Reading if:

o 10 mm induration or diameter of the wheal (hardness or pantal but not the erythema) o 5 mm induration for HIV positive patients Important Concepts! A positive result or a positive Mantoux Test does not mean that a person has PTB It only means that the person had been exposed to the invading bacteria Then, it is advised that the other tests would be performed The most credible test is the SPUTUM TEST (also for pneumonia) You will know the microorganism You will know the drug to be used Signs and Symptoms of PTB Fever o Low grade fever (onset) in the afternoon o Patients resistance is low at this time o Virulence also increases o If PTB is advanced, fever does not manifest as low grade Excessive Sweating o Hyperhidrosis Dehydration o Management is to increase oral fluid intake Anorexia Weight Loss Easy Fatigability Management of PTB patients Bed Rest Positioning 9

For patients with dyspnea, place in high-Fowlers position Provide good and proper nutrition Increase Fluid Intake Medication o Triple Chemotherapy o Rifampicin Brick orange urine o Isoniazid (INH) Peripheral neuritis Provide Vitamin B6 or pyridoxine o Pyrazinamide (PZA) Gout formation Uric acid crystals Important Concepts!!! In PTB, there is an onset of lowgrade fever In Pneumonia, there is an onset of high-grade fever Short-Course Chemotherapy Six (6) months Prolonged o More than one year Use Ethambutol o Side effect is OPTICAL NEURITIS Use Streptomycin o Side effect is on the 8th cranial nerve o Therefore, this is OTOTOXIC CHRONIC OBSTRUCTIVE PULMONARY DISEASES Mnemonic is ABBE Asthma Bronchitis Bronchiectasis o With scarring or nodules called SARCOID

o With numerous sarcoids called SARCOIDOSIS May lead to: o Lung cancer o Emphysema Important Concept on COPDs!!! All COPDs are characterized by: Presence of phlegm Obstruction by phlegm Signs and Symptoms of COPD Productive Cough Exertional Dyspnea o In asthmatic Pink Cyanosis o Due to compensatory mechanism Blue bloaters o Cyanosis o Hyperventilate o Reddish during attack hyperemia o Increases altitude and decreased PO2 results into hyperemia Wheezing o Expiratory Barrel Chest o Common in emphysema Anorexia Followed by weight loss, body malaise, etc. Respiratory infection Fatigue Cor Pulmonale o Right Ventricular Hypertrophy due to increased vascular resistance or vasoconstriction Results into a BOOT-SHAPED HEART

Nursing Interventions for COPD patients: Assess the following: o Breathing pattern o Breath sounds o Secretions Promote mobilization of secretions through: o Mucolytic agents o For productive cough, use expectorants o Increased humidification of moistening o Fluid intake of 1.5 to 2.0 liters per day Saliva is not part of daily fluid loss o Suctioning o Chest Physiotherapy o Positioning to allow maximum breathing o Teach the patient to use pursed lip breathing Administer low flow oxygen Monitor therapeutic and side effects of the medications used Bed rest Encourage Range of Motion exercises Assist with activities of daily living (ADL) as needed Assess for signs of infection Provide proper caloric requirement: Increase protein intake Provide health teachings: o Avoidance of smoking, irritants, infection o Avoidance of extreme temperatures o Proper nutrition and hydration o Use measures to conserve energy

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Important Concepts!!! For Orthopnea o Do the Orthopnic position o Fowlers Position and lean forward o Lung is most expanded in this position o Lung is most open in this position o Lungs expand but they do not thicken Atelectasis o Lung collapse o Overdistended lung collapse Emphysema o Bursting of alveoli o Bleeding occurs o If there is pus, it is called EMPYEMA Pyothorax o Presence of pus in the pleural space Important Concepts!!! The heart is located at the center of the chest The apex of the heart is positioned to the left of the chest Right Atrium is larger than the other chambers The Left Ventricle has the highest pressure among the four chambers of the heart This serves as the main pump of the heart Cardiac Output o Five (5) to seven (7) liters o Average is six (6) liters Stroke Volume o Amount or volume of blood released through the heart in one beat

o Equivalent to about fifty (50) to seventy (70) ml Tidal Volume is about 500 to 700 ml per respiration Cardiac Output o 5 7 liters per minute Stroke Volume o 50 70 ml per beat Tidal Volume o 500 700 ml per respiration

Important Concepts!!! Approximate Distribution of Oxygen in the Body Brain 15% of oxygen in the circulating blood Heart 5% of oxygen in the circulating blood GI and Liver 25% of oxygen in the circulating blood Renal System 25% of oxygen in the circulating blood Extremities 30% of oxygen in (upper and the circulating lower) blood Important Concepts!!! Decreased level of consciousness Caused by peripheral hypoxia Syncope o Fainting Tachycardia o Early sign of decreased level of consciousness Bradycardia o Late sign of decreased level of consciousness Interjected Concepts!!! Angina Pectoris 11

o Stabbing pain o Unifocal pain Myocardial Infarction o Crushing pain o Excruciating pain o Radiating to the left Due to the fact that the output is at the left Coarctation of the aorta Other Important Concepts!!! Pulse Deficit o The difference between the APICAL and the BRACHIAL PULSE o Normally, the difference between these values is ZERO o Difference signifies the presence of an OCCLUSION Pulse Rate resembles the Heart Rate Pulse Pressure o Systolic-Diastolic o Normal is 40 mm Hg o Artery is 40 mm Hg o Vein is 10 mm Hg o Artery has pulse Tricuspid Valve is located between the Right Atrium and the Right Ventricle Important Concept!!! Cor Pulmonale Also called Right Ventricular Hypertropy Pulmonary artery constriction leads to decreased blood flow to the lungs for oxygenation Blood is, therefore, retained at the Right Ventricle

A sphincter can be opened by increased pressure A valve cannot be opened by increased pressure Therefore, there is an INCREASE IN THE SIZE OF THE RIGHT VENTRICLE Cor Pulmonale results into a BOOT-SHAPED HEART Suctioning OB-gyne o The first thing to do to the newborn in the Philippine setting is to SUCTION THE BABY CGFNS o The first thing to do to the newborn is to WRAP THE BABY to prevent hypothermia Situation: Newborn has mucus on mouth and nose. Question: Which do you suction first? Answer The mouth! Rationale: There is more mucus in the mouth from the GI tract. This gives rise to greater risk for aspiration Then place the patient on lateral trendelenberg Important Concept!! Infants are obligate nose breathers Important Concepts!!! After a month, if the infant has a respiratory disorder o Suction the NOSE FIRST

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 In adults, the nose is cleaner Therefore, the proper sequence of suctioning is from cleaner to dirtier (nose then mouth) Interjected Concepts!!! Wash the breast of a woman with lukewarm water Important Concepts!!! For patient with increased Intracranial pressure and mucus at both the nose and the mouth o Do suctioning only at the mouth o Do not suction at the nose o This would cause the patient to sneeze Sneezing further increases intracranial pressure Chest Physiotherapy (CPT) Done on the chest in a gentle manner If the patient is female, do it at the upper part of the chest Composed of: o Tapping Using one hand With greater force o Clapping Using both hands o Cupping Using one hand Position o Semi-Fowlers Position Important Concepts! Back tapping, back clapping and back cupping is not part of CPT Low-flow oxygenation is used in COPDs to maintain hypoxic drive o CO2 stimulates breathing Use pursed lip breathing for acidosis to maintain positive (+) pressure as expiration is longer 13

Signs and Symptoms of Infection Mnemonic is SHIRP S is for: o Swelling H is for: o Heat I is for: o Impaired Motor Function R is for: o Redness P is for: o Pain Important Concepts!!! If infection is present, there is ALWAYS INFLAMMATION But not all inflammation is accompanied by infection Increase protein in diet for tissue repair Increase protein in diet for repair of lung tissue Extreme temperature is a triggering factor for asthma but is not an allergen PNEUMONIA Viral and bacterial With consolidation With fever High-grade at onset During an attack of pain, position the patient ON THE AFFECTED SIDE Management o Turn patient Turning promotes circulation Without circulation, one cannot remove the consolidation of phlegm o Cough-up

Priority intervention First thing to do Increases circulation to remove consolidated phlegm o Deep Breathing LUNG CANCER Biopsy is needed to confirm this disease Real cause is unknown, idiopathic Smoking only decreases cellular resistance Predisposing Factors in Lung Cancer Familial o Genetic / hereditary Cigarette smoking o Second hand smoke o Filtered cigarettes lessens contamination Exposure to occupational carcinogens o Asbestos Asbestos in lungs in increasing quantities causes lung cancer o Silicosis Silicon oxide in lungs o Talcosis Cement in the lungs o Bronchiectasis Nodules are sarcoid Benign or malignant Diagnostic Tests for Lung Cancer Chest X-ray To know where the tumor is 14

CT Scan CAT Scan For axial skeleton Sputum Examination Cytologic examination of the sputum Bronchoscopy Direct visualization of the trachea and the bronchus If with biopsy, it is called FIBEROPTIC BRONCHOSCOPY Pre-procedure o Anesthesia is given o Xylocaine applied Post-procedure o NPO until gag reflex returns Without the presence of the gag reflex, there is a risk for aspiration Signs and Symptoms of Lung Cancer Persistent Coughing and Expectoration o Phlegm o Irritation due to the presence of tumor o This is the CLASSIC SIGN and SYMPTOM of lung cancer Dyspnea Dysphagia Hoarseness of voice o Vocal cords are compressed by the tumor Anorexia Important Interjected Concepts!!! Pediculosis o Presence of lice PTB is characterized by: o Bacterial causation

o Cavitaries in the lungs o Low-grade fever (onset) with chills Lightening o Fetus if floating above pelvis Descent o Also considered as STATION o Fetus is no longer floating above pelvis but is at the level of the ischial spine Crowning o Fetus is at about +3 or +4 relative to level of the ischial spine Chest Tube Thoracostomy Tube Purposes: o Primary Purpose For re-expansion of the lung o Secondary Purpose To maintain negative pressure in the lung through drainage Important Concepts! All chest surgeries require chest tubes In pneumonectomy, no lungs are left All bottles should be placed below the chest level Bubbling must be intermittent If bubbling is continuous, there IS A LEAKAGE Fluctuations in water level is normal Upon INSPIRATION o The water at the tube DESCENDS

o The water level at the bottle ASCENDS Upon EXPIRATION o The water at the tube ASCENDS o The water level at the bottle DESCENDS Avoid milking and kinking the tube o These are not routinely done Negative pressure is suction pressure Clamping of the tube is NOT DONE

Indicators for Chest Tube Removal Absence of distress Absence of fluctuation o This means that the lung is already re-expanded Normal breath sounds in the area Fully expanded lung on X-ray is the most determinant indicator o This means that the primary purpose has been served Important Concepts!!! When pulling out the Chest Tube o Ask the patient to EXPIRE o Thorax should be airtight o Petroleum gauze is needed before pulling out the tube If Valsalva is included in the choices in the board examination, CHOOSE VALSALVA Interjected Concept!!! In the removal of the Foley Catheter, o Ask the patient to INSPIRE This allows the patient to relax 15

GENITOURINARY TRACT Important Concepts! The female labia majora is homologous to the male scrotum The female clitoris is homologous to the male glans penis Both these structures have a special type of blood vessel containing erectiles The meatus is the area where the urine is passed out The female urethra is the avenue for passage of urine while the male urethra is the avenue for the passage of both urine and sperm The females have a vaginal opening a canal serving as the receptacle for the penis Both sexes have a rectum and an anus Catheterization Done to prevent urinary retention and bladder distention Important Concepts!!! The urinary bladder is paralyzed by anesthesia Vaginal Opening o Speculum For pap smear For dilatation and curettage Vaginal Douche o For Vaginitis o This is an acidic solution o Contains lactic acid or acetic acid o Normal pH of the vagina is 4.5 to 5.5 o Acidic environment aids to prevent possible infection Enema 16

o Applied to the rectum o For diagnostic purposes: Barium Enema White and milky o For cleansing purposes Base enema Soap enema Important Concepts!!! Upper GI Series o Barium Swallow Lower GI Series o Barium Enema Skenes Gland in Females o Found at the sides of the urinary meatus o For lubrication purposes o Homologous to the Cowpers gland in males Bartholins Gland o Found at the sides of the vaginal opening o Also for lubrication purposes Smegma o This is the cheesy white substance found around the clitoris Radical Perineal Prostatectomy o This is a procedure done to males o Therefore, males also have a perineum Fourchette o Site of episiotomy o Site of episiorraphy On the mons pubis o APOCRINE GLANDS are present Sweat glands Present at puberty o When young, these are ECCRINE GLANDS

KIDNEYS Paired, comes in the same size Position o Right kidney is lower due to the anatomical position of the liver o Fat anchors the kidney to maintain it at the retroperitoneal area Important Concepts!!! Glomerular Filtration Rate (GFR) Normal Value o 125 ml per minute Normal Urine Production o 0.5 to 1.0 ml per minute o 24 ml reabsorbed by the kidney Micturition Reflex o 250 450 ml o 125 ml can still be contained Hydronephrosis o Drowning of the kidney in urine Nephrotosis o Falling of the kidneys o When fat is lost o Kidney falls o Ureter kinks Nephrosclerosis o Hardening of the Kidney Arteriosclerosis o Hardening of the arteries Important Terminologies!!! Nephrolithiasis o Stones in the kidney Ureterolithiasis o Stones in the ureter Cystolithiasis o Stones in the bladder Urolithiasis

o Stones in the urinary tract Stones in the Biliary Tract o Cholelithiasis Stones in the gall bladder o Choledocholitihasis Stones in the bile duct BREAST CANCER Idiopathic Left breast o Commonly first to develop tumor o Less active tissue is tumor prone Heart is an involuntary organ o Heart is active o Thus, there is no cancer of the heart Predisposing Factors in Breast Cancer Familial o Genetic Hormones o Estrogen o Extremes of estrogen Positive estrogen receptor tumor Negative estrogen receptor tumor In menopause, there is higher negative estrogen receptor tumor Early Menarche (first menstruation) Positive estrogen receptor tumor o Nulliparity

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Unable to give birth due to inability to become pregnant Reproductive age is from 15 to 45 o Also due to failure to breast feed o Andropause is male menopause o Radiation Breast tumor Breast gland tumor Adenocarcinoma o Obesity 20% and above ideal weight o Multiple Pregnancy Presence of more than one (1) fetus Uniovular One (1) zygote Monozygotic twins Same sex Biovular Two (2) egg cells Two (2) zygotes Dizygotic twins or fraternal twins May be of different sexes o Isograft Graft from identical twin Signs and Symptoms of Breast Cancer Cyst o Movable Breast Tumor

o Fixed o Non-encapsulated o Therefore, it can metastasize o Commonly located at: Upper outer quadrant near the axial (tail of Spence) Below the nipple o This results to ELEVATION when the tumor is SHALLOWLY LOCATED o This may also result to RETRACTION when the tumor is DEEPLY LOCATED Usually painless INITIALLY o Pain is present at VERY LATE STAGE With discharge that may be clear or bloody Skin Dimpling Skin Elevation Lymphadenopathy on affected arm

Important Concept! For non-lactating women with breast discharge: o No cancer yet o Have check-up Diagnostic Test for Breast Cancer Biopsy o Excisional Biopsy Tumor is removed o Incisional Biopsy Only a portion is removed o Needle Biopsy

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Done through aspiration

Management of Breast Cancer Medical management Surgical management o Lumpectomy Surgical removal of non-cancerous mass Wedge resection o Mastectomy Removal of the breast o Radical Mastectomy Removal of the breast and other tissues o Simple Mastectomy Breast alone is removed Fat alone Important Concepts!!! Post-mastectomy o Elevate affected arm above chest or heart level o Use pillows to elevate arm Hemovac o Suction Check the back for bleeding Protect affected arm o Prevent overuse for first two months o Overuse of affected arm is contraindicated No exercise that is strenuous No exposure to sunlight Breast Self Examination (BSE) o Done one (1) week after menstruation o Because estrogen is elevated o Use one hand

Three fingers Outer to inner Anytime of the day Lift up affected arm If lying down, put a pillow at the back o If patient is already menopause, BSE could be done anytime o o o o o Interjected Concepts!!! In thyroidectomy, check the nape In obtaining urine specimen: o Get this early in the morning o First void is discarded o Midstream void is collected as specimen Parasympathetic Nervous System o Increases smooth muscle activity of glands o Salivation during sleep Atropine Sulfate o Used to decrease secretions With anti-cholinergic effect URINARY TRACT Kidneys Most aggressive Functions of the Kidney: Homeostatic Functions o Fluid and Electrolyte Balance o Acid-Base Balance o Hemoconcentration Through filtration Secretory Functions o Urine o Renin o Erythropoietin Excretory Functions

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Water Electrolytes Metabolic Wastes Urea Purines converted into uric acid o Creatinine Metabolic waste from muscles Reaction to tissue damage Very credible measure of kidney function o Presence of damaged tissues and cells results to increase in Creatinine levels o In Brain Damage Creatinine released is creatinine kinase or BB o In Heart Damage Creatinine released is MB o In damage of other muscles Creatinine released is MM o Blood Urea Nitrogen Affected by protein diet Vitamin D Synthesis o Vitamin D comes from food o Raw vitamin D o Goes to the kidney and the skin o Must be exposed to ultraviolet radiation to be converted to its active form o Deficiency of Vitamin D results into weak bones Ricketts in children o o o o o

Osteomalacia in adults

Abnormal Constituents of Urine Normal urine has hormones Glucosuria o Presence of glucose in Diabetes mellitus patients Diabetes insipidus patients have decreased levels of Anti-diuretic Hormone or ADH o This leads to the two (2) Ps Polyuria Polydipsia Diabetes mellitus patients have problems with insulin o This leads to the three (3) Ps Polyuria Polydipsia Polyphagia Types of Diabetes Mellitus Type 1 Diabetes mellitus Insulin Dependent Diabetes Mellitus Juvenile onset More controlled diet is necessary More severe type of diabetes Pancreas could not produce insulin Insulin is administered to the patient Fats and proteins are utilized by the body in a process called gluconeogenesis Utilization of fats results in the formation of ketones This leads to DIABETIC KETOACIDOSIS Blood becomes more viscous

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 There is less plasma due to dehydration secondary to polyuria Type 2 Diabetes mellitus Adult onset Non-ketotic diabetes Management: o Diet o Exercise o Oral hypoglycemics Type 3 Diabetes mellitus Gestational Diabetes Type 4 Diabetes mellitus Secondary DM Caused by disease Important Interjected Concepts!!! In polycythemia vera o There is also increase blood viscosity o However, there is no decrease in blood volume (this occurs in DM) Hematuria o Blood in the urine o This is ABNORMAL Pyuria o Pus in the urine o This is ABNORMAL Proteinuria o Presence of protein in the urine o This is ABNORMAL Blood contains the following: o Albumin o Globulin o Fibrinogen Albuminuria o Presence of albumin in the urine

o Results into decreased albumin in the blood o This brings about DECREASED OSMOTIC COLLOID PRESSURE o This leads to EDEMA o To compensate for Albumin loss, lipid levels increase in the blood o This results to HYPERLIPIDEMIA o Hyperlipidemia contributes to both: Atherosclerosis Deposition of fat at the blood vessel Arteriosclerosis Hardening of the blood vessels Hypertension o Increased pressure o Decreased perfusion Thirty percent (30%) of oxygen goes to the extremities SEIZURE DISORDERS Epilepsy Convulsions Types of Seizures Petit mal seizures o Short-term seizures Grand mal seizures o Involves the whole body o With aura o Lasts for one (1) to two (2) minutes Myoclonic Seizures o Involves the upper extremities Akinetic Seizures o Patient collapses

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o Drop attack Jacksonian Seizures o Partial seizures o Patient can still walk Psychomotor Seizures o Decorticated o Decerebrated Types of Convulsions Tonic o Sustained o Prolonged Clonic o kabilaan Tonic-Clonic o kabilaan at matagalan Epiliptiform o Can recover quickly Important Concepts!!! Epilepsy is more serious than convulsions Fainting always occurs with epilepsy In epilepsy, EEG is needed URINARY TRACT INFECTION (UTI) Urethra is affected Females are commonly affected o Due to the proximity of the anus to the urinary meatus E. coli o Normally present in the colon o Normal flora in the colon o Comes out even during flatus Management of UTI Increase fluid intake Collect sterile urine specimen o First void is discarded o Midstream void is collected

o For urine culture and sensitivity test Provide warm SITZ BATH o In the hospital, warm water is used to submerge patient up to below the level of the umbilicus o Also called HIP BATH Suob o Warm compress Medications for UTI Antibiotics are given Important Concepts!!! Nystatin is given In cases of fungal infection related to antibiotic therapy Oral Thrush Management o Padded tongue depressor Swab ACUTE GLOMERULONEPHRITIS (AGN) Causative organism Group A Beta-hemolytic Streptococcus (GABHS) Assess to rule out Upper Respiratory Tract Infections Tonsillitis 6x or chronic type Suggestive of tonsillectomy Both are indication or complication of Acute Glomerulonephritis and Rheumatic Heart Disease Anasarca o More prominent in lower extremities o Prevent complications Management of Lower Extremity Edema Modified trendelenberg 22

 Elevate Types of Edema Bipedal Edema o Feet Edema Sacral Edema Ascites Carpal Edema Facial Edema Periorbital Edema Important Concepts!!! Right-sided Congestive Heart Failure o Systemic effects o Compromises the kidney Important Concepts in Acute Glomerulonephritis This would bring about perforations in the glomeruli and damage the permeability of the glomerular wall Assess for Albuminuria Hypoalbuminemia or Albuminuria o Gives rise to decreased COLLOID OSMOTIC PRESSURE o Decreased colloid osmotic pressure gives rise to EDEMA Heart o Left-Sided Congestive Heart Failure Affects the Pulmonary Circulation o Right-Sided Congestive Heart Failure Affects the Systemic Circulation Kidney o Anasarca or full-body edema 23

Increase in Lipids o Hyperlipidemia o Gives rise to Hypertension o Hypertension gives rise to seizures o Seizures gives rise to convulsions Edema o Results into decreased blood volume o Decreased blood volume translates to hypovolemia Oliguria o Scanty urine Hematuria o Blood in the urine o Brought about by perforations in the kidney caused by GABHS Blood Urea Nitrogen Clearance o The manner in which the kidney can clear Blood Urea Nitrogen o This decreases in AGN Blood Urea Nitrogen (BUN) o Increases due to the presence of oliguria o Normal Value 10 20 mg / dl o Other sources say it is: 5 25 mg / dl 8 25 mg / dl o Lowest BUN value in Females is 4 8 mg / dl o Therefore, always assess for BUN AGN onset with Hypertension NEPHROTIC SYNDROME A cluster of diseases End point of a variety of diseases damaging the permeability of the glomerular wall Therefore, there is POLYURIA

 During the onset, there is. . . o HYPOTENSION During the latter stage, there is. . . o HYPERTENSION When the glomerular wall becomes perforated and the permeability is damaged Proteinuria Edema Hyperlipidemia Hypertension

For the brain I.V. route for quick effect Example: o Mannitol Important Concepts!!! To decrease lipid levels in hyperlipidimia o Use LIPOSTAT Prevents lipid proliferation Hyperlipidemia o Increased lipid levels in blood o Results into scarring of blood vessels o Blood accumulates in scarred areas o Thrombus formation or blood clots occur in the scarred areas of the blood vessel walls o Thrombus detaches from the blood vessel wall and is carried by the blood. Thrombus is now called an embolus Important Terminologies!!! Thrombosis o Presence of plenty of thrombi Venous Thrombosis o Presence of plenty of thrombi in the veins Thrombophlebitis o Inflammation of the veins Arteritis o Inflammation of the arteries Interjected Concepts!!! Angio signifies arteries Thromboangitiis obliterans o Buergers Disease 24

Management of Edema Use diuretics 1. Chlorothiazide Group Example: o Diuril 2. Loop Diuretics Stops reabsorption of water at the loop of Henle Example: o Lasix 3. Potassium-sparing Diuretics For patients with heart condition Allows sodium out and lets potassium get in Example: o Spironolactone 4. Osmotic Diuretics

o Brought about by smoking o Nicotine causes vasoconstriction o Lower extremities usually affected Raynauds Disease o Affects mostly females o Upper extremity affectation Avascularity o Peripheral Vascular Diseases Raynauds Disease Buergers Disease Gangrene Massive blood vessel death Amputation is needed in gangrene All thrombi are blood clots o Therefore, all thrombi are blood But not all emboli are blood o Other types of emboli are: Air emboli Fat emboli Anticoagulants o Heparin Provides quicker anti-coagulant effect Effect manifested in hours or in one (1) hour o Warfarin Provides slower anti-coagulant effect Effect manifested in two (2) to three (3) days Heparin o Protamine Sulfate

Antidote of heparin Partial Thromboplastin Time (PTT) o Related to heparin o Normal is 26 to 32 seconds This is without heparin o In the presence of heparin PTT increases to one and one-half to two times its normal value (1.5x to 2.0x normal value) Approximately sixtyfour seconds (64 secs.) PTT Range of 60 70 seconds indicates that patient is properly heparinized o Thromboplastin is clotting factor number three Warfarin o Antidote is Vitamin K Prothrombin Time (PT) o Related to warfarin o Normal is 11 to 12 seconds o Other sources say that normal PT is 9.5 to 11.3 seconds o This is in the absence of warfarin o In the presence of warfarin, PT is lengthened or increased to 1.5x to 2.0x its normal value Effect of warfarin is manifested in two (2) to three (3) days NEPHROLITHIASIS Renal Calculi Two Types 25

o Acid Stone o Alkali Stone Acid Stone Uric Acid Stone Vitamin C Alkali Stone Calcium oxalate o Magnesium o Phosphate o Ammonium Vitamin D Predisposing Factors in Nephrolithiasis Diet rich in the following: o Vitamin C o Vitamin D o Calcium Immobility o Blood stasis Frequent Urinary Tract Infections o Scanty urine that does not irritate Signs and Symptoms of Nephrolithiasis Pain o Flank pain o In person with Cystitis There is a drip Oliguria Hydronephrosis Hematuria High-grade fever with chills Management of Nephrolithiasis Increase oral fluid intake Lithotripsy Intraurethral Lithotripsy o No incision Percutaneous Lithotripsy

o With small incision o With suction o Basket type Extracorporeal Shock Wave Lithotripsy (ESWL) o External o No incision o Increase fluid intake to remove stones which have been rendered smaller in size by the procedure Lithotomy Removal of stones o Nephrolithotomy Removal of stones in the kidney o Cystolithotomy Removal of stones in the urinary bladder o Ureterolithotomy Removal of stones in the ureter Urolithotomy o Removal of stones in the urinary tract RENAL FAILURE Two (2) Types Acute Renal Failure Chronic Renal Failure Acute Renal Failure Characterized by: Onset of sudden loss of glomerular function Potassium intoxication Metabolic acidosis Chronic Renal Failure Characterized by: Onset of gradual loss of glomerular function 26

 Potassium intoxication Metabolic acidosis Important Concepts in Renal Failure Potassium goes out This gives rise to potassium intoxication Sodium gets in H+ goes out when sodium comes in o This makes the blood acidic o This produces a decrease in bicarbonate (HCO3-) levels, giving rise to Metabolic Acidosis Signs and Symptoms of Renal Failure Lethargy o Due to cerebral hypoxia Edema o In the form of anasarca Decreased blood volume o Hypovolemia o Hypotension o Dizziness o No pain Hypertension o Occipital Headache o Problems with blood passageway o They become more constricted o Dizziness then sets in Pale o Decreased blood supply Ascites Abdominal Pain Anorexia Weight Loss Body malaise

Management of Renal Failure Dietary o Decreased protein or low protein diet Protein contributes to nitrogenous wastes Decreased sodium o Presence of sodium promotes edema Bed rest Prevent infection Skin Care o Dry skin Due to edema and hypovolemia o Cracked skin o Injured skin o Uremic frost occurs Urea on skin Parang amag Use dilute vinegar solution Weigh the patient o There is increase in weight due to edema Pharmacological Management of Renal Failure Diuretics Medical Management of Renal Failure Dialysis o Peritoneal Dialysis Infection or peritonitis is a common complication Hemodialysis o Hemorrhage is a common complication Renal Transplant o Alternative surgical management

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Interjected Concepts!!! Levels of Consciousness Alert o Awake, aware Obtunded person o Awake but not aware o tulala Lethargy Stupor o Asleep o Response to painful stimuli at sternum and sole of feet Coma o Deep Coma o Cannot be revived o Respirator sustains life Euthanasia or mercy killing GASTROINTESTINAL SYSTEM Oxygen distribution to the different body organs: Brain 15% of oxygen in the circulating blood Heart 5% of oxygen in the circulating blood GI and Liver 25% of oxygen in the circulating blood Renal System 25% of oxygen in the circulating blood Extremities 30% of oxygen in (upper and the circulating lower) blood Important Concepts!!! Small Intestine o Final digestion occurs in this organ o Digested products are absorbed by the villi 28

Mouth o Preliminary digestion occurs here o Initial digestion o Digestive juice is the saliva, which contains enzyme for carbohydrate digestion: Amylase Ptyalin Stomach o Partial digestion occurs here o Digestive juice in the stomach: o Gastric Juice Hydrochloric Acid Pepsin o Food remains in the stomach for about two (2) to four (4) hours o If food is fatty or has much protein content, food remains in the stomach for about three (3) to four (4) hours o Stomach is curved to the left Cardiac Sphincter Upper sphincter Prevents backflow of food to the esophagus Pyloric Sphincter Lower sphincter Prevents backflow of food from the small intestine Small Intestine

o Digestive Juice: Bile Pancreatic Juice Pancreatic Amylase Pancreatic Lipase Pancreatic Trypsin Induces sleep Tryptophan in milk Warm milk for vasodilation Increases trypsin levels Induces sleep Proteases Liver o Produces bile o Bile passes through the hepatic duct o Bile is stored in the gall bladder Gall bladder o Storage of bile o Bile passes through the common bile duct o Bile passes through the Sphincter of Oddi going to the duodenum After food is absorbed in the Small Intestine, the absorbed products are carried by the blood into the liver for storage Organs Filtering the Blood Kidney o Filters out metabolic wastes Liver o Filters out toxins Spleen 29

o Filters out resistant microorganisms o Red Blood Cells (old RBCs are phagocytosed o Main source of anti-bodies Lymph nodes o Also filters blood o Destroys microorganisms Important Concepts!!! Large Intestine o No digestion occurs here o Water absorption o Electrolyte absorption Diarrhea or Dehydration o Causes electrolyte imbalance Vomiting o Sodium (Na+) is the electrolyte that is most abundantly lost in vomiting Diarrhea o Sodium (Na+) is the electrolyte that is most abundantly lost in diarrhea Gastrointestinal Tract o Extracellular o Sodium is more abundant Blood o Extracellular o Sodium is more abundant Important Concept!!! Question: o Which electrolyte loss is of greater concern? Answer: o Potassium (K+) Rationale o Heart suffers from arrhythmia or absence of rhythm during increased or decreased levels of potassium

o Hypokalemia Decreased levels of potassium Decreased contraction Flaccid o Hyperkalemia Increased levels of potassium Increased contraction Spastic Dysrhythmia o Irregular heart rhythms Arrhythmias o Lub-lub-dub o Lub-dub-dub Initially, vomiting results into metabolic alkalosis o Hydrochloric acid is being expelled through the mouth Initially, diarrhea results into metabolic acidosis o Base (in the form of bitter, biting bile) is being eliminated through the anus Bile o Emulsifies fat o Gives color to the stool o Normal color of the stool Yellowish brown o Transitional color of the stool Golden Yellow o Stool of infants From greenish to yellow o Adult Stool Golden Brown o Abnormal color of the Stool Gray colored Stool

Acholic Stool Anus o End of the colon Appendix o Living cell o Composed of fecalith matter o Immunologic Contains antibodies But this is still under study Interjected Concept! Nail beds and hair roots are alive, just like the appendix, which is composed of living cells Common Gastrointestinal Disorders (these are manifestations only and are not considered as diseases) Anorexia Nausea o Urge to vomit Vomiting Diarrhea Constipation Interjected Concept! The epiglottis, a flap-like structure and the glottis, an opening, are both part of the respiratory system Oral Cavity Disorder Gingivitis PEPTIC ULCER Also called Gastric Ulcer Two (2) major causes: Extrinsic Factor Intrinsic Factor Extrinsic Factor Microbial invasion 30

o Virus o Bacteria Intrinsic Factor Integrity of Gastric Mucosa Mucosa o Secretes gastric mucous o If gastric mucosa is destroyed, acidity causes ulceration o Therefore, decreased integrity of gastric mucosa causes ulceration Frank hyperacidity PREDISPOSING FACTORS in PEPTIC ULCER 1. Emotional Stress Constriction of blood vessels Reaction is to produce more acid Results to hyperacidity Interjected Concept! Ulcer due to severe burns is called CURLING ULCER Also due to stress brought about by burns 2. Excessive Smoking Nicotine causes constriction Decreased blood flow brings about ischemia 3. Ingestion of Steroids (antiinflammatory drugs) Steroid releases Histamine Hydrogen (H+) o This reacts with chloride (Cl-) ion Chloride ion is the most abundant anion outside the cell o H+ + Cl- ----- HCl o Therefore, STEROIDS are GASTRIC IRRITANTS 31

Nursing Responsibility o Give with meals or after meals Example is PREDNISONE 4. Irregular Eating Pattern Interjected Concept! Number of times to chew before swallowing solid food is: o Five (5) to ten (10) or o Six (6) to nine (9) Assessment (to Rule Out Gastric Ulcer) 1. Pain Mid-upper abdomen o Epigastric region May start a couple of hours when stomach is empty and after eating Relieved by eating and by an antacid Antacid relieves hyperacidity only Occurs at night o Due to parasympathetic activity o This occurs whether patient had taken meals or not 2. Dietary Pattern 2.1) Types of Foods Ensure nutritious meals o To promote healing 2.2) Avoid the following foods: Spicy Foods o Have vasodilating effect but are irritating Greasy and Fatty Foods o These are hard to digest Gas-forming Foods

o Most common in foods rich in carbohydrates o Sweet potato, yam, ube, hard-boiled eggs o Can increase pressure inside 2.3) Avoid prolonged use of milk and cream Patients with ulcer can consume some milk but PROLONGED USE IS DISCOURAGED Lactic acid is produced as a byproduct of milk digestion o This results into LACTIC ACIDOSIS Also contraindicated in Ulcerative Colitis patients o There is lactose intolerance due to the absence of lactulase 2.4) Avoid Alcohol Alcohol promotes release of Gastrin Alcohol triggers pancreatitis (similar to drugs) 2.5) Avoid beverages causing vasoconstriction Tea o Green Tea contains the least amount of caffeine among the different types of tea Cola o With caffeine o Contains citric acid o Also avoid all other types of soda with the same color as soda (i.e. root beer, sarsa parilla) Coffee Caffeine

2.6) Avoid Snacks at Bedtime Common in cold weather countries Increases acid levels Increases pain, which attacks at night 2.7) Provide Iron for Healing Heme is iron Heme + globulin --- Hemoglobin Hemoglobin carries oxygen Increased oxygenation coupled with increased blood flow and venous return enhances healing Iron is present in the following foods: o Green leafy vegetables o Liver o Egg yolk 3. Observe for Complications 3.1) Hemorrhage Coffee ground emesis o Old blood Melena o Black tarry stool o Sign of Upper GI bleeding Hematamesis o Vomiting of blood Hematochezia o Fresh blood in the stool o Sign of Lower GI bleeding Interjected Concepts!!! Spicy foods do not cause hemorrhoids o Rather, it makes hemorrhoids more severe o Spicy foods trigger more dilation Pregnancy and increased pressure causes hemorrhoids

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3.2) Perforation 3.3) Pyloric Obstruction Implementation: What to do during Ulcer? 1. Medications 1.1) Antacids Basic Given one (1) hour after meal Mg(OH)2 o Milk of magnesia o Side effect is diarrhea Al(OH)2 o Amphojel o Side effect is constipation o Absorbs water and phosphate NaHCO3 CaCO3 MgAl(OH) o Maalox o Simeco o Mylanta o No diarrhea o No constipation 1.2) Sucralfate and Carafate Given one (1) hour antecebum Protective agent o Coats the lining of the stomach Again, give before eating 1.3) Anti-cholinergic Anti-parasympathetic drugs Atropine Sulfate o Anti-diarrheal To decrease the motility of the bowel (diarrhea) o Anti-emetic

To decrease GI motility o Increased heart rate o Indicated for Bradycardia o A chronotropic drug 1.4) Histamine H2-receptor Antagonist o Taken per orem Cimetidine o Tagamet Ranitidine o Zantac Coats chloride to prevent the formation of hydrochloric acid 2. Reduce Stressful Situations Non-specific 3. Promote Rest 4. Provide Health Teachings Dietary therapy 5. Provide Dietary Control 6. Observe for Complications 7. Provide Moral Support Interjected Concepts!!! Inotropic Drugs o Increases cardiac contractility o Examples are: Dopamine Dobutamine Digoxin Beta-Adrenergic Blockers o Decreases heart rate in tachycardic patients Surgery for Ulcer 33

Vagotomy Cutting of the vagus nerve (pneumogastric nerve) Innervates the upper region of the respiratory tract (increased intracranial pressure during GI suctioning Indicated for hypersecretion of acid o Do vagotomy o Complication is diarrhea o No more acids are present for digestion 2. Gastroenterostomy or Pyloroplasty Decreases stimulation of Gastrin Formation in the antral region Stomach and Small intestine are anastomosed Shortening of the pylorus Reinforcement of the pylorus Bariatic surgery o Indicated for obese patients 3. Partial Gastrectomy Complication is hemorrhage Increased pressure leads to hematamesis Two types: o Billroth I o Billroth II 3.1) Billroth I or Gastroduodenostomy Removal of the pylorus High abdominal incision results to pulmonary complications Anastomosis is done 3.2) Billroth II or Gastrojejunostomy Two structures are removed: o Pylorus o Duodenum 34

Anastomosis is done Important Concept! -plasty means repair or reinforcement Post-operative Complications 1. Hypovolemic Shock Decrease in blood volume 2. Hematamesis 3. Pulmonary Complications Atelectasis o First complication o Lung collapse o Loss of function of the lungs o Anesthesia may cause atelectasis Bronchitis o Infection o This may occur around three (3) days postoperatively Pneumonia 4. Fluid and Electrolyte Imbalance 5. Dumping Syndrome Recline patient or place patient in recumbent position after meals 6. Hemorrhage 7. Diarrhea Due to vagotomy 8. Vitamin B12 deficiency Due to malabsorption syndrome Vitamin B12 is cyanocobalamin This is for RBC maturation

 There is no absorption of Vitamin B12 o A GIT problem o An intrinsic problem 9. Anemia Absence of Vitamin B12 results to pernicious anemia Decreased levels of RBC if there is a GIT problem with intrinsic factor Interjected Concepts! If GIT is functional and Vitamin B12 is lacking o Extrinsic Problem o Megaloblastic Anemia o Vitamin B12 and Vitamin B9 needed for maturation Decrease in Iron o Iron deficiency anemia Decrease in food o Nutritional anemia o An Extrinsic problem Yellow Bone Marrow o Indirect Red Blood Cell formation Red Bone Marrow o Direct Red Blood Cell formation Bone Marrow Extraction o Pelvic Bone This has less complications o Sternum and Scapula Has pulmonary complications In Bone Marrow Extraction o Consider the following bones in the following order: Pelvis Posterior Iliac Crest

Position patient at affected side for prevention of bleeding Apply pressure Sternum Scapula Flat bones contain Red Bone Marrow Ischial Tuberosity o inuupuan o nangingitim Ischial Spine o Reference for fetal descent If Bone Marrow does not produce RBC o The resulting RBC deficiency is called APLASTIC ANEMIA In SICKLE CELL ANEMIA o RBCs have decreased oxygen-carrying capacity In whatever type of anemia, a blood loss of five-hundred milliliters (500 ml) and above REQUIRES BLOOD TRANSFUSION

BLOOD TYPING AND CROSS MATCHING Blood Type O o The universal DONOR Blood Type AB o The universal RECIPIENT Consider the following figure: In cross matching, arrow indicates which blood type could be a donor to which blood type No counter flow is observed

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o Meaning blood type, where arrow points, cannot be a donor to the blood type where the arrow begins No crossing of vertical or horizontal lines is allowed (except when there is an arrow indicating source can donate blood to where arrow is pointing) o Meaning, that blood types connected by lines without arrows cannot donate to each other. Type O

All blood types can receive blood from other individuals with the same blood type

ERYTHROBLASTOSIS FETALIS Important Concepts!!! Blood type is in the Red Blood Cell The liver and the spleen of the child is responsible for the RBC of the child Types of Placental Separation o Duncan side Dull side Side is tearing off Bloody separation Revealed placental expulsion Durky o Schultz side Center is tearing off Shiny side Concealed placental expulsion When placenta separates either: o At birth o During birth o Abortion o Still Birth Blood from the infant may flow to the mother Direction of flow upon placental breakage is from the newborn to the mother o If the mother is type AB (universal acceptor) there in no incompatibility o If the mother is type O (universal donor) there is high-risk for incompatibility

Type A

Type B

Type AB Therefore, from the figure above Type O individuals could o Donate blood to type A individuals o Donate blood to type B individuals o Donate blood to type AB individuals Type A individuals could o Donate blood to type AB individuals Type B individuals could o Donate blood to type AB individuals Type O individuals could not receive blood from any of the other blood groups Type A individuals cannot receive blood from type B individuals Type B individuals cannot receive blood from type A individuals 36

 Therefore, always check if the placenta is intact o The placental breakage during separation causes incompatibility If the mother is Rh- and the newborn is Rh+, upon placental separation there is flow of fetal blood to the mother. o The mother will then develop antibodies for Rh+ o This situation would give rise to problems with the subsequent fetuses which are also Rh+ Second child or fetus with Rh+ blood will have increased risk for fatality due to hemolysis as mother has antibodies for Rh+ Third child or fetus with Rh+ blood will have even greater risk for fatality, also due to hemolysis, again, as mother has antibodies for Rh+ Preventive measure would be the administration of RHOGAM within seventy-two (72) hours after delivery or abortion or still birth. If antibody is inactive, this indicates that RHOGAM IS EFFECTIVE If antibody is active, and it causes hemolysis and fatality to the second or third child, then RHOGAM IS INEFFECTIVE CHRONS DISEASE Regional Enteritis

Volvolus Intertwining of the bowels Common in pediatric patients Intussusception Telescoping of the bowel Part or segment of the intestine goes into another segment Colitis Inflammation of the Large Intestine Ulcerative Colitis Occurs at right side or at ASCENDING COLON Classical sign is DIARRHEA Reabsorption of water is a normal function of the large intestine o If the large intestine is inflammed, it cannot reabsorb water o This gives rise to diarrhea Milk cannot be administered to Ulcerative Colitis patient o There is lactose intolerance o LACTAMASE cannot be produced (lactobacilli) o If the large intestine is impaired, lactamase cannot be synthesized Diverticulum Out-pouching of the membrane in the sigmoid area Diverticulosis Exists when multiple diverticula are present without inflammation or symptoms Diverticulitis Occurs when food and bacteria are retained in a diverticulum

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 This produces infection and inflammation that can impede drainage and lead to perforation or abscess formation With left side pain At side of sigmoid Hemorrhoids Protrusion of rectal vein at the rectum Varicosity A ballooning of the vein Aneurysm A ballooning of the artery INTESTINAL HERNIA 1. Inguinal Hernia (bituka) Part of intestine goes to the male scrotum 2. Femoral Hernia Herniation along the femoral head 3. Umbilical Hernia 4. Incisional Hernia After appendectomy Evisceration is an example of incisional hernia APPENDICITIS Characterized by the presence of pain at the right lower region Rebound Tenderness is present Palpate at the left side McBurneys Point McBurneys Sign o To rule out appendicitis o Do Rovsings Test o Pinch at the left side of the abdomen o There will be pain at the right side of the abdomen 38

o Presence of pain indicates positive for McBurneys sign. Analgesics are not given o They mask the symptoms of pain ACCESSORY ORGANS OF THE GASTROINTESTINAL TRACT LIVER CIRRHOSIS Degenerative Necrotic Hepatocytes are no longer functional Important Interjected Concepts Viral infections are self-limiting There are five (5) types of hepatitis: o Hepatitis A Infectious hepatitis Oral Fecal route o Hepatitis B Serum hepatitis Blood Death through hepatitis B is quicker than death through AIDS Death through hepatitis B may only be months away o Hepatitis C o Hepatitis D o Hepatitis E Liver Cirrhosis (continued) A chronic progressive degenerative disease of he liver with structural changes Scarring is the biological or structural change

Types of Liver Cirrhosis 1. Laennecs Cirrhosis This is the original liver cirrhosis Portal, nutritional or alcoholic cirrhosis 2. Post-necrotic Cirrhosis Post-hepatitis or toxin induced hepatitis Viruses excrete toxins; after the death of liver cells

o Used to constrict blood vessels o If vessels are not reinforced, portal vein will explode Backflow of pressure is toward the Gastrointestinal Tract / GI syndrome composed of: o Esophageal Varices o Hemorrhoids Caput Medusae Pathophysiology of Liver Cirrhosis

3. Biliary Cirrhosis Related to prolonged biliary obstructive jaundice due to infection Jaundice is yellowish discoloration due to bilirubin May involve any of the following: o Bile duct o Biliary duct and biliary stones o Cholelithiasis o Choledocholithiasis 4. Cardiac Cirrhosis Related to long-standing Congestive Heart Failure Right-Sided CHF With Primary and Secondary Hypertension due to arterial system constraint Scar Structural change Decreased blood flow to the liver Most blood stays in the portal vein Portal hypertension occurs Portal veins are dilated This is localized Vasopressin or Pitressin 39

Toxic Effect on Liver Common causes are alcohol, drugs or nutrition; with incidence in men Liver Cells are Damaged Tissue Scarring and Fibrosis Distortion of Normal Liver Structure Interferes with blood flow through the liver Portal Hypertension (Enlargement of umbilical, esophageal, and rectal veins resulting to liver dysfunction) Insufficient removal of metabolic wastes Fluid retention in peritoneal cavity Hepatic encephalopathy Coma Types of Jaundice Physiologic Type

 Pathologic Type Physiologic Jaundice Immature body part or organ Occurs in infants only Immature liver of the infant o Lacks enzymes o Glucoronyl Transferase is lacking o Conjugation of bilirubin is not facilitated Jaundice occurs after twenty-four hours Yellowish skin is exhibited within seven (7) to ten (10) days Patient is most yellowish at around third (3rd) to fourth (4th) day Always get the middle!!! Pathologic Jaundice Jaundice within twenty-four (24) hours Erythroblastosis fetalis Interjected Concepts!!! Liver o The biochemist of the body o The biochemist of all the body functions o Filters toxins If this is not facilitated, the toxins will stay in the blood Toxins will get to the brain and would lead to encephalopathy, hepatic coma and brain coma Alters protein synthesis

Decreased levels of protein in blood results to decreased colloid osmotic pressure This would lead to Edema or ascites o Cirrhosis is a term used for the liver only Infarction is a term used for the heart and the brain Cerebral Infarction o Brain infarction Myocardial Infarction o Heart infarction Adult Jaundice It is always PATHOLOGIC Types of Adult Jaundice 1. Hepatocellular Jaundice Hepatocytes die 2. Hemolytic Jaundice RBCs are hemolyzed Increased bilirubin escapes 3. Obstructive Jaundice Biliary problems Gall stones Important Concepts!!! Increased bilirubin in blood o Unconjugated Indirect bilirubin Also known as b1 Normal value is twice that of b2 Normal value is 0.8 mg / dl o Conjugated Direct bilirubin Also known as b2 Normal value is about half of b1 40

Normal value is 0.4 mg / dl o Total Bilirubin Represents the cumulative value of Unconjugated (b1) and Conjugated (b2) bilirubin Normal value is 1.2 mg / dl This is a gauge used to determine if there is jaundice At birth, if Total Bilirubin level is 2.0, then there is physiologic jaundice Signs and Symptoms of Liver Cirrhosis 1. Anorexia, dyspepsia, indigestion, change in bowel habits, flatulence, constipation, fatigue Anorexia o Gives rise to weight loss and body weakness Dyspepsia o Inability of the stomach to produce pepsin for digestion o The absence of pepsin gives rise to indigestion Flatulence o Kabag leads to flatus formation o Due to increased pressure (blood flows back to the GIT) 2. Hepatomegaly, Splenomegaly and Jaundice Increased PT or prothrombin time Newborn

o Prone to bleed at umbilical cord o Immature liver cannot produce prothrombin o Therefore, give Vitamin K o Administer via I.M. route o Site is at vastus lateralis Never inject at the buttocks Sciatic nerve may be damaged and this will cause irreversible paralysis o Allow the child to walk first before administering injections at the buttocks 3. Edema of the Extremities, Ascites, Hematamesis 4. Caput medusae Prominent abdominal wall veins Big ones 5. Anemia, Esophageal varices, Emaciation Anemia o Pernicious anemia o GI is affected Esophageal Varices o Use SengstakenBlakemore tube Emaciation o Excessive or severe weight loss or cachexia 6. Altered Hair Distribution, Spider nevi, Angiomas Altered Hair Distribution o Decreased keratin synthesis by the liver o This affects the skin, the hair and the nails

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o Deceased collagen synthesis by the liver affects the structure of the internal organs Deficiency in collagen leads to Systemic Lupus Erythematosus Important Interjected Concepts!!! In order for adults to fart, place them in NICHES POSITION o If not, use a rectal tube and a basin of water In infants, COLIC is equivalent to flatulence Prone position is best Hagod sa likod nagburp pataas Thoracentesis If air is to be removed, insert trocar at the level of the second (2nd) or third (3rd) intercostal space If fluid (i.e. water) is to be removed, insert trocar at the level of the sixth (6th) to eighth (8th) intercostal space Implementation in Liver Cirrhosis 1. Provide adequate nutritional intake High Calorie diet o 3,000 calories per day Carbohydrates o 300 400 grams per day Proteins o If pre-coma 70 100 grams per day o If comatose Totally eliminate proteins from the diet Fats 42

o 100 150 grams per day Low sodium diet o 0.5 to 1.0 gram per day 2. Bed rest 3. Maintain clean and dry skin 4. Assess level of pain and prevent bleeding 5. Maintain Fluid Balance 1.0 to 1.5 liters per day 6. Monitor for signs of mental deterioration Allow the client to demonstrate signature daily Avoid tranquilizers and sedatives o These drugs mask the signs of mental deterioration o Cardiovascular and neuromuscular drugs are all hepatotoxic o Liver cannot detoxify these drugs Administer lactulose if ordered o Duphalac is an ammonia detoxicant o Also a laxative for easy passage of stools Stool softeners soften the stool Important Interjected Concepts!!! Mesentery o Membrane that suspends an organ Omentum o Organ to organ suspension Collagen o Internal protein or protein of internal organs Desquamation

o tuklap ang balat Infant with Desquamation o Due to environmental adaptation to external environment Important Concepts!!! Liver Flap o Flapping Tremors o Asterixis Sign of impending hepatic coma Due to accumulation of ammonia in the bloodstream Hyperthyroid Person has FINE TREMORS Protein is metabolized to ammonia Ammonia is converted by the liver to urea Urea is removed by the kidneys Therefore, the liver and the kidney are both blood filters Renal Failure o Characterized by: o Increased levels of Blood Urea Nitrogen o Decreased levels of Blood Urea Nitrogen Clearance o Decreased protein or controlled protein diet o Decreased intake of sodium due to the presence of edema Liver Cirrhosis o Characterized by: o Controlled protein intake o Controlled fat intake (as bile is not produced) o Decreased intake of sodium due to the presence of edema

Important Concepts in the Management of Renal Failure and Liver Cirrhosis In Renal Failure o Bed rest is needed o Skin is Dry o Skin is whitish due to the presence of UREMIC FROST o Therefore, apply vinegar In Liver Cirrhosis o Bed rest is needed o Skin is dry due to edema and dehydration o Urticaria is present o Rashes are present Implementation in Liver Cirrhosis (continued. . .) 7. Assist client to comply with prescribed bed therapy 8. Maintain normal respiratory function 9. Encourage patient to express feelings Sengstaken-Blakemore Tube This tube is inserted at the nose It has three (3) lumens o First lumen For nasogastric suction Suction to prevent vomiting o Second lumen For inflation of esophageal balloon o Third lumen To inflate the gastric balloon Complication o Congestion in the lung 43

o Keep scissors ready o If respiratory depression or arrest occurs: Cut the tube Deflate the balloon Remove the SengstakenBlakemore Tube Interjected Concepts!!! Striae Gravidarum o In primigravida This is pinkish o In multigravida This is silvery white Increased pigmentation is due to estrogen o This intensifies the activity of Melanin For neurologic problem and heart problem patients, give stool softeners and not laxatives Medications used in the Management of Liver Cirrhosis Neomycin Anti-biotic that reduces colonic bacteria It decreases the number of microorganisms thriving in ammonia If normal flora in the colon becomes violent, there is infection Pitressin or Vasopressin Decreases portal blood pressure This constricts the dilated veins Lactulose Cephulac o For ammonia detoxification o As a laxative

Furosemide Lasix o A diuretic Spironolactone Aldactone Diuretic Aldosterone antagonist Potassium sparing Retains potassium but not sodium Vitamin B9 Folic Acid For maturation of RBCs to promote healing Increased RBC levels leads to increased oxygenation Increased oxygenation facilitates healing Vitamin B12 is also for maturation of RBCs CHOLELITHIASIS Stones in the gall bladder CHOLECYSTITIS Inflammation of the gall bladder Not always due to the presence of stones Renal Calculi Two (2) Types: Acidic Calculi Basic Calculi Important Concepts!!! Gall Stones o Are alkali only The following are all basic: o Bile o Bile pigment o Cholesterol o Calcium

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 In Cholelithiasis and cholecystitis, there is pain at the UPPER RIGHT QUADRANT In Appendicitis, there is pain at the RIGHT ILIAC or the RIGHT LOWER QUADRANT Murphys Sign o For Cholelithiasis with cholecystitis McBurneys Sign o For Appendicitis Important Concepts in Cholelithiasis and Cholecystitis Fatty foods are not given Steatorrhea o Foul-smelling stool o Fatty stool o Frothy stool Frequent Stool (diarrhea) Important Interjected Concepts!!! In asthma o Avoid antitussives o Avoid anti-biotics Important Concepts!!! Acholic Stool o Clay-colored stool Liver Cirrhosis patients are with nasogastric tube (NGT) For Gall Bladder with stones, medical management may involve LITHOTRIPSY o Percutaneous Lithotripsy o Extracorporeal Shockwave Lithotripsy Cholelithotomy o Removal of stones in the gall bladder Cholecystectomy o Removal of the gall bladder o T-tube is used with Jackson-Pratt (JP) Drain 45

o Initially, there will be copious drainage from the JP drain This is because the bile duct is inflammed Failure to drain would result to congestion o Later, if there is less drainage, Bile duct is no longer inflammed Bile goes to the duodenum PANCREATITIS The head of the pancreas is located posterior to the liver The body and tail of the pancreas is locate near the stomach at the left upper quadrant Therefore, pain in pancreatitis is situated at the left upper quadrant Inflammation of the Pancreas is due to the following: 1. Fat necrosis Increase in pancreatic amylase and pancreatic lipase gives rise to lipolysis This can trigger autodigestion of the pancreas Pancreatic Lipase levels is a much better determinant of the presence of pancreatitis 2. Pancreatic Edema 3. Acute Hemorrhagic Pancreatitis Deadly Important Concepts in Pancreatitis Demerol

o Drug of choice in the treatment of pancreatitis Non-narcotic o Does not cause drowsiness o Blocks prostaglandin synthesis Morphine o Can constrict the sphincter of Oddi Interjected Concepts!!! In checking for the proper placement of the Nasogastric Tube or NGT, the following could be done: X-ray o Most effective Aspirate o Second most effective way is to check the pH Auscultate o This is the most common method of checking o Gurgling sound at the abdominal region indicates proper placement Dipping the end of the tube in water and noting for bubbles o This indicates that the NGT is displaced and is in the lungs o Not an advisable thing to do Damage to heart muscle is indicated by increased levels of CK-MB and CK-MM o Troponin T and Troponin I are more reliable indicators of cardiac tissue damage Peculiarity of Pancreatitis Hematoma Ecchymosis around the navel

o Also known as Cullens Sign Petechiae Interjected Concept! Cullens Sign is also present in ECTOPIC PREGNANCY Important Additional Concepts in Pancreatitis Gray Turners Spot o Ecchymosis at the flank o Indicative of Hemorrhagic Pancreatitis Increase in Trypsin levels o Pancreatic enzyme that promotes sleep o Patient is not awakened by the pain he feels but moaning is present o Defecation and urination is present in the late stages of pancreatitis MUSCULOSKELETAL SYSTEM Muscle is composed of three (3) types: Skeletal Muscle Cardiac Muscle Smooth Muscle Types of Skeleton: Axial Skeleton o Skull o Ribs o Spinal Cord Appendicular Skeleton o Clavicle o Scapula o Limbs Joints Also called arthroses Articulating joints

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Three (3) Types of Joints based on Motion 1. Synarthrosis Fibrous joint Creates no motion No movement 2. Amphiarthrosis Cartilaginous joint Creates small amount of motion 3. Diarthrosis Synovial joint Maximum amount of motion Creates large amount of motion Muscle has two (2) types of protein Actin Myosin Important Concepts!!! Calcium is needed in muscular contraction Acetylcholine is a neurotransmitter needed in muscle contraction Myasthenia Gravis is an autoimmune disorder wherein the body destroys acetylcholine receptor sites Skeletal Muscle 1. Synergist Muscles Group of muscles When they contract, they stabilize the area Examples are: o Pectoralis o Intercostals Antagonist Muscles When one muscle contracts, the other relaxes 47

For reciprocity of motion Prime Mover When they contract, maximum amount of motion is created Range of Motion 360 degrees o Shoulder Joint 180 degrees o Cervical Joint FRACTURES Break in the continuity of the bone o Trauma o Accident o Crashing o Twisting o Compression Pathologic o Potts Disease Tuberculosis of the spine Gibbus formation is the pathognomonic sign of Potts Disease o Spina Bifida Neural Tube Defect o Cystica Presence of a bulge o Meningocoel Meninges protrude Cerebrospinal Fluid o Myelomeningocoel Spinal cord lesions Herniated Nucleus Polposus o Occulta Presence of a depression or a dimpling o Lumbar Spine

o o o o

Bears most of the body weight Lumbar Coma Slipped disk Lordosis Waddling walk Not a flirting walk

Transverse Oblique Important Concepts regarding Fractures!!! First Aid o At the site of the incident, IMMOBILIZE Treatment at the Hospital o Bone Reduction o Re-alignment of the bone Treatment of Fractures 1. Reduction or Re-alignment For Closed Reduction o Casting o Splinting o Sling For Open Reduction o Surgical plates, pins, rods, wires o Uses plates (metal or stainless steel) o Uses screws and nails o Uses pins intramedullary pins 2. Immobilization 3. Restoration of Function Important Concepts!!! Casting o Utilizes plaster of Paris Scoliosis o Utilizes Harrington Rod Wires o Used for flat bones (i.e. mandible) TRACTION Two forces are applied in opposite direction

Types of Fractures Closed Fracture o Did not penetrate the skin o Immediate care Do not move Open Fracture o Broken portion of the bone protrudes through the skin Fracture Patterns Transverse Longitudinal Oblique Spiral Depressed Comminuted Impacted Stellate o Fracture radiates from a point Important Concepts!! In comminuted or crushed fractures, bone debridement is done Mandibular Wiring o Use wire cutter o Suction Anticipate vomiting to prevent aspiration Interjected Concept! Types of Fetal Lie Longitudinal

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Purposes of Traction To immobilize the affected part Bone re-alignment Regain normal strength Reduce muscle sprain Types of Traction Mechanical Traction o With screw and pin o With invasion o Steinman Using pins o Kirchner Using wires o Crutch-Field Tongs for cervical affectations Balanced Suspension Traction o Thomas Splint with Pearsons Attachment Skin Traction o No invasion o Pad areas which are pressured o Russell For fractured femur Pulls the knees and the foot o Cervical Cervical spasm o Pelvic Relieves low back pain Important Concepts!!! Bryant Traction For children Signs and Symptoms of Fracture Swelling Heat Impaired function Redness Pain

Crepitus o Grating sound Deformity o Contracture Shortening of bone Discoloration o Bluish and reddish indicative of hematoma Bleeding Tenderness o Pain aggravated by touch STAGES OF WOUND HEALING Important Concepts!!! In pediatric patients o Wound healing is faster o Occurs in about three (3) to four (4) weeks o Due to quicker Basal Metabolic Rate In adults o Wound healing occurs in about eight (8) to twelve (12) weeks 1. Hematoma Formation Occurs after twenty-four (24) hours 2. Cellular Proliferation Production of OSTEOIDS Bridging of blood vessels 3. Callous Formation Bridging large mass of differentiated tissues 3. Ossification Fractured ends meet together Three lipids in cell membrane: o Glycolipids o Phospholipids o Cholesterol 4. Remodelling

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 Compact-bone formation Complications of Fractures Pulmonary Embolism Fat Embolism o Common embolus o From the marrow o Pure cholesterol Gangrene o Blood vessel problem o Massive avascularity Tetanus o Burns o Fractures o Causative agent is Clostridium tetani o Signs and Symptoms include: Risus sardonicus Lockjaw Ophistotonus Seizure with arching of the back Vertigo Environment is moving, swirling Dizziness o Preventive measure Tetanus Toxoid vaccine MUSCULOSKELETAL DISORDERS 1. Osteomyelitis Inflammation or infection of the bone marrow Affects weight-bearing bones Causative agent is Staphylococcus aureus 2. Supracondylar Fracture Elbow affectation

3. Congenital Club Foot Talipes Equinovarus Use Dennis Browne shoe Cast 4. Hip Dislocation Unilateral or Bilateral If unrelieved, TOTAL HIP REPLACEMENT using prosthesis is done Kept abducted o Use abductor splint or pillow between the legs o Reinforce with TROCHANTER ROLL or blanket 5. Coxa Plana Aseptic necrosis of the femoral head Legg-Calves Perthes No infections Ten times more common in white children than in blacks 6. Scoliosis Gait is changed Spinal Column deformity Lateral Curvature Based on Origin: o Structural Ligaments holding the spine have problems Can be relieved by exercise o Functional Work Management o Bottleblowing for scoliosis o Swimming is best for scoliosis o Milwaukee brace Pelvis to chin cup

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Worn for twentythree (23) hours in a day and one (1) free hour for inspections Scoliotic to the left o Right hip is up o Left shoulder is up 7. Potts Disease Tuberculosis of the Spine 8. Arthritis Rheumatoid Arthritis o Systemic, bilateral, symmetrical Osteoarthritis o Weight-bearing joints o Unilateral Gouty Arthritis o Affects great toe o Uric acid o Monosodium urate crystals o Tophi 9. Slipped Disc Laminectomy is the surgery of choice Herniated Nucleus Polposus 10. Intertrochanteric Fracture Greater to lesser or letter to greater trochanteric break Interjected Concepts!!! Combination disorders: o Scoliokyphosis o Kyphoscoliosis o Lordokyphosis o Kypholordosis Sickle Cell Anemia o Blacks are mostly the ones affected

CARE OF CASTS 1. If not yet dry, use the palm in moving to avoid deforming its contour 2. If dry, also use the palm in moving for safety Cast should not be too tight This may impede circulation Fingers and toes should be able to wiggle Cast should not be too loose 3. Observe for cyanosis 4. Open fractures Use window type of cast 5. Observe odor Foul odor may indicate infection Important Concept!!! When there is itchiness, blow air under the cast to eliminate moisture ASSISTIVE DEVICES 1. Cane Principle in use: o Use on the HAND ON THE UNAFFECTED SIDE 2. Walker If patient is a child o Rota Walker o andador o No sense of direction If patient is an adult o Four-legged walker 3. Crutch (saklay) Principle in use: o Weight of body borne by the ARM not by the axilla o Therefore, it should be about two (2) inches from the axilla (above the crutch

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to the axilla there should be about two (2) inches) o Tip of crutch from foot is about six (6) to eight (8) inches (to side) Four-Point Gait o Two (2) crutches used o Two (2) legs used o First to move: Crutch before foot; Left or Right o Sequence of movement: Crutch, opposite leg Crutch, opposite leg Two-Point Gait o An acceleration of the Four-Point Gait o Two (2) legs used o Crutch and opposite leg moves simultaneously Three-Point Gait o Not both legs are used o One may be amputated / cemented o Crutch is moved first In going upstairs, use FOOT FIRST o To remember this, remember the saying good leg goes to heaven In going downstairs, use CRUTCH FIRST Swing Through / Swing To o Two (2) legs are not used o Both legs are not usable o Principle is momentum

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