FOCUS!

AND AIM HIGH WITH GOD

Graphics & Edited By:

J. F. ADORABLE, RN.
Text from Pentagon Review Center

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

AUTONOMIC NERVOUS SYSTEM Sympathetic Nervous System (ADRENERGIC) - Involved in fight or aggression response. - Release of Norepinephrine (cathecolamines) from adrenal glands and causes vasoconstriction. - Increase all bodily activity except GIT EFFECTS OF SNS - Dilation of pupils(mydriasis) in order to be aware. - Dry mouth (thickened saliva). - Increase BP and Heart Rate. - Bronchodilation, Increase RR - Constipation. - Urinary Retention. FLUID VOLUME EXCESS - Increase blood supply to brain, heart and skeletal muscles. - SNS I. Adrenergic Agents - Give Epinephrine. [ADRENALIN] Signs and Symptoms: - SNS Contraindication: - Contraindicated to patients suffering from COPD (Broncholitis, Bronchoectasis, Emphysema, Asthma). II. Anti-cholinergic Agents - To counter cholinergic agents. - Atropine Sulfate – decreased mucus production Side Effects - SNS Antipsychotics:  Haloperidol [Haldol], chlorpromazine  Thorazine, etc. Side effect of THORAZINE: atopic dermatitis and foul smelling odor. Side effect of all antipsychotic: signs of PARKINSON‘S DISEASE, therefore antipsychotic are given together with antiparkinson drugs Anti-parkinson drugs:  C.A.P.A.B.L.E.S Parasympathetic Nervous System (CHOLINERGIC, VAGAL, SYMPATHOLYTIC) - Involved in fight or withdrawal response. - Release of Acetylcholine. - vasodilation bronchoconstriction - Decreases all bodily activities except GIT. EFFECTS OF PNS - Constriction of pupils (meiosis). - Increase salivation. - Decrease BP and Heart Rate. - Bronchoconstriction, Decrease RR. - Diarrhea - Urinary frequency. FLUID VOLUME DEF. - antihypertension

I. Cholinergic Agents - Mestinon, Neostigmine. Side Effects - PNS

II. Beta-adrenergic Blocking Agents - Also called Beta-blockers. - All ending with ―lol‖ - Propranolol [Inderal], Atenelol, Metoprolol. Effects of Beta-blockers B – roncho spasm E – licits a decrease in myocardial contraction. T – reats hypertension. A – V conduction slows down.  Should be given to patients with Angina Pectoris, Myocardial Infarction, and Hypertension. ANTI- HYPERTENSIVE AGENTS 1. Beta-blockers – ―lol‖ 2. Ace Inhibitors – Angiotensin, ―pril‖ (Captopril, Enalapril) 3. Calcium Antagonist – Nifedipine (Calcibloc)  In chronic cases of arrhythmia give Lidocaine(Xylocaine)

CENTRAL NERVOUS SYSTEM Brain and Spinal Cord. [Spinal cord terminates at L1 to L2 therefore a LUMBAR TAP is performed spinal cord damage] I. CELLS A. NEURONS Basic cells for nerve impulse and conduction. PROPERTIES Excitability – ability of neuron to be affected by changes in external environment. Conductivity – ability of neuron to transmit a wave of excitation from one cell to another. Permanent Cell – once destroyed not capable of regeneration. TYPES OF CELLS BASED ON REGENERATIVE CAPACITY 1. Labile Capable of regeneration. Epidermal cells, GIT cells, GUT cells, cells of lungs. 2. Stable Capable of regeneration with limited time, survival period. Kidney cells, Liver cells, salivary cells, pancreas. 3. Permanent Not capable of regeneration. Myocardial cells, Neurons, Bone cells, Osteocytes, Retinal Cells. B. NEUROGLIA

at L3 , L4 or L5 no risk for

Support and protection of neurons.

TYPES 1. Astrocytes – maintains blood brain barrier semi-permeable.  3. Microglia 4. Epindymal SUBSTANCES THAT CAN PASS THE BLOOD-BRAIN BARRIER 1. Ammonia
   

Majority of brain tumors (90%) arises from called astrocytoma. impulse transmission

2. Oligodendria Produces myelin sheath in CNS. Act as insulator and facilitates rapid nerve

Cerebral toxin Hepatic Encephalopathy (Liver Cirrhosis) Ascites Esophageal Varices asterixis (flapping hand tremors). Headache Dizziness Confusion Fetor hepaticus (ammonia like breath) Decrease LOC [hepatic coma]

Early Signs of Hepatic Encephalopathy

Late Signs of Hepatic Encephalopathy
    

[AIRWAY FOR HEPATIC COMA] 2. Carbon Monoxide and Lead Poisoning

Can lead to Parkinson’s disease. [PILL ROLLING TREMORS] Epilepsy Treat with ANTIDOTE: Calcium EDTA For Lead poisoning Hyperbaric oxygenation (100% O2) For carbon monoxide poisoning

 

PATHOGNOMONIC SIGNS
1. PTB 2. PNEUMONIA 3. ASTHMA 4. EMPHYSEMA 5. KAWASAKI DISEASE 6. PERNICIOUS ANEMIA 7. DOWN SYNDROME 8. CHOLERA 9. MALARIA 10. TYPHOID 11. DIPTHERIA 12. MEASLES 13. SLE 14. LIVER CIRRHOSIS 15. LEPROSY 16. BULIMIA NERVOSA 17. APPENDICITIS. 18. DENGUE 19. MENINGITIS 20. TETANY 21. TETANUS 22. PANCREATITIS 23. PYLORIC STENOSIS 24. PDA 25. ADDISON’S DISEASE 26. CUSHING’S SYNDROME 27. HYPERTHYROIDISM/GRAVE’S DISEASE 28. INTUSSUSCEPTION 29. PARKINSON’S DISEASE 30. HEPATITIS 31. THROMBOPHEBITIS 32. CATARACT 33. GLAUCOMA 34. RETINAL DETACHMENT 35. CHOLECYSTITIS 36. ANGINA PECTORIS 37. MYASTHENIA GRAVIS 38. TETRALOGY OF FALLOT Low-grade afternoon fever. Rusty sputum. Wheezing on expiration. Barrel chest. Strawberry tongue. Red beefy tongue. Protruding tongue / semian crease on palm Rice watery stool. Stepladder like fever and chills. Rose spots in abdomen. pseudo membrane formation (pharynx, tonsils, nasal) Koplik’s spots. Butterfly rashes. spider angioma, due to esophageal varices lioning face Chipmunk face. Parotid gland swelling rebound tenderness petechiae or (+) Herman’s sign Kernig’s sign (leg pain), Brudzinski sign (neck pain). HYPOCALCEMIA (+) Trousseau’s sign/carpopedal spasm; Chvostek sign (facial spasm). risus sardonicus. Cullen’s sign (ecchymosis of umbilicus); (+) Grey turners spots. olive SHAPE mass on the abdomen machine like murmur Bronze like skin pigmentation. Moon face appearance and buffalo hump. Exopthalmus sausage shaped mass Pill rolling tremors Jaundice Homan’s sign Hazy vision / loss of central vision Tunnel vision / loss of peripheral vision Curtain veil-like vision / flashes and floaters Murphy’s sign (pain on deep inspiration, a inflammation of the gallbladder Levine’s sign [hand clutching in the chest] Ptosis [drooping of the upper eyelid] Clubbing of fingers

3. Type 1 DM (IDDM) [KETONES]
      

Causes diabetic ketoacidosis. And increases breakdown of fats. And free fatty acids Resulting to cholesterol and (+) to Ketones (CNS depressant). Resulting to acetone breath odor/fruity odor. KUSSMAUL’S respiration, a rapid shallow respiration. This may lead to diabetic coma. Signs of jaundice (icteric sclerae). Caused by bilirubin (yellow pigment) Increase bilirubin in brain (Kernicterus). Causing irreversible brain damage.

4. Hepatitis
 

5. Bilirubin
 

DEMYELINATING DISORDERS 1. ALZHEIMER’S DISEASE

Atrophy of brain tissues. Progressive, irreversible, degenerative neurologic disease characterized by gradual losses of cognitive fx. And disturbances in behavior and affect.

Sign and Symptoms 4 A’s of Alzheimer a. Amnesia – partial or total loss of memory. b. Agnosia – no recognition of inanimate objects. c. Apraxia – no recognition of objects function. d. Aphasia – no speech (nodding). *Expressive aphasia (Broca‘s Aphasia) frontal lobe
 

―motor speech center‖ Nursing mgt. provide PICTURE BOARD Inability to understand spoken words. Irrational thoughts/illogical General Knowing Gnostic Area or General Interpretative Area.

*Receptive aphasia (Wernicke‘s Aphasia) temporal lobe
  

DRUG OF CHOICE: ARICEPT (taken at bedtime) and COGNEX. [increasing acetylcholine] 2. MULTIPLE SCLEROSIS [Autoimmune process]
          

Chronic intermittent disorder of CNS characterized by white patches of demyelination in brain and spinal cord. Characterized by remission and exacerbation. Women ages 15-35 are prone Unknown Cause Slow growing virus Autoimmune disorders Pernicious anemia Myasthenia gravis Lupus Hypothyroidism GBS

Ig G – only antibody that pass placental circulation causing passive immunity. - Short term protection. - Immediate action. Ig A – present in all bodily secretions (tears, saliva, colostrums). Ig M – acute in inflammation. Ig E – for allergic reaction. Ig D – for chronic inflammation. * Give palliative or supportive care. Signs and Symptoms 1. Visual disturbances
  

blurring of vision (primary) Diplopia (double vision) scotomas (blind spots)

2. Impaired sensation
   

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

3. Mood swings

euphoria (sense of well being) weakness spasticity paralysis scanning speech TRIAD SIGNS OF MS Ataxia (Unsteady gait, (+) Romberg’s test)

4. Impaired motor function
  

5. Impaired cerebral function

CHARCOTS TRIAD

ANI

Intentional tremors 6. Urinary retention/incontinence 7. Constipation 8. Decrease sexual capacity DIAGNOSTIC PROCEDURE
  

Nystagmus

CSF analysis (increase in IgG and Protein). MRI (reveals site and extent of demyelination). (+) Lhermitte’s sign a continuous and increase contraction of spinal column/cord following laminotomy.

NURSING MANAGEMENT 1. Administer medications as ordered a. ACTH (Adreno Corticotropic Hormone)/ Steroids for acute exacerbation to reduce edema at site of demyelination to prevent paralysis. [Best given in Morning to mimic body normal rhythm] b. Baclofen (Dioresal)/ Dantrolene Sodium (Dantrene) – muscle relaxants. c. Interferons – alter immune response. d. Immunosupresants 2. Maintain side rails to prevent injury related to falls. 3. Institute stress management techniques. a. Deep breathing exercises b. Yoga 4. Increase fluid intake and increase fiber to prevent constipation. 5. Catheterization to prevent retention. a. Diuretics b. Bethanicol Chloride (Urecholine) – treat urinary retention Nursing Management
  

Only given subcutaneous. Monitor side effects bronchospasm and wheezing. Monitor breath sounds 1 hour after subcutaneous administration. Anti spasmodic agent a. Prophantheline Bromide (Probanthine) – antispasmodic drug to treat urinary incontinence
 

c. For Urinary Incontinence

Acid ash diet like cranberry juice, plums, prunes, pineapple, vitamin C and orange. To acidify urine and prevent bacterial multiplication.

COMMON CAUSE OF UTI Female
  

short urethra (3-5 cm, 1-1 ½ inches) poor perineal hygiene vaginal environment is moist avoid bubble bath (can alter Ph of vagina). avoid use of tissue papers avoid using talcum powder and perfume. Urethra (20 cm, 8 inches) urinate after intercourse

Nursing Management
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Male
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MICROGLIA

stationary cells that carry on phagocytosis (engulfing of bacteria or cellular debris, eating), pinocytosis (cell drinking). MACROPHAGE Microglia Monocytes Kupffers cells Histiocytes Alveolar Macrophage ORGAN Brain Blood Kidney Skin Lung

EPINDYMAL CELLS

Secretes a glue called chemo attractants that concentrate the bacteria. 80% brain mass 10% blood 10% CSF

COMPOSITION OF BRAIN
  

I. Brain Mass PARTS OF THE BRAIN 1. CEREBRUM
 

largest part Composed of the Right Cerebral Hemisphere and Left Cerebral Hemisphere enclosed in the Corpus Callosum.

Functions of Cerebrum
  

integrative sensory motor

Lobes of Cerebrum 1. Frontal
   

higher cortical thinking controls personality controls motor activity Broca‘s Area (motor speech area) when damaged results to garbled speech.

2. Temporal
 

hearing short term memory for appreciation Discrimination of sensory impulses to pain, touch, pressure, heat, cold, numbness. for vision

3. Parietal
 

4. Occipital

Insula (Island of Reil)

Visceral function activities of internal organ like gastric motility. controls smell and if damaged results to Anosmia (absence of smell). controls libido [the true sense of sexual arousal is when you smelled the fumes of the natural body] controls long term memory

Limbic System (Rhinencephalon)
  

2. BASAL GAGLIA
 

areas of grey matter located deep within each cerebral hemisphere. release dopamine (controls gross voluntary movement.) NEURO TRANSMITTER Acethylcholine Dopamine DECREASE Myasthenia Gravis Parkinson’s Disease INCREASE Bi-polar Disorder Schizophrenia

3. MIDBRAIN/ MESENCEPHALON
     

acts as relay station for sight and hearing. size of pupil is 2 – 3 mm. equal size of pupil is isocoria. unequal size of pupil is anisocoria. hearing acuity is 30 – 40 dB. positive PERRLA [Pupils equal, round, reactive to light and accommodation]

4. INTERBRAIN/ DIENCEPHALON Parts of Diencephalon A. Thalamus

Acts as relay station for sensation. Controls temperature (thermoregulatory center). controls blood pressure controls thirst appetite/satiety sleep and wakefulness Controls some emotional responses like fear, anxiety and excitement. controls pituitary functions Androgenic hormones promote secondary sex characteristics. early sign for males are testicular and penile enlargement late sign is deepening of voice. early sign for females telarche and late sign is menarche.

B. Hypothalamus
          

5. BRAIN STEM

located at lowest part of brain

Parts of Brain Stem 1. Pons

pneumotaxic center controls the rate, rhythm and depth of respiration. Controls respiration, heart rate, and swallowing, vomiting, hiccup, vasomotor center (dilation and constriction of bronchioles). [damage to medulla is most life threatening]

2. Medulla Oblongata

3. Cerebellum
  

Smallest part of the brain. Lesser brain. Controls balance, equilibrium, posture and gait.

INTRA CRANIAL PRESSURE Monroe Kellie Hypothesis Skull is a closed container Any alteration or increase in one of the intracranial components Increase intra-cranial pressure (normal ICP is 0 – 15 mmHg) Cervical 1 – also known as ATLAS. Cervical 2 – also known as AXIS. Foramen Magnum Medulla Oblongata Brain Herniation Increase intra cranial pressure * Alternate hot and cold compress to prevent HEMATOMA
 CSF

cushions brain (shock absorber) of flow of CSF will lead to enlargement of skull posteriorly called hydrocephalus. closure of posterior fontanels causes posterior enlargement of skull in hydrocephalus.

 Obstruction  Early

NEUROLOGIC DISORDERS
INCREASE INTRACRANIAL PRESSURE – increase in intra-cranial bulk brought about by an increase in one of the 3 major intra cranial components. NORMAL ICP: 0-15 mmhg Causes:
   

head trauma/injury localized abscess cerebral edema hemorrhage

  

inflammatory condition (stroke) hydrocephalus tumor (rarely)

Signs and Symptoms (Early)
  

decrease LOC restlessness/agitation irritability changes in vital signs

 

lethargy/stupor coma

Signs and Symptoms (Late)
           

Blood pressure (systolic blood pressure increases but diastolic remains the same). Widening of pulse pressure is neurologic in nature (if narrow cardiac in nature). heart rate decrease respiratory rate decrease Temperature increase directly proportional to blood pressure. projective vomiting headache papilledema (edema of optic disc) abnormal posturing, [may positive to babinski reflex] Decorticate posturing (damage to cortex and spinal cord). decerebrate posturing (damage to upper brain stem that includes pons, cerebellum and midbrain). unilateral dilation of pupils called uncal herniation bilateral dilation of pupils called tentorial herniation resulting to mild headache possible seizure activity

   

Nursing Management 1. Maintain patent and adequate ventilation by: a. Prevention of hypoxia and hypercarbia Early signs of hypoxia
  

Restlessness Agitation Tachycardia Bradycardia Extreme restlessness Dyspnea Cyanosis

Late signs of hypoxia
   

HYPERCARBIA
 

Increase CO2 (most powerful respiratory stimulant) retention. In chronic respiratory distress syndrome decrease O2 stimulates respiration.

b. Before and after suctioning hyper oxygenate client 100% and done 10 – 15 seconds only. c. Assist in mechanical ventilation 2. Elevate bed of client 30 – 35 angle with neck in neutral position unless contraindicated to promote venous drainage. 3. Limit fluid intake to 1200 – 1500 ml/day (in force fluids 2000 – 3000 ml/day). 4. Monitor strictly input and output and neuro check 5. Prevent complications of 6. Prevent further increase ICP by: a. provide an comfortable and quite environment. b. avoid use of restraints. c. maintain side rails. d. instruct client to avoid forms of valsalva maneuver like: straining stool excessive vomiting (use anti emetics) excessive coughing (use anti tussive like dextromethorphan) avoid stooping/bending avoid lifting heavy objects e. avoid clustering of nursing activity together. 7. Administer medications like: a. Osmotic diuretic (Mannitol) for cerebral diuresis Nursing Management monitor vital signs especially BP (hypotension). monitor strictly input and output every 1 hour notify physician if output is less 30 cc/hr. administered via side drip Regulated fast drip to prevent crystal formation. b. Loop diuretic (Lasix, Furosemide)
 
o

Drug of choice for CHF (pulmonary edema) Loop of Henle in kidneys. Monitor vital signs especially BP (hypotension). monitor strictly input and output every 1 hour notify physician if output is less 30 cc/hr. Administered IV push or oral.

Nursing Management
  

  

given early morning Immediate effect of 10 – 15 minutes. maximum effect of 6 hours. [monitor for potassium depletion]

c. Corticosteroids
    

Dexamethasone (Decadron) Hydrocortisone Prednisone (to reduce edema that may lead to increase ICP) Mild Analgesics (Codeine Sulfate for respiratory depression) Anti Convulsants (Dilantin, Phenytoin)

*CONGESTIVE HEART FAILURE Signs and Symptoms
            

dyspnea orthopnea paroxysmal nocturnal dyspnea productive cough frothy salivation cyanosis rales/crackles bronchial wheezing pulsus alternans anorexia and general body malaise PMI (point of maximum impulse/apical pulse rate) is displaced laterally S3 (ventricular gallop) Predisposing Factors/Mitral Valve   RHD Aging

TREATMENT Morphine Sulfate Aminophelline Digoxin Diuretics Oxygen Gases, blood monitor RIGHT CONGESTIVE HEART FAILURE (Venous congestion) Signs and Symptoms
        

jugular vein distention (neck) ascites pitting edema weight gain hepatosplenomegaly jaundice pruritus esophageal varices anorexia and general body malaise

Signs and Symptoms of Lasix in terms of electrolyte imbalances 1. Hypokalemia
 

decrease potassium level normal value is 3.4 – 5.5 meq/L weakness and fatigue

Sign and Symptoms

 

constipation positive U wave on ECG tracing administer potassium supplements as ordered (Kalium Durule, Oral Potassium Chloride) increase intake of foods rich in potassium FRUITS Apple Banana Cantalope Oranges VEGETABLES Asparagus Brocolli Carrots Spinach

Nursing Management
 

2. Hypocalcemia/ Tetany
 

decrease calcium level normal value is 8.5 – 10.5 mg/100 ml tingling sensation paresthesia numbness (+) Trousseau’s sign/ Carpopedal spasm (+) Chvostek’s sign Arrhythmia Seizures Calcium Gluconate per IV slowly as ordered

Signs and Symptoms
    

Complications  

Nursing Management

* Calcium Gluconate toxicity – results to SEIZURE Magnesium Sulfate Magnesium Sulfate toxicity [B.U.R.P] S/S BP Urine output Respiratory rate Patellar relfex absent 3. Hyponatremia
 

DECREASE

decrease sodium level normal value is 135 – 145 meq/L hypotension dehydration signs (Initial sign in adult is THIRST, in infant TACHYCARDIA) agitation dry mucous membrane poor skin turgor weakness and fatigue

Signs and Symptoms
     

Nursing Management
 

force fluids administer isotonic fluid solution as ordered

4. Hyperglycemia

normal FBS is 80 – 100 mg/dl

Signs and Symptoms - 3 P’s

  

polyuria polydypsia polyphagia monitor FBS increase uric acid (purine metabolism) foods high in uric acid (sardines, organ meats and anchovies) *Increase in tophi deposit leads to Gouty arthritis. joint pain (great toes) swelling force fluids administer medications as ordered Drug of choice for gout. Mechanism of action: inhibits synthesis of uric acid. Acute gout Mechanism of action: promotes excretion of uric acid.

Nursing Management

5. Hyperuricemia
  

Signs and Symptoms
 

Nursing Management
 

a. Allopurinol (Zyloprim)
 

b. Colchecine
 

KIDNEY STONES
Signs and Symptoms
 

renal colic Cool moist skin force fluids administer medications as ordered Morphine Sulfate ANTIDOTE: Naloxone (Narcan) toxicity leads to tremors.

Nursing Management
 

a. Narcotic Analgesic
 

b. Allopurinol (Zyloprim) Side Effects

Respiratory depression (check for RR)

PARKINSON’S DISEASE/ PARKINSONISM

Chronic progressive disorder of CNS characterized by degeneration of dopamine producing cells in the SUBSTANCIA NIGRA of the midbrain and basal ganglia.

Predisposing Factors 1. Poisoning (lead and carbon monoxide) 2. Arteriosclerosis 3. Hypoxia 4. Encephalitis 5. Increase dosage of the following drugs: a. Reserpine(Serpasil) b. Methyldopa(Aldomet) c. Haloperidol(Haldol) d. Phenothiazine AntipsychoticS AntihypertensiveS

SIDE EFFECTS RESERPINE  Major depression leading to suicide

Aloneness

Multiple loss causes suicide

Loss of spouse direct approach towards the client close surveillance is a nursing priority

Loss of Job

  

time to commit suicide is on weekends early morning

Signs and Symptoms for Parkinson’s
            

pill rolling tremors of extremities especially the hands. bradykinesia (slowness of movement) rigidity (cogwheel type) stooped posture shuffling and propulsive gait over fatigue mask like facial expression with decrease blinking of the eyes. difficulty rising from sitting position. Dysphonia – soft slurred Monotone type speech mood lability (in state of depression) Micrographia-shrinking slow handwriting increase salivation (drooling type) autonomic changes a. increase sweating b. increase lacrimation c. seborrhea d. constipation e. decrease sexual capacity

Nursing Management 1. Administer medications as ordered Anti Parkinsonian agents
  

Levodopa (L-dopa) short acting Amantadine Hydrochloride (Symmetrel) Carbidopa (Sinemet) increase level of dopamine GIT irritation (should be taken with meals

Mechanism of Action

Side Effects
   

orthostatic hypotension (CBQ)
arrhythmia hallucinations clients with narrow angle closure glaucoma clients taking MAOI‘s (no foods with tryptophan and thiamine: cheese, beer, avocado, wine) urine and stool may be darkened no Vitamin B6 (Pyridoxine) reverses the therapeutic effects of Levodopa

Contraindications
   

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

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

inhibits action of acethylcholine SNS

Side Effects

Anti Histamine (Dipenhydramine Hydrochloride) Side Effects Adult: drowsiness Children: CNS excitement (hyperactivity) because blood brain barrier is not yet fully developed. Dopamine Agonist - relieves tremor rigidity Bromocriptene Hydrochloride (Parlodel) Side Effects

Respiratory depression

2. Maintain side rails to prevent injury 3. Prevent complications of immobility 4. Decrease protein in morning and increase protein in afternoon to induce sleep 5. Encourage increase fluid intake and fiber. 6. Assist/supervise in ambulation 7. Assist in Stereotaxic Thalamotomy –a portion of thalamus is destroyed to reduce tremors

MAGIC 2’s IN DRUG MONITORING [D.L.A.D.A]
DRUG Digoxin/ Lanoxin (Increase force of cardiac output) Lithium/ Lithane (Decrease level of Ach/NE/Serotonin) Aminophylline (Dilates bronchial tree) Dilantin/ Phenytoin Acetaminophen/Tylenol NORMAL RANGE .5 – 1.5 meq/L .6 – 1.2 meq/L 10 – 19 mg/100 ml 10 – 19 mg/100 ml 10 – 30 mg/100 ml TOXICITY LEVEL 2 2 20 20 200 INDICATION CHF Bipolar COPD Seizures Osteoarthritis CLASSIFICATION Cardiac Glycoside Anti-Manic Agents Bronchodilators Anti-Convulsant Non-narcotic Analgesic

1. Digitalis Toxicity Signs and Symptoms
    

nausea and vomiting / anorexia diarrhea confusion / fatigue / depression / malaise photophobia changes in color perception (yellowish or green halo around lights or ―snowy‖ vision)

Antidote: Digibind – digoxin immune FAB 2. Lithium Toxicity – anti-manic agent/ mood stabilizing agent Signs and Symptoms
    

anorexia nausea and vomiting diarrhea dehydration causing fine tremors hypothyroidism (cretinism – the only endocrine disorder that can lead to mental retardation) force fluids increase sodium intake to 4 – 10 g% daily

Nursing Management
 

3. Aminophylline Toxicity Signs and Symptoms
  

tachycardia palpitations CNS excitement (tremors, irritability, agitation and restlessness) Only mixed with plain NSS or 0.9 NaCl to prevent development of crystals or precipitate. administered sandwich method avoid taking alcohol because it can lead to severe CNS depression avoid caffeine

Nursing Management
   

4. Dilantin phenytoin Toxicity Signs and Symptoms
   

gingival hyperplasia (swollen & tender gums) hairy tongue ataxia nystagmus provide oral care massage gums

Nursing Management
 

5. Acetaminophen Toxicity Signs and Symptoms
    

hepatotoxicity (monitor for liver enzymes) SGPT/ALT (Serum Glutamic Pyruvate Transaminace) SGOT/AST (Serum Glutamic Oxalo-Acetil Transaminace) nephrotoxicity monitor BUN (10 – 20) and Creatinine (.8 – 1) hypoglycemia

Tremors, tachycardia Irritability Restlessness Extreme fatigue Diaphoresis, depression Antidote: Acetylcisteine (mucomyst) prepare suction apparatus at bedside.

MYASTHENIA GRAVIS

Neuromuscular disorder characterized by a disturbance in the transmission of impulses from nerve to muscle cells at the neuromuscular junction leading to descending muscle weakness.

Incidence rate: women 20 – 40 years old Predisposing factors
 

unknown Autoimmune: it involves release of cholinesterase an enzyme that destroys Acetylcholine initial sign is ptosis a clinical parameter to determine ptosis is palpebral fissure. (drooping of eyelid) diplipia mask like facial expression dysphagia hoarseness of voice [dysphonia-voice impairment] respiratory muscle weakness that may lead to respiratory arrest (tracheostomy at bed side) extreme muscle weakness especially during activity or exertion Tensilon test (Edrophonium Hydrochloride) provides temporary relief of signs and symptoms for about 5 – 10 minutes and a maximum of 15 minutes. if there is no effect there is damage to occipital lobe and midbrain and is negative for M.G.

Signs and Symptoms
      

Diagnostic Procedure

Nursing Management 1. Airway 2. Aspiration 3. Immobility * assist in mechanical ventilation and monitor pulmonary function test * monitor strictly vital signs, input and output and neuro check * monitor strength or motor grading scale 4. Maintain side rails to prevent injury related to falls 5. Institute NGT feeding 6. Administer medications as ordered a. Cholinergic (Mestinon) – pyridostigmine bromide b. Anti Cholenisterase (Prostigmin) – neostigmine bromide Mechanism of Action

maintain patent airway and adequate ventilation

increase level of Ach PNS Cortocosteroids suppress immune response monitor for 2 types of crisis: MYASTHENIC CRISIS CHOLINERGIC CRISIS Cause: over medication Signs and Symptoms PNS Tensilon test doesn‘t improve MG Treatment Administer anti cholinergic agents (Atropine Sulfate)

Side Effects
  

Causes: under medication stress (disease exacerbation, high temp.) infection Signs and Symptoms The client is unable to see, swallow, speak, breathe Treatment administer cholinergic agents as ordered

7. Assist in surgical procedure known as thymectomy because it is believed that the thymus gland is responsible for M.G. 8. Assist in plasma paresis and removing auto immune anti bodies 9. Prevent complications

INFLAMMATORY CONDITIONS OF THE BRAIN
MENINGITIS Meninges
   

3 fold membrane that covers brain and spinal cord. for support and protection for nourishment blood supply

LAYERS OF THE MENINGES 1. Dura matter – outer layer 2. Arachnoid – middle layer 3. Pia matter – inner layer
 

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

A. Etiology 1. Meningococcus – most dangerous 2. Pneumococcus 3. Streptococcus - causes adult meningitis 4. Hemophilus Influenzae – causes pediatric meningitis B. Mode of transmission

airborne transmission (droplet nuclei)

C. Signs and Symptoms
      

headache photophobia projectile vomiting fever & chills, anorexia, generalized body malaise and weight loss Possible increase in ICP and seizure activity Abnormal posturing (decorticate and decerebrate) Signs of meningeal irritation a. Nuchal rigidity or stiff neck b. Opisthotonus (arching of back) c. (+) Kernig’s sign (leg pain) d. (+) Brudzinski sign (neck pain)

D. Diagnostic Procedures

Lumbar puncture: a hollow spinal needle is inserted in the subarachnoid space between the L3 – L4 to L5.

Nursing Management for LP Before Lumbar Puncture. [note all surgery procedure explain by the doctor, diagnostic procedure is by the nurse] 1. Secure informed consent and explain procedure. 2. Empty bladder and bowel to promote comfort. 3. Encourage to arch back to clearly visualize L3-L4. (fetal position) Post Lumbar Puncture o 1. Place flat on bed 12 – 24 2. Force fluids 3. Check punctured site for any discoloration, drainage and leakage to tissues. 4. Assess for movement and sensation of extremities. CSF analysis reveals 1. Increase CHON and WBC 2. Decrease glucose 3. Increase CSF opening pressure (normal pressure is 50 – 100 mmHg) 4. (+) cultured microorganism (confirms meningitis) CBC reveals 1. Increase wbc E. Nursing Management 1. Enforce complete bed rest 2. Administer medications as ordered a. Broad spectrum antibiotics (Penicillin, Tetracycline) b. Mild analgesics c. Anti pyretics 3. Institute strict respiratory isolation 24 hours after initiation of anti biotic therapy 4. Elevate head 30-45
o

notes on hematology: RBC WBC PLATELETS

INCREASED Polycythemia Leukocytosis Thrombocytosis

DECREASED Anemia Leukopenia Thrombocytopenia

5. Monitor strictly V/S, input and output and neuro check 6. Institute measures to prevent increase ICP and seizure. 7. Provide a comfortable and darkened environment. 8. Maintain fluid and electrolyte balance. 9. Provide client health care and discharge planning concerning: a. Maintain good diet of increase CHO, CHON, calories with small frequent feedings. b. Prevent complications
  

most feared is hydrocephalus hearing loss/nerve deafness is second complication consult audiologist mental retardation delayed psychomotor development

c. Rehabilitation for neurological deficit
 

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

a partial or complete disruption in the brains blood supply. 2 most common cerebral artery affected by stroke

a. Mid Cerebral Artery b. Internal Cerebral Artery – the 2 largest artery A. Incidence Rate

men are 2-3 times high risk

B. Predisposing Factors
 

thrombus (attached) embolus (detached and most dangerous because it can go to the lungs and cause pulmonary embolism or the brain and cause cerebral embolism.

Signs and Symptoms of Pulmonary Embolism
     

Sudden sharp chest pain Unexplained dyspnea Tachycardia Palpitations Diaphoresis Mild restlessness Headache and dizziness Confusion Restlessness Decrease LOC

Signs and Symptoms of Cerebral Embolism
   

   

Fat embolism is the most feared complications after femur fracture. Yellow bone marrow are produced from the medullary cavity of the long bones and produces fat cells. If there is bone fracture there is hemorrhage and there would be escape of the fat cells in the circulation. Compartment syndrome (compression of arteries and nerves)

C. Risk Factors 1. Hypertension, Diabetes Mellitus, Myocardial Infarction, Atherosclerosis, Valvular Heart Disease, Post Cardiac Surgery (mitral valve replacement) 2. Lifestyle (smoking), sedentary lifestyle 3. Obesity (increase 20% ideal body weight) 4. Hyperlipidemia more on genetics/genes that binds to cholesterol 5. Type A personality a. deadline driven b. can do multiple tasks c. usually fells guilty when not doing anything 6. Related to diet: increase intake of saturated fats like whole milk 7. Related stress physical and emotional 8. Prolong use of oral contraceptives promotes lypolysis (breakdown of lipids) leading to atherosclerosis that will lead to hypertension and eventually CVA. D. Signs and Symptoms

dependent on stages of development Initial sign of stroke or warning sign headache and dizziness tinnitus visual and speech disturbances paresis to plegia possible increase ICP

1. TIA

Signs and Symptoms
    

2. Stroke in evolution -progression of signs and symptoms of stroke 3. Complete stroke

resolution phase characterized by: headache and dizziness Cheyne Stokes Respiration anorexia, nausea and vomiting dysphagia (+) Kernig’s sign and Brudzinski sign which may lead to hemorrhagic stroke focal neurological deficits a. phlegia b. aphasia c. dysarthria (inability to articulate words) d. alexia (difficulty reading) e. agraphia (difficulty writing) f. homonymous hemianopsia (loss of half of visual field)
Notes: “Plegia” – paralysis Ex: Hemiplegia – paralysis of one side of the body. “Paresis” – weakness Ex: Hemiparesis - weakness of one side of the body.

Signs and Symptoms
    

E. Diagnostic Procedure 1. CT Scan – reveals brain lesions 2. Cerebral Arteriography
      

reveals the site and extent of malocclusion uses dye for visualization most of dye are iodine based check for shellfish allergy after diagnostic exam force fluids to release dye because it is nephro toxic check for distal pulse (femoral) check for hematoma formation

F. Nursing Management 1. Maintain patent airway and adequate ventilation by: a. assist in mechanical ventilation b. administrate O2 inhalation 2. Restrict fluids to prevent cerebral edema that might increase ICP 3. Elevate head 30 – 45
o

4. Monitor strictly vitals signs, I & O and neuro check 5. Prevent complications of immobility by: a. turn client to side b. provide egg crate mattresses or water bed c. provide sand bag or foot board. 6. Assist in passive ROM exercise every 4 hours to promote proper bodily alignment and prevent contractures 7. Institute NGT feeding 8. Provide alternative means of communication a. non verbal cues b. magic slate 9. If positive to hemianopsia approach client on unaffected side 10. Administer medications as ordered a. Osmotic Diuretics (Mannitol) b. Loop Diuretics (Lasix, Furosemide) c. Cortecosteroids d. Mild Analgesics e. Thrombolytic/Fibrinolytic Agents – dissolves thrombus

Streptokinase  Side Effect: Allergic Reaction Urokinase Tissue Plasminogen Activating Factor  Side Effect: Chest Pain

 

f. Anti Coagulants

Heparin (short acting)   check for partial thromboplastin time if prolonged there is a risk for bleeding. give Protamine Sulfate give simultaneously because Coumadin will take effect after 3 days check for prothrombin time if prolonged there is a risk for bleeding give Vit. K (Aqua Mephyton)

Comadin/ Warfarin (long acting)   

g. Anti Platelet
 

PASA (Aspirin) Contraindicated for dengue, ulcer and unknown cause of headache because it may potentiate bleeding

11. Provide client health teachings and discharge planning concerning a. avoidance of modifiable risk factors (diet, exercise, smoking) b. prevent complication (subarachnoid hemorrhage is the most feared complication) c. dietary modification (decrease salt, saturated fats and caffeine) d. importance of follow up care

GUILLAIN BARRE SYNDROME (Acute Ediopathic Polyneuropathy)

a disorder of the CNS characterized by bilateral symmetrical polyneuritis leading to ascending muscle paralysis/weakness.

A. Predisposing Factors 1. Autoimmune 2. Antecedent viral infections such as LRT infections

B. Signs and Symptoms 1. Clumsiness (initial sign) 2. Dysphagia 3. Ascending muscle weakness leading to paralysis 4. Decreased of diminished deep tendon reflex 5. Alternate hypotension to hypertension ** ARRYTHMIA (most feared complication) 6. Autonomic symptoms that includes a. increase salivation b. increase sweating c. constipation C. Diagnostic Procedures 1. CSF analysis reveals increase in IgG and protein D. Nursing Management 1. Maintain patent airway and adequate ventilation by: a. assist in mechanical ventilation b. monitor pulmonary function test 2. Monitor strictly the following a. vital signs b. intake and output c. neuro check d. ECG 3. Maintain side rails to prevent injury related to fall 4. Prevent complications of immobility by turning the client every 2 hours 5. Institute NGT feeding to prevent aspiration 6. Assist in passive ROM exercise 7. Administer medications as ordered a. Corticosteroids – suppress immune response b. Anti Cholinergic Agents – Atrophine Sulfate c. Anti Arrythmic Agents
 

Lidocaine, Zylocaine Bretylium – blocks release of norepinephrine to prevent increase of BP

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

for liver cirrhosis to decompress bleeding esophageal verices (prepare scissor to cut tube incase of difficulty in breathing to release air in the balloon for hemodialysis prepare bulldog clips to prevent air embolism.

CONVULSIVE DISORDER/ CONVULSION

Disorder of CNS characterized by paroxysmal seizure with or without loss of consciousness abnormal motor activity alternation in sensation and perception and changes in behavior. Seizure – first convulsive attack Epilepsy – second or series of attacks Febrile seizure – normal in children age below 5 years

  

A. Predisposing Factors 1. Head injury due to birth trauma 2. Genetics 3. Presence of brain tumor 4. Toxicity from a. lead b carbon monoxide 5. Nutritional and Metabolic deficiencies 6. Physical and emotional stress 7. Sudden withdrawal to anti convulsant drug is predisposing factor for status epilepticus (drug of choice is Diazepam, Valium) B. Signs and Symptoms

Dependent on stages of development or types of seizure

I. Generalized Seizure 1. Grand mal Seizure (tonic-clonic seizure) a. Signs or aura with auditory, olfactory, visual, tactile, sensory experience b. Epileptic cry – is characterized by fall and loss of consciousness for 3 – 5 minutes c. Tonic contractions - direct symmetrical extension of extremities Clonic contractions - contraction of extremities d. Post ictal sleep – unresponsive sleep 2. Petit mal Seizure – absence of seizure common among pediatric clients characterized by a. blank stare b. decrease blinking of eyes c. twitching of mouth d. loss of consciousness (5 – 10 seconds) II. Partial or Localized Seizure 1. Jacksonian Seizure (focal seizure)

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

2. Psychomotor Seizure (focal motor seizure) a. automatism – stereotype repetitive and non propulsive behavior b. clouding of consciousness – not in contact with environment c. mild hallucinatory sensory experience III. Status Epilepticus

A continuous uninterrupted seizure activity, if left untreated can lead to hyperpyrexia and lead to coma and eventually death. Drug of choice: Diazepam, Valium and Glucose

C. Diagnostic Procedures 1. CT Scan – reveals brain lesions 2. EEG – reveals hyper activity of electrical brain waves D. Nursing Management 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 (Tegretol) – Trigeminal neuralgia d. Phenobarbital, Luminal 4. Institute seizure and safety precaution post seizure attack a. administer O2 inhalation b. provide suction apparatus 5. Document and monitor the following a. onset and duration b. types of seizures c. duration of post ictal sleep may lead to status epilepticus d. assist in surgical procedure cortical resection COMPREHENSIVE NEURO EXAM GLASGOW COMA SCALE

objective measurement of LOC sometimes called as the quick neuro check Conscious Lethargy Stupor Coma Deep Coma 15 – 14 13 – 11 10 – 8 7 3

Components 1. Motor response 2. Verbal response 3. Eye opening

Survey of mental status and speech a. LOC b. Test of memory Levels of orientation Cranial nerve assessment Sensory nerve assessment Motor nerve assessment Deep tendon reflex Autonimics Cerebellar test a, Romberg‘s test – 2 nurses, positive for ataxia b. Finger to nose test – positive result mean dimetria (inability of body to stop movement at desired point) c. Alternate supination and pronation – positive result mean dimetria

      

I. LEVEL OF CONSCIOUSNESS 1. Conscious - awake 2. Lethargy – lethargic (drowsy, sleepy, obtunded) 3. Stupor
  

stuporous (awakened by vigorous stimulation) generalized body weakness decrease body reflex comatose light coma (positive to all forms of painful stimulus) deep coma (negative to all forms of painful stimulus)

4. Coma
  

DIFFERENT PAINFUL STIMULATION 1. Deep sternal stimulation/ deep sternal pressure 2. Orbital pressure 3. Pressure on great toes 4. Corneal or blinking reflex  Conscious client use a wisp of cotton  Unconscious client place 1 drop of saline solution II. TEST OF MEMORY 1. Short term memory
 

ask most recent activity positive result mean anterograde amnesia and damage to temporal lobe ask for birthday and validate on profile sheet positive result mean retrograde amnesia and damage to limbic system consider educational background CRANIAL NERVES I. OLFACTORY II. OPTIC III OCCULOMOTOR FUNCTION S S M M (Smallest) B (Largest) M B S B B (Longest) M M

2. Long term memory
  

III. LEVELS OF ORIENTATION 1. Time – first asked 2. Person – second asked 3. Place – third asked CRANIAL NERVES CRANIAL NERVE I: OLFACTORY

IV. TROCHLEAR V. TRIGEMINAL VI. ABDUCENSE

sensory function for smell don‘t use alcohol, ammonia, perfume because it is irri tating and highly diffusible. use coffee granules, vinegar, bar of soap, cigarette test each nostril by occluding each nostril VII. FACIAL VIII. ACOUSTIC IX. GLOSSOPHARYNGEAL X. VAGUS XI. SPINAL ACCESSORY XII. HYPOGLOSSAL

Material Used

Procedure

Abnormal Findings 1. Hyposnia – decrease sensitivity to smell 2. Dysosmia – distorted sense of smell 3. Anosmia – absence of smell Indicative of

1. head injury damaging the cribriform plate of ethmoid bone where olfactory cells are located 2. may indicate inflammatory conditions (sinusitis) CRANIAL NERVE II: OPTIC

sensory function for vision or sight

Functions 1. Test visual acuity or central vision or distance
        

use Snellen’s Chart Snellen‘s Alphabet chart: for literate clients Snellen‘s E chart: for illiterate clients Snellen‘s Animal chart: for pediatric clients normal visual acuity 20/20 numerator is constant, it is the distance of person from the chart (6 – 7 m, 20 feet) denominator changes, indicates distance by which the person normally can see letter in the chart. - 20/200 indicates blindness 20/20 visual acuity if client is able to read letters above the red line.

2. Test of visual field or peripheral vision

a. Superiorly b. Bitemporaly c. Nasally d. Inferiorly COMMON VISUAL DISORDERS 1. Glaucoma
  

increase IOP normal IOP is 12 – 21 mmHg preventable but not curable Common among 40 years old and above Hereditary Hypertension Obesity

A. Predisposing Factors
   

B. Signs and Symptoms 1. Loss of peripheral vision

pathognomonic sign is tunnel vision steamy cornea may lead to blindness

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

C. Diagnostic Procedures 1. Tonometry 2. Perimetry 3. Gonioscopy D. Treatment 1. Miotics – constricts pupil a. Pilocarpine Sodium, Carbachol 2. Epinephrine eyedrops – decrease formation of aqueous humor 3. Carbonic Anhydrase Inhibitors a. Acetazolamide (Diamox) – promotes increase outflow of aqueous humor or drainage 4. Timoptics (Timolol Maleate) E. Surgical Procedures 1. TRABECULECTOMY (Peripheral Indectomy) – drain aqueous humor

2. CATARACT

Decrease opacity of lens

A. Predisposing Factor 1. Aging 65 years and above 2. Related to congenital 3. Diabetes Mellitus 4. Prolonged exposure to UV rays B. Signs and Symptoms 1. Loss of central vision C. Pathognomonic Signs 1. Blurring or hazy vision 2. Milky white appearance at center of pupils 3. Decrease perception to colors

Complication is blindness

D. Diagnostic Procedure 1. Opthalmoscopic exam E. Treatment 1. Mydriatics (Mydriacyl) – dilating pupils 2. Cyclopegics (Cyclogyl) – paralyses cilliary muscle F. Surgical Procedure Extra Capsular Cataract Lens Extraction - Partial removal

Intra Capsular Cataract Lens Extraction - Total removal of cataract with its surrounding capsules

Most feared complication post op is RETINAL DETACHMENT

3. Retinal Detachment

Separation of epithelial surface of retina

A. Predisposing Factors 1. Post Lens Extraction 2. Myopia (near sightedness) B. Signs and Symptoms 1. Curtain veil like vision 2. Floaters C. Surgical Procedures 1. Scleral Buckling 2. Cryosurgery – cold application 3. Diathermy – heat application

4. Macular Degeneration

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

A. Signs and Symptoms 1. Black Spots CRANIAL NERVE III, IV, VI: OCULOMOTOR, TROCHLEAR, ABDUCENS
 
A. normal retina B. ―wet‖ macular degeneration c. ―dry‖ macular degeneration

Controls or innervates the movement of extrinsic ocular muscle (EOM) 6 muscles

Superior Rectus

Superior Oblique

Lateral Rectus

Medial Rectus

Inferior Oblique

Inferior Rectus

  

trochlear controls superior oblique abducens controls lateral rectus oculomotor controls the 4 remaining EOM

Oculomotor
    

controls the size and response of pupil normal pupil size is 2 – 3 mm equal size of pupil: Isocoria Unequal size of pupil: Anisocoria Normal response: positive PERRLA

CRANIAL NERVE V: TRIGEMINAL
     

largest cranial nerve consists of ophthalmic, maxillary, mandibular sensory: controls sensation of face, mucous membrane, teeth, soft palate and corneal reflex) motor: controls the muscle of mastication or chewing damage to CN V leads to trigeminal neuralgia/tic douloureux (nerve pain) medication: Carbamezapine(Tegretol) - anticonvulsant

CRANIAL NERVE VII: FACIAL
   

Sensory: controls taste, anterior 2/3 of tongue pinch of sugar and cotton applicator placed on tip of tongue Motor: controls muscle of facial expression Instruct client to smile, frown and if results are negative there is facial paralysis or Bell‘s palsy and the primary cause is forceps delivery.

CRANIAL NERVE VIII: ACOUSTIC/VESTIBULOCOCHLEAR

Controls balance particularly kinesthesia or position sense, refers to movement and orientation of the body in space.

Parts of the Ear 1. Outer Ear
 

Pinna Eardrum Hammer Anvil Stirrup Malleus Incus Stapes

2. Middle Ear
  

3. Inner Ear
   

Vestibule: Meinere’s Disease Cochlea Mastoid Cells Endolymph and Perilymph

 

COCHLEA: controls hearing, contains the Organ of Corti (the true organ of hearing) Let client repeat words uttered

CRANIAL NERVE IX, X: GLOSOPHARYNGEAL, VAGUS NERVE
   

Glosopharyngeal: controls taste, posterior 1/3 of tongue Vagus: controls gag reflex Uvula should be midline and if not indicative of damage to cerebral hemisphere Effects of vagal stimulation is PNS

CRANIAL NERVE XI: SPINAL ACCESSORY

Innervates with sternocleidomastoid (neck) and trapezius (shoulder)

CRANIAL NERVE XII: HYPOGLOSSAL

 

Controls the movement of tongue Let client protrude tongue and it should be midline and if unable to do indicative of damage to cerebral hemisphere and/or has short frenulum.

ENDOCRINE SYSTEM
Overview of the structures and functions 1. Pituitary Gland (Hypophysis Cerebri) o o o Located at base of brain particularly at sella turcica Master gland or master clock Controls all metabolic function of body

PARTS OF THE PITUITARY GLAND 1. Anterior Pituitary Gland o o o o o o o o called as adenohypophysis called as neurohypophysis secretes hormones oxytocin -promotes uterine contractions preventing bleeding/ hemorrhage administrate oxytocin immediately after delivery to prevent uterine atony. initiates milk let down reflex with help of hormone prolactin
ADH OXYTOCIN Anterior pituitary GH ACTH TSH FSH & LH PROLACTIN MSH Posterior pituitary

2. Posterior Pituitary Gland

2. Antidiuretic Hormone Pitressin (Vasopressin) Function: prevents urination thereby conserving water Diabetes Insipidus/ Syndrome of Inappropriate Anti Diuretic Hormone DIABETES INSIPIDUS (Dalas Ihi) o o o o o 1. Polyuria 2. Signs of dehydration a. Adult: thirst b. Agitation c. Poor Skin turgor d. Dry mucous membrane 3. Weakness and fatigue 4. Hypotension 5. Weight loss (payat) 6. If left untreated results to hypovolemic shock (sign is anuria) C. Diagnostic Procedures 1. Urine Specific Gravity o o o 1. Force fluids 2. Monitor strictly vital signs and intake and output 3. Administer medications as ordered a. Pitressin (Vasopresin Tannate) – administered IM Z-tract Normal value: 1.015 – 1.030 Ph 4 – 8 Increase resulting to hypernatremia Decrease production of anti diuretic hormone Related to pituitary surgery Trauma Inflammation Presence of tumor A. Predisposing Factor

B. Signs and Symptoms

2. Serum Sodium D. Nursing Management

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

SIADH – lunod sa tubig
o hypersecretion of antidiuretic hormone

A. Predisposing Factors 1. Head injury 2. Related to presence of bronchogenic cancer o o initial sign of lung cancer is non productive cough non invasive procedure is chest x-ray

3. Related to hyperplasia (increase size of organ brought about by increase of number of cells) of pituitary gland. B. Signs and Symptoms 1. Fluid retention a. Hypertension b. Edema c. Weight gain (mataba) 2. Water intoxication may lead to cerebral edema and lead to increase ICP – may lead to seizure activity C. Diagnostic Procedure 1. Urine specific gravity is increased 2. Serum Sodium is decreased (hyponatremia 135 mg/dl) D. Nursing Management 1. Restrict fluid 2. Administer medications as ordered a. Loop diuretics (Lasix) b. Osmotic diuretics (Mannitol) 3. Monitor strictly vital signs, intake and output and neuro check 4. Weigh patient daily and assess for pitting edema 5. Provide meticulous skin care 6. Prevent complications ANTERIOR PITUITARY GLAND o also called ADENOHYPOPHYSIS secretes o o o o o Promotes elongation of long bones Hyposecretion of GH among children results to Dwarfism Hypersecretion of GH results to Gigantism Hypersecretion of GH among adults results to Acromegaly (square face) Drug of choice: Ocreotide (Sandostatin) 1. Growth hormones (somatotropic hormone)

2. Melanocyte Stimulating hormone o o o for skin pigmentation Hyposecretion of MSH results to Albinism Most feared complications of albinism

a. Lead to blindness due to severe photophobia b. Prone to skin cancer o Hypersecretion of MSH results to Vitiligo

3. Adrenochorticotropic hormone (ACTH) o promotes development of adrenal cortex

4. Lactogenic homone (Prolactin) o o promotes development of mammary gland with help of oxytocin it initiates milk let down reflex

5. Leutinizing hormone o o secretes estrogen secretes progesterone 6. Follicle stimulating hormone

PINEAL GLAND o o o secretes melatonin inhibits LH secretion it controls/regulates circadian rhythm (body clock)

THYROID GLAND o located anterior to the neck 3 Hormones secreted 1. T3 (Tri iodothyronine) - 3 molecules of iodine (more potent) 2. T4 (tetra iodothyronine, Thyroxine) o o T3 and T4 are metabolic or calorigenic hormone promotes cerebration (thinking)

3. Thyrocalcitonin – antagonizes the effects of parathormone to promote calcium resorption. HYPOTHYROIDISM – thyroid deficiency o o o o o o o o o o o o o o o o o o o o all are decrease except weight and menstruation memory impairment there is loss of appetite but there is weight gain menorrhagia or amenorrhea cold intolerance constipation can lead to Myxedema extreme fatigue babagsak sa exam (mental proc. Decreased) weight gain hypothermic all are increase except weight and menstruation increase appetite but there is weight loss amenorrhea exophthalmos Tachycardia, palpitations insomnia restlessness agitation Heat intolerance HPN

Signs and Symptoms

HYPERTHYROIDISM Signs and Symptoms
Pharmacologic therapy for hypothyroidism Synthetic levothyroxine (syndroid or levothroid) Myxedema coma Severe hypothyroidism Increased lethargic Hypothermic Stupor coma

THYROID DISORDERS SIMPLE GOITER o enlargement of thyroid gland due to iodine deficiency A. Predisposing Factors 1. Goiter belt area a. places far from sea b. Mountainous regions 2. Increase intake of goitrogenic foods o o contains pro-goitrin an anti thyroid agent that has no iodine. cabbage, turnips, radish, strawberry, carrots, sweet potato, broccoli, all nuts

o o

soil erosion washes away iodine goitrogenic drugs a. Anti Thyroid Agent – Prophylthiuracil (PTU) b. Lithium Carbonate c. PASA (Aspirin) d. Cobalt e. Phenylbutazones (NSAIDs) - if goiter is caused by

B. Signs and Symptoms 1. Enlarged thyroid gland 2. Mild dysphagia 3. Mild restlessness C. Diagnostic Procedures 1. Serum T3 and T4 – reveals normal or below normal 2. Thyroid Scan – reveals enlarged thyroid gland. 3. Serum Thyroid Stimulating Hormone (TSH) – is increased (confirmatory diagnostic test)

D. Nursing Management 1. Enforce complete bed rest 2. Administer medications as ordered a. Lugol’s Solution/SSKI ( Saturated Solution of Potassium Iodine) o o 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 (drug of choice for pyelonephritis) b. Thyroid Hormones o o o Levothyroxine (Synthroid) Liothyronine (Cytomel) Thyroid Extracts

Nursing Management when giving Thyroid Hormones 1. Instruct client to take in the morning to prevent insomnia 2. Monitor vital signs especially heart rate because drug causes tachycardia and palpitations 3. Monitor side effects o o o o o o o insomnia tachycardia and palpitations hypertension heat intolerance 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 it is easily destroyed by heat 5. Assist in surgical procedure of subtotal thyroidectomy HYPOTHYROIDISM o o o hyposecretion of thyroid hormone adults: MYXEDEMA non pitting edema children: CRETINISM the only endocrine disorder that can lead to mental retardation

4. Increase dietary intake of foods rich in iodine

A. Predisposing Factors 1. Iatrogenic Cause – disease caused by medical intervention such as surgery 2. Related to atrophy of thyroid gland due to trauma, presence of tumor, inflammation 3. Iodine deficiency

4. Autoimmune (Hashimotos Disease) B. Signs and Symptoms (Early Signs) 1. Weakness and fatigue 2. Loss of appetite but with weight gain which promotes lipolysis leading to atherosclerosis and MI 3. Dry skin 4. Cold intolerance 5. Constipation (Late Signs) 1. Brittleness of hair and nails 2. Non pitting edema (Myxedema) 3. Hoarseness of voice 4. Decrease libido 5. Decrease in all vital signs – hypotension, bradycardia, bradypnea, hypothermia 6. CNS changes o o o o lethargy memory impairment (forgetfulness) psychosis menorrhagia

C. Diagnostic Procedures 1. Serum T3 and T4 is decreased 2. Serum Cholesterol is increased 3. RAIU (Radio Active Iodine Uptake) is decreased D. Nursing Management 1. Monitor strictly vital signs and intake and output to determine presence of o Myxedema coma is a complication of hypothyroidism and an emergency case a severe form of hypothyroidism is characterized by severe hypotension, bradycardia, bradypnea, hypoventilation, hyponatremia, hypoglycemia, hypothermia leading to pregressive stupor and coma. Nursing Management for Myxedema Coma    2. Force fluids 3. Administer isotonic fluid solution as ordered 4. Administer medications as ordered Thyroid Hormones a. Levothyroxine b. Leothyronine c. Thyroid Extracts 5. Provide dietary intake that is low in calories – due to wt. gain 6. Provide comfortable and warm environment – due to cold intolerance 7. Provide meticulous skin care 8. Provide client health teaching and discharge planning concerning a. Avoid precipitating factors leading to myxedema coma o o o o o o o stress infection cold intolerance use of anesthetics, narcotics, and sedatives prevent complications (myxedema coma, hypovolemic shock hormonal replacement therapy for lifetime importance of follow up care Assist in mechanical ventilation Administer thyroid hormones as ordered Force fluids

HYPERTHYROIDISM – grave‘s disease or thyroid toxicosis (everything is up except wt. and mens. o o o increase in T3 and T4 Grave’s Disease or Thyrotoxicosis developed by Robert Graves

A. Predisposing Factors 1. Autoimmune – it involves release of long acting thyroid stimulator causing exopthalmus (protrusion of eyeballs) enopthalmus (late sign of dehydration among infants) 2. Excessive iodine intake 3. Related to hyperplasia of TG (increase size) B. Signs and Symptoms 1. Increase appetite (hyperphagia) but there is weight loss due to increased metabolism 2. Moist skin 3. Heat intolerance 4. Diarrhea 5. All vital signs are increased 6. CNS involvement a. Irritability and agitation b. Restlessness c. Tremors d. Insomnia e. Hallucinations 7. Goiter 8. Exopthalmus (Pathognomonic sign) 9. Amenorrhea C. Diagnostic Procedures 1. Serum T3 and T4 is increased 2. RAIU (Radio Active Iodine Uptake) is increased 3. Thyroid Scan- reveals an enlarged thyroid gland D. Nursing Management 1. Monitor strictly vital signs and intake and output - determine thyroid storm or most feared complication: Thyrotoxicosis 2. Administer medications as ordered Anti Thyroid Agent a. Prophythioracill (PTU) b. Methymazole (Tapazole) Most toxic Side Effects Agranulocytosis o o o o o increase lymphocytes and monocytes fever and chills sore throat (throat swab/culture) leukocytosis (CBC) Most feared complication : Thrombosis – stroke CVS

3. Provide dietary intake that is increased in calories. 4. Provide meticulous skin care 5. Comfortable and cold environment 6. Maintain side rails - due to agitation/restlessness 7. Provide bilateral eye patch to prevent drying of the eyes. 8. Assist in surgical procedures known as subtotal thyroidectomy * Before thyroidectomy administer Lugol’s Solution (SSKI) to decrease vascularity of the thyroid gland to prevent bleeding and hemorrhage.

POST OPERATIVELY, 1. Watch out for signs of thyroid storm/ thyrotoxicosis Agitation

TRIAD SIGNS

Hyperthermia o administer medications as ordered a. Anti Pyretics b. Beta-blockers – tachycardia o o o Monitor strictly vital signs, input and output and neuro check. maintain side rails offer TSB

Tachycardia

2. Watch out for accidental removal of parathyroid gland (secretes parathormone) that may lead to Hypocalcemia (tetany) Signs and Symptoms o o o (+) trousseau‘s sign (+) chvostek sign Watch out for arrhythmia, seizure give Calcium Gluconate IV slowly as ordered Ca gluconate toxicity – antidote – MgSO4 3. Watch out for accidental Laryngeal (voice box) damage which may lead to hoarseness of voice Nursing Management o encourage client to talk/speak immediately after operation and notify physician

4. Signs of bleeding (feeling of fullness at incisional site) Nursing Management o o Check the soiled dressings at the back or nape area. Sign of laryngeal spasm – DOB, SOB (tracheostomy at bed side)

5. Hormonal replacement therapy for lifetime 6. Importance of follow up care PARATHYROID GLAND o o o o o o A pair of small nodules behind the thyroid gland Secretes parathormone Promotes calcium reabsorption Thyrocalcitonin – antagonises secretion of parathyroid hormone Hypoparathyroidism Hyperparathyroidism

HYPOPARATHYROIDISM o o Decrease secretion of parathormone leading to hypocalcemia (tetany) Resulting to Hyperphosphatemia

[If Ca decreases, phosphate increases] A. Predisposing Factors 1. Following subtotal thyroidectomy 2. Atrophy of parathyroid gland due to: a. inflammation

b. tumor c. trauma B. Signs and Symptoms 1. Acute tetany a. tingling sensation b. paresthesia c. numbness d. dysphagia e. positive trousseau’s sign/carpopedal spasm f. positive chvostek sign g. laryngospasms / broncospasm h. seizure i. arrhythmia 2. Chronic tetany a. photophobia and cataract formation b. loss of tooth enamel c. anorexia, nausea and vomiting d. agitation and memory impairment (irritable) C. Diagnostic Procedures 1. Serum Calcium is decreased (normal value: 8.5 – 10.5 mg/100 ml) 2. Serum Phosphate is increased (normal value: 2.5 – 4.5 mg/100 ml) 3. X-ray of long bones reveals a decrease in bone density 4. CT Scan – reveals degeneration of basal ganglia D. Nursing Management 1. Administer medications as ordered such as: a. Acute Tetany  Calcium Gluconate IV slowly b. Chronic Tetany  Oral Calcium supplements  Calcium Gluconate  Calcium Lactate  Calcium Carbonate c. Vitamin D (Cholecalciferol) for absorption of calcium
VIT. D (CHOLECALCEFEROL) DRUG DIET SUNLIGHT

feared complications

Cholecalceferol

calcidiol

calcitriol 7am – 9am

d. Phosphate binder   Aluminum Hydroxide Gel (Ampogel) Side effect: constipation ANTACID A.A.C ▼ Aluminum Containing Antacids ▼ Aluminum Hydroxide Gel ▼ Side Effect: Constipation MAD ▼ Magnesium Containing Antacids ▼ Ex. Milk of magnesia (Maalox – magnesium & aluminum - Less s/e) Side Effect: Diarrhea

2. Avoid precipitating stimulus such as glaring lights and noise 3. Encourage increase intake of foods rich in calcium (decreased phosphorus) a. anchovies - increase Ca, decrease phosphorus + inc uric acid. Tuna & green turnips- Inc Ca. b. salmon c. green turnips Don„t give milk – due to increase phosphorus 4. Institute seizure and safety precaution 5. Encourage client to breathe using paper bag to produce mild respiratory acidosis result. 6. Prepare trachea set at bedside for presence of laryngospasm 7. Prevent complications 8. Hormonal replacement therapy for lifetime 9. Importance of follow up care. HYPERPARATHYROIDISM o o o Decrease parathormone Hypercalcemia: bone demineralization leading to bone fracture (calcium is stored 99% in bone and 1% blood) Kidney stones

(parathormone pullout the Ca in from the bone to the blood) A. Predisposing Factors 1. Hyperplasia of parathyroid gland 2. over compensation of parathyroid gland due to vitamin D deficiency a. Children: Rickets - the bone do not hardened b. Adults: Osteomalacia - softening of the bone B. Signs and Symptoms 1. Bone pain especially at back (bone fracture) 2. Kidney stones a. renal cholic b. cool moist skin 3. Anorexia, nausea and vomiting 4. Agitation and memory impairment C. Diagnostic Procedures 1. Serum Calcium is increased 2. Serum Phosphate is decreased 3. X-ray of long bones reveals bone demineralization D. Nursing Management 1. Force fluids to prevent kidney stones 2. Strain all the urine using gauze pad for stone analysis 3. Provide warm sitz bath 4. Administer medications as ordered a. Morphine Sulfate (Demerol) 5. Encourage increase intake of foods rich in phosphate but decrease in calcium 6. Provide acid ash in the diet to acidify urine and prevent bacterial growth 7. Assist/supervise in ambulation 8. Maintain side rails 9. Prevent complications (seizure and arrhythmia) most feared renal failure 10. Assist in surgical procedure known as parathyroidectomy 11. Hormonal replacement therapy for lifetime 12. Importance of follow up care

ADRENAL GLAND o o Located atop of each kidney 2 layers of adrenal gland

a. Adrenal Cortex – outermost b. Adrenal Medulla – innermost (secretes catecholamine’s a power hormone) 2 Types of Catecholamines o o o o o Epinephrine and Norepinephrine (vasoconstrictor) increased BP Pheochromocytoma (adrenal medulla) Increase secretion of norepinephrine Leading to hypertension which is resistant to pharmacological agents leading to CVA Use beta-blockers

PHEOCHROMOCYTOMA- presence of tumor at adrenal medulla
Increase norepinephrine. HPN with pounding headache. with HPN and resistant to drugs drug of choice: beta blockers complication: HPN crisis = lead to stroke no valsalva maneuver. Don‗t smoke. No caffeine. ADRENAL CORTEX 3 Zones/Layers 1. Zona Fasciculata - secretes glucocortocoids (cortisol) - function: controls glucose metabolism - Sugar 2. Zona Reticularis - secretes traces of glucocorticoids and androgenic hormones - function: promotes secondary sex characteristics - Sex 3. Zona Glumerulosa - secretes mineralocorticoids (aldosterone) - function: promotes sodium and water reabsorption and excretion of potassium - Salt

I love Sex!!!

ADDISON’S DISEASE - payat o Hyposecretion of adreno cortical hormone leading to ex ugar alt – secondary sex disturbances / decreased libido - metabolic disturbance / hypoglycemia – fluid & electrolytes imbalance

s

A. Predisposing Factors 1. Related to atrophy of adrenal glands 2. Fungal infections B. Signs and Symptoms 1. Hypoglycemia – TIRED 2. Decrease tolerance to stress 3. Hyponatremia - hypotension - signs of dehydration - weight loss 4. Hyperkalemia - agitation - diarrhea - arrhythmia 5. Decrease libido 6. Loss of pubic and axillary hair 7. Bronze like skin pigmentation

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

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

C. Diagnostic Procedures 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) D. Nursing Management 1. Monitor strictly vital signs, input and output to determine presence of Addisonian crisis (complication of addison‘s disease) o Addisonian crisis results from acute exacerbation of addison‘s disease characterized by a. severe hypotension b. hypovolemic shock c. hyponatremia leading to progressive stupor and coma Nursing Management for Addisonian Crisis 1. Assist in mechanical ventilation, - administer steroids as ordered - force fluids 2. Administer isotonic fluid solution as ordered 3. Force fluids 4. Administer medications as ordered

Corticosteroids a. Dexamethasone (Decadrone) b. Prednisone c. Hydrocortisone (Cortison) Nursing Management when giving steroids 1. Instruct client to take 2/3 dose in the morning and 1/3 dose in the afternoon to mimic the normal diurnal rhythm 2. Taper dose (withdraw gradually from drug) 3. Monitor side effects a. hypertension b. edema c. hirsutism d. increase susceptibility to infection e. moon face appearance 4. Mineralocorticoids (Flourocortisone) 5. Provide dietary intake, increase calories, carbohydrates, protein but decrease in potassium 6. Provide meticulous skin care 7. Provide client health teaching and discharge planning a. avoid precipitating factor leading to addisonian crisis leading to - stress - infection - sudden withdrawal to steroids b. prevent complications - addisonian crisis - hypovolemic shock c. hormonal replacement for lifetime d. importance of follow up care
Cushing’s syndrome. A. Client prior to syndrome. B. Client 4 months after diagnosis of syndrome.

CUSHING SYNDROME - mataba o Hypersecretion of adenocortical hormones

A. Predisposing Factors 1 Related to hyperplasia of adrenal gland 2. Increase susceptibility to infections 3. Hypernatremia a. hypertension b. edema c. weight gain d. moon face appearance and buffalo hump e. obese trunk f. pendulous abdomen g. thin extremities 4. Hypokalemia a. weakness and fatigue b. constipation c. U wave upon ECG (T wave hyperkalemia) 5. Hirsutism 6. Acne and striae 7. Easy bruising 8. Increase masculinity among females B. Diagnostic Procedures 1. FBS is increased 2. Plasma Cortisol is increased

3. Serum Sodium is increased 4. Serum Potassium is decreased 5. Dexamethasone suppression test C. Nursing Management 1. Monitor strictly vital signs and intake and output 2. Weigh patient daily and assess for pitting edema 3. Measure abdominal girth daily and notify physician 4. Restrict sodium intake 5. Provide meticulous skin care 6. Administer medications as ordered a. Spinarolactone – potassium sparring diuretics 7. Prevent complications (DM) 8. Assist in surgical procedure (bilateral adrenoraphy) 9. Hormonal replacement for lifetime 10. Importance of follow up care PANCREAS - Located behind the stomach - Mixed gland (exocrine and endocrine) - Consist of acinar cells which secretes pancreatic juices that aids in digestion thus it is an exocrine gland Type 1 (IDDM) - Juvenile onset type - Brittle disease A. Incidence Rate - 10% general population has type 1 DM B. Predisposing Factors 1. Hereditary (total destruction of pancreatic cells) 2. Related to viruses 3. Drugs a. Lasix b. Steroids 4. Related to carbon tetrachloride toxicity C. Signs and Symptoms 1. Polyuria 2. Polydypsia 3. Polyphagia 4. Glycosuria 5. Weight loss 6. Anorexia, nausea and vomiting 7. Blurring of vision 8. Increase susceptibility to infection 9. Delayed/poor wound healing D. Treatment 1. Insulin therapy 2. Diet 3. Exercise E. Complication 1. Diabetic Ketoacidosis E. Complications 1. Hyper 2. Osmolar 3. Non 4. Ketotic 5. Coma D. Treatment 1. Oral Hypoglycemic agents 2. Diet 3. Exercise C. Signs and Symptoms 1. Usually asymptomatic 2. Polyuria 3. Polydypsia 4. Polyphagia 5. Glucosuria 6. Weight gain - Adult onset - Maturity onset type - Obese over 40 years old A. Incidence Rate - 90% of general population has type 2 DM B. Predisposing Factors 1. Obesity – because obese persons lack insulin receptor binding sites Type 2 (NIDDM)
Best example of CUSHING SYNDROME is no other than JOLLIBEE – moon face & big body with thin extremities

- Consist of islets of langerhans - Has alpha cells that secretes glucagons (function: hyperglycemia) - Beta cells secretes insulin (function: hypoglycemia) - Delta cells secretes somatostatin (function: antagonizes the effects of growth hormones) 3 Main Disorders of Pancreas 1. Pancreatic Tumor/Cancer 2. Diabetes Mellitus 3. Pancreatitis DIABETES MELLITUS - Metabolic disorder characterized by non utilization of carbohydrates, protein and fat metabolism MAIN FOODSTUFF 1. Carbohydrates 2. Protein 3. Fats

ANABOLISM

CATABOLISM

Glucose Amino Acids Fatty Acids

Glycogen Nitrogen Free Fatty Acids - Cholesterol - Ketones

HYPERGLYCEMIA Increase osmotic diuresis Glycosuria Cellular starvation – weight loss Stimulates the appetite/satiety center (Hypothalamus) Polyphagia Polyuria Cellular dehydration Stimulates the thirst center (Hypothalamus) Polydypsia

* Liver has glycogen that undergo glycogenesis/ glycogenolysis GLUCONEOGENESIS Formation of glucose from non-CHO sources Increase protein formation ▼ Negative Nitrogen balance ▼ Tissue wasting (Cachexia) ▼ INCREASE FAT CATABOLISM ▼ Free fatty acids Cholesterol ▼ Atherosclerosis ▼ Hypertension MI CVA Ketones ▼ Diabetic Keto Acidosis Acetone Breath odor Kussmaul‘s Respiration

Death

Diabetic Coma

DIABETIC KETOACIDOSIS - Acute complication of type 1 DM due to severe hyperglycemia leading to severe CNS depression A. Predisposing Factors 1. Hyperglycemia 2. Stress – number one precipitating factor 3. Infection B. Signs and Symptoms 1. Polyuria 2. Polydypsia 3. Polyphagia 4. Glucosuria 5. Weight loss 6. Anorexia, nausea and vomiting 7. Blurring of vision 8. Acetone breath odor 9. Kussmaul’s Respiration (rapid shallow breathing) 10 CNS depression leading to coma C. Diagnostic Procedures 1. FBS is increased 2. BUN (normal value: 10 – 20) 3. Creatinine (normal value: .8 – 1) 4. Hct (normal value: female 36 – 42, male 42 – 48) due to severe dehydration D. Nursing Management 1. Assist in mechanical ventilation 2. Administer 0.9 NaCl followed by .45 NaCl (hypotonic solutions) to counteract dehydration and shock 3. Monitor strictly vital signs, intake and output and blood sugar levels 4. Administer medications as ordered a. Insulin therapy (regular acting insulin/rapid acting insulin peak action of 2 – 4 hours) b. Sodium Bicarbonate to counteract acidosis c. Antibiotics to prevent infection HYPER OSMOLAR NON KETOTIC COMA - Hyperosmolar: increase osmolarity (severe dehydration) - Non ketotic: absence of lypolysis (no ketones) A. Signs and Symptoms 1. Headache and dizziness 2. Restlessness 3. Seizure activity 4. Decrease LOC – diabetic coma B. Nursing Management 1. Assist in mechanical ventilation 2. Administer 0.9 NaCl followed by .45 NaCl (hypotonic solutions) to counteract dehydration and shock 3. Monitor strictly vital signs, intake and output and blood sugar levels 4. Administer medications as ordered a. Insulin therapy (regular acting insulin peak action of 2 – 4 hours) - for DKA use rapid acting insulin b. Antibiotics to prevent infection

Types of Insulin

Color & consistency

INSULIN THERAPY A. Sources of Insulin 1. Animal sources - Derived from beef and pork 2. Human Sources

Rapid Intermediate Long acting

Clear Cloudy Cloudy

Peak 2-4 6-12 12-24

- Rarely used because it can cause severe allergic reaction

- Frequently used type because it has less antigenicity property thus less allergic reaction 3. Artificially Compound Insulin B. Types of Insulin 1. Rapid Acting Insulin (clear) - Regular acting insulin (IV only) - Peak action is 2 – 4 hours 2. Intermediate Acting Insulin (cloudy) - Non Protamine Hagedorn Insulin (NPH) - Peak action is 8 – 16 hours 3. Long Acting Insulin (cloudy) - Ultra Lente - Peak action is 16 – 24 hours C. Nursing Management for Insulin Injections 1. Administer at room temperature to prevent development of lipodystrophy (atrophy, hypertrophy of subcutaneous tissues) 2. Place in refrigerator once opened 3. Avoid shaking insulin vial vigorously instead gently roll vial between palms to prevent formation of bubbles 4. Use gauge 25 – 26 needle 5. Administer insulin either 45 – 90 depending on amount of clients tissue deposit 6. No need to aspirate upon injection 7. Rotate insulin injection sites to prevent development of lipodystrophy 8. Most accessible route is abdomen 9. When mixing 2 types of insulin aspirate first the clear insulin before cloudy to prevent contaminating the clear insulin and promote proper calibration. 10. Monitor for signs of local complications such as a. Allergic reactions b. Lipodystrophy c. Somogyi Phenomenon – rebound effect of insulin characterized by hypoglycemia to hyperglycemia ORAL HYPOGLYCEMIC AGENTS - OHA - Stimulates the pancreas to secrete insulin A. Classsification 1. First Generation Sulfonylureas a. Chlorpropamide (Diabenase) b. Tolbutamide (Orinase) c. Tolamazide (Tolinase) 2. Second Generation Sulfonylureas a. Glipzide (Glucotrol) b. Diabeta (Micronase) Nursing Management when giving OHA 1. Instruct the client to take it with meals to lessen GIT irritation and prevent hypoglycemia 2. Instruct the client to avoid taking alcohol because it can lead to severe hypoglycemia reaction or Disulfiram (Antabuse) toxicity symptoms
o o

B. Diagnostic Procedures for DM 1. FBS is increased (3 consecutive times with signs or
polyuria, polydypsia, polyphagia and glucosuria confirmatory for DM)

2. Random Blood Sugar is increased 3. Oral glucose tolerance test is increased – most sensitive test 4. Alpha Glycosylated Hemoglobin is increased C. Nursing Management 1. Monitor for peak action of insulin and OHA and notify physician 2. Administer insulin and OHA therapy as ordered 3. Monitor strictly vital signs, intake and output and blood sugar levels 4. Monitor for signs of hypoglycemia and hyperglycemia - administer simple sugars - for hypoglycemia (cold and clammy skin) give simple sugars - for hyperglycemia (dry and warm skin) 5. Provide nutritional intake of diabetic diet that includes: carbohydrates 50%, protein 30% and fats 20% or offer alternative food substitutes 6. Instruct client to exercise best after meals when blood glucose is rising 7. Monitor signs for complications a. Atherosclerosis (HPN, MI, CVA) b. Microangiopathy (affects small minute blood vessels of eyes and kidneys) c. HPN and DM major cause of renal failure d. Gangrene formation e. Shock due to dehydration - peripheral neuropathy - diarrhea/constipation - sexual impotence 8. Institute foot care management a. instruct client to avoid walking barefooted b. instruct client to cut toenails straight c. instruct client to avoid wearing constrictive garments d. encourage client to apply lanolin lotion to prevent skin breakdown e. assist in surgical wound debriment (give analgesics 15 – 30 mins prior) 9. Instruct client to have an annual eye and kidney exam 10. Monitor for signs of DKA and HONKC 11. Assist in surgical procedure
EYES -PREMATURE CATARACT - Blindness KIDNEY -RECURRENT PYELONEPHRITIS - Renal failure

CHRONIC HEMORRHAGIC PANCREATITIS- ―bangugot
Predisposing factors - unknown Risk factor: History of hepatobiliary disorder Alcohol Drugs – thiazide diuretics, oral contraceptives, aspirin, penthan Obesity Hyperlipidemia Hyperthyroidism High intake of fatty food – saturated fats Overview only:

PANCREATITIS - acute inflammation of pancreas leading to pancreatic edema, hemorrhage & necrosis due to
Autodigestion – self-digestion Cause: unknown/idiopathic alcoholism Pathognomonic sign- (+) Cullen‘s sign - Ecchymosis of umbilicus (bluish color)- pasa (+) Grey turner‗s sign – ecchymosis of flank area

HEMATOLOGICAL SYSTEM

I. Blood 55% Plasma Serum 45% Formed

II. Blood Vessels 1. Arteries 2. Veins

III. Blood Forming Organs 1. Liver 3. Spleen 4. Lymphoid Organ 5. Lymph Nodes 6. Bone Marrow

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

ALBUMIN - Largest and numerous plasma CHON - Maintains osmotic pressure preventing edema GLOBULINS - Alpha globulins - transport steroids, bilirubin and hormones - Beta globulins – iron and copper - Gamma globulins a. anti-bodies and immunoglobulins b. prothrombin and fibrinogen clotting factors FORMED ELEMENTS 1. RBC (ERYTHROCYTES) - normal value: 4 – 6 million/mm - only unnucleated cell - biconcave discs - consist of molecules of hgb (red pigment) bilirubin (yellow pigment) biliverdin (green pigment) hemosiderin (golden brown pigment) - transports and carries oxygen to tissues - hemoglobin: normal value female 12 – 14 gms% male 14 – 16 gms% - hematocrit red cell percentage in wholeblood - normal value: female 36 – 42% male 42 – 48% - substances needed for maturation of RBC a. folic acid b. iron c. vitamin c d. vitamin b12 (cyanocobalamin) e. vitamin b6 (pyridoxine) f. intrinsic factor - Normal life span of RBC is 80 – 120 days and is killed in red pulp of spleen 2. WBC (LEUKOCYTES) - normal value: 5000 – 10000/mm A. Granulocytes 1. Polymorpho Neutrophils - 60 – 70% of WBC - involved in short term phagocytosis for acute inflammation 2. Polymorphonuclear Basophils - for parasite infections - responsible for the release of chemical mediation for inflammation 3. Polymorphonuclear Eosinophils - for allergic reaction B. Non Granulocytes 1. Monocytes
3 3

- macrophage in blood - largest WBC - involved in long term phagocytosis for chronic inflammation 2. Lymphocytes

B-cell T-cell - bone marrow - thymus for immunity

Natural killer cell - anti viral and anti tumor property

HIV - 6 months – 5 years incubation period - 6 months window period - western blot opportunistic - ELISA - drug of choice AZT (Zidon Retrovir) 2 Common fungal opportunistic infection in AIDS 1. Kaposi‘s Sarcoma 2. Pneumocystis Carinii Pneumonia 3. Platelets (THROMBOCYTES) - Normal value: 150,000 – 450,000/mm
3

- Promotes hemostasis (prevention of blood loss) - Consist of immature or baby platelets or megakaryocytes which is the target of dengue virus - Normal life span of platelet is 9 – 12 days Signs of Platelet Dysfunction 1. Petechiae 2. Echhymosis 3. Oozing of blood from venipunctured site

BLOOD DISORDERS
Iron Deficiency Anemia - A chronic microcytic anemia resulting from inadequate absorption of iron leading to hypoxemic tissue injury A. Incidence Rate 1. Common among developed countries 2. Common among tropical zones 3. Common among women 15 – 35 years old 4. Related to poor nutrition B. Predisposing Factors 1. Chronic blood loss due to trauma a. Heavy menstruation b. Related to GIT bleeding resulting to hematemesis and melena (sign for upper GIT bleeding) c. fresh blood per rectum is called hematochezia 2. Inadequate intake of iron due to a. Chronic diarrhea b. Related to malabsorption syndrome c. High cereal intake with low animal protein digestion d. Subtotal gastrectomy 4. Related to improper cooking of foods C. Signs and Symptoms 1. Usually asymptomatic 2. Weakness and fatigue (initial signs)

3. Headache and dizziness 4. Pallor and cold sensitivity 5. Dyspnea 6. Palpitations 7. Brittleness of hair and spoon shape nails (koilonychias) 8. Atropic Glossitis (inflammation of tongue) - Stomatitis - Dysphagia 9. PICA (abnormal appetite or craving for non edible foods D. Diagnostic Procedures 1. RBC is decreased 2. Hgb is decreased 3. Hct is deceased 4. Iron is decreased 5. Reticulocyte is decreased 6. Ferritin is decreased E. Nursing Management 1. Monitor for signs of bleeding of all hema test including urine, stool and GIT 2. Enforce CBR so as not to over tire client 3. Instruct client to take foods rich in iron a. Organ meat b. Egg (yolk) c. Raisin d. Sweet potatoes e. Dried fruits f. Legumes g. Nuts 4. Instruct the client to avoid taking tea and coffee because it contains tannates which impairs iron absorption 5. Administer medications as ordered Oral Iron Preparations a. Ferrous Sulfate b. Ferrous Fumarate c. Ferrous Gluconate - 300 mg/day Nursing Management when taking oral iron preparations 1. Instruct client to take with meals to lessen GIT irritation 2. When diluting it in liquid iron preparations administer with straw to prevent staining of teeth Medications administered via straw Lugol‘s solution Iron Tetracycline Nitrofurantoin (Macrodentin) 3. Administer with Vitamin C or orange juice for absorption 4. Monitor and inform client of side effects a. Anorexia b. Nausea and vomiting c. Abdominal pain d. Diarrhea/constipation e. Melena 5. If client cant tolerate/no compliance administer parenteral iron preparation a. Iron Dextran (IM, IV) b. Sorbitex (IM) Nursing Management when giving parenteral iron preparations 1. Administer Z tract technique to prevent discomfort, discoloration and leakage to tissues 2. Avoid massaging the injection site instead encourage to ambulate to facilitate absorption 3. Monitor side effects PLUMBER VINSON’S SYNDROME

a. Pain at injection site b. Localized abscess c. Lymphadenopathy d. Fever and chills e. Skin rashes f. Pruritus/orticaria g. Hypotension (anaphylactic shock)

PERNICIOUS ANEMIA - Chronic anemia characterized by a deficiency of intrinsic factor leading to hypochlorhydria (decrease hydrochloric acid secretion) A. Predisposing Factors 1. Subtotal gastrectomy 2. Hereditary factors 3. Inflammatory disorders of the ileum 4. Autoimmune 5. Strictly vegetarian diet

STOMACH ▼ Pareital cells/ Argentaffin or Oxyntic cells Produces intrinsic factors ▼ Promotes reabsorption of Vit B12 ▼ Promotes maturation of RBC B. Signs and Symptoms 1. Weakness and fatigue 2. Headache and dizziness 3. Pallor and cold sensitivity 4. Dyspnea and palpitations as part of compensation 5. GIT changes that includes a. mouth sore b. red beefy tongue c. indigestion/dyspepsia d. weight loss e. jaundice 6. CNS changes a. tingling sensation b. numbness c. paresthesia d. positive to Romberg’s test – damage to cerebellum resulting to ataxia e. result to psychosis C. Diagnostic Procedure Schilling’s Test – reveals inadequate/decrease absorption of Vitamin B12 D. Nursing Management 1. Enforce CBR Secretes hydrochloric acid ▼ Aids in digestion

2. Administer Vitamin B12 injections at monthly intervals for lifetime as ordered - Never given orally because there is possibility of developing tolerance - Site of injection for Vitamin B12 is dorsogluteal and ventrogluteal - No side effects 3. Provide a dietary intake that is high in carbohydrates, protein, vitamin c and iron 4. Instruct client to avoid irritating mouth washes instead use soft bristled toothbrush 5. Avoid heat application to prevent burns

APLASTIC ANEMIA - Stem cell disorder leading to bone marrow depression leading to pancytopenia PANCYTOPENIA Decrease RBC (anemia) A. Predisposing Factors 1. Chemicals (Benzine and its derivatives) 2. Related to irradiation/exposure to x-ray 3. Immunologic injury 4. Drugs Broad Spectrum Antibiotics a. Chloramphenicol (Sulfonamides) Chemotherapeutic Agents a. Methotrexate (Alkylating Agent) b. Vincristine (Plant Alkaloid) c. Nitrogen Mustard (Antimetabolite) Phenylbutazones (NSAIDS) B. Signs and Symptoms 1. Anemia a. Weakness and fatigue b. Headache and dizziness c. Pallor and cold sensitivity d. Dyspnea and palpitations 2. Leukopenia a. Increase susceptibility to infection 3. Thrombocytopenia a. Petechiae (multiple petechiae is called purpura) b. Ecchymosis c. Oozing of blood from venipunctured sites C. Diagnostic Procedures 1. CBC reveals pancytopenia 2. Bone marrow biopsy/aspiration (site is the posterior iliac crest) – reveals fat necrosis in bone marrow D. Nursing Management 1. Removal of underlying cause 2. Institute BT as ordered 3. Administer oxygen inhalation 4. Enforce CBR 5. Institute reverse isolation 6. Monitor for signs of infection a. fever b. cough When all of the blood elements are depressed, the term ―pancytopenia‖ is used. ―Pan‖ meaning everything. Decrease WBC (leucopenia) Decrease Platelet (thrombocytopenia)

7. Avoid IM, subcutaneous, venipunctured sites 8 Instead provide Heplock 9. Instruct client to use electric razor when shaving 10. Administer medications as ordered a. Corticosteroids – caused by immunologic injury b. Immunosuppressants Anti Lymphocyte Globulin ▼ Given via central venous catheter ▼ Given 6 days to 3 weeks to achieve Maximum therapeutic effect of drug DISSEMINATED INTRAVASCULAR COAGULATION Acute hemorrhagic syndrome characterized by wide spread bleeding and thrombosis due to a deficiency of prothrombin and fibrinogen A. Predisposing Factors 1. Related to rapid blood transfusion 2. Massive burns 3. Massive trauma 4. Anaphylaxis 5. Septicemia 6. Neoplasia (new growth of tissue) 7. Pregnancy B. Signs and Symptoms 1. Petechiae (widespread and systemic) eye, lungs and lower extremities 2. Ecchymosis 3. Oozing of blood from punctured sites 4. Hemoptysis 6. Oliguria (late sign) C. Diagnostic Procedures 1. CBC reveals decreased platelets 2. Stool occult blood positive 3. ABG analysis reveals metabolic acidosis 4. Opthamoscopic exam reveals sub retinal hemorrhages D. Nursing Management 1. Monitor for signs of bleeding of all hema test including stool and GIT 2. Administer isotonic fluid solution as ordered 3. Administer oxygen inhalation 4. Force fluids 5. Administer medications as ordered a. Vitamin K b. Pitressin/ Vasopresin to conserve fluids c. Heparin/Coumadin is ineffective 6. Provide heparin lock 7. Institute NGT decompression by performing gastric lavage by using ice or cold saline solution of 500 – 1000 ml 8. Monitor NGT output 9. Prevent complication a. Hypovolemic shock b. Anuria – late sign

BLOOD TRANSFUSION
Goals/Objectives 1. Replace circulating blood volume 2. Increase the oxygen carrying capacity of blood 3. Prevent infection in there is a decrease in WBC 4. Prevent bleeding if there is platelet deficiency Principles of blood transfusion 1. Proper refrigeration - Expiration of packed RBC is 3 – 6 days - Expiration of platelet is 3 – 5 days 2. Proper typing and cross matching a. Type O – universal donor b. Type AB – universal recipient c. 85% of population is RH positive 3. Aseptically assemble all materials needed for BT a. Filter set b. Gauge 18 – 19 needle c. Isotonic solution (0.9 NaCl/plain NSS) to prevent hemolysis 4. Instruct another RN to re check the following a. Client name b. Blood typing and cross matching c. Expiration date d. Serial number 5. Check the blood unit for bubbles cloudiness, sediments and darkness in color because it indicates bacterial contamination - Never warm blood as it may destroy vital factors in blood. - Warming is only done during emergency situation and if you have the warming device - Emergency rapid BT is given after 30 minutes and let natural room temperature warm the blood. 6. BT should be completed less than 4 hours because blood that is exposed at room temperature more than 2 hours causes blood deterioration that can lead to BACTERIAL CONTAMINATION 7. Avoid mixing or administering drugs at BT line to prevent HEMOLYSIS 8. Regulate BT 10 – 15 gtts/min or KVO rate or equivalent to 100 cc/hr to prevent circulatory overload 9. Monitor strictly vital signs before, during and after BT especially every 15 minutes for first hour because majority of transfusion reaction occurs during this period a. Hemolytic reaction b. Allergic reaction c. Pyrogenic reaction d. Circulatory overload e. Air embolism f. Thrombocytopenia g. Cytrate intoxication h. Hyperkalemia (caused by expired blood) Signs and Symptoms of Hemolytic reaction 1. Headache and dizziness 2. Dyspnea 3. Diarrhea/Constipation 4. Hypotension 5. Flushed skin 6. Lumbar/sternal/ Flank pain 7. Urine is color red/ portwine urine

Nursing Management 1. Stop BT 2. Notify physician 3. Flush with plain NSS 4. Administer isotonic fluid solution to prevent shock and acute tubular necrosis 5. Send the blood unit to blood bank for re examination 6. Obtain urine and blood sample and send to laboratory for re examination 7. Monitor vital signs and intake and output SIGNS AND SYMPTOMS OF ALLERGIC REACTION 1. Fever 2. Dyspnea 3. Broncial wheezing 4. Skin rashes 5. Urticaria 6. Laryngospasm and Broncospasm Nursing Management 1. Stop BT 2. Notify physician 3. Flush with plain NSS 4. Administer medications as ordered a. Anti Histamine (Benadryl) - if positive to hypotension, anaphylactic shock treat with Epinephrine 5. Send the blood unit to blood bank for re examination 6. Obtain urine and blood sample and send to laboratory for re examination 7. Monitor vital signs and intake and output SIGNS AND SYMPTOMS PYROGENIC REACTIONS (FEVER) 1. Fever and chills 2. Headache 3. Tachycardia 4. Palpitations 5. Diaphoresis 6. Dyspnea Nursing Management 1. Stop BT 2. Notify physician 3. Flush with plain NSS 4. Administer medications as ordered a. Antipyretic b. Antibiotic 5. Send the blood unit to blood bank for re examination 6. Obtain urine and blood sample and send to laboratory for re examination 7. Monitor vital signs and intake and output 8. Render TSB SIGNS AND SYMPTOMS OF CIRCULATORY REACTION 1. Orthopnea 2. Dyspnea 3. Rales/Crackles upon auscultation 4. Exertional discomfort Nursing Management 1. Stop BT 2. Notify physician 3. Administer medications as ordered a. Loop diuretic (Lasix

CARDIOVASCULAR SYSTEM
OVERVIEW OF THE STRUCTURE AND FUNCTIONS OF THE HEART HEART - Muscular pumping organ of the body. - Located on the left mediastinum - Resemble like a close fist - Weighs approximately 300 – 400 grams - Covered by a serous membrane called the pericardium 2 layers of pericardium a. Parietal – outer layer b. Visceral – inner layer - In between is the pericardial space filled w/ fluid which is 10 – 30 cc lubricates the surface to reduces friction during systole. - Common among MI, pericarditis, Cardiac tamponade A. Layers of Heart 1. Epicardium – outer layer 2. Myocardium – middle layer 3. Endocardium – inner layer - Myocarditis can lead to cardiogenic shock and rheumatic heart disease B. Chambers of the Heart 1. Upper Chamber (connecting or receiving) a. Atria 2. Lower Chamber (contracting or pumping) a. Ventricles - Left ventricle has increased pressure which is 120 – 180 mmHg - In order to propel blood to the systemic circulation - Right atrium has decreased pressure which is 60 – 80 mmHg C. Valves - To promote unidimensional flow or prevent backflow 1. Atrioventricular Valves – guards opening between a. tricuspid valve b. mitral valve - Closure of AV valves give rise to first heart sound (S1 “lub”) 2. Semi – lunar Valves a. pulmonic b. aortic - Closure of SV valve give rise to second heart sound (S2 “dub”) Extra Heart Sounds 1. S3 – ventricular gallop usually seen in Left Congestive Heart Failure sound occurring during rapid ventricular filling 2. S4 – atrial gallop usually seen in Myocardial Infarction and Hypertension sound head during atrial contraction (often heard when the ventricle is enlarged or hypertrophied

D. Coronary Arteries - Arises from base of the aorta Types of Coronary Arteries 1. Right Main Coronary Artery 2. Left Main Coronary Arterying - Supplies the myocardium E. Cardiac Conduction System 1. Sino – Atrial Node (SA or Keith Flack Node) - Located at the junction of superior vena cava and right atrium - Acts as primary pacemaker of the heart - Initiates electrical impulse of 60 – 100 bpm 2. Atrio – Ventricular Node (AV or Tawara Node) - Located at the inter atrial septum - Delay of electrical impulse for about .08 milliseconds to allow ventricular filling 3. Bundle of His - Right Main Bundle of His - Left Main Bundle of His - Located at the interventricular septum 4. Purkinje Fibers terminal point in the conduction system (point which the myocardial cells are stimulated causing ventricular contraction) - Located at the walls of the ventricles for ventricular contraction - P WAVE (atrial depolarization) contraction - QRS WAVE (ventricular depolarization) - T WAVE (ventricular repolarization)  Insert pacemaker if there is complete heart block  Most common pacemaker is the metal pacemaker and lasts up to 2 – 5 years Cardiac electrical activity is the result of the movement of ions (charged particles such as SODIUM, POTASSIUM, AND CALCIUM) across the cell membrane.

ABNORMAL ECG TRACING
1. Positive U wave 2. Peak T wave 3. ST segment depression 4. ST segment elevation 5. T wave inversion 6. Widening of QRS complexes - Hypokalemia – Hyperkalemia – Angina Pectoris – Myocardial Infarction – Myocardial Infarction – Arrhythmias

CARDIAC DISORDERS
Coronary Arterial Disease/ Ischemic Heart Disease Stages of Development of Coronary Artery Disease 1. Myocardial Injury - Atherosclerosis 2. Myocardial Ischemia – Angina Pectoris 3. Myocardial Necrosis – Myocardial Infarction

ATHEROSCLEROSIS ATHEROSCLEROSIS - narrowing of artery - lipid or fat deposits (plaques) - tunica intima ARTERIOSCLEROSIS - hardening of artery, thicken - calcium and protein deposits - tunica media

A. Predisposing Factors
1. Sex – male 2. Race – black 3. Smoking 4. Obesity 5. Hyperlipidemia 6. Sedentary lifestyle 7. Diabetes Mellitus 8. Hypothyroidism 9. Diet – increased saturated fats 10. Type A personality

B. Signs and Symptoms
1. Chest pain 2. Dyspnea 3. Tachycardia 4. Palpitations 5. Diaphoresis

C. Treatment Percutaneous Transluminal Coronary Angioplasty

Objectives of PTCA 1. Revascularize myocardium 2. To prevent angina 3. Increase survival rate - Done to single occluded vessels - If there is 2 or more occluded blood vessels CABG is done

Coronary Arterial Bypass And Graft Surgery
3 Complications of CABG 1. Pneumonia – encourage to perform deep breathing, coughing exercise and use of incentive spirometer 2. Shock 3. Thrombophlebitis ANGINA PECTORIS (SYNDROME) Clinical syndrome characterized by paroxysmal chest pain that is usually relieved by rest or nitroglycerine due to temporary myocardial ischemia A. Predisposing Factors 1. Sex – male 2. Race – black 3. Smoking 4. Obesity 5. Hyperlipidemia 6. Sedentary lifestyle 7. Diabetes Mellitus 8. Hypothyroidism 9. Diet – increased saturated fats 10. Type A personality B. Precipitating Factors 4 E’s of Angina Pectoris 1. Excessive physical exertion – heavy exercises 2. Exposure to cold environment 3. Extreme emotional response – fear, anxiety, excitement 4. Excessive intake of foods rich in saturated fats – skimmed milk C. Signs and Symptoms 1. Levine’s Sign – initial sign that shows the hand clutching the chest 2. Chest pain characterized by sharp stabbing pain located at sub sterna usually radiates from back, shoulder, arms, axilla and jaw muscles, usually relieved by rest or taking nitroglycerine 3. Dyspnea 4. Tachycardia 5. Palpitations 6. Diaphoresis D. Diagnostic Procedure 1. History taking and physical exam 2. ECG tracing reveals ST segment depression 3. Stress test – treadmill test, reveal abnormal ECG 4. Serum cholesterol and uric acid is increased E. Nursing Management 1. Enforce complete bed rest 2. Administer medications as ordered a. Nitroglycerine (NTG) – when given in small doses will act as venodilator, but in large doses will act as vasodilator - Give first dose of NTG (sublingual) 3 – 5 minutes Angina is usually caused by ATHEROSCLEROTIC Disease. - narrowing of artery - lipid or fat deposits - tunica intima

- Give second dose of NTG if pain persist after giving first dose with interval of 3 - 5 minutes - Give third and last dose of NTG if pain still persists at 3 – 5 minutes interval Nursing Management when giving NTG Keep the drug in a dry place, avoid moisture and exposure to sunlight as it may inactivate the drug Monitor side effects Orthostatic hypotension Transient headache and dizziness Instruct the client to rise slowly from sitting position Assist or supervise in ambulation When giving nitrol or transdermal patch o o o Avoid placing near hairy areas as it may decrease drug absorption Avoid rotating transdermal patches as it may decrease drug absorption Avoid placing near microwave ovens or during defibrillation as it may lead to burns ( most important thing to remember) b. Beta-blockers - (lol) - Propanolol - side effects PNS - broncho constriction, vasodilation - Not given to COPD cases because it causes Bronchospasm c. ACE Inhibitors - (pril) - Enalapril, captopril, april jane dolo d. Calcium Antagonist - calciblock - Nifedipine, diltiazem 3. Administer oxygen inhalation 4. Place client on semi fowler‘s position 5. Monitor strictly vital signs, intake and output and ECG tracing 6. Provide decrease saturated fats sodium and caffeine 7. Provide client health teachings and discharge planning a. Avoidance of 4 E‘s b. Prevent complication (myocardial infarction) c. Instruct client to take medication before indulging into physical exertion to achieve the maximum therapeutic effect of drug d. The importance of follow up care

MYOCARDIAL INFARCTION – areas in myocardial cells in the heart are permanently destroyed. Heart attack Terminal stage of coronary artery disease characterized by malocclusion, necrosis and scarring. A. Types 1. Transmural Myocardial Infarction – most dangerous type characterized by occlusion of both right and left coronary artery 2. Subendocardial Myocardial Infarction – characterized by occlusion of either right or left coronary artery B. The Most Critical Period Following Diagnosis of Myocardial Infarction ** 6 – 8 hours because majority of death occurs due to arrhythmia leading to PVC’s C. Predisposing Factors

1. Sex – male 2. Race – black 3. Smoking 4. Obesity 5. Hyperlipidemia 6. Sedentary lifestyle 7. Diabetes Mellitus 8. Hypothyroidism 9. Diet – increased saturated fats 10. Type A personality

D. Signs and Symptoms 1. Chest pain - Excruciating visceral, viselike pain located at substernal and rarely in precordial - Usually radiates from back, shoulder, arms, axilla, jaw and abdominal muscles (abdominal ischemia) and hands - Not usually relieved by rest or by nitroglycerine 2. Dyspnea 3. Increase in blood pressure (initial sign) 4. Hyperthermia 5. Ashen skin (pale), cool, clammy, diaphoretic 6. Mild restlessness and apprehension, anxiety 7. Occasional findings a. Pericardial friction rub b. Split S1 and S2 c. Rales/Crackles upon auscultation d. S4 or atrial gallop E. Diagnostic Procedure 1. Cardiac Enzymes a. CPK – MB - Creatinine phosphokinase is increased - Heart only, 12 – 24 hours b. LDH – Lactic dehydroginase is increased c. SGPT – Serum glutamic pyruvate transaminase is increased d. SGOT – Serum glutamic oxal-acetic transaminase is increased 2. Troponin Test – is increased (protein in myocardial) 3. ECG tracing reveals a. ST segment elevation b. T wave inversion c. Widening of QRS complexes indicates that there is arrhythmia in MI 4. Serum Cholesterol and uric acid are both increased 5. CBC – increased WBC F. Nursing Management Goal: Decrease myocardial oxygen demand 1. Decrease myocardial workload (rest heart) - Administer narcotic analgesic/morphine sulfate - Side Effects: respiratory depression - Antidote: Narcan/Naloxone

- Side Effects of Naloxone Toxicity is tremors 2. Administer oxygen low inflow to prevent respiratory arrest at 2 – 3 L/min 3. Enforce CBR without bathroom privileges a. Using bedside commode 4. Instruct client to avoid forms of valsalva maneuver 5. Place client on semi fowler‘s position 6. Monitor strictly vital signs, intake and output and ECG tracing 7. Provide a general liquid to soft diet that is low in saturated fats, sodium and caffeine 8. Encourage client to take 20 – 30 cc/week of wine, whisky and brandy to induce vasodilation 9. Administer medication as ordered : a. Vasodilators - Nitroglycerine - ISD (Isosorbide Dinitrate, Isordil) sublingual b. Anti Arrythmic Agents - Lidocaine (Xylocane - Side Effects: confusion and dizziness - Brutylium c. Beta-blockers - (-lol) d. ACE Inhibitors - (-pril) e. Calcium Antagonist - amlodipine, verapamil, diltiazem f. Thrombolytics/ Fibrinolytic Agents - Streptokinase - Side Effects: allergic reaction, pruritus - Urokinase - TIPAF (tissue plasminogen activating factor) - Side Effects: chest pain - Monitor for bleeding time g. Anti Coagulant - Heparin (check for partial thrombin time) - Antidote: protamine sulfate - Coumadin/ Warfarin Sodium (check for prothrombin time) - Antidote: Vitamin K h. Anti Platelet - PASA (Aspirin) - Anti thrombotic effect - Side Effects of Aspirin       Tinnitus Heartburn Indigestion/Dyspepsia Dengue Peptic Ulcer Disease Unknown cause of headache

- Contraindication

10. Provide client health teaching and discharge planning concerning a. Avoidance of modifiable risk factors

- Arrhythmia (caused by premature ventricular contraction) b. Cardiogenic shock - late sign is oliguria c. Left Congestive Heart Failure d. Thrombophlebitis - homan’s sign e. Stroke/CVA f. Post MI Syndrome/Dressler’s Syndrome - Client is resistant to pharmacological agents; administer 150,000 – 450,000 units of streptokinase as ordered g. Resumption of ADL particularly sexual intercourse is 4 – 6 weeks post cardiac rehab, post CABG and instruct to - make sex as an appetizer rather than dessert - instruct client to assume a non weight bearing position Client can resume sexual intercourse if can climb staircase - dietary modification h. Strict compliance to mediation and importance of follow up care CONGESTIVE HEART FAILURE Inability of the heart to pump blood towards systemic circulation Types of Heart Failure 1. LEFT SIDED HEART FAILURE A. Predisposing Factors 1. 90% is mitral valve stenosis due to a. RHD – inflammation of mitral valve due to invasion of Group A beta-hemolytic streptococcus - Formation of aschoff bodies in the mitral valve - Common among children (throat infection) - ASO Titer (Anti streptolysin O titer) - Penicillin - Aspirin b. Aging 2. Myocardial Infarction 3. Ischemic heart disease 4. Hypertension 5. Aortic valve stenosis B. Signs and Symptoms 1. Dyspnea 2. Paroxysmal nocturnal dyspnea – client awakened at night due to DOB (sudden attacks of Orthopnea at night) 3. Orthopnea – use 2 – 3 pillows when sleeping or place in high fowlers 4. Productive cough with blood tinged sputum (severe pulmonary edema) 5. Frothy salivation 6. Cyanosis 7. Rales/Crackles (bi-basilar lobes that do not clear w/ coughing ) 8. Bronchial wheezing 9. Pulsus Alternans – weak pulse followed by strong bounding pulse 10. PMI is displaced laterally due to cardiomegaly 11. There is anorexia and generalized body malaise 12. S3 – ventricular gallop 13. Oliguria – blood flow to the kidney decreases, causing decreased perfusion and reduce urine output. (Daytime) 14. Nocturia – sleeping cardiac workload decreased, improving renal perfusion, which then leads to frequent urination at Night.

C. Diagnostic Procedure 1. Chest x-ray – reveals cardiomegaly 2. PAP (pulmonary arterial pressure) – measures pressure in right ventricle or cardiac status PCWP (pulmonary capillary wedge pressure) – measures end systolic and dyastolic pressure both are increased done by cardiac catheterization (insertion of swan ganz catheter)

3. Echocardiography – enlarged heart chamber (cardiomyopathy), dependent on extent of heart failure 4. ABG – reveals PO2 is decreased (hypoxemia), PCO 2 is increased (respiratory acidosis)

2. RIGHT SIDED HEART FAILURE – RIGHT VENT. FAILS.
A. Predisposing Factors 1. Tricuspid valve stenosis 2. Pulmonary embolism 3. Related to COPD 4. Pulmonic valve stenosis 5. Left sided heart failure

B. Signs and Symptoms (venous congestion) 1. Neck/jugular vein distension 2. Pitting edema (lower extremities) 3. Ascites 4. Weight gain 5. Hepatosplenomegaly 6. Jaundice 7. Pruritus (albumin) 8. Anorexia 9. Esophageal varices C. Diagnostic Procedures 1. Chest x-ray – reveals cardiomegaly 2. Central venous pressure (CVP) - Measure pressure in right atrium (4 – 10 cm of water) - CVP fluid status measure

- If CVP is less than 4 cm of water hypovolemic shock - Do the fluid challenge (increase IV flow rate) - If CVP is more than 10 cm of water hypervolemic shock - Administer loop diuretics as ordered - When reading CVP patient should be flat on bed - Upon insertion place client in Trendelenburg position to promote ventricular filling and prevent pulmonary embolism

3. Ecocardiography – reveals enlarged heart chambers (cardiomyopathy) 4. Liver enzymes – SGPT and SGOT is increased D. Nursing Management Goal: increase cardiac contractility thereby increasing cardiac output (3 – 6 L/min) 1. Enforce CBR 2. Administer medications as ordered a. Cardiac glycosides - Increase force of cardiac contraction - If heart rate is decreased do not give b. Loop Diuretics - Lasix (Furosemide) peak 1-2 hrs, duration 6-8 hrs (monitor for hyperkalemia) c. Bronchodilators aminophylline d. Narcotic analgesics - Morphine Sulfate e. Vasodilators - Nitroglycerine f. Anti Arrhythmic - Lidocaine (Xylocane) 3. Administer oxygen inhalation with high inflow, 3 – 4 L/min, delivered via nasal cannula 4. High fowler‘s position 5. Monitor strictly vital signs, intake and output and ECG tracing 6. Measure abdominal girth daily and notify physician 7. Provide a dietary intake of low sodium, cholesterol and caffeine 8. Provide meticulous skin care 9. Assist in bloodless phlebotomy – rotating tourniquet, rotated clockwise every 15 minutes to promote decrease venous return 10. Provide client health teaching and discharge planning a. Prevent complications - Arrhythmia - Shock - Right ventricular hypertrophy - MI - Thrombophlebitis b. Dietary modification c. Strict compliance to medications
B. dilated cardiomyopathy B. hypertrophic cardiomyopathy

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

PERIPHERAL VASCULAR DISORDER Arterial Ulcer I. ThromboAngIitis Obliterans (BUERGER’S DISEASE)  Burger’s Disease - male/ feet  Reynaud’s Disease - female/ hands Venous Ulcer 1. Varicose Veins 2. Thrombophlebitis (deep vein thrombosis)

THROMBOANGIITIS OBLITERANS or BUERGER’S DISEASE (MALE FEET) 20-35 yrs old
Acute inflammatory disorder usually affecting the small medium sized arteries and veins of the lower extremities (Autoimmune disease) A. Predisposing Factors 1. High risk groups – men 30 years old and above 2. Smoking 3. Thrombus formation and occlusion of the vessels 4. Age 20-35 yrs B. Signs and Symptoms (pain is the outstanding symptom) 1. Intermittent claudication – leg pain upon walking (foot cramps, especially the arch (instep claudication after exercise) 2. Cold sensitivity and changes in skin color rubor (reddish blue discoloration, pallor, and cyanosis) 3. Decreased peripheral pulses 4. Trophic changes 5. Ulceration 6. Gangrene formation 7. Absence of pedal pulse but with normal femoral pulse and popliteal pulses. 8. Radial and ulnar artery pulses are absent or diminished. C. Diagnostic Procedures 1. Oscillometry – decrease in peripheral pulses 2. Doppler UTZ – decrease blood flow to the affected extremity 3. Angiography – reveals site and extent of malocclusion 4. Segmental limb blood pressure (alternation of tourniquet) D. Nursing Management 1. Encourage a slow progressive physical activity A. walking 3 – 4 times a day B. out of bed 3 – 4 times a day 2. Administer medications as ordered a. Analgesics b. Vasodilators c. Anti coagulants 3. Institute foot care management 4. Instruct client to avoid smoking and exposure to cold environment 5. Assist in surgical procedure – bellow knee amputation (elevate the stump for 24 hrs postop to promote venous return and minimize edema). 6. Pain is relieve by rest Lower the extremities below the level of the heart – if the condition is arterial in nature Elevate the extremities above the heart level – if the condition is venous in nature

REYNAUD’S DISEASE
Disorder characterized by acute episodes of arterial (small arteries) spasm/vasoconstriction that result in coldness, pain, and pallor involving the fingers or digits of the hands. A. Predisposing Factors 1. High risk group – female 16-40 years old and above 2. Smoking 3. Collagen diseases a. SLE (butterfly rash) b. Rheumatoid Arthritis 4. Direct hand trauma a. Piano playing b. Excessive typing c. Operating chainsaw 5. Cold climates and during winter B. Signs and Symptoms 1. Intermittent claudication – leg pain upon walking 2. Cold sensitivity and changes in skin color (pallor, cyanosis then rubor) 3. Trophic changes 4. Ulceration 5. Gangrene formation 6. Raynaud’s phenomenon – refer to localized, intermittent episodes of vasoconstriction of small arteries of the hands that causes changes in color and temperature. (as white, blue, and red) C. Diagnostic Procedures 1. Doppler UTZ – decrease blood flow to the affected extremity 2. Angiography – reveals site and extent of malocclusion D. Nursing Management 1. Administer medications as ordered a. Analgesics b. Vasodilators (calcium channel blockers: nifedipine) 2. Encourage to wear gloves 3. Instruct client on importance of cessation of smoking and exposure to cold environment

VARICOSITIES
Dilated, tortuous, superficial veins caused by incompetent venous valves Abnormal dilation of veins of lower extremities and trunks due to Incompetent valve resulting to Increased venous pooling resulting to Venous stasis causing Decrease venous return A. Predisposing Factors 1. Hereditary 2. Congenital weakness of veins 3. Thrombophlebitis 4. Cardiac disorder 5. Pregnancy 6. Obesity 7. Prolonged standing or sitting 8. Tortuous veins (saphenous veins)

B. Signs and Symptoms 1. Pain after prolonged standing 2. Dilated tortuous skin veins 3. Warm to touch 4. Heaviness in legs

C. Diagnostic Procedure 1. Venography 2. Trendelenburg‘s Test - veins distends quickly in less than 35 seconds D. Nursing Management 1. Elevate legs above heart level to promote increased venous return by placing 2 – 3 pillows under the legs 2. Measure the circumference of leg muscle to determine if swollen 3. Wear anti embolic stockings 4. Administer medications as ordered a. Analgesics 5. Assist in surgical procedure a. Vein stripping and ligation (most effective) b. Sclerotherapy – can recur and only done small/ spider web varicosities and danger of thrombosis (2 – 3 years for embolism) - sclerosing agent is injected into the vein, irritating the venous endothelium and producing localized phlebitis and fibrousis, thereby obliterating the lumen of the vein.

THROMBOPHLEBITIS
Deep vein thrombosis Inflammation of the veins with thrombus formation 3 factors known as VIRCHOW’S TRIAD believe to play a significant role in its development: Stasis of the blood (venous stasis) Vessel wall injury Altered blood coagulation A. Predisposing Factors 1. Obesity 2. Smoking 3. Related to pregnancy 4. Chronic anemia 5. Prolong use of oral contraceptives – promotes lipolysis 6. Diabetes mellitus 7. Congestive heart failure 8. Myocardial infarction 9. Post op complication 10. Post cannulation – insertion of various cardiac catheter. 11. Increase in saturated fats in the diet. B. Signs and Symptoms 1. Pain at affected extremity 2. Warm to touch 3. Dilated tortuous skin veins 4. Positive Homan‘s Signs – pain at the calf or leg muscle upon dorsiflexion of the foot C. Diagnostic Procedure 1. Venography

2. Angiography D. Nursing Management 1. Elevate legs above heart level to promote increase venous return 2. Apply warm moist pack – to reduce lymphatic congestion 3. Measure circumference of leg muscle to determine if swollen 4. Encourage to wear anti embolic stockings or knee elastic stockings 5. Administer medications as ordered a. Analgesics b. Anti Coagulant – take at the same time each day, usually bet. 8-9 am - Heparin Note: if any of the ff. sign are appear, report them immediately Faintness, dizziness, or increased weakness Severe headaches or abdominal pain Reddish or brownish urine Any bleeding – nose bleeding, cuts, and unusual Red black bowel movements Rash 6. Monitor for signs of complications Embolism a. Pulmonary - Sudden sharp chest pain - Unexplained dyspnea - Tachycardia - Palpitations - Diaphoresis - Restlessness b. Cerebral - Headache - Dizziness - Decrease LOC MURPHY’S SIGN is seen in clients with cholelithiasis, cholecystitis characterized by pain at the right upper quadrant with tenderness (inflammation of the gall bladder)

RESPIRATORY SYSTEM
OVERVIEW OF THE STRUCTURES AND FUCNTIONS OF THE RESPIRATORY SYSTEM I. Upper Respiratory System 1. Filtering of air 2. Warming and moistening of air 3. Humidification A. Nose - Cartillage - Right nostril - Left nostril - Separated by septum - Consist of anastomosis of capillaries known as Kesselbach’s Plexus (the site of nose bleeding) B. Pharynx/Throat - Serves as a muscular passageway for both food and air

C. Larynx - For phonation (voice production) - For cough reflex Glottis - Opening of larynx - Opens to allow passage of air - Closes to allow passage of food going to the esophagus - The initial sign of complete airway obstruction is the inability to cough II. Lower Respiratory System - For gas exchange A. Trachea/Windpipe - Consist of cartilaginous rings - Serves as passageway of air going to the lungs - Site of tracheostomy B. Bronchus - Right main bronchus - Left main bronchus C. Lungs - Right lung (consist of 3 lobes, 10 segments) - Left lung (consist of 2 lobes, 8 segments) - Serous membranes Pleural Cavity a. Pareital b. Pleural fluid c. Visceral With Pleuritic Friction Rub a. Pneumonia b. Pleural effusion c. Hydrothorax (air and blood in pleural space Alveoli – acinar cells - Site of gas exchange (CO2 and O2) - Diffusion (Dalton‘s law of partial pressure of gases) Respiratory Distress Syndrome - Decrease oxygen stimulates breathing - Increase carbon dioxide is a powerful stimulant for breathing Ventilation – movement of air in & out of lungs Respiration – movement of air into cells Type II Cells of Alveoli - Secretes surfactant - Decrease surface tension - Prevent collapse of alveoli - Composed of lecithin and spingomyelin - L/S ratio to determine lung maturity - Normal L/S ratio is 2:1 - In premature infants 1:2 - Give oxygen of less 40% in premature to prevent atelectasis and retrolental fibroplasias - retinopathy/blindness in prematurity

Disorders of Respiratory System
1. PTB/Pulmonary Tuberculosis (Koch’s Disease) - Infection of lung tissue caused by invasion of mycobacterium tuberculosis or tubercle bacilli - An acid fast, gram negative, aerobic and easily destroyed by heat or sunlight A. Precipitating Factors 1. Malnutrition 2. Overcrowded places 3. Alcoholism 4. Over fatigue 5. Ingestion of infected cattle with mycobacterium bovis 6. Virulence (degree of pathogenecity) of microorganism B. Mode of Transmission 1. Airborne transmission via droplet nuclei C. Signs and Symptoms 1. Low grade afternoon fever, night sweats 2. Productive cough (yellowish sputum) 3. Anorexia, generalized body malaise 4. Weight loss 5. Dyspnea 6. Chest pain 7. Hemoptysis (chronic)

D. Diagnostic Procedure 1. Mantoux Test (skin test) - Purified protein derivative - DOH 8 – 10 mm induration, 48 – 72 hours - WHO 10 – 14 mm induration, 48 – 72 hours - Positive Mantoux test (previous exposure to tubercle bacilli but without active TB) 2. Sputum Acid Fast Bacillus - Positive to cultured microorganism 3. Chest X-ray - Reveals pulmonary infiltrates (chalk thorax) 4. CBC - Reveals increase WBC E. Nursing Management 1. Enforce CBR 2. Institute strict respiratory isolation 3. Administer oxygen inhalation 4. Force fluids to liquefy secretions 5. Place client on semi fowler‘s position to promote expansion of lungs 6. Encourage deep breathing and coughing exercise 7. Nebulize and suction when needed 8. Comfortable and humid environment

9. Institute short course chemotherapy a. Intensive phase - INH (Isonicotinic Acid Hydrazide) - Rifampicin (Rifampin) - PZA (Pyrazinamide) - Given everyday simultaneously to prevent resistance - INH and Rifampicin is given for 4 months, taken before meals to facilitate absorption - PZA is given for 2 months, taken after meals to facilitate absorption - Side Effect INH: peripheral neuritis/neuropathy (increase intake of Vitamin B6/Pyridoxine) - Side Effect Rifampicin: all bodily secretions turn to red orange color - Side Effect PZA: allergic reaction, hepatotoxicity, nephrotoxicity - PZA can be replaced by Ethambutol - Side Effect Ethambutol: optic neuritis b. Standard phase - Injection of streptomycin (aminoglycoside) - Kanamycin - Amikacin - Neomycin - Gentamycin - Side Effect: - Ototoxicity damage to the 8 cranial nerve resulting to tinnitus leading to hearing loss - Nephrotoxicity check for BUN and Creatinine - Give aspirin if there is fever - Side Effect: tinnitus, dyspepsia, heartburn 10. Provide increase carbohydrates, protein, vitamin C and calories 11. Provide client health teaching and discharge planning a. Avoidance of precipitating factors b. Prevent complications (Atelectasis, military tuberculosis) PTB - Bones (potts) - Meninges - Eyes - Skin - Adrenal gland c. Strict compliance to medications d. Importance of follow up care
th

PNEUMONIA
Inflammation of the lung parenchyma leading to pulmonary consolidation as the alveoli is filled with exudates A. Etiologic Agents 1. Streptococcus Pneumonae – causing pneumococal pneumonia 2. Hemophylus Influenzae – causing broncho pneumonia (children) 3. Diplococcus Pneumoniae 4. Klebsella Pneumoniae 5. Escherichia Pneumoniae 6. Pseudomonas B. High Risk Groups 1. Children below 5 years old 2. Elderly C. Predisposing Factors bec. Of low resistance

1. Smoking 2. Air pollution 3. Immuno compromised a. AIDS - Pneumocystic carini pneumonia - Drug of choice is Retrovir b. Bronchogenic Cancer - Initial sign is non productive cough to productive cough - Chest x-ray confirms lung cancer 4. Related to prolonged immobility (CVA clients), causing hypostatic pneumonia 5. Aspiration of food causing aspiration pneumonia D. Signs and Symptoms 1. Productive cough with greenish to rusty sputum 2. Dyspnea with prolong expiratory grunt 3. Fever, chills, anorexia and general body malaise 4. Weight loss 5. Rales/crackles 6. Bronchial wheezing 7. Cyanosis 8. Pleuritic friction rub 9. Chest pain 10. Abdominal distention leading to paralytic ileus (absence of peristalsis) E. Diagnostic Procedure 1. Sputum Gram Staining and Culture Sensitivity – positive to cultured microorganisms 2. Chest x-ray – reveals pulmonary consolidation 3. ABG analysis – reveals decrease PO2 4. CBC – reveals increase WBC, erythrocyte sedimentation rate is increased F. Nursing Management 1. Enforce CBR 2. Administer oxygen inhalation low inflow 3. Administer medications as ordered Broad Spectrum Antibiotic a. Penicillin b. Tetracycline c. Microlides (Zethromax) Azethromycin (Side Effect: Ototoxicity) Antipyretics Mucolytics/Expectorants Analgesics

4. Force fluid 5. Place on semi fowler‘s position 6. Institute pulmonary toilet (tends to promote expectoration) - Deep breathing exercises - Coughing exercises - Chest physiotherapy - Turning and reposition 7. Nebulize and suction as needed 8. Assist in postural drainage - Drain uppermost area of lungs - Placed on various position

Nursing Management for Postural Drainage a. Best done before meals or 2 – 4 hours after meals to prevent gastro esophageal reflux b. Monitor vital signs c. Encourage client deep breathing exercises normal breathe sound bronchovesicular d. Administer bronchodilators 15 – 30 minutes before procedure e. Stop if client cannot tolerate procedure f. Provide oral care after procedure g. Contraindicated with - Unstable vital signs - Hemoptysis - Clients with increase intra ocular pressure (Normal IOP 12 – 21 mmHg) - Increase ICP 9. Provide increase carbohydrates, calories, protein and vitamin C 10. Health teaching and discharge planning a. Avoid smoking b. Prevent complications - Atelectasis - Meningitis (nerve deafness, hydrocephalus) c. Regular adherence to medications d. Importance of follow up care

HISTOPLASMOSIS
Acute fungal infection caused by inhalation of contaminated dust or particles with histoplasma capsulatum derived from birds manure A. Signs and Symptoms PTB or Pneumonia like 1. Productive cough 2. Dyspnea 3. Fever, chills, anorexia, general body malaise 4. Cyanosis 5. Hemoptysis 6. Chest and joint pains B. Diagnostic Procedures 1. Histoplasmin Skin Test – positive 2. ABG analysis PO2 decrease C. Nursing Management 1. Enforce CBR 2. Administer oxygen inhalation 3. Administer medications as ordered a. Antifungal - Amphotericin B - Fungizone (Nephrotoxicity, check for BUN and Creatinine, Hypokalemia) b. Steroids c. Mucolytics d. Antipyretics 4. Force fluids to liquefy secretions 5. Nebulize and suction as needed 6. Prevent complications – bronchiectasis 7. Prevent the spread of infection by spraying of breeding places

COPD (Chronic Obstructive Pulmonary/Lung Disease)

Chronic Bronchitis
Inflammation of bronchus resulting to hypertrophy or hyperplasia of goblet mucous producing cells leading to narrowing of smaller airways A. Predisposing Factors 1. Smoking 2. Air pollution B. Signs and Symptoms 1. Productive cough (consistent to all COPD) 2. Dyspnea on exertion 3. Prolonged expiratory grunt 4. Anorexia and generalized body malaise 5. Scattered rales/ronchi 6. Cyanosis 7. Pulmonary hypertension a. Peripheral edema b. Cor Pulmonale (right ventricular hypertrophy)

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

Bronchial Asthma
Reversible inflammatory lung condition due to hypersensitivity to allergens leading to narrowing of smaller airways A. Predisposing Factors (Depending on Types) 1. Extrinsic Asthma (Atopic/ Allergic) Causes a. Pollen b. Dust c. Fumes d. Smoke e. Gases f. Danders g. Furs h. Lints 2. Intrinsic Asthma (Non atopic/Non allergic) Causes a. Hereditary b. Drugs (aspirin, penicillin, beta blocker) c. Foods (seafoods, eggs, milk, chocolates, chicken d. Food additives (nitrates) e. Sudden change in temperature, air pressure and humidity f. Physical and emotional stress 3. Mixed Type  90 – 95% B. Signs and Symptoms 1. Cough that is non productive 2. Dyspnea 3. Wheezing on expiration

4. Cyanosis 5. Mild Stress/apprehension 6. Tachycardia, palpitations 7. Diaphoresis C. Diagnostic Procedure 1. Pulmonary Function Test - Incentive spirometer reveals decrease vital lung capacity 2. ABG analysis – PO2 decrease - Before ABG test for positive Allens Test, apply direct pressure to ulnar and radial artery to determine presence of collateral circulation D. Nursing Management 1. Enforce CBR 2. Oxygen inhalation, with low inflow of 2 – 3 L/min 3. Administer medications as ordered a. Bronchodilators – given via inhalation or metered dose inhalaer or MDI for 5 minutes b. Steroids – decrease inflammation c. Mucomysts (acetylceisteine) d. Mucolytics/expectorants e. Anti histamine 4. Force fluids 5. Semi fowler‘s position 6. Nebulize and suction when needed 7. Provide client health teachings and discharge planning concerning a. Avoidance of precipitating factor b. Prevent complications - Emphysema - Status Asthmaticus (give drug of choice) - Epinephrine - Steroids - Bronchodilators c. Regular adherence to medications to prevent development of status asthmaticus d. Importance of follow up care

BRONCHIECTASIS
Abnormal permanent dilation of bronchus leading to destruction of muscular and elastic tissues of alveoli A. Predisposing Factors 1. Recurrent lower respiratory tract infections 2. Chest trauma 3. Congenital defects 4. Related to presence of tumor B. Signs and Symptoms 1. Productive cough 2. Dyspnea 3. Cyanosis 4. Anorexia and generalized body malaise 5. Hemoptysis (only COPD with sign)

C. Diagnostic Procedure 1. ABG – PO2 decrease

2. Bronchoscopy – direct visualization of bronchus using fiberscope Nursing Management PRE Bronchoscopy 1. Secure inform consent and explain procedure to client 2. Maintain NPO 6 – 8 hours prior to procedure 3. Monitor vital signs and breathe sound POST Bronchoscopy 1. Feeding initiated upon return of gag reflex 2. Avoid talking, coughing and smoking, may cause irritation 3. Monitor for signs of gross 4. Monitor for signs of laryngeal spasm – prepare tracheostomy set D. Treatment 1. Surgery (pneumonectomy, 1 lung is removed and position on affected side) 2. Segmental Wedge Lobectomy (promote re expansion of lungs) - Unaffected lobectomy facilitate drainage

EMPHYSEMA
Irreversible terminal stage of COPD characterized by a. Inelasticity of alveoli b. Air trapping c. Maldistribution of gases d. Over distention of thoracic cavity (barrel chest) A. Predisposing Factors 1. Smoking 2. Air pollution 3. Allergy 4. High risk: elderly 5. Hereditary – it involves deficiency of ALPHA-1 ANTI TRYPSIN (needed to form Elastase, for recoil of alveoli) B. Signs and Symptoms 1. Productive cough 2. Dyspnea at rest 3. Prolong expiratory grunt 4. Anorexia and generalized body malaise 5. Resonance to hyperresonance 6. Decrease tactile fremitus 7. Decrease or diminished breath sounds 8. Rales or ronchi 9. Bronchial wheezing 10. Barrel chest 11. Flaring of alai nares 12. Purse lip breathing to eliminates excess CO2 (compensatory mechanism) C. Diagnostic Procedure 1. Pulmonary Function Test – reveals decrease vital lung capacity 2. ABG analysis reveals a. Panlobular/ centrilobular - Decrease PO2 (hypoxemia leading to chronic bronchitis, ―Blue Bloaters‖) - Decrease ph

- Increase PCO2 - Respiratory acidosis b. Panacinar/ centriacinar - Increase PO2 (hyperaxemia, ―Pink Puffers‖) - Decrease PCO2 - Increase ph - Respiratory alkalosis D. Nursing Management 1. Enforce CBR 2. Administer oxygen inhalation via low inflow 3. Administer medications as ordered a. Bronchodilators b. Steroids c. Antibiotics d. Mucolytics/expectorants 4. High fowlers position 5. Force fluids 6. Institute pulmonary toilet 7. Nebulize and suction when needed 8. Institute PEEP (positive end expiratory pressure) in mechanical ventilation promotes maximum alveolar lung expansion 9. Provide comfortable and humid environment 10. Provide high carbohydrates, protein, calories, vitamins and minerals 11. Health teachings and discharge planning concerning a. Avoid smoking b. Prevent complications - Atelectasis - Cor Pulmonale - CO2 narcosis may lead to coma - Pneumothorax c. Strict compliance to medication d. Importance of follow up care

RESTRICTIVE LUNG DISORDER
PNEUMOTHORAX – partial / or complete collapse of lungs due to entry or air in pleural space. Types: 1. Spontaneous pneumothorax – entry of air in pleural space without obvious cause. eg. Rupture of bleb (alveoli filled sacs) in pt with inflammed lung conditions 2. Open pneumothorax – air enters pleural space through an opening in chest wall -Stab/ gunshot wound 3. Tension Pneumothorax – air enters plural space with @ inspiration & can‘t escape leading to over distension of thoracic cavity resulting to shifting of mediastinum content to unaffected side. Eg. Flail chest – ―paradoxical breathing pattern‖

Predisposing factors: 1. Chest trauma 2. Inflammatory lung conditions 3. Tumor S/Sx: 1. Sudden sharp chest pain 2. unexplained Dyspnea or SOB 3. Cyanosis 4. Diminished or decreased breath sound of affected lung 5. Cool moist skin- initial sign of shock 6. Mild restlessness/ apprehension, anxiety 7. Resonance to hyperresonance 8. decreased tactile fremitus Diagnosis: 1. ABG – pO2 decrease – 2. CXR – confirms pneumothorax/collapse of lung Nursing Mgt: 1. Assist in endotracheal intubation 2. Assist in thoracenthesis 3. Administer meds – Morphine SO4 – due to pain - Anti microbial agents- due to bacteria 4. Assist in test tube thoracotomy attached to H2O sealed drainage system

If client has a tension pneumothorax, the initial treatment of choice is to insert a large-bore needle into the second intercostal space midclavicular line to relieve pressure. Next, a chest tube system is placed into the fourth intercostal space. A small chest tube(28 french) is inserted near the second intercostal space; this space is used because it is the thinnest part of the chest wall, minimizes the danger of contracting the thoracic nerve, and leave small scar. If the patient has also hemothorax, a large-diameter chest tube (32 french) or greater is inserted usually in the 4 th or 5th interscostal space at the midaxillary line. Purpose of H2O sealed drainage 1. Reestablish (-) pressure in the lungs-lung 6-12mm Hg 2. Promote re-expansion of the lungs 3. Drain fluid, blood and air 4. To prevent reflux of blood fluid and air Nursing Mgt if pt is on CPT attached to H2O drainage 1. Maintain strict aseptic technique 2. DBE 3. At bedside a.) Petroleum gauze pad if dislodged Hemostat b.) If with air leakage – clamp c.) Extra bottle 4. Meds – Morphine SO4 Antimicrobial 5. Monitor & assess for oscillation fluctuations or bubbling a.) If (+) to intermittent bubbling means normal or intact - H2O rises upon inspiration - H2O goes down upon expiration b.) If (+) to continuous, remittent bubbling 1. Check for air leakage 2. Clamp towards chest tube 3. Notify MD c.) If (-) to bubbling 1. Check for loop, clots, and kink 2. Milk towards H2O seal 3. Indicates re-expansion of lungs normal 4. Auscultate for breath sounds, Xrays 5. Removal of CTT

When will MD remove chest tube? 1. If (-) fluctuations 2. (+) Breath sounds 3. CXR – full expansion of lungs Nursing Mgt of removal of chest tube 1. Encourage DBE 2. Instruct to perform Valsalva maneuver for easy removal, to prevent entry of air in pleural space. 3. Apply vaselinated air occlusive dressing and pressure dressing - Maintain dressing dry & intact 4. Prepare: Extra bottle, excellent clamp, petroleum gauze

Gastro Intestinal Tract
I. Upper alimentary canal - function for digestion a. Mouth b. Pharynx (throat) c. Esophagus d. Stomach- site of digestion e. 1st half of duodenum II. Middle Alimentary canal – Function: for absorption - Complete absorption – large intestine a. 2nd half of duodenum for absorption b. Jejunum c. Ileum d. 1st half of ascending colon III. Lower Alimentary Canal – Function: elimination a. 2nd half of ascending colon for elimination b. Transverse for complete absorption— L I c. Descending colon d. Sigmoid e. Rectum IV. Accessory Organ a. Salivary gland b. Verniform appendix c. Liver d. Pancreas – auto digestion e. Gallbladder – storage of bile I. Salivary Glands 1. Parotid – below & front of ear 2. Sublingual 3. Submaxillary Produces saliva – for mechanical digestion 1,200 -1,500 ml/day - saliva produced Lacrimal gland- depression on the frontal bone Lacrimal duct- outer canthus

PAROTITIS – ―mumps‖ – inflammation of parotid gland
-Paramyxovirus S/Sx: 1. 2. 3. 4. 5. Fever, chills anorexia, generalized body malaise enlarged parotid gland Swelling of parotid gland Dysphagia Earache – otalgia

Mode of transmission: Direct transmission & droplet nuclei Incubation period: 14 – 21 days Period of communicability – 1 week before swelling & immediately when swelling begins. Nursing Mgt: 1. CBR 2. Institute a strict respiratory isolation 3. Meds: analgesic Antipyretic Antibiotics – to prevent 2 complications 4. Alternate warm & cold compress at affected part (vinegar promotes cooling)

5. General liquid to soft diet 6. Complications Women – cervicitis, vaginitis, oophoritis Both sexes – meningitis & encephalitis/ reason why antibiotics is needed Men – orchitis might lead to sterility if it occurs during / after puberty. VERNIFORM APPENDIX – Rt. iliac or Rt. inguinal area - Function – lymphatic organ – produces WBC during fetal life - ceases to function upon birth of baby APENDICITIS – inflamation of verniform appendix Predisposing factor: 1. Microbial infection 2. Feacalith – undigested food particles – tomato seeds, guava seeds 3. Intestinal obstruction S/Sx: 1. 2. 3. 4. 5. Pathognomonic sign: (+) rebound tenderness Low grade fever, anorexia, n/v Diarrhea &/ or constipation Pain at Rt. iliac region-- MCBURNEY‘S point – site of surgical incision Late sign due pain – tachycardia

Rovsing’s sign – elicited by palpating the left lower quadrant; this paradoxically causes pain to be felt in the right lower quadrant. Diagnosis: 1. CBC – mild leukocytosis – increase WBC 2. PE – (+) rebound tenderness (flex Rt leg, palpate Rt iliac area – rebound) 3. Urinalysis—(+) acetone in urine Treatment: - appendectomy 24 – 45 Nursing Mgt: 1. Secure consent 2. Routinely nursing measures: a.) Skin prep b.) NPO c.) Avoid enema/laxatives – lead to rupture of appendix 3. Meds: Antipyretic Antibiotics *Don’t give analgesic – pre-diagnosis will mask pain Give analgesic – post diagnosis - Presence of pain means appendix has not ruptured. 4. Avoid heat application – will rupture appendix. 5. Monitor VS, I&O bowel sound 6. Maintain a patent IV line Complications: Peritonitis Septicemia Nursing Mgt: post op 1. If (+) to Penrose drain – indicates rupture of appendix Position- affected side to drain 2. Meds: analgesic due post op pain Antibiotics, Antipyretics PRN 3. Monitor VS, I&O, bowel sound- N- borborygmy sound 4. Maintain patent IV line 5. Complications- peritonitis, septicemia

PEPTIC ULCER DISEASE – (PUD) – excoriation / erosion of submucosa & mucosal lining due to: a.) Hyper secretion of acid – pepsin b.) Decrease resistance to mucosal barrier Incidence Rate: 1. Men – 40 – 55 yrs old 2. Aggressive persons/ type A personality 3. Hereditary 4. Emotional Stress Predisposing factors: 1. Hereditary 2. Emotional 3. Smoking – vasoconstriction – GIT ischemia 4. Alcoholism – stimulates release of histamine = Parietal cell release Hcl acid = ulceration 5. Caffeine – tea, soda, chocolate 6. Irregular diet

7. Rapid eating 8. Ulcerogenic drugs – NSAIDS, aspirin, steroids, indomethacin, ibuprofen Indomethacin - S/E corneal cloudiness. Needs annual eye check up. NSAID and steroids= gastropathy 9. Gastrin producing tumor or gastrinoma – Zollinger Ellisons syndrome 10. Microbial invasion – helicobacter pylori. Metronidazole (Flagyl)

Types of ulcers
Ascending to severity 1. Acute – affects submucosal lining 2. Chronic – affects underlying tissues – heals & forms a scar, deeper According to location 1. Stress ulcer 2. Gastric ulcer 3. Duodenal ulcer – most common Stress ulcers – common among critically ill clients 2 types 1. Curling’s ulcer – cause: trauma & Burns Hypovolemia GIT schemia Decrease resistance of mucosal barriers to Hcl acid Ulcerations 2. Cushing’s ulcer – cause – stroke/CVA/ head injury Increase vagal stimulation Hyperacidity Ulcerations Treatment: Vagotomy - done to prevent hemorrhage and shock prior to surgery on the stomach

GASTRIC ULCER SITE PAIN Antrum or lesser curvature - 30 min – 1 hr after eating - epigastrium - gaseous & burning - not usually relieved by food & antacid - Eating leads to pain Normal gastric acid secretion common hematemesis Wt loss a. stomach cancer b. hemorrhage 50 or 60 years old and above Male; female = 1:1 15% of peptic ulcers are gastric

DUODENAL ULCER Duodenal bulb - 2-3 hrs after eating - mid epigastrium - cramping & burning pain - usually relieved by food & antacid - 12 MN – 3am pain - Eating lessens pain Increased gastric acid secretion Not common Melena Wt gain a. perforation 20 years old and above Male: Female = 2-3:1 80% of peptic ulcers are duodenal

HYPERSECRETION VOMITING HEMORRHAGE WT COMPLICATIONS HIGH RISK INCIDENCE

90-95% is cases of duodenal ulcers - less bicarbonate ions, decrease so increase incidence Diagnosis: 1. Endoscopic exam 2. Stool from occult blood (+) 3. Gastric analysis – Gastric Ulcer: normal gastric acid secretion Duodenal: increased gastric acid secretion 4. GI series – confirms presence of ulceration Nursing Mgt: 1. Diet – bland, non irritating, non spicy 2. Avoid caffeine & milk/ milk products Increase gastric acid secretion 3. Administer meds

a.) Antacids ACA Aluminum containing antacids Magnesium containing antacids

ex. aluminum hydroxide gel ex. milk of magnesia (Amphogel) S/E diarrhea S/E constipation Maalox (fever S/E) b.) H2 receptor antagonist: 1. Ranitidine (Zantac) SE: fever 2. Cimetidine (Tagamet)—hastens the effect of oral anticoagulants 3. Famotidine (Pepcid) SE: fever - Avoid smoking – decrease effectiveness of drug Nursing Mgt: 1. Administer antacid & H2 receptor antagonist (Cimetidine) – 1hr apart -Cemetidine decrease antacid absorption & vise versa c.) Cytoprotective agents Ex 1. Sucralfate (Carafate) - Provides a paste like subs that coats mucosal lining of stomach 2. Misoprostol (Cytotec) –SE: menstrual spotting d.) Sedatives/ Tranquilizers - Valium, lithium e.) Anticholinergics / Antispasmodic 1. Atropine SO4 2. Prophantheline Bromide (Profanthene) (Pt has history of hpn crisis with peptic ulcer disease. Rn should not administer alka seltzer- has large amount of Na. 3. Surgery: subtotal gastrectomy - Partial removal of stomach Billroth I (Gastroduodenostomy)  Removal of ½ of stomach & anastomoses of gastric stump to the duodenum. Billroth II (Gastrojejunostomy)  Removal of ½ -3/4 of stomach & duodenal bulb & anastomostoses of gastric stump to jejunum.

Before surgery for BI or BII - Do vagotomy (severing of vagus nerve) & pyloroplasty (drainage) first. Nursing Mgt: 1. Monitor NGT output or drainage immediately post op- bright red a.) Immediately post op should be bright red b.) Within 36- 48h – output is yellow green c.) After 48h – output is dark red due to HCl acid 2. Administer meds: a.) Analgesic b.) Antibiotic c.) Antiemetics 3. Maintain patent IV line 4. VS, I&O & bowel sounds 5. Complications: a.) Hemorrhage – hypovolemic shock Late signs – anuria b.) Peritonitis c.) Paralytic ileus – most feared d.) Hypokalemia e.) Thrombophlebitis f.) Pernicious anemia g.) Septicemia 7.) Dumping syndrome – common complication – rapid gastric emptying of hypertonic food solutions – CHYME leading to hypovolemia. Sx of Dumping syndrome: 1. Dizziness 2. Diaphoresis 3. Diarrhea 4. Palpitations Nursing mgt: 1. Avoid fluids in chilled solutions, sweets (fluids must be taken after meals) 2. Small frequent feedings-6 equally divided feedings 3. Diet – decrease CHO, moderate fats & CHON 4. Flat on bed 15 -30 minutes after q feeding

DIVERTICULITIS/DIVERTICULOSIS
1. 2. 3. A. Diverticulum- an outpouching of the intestinal mucosa particularly the sigmoid colon Diverticulosis- multiple diverticulum Diverticulitis- inflammation of diverticula Predisposing Factors 1. High Risk Groups- men (40-45yo) 2. Congenital weakness of muscle fibers of the intestine. 3. Low roughage and fiber in the diet 1. Intermittent lower left abdominal quadrant pain, particularly in the rectosigmoid area 2. tenderness 3. alternating bouts of constipation or diarrhea with blood or mucous

S/S:

Dx: 1. Barium enema—reveals inflammatory process 2. CBC reveals: decreased hematocrit and hemoglobin Nsg Mgt: 1. Administer meds as ordered: a. antibiotics b. bulk laxatives c. stool softeners d. anti spasmodic agents 2. Instruct clients to take foods high in fiber if there is diverticulosis 3. Monitor for signs of infection Feared complications: Peritonitis 4. Assists in surgical procedure Resection of the diseased bowel and creation of a colostomy

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

Function: 1. Produces bile Bile – emulsifies fats—H2O and bile salts= cholesterol Right sided pain: Cholelithiasis- easy bruising Left sided pain: Pancreatitis - Composed of H2O & bile salts -Gives color to urine – urobilin Stool color – stechobilin 2. Detoxifies drugs 3. Promotes synthesis of vit A, D, E, K - fat soluble vitamins (needs fat for absorption) Hypervitaminosis – vit D & K Vit A – retinol (Def Vit A – night blindness) Vit D – cholecalciferon - Helps calcium - Rickets, osteoarthritis 4. It destroys excess estrogen hormone 5. for metabolism A. CHO – 1. Glycogenesis – synthesis of glycogens 2. Glycogenolysis – breakdown of glycogen 3. Gluconeogenesis – formation of glucose from CHO sources B. CHON1. Promotes synthesis of albumin & globulin Liver Cirrhosis – decrease albumin; ascites and edema Albumin – maintains osmotic pressure, prevents edema 2. Promotes synthesis of prothrombin & fibrinogen 3. Promotes conversion of ammonia to urea. Ammonia like breath – fetor hepaticus – a sweet, slightly fecal odor to the breath presumed 2 be intestinal orig. C. FATS – promotes synthesis of cholesterol to neutral fats – called triglycerides

LIVER CIRRHOSIS - lost of architectural design of liver leading to fat necrosis & scarring
Laennac Cirrhosis- loss of architectural design of the liver leading to fat necrosis and scarring Early sign – hepatic encephalopathy – accumulation of ammonia and other toxic substance in the blood 1. Asterixis – flapping hand tremors Late signs – headache, restlessness, disorientation, decrease LOC – hepatic coma. Nursing priority – assist in mechanical ventilation Predisposing factor: Decrease Laennac‘s cirrhosis – caused by alcoholism 1. Chronic alcoholism- major cause 2. Malnutrition – decreaseVit B, thiamin - primary cause 3. Virus – 4. Toxicity- eg. Carbon tetrachloride (CCL4) 5. Use of hepatotoxic agents S/Sx: 1. Early signs: a.) Weakness, fatigue b.) Anorexia, n/v c.) Stomatitis d.) Urine – tea color Stool – clay color e.) Amenorrhea f.) Decrease sexual urge

g.) h.) i.) j.) k.)

Loss of pubic, axilla hair Hepatomegaly Jaundice Pruritus or urticaria (palmar erythema) Decrease bowel sounds a.) Hematological changes – all blood cells decrease Leukopenia- decrease Thrombocytopenia- bleeding tendencies Anemia- decrease b.) Endocrine changes Spider angiomas, Gynecomastia Caput medusae, Palmar erythema, loss of tortousity of the umbilicus c.) GIT changes Ascites, bleeding esophageal varices – due to portal HPN d.) Neurological changes: hepatic encephalopathy

2. Late signs

Hepatic encephalopathy - ammonia (cerebral toxin)
Late signs: Headache and dizziness Fetor hepaticus Confusion Restlessness Hypoactive deep tendon reflexes Decrease LOC Hepatic coma Diagnosis: 1. Liver enzymes- increase SGPT (ALT) SGOT (AST) Serum cholesterol & ammonia increase Indirect or conjugated bilirubin increase CBC - pancytopenia PTT – prolonged bleeding Hepatic ultrasonogram – fat necrosis of liver globules Early signs: asterexis - flapping hand tremors Minor mental changes and motor disturbances hyperactive deep tendon reflexes flaccid

2. 3. 4. 5. 6.

Nursing Mgt 1. CBR 2. Restrict Na! 3. Monitor VS, I&O 4. Weigh pt daily & assess pitting edema 5. Measure abdominal girth daily – notify MD 6. Meticulous skin care 7. Diet – increase CHO, vit & minerals. Moderate fats. Decrease CHON Well balanced diet 8. Complications of liver cirrhosis: a.) Ascites – fluid in peritoneal cavity Nursing Mgt: 1. Meds: Loop diuretics – 10 – 15 min effect or potassium sparing diuretic 2. Assist in abdominal paracentesis - aspiration of fluid - Void before paracentesis to prevent accidental puncture of bladder as trochar is inserted b.) Bleeding esophageal varices - Dilation of esophageal veins 1. Meds: Vit K Pitressin or Vasopressin (IM) 2. NGT decompression- lavage - Give before lavage – ice or cold saline solution - Monitor NGT output 3. Assist in mechanical decompression - Insertion of Sengstaken-Blackemore tube - to decompress veins of esophagus-to prevent esophageal varices - 3 lumen typed catheter - Scissors at bedside to deflate/decompress balloon. Prep scissors when pt complains of DOB c.) Hepatic encephalopathy – 1. Assist in mechanical ventilation – due coma 2. Monitor VS, neuro check 3. Siderails – due restless 4. Meds – Laxatives – to excrete ammonia (Lactulose)

HEPATITIS - jaundice (icteric sclera)
Bilirubin Kernicterus/ hyperbilirubinia Irreversible brain damage

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

INFECTION CONTROL

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

Hepatitis B
Hepatitis B (HBV) is one of the five hepatitis viruses that infect the liver. This virus has a complex structure capable of attacking and destroying liver cells, resulting in illness or disease. Cellular destruction results in architectural changes of the normal structure, of the liver which leads to a disruption in the flow of blood and bile. Illness can range from mild signs and symptoms to chronic disease, such as fatal cirrhosis or liver cancer. BLOOD CARRIER

Pancreas – mixed gland (exocrine & endocrine gland); found behind the stomach PANCREATITIS – acute or chronic inflammation of pancreas leading to pancreatic edema, hemorrhage & necrosis due to auto digestion (self-digestion). Bleeding of pancreas - Cullen’s sign on umbilical area Predisposing factors: 1. Chronic alcoholism 2. Hepatobilary disease 3. Obesity 4. Hyperlipidemia

5. Hyperparathyroidism 6. Drugs – Thiazide diuretics,aspirin, pills, Pentamidine HCL (Pentam) for clients with AIDS, 7. Diet – increase saturated fats S/Sx: 1. Severe Midepigastrium epigastric pain – radiates from back & flank area (left upper quadrant) - 24-48 hrs. Aggravated by heavy meals/eating, accompanied by DOB 2. N/V 3. Tachycardia 4. Palpitation due to pain (abdominal guarding) 5. Dyspepsia /indigestion (rigid board like abdomen) 6. Decrease bowel sounds 7. (+) Cullen’s sign - ecchymosis of umbilicus hemorrhage 8. (+) Grey Turner’s spots – ecchymosis of flank area 9. Hypocalcemia Diagnosis: 1. Serum amylase & lipase – increase 2. Urine lipase – increase 3. Serum Ca – decrease Nursing Mgt: 1. Meds a.) Narcotic analgesic - Meperidine Hcl (Demerol) Don‘t give Morphine SO4 –will cause spasm of the sphincter of ODDI. b.) Smooth muscle relaxant/ anticholinergic - Ex. Papavarine Hcl Prophantheline Bromide (Profanthene) c.) Vasodilator – NTG d.) Antacid – Maalox e.) H2 receptor antagonist - Ranitidin (Zantac) to decrease pancreatic stimulation f.) Ca – gluconate 2. Withold food & fluid – aggravates pain (total NPO) 3. Assist in Total Parenteral Nutrition (TPN) or hyperalimentation Complications of TPN 1. Infection—maintain a strict aseptic technique 2. Pulmonary Embolism—check all connection to system 3. Hyperglycemia 4. Hyperkalemia 4. Institute stress mgt tech a.) DBE b.) Biofeedback 5. Comfy position - Knee chest or fetal lie position 6. If pt can tolerate food, give increase CHO, decrease fats, and moderate CHON 7. Complications: Chronic hemorrhagic pancreatitis, Peritonitis, Septicemia, Shock

GALLBLADDER – storage of bile – made up of cholesterol.

Definition of terms: Biliary
Cholecystitis Cholelithiasis Cholecystectomy Cholecystostomy Choledochotomy Choledocholithiasis Choledocholitholithotomy Choledochoduodenostomy Choledochojejunostomy Lithotripsy Laparoscopic cholecystectomy Laser cholecystectomy Inflammation of the gallbladder The presence of calculi in the gallbladder Removal of the gallbladder Opening and drainage of the gallbladder Opening into the common duct Stones in the common duct Incision of common bile duct for removal of stones Anastomosis of common duct to duodenum Anastomosis of common duct to jejunum Disintegration of gallstones by shock waves Removal of gallbladder through endoscopic procedure Removal of gallbladder using laser rather than scalpel and traditional surgical instruments

CHOLECYSTITIS / CHOLELITHIASIS – inflammation of gallbladder with gallstone formation.
Predisposing factor: 1. High risk – women 40 years old 2. Post menopausal women – undergoing estrogen therapy 3. Obesity 4. Sedentary lifestyle, prolonged immobility 5. Hyperlipidemia 6. Neoplasm 7. Obstruction S/Sx: 1. Severe Right abdominal pain (after eating fatty food). Occurring especially at night = epigastric or right abdominal quadrant after eating a heavy meal 2. Fat intolerance 3. Anorexia, n/v, feeling of fullness 4. Jaundice 5. Pruritus 6. Easy bruising 7. Tea colored urine 8. Steatorrhea Diagnosis: 1. Oral cholecystogram (or gallbladder series) - confirms presence of gall stones 2. Increased indirect bilirubin 3. Increased alkaline phosphatase 4. increased serum and amylase Nursing Mgt: 1. Meds – a.) Narcotic analgesic - Meperdipine Hcl – Demerol b.) Anti cholinergic/Anti-spasmodic - Atropine SO4 c.) Anti emetic Phenergan – Phenothiazide with anti emetic properties d) Broad spectrum antibiotics 2. Diet – increase CHO, moderate CHON, decrease fats 3. Meticulous skin care 4. Surgery: Cholecystectomy Nursing Mgt post cholecystectomy -Maintain patency of T-tube intact & prevent infection

Stomach – widest section of alimentary canal
J shaped structures 1. Anthrum 2. Pylorus 3. Fundus Valves – prevent GERD 1. cardiac sphincter valve 2. Pyloric sphincter valve- stomach and first half of duodenum Cells 1. Chief/ Zymogenic cells – secrets a.) Gastric amylase - digest CHO / sugars b.) Gastric lipase – digest fats c.) Pepsin – CHON d.) Rennin – digests milk products

2. Parietal / Argentaffin / oxyntic cells Function: a.) Produces intrinsic factor – promotes reabsorption of vit B12 cyanocobalamin – promotes maturation of RBC b.) Secrets Hcl acid – aids in digestion 3. Endocrine cells - Secretes gastrin – increase Hcl acid secretion Function of the stomach 1. Mechanical digestion 2. Chem. 3. Storage of food -CHO, CHON- stored 1 -2 hrs. Fats – stored 2 – 3 hrs

BURNS – direct tissue injury caused by thermal, electric, chemical & smoke inhaled (TECS)
Nursing Priority – infection (all kinds of burns) Head burn-priority - Airway nd st nd 2 priority for 1 & 2 burn - pain nd rd 2 priority for 3 burn - Fluid and electrolytes Thermal - direct contact – flames, hot grease, sunburn. Electric, – wires Chemical – direct contact – corrosive materials acids Smoke – gas / fume inhalation Stages: Emergent phase – Removal of pt from cause of burn. Determine source or location of burn Shock phase – 48 - 72 . Characterized by shifting of fluids from intravascular to interstitial space (Hypovolemia) S/Sx: BP decrease Urine output HR increase Hct. increase Serum Na decrease Serum K increase Met acidosis Diuretic/ Fluid remobilization phase - 3 to 5 days. Return of fluid from interstitial to intravascular space Recovery/ convalescent phase – complete diuresis. Wound healing starts immediately after tissue injury. Class: I. Partial Burn 1. 1 degree – superficial burns - Affects epidermis - Cause: thermal burn - Painful - Redness (erythema) & blanching upon pressure with no fluid filled vesicles nd 2. 2 degree – deep burns - Affects epidermis & dermis - Cause –chem. burns - very painful - Erythema & fluid filled vesicles (blisters) II Full thickness Burns 1. Third & 4 degrees burn - Affects all layers of skin, muscles, bones - Cause – electrical - Less painful - Dry, thick, leathery wound surface – known as ESCHAR – devitalized or necrotic tissue. Assessment findings: Rule of nines Head & neck Ant chest Post chest @ Arm 9+9 @ leg 18+18 Genitalia/ perineum Total Nursing Mgt: 1. Meds
th st

= 9% = 18% = 18% = 18% = 18% = 1% 100%

a.) Tetanus toxoid- burn surface area is source of anaerobic growth – Claustridium tetany Tetany Tetanolysin Hemolysis tetanospasmin muscle spasm

b.) Morphine SO4 c.) Systemic antibiotics 1. Ampicillin 2. Cephalosporin 3. Tetracyclin 4. Topical antibiotic: 1. Silver Sulfadiazene (silvadene) 2. Sulfamylon 3. Silver nitrate 4. Povidone iodine (betadine) 2. Administer isotonic fluid sol & CHON replacements 3. Strict aseptic technique 4. Diet – increase CHO, increase CHON, increase Vit C, and increase K- orange 5. If (+) to burns on head, neck, face - Assist in intubation 6. Assist in hydrotherapy 7. Assist in surgical wound debridement. Administer analgesic 15 – 30 minutes before debridement 8. Complications: a.) Infection b.) Shock c.) Paralytic ileus - due to hypovolemia & hypokalemia d.) Curling‘s ulcer – H2 receptor antagonist e.) Septicemia blood poisoning f.) Surgery: skin grafting

GUT – genito-urinary tract
Function: 1. Promote excretion of nitrogenous waste products 2. Maintain F&E & acid base balance 1. Kidneys – pair of bean shaped organ - Located retroperitonially (back of peritoneum) on either side of vertebral column . Encased in Bowmans‘s capsule. Parts: 1. Renal pelvis – Pyelonephritis – inflammation of the renal pelvis 2. Cortex 3. Medulla Nephrons – basic living unit of the kidneys consisting of glomerulus Glomerulus – filters blood going to kidneys

Function of kidneys: 1. Urine formation 2. Regulation of BP Urine formation – 25% of total CO (Cardiac Output) is received by kidneys (3,000-6,000 ml.) 125ml/ min filtered by the glomerulus > Glomerular filtration rate 1. Filtration 2. Tubular Reabsorption—124ml of ultra filtered are reabsorbed in the blood 3. Tubular Secretion- 1 ml is excreted in the urine Filtration – Normal GFR/ min is 125 ml of blood Tubular reabsorption – 124ml of ultra infiltrates (H2O & electrolytes is for reabsorption) Tubular secretion – 1 ml is excreted in urine Causes of CRF: 1. HPN 2. DM Regulation of BP: Predisposing factor: Ex CS – Hypovolemia – decrease BP going to kidneys Activation of RAAS

Causes of Transient Incontinence: DIAPPERS Delirium Infection of urinary tract Atrophic vaginitis, urethritis Pharmacologic agents (anticholinergic) Psychological factors (depression, regression) Excessive urine production (DI, diabetic keto, inc. intake) Restricted activity Stool imfaction

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

Urethra – extends to external surface of body. Passage of urine, seminal & vaginal fluids. - Women 3 – 5 cm or 1 to 1 ½ ― - Male – 20cm or 8‖

UTI
CYSTITIS – inflammation of bladder
Predisposing factors: 1. Microbial invasion – E. coli 2. High risk – women 3. Obstruction 4. Urinary retention 5. Increase estrogen levels 6. Sexual intercourse In the older adult, the most S/Sx: common signs & symptoms of 1. Pain – flank area 2. Urinary frequency & urgency cystitis or UTI: 1. Fatigue. 3. Burning upon urination 2. Change in cognitive status. 4. Dysuria & hematuria 5. Fever, chills, anorexia, gen body malaise 6. Nocturia

Diagnosis: Urine culture & sensitivity - 80% of the cases are (+) to E. coli Nursing Mgt: 1. Force fluid – 2000 ml= to prevent bacterial multiplication 2. Warm sitz bath – to promote comfort 3. Monitor & assess for gross hematuria 4. Monitor and assess urine for color, odor, and bleeding N pH: 4.8 5. Acid ash diet – cranberry, vit C -OJ to acidify urine & prevent bacterial multiplication 6. Meds: systemic antibiotics Ampicillin Cephalosporin Sulfonamides – cotrimoxazole (Bactrim) - Gantrism (ganthanol) Aminoglycosides: Gentamycin Urinary antiseptics – Nitrofurantoin (Macrodantin) Urinary analgesic- Pyridum 7. Ht a.) Importance of Hydration b.) Void after sex (male and female) c.) Female – avoids cleaning back & front Bubble bath, Tissue paper, Powder, perfume d.) Complications: Pyelonephritis

PYELONEPHRITIS – acute/ chronic inflammation of 1 or 2 renal pelvis of kidneys leading to tubular destruction,
interstitial abscess formation. - Lead to Renal Failure Predisposing factor: 1. Microbial invasion (Bacterial) a.) E. Coli b.) Streptococcus 2. Urinary retention /obstruction 3. Pregnancy 4. DM 5. Exposure to renal toxins or nephrotoxic agents S/Sx: Acute pyelonephritis a.) Costovertibral angle pain, tenderness b.) Fever, anorexia, gen body malaise c.) Urinary frequency, urgency d.) Nocturia, dysuria, hematuria e.) Burning upon urination f.) FLANK PAIN g.) Enlarged kidney Chronic Pyelonephritis a.) Fatigue, wt loss, weakness b.) Polyuria, polydypsia c.) HPN Diagnosis: 1. Urine culture & sensitivity – (+) E. coli & streptococcus 2. Urinalysis (+) WBC, (+)RBC, (+) Pus cells 3. Cystoscopic exam – urinary obstruction Nursing Mgt: 1. Provide CBR – especially during acute phase 2. Force fluid 3. Acid ash diet 4. Provide a warm sitz bath for comfort 5. Meds: a.) Urinary antiseptic – nitrofurantoin (macrodantin) SE: peripheral neuropathy GI irritation Hemolytic anemia Staining of teeth b.) Urinary analgesic – Pyridium 6. Complication - Renal Failure

NEPHROLITHIASIS/ UROLITHIASIS- formation of stones at urinary tract
- calcium , milk oxalate, cabbage cranberries nuts tea chocolates uric acid anchovies organ meat nuts sardines

Predisposing factors: 1. Diet – increase Ca & oxalate 2. Hereditary – gout 3. Obesity 4. Sedentary lifestyle 5. Hyperparathyroidism S/Sx: 1. Renal colic 2. Cool moist skin (shock) 3. Burning upon urination 4. Hematuria 5. Anorexia, n/v Diagnosis: 1. IVP – intravenous pyelography. Reveals location of stone 2. KUB – reveals location of stone 3. Cytoscopic exam- urinary obstruction 4. Stone analysis – composition & type of stone 5. Urinalysis – increase EBC, increase CHON 6. X-ray Nursing Mgt: 1. Force fluid 2. Strain urine using gauze pad 3. Warm sitz bath – for comfort 4. Alternate warm compress at flank area 5. a.) Narcotic analgesic- Morphine SO4 b.) Allopurinol (Zyeoprim) c.) Patent IV line d.) Diet – if + Ca stones – acid ash diet If + oxalate stone – alkaline ash diet - (Ex milk/ milk products) If + uric acid stones – decrease organ meat / anchovies sardines 6. Surgery a.) Nephectomy – removal of affected kidney Litholapoxy – removal of 1/3 of stones- Stones will recur. Not advised for pt with big stones b.) Extracorporeal shock wave lithotripsy - Non - invasive - Dissolve stones by shock wave 7. Complications: Renal Failure

BENIGN PROSTATIC HYPERTROPHY - enlarged prostate gland leading to
a.) Hydro ureters – dilation of ureters b.) Hydronephrosis – dilation of renal pelvis c.) Kidney stones Stone formation-- Renal failure d.) Renal failure encircles the neck of the bladder decreased form of urinary stream Cause is unknown

  

Predisposing factor: 1. High risk – 50 years old & above 60 – 70 – (3 to 4 x at risk) Prostate cancer: 40 years old & above 2. Influence of male hormone S/Sx: 1. Decrease force of and amount of urinary stream 2. Dysuria 3. Hematuria 4. Burning upon urination 5. Terminal dribbling—early sign of BPH 6. Backache 7. Sciatica 8. Hesitancy Diagnosis: 1. Digital rectal exam – enlarged prostate gland 2. KUB – urinary obstruction 3. Cystoscopic exam – obstruction 4. Urinalysis – increase WBC, CHON, RBC Nursing Mgt: 1. Prostatic message – promotes evacuation of prostatic fluid 2. Limit fluid intake 3. Provide catheterization 4. Provide a warm sitz bath for comfort 5. Meds: a. Terazozine (hytrin) - Relaxes bladder sphincter, relaxes the smooth muscle of urinary sphincter S/E: HA, hypotension b. Fenasteride (Proscar) - Atrophy of Prostate Gland (given after meals) S/E: N&V, Anorexia

5. Surgery: Prostatectomy – TURP- Transurethral resection of Prostate- No incision Without incision: for debilitated clients -Assist in cystoclysis or continuous bladder irrigation. Complication: 1. Hemorrhage 2. Urinary obstruction 3. Penile dysfunction Nursing mgt: c. Monitor signs and symptoms of infection d. Monitor symptoms gross/ frank bleeding. Normal bleeding within 24h. 3. Maintain irrigation or tube patent to flush out clots - to prevent bladder spasm & distention

ACUTE RENAL FAILURE – sudden immobility of kidneys to excrete nitrogenous waste products & maintain F&E
balance due to a decrease in GFR. (N 125 ml/min) Predisposing factors: Pre renal cause- decrease blood flow Causes: 1. Septic shock 2. Hypovolemia 3. Hypotension 4. CHF 5. Hemorrhage 6. Dehydration (chronic diarrhea)

decrease blood flow to the kidneys

Intra-renal cause – involves renal pathology= kidney problem 1. Acute tubular necrosis 3. HPN 2. Pyelonephritis 4. Acute Glom. Post renal cause – involves mechanical obstruction Causes: 1. Urinary strictures 2. Urolithiasis 3. BPH 4. Presence of tumors Stages: Initiation period begins with the initial insult and ends when oliguria develops. I. OLIGURIC STAGE (1-2 weeks) Increased serum concentration: - involves passage of urine < 400ml/day Urea - S/S: Creatinine a. Hyperkalemia- arrhythmia Uric acid b. Hypernatremia Organic acids c. Hyperphosphatemia Intra cellular cations Potassium d. Hypocalcemia Magnesium e. High BUN 10-20 and creatinine .8-1 f. Metabolic acidosis 1-2wks II. DIURETIC PHASE 2-3 weeks Increased amount of urine a. Hypokalemia b. Hyponatremia c. Metabolic Acidosis d. Increased Creatinine and BUN III. CONVALESCENT/RECOVERY PHASE—3-12 months

CHRONIC RF – irreversible loss of kidney function
Predisposing factors: 1. DM 2. HPN 3. Recurrent UTI/ nephritis/ pyelonephritis 4. Exposure to renal toxins Stages of CRF 1. Diminished Reserve Volume – asymptomatic Normal BUN & Crea, GFR < 10 – 30% 2. Renal Insufficiency 3. End Stage Renal disease

S/Sx:
1.) Urinary System a.) polyuria b.) nocturia c.) hematuria d.) Dysuria e.) oliguria 3.) CNS a.) headache b.) lethargy c.) disorientation d.) restlessness e.) memory impairment 5.) Respiratory a.) Kassmaul’s resp b.) decrease cough reflex c.) crackles 7.) Fluid & Electrolytes a.) hyperkalemia b.) hypernatermia c.) hypermagnesemia d.) hyperposphatemia e.) hypocalcemia f.) met acidosis 2.) Metabolic disturbances a.) azotemia (increase BUN & Crea) b.) hyperglycemia c.) hyperinulinemia

4.) GIT a.) n/v b.) stomatitis c.) uremic breath d.) diarrhea/ constipation 6.) hematological a.) Normocytic anemia bleeding tendencies 8.) Integumentary a.) itchiness/ pruritus b.) uremic frost 9.) Cardiovascular changes a. HPN b. CHF c. Pericarditis

Nursing Mgt: 1. Enforce CBR, reverse isolation 2. Monitor strictly VS, I&O, neurocheck, monitor for signs of hypocalcemia (increased phosphate) 3. Meticulous skin care. Uremic frost – assist in bathing pt 4. Meds: a.) Na HCO3 – due Hyperkalemia b.) Kayexelate enema c.) Anti HPN – Hydralazine (Apresoline) d.) Vit & minerals (Multivitamins) e.) Phosphate binder (Amphogel) Al OH gel - S/E constipation f.) Decrease Ca – Ca gluconate 5. Assist in hemodialysis 1.) Consent/ explain procedure 2.) Weigh patient 3.) Obtain baseline data & monitor VS before and during q30mins, I&O, wt, blood exam 4.) Encourage patient to void 5.) Strict aseptic technique 6.) Monitor for signs of complications: B – bleeding (due to heparin) E – embolism D – disequilibrium syndrome S – septicemia S – shock – decrease in tissue perfusion Disequilibrium syndrome – from rapid removal of urea & nitrogenous waste product leading to: a.) n/v b.) HPN c.) Leg cramps d.) Disorientation e.) Paresthesia 5. Avoid BP taking, blood extraction, IV, at side of shunt or fistula. Can lead to compression of fistula. 6. Maintain patency of shunt by: i. Palpate for thrills & auscultate for bruits if (+) patent shunt! ii. Bedside- bulldog clip If with accidental removal of fistula to prevent embolism. Infersole (diastole) – common dialisate used 7. Complication - Peritonitis (most feared) - Shock Inflow time: 10-20mins Indwelling time: 30-45 mins 8. Assist in surgery: Renal transplantation: Complication – rejection (feared complication). Reverse isolation Rejection time in acute—6mos to 1 year Rejection time in chronic—5-10 years

EYES
External parts 1. Orbital cavity – made up of connective tissue protects eye form trauma. 2. EOM – extrinsic ocular muscles – involuntary muscles of eye needed for gazing movement. 3. Eyelashes/ eyebrows – esthetic purposes 4. Eyelids – palpebral fissure – opening upper & lower lid. Protects eye from direct sunlight Meibomean gland – secrets a lubricating fluid inside eyelid b.) Stye/ sty or Hordeolum- inflamed Meibomean gland 5. Conjunctiva 6. Lacrimal apparatus – tears Process of grieving a. b. c. d. e. Denial Anger Bargaining Depression Acceptance

Intrinsic coat I. sclerotic coat – outer most a.) Sclera – white. Occupies ¾ post of eye. Refracts light rays b.) Canal of schlera – site of aqueous humor drainage c.) Cornea – transparent structure of eye II. Uveal tract – nutritive care Uveitis – infl of uveal tract Consist of: a.) Iris – colored muscular ring of eye 2 muscles of iris: 1. Circular smooth muscle fiber - Constricts the pupil 2.radial smooth muscle fiber - Dilates the pupil 2 chambers of the eye 1. Anterior a.) Vitreous Humor – maintains spherical shape of the eye b.) Aqueous Humor – maintains intrinsic ocular pressure Normal IOP= 12-21 mmHg

II. Retina (innermost layer) i. Optic discs or blind spot – nerve fibers only No auto receptors cones (daylight/ colored vision) phototopic vision rods – night twilight vision ―scotopic vision‖ = vit A deficiency – rods insufficient

ii. Maculla lutea – yellow spot center of retina iii. Fovea centralis – area with highest visual acuity or acute vision Physiology of vision 4 Physiological processes for vision to occur: 1. Refraction of light rays – bending of light rays 2. Accommodation of lens 3. Constriction & dilation of pupils 4. Convergence of eyes Unit of measurements of refraction – diopters Normal eye refraction – emmetropia ERROR of refraction 1. Myopia – near sightedness – Treatment: biconcave lens 2. Hyperopia/ or farsightedness – Treatment: biconvex lens 3. Astigmatisim – distorted vision – Treatment: cylindrical 4. Presbyopia – ―old slight‖ – inelasticity of lens due to aging – Treatment: bifocal lens or double vista Accommodation of lenses – based on Helmholtz theory of accommodation Near vision = Ciliary muscle contracts= Lens bulges Convergence of the eye: Error: 1. Exotropia – 1 eye n. 2. Esophoria – 3. Strabismus- squint 4. Amblyopia – prolong squinting far vision= ciliary muscle dilates / relaxes= lens is flat

corrected by corrective eye surgery

GLAUCOMA – increase IOP – if untreated, atrophy of optic nerve disc – blindness
Predisposing factors: 1. High risk group – 40 & above (nearsightedness) 2. HPN 3. DM 4. Hereditary 5. Obesity 6. Recent eye trauma, infl, surgery Type: 1. Chronic – (open angle G.) – most common type Obstruct in flow of aqueous humor at trabecular meshwork of canal of schlema 2. Acute (close angle G.) – Most dangerous type Forward displacement of iris to cornea leading to blindness. 3. Chronic (closed – angle) - Precipitated by acute attack S/Sx: 1. 2. 3. 4. 5. 6. 7. Loss of peripheral vision – tunnel vision Halos around lights Headache n/v Steamy cornea Eye discomfort If untreated – gradual loss of central vision – blindness

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

Nursing mgt: 1. Enforce CBR 2. Maintain siderails 3. Administer meds a.) Miotics – lifetime - contracts ciliary muscles & constricts pupil. Ex Pilocarpine Na (Carbachol) b.) Epinephrine eye drops – decrease secretion of aqueous humor c.) Carbonic anhydrase inhibitors. Ex. Acetazolamide (Diamox) - Promotes increase out flow of aquaeous humor d.) Temoptics (Timolol maleate)- Increase outflow of aquaous humor 4. Surgery: Invasive: a.) Trabeculectomy – eyetrephining – removal of trabelar meshwork of canal or schlera to drain aqueous humor b.) Peripheral Iridectomy – portion of iris is excised to drain aqueous humor Non-invasive: Trabeculoctomy (eye laser surgery)

Nursing Mgt pre op- all types surgery 1. Apply eye patch on unaffected eye to force weaker eye to become stronger. Nursing Mgt post op – all types of surgery 1. Position unaffected/ unoperated side - to prevent tension on suture line. 2. Avoid valsalva maneuver 3. Monitor for symptoms of IOP a.) Headache b.) n/v c.) Eye discomfort d.) Tachycardia 4. Eye patch – both eyes - post op

CATARACT – partial/ complete opacity of lens
Predisposing factor: 1. 90-95% - aging (degenerative/ senile cataract) 2. Congenital 3. Prolonged exposure to UV rays 4. DM S/Sx: 1. Loss of central vision - ―Hazy or blurring of vision‖ 2. Painless blurry vision

3. Milky white appearance at center of pupil 4. Decrease perception of colors 5. Diplopia Diagnosis: Nsg Mgt: 1. Reorient pt to environment – due opacity 2. Side rails 3. Meds: a.) Mydriatics – dilate pupil – not lifetime (SNS) Ex. Mydriacyl c.) Cyslopegics – paralyzes ciliary muscle. Ex. Cyclogye 4. Surgery E – extra C - capsular C – cataract L - lens E – extraction I - intra C - capsular C – cataract L - lens E – extraction Nursing Mgt: 1. Position unaffected/ unoperated side - to prevent tension on suture line. 2. Avoid valsalva maneuver 3. Monitor symptoms of IOP a.) Headache b.) n/v c.) Eye discomfort d.) Tachycardia 4. Eye patch – both eyes - post op Opthalmoscopic exam – (+) opacity of lens

partial removal of lens

total removal of lens & surrounding capsules

RETINAL DETACHMENT- separation of 2 layers of retina
Predisposing factors: 1. Severe myopia – nearsightedness 2. Diabetic Retinopathy 3. Trauma 4. Following lens extraction 5. HPN S/Sx: 1. 2. 3. 4. 5. 6. ―Curtain –veil‖ like vision Flashes of lights Floaters Gradual decrease in central vision Headache Cobwebs

Diagnosis: ophthalmoscopic exam Nursing Mgt: 1. Side rails (all visual disease) 2. Surgery: a.) Cryosurgery – cold application (Diathermy – heat application) b.) Scleral buckling

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

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

Disorders of outer ear
Entry of insects – put flashlight to give route of exit Foreign objects – beans (bring to MD) H2O - drain 2. Middle ear a.) Ear osssicle 1. Hammer -malleus 2. Anvil -Incus 3. Stirrups -stapes for bone conduction disorder conductive hearing loss

b. Eustachian tube - Opens to allow equalization of pressure on both ears - Yawn, chew, and swallow Children – straight, wide, short c.) Otitis media Adult – long, narrow & slanted c. Muscles 1. Stapedius 2. Tensor tympani 3. Inner ear a. Bony labyrinth – for balance, vestibule Utricle & succule Otolithe or ear stone – has Ca carbonate Movement of head = Righting reflex = Kinesthesia b. Membranous Labyrinth 1. Cochlea – ( function for hearing) has organ of corti 2. Endolymph & perilymph – for static equilibrium 3. Mastoid air cells – air filled spaces in temporal bone in skull Complications of Mastoditis – meningitis Types of hearing loss: 1. Conductive hearing loss – transmission hearing loss Causes: a.) Impacted cerumen – tinnitus & conduction hearing loss- assist in ear irrigation b.) Immobility of stapes – OTOSCLEROSIS d.) Middle ear disease char by formation of spongy bone in the inner ear causing fixation or immobility of stapes e.) Stapes can‘t transmit sound waves Surgery Stapedectomy – removal of stapes, spongy bone & implantation of graft/ ear prosthesis Predisposing factor: 1. Familiar tendency 2. Ear trauma & surgery S/Sx: 1. Tinnitus 2. Conductive hearing loss

Diagnosis: 1. Audiometry – various sound stimulates (+) conductive hearing loss 2. Weber‘s test – Normal AC> BC result BC > AC Stapedectomy Nursing Mgt post op 1. Position pt unaffected side 2. DBE No coughing & blowing of nose - Night lead to removal of graft 3. Meds: a.) Analgesic b.) Antiemetic c.) Antimotion sickness agent. Ex. meclesine Hcl (Bonamine) 4. Assess – motor function – facial nerve - (Smile, frown, raise eyebrow) 5. Avoid shampoo hair for 1 to 2 weeks. Use shower cap

SENSORY NEURAL HEARING LOSS/ NERVE DEAFNESS Cause: 1. Tumor on cocheal 2. Loud noises (gun shot) 3. Presbycusis – bilateral progressive hearing loss especially at high frequencies – elderly Face elderly to promote lip reading 4. Meniere’s disease – endolymphatic hydrops f.) Inner ear disease char by dilation of endolympathic system leading to increase volume of endolin Predisposing factor of MENIERE’S DISEASE  Smoking  Hyperlipidemia  30 years old  Obesity – (+) chosesteatoma  Allergy  Ear trauma & infection S/Sx: 1. TRIAD symptoms of Meniere’s disease a.) Tinnitus b.) Vertigo c.) Sensory neural hearing loss 2. Nystagmus 3. n/v 4. Mild apprehension, anxiety 5. Tachycardia 6. Palpitations 7. Diaphoresis Diagnosis: 1. Audiometry – (+) sensory hearing loss 1. 2. 3. 4. Nursing mgt: Comfy & darkened environment Siderails Emetic basin Meds: a.) Diuretics –to remove endolymph b.) Vasodilator c.) Antihistamine d.) Antiemetic e.) Antimotion sickness agent f.) Sedatives/ tranquilizers Restrict Na Limit fluid intake Avoid smoking Surgery – endolymphatic sac decompression - Shunt

5. 6. 7. 8.

OTITIS MEDIA – Inflammation of the middle ear. (last less than 6 wks)
Sign and symptoms: Pain Temporary hearing loss Tugging at the affected ear Difficulty sleeping Draining fluid / pus Frequent pulling of the ear (children) Fever Nursing management: Usually self limiting and resolved spontaneously Antibiotic Drainage (lean on the affected side to facilitate drainage) Complication:    

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

OTHER MNEMONICS

IV NOTES
Clindamycin, KCl===NOT for IV push—it may cause arrhythmia Chloramphenicol===NOT for IM Procaine, Penicillin, Benzatine, Pen G, Vancomycin HCl, Acyclovir (Zovirax) ===NOT for IV Opened bottles must be used in 8 hours HepLock- flush with NSS KCl < 80meq/L Epinephrine 1:10,000 Lidocaine- 4 mg /ml (1g/250ml) COMPATIBLE WITH PNSS ONLY o Phenytoin o Vit K o Vit B6 o Vit C o Hydralazine o Furosemide COMPATIBLE WITH D5W ONLY o Epinephrine o Norepinephrine o Ephedrine o Dopamine o Dobutamine o Nitroprusside o NaHCO3 Not to be diluted in LR Penicillin G Ampicillin Cephalosporin NaHCO3 PRBC—to be infused within 2-4hours FFP—1-1. 5 hours Platelet concentrates—infuses immediately and quickly

Autoimmune diseases

Apparatus needed at bedside Acetaminophen toxicityAcetylcisteine Myasthenia Gravis Hemodyalisis Senkstaken tube Guillain Barre Syndrome Convulsion- suction apparatus Hyperthyroidism Goiter Hypoparathyroidism Prepare suction apparatusacetylcysteine causes outpouring of secretions tracheostomy set. For respiratory arrest bulldog clip scissors to deflate balloon tracheostomy set. For respiratory arrest Increased secretions tracheostomy set. For laryngeal spasm post subtotal thyroidectomy complication tracheostomy set. For laryngeal spasm post subtotal thyroidectomy complication tracheostomy set. For laryngeal spasm

Multiple Sclerosis Hypothyroidism Acute Glomerulonephritis Myasthenia Gravis Hyperthyroidism GBS Pernicious Anemia

NEURO TRANSMITTER Acethylcholine Dopamine

DECREASE Myasthenia Gravis / Alzheimer Parkinson’s Disease

INCREASE Bi-polar Disorder Schizophrenia

Jerome Adorable, RN 2010

PATHOGNOMONIC SIGNS
1. PTB 2. PNEUMONIA 3. ASTHMA 4. EMPHYSEMA 5. KAWASAKI DISEASE 6. PERNICIOUS ANEMIA 7. DOWN SYNDROME 8. CHOLERA 9. MALARIA 10. TYPHOID 11. DIPTHERIA 12. MEASLES 13. SLE 14. LIVER CIRRHOSIS 15. LEPROSY 16. BULIMIA NERVOSA 17. APPENDICITIS. 18. DENGUE 19. MENINGITIS 20. TETANY 21. TETANUS 22. PANCREATITIS 23. PYLORIC STENOSIS 24. PDA 25. ADDISON’S DISEASE 26. CUSHING’S SYNDROME 27. HYPERTHYROIDISM/GRAVE’S DISEASE 28. INTUSSUSCEPTION 29. PARKINSON’S DISEASE 30. HEPATITIS 31. THROMBOPHEBITIS 32. CATARACT 33. GLAUCOMA 34. RETINAL DETACHMENT 35. CHOLECYSTITIS 36. ANGINA PECTORIS 37. MYASTHENIA GRAVIS 38. TETRALOGY OF FALLOT Low-grade afternoon fever. Rusty sputum. Wheezing on expiration. Barrel chest. Strawberry tongue. Red beefy tongue. Protruding tongue / semian crease on palm Rice watery stool. Stepladder like fever and chills. Rose spots in abdomen. pseudo membrane formation (pharynx, tonsils, nasal) Koplik’s spots. Butterfly rashes. spider angioma, due to esophageal varices lioning face Chipmunk face. Parotid gland swelling rebound tenderness petechiae or (+) Herman’s sign Kernig’s sign (leg pain), Brudzinski sign (neck pain). HYPOCALCEMIA (+) Trousseau’s sign/carpopedal spasm; Chvostek sign (facial spasm). risus sardonicus. Cullen’s sign (ecchymosis of umbilicus); (+) Grey turners spots. olive SHAPE mass on the abdomen machine like murmur Bronze like skin pigmentation. Moon face appearance and buffalo hump. Exopthalmus sausage shaped mass Pill rolling tremors Jaundice Homan’s sign Hazy vision / loss of central vision Tunnel vision / loss of peripheral vision Curtain veil-like vision / flashes and floaters Murphy’s sign (pain on deep inspiration, a inflammation of the gallbladder Levine’s sign [hand clutching in the chest] Ptosis [drooping of the upper eyelid] Clubbing of fingers

Jerome Adorable, RN 2010

GASTRIC ULCER SITE Antrum or lesser curvature - 30 min – 1 hr after eating - epigastrium - gaseous & burning - not usually relieved by food & antacid - Eating leads to pain Normal gastric acid secretion common hematemesis Wt loss a. stomach cancer b. hemorrhage 50 or 60 years old and above Male; female = 1:1 15% of peptic ulcers are gastric

DUODENAL ULCER Duodenal bulb - 2-3 hrs after eating - mid epigastrium - cramping & burning pain - usually relieved by food & antacid - 12 MN – 3am pain - Eating lessens pain Increased gastric acid secretion Not common Melena Wt gain a. perforation 20 years old and above Male: Female = 2-3:1 80% of peptic ulcers are duodenal

PAIN HYPERSECRETION VOMITING HEMORRHAGE WT COMPLICATIONS HIGH RISK INCIDENCE

ATHEROSCLEROSIS - narrowing of artery - lipid or fat deposits (plaques) - tunica intima

ARTERIOSCLEROSIS - hardening of artery, thicken - calcium and protein deposits - tunica media

THE 5 MOST COMMON DRUG GIVEN IN BOARD EXAM: D.L.A.D.A MAJIC 2’s DRUG Digoxin/ Lanoxin (Increase force of cardiac output) Lithium/ Lithane (Decrease level of Ach/NE/Serotonin) Aminophylline (Dilates bronchial tree) Dilantin/ Phenytoin Acetaminophen/Tylenol NORMAL RANGE .5 – 1.5 meq/L .6 – 1.2 meq/L 10 – 19 mg/100 ml 10 – 19 mg/100 ml 10 – 30 mg/100 ml TOXICITY LEVEL 2 2 20 20 200 INDICATION CHF Bipolar COPD Seizures Osteoarthritis CLASSIFICATION Cardiac Glycoside Anti-Manic Agents Bronchodilators Anti-Convulsant Non-narcotic Analgesic

PITUITARY SECRETIONS Anterior pituitary Posterior pituitary

ADH OXYTOCIN

GH ACTH TSH FSH & LH PROLACTIN MSH

JESUS EVERY TIME I SAY JESUS I wish to offer to GOD the infinite merits of Jesus Christ, His passion and death, with all the masses being said all over the world for: (a) The glory of GOD, (b) my own intentions, (c) the peace of the World.
Jerome Adorable, RN 2010 CSLRM

“Happiness is only real, when it shared”

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