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Medical Surgical Nursing Review
Medical Surgical Nursing Review
2.
1. Cerebrum largest -
Cerebellar Tests:
a.) R Rombergs test- needs 2 RNs to assist
- Normal anatomical position 5 10 min
(+) Rombergs test (+) ataxia or unsteady gait or drunken like movement with loss of balance.
b.) Finger to nose test
(+) To FTNT dymetria inability to stop a movement at a desired point
c.) Alternate pronation & supination
Palm up & down . (+) To alternate pronation & supination or damage to cerebellum dymentrium
Composition of brain - based on Monroe Kellie Hypothesis
- Skull is a closed container. Any alteration in 1 of 3 intracranial components = increase in ICP
Normal ICP 0 15 mmHg
Foramen Magnum
C1 atlas
C2 axis
(+) Projectile vomiting = increase ICP
Observe for 24 - 48 hrs
CSF cushions the brain, shock absorber
Obstruction of flow of CSF = increase ICP
Hydrocephalus posteriorly due to closure of posterior fontanel
CVA partial/ total obstruction of blood supply
INCREASED ICP increase ICP is due to increase in 1 of the Intra Cranial components.
Predisposing factors:
1.) Head injury
2.) Tumor
3.) Localized abscess
4.) Hemorrhage (stroke)
5.) Cerebral edema
6.) Hydrocephalus
7.) Inflammatory conditions - Meningitis, encephalitis
B. S&Sx
change in VS = always late symptoms
Earliest Sx:
a.) Change or decrease LOC Restlessness to confusion
Wide pulse pressure: Increased ICP
- Disorientation to lethargy
Narrow pp: Cardiac disorder, shock
- Stupor to coma
Late sign change in V/S
1. BP increase (systolic increase, diastole- same)
2. Widening pulse pressure
Normal adult BP 120/80 120 80 = 40 (normal pulse pressure)
Increase ICP = BP 140/80 = 140 80= 60 PP (wide)
3. RR is decreased (Cheyne-Stokes = bet period of apnea or hyperpnea with periods of apnea)
4. Temp increase
Increased ICP: Increase BP
Shock decrease BP
Decrease HR
Increase HR
CUSHINGS EFFECT
Decrease RR
Increase RR
Increase Temp
Decrease temp
b.) Headache
Projectile vomiting
Papilledima (edema of optic disk outer surface of retina)
Decorticate (abnormal flexion) = Damage to cortico spinal tract /
Decerebrate (abnormal extension) = Damage to upper brain stem-pons/
c.) Uncal herniation unilateral dilation of pupil. (Bilateral dilation of pupil tentorial herniation.)
d.) Possible seizure.
Nursing priority:
1.) Maintain patent a/w & adequate ventilation
a. Prevention of hypoxia (decrease tissue oxygenation) & hypercarbia (increase in CO2 retention).
Hypoxia cerebral edema - increase ICP
Hypoxia inadequate tissue oxygenation
Late symptoms of hypoxia B bradycardia
E extreme restlessness
D dyspnea
C cyanosis
Early symptoms R restlessness
A agitation
T tachycardia
Increase CO2 retention/ hypercarbia cerebral vasodilatation = increase ICP
Most powerful respiratory stimulant increase in CO2
Hyperventilate decrease CO2 excrete CO2
Respiratory Distress Syndrome (RDS) decrease Oxygen
Suctioning 10-15 seconds, max 15 seconds. Suction upon removal of suction cap.
Ambu bag pump upon inspiration
c. Assist in mechanical ventilation
1. Maintain patent a/w
2. Monitor VS & I&O
3. Elevate head of bed 30 45 degrees angle neck in neutral position unless contra indicated to promote venous
drainage
4. Limit fluid intake 1,200 1,500 ml/day
(FORCE FLUID means:Increase fluid intake/day 2,000 3,000 ml/day)- not for inc ICP.
5. Prevent complications of immobility
6. Prevent increase ICP by:
a. Maintain quiet & comfy environment
b. Avoid use of restraints lead to fractures
c. Siderails up
d. Instruct patient to avoid the ff:
-Valsalva maneuver or bearing down, avoid straining of stool
(give laxatives/ stool softener Dulcolax/ Duphalac)
- Excessive cough antitussive
Dextrometorpham
-Excessive vomiting anti emetic (Plasil Phil only)/ Phenergan
- Lifting of heavy objects
- Bending & stooping
e. Avoid clustering of nursing activities
7. Administer meds as ordered:
1.) Osmotic diuretic Mannitol./Osmitrol promotes cerebral diuresis by decompressing brain tissue
Nursing considerations: Mannitol
1. Monitor BP SE of hypotension
2. Monitor I&O every hr. report if < 30cc out put
3. Administer via side drip
4. Regulate fast drip to prevent formation of crystals or precipitate
2.) Loop diuretic - Lasix (Furosemide)
Nursing Mgt: Lasix
Same as Mannitol except
- Lasix is given via IV push (expect urine after 10-15mins) should be in the
morning. If given at 7am. Pt will urinate at 7:15
Immediate effect of Lasix within 15 minutes. Max effect 6 hrs due (7am 1pm)
S/E of Lasix
S&Sx
Weakness & fatigue
Constipation
(+) U wave in ECG tracing
Nursing Mgt:
1.) Administer K supplements ex Kalium Durule, K chloride
Potassium Rich food:
ABCs of K
Vegetables
Fruits
A - asparagus
A apple
B broccoli (highest)
B banana green
C carrots
C cantalope/ melon
O orange (highest) for digitalis toxicity also.
Vit A squash, carrots yellow vegetables & fruits, spinach, chesa
Iron raisins,
Food appropriate for toddler spaghetti! Not milk increase bronchial secretions
Dont give grapes may choke
S/E of Lasix:
1.) Hypokalemia
Hypotension
Signs of Dehydration: dry skin, poor skin turgor, gen body malaise.
Early signs Adult: thirst and agitation / Child: tachycardia
Mgt: force fluid
Administer isotonic fluid sol
4.) Hyperglycemia increase blood sugar level
P polyuria
P polyphagia
P polydipsia
Nsg Mgt:
a. Monitor FBS (N=80 120 mg/dl)
5.) Hyperurecemia increase serum uric acid. Tophi- urate crystals in joint.
Gou
ty arthritis
N range
.5 1.5 meq/L
.6 1.2 meq/L
10 19 mg/100ml
10 -19 mg/100 ml
10 30 mg/100ml
Toxicity
2
2
20
20
200
Classification
cardiac glycosides
antimanic
bronchodilator
anticonvulsant
narcotic analgesic
Indication
CHF
bipolar
COPD
seizures
osteoarthritis
e.
f.
Photophobia
Changes in color perception yellow spots
(Ok to give to pts with renal failure. Digoxin is metabolized in liver not in kidney.)
L lithium (lithane) decrease levels of norepinephrine, serotonine, acetylcholine
a.)
b.)
c.)
d.)
e.)
Antimanic agent
Lithium toxicity
S/Sx Anorexia
n/s
Diarrhea
Dehydration force fluid, maintain Na intake 4 10g daily
Hypothyroidism
(CRETINISM the only endocrine disorder that can lead to mental retardation)
MAOI antidepressant
m AR plan
n AR dil
can lead to CVA or hypertensive crisis
p AR nate
3 4 weeks - before MAOI will take effect
Anti Parkinsonian agents Vit B6 Pyridoxine reverses effect of Levodopa
T tremors, Tachycardia
I irritability
R restlessness
E extreme fatigue
D depression (nightmares) , Diaphoresis
Antidote for acetaminophen toxicity Acetylcesteine = causes outporing of secretions. Suction.
Prepare suctioning apparatus.
Question: The following are symptoms of hypoglycemia except:
a. Nightmares
b. Extreme thirst hyperglycemia symptoms
c. Weakness
d. Diaphoresis
PARKINSONS DSE (parkinsonism) - chronic, progressive disease of CNS char by degeneration of dopamine
producing cells in substancia nigra at mid brain & basal ganglia
- Palliative, Supportive
Function of dopamine: controls gross voluntary motors.
Predisposing Factors:
1. Poisoning (lead & carbon monoxide). Antidote for lead = Calcium EDTA
2. Hypoxia
3. Arteriosclerosis
4. Encephalitis
High doses of the ff:
a. Reserpine (serpasil)
anti HPN, SE 1.) depression - suicidal 2.) breast cancer
b. Methyldopa (aldomet)
- promote safety
c. Haloperidol (Haldol)- anti psychotic
d. Phenothiazide - anti psychotic
SE of anti psychotic drugs Extra Pyramidal Symptom
Over meds of anti psychotic drugs neuroleptic malignant syndrome char by tremors (severe)
S/Sx: Parkinsonism
1. Pill rolling tremors of extremities early sign
2. Bradykinesia slow movement
3. Over fatigue
4. Rigidity (cogwheel type)
a. Stooped posture
b. Shuffling most common
c. Propulsive gait
5. Mask like facial expression with decrease blinking eyes
6. Monotone speech
7. Difficulty rising from sitting position
8. Mood labilety always depressed suicide
Nsg priority: Promote safety
9. Increase salivation drooling type
10. Autonomic signs:
- Increase sweating
- Increase lacrimation
- Seborrhea (increase sebaceous gland)
- Constipation
- Decrease sexual activity
Nsg Mgt
1.) Anti parkinsonian agents
- Levodopa (L-Dopa), Carbidopa (Sinemet), Amantadine Hcl (Symmetrel)
Mechanism of action
Increase levels of dopa relieving tremors & bradykinesia
S/E of anti parkinsonian
- Anorexia
- n/v
- Confusion
- Orthostatic hypotension
- Hallucination
- Arrhythmia
Contraindication:
1. Narrow angled closure glaucoma
2. Pt taking MAOI (Parnate, Marplan, Nardil)
Nsg Mgt when giving anti-parkinsonian
1. Take with meals to decrease GIT irritation
2. Inform pt urine/ stool may be darkened
3. Instruct pt- dont take food Vit B6 (Pyridoxine) cereals, organ meats, green leafy veg
- Cause B6 reverses therapeutic effects of levodopa
Give INH (Isoniazide-Isonicotene acid hydrazide.) SE-Peripheral neuritis.
2.) Anti cholinergic agents relieves tremors
Artane
mech inhibits acetylcholine
Cogentin
action , S/E - SNS
3.) Antihistamine Diphenhydramine Hcl (Benadryl) take at bedtime
S/E: adult drowsiness, avoid driving & operating heavy equipt. Take at bedtime.
Child hyperactivity CNS excitement for kids.
4.) Dopamine agonist
Bromotriptine Hcl (Parlodel) respiratory depression. Monitor RR.
Nsg Mgt Parkinson
1.)
Maintain siderails
2.)
Prevent complications of immobility
- Turn pt every 2h
Turn pt every 1 h elderly
3.)
Assist in passive ROM exercises to prevent contractures
4.)
Maintain good nutrition
CHON in am
CHON in pm to induce sleep due Tryptopan Amino Acid
5.)
Increase fluid in take, high fiber diet to prevent constipation
6.)
Assist in surgery Sterotaxic Thalamotomy
Complications in sterotaxic thalmotomy- 1.) Subarachnoid hemorrhage 2.) aneurism 3.) encephalitis
10
MYASTHENIA GRAVIS (MG) disturbance in transmission of impulses from nerve to muscle cell at neuro muscular
junction.
Common in Women, 20 40 yo, unknown cause or idiopathic
Autoimmune release of cholenesterase enzyme
Cholinesterase destroys ACH (acetylcholine) = Decrease acetylcholine
Descending muscle weakness
(Ascending muscle weakness Guillain Barre Syndrome)
Nsg priority:
1) a/w
2) aspiration
3) immobility
S/ Sx:
11
Cholinergic crisis
Cause: 1 over meds
S/Sx - PNS
12
Constipation
Dx most important: CSF analysis thru lumbar puncture reveals increase in : IgG & CHON (same with MS)
Nsg Mgt
1. Maintain patent a/w & adequate vent
a. Assist in mechanical vent
b. Monitor pulmonary function test
2. Monitor vs., I&O neuro check, ECG tracing due to arrhythmia
3. Siderails
4. Prevent compl immobility
5. Assist in passive ROM exercises
6. Institute NGT feeding due dysphagia
7. Adm meds (GBS) as ordered: 1. Anti cholinergic atropine SO4
2. Corticosteroids to suppress immune response
3. Anti arrhythmic agents
a.) Lidocaine /Xylocaine SE confusion = VTach
b.) Bretyllium
c.) Quinines/Quinidine anti malarial agent. Give with meals.
- Toxic effect cinchonism
Quinidine toxicity
S/E anorexia, n/v, headache, vertigo, visual disturbances
8. Assist in plasmaparesis (MG. GBS)
9. Prevent comp arrhythmias, respiratory arrest
Prepare tracheostomy set at bedside.
INFL CONDITONS OF BRAIN
Meninges 3-fold membrane cover brain & spinal cord
Fx:
Protection & support
Nourishment
Blood supply
3 layers
1. Duramater
sub dural space
2. Arachmoid matter
3. Pia matter
sub arachnoid space
13
Leg pain
neck pain
Dx:
1. Lumbar puncture lumbar/ spinal tap use of hallow spinal needle sub arachnoid space L3 & L4 or L4 & L5
Aspirate CSF for lumbar puncture.
Nsg Mgt for lumbar puncture invasive
1. Consent / explain procedure to pt
- RN dx procedure (lab)
- MD operation procedure
2. Empty bladder, bowel promote comfort
3. Arch back to clearly visualize L3, L4
Nsg Ngt post lumbar
1. Flat on bed 12 24 h to prevent spinal headache & leak of CSF
2. Force fluid
3. Check punctured site for drainage, discoloration & leakage to tissue
4. Assess for movement & sensation of extremeties
Result
1. CSF analysis:
14
Predisposing factor:
1. Thrombosis clot (attached)
2. Embolism dislodged clot pulmo embolism
S/Sx: pulmo embolism
Sudden sharp chest pain
Unexplained dyspnea, SOB
Tachycardia, palpitations, diaphoresis & mild restlessness
S/Sx: cerebral embolism
Headache, disorientation, confusion & decrease in LOC
Femur fracture complications: fat embolism most feared complication w/in 24hrs
Yellow bone marrow produces fat cells at meduallary cavity of long bone
Red bone marrow provides WBC, platelets, RBC found at epiphisis
2.)
3.)
Hemorrhage
Compartment syndrome compression of nerves/ arteries
Risk factors of CVA: HPN, DM, MI, artherosclerosis, valvular heart dse - Post heart surgery mitral valve replacement
Lifestyle:
S & Sx
1. TIA- warning signs of impending stroke attacks
- Headache (initial sx), dizziness/ vertigo, numbness, tinnitus, visual & speech disturbances, paresis or plegia (monoplegia 1
extreme)
Increase ICP
2. Stroke in evolution progression of S & Sx of stroke
3. Complete stroke resolution of stroke
a.) Headache
b.) Cheyne-Stokes Resp
c.) Anorexia, n/v
d.) Dysphagia
15
e.) Increase BP
f.) (+) Kernigs & Brudzinski sx of hemorrhagic stroke
g.) Focal & neurological deficit
1. Phlegia
2. Dysarthria inability to vocalize, articulate words
3. Aphasia
4. Agraphia diff writing
5. Alesia diff reading
6. Homoninous hemianopsia loss of half of field of vision
Left sided hemianopsia approach Right side of pt the unaffected side
Dx
1. CT Scan reveals brain lesion
2. Cerebral arteriography site & extent of mal occlusion
- Invasive procedure due to inject dye
- Allergy test
All graphy invasive due to iodine dye
Post
1.) Force fluid to excrete dye is nephrotoxic
2.) Check peripheral pulses - distal
Nsg Mgt
1. Maintain patent a/w & adequate vent
- Assist mechanical ventilation
- Administer O2
2. Restrict fluids prevent cerebral edema
3. Elevate head of bed 30-45 degrees angle. Avoid valsalva maneuver.
4. Monitor vs., I&O, neuro check
5. Prevent compl of immobility by:
a. Turn client q2h
Elderly q1h
- To prevent decubitus ulcer
- To prevent hypostatic pneumonia after prolonged immobility.
b. Egg crate mattress or H2O bed
c. Sand bag or foot board- prevent foot drop
6. NGT feeding if pt cant swallow
7. Passive ROM exercise q4h
8. Alternative means of communication
- Non-verbal cues
- Magic slate. Not paper and pen. Tiring for pt.
- (+) To hemianopsia approach on unaffected side
9. Meds
Osmotic diuretics Mannitol
Loop diuretics Lasix/ Furosemide
Corticosteroids dextamethazone
Mild analgesic
Thrombolytic/ fibrolitic agents tunaw clot. SE-Urticaria, pruritus-caused by foreign subs.
Streptokinase
Urokinase
Tissue plasminogen activating
Monitor bleeding time
Anticoagulants Heparin & Coumadin sabay
Coumadin will take effect after 3 days
Heparin monitor PTT partial thromboplastin time if prolonged bleeding give Protamine SO4- antidote.
Coumadin Long term. monitor PT prothrombin time if prolonged- bleeding give Vit K Aquamephyton- antidote.
Antiplatelet PASA aspirin paraanemo aspirin, dont give to dengue, ulcer, and unknown headache.
Health Teaching
1. Avoidance modifiable lifestyle
- Diet, smoking
2. Dietary modification
16
CONVULSIVE Disorder (CONVULSIONS)- disorder of the CNS char. by paroxysmal seizures with or without loss of
consciousness, abnormal motor activity, alteration in sensation & perception & change in behavior.
Can you outgrow febrile seizure?
Febrile seizure Normal if < 5 yo
Pathologic if > 5 yo
Difference between:
Predisposing Factor
Head injury due birth trauma
Toxicity of carbon monoxide
Brain tumor
Genetics
Nutritional & metabolic deficit
Physical stress
Sudden withdrawal to anticonvulsants will bring about status epilepticus
Status epilepticus drug of choice: Diazepam & glucose
S & Sx
I. Generalized Seizure
a.) Grand mal / tonic clonic seizures
With or without aura warning symptoms of impending seizure attack- Epigastric pain- associated with
olfactory, tactile, visual, auditory sensory experience
- Epileptic cry fall
- Loss of consciousness 3 5 min
- Tonic clonic contractions
- Direct symmetrical extension of extremities-TONIC. Contractions-CLONIC
- Post ictal sleep -state of lethargy or drowsiness - unresponding sleep after tonic clonic
b.) Petimal seizure (same as daydreaming!) or absent seizure.
- Blank stare
- Decrease blinking eye
- Twitching of mouth
- Loss of consciousness 5 10 secs (quick & short)
II. Localized/partial seizure
a.) Jacksonian seizure or focal seizure tingling/jerky movement of index finger/thumb & spreads to shoulder &
1 sideof the body with janksonian march
b.) Psychomotor/ focal motor - seizure
-Automatism stereotype repetitive & non-purposive behavior
- Clouding of consciousness not in control with environment
- Mild hallucinatory sensory experience
1.
2.
3.
HALLUCINATIONS
Auditory schitzo paranoid type
Visual korsakoffs psychosis chronic alcoholism
Tactile addict substance abuse
III. Status epilecticus continuous, uninterrupted seizure activity, if untreated, lead to hyperprexia coma death
Seizure: inc electrical firing in brain=increased metabolic activity in brain=brain using glucose and O2=dec glucose, dec O2.
Tx:Diazepam (drug of choice), glucose
17
Ginguial hyperplasia
H-hairy tongue
A-ataxia
N-nystagmus
A-acetaminophen- febrile pt
Mix with NSS
- Dont give alcohol lead to CNS depression
b. (Tegretol) Carbamasene- given also to Trigeminal Neuralgia. SE: arrythmia
c. Phenobarbital (Luminal)- SE: hallucinations
2. Institute seizure & safety precaution. Post seizure: Administer O2. Suction apparatus ready at bedside
3. Monitor onset & duration
- Type of seizure
- Duration of post ictal sleep. The longer the duration of post ictal sleep, the higher chance of having status
epilepticus!
4. Assist in surgical procedure. Cortical resection
5. Complications: Subarachnoid hemorrhage and encephalitis
Question: 1 yo grand mal immediate nursing action = a/w & safety
a. Mouthpiece 1 yr old little teeth only
b. Adm o2 inhalation post!
c. Give pillow safety (answer)
d. Prepare suction
Neurological assessment:
1. Comprehensive neuro exam
2. GCS - Glasgow coma scale obj measurement of LOC or quick neuro check
3 components of ECS
M motor
6
V verbal resp 5
E eye opening 4
15
15 14 conscious
13 11 lethargy
10 8 stupor
7 coma
3 deep coma lowest score
Survey of mental status & speech (Comprehensice Neuro Exam)
1.) LOC & test of memory
18
2.)
3.)
4.)
5.)
6.)
7.)
8.)
Levels of orientation
CN assessment
Motor assessment
Sensory assessment
Cerebral test Romhberg, finger to nose
DTR
Autonomics
CN assessment:
I
II
III
IV
V
VI
VII
VIII
IX
X
XI
XII
Olfactory
Optic
Oculomotor
Trocheal
Trigeminal
Abducens
Facial
Acustic/auditory
Glassopharyngeal
Vagus
Spinal accessory
Hypoglossal
s
s
m
m
b
m
smallest CN
largest CN
b
s
b
b
m
longest CN
I. Olfactory dont use ammonia, alcohol, cologne irritating to mucosa use coffee, bar soap, vinegar, cigarette tar
- Hyposmia decrease sensitivity to smell
- Diposmia distorted sense of smell
19
Common Disorders see page 85-87 for more info on glaucoma, etc.
1. Glaucoma Normal 12 21 mmHg pressure
- Increase IOP - Loss of peripheral vision tunnel vision
2. Cataract opacity of lens - Loss of central vision, Blurring or hazy vision
3. Retinal detachment curtain veil like vision & floaters
4. Macular degeneration black spots
III, IV, VI tested simultaneously
- Innervates the movementt of extrinsic ocular muscle
6 cardinal gaze EOM
Rt eye
IO
SO
LR
S
MR E
N
O
left eye
SR
3 4 EOM
IV sup oblique
VI lateral rectus
Normal response PERRLA (isocoria equal pupil)
Anisocoria unequal pupil
Oculomotor
1. Raising of eyelid Ptosis
2. Controls pupil size 2 -3 cm or 1.5 2 mm
V Trigeminal Largest consists of - ophthalmic, maxillary, mandibular
Sensory controls sensation of the face, mucus membrane; teeth & cornea reflex
Unconscious instill drop of saline solution
Motor controls muscles of chewing/ muscles of mastication
Trigeminal neuralgia diff chewing & swallowing extreme food temp is not recommended
Question: Trigeminal neuralgia, RN should give
a. Hot milk, butter, raisins
b. Cereals
c. Gelatin, toast, potato all correct but
d. Potato, salad, gelatin salad easier to chew
20
VI Facial: Sensory controls taste ant 2/3 of tongue test cotton applicator put sugar.
-Put applicator with sugar to tip to tongue.
-Start of taste insensitivity: Age group 40 yrs old
Motor- controls muscles of facial expression, smile frown, raise eyebrow
Damage Bells palsy facial paralysis
Cause bells palsy pedia R/T forcep delivery
Temporary only
Most evident clinical sign of facial symmetry: Nasolabial folds
VIII Acoustic/ vestibule cochlear (controls hearing) controls balance (kenesthesia or position sense)
- Movement & orientation of body in space
- Organ of Corti for hearing true sense organ of hearing
ENDOCRINE
Fx of endocrine ductless gland
Main gland Pituitary gland located at base of brain of Stella Turcica
Master gland of body
Master clock of body
21
Dx Proc:
1. Decrease urine specific gravity- concentrated urine
N= 1.015 1.035
2. Serum Na = increase (N=135 -145 meq/L) Hypernatremia
Mgt:
1.
2.
3.
4.
22
S&Sx
1.
2.
3.
4.
5.
Fluid retention
Increase BP HPN
Edema
Wt gain
Danger of H2O intoxication Complications: 1. cerebral edema increase ICP 2. seizure
Dx Proc:
1. Urine specific gravity increase diluted urine
2. Hyponatremia Decreased Na
Nsg Mgt:
1. Restrict fluid
2. Administer meds as ordered eg. Diuretics: Loop and Osmotic
3. Monitorstrictly V/S, I&O, neuro check increase ICP
4. Weigh daily
5. Assess for presence edema
6. Provide meticulous skin care
7. Prevent complications increase ICP & seizures activity
Anterior Pituitary Gland adeno
1. Growth hormone (GH) (Somatotropic hormone)
Fx: Elongation of long bones
Decrease GH dwarfism children
Increase GH gigantism
Increase GH acromegaly adult
Puberty 9 yo 21 yo
Epiphyseal plate closes at 21 yo
Square face
Square jaw
Drug of choice in acromegaly: Ocreotide (Sandostatin) SE dizziness
Somatostatin Hormone antagonizes the release of of GH
Melanocytes stimulating hormone - MSH
Skin pigmentation
3. Prolactin/luteotrpic hormone/ lactogenic hormone - Promotes development of mammary gland
(Oxytocin-Initiates milk letdown reflex)
4. Adrenocorticotropic hormone ACTH - Development & maturation of adrenal cortex
5. Luteinizing hormone produces progesterone.
6. FSH- produces estrogen
2.
-
PINEAL GLAND
1. Secretes Melatonin inhibits lutenizing hormone (LH) secretion
THYROID GLAND (TG)
Question: Normal physical finding on TG:
a. With tenderness thyroid never tender
b. With nodular consistency- answer
c. Marked asymmetry only 1 TG
d. Palpable upon swallowing - Normal TG never palpable unless with goiter
TG hormones:
T3
- Triodothyronine
T4
-Tetraiodothyronine/ Tyroxine
- 3 molecules of iodine
- 4 molecules of iodine
Thyrocalcitonin
FX antagonizes effects of parathormone
23
Metabolic hormone
Increase metabolism brain inc cerebration, inc v/s
24
Tachycardia, palpitations
Signs of
insomnia
Hyperthyroidism restlessness agitation
Heat intolerance
HPN
4. Assist surgery- Sub total thyroidectomyComplication: 1. Tetany 2. laryngeal nerve damage 3.Hemorrhage-feeling of fullness at incision site.Check nape for
wet blood. 4.Laryngeal spasm DOB, SOB trache set ready at bedside.
2.)
Adult myxedema
Child- cretinism only endocrine dis lead to mental retardation
Predisposing factor:
1. `Iatrogenic causes caused by surgery
2. Atrophy of TG due to:
a. Irradiation
b. Trauma
c. Tumor, inflammation
3. Iodine def
4. Autoimmune Hashimoto disease
S&Sx everything decreased except wt gain & mens increase)
Early signs weakness and fatigue
Loss of appetite increased lypolysis breakdown of fats causing atherosclerosis = MI
Wt gain
Cold intolerance myxedema - coma
Constipation
Late Sx brittle hair/ nails
Non pitting edema due increase accumulation of mucopolysacharide in SQ tissue -Myxedema
Horseness voice
Decrease libido
Decrease VS hypotension bradycardia, bradypnea, and hypothermia
Lethargy
Memory impairment leading to psychosis-forgetfulness
Menorrhagia
Dx:
1.
2.
3.
Serum T3 T4 decrease
Serum cholesterol increase can lead to MI
RA IU radio iodine uptake decrease
Nsg Mgt:
1. Monitor strictly V/S. I&O to determine presence of myxedema coma!
Myxedema Coma - Severe form of hypothyroidism
Hypotension, hypoventilation, bradycardia, bradypnea, hyponatremia, hypoglycemia, hypothermia
Might lead to progressive stupor & coma
Impt mgt for Myxedema coma
1. Assist mech vent priority a/w
2. Adm thyroid hormone
3. Adm IVF replacement force fluid
25
Nsg Mgt:
1. Monitor VS & I & O determine presence of thyroid storm or most feared complication: Thyrotoxicosis
2. Administer meds
a. Antithyroid agents
1. Prophylthiuracil (PTU)
2. Methymazole (Tapazole)
Most toxic s/e agranulocytosis- fever, sore throat, leukocytosis=inc wbc: check cbc and throat swab culture
Most feared complication : Thrombosis stroke CVS
26
3.
4.
5.
6.
7.
8.
27
Hyperphosphatemia
Chronic tetany
a. Loss of tooth enamel
b. Photophobia & cataract formation
c. GIT changes anorexia, n/v, general body malaise
d. CNS changes memory impairment, irritability
Dx:
Nsg Mgt:
1. Administration of meds:
a.) Acute tetany
Ca gluconate IV, slowly
b.) Chronic tetany
1. Oral Ca supplements
Ex. Ca gluconate
28
Ca carbonate
Ca lactate
Vit D (Cholecalceferol)
Drug
Cholecalceferol
diet
sunlight
calcidiol
calcitriol
2. Phosphate binder
Alumminum DH gel (ampho gel)
SE constipation
Antacid
AAC
MAD
Aluminum containing acids
Aluminum OH gel
7am 9am
Mg containing antacids
Ex. Milk or magnesia
Diarrhea
Constipation
Maalox magnesium & aluminum - Less s/e
2. Avoid precipitating stimulus such as bright lights & noise: photophobia leading to seizure
3. Diet increase Ca & decrease phosphorus
- Dont give milk due to increase phosphorus
Good = anchovies increase Ca, decrease phosphorus + inc uric acid. Tuna & green turnips- Inc Ca.
4. Bedside tracheostomy set due to laryngospasm
5. Encourage to breath with paper bag in order to produce mild respiratory acidosis to promote increase ionized Ca levels
6. Most feared complication : Seizure & arrhythmia
7. Hormonal replacement therapy - lifetime
8. Important fallow up care
kidney stones
29
2.
3.
4.
Kidney stone
a. Renal colic
b. Cool moist skin
GIT changes anorexia, n/v, ulcerations
CNS involvement irritability, memory impairment
Dx Proc:
1. Serum Ca increase
2. Serum phosphorus decreases
3. X-ray long bones reveals bone demineralization
Nsg Mgt: Kidney Stone
1.
2.
3.
4.
5.
6.
ADRENAL GLAND
12. Atop of @ kidney
13. 2 parts
Adrenal cortex outermost layer
Adrenal medulla - innermost layer
14. Secrets cathecolamines
a.) Epinephrine / Norephinephrine potent vasoconstrictor adrenaline=Increase BP
Adrenal Medullas only disease:
Adrenal Cortex
1.
2.
30
3.
Nsg Mgt:
1.
31
2.
Administer meds
a.) Corticosteroids - (Decadron) or Dexamethazone
- Hydrocortisone (cortisone)- Prednisone
Nsg Mgt with Steroids
1. Adm 2/3 dose in AM & 1/3 dose in PM in order to mimic the normal diurnal rhythm.
2. Taper the dose (w/draw, gradually from drug) sudden withdrawal can lead to addisonian crisis
3. Monitor S/E (Cushings syndrome S/Sx)
a.) HPN
b.) Hirsutism
c.) Edema
d.) Moon face & buffalo hump
e.) Increase susceptibility to infection sue to steroids- reverse isolation
b.) Mineralocorticoids ex. Flourocortisone
3.
4.
5.
6.
7.
Force fluid
8.
9.
32
4.
5.
6.
7.
Obese trunk
Pendulous abdomen
Thin extremities
Hypokalemia
a. Weakness & fatigue
b. Constipation
c. ECG (+) U wave
Hirsutism increase sex
Acne & striae
Increase muscularity of female
classic signs
Dx:
5.
6.
7.
8.
9.
10.
Restrict Na
Provide Dietary intake low in CHO, low in Na & fats
High in CHON & K
Weigh pt daily & assess presence of edema- measure abdominal girth- notify doc.
Reverse isolation
Skin care due acne & striae
Prevent complication
- Most feared arrhythmia & DM
(Endocrine disorder lead to MI Hypothyroidism & DM)
Surgical bilateral Adrenolectomy
Hormonal replacement therapy lifetime due to adrenal gland removal- no more corticosteroid!
PANCREAS behind the stomach, mixed gland both endocrine and exocrine gland
Acinar cells (exocrine gland)
cells
secrets glucagon
Fxn: hyperglycemia (high glucose)
Cells
Secrets insulin
Fxn: hypoglycemia
Delta Cells
33
Secrets somatostatin
Fxn: antagonizes growth hormone
Overview only:
PANCREATITIS (check page 72) acute inflammation of pancreas leading to pancreatic edema, hemorrhage & necrosis due to
Autodigestion self-digestion
Cause: unknown/idiopathic
18. Or alcoholism
Pathognomonic sign- (+) Cullens sign - Ecchymosis of umbilicus (bluish color)- pasa
(+) Grey turners sign ecchymosis of flank area
Both sx means hemorrhage
DIABETES MELLITUS - metabolic disorder characterized by non utilization of CHO, CHON,& fat metabolism
Classification:
I.
34
6.) Anorexia
7.) N/V
8.) Blurring of vision
9.) Increase susceptibility to infection
10.) Delayed/ poor wound healing
Mgt:
1.
Insulin Therapy
Diet
Exercise
Complications Diabetic Ketoacidosis (DKA)
Diabetic Ketoacidosis (DKA) due to increase fat catabolism or breakdown of fats
DKA (+) fruity or acetone breath odor
Kassmauls respiration rapid, shallow breathing
Diabetic coma (needs oxygen)
II.
Type II DM (NIDDM)
Asymptomatic
3 Ps and 1G
Tx:
Diet
Exercise
Complication: HONKC
H hyper
O osmolar
N non
K ketotic
C coma
III. GESTATIONAL DM occurs during pregnancy & terminates upon delivery of child
Predisposing Factors:
1. Unknown/ idiopathic
2. Influence of maternal hormones
S/Sx :
Same as type II
1. Asymptomatic
2. 3 Ps & 1G
Type of delivery CS due to large baby
Sx of hypoglycemia on infant
1. High pitched shrill cry
35
Catabolism
glycogen
nitrogen
free fatty acids (FFA) Cholesterol & Ketones
polyuria
Cellular dehydration
Polyphagia
Stimulates thirst center (hypothalamus)
Polydipsia
Increased CHON catabolism
Lead to (-) nitrogen balance
Tissue wasting (cachexia)
ketones
Atherosclerosis
HPN
MI
DKA
coma
death
stroke
Acute complication of Type I DM due to severe hyperglycemia leading to CNS depression & Coma.
Ketones- a CNS depressant
Predisposing factor:
36
Hyperglycemia
Infection
S/Sx:
1.
2.
3.
4.
5.
6.
3 Ps & 1G
Polyuria
Polydipsia
Polyphagia
Glycosuria
Wt loss
Anorexia, N/V
7. (+) Acetone breath odor- fruity odor
8. Kussmaul's resp-rapid shallow respiration
9. CNS depression
10. Coma
pathognomonic DKA
Dx Proc:
1. FBS increase, Hct increase (compensate due to dehydration)
N =BUN 10 -20 mg/100ml
--increased due to severe dehydration
Crea - .8 1 mg/100ml
Hct 42% (should be 3x high)-nto hgb
Nsg Mgt:
1. Can lead to coma assist mechanical ventilation
2. Administer .9NaCl isotonic solution
Followed by .45NaCl hypotonic solution
To counteract dehydration.
3. Monitor VS, I&O, blood sugar levels
4. Administer meds as ordered:
a.) Insulin therapy IV push
Regular Acting Insulin clear (2-4hrs, peak action)
b.) To counteract acidosis Na HCO3
c.) Antibiotic to prevent infection
Insulin Therapy
A. Sources:
1. Animal source beef/ pork-rarely used. Causes severe allergic reaction.
2. Human has less antigenecity property
Cause less allergic reaction. Humulin
3.
If kid is allergic to chicken dont give measles vaccine due it comes from chicken embryo.
Artificially compound
B. Types of Insulin
1. Rapid Acting Insulin - Ex. Regular acting I
2. Intermediate acting I - Ex. NPH (non-protamine Hagedorn I)
3. Long acting I - Ex. Ultra lente
Types of Insulin
1. Rapid
2. Intermediate
3. Long acting
onset
-
peak
duration
2-4h
6-12h
12-24h
-
37
- - 1 cc = 100 units
- - .5cc = 50 units
- - .1 cc = 10 units
6 units RA
Most Feared Complication of Type II DM
Hyper
osmolarity = severe dehydration
Osmolar
Non
- absence of lipolysis
Ketotic
- no ketone formation
Coma S/Sx: headache, restlessness, seizure, decrease LOC = coma
Nsg Mgt; - same as DKA except dont give NaHCO3!
1.Can lead to coma assist mechanical ventilation
2. Administer .9NaCl isotonic solution
Followed by .45NaCl hypotonic solution
To counteract dehydration.
3.Monitor VS, I&O, blood sugar levels
4.Administer meds
a.) Insulin therapy IV
b.) Antibiotic to prevent infection
Tx:
O ral
H ypoglycemic
A gents
19. Stimulates pancreas to secrete insulin
Classifications of OHA
1. First generation Sulfonylurear
a. Chlorpropamide (diabenase)
b. Tolbutamide (orinase)
c. Tolazamide (tolinase)
38
=confirms DM!!
Nsg Mgt;
1. Monitor for PEAK action of OHA & insulin
Notify Doc
2. Monitor VS, I&O, neurocheck, blood sugar levels.
3. Administer insulin & OHA therapy as ordered.
4. Monitor signs of hyper & hypoglycemia.
Pt DM hinimatay
20. You dont know if hypo or hyperglycemia.
Give simple sugar
(Brain can tolerate high sugar, but brain cant tolerate low sugar!)
Cold, clammy skin hypo Orange Juice or simple sugar / warm to touch hyper adm insulin
5. Provide nutritional intake of diabetic diet:
CHO 50%
CHON 30%
Fats 20%
-Or offer alternative food products or beverage.
-Glass of orange juice.
6. Exercise after meals when blood glucose is rising.
7. Monitor complications of DM
a. Atherosclerosis HPN, MI, CVA
b. Microangiopathy small blood vessels
Eyes diabetic retinopathy , premature cataract & blindness
Kidneys recurrent pyelonephritis & Renal Failure
(2 common causes of Renal Failure : DM & HPN)
c. Gangrene formation
d. Peripheral neuropathy
1. Diarrhea/ constipation
2. Sexual impotence
e. Shock due to cellular dehydration
8. Foot care mgt
a. Avoid waking barefooted
b. Cut toe nails straight
c. Apply lanolin lotion prevent skin breakdown
d. Avoid wearing constrictive garments
9. Annual eye & kidney exam
10. Monitor urinalysis for presence of ketones
Blood or serum more accurate
11. Assist in surgical wound debridement
12. Monitor signs or DKA & HONKC
13. Assist surgical procedure
39
Formed Elements:
1. RBC (erythrocytes)
Spleen life span = 120 days
(N) 3 6 M/mm3
- Anucleated
- Biconcave discs
- Has molecules of Hgb (red cell pigment)
Transports & carries O2
SICKLE CELL ANEMIA sickle shaped RBC. Should be round. Impaired circulation of RBC.
-immature cells=hemolysis of RBC=decreased hgb
3 Nsg priority
1. a/w avoid deoxygenating activities
- High altitude is bad
2. Fluid deficit promote hydration
3. Pain & comfort
Hgb ( hemoglobin)
F= 12 14 gms %
M = 14-16 gms %
Hct 3x hgb
12 x 3 = 36
(hamatocrit)
F 36 42%
14 x 3 = 42
M 42 48%
Average 42%
- Red cell percentage in whole red
40
NON-GRANULOCYTES
1. Monocytes (macrophage) - largest WBC
- involved in long term phagocytes
- For chronic inflammation
- Other name macrophage
Macrophage in CNS- microglia
Macrophage in skin Histiocytes
Macrophage in lungs alveolar macrophage
Macrophage in Kidneys Kupffer cells
2. Lymphocytes
B Cell L bone marrow or bursa dependent
T cell devt of immunity- target site for HIV
NK cell natural killer cell
Have both antiviral & anti-tumor properties
3.Platelets (thrombocytes)
N- 150,000 450, 000/ mm3
it promotes hemostasis prevention of blood loss by activating clotting
- Consists of immature or baby platelets known as megakaryocytes target of virus
dengue
- Normal lifespan 9 12 days
ANEMIA
Iron deficiency Anemia chronic normocytic, hypocromic (pale), microcytic anemia due to inadequate absorption of iron leading to
hypoxemic injury.
Incidence rate:
1. Common developed country due to high cereal intake
Due to accidents common on adults
2. Common tropical countries blood sucking parasites
3. Women 15 35yo reproductive yrs
4. Common among the poor poor nutritional intake
41
Asymptomatic
Headache, dizziness, dyspnea, palpitations, cold sensitivity, gen body malaise, pallor
Brittle hair, spoon shaped nails (KOILONYCHIA)=Dec O2=hypoxia=atrophy of epidermal cells
Atropic glossitis, dysphagia, stomatitis
Pica abnormal craving for non edible food (caused by hypoxia=dec tissue perfusion=psychotic behavior)
42
1.
2.
Straw
1.
2.
3.
4.
Lugols
Tetracycline
Oral iron
Macrodantine
If pt cant tolerate oral iron prep administer parenteral iron prep example:
1. Iron dextran (IV, IM)
2. Sorbitex (IM)
Nsg Mgt parenteral iron prep
1. Administer of use Z tract method to prevent discomfort, discoloration leakage to tissues.
2. Dont massage injection site. Ambulate to facilitate absorption.
3. Monitor S/E:
a.) Pain at injury site
b.) Localized abscess (nana)
c.) Lymphadenopathy
d.) Fever/ chills
e.) Urticaria itchiness
f.) Hypotension anaphylactic shock
Anaphylactic shock give epinephrine
PERNICIOUS ANEMIA - megaloblastic, chronic anemia due to deficiency of intrinsic factor leading to
Hypochlorhydria decrease Hcl acid secretion. Lifetime B12 injections. With CNS involvement.
Predisposing factor
1. Subtotal gastrectomy removal stomach
2. Hereditary
3. Infl dse of ileum
4. Autoimmune
5. Strict vegetable diet
STOMACH
Parietal or ergentaffen Oxyntic cells
Fxn produce intrinsic factor
Fx aids in digestion
Headache dizziness, dyspnea, palpitations, cold sensitivity, gen body malaise, pallor
43
2.
GIT changes
a. Red beefy tongue PATHOGNOMONIC mouth sores
b. Dyspepsia indigestion
c. Wt loss
d. Jaundice
3. CNS
Most dangerous anemia: pernicious due to neuroglogic involvement.
a. Tingling sensation
b. Paresthesia
c. (+) Rombergs test
Ataxia
d. Psychosis
Dx:- Shillings test
Nsg Mgt Pernicious anemia
1. Enforce CBR
2. Administer B12 injections at monthly intervals for lifetime as ordered. IM- dorsogluteal or ventrogluteal. Not given oral
due pt might have tolerance to drug
3. Diet high calorie or CHO. Increase CHON, iron & Vit C
4. Avoid irritating mouthwashes. Use of soft bristled toothbrush is encouraged.
5. Avoid applying electric heating pads can lead to burns
APLASTIC ANEMIA stem cell disorder due to bone marrow depression leading to pancytopenia all RBC are decreased
Decrease RBC
Anemia
decrease WBC
leukopenia
decrease platelets
thrombocytopenia
44
3.
4.
5.
6.
7.
8.
9.
BLOOD TRANSFUSION:
Objectives:
1. To replace circulating blood volume
2. To increase O2 carrying capacity of blood
3. To combat infection if theres decrease WBC
4. To prevent bleeding if theres platelet deficiency
Nsg Mgt & principles in Blood Transfusion
1. Proper refrigeration
2. Proper typing & crossmatching
Type O universal donor
AB universal recipient
85% of people is RH (+)
3. Asceptically assemble all materials needed:
a.) Filter set
b.) Isotonic or PNSS or .9NaCl to prevent Hemolysis
Hypotonic sol swell or burst
Hypertonic sol will shrink or crenate
c.) Needle gauge 18 - 19 or large bore needle to prevent hemolysis.
d.) Instruct another RN to recheck the following .
Pts name, blood typing & cross typing expiration date, serial number.
e.) Check blood unit for presence of bubbles, cloudiness, dark in color & sediments indicates bacterial contamination.
Dont dispose. Return to blood bank.
f.) Never warm blood products may destroy vital factors in blood.
- Warming is done if with warming device only in EMERGENCY! For multiple BT.
- Within 30 mins room temp only!
g.) Blood transfusion should be completed < 4hrs because blood that is exposed at room temp for > 2h causes blood
deterioration.
h.) Avoid mixing or administering drug at BT line leads to hemolysis
i.) Regulate BT 10 15 gtts/min KVO or 100cc/hr to prevent circulatory overload
j.) Monitor VS before, during & after BT especially q15 mins(local board) for 1st hour. NCLEX-q5min for 1st 15min.
- Majority of BT reaction occurs within 1h.
BT reactions
S/Sx Hemolytic reaction:
H hemolytic Reaction
1. Headache, dizziness, dyspnea, palpitation, lumbar/ sterna/ flank pain,
A allergic Reaction
hypotension, flushed skin , (red) port wine urine.
P pyrogenic Reaction
C circulatory overload
A air embolism
T - thrombocytopenia
C citrate intoxication expired blood =hyperkalemia
H hyperkalemia
Nsg Mgt: Hemolytic Reaction:
1. Stop BT
45
2.
3.
4.
5.
6.
7.
Notify Doc
Flush with plain NSS
Administer isotonic fluid sol to prevent acute tubular necrosis & conteract shock
Send blood unit to blood bank for reexamination
Obtain urine & blood samples of pt & send to lab for reexamination
Monitor VS & Allergic Rxn
Allergic Reaction:
S/Sx
1.
2.
3.
4.
5.
Fever/ chills
Urticaria/ pruritus
Dyspnea
Laryngospasm/ bronchospasm
Bronchial wheezing
Nsg Mgt:
1. Stop BT
2. Notify Doc
3. Flush with PNSS
4. Administer antihistamine diphenhydramine Hcl (Benadryl). Give bedtime.SE-Adult-drowsiness. Child-hyperactive
If (+) Hypotension anaphylactic shock administer epinephrine
5. Send blood unit to blood bank
6. Obtain urine & blood samples send to lab
7. Monitor VS & IO
8. Adm. Antihistamine as ordered for AllergicRxn, if (+) to hypotension indicates anaphylactic shock
24. administer epinephrine
9. Adm antipyretic & antibiotic for pyrogenic Rxn & TSB
Pyrogenic Reaction:
S/Sx
d. tachycardia
e. palpitations
f. diaphoresis
Nsg Mgt:
1.
2.
3.
4.
5.
6.
7.
8.
Stop BT
Notify Doc
Flush with PNSS
Administer antipyretics, antibiotics
Send blood unit to blood bank
Obtain urine & blood samples send to lab
Monitor VS & IO
Tepid sponge bath offer hypothermic blanket
Circulatory Overload:
Sx
a.
b.
c.
d.
Dyspnea
Orthopnea
Rales or crackles
Exertional discomfort
Nsg Mgt:
1. Stop BT
2. Notify Doc. Dont flush due pt has circulatory overload.
3. Administer diuretics
Priority cases:
Hemolytic Rxn 1st due to hypotension 1st priority attend to destruction of Hgb O2 brain damage
46
Allergic
Pyrogenic
Circulatory
3rd
4th
2nd
Hemolytic
Anaphylitic
2nd
1st priority
25. Acute hemorrhagic syndrome char by wide spread bleeding & thrombosis due to a def of clotting factors (Prothrombin &
Fibrinogen).
Predisposing factor:
1. Rapid BT
2. Massive trauma
3. Massive burns
4. Septicemia
5. Hemolytic reaction
6. Anaphylaxis
7. Neoplasia growth of new tissue
8. Pregnancy
S/Sx
1.
2.
3.
4.
5.
6.
Dx Proc
1. CBC reveals decrease platelets
2. Stool for occult blood (+)
Specimen stool
3. Opthalmoscopic exam sub retinal hemorrhage
4. ABG analysis metabolic acidosis
pH
pH
HCO3
PCO2
respiratory alkalosis
ph
PCO2
respiratory acidosis
ph
HCO3
metabolic alkalosis
ph
HCO3
metabolic acidosis
2.
3.
4.
47
a.
Vit K aquamephyton
NGT lavage
- Use iced saline lavage
6. Monitor NGT output
7. Provide heplock
8. Prevent complication: hypovolemic shock
Late signs of hypovolemic shock : anuria
Oncologic Nsg:
Oncology study of neoplasia new growth
Benign (tumor)
Malignancy (cancer)
Diff
- well differentiated
Encapulation (+)
Metastasis (-)
Prognosis good
Therapeutic modality surgery
poorly or undifferentiated
(-)
(+)
poor
1. Chemotherapy plenty S/E
2. Radiation
3. Surgery
most preferred treatment
4. Bone marrow transplant - Leukemia only
48
1. Chemotherapy use various chemotherapeutic agents that kills cancer cells & kills normal rapidly producing cells GIT,
bone marrow, and hair follicle.
Classification:
a.) Alkylating agents
b.) Plant alkaloids vincristine
c.) Anti metabolites nitrogen mustard
d.) Hormones DES
Steroids
e.) Antineoplastic antibiotics
S/E & mgt
GIT - -Nausea & vomiting
Nsg Mgt:
1. Administer anti emetic 4 6h before start of chemo
Plasil
2. Withhold food/ fluid before start of chemo
3. Provide bland diet post chemo
26. Non irritating / non spicy
- Diarrhea
1. Administer anti diarrheal 4 6h before start of chemo
2. Monitor urine, I&O qh
- Stomatitis/ mouth sores
1. Oral care offer ice chips/ popsickles
2. Inform pt hair loss temporary alopecia
Hair will grow back after 4 6 months post chemo.
-Bone marrow depression anemia
1. Enforce CBR
2. O2 inhalation
3. Reverse isolation
4. Monitor signs of bleeding
Repro organ sterility
1. Do sperm banking before start of chemo
Renal system increase uric acid
1. Administer allopurinol/ xyloprin (gout)
27. Inhibits uric acid
28. Acute gout colchicines
29. Increase secretion of uric acid
Neurological changes peristalsis paralytic ileus
Most feared complication ff any abdominal surgery
Vincristine plant alkaloid causes peripheral neuropathy
2. Radiation therapy involves use of ionizing radiation that kills cancer cells & inhibit their growth & kill N rapidly producing
cells.
Types of energy emitted
1. Alpha rays rarely used doesnt penetrate skin tissues
2. Beta rays internal radiation more penetration
3. Gamma ray external radiation penetrates deeper underlying tissues
49
Methods of delivery
1. External radiation- involves electro magnetic waves
Ex. cobalt therapy
2. Internal radiation injection/ implantation of radioisotopes proximal to CA site for a specific period of time.
2 types:
a.) Sealed implant radioisotope with a container & doesnt contaminate body fluid.
b.) Unsealed implant radioisotope without a container & contaminates body fluid.
Ex. Phosphorus 32
3 Factors affecting exposure:
A.) Half life time period required for half of radioisotopes to decay.
- At end of half life less exposure
B.) Distance the farther the distance lesser exposure
C. ) Time the shorter the time, the lesser exposure
D.) Shielding rays can be shielded or blocked by using rubber gloves & gamma use thick lead on concrete.
S/E & Mgt:
a.) Skin errythema, redness, sloughing
1. Assist in battling pt
2. Force fluid 2,000 3,000 ml/day
3. Avoid lotion or talcum powder skin irritation
4. Apply cornstarch or olive oil
b.) GIT nausea / vomiting 1. Administer antiemetic 4 6h before start of chemo - Plasil
2 Withhold food/ fluid before start of chemo
3. Provide bland diet post chemo
Non irritating / non spicy
Dysglusia decrease taste sensitivity
-When atrophy papilla (taste buds) 40 yo
Stomatitis
c.) Bone marrow depression
1. Enforce CBR
2. O2 inhalation
3. Reverse isolation
4. Monitor signs of bleeding
Pericardial
Fluid prevent
Friction rub
Visceral layer
Layer
1. Epicardium outermost
2. Myocardium inner responsible for pumping action/ most dangerous layer - cardiogenic shock
3. Endocardium innermost layer
Chambers
1. Upper collecting/ receiving chamber - Atria
2. Lower pumping/ contracting chamber - Ventricles
Valves
1. Atrioventricular valves - Tricuspid & mitral valve
50
AV
Purkenjie Fibers
Bundle of His
Complete heart block insertion of pacemaker at Bundle Branch
Metal Pace Maker change q3 5 yo
Prolonged PR atrial fib
ST segment depression angina
ST elev MI
T wave inversion MI
widening QRS arrhythmia
ARTEROSCLEROSIS
- Narrowing or artery due to calcium & CHON deposits at tunica
media.
51
3. Hyperlipidemia
4. Smoking
5. HPN
6. DM
7. Oral contraceptive- prolonged use
8. Sedentary lifestyle
9. Obesity
10. Hypothyroidism
Signs & Symptoms
1. Chest pain
2. Dyspnea
3. Tachycardia
4. Palpitations
5. Diaphoresis
Treatment
P percutaneous
T tansluminar
C coronary
A angioplasty
Obj:
1.
2.
3.
ANGINA PECTORIS- A clinical syndrome characterized by paroxysmal chest pain usually relieved by REST or NGT
nitroglycerin, resulting fr temp myocardial ischemia.
Predisposing Factor:
1. sex male
2. black raise
3. hyperlipidemia
4. smoking
5. HPN
6. DM
7. oral contraceptive prolonged
8. sedentary lifestyle
9. obesity
10.hypothyroidism
Precipitating factors
4 Es
1. Excessive physical exertion
2. Exposure to cold environment - Vasoconstriction
3. Extreme emotional response
4. Excessive intake of food saturated fats.
Signs & Symptoms
52
3.)
4.)
5.)
6.)
7.)
53
Types:
Predisposing factors
1. sex male
2. black raise
3. hyperlipidemia
4. smoking
5. HPN
6. DM
7. oral contraceptive
prolonged
8. sedentary lifestyle
9. obesity
10. hypothyroidism
Diagnostic Exam
1. cardiac enzymes
a.) CPK MB Creatinine
Phosphokinase
b.) LDH lactic acid dehydrogenase
c.) SGPT (ALT) Serum Glutanic
Pyruvate Transaminase- increased
d.) SGOT (AST) Serum Glutamic Oxaloacetic - increased
2. Troponin test increase
3. ECG tracing ST segment increase,
widening or QRS complexes means
arrhythmia in MI indicating PVC
4. serum cholesterol & uric acid - increase
5. CBC increase WBC
Nursing Management
1. Narcotic analgesics Morphine SO4 to induce vasodilation & decrease levels of anxiety.
2. Administer O2 inhalation low inflow (CHF-increase inflow)
3. Enforce CBR without BP
a.) Bedside commode
4. Avoid valsalva maneuver
5. Semi fowler
6. General liquid to soft diet decrease Na, saturated fat, caffeine
7. Monitor VS, I&O & ECG tracings
8. Take 20 30 ml/week wine, brandy/whisky to induce vasodilation.
9. Assist in surgical; CABAG
10. Provide pt HT
a.) Avoid modifiable risk factors
b.) Prevent complications:
1. Arrhythmias PVC
2. Shock cardiogenic shock. Late signs of cardiogenic shock in MI oliguria
3. thrombophlebitis - deep vein
4. CHF left sided
5. Dresslers syndrome post MI syndrome
-Resistant to medications
-Administer 150,000 450,000 units of streptokinase
c.) Strict compliance to meds
- Vasodilators
1. NTG
2. Isordil
- Antiarrythmic
1. Lydocaine
blocks release of norepenephrine
2. Brithylium
- Beta-blockers lol
1. Propanolol (inderal)
- ACE inhibitors - pril
54
1. Captopril (enalapril)
- Ca antagonist
1. Nifedipine
- Thrombolitics or fibrinolytics to dissolve clots/ thrombus
S/E allergic reactions/ uticaria
1. Streptokinase
2. Urokinase
3. Tissue plasminogen adjusting factor
PTT
PT
If prolonged bleeding
prolonged bleeding
Antidote
antidote Vit K
Protamine sulfate
- Anti platelet PASA (aspirin)
d.) Resume ADL sex/ activity 4 to 6 weeks
Post-cardiac rehab
1.)Sex as an appetizer rather then dessert
Before meals not after, due after meals increase metabolism heart is pumping hard after meals.
2.) Position non-weight bearing position.
When to resume sex/ act: When pt can already use staircase, then he can resume sex.
e.) Diet decrease Na, Saturated fats, and caffeine
f.) Follow up care.
CHF CONGESTIVE HEART FAILURE - Inability of heart to pump blood towards systemic circulation.
- Backflow
1.) Left sided heart failure:
Predisposing factors:
1.) 90% mitral valve stenosis due RHD, aging
RHD affects mitral valve streptococcal infection
Dx: - Aso titer anti streptolysine O > 300 total units
- Steroids
- Penicillin
- Aspirin
Complication: RS-CHF
Aging degeneration / calcification of mitral valve
Ischemic heart disease
HPN, MI, Aortic stenosis
S/Sx
Pulmonary congestion/ Edema
1. Dyspnea
2. Orthopnea (Diff of breathing sitting pos platypnea)
3. Paroxysmal nocturnal dysnea PNO- nalulunod
4. Productive cough with blood tinged sputum
5. Frothy salivation (from lungs)
6. Cyanosis
7. Rales/ crackles due to fluid
8. Bronchial wheezing
55
9.
10.
11.
12.
1.
CXR cardiomegaly
PAP Pulmonary Arterial Pressure
PCWP Pulmonary CapillaryWedge Pressure
Dx
2.
3.
4.
CXR cardiomegaly
CVP measures the pressure at R atrium
Normal: 4 to 10 cm of water
Increase CVP > 10 hypervolemia
Decrease CVP < 4 hypovolemia
Flat on bed post of pt when giving CVP
Position during CVP insertion Trendelenburg to prevent pulmonary embolism & promote ventricular
filling.
56
venous ulcer
1. Varicose veins
2. Thrombophlebitis
Predisposing factors:
- Male
- Smokers
57
S/Sx
1. Intermittent claudication leg pain upon walking - Relieved by rest
2. Cold sensitivity & skin color changes
White
bluish
red
Pallor
cyanosis
rubor
3.
5.
Nsg Mgt:
1. Encourage a slow progression of physical activity
a.) Walk 3 -4 x / day
b.) Out of bed 2 3 x a / day
2. Meds
a.) Analgesic
b.) Vasodilator
c.) Anticoagulant
3. Foot care mgt like DM
a.) Avoid walking barefoot
b.) Cut toe nails straight
c.) Apply lanolin lotion prevent skin breakdown
d.) Avoid wearing constrictive garments
4. Avoid smoking & exposure to cold environment
5. Surgery: BKA (Below the knee amputation)
2.)REYNAUDS
PHENOMENON acute episodes of arterial spasm affecting digits of hands & fingers
Predisposing factors:
1.
2.
3.
4.
S/Sx:
Female, 40 yrs
Smoking
Collagen dse
a.) SLE pathognomonic sign butterfly rash on face
Chipmunk face bulimia nervosa
Cherry red skin carbon monoxide
Spider angioma liver cirrhosis
Caput medusae leg & trunk
Lion face leprosy
poisoning
umbilicus- Liver cirrhosis
Nsg Mgt:
58
a.
b.
c.
d.
Analgesics
Vasodilators
Encourage to wear gloves especially when opening a refrigerator.
Avoid smoking & exposure to cold environment
VENOUS ULCERS
1. VARICOSITIES / Varicose veins - Abnormal dilation of veins lower ext & trunk
- Due to:
a.) Incompetent valves leading to
b.) Increase venous pooling & stasis leading to
c.) Decrease venous return
Predisposing factors:
a. Hereditary
b. Congenital weakness of veins
c. Thrombophlebitis
d. Heart dse
e. Pregnancy
f. Obesity
g. Prolonged immobility - Prolonged standing
S/Sx:
1. Pain especially after prolonged standing
2. Dilated tortuous skin veins
3. Warm to touch
4. Heaviness in legs
Dx:
1.
Venography
59
Dx:
1. Angiography
2. Doppler UTZ
Nsg Mgt:
1. Elevate legs above heart level.
2. Apply warm, moist packs to decrease lymphatic congestion.
3. Measure circumference of leg muscles to detect if swollen.
4. Use anti embolic stockings.
5. Meds: Analgesics.
Anticoagulant: Heparin
6. Complication:
Pulmonary Embolism:
- Sudden sharp chest pain
- Dyspnea
- Tachycardia
- Palpitation
- Diaphoresis
- Mild restlessness
OVERVIEW OF RESPIRATORY SYSTEM:
I. Upper respiratory tract:
Fx:
1. Filtering of air
2. Warming & moistening
3. Humidification
a. Nose cartilage
- Parts:
Rt nostril
separated by septum
Lt nostril
-
For phonation
Cough reflex
Glottis opening
Opens to allow passage of air
Closes to allow passage of food
II. Lower Rt Fx for gas exchange
a. Trachea windpipe
- has cartillagenous rings
- site for permanent/ artificial a/w tracheostomy
b. Bronchus R & L main bronchus
c. Lungs R 3 lobes = 10 segments
L 2 lobes 8 segments
Post pneumonectomy - position affected side to promote expansion of lungs
Post segmental lobectomy position unaffected side to promote drainage
Lungs covered by pleural cavity, parietal lobe & visceral lobe
Alveoli acinar cells
- site of gas exchange (O2 & CO2)
60
I. PNEUMONIA inflammation of lung parenchyma leading to pulmonary consolidation as alveoli is filled with exudates.
Etiologic agents:
1. Streptococcus pneumoniae (pnemococcal pneumonia)
2. Hemophilus pneumoniae(Bronchopneumonia)
3. Escherichia coli
4. Klebsiella P.
5. Diplococcus P.
High risk elderly & children below 5 yo
Predisposing factors:
1. Smoking
2. Air pollution
3. Immuno-compromised
a. AIDS PLP
b. Bronchogenic CA - Non-productive to productive cough
4. Prolonged immobility CVA- hypostatic pneumonia
5. Aspiration of food
6. Over fatigue
S/Sx:
61
Nsg Mgt:
1.
2.
3.
Enforce CBR
Strict respiratory isolation
Meds:
a.) Broad spectrum antibiotics
Penicillin or tetracycline
Macrolides ex azythromycin (zythromax)
b.) Anti pyretics
c.) Mucolytics or expectorants
4. Force fluids 2 to 3 L/day
5. Institute pulmonary toileta.) Deep breathing exercise
b.) Coughing exercise
c.) Chest physiotherapy cupping
d.) Turning & reposition - Promote expectoration of secretions
6. Semi-fowler
7. Nebulize & suction
8. Comfy & humid environment
9. Diet: increase CHO or calories, CHON & vit C
10. Postural drainage - To drain secretions using gravity
Mgt for postural drainage:
a.) Best done before meals or 2 4 hrs after meals to prevent Gastroesophageal Reflux
b.) Monitor VS & breath sounds
Normal breath sound bronchovesicular
c.) Deep breathing exercises
d.) Adm bronchodilators 15 30 min before procedure
e.) Stop if pt cant tolerate procedure
f.) Provide oral care it may alter taste sensation
g.) C/I pt with unstable VS & hemoptysis, increase ICP, increase IOP (glaucoma)
Normal IOP 12 21 mmHg
11. HT:
a.) Avoidance of precipitating factors
b.) Complication: Atelectacies & meningitis
c.) Compliance to meds
PULMONARY TUBERCULOSIS (KOCH DSE) - Inflammation of lung tissue caused by invasion of mycobacterium TB or
tubercle bacilli or acid fast bacilli gram (+) aerobic, motile & easily destroyed by heat or sunlight.
Predisposing factors:
1.
Malnutrition
2.
Overcrowding
3.
Alcoholism
4.
Ingestion of infected cattle (mycobacterium BOVIS)
5.
Virulence
6. Over fatigue
S/Sx:
1.
2.
3.
4.
5.
6.
7.
Diagnosis:
1. Skin test mantoux test infection of Purified CHON Derivative PPD
DOH 8-10 mm induration
WHO 10-14 mm induration
Result within 48 72h
62
Intensive phase
INH isoniazide
Rifampicin
PZA Pyrazinamide given 2 mos/ after meals. S/E: allergic rxn, nephrotoxicity & hepatoxicity
Standard regimen
1. Injection of streptomycin aminoglycoside
Ex. Kanamycin, gentamycin, neomycin
S/E:
a.) Ototoxicity damage CN # 8 tinnitus hearing loss
b.) Nephrotoxicicity monitor BUN & Crea
HT:
a.) Avoid pred factors
b.) Complications:
1.) Atelectasis
2.) Miliary TB spread of Tb to other system
b.) Compliance to meds
- Religiously take meds
HISTOPLASMOSIS- acute fungal infection caused by inhalation of contaminated dust with histoplasma capsulatum transmitted
to birds manure.
S/Sx: Same as pneumonia & PTB like
1. Productive cough
2. Dyspnea
3. Chest & joint pains
4. Cyanosis
5. Anorexia, gen body malaise, wt loss
6. Hemoptysis
Dx:
1.
2.
63
Nsg Mgt:
1. CBR
2. Meds:
a.) Anti fungal agents
Amphotericin B (Fungizone)
S/E :
a.) Nephrotoxcicity check BUN
b.) Hypokalemia
b.)Corticosteroids
c.) Mucolytic/ or expectorants
3. O2 force fluids
4. Nebulize, suction
5. Complications:
a.) Atelectasis
b.) Bronchiectasis COPD
6. Prevent spread of histoplasmosis:
a.) Spray breading places or kill the bird.
Chronic bronchitis
Bronchial asthma
Bronchiectasis
Pulmonary emphysema terminal stage
CHRONIC BRONCHITIS - called BLUE BLOATERS inflammation of bronchus due to hypertrophy or hyperplasia of goblet
mucus producing cells leading to narrowing of smaller airways.
Predisposing factors:
1. Smoking all COPD types
2. Air pollution
S/Sx:
1. Prod cough
2. Dyspnea on exertion
3. Prolonged expiratory grunt
4. Scattered rales/ rhonchi
5. Cyanosis
6. Pulmo HPN a.)Leading to peripheral edema
b.) Cor pulmonary respiratory in origin
7. Anorexia, gen body malaise
Dx:
1.
ABG
PO2
PCO2
Resp acidosis
64
e.) Dander
f.) Lints
2. Intrinsic AsthmaCause:
Herediatary
Drugs aspirin, penicillin, blockers
Food additives nitrites
Foods seafood, chicken, eggs, chocolates, milk
Physical/ emotional stress
Sudden change of temp, humidity &air pressure
3. mixed type: combi of both ext & intr. Asthma
90% cause of asthma
S/Sx:
1.
2.
4.
5.
6.
7.
1.
2.
3.
Dx:
Nsg Mgt:
1. CBR all COPD
2. Medsa.) Bronchodilator through inhalation or metered dose inhaled / pump. Give 1st before corticosteroids
b.) Corticosteroids due inflammatory. Given 10 min after adm bronchodilator
c.) Mucolytic/ expectorant
d.) Mucomist at bedside put suction machine.
e.) Antihistamine
2. Force fluid
3. O2 all COPD low inflow to prevent resp distress
4. Nebulize & suction
5. Semifowler all COPD except emphysema due late stage
6. HT
a.) Avoid pred factors
b.) Complications:
- Status astmaticus- give epinephrine & bronchodilators
- Emphysema
c.) Adherence to med
BRONCHIECTASIS abnormal permanent dilation of bronchus resulting to destruction of muscular & elastic tissues of alveoli.
Predisposing factors:
1. Recurrent upper & lower RI
2. Congenital anomalies
3. Tumors
4. Trauma
S/Sx:
1. Productive cough
2. Dyspnea
3. Anorexia, gen body malaise- all energy are used to increase respiration.
4. Cyanosis
5. Hemoptisis
65
Dx:
1.
Productive cough
66
b.) Corticosteroids
c.) Antimicrobial agents
d.) Mucolytics/ expectorants
3. O2 Low inflow
4. Force fluids
5. High fowlers
6. Neb & suction
7. Institute
P posture
E end
E expiratory
to prevent collapse of alveoli
P pressure
8. HT
a.) Avoid smoking
b.) Prevent complications
1.) Cor pulmonary R ventricular hypertrophy
2.) CO2 narcosis lead to coma
3.) Atelectasis
4.) Pneumothorax air in pleural space
9. Adherence to meds
67
68
5.
Diagnosis:
1. CBC mild leukocytosis increase WBC
2. PE (+) rebound tenderness (flex Rt leg, palpate Rt iliac area rebound)
3. Urinalysis
Treatment: - appendectomy 24 45
Nursing Mgt:
1. Consent
2. Routinary nursing measures:
a.) Skin prep
b.) NPO
c.) Avoid enema lead to rupture of appendix
3. Meds:
Antipyretic
69
Antibiotics
*Dont give analgesic will mask pain
- Presence of pain means appendix has not ruptured.
4. Avoid heat application will rupture appendix.
5. Monitor VS, I&O bowel sound
Nursing Mgt: post op
1. If (+) to Pendrose 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
4. Maintain patent IV line
5. Complications- peritonitis, septicemia
Liver largest gland
- Occupies most of right hypochondriac region
- Color: scarlet red
- Covered by a fibrous capsule Glissons capsule
- Functional unit liver lobules
Function:
1.
Produces bile
Bile emulsifies fats
- Composed of H2O & bile salts
-Gives color to urine urobilin
Stool stircobilin
2. Detoxifies drugs
3. Promotes synthesis of vit A, D, E, K - fat soluble vitamins
Hypevitaminosis 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
Cirrhosis decrease albumin
Albumin maintains osmotic pressure, prevents edema
2. Promotes synthesis of prothrombin & fibrinogen
3. Promotes conversion of ammonia to urea.
Ammonia like breath fetor hepaticus
C. FATS promotes synthesis of cholesterol to neutral fats called triglycerides
LIVER CIRRHOSIS - lost of architectural design of liver leading to fat necrosis & scarring
Early sign hepatic encephalopathy
1. Asterixis flapping hand tremors
Late signs headache, restlessness, disorientation, decrease LOC hepatic coma.
Nursing priority assist in mechanical ventilation
Predisposing factor:
70
2.
3.
4.
5.
6.
SGPT (ALT)
SGOT (AST)
Serum cholesterol & ammonia increase
Indirect bilirubin increase
CBC - pancytopenia
PTT prolonged
Hepatic ultrasonogram fat necrosis of liver lobules
Nursing Mgt
1. CBR
2. Restrict Na!
3. Monitor VS, I&O
4. With pt daily & assess pitting edema
5. Measure abdominal girth daily notify MD
6. Meticulous skin care
71
7.
8.
Diet increase CHO, vit & minerals. Moderate fats. Decrease CHON
Well balanced diet
Complications:
a.) Ascites fluid in peritoneal cavity
Nursing Mgt:
1. Meds: Loop diuretics 10 15 min effect
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
Pitrisin or Vasopresin (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
- 3 lumen typed catheter
- Scissors at bedside to deflate balloon.
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
PANCREATITIS acute or chronic inflammation of pancreas leading to pancreatic edema, hemorrhage & necrosis due to auto
digestion.
Bleeding of pancreas - Cullens sign at umbilicus
Predisposing factors:
1. Chronic alcoholism
2. Hepatobilary disease
3. Obesity
4. Hyperlipidemia
5. Hyperparathyroidism
6. Drugs Thiazide diuretics, pills Pentamidine HCL (Pentam)
7. Diet increase saturated fats
S/Sx:
1. Severe Lt epigastric pain radiates from back &flank area
- Aggravated by eating, with DOB
2. N/V
3. Tachycardia
4. Palpitation due to pain
5. Dyspepsia indigestion
6. Decrease bowel sounds
72
hemorrhage
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)
Dont give Morphine SO4 will cause spasm of sphincter.
b.) Smooth muscle relaxant/ anti cholinergic
- 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
3. Assist in Total Parenteral Nutrition (TPN) or hyperalimentation
Complications of TPN
1. Infection
2. Embolism
3. Hyperglycemia
4. Institute stress mgt tech
a.) DBE
b.) Biofeedback
5. Comfy position - Knee chest or fetal like position
6. If pt can tolerate food, give increase CHO, decrease fats, and increase CHON
7. Complications: Chronic hemorrhagic pancreatitis
GALLBLADDER storage of bile made up of cholesterol.
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
5. Hyperlipidemia
6. Neoplasm
S/Sx:
1. Severe Right abdominal pain (after eating fatty food). Occurring especially at night
2. Fatty intolerance
3. Anorexia, n/v
4. Jaundice
5. Pruritus
6. Easy bruising
7. Tea colored urine
8. Steatorrhea
Diagnosis:
1. Oral cholecystogram (or gallbladder series)- confirms presence of stones
Nursing Mgt:
1. Meds a.) Narcotic analgesic - Meperdipine Hcl Demerol
b.) Anti cholinergic - Atropine SO4
c.) Anti emetic
Phenergan Phenothiazide with anti emetic properties
73
2.
3.
4.
2.
3.
PEPTIC ULCER DISEASE (PUD) excoriation / erosion of submucosa & mucosal lining due to:
a.) Hypercecretion of acid pepsin
b.) Decrease resistance to mucosal barrier
Incidence Rate:
1. Men 40 55 yrs old
2. Aggressive persons
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.
9.
74
According to location
1. Stress ulcer
2. Gastric ulcer
3. Duodenal ulcer most common
Stress ulcers common among eritically ill clients
2 types
1.Curings ulcer cause: trauma & birth
hypovolemia
GIT schemia
Decrease resistance of mucosal barriers to Hcl acid
Ulcerations
2.Cushings ulcer cause stroke/CVA/ head injury
Increase vagal stimulation
Hyperacidity
Ulcerations
SITE
PAIN
HYPERSECRETION
VOMITING
HEMORRHAGE
WT
COMPLICATIONS
GASTRIC ULCER
Intrum or lesser curvature
-30 min 1 hr after eating
- epigastrium
- gaseous & burning
- not usually relieved by food &
antacid
Normal gastric acid secretion
common
hematemeis
Wt loss
a. stomach cause
b. hemorrhage
60 years old
HIGH RISK
Diagnosis:
1. Endoscopic exam
2. Stool from occult blood
3. Gastric analysis N gastric
Increase duodenal
4. GI series confirms presence of ulceration
DUODENAL ULCER
Duodenal bulb
-2-3 hrs after eating
- mid epigastrium
- cramping & burning
- usually relieved by food & antacid
- 12 MN 3am pain
Increased gastric acid secretion
Not common
Melena
Wt gain
a. perforation
20 years old
Nursing Mgt:
1. Diet bland, non irritating, non spicy
2. Avoid caffeine & milk/ milk products
Increase gastric acid secretion
3.
Administer meds
75
a.) Antacids
AAC
Aluminum containing antacids
Ex. aluminum OH gel
(Ampho-gel)
S/E constipation
76
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
2. Small frequent feeding s-6 equally divided feedings
3. Diet decrease CHO, moderate fats & CHON
4. Flat on bed 15 -30 minutes after q feeding
BURNS direct tissue injury caused by thermal, electric, chemical & smoke inhaled (TECS)
Nursing Priority infection (all kinds of burns)
Head burn-priority- a/w
2nd priority for 1st & 2nd - pain
2nd priority for 3rd - F&E
Thermal- direct contact flames, hot grease, sunburn.
Electric, wires
Chem. direct contact corrosive materials acids
Smoke gas / fume inhalation
Stages:
1. Emergent phase Removal of pt from cause of burn. Determine source or loc or burn
2. 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
3. Diuretic/ Fluid remobilization phase - 3 to 5 days. Return of fluid from interstitial to intravascular space
4. Recovery/ convalescent phase complete diuresis. Wound healing starts immediately after tissue injury.
Class:
I. Partial Burn
1. 1st degree superficial burns
- Affects epidermis
- Cause: thermal burn
- Painful
- Redness (erythema) & blanching upon pressure with no fluid filled vesicles
2. 2nd degree deep burns
- Affects epidermis & dermis
- Cause chem. burns
- very painful
- Erythema & fluid filled vesicles (blisters)
II Full thickness Burns
1. Third & 4th 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.
77
Assessment findings
Rule of nines
Head & neck = 9%
Ant chest =
18%
Post chest =
18%
@ Arm 9+9 = 18%
@ leg 18+18 = 18%
Genitalia/ perineum= 1%
Total
100%
Nursing Mgt
1. Meds
a.) Tetanus toxoid- burn surface area is source of anaerobic growth Claustridium tetany
Tetany
Tetanolysin
tetanospasmin
Hemolysis
muscle spasm
78
Function of kidneys:
1. Urine formation
2. Regulation of BP
Urine formation 25% of total CO (Cardiac Output) is received by kidneys
1. Filtration
2. Tubular Reabsorption
3. Tubular Secretion
Filtration Normal GFR/ min is 125 ml of blood
Tubular reabsorption 124ml of ultra infiltrates (H2O & electrolytes is for reabsorption)
Tubular secretion 1 ml is excreted in urine
Regulation of BP:
Predisposing factor:
Ex CS hypovolemia decrease BP going to kidneys
Activation of RAAS
Release of Renin (hydrolytic enzyme) at juxtaglomerular apparatus
Angiotensin I mild vasoconstrictor
Angiotensin II vasoconstrictor
Adrenal cortex
increase CO
increase PR
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 or urine
1200 1800 ml Normal adult can hold
200 500 ml needed to initiate micturition reflex
Color
amber
Odor
aromatic
Consistency
clear or slightly turbid
pH
4.5 8
Specific gravity 1.015 1.030
WBC/ RBC
(-)
Albumin
(-)
E coli
(-)
Mucus thread few
Amorphous urate (-)
Urethra extends to external surface of body. Passage of urine, seminal & vaginal fluids.
- Women 3 5 cm or 1 to 1
- Male 20cm or 8
UTI
79
PYELONEPHRITIS acute/ chronic infl of 1 or 2 renal pelvis of kidneys leading to tubular destruction, interstitial abscess
formation.
- Lead to Renal Failure
Predisposing factor:
1. Microbial invasion
a.) E. Coli
b.) Streptococcus
2. Urinary retention /obstruction
3. Pregnancy
4. DM
5. Exposure to renal toxins
S/Sx:
Acute pyelonephritis
a.) Costovertibral angle pain, tenderness
b.) Fever, anorexia, gen body malaise
c.) Urinary frequency, urgency
d.) Nocturia, dsyuria, hematuria
e.) Burning on urination
Chronic Pyelonephritis
a.) Fatigue, wt loss
b.) Polyuuria, polydypsia
c.) HPN
80
Diagnosis:
1. Urine culture & sensitivity (+) E. coli & streptococcus
2. Urinalysis
Increase WBC, CHON & pus cells
3. Cystoscopic exam urinary obstruction
Nursing Mgt:
1. Provide CBR acute phase
2. Force fluid
3. Acid ash diet
4. Meds:
a.) Urinary antiseptic nitrofurantoin (macrodantin)
SE: peripheral neuropathy
GI irritation
Hemolytic anemia
Staining of teeth
b.) Urinary analgesic Peridium
2. Complication- Renal Failure
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
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
81
7.
- Non - invasive
- Dissolve stones by shock wave
Complications: Renal Failure
Predisposing factor:
1. High risk 50 years old & above
60 70 (3 to 4 x at risk)
2. Influence of male hormone
S/Sx:
1.Decrease force of urinary stream
2.Dysuria
3.Hematuria
4.Burning upon urination
5.Terminal bubbling
6.Backache
7.Sciatica
Diagnosis:
1. Digital rectal exam enlarged prostate gland
2. KUB urinary obstruction
3. Cystoscopic exam obstruction
4. Urinalysis increase WBC, CHON
Nursing Mgt:
1. Prostatic message promotes evacuation of prostatic fluid
2. Limit fluid intake
3. Provide catheterization
4. Meds:
a. Terazozine (hytrin) - Relaxes bladder sphincter
b. Fenasteride (Proscar) - Atrophy of Prostate Gland
5. Surgery: Prostatectomy TURP- Transurethral resection of Prostate- No incision
-Assist in cystoclysis or continuous bladder irrigation.
Nursing mgt:
c. Monitor symptoms of infection
d. Monitor symptoms gross/ flank 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 factor:
Pre renal cause- decrease blood flow
Causes:
1. Septic shock
2. Hypovolemia
3. Hypotension
decrease flow to kidneys
4. CHF
5. Hemorrhage
6. Dehydration
Intra-renal cause involves renal pathology= kidney problem
1. Acute tubular necrosis-
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2.
3.
4.
Pyelonephritis
HPN
Acute GN
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2.) Obtain baseline data & monitor VS, I&O, wt, blood exam
3.) Strict aseptic technique
4.) Monitor for signs of complications:
B bleeding
E embolism
D disequilibrium syndrome
S septicemia
S shock decrease in tissue perfusion
Disequilibrium syndrome from rapid removal of urea & nitrogenous waste prod leading to:
a.) n/v
b.) HPN
c.) Leg cramps
d.) Disorientation
e.) Paresthesia
2.
3.
Avoid BP taking, blood extraction, IV, at side of shunt or fistula. Can lead to compression of fistula.
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
- Shock
8. Assist in surgery:
Renal transplantation : Complication rejection. Reverse isolation
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. Denial
b. Anger
c. Bargaining
d. Depression
e. Acceptance
2. Intrinsic coat
I. sclerotic coat outer most
a.) Sclera white. Occupies 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
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far vision=
ciliary muscle dilates / relaxes=
lens is flat
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4.
5.
6.
Type:
1.
2.
3.
Hereditary
Obesity
Recent eye trauma, infl, surgery
Chronic (open angle G.) most common type
Obstruct in flow of aqueous humor at trabecular meshwork of canal of schlema
Acute (close angle G.) Most dangerous type
Forward displacement of iris to cornea leading to blindness.
Chronic (closed angle) - Precipitated by acute attack
S/Sx:
1.
2.
3.
4.
5.
6.
7.
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. acetapolamide (Diamox)
- Promotes increase out flow of aquaeous humor
d.) Temoptics (Timolol maleate)- Increase outflow of aquaous humor
2. 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)
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1.
2.
3.
4.
S/Sx:
Painless
Milky white appearance at center of pupil
Decrease perception of colors
Diagnosis:
Opthalmoscopic exam (+) opacity of lens
Nsg Mgt:
1. Reorient pt to environment due opacity
2. Siderails
3. Meds a.) Mydriatics dilate pupil not lifetime
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
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-malleus
for bone conduction
-stapes
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Surgery
Stapedectomy removal of stapes, spongy bone & implantation of graft/ ear prosthesis
Predisposing factor:
1. Familiar tendency
2. Ear trauma & surgery
S/Sx:
1.
2.
Tinnitus
Conductive hearing loss
Diagnosis:
1. Audiometry various sound stimulates (+) conductive hearing loss
2. Webers 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
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2.
3.
4.
5.
6.
7.
Nystagmus
n/v
Mild apprehension, anxiety
Tachycardia
Palpitations
Diaphoresis
Diagnosis:
1. Audiometry (+) sensory hearing loss
1.
2.
3.
4.
5.
6.
7.
8.
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
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