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NERVOUS SYSTEM Overview of structures and functions: Central Nervous System
Brain Spinal Cord Cranial Nerves Spinal Nerves Sympathetic nervous system Parasympathetic nervous system AUTONOMIC NERVOUS SYSTEM
Peripheral 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. - Increase blood supply to brain, heart and skeletal muscles. - SNS I. Adrenergic Agents - Give Epinephrine. Signs and Symptoms: - SNS Contraindication: - Contraindicated to patients suffering from COPD (Broncholitis, Bronchoectasis, Emphysema, Asthma). II. Beta-adrenergic Blocking Agents - Also called Beta-blockers. - All ending with “lol” - Propranolol, Atenelol, Metoprolol. 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, 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)
Parasympathetic Nervous System (CHOLINERGIC, VAGAL, SYMPATHOLYTIC) - Involved in fight or withdrawal response. - Release of Acetylcholine. - 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.
I. Cholinergic Agents - Mestinon, Neostigmine. Side Effects - PNS
II. Anti-cholinergic Agents - To counter cholinergic agents. - Atropine Sulfate Side Effects - SNS
CENTRAL NERVOUS SYSTEM
Brain and Spinal Cord.
I. CELLS A. NEURONS
Basic cells for nerve impulse and conduction.
PROPERTIES Excitability – ability of neuron to be affected by changes in external environment. Conductivity – ability of neuron to transmit a wave of excitation from one cell to another. Permanent Cell – once destroyed not capable of regeneration. TYPES OF CELLS BASED ON REGENERATIVE CAPACITY 1. Labile
Capable of regeneration. Epidermal cells, GIT cells, GUT cells, cells of lungs. Capable of regeneration with limited time, survival period. Kidney cells, Liver cells, Salivary cells, pancreas. Not capable of regeneration. Myocardial cells, Neurons, Bone cells, Osteocytes, Retinal Cells.
Support and protection of neurons.
TYPES 1. Astrocytes – maintains blood brain barrier semi-permeable. 2. Oligodendria 3. Microglia 4. Epindymal SUBSTANCES THAT CAN PASS THE BLOOD-BRAIN BARRIER 1. Ammonia
Majority of brain tumors (90%) arises from called astrocytoma.
Cerebral toxin Hepatic Encephalopathy (Liver Cirrhosis) Ascites Esophageal Varices asterixis (flapping hand tremors). Headache Dizziness Confusion Fetor hepaticus (ammonia like breath) Decrease LOC
Early Signs of Hepatic Encephalopathy
Late Signs of Hepatic Encephalopathy
PATHOGNOMONIC SIGNS 1. PTB – low-grade afternoon fever. 2. PNEUMONIA – rusty sputum. 3. ASTHMA – wheezing on expiration. 4. EMPHYSEMA – barrel chest. 5. KAWASAKI SYNDROME – strawberry tongue. 6. PERNICIOUS ANEMIA – red beefy tongue. 7. DOWN SYNDROME – protruding tongue. 8. CHOLERA – rice watery stool. 9. MALARIA – stepladder like fever with chills. 10. TYPHOID – rose spots in abdomen. 11. DIPTHERIA – pseudo membrane formation 12. MEASLES – koplik’s spots. 13. SLE – butterfly rashes. 14. LIVER CIRRHOSIS – spider like varices. 15. LEPROSY – lioning face. 16. BULIMIA – chipmunk face. 17. APPENDICITIS – rebound tenderness. 18. DENGUE – petechiae or (+) Herman’s sign. 19. MENINGITIS – Kernig’s sign (leg pain), Brudzinski sign (neck pain). 20. TETANY – HYPOCALCEMIA (+) Trousseau’s sign/carpopedal spasm; Chvostek sign (facial spasm). 21. TETANUS – risus sardonicus. 22. PANCREATITIS – Cullen’s sign (ecchymosis of umbilicus); (+) Grey turners spots. 23. PYLORIC STENOSIS – olive like mass. 24. PDA – machine like murmur. 25. ADDISON’S DISEASE – bronze like skin pigmentation. 26. CUSHING’S SYNDROME – moon face appearance and buffalo hump. 27. HYPERTHYROIDISM/GRAVE’S DISEASE – exopthalmus. 28. INTUSSUSCEPTION – sausage shaped mass 2. Carbon Monoxide and Lead Poisoning
Can lead to Parkinson’s Disease. Epilepsy Treat with ANTIDOTE: Calcium EDTA. 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. Which may lead to diabetic coma. Signs of jaundice (icteric sclerae). Caused by bilirubin (yellow pigment) Increase bilirubin in brain (Kernicterus). Causing irreversible brain damage.
3. Type 1 DM (IDDM)
Maintains integrity of blood brain barrier. Produces myelin sheath in CNS Act as insulator and facilitates rapid nerve impulse transmission.
tingling sensation paresthesia numbness euphoria (sense of well being) 3. Signs and Symptoms 1.DEMYELINATING DISORDERS 1. ALZHEIMER’S DISEASE Atrophy of brain tissues. b. d. *Expressive aphasia “motor speech center” Broca’s Aphasia inability to understand spoken words. . Characterized by remission and exacerbation. *Receptive aphasia DRUG OF CHOICE: ARICEPT (taken at bedtime) and COGNEX. Wernicke’s Aphasia General Knowing Gnostic Area or General Interpretative Area.short term protection. . Sign and Symptoms 4 A’s of Alzheimer a. 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. heat and cold. Amnesia – loss of memory. c. Mood swings . Aphasia – no speech (nodding). pressure. Ig A – present in all bodily secretions (tears. pain. colostrums). Visual disturbances blurring of vision (primary) diplopia (double vision) scotomas (blind spots) 2. MULTIPLE SCLEROSIS Chronic intermittent disorder of CNS characterized by white patches of demyelination in brain and spinal cord. Apraxia – no recognition of objects function. Impaired sensation to touch. Ig M – acute in inflammation. Agnosia – no recognition of inanimate objects. * Give palliative or supportive care.Immediate action. 2. saliva. Ig D – for chronic inflammation. Ig E – for allergic reaction.
Monitor breath sounds 1 hour after subcutaneous administration. Bethanicol Chloride (Urecholine) Nursing Management Only given subcutaneous. b. Deep breathing exercises b. pineapple. Decrease sexual capacity DIAGNOSTIC PROCEDURE Nystagmus CSF analysis (increase in IgG and Protein). Prophantheline Bromide (Promanthene) Acid ash diet like cranberry juice. Constipation 8. Impaired cerebral function CHARCOTS TRIAD IAN Intentional tremors 6. To acidify urine and prevent bacterial multiplication. Monitor side effects bronchospasm and wheezing. Increase fluid intake and increase fiber to prevent constipation. NURSING MANAGEMENT 1. ACTH (Adreno Corticotropic Hormone)/ Steroids for acute exacerbation to reduce edema at site of demyelination to prevent paralysis. c. c. prunes. Urinary retention/incontinence 7. Immunosupresants 2. plums. Diuretics b. Administer medications as ordered a. (+) Romberg’s test) 5. . Impaired motor function weakness spasticity paralysis scanning speech TRIAD SIGNS OF MS Ataxia (Unsteady gait. 5. vitamin C and orange. d. Maintain side rails to prevent injury related to falls. For Urinary Incontinence Anti spasmodic agent a. Institute stress management techniques. Interferons – alter immune response. 3. Baclofen (Dioresal)/ Dantrolene Sodium (Dantrene) – muscle relaxants. Yoga 4. Catheterization to prevent retention. a. a.4. (+) Lhermitte’s sign a continuous and increase contraction of spinal column. MRI (reveals site and extent of demyelination).
Brain Mass PARTS OF THE BRAIN 1. Urethra (20 cm. Frontal higher cortical thinking controls personality controls motor activity Broca’s Area (motor speech area) when damaged results to garbled speech. pressure. Functions of Cerebrum integrative sensory motor Lobes of Cerebrum 1. 8 inches) urinate after intercourse Nursing Management Male MICROGLIA stationary cells that carry on phagocytosis (engulfing of bacteria or cellular debris. avoid use of tissue papers avoid using talcum powder and perfume. 80% brain mass 10% blood 10% CSF COMPOSITION OF BRAIN I. eating). Occipital . touch. Parietal 4. cold. CEREBRUM largest part composed of the Right Cerebral Hemisphere and Left Cerebral Hemisphere enclosed in the Corpus Callosum. heat. ORGAN Brain Blood Kidney Skin Lung MACROPHAGE Microglia Monocytes Kupffers cells Histiocytes Alveolar Macrophage EPINDYMAL CELLS Secretes a glue called chemo attractants that concentrate the bacteria. 2. 1-1 ½ inches) poor perineal hygiene vaginal environment is moist avoid bubble bath (can alter Ph of vagina). numbness. pinocytosis (cell drinking).COMMON CAUSE OF UTI Female short urethra (3-5 cm. 3. Temporal hearing short term memory for appreciation discrimination of sensory impulses to pain.
B. positive PERRLA 4. Hypothalamus 5. INTERBRAIN/ DIENCEPHALON Parts of Diencephalon A. unequal size of pupil is anisocoria. MIDBRAIN/ MESENCEPHALON acts as relay station for sight and hearing. early sign for males are testicular and penile enlargement late sign is deepening of voice. vasomotor center (dilation and constriction of bronchioles). anxiety and excitement. release dopamine (controls gross voluntary movement. BASAL GAGLIA areas of grey matter located deep within each cerebral hemisphere. early sign for females telarche and late sign is menarche. equal size of pupil is isocoria. controls respiration. Medulla Oblongata 3. size of pupil is 2 – 3 mm. swallowing. Cerebellum smallest part of the brain. BRAIN STEM located at lowest part of brain Parts of Brain Stem 1. hearing acuity is 30 – 40 dB. lesser brain. rhythm and depth of respiration. . hiccup. controls libido controls long term memory Insula (Island of Reil) Limbic System (Rhinencephalon) 2. heart rate. vomiting. controls pituitary functions androgenic hormones promotes secondary sex characteristics. Pons pneumotaxic center controls the rate. DECREASE Myasthenia Gravis Parkinson’s Disease INCREASE Bi-polar Disorder Schizophrenia NEURO TRANSMITTER Acethylcholine Dopamine 3. for vision visceral function activities of internal organ like gastric motility. controls blood pressure controls thirst appetite/satiety sleep and wakefulness controls some emotional responses like fear. Thalamus acts as relay station for sensation. controls smell and if damaged results to Anosmia (absence of smell). controls temperature (thermoregulatory center). 2.
Cervical 2 – also known as AXIS. . heart rate decrease respiratory rate decrease temperature increase directly proportional to blood pressure. controls balance. widening of pulse pressure is neurologic in nature (if narrow cardiac in nature). Causes: head trauma/injury localized abscess cerebral edema hemorrhage decrease LOC restlessness/agitation irritability inflammatory condition (stroke) hydrocephalus tumor (rarely) Signs and Symptoms (Early) lethargy/stupor coma Signs and Symptoms (Late) changes in vital signs blood pressure (systolic blood pressure increases but diastolic remains the same). NEUROLOGIC DISORDERS INCREASE INTRACRANIAL PRESSURE – increase in intra-cranial bulk brought about by an increase in one of the 3 major intra cranial components. Early closure of posterior fontanels causes posterior enlargement of skull in hydrocephalus. projective vomiting headache papilledema (edema of optic disc) abnormal posturing decorticate posturing (damage to cortex and spinal cord). equilibrium. posture and gait. Foramen Magnum Medulla Oblongata Brain Herniation Increase intra cranial pressure * Alternate hot and cold compress to prevent HEMATOMA CSF cushions brain (shock absorber) Obstruction of flow of CSF will lead to enlargement of skull posteriorly called hydrocephalus. 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.
cerebellum and midbrain). Loop diuretic (Lasix. Assist in mechanical ventilation 2. provide an comfortable and quite environment. c. d. monitor strictly input and output every 1 hour notify physician if output is less 30 cc/hr. Elevate bed of client 30 – 35o angle with neck in neutral position unless contraindicated to promote venous drainage. Monitor strictly input and output and neuro check 5. Late signs of hypoxia HYPERCARBIA b. 7. Prevention of hypoxia and hypercarbia Early signs of hypoxia restlessness agitation tachycardia Bradycardia Extreme restlessness Dyspnea Cyanosis Increase CO2 (most powerful respiratory stimulant) retention. 3. 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. c. avoid use of restraints. unilateral dilation of pupils called uncal herniation bilateral dilation of pupils called tentorial herniation resulting to mild headache possible seizure activity Nursing Management 1. 4. Limit fluid intake to 1200 – 1500 ml/day (in force fluids 2000 – 3000 ml/day). Prevent complications of 6. In chronic respiratory distress syndrome decrease O2 stimulates respiration. Nursing Management . Maintain patent and adequate ventilation by: a. Osmotic diuretic (Mannitol) for cerebral diuresis Nursing Management monitor vital signs especially BP (hypotension). avoid clustering of nursing activity together. Prevent further increase ICP by: a. administered via side drip regulated fast drip to prevent crystal formation. b. Administer medications like: a. Before and after suctioning hyper oxygenate client 100% and done 10 – 15 seconds only. Furosemide) Drug of choice for CHF (pulmonary edema) Loop of Henle in kidneys. decerebrate posturing (damage to upper brain stem that includes pons. maintain side rails. b.
Phenytoin) c. maximum effect of 6 hours. Monitor vital signs especially BP (hypotension). Corticosteroids *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. Dexamethasone (Decadron) Hydrocortisone Prednisone (to reduce edema that may lead to increase ICP) Mild Analgesics (Codeine Sulfate for respiratory depression) Anti Convulsants (Dilantin. administered IV push or oral. 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 . monitor strictly input and output every 1 hour notify physician if output is less 30 cc/hr. given early morning immediate effect of 10 – 15 minutes.
in infant TACHYCARDIA) agitation dry mucous membrane poor skin turgor weakness and fatigue .Signs and Symptoms of Lasix in terms of electrolyte imbalances 1. Hyponatremia DECREASE decrease sodium level normal value is 135 – 145 meq/L Signs and Symptoms hypotension dehydration signs (Initial sign in adult is THIRST.5 meq/L weakness and fatigue constipation positive U wave on ECG tracing Sign and Symptoms Nursing Management administer potassium supplements as ordered (Kalium Durule. Hypokalemia decrease potassium level normal value is 3.5 – 11 mg/100 ml Signs and Symptoms tingling sensation paresthesia numbness (+) Trousseau’s sign/ Carpopedal spasm (+) Chvostek’s sign Complications Arrhythmia Seizures Nursing Management Calcium Gluconate per IV slowly as ordered * Calcium Gluconate toxicity – results to SEIZURE Magnesium Sulfate Magnesium Sulfate toxicity S/S BP Urine output Respiratory rate Patellar relfex absent 3. Oral Potassium Chloride) increase intake of foods rich in potassium FRUITS Apple Banana Cantalop e Oranges 2. Hypocalcemia/ Tetany VEGETABLES Asparagus Brocolli Carrots Spinach decrease calcium level normal value is 8.4 – 5.
Allopurinol (Zyloprim) b. joint pain (great toes) swelling force fluids administer medications as ordered Drug of choice for gout. Nursing Management a. Hyperglycemia normal FBS is 80 – 100 mg/dl polyuria polydypsia polyphagia monitor FBS Signs and Symptoms Nursing Management 5. organ meats and anchovies) *Increase in tophi deposit leads to Gouty arthritis. Acute gout Mechanism of action: promotes excretion of uric acid. Signs and Symptoms Nursing Management a. Narcotic Analgesic b. Allopurinol (Zyloprim) Side Effects Respiratory depression (check for RR) .Nursing Management force fluids administer isotonic fluid solution as ordered 4. Hyperuricemia increase uric acid (purine metabolism) foods high in uric acid (sardines. Mechanism of action: inhibits synthesis of uric acid. 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.
Arteriosclerosis 3. Monotone type speech mood lability (in state of depression) increase salivation (drooling type) autonomic changes a. 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. constipation e. Increase dosage of the following drugs: a.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. Hypoxia 4. 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. Predisposing Factors 1. Poisoning (lead and carbon monoxide) 2. Reserpine(Serpasil) b. increase sweating b. decrease sexual capacity Nursing Management 1. Encephalitis 5. difficulty rising from sitting position. seborrhea d. Administer medications as ordered Anti Parkinsonian agents Levodopa (L-dopa) short acting Amantadine Hydrochloride (Symmetrel) Carbidopa (Sinemet) . increase lacrimation c.
Maintain side rails to prevent injury 3. Assist/supervise in ambulation 7. Isonicotinic Acid Hydrazide Anti Cholinergic Agents (ARTANE and COGENTIN) . Decrease protein in morning and increase protein in afternoon to induce sleep 5. Assist in Stereotaxic Thalamotomy MAGIC 2’s IN DRUG MONITORING 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 . Prevent complications of immobility 4. Dopamine Agonist .5 – 1. Encourage increase fluid intake and fiber.5 meq/L .Mechanism of Action increase level of dopamine GIT irritation (should be taken with meals orthostatic hypotension arrhythmia hallucinations clients with narrow angle closure glaucoma clients taking MAOI’s (no foods with triptophan and thiamine) urine and stool may be darkened no Vitamin B6 (Pyridoxine) reverses the therapeutic effects of Levodopa Side Effects Contraindications * Increase Vitamin B when taking INH (Isoniazid).relieves tremor rigidity Bromocriptene Hydrochloride (Parlodel) Side Effects Respiratory depression 2.6 – 1. 6.2 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 Osteo Arthritis CLASSIFICATION Cardiac Glycoside Anti-Manic Agents Bronchodilators Anti-Convulsant Non-narcotic Analgesic .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.
agitation and restlessness) only mixed with plain NSS or 0. administered sandwich method avoid taking alcohol because it can lead to severe CNS depression avoid caffeine Nursing Management 4. 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 (. Digitalis Toxicity Signs and Symptoms nausea and vomiting diarrhea confusion photophobia changes in color perception (yellowish spots) Antidote: Digibind 2. depression Antidote: Acetylcisteine (mucomyst) prepare suction apparatus as bedside. Aminophylline Toxicity Signs and Symptoms tachycardia palpitations CNS excitement (tremors. tachycardia Irritability Restlessness Extreme fatigue Diaphoresis. Lithium Toxicity Signs and Symptoms anorexia nausea and vomiting diarrhea dehydration causing fine tremors hypothyroidism force fluids increase sodium intake to 4 – 10 g% daily Nursing Management 3.9 NaCl to prevent development of crystals or precipitate.1. irritability. . Dilantin Toxicity Signs and Symptoms gingival hyperplasia (swollen gums) hairy tongue ataxia nystagmus provide oral care massage gums Nursing Management 5.8 – 1) hypoglycemia Tremors.
input and output and neuro check * monitor strength or motor grading scale 4. airway 2.The client is unable to see. swallow. Anti Cholenisterase (Neostegmin) Mechanism of Action maintain patent airway and adequate ventilation increase level of Ach PNS Cortocosteroids suppress immune response monitor for 2 types of crisis: CHOLINERGIC CRISIS Cause: .over medication Signs and Symptoms .stress . 8. Incidence rate: women 20 – 40 years old Predisposing factors unknown autoimmune: it involves release of cholinesterase an enzyme that destroys Ach. administer medications as ordered a. Prevent complications . breathe Treatment . maintain side rails to prevent injury related to falls 5. mmobility * assist in mechanical ventilation and monitor pulmonary function test * monitor strictly vital signs. Assist in surgical procedure known as thymectomy because it is believed that the thymus gland is responsible for M. Nursing Management 1. speak. institute NGT feeding 6.Administer anti cholinergic agents (Atropine Sulfate) Side Effects MYASTHENIC CRISIS Causes: .G. Cholinergic (Mestinon) b. initial sign is ptosis a clinical parameter to determine ptosis is palpebral fissure.administer cholinergic agents as ordered 7. Assist in plasma paresis and removing auto immune anti bodies 9. diplipia mask like facial expression dysphagia hoarseness of voice respiratory muscle weakness that may lead to respiratory arrest extreme muscle weakness especially during exertion and morning Tensilon test (Edrophonium Hydrochloride) provides temporary relief of signs and symptoms for about 5 – 10 minutes and a maximum of 15 minutes.under medication . if there is no effect there is damage to occipital lobe and midbrain and is negative for Signs and Symptoms Diagnostic Procedure M. aspiration 3.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.infection Signs and Symptoms .G.PNS Treatment .
Signs and Symptoms headache photophobia projectile vomiting fever. anorexia. Arachnoid – middle layer 3. CSF aspiration is done. Nuchal rigidity or stiff neck b. Meningococcus – most dangerous 2. Place flat on bed 12 – 24 o 2. Secure informed consent and explain procedure. 4. (+) Brudzinski sign (neck pain) D. (+) cultured microorganism (confirms meningitis) CBC reveals 1. Nursing Management for LP Before Lumbar Puncture 1. Check punctured site for any discoloration.INFLAMMATORY CONDITIONS OF THE BRAIN MENINGITIS Meninges 3 fold membrane that covers brain and spinal cord. Hemophilus Influenzae – causes pediatric meningitis B. Etiology 1. Pia matter – inner layer subdural space between the dura and arachnoid subarachnoid space between the arachnoid and pia. general body malaise and weight loss Possible increase in ICP and seizure activity Abnormal posturing (decorticate and decerebrate) Signs of meningeal irritation a. Decrease glucose 3. for support and protection for nourishment blood supply LAYERS OF THE MENINGES 1. Mode of transmission airborne transmission (droplet nuclei) C. Empty bladder and bowel to promote comfort. Assess for movement and sensation of extremities. 3. CSF analysis reveals 1. Post Lumbar Puncture 1. Encourage to arch back to clearly visualize L3-L4. A. chills. Increase CHON and WBC 2. Increase CSF opening pressure (normal pressure is 50 – 100 mmHg) 4. Pneumococcus 3. (+) Kernig’s sign (leg pain) d. Increase wbc . 2. drainage and leakage to tissues. Force fluids 3. Opisthotonus (arching of back) c.causes adult meningitis 4. Diagnostic Procedures Lumbar puncture: a hollow spinal needle is inserted in the subarachnoid space between the L3 – L4 to L5. Dura matter – outer layer 2. Streptococcus .
7. Yellow bone marrow are produced from the medullary cavity of the long bones and produces fat cells. Internal Cerebral Artery – the 2 largest artery A. Anti pyretics 3. Maintain fluid and electrolyte balance. Mid Cerebral Artery b. Provide a comfortable and darkened environment. Incidence Rate men are 2-3 times high risk B. Prevent complications most feared is hydrocephalus hearing loss/nerve deafness is second complication consult audiologist mental retardation delayed psychomotor development c. Maintain good diet of increase CHO. Tetracycline) b. Provide client health care and discharge planning concerning: a. Mild analgesics c. 9. input and output and neuro check 6. 2 most common cerebral artery affected by stroke a. 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. Monitor strictly V/S. 8. Broad spectrum antibiotics (Penicillin. Enforce complete bed rest 2. Institute strict respiratory isolation 24 hours after initiation of anti biotic therapy 4. calories with small frequent feedings. CHON. Institute measures to prevent increase ICP and seizure. Elevate head 30-45o 5. Administer medications as ordered a. Rehabilitation for neurological deficit CVA (STROKE/BRAIN ATTACK/ ADOPLEXY/ CEREBRAL THROMBOSIS) a partial or complete disruption in the brains blood supply. Compartment syndrome (compression of arteries and nerves) .E. Nursing Management 1. If there is bone fracture there is hemorrhage and there would be escape of the fat cells in the circulation. 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. b.
Signs and Symptoms Heart Disease. Myocardial Infarction. Risk Factors 1. TIA Signs and Symptoms 2. deadline driven b. CT Scan – reveals brain lesions 2. homonymous hemianopsia (loss of half of visual field) 1. can do multiple tasks c. Obesity (increase 20% ideal body weight) 4. Valvular Cardiac Surgery (mitral valve replacement) 2. sedentary lifestyle 3. Hyperlipidemia more on genetics/genes that binds to cholesterol 5. phlegia b. Diabetes Mellitus. Diagnostic Procedure 1. 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 . Related stress physical and emotional 8.C. aphasia c. D. alexia (difficulty reading) e. usually fells guilty when not doing anything 6. Prolong use of oral contraceptives promotes lypolysis (breakdown of lipids) leading to atherosclerosis that will lead to hypertension and eventually CVA. Lifestyle (smoking). Atherosclerosis. Hypertension. Complete stroke Signs and Symptoms E. Related to diet: increase intake of saturated fats like whole milk 7. Post dependent on stages of development Initial sign of stroke or warning sign headache and dizziness tinnitus visual and speech disturbances paresis (plegia) possible increase ICP progression of signs and symptoms of stroke resolution phase characterized by: headache and dizziness Cheyne Stokes Respiration anorexia. agraphia (difficulty writing) f. Stroke in evolution 3. dysarthria (inability to articulate words) d. Type A personality a. nausea and vomiting dysphagia (+) Kernig’s sign and Brudzinski sign which may lead to hemorrhagic stroke focal neurological deficits a.
ulcer and unknown cause of headache because it may potentiate bleeding 11. Mild Analgesics e. turn client to side b. avoidance of modifiable risk factors (diet.F. dietary modification (decrease salt. Prevent complications of immobility by: a. magic slate 9. Loop Diuretics (Lasix. Elevate head 30 – 45o 4. Nursing Management 1. Cortecosteroids d. If positive to hemianopsia approach client on unaffected side 10. prevent complication (subarachnoid hemorrhage is the most feared complication) c. Furosemide) c. saturated fats and caffeine) d. Provide client health teachings and discharge planning concerning a. provide egg crate mattresses or water bed c. provide sand bag or food board. Institute NGT feeding 8. Thrombolytic/Fibrinolytic Agents – dissolves thrombus Streptokinase Side Effect: Allergic Reaction Urokinase Tissue Plasminogen Activating Factor Side Effect: Chest Pain f. Anti Platelet PASA (Aspirin) Contraindicated for dengue. smoking) b. give Protamine Sulfate Comadin/ Warfarin (long acting) give simultaneously because Coumadin will take effect after 3 days check for prothrombin time if prolonged there is a risk for bleeding give Vit. importance of follow up care . Monitor strictly vitals signs. Osmotic Diuretics (Mannitol) b. Provide alternative means of communication a. Restrict fluids to prevent cerebral edema that might increase ICP 3. assist in mechanical ventilation b. non verbal cues b. administrate O2 inhalation 2. Maintain patent airway and adequate ventilation by: a. 6. Assist in passive ROM exercise every 4 hours to promote proper bodily alignment and prevent contractures 7. exercise. K (Aqua Mephyton) g. Administer medications as ordered a. Anti Coagulants Heparin (short acting) check for partial thromboplastin time if prolonged there is a risk for bleeding. I & O and neuro check 5.
Zylocaine Bretylium – blocks release of norepinephrine to prevent increase of BP 8. ECG 3. Prevent complications a. intake and output c. Antecedent viral infections such as LRT infections B. . Nursing Management 1. Prevent complications of immobility by turning the client every 2 hours 5. constipation C. Predisposing Factors 1. Arrythmia b. Administer medications as ordered a. Anti Arrythmic Agents Lidocaine. A. Signs and Symptoms 1. Assist in passive ROM exercise 7. 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. Maintain patent airway and adequate ventilation by: a. Monitor strictly the following a. Autoimmune 2. assist in mechanical ventilation b. CSF analysis reveals increase in IgG and protein D. increase salivation b. Autonomic symptoms that includes a. Dysphagia 3. Alternate hypotension to hypertension ** ARRYTHMIA (most feared complication) 6. Decreased of diminished deep tendon reflex 5. Corticosteroids – suppress immune response b. monitor pulmonary function test 2. increase sweating c. Diagnostic Procedures 1. Assist in plasma pharesis (filtering of blood to remove autoimmune anti-bodies) 9. Clumsiness (initial sign) 2. Ascending muscle weakness leading to paralysis 4. neuro check d. vital signs b. Anti Cholinergic Agents – Atrophine Sulfate c. Maintain side rails to prevent injury related to fall 4.GUILLAIN BARRE SYNDROME a disorder of the CNS characterized by bilateral symmetrical polyneuritis leading to ascending muscle paralysis. Institute NGT feeding to prevent aspiration 6.
sensory experience b. Predisposing Factors 1. CT Scan – reveals brain lesions 2. Post ictal sleep – unresponsive sleep 2. clouding of consciousness – not in contact with environment c. Drug of choice: Diazepam. twitching of mouth d. EEG – reveals hyper activity of electrical brain waves . Genetics 3.direct symmetrical extension of extremities Clonic contractions . Signs and Symptoms Dependent on stages of development or types of seizure I. mild hallucinatory sensory experience III. Head injury due to birth trauma 2. Tonic contractions . Nutritional and Metabolic deficiencies 6. Physical and emotional stress 7. loss of consciousness (5 – 10 seconds) II. Grand mal Seizure (tonic-clonic seizure) a. blank stare b. Seizure – first convulsive attack Epilepsy – second or series of attacks Febrile seizure – normal in children age below 5 years A. olfactory. if left untreated can lead to hyperpyrexia and lead to coma and eventually death. Presence of brain tumor 4.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. Diagnostic Procedures 1. Partial or Localized Seizure 1. visual. Toxicity from a. automatism – stereotype repetitive and non propulsive behavior b. Valium and Glucose C. Epileptic cry – is characterized by fall and loss of consciousness for 3 – 5 minutes c. Sudden withdrawal to anti convulsant drug is predisposing factor for status epilepticus (drug of choice is Diazepam. decrease blinking of eyes c. 2. lead b carbon monoxide 5. Psychomotor Seizure (focal motor seizure) a. Generalized Seizure 1. Signs or aura with auditory. Petit mal Seizure – absence of seizure common among pediatric clients characterized by a. Status Epilepticus A continuous uninterrupted seizure activity. Valium) B.contraction of extremities d. tactile. 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.
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
Components 1. Motor response 2. Verbal response 3. Eye opening Conscious Lethargy Stupor Coma Deep Coma 15 – 14 13 – 11 10 – 8 7 3
Survey of mental status and speech a. LOC b. Test of memory Levels of orientation Cranial nerve assessment Sensory nerve assessment Motor nerve assessment Deep tendon reflex Autonimics Cerebellar test a, 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)
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
2. Long term memory
III. LEVELS OF ORIENTATION 1. Time – first asked 2. Person – second asked 3. Place – third asked CRANIAL NERVES CRANIAL NERVES I. OLFACTORY II. OPTIC III OCCULOMOTOR IV. TROCHLEAR V. TRIGEMINAL VI. ABDUCENSE VII. FACIAL VIII. ACOUSTIC IX. GLOSSOPHARYNGEAL X. VAGUS FUNCTION S S M M (Smallest) B (Largest) M B S B B
(Longest) XI. SPINAL ACCESSORY M XII. HYPOGLOSSAL M CRANIAL NERVE I: OLFACTORY
sensory function for smell
don’t use alcohol, ammonia, perfume because it is irritating and highly diffusible. use coffee granules, vinegar, bar of soap, cigarette test each nostril by occluding each nostril
Abnormal Findings 1. Hyposnia – decrease sensitivity to smell 2. Dysosmia – distorted sense of smell 3. Anosmia – absence of smell Indicative of 1. head injury damaging the cribriform plate of ethmoid bone where olfactory cells are located 2. may indicate inflammatory conditions (sinusitis) CRANIAL NERVE II: OPTIC
sensory function for vision or sight
Functions 1. Test visual acuity or central vision or distance
use 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. a. Superiorly b. Bitemporaly c. Nasally d. Inferiorly
2. Test of visual field or peripheral vision
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
Diabetes Mellitus 4. Blurring or hazy vision 2. Retinal Detachment Separation of epithelial surface of retina .Partial removal Intra Capsular Cataract Lens Extraction . Carbonic Anhydrase Inhibitors a. Timoptics (Timolol Maleate) E. Cyclopegics (Cyclogyl) – paralyses cilliary muscle F. Treatment 1. Acetazolamide (Diamox) – promotes increase outflow of aqueous humor or drainage 4. Pilocarpine Sodium. TRABECULECTOMY (Peripheral Indectomy) – drain aqueous humor 2. Epinephrine eyedrops – decrease formation of aqueous humor 3. Loss of central vision C. Decrease perception to colors Complication is blindness D. Cataract Decrease opacity of lens A. Diagnostic Procedure 1. Gonioscopy D. Opthalmoscopic exam E. Mydriatics (Mydriacyl) – constricts pupils 2. Milky white appearance at center of pupils 3. Carbachol 2. Miotics – constricts pupil a. Aging 65 years and above 2.Total removal of cataract with its surrounding capsules Most feared complication post op is RETINAL DETACHMENT 3. Surgical Procedure Extra Capsular Cataract Lens Extraction . Surgical Procedures 1. Treatment 1. Pathognomonic Signs 1. Signs and Symptoms 1. Related to congenital 3. Predisposing Factor 1.3. Prolonged exposure to UV rays B.
maxillary. Predisposing Factors 1. Post Lens Extraction 2. TROCHLEAR. Scleral Buckling 2. IV. mandibular . ABDUCENS Controls or innervates the movement of extrinsic ocular muscle (EOM) 6 muscles Superior Rectus Superior Oblique Lateral Rectus Medial Rectus Inferior Oblique Inferior Rectus trochlear controls superior oblique abducens controls lateral rectus oculomotor controls the 4 remaining EOM Oculomotor controls the size and response of pupil normal pupil size is 2 – 3 mm equal size of pupil: Isocoria Unequal size of pupil: Anisocoria Normal response: positive PERRLA CRANIAL NERVE V: TRIGEMINAL largest cranial nerve consists of ophthalmic. Curtain veil like vision 2. Signs and Symptoms 1. Cryosurgery – cold application 3. Myopia (near sightedness) B. Floaters C. Diathermy – heat application 4.A. Macular Degeneration Degeneration of the macula lutea (yellowish spot at the center of retina) A. Black Spots CRANIAL NERVE III. Surgical Procedures 1. VI: OCULOMOTOR. Signs and Symptoms 1.
X: GLOSOPHARYNGEAL. teeth. frown and if results are negative there is facial paralysis or Bell’s Palsy and the primary cause is forcep delivery. Middle Ear 3. refers to movement and orientation of the body in space. CRANIAL NERVE VIII: ACOUSTIC/VESTIBULOCOCHLEAR Controls balance particularly kinesthesia or position sense. 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. 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. Inner Ear Vestibule: Meinere’s Disease Cochlea Mastoid Cells Endolymph and Perilymph COCHLEA: controls hearing. Parts of the Ear 1. ENDOCRINE SYSTEM Overview of the structures and functions 1. contains the Organ of Corti (the true organ of hearing) Let client repeat words uttered CRANIAL NERVE IX. Pituitary Gland (Hypophysis Cerebri) . VAGUS NERVE Glosopharyngeal: controls taste. sensory: controls sensation of face. soft palate and corneal reflex) motor: controls the muscle of mastication or chewing damage to CN V leads to trigeminal neuralgia/thickdolorum medication: Carbamezapine(Tegretol) CRANIAL NERVE VII: FACIAL Sensory: controls taste. Outer Ear Pinna Eardrum Hammer Anvil Stirrup Malleus Incus Stapes 2. mucous membrane.
Weakness and fatigue 4. Polyuria 2. Poor Skin turgor d. Adult: thirst b. Pitressin (Vasopresin Tannate) – administered IM Z-tract 4. Force fluids 2. Diagnostic Procedures 1. Predisposing Factor o o o o 1. Nursing Management . If left untreated results to hypovolemic shock (sign is anuria) C. initiates milk let down reflex with help of hormone prolactin called as adenohypophysis called as neurohypophysis secretes hormones oxytocin -promotes uterine contractions preventing bleeding/ 2. Hypotension 5. Posterior Pituitary Gland 2. Dry mucous membrane 3. Administer medications as ordered a.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. Signs of dehydration a. Urine Specific Gravity o o o 1. Weight loss 6.030 Ph 4 – 8 Increase resulting to hypernatremia Related to pituitary surgery Trauma Inflammation Presence of tumor B. Agitation c. Antidiuretic Hormone o o o Pitressin (Vasopressin) Function: prevents urination thereby conserving water Diabetes Insipidus/ Syndrome of Inappropriate Anti Diuretic Hormone DIABETES INSIPIDUS o Decrease production of anti diuretic hormone A. Anterior Pituitary Gland o o o hemorrhage o o administrate oxytocin immediately after delivery to prevent uterine atony. Serum Sodium D. Signs and Symptoms 2. Prevent complilcations – HYPOVOLEMIC SHOCK is the most feared complication Normal value: 1.015 – 1. Monitor strictly vital signs and intake and output 3.
Fluid retention a. Water intoxication may lead to cerebral edema and lead to increase ICP – may lead to seizure activity C. Diagnostic Procedure 1. Hypertension b. Signs and Symptoms 1. Predisposing Factors 1. Weight gain 2. B. Lead to blindness due to severe photophobia b. Melanocyte Stimulating hormone o o o for skin pigmentation Hyposecretion of MSH results to Albinism Most feared complications of albinism a. Loop diuretics (Lasix) b. Adrenochorticotropic hormone (ACTH) o promotes development of adrenal cortex . Head injury 2. Related to hyperplasia (increase size of organ brought about by increase of number of cells) of pituitary 2.SIADH o hypersecretion of anti diuretic hormone A. Osmotic diuretics (Mannitol) 3. Monitor strictly vital signs. Related to presence of bronchogenic cancer o o gland. Urine specific gravity is increased 2. Weigh patient daily and assess for pitting edema 5. Nursing Management 1. Edema c. Administer medications as ordered a. Serum Sodium is decreased D. Growth hormones (somatotropic hormone) o o o o o initial sign of lung cancer is non productive cough non invasive procedure is chest x-ray 3. Provide meticulous skin care 6. Prone to skin cancer o Hypersecretion of MSH results to Vitiligo 3. intake and output and neuro check 4. Prevent complications ANTERIOR PITUITARY GLAND o also called ADENOHYPOPHYSIS secretes 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. Restrict fluid 2.
carrots. all nuts soil erosion washes away iodine . Mountainous regions 2. broccoli. Increase intake of goitrogenic foods o o o contains pro-goitrin an anti thyroid agent that has no iodine. cabbage. sweet potato. places far from sea b. Thyroxine) o o T3 and T4 are metabolic or calorigenic hormone promotes cerebration (thinking) 3. Leutinizing hormone 6.4. turnips. 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) . Lactogenic homone (Prolactin) o o o o promotes development of mammary gland with help of oxytocin it initiates milk let down reflex secretes estrogen secretes progesterone 5. Goiter belt area a. Predisposing Factors 1.3 molecules of iodine (more potent) 2. Thyrocalcitonin – antagonizes the effects of parathormone to promote calcium resorption. HYPOTHYROIDISM 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 cold intolerance constipation Signs and Symptoms HYPERTHYROIDISM o o o o all are increase except weight and menstruation increase appetite but there is weight loss amenorrhea exophthalmos Signs and Symptoms THYROID DISORDERS SIMPLE GOITER o enlargement of thyroid gland due to iodine deficiency A. T4 (tetra iodothyronine. radish. strawberry.
iodized salt. Enlarged thyroid gland 2. Serum Thyroid Stimulating Hormone (TSH) – is increased (confirmatory diagnostic test) D. 4 Medications to be taken via straw: Lugol’s. Diagnostic Procedures 1. Instruct client to take in the morning to prevent insomnia 2. Signs and Symptoms 1. 3. Mild restlessness C. Serum T3 and T4 – reveals normal or below normal 2. Nitrofurantoin (drug of choice for pyelonephritis) b. best taken raw because it it is easily destroyed by heat 5. crabs. Thyroid Hormones o o o Levothyroxine (Synthroid) Liothyronine (Cytomel) Thyroid Extracts Nursing Management when giving Thyroid Hormones 1. Increase dietary intake of foods rich in iodine A. Enforce complete bed rest 2. Nursing Management 1. Tetracycline. Predisposing Factors 1. PASA (Aspirin) d. Phenylbutazones (NSAIDs) . Iron. Monitor vital signs especially heart rate because drug causes tachycardia and palpitations 3. Thyroid Scan – reveals enlarged thyroid gland. Lithium Carbonate c. 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. Iatrogenic Cause – disease caused by medical intervention such as surgery 2.o goitrogenic drugs a. Related to atrophy of thyroid gland due to trauma. Anti Thyroid Agent – Prophylthiuracil (PTU) b. Cobalt e. Mild dysphagia 3. Monitor side effects o o o o o o o insomnia tachycardia and palpitations hypertension heat intolerance seaweeds seafood’s like oyster.if goiter is caused by B. inflammation . 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. presence of tumor. clams and lobster but not shrimps because it contains lesser amount of iodine.
Provide dietary intake that is low in calories 6. Monitor strictly vital signs and intake and output to determine presence of o o Myxedema coma is a complication of hypothyroidism and an emergency case a severe form of hypothyroidism is characterized by severe hypotension. hypothermia leading to pregressive stupor and coma. Serum Cholesterol is increased 3. Avoid precipitating factors leading to myxedema coma o o stress infection Assist in mechanical ventilation Administer thyroid hormones as ordered Force fluids . Leothyronine c. Autoimmune (Hashimotos Disease) B. hypoglycemia. bradypnea. Weakness and fatigue 2. Provide meticulous skin care 8. hyponatremia. hypothermia 6. bradycardia. Provide comfortable and warm environment 7. Force fluids 3. Non pitting edema (Myxedema) 3. bradypnea. Levothyroxine b. Decrease libido 5. Iodine deficiency 4. bradycardia. Hoarseness of voice 4. Decrease in all vital signs – hypotension. Diagnostic Procedures 1. Administer medications as ordered Thyroid Hormones a.3. Cold intolerance 5. CNS changes o o o o lethargy memory impairment psychosis menorrhagia C. RAIU (Radio Active Iodine Uptake) is decreased D. Serum T3 and T4 is decreased 2. Brittleness of hair and nails 2. Provide client health teaching and discharge planning concerning a. Nursing Management for Myxedema Coma 2. hypoventilation. Signs and Symptoms (Early Signs) 1. Constipation (Late Signs) 1. Administer isotonic fluid solution as ordered 4. Nursing Management 1. Loss of appetite but with weight gain which promotes lipolysis leading to atherosclerosis and MI 3. Dry skin 4. Thyroid Extracts 5.
Diarrhea 5. Exopthalmus 9. Amenorrhea C. All vital signs are increased 6. narcotics. Irritability and agitation b. Diagnostic Procedures 1. Predisposing Factors 1. Administer medications as ordered Anti Thyroid Agent a. Goiter 8. Nursing Management 1.reveals an enlarged thyroid gland D. Comfortable and cold environment 6. Monitor strictly vital signs and intake and output 2. RAIU (Radio Active Iodine Uptake) is increased 3. and sedatives prevent complications (myxedema coma. Heat intolerance 4.o o o o o o o o cold intolerance use of anesthetics. 4. Provide meticulous skin care 5. hypovolemic shock hormonal replacement therapy for lifetime importance of follow up care increase in T3 and T4 Grave’s Disease or Thyrotoxicosis developed by Robert Grave HYPERTHYROIDISM A. Signs and Symptoms 1. Restlessness c. CNS involvement a. Autoimmune – it involves release of long acting thyroid stimulator causing exopthalmus (protrusion of eyeballs) enopthalmus (late sign of dehydration among infants) 2. Related to hyperplasia (increase size) B. Serum T3 and T4 is increased 2. Prophythioracill (PTU) b. Moist skin 3. Insomnia e. Hallucinations 7. Increase appetite (hyperphagia) but there is weight loss 2. Maintain side rails . Provide dietary intake that is increased in calories. Excessive iodine intake 3. Tremors d. Methymazole (Tapazole) Side Effects of Agranulocytosis o o o o increase lymphocytes and monocytes fever and chills sore throat (throat swab/culture) leukocytosis (CBC) 3. Thyroid Scan.
Importance of follow up care PARATHYROID GLAND o o o o o A pair of small nodules behind the thyroid gland Secretes parathormone Promotes calcium reabsorption Hypoparathyroidism Hyperparathyroidism HYPOPARATHYROIDISM o o Decrease secretion of parathormone leading to hypocalcemia Resulting to hyperphospatemia . seizure give Calcium Gluconate IV slowly as ordered 3. Provide bilateral eye patch to prevent drying of the eyes. POST OPERATIVELY. 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. Hormonal replacement therapy for lifetime 6. Beta-blockers o o o monitor strictly vital signs. Watch out for accidental Laryngeal damage which may lead to hoarseness of voice Nursing Management o encourage client to talk/speak immediately after operation and notify physician 4. 8. Signs of bleeding (feeling of fullness at incisional site) Nursing Management o Check the soiled dressings at the back or nape area. 1. maintain side rails offer TSB Tachycardia 2. 5. Anti Pyretics b. input and output and neuro check. Watch out for signs of thyroid storm/ thyrotoxicosis Agitation TRIAD SIGNS Hyperthermia o administer medications as ordered a. Watch out for accidental removal of parathyroid gland that may lead to Hypocalcemia (tetany) Signs and Symptoms o o o (+) trousseau’s sign (+) chvostek sign Watch out for arrhythmia.7.
Phosphate binder Aluminum Hydroxide Gel (Ampogel) Side effect: constipation ANTACID A. X-ray of long bones reveals a decrease in bone density 4.5 – 4. Serum Phosphate is decreased (normal value: 2. Vitamin D (Cholecalciferol) for absorption of calcium CHOLECALCIFEROL ARE DERIVED FROM Drug Diet (Calcidiol) Sunlight (Calcitriol) feared complications d.5 – 11 mg/100 ml) 2. photophobia and cataract formation b. Acute tetany a. agitation and memory impairment C. paresthesia c. seizure i.C MAD . Following subtotal thyroidectomy 2. inflammation b. Acute Tetany Calcium Gluconate IV slowly b. positive chvostek sign g.A. tumor c. arrhythmia 2. anorexia. CT Scan – reveals degeneration of basal ganglia D. nausea and vomiting d. tingling sensation b. Administer medications as ordered such as: a. Chronic tetany a. Chronic Tetany Oral Calcium supplements Calcium Gluconate Calcium Lactate Calcium Carbonate c. Diagnostic Procedures 1. Signs and Symptoms 1. numbness d. positive trousseu’s sign/carpopedal spasm f. trauma B.A. laryngospasm/broncospasm h. dysphagia e. Serum Calcium is decreased (normal value: 8. Predisposing Factors 1. Atrophy of parathyroid gland due to: a.5 mg/100 ml) 3. loss of tooth enamel c. Nursing Management 1.
anchovies b. X-ray of long bones reveals bone demineralization D. HYPERTHYROIDISM o o o Decrease parathormone Hypercalcemia: bone demineralization leading to bone fracture (calcium is stored 99% in bone and 1% blood) Kidney stones A. Morphine Sulfate (Demerol) 5. Encourage increase intake of foods rich in phosphate but decrease in calcium 6. Force fluids to prevent kidney stones 2. 6. Kidney stones a.▼ Aluminum Containing Antacids ▼ Aluminum Hydroxide Gel ▼ Side Effect: Constipation ▼ Magnesium Containing Antacids ▼ Side Effect: Diarrhea 2. Importance of follow up care. Hyperplasia of parathyroid gland 2. Provide warm sitz bath 4. Provide acid ash in the diet to acidify urine and prevent bacterial growth 7. Children: Ricketts b. Bone pain especially at back (bone fracture) 2. renal cholic b. Institute seizure and safety precaution 5. Assist/supervise in ambulation 8. Prevent complications 8. nausea and vomiting 4. Predisposing Factors 1. Agitation and memory impairment C. Encourage client to breathe using paper bag to produce mild respiratory acidosis result. Administer medications as ordered a. salmon c. Avoid precipitating stimulus such as glaring lights and noise 3. Nursing Management 1. Anorexia. Maintain side rails . Adults: Osteomalacia B. Strain all the urine using gauze pad for stone analysis 3. Serum Phosphate is decreased 3. Encourage increase intake of foods rich in calcium a. Serum Calcium is increased 2. Diagnostic Procedures 1. Over compensation of parathyroid gland due to vitamin D deficiency a. Signs and Symptoms 1. Prepare trache set at bedside for presence of laryngo spasm 7. Hormonal replacement therapy for lifetime 9. green turnips 4. cool moist skin 3.
secretes mineralocorticoids (aldosterone) . Adrenal Cortex – outermost b. Hypoglycemia – TIRED 2.hypotension . fluid and electrolyte imbalance – Salt c. Decrease tolerance to stress 3. Predisposing Factors 1. Zona Reticularis .secretes traces of glucocorticoids and androgenic hormones . Signs and Symptoms 1.function: promotes sodium and water reabsorption and excretion of potassium . Zona Glumerulosa . Hormonal replacement therapy for lifetime 12.signs of dehydration .secretes glucocortocoids (cortisol) . Related to atrophy of adrenal glands 2.weight loss . Importance of follow up care ADRENAL GLAND o o Located atop of each kidney 2 layers of adrenal gland a.Sex 3.9. Assist in surgical procedure known as parathyroidectomy 11.Salt ADDISON’S DISEASE o Hyposecretion of adreno cortical hormone leading to a. Hyponatremia . Fungal infections B. Zona Fasciculata . Adrenal Medulla – innermost (secretes catecholamines a power hormone) 2 Types of Catecholamines o o o o o Epinephrine and Norepinephrine (vasoconstrictor) Pheochromocytoma (adrenal medulla) Increase secretion of norepinephrine Leading to hypertension which is resistant to pharmacological agents leading to CVA Use beta-blockers ADRENAL CORTEX 3 Zones/Layers 1.function: controls glucose metabolism .Sugar 2. metabolic disturbance – Sugar b. deficiency of neuromuscular function – Salt/Sex A.function: promotes secondary sex characteristics . Prevent complications (seizure and arrhythmia) 10.
Bronze like skin pigmentation C. Mineralocorticoids (Flourocortisone) 5.4. Plasma Cortisol is decreased 3. Provide meticulous skin care 7. Prednisone c. Diagnostic Procedures 1. Hyperkalemia . Serum Sodium is decrease (normal value: 135 – 145 meq/L) 4. severe hypotension b. 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. carbohydrates.agitation . Force fluids 4.5 – 4. FBS is decreased (normal value: 80 – 100 mg/dl) 2.arrhythmia 5. Monitor strictly vital signs. moon face appearance 4. hypertension b. Dexamethasone (Decadrone) b. hypovolemic shock c. Nursing Management 1. increase calories. Provide client health teaching and discharge planning a. Assist in mechanical ventilation.hypovolemic shock . . Loss of pubic and axillary hair 7.administer steroids as ordered .diarrhea . Instruct client to take 2/3 dose in the morning and 1/3 dose in the afternoon to mimic the normal diurnal rhythm 2. protein but decrease in potassium 6. Serum Potassium is increased (normal value: 3.stress .5 meq/L) D. Hydrocortisone (Cortison) Nursing Management when giving steroids 1.sudden withdrawal to steroids b. edema c. Administer isotonic fluid solution as ordered 3. prevent complications . increase susceptibility to infection e. hirsutism d.addisonian crisis . avoid precipitating factor leading to addisonian crisis leading to . Administer medications as ordered Corticosteroids a.infection . hyponatremia leading to progressive stupor and coma Nursing Management for Addisonian Crisis 1. Taper dose (withdraw gradually from drug) 3. Provide dietary intake.force fluids 2. Monitor side effects a. Decrease libido 6.
Serum Sodium is increased 4. Acne and striae 7. hormonal replacement for lifetime d. hypertension b. Assist in surgical procedure (bilateral adrenoraphy) 9. weakness and fatigue b. U wave upon ECG (T wave hyperkalemia) 5. Hormonal replacement for lifetime 10. Prevent complications (DM) 8. Easy bruising 8. pendulous abdomen g.Mixed gland (exocrine and endocrine) . Weigh patient daily and assess for pitting edema 3. Provide meticulous skin care 6. FBS is increased 2. Administer medications as ordered a. Predisposing Factors 1 Related to hyperplasia of adrenal gland 2. Serum Potassium is decreased C. importance of follow up care CUSHING SYNDROME o Hypersecretion of adenocortical hormones A. thin extremities 4. Spinarolactone – potassium sparring diuretics 7. moon face appearance and buffalo hump e. Importance of follow up care PANCREAS . Hirsutism 6. Nursing Management 1. obese trunk f. Increase masculinity among females B. Measure abdominal girth daily and notify physician 4.c. Increase susceptibility to infections 3. Hypernatremia a. edema c. Hypokalemia a. Diagnostic Procedures 1.Located behind the stomach . Monitor strictly vital signs and intake and output 2. weight gain d. Plasma Cortisol is increased 3. constipation c. Restrict sodium intake 5.
Predisposing Factors 1. Glucosuria 5. Insulin therapy 2. Predisposing Factors 1.90% of general population has type 2 DM B. Pancreatitis DIABETES MELLITUS . Polyphagia 5. Exercise E. Coma C. Hyper 2. Anorexia.Delta cells secretes somatostatin (function: antagonizes the effects of growth hormones) 3 Main Disorders of Pancreas 1. Oral Hypoglycemic agents 2. Pancreatic Tumor/Cancer 2. Non 4.10% general population has type 1 DM B. Polyuria 3. Blurring of vision 8.Beta cells secretes insulin (function: hypoglycemia) .Brittle disease A. Signs and Symptoms 1. Delayed/poor wound healing D. Drugs a. Usually asymptomatic 2. Polydypsia 3. Related to carbon tetrachloride toxicity C. Diabetes Mellitus 3.Maturity onset type . Polyphagia 4. nausea and vomiting 7. Related to viruses 3. Signs and Symptoms 1. Increase susceptibility to infection 9. Osmolar 3.Obese over 40 years old A.metabolic disorder characterized by non utilization of carbohydrates. Hereditary (total destruction of pancreatic cells) 2. Polyuria 2. Obesity – because obese persons lack insulin receptor binding sites .Consist of acinar cells which secretes pancreatic juices that aids in digestion thus it is an exocrine gland . Diet 3. Incidence Rate .Consist of islets of langerhans . Weight gain Type 2 (NIDDM) . Ketotic 5. Complication 1.. Incidence Rate .Has alpha cells that secretes glucagons (function: hyperglycemia) . Lasix b. Exercise E. Treatment 1. Diet 3. Weight loss 6. Steroids 4. Treatment 1.Juvenile onset type . Diabetic Ketoacidosis D. Polydypsia 4.Adult onset . Complications 1. protein and fat metabolism CLASSIFICATION OF DM Type 1 (IDDM) . Glucosuria 6.
Fats ANABOLISM CATABOLISM Glucose Amino Acids Fatty Acids Glycogen Nitrogen Free Fatty Acids .Cholesterol . Protein 3.MAIN FOODSTUFF 1. Carbohydrates 2.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 .
Infection B. Sodium Bicarbonate to counteract acidosis c. Hct (normal value: female 36 – 42. Nursing Management 1. Monitor strictly vital signs. Predisposing Factors 1. Diagnostic Procedures 1. Antibiotics to prevent infection HYPER OSMOLAR NON KETOTIC COMA . Weight loss 6. Polydypsia 3.9 NaCl followed by .Hyperosmolar: increase osmolarity (severe dehydration) . Seizure activity 4. Kussmaul’s Respiration (rapid shallow breathing) 10 CNS depression leading to coma C. Signs and Symptoms 1. Decrease LOC – diabetic coma . Administer 0. Signs and Symptoms 1.Non ketotic: absence of lypolysis (no ketones) A. Stress – number one precipitating factor 3. Blurring of vision 8.DIABETIC KETOACIDOSIS . Insulin therapy (regular acting insulin/rapid acting insulin peak action of 2 – 4 hours) b. BUN (normal value: 10 – 20) 3. male 42 – 48) due to severe dehydration D. Restlessness 3. Polyphagia 4. Administer medications as ordered a. Anorexia. Headache and dizziness 2. Acetone breath odor 9.8 – 1) 4. Glucosuria 5. Assist in mechanical ventilation 2. Polyuria 2. nausea and vomiting 7. intake and output and blood sugar levels 4. Creatinine (normal value: . Hyperglycemia 2.Acute complication of type 1 DM due to severe hyperglycemia leading to severe CNS depression A. FBS is increased 2.45 NaCl (hypotonic solutions) to counteract dehydration and shock 3.
10.Rarely used because it can cause severe allergic reaction .Frequently used type because it has less antigenicity property thus less allergic reaction 3.Ultra Lente . Use gauge 25 – 26 needle 5. Sources of Insulin 1. Antibiotics to prevent infection INSULIN THERAPY A. Administer 0.Peak action is 8 – 16 hours 3. Intermediate Acting Insulin (cloudy) . Long Acting Insulin (cloudy) . Allergic reactions b. Administer insulin either 45o – 90o depending on amount of clients tissue deposit 6.45 NaCl (hypotonic solutions) to counteract dehydration and shock 3. Artificially Compound Insulin B. First Generation Sulfonylureas a. Monitor for signs of local complications such as a. Administer medications as ordered a. Lipodystrophy c. Rapid Acting Insulin (clear) . Most accessible route is abdomen 9. Monitor strictly vital signs. hypertrophy of subcutaneous tissues) 2. Nursing Management for Insulin Injections 1.Stimulates the pancreas to secrete insulin A. Animal sources . intake and output and blood sugar levels 4. Tolbutamide (Orinase) . Administer at room temperature to prevent development of lipodystrophy (atrophy. Place in refrigerator once opened 3.9 NaCl followed by . No need to aspirate upon injection 7. Assist in mechanical ventilation 2.for DKA use rapid acting insulin b. Classsification 1.Peak action is 2 – 4 hours 2. Avoid shaking insulin vial vigorously instead gently roll vial between palm to prevent formation of bubbles 4. Rotate insulin injection sites to prevent development of lipodystrophy 8. Somogyis Phenomenon – rebound effect of insulin characterized by hypoglycemia to hyperglycemia ORAL HYPOGLYCEMIC AGENTS . Human Sources . Nursing Management 1.Peak action is 16 – 24 hours C.B. Chlorpropamide (Diabenase) b.Regular acting insulin (IV only) . Insulin therapy (regular acting insulin peak action of 2 – 4 hours) . Types of Insulin 1. When mixing 2 types of insulin aspirate first the clear insulin before cloudy to prevent contaminating the clear insulin and promote proper calibration.Derived from beef and pork 2.Non Protamine Hagedorn Insulin (NPH) .
polyphagia and glucosuria confirmatory for DM) 2. Blood Vessels III.for hyperglycemia (dry and warm skin) 5. FBS is increased (3 consecutive times with signs or polyuria. assist in surgical wound debriment (give analgesics 15 – 30 mins prior) 9.for hypoglycemia (cold and clammy skin) give simple sugars . Microangiopathy (affects small minute blood vessels of eyes and kidneys) EYES -PREMATURE CATARACT . Diagnostic Procedures 1. Glipzide (Glucotrol) b. instruct client to avoid wearing constrictive garments d. instruct client to cut toenails straight c. Diabeta (Micronase) Nursing Management when giving OHA 1.sexual impotence 8. Provide nutritional intake of diabetic diet that includes: carbohydrates 50%.administer simple sugars . Monitor for signs of hypoglycemia and hyperglycemia . CVA) b. HPN and DM major cause of renal failure d. Blood Forming Organs . Monitor strictly vital signs. MI.c. Instruct the client to take it with meals to lessen GIT irritation and prevent hypoglycemia 2. encourage client to apply lanolin lotion to prevent skin breakdown e. Alpha Glycosylated Hemoglobin is increased C.Renal failure c. Assist in surgical procedure HEMATOLOGICAL SYSTEM I. intake and output and blood sugar levels 4. Oral glucose tolerance test is increased – most sensitive test 4. Instruct the client to avoid taking alcohol because it can lead to severe hypoglycemia reaction or Disulfiram (Antabuse) toxicity symptoms B. instruct client to avoid walking barefooted b. Atherosclerosis (HPN. Instruct client to exercise best after meals when blood glucose is rising 7. Institute foot care management a. Tolamazide (Tolinase) 2. Gangrene formation e. Monitor for peak action of insulin and OHA and notify physician 2. Blood II. Monitor for signs of DKA and HONKC 11. Instruct client to have an annual eye and kidney exam 10. Nursing Management 1. Monitor signs for complications a. Shock due to dehydration .diarrhea/constipation . Random Blood Sugar is increased 3. Administer insulin and OHA therapy as ordered 3.Blindness KIDNEY -RECURRENT PYELONEPHRITIS . polydypsia. protein 30% and fats 20% or offer alternative food substitutes 6.peripheral neuropathy . Second Generation Sulfonylureas a.
Liver 3.Maintains osmotic pressure preventing edema GLOBULINS . Bone Marrow ALBUMIN . vitamin b12 (cyanocobalamin) e.Gamma globulins a.Beta globulins – iron and copper . folic acid b.normal value: 4 – 6 million/mm3 .for parasite infections . Globulins 3. anti-bodies and immunoglobulins b. bilirubin and hormones .only unnucleated cell .largest WBC .transport steroids.consist of molecules of hgb (red pigment) bilirubin (yellow pigment) biliverdin (green pigment) hemosiderin (golden brown pigment) .responsible for the release of chemical mediation for inflammation 3. Polymorphonuclear Basophils .transports and carries oxygen to tissues .for allergic reaction B. RBC (ERYTHROCYTES) .hematocrit red cell percentage in wholeblood .biconcave discs . prothrombin and fibrinogen clotting factors FORMED ELEMENTS 1.hemoglobin: normal value female 12 – 14 gms% male 14 – 16 gms% . Non Granulocytes 1. Granulocytes 1. vitamin c d.macrophage in blood . Lymphoid Organ 5.involved in short term phagocytosis for acute inflammation 2.60 – 70% of WBC . WBC (LEUKOCYTES) .normal value: female 36 – 42% male 42 – 48% . Polymorphonuclear Eosinophils . Prothrombin and Fibrinogen 1. Spleen 4. Monocytes . vitamin b6 (pyridoxine) f.55% Plasma Serum 45% Formed 1. Albumin 2. iron c. Arteries 2.substances needed for maturation of RBC a.Normal life span of RBC is 80 – 120 days and is killed in red pulp of spleen 2. Lymph Nodes 6.Alpha globulins . Veins Plasma CHON (formed in liver) 1.Largest and numerous plasma CHON .normal value: 5000 – 10000/mm3 A. intrinsic factor . Polymorpho Neutrophils .
Promotes hemostasis (prevention of blood loss) .bone marrow . Heavy menstruation b. Kaposi’s Sarcoma 2. Chronic blood loss due to trauma a. Related to GIT bleeding resulting to hematemesis and melena (sign for upper GIT bleeding) c.ELISA . Incidence Rate 1.000/mm3 .Normal life span of platelet is 9 – 12 days Signs of Platelet Dysfunction 1.Consist of immature or baby platelets or megakaryocytes which is the target of dengue virus . Related to poor nutrition B. Lymphocytes B-cell T-cell . Related to malabsorption syndrome c.. Signs and Symptoms 1. Common among women 15 – 35 years old 4. Common among developed countries 2.000 – 450. Predisposing Factors 1. Subtotal gastrectomy 4. Headache and dizziness . Related to improper cooking of foods C. Common among tropical zones 3.6 months window period . High cereal intake with low animal protein digestion d. Oozing of blood from venipunctured site BLOOD DISORDERS Iron Deficiency Anemia . Usually asymptomatic 2. Pneumocystis Carinii Pneumonia 3. Weakness and fatigue (initial signs) 3. fresh blood per rectum is called hematochezia 2.western blot opportunistic .anti viral and anti tumor property HIV . Petechiae 2.Normal value: 150.6 months – 5 years incubation period .drug of choice AZT (Zidon Retrovir) 2 Common fungal opportunistic infection in AIDS 1.thymus for immunity Natural killer cell .A chronic microcytic anemia resulting from inadequate absorption of iron leading to hypoxemic tissue injury A. Echhymosis 3.involved in long term phagocytosis for chronic inflammation 2. Chronic diarrhea b. Inadequate intake of iron due to a. Platelets (THROMBOCYTES) .
Atropic Glossitis (inflammation of tongue) . Brittleness of hair and spoon shape nails (koilonychias) 8. Reticulocyte is decreased 6. Enforce CBR so as not to over tire client 3. Diagnostic Procedures 1. Diarrhea/constipation e. Hgb is decreased 3. stool and GIT 2. Instruct the client to avoid taking tea and coffee because it contains tannates which impairs iron absorption 5. Legumes g. Administer medications as ordered Oral Iron Preparations a. Pain at injection site PLUMBER VINSON’S SYNDROME .Dysphagia 9.Tetracycline . Ferrous Sulfate b. Iron is decreased 5. PICA (abnormal appetite or craving for non edible foods D.Stomatitis . Nausea and vomiting c. discoloration and leakage to tissues 2. Instruct client to take with meals to lessen GIT irritation 2. Avoid massaging the injection site instead encourage to ambulate to facilitate absorption 3. Palpitations 7.300 mg/day Nursing Management when taking oral iron preparations 1. Nursing Management 1. Administer with Vitamin C or orange juice for absorption 4. Administer Z tract technique to prevent discomfort.Lugol’s solution . When diluting it in liquid iron preparations administer with straw to prevent staining of teeth Medications administered via straw . Ferritin is decreased E. Pallor and cold sensitivity 5. Raisin d. Anorexia b. Sweet potatoes e. If client cant tolerate/no compliance administer parenteral iron preparation a. Iron Dextran (IM. Sorbitex (IM) Nursing Management when giving parenteral iron preparations 1. Hct is deceased 4. Ferrous Gluconate . Melena 5. Monitor and inform client of side effects a. Monitor side effects a.Iron . Nuts 4.Nitrofurantoin (Macrodentin) 3. Dried fruits f.4. Monitor for signs of bleeding of all hema test including urinw. Egg (yolk) c. Ferrous Fumarate c. Instruct client to take foods rich in iron a. IV) b. Dyspnea 6. Organ meat b. RBC is decreased 2. Abdominal pain d.
Inflammatory disorders of the ileum 4. Weakness and fatigue 2. Lymphadenopathy d. Dyspnea and palpitations as part of compensation 5. mouth sore b.b. Fever and chills e. Skin rashes f.Never given orally because there is possibility of developing tolerance Secretes hydrochloric acid ▼ Aids in digestion . jaundice 6. Signs and Symptoms 1. paresthesia d. result to psychosis C. tingling sensation b. Localized abscess c. red beefy tongue c. Strictly vegetarian diet STOMACH ▼ Pareital cells/ Argentaffin or Oxyntic cells Produces intrinsic factors ▼ Promotes reabsorption of Vit B12 ▼ Promotes maturation of RBC B. Nursing Management 1. CNS changes a. Hereditary factors 3. GIT changes that includes a. Pruritus/orticaria g. Hypotension (anaphylactic shock) PERNICIOUS ANEMIA . Subtotal gastrectomy 2. Diagnostic Procedure Schilling’s Test – reveals inadequate/decrease absorption of Vitamin B12 D.Chronic anemia characterized by a deficiency of intrinsic factor leading to hypochlorhydria (decrease hydrochloric acid secretion) A. Predisposing Factors 1. weight loss e. numbness c. Enforce CBR 2. positive to Romberg’s test – damage to cerebellum resulting to ataxia e. Administer Vitamin B12 injections at monthly intervals for lifetime as ordered . Pallor and cold sensitivity 4. Headache and dizziness 3. Autoimmune 5. indigestion/dyspepsia d.
Methotrexate (Alkylating Agent) b. Thrombocytopenia a. fever Decrease WBC (leucopenia) Decrease Platelet (thrombocytopenia) . Enforce CBR 5. Related to irradiation/exposure to x-ray 3. vitamin c and iron 4. Leukopenia a.Site of injection for Vitamin B12 is dorsogluteal and ventrogluteal . Monitor for signs of infection a.Stem cell disorder leading to bone marrow depression leading to pancytopenia PANCYTOPENIA Decrease RBC (anemia) A. Pallor and cold sensitivity d. protein. Headache and dizziness c. Predisposing Factors 1. CBC reveals pancytopenia 2. Institute reverse isolation 6. Immunologic injury 4. Petechiae (multiple petechiae is called purpura) b. Provide a dietary intake that is high in carbohydrates. Dyspnea and palpitations 2. Drugs Broad Spectrum Antibiotics a. Diagnostic Procedures 1. Instruct client to avoid irritating mouth washes instead use soft bristled toothbrush 5. Chemicals (Benzine and its derivatives) 2. Nursing Management 1. Increase susceptibility to infection 3. Weakness and fatigue b. Ecchymosis c. Anemia a. Chloramphenicol (Sulfonamides) Chemotherapeutic Agents a. Avoid heat application to prevent burns APLASTIC ANEMIA . Nitrogen Mustard (Antimetabolite) Phenylbutazones (NSAIDS) B. Bone marrow biopsy/aspiration (site is the posterior iliac crest) – reveals fat necrosis in bone marrow D. Vincristine (Plant Alkaloid) c. Institute BT as ordered 3. Signs and Symptoms 1. Oozing of blood from venipunctured sites C. Removal of underlying cause 2..No side effects 3. Administer oxygen inhalation 4.
Opthamoscopic exam reveals sub retinal hemorrhages D. Avoid IM.b. Monitor NGT output 9. 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. Administer medications as ordered a. Pregnancy B. Prevent complication . cough 7. Pitressin/ Vasopresin to conserve fluids c. Instruct client to use electric razor when shaving 10. Institute NGT decompression by performing gastric lavage by using ice or cold saline solution of 500 – 1000 ml 8. Related to rapid blood transfusion 2. Provide heparin lock 7. Ecchymosis 3. Massive trauma 4. Anaphylaxis 5. Administer isotonic fluid solution as ordered 3. Septecemia 6. Neoplasia (new growth of tissue) 7. ABG analysis reveals metabolic acidosis 4. CBC reveals decreased platelets 2. Petechiae (widespread and systemic) eye. Nursing Management 1. Administer oxygen inhalation 4. subcutaneous. Oliguria (late sign) C. Corticosteroids – caused by immunologic injury b. Vitamin K b. Oozing of blood from punctured sites 4. lungs and lower extremities 2. Diagnostic Procedures 1. Monitor for signs of bleeding of all hema test including stool and GIT 2. Force fluids 5. Predisposing Factors 1. Administer medications as ordered a. Signs and Symptoms 1. Hemoptysis 6. Massive burns 3. Stool occult blood positive 3. venipunctured sites 8 Instead provide heparin lock 9. Heparin/Coumadin is ineffective 6.
Type AB – universal recipient c. Hemolytic reaction b. Blood typing and cross matching c. 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. Check the blood unit for bubbles cloudiness.a. Client name b. Instruct another RN to re check the following a. Aseptically assemble all materials needed for BT a. Circulatory overload e.Expiration of packed RBC is 3 – 6 days . Pyrogenic reaction d. Hyperkalemia (caused by expired blood) . Replace circulating blood volume 2. 6. during and after BT especially every 15 minutes for first hour because majority of transfusion reaction occurs during this period a. sediments and darkness in color because it indicates bacterial contamination . Cytrate intoxication h. Prevent bleeding if there is platelet deficiency Principles of blood transfusion 1. Gauge 18 – 19 needle c. Regulate BT 10 – 15 gtts/min or KVO rate or equivalent to 100 cc/hr to prevent circulatory overload 9. Proper typing and cross matching a. Anuria – late sign BLOOD TRANSFUSION Goals/Objectives 1. Hypovolemic shock b. Type O – universal donor b.Expiration of platelet is 3 – 5 days 2. 85% of population is RH positive 3. Expiration date d.Emergency rapid BT is given after 30 minutes and let natural room temperature warm the blood.Never warm blood as it may destroy vital factors in blood. Filter set b. Allergic reaction c. Increase the oxygen carrying capacity of blood 3. Avoid mixing or administering drugs at BT line to prevent HEMOLYSIS 8. Serial number 5. Monitor strictly vital signs before. Proper refrigeration . Thrombocytopenia g.9 NaCl/plain NSS) to prevent hemolysis 4. . Air embolism f. Isotonic solution (0.Warming is only done during emergency situation and if you have the warming device . Prevent infection in there is a decrease in WBC 4.
Diaphoresis 6. anaphylactic shock treat with Epinephrine 5. Flush with plain NSS . Fever and chills 2. Hypotension 5. Dyspnea 3. Broncial wheezing 4. Fever 2. Palpitations 5. Lumbasternal/ Flank pain 7. Flush with plain NSS 4. Laryngospasm and Broncospasm Nursing Management 1. Flush with plain NSS 4. Stop BT 2. Skin rashes 5. Notify physician 3. Headache 3.Signs and Symptoms of Hemolytic reaction 1. Monitor vital signs and intake and output SIGNS AND SYMPTOMS PYROGENIC REACTIONS 1. Administer medications as ordered a. Anti Histamine (Benadryl) . Notify physician 3. Obtain urine and blood sample and send to laboratory for re examination 7. Administer isotonic fluid solution to prevent shock and acute tubular necrosis 5. Flushed skin 6. Urticaria 6. Send the blood unit to blood bank for re examination 6. Urine is color red/ portwine urine Nursing Management 1. Dyspnea Nursing Management 1. Headache and dizziness 2. Stop BT 2.if positive to hypotension. Monitor vital signs and intake and output SIGNS AND SYMPTOMS OF ALLERGIC REACTION 1. Diarrhea/Constipation 4. Tachycardia 4. Notify physician 3. Obtain urine and blood sample and send to laboratory for re examination 7. Dyspnea 3. Send the blood unit to blood bank for re examination 6. Stop BT 2.
Epicardium – outer layer 2. Stop BT 2. Monitor vital signs and intake and output 8. Administer medications as ordered a.Resemble like a close fist . Cardiac tamponade A. . Antipyretic b.Right atrium has decreased pressure which is 60 – 80 mmHg C.Common among MI. Endocardium – inner layer . Atrioventricular Valves – guards opening between a. Send the blood unit to blood bank for re examination 6. Notify physician 3. Orthopnea 2. Atria 2. Ventricles . Valves . Upper Chamber (connecting or receiving) a. Loop diuretic (Lasix) CARDIOVASCULAR SYSTEM OVERVIEW OF THE STRUCTURE AND FUNCTIONS OF THE HEART HEART .Prevent pericardial friction rub . tricuspid valve . Render TSB SIGNS AND SYMPTOMS OF CIRCULATORY REACTION 1. Visceral – inner layer .4.In order to propel blood to the systemic circulation . Antibiotic 5. Rales/Crackles upon auscultation 4.Muscular pumping organ of the body. Exertional discomfort Nursing Management 1.To promote unidimensional flow or prevent backflow 1.Covered by a serous membrane called the pericardium 2 layers of pericardium a.Located on the left mediastinum . Administer medications as ordered a.Myocarditis can lead to cardiogenic shock and rheumatic heart disease B. Lower Chamber (contracting or pumping) a. pericarditis. Myocardium – middle layer 3. Parietal – outer layer b. Layers of Heart 1.Weighs approximately 300 – 400 grams .Left ventricle has increased pressure which is 120 – 180 mmHg .In between is the pericardial fluid which is 10 – 20 cc . Chambers of the Heart 1. Dyspnea 3. Obtain urine and blood sample and send to laboratory for re examination 7.
Initiates electrical impulse of 60 – 100 bpm 2. Bundle of His . S4 – atrial gallop usually seen in Myocardial Infarction and Hypertension D.Left Main Bundle of His . Left Main Coronary Artery .08 milliseconds to allow ventricular filling 3.Acts as primary pacemaker of the heart .b.Closure of SV valve give rise to second heart sound (S2 “dub”) Extra Heart Sounds 1.Located at the junction of superior vena cava and right atrium .QRS WAVE (ventricular depolarization) . Coronary Arteries . Sino – Atrial Node (SA or Keith Flack Node) . Atrio – Ventricular Node (AV or Tawara Node) . S3 – ventricular gallop usually seen in Left Congestive Heart Failure 2. Right Main Coronary Artery 2.Supplies the myocardium E.Located at the walls of the ventricles for ventricular contraction SA NODE AV NODE BUNDLE OF HIS JLJLJLJJLJLJL PURKINJE FIBERS . pulmonic b.Closure of AV valves give rise to first heart sound (S1 “lub”) 2. Semi – lunar Valves a.Delay of electrical impulse for about .T WAVE (ventricular repolarization) . mitral valve .Located at the inter atrial septum . Purkinje Fibers . aortic .Located at the interventricular septum 4.P WAVE (atrial depolarization) contraction . Cardiac Conduction System 1.Arises from base of the aorta Types of Coronary Arteries 1.Right Main Bundle of His .
Race – black 3. Treatment Percutaneous Transluminal Coronary Angioplasty Objectives of PTCA 1.tunica media . To prevent angina 3. Signs and Symptoms 1. Diet – increased saturated fats 10. Revascularize myocardium 2. T wave inversion – Myocardial Infarction 6.lipid or fat deposits .calcium and protein deposits . Widening of QRS complexes – Arrythmia CARDIAC DISORDERS Coronary Arterial Disease/ Ischemic Heart Disease Stages of Development of Coronary Artery Disease 1. Insert pacemaker if there is complete heart block Most common pacemaker is the metal pacemaker and lasts up to 2 – 5 years ABNORMAL ECG TRACING 1. Hyperlipidemia 6.hardening of artery . Smoking 4. Increase survival rate ARTERIOSCLEROSIS .Atherosclerosis 2. Predisposing Factors 1. Peak T wave – Hyperkalemia 3. Myocardial Ischemia – Angina Pectoris 3. Hypothyroidism 9. Chest pain 2. ST segment elevation – Myocardial Infarction 5. Myocardial Injury . Myocardial Necrosis – Myocardial Infarction ATHEROSCLEROSIS ATHEROSCLEROSIS . Dyspnea 3. Positive U wave . Type A personality B. sedentary lifestyle 7.Hypokalemia 2.tunica intima A. ST segment depression – Angina Pectoris 4. Tachycardia 4. Sex – male 2. Diabetes Mellitus 8. Palpitations 5.narrowing of artery . Duaphoresis C. Obesity 5.
Hyperlipidemia 6. Stress test – treadmill test. 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. Hypothyroidism 9. Serum cholesterol and uric acid is increased E. anxiety. Predisposing Factors 1.. Race – black 3. Enforce complete bed rest 2. Signs and Symptoms 1. Dyspnea 4. Diaphoresis D. Shock 3. Excessive intake of foods rich in saturated fats – skimmed milk C. Nitroglycerine (NTG) – when given in small doses will act as venodilator. Extreme emotional response – fear. Sex – male 2. axilla and jaw muscles. excitement 4. Chest pain characterized by sharp stabbing pain located at sub sterna usually radiates from back.If there is 2 or more occluded blood vessels CABG is done Coronary Arterial Bypass And Graft Surgery 3 Complications of CABG 1. Excessive physical exertion – heavy exercises 2. arms. but in large doses will act as vasodilator .5 minutes . Exposure to cold environment 3. Administer medications as ordered a.Give first dose of NTG (sublingual) 3 – 5 minutes . Obesity 5. Precipitating Factors 4 E’s of Angina Pectoris 1. Palpitations 6. usually relieved by rest or taking nitroglycerine 3. shoulder. reveal abnormal ECG 4. Pneumonia – encourage to perform deep breathing.Give second dose of NTG if pain persist after giving first dose with interval of 3 . Smoking 4. ECG tracing reveals ST segment depression 3. History taking and physical exam 2. sedentary lifestyle 7. Diet – increased saturated fats 10. Diabetes Mellitus 8. Levine’s Sign – initial sign that shows the hand clutching the chest 2. Tachycardia 5. coughing exercise and use of incentive spirometer 2. Nursing Management 1.Done to single occluded vessels . Diagnostic Procedure 1. Type A personality B.
Avoidance of 4 E’s b.NIfedipine 3. Transmural Myocardial Infarction – most dangerous type characterized by occlusion of both right and left coronary artery 2.. Place client on semi fowlers position 5. Instruct client to take medication before indulging into physical exertion to achieve the maximum therapeutic effect of drug d. Race – black 3. A. Beta-blockers . The importance of follow up care MYOCARDIAL INFARCTION Heart attack Terminal stage of coronary artery disease characterized by malocclusion. ACE Inhibitors .Give third and last dose of NTG if pain still persist at 3 – 5 minutes interval Nursing Management when giving NTG Keep the drug in a dry place. Smoking 4. Prevent complication (myocardial infarction) c. Types 1. intake and output and ECG tracing 6. Provide client health teachings and discharge planning a. necrosis and scarring. Hyperlipidemia . Obesity 5. Subendocardial Myocardial Infarction – characterized by occlusion of either right or left coronary artery B. Administer oxygen inhalation 4. avoid moisture and exposure to sunlight as it may inactivate the drug Monitor side effects o o 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 duting defibrillation as it may lead to burns (most important thing to remember) b.Enalapril d. Sex – male 2.Propanolol . Calcium Antagonist . Provide decrease saturated fats sodium and caffeine 7.side effects PNS . Monitor strictly vital signs. Predisposing Factors 1.Not given to COPD cases because it causes bronchospasm c. 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.
Troponin Test – is increased 3.Side Effects: respiratory depression . shoulder.Not usually relieved by rest or by nitroglycerine 2. Administer oxygen low inflow to prevent respiratory arrest at 2 – 3 L/min 3. ECG tracing reveals a.Excruciating visceral. Type A personality D. ST segment elevation b. Split S1 and S2 c. S4 or atrial gallop E. Diabetes Mellitus 8. Signs and Symptoms 1.6. Mild restlessness and apprehension 7. Dyspnea 3. CBC – increased WBC F. Occasional findings a. Cardiac Enzymes a. Pericardial friction rub b. Serum Cholesterol and uric acid are both increased 5. Hyperthermia 5. sedentary lifestyle 7. Diagnostic Procedure 1. Increase in blood pressure (initial sign) 4. Rales/Crackles upon auscultation d.Administer narcotic analgesic/morphine sulfate . Enforce CBR without bathroom privileges a. Widening of QRS complexes indicates that there is arrhythmia in MI 4. Ashen skin 6.Antidote: Narcan/Naloxone . Diet – increased saturated fats 10. T wave inversion c. viselike pain located at substernal and rarely in precordial . 12 – 24 hours b.Heart only. CPK – MB .Creatinine phosphokinase is increased . SGOT – Serum glutamic oxal-acetic transaminase is increased 2. arms. Hypothyroidism 9.Usually radiates from back. axilla. Chest pain . jaw and abdominal muscles (abdominal ischemia) . Using bedside commode 4. LDH – Lactic acid dehydroginase is increased c. Decrease myocardial workload (rest heart) . SGPT – Serum glutamic pyruvate transaminase is increased d. Nursing Management Goal: Decrease myocardial oxygen demand 1. Instruct client to avoid forms of valsalva maneuver 5. Place client on semi fowlers position .Side Effects of Naloxone Toxicity is tremors 2.
Isodil) sublingual b.Antidote: protamine sulfate . ACE Inhibitors e.Heparin (check for partial thrombin time) . Provide client health teaching and discharge planning concerning a.Nitroglycerine . Anti Platelet .Streptokinase .Anti thrombotic effect .Antidote: Vitamin K h. Beta-blockers d.homan’s sign e. Cardiogenic shock . Administer medication as ordered a.ISD (Isosorbide Dinitrate.Side Effects: allergic reaction. Monitor strictly vital signs. Stroke/CVA .Side Effects: confusion and dizziness .Lidocaine (Xylocane . Thrombophlebitis . Provide a general liquid to soft diet that is low in saturated fats. whisky and brandy to induce vasodilation 9. Encourage client to take 20 – 30 cc/week of wine. pruritus . Anti Coagulant .Coumadin/ Warfarin Sodium (check for prothrombin time) .Brutylium c.late sign is oliguria c.6. Left Congestive Heart Failure d.Side Effects of Aspirin Tinnitus Heartburn Indigestion/Dyspepsia . Thrombolytics/ Fibrinolytic Agents .Urokinase .TIPAF (tissue plasminogen activating factor) .PASA (Aspirin) . Vasodilators . sodium and caffeine 8. Anti Arrythmic Agents .arrhythmia (caused by premature ventricular contraction) b.Side Effects: chest pain . Calcium Antagonist f. Avoidance of modifiable risk factors . intake and output and ECG tracing 7.Monitor for bleeding time g.Contraindication Dengue Peptic Ulcer Disease Unknown cause of headache 10.
Bronchial wheezing 9. Diagnostic Procedure 1. RHD – inflammation of mitral valve due to invasion of Grp.ASO Titer (Anti streptolysin O titer) .Formation of aschoff bodies in the mitral valve . LEFT SIDED HEART FAILURE A. administer 150. Aging 2.000 units of streptokinase as ordered g. Signs and Symptoms 1. Cyanosis 7. Chest x-ray – reveals cardiomegaly 2. Hypertension 5. Predisposing Factors 1. Pulsus Alternans – weak pulse followed by strong bounding pulse 10.Aspirin b. 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. 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. ABG – reveals PO2 is decreased (hypoxemia).Penicillin . dependent on extent of heart failure 4. post CABG and instruct to . Dyspnea 2.client can resume sexual intercourse if can climb staircase .000 – 450.make sex as an appetizer rather than dessert . 90% is mitral valve stenosis due to a.instruct client to assume a non weight bearing position . Aortic valve stenosis B. Orthopnea – use 2 – 3 pillows when sleeping or place in high fowlers 4.Common among children . PCO2 is increased (respiratory acidosis) 2.dietary modification h. There is anorexia and generalized body malaise 12. Ecocardiography – enlarged heart chamber (cardiomyopathy). Myocardial Infarction 3. S3 – ventricular gallop C. RIGHT SIDED HEART FAILURE . Resumption of ADL particularly sexual intercourse is 4 – 6 weeks post cardiac rehab.client is resistant to pharmacological agents. Rales/Crackles 8.f. Frothy salivation 6. PMI is displaced laterally due to cardiomegaly 11. Productive cough with blood tinged sputum 5. Ischemic heart disease 4. Paroxysmal nocturnal dyspnea – client is awakened at night due to difficulty of breathing 3. A beta-hemolytic streptococcus . Post MI Syndrome/Dressler’s Syndrome .
Vasodilators . Signs and Symptoms (venous congestion) 1. Diagnostic Procedures 1.If CVP is less than 4 cm of water hypovolemic shock . Loop Diuretics .Lasix (Furosemide) c. Esophageal varices C. Liver enzymes – SGPT and SGOT is increased D. Predisposing Factors 1.Administer loop diuretics as ordered . Enforce CBR 2. Administer medications as ordered a. Tricuspid valve stenosis 2. Central venous pressure (CVP) . Ecocardiography – reveals enlarged heart chambers (cardiomyopathy 4. 3 – 4 L/min. Nursing Management Goal: increase cardiac contractility thereby increasing cardiac output (3 – 6 L/min) 1. Pulmonary embolism 3. Narcotic analgesics . Bronchodilators d.When reading CVP patient should be flat on bed .Measure pressure in right atrium (4 – 10 cm of water) . Cardiac glycosides .Lidocaine (Xylocane) 3. Anti Arrhythmic . Pulmonic valve stenosis 5.Digoxin (Lanoxin) . Left sided heart failure B. Jaundice 7.Morphine Sulfate e. delivered via nasal cannula 4. Chest x-ray – reveals cardiomegaly 2.Do the fluid challenge (increase IV flow rate) . Pruritus 8.If heart rate is decreased do not give b. High fowlers position .If CVP is more than 10 cm of water hypervolemic shock .Nitroglycerine f. Related to COPD 4. Pitting edema 3. Weight gain 5.A.Upon insertion place client in trendelendberg position to promote ventricular filling and prevent pulmonary embolism 3.CVP fluid status measure . Hepatosplenomegaly 6. Neck/jugular vein distension 2. Anorexia 9. Administer oxygen inhalation with high inflow. Ascites 4.Increase force of cardiac contraction .
Intermittent claudication – leg pain upon walking 2. Varicose Veins 2. Provide client health teaching and discharge planning a. out of bed 3 – 4 times a day 2. Trophic changes 5. Prevent complications .Arrythmia . Doppler UTZ – decrease blood flow to the affected extremity 3.5. cyanosis then rubor) 3. Signs and Symptoms 1. High risk groups – men 30 years old and above 2. walking 3 – 4 times a day b. Provide a dietary intake of low sodium. Strict compliance to medications PERIPHERAL VASCULAR DISORDER Arterial Ulcer I. Provide meticulous skin care 9. Ulceration 6. Dietary modification c. Assist in bloodless phlebotomy – rotating tourniquet. Administer medications as ordered a. Nursing Management 1. Thrombo Angitis Obliterans Venous Ulcer 1. Decreased peripheral pulses 4. Analgesics Burger’s Disease Reynaud’s Disease .Right ventricular hypertrophy . Predisposing Factors 1.Shock .MI . rotated clockwise every 15 minutes to promote decrease venous return 10. Diagnostic Procedures 1. Angiography – reveals site and extent of malocclusion D. intake and output and ECG tracing 6. Thrombophlebitis (deep vein thrombosis) THROMBOANGITIS OBLITERANS Acute inflammatory disorder usually affecting the small medium sized arteries and veins of the lower extremities A. cholesterol and caffeine 8. Measure abdominal girth daily and notify physician 7. Oscillometry – decrease in peripheral pulses 2. Encourage a slow progressive physical activity a. Smoking B. Cold sensitivity and changes in skin color (pallor.Thrombophlebitis b. Gangrene formation C. Monitor strictly vital signs.
Hereditary 2. Signs and Symptoms 1. Diagnostic Procedures 1. Trophic changes 4. cyanosis then rubor) 3. Operating chainsaw B. Doppler UTZ – decrease blood flow to the affected extremity 2. Analgesics b. Excessive typing c. Collagen diseases a. Vasodilators 2. Pregnancy . Assist in surgical procedure – bellow knee amputation REYNAUD’S DISEASE Disorder characterized by acute episodes of arterial spasm involving the fingers or digits of the hands A. Instruct client on importance of cessation of smoking and exposure to cold environment VARICOSITIES Abnormal dilation of veins of lower extremities and trunks due to Incompetent valve resulting to Increased venous pooling resulting to Venous stasis causing Decrease venous return A. Nursing Management 1. Encourage to wear gloves 3. Smoking 3. Institute foot care management 4. Angiography – reveals site and extent of malocclusion D. Ulceration 5. Gangrene formation C. Anti coagulants 3. Rheumatoid Arthritis 4. Cold sensitivity and changes in skin color (pallor. Cardiac disorder 5. Predisposing Factors 1. High risk group – female 40 years old and above 2. Vasodilators c. Instruct client to avoid smoking and exposure to cold environment 5. Thrombophlebitis 4. SLE (butterfly rash) b. Piano playing b. Direct hand trauma a. Administer medications as ordered a. Intermittent claudication – leg pain upon walking 2. Predisposing Factors 1.b. Congenital weakness of veins 3.
Nursing Management .veins distends quickly in less than 35 seconds D. Wear anti embolic stockings 4. Elevate legs above heart level to promote increased venous return by placing 2 – 3 pillows under the legs 2. Positive Hpman’s Signs – pain at the calf or leg muscle upon dorsi flexion of the foot C. Warm to touch 4. Dilated tortuous skin veins 3. Trendelenburg’s Test . Related to pregnancy 4. Congestive heart failure 8. Dilated tortuous skin veins 4. Heaviness in legs C. Analgesics 5. B. Obesity 7. Angiography D. Obesity 2. Measure the circumference of leg muscle to determine if swollen 3. Vein stripping and ligation (most effective) b. Prolong use of oral contraceptives – promotes lipolysis 6. Warm to touch 3. Nursing Management 1. Pain at affected extremity 2. Pain after prolonged standing 2. Prolonged standing or sitting B. Diagnostic Procedure 1. Post cannulation – insertion of various cardiac catheter 11. Diabetes mellitus 7. Increase in saturated fats in the diet.6. Signs and Symptoms 1. Administer medications as ordered a. Predisposing Factors 1. Venography 2. Venography 2. Chronic anemia 5. Post op complication 10. Signs and Symptoms 1. Myocardial infarction 9. Sclerotherapy – can recur and only done in spider web varicosities and danger of thrombosis (2 – 3 years for embolism) THROMBOPHLEBITIS Deep vein thrombosis Inflammation of the veins with thrombus formation A. Smoking 3. Diagnostic Procedure 1. Assist in surgical procedure a.
The initial sign of complete airway obstruction is the inability to cough II. Cerebral .Decrease LOC • MURPHY’S SIGN is seen in clients with cholelithiasis.For cough reflex Glottis . Analgesics b.Diaphoresis . Encourage to wear anti embolic stockings or knee elastic stockings 5.Serves as a muscular passageway for both food and air C.Consist of cartilaginous rings . Filtering of air 2.For phonation (voice production) . Larynx . Warming and moistening of air 3.Closes to allow passage of food going to the esophagus .Tachycardia . Apply warm moist pack – to reduce lymphatic congestion 3.Serves as passageway of air going to the lungs . Elevate legs above heart level to promote increase venous return 2.Consist of anastomosis of capillaries known as Keissel Rach Plexus (the site of nose bleeding) B.Headache .Sudden sharp chest pain .Right nostril . Lower Respiratory System . Humidification A. Pulmonary .Restlessness b.Dizziness . Administer medications as ordered a.Heparin 6. Nose .Left nostril . Measure circumference of leg muscle to determine if swollen 4. Monitor for signs of complications Embolism a. Upper Respiratory System 1.Unexplained dyspnea .Cartillage .Separated by septum .Opening of larynx .1.Opens to allow passage of air . Pharynx/Throat . Anti Coagulant .For gas exchange A. Trachea/Windpipe .Palpitations . cholecystitis characterized by pain at the right upper quadrant with tenderness RESPIRATORY SYSTEM OVERVIEW OF THE STRUCTURES AND FUCNTIONS OF THE RESPIRATORY SYSTEM I.
.Infection of lung tissue caused by invasion of mycobacterium tuberculosis or tubercle bacilli . Mode of Transmission 1.Right lung (consist of 3 lobes.Left main bronchus C. Pleural effusion c. 10 segments) .Serous membranes Pleural Cavity a.Prevent collapse of alveoli . Precipitating Factors 1.Left lung (consist of 2 lobes.Site of gas exchange (CO2 and O2) . Pleural fluid c. Pneumonia b. aerobic and easily destroyed by heat or sunlight A. night sweats 2.Secretes surfactant . Hydrothorax (air and blood in pleural space Alveoli . Productive cough (yellowish sputum) .L/S ratio to determine lung maturity .Increase carbon dioxide is a powerful stimulant for breathing Type II Cells of Alveoli . Over fatigue 5. Lungs .Site of tracheostomy B. gram negative. Malnutrition 2. Overcrowded places 3. Signs and Symptoms 1.Diffusion (Dalton’s law of partial pressure of gases) Respiratory Distress Syndrome .retinopathy/blindness in prematurity Disorders of Respiratory System 1. 8 segments) .An acid fast.Decrease surface tension . Alcoholism 4.Right main bronchus .Normal L/S ratio is 2:1 . Pareital b. Ingestion of an infected cattle with mycobacterium bovis 6. Low grade afternoon fever. Visceral With Pleuritic Friction Rub a. Airborne transmission via droplet nuclei C. Virulence (degree of pathogenecity) of microorganism B. Bronchus . PTB/Pulmonary Tuberculosis (Koch’s Disease) .In premature infants 1:2 .Decrease oxygen stimulates breathing .Give oxygen of less 40% in premature to prevent atelectasis and retrolental fibroplasias .Composed of lecithin and spingomyelin .
Side Effect PZA: allergic reaction. Chest pain 7.Positive Mantoux test (previous exposure to tubercle bacilli but without active TB) 2.INH and Rifampicin is given for 4 months.WHO 10 – 14 mm induration. Nursing Management 1. Hemoptysis (chronic) D. Place client on semi fowlers position to promote expansion of lungs 6.Side Effect Rifampicin: all bodily secretions turn to red orange color . 48 – 72 hours .PZA is given for 2 months. Diagnostic Procedure 1.Reveals pulmonary infiltrates 4.DOH 8 – 10 mm induration. Administer oxygen inhalation 4. Enforce CBR 2. Intensive phase . CBC . Mantoux Test (skin test) .Side Effect Ethambutol: optic neuritis b.Amikacin .3.PZA (Pyrazinamide) .Purified protein derivative .Positive to cultured microorganism 3.Kanamycin .INH (Isonicotinic Acid Hydrazide) . taken before meals to facilitate absorption .Reveals increase WBC E. 48 – 72 hours .Rifampicin (Rifampin) . generalized body malaise 4. Institute short course chemotherapy a. Encourage deep breathing and coughing exercise 7. nephrotoxicity . Force fluids to liquefy secretions 5. taken after meals to facilitate absorption . Comfortable and humid environment 9. Sputum Acid Fast Bacillus .Neomycin . hepatotoxicity. Nebulize and suction when needed 8.Given everyday simultaneously to prevent resistance . Weight loss 5.PZA can be replaced by Ethambutol .Gentamycin .Injection of streptomycin (aminoglycoside) . Chest X-ray . Anorexia. Standard phase .Side Effect INH: peripheral neuritis/neuropathy (increase intake of Vitamin B6/Pyridoxine) . Dyspnea 6. Institute strict respiratory isolation 3.
Bronchial wheezing . chills. Diplococcus Pneumoniae 4. Aspiration of food causing aspiration pneumonia D.Eyes .Give aspirin if there is fever . Escherichia Pneumoniae 6. military tuberculosis) PTB . Productive cough with greenish to rusty sputum 2. Avoidance of precipitating factors b. Hemophylus Influenzae – causing broncho pneumonia 3. Dyspnea with prolong expiratory grunt 3. Importance of follow up care PNEUMONIA Inflammation of the lung parenchyma leading to pulmonary consolidation as the alveoli is filled with exudates A.Side Effect: tinnitus. Related to prolonged immobility (CVA clients).Adrenal gland c. Signs and Symptoms 1. Pseudomonas B. AIDS . Provide increase carbohydrates. Fever. Immuno compromised a.Drug of choice is Retrovir b. Strict compliance to medications d. Klebsella Pneumoniae 5. Provide client health teaching and discharge planning a. Smoking 2.Chest x-ray confirms lung cancer 4. anorexia and general body malaise 4.Pneumocystic carini pneumonia .Nephrotoxicity check for BUN and Creatinine . heartburn 10. High Risk Groups 1. protein.Skin .. Predisposing Factors 1.Side Effect: . Bronchogenic Cancer .Bones (potts) . Streptococcus Pneumonae – causing pneumococal pneumonia 2. Rales/crackles 6. Elderly C.Initial sign is non productive cough . Air pollution 3. causing hypostatic pneumonia 5. Etiologic Agents 1.Meninges . Children below 5 years old 2. Weight loss 5. dyspepsia.Ototoxicity damage to the 8th cranial nerve resulting to tinnitus leading to hearing loss . vitamin C and calories 11. Prevent complications (atelectasis.
Unstable vital signs . Chest x-ray – reveals pulmonary consolidation 3. calories. Health teaching and discharge planning a.Deep breathing exercises . Stop if client cannot tolerate procedure f.Increase ICP 9. erythrocyte sedimentation rate is increased F. Monitor vital signs c.Coughing exercises . Place on semi fowlers position 6.Chest physiotherapy . Institute pulmonary toilet (tends to promote expectoration) . Prevent complications .Placed on various position Nursing Management for Postural Drainage a. Administer oxygen inhalation low inflow 3. Enforce CBR 2. Abdominal distention leading to paralytic ileus (absence of peristalsis) E. Assist in postural drainage . protein and vitamin C 10. Pleuritic friction rub 9. Best done before meals or 2 – 3 hours to prevent gastro esophageal reflux b. Nursing Management 1. Sputum Gram Staining and Culture Sensitivity – positive to cultured microorganisms 2. Avoid smoking b. Diagnostic Procedure 1. Microlides (Zethromax) Azethromycin (Side Effect: Ototoxicity) Antipyretics Mucolytics/Expectorants Analgesics 4. Penicillin b.Hemoptysis . Provide increase carbohydrates.7. Administer bronchodilators 15 – 30 minutes before procedure e.Clients with increase intra ocular pressure (Normal IOP 12 – 21 mmHg) . CBC – reveals increase WBC. Tetracycline c. Force fluid 5. Cyanosis 8. Contraindicated with .Drain uppermost area of lungs . Provide oral care after procedure g. ABG analysis – reveals decrease PO2 4.Turning and reposition 7. Administer medications as ordered Broad Spectrum Antibiotic a. Nebulize and suction as needed 8. Chest pain 10. Encourage client deep breathing exercises d.
Enforce CBR 2. 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. Histoplasmin Skin Test – positive 2. Dyspnea on exertion 3. Prevent complications – bronchiectasis 7. Antipyretics 4. 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.. general body malaise 4. chills.Amphotericin B . ABG analysis PO2 decrease C. Steroids c. check for BUN and Creatinine. Diagnostic Procedures 1.Fungizone (Nephrotoxicity. anorexia. Administer oxygen inhalation 3. Prolonged expiratory grunt 4. Smoking 2. Mucolytics d. Antifungal . Chest and joint pains B. Dyspnea 3. Nursing Management 1. Anorexia and generalized body malaise . Air pollution B. Signs and Symptoms 1. Predisposing Factors 1.Atelectasis .Meningitis (nerve deafness. Productive cough 2. Signs and Symptoms PTB or Pneumonia like 1. Fever. hydrocephalus) c. Regular adherence to medications d. Hemoptysis 6. Hypokalemia) b. Productive cough (consistent to all COPD) 2. Cyanosis 5. Nebulize and suction as needed 6. Administer medications as ordered a. Force fluids to liquefy secretions 5.
Predisposing Factors (Depending on Types) 1. Cough that is non productive 2. beta blocker) c. Gases f. Wheezing on expiration 4. Intrinsic Asthma (Non atopic/Non allergic) Causes a. Tachycardia. Pulmonary hypertension a. Danders g. ABG analysis – PO2 decrease . Nursing Management 1. palpitations 7. Dust c. apply direct pressure to ulnar and radial artery to determine presence of collateral circulation D. Dyspnea 3. penicillin. Cyanosis 7. Enforce CBR . Diaphoresis C. Hereditary b. Food additives (nitrates) e. Lints 2. Drugs (aspirin. Mild Stress/apprehension 6. milk. pH decrease Bronchial Asthma Reversible inflammatory lung condition due to hypersensitivity to allergens leading to narrowing of smaller airways A. Signs and Symptoms 1. Smoke e. Physical and emotional stress 3. Diagnostic Procedure ABG analysis – reveals PO2 decrease (hypoxemia). air pressure and humidity f. Cyanosis 5. eggs.Incentive spirometer reveals decrease vital lung capacity 2. Foods (seafoods. chocolates. chicken d. Scattered rales/ronchi 6. Furs h. Cor Pulmonale (right ventricular hypertrophy) C. Pollen b. Extrinsic Asthma ( Atopic/ Allergic ) Causes a.Before ABG test for positive Allens Test. Diagnostic Procedure 1. Peripheral edema b. Sudden change in temperature. Pulmonary Function Test . Mixed Type 90 – 95% B. Fumes d.5. PCO2 increase.
Steroids . Hemoptysis (only COPD with sign) C.Bronchodilators c. Force fluids 5. Monitor vital signs and breath sound POST Bronchoscopy 1. Recurrent lower respiratory tract infections 2. Congenital defects 4. Bronchodilators – given via inhalation or metered dose inhalaer or MDI for 5 minutes b. Monitor for signs of gross 4. ABG – PO2 decrease 2. Provide client health teachings and discharge planning concerning a. Bronchoscopy – direct visualization of bronchus using fiberscope Nursing Management PRE Bronchoscopy 1. Related to presence of tumor B. may cause irritation 3. Semi fowlers position 6. Maintain NPO 6 – 8 hours prior to procedure 3.Status Asthmaticus (give drug of choice) . with low inflow of 2 – 3 L/min 3. Dyspnea 3. Feeding initiated upon return of gag reflex 2. Chest trauma 3. Steroids – decrease inflammation c. Anti histamine 4. Prevent complications . Productive cough 2. Administer medications as ordered a. Nebulize and suction when needed 7.2. Predisposing Factors 1. Treatment .Epinephrine . 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. Signs and Symptoms 1. Avoidance of precipitating factor b. Diagnostic Procedure 1. Monitor for signs of laryngeal spasm – prepare tracheostomy set D. Cyanosis 4. Oxygen inhalation. Anorexia and generalized body malaise 5. coughing and smoking. Secure inform consent and explain procedure to client 2.Emphysema . Avoid talking. Mucomysts (acetylceisteine) d. Mucolytics/expectorants e.
Decrease ph . Flaring of alai nares 12. Dyspnea at rest 3. Smoking 2. Prolong expiratory grunt 4.1. “Pink Puffers”) . Barrel chest 11. “Blue Bloaters”) . Predisposing Factors 1. Bronchial wheezing 10. Surgery (pneumonectomy . Air trapping c.Decrease PCO2 . Pulmonary Function Test – reveals decrease vital lung capacity 2. Rales or ronchi 9.Increase PCO2 . Purse lip breathing to eliminates excess CO2 (compensatory mechanism) C.Increase ph .Respiratory alkalosis D. Decrease or diminished breath sounds 8. Diagnostic Procedure 1.Increase PO2 (hyperaxemia. Panlobular/ centrilobular . Resonance to hyperresonance 6. Allergy 4. Over distention of thoracic cavity (barrel chest) A.Respiratory acidosis b. High risk: elderly 5. Enforce CBR . Anorexia and generalized body malaise 5. Nursing Management 1. Productive cough 2. Hereditary – it involves deficiency of ALPHA-1 ANTI TRYPSIN (needed to form Elastase. Segmental Wedge Lobectomy (promote re expansion of lungs) . Decrease tactile fremitus 7. Maldistribution of gases d.Unaffected lobectomy facilitate drainage EMPHYSEMA Irreversible terminal stage of COPD characterized by a.Decrease PO2 (hypoxemia leading to chronic bronchitis. 1 lung is removed and position on affected side) 2. Inelasticity of alveoli b. ABG analysis reveals a. Panacinar/ centriacinar . Air pollution 3. Signs and Symptoms 1. for recoil of alveoli) B.
Force fluids 6. vitamins and minerals 11. Provide comfortable and humid environment 10.Atelectasis . calories. Institute pulmonary toilet 7. Provide high carbohydrates.Cor Pulmonale . High fowlers position 5. Prevent complications . Strict compliance to medication d. Institute PEEP (positive end expiratory pressure) in mechanical ventilation promotes maximum alveolar lung expansion 9. Steroids c. Antibiotics d. Mucolytics/expectorants 4. Health teachings and discharge planning concerning a. Bronchodilators b. Avoid smoking b. Administer medications as ordered a. protein.Pneumothorax c. Administer oxygen inhalation via low inflow 3. Importance of follow up care .2. Nebulize and suction when needed 8.CO2 narcosis may lead to coma .
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