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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.
DEMYELINATING DISORDERS 1. d. . colostrums). Signs and Symptoms 1. * Give palliative or supportive care. *Receptive aphasia DRUG OF CHOICE: ARICEPT (taken at bedtime) and COGNEX. 2. Characterized by remission and exacerbation. b. Visual disturbances blurring of vision (primary) diplopia (double vision) scotomas (blind spots) 2.Immediate action. Mood swings . Ig M – acute in inflammation. heat and cold. Ig A – present in all bodily secretions (tears. Ig E – for allergic reaction. Agnosia – no recognition of inanimate objects. . Sign and Symptoms 4 A’s of Alzheimer a. pain. Aphasia – no speech (nodding). pressure.short term protection. Ig D – for chronic inflammation. tingling sensation paresthesia numbness euphoria (sense of well being) 3. Apraxia – no recognition of objects function. saliva. 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. *Expressive aphasia “motor speech center” Broca’s Aphasia inability to understand spoken words. Amnesia – loss of memory. ALZHEIMER’S DISEASE Atrophy of brain tissues. c. Impaired sensation to touch. Wernicke’s Aphasia General Knowing Gnostic Area or General Interpretative Area. MULTIPLE SCLEROSIS Chronic intermittent disorder of CNS characterized by white patches of demyelination in brain and spinal cord.
. Deep breathing exercises b. c. Increase fluid intake and increase fiber to prevent constipation. vitamin C and orange. (+) Lhermitte’s sign a continuous and increase contraction of spinal column. Yoga 4. plums. Catheterization to prevent retention. a. Decrease sexual capacity DIAGNOSTIC PROCEDURE Nystagmus CSF analysis (increase in IgG and Protein). Interferons – alter immune response. prunes. d. a. For Urinary Incontinence Anti spasmodic agent a. Institute stress management techniques. Baclofen (Dioresal)/ Dantrolene Sodium (Dantrene) – muscle relaxants. Administer medications as ordered a. b.4. c. Monitor breath sounds 1 hour after subcutaneous administration. Impaired cerebral function CHARCOTS TRIAD IAN Intentional tremors 6. NURSING MANAGEMENT 1. (+) Romberg’s test) 5. Impaired motor function weakness spasticity paralysis scanning speech TRIAD SIGNS OF MS Ataxia (Unsteady gait. Constipation 8. 5. Prophantheline Bromide (Promanthene) Acid ash diet like cranberry juice. Immunosupresants 2. To acidify urine and prevent bacterial multiplication. Diuretics b. Monitor side effects bronchospasm and wheezing. pineapple. Maintain side rails to prevent injury related to falls. Urinary retention/incontinence 7. MRI (reveals site and extent of demyelination). ACTH (Adreno Corticotropic Hormone)/ Steroids for acute exacerbation to reduce edema at site of demyelination to prevent paralysis. 3. Bethanicol Chloride (Urecholine) Nursing Management Only given subcutaneous.
8 inches) urinate after intercourse Nursing Management Male MICROGLIA stationary cells that carry on phagocytosis (engulfing of bacteria or cellular debris. numbness.COMMON CAUSE OF UTI Female short urethra (3-5 cm. 80% brain mass 10% blood 10% CSF COMPOSITION OF BRAIN I. Parietal 4. heat. Functions of Cerebrum integrative sensory motor Lobes of Cerebrum 1. 1-1 ½ inches) poor perineal hygiene vaginal environment is moist avoid bubble bath (can alter Ph of vagina). cold. avoid use of tissue papers avoid using talcum powder and perfume. Urethra (20 cm. 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. Temporal hearing short term memory for appreciation discrimination of sensory impulses to pain. eating). Brain Mass PARTS OF THE BRAIN 1. pinocytosis (cell drinking). 2. CEREBRUM largest part composed of the Right Cerebral Hemisphere and Left Cerebral Hemisphere enclosed in the Corpus Callosum. touch. Frontal higher cortical thinking controls personality controls motor activity Broca’s Area (motor speech area) when damaged results to garbled speech. Occipital . for vision 3. pressure.
Insula (Island of Reil) visceral function activities of internal organ like gastric motility. lesser brain. DECREASE Myasthenia Gravis Parkinson’s Disease INCREASE Bi-polar Disorder Schizophrenia NEURO TRANSMITTER Acethylcholine Dopamine 3. vasomotor center (dilation and constriction of bronchioles). controls libido controls long term memory Limbic System (Rhinencephalon) 2. unequal size of pupil is anisocoria. Cerebellum smallest part of the brain. Hypothalamus 5. equal size of pupil is isocoria. INTERBRAIN/ DIENCEPHALON Parts of Diencephalon A. positive PERRLA 4. Thalamus acts as relay station for sensation. rhythm and depth of respiration. 2. controls pituitary functions androgenic hormones promotes secondary sex characteristics. early sign for females telarche and late sign is menarche. hearing acuity is 30 – 40 dB. controls smell and if damaged results to Anosmia (absence of smell). early sign for males are testicular and penile enlargement late sign is deepening of voice. B. posture and gait. controls respiration. release dopamine (controls gross voluntary movement. MIDBRAIN/ MESENCEPHALON acts as relay station for sight and hearing. anxiety and excitement. controls blood pressure controls thirst appetite/satiety sleep and wakefulness controls some emotional responses like fear. heart rate. equilibrium. Medulla Oblongata 3. controls balance. swallowing. BASAL GAGLIA areas of grey matter located deep within each cerebral hemisphere. size of pupil is 2 – 3 mm. . controls temperature (thermoregulatory center). vomiting. Pons pneumotaxic center controls the rate. BRAIN STEM located at lowest part of brain Parts of Brain Stem 1. hiccup.
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. decerebrate posturing (damage to upper brain stem that includes pons. 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. Early closure of posterior fontanels causes posterior enlargement of skull in hydrocephalus. Cervical 2 – also known as AXIS. widening of pulse pressure is neurologic in nature (if narrow cardiac in nature). projective vomiting headache papilledema (edema of optic disc) abnormal posturing decorticate posturing (damage to cortex and spinal cord). NEUROLOGIC DISORDERS INCREASE INTRACRANIAL PRESSURE – increase in intra-cranial bulk brought about by an increase in one of the 3 major intra cranial components. heart rate decrease respiratory rate decrease temperature increase directly proportional to blood pressure. 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). . cerebellum and midbrain).
maintain side rails. 7. avoid use of restraints. Loop diuretic (Lasix. Prevent further increase ICP by: a. d. Osmotic diuretic (Mannitol) for cerebral diuresis Nursing Management monitor vital signs especially BP (hypotension). b. Monitor vital signs especially BP (hypotension). b. Elevate bed of client 30 – 35o angle with neck in neutral position unless contraindicated to promote venous drainage. Furosemide) Drug of choice for CHF (pulmonary edema) Loop of Henle in kidneys. c. avoid clustering of nursing activity together. Late signs of hypoxia HYPERCARBIA b. Nursing Management . monitor strictly input and output every 1 hour notify physician if output is less 30 cc/hr. unilateral dilation of pupils called uncal herniation bilateral dilation of pupils called tentorial herniation resulting to mild headache possible seizure activity Nursing Management 1. In chronic respiratory distress syndrome decrease O2 stimulates respiration. Assist in mechanical ventilation 2. 4. Monitor strictly input and output and neuro check 5. 3. Administer medications like: a. Limit fluid intake to 1200 – 1500 ml/day (in force fluids 2000 – 3000 ml/day). provide an comfortable and quite environment. Maintain patent and adequate ventilation by: a. administered via side drip regulated fast drip to prevent crystal formation. 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. monitor strictly input and output every 1 hour notify physician if output is less 30 cc/hr. Before and after suctioning hyper oxygenate client 100% and done 10 – 15 seconds only. Prevent complications of 6. Prevention of hypoxia and hypercarbia Early signs of hypoxia restlessness agitation tachycardia Bradycardia Extreme restlessness Dyspnea Cyanosis Increase CO2 (most powerful respiratory stimulant) retention.
blood monitor RIGHT CONGESTIVE HEART FAILURE (Venous congestion) Signs and Symptoms jugular vein distention (neck) ascites pitting edema weight gain hepatosplenomegaly jaundice pruritus esophageal varices anorexia and general body malaise Signs and Symptoms of Lasix in terms of electrolyte imbalances 1. Phenytoin) c. 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. administered IV push or oral. given early morning immediate effect of 10 – 15 minutes. maximum effect of 6 hours. Dexamethasone (Decadron) Hydrocortisone Prednisone (to reduce edema that may lead to increase ICP) Mild Analgesics (Codeine Sulfate for respiratory depression) Anti Convulsants (Dilantin. Hypokalemia decrease potassium level .
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.4 – 5. Hyponatremia DECREASE decrease sodium level normal value is 135 – 145 meq/L Signs and Symptoms hypotension dehydration signs (Initial sign in adult is THIRST. in infant TACHYCARDIA) agitation dry mucous membrane poor skin turgor weakness and fatigue Nursing Management force fluids administer isotonic fluid solution as ordered . Oral Potassium Chloride) increase intake of foods rich in potassium FRUITS Apple Banana Cantalope Oranges 2. Hypocalcemia/ Tetany VEGETABLES Asparagus Brocolli Carrots Spinach decrease calcium level normal value is 8.5 – 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. normal value is 3.
Allopurinol (Zyloprim) b. Mechanism of action: inhibits synthesis of uric acid. Signs and Symptoms Nursing Management a. Hyperuricemia increase uric acid (purine metabolism) foods high in uric acid (sardines. Hyperglycemia normal FBS is 80 – 100 mg/dl polyuria polydypsia polyphagia monitor FBS Signs and Symptoms Nursing Management 5. Allopurinol (Zyloprim) Side Effects Respiratory depression (check for RR) PARKINSON’S DISEASE/ PARKINSONISM Chronic progressive disorder of CNS characterized by degeneration of dopamine producing cells in the SUBSTANCIA NIGRA of the midbrain and basal ganglia. Acute gout Mechanism of action: promotes excretion 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. organ meats and anchovies) *Increase in tophi deposit leads to Gouty arthritis. . Nursing Management a. Narcotic Analgesic b. joint pain (great toes) swelling force fluids administer medications as ordered Drug of choice for gout.4.
seborrhea d. Methyldopa(Aldomet) c. Arteriosclerosis 3. Haloperidol(Haldol) d. Reserpine(Serpasil) b. increase sweating b. increase lacrimation c. Monotone type speech mood lability (in state of depression) increase salivation (drooling type) autonomic changes a. Increase dosage of the following drugs: a. Phenothiazine AntipsychoticS AntihypertensiveS SIDE EFFECTS RESERPINE Major depression leading to suicide Aloneness Multiple loss causes suicide Loss of spouse direct approach towards the client close surveillance is a nursing priority Loss of Job time to commit suicide is on weekends early morning Signs and Symptoms for Parkinson’s pill rolling tremors of extremities especially the hands. bradykinesia (slowness of movement) rigidity (cogwheel type) stooped posture shuffling and propulsive gait over fatigue mask like facial expression with decrease blinking of the eyes. Poisoning (lead and carbon monoxide) 2. difficulty rising from sitting position. decrease sexual capacity Nursing Management 1. Encephalitis 5. Administer medications as ordered Anti Parkinsonian agents Levodopa (L-dopa) short acting Amantadine Hydrochloride (Symmetrel) Carbidopa (Sinemet) increase level of dopamine Mechanism of Action Side Effects .Predisposing Factors 1. constipation e. Hypoxia 4.
relieves tremor rigidity Bromocriptene Hydrochloride (Parlodel) Side Effects Respiratory depression 2. 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 . Isonicotinic Acid Hydrazide Anti Cholinergic Agents (ARTANE and COGENTIN) . 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 Contraindications * Increase Vitamin B when taking INH (Isoniazid). Prevent complications of immobility 4.6 – 1. Digitalis Toxicity Signs and Symptoms nausea and vomiting .5 – 1. 6.5 meq/L . Encourage increase fluid intake and fiber. Dopamine Agonist .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 1. Decrease protein in morning and increase protein in afternoon to induce sleep 5.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. Assist/supervise in ambulation 7. Maintain side rails to prevent injury 3.
9 NaCl to prevent development of crystals or precipitate. depression Antidote: Acetylcisteine (mucomyst) prepare suction apparatus as bedside. MYASTHENIA GRAVIS neuromuscular disorder characterized by a disturbance in the transmission of impulses from nerve to muscle cells at the neuromuscular junction leading to descending muscle weakness. diarrhea confusion photophobia changes in color perception (yellowish spots) Antidote: Digibind 2. tachycardia Irritability Restlessness Extreme fatigue Diaphoresis.8 – 1) hypoglycemia Tremors. administered sandwich method avoid taking alcohol because it can lead to severe CNS depression avoid caffeine Nursing Management 4. Dilantin Toxicity Signs and Symptoms gingival hyperplasia (swollen gums) hairy tongue ataxia nystagmus provide oral care massage gums Nursing Management 5. agitation and restlessness) only mixed with plain NSS or 0. irritability. 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 (. 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. . Aminophylline Toxicity Signs and Symptoms tachycardia palpitations CNS excitement (tremors.
airway 2. initial sign is ptosis a clinical parameter to determine ptosis is palpebral fissure. 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: . Assist in plasma paresis and removing auto immune anti bodies 9. Prevent complications INFLAMMATORY CONDITIONS OF THE BRAIN . maintain side rails to prevent injury related to falls 5. mmobility * assist in mechanical ventilation and monitor pulmonary function test * monitor strictly vital signs.under medication . 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. breathe Treatment . if there is no effect there is damage to occipital lobe and midbrain and is negative for Signs and Symptoms Diagnostic Procedure M.infection Signs and Symptoms . Nursing Management 1.The client is unable to see.over medication Signs and Symptoms . Cholinergic (Mestinon) b. speak. administer medications as ordered a. 8.G. aspiration 3. input and output and neuro check * monitor strength or motor grading scale 4.G. Assist in surgical procedure known as thymectomy because it is believed that the thymus gland is responsible for M.stress .PNS Treatment . institute NGT feeding 6.administer cholinergic agents as ordered 7. swallow.Incidence rate: women 20 – 40 years old Predisposing factors unknown autoimmune: it involves release of cholinesterase an enzyme that destroys Ach.Administer anti cholinergic agents (Atropine Sulfate) Side Effects MYASTHENIC CRISIS Causes: .
Encourage to arch back to clearly visualize L3-L4. Assess for movement and sensation of extremities. Signs and Symptoms headache photophobia projectile vomiting fever. Increase CSF opening pressure (normal pressure is 50 – 100 mmHg) 4. Post Lumbar Puncture 1. Nursing Management for LP Before Lumbar Puncture 1. Etiology 1. chills. Hemophilus Influenzae – causes pediatric meningitis B. Empty bladder and bowel to promote comfort. Dura matter – outer layer 2. 2. (+) cultured microorganism (confirms meningitis) CBC reveals 1. 4. (+) Kernig’s sign (leg pain) d. Increase CHON and WBC 2. A. CSF analysis reveals 1. for support and protection for nourishment blood supply LAYERS OF THE MENINGES 1. Pneumococcus 3. Nuchal rigidity or stiff neck b. Arachnoid – middle layer 3. (+) Brudzinski sign (neck pain) D. Diagnostic Procedures Lumbar puncture: a hollow spinal needle is inserted in the subarachnoid space between the L3 – L4 to L5. drainage and leakage to tissues.causes adult meningitis 4. Pia matter – inner layer subdural space between the dura and arachnoid subarachnoid space between the arachnoid and pia. Mode of transmission airborne transmission (droplet nuclei) C. anorexia. Secure informed consent and explain procedure. general body malaise and weight loss Possible increase in ICP and seizure activity Abnormal posturing (decorticate and decerebrate) Signs of meningeal irritation a. Opisthotonus (arching of back) c. Check punctured site for any discoloration. Streptococcus . 3. Meningococcus – most dangerous 2. Decrease glucose 3. Nursing Management . Increase wbc E. Force fluids 3. CSF aspiration is done. Place flat on bed 12 – 24 o 2.MENINGITIS Meninges 3 fold membrane that covers brain and spinal cord.
Tetracycline) b. 8. 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. Maintain good diet of increase CHO. Prevent complications most feared is hydrocephalus hearing loss/nerve deafness is second complication consult audiologist mental retardation delayed psychomotor development c. Compartment syndrome (compression of arteries and nerves) C. Institute measures to prevent increase ICP and seizure. If there is bone fracture there is hemorrhage and there would be escape of the fat cells in the circulation. input and output and neuro check 6. Incidence Rate men are 2-3 times high risk B. Anti pyretics 3. 9. Maintain fluid and electrolyte balance. 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. Provide client health care and discharge planning concerning: a. Institute strict respiratory isolation 24 hours after initiation of anti biotic therapy 4. Risk Factors . Rehabilitation for neurological deficit CVA (STROKE/BRAIN ATTACK/ ADOPLEXY/ CEREBRAL THROMBOSIS) a partial or complete disruption in the brains blood supply. Monitor strictly V/S. Administer medications as ordered a. Mild analgesics c. Elevate head 30-45o 5. 7. Provide a comfortable and darkened environment.1. CHON. Enforce complete bed rest 2. b. Broad spectrum antibiotics (Penicillin. calories with small frequent feedings. 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. 2 most common cerebral artery affected by stroke a. Mid Cerebral Artery b.
Cerebral Arteriography reveals the site and extent of malocclusion uses dye for visualization most of dye are iodine based check for shellfish allergy after diagnostic exam force fluids to release dye because it is nephro toxic check for distal pulse (femoral) check for hematoma formation F. Post Cardiac Surgery (mitral valve replacement) 2. TIA Signs and Symptoms 2. Diabetes Mellitus. Type A personality a. Hyperlipidemia more on genetics/genes that binds to cholesterol 5. D. Lifestyle (smoking). Stroke in evolution 3. agraphia (difficulty writing) f. Complete stroke Signs and Symptoms E. nausea and vomiting dysphagia (+) Kernig’s sign and Brudzinski sign which may lead to hemorrhagic stroke focal neurological deficits a. deadline driven b. phlegia b. CT Scan – reveals brain lesions 2.1. alexia (difficulty reading) e. can do multiple tasks c. Myocardial Infarction. Signs and Symptoms 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. Hypertension. Related stress physical and emotional 8. Diagnostic Procedure 1. aphasia c. Obesity (increase 20% ideal body weight) 4. sedentary lifestyle 3. dysarthria (inability to articulate words) d. Valvular Heart Disease. homonymous hemianopsia (loss of half of visual field) 1. Nursing Management . Related to diet: increase intake of saturated fats like whole milk 7. Atherosclerosis. Prolong use of oral contraceptives promotes lypolysis (breakdown of lipids) leading to atherosclerosis that will lead to hypertension and eventually CVA. usually fells guilty when not doing anything 6.
non verbal cues b. Osmotic Diuretics (Mannitol) b. If positive to hemianopsia approach client on unaffected side 10. prevent complication (subarachnoid hemorrhage is the most feared complication) c. Prevent complications of immobility by: a. Maintain patent airway and adequate ventilation by: a. 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. Mild Analgesics e. 6. saturated fats and caffeine) d. dietary modification (decrease salt. provide egg crate mattresses or water bed c. Monitor strictly vitals signs. Thrombolytic/Fibrinolytic Agents – dissolves thrombus Streptokinase Side Effect: Allergic Reaction Urokinase Tissue Plasminogen Activating Factor Side Effect: Chest Pain f. Provide client health teachings and discharge planning concerning a. Loop Diuretics (Lasix. provide sand bag or food board. Elevate head 30 – 45o 4. turn client to side b. K (Aqua Mephyton) g.1. Administer medications as ordered a. exercise. ulcer and unknown cause of headache because it may potentiate bleeding 11. assist in mechanical ventilation b. administrate O2 inhalation 2. Institute NGT feeding 8. avoidance of modifiable risk factors (diet. magic slate 9. smoking) b. Provide alternative means of communication a. Restrict fluids to prevent cerebral edema that might increase ICP 3. importance of follow up care . Anti Platelet PASA (Aspirin) Contraindicated for dengue. Assist in passive ROM exercise every 4 hours to promote proper bodily alignment and prevent contractures 7. Furosemide) c. I & O and neuro check 5. Anti Coagulants Heparin (short acting) check for partial thromboplastin time if prolonged there is a risk for bleeding. Cortecosteroids d.
Clumsiness (initial sign) 2. constipation C. CSF analysis reveals increase in IgG and protein D. Zylocaine Bretylium – blocks release of norepinephrine to prevent increase of BP 8. A. Assist in passive ROM exercise 7. assist in mechanical ventilation b. Dysphagia 3. Monitor strictly the following a. vital signs b. ECG 3. Diagnostic Procedures 1. Institute NGT feeding to prevent aspiration 6. 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. increase sweating c. Signs and Symptoms 1. Alternate hypotension to hypertension ** ARRYTHMIA (most feared complication) 6. monitor pulmonary function test 2. Autonomic symptoms that includes a. Maintain patent airway and adequate ventilation by: a. Autoimmune 2. . Administer medications as ordered a. Maintain side rails to prevent injury related to fall 4. Anti Arrythmic Agents Lidocaine. Nursing Management 1.GUILLAIN BARRE SYNDROME a disorder of the CNS characterized by bilateral symmetrical polyneuritis leading to ascending muscle paralysis. Arrythmia b. Ascending muscle weakness leading to paralysis 4. Antecedent viral infections such as LRT infections B. Prevent complications a. Assist in plasma pharesis (filtering of blood to remove autoimmune anti-bodies) 9. increase salivation b. Corticosteroids – suppress immune response b. intake and output c. Predisposing Factors 1. Anti Cholinergic Agents – Atrophine Sulfate c. neuro check d. Prevent complications of immobility by turning the client every 2 hours 5. Decreased of diminished deep tendon reflex 5.
visual. olfactory.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. Genetics 3. tactile. Toxicity from a. EEG – reveals hyper activity of electrical brain waves . Tonic contractions . Epileptic cry – is characterized by fall and loss of consciousness for 3 – 5 minutes c. lead b carbon monoxide 5. Physical and emotional stress 7. Petit mal Seizure – absence of seizure common among pediatric clients characterized by a. Drug of choice: Diazepam.direct symmetrical extension of extremities Clonic contractions . Head injury due to birth trauma 2. CT Scan – reveals brain lesions 2. sensory experience b. loss of consciousness (5 – 10 seconds) II. Partial or Localized Seizure 1. mild hallucinatory sensory experience III. Predisposing Factors 1. clouding of consciousness – not in contact with environment c. automatism – stereotype repetitive and non propulsive behavior b. Seizure – first convulsive attack Epilepsy – second or series of attacks Febrile seizure – normal in children age below 5 years A. Status Epilepticus A continuous uninterrupted seizure activity. Valium and Glucose C. Generalized Seizure 1.contraction of extremities d. blank stare b. Signs or aura with auditory. twitching of mouth d. Nutritional and Metabolic deficiencies 6. 2. if left untreated can lead to hyperpyrexia and lead to coma and eventually death. Post ictal sleep – unresponsive sleep 2. decrease blinking of eyes c. Grand mal Seizure (tonic-clonic seizure) a. Psychomotor Seizure (focal motor seizure) a. Valium) B. Diagnostic Procedures 1. Sudden withdrawal to anti convulsant drug is predisposing factor for status epilepticus (drug of choice is Diazepam. Presence of brain tumor 4. Signs and Symptoms Dependent on stages of development or types of seizure I. 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 3. Gonioscopy
Milky white appearance at center of pupils 3.Total removal of cataract with its surrounding capsules Most feared complication post op is RETINAL DETACHMENT 3.Partial removal Intra Capsular Cataract Lens Extraction . Aging 65 years and above 2. Related to congenital 3. Predisposing Factor 1. Acetazolamide (Diamox) – promotes increase outflow of aqueous humor or drainage 4. Treatment 1. Cataract Decrease opacity of lens A. Retinal Detachment Separation of epithelial surface of retina A. Predisposing Factors . Epinephrine eyedrops – decrease formation of aqueous humor 3. Miotics – constricts pupil a. Blurring or hazy vision 2. Timoptics (Timolol Maleate) E. Pilocarpine Sodium. Loss of central vision C.D. Carbonic Anhydrase Inhibitors a. Pathognomonic Signs 1. Surgical Procedures 1. Decrease perception to colors Complication is blindness D. TRABECULECTOMY (Peripheral Indectomy) – drain aqueous humor 2. Surgical Procedure Extra Capsular Cataract Lens Extraction . Cyclopegics (Cyclogyl) – paralyses cilliary muscle F. Diagnostic Procedure 1. Diabetes Mellitus 4. Signs and Symptoms 1. Mydriatics (Mydriacyl) – constricts pupils 2. Prolonged exposure to UV rays B. Carbachol 2. Opthalmoscopic exam E. Treatment 1.
Myopia (near sightedness) B. VI: OCULOMOTOR. Floaters C. Macular Degeneration Degeneration of the macula lutea (yellowish spot at the center of retina) A. Curtain veil like vision 2. IV.1. 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. Post Lens Extraction 2. Cryosurgery – cold application 3. TROCHLEAR. mucous membrane. mandibular sensory: controls sensation of face. teeth. maxillary. soft palate and corneal reflex) . Signs and Symptoms 1. Signs and Symptoms 1. Surgical Procedures 1. Diathermy – heat application 4. Scleral Buckling 2. Black Spots CRANIAL NERVE III.
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. Middle Ear 3. Inner Ear Vestibule: Meinere’s Disease Cochlea Mastoid Cells Endolymph and Perilymph COCHLEA: controls hearing. Parts of the Ear 1. CRANIAL NERVE VIII: ACOUSTIC/VESTIBULOCOCHLEAR Controls balance particularly kinesthesia or position sense. Pituitary Gland (Hypophysis Cerebri) o Located at base of brain particularly at sella turcica . frown and if results are negative there is facial paralysis or Bell’s Palsy and the primary cause is forcep delivery. VAGUS NERVE Glosopharyngeal: controls taste. anterior 2/3 of tongue pinch of sugar and cotton applicator placed on tip of tongue Motor: controls muscle of facial expression instruct client to smile. ENDOCRINE SYSTEM Overview of the structures and functions 1. X: GLOSOPHARYNGEAL. contains the Organ of Corti (the true organ of hearing) Let client repeat words uttered CRANIAL NERVE IX. 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. refers to movement and orientation of the body in space. Outer Ear Pinna Eardrum Hammer Anvil Stirrup Malleus Incus Stapes 2.
If left untreated results to hypovolemic shock (sign is anuria) C. Posterior Pituitary Gland 2.015 – 1. Anterior Pituitary Gland o o o hemorrhage o o administrate oxytocin immediately after delivery to prevent uterine atony. Hypotension 5. 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. Agitation c. Prevent complilcations – HYPOVOLEMIC SHOCK is the most feared complication Normal value: 1. Administer medications as ordered a. Predisposing Factor o o o o 1. Serum Sodium D. Signs of dehydration a. Dry mucous membrane 3. Signs and Symptoms 2. Weakness and fatigue 4. Nursing Management SIADH o hypersecretion of anti diuretic hormone .030 Ph 4 – 8 Increase resulting to hypernatremia Related to pituitary surgery Trauma Inflammation Presence of tumor B. Weight loss 6. Monitor strictly vital signs and intake and output 3.o o Master gland or master clock Controls all metabolic function of body PARTS OF THE PITUITARY GLAND 1. Polyuria 2. Diagnostic Procedures 1. Force fluids 2. Urine Specific Gravity o o o 1. Pitressin (Vasopresin Tannate) – administered IM Z-tract 4. Adult: thirst b. Poor Skin turgor d. 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.
Nursing Management 1. intake and output and neuro check 4. Fluid retention a. B. Predisposing Factors 1. Administer medications as ordered a. Hypertension b. Lactogenic homone (Prolactin) o promotes development of mammary gland . Weight gain 2. Adrenochorticotropic hormone (ACTH) o promotes development of adrenal cortex 4. Related to hyperplasia (increase size of organ brought about by increase of number of cells) of pituitary gland. Urine specific gravity is increased 2. Restrict fluid 2.A. Lead to blindness due to severe photophobia b. Diagnostic Procedure 1. Growth hormones (somatotropic hormone) o o o o o 2. Related to presence of bronchogenic cancer o o initial sign of lung cancer is non productive cough non invasive procedure is chest x-ray 3. Melanocyte Stimulating hormone o o o for skin pigmentation Hyposecretion of MSH results to Albinism Most feared complications of albinism a. Edema c. 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. Provide meticulous skin care 6. Weigh patient daily and assess for pitting edema 5. Loop diuretics (Lasix) b. Osmotic diuretics (Mannitol) 3. Prone to skin cancer o Hypersecretion of MSH results to Vitiligo 3. Water intoxication may lead to cerebral edema and lead to increase ICP – may lead to seizure activity C. Monitor strictly vital signs. Serum Sodium is decreased D. Signs and Symptoms 1. Head injury 2.
Goiter belt area a. Leutinizing hormone 6. Mountainous regions 2.o o o with help of oxytocin it initiates milk let down reflex secretes estrogen secretes progesterone 5. broccoli. all nuts soil erosion washes away iodine goitrogenic drugs a. Thyrocalcitonin – antagonizes the effects of parathormone to promote calcium resorption. 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. strawberry. places far from sea b. T4 (tetra iodothyronine. Thyroxine) o o T3 and T4 are metabolic or calorigenic hormone promotes cerebration (thinking) 3. Increase intake of goitrogenic foods o o o o contains pro-goitrin an anti thyroid agent that has no iodine. turnips. T3 (Tri iodothyronine) . Predisposing Factors 1. 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. sweet potato. radish. carrots.3 molecules of iodine (more potent) 2. Lithium Carbonate . Anti Thyroid Agent – Prophylthiuracil (PTU) b. cabbage.
Increase dietary intake of foods rich in iodine A. Administer medications as ordered a. PASA (Aspirin) d. best taken raw because it it is easily destroyed by heat 5. inflammation 3. Phenylbutazones (NSAIDs) . 4 Medications to be taken via straw: Lugol’s. Predisposing Factors 1. iodized salt. Nursing Management 1. Instruct client to take in the morning to prevent insomnia 2.c. Enforce complete bed rest 2. Monitor side effects o o o o o o o insomnia tachycardia and palpitations hypertension heat intolerance seaweeds seafood’s like oyster. Iatrogenic Cause – disease caused by medical intervention such as surgery 2. Mild dysphagia 3. 3. Mild restlessness C. Diagnostic Procedures 1. Thyroid Scan – reveals enlarged thyroid gland. Thyroid Hormones o o o Levothyroxine (Synthroid) Liothyronine (Cytomel) Thyroid Extracts Nursing Management when giving Thyroid Hormones 1. Related to atrophy of thyroid gland due to trauma. Serum T3 and T4 – reveals normal or below normal 2. crabs. Lugol’s Solution/SSKI ( Saturated Solution of Potassium Iodine) o o color purple or violet and administered via straw to prevent staining of teeth. Iron. Iodine deficiency 4. Nitrofurantoin (drug of choice for pyelonephritis) b. Autoimmune (Hashimotos Disease) . Cobalt e. Signs and Symptoms 1. Serum Thyroid Stimulating Hormone (TSH) – is increased (confirmatory diagnostic test) D. Tetracycline. Enlarged thyroid gland 2.if goiter is caused by B. clams and lobster but not shrimps because it contains lesser amount of iodine. Monitor vital signs especially heart rate because drug causes tachycardia and palpitations 3. 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.
CNS changes o o o o lethargy memory impairment psychosis menorrhagia C. Brittleness of hair and nails 2. bradycardia. hypothermia leading to pregressive stupor and coma. Provide client health teaching and discharge planning concerning a. hypovolemic shock Assist in mechanical ventilation Administer thyroid hormones as ordered Force fluids . bradycardia. and sedatives prevent complications (myxedema coma. Nursing Management 1. hypothermia 6. Non pitting edema (Myxedema) 3. Provide meticulous skin care 8. narcotics. Decrease in all vital signs – hypotension. Constipation (Late Signs) 1. Provide dietary intake that is low in calories 6. Nursing Management for Myxedema Coma 2. Administer medications as ordered Thyroid Hormones a. Leothyronine c. Thyroid Extracts 5. Signs and Symptoms (Early Signs) 1. Levothyroxine b. Force fluids 3. Serum T3 and T4 is decreased 2. Hoarseness of voice 4.B. Administer isotonic fluid solution as ordered 4. bradypnea. hypoventilation. 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. bradypnea. Decrease libido 5. hypoglycemia. hyponatremia. Provide comfortable and warm environment 7. RAIU (Radio Active Iodine Uptake) is decreased D. Weakness and fatigue 2. Serum Cholesterol is increased 3. Loss of appetite but with weight gain which promotes lipolysis leading to atherosclerosis and MI 3. Avoid precipitating factors leading to myxedema coma o o o o o stress infection cold intolerance use of anesthetics. Cold intolerance 5. Dry skin 4. Diagnostic Procedures 1.
Thyroid Scan. Provide meticulous skin care 5. Diarrhea 5. Provide dietary intake that is increased in calories. Monitor strictly vital signs and intake and output 2. Increase appetite (hyperphagia) but there is weight loss 2. Moist skin 3. Heat intolerance 4. Comfortable and cold environment 6.reveals an enlarged thyroid gland D. . Related to hyperplasia (increase size) B. Tremors d. All vital signs are increased 6. Autoimmune – it involves release of long acting thyroid stimulator causing exopthalmus (protrusion of eyeballs) enopthalmus (late sign of dehydration among infants) 2. RAIU (Radio Active Iodine Uptake) is increased 3. CNS involvement a. Provide bilateral eye patch to prevent drying of the eyes. 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. 4. Irritability and agitation b. Administer medications as ordered Anti Thyroid Agent a. 8. Predisposing Factors 1. Goiter 8. Serum T3 and T4 is increased 2. Signs and Symptoms 1. Prophythioracill (PTU) b. Exopthalmus 9.o o o o o 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. Insomnia e. Excessive iodine intake 3. Hallucinations 7. Restlessness c. Amenorrhea C. Maintain side rails 7. Diagnostic Procedures 1. Nursing Management 1. 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.
Predisposing Factors 1. Atrophy of parathyroid gland due to: . seizure give Calcium Gluconate IV slowly as ordered 3. Watch out for signs of thyroid storm/ thyrotoxicosis Agitation TRIAD SIGNS Hyperthermia o administer medications as ordered a.POST OPERATIVELY. 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. Beta-blockers o o o monitor strictly vital signs. 1. Anti Pyretics b. 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. Following subtotal thyroidectomy 2. input and output and neuro check. Hormonal replacement therapy for lifetime 6. Signs of bleeding (feeling of fullness at incisional site) Nursing Management o Check the soiled dressings at the back or nape area. maintain side rails offer TSB Tachycardia 2. 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 A. 5.
Acute Tetany Calcium Gluconate IV slowly b.C ▼ Aluminum Containing Antacids ▼ Aluminum Hydroxide MAD ▼ Magnesium Containing Antacids ▼ . Administer medications as ordered such as: a.a. positive chvostek sign g. agitation and memory impairment C. X-ray of long bones reveals a decrease in bone density 4. trauma B. photophobia and cataract formation b. CT Scan – reveals degeneration of basal ganglia D.5 – 4. Phosphate binder Aluminum Hydroxide Gel (Ampogel) Side effect: constipation ANTACID A. arrhythmia 2. Chronic Tetany Oral Calcium supplements Calcium Gluconate Calcium Lactate Calcium Carbonate c.A. Serum Phosphate is decreased (normal value: 2. loss of tooth enamel c. Serum Calcium is decreased (normal value: 8. tingling sensation b. dysphagia e. tumor c. positive trousseu’s sign/carpopedal spasm f. Acute tetany a. anorexia. 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. Signs and Symptoms 1. numbness d. inflammation b. Chronic tetany a. Diagnostic Procedures 1. Nursing Management 1. seizure i. paresthesia c. laryngospasm/broncospasm h.5 mg/100 ml) 3. nausea and vomiting d.
Children: Ricketts b. Over compensation of parathyroid gland due to vitamin D deficiency a. Importance of follow up care. Bone pain especially at back (bone fracture) 2. Morphine Sulfate (Demerol) 5. Diagnostic Procedures 1.Gel ▼ Side Effect: Constipation Side Effect: Diarrhea 2. renal cholic b. Hormonal replacement therapy for lifetime 12. Provide acid ash in the diet to acidify urine and prevent bacterial growth 7. Nursing Management 1. Kidney stones a. Administer medications as ordered a. Prevent complications 8. anchovies b. cool moist skin 3. Anorexia. Serum Calcium is increased 2. Serum Phosphate is decreased 3. Agitation and memory impairment C. Prevent complications (seizure and arrhythmia) 10. Assist in surgical procedure known as parathyroidectomy 11. Institute seizure and safety precaution 5. Hormonal replacement therapy for lifetime 9. Force fluids to prevent kidney stones 2. Encourage client to breathe using paper bag to produce mild respiratory acidosis result. nausea and vomiting 4. Strain all the urine using gauze pad for stone analysis 3. salmon c. Hyperplasia of parathyroid gland 2. Predisposing Factors 1. 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. Assist/supervise in ambulation 8. green turnips 4. Signs and Symptoms 1. Encourage increase intake of foods rich in calcium a. Adults: Osteomalacia B. Importance of follow up care . Avoid precipitating stimulus such as glaring lights and noise 3. 6. X-ray of long bones reveals bone demineralization D. Prepare trache set at bedside for presence of laryngo spasm 7. Maintain side rails 9. Encourage increase intake of foods rich in phosphate but decrease in calcium 6. Provide warm sitz bath 4.
Salt ADDISON’S DISEASE o Hyposecretion of adreno cortical hormone leading to a. metabolic disturbance – Sugar b.function: controls glucose metabolism .secretes mineralocorticoids (aldosterone) .function: promotes sodium and water reabsorption and excretion of potassium .secretes traces of glucocorticoids and androgenic hormones . fluid and electrolyte imbalance – Salt c. Adrenal Cortex – outermost b.arrhythmia . deficiency of neuromuscular function – Salt/Sex A.ADRENAL GLAND o o Located atop of each kidney 2 layers of adrenal gland a. Hyponatremia .Sex 3.function: promotes secondary sex characteristics . Zona Reticularis .hypotension . Zona Fasciculata .diarrhea .Sugar 2. 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.signs of dehydration .secretes glucocortocoids (cortisol) . Decrease tolerance to stress 3. Zona Glumerulosa . Predisposing Factors 1. Fungal infections B. Related to atrophy of adrenal glands 2. Signs and Symptoms 1.weight loss 4. Hypoglycemia – TIRED 2. Hyperkalemia .agitation .
Decrease libido 6.5. hyponatremia leading to progressive stupor and coma Nursing Management for Addisonian Crisis 1. Plasma Cortisol is decreased 3. Dexamethasone (Decadrone) b. Taper dose (withdraw gradually from drug) 3. 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. Instruct client to take 2/3 dose in the morning and 1/3 dose in the afternoon to mimic the normal diurnal rhythm 2. prevent complications .addisonian crisis . Monitor strictly vital signs. Provide meticulous skin care 7. Provide dietary intake. importance of follow up care . Administer medications as ordered Corticosteroids a. avoid precipitating factor leading to addisonian crisis leading to . Assist in mechanical ventilation. moon face appearance 4.hypovolemic shock c. increase calories. Bronze like skin pigmentation C. Diagnostic Procedures 1. protein but decrease in potassium 6. hirsutism d. Loss of pubic and axillary hair 7.5 – 4. Serum Sodium is decrease (normal value: 135 – 145 meq/L) 4. severe hypotension b. hypertension b. carbohydrates. . Administer isotonic fluid solution as ordered 3. Provide client health teaching and discharge planning a.sudden withdrawal to steroids b. increase susceptibility to infection e.force fluids 2. Mineralocorticoids (Flourocortisone) 5.infection . Nursing Management 1. edema c.5 meq/L) D. Serum Potassium is increased (normal value: 3. FBS is decreased (normal value: 80 – 100 mg/dl) 2. hormonal replacement for lifetime d. Prednisone c.administer steroids as ordered . Monitor side effects a. hypovolemic shock c. Force fluids 4. Hydrocortisone (Cortison) Nursing Management when giving steroids 1.stress .
Increase masculinity among females B.Has alpha cells that secretes glucagons (function: hyperglycemia) . FBS is increased 2. Easy bruising 8. Hormonal replacement for lifetime 10. weakness and fatigue b. thin extremities 4.Consist of acinar cells which secretes pancreatic juices that aids in digestion thus it is an exocrine gland . Importance of follow up care PANCREAS . Hypernatremia a. Assist in surgical procedure (bilateral adrenoraphy) 9. constipation c.Consist of islets of langerhans . Hirsutism 6. Predisposing Factors 1 Related to hyperplasia of adrenal gland 2. Nursing Management 1. Weigh patient daily and assess for pitting edema 3. obese trunk f. Serum Sodium is increased 4. Serum Potassium is decreased C.Beta cells secretes insulin (function: hypoglycemia) . U wave upon ECG (T wave hyperkalemia) 5. Administer medications as ordered a. weight gain d. moon face appearance and buffalo hump e. pendulous abdomen g. Provide meticulous skin care 6. Acne and striae 7.Delta cells secretes somatostatin (function: antagonizes the effects of growth hormones) . Hypokalemia a. Measure abdominal girth daily and notify physician 4. Spinarolactone – potassium sparring diuretics 7. Restrict sodium intake 5.CUSHING SYNDROME o Hypersecretion of adenocortical hormones A.Mixed gland (exocrine and endocrine) . Monitor strictly vital signs and intake and output 2. Prevent complications (DM) 8. edema c. hypertension b. Diagnostic Procedures 1. Plasma Cortisol is increased 3. Increase susceptibility to infections 3.Located behind the stomach .
Adult onset . Signs and Symptoms 1. Weight gain Type 2 (NIDDM) . Usually asymptomatic 2. Polydypsia 3. Insulin therapy 2. Treatment 1. Signs and Symptoms 1. Predisposing Factors 1. protein and fat metabolism CLASSIFICATION OF DM Type 1 (IDDM) .Maturity onset type .metabolic disorder characterized by non utilization of carbohydrates. Hereditary (total destruction of pancreatic cells) 2. Pancreatic Tumor/Cancer 2. Osmolar 3. Blurring of vision 8. Complication 1. Weight loss 6. Complications 1.Juvenile onset type . Coma C. Anorexia. Polyuria 2. Diet 3. Non 4. Related to viruses 3. Oral Hypoglycemic agents 2. Incidence Rate . Incidence Rate .Brittle disease A. Diabetes Mellitus 3. Steroids 4. Pancreatitis DIABETES MELLITUS . Polyuria 3. Lasix b. Exercise E. Treatment 1. Diet 3. Predisposing Factors 1.90% of general population has type 2 DM B. Related to carbon tetrachloride toxicity C.Obese over 40 years old A. Polyphagia 4. Glucosuria 5. Polyphagia 5. nausea and vomiting 7. Increase susceptibility to infection 9. Ketotic 5.10% general population has type 1 DM B. Hyper 2. Delayed/poor wound healing D. Obesity – because obese persons lack insulin receptor binding sites . Exercise E. Drugs a. Polydypsia 4. Diabetic Ketoacidosis D. Glucosuria 6.3 Main Disorders of Pancreas 1.
Carbohydrates 2. Protein 3.Cholesterol . Fats ANABOLISM Glucose Amino Acids Fatty Acids CATABOLISM Glycogen Nitrogen Free Fatty Acids .MAIN FOODSTUFF 1.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 .
Assist in mechanical ventilation 2. Polydypsia 3. Sodium Bicarbonate to counteract acidosis c. Nursing Management 1. Assist in mechanical ventilation 2. Infection B. Acetone breath odor 9. Predisposing Factors 1. Anorexia.45 NaCl (hypotonic solutions) to counteract dehydration and shock 3. FBS is increased 2. Headache and dizziness 2. Insulin therapy (regular acting insulin/rapid acting insulin peak action of 2 – 4 hours) b. Decrease LOC – diabetic coma B. Monitor strictly vital signs. Hct (normal value: female 36 – 42. Glucosuria 5. nausea and vomiting 7.Hyperosmolar: increase osmolarity (severe dehydration) . Creatinine (normal value: . Polyphagia 4.45 NaCl (hypotonic solutions) to counteract dehydration and shock 3.8 – 1) 4. Hyperglycemia 2. Administer medications as ordered a.DIABETIC KETOACIDOSIS . Diagnostic Procedures 1. Signs and Symptoms 1. Weight loss 6. Administer 0. Kussmaul’s Respiration (rapid shallow breathing) 10 CNS depression leading to coma C. male 42 – 48) due to severe dehydration D. Administer medications as ordered a.Acute complication of type 1 DM due to severe hyperglycemia leading to severe CNS depression A. intake and output and blood sugar levels 4. Polyuria 2. Monitor strictly vital signs.9 NaCl followed by . BUN (normal value: 10 – 20) 3. Insulin therapy (regular acting insulin peak action of 2 – 4 hours) . Seizure activity 4. Blurring of vision 8. Administer 0. intake and output and blood sugar levels 4. Stress – number one precipitating factor 3. Restlessness 3.Non ketotic: absence of lypolysis (no ketones) A. Antibiotics to prevent infection HYPER OSMOLAR NON KETOTIC COMA . Signs and Symptoms 1. Nursing Management 1.9 NaCl followed by .
for DKA use rapid acting insulin b. Animal sources .Peak action is 8 – 16 hours 3.Regular acting insulin (IV only) . Long Acting Insulin (cloudy) . Glipzide (Glucotrol) b. Artificially Compound Insulin B. First Generation Sulfonylureas a. When mixing 2 types of insulin aspirate first the clear insulin before cloudy to prevent contaminating the clear insulin and promote proper calibration. Monitor for signs of local complications such as a.Ultra Lente . Administer at room temperature to prevent development of lipodystrophy (atrophy.Peak action is 16 – 24 hours C. hypertrophy of subcutaneous tissues) 2. No need to aspirate upon injection 7. Allergic reactions b. Chlorpropamide (Diabenase) b. Rapid Acting Insulin (clear) . Instruct the client to take it with meals to lessen GIT irritation and prevent hypoglycemia . Antibiotics to prevent infection INSULIN THERAPY A.Peak action is 2 – 4 hours 2.. Lipodystrophy c. Diabeta (Micronase) Nursing Management when giving OHA 1. Most accessible route is abdomen 9.Derived from beef and pork 2. Rotate insulin injection sites to prevent development of lipodystrophy 8. Sources of Insulin 1. 10.Frequently used type because it has less antigenicity property thus less allergic reaction 3.Rarely used because it can cause severe allergic reaction . Administer insulin either 45o – 90o depending on amount of clients tissue deposit 6.Non Protamine Hagedorn Insulin (NPH) .Stimulates the pancreas to secrete insulin A. Nursing Management for Insulin Injections 1. Avoid shaking insulin vial vigorously instead gently roll vial between palm to prevent formation of bubbles 4. Types of Insulin 1. Somogyis Phenomenon – rebound effect of insulin characterized by hypoglycemia to hyperglycemia ORAL HYPOGLYCEMIC AGENTS . Classsification 1. Intermediate Acting Insulin (cloudy) . Place in refrigerator once opened 3. Use gauge 25 – 26 needle 5. Tolbutamide (Orinase) c. Second Generation Sulfonylureas a. Human Sources . Tolamazide (Tolinase) 2.
CVA) b. Gangrene formation e.sexual impotence 8. Shock due to dehydration . Nursing Management 1. Albumin 2. Veins III. Diagnostic Procedures 1. Globulins 3. instruct client to cut toenails straight c. HPN and DM major cause of renal failure d. Assist in surgical procedure HEMATOLOGICAL SYSTEM I. Instruct client to exercise best after meals when blood glucose is rising 7. Blood Forming Organs 1.Renal failure c. Alpha Glycosylated Hemoglobin is increased C. Monitor strictly vital signs. Random Blood Sugar is increased 3. Spleen 4. Instruct client to have an annual eye and kidney exam 10.2. Provide nutritional intake of diabetic diet that includes: carbohydrates 50%.Blindness KIDNEY -RECURRENT PYELONEPHRITIS . protein 30% and fats 20% or offer alternative food substitutes 6. Prothrombin and Fibrinogen . Lymph Nodes 6. FBS is increased (3 consecutive times with signs or polyuria.peripheral neuropathy . Monitor for signs of hypoglycemia and hyperglycemia . polydypsia. assist in surgical wound debriment (give analgesics 15 – 30 mins prior) 9.administer simple sugars . Bone Marrow Plasma CHON (formed in liver) 1. polyphagia and glucosuria confirmatory for DM) 2. Blood 55% Plasma Serum 45% Formed II. encourage client to apply lanolin lotion to prevent skin breakdown e. Arteries 2. Blood Vessels 1. Atherosclerosis (HPN. Liver 3. Microangiopathy (affects small minute blood vessels of eyes and kidneys) EYES -PREMATURE CATARACT . Instruct the client to avoid taking alcohol because it can lead to severe hypoglycemia reaction or Disulfiram (Antabuse) toxicity symptoms B. Monitor for peak action of insulin and OHA and notify physician 2. Oral glucose tolerance test is increased – most sensitive test 4. Monitor signs for complications a. Monitor for signs of DKA and HONKC 11. instruct client to avoid walking barefooted b. Lymphoid Organ 5. MI. instruct client to avoid wearing constrictive garments d.for hyperglycemia (dry and warm skin) 5. Administer insulin and OHA therapy as ordered 3. Institute foot care management a. intake and output and blood sugar levels 4.diarrhea/constipation .for hypoglycemia (cold and clammy skin) give simple sugars .
Polymorpho Neutrophils .normal value: female 36 – 42% male 42 – 48% .involved in short term phagocytosis for acute inflammation 2.transport steroids. vitamin b6 (pyridoxine) f.consist of molecules of hgb (red pigment) bilirubin (yellow pigment) biliverdin (green pigment) hemosiderin (golden brown pigment) . prothrombin and fibrinogen clotting factors FORMED ELEMENTS 1.hemoglobin: normal value female 12 – 14 gms% male 14 – 16 gms% . Polymorphonuclear Eosinophils . vitamin c d.for allergic reaction B.60 – 70% of WBC .normal value: 5000 – 10000/mm3 A.only unnucleated cell .thymus for immunity Natural killer cell .substances needed for maturation of RBC a. Granulocytes 1.Normal life span of RBC is 80 – 120 days and is killed in red pulp of spleen 2.Alpha globulins .responsible for the release of chemical mediation for inflammation 3. Non Granulocytes 1. intrinsic factor .Largest and numerous plasma CHON .ALBUMIN .hematocrit red cell percentage in wholeblood .biconcave discs .Beta globulins – iron and copper . WBC (LEUKOCYTES) . iron c.involved in long term phagocytosis for chronic inflammation 2. folic acid b.macrophage in blood . RBC (ERYTHROCYTES) . bilirubin and hormones .bone marrow . Monocytes .normal value: 4 – 6 million/mm3 .Maintains osmotic pressure preventing edema GLOBULINS .transports and carries oxygen to tissues . Lymphocytes B-cell T-cell .for parasite infections .anti viral and anti tumor property . anti-bodies and immunoglobulins b. Polymorphonuclear Basophils .largest WBC . vitamin b12 (cyanocobalamin) e.Gamma globulins a.
Normal value: 150. Chronic blood loss due to trauma a. Heavy menstruation b. Related to GIT bleeding resulting to hematemesis and melena (sign for upper GIT bleeding) c. Headache and dizziness 4. Oozing of blood from venipunctured site BLOOD DISORDERS Iron Deficiency Anemia . Related to improper cooking of foods C.6 months – 5 years incubation period . Echhymosis 3.Normal life span of platelet is 9 – 12 days Signs of Platelet Dysfunction 1. Signs and Symptoms 1.000 – 450. Common among women 15 – 35 years old 4. Incidence Rate 1. Pneumocystis Carinii Pneumonia 3.Promotes hemostasis (prevention of blood loss) . Common among tropical zones 3. Palpitations 7. Kaposi’s Sarcoma 2.000/mm3 . Weakness and fatigue (initial signs) 3. Common among developed countries 2.A chronic microcytic anemia resulting from inadequate absorption of iron leading to hypoxemic tissue injury A.HIV . Usually asymptomatic 2. High cereal intake with low animal protein digestion d. Predisposing Factors 1.6 months window period . Related to malabsorption syndrome c. Inadequate intake of iron due to a. Brittleness of hair and spoon shape nails (koilonychias) 8. fresh blood per rectum is called hematochezia 2. Platelets (THROMBOCYTES) . Pallor and cold sensitivity 5.drug of choice AZT (Zidon Retrovir) 2 Common fungal opportunistic infection in AIDS 1.Consist of immature or baby platelets or megakaryocytes which is the target of dengue virus .western blot opportunistic . Chronic diarrhea b.ELISA . Dyspnea 6. Subtotal gastrectomy 4. Atropic Glossitis (inflammation of tongue) .Stomatitis PLUMBER VINSON’S SYNDROME . Related to poor nutrition B. Petechiae 2.
Administer medications as ordered Oral Iron Preparations a. Melena 5. Ferrous Sulfate b. Enforce CBR so as not to over tire client 3.. Anorexia b. Avoid massaging the injection site instead encourage to ambulate to facilitate absorption 3. Legumes g. Monitor and inform client of side effects a. Hypotension (anaphylactic shock) . discoloration and leakage to tissues 2. Hct is deceased 4.Lugol’s solution . Sweet potatoes e. RBC is decreased 2.Iron . Hgb is decreased 3. Fever and chills e. Ferritin is decreased E. Egg (yolk) c. Instruct client to take foods rich in iron a. Skin rashes f. Ferrous Fumarate c. Monitor side effects a. Instruct client to take with meals to lessen GIT irritation 2. Nursing Management 1. If client cant tolerate/no compliance administer parenteral iron preparation a. Abdominal pain d. Iron is decreased 5. Nausea and vomiting c. Administer Z tract technique to prevent discomfort. stool and GIT 2. Ferrous Gluconate . Sorbitex (IM) Nursing Management when giving parenteral iron preparations 1.Dysphagia 9. Reticulocyte is decreased 6. Nuts 4.Tetracycline . Pain at injection site b. Raisin d. Dried fruits f. IV) b.Nitrofurantoin (Macrodentin) 3. PICA (abnormal appetite or craving for non edible foods D. When diluting it in liquid iron preparations administer with straw to prevent staining of teeth Medications administered via straw . Organ meat b. Diarrhea/constipation e. Diagnostic Procedures 1. Pruritus/orticaria g. Instruct the client to avoid taking tea and coffee because it contains tannates which impairs iron absorption 5. Administer with Vitamin C or orange juice for absorption 4. Localized abscess c.300 mg/day Nursing Management when taking oral iron preparations 1. Monitor for signs of bleeding of all hema test including urinw. Iron Dextran (IM. Lymphadenopathy d.
Headache and dizziness 3. Hereditary factors 3. tingling sensation b. Weakness and fatigue 2. Dyspnea and palpitations as part of compensation 5.Never given orally because there is possibility of developing tolerance . GIT changes that includes a.No side effects 3. Inflammatory disorders of the ileum 4. indigestion/dyspepsia d. positive to Romberg’s test – damage to cerebellum resulting to ataxia e. CNS changes a. mouth sore b. red beefy tongue c.PERNICIOUS ANEMIA . Signs and Symptoms 1. Administer Vitamin B12 injections at monthly intervals for lifetime as ordered . jaundice 6. Subtotal gastrectomy 2. Enforce CBR 2. numbness c. Autoimmune 5. Pallor and cold sensitivity 4. Nursing Management 1. protein. Predisposing Factors 1. Diagnostic Procedure Schilling’s Test – reveals inadequate/decrease absorption of Vitamin B12 D. paresthesia d. Avoid heat application to prevent burns Secretes hydrochloric acid ▼ Aids in digestion .Chronic anemia characterized by a deficiency of intrinsic factor leading to hypochlorhydria (decrease hydrochloric acid secretion) A. Strictly vegetarian diet STOMACH ▼ Pareital cells/ Argentaffin or Oxyntic cells Produces intrinsic factors ▼ Promotes reabsorption of Vit B12 ▼ Promotes maturation of RBC B. Provide a dietary intake that is high in carbohydrates. Instruct client to avoid irritating mouth washes instead use soft bristled toothbrush 5. result to psychosis C. weight loss e.Site of injection for Vitamin B12 is dorsogluteal and ventrogluteal . vitamin c and iron 4.
Diagnostic Procedures 1. Dyspnea and palpitations 2. cough 7. Removal of underlying cause 2. venipunctured sites 8 Instead provide heparin lock 9.Stem cell disorder leading to bone marrow depression leading to pancytopenia PANCYTOPENIA Decrease RBC (anemia) A. Corticosteroids – caused by immunologic injury Decrease WBC (leucopenia) Decrease Platelet (thrombocytopenia) . Ecchymosis c. Institute BT as ordered 3. Nursing Management 1. Pallor and cold sensitivity d. Predisposing Factors 1. Chemicals (Benzine and its derivatives) 2. Anemia a. Bone marrow biopsy/aspiration (site is the posterior iliac crest) – reveals fat necrosis in bone marrow D. Vincristine (Plant Alkaloid) c. Weakness and fatigue b. Increase susceptibility to infection 3. Institute reverse isolation 6. fever b. Thrombocytopenia a. Related to irradiation/exposure to x-ray 3. Monitor for signs of infection a. Signs and Symptoms 1. subcutaneous. CBC reveals pancytopenia 2. Methotrexate (Alkylating Agent) b. Petechiae (multiple petechiae is called purpura) b. Nitrogen Mustard (Antimetabolite) Phenylbutazones (NSAIDS) B. Enforce CBR 5. Leukopenia a.APLASTIC ANEMIA . Oozing of blood from venipunctured sites C. Drugs Broad Spectrum Antibiotics a. Chloramphenicol (Sulfonamides) Chemotherapeutic Agents a. Immunologic injury 4. Administer medications as ordered a. Administer oxygen inhalation 4. Instruct client to use electric razor when shaving 10. Headache and dizziness c. Avoid IM.
b. CBC reveals decreased platelets 2. ABG analysis reveals metabolic acidosis 4. Hemoptysis 6. Anaphylaxis 5. Opthamoscopic exam reveals sub retinal hemorrhages D. Anuria – late sign . Vitamin K b. Oozing of blood from punctured sites 4. Institute NGT decompression by performing gastric lavage by using ice or cold saline solution of 500 – 1000 ml 8. Ecchymosis 3. Monitor NGT output 9. Related to rapid blood transfusion 2. Oliguria (late sign) C. lungs and lower extremities 2. Massive burns 3. Force fluids 5. Hypovolemic shock b. Stool occult blood positive 3. Petechiae (widespread and systemic) eye. Neoplasia (new growth of tissue) 7. Prevent complication a. Pitressin/ Vasopresin to conserve fluids c. Massive trauma 4. Pregnancy B. Monitor for signs of bleeding of all hema test including stool and GIT 2. Diagnostic Procedures 1. Administer oxygen inhalation 4. Septecemia 6. 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. Heparin/Coumadin is ineffective 6. Provide heparin lock 7. Signs and Symptoms 1. Nursing Management 1. Administer medications as ordered a. Predisposing Factors 1. Administer isotonic fluid solution as ordered 3.
Prevent bleeding if there is platelet deficiency Principles of blood transfusion 1. Replace circulating blood volume 2. Cytrate intoxication h. Isotonic solution (0. Instruct another RN to re check the following a. Serial number 5. Check the blood unit for bubbles cloudiness.Never warm blood as it may destroy vital factors in blood. Monitor strictly vital signs before. Proper refrigeration .Expiration of platelet is 3 – 5 days 2.BLOOD TRANSFUSION Goals/Objectives 1. Circulatory overload e.9 NaCl/plain NSS) to prevent hemolysis 4.Expiration of packed RBC is 3 – 6 days . Avoid mixing or administering drugs at BT line to prevent HEMOLYSIS 8. Increase the oxygen carrying capacity of blood 3. Type AB – universal recipient c. Air embolism f. Type O – universal donor b.Emergency rapid BT is given after 30 minutes and let natural room temperature warm the blood. during and after BT especially every 15 minutes for first hour because majority of transfusion reaction occurs during this period a. Gauge 18 – 19 needle 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. Expiration date d. Hemolytic reaction b. Blood typing and cross matching c. Proper typing and cross matching a. Hyperkalemia (caused by expired blood) . 85% of population is RH positive 3. Allergic reaction c. Regulate BT 10 – 15 gtts/min or KVO rate or equivalent to 100 cc/hr to prevent circulatory overload 9. sediments and darkness in color because it indicates bacterial contamination . Thrombocytopenia g. Pyrogenic reaction d. Client name b. 6.Warming is only done during emergency situation and if you have the warming device . Aseptically assemble all materials needed for BT a. Prevent infection in there is a decrease in WBC 4. Filter set b.
Hypotension 5. Palpitations 5. Urine is color red/ portwine urine Nursing Management 1. Administer isotonic fluid solution to prevent shock and acute tubular necrosis 5. Headache and dizziness 2. Antipyretic b. Monitor vital signs and intake and output SIGNS AND SYMPTOMS PYROGENIC REACTIONS 1. Notify physician 3. Lumbasternal/ Flank pain 7. Stop BT 2. Diarrhea/Constipation 4. Administer medications as ordered a. Dyspnea 3. Dyspnea Nursing Management 1. anaphylactic shock treat with Epinephrine 5.Signs and Symptoms of Hemolytic reaction 1. Diaphoresis 6. Fever and chills 2. Send the blood unit to blood bank for re examination 6. Antibiotic 5. Flush with plain NSS 4. Laryngospasm and Broncospasm Nursing Management 1. Anti Histamine (Benadryl) . Obtain urine and blood sample and send to laboratory for re examination 7. Flushed skin 6. Fever 2. Headache 3. Obtain urine and blood sample and send to laboratory for re examination 7. Dyspnea 3. Stop BT 2. Administer medications as ordered a. Send the blood unit to blood bank for re examination 6. Urticaria 6. Tachycardia 4.if positive to hypotension. Notify physician 3. Stop BT 2. Broncial wheezing 4. Send the blood unit to blood bank for re examination 6. Monitor vital signs and intake and output SIGNS AND SYMPTOMS OF ALLERGIC REACTION 1. Obtain urine and blood sample and send to laboratory for re examination 7. Flush with plain NSS 4. Skin rashes 5. Flush with plain NSS 4. Notify physician 3. Monitor vital signs and intake and output .
Muscular pumping organ of the body.8.Resemble like a close fist . Endocardium – inner layer .In between is the pericardial fluid which is 10 – 20 cc . Atria 2.To promote unidimensional flow or prevent backflow 1. Atrioventricular Valves – guards opening between a. Rales/Crackles upon auscultation 4.Myocarditis can lead to cardiogenic shock and rheumatic heart disease B. Lower Chamber (contracting or pumping) a.Left ventricle has increased pressure which is 120 – 180 mmHg . Myocardium – middle layer 3. Epicardium – outer layer 2.Common among MI. Orthopnea 2. Layers of Heart 1. . Ventricles . Valves . tricuspid valve b. Administer medications as ordered a. aortic . pericarditis. Upper Chamber (connecting or receiving) a.Closure of AV valves give rise to first heart sound (S1 “lub”) 2.Right atrium has decreased pressure which is 60 – 80 mmHg C.Prevent pericardial friction rub . Chambers of the Heart 1. Notify physician 3.In order to propel blood to the systemic circulation .Covered by a serous membrane called the pericardium 2 layers of pericardium a.Weighs approximately 300 – 400 grams .Located on the left mediastinum . Parietal – outer layer b. Semi – lunar Valves a. Dyspnea 3. Cardiac tamponade A. Loop diuretic (Lasix) CARDIOVASCULAR SYSTEM OVERVIEW OF THE STRUCTURE AND FUNCTIONS OF THE HEART HEART . Stop BT 2. pulmonic b. Visceral – inner layer . Render TSB SIGNS AND SYMPTOMS OF CIRCULATORY REACTION 1. mitral valve . Exertional discomfort Nursing Management 1.
08 milliseconds to allow ventricular filling 3.Located at the interventricular septum 4. Coronary Arteries .P WAVE (atrial depolarization) contraction .. Right Main Coronary Artery 2.Initiates electrical impulse of 60 – 100 bpm 2.QRS WAVE (ventricular depolarization) .Located at the walls of the ventricles for ventricular contraction SA NODE AV NODE BUNDLE OF HIS JLJLJLJJLJLJL PURKINJE FIBERS . S4 – atrial gallop usually seen in Myocardial Infarction and Hypertension D. S3 – ventricular gallop usually seen in Left Congestive Heart Failure 2.Supplies the myocardium E.Located at the inter atrial septum .Delay of electrical impulse for about . Purkinje Fibers .Right Main Bundle of His .T WAVE (ventricular repolarization) Insert pacemaker if there is complete heart block Most common pacemaker is the metal pacemaker and lasts up to 2 – 5 years . Atrio – Ventricular Node (AV or Tawara Node) . Sino – Atrial Node (SA or Keith Flack Node) . Bundle of His . Cardiac Conduction System 1. Left Main Coronary Artery .Closure of SV valve give rise to second heart sound (S2 “dub”) Extra Heart Sounds 1.Arises from base of the aorta Types of Coronary Arteries 1.Located at the junction of superior vena cava and right atrium .Acts as primary pacemaker of the heart .Left Main Bundle of His .
Chest pain 2. Smoking 4.tunica intima A.Atherosclerosis 2. Peak T wave – Hyperkalemia 3.narrowing of artery . Diet – increased saturated fats 10.Done to single occluded vessels . Thrombophlebitis ARTERIOSCLEROSIS . Myocardial Ischemia – Angina Pectoris 3. Obesity 5. ST segment elevation – Myocardial Infarction 5. Diabetes Mellitus 8. To prevent angina 3.calcium and protein deposits . Pneumonia – encourage to perform deep breathing. Hypothyroidism 9. Predisposing Factors 1. Positive U wave .If there is 2 or more occluded blood vessels CABG is done Coronary Arterial Bypass And Graft Surgery 3 Complications of CABG 1. Duaphoresis C.Hypokalemia 2. T wave inversion – Myocardial Infarction 6. Palpitations 5. Shock 3. Sex – male 2. Signs and Symptoms 1.lipid or fat deposits . Dyspnea 3. Widening of QRS complexes – Arrythmia CARDIAC DISORDERS Coronary Arterial Disease/ Ischemic Heart Disease Stages of Development of Coronary Artery Disease 1. Race – black 3. Myocardial Necrosis – Myocardial Infarction ATHEROSCLEROSIS ATHEROSCLEROSIS . Myocardial Injury . Tachycardia 4. ST segment depression – Angina Pectoris 4.ABNORMAL ECG TRACING 1. Hyperlipidemia 6. Revascularize myocardium 2.hardening of artery . Treatment Percutaneous Transluminal Coronary Angioplasty Objectives of PTCA 1. sedentary lifestyle 7.tunica media . coughing exercise and use of incentive spirometer 2. Type A personality B. Increase survival rate .
Give second dose of NTG if pain persist after giving first dose with interval of 3 . History taking and physical exam 2. Stress test – treadmill test. Predisposing Factors 1. sedentary lifestyle 7. Race – black 3. Hypothyroidism 9. Palpitations 6. Extreme emotional response – fear. Nitroglycerine (NTG) – when given in small doses will act as venodilator. anxiety. ECG tracing reveals ST segment depression 3. Serum cholesterol and uric acid is increased E. Levine’s Sign – initial sign that shows the hand clutching the chest 2. Chest pain characterized by sharp stabbing pain located at sub sterna usually radiates from back.5 minutes . Nursing Management 1. axilla and jaw muscles. Administer medications as ordered a. Exposure to cold environment 3. Enforce complete bed rest 2.ANGINA PECTORIS (SYNDROME) Clinical syndrome characterized by paroxysmal chest pain that is usually relieved by rest or nitroglycerine due to temporary myocardial ischemia A. Signs and Symptoms 1. Sex – male 2. usually relieved by rest or taking nitroglycerine 3. Diaphoresis D. Hyperlipidemia 6. but in large doses will act as vasodilator . Obesity 5. shoulder. Precipitating Factors 4 E’s of Angina Pectoris 1. Smoking 4.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. arms. Excessive intake of foods rich in saturated fats – skimmed milk C. Diabetes Mellitus 8. Diagnostic Procedure 1. Tachycardia 5.Give first dose of NTG (sublingual) 3 – 5 minutes . reveal abnormal ECG 4. Excessive physical exertion – heavy exercises 2. excitement 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 . Type A personality B. Dyspnea 4. Diet – increased saturated fats 10.
Subendocardial Myocardial Infarction – characterized by occlusion of either right or left coronary artery B.- 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. Avoidance of 4 E’s b. Hypothyroidism 9. 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. ACE Inhibitors . Provide client health teachings and discharge planning a.Not given to COPD cases because it causes bronchospasm c. sedentary lifestyle 7. A. intake and output and ECG tracing 6. Types 1. Diabetes Mellitus 8. Beta-blockers . Predisposing Factors 1. Type A personality . necrosis and scarring. Diet – increased saturated fats 10. Calcium Antagonist .side effects PNS . Obesity 5. Administer oxygen inhalation 4. Monitor strictly vital signs. Instruct client to take medication before indulging into physical exertion to achieve the maximum therapeutic effect of drug d. Place client on semi fowlers position 5. Prevent complication (myocardial infarction) c. Race – black 3. Hyperlipidemia 6.NIfedipine 3. The importance of follow up care MYOCARDIAL INFARCTION Heart attack Terminal stage of coronary artery disease characterized by malocclusion. Provide decrease saturated fats sodium and caffeine 7. Sex – male 2.Enalapril d.Propanolol . Smoking 4. Transmural Myocardial Infarction – most dangerous type characterized by occlusion of both right and left coronary artery 2.
Using bedside commode 4. S4 or atrial gallop E.Antidote: Narcan/Naloxone .D. Dyspnea 3.Side Effects of Naloxone Toxicity is tremors 2. Monitor strictly vital signs. LDH – Lactic acid dehydroginase is increased c. Pericardial friction rub b. Encourage client to take 20 – 30 cc/week of wine. T wave inversion c. Serum Cholesterol and uric acid are both increased 5. Nursing Management Goal: Decrease myocardial oxygen demand 1. Enforce CBR without bathroom privileges a. Administer oxygen low inflow to prevent respiratory arrest at 2 – 3 L/min 3. Split S1 and S2 c. intake and output and ECG tracing 7.ISD (Isosorbide Dinitrate. Increase in blood pressure (initial sign) 4.Excruciating visceral.Creatinine phosphokinase is increased . arms. Administer medication as ordered a.Usually radiates from back.Heart only. SGPT – Serum glutamic pyruvate transaminase is increased d. Diagnostic Procedure 1. whisky and brandy to induce vasodilation 9. CBC – increased WBC F. axilla. Cardiac Enzymes a. Place client on semi fowlers position 6.Side Effects: respiratory depression . Hyperthermia 5. Ashen skin 6. sodium and caffeine 8. viselike pain located at substernal and rarely in precordial . ST segment elevation b.Nitroglycerine . CPK – MB . Chest pain . Troponin Test – is increased 3. Signs and Symptoms 1. Provide a general liquid to soft diet that is low in saturated fats. 12 – 24 hours b. Mild restlessness and apprehension 7.Not usually relieved by rest or by nitroglycerine 2. Widening of QRS complexes indicates that there is arrhythmia in MI 4. Decrease myocardial workload (rest heart) . shoulder. Occasional findings a. SGOT – Serum glutamic oxal-acetic transaminase is increased 2. Vasodilators . Isodil) sublingual . Rales/Crackles upon auscultation d.Administer narcotic analgesic/morphine sulfate . ECG tracing reveals a. Instruct client to avoid forms of valsalva maneuver 5. jaw and abdominal muscles (abdominal ischemia) .
Left Congestive Heart Failure d. Provide client health teaching and discharge planning concerning a.TIPAF (tissue plasminogen activating factor) .instruct client to assume a non weight bearing position .PASA (Aspirin) . Post MI Syndrome/Dressler’s Syndrome . Avoidance of modifiable risk factors .Monitor for bleeding time g.000 units of streptokinase as ordered g.Side Effects of Aspirin Tinnitus Heartburn Indigestion/Dyspepsia .arrhythmia (caused by premature ventricular contraction) b. Stroke/CVA f.Urokinase . post CABG and instruct to . pruritus .late sign is oliguria c.Contraindication Dengue Peptic Ulcer Disease Unknown cause of headache 10.Lidocaine (Xylocane .Brutylium c.Antidote: protamine sulfate . Calcium Antagonist f.client is resistant to pharmacological agents.Streptokinase . Anti Arrythmic Agents .make sex as an appetizer rather than dessert .Side Effects: chest pain .Side Effects: confusion and dizziness . Beta-blockers d.Side Effects: allergic reaction. Anti Platelet . Cardiogenic shock .homan’s sign e. ACE Inhibitors e.Antidote: Vitamin K h. Thrombophlebitis . Thrombolytics/ Fibrinolytic Agents .Anti thrombotic effect .Coumadin/ Warfarin Sodium (check for prothrombin time) .Heparin (check for partial thrombin time) . Anti Coagulant . Resumption of ADL particularly sexual intercourse is 4 – 6 weeks post cardiac rehab.b. administer 150.000 – 450.
Chest x-ray – reveals cardiomegaly 2.ASO Titer (Anti streptolysin O titer) . LEFT SIDED HEART FAILURE A. RIGHT SIDED HEART FAILURE A. Pulmonic valve stenosis 5. Tricuspid valve stenosis 2. ABG – reveals PO2 is decreased (hypoxemia). Ischemic heart disease 4. Bronchial wheezing 9. Predisposing Factors 1.. Aortic valve stenosis B. Pulmonary embolism 3. Related to COPD 4. Hypertension 5. 90% is mitral valve stenosis due to a. There is anorexia and generalized body malaise 12. Rales/Crackles 8. Myocardial Infarction 3. Left sided heart failure . Orthopnea – use 2 – 3 pillows when sleeping or place in high fowlers 4. Aging 2. Predisposing Factors 1. Paroxysmal nocturnal dyspnea – client is awakened at night due to difficulty of breathing 3. dependent on extent of heart failure 4. Dyspnea 2. PMI is displaced laterally due to cardiomegaly 11. 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.client can resume sexual intercourse if can climb staircase .Penicillin . Cyanosis 7. Frothy salivation 6. Pulsus Alternans – weak pulse followed by strong bounding pulse 10.Aspirin b.dietary modification h. Signs and Symptoms 1. PCO2 is increased (respiratory acidosis) 2. PAP (pulmonary arterial pressure) – measures pressure in right ventricle or cardiac status PCWP (pulmonary capillary wedge pressure) – measures end systolic and dyastolic pressure both are increased done by cardiac catheterization (insertion of swan ganz catheter) 3.Common among children . S3 – ventricular gallop C. Diagnostic Procedure 1. A beta-hemolytic streptococcus .Formation of aschoff bodies in the mitral valve . RHD – inflammation of mitral valve due to invasion of Grp. Ecocardiography – enlarged heart chamber (cardiomyopathy). Productive cough with blood tinged sputum 5.
Enforce CBR 2. Measure abdominal girth daily and notify physician 7. Esophageal varices C. rotated clockwise every 15 minutes to promote decrease venous return 10. Weight gain 5. Nursing Management Goal: increase cardiac contractility thereby increasing cardiac output (3 – 6 L/min) 1. Signs and Symptoms (venous congestion) 1. Anorexia 9.If CVP is more than 10 cm of water hypervolemic shock . Administer medications as ordered a. intake and output and ECG tracing 6.Lidocaine (Xylocane) 3. High fowlers position 5. Provide a dietary intake of low sodium.If heart rate is decreased do not give b. Jaundice 7. Neck/jugular vein distension 2.B. Provide meticulous skin care 9. Narcotic analgesics . Anti Arrhythmic .Upon insertion place client in trendelendberg position to promote ventricular filling and prevent pulmonary embolism 3. Liver enzymes – SGPT and SGOT is increased D. Pitting edema 3.Morphine Sulfate e. Provide client health teaching and discharge planning . Vasodilators .Lasix (Furosemide) c.If CVP is less than 4 cm of water hypovolemic shock . Hepatosplenomegaly 6. Diagnostic Procedures 1. Bronchodilators d. Cardiac glycosides .When reading CVP patient should be flat on bed . Chest x-ray – reveals cardiomegaly 2. Ecocardiography – reveals enlarged heart chambers (cardiomyopathy 4.Digoxin (Lanoxin) . Ascites 4.Nitroglycerine f.CVP fluid status measure . Central venous pressure (CVP) . delivered via nasal cannula 4. 3 – 4 L/min. Pruritus 8. cholesterol and caffeine 8.Do the fluid challenge (increase IV flow rate) .Measure pressure in right atrium (4 – 10 cm of water) . Administer oxygen inhalation with high inflow.Administer loop diuretics as ordered . Assist in bloodless phlebotomy – rotating tourniquet. Loop Diuretics .Increase force of cardiac contraction . Monitor strictly vital signs.
Thrombophlebitis b. Institute foot care management 4.Shock . Strict compliance to medications PERIPHERAL VASCULAR DISORDER Arterial Ulcer I. Trophic changes 5. Dietary modification c. Prevent complications . Anti coagulants 3. Smoking B. Thrombo Angitis Obliterans Venous Ulcer 1. Administer medications as ordered a.MI . Assist in surgical procedure – bellow knee amputation Burger’s Disease Reynaud’s Disease . Vasodilators c. Angiography – reveals site and extent of malocclusion D.a. Diagnostic Procedures 1. Signs and Symptoms 1. Varicose Veins 2. Oscillometry – decrease in peripheral pulses 2. Intermittent claudication – leg pain upon walking 2. Analgesics b. Doppler UTZ – decrease blood flow to the affected extremity 3. Cold sensitivity and changes in skin color (pallor. High risk groups – men 30 years old and above 2.Right ventricular hypertrophy . cyanosis then rubor) 3. walking 3 – 4 times a day b. Nursing Management 1. out of bed 3 – 4 times a day 2. Decreased peripheral pulses 4. Thrombophlebitis (deep vein thrombosis) THROMBOANGITIS OBLITERANS Acute inflammatory disorder usually affecting the small medium sized arteries and veins of the lower extremities A. Ulceration 6.Arrythmia . Encourage a slow progressive physical activity a. Instruct client to avoid smoking and exposure to cold environment 5. Predisposing Factors 1. Gangrene formation C.
Direct hand trauma a. Vasodilators 2. Warm to touch 4. Angiography – reveals site and extent of malocclusion D. SLE (butterfly rash) b. Obesity 7. Rheumatoid Arthritis 4. Collagen diseases a. Ulceration 5.REYNAUD’S DISEASE Disorder characterized by acute episodes of arterial spasm involving the fingers or digits of the hands A. Excessive typing c. Thrombophlebitis 4. Cardiac disorder 5. Diagnostic Procedures 1. Gangrene formation C. Predisposing Factors 1. Nursing Management 1. Congenital weakness of veins 3. Signs and Symptoms 1. High risk group – female 40 years old and above 2. cyanosis then rubor) 3. Doppler UTZ – decrease blood flow to the affected extremity 2. Analgesics b. Encourage to wear gloves 3. Smoking 3. Signs and Symptoms 1. Heaviness in legs . Operating chainsaw B. Hereditary 2. Administer medications as ordered a. Dilated tortuous skin veins 3. Cold sensitivity and changes in skin color (pallor. 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. Intermittent claudication – leg pain upon walking 2. Pain after prolonged standing 2. Piano playing b. Trophic changes 4. Predisposing Factors 1. Prolonged standing or sitting B. Pregnancy 6.
Encourage to wear anti embolic stockings or knee elastic stockings 5. Related to pregnancy 4. Nursing Management 1.Heparin . Diagnostic Procedure 1. Positive Hpman’s Signs – pain at the calf or leg muscle upon dorsi flexion of the foot C. Assist in surgical procedure a. Anti Coagulant . Apply warm moist pack – to reduce lymphatic congestion 3. Elevate legs above heart level to promote increased venous return by placing 2 – 3 pillows under the legs 2. Administer medications as ordered a. Post cannulation – insertion of various cardiac catheter 11. Predisposing Factors 1. Nursing Management 1. Analgesics 5. Signs and Symptoms 1. Elevate legs above heart level to promote increase venous return 2. Increase in saturated fats in the diet.C.veins distends quickly in less than 35 seconds D. Vein stripping and ligation (most effective) b. Measure the circumference of leg muscle to determine if swollen 3. Diagnostic Procedure 1. Measure circumference of leg muscle to determine if swollen 4. Prolong use of oral contraceptives – promotes lipolysis 6. Smoking 3. Venography 2. Analgesics b. Chronic anemia 5. 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. Venography 2. Wear anti embolic stockings 4. Administer medications as ordered a. Post op complication 10. Congestive heart failure 8. Trendelenburg’s Test . Angiography D. Pain at affected extremity 2. Myocardial infarction 9. Dilated tortuous skin veins 4. B. Warm to touch 3. Obesity 2. Diabetes mellitus 7.
Left nostril .Dizziness . Larynx .Left main bronchus C.Diaphoresis . Lower Respiratory System .Right lung (consist of 3 lobes.Site of tracheostomy B.Serves as passageway of air going to the lungs . Trachea/Windpipe . Bronchus .The initial sign of complete airway obstruction is the inability to cough II.Serous membranes . Filtering of air 2. Pharynx/Throat .Serves as a muscular passageway for both food and air C.Left lung (consist of 2 lobes. Humidification A.Right nostril .Right main bronchus . Monitor for signs of complications Embolism a.Consist of cartilaginous rings . Nose .Headache . 8 segments) . Cerebral .For phonation (voice production) .For gas exchange A.Closes to allow passage of food going to the esophagus .Opening of larynx . cholecystitis characterized by pain at the right upper quadrant with tenderness RESPIRATORY SYSTEM OVERVIEW OF THE STRUCTURES AND FUCNTIONS OF THE RESPIRATORY SYSTEM I.Opens to allow passage of air .Palpitations .Decrease LOC • MURPHY’S SIGN is seen in clients with cholelithiasis. Upper Respiratory System 1.Separated by septum .For cough reflex Glottis .Consist of anastomosis of capillaries known as Keissel Rach Plexus (the site of nose bleeding) B. Lungs .Cartillage . Pulmonary .Unexplained dyspnea . Warming and moistening of air 3. 10 segments) .Sudden sharp chest pain .6.Restlessness b.Tachycardia .
Dyspnea 6. PTB/Pulmonary Tuberculosis (Koch’s Disease) .Decrease oxygen stimulates breathing .Increase carbon dioxide is a powerful stimulant for breathing Type II Cells of Alveoli . Airborne transmission via droplet nuclei C.Diffusion (Dalton’s law of partial pressure of gases) Respiratory Distress Syndrome . Low grade afternoon fever. Visceral With Pleuritic Friction Rub a.Site of gas exchange (CO2 and O2) . Virulence (degree of pathogenecity) of microorganism B. Pareital b.In premature infants 1:2 . Hemoptysis (chronic) .Normal L/S ratio is 2:1 .Composed of lecithin and spingomyelin . Anorexia. Malnutrition 2.Decrease surface tension . Over fatigue 5. Pneumonia b.Infection of lung tissue caused by invasion of mycobacterium tuberculosis or tubercle bacilli . Alcoholism 4. aerobic and easily destroyed by heat or sunlight A. Pleural fluid c. Overcrowded places 3.L/S ratio to determine lung maturity . generalized body malaise 4.An acid fast. Productive cough (yellowish sputum) 3.Pleural Cavity a. Signs and Symptoms 1. Weight loss 5.Prevent collapse of alveoli . Chest pain 7. gram negative. Ingestion of an infected cattle with mycobacterium bovis 6. Precipitating Factors 1. night sweats 2.Secretes surfactant . Pleural effusion c.Give oxygen of less 40% in premature to prevent atelectasis and retrolental fibroplasias .retinopathy/blindness in prematurity Disorders of Respiratory System 1. Mode of Transmission 1. Hydrothorax (air and blood in pleural space Alveoli .
Neomycin .Side Effect Rifampicin: all bodily secretions turn to red orange color . Place client on semi fowlers position to promote expansion of lungs 6.PZA can be replaced by Ethambutol .Side Effect: .Given everyday simultaneously to prevent resistance . Provide increase carbohydrates. vitamin C and calories 11. Intensive phase . Nursing Management 1.WHO 10 – 14 mm induration.Injection of streptomycin (aminoglycoside) .PZA (Pyrazinamide) .Positive Mantoux test (previous exposure to tubercle bacilli but without active TB) 2. taken after meals to facilitate absorption .Side Effect INH: peripheral neuritis/neuropathy (increase intake of Vitamin B6/Pyridoxine) .D.Ototoxicity damage to the 8th cranial nerve resulting to tinnitus leading to hearing loss .PZA is given for 2 months. 48 – 72 hours . nephrotoxicity .Nephrotoxicity check for BUN and Creatinine . Sputum Acid Fast Bacillus . Chest X-ray .Give aspirin if there is fever .Rifampicin (Rifampin) .Purified protein derivative . Force fluids to liquefy secretions 5. Avoidance of precipitating factors . protein.Positive to cultured microorganism 3.Amikacin . Provide client health teaching and discharge planning a. 48 – 72 hours .Side Effect PZA: allergic reaction. CBC .Reveals pulmonary infiltrates 4.Kanamycin .Reveals increase WBC E.Side Effect Ethambutol: optic neuritis b.INH (Isonicotinic Acid Hydrazide) . heartburn 10. Institute strict respiratory isolation 3. Administer oxygen inhalation 4. Encourage deep breathing and coughing exercise 7. dyspepsia. hepatotoxicity.INH and Rifampicin is given for 4 months.Side Effect: tinnitus. Standard phase . Mantoux Test (skin test) .Gentamycin .DOH 8 – 10 mm induration. taken before meals to facilitate absorption . Institute short course chemotherapy a. Comfortable and humid environment 9. Diagnostic Procedure 1. Enforce CBR 2. Nebulize and suction when needed 8.
Air pollution 3. anorexia and general body malaise 4. Smoking 2. Pleuritic friction rub 9.Chest x-ray confirms lung cancer 4.Drug of choice is Retrovir b. Immuno compromised a.Meninges . Abdominal distention leading to paralytic ileus (absence of peristalsis) .Bones (potts) . Pseudomonas B. Signs and Symptoms 1. chills. Children below 5 years old 2. Productive cough with greenish to rusty sputum 2. Chest pain 10. Fever. Etiologic Agents 1. Bronchogenic Cancer . Cyanosis 8. causing hypostatic pneumonia 5.Adrenal gland c.b. Aspiration of food causing aspiration pneumonia D. Related to prolonged immobility (CVA clients). Bronchial wheezing 7.Initial sign is non productive cough . Predisposing Factors 1. Strict compliance to medications d. military tuberculosis) PTB . Weight loss 5. Elderly C. Escherichia Pneumoniae 6.Skin .Pneumocystic carini pneumonia . High Risk Groups 1. Rales/crackles 6. AIDS . Importance of follow up care PNEUMONIA Inflammation of the lung parenchyma leading to pulmonary consolidation as the alveoli is filled with exudates A. Klebsella Pneumoniae 5.Eyes . Dyspnea with prolong expiratory grunt 3. Prevent complications (atelectasis. Streptococcus Pneumonae – causing pneumococal pneumonia 2. Hemophylus Influenzae – causing broncho pneumonia 3. Diplococcus Pneumoniae 4.
Provide increase carbohydrates.Atelectasis .Drain uppermost area of lungs . Force fluid 5. Administer bronchodilators 15 – 30 minutes before procedure e.Chest physiotherapy . Importance of follow up care . Institute pulmonary toilet (tends to promote expectoration) .Clients with increase intra ocular pressure (Normal IOP 12 – 21 mmHg) . Best done before meals or 2 – 3 hours to prevent gastro esophageal reflux b.Placed on various position Nursing Management for Postural Drainage a. Tetracycline c. Chest x-ray – reveals pulmonary consolidation 3. hydrocephalus) c. Diagnostic Procedure 1. Encourage client deep breathing exercises d. Administer medications as ordered Broad Spectrum Antibiotic a. Health teaching and discharge planning a. Nursing Management 1. erythrocyte sedimentation rate is increased F. Prevent complications .E.Unstable vital signs . Nebulize and suction as needed 8. protein and vitamin C 10. Monitor vital signs c.Turning and reposition 7. Avoid smoking b.Coughing exercises . Administer oxygen inhalation low inflow 3. Regular adherence to medications d. Stop if client cannot tolerate procedure f. Enforce CBR 2.Increase ICP 9.Hemoptysis . CBC – reveals increase WBC. Microlides (Zethromax) Azethromycin (Side Effect: Ototoxicity) Antipyretics Mucolytics/Expectorants Analgesics 4. Contraindicated with . calories.Meningitis (nerve deafness. ABG analysis – reveals decrease PO2 4. Penicillin b.Deep breathing exercises . Sputum Gram Staining and Culture Sensitivity – positive to cultured microorganisms 2. Assist in postural drainage . Place on semi fowlers position 6. Provide oral care after procedure g.
Enforce CBR 2. Signs and Symptoms PTB or Pneumonia like 1. Signs and Symptoms 1. Pulmonary hypertension a. Histoplasmin Skin Test – positive 2. Steroids c. 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. PCO2 increase. Cor Pulmonale (right ventricular hypertrophy) C. Administer oxygen inhalation 3. Productive cough (consistent to all COPD) 2. Nursing Management 1. Smoking 2. Diagnostic Procedures 1. Dyspnea 3. Antipyretics 4. pH decrease . Cyanosis 5. Force fluids to liquefy secretions 5. Diagnostic Procedure ABG analysis – reveals PO2 decrease (hypoxemia). ABG analysis PO2 decrease C. Productive cough 2. Chest and joint pains B. Prolonged expiratory grunt 4. Fever. Prevent complications – bronchiectasis 7. Antifungal . chills. Air pollution B. Nebulize and suction as needed 6. Administer medications as ordered a. Hypokalemia) b. general body malaise 4. Mucolytics d.Fungizone (Nephrotoxicity. Peripheral edema b.HISTOPLASMOSIS Acute fungal infection caused by inhalation of contaminated dust or particles with histoplasma capsulatum derived from birds manure A. Scattered rales/ronchi 6. Hemoptysis 6.Amphotericin B . Cyanosis 7. Predisposing Factors 1. Dyspnea on exertion 3. check for BUN and Creatinine. anorexia. Anorexia and generalized body malaise 5.
Sudden change in temperature. Foods (seafoods. Fumes d. Lints 2. Force fluids . Gases f. Pollen b. palpitations 7. with low inflow of 2 – 3 L/min 3. Mixed Type 90 – 95% B. ABG analysis – PO2 decrease . beta blocker) c. penicillin. Smoke e. milk. Mild Stress/apprehension 6. Wheezing on expiration 4. Bronchodilators – given via inhalation or metered dose inhalaer or MDI for 5 minutes b. Drugs (aspirin.Incentive spirometer reveals decrease vital lung capacity 2. Tachycardia. Food additives (nitrates) e. Steroids – decrease inflammation c. Intrinsic Asthma (Non atopic/Non allergic) Causes a. Furs h. Diaphoresis C. air pressure and humidity f. Physical and emotional stress 3. Diagnostic Procedure 1. Anti histamine 4. Signs and Symptoms 1. Dust c. Dyspnea 3. Extrinsic Asthma ( Atopic/ Allergic ) Causes a. Enforce CBR 2. chicken d. eggs. Oxygen inhalation.Bronchial Asthma Reversible inflammatory lung condition due to hypersensitivity to allergens leading to narrowing of smaller airways A. Mucolytics/expectorants e. Cough that is non productive 2. Predisposing Factors (Depending on Types) 1. Hereditary b. Mucomysts (acetylceisteine) d. chocolates.Before ABG test for positive Allens Test. Danders g. Pulmonary Function Test . Administer medications as ordered a. apply direct pressure to ulnar and radial artery to determine presence of collateral circulation D. Nursing Management 1. Cyanosis 5.
Status Asthmaticus (give drug of choice) . Avoidance of precipitating factor b. Chest trauma 3. Secure inform consent and explain procedure to client 2. Congenital defects 4. Dyspnea 3. Cyanosis 4.Bronchodilators c. Recurrent lower respiratory tract infections 2. Regular adherence to medications to prevent development of status asthmaticus d. Nebulize and suction when needed 7. Monitor for signs of laryngeal spasm – prepare tracheostomy set D. Segmental Wedge Lobectomy (promote re expansion of lungs) . Anorexia and generalized body malaise 5. Importance of follow up care BRONCHIECTASIS Abnormal permanent dilation of bronchus leading to destruction of muscular and elastic tissues of alveoli A.Epinephrine . Monitor for signs of gross 4. Avoid talking.Steroids . Hemoptysis (only COPD with sign) C. Diagnostic Procedure 1. Surgery (pneumonectomy . ABG – PO2 decrease 2.Unaffected lobectomy facilitate drainage . Semi fowlers position 6. Predisposing Factors 1. Treatment 1. Prevent complications .Emphysema . may cause irritation 3. coughing and smoking. Maintain NPO 6 – 8 hours prior to procedure 3. Related to presence of tumor B.5. 1 lung is removed and position on affected side) 2. Signs and Symptoms 1. Provide client health teachings and discharge planning concerning a. Bronchoscopy – direct visualization of bronchus using fiberscope Nursing Management PRE Bronchoscopy 1. Productive cough 2. Monitor vital signs and breath sound POST Bronchoscopy 1. Feeding initiated upon return of gag reflex 2.
Mucolytics/expectorants 4. Rales or ronchi 9. Administer medications as ordered a. Pulmonary Function Test – reveals decrease vital lung capacity 2. Nursing Management 1. Decrease or diminished breath sounds 8. Enforce CBR 2.Respiratory alkalosis D. Air pollution 3. Force fluids 6. Smoking 2.Respiratory acidosis b. “Blue Bloaters”) . Dyspnea at rest 3. Steroids c. Antibiotics d. Bronchial wheezing 10.Increase ph . Productive cough 2. Predisposing Factors 1.Decrease ph . Institute pulmonary toilet . Flaring of alai nares 12. for recoil of alveoli) B. Over distention of thoracic cavity (barrel chest) A. Barrel chest 11. Air trapping c. Allergy 4. Bronchodilators b. Administer oxygen inhalation via low inflow 3.Decrease PO2 (hypoxemia leading to chronic bronchitis. Resonance to hyperresonance 6. High fowlers position 5. Diagnostic Procedure 1.Increase PCO2 . Prolong expiratory grunt 4. Panacinar/ centriacinar . Inelasticity of alveoli b.Increase PO2 (hyperaxemia.EMPHYSEMA Irreversible terminal stage of COPD characterized by a. High risk: elderly 5. Anorexia and generalized body malaise 5. ABG analysis reveals a. Signs and Symptoms 1. Panlobular/ centrilobular . Hereditary – it involves deficiency of ALPHA-1 ANTI TRYPSIN (needed to form Elastase. Purse lip breathing to eliminates excess CO2 (compensatory mechanism) C. Maldistribution of gases d. “Pink Puffers”) . Decrease tactile fremitus 7.Decrease PCO2 .
Cor Pulmonale . Prevent complications .CO2 narcosis may lead to coma . protein.Atelectasis . Institute PEEP (positive end expiratory pressure) in mechanical ventilation promotes maximum alveolar lung expansion 9. Avoid smoking b. Strict compliance to medication d.Pneumothorax c. Importance of follow up care . Provide high carbohydrates. vitamins and minerals 11.7. Provide comfortable and humid environment 10. Nebulize and suction when needed 8. Health teachings and discharge planning concerning a. calories.
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