Competency Appraisal 1 Reviewer-1

jcmendiola_Achievers2013 1
Competency Appraisal 1
(CA I)
REVIEW REVIEW!!!

Pediatric Disorders
RESPIRATORY DISTRESS
SYNDROME
Definition:
Formerly termed Hyaline-membrane disease

Etiology:
Preterm infants < 35 weeks
Premenopausal mothers: Age >35 y/o
Diabetic mothers
Cesarean births
Meconium aspirated babies
REMEMBER: Surfactant production 24 weeks, matures at
36
th
week
MAIN CAUSE: Low level or absence of surfactant
Pathologic Feature:
o Formation of hyaline-like membrane that forms from
an exudate of the infants blood that lines the terminal
bronchioles, alveolar ducts and alveoli
o Which will prevent the exchange of carbon dioxide
and oxygen and alveolar-capillary membrane

Signs and Symptoms
CARDINAL SIGNS:
Low body temperature
Nasal flaring
Sternal and Subcostal retractions
Tachypnea (> 60 rpm)
Cyanotic mucous membranes (Central Cyanosis)

Diagnosis
Chest Radiograph: Ground Glass (Haziness)
ABGs: Respiratory Acidosis
Blood Culture and CSF Culture: B-hemolytic, group B streptococcal infection

Nursing Diagnoses
Impaired gas exchange
Impaired spontaneous ventilation
Impaired breathing pattern
Ineffective tissue perfusion
Risk for infection

Topics Discussed Here Are: Page
1. Pediatric Disorders:
a. Respiratory Distress Syndrome
b. Megacolon
c. Placenta Previa (Abruptio Placenta)
d. Pregnancy Induced Hypertension
e. Erythroblastosis Fetalis
2. Sensory Disorders
a. Glaucoma
b. Cataract
c. Retinal Detachment
d. Macular Degeneration
3. Neurologic Disorders
a. Parkinsons Disease
b. Multiple Sclerosis
4. Endocrine Disorders
a. Hyperthyroidism
b. Cushings Syndrome
5. Communicable Diseases
a. Rabies
b. Leptospirosis
6. Respiratory Disorders
a. COPD
b. Pneumonia
c. Pulmonary Tuberculosis
7. Gastrointestinal + Diabetes Mellitus
a. Crohns Disease (Ulcerative
Colitis)
b. Diabetes Mellitus
8. Cardiovascular + Renal Disorders
a. Chronic Kidney Disease
b. Myocardial Infarction
c. Tetralogy of Fallot

1
3
5
9
12

15
18
20
21

23
27

32
36

37
41

44
47
50

53

LOOKY
HERE
As Distress Increase:
Seesaw Respirations
Heart failure Due to UO and Edema
Pale gray skin
Periods of apnea
Bradycardia
Pneumothorax
2 jcmendiola_Achievers2013

Therapeutic Management
Surfactant Replacement
o Spraying of synthetic surfactant (Via ET Tube)
o Do not suction infant after administration
Oxygen Administration
o Used to maintain correct PO
2
and pH Levels
o CPAP or PEEP Will exert pressure on alveoli at end of expiration to keep alveoli from
collapsing
o Complication: Retinopathy of prematurity / Bronchopulmonary Dysplasia
Ventilation
o Normal: Inspiration is shorter than Expiration (I/E Ratio 1:2)
o Ventilator: I/E Ratio 2:1 to help facilitate inspiration
Extracorporeal Membrane Oxygenation (ECMO)
Liquid Ventilation
Nitric Oxide

MEDICATIONS:
O Indomethacin or Ibuprofen Used for closure of a Patent Ductus Arteriosus
o Indomethacin Known for AE such as; Renal function, Platelet count, Gastric irritation
O Pancronium (Pavulon) Muscle Relaxant to increase pulmonary blood flow
o Administered to abolish spontaneous respiratory actions
o Antidote: Atropine or Injectible Neostigmine Methylsulfate

Nursing Interventions
- Keep infants warm
o Cooling increases acidosis
o Warming infant reduces metabolic oxygen demand
- Assist with insertion of NGT for nutrition (Breast milk)
- Allow parents to be participative
- Discharge Planning:
o Instruct to continue breastfeeding
o Teach proper douching / suckling of infant
- Prevention:
o Assess for levels of Lecithin-Sphingomyelin Ratio
o Prevent hypothermia (Provide neutral environment)
o Prevention of infection:
Handwashing
Prevent contact with people who have respiratory disorders
Give immunizations
o Instruct mother that REGULAR CHECK-UP / PRENATAL CHECK-UP is needed

MEGACOLON (HIRSCHSPRUNGS DISEASE)
Definition:
The absence of ganglionic innervations to the muscle of a section of the bowel
Most common site: Lower portion of the sigmoid colon, just above the anus

Ways of Losing Heat
Evaporation Dry the infant!
Conduction Line the sides of the crib
with pillows
Convection Do not place crib near
aircon
Radiation Imbalanced environment


Assessment
Pathognomonic Sign: Ribbon-like Stools
Meconium has not yet passed (24 hours of age)
Increasing abdominal distention
Thin and undernourshished (Deceptively)
Does not become apparent until 6 12 months
o History of constipation (Ask for duration, ask parent definition of constipation)
o Intermittent constipation
o Diarrhea (Ask for consistency of stool)

Diagnostic Procedures
- Digital Rectal Examination: No stool in rectum
- Barium Enema: To outline the NARROW and NERVELESS portions of the bowel
- Biopsy: Of the affected segment Most definitive diagnosis (Shows the lack of innervations)
- Anorectal Manometry: Used to test the strength or innervations of the internal rectal sphincter by inserting
a balloon catheter in the rectum and measuring the pressure exerted against it

Therapeutic Management
Pull-Through Operation
o Repair of the aganglionic Megacolon (Dissection and removal with anastomosis)
o 1
st
Stage: Temporary colostomy is established
o 2
nd
Stage: Bowel repair at 12 18 months of age

Nursing Diagnoses with Interventions (CNC)
Constipation related to reduced bowel function
Outcome Evaluation: Child has a daily bowel movement through either a colostomy or by enema
Interventions:
^ Daily enemas may be prescribed To achieve bowel movements
Ensure to use Normal Saline (0.9% NaCl) and NOT TAP WATER (Hypotonic)
^ Teach parents how to prepare and administer saline enemas at home
Mixing 2 tsp of noniodized salt to 1 quart of water
Imbalanced nutrition, less than body requirements related to reduced bowel function
Outcome Evaluation: Child ingests a low-residue diet; weight follows a percentile curve on a growth
chart
Interventions:
^ If patient has poor nutrition, may be returned home and get:
Minimal-residue diet, stool softeners, vitamin supplements or enemas until condition
improves
^ Assist in giving TPN
^ Teach parents about minimal-residue diets, or low in undigestible fiber, connective fiber and
residue
^ OMIT: Fried foods and seasoned foods

^ Help parents make a reminder sheet for the stool softener
^ Tell parents to avoid giving new feeding methods (Cups, spoons) when special diet has started
^ POSTOPERATIVE:
Will be in an:
Breakfast Lunch Dinner
C. strained fruit juice
1 serving refined cereal
1 egg
1 slice toast
1 tsp. Butter or margarine
Jelly
Heavy cream
Hot beverage
Sugar
Salt
C. strained fruit juice and/or clear broth
2 oz. Meat
c. allowed potato substitute
Crackers
1 tsp. butter or margarine
1 serving allowed dessert
Beverage
Sugar
Salt
C. strained fruit juice and/or clear broth
3 oz. Meat
C. allowed potato substitute
C. vegetables juice
1 slice bread or roll
1 tsp. butter or margarine
1 serving allowed dessert
Beverage
Sugar
Salt
NGT
Low suction
IV infusion
Indwelling urinary catheter
Observe for abdominal distention
Assess for bowel sounds, flatus and stools (Return in 24 hours)
NGT can be removed and offered small, frequent feedings of fluids
Gradually to full fluids, soft diet and minimal-residue diet and finally a normal diet
Risk for compromised family coping related to chronic illness in child
Outcome Evaluation: Parents state they are able to cope with the level of stress present from their
childs condition
Interventions:
^ Child may still be a fussy eater PostOp
^ Help parents diminish the importance of meals gradually To schedule periods during the
day
^ Tell parent to give praise to the child for pleasant and not difficult behavior

PLACENTA PREVIA
Definition
Placenta is implanted abnormally in the uterus
Most common cause of PAINLESS BLEEDING in the 3
rd
trimester of pregnancy
The abnormal implantation of placenta in the lower uterine segment, partially or completely covering the
internal cervical os

Etiology
Increased parity
Advanced maternal age
Past cesarean births
Past uterine curettage
Multiple gestations
Male fetus

Four Degrees of Placenta Previa
1. Low-lying Placenta Implantation in the lower rather than in the upper portion of the uterus
2. Marginal Implantation The placental edge approaches that of the cervical os
3. Partial Placenta Previa Occludes a portion of the cervical os
4. Total/Complete Placenta Previa Totally obstructs the cervical os

NURSING PROCESS
Assessment
E Determine the amount and type of bleeding
E Inquire as to presence or absence of pain in association with the
bleeding
E Record maternal and fetal VS
E Palpate for the presence of uterine contractions
E Evaluate laboratory data on Hct and Hgb
E Assess fetal status with continuous fetal monitoring
E Never perform a vaginal examination when patient is bleeding

Assessment
E Bleeding that is PAINLESS
and ABRUPT
E Bright red
E Sudden enough to frighten
woman
E BLEEDING IS NOT
ASSOCIATED WITH
INCREASED ACTIVITY

Nursing Diagnoses
: Altered tissue perfusion related to excessive bleeding causing fetal compromise
o Interventions:
Frequently monitor mother and fetus
Administer IVF as prescribed
Position on side to promote placental perfusion
Administer O2 as face mask as indicated (8 10 per minute)
: Fluid volume deficit related to excessive bleeding
o Establish and maintain a large-bore IV line, as prescribed and draw blood for type and screen for
blood replacement
o Position in a sitting position to allow weight of fetus to compress the placenta and decrease
bleeding
o Maintain strict bed rest during any bleeding episode
o Prepare woman for cesarean delivery
o Administer blood or blood products protocol per institutional policy
: Altered tissue perfusion related to excessive bleeding causing fetal compromise
o Frequently monitor mother and fetus
o Administer IV fluids as prescribed
o Position on side to promote placental perfusion
o Administer oxygen as facemask as indicated (8 10 minute)
: Risk for infection related to excessive blood loss
o Use aseptic technique when providing care
o Evaluate temperature q4h unless elevated; then evaluate q2h
o Evaluate WBC and differential count
o Teach perineal care and hand washing techniques
o Assess odor of all vaginal bleeding or lochia
: Anxiety related to excessive bleeding
o Explain all treatments and procedure
o Encourage verbalization of feelings by patient and family
o Provide information on a CS delivery
o Discuss the effects of long-term hospitalization or prolonged bed rest
: Impaired fetal gas exchange related to altered blood flow, altered O2-carrying capacity of blood, decreased
surface area of gas exchange at site of placental attachment
: Fear related to outcome of pregnancy after episodes of bleeding
o Explain all treatments and procedure
o Encourage verbalization of feelings by patient and family
o Provide information on a CS delivery
: Risk for deficient diversional activity
: Risk for deficient fluid volume

Complications
Placenta accrete
Immediate hemorrhage with possible shock and maternal death
Increased risk for anemia secondary to blood loss and infection secondary to invasive procedures to
resolve bleeding
Intrauterine growth restriction (IUGR)
Congenital anomalies
Fetal mortality resulting from hypoxia in utero and prematurity

Risk Factors
Previous placenta previa, delivery, cesarean delivery or abortion
Woman who have previous pregnancies, especially a large number of closely spaced pregnancies, are at
higher risk

Women who have had previous pregnancies, especially a large number of closely spaced pregnancies are at
higher risk
Women who are younger than 20 are at higher risk and women older than 30 are at increasing risk as they
get older
Women with larger placenta from twins or erythroblastosis are the higher risk
Women who smoke or use cocaine may be at higher risk
Race if a controversial risk factor, with some studies finding that people from Asia and Africa are at higher
risk and others finding no difference

Medical and Surgical Management

Medical Management Surgical Management
O IV access
O Laboratory examinations
O Blood typing and cross matching
O Administration of Betamethasone (Celestine)
O Amniocentesis
O CS Section

Signs and Symptoms

CHARACTERISTIC Placenta Previa Abruptio Placenta
Onset O Third trimester, commonly at 32
weeks
O Third trimester
Bleeding O Mostly external small to profuse
in amount
O Bright red
O May be concealed
O External dark hemorrhage or
bloody amniotic fluid
Pain and Uterine Tenderness O Usually absent
O Uterus is soft
O Usually present
O Irritable uterus
O Progresses to board-like
consistency
Fetal Heart Tone O Usually normal O May be irregular or absent
Presenting Part O Usually not engaged O May be engaged
Shock O Usually not present unless
bleeding is excessive
O Moderate to severe
depending on extent of
concealed and external
hemorrhage
Delivery O Delivery may be delayed
depending on size of fetus and
amount of bleeding
O Immediate delivery, usually
by CS section
PREGNANCY INDUCED HYPERTENSION
Definition:
A condition in which vasospasms occurs during pregnancy in both small and large arteries
Signs and Symptoms:
o Cardinal Signs: (PEH)
Proteinuria
Edema
Hypertension


Assessment
Classifications of PIH
Gestational Hypertension
o Elevated BP (140/90 mm Hg)
o NO PROTEINURIA and EDEMA
o No drug therapy is necessary
Mild Pre-eclampsia
o Elevated BP (140/90 mm Hg) Taken on 2 occasions 6 hours apart
o Proteinuria (1+ or 2+)
o Edema develops Due to loss of protein, sodium loss and lowered glomerular filtration rate
May develop into the upper part of the body
Weight gain (Indicates abnormal tissue fluid retention):
>2 lb/wk in 2
nd
trimester
1 lb/wk in 3
rd
trimester
Severe Pre-eclampsia
o Elevated BP (160/110 mm Hg) Taken on 2 occasions 6 hours apart
Best position to assess BP (BED REST)
o Proteinuria (+3 or +4 / More than 5 g in a 24-hour sample)
o Extensive edema
Palpated over bony surfaces
Over tibia on anterior legs
Ulnar surfaces of the forearm
Cheekbones
Edema on lower extremities and upper
extremities and face
Cerebral Edema: Visual disturbances (Blurred vision / seeing spots)
Severe head ache / marked hyperreflexia / ankle clonus
Eclampsia
o Most severe classification of PIH
o Cerebral edema that grand-mal seizure (tonic-clonic) or coma occurs
o Premature separation of placenta may occur (Abruptio Placenta)

Nursing Diagnoses
+ Ineffective tissue perfusion related to vasoconstriction of blood vessels
+ Deficient fluid volume related to fluid loss to subcutaneous tissue
+ Risk for fetal injury related to reduced placental perfusion secondary to vasospasm
+ Social isolation related to prescribed bed rest

MILD PIH
Q Monitor Antiplatelet Therapy
o Mild Antiplatelet agents: Low-dose aspirin
Teach patient to not underestimate taking of aspirin
Q Promote Bed Rest
o Position the patient in a RECUMBENT POSITION (Prevents uterine vena cava pressure)
Sodium tends to be excreted faster
Bed rest Best method of evacuation of sodium and encouraging diuresis
Q Promote Good Nutrition
o Inform the woman to continue her usual pregnancy nutrition
o No sodium restriction is needed, only moderate it
Q Provide Emotional Support
o Inform the mother of the seriousness of her condition
o Ask if there would be possible family members that can take care of her child (If has)
o Make child care arrangements so mother can get rest
Edema Grading:
1+ - Can be indented slightly
2+ - Moderate indentation
3+ - Deep indentation
4+ - Indentation remains after removal of finger
SEVERE PIH
Q Patient is admitted to a health care facility
Q Take amniocentesis to check for fetal lung maturity
Q Support Bed Rest
o Restrict visitors
o Minimize loud noises May trigger a seizure initiating eclampsia
o Raise the side rails to prevent injury
o Darken room
o Allow opportunities to express feelings
Q Monitor Maternal Well-being
o Monitor BP q4 hours
o Obtain Blood Studies:
CBC, Platelet Count, Liver Function, BUN, Creatinine (Assess renal and liver function) and;
Fibrin Degradation Products (For formation of DIC)
o Assess for premature separation of placenta
o Obtain daily weights of mother
o Assist with insertion of indwelling urinary catheter To monitor I&O (Should be 600 mL/24hrs)
More than 30 ml/hr
Q Monitor Fetal Well-being
o Assess with Doppler Auscultation q4 hours
o Assess for non-stress test or biophysical profile done daily (To assess uteroplacental sufficiency)
o Give Oxygen to the mother To prevent fetal bradycardia
Q Support Nutritious Diet
o Diet needs moderate-to-high protein and moderate sodium, to compensate for protein lost
Q Administer Medications to Prevent Eclampsia
Drug Action Nursing Responsibilities
Hydralazine (Apresoline)
Labetalol (Normodyne)
Nifedipine
Act to lower blood
pressure by peripheral
dilatation
Assess for pulse and BP before and
after administration (Can cause
tachycardia)
Magnesium Sulfate CNS depressant that
blocks neuromuscular
transmission of ACh to
halt convulsions
Also halts premature labor
as it relaxes smooth
muscles
Assess for maternal BP and fetal HR
continuously
Assess for DTR q1-4 hours
Monitor I&O (AE: UO)
Assess RR: Should be >12/min
Assess LOC
Obtain serum magnesium levels q6-8
hours
Keep calcium gluconate available
May cause respiratory depression if
given close to birth

ECLAMPSIA
Occurs when cerebral irritation from increasing cerebral edema becomes so acute that seizure occurs
Can occur up to 48 hours after childbirth
Q Tonic-Clonic Seizures:
o Muscles contract, back arches, arms and legs stiffen and jaw closes abruptly
o Tonic Phase, 20 seconds
Respirations halt because her thoracic muscles are held in contractions
o Clonic Phase, 1 minute
Bladder and bowel contract and relax, incontinence of urine and feces occur
o PRIORITY CARE:
Maintain a patent airway: Oxygen by facemask
Prevent aspiration: Turn on side to drain secretions
Administer MgSO4 / Diazepam (Valium)
o Assess for O2 Saturation

o Continuously assess FHR and uterine contractions
o Check for vaginal bleeding to detect placental separation
o Postictal State
Semicomatose, cannot be roused except by painful stimuli (can initiate another seizure)
Assess for premature separation of placenta
May start labor, and woman cannot report contractions
Keep woman on the side to pool secretions
Give nothing to eat or drink
Keep noise down
Continuously monitor FHT and contractions
Check for vaginal bleeding q15 minutes
Q Birth
o If gestational age is >24 weeks, a decision must be made if birth will be made
o Unexplained reason, fetal lung maturity appears to advance rapidly with PIH
May be due to intrauterine stress
o Cesarean birth may be hazardous for the fetus Due to retained lung fluid
A woman with eclampsia is not a good candidate for surgery
Induction of pregnancy may be initiated if necessary

NURSING INTERVENTIONS DURING POSTPARTUM PERIOD
Postpartum Hypertension may occur up to 10 14 days after birth
o May occur no more than 48 hours
o Monitor BP and be alert for eclampsia
o Urge who have had an elevated BP to return for postpartum check-up

ERYTHROBLASTOSIS FETALIS
Definition
Also known as Hemolytic disease of the newborn
It is a disease in the fetus / newborn caused by transplacental transmission of maternal antibody, usually
resulting from maternal and fetal blood group incompatibility
Rh incompatibility develop when a WOMAN who has Rh NEGATIVE blood becomes pregnant by a MAN
with Rh NEGATIVE blood and conceives a FETUS with Rh POSITIVE blood
o In other words: () Woman + (+) Man = () Baby
RBCs from the fetus leak across the placenta and enters the womans circulation throughout pregnancy with the
greatest transfer occurring at delivery
This disease usually occurs greatly in the 2
nd
baby of the mother

IN SUCCEEDING PREGNANCIES
The antibodies reach the fetus via the placenta and destroy (lyse) the fetal RBCs
The resulting anemia may be due to profound that the fetus may die in utero
Reacting to the anemia; the fetal bone marrow may release immature RBCs / erythroblasts into the fetal
peripheral circulation causing Erythroblastosis Fetalis
Maternal fetal incompatibility of ABO blood types to neonatal erythroblastosis are less severe and less common
than those of the Rh factor
2 Types
o Rh Incompatibility
o ABO Incompatibility Most common

Clinical Manifestations
- Jaundice serum levels of unconjugated bilirubin (Hyperbilirubinemia)
- Anemia Due to hemolysis of erythrocytes
- Hepatosplenomegaly
- Hydrops Fetalis (Accumulation of fluids in body tissues)
- Other:
o level of insulin
o blood sugar
Nursing Diagnoses
Impaired tissue perfusion related to destruction of red blood cells
Ineffective family coping related to current condition of new born
Risk for CNS involvement related to destruction of red blood cells

Diagnostic Examinations
Before birth:
o Check mothers blood type
o For antibody screening
o Indirect Coombs Test = Measures the number of antibodies in the maternal blood
o PUBS
o Amniocentesis
o Ultrasound
After birth:
o CBC
o Bilirubin test
o Direct Coombs Test = Which may get the level of maternal antibody attached to the babys RBC
o Blood typing and Cross Matching
Medications and Treatment


Aqueous
Humor
Aqueous Humor Flow
Posterior
Chamber
Anterior
Chamber
Trabecular
Meshwork
Canal of
Schlemm
Capillary
Network
Episcleral
Veins
4 Rhogam Given within 72 hours after birth
o This immunoglobulin destroys any fetal blood cells in the mother preventing formation of Rh positive
(+) antibodies
o In cases where this precaution is not taken, antibodies are created and future pregnancies may be
complicated
o The preparation must be given after each pregnancy, whether it ends in delivery, or ectopic pregnancy
4 Phototherapy
o Cover eyes to protect sclera
o Cover genetalia
o Expose entire body and be concerned about hydration of baby

Sensory Disorders
GLAUCOMA

Definition:
Refers to a group of ocular conditions characterized by OPTIC NERVE DAMAGE
The OPTIC NERVE gets damaged due to the increase in IOP; due to the congestion of aqueous humor in the
eyes which may lead to VISION LOSS
NOTE: There is NO CURE

NORMAL PHYSIOLOGY

Aqueous humor flows between the IRIS and LENS which nourishes the
CORNEA and LENS
Most of the fluid (90%) flows out through the ANTERIOR CHAMBER
going to TRABECULAR MESHWORK and then to the CANAL OF
SCHLEMM
About 10% flows through the CILIARY BODY going to the
SUBCHOROIDAL SPACE and then to the VENOUS CIRCULATION
of the CILIARY BODY, CHOROID and SCLERA
IOP is determined by the rate of aqueous humor production
N: 10 21 mm Hg

FACTORS that IOP:
- Time of day
- Exertion
- Diet
- Medications
- Blinking
- Tight lid squeezing
- Upward gazing
- Diseases: Diabetes, Uveitis, Retinal Detachment

Refractive Errors
Myopia my (Nearsightedness)
Hyperopia hy High (Farsightedness)
Astigmatism Blurred at any distance

Types of Glaucoma
1. Open-Angle Glaucoma (Wide Angle Glaucoma)
Unclear Etiology
Caused by a in outflow of Aqueous Humor into the Canal of Schlemm
Usually affects both eyes (OU)
Usually asymptomatic
2. Closed-Angle Glaucoma (Narrow Angle Glaucoma / Acute Angle Closure Glaucoma)
Characterized by suddenly impaired vision due to intraocular tension caused by an imbalance in
production and excretion of Aqueous Humor
Results from abnormal displacement of iris against the angle of aqueous chamber
Often unilateral, other eye may be affected
Emergency treatment if necessary, IOP can exceed 30 mm Hg
3. Secondary Glaucoma
Related to conditions that narrow the Canal of Schlemm

PATHOPHYSIOLOGY
Theories in how the increase of IOP damages the Retina
Direct Mechanical Theory: IOP damages the retinal layer as it passes through the optic nerve head
Indirect Ischemic Theory: IOP compresses the microcirculation in the optic nerve head leading to cell injury
and death


Clinical Manifestations:
Open Angle Glaucoma (Wide Angle Glaucoma)
o Open Angle Glaucoma Mnemonic~
OPEN
O Occasionally sees HALOS AROUND LIGHTS
P Peripheral Vision is gradually lost (Progressive vision loss)
E Early stage is ASYMPTOMATIC
N NOT an EMERGENCY
o Usually Bilateral
o Slowly progressive
o Signs and Symptoms appear late as:
1. Mild aching in the eye
2. Gradual loss of peripheral vision
3. Seeing halos around lights
4. Visual acuity, especially at night
Narrow Angle Glaucoma (Closed Angle Glaucoma)
o Rapid onset, may consult an ophthalmologist
o May feel eye pain, nausea and headache
o Vision is blurred and cornea appears bulging and cloudy
o Pupil unresponsive to light
o Requires IMMEDIATE Treatment to prevent further damage

Assessment
Demographic Profile
Family History
History of ocular surgeries, infections or trauma
History of current medications

Possible Nursing Diagnoses
Disturbed sensory perception
o Related to:
O Altered sensory reception, Altered status of sense organ ( IOP / atrophy)
o Evidenced by:
O Progressive loss of visual field
Anxiety
o Related to:
O Change in health status, Presence of pain, Reality of loss of vision, Unmet needs, Negative
self-talk
o Evidenced by:
O Apprehension, Uncertain and Expressed Concern regarding changes in life
Knowledge deficit
Ineffective therapeutic regimen

Diagnostic Tests
- Tonometry
o Method of measuring the IOP using a calibrated instrument that flattens the corneal apex
o Used to check for Glaucoma
o Performed yearly after 40 years old
o N: IOP = 10 21 mm Hg (Pero sabi sa Brunner 10 20 mm Hg)
o Nursing Responsibilities:
4 Do not rub after procedure
4 Contacts are REMOVED
- Ophthalmoscopy
o Examine external structures and interior of eyes
- Gonioscopy
o Measures the angle of the anterior chamber
o Determines whether it is Open Angle Glaucoma or Closed Angle Glaucoma
- Slit Lamp Examination
o Examination of anterior ocular structures under micromagnification
4 Remove contacts
4 Drops will make eyes blurred (40 minutes 2 hours)
4 Advise to wear dark glasses

Medications
B Beta Blockers
o Production of Aqueous Humor (Timolol, Betaxolol)
O Contraindicated for patients with Asthma and COPD
O Assess for Bradycardia
A Anhydrase Inhibitors
o Rate of formation of fluids (Acetazolamide)
o Side Effect: Anorexia
H Hyperosmotics
o Rate of formation of fluids (Mannitol)
O Check for BP
O Weight daily
O Monitor Signs and Symptoms of F&E imbalance
M Miotics
o Facilitates outflow of Aqueous Humor (Pilocarpine)
o For constriction of pupils
o Nursing Responsibility:
O Can cause blurring of vision, advise to stop for a while

Surgical Procedures
Laser Trabeculoplasty: Use of laser to create an opening in the Trabecular Meshwork to increase the outflow of
Aqueous Humor
Filtering Procedure:
o Trephinate
o To create an outflow channel from the anterior chamber to subconjunctival space
o Aqueous humor is absorbed in the conjunctival spaces
Iridotomy
o Formation of a new route for the flow of aqueous humor

NURSING RESPONSIBILITIES
PRE OP
Prepare patient
Explain procedure
Waiting period 1 2 hours and WOF in IOP
Ask a relative to accompany patient due to IOP

POST OP
Protect eyes from light
Monitor frequently IOP


PATIENT EDUCATION
* Regular Exercise
* Medic-alert Card
* Compensate for reduced vision
* Stress importance of compliance to medications
* Read OTC Drugs, can IOP
* Review signs and symptoms of infection and
IOP
* Rationalize for eye shields
* Avoid rubbing / pressure

CATARACT
Definition:
o A cataract is a lens opacity or cloudiness

Painless, blurry vision
Dimmer surroundings (As if glasses need cleaning)
Reduced contrast sensitivity
Sensitivity to glares
Visual acuity
Myopic Shift (Return of ability to do close work)
Astigmatism
Diplopia
Color shift
Brunescens (Color values shift to yellow-brown)

Assessment and Diagnostic Findings
+ Snellen Visual Acuity Test
+ Ophthalmoscopy
+ Slit-lamp Biomicroscopic Examination
Medical Management

Characteristics of Cataract
Cloudy, opaque lens
Acuity
No pain
Occurs gradually

Treatment:
Removal of lens with lens implant
= No surgical treatment cures cataracts or prevents age-related cataracts
= Meaning SURGICAL INTERVENTION IS NEEDED

Surgical Management
If reduced vision from cataract does not interfere with normal activities, surgery may not be needed
Done in an outpatient basis and takes less than 1 hour with the patient being discharged 30 minutes or less
afterward

NURSING MANAGEMENT
- Provide PreOp Care
1. Withhold anticoagulant 5 7 days before surgery
2. Administer dilating drugs 10 minutes before surgery
3. Administer antibiotics, corticosteroids, anti-inflammatory drugs, drops may be administered
prophylactically
- Administer mild analgesics PostOp
- Administration of antibiotics, corticosteroids, anti-inflammatory drops may be administered PostOp
- Provide written instructions for discharge
1. Wear glasses / metal eye shields at all times
2. Wash before and after touching the eyes
3. Wipe the closed eyes with a single gesture from the inner to outer canthus
4. Avoid lying on the affected side
5. Keep activities light
6. Avoid bending / lifting, pushing heavier than 15 lbs

REMEMBER:
- Cataract Glasses (Aphakic Glasses) magnify, so that everything appears about closer than it is
- Use of contact lenses improves visual correction and better comments appearance
- Intraocular Lens Implant
Alteration to cataract glasses and contact lenses
Made from polymethylmethacrylate, is implanted at the time of cataract extraction into the capsular
sac
Main advantage of the implanted lens is better binocular vision

- Disturbed visual sensory perception
Related to:
Altered sensory reception, Status of sense organ, Therapeutically restricted environment
(Surgical procedure, patching)
Evidenced by:
Diminished acuity, Visual distortions, Change in usual response to stimuli
- Risk for trauma
Risk Factors:
Poor vision, Reduced hand/eye coordination
- Anxiety
Related to:
Alteration in visual acuity, Threat to permanent loss of vision
Evidenced by:
Expressed concerns, Apprehension, Feelings of uncertainty
- Knowledge deficit (Regarding ways of coping with altered abilities, therapy choices, lifestyle changes)
Related to:
Lack of exposure/recall, Misinterpretations, Cognitive limitations
Evidenced by:
Requests for information, Statement of concern, Inaccurate follow-through of instructions

RETINAL DETACHMENT
Definition:
Refers to the separation of the RPE (Retinal Pigment Epithelium) from the sensory layer

TYPES OF RETINAL DETACHMENT
1. Rhegmatogenous RD
C Most common
C Hole or tear develops in the sensory retina
C Which allows seeping of vitreous liquid through the sensory retina and detach it from the RPE
C Possibly due to: S/p Cataract surgery, trauma and proliferative retinopathy
2. Traction RD
C Due to tension or a pulling force
C Formation of fibrous scars on the retina due to conditions like; diabetic retinopathy, vitreous
hemorrhage, or retinopathy of prematurity
C The hemorrhages and fibrous proliferation exert a pulling force on the delicate retina
3. Combination of Rhegmatogenous and Traction
4. Exudative RD
C Due to production of serous fluid under the retina from the choroid
C Possibly due to diseases like; Uveitis and Macular Degeneration
C This production of serous fluid detaches the RPE from the sensory layer

Surgical Management
= Scleral Buckle
o The compression of the sclera to indent the scleral wall from the outside of the eye and bring the two
retinal layers in contact
o Has a high success rate if with a very good surgeon, it causes less damage to the lens of the eye in
phakic patients
o SE: Increased chance of Diplopia, induced myopia and postoperative pain

= Pars Plana Vitrectomy
o 1 4 mm incisions are made at the pars plana for the introduction of a light source and for the portal of
the vitrectomy instrument
= Pneumotaxic Retinopexy
o Used for repair of a rhegmatogenous retinal detachment
o The most least invasive surgical treatment for retinal detachment
o A gas bubble, silicone oil or perfluorocarbon and liquids may be injected in the vitreous cavity which
will help push the sensory retina against the RPE
= Transconjunctival Sutureless Vitrectomy
o Allows for self-sealing transconjunctival pars plana sclerotomies

Nursing Management
Health Education and Supportive Care is the focus for patients with Retinal Detachment
Post Operative (Pneumotaxic Retinopexy)
o Prone Position
Because the injected bubble must float into a position overlying the area of detachment
Which will give consistent pressure to reattach the sensory retina
o Inform patient of possibility of (2) eye patches after surgery
Teaching About Complications
o Advise patient for a follow-up check up
o Teach patient signs and symptoms of increased IOP, endophthalmitis
o Continuous blurring of vision despite surgery
o Give patients a telephone number of the ophthalmic team in case of emergencies

Disturbed visual sensory perception
o Related to:
Decreased sensory perception
o Evidenced by:
Visual distortions
Decreased visual field
Changes in visual acuity
Knowledge deficit (Therapy, prognosis and or self-care needs)
o Related to:
Lack of information/misconceptions
o Evidenced by:
Statements of concerns
Risk for impaired home maintenance
o Risk Factors:
Visual limitations
Activity Restrictions

MACULAR DEGENERATION
Definition:
Characterized by tiny, yellowish spots called drusen beneath the retina
Drusen Small clusters of debris or waste materials that lie deep within the RPE and if they are in macular
area, they affect vision
Common among 60 years old or older

SIGNS and SYMPTOMS
Central vision loss (Patients retain peripheral vision)
Two Types:
o Dry Type: Non-neovascular, Non-exudative
= The outer layers of the retina slowly breakdown

= With this breakdown, drusen appears
If it occurs outside the macula, no blurring
If it occurs within the macula, blurring
o Wet Type: Neo-vascular, Exudative
= Abrupt onset
= Proliferation of abnormal blood vessels
Report straight lines appear crooked and distorted
Letters in words appear broken
= Possible leakage of fluid, blood which elevate the retina

Medical Management
There is no known cure for Dry Type of MD
Administration of large doses of macronutrients Can slow the progression of the disease
o Antioxidants: Vitamin C, Vitamin E and Beta-carotene
o Minerals: Zinc oxide
Antiangiogenic Therapy
o Treatment for Wet Type:
Pegaptanib sodium (Macugen)
VEGF (Vascular endothelial growth factor) antagonist Used to inhibit the ability of
VEGF to bind to cellular receptors
Ranibizumab (Lucentis)
Designed to bind and inactivate all isoforms of VEGF
Via intravitreal once a month
Bevacizumab (Avastin)
Monoclonal antibody, helpful in treatment of neovascular AMD

Nursing Management
* Instruct patient on how to use the Amsler Grid
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o To monitor for a sudden onset or distortion
o Can help determine the extent of the disease if getting worse
o Encourage to look at the grid ONE EYE AT A TIME several times each week with glasses on
o If change in the grid has been noticed, INFORM IMMEDIATELY

Neurologic Disorders
PARKINSONS DISEASE (PD)
Definition:
Chronic slowly progressive neurologic movement disorder which leads to disability

Etiology
Primary / Idiopathic PD
o Usually develops after age 60
o Occurs on both genders
o Probable causes are viruses or toxins on cells
Secondary PD
o May be due to:
Encephalitis, Trauma, or Vascular Disease
Drugs: Phenothiazines (e.g. Chlorpromazine)

Overview of Parkinsons Disease
Also known as: Paralysis Agitans


Progressive neurodegenerative disease:
o Progresses in a chronic period of time
o Emotionally incapacitating
o Change in the brain overtime
May be detrimental to the person
Functioning of the brain
Debilitating:
o Causes physical exhaustion for the person
o Affects the emotional, physiological and psychological aspect of a person
Affects motor activity

4 Cardinal Symptoms for Parkinsons Disease (TRAP)
T = Tremors (Resting Tremors) Different from MS (Intentional Tremors)
o Disappears with purposeful movement
o Evident when motionless (Concentrating, feeling anxious)
o Manifested as slow turning motion of forearm
o Pill-rolling Motion of hands
R = Rigidity Resistance to passive limb movement
o Lead-pipe or Cog-wheel movement
o Stiffness increases when another extremity is doing an action
o Patient complains of shoulder pain due to rigidity
o Loss of arm-swinging
A = Akinesia / Bradykinesia
o Overall slowing of active movement
o Patients have difficulty initiating movement
P = Postural Instability
o Patient stands with head bent forward and walks with a propulsive gait
o Shuffling gait is evident, due to the persons effort to move faster and faster
o Stooped posture

OTHER SIGNS and SYMPTOMS
- Mask-like appearance, decrease in blinking reflex
- Uncontrolled sweating, paroxysmal flushing, orthostatic hypotension, gastric and urinary retention,
constipation and sexual dysfunction
- Psychiatric Changes:
o Depression, Dementia, Delirium and Hallucinations (Auditory and Visual)
- Hypokinesia Abnormally diminished movement that appears after tremors
- Micrographia (Small handwriting)
- Dysphonia (Soft, slurred, low-pitched and less audible speech)
- Dysphagia and drooling

STAGES of Parkinsons Disease
STAGE MANIFESTATIONS
Stage I Symptoms on one side of the body
Stage II Symptoms on both sides of the body; no impairment in balance
Stage III Balance impairment, mild to moderate disease; physically independent
Stage IV Severe disability, but still able to walk/stand unassisted
Stage V Wheel-chair bound/bed-ridden

There is no diagnostic procedure that can tell if the patient has Parkinsons Disease, but PET (Positron Emission
Tomography) and SPECT (Single Photon Emission Computed Tomography) can be helpful with the presence
of 2 or more of the cardinal signs and symptoms TRAP

Medical Management
Treatment is directed at controlling symptoms and maintain functional independence
Pharmacologic treatment is the mainstay of treatment

Pharmacologic Treatment
Antiparkinsonian Drugs
o striatal dopaminergic activity
o excessive influence of excitatory cholinergic neurons on the extrapyramidal tract which restores
dopaminergic and cholinergic activities
o Act on neurotransmitter pathways other than the dopaminergic pathway
Levodopa (Larodopa)
o Most effective agent and the mainstay of treatment for PD
o It is converted to dopamine in the basal ganglia which produces symptom relief
o Adverse Effects: Confusion, hallucinations, depression and sleep alterations
o After 5 10 years of drug use:
Dyskinesia (Abnormal involuntary movements)
Facial grimacing
Rhythmic jerking movement of the hands
Head bobbing
Chewing and smacking movements
Involuntary movements of the trunk and extremities
On-off Syndrome May occur
o Neuroleptic Malignant Syndrome
Characterized by; severe rigidity, stupor and hyperthermia

Surgical Management
- Stereotactic Procedures
o Thalamotomy and Pallidotomy
For patients who have Idiopathic
PD
With maximum doses of
Antiparkinsonian drugs
Done to interrupt the nerve
pathways which alleviates
tremor and rigidity
Pallidotomy: Destruction of part
of the ventral aspect of the
medial globus pallidus which
will reduce rigidity,
bradykinesia and dyskinesia
o Stereotactic Frames will be used after the
procedure to help position the patients
head
- Neural Transplantation
o Transplantation of porcine neuronal cells,
human fetal cells and stem cells
- Deep Brain Stimulation
o Pacemakerlike brain implants are used to relieve tremors
o A high-frequency electrical impulse is sent through a wire which blocks nerve pathways in the brain
that cause tremors

Nursing Process
ASSESSMENT
ABCDE of Parkinsons Disease Medications
A = Amantadine (Symmetrel)
Antiviral and Antiparkinsonian Drug
Promotes availability of dopamine in receptor sites
B = Bromocriptine (Parlodel)
Used when Levodopa is already gone/faded away
Mimics effects of dopamine
Does not need to be metabolized and converted
C = Carbidopa (Sinemet)
Prevents breakdown of Levodopa
Amino acid decarboxylase inhibitor ( CHON in diet)
D = Dopar (Levodopa)
Causes longer periods of remission
AE: Confusion, hallucination, depression and sleep
alteration
E = Entacapone (Comtan)
Used in psychiatric patients,
Hypersensitivity: History of MI and CVA
AE: Dystonia, hand tremors
SE: GI Upset

- Observe for: Quality of speech, loss of facial expression, swallowing deficits (Drooling, poor head control, and
coughing), tremors, slowness of movement, weakness, forward posture, rigidity, mental slowness and confusion

POSSIBLE NURSING DIAGNOSES
- Impaired physical mobility related to muscle rigidity and motor weakness
- Self-care deficits (feeding, dressing, hygiene, and toileting) related to tremor and motor disturbance
- Constipation related to medication and reduced activity
- Imbalanced nutrition: less than body requirements, related to tremor, slowness in eating, difficulty in chewing
and swallowing
- Impaired verbal communication related to decreased speech volume, slowness of speech, inability to move
facial muscles
- Ineffective coping related to depression and dysfunction due to disease progression

PLANNING (MIB-NCC)
After ______ of nursing interventions, the patient will be able to:
o Improve functional mobility
o Maintain independence in ADLs
o Achieve adequate bowel elimination
o Attain and maintaining acceptable nutritional status
o Achieve effective communication
o Develop positive coping mechanisms

NURSING INTERVENTIONS
` Improving Mobility
Give a progressive program of daily exercise
To increase muscle strength
Improve coordination and dexterity
Reduce muscular rigidity
Prevent contractures
Walking, Stretching and ROM Exercises promote joint flexibility (Yoga, Taichi) Relaxes muscles
Collaborating with a Physical Therapist can be helpful in developing an individualized exercise
program
Faithful adherence to an exercise and walking program delays progress of the disease
Warm baths and massage Also helps relax muscles and relieve painful muscle spasms
Balance may be affected:
Teach special walking techniques to offset shuffling gait
Taught to concentrate on walking erect
Watch the horizon and use a WIDE-BASED GAIT
Practice with marching music~
Perform breathing exercises while walking (Helps move the rib cage and aerate parts of the lungs
` Enhancing Self-Care Activities
Environmental modifications (To compensate for disabilities)
Adaptive / assistive devices may be useful (Side-rails, overbed frame with trapeze)
Collaborate with an Occupational Therapist
` Improving Bowel Elimination
Establish a regular bowel routine
Increase oral fluid intake (OFI)
Eat foods with moderate fiber content
DO NOT USE LAXATIVES May impair the ability of the bowel to sense bowel fullness
Raised toilet seat (Due to the difficulty of the patient in moving from a standing-sitting position)
` Improving Nutrition
Monitor weight on a weekly basis
Give supplemental feedings to increase caloric intake
An NGT (Nasogastric Tube) or PEG (Percutaneous Endoscopic Gastroscopy) may be inserted
Collaborate with a dietitian regarding nutritional needs
` Enhancing Swallowing
Inform patient to eat in an upright position to improve swallowing
Give a meal with SEMISOLID DIET with THICK LIQUIDS (Avoid THIN LIQUIDS)
Inform patient of the Swallowing sequence
Put food on tongue
Close lips and teeth
Lift the tongue up and then back and SWALLOW
Encourage patient to chew first on one side, then on the other
Massaging the face and neck may be beneficial
` Encourage the Use of Assistive Devices
Use of electric warming tray (To keep food warm)
Use of special utensils
Stabilized plate with nonspill cups
Collaborate with the Occupational Therapist
` Improving Communication
Make an effort to speak slowly
Remind the patient to face the listener, and EXAGGERATE the pronunciation of words
Speak in short sentences
Take a few deep breaths before speaking
Collaborate with a Speech Therapist to help how to fully communicate with patient
` Supporting Coping Abilities
Help patient set achievable goals

Promoting Home and Community-Based Care
TEACHING PATIENTS SELF-CARE
- Do not overwhelm patient and family with too much information
- Provide a clear explanation of the disease
- Goal of assisting the patient to remain functionally independent as long as possible
- Teach the side effects of medications and importance of reporting side effects

EVALUATION

MULTIPLE SCLEROSIS
Definition:
Immune-mediated, progressive demyelinating disease of the CNS
Usually affects ages 20 40 years
Affects women more than men

Etiology:
Idiopathic
Genetics: Presence of Specific cluster (haplotype) oh Human Leukocyte Antigen (HLA) on cell wall
Environmental exposures

o Symptoms are mild and patients do not seek much treatment
o Relapsing Remitting (RR) Course
o 80 85% of patients
o With each relapse, recovery is complete; however, residual deficits may occur and accumulate over
time which contribute to functional decline
o Primary Progressive
o May result in quadriparesis, cognitive dysfunction, visual loss and brain syndromes
o Least common presentation, 5%
o Relapses with continuous disabling progression between exacerbations
o Primary Symptoms:

o Fatigue, depression, weakness, numbness, difficulty in coordination, loss of balance and pain (SIN:
Scanning Speech, Intentional Tremors, Nystagmus)
o Visual disturbance:
Lesions in optic nerves or their connections
Blurring of vision, Diplopia, patchy blindness (scotoma), total blindness
o Fatigue:
Most debilitating symptom
Factors that exacerbate: Heat, depression, anemia, deconditioning and medications, therefore,
avoid hot temperatures
Effective treatment of depression and anemia and collaborating with PTs and OTs can help
control fatigue
o Pain:
Possible isolation
Cause of pain is because of lesions on sensory pathways
Additional sensory manifestations:
Paresthesias, dysesthesias, and proprioception loss
Manage with: Analgesics, opioids, anti-seizure medications, anti depressants
o Spasticity: Muscle Hypertonicity and Loss of abdominal reflexes
Due to involvement of main motor pathways (pyramidal tract) of the spinal cord
o Ataxia and Tremor
Due to involvement of the cerebellum or basal ganglia

MRI: Presence of multiple plaques
Electrophoresis of CSF: Presence of oligoclonal banding (Several bands of IgG)

Medical Management
NO CURE EXISTS
Only to RELIEVE and PROVIDE SUPPORT
Goals of treatment:
o Delay progression of disease
o Manage chronic symptoms
o Treat acute exacerbations

Pharmacologic Therapy:
DISEASE-MODIFYING THERAPIES
Action:
o Reduce frequency of relapse
o Reduce duration of relapse
o Reduce number and size of plaques on MRI
All are injectables
Medication IM-GM Action
Interferon beta-1a (Avonex, Rebif) Rebif administered: SubQ
Avonex administered: IM
SE: Flulike symptoms, liver damage, fetal anomalies, depression
Glatiramir acetate (Copaxone) Reduces rate of relapse in the RR course
Increases the time between relapses
Increases the antigen-specific suppressor T-cells
Administered: SubQ
Takes about 6 months for evidence of immune response
Methylprednisolone Key agent for treating acute relapses in RR
Shortens duration of relapses
Exerts anti-inflammatory effects by acting on T cells and cytokines
Administered: IV
SE: Mood swings, weight gain, electrolyte imbalance
Mitoxantrone (Novantrone) Reduce frequency of clinical relapses in patients with secondary-
progressive or worsening relapsing-remitting
Administered: IV
SE: Cardiac toxicity

SYMPTOM MANAGEMENT THERAPIES
Medication Action
Baclofen (Lioresal) Gamma-aminobutyric Acid (GABA) agonist
Medication of choice for SPASTICITY
Administered: Orally / Intrathecal
Benzodiazepines (Valium)
Tizanidine (Zanaflex)
Dantrolene (Dantrium)
Can also be used to treat SPASTICITY
Amantadine (Symmetrel)
Pemoline (Cylert)
Fluoxetine (Prozac)
Used to treat fatigue that interferes with ADLs
Beta-adrenergic Blockers (Inderal)
Antiseizure Agents (Neurontin)
Benzodiazepines (Klonopin)
Used to treat ataxia
Anticholinergic agents
Alpha-adrenergic blockers
Antispasmodic agents
Used to treat bladder and bowel problems
Ascorbic Acid (Vitamin C) Used to treat UTI and ACIDIFY urine

Symptoms Needing Immediate Intervention
Spasticity
Fatigue
Bladder dysfunction
Ataxia

NURSING PROCESS
Assessment
- Assess for weakness, spasticity, visual impairment, incontinence and difficulty swallowing and in speech

Impaired bed and physical mobility related to weakness, muscle paresis, spasticity
Risk for injury related to sensory and visual impairment
Impaired urinary and bowel elimination (urgency, frequency, incontinence, constipation) related to nervous
system dysfunction
Impaired verbal communication and risk for aspiration related to cranial nerve involvement
Disturbed thought process (loss of memory, dementia, euphoria) related to cerebral dysfunction
Ineffective individual coping related to uncertainty of course of MS
Impaired home maintenance management related to physical, psychological, and social limits imposed by MS
Potential for sexual dysfunction related to lesions or psychological reaction

Planning and Goals (MIB-CCMS)
After ____ of nursing intervention, the patient will have/be able to:
o Promote physical mobility
o Avoid injury
o Achieve bladder and bowel continence
o Improve cognitive function
o Develop coping strengths
o Improve home maintenance management
o Adapt to sexual dysfunction

Interventions
PROMOTING PHYSICAL MOBILITY
Relaxation and coordination exercises Promotes muscle efficiency
EXERCISES:
o Walking Improves gait
o Instruct that assistive devices are available
MINIMIZING SPASTICITY AND CONTRACTURES
o Spasticity:
Characterized by severe adductor spasms of the hips with flexor spasm of the hips and knees
Use of warm packs are beneficial, AVOID HOT BATHS
o Contractures:
Do daily exercises for muscle stretching
Stretch-hold-relax routine
ACTIVITY AND REST
o Encourage to work and exercise to a point just short of fatigue
o Take frequent rest periods (Lying down)
MINIMIZING EFFECTS OF IMMOBILITY
o Assess and maintain skin integrity
o Perform coughing and deep-breathing exercises

PREVENTING INJURY
Teach patient to walk with feet apart To widen the base of support
Tell patient to watch feet while walking If loss of position sense occurs
Use of assistive devices is available

ENHANCING BLADDER AND BOWEL CONTROL
Categories:
o Inability to store urine (Hyperreflexic, uninhibited)
o Inability to empty bladder (Hyporeflexic, hypotonic)
o Mixture of both
Ready the bed-pan near patients bed
Establish a voiding time (Every 1.5 2 hours with gradual lengthening of interval)
Instruct to drink a measured amount q2 hours and attempt to void
Encourage to take prescribed medications
Teach how to do intermittent self-catheterization
Bowel problems:
o Adequate fluids, dietary fiber and bowel-training program

ENHANCING COMMUNICATION AND MANAGING SWALLOWING DIFFICULTIES
Collaborate with a speech therapist regarding speech and swallowing
Have suction apparatus available, careful feeding and proper position the patient when eating

IMPROVING SENSORY and COGNITIVE FUNCTION
Vision
Eye patch / covered eyeglass lens Used to block visual impulses if has Diplopia
Prism glasses Difficulty reading in a supine position
Cognition and Emotional Responses
Support of family and friends is a primary need
Instruct patient to remain as active as possible
Strengthening Coping Mechanisms
No two patients with MS have identical symptoms or course of illness
Help alleviate anxieties Help define the problem, develop alternatives for management
Collaborate with social services, speech therapists, PTs and home maker services if too complex a problem
arises

IMPROVING HOME MANAGEMENT
Other abilities are impossible to regain after they are lost
Allow patient to be independent

PROMOTE SEXUAL FUNCTIONING
Collaborate with patient, family and health care for supporting intimacy
Alternatives for methods of sexual expressions

Promoting Home and Community-Based Care
Teaching Self Care
- Self-care education
o Assistive devices, self-catheterizations, medication administration
- Teaching plan about IM or SQ administration

Evaluation

Endocrine Disorders
HYPERTHYROIDISM
Definition:
It is the excessive secretion of TH
Affects women more than males
Occurs in the ages between 20 and 40 years old

Etiology and Risk Factors
o Graves Disease (Toxic, Diffuse Goiter) Most
common form of Hyperthyroidism
o An autoimmune disorder mediated by
immunoglobulin G (IgG) antibody that binds to and
activates TSH receptors
o 3 Principal Hallmarks
o Hyperthyroidism
o Goiter (Thyroid Gland Enlargement)
o Exophthalmos (Abnormal protrusion of eyes)

Assessment Hyperthyroidism Assessment Goiter / Heart Ds Assessment Exophthalmos
* Extremely agitated (Irritable)
* Resting hand tremors
* Ravenous appetite but still has
weight loss
* Loose bowel movements
* Heat intolerance (Profuse
diaphoresis)
* Tachycardia
* Incoordination
* Warm, smooth and moist skin
* Thin and soft hair
* Changing moods
* Fatigue and depression
*SEE PATHOPHYSIOLOGY
* Enlarged neck
* Due to hyperplasia and
hypertrophy of thyroid cells
because of the TH release

Heart Disease
* Administration of Beta-
adrenergic blockers
* Occurs due to the autoimmunity
against retro-orbital tissues
* Protruding eyes
* Fixed stare
* Gritty sensation in eyes
* Photophobia
* Lacrimation
* Inflammatory changes
* Dyslogia Impaired ability to
express ideas verbally
*Does not regress with therapy

Medical Interventions:
* Diuretics
* Glucocorticoids (Prednisone)
* Methylcellulose Eye drops
* Radiation Therapy
* Surgical Decompression

Nursing Interventions:
* Wear dark eye glasses
* Avoid dust / dirt in eyes
* Wear sleeping mask / tape
* Elevate HOB at night
* Restrict salt intake

Medical Management
To Curtail Excessive Secretion of TH
Propylthiouracil (PTU)
o Most commonly used antithyroid medication
o Corrects hyperthyroidism by impairing TH synthesis
Thyroid Storm (Thyrotoxicosis)
High fever
Severe tachycardia
Delirium
Dehydration
Extreme irritability

Treatment:
Hypothermia blankets
IVF
Suppressing hormone release
Inhibiting hormone synthesis
Blocking conversion of T4 to T3
Inhibiting effects of TH on body tissues
Treating precipitating cause
o Toxic SE: Agranulocytosis (Deficiency of granulocytes in the blood)
o Less Severe SE: Allergies, rash and pruritus
Iodine Therapy:
o Given to:
Reduce vascularity of the thyroid gland before subtotal or total thyroidectomy
Treat thyroid storm
o Act temporarily to prevent release of TH into the circulation by increasing the amount of TH stored in
the gland
o Must be given only for 10 14 days before surgery
o Iodine Medication of Choice:
Potassium Iodide
Lugols Solution
Radioactive Iodine (
131
I)
o For middle-age and older adults
o Advantage: Simple to administer and is economical, can be given on an out-patient basis
o Action:
Thyroid gland is unable to distinguish between REGULAR IODINE ATOMS and
RADIOIODINE ATOMS
If patient receives
131
I, thyroid gland picks up RADIOIODINE and concentrate it as
REGULAR IODINE
As a result, cells that concentrate
131
I to make T
4
are destroyed by local irradiation
o Manifestations of Hyperthyroidism subside within 6 12 weeks after

Prevent and Treat Complications
Adrenergic Blocking Agents (Propranolol)
o Helps lessen manifestations of:
Palpitations
Tachycardia
Tremors and Nervousness
Diet:
o High calorie diet (4000 5000 calories)
o High protein diet To compensate for hypermetabolic state and prevent a negative nitrogen balance
and weight loss

Nursing Process
Assessment
- Complete History:
o Weight, appetite, activity, heat intolerance and bowel activity
o Enlarged thyroid gland (Soft and pulsating, thrill can be palpated, bruit is heard)
- Diagnostic Test:
o Based on the symptoms
o Serum TSH: Decreased
o T4: Increased
o Radioactive Iodine Uptake: Increased

Planning and Goals
After ___ of nursing intervention, the patient will have:
o Improved nutritional status
o Improved coping ability
o Improved self-esteem
o Maintenance of normal body temperature
o Absence of complications
Nursing Diagnoses and Interventions

C Imbalanced nutrition: less than body requirements related to exaggerated metabolic rate, excessive appetite, and
increased gastrointestinal activity
o Appetite is increased Give several, well-balanced meals of small sizes (6 meals a day)
o Diarrhea: Discourage highly seasoned foods and stimulants
o Encourage high-calorie, high-protein foods
o Give a quiet atmosphere for eating
o Record weight and dietary intake
C Ineffective coping related to irritability, hyperexcitability, apprehension and emotional instability
o Reassure about emotional reactions are because of disorder, can be controlled
o Use a calm, unhurried approach
o Minimize stressful experiences
Give a private room
Minimize noises (Music, conversations, equipment alarms)
o Encourage relaxation techniques
o Repetition of instructions for Preoperative teaching may be required
C Low self-esteem related to changes in appearance, excessive appetite and weight loss
o Nurse conveys an understanding of patients concern about problems
o Cover/remove mirrors (If disturbing for the client)
o Explain that with effective treatment, symptoms will disappear
o If patient is embarrassed with eating large meals, leave the room avoid commenting
C Altered body temperature
o Normal room temperature may be too WARM
o Maintain environment at a COOL, COMFORTABLE temperature
o Change linens and clothing as needed
o Cool baths / cool fluids may give relief
o Explain the reason for discomfort

Surgical Interventions
Thyroidectomy
Removal of the thyroid gland:
o Total Thyroidectomy To remove completely due to thyroid cancer (Need hormone replacement)
o Subtotal Thyroidectomy Removal of 5/6
th
the gland (Does not need hormone replacement)
Nursing Interventions:
- Preoperative Care:
E Patient is EUTHYROID
E Manifestations of THYROTOXICOSIS are diminished / absent
E Client appears RESTED and RELAXED
E Weight and nutrition are normal (Lost weight was regained)
E Cardiac problems are under control
- Postoperative Care:
E Assemble needed equipment at bedside
BP Cuff with stethoscope
Additional pillows
Oxygen with suction equipment
Intubation supplies
Tracheostomy Set
Ampules of Calcium Gluconate
E Monitor and Treat Hypocalcemia
Assess for muscle twitching and hyperirritability
Monitor Chvosteks and Trousseaus Signs
Home Care Instructions
= Neck Exercises: - Teach client how to support weight of the head and neck when sitting up
= Medications:
- Explain self-administration of thyroid medications
- Explain lifelong replacement therapy
= Follow-up Monitoring:
- Make an appointment after discharge
- At least twice a year
= Promote Wound Healing
- Use lanolin or Vitamin E cream to soften wound and minimize scarring


CUSHINGS SYNDROME (HYPERCORTISOLISM)
Definition:
Overactivity of the adrenal glands, hypersecretion of glucocorticoids
Occurs more frequently to women (Age 20 and 40 or 60)

1. Central Nervous System:
Emotional lability
2. Sleepiness / sleeplessness
3. Psychosis
4. Skin: Blood vessels become fragile
Easy bruising
Straie
Poor wound healing
Acne
Facial hair
5. Cardiovascular System
Abnormal sodium and water absorption
(Retention)
Hypervolemia = BP and HR
Edema
6. Musculo-Skeletal System
Muscle weakness
Easy fatigability
Abnormal absorption of Calcium =
Osteoporosis
7. Abnormal fat metabolism
Moon face
Buffalo Hump
8. Immune System
Immunocompromised
9. Glucose
Slow circulation of glucose
Increased due to increased cortisol and
gluconeogenesis
10. No menstrual flow

Nursing Process
Assessment
History taking
- Level of activity
- Ability to carry out routine and self-care activities
Physical Assessment:
- Skin: Trauma, infection, breakdown, bruising / edema
- Changes in physical appearance
- Responses to the changes are noted
- Mental function: Mood, Responses, Awareness, Level of
depression
Diagnostic Tests
CT Scan / MRI = Tumor
Blood Culture
Urine Specimen
Saliva
Cortisol Level

Nursing Diagnoses
Risk for injury related to weakness
Risk for infection related to altered protein metabolism and inflammatory response
Self-care deficit related to weakness, fatigue, muscle wasting and altered sleep patterns
Impaired skin integrity related to edema, impaired healing, and thin and fragile skin
Disturbed body image related to altered physical appearance, impaired sexual functioning and
decreased activity level
Disturbed thought processes related to mood swings, irritability and depression

Planning and Goals
After ____ of nursing intervention, the patient will be able have:
Decreased risk of injury
Decreased risk of infection
Mnemonic for
Immunocompromised
Patients
C Cushings Syndrome
A Agranulocytosis
S Steroids
H HIV

Increased ability to carry out self-care activities
Improved skin integrity
Improved body image
Improved mental function
Absence of complications

Interventions
Risk for injury related to weakness
- Establish protective environment (Prevent falls, fractures and other injuries)
- Give assistance when ambulating
- Encourage foods high in CHON, Ca and Vitamin D To minimize muscle wasting and
osteoporosis
- Collaborate with dietitian if necessary
Risk for infection related to altered protein metabolism and inflammatory response
- Avoid exposure to others with diseases
- Assess for subtle signs of infection (Anti-inflammatory signs may be masked)
Self-care deficit related to weakness, fatigue, muscle wasting and altered sleep patterns
- Encourage client to do ADLs Despite weakness, fatigue, and muscle wasting To prevent
complications of immobility
- Promote self-esteem
- Plan and space rest periods throughout the day
- Promote a relaxing, quiet environment for rest and sleep
Impaired skin integrity related to edema, impaired healing, and thin and fragile skin
- Give meticulous skin care To avoid traumatizing the patients skin
- DO NOT USE ADHESIVE TAPES
- Assess skin and bony prominences
- Change position of client every 2 hours to prevent skin breakdown
Disturbed body image related to altered physical appearance, impaired sexual functioning and
decreased activity level
- Encourage verbalization of feelings by the patient regarding condition they have had
- Modify weight gain and edema by giving:
E LOW CARBOHYDRATE
E LOW SODIUM
E HIGH PROTEIN
Disturbed thought processes related to mood swings, irritability and depression
- Explain to patient and family about cause of emotional instability
- Report any psychotic behavior by the patient
- Encourage further verbalization of feelings by patient and family

Health Teaching
Do not let the patient and family abruptly stop the corticosteroid medication
Emphasize the need to ensure an adequate supply of corticosteroids
Stress the need for dietary modification
Teach family on how to take:
- Blood pressure
- Blood glucose levels
- Weight

Communicable Diseases
RABIES (HYDROPHOBIA / LYSSA)
A specific, acute, viral infection communicated to man by the saliva of an infected animal

38

ETIOLOGIC AGENT
Rhabdovirus (DNA and RNA Creates a protection)
o A bullet-shaped filterable virus with strong affinity for the CNS
o Sensitive to sunlight, UV light, ether, formalin, mercury, and nitric acid
o Resistant to phenol, merthoilate and common antibacterial agents

INCUBATION PERIOD
1 Week 7 Months in Dogs
10 Days 15 Years in Humans
Depends on the following factors
1) Distance of the bite to the brain
2) Extensiveness of the bite
3) Species of the animal
4) Richness of the nerve supply
5) Resistant to host

PERIOD OF COMMUNICABILITY
The client is communicable 3 5 days
BEFORE the onset of the symptoms until the
entire course of illness

CLINICAL MANIFESTATIONS
(3 Phases)
1. Prodromal / Invasion Phase
o Fever, anorexia, malaise, sore throat,
copious salivation (microorganism
grows and multiplies in the salivary glands), Lacrimation, perspiration, irritability,
hyperexcitability, apprehensiveness, restlessness, drowsiness, mental depression,
melancholia and marked insomnia
o Pain / tingling sensation at original site and different body parts, HA, nausea
o Sensitive to light, sound and temperature
o Anesthesia, numbness, burning and cold sensations may be felt along the peripheral
nerves involved
o Mild difficulty in swallowing
2. Excitement or Neurological Phase
o Marked excitability apprehension and even terror may occur
o Delirium associated with Nuchal rigidity, involuntary twitching or generalized
convulsions
o Maniacal behavior, eyes are fixed and glossy, skin is cold and clammy
o Severe and painful spasms of the muscles of the mouth, pharynx and larynx on attempt to
swallow water or food or even the mere sight of them
(Amygdala Organ for emotion. Pain, fear, climax)
o Aerophobia / fear of air
3. Terminal / Paralytic Phase
o Client becomes quiet and unconscious
o Loss of bowel and urinary control
o Spasms cease with progressive paralysis
o Tachycardia, labored irregular respiration
o Death occurs due to respiratory paralysis, circulatory collapse / heart failure
DIAGNOSTIC PROCEDURES
1. Virus Isolation From clients saliva or throat
2. Fluorescent Rabies Antibody (FRA) Provides most definitive diagnosis
3. Negri Bodies Found in dogs brain

Incubation Period
1 week 8 months (Dog)
1 year 19 years (Man)
Types of Canine Rabies Viruses
1. Furious Type:
- Tame to wild
- Frantically runs biting anyone
- Salivation: Foaming, thick and
sticky
- Dog refuses to eat
- Restless
2. Dumb Type
- Depressed, dark and quiet
- Far away look
- Dropping jaw, hanging tongue
- Continuously salivating
- Rejects food
- Sudden death


MODALITIES OF TREATMENT
1. Wash wounds from bite and scratches with soap and running water for 3 minutes (As FIRST AID)
2. Immunization status (Tetanus Toxoid if needed)
3. Tetanus antiserum infiltrated around the wound or given IM after a negative (-) skin test
4. Anti-rabies vaccine
5. Prepare a Dakins Solution (Bleach)
a. Ethanol 70%
b. Povidone-Iodine

NURSING MANAGEMENT
1. Isolate the patient and LEASH the dog
2. Emotional and spiritual support to the client and the family to help them cope with clients
symptoms
3. Optimum comfort
4. Darken room and provide quiet environment
5. Client should not be bathed, no running water in the room, within the hearing distance of the
patient
6. If IV is given, wrap it!
7. Continuous monitoring of heart and respiration
8. Administer:
a. PCEC (Purified Chick Embryo Cell Vaccine)
b. PVRV (Purified Vero Cell Rabies Vaccine)

PREVENTION and CONTROL
1. Vaccination of all dogs
2. Pick-up and DESTRUCTION of stray dogs
3. 10 14 Day confinement of dog that bit a person
4. Availability of labs
5. Providing public education

NURSING DIAGNOSES and INTERVENTIONS
Nursing Diagnosis Nursing Interventions
Hyperthermia related to increased metabolic rate,
and increased body temperature as manifested by
complaints of headache and a low-grade fever
Assess VS, note for the value of temperature for
baseline comparison
Perform tepid sponge bath
Administer medications to treat underlying cause
(Antibiotics)
Administer replacement fluid and electrolytes to
support circulating volume and tissue perfusion
Maintain bed rest to reduce metabolic demands
and oxygen consumption
Categories of Exposure
Category I No vaccine needed
Feeding / touching an animal
(Wash with soap/water)
Licking of intact skin
(No vaccine needed / RIG)

Category II Contact
5 doses (Days)
0, 3, 14, 28 and 30
If S/Sx arise, STOP
medication

Category III
Give RIG
Same management as
Category II
Program Jointly Implemented
By:
Department of Agriculture
Department of Health
Department of Education,
Culture and Sports
Department of Interior and
Local Government and Non-
Government Organizations

REMEMBER: RA 9482

40

Monitor respirations (WOF: Respiratory
distress)
Acute pain related to biological agents as
manifested by verbal reports of pain in the
abdomen, chest, and changes in muscle tone
Assess clients level of pain (Pain scale)
Including PQRST of pain
Observe non-verbal cues and other objective
defining characteristics as noted
Monitor skin / color, temperature, check VS
which are usually altered in acute pain
Provide comfort measures:
- Providing quiet environment
- Darken the room
- Provide calm activities
Encourage relaxation techniques:
- Deep-breathing Exercises
- Listening to soft music
- Guided imagery
Administer analgesics as indicated to maintain
acceptable levels of pain
Encourage adequate rest periods to prevent
fatigue
Evaluate clients response to pain management
Impaired skin integrity Assess blood supply and sensation of affected
areas
Assess skin color, texture and turgor
Palpate skin lesions for size, shape, consistency,
texture, temperature and hydration
Determine degree / depth / injury damage to the
integumentary system
Monitor progress of wound healing
Keep the wound area clean, dry, and carefully
dress the wound
Apply appropriate dressing
Avoid use of plastic materials
Remove wet / wrinkled linens promptly


LEPTOSPIROSIS
(Weils Diseases/Canicola Fever/Hemorrhagic Jaundice/Mud Fever/Swine Herd Disease)
Zoonotic infectious bacterial diseases carried by animals, both domestic and wild
Water / Food is contaminated by the infected which causes diseases when ingested / inoculated
through the skin

ETIOLOGIC AGENT
- Leptospira interrogans Spirochete genus of Leptospira

INCUBATION PERIOD
- 6 15 DAYS

PERIOD OF COMMUNICABILITY
Leptospira Urine (10 20 Days after onset)

SOURCE OF INFECTION
Rats L. icterohaemorrhagiae, L. bataviae
Dogs L. canicola
Mice L. grippotyphosa

MODE OF TRANSMISSION
- Direct contact (Skin / mucous membranes) ANIMALS, Human transmission is RARE
Eyes, nose, mouth, semen / breaks in skin

CLINICAL MANIFESTATIONS
1. Septic Stage
Febrile (4 7 Days)
Abrupt onset of remittent fever, chills, HA, anorexia
Abdominal pain and severe prostration
Respiratory distress
2. Immune or Toxic Stage
With or without Jaundice (4 30 Days)
If SEVERE: Death occurs in 9
th
16
th
Day
1. Anicteric Phase (Without Jaundice)
Low-grade fever with rash
2. Icteric Phase (With Jaundice) Wet Syndrome
Hepatic and renal manifestations (Prominent)
o Oliguria / Anuria

42

LABORATORY DIAGNOSIS
1. BUN and Creatinine
2. Agglutination Test done after 2
nd
/3
rd
Week
a. Microagglutination
b. Macroagglutination
c. Indirect Hemoagglutination
3. Impaired liver and kidney Tests

ORGANS OF THE BODY INVADED BY THE ORGANISM
1. LIVER = After gaining entrance, it multiplies in the bloodstream and invades this organ
causing JAUNDICE (Icteric Gives an orange-colored skin)
2. KIDNEYS = Inflammation of the nephrons and tubular necrosis resulting in RENAL
FAILURE
3. Leptospira = May affect the muscles, causing PAIN and or EDEMA
4. EYES = Conjunctivitis, orange-colored sclera due to Icteric

TREATMENT (MANAGEMENT)
1. Medical
a. Suppression of causative agent
b. Fighting possible complications
1. Aetiotropic Drugs Penicillin, Doxycycline, Ampicillin, Amoxicillin
Doxycycline 100 mg PO q12 hrs (1 week)
2. Peritoneal Dialysis If client has kidney failure
3. Administration of F&E and blood as indicated
2. Nursing
a. Isolate (Proper disposition of urine)
b. Darken room (Irritating to clients eyes)
c. Skin care to ease pruritus No ointments on skin, except Calamine Lotion
d. Close surveillance
e. Keep homes clean
f. Eradicate rats and rodents
g. Health education on modes of transmission
h. Encourage OFI (Oral fluid intake)

PREVENTION and CONTROL
1. Sanitation in homes, workplaces and farms
2. Need for proper drainage system and control of rodents (40% - 60% infected)
3. Animals must be vaccinated (Cattle, dogs, cats and pigs)
4. Infected human and pets should be treated
5. Information dissemination campaign

NURSING DIAGNOSIS
Body image disturbance
High risk for injury
Anxiety
Altered nutrition: Less than body requirements
Impaired physical mobility
Impaired skin integrity
Knowledge deficit


Causative Agent:
Leptospira interrogans
Reservoir:
Animals (Rats, Dogs,
Cattle, Livestock)
Portal of Exit:
Urine of infected
Mode of Transmission:
Exposure to the urine
Portal of Entry:
Splashing in eyes
Swallowing of
contaminated water
Bite / Wound Breaks
Susceptible Host:
Man
CHAIN OF INFECTION
FOR LEPTOSPIROSIS

44

Respiratory Disorders
CHRONIC OBSTRUCTIVE PULMONARY
DISEASE (COPD)

COPD is Characterized By:
Airflow limitation that is not FULLY REVERSIBLE! :o
o ASTHMA IS SEPRATED FROM COPD because it is REVERSIBLE
RECURRENT OBSTRUCTION of airflow in the pulmonary airways
Obstruction is usually PROGRESSIVE and
May be accompanied by HYPERACTIVITY of GOBLET Cells / mucus secreting cells
Problem with lung recoil / chronic inflammation

Mechanism:
Involves multiple pathogenesis
Includes INFLAMMATION and FIBROSIS (Stiffening) of the bronchial wall, hypertrophy of the
submucosal glands and HYPERSECRETION of mucus
There is a LOSS OF ELASTIC FIBER and ALVEOLAR tissue

Pathophysiology of COPD

1.
2. Chronic Bronchitis
. Airway obstruction caused by INFLAMMATION of major or small airway
. Commonly seen on middle-aged men and associated with chronic irritation and recurrent
infections

Types of COPD
1. Emphysema
. Characterized by:
LOSS of lung elasticity and
Abnormal ENLARGEMENT of the air
spaces distal to the terminal bronchioles
with DESTRUCTION of alveolar wall and
capillary beds
. Etiology:
Smoking
Genetic: Absence of Alpha
1
anti-trypsin
Responsible for synthesis of ELASTIC
FIBER

PATHOPHYSIOLOGY of Emphysema

. Etiology or Risk Factors:
Smoking, Gender, Age
Viral / bacterial cause
History of recurrent RTI
Exposure to irritants
. Medical Management
Depends on the stage of the disease
Administration of PHARMACOLOGIC TREATMENTS
1. Bronchodilators
2. Adrenergic Drugs
3. Anticholinergics Drugs
4. Theophylline
5. Corticosteroids
Administer Corticosteroids (Prednisone)
Administer Antibiotics (INFECTIONS)
Lung resection for distended areas of the lungs

LETS DIFFERENTIATE EMPHYSEMA and CHRONIC BRONCHITIS
Characteristics Emphysema (Pink Puffer) Chronic Bronchitis (Blue Bloater)
Smoking Usual Usual
Age of Onset 40 50 30 40
Barrel Chest After Maybe present
Weight Loss May be severe / advanced stage Infrequent
SOB Absent in early stage Predominant early sign!!
Breath Sounds Characteristic (Alveolar wall distention) Variable
Wheezing ABSENT Variable
Rhonchi Absent/minimal Other prominent
Sputum May be absent / may develop Frequent early manifestation!!
Cyanosis Advanced stage Often dramatic
Blood Gases Relatively normal until later in the disease Hypercapnia!
Cor Pulmonale Only in advanced stages Frequent in peripheral edema
Polycythemia Advanced cases Frequent
Prognosis Slowly debilitating case Life-threatening due to acute exacerbation
IRREVERSIBLE IRREVERSIBLE

46

Nursing Process
Assessment
Health History
o Exposure to risk factors (Intensity and durations)
o Past Medical history (Past respiratory problems/diseases)
o Family history of COPD / other Respiratory diseases
o History of exacerbations
o Current medical treatment

Nursing Diagnoses and Interventions with Planning
Impaired gas exchange related to decreased ventilation and mucus plugs
o Outcomes: The client will maintain adequate gas exchange evidenced by normal ABG
values
o Interventions:
Monitor respiratory rate, pulse oximetry, ABG and manifestations of
hypoxia/hypercapnia
Administer low-flow O
2
therapy (1 3 L/min)
Position client: High-fowlers position
Administer medications: Bronchodilators as needed
Ineffective airway clearance related to excessive secretions and ineffective coughing
o Outcomes: The client will have improved airway clearance as evidenced by effecting
coughing techniques and a patent airway
o Interventions:
Monitor lung sounds q 4 8 hours before and after coughing episodes
Encourage drinking 8 10 glasses of water per day
Encourage coughing exercises
Teach on how to use incentive spirometry 10 times per hour
Teach/perform CPT
Assess condition of oral mucous membranes
Give oral care q 2 hours
Anxiety related to breathing difficulties and fear of suffocation
o Outcomes: The client will express an increase in psychological comfort and demonstrate
use of effective coping mechanisms
o Interventions
Remain with client
Provide quiet, calm environment
Give adequate space during acute episodes (Limit external stimuli)
Encourage breathing exercises and relaxation techniques
Give sedatives / tranquilizers as needed
Activity intolerance related to inadequate oxygenation and dyspnea
o Outcomes: The client will have improved activity intolerance as evidenced by
maintaining a realistic activity level
o Interventions:
Monitor dyspnea and O2 saturation
Stop / slow activities that change respiratory rate
Maintain O2 therapy as needed during activity
Schedule active exercises after respiratory treatment
Avoid activities that increase O2 demand
Teach on how to do pursed-lip breathing and diaphragmatic breathing
techniques
Imbalanced nutrition: less than body requirements related to reduced appetite, decreased energy
level and dyspnea
o Outcomes: The client will eat 75% of served foods during the acute phase and maintain
body weight within normal limits and lab values will be within normal values

o Interventions:
Give oral care before meals as needed
Advise to eat small, frequent meals (High in CHON and Low in CHO)
Advise to avoid gas-producing foods (Beans & Cabbage)
Instruct in the use of high calorie liquid supplements
Advise to use oxygen via nasal cannula during meals
Suggest methods to make meal preparations more convenient
Collaborate with dietitian to assist for food choices
Monitor food intake, weight and serum hemoglobin
Disturbed sleep pattern related to dyspnea and external stimuli
o Outcomes: The client will report feeling adequately rested
o Interventions:
Promote relaxation by providing a darkened, quiet environment; adequate room
ventilation
Schedule care activities
Avoid use of sleeping pills
Interrupted family processes related to chronic illness of a family member
o Outcomes: The family will verbalize their feelings, participate in the care of the ill family
member, and seek external resources as needed
o Interventions:
Encourage patient in participation of planning process
Assess family communication patterns
Encourage social support networks

PNEUMONIA
- It is an inflammation of the lung parenchyma caused by various microorganisms
- Classifications of Pneumonia
o Community Acquired Pneumonia
o Hospital Acquired Pneumonia
o Aspiration Pneumonia
- It may develop as a primary acute infection / secondary to another respiratory / systemic condition

Community Acquired Pneumonia
Occurs in community setting or within the 1
st
48 HOURS after hospitalization
Commonly causative factors are as follows:
1. S. Pneumoniae
2. H. Influenzae
3. Legionella
4. Pseudomonas Aeruginosa
5. Other gram negative rods

Hospital Acquired Pneumonia
Nosocomial infection
Defined as the onset of pneumonia symptoms more than 48 HOURS after
admission in clients without evidence of infection at the right time of admission
Client in the hospital are exposed to potential bacterial invasion

Aspiration Pneumonia
Refers to the pulmonary consequences resulting from entry of endogenous /
exogenous substances into the lower airway

RISK FACTORS
Client with mucous / bronchial obstruction
Smoking

48

Immunocompromised clients
Prolonged immobility
Depressed cough reflex
Incompetent epiglottis
Client with NGT, ET Tube, use of suction machine
Advanced age
Improper isolation technique
Systemic infection

PATHOPHYSIOLOGY (OLD)

C
o
u
g
h
C
r
a
c
k
l
e
s

DIAGNOSTIC PROCEDURES
- Chest X-Ray
- Sputum / Blood Cultures
- Physical Examination

Types of Pneumonia
Involving Different Parts of the Lungs
Segmental Pneumonia: One or more lobe segments
Lobar Pneumonia: One or more entire lobes
Bilateral Pneumonia: Lobes in both lungs
Based on Location and Radiologic Appearance
Bronchopneumonia (Bronchial Pneumonia): Terminal bronchioles and
alveoli
Interstitial Pneumonia (Reticular Pneumonia): Inflammatory responses
within lung tissue surrounding air spaces / vascular structures
Alveolar Pneumonia (Acinar Pneumonia): Fluid accumulation in lungs
distal air spaces
Necrotizing Pneumonia: Death of a portion of lung tissue

Medical Management
Pharmacologic Management
Antibiotic / Anti-infectives
Mucolytics
Antipyretic
Nasal Decongestants
Antihistamines

Nursing Management
- Assess for SYMPTOMS such as:
o Fever
o Chills
o Night Sweats
o Respiratory Function Use of accessory muscles
o Pleuritic-type pain
o Fatigue
o Coughing and Purulent Sputum
RUSTY COLORED SPUTUM
Productive COUGH
- Conduct respiratory assessment (q4 Hours)
- For elderly, assess for mental status, dehydration, excessive fatigue and heart failure
- For clients with methicillin resistance Methicillin Sensitive Staphylococcus Aureus
(MRSA) Isolated in room, contact precaution

Nursing Responsibility
- When transporting, clients must apply appropriate precaution
- For VIRAL PNEUMONIA Support Management
- Provide Health Education on prevention of pneumonia Vaccine for elderly clients
o Pneumococcal Vaccine (65 Years Old)

50

Nursing Process:
Nursing Diagnoses and Interventions
Ineffective airway clearance related to copious tracheobronchial secretions
= Suction clients secretion as needed
= Encourage water intake (2 3 L/day)
= Humidified oxygen may help loosen secretions
= Encourage coughing exercises, deep breathing exercises and diaphragmatic exercises
= Teach client or significant other about chest physiotherapy
Sputum retention not responding to coughing
History of pulmonary problems
Continued evidence of retained secretions
Abnormal chest x-rays
= Administer and titrate oxygen as prescribed
Activity intolerance related to impaired respiratory function
= Encourage patient to rest and avoid overexertion
= Position client for comfort (Semi-fowler)
= Change position frequently
= Encourage moderate activity only
Risk for deficient fluid volume related to fever and a rapid respiratory rate
= Encourage intake of fluids at least 2 L/day unless contraindicated
Imbalanced nutrition: less than body requirements
= If decreased appetite, give liquids (With calories and electrolytes)
= Assist with administering IVF
Deficient knowledge about the treatment regimen and preventive health measures
= Explain cause, management, signs and symptoms and follow-up for pneumonia
= Remember to give simple explanations
= Give written instructions if possibl

Planning and Evaluation
After ____ of nursing intervention, the client will have
Improved airway patency
Rest to conserve energy
Maintenance of proper fluid volume
Maintenance of adequate nutrition
An understanding of the treatment protocol and preventive measures
Absence of complications

PULMONARY TUBERCULOSIS
Pulmonary Tuberculosis
- Infection caused by mycobacterium tuberculosis
- Closely associated with poverty, malnutrition, overcrowding, substandard housing and inadequate
health care
- Airborne transmission

- Low grade fever
- Cough
- Night Sweats
- Fatigue
- Weight loss
- Hemoptysis

Medical Management
Pharmacologic Management
(Administer for 6 12 months)
Rifampicin
Pyrazinamide
Isoniazid
Ethambutol


PATHOPHYSIOLOGY (OLD)

Nursing Responsibility (NO TO CPT)
Perform complete history taking
Performs assessment of respiratory function
Assess for associated symptoms
Palpate for any enlarged lymph nodes
Administer anti-tuberculosis medications
Provides health education on the different effects of medication

ANTI-TUBERCULAR MEDICATIONS
- Contraindicated to clients with LIVER DISEASE (Hepatotoxic Medications!!)
- Single Drug Therapy combined with Isoniazid
- Multi-drug Therapy

NURSING ALERT!!
Aminoglycosides May cause ototoxicity and nephrotoxicity
Factors to consider are the AGE, RENAL FUNCTION and DRUG DOSE
Careful drug dosing is important when administering to younger and older clients
Isoniazid Peripheral Neuropathy are common to clients who are malnourished; diabetic and
alcoholic
Hyperglycemia, Hyperkalemia, Hypophosphatemia and Hypocalcemia
Hepatotoxicity is an adverse reaction of Isoniazid, Rifampicin and Streptomycin
Clients taking in Isoniazid, Rifampicin and Streptomycin may develop:
Head aches
Blood dyscrasias
Paresthesia
GI Distress (Tell client to take drug on an empty stomach, or 1 hour AC) and;
Ocular toxicity

Nursing Responsibility
- Educate the client taking Rifampicin that it turns their body fluids color ORANGE; soft contact
lenses may be permanently discolored
- Clients taking Ethambutol may develop dizziness, confusion, hallucinations and joint pain

52

NURSING ALERT!!
Streptomycin may lead to many adverse reactions Ototoxicity, optic nerve toxicity,
encephalopathy, angioedema, CNS and respiratory depression, nephrotoxicity and hepatotoxicity
Isoniazid
NO TO FOOD RICH IN TYRAMINE and HISTAMINE (Tuna, Red wine, Soy Sauce,
Yeast Extract, Aged Cheese) it may result to HYPOTENSION: Head ache, flushing, light
headedness, palpitations and dizziness
WOF Drug to drug interaction
Rifampin
Can increase metabolism of other medications (Beta-blockers, oral anticoagulants
(Warfarin), digoxin, quinidine, corticosteroids, oral hypoglycemic agents, oral
contraceptives, theophylline and verapamil

- Ineffective airway clearance related to copious tracheobronchial secretions
- Knowledge deficit about treatment regimen and preventive health measures and related ineffective
individual health management of the therapeutic regimen (non compliance)
- Activity intolerance related to fatigue, altered nutritional status and fever

Plan of Care
- To promote patent airway
- To gain, acquire knowledge regarding the management of tuberculosis
- To promote adequate nutrition
- To prevent the spread of infection

- Promote airway clearance
- Advocating to treatment regimen
- Promoting adequate nutrition
- Health education on the different side effects of medication therapy

Nursing Responsibilities
Encourage to increase oral fluid intake
Increase caloric intake
During active phase, isolate the client and correctly explain the rationale to the client
Administer due meds
Monitor for any side effects
Reinforce the implication of regimen
Position client in high fowlers position
Encourage to eat food rich in Vitamin C
Instruct client to avoid going to crowded places

Evaluation
- Maintained patent airway
- Demonstrated adequate knowledge
- Adherence to medication therapy

Crohns Disease + Diabetes Mellitus
CROHNS DISEASE

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