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A. Myasthenia gravis

Definiton: -is an autoimmuneneuromuscular disease leading to fluctuating muscle

weakness and fatiguability
- It is an autoimmune disorder, in which weakness is caused by
circulating antibodies that block acetylcholine receptors at the post-
synaptic neuromuscular junction, inhibiting the stimulative effect of
the neurotransmitter acetylcholine.

Predisposing Factors: -most commonly affects young adult women (under 40) and older men (over 60)

Etiologic agent: -autoimmune

Clinical Manifestation: Swallowing difficulty, frequent gagging, or choking

Muscles that function best after rest
Drooping head
Difficulty climbing stairs
Difficulty lifting objects
Need to use hands to rise from sitting positions
Difficulty talking
Difficulty chewing
Double vision
Difficulty maintaining steady gaze
Eyelid drooping

Clinical Management: -Pyridostigmine (Mestinon) is the usual first line treatment for MG.
-Prednisone and Cyclosporine A are used for long-term immunosuppression
when further benefit is needed and relatively rapid onset of benefit is desired.
Prednisone is the most effective treatment for ocular MG.
-Azathioprine provides long-term immunosuppression with relatively few side
effects. However, it has a long latency before benefit begins, and some patients
do not improve at all.
-Mycophenolate mofetil may be a useful substitute for azathioprine with fewer
side effects and a shorter latency of action. More experience is required.
-Plasma exchange (PE) and Human immune globulin are used when MG
patients have life-threatening signs such as respiratory insufficiency or dysphagia
and a very rapid response to treatment is desired. PE is preferred.
-Thymectomy is performed for long-term benefit in patients age
d 8 to 55 with generalized MG.

Nursing Mgt: - Encourage the patient to keep a 24-hour fatigue/activity log for at
least 1 week.
- assist the patient to develop a schedule for daily activity and rest.
- refer the patient to an occupational therapist
- Monitor the patient’s nutritional intake for adequate energy sources
and metabolic requirements.

Prognosis: -The outlook for most patients with myasthenia gravis is bright: they will have
significant improvement of their muscle weakness and they can expect to lead
normal or nearly normal lives. In a few cases, the severe weakness of
myasthenia gravis may cause a crisis (respiratory failure), which requires
immediate emergency medical care. In some cases, however, symptoms may
worsen even with vigorous treatment, leading to generalized weakness and
disability. myasthenia gravis rarely causes early death except from myasthenic

Possible Nursing Dx: -Activity Intolerance related to muscle weakness and fatigability,
-Constipation related to inadequate fluid intake and low fiber diet
-Disturbed sensory (visual) perception related to ptosis
-Fear related to anticipation of disease
-Compromised family coping related to overwhelming
- Risk for aspiration related to impaired swallowing
- Risk for falls related to visual difficulties and impaired physical
-Risk for peripheral neurovascular dysfunction related to vascular
B. Upper Gastrointestinal Bleeding

Definiton: -refers to hemorrhage in the upper gastrointestinal tract

-is a potentially life-threatening abdominal emergency that remains a common
cause of hospitalization.

Predisposing Factors: -Alcohol abuse

-Chronic renal failure
-Non-steroidal anti-inflammatory use
-Low socio-economic class

Etiologic agent: -Peptic ulcers

-Esophageal varices
-Mallory-Weiss tears

Clinical Manifestation: -Paroxysmal Shivering

-Rigors/Shaking chills
-Capillary Refill Time/CRT Abnormal
-Low Blood Pressure
-Signs of Poor Perfusion
-Sudden pallor
-Black vomit
-Blood in stool
-Coffee ground vomitus
-Dark/Black stool
-Flatus/gas foul smelling
-Foul stool

Clinical Management: -Proton pump inhibitors (PPIs), which reduce gastric acid production and
accelerate healing of certain gastric, duodenal and esophageal sources of
-Octreotide is a somatostatin analog believed to shunt blood away from the
splanchnic circulation.
-Terlipressin is a vasopressin analog
-Antibiotics are prescribed in upper GI bleeds

Nursing Mgt: -Increase fluid intake

- avoid caffeinated beverages and acidic foods
-administer medications.

Prognosis: - self-limiting in more than 80% of cases: the body is able to stop the bleeding on
its own. Patients who continue to bleed or who have symptoms of a sudden loss
of a large amount of blood usually are hospitalized and often are admitted to an
intensive care unit.

Possible Nursing Dx: -Fluid Volume deficient

-risk for ineffective
-Pain, acute/chronic
-Knowledge deficient regarding disease process, prognosis,
treatment, self-care, and discharge needs.
C. Thyroid Storm

Definiton: -also referred to as thyrotoxic crisis, is an acute, life-threatening, hypermetabolic

state induced by excessive release of thyroid hormones (THs) in individuals with

Predisposing Factors: -Infection: lung infection, throat infection or pneumonia

-Blood sugar changes: Diabetic ketoacidosis, insulin-induced hypoglycemia
-Recent surgery to the thyroid
-Abrupt withdrawal of antithyroid medications
-Radioactive iodine (RAI) treatment of the thyroid
-Excessive palpation (handling/manipulation) of the thyroid
-Severe emotional stress
-An overdose of thyroid hormone
-Toxemia of pregnancy and labor

Etiologic agent: - untreated hyperthyroidism

Clinical Manifestation: -High fever of 100 to as high as 106

-A high heart rate that can be as high as 200 beats per minute
-Palpitations, chest pain, shortness of breath
-High blood pressure
-Confusion, delirium and even psychosis
-Extreme weakness and fatigue
-Extreme restlessness, nervousness, mood swings
-Exaggerated reflexes
-Difficulty breathing
-Nausea, vomiting, diarrhea
-Recent dramatic weight loss may have taken place recently
-Profuse sweating, dehydration
-Stupor or coma

Clinical Management: -first priority should be to ensure adequate oxygenation

-IV and a nasogastric tube so that you can administer antithyroid medications.
-The mainstay of treatment for TS is drug therapy with antithyroid thioamide
medications, also called thioureas.

Nursing Mgt: -Assess the patient

-ask questions concerning about the weight, appetite, and activity, -heat
tolerance, and bowel activity
-Ask about mood alterations, irritability, decreased attention span, and manic
-hemodynamic monitoring
-may need to assist with pulmonary artery catheter insertion
-measure cardiac output, pulmonary artery pressure, and other cardiac

Prognosis: - With adequate thyroid-suppressive therapy and sympathetic blockade, clinical

improvement should occur within 24 hours. Adequate therapy should resolve
the crisis within a week. Treatment for adults has reduced mortality to less than

Possible Nursing Dx: -Imbalanced Nutrition: Less than body requirements

-Activity Intolerance
-Risk for Injury and Impaired Social Interaction.
D.Sheehan’s Syndrome

Definiton: - also known as postpartum hypopituitarism or postpartum pituitary necrosis,

is hypopituitarism (decreased functioning of thepituitary gland)
- condition in which hypopituitarism develops after severe bleeding ('Postpartum
hemorrhage') during or immediately afterchildbirth .

Predisposing Factors: Estrogen therapy, oral contraceptives, pregnancy may increase

Etiologic agent: -Invasion (pituitary tumors, CNS tumors, carotid aneurysm), Infarction
(postpartum necrosis, pituitary apoplexy),
- Infiltration (sarcoidosis, hemochromatosis), Injury (head trauma, child abuse),
-Immunologic (lymphocytic, hypophysitis), Iatrogenic (surgery, radiation, therapy)
- Infectious (mycoses, tuberculosis, syphilis)
-Idiopathic (familial)
-Isolated (deficiency of an anterior pituitary hormone such as growth hormone,
LH, ESH, thyroid-stimulating hormone)

Clinical Manifestation: Inability to breast-feed (breast milk never "comes in")

Lack of menstrual bleeding
Loss of pubic and axillary hair
Low blood pressure

Clinical Management: - Treatment is essentially by replacing the hormones that the pituitary gland fails
to produce. Hormones like corticosteroids, thyroid hormones and estrogens
- Treatment involves estrogen and progesterone hormone replacement therapy,
which must be taken for the rest of your life. Thyroid and adrenal hormones also
must be taken.

Nursing Mgt: -Maintain or restore circulating volume/tissue perfusion.

-Prevent complications.
-Provide information and appropriate support for client/couple.
-Have plan in place to meet needs after discharge

Prognosis: - The outlook with early diagnosis and treatment is excellent.

Possible Nursing Dx: -fluid volume deficit related to excessive vascular loss
-altered tissue perfusion related to hypovolemia
-mild anxiety related to situational crisis
-risk for infection related to traumatized tissue
-risk for pain related to tissue trauma
-knowledge deficit related to unfamiliar resources
1. Explain the pathophysiology of a decreasing clotting factor of a patient with
dengue hemorrhagic fever
Dengue virus infection induces transient immune aberrant activation of CD4/CD8 ratio inversion and cytokine
overproduction, and infection of endothelial cells and hepatocytes causes apoptosis and dysfunction of these
cells. The coagulation and fibrinolysis systems are also activated after dengue virus infection. We propose a
new hypothesis for the immunopathogenesis for dengue virus infection. The aberrant immune responses not
only impair the immune response to clear the virus, but also result in overproduction of cytokines that affect
monocytes, endothelial cells, and hepatocytes. Platelets are destroyed by crossreactive anti-platelet
autoantibodies. Dengue-virus-induced vasculopathy and coagulopathy must be involved in the pathogenesis
of hemorrhage, and the unbalance between coagulation and fibrinolysis activation increases the likelihood of
severe hemorrhage in DHF/DSS. Hemostasis is maintained unless the dysregulation of coagulation and
fibrinolysis persists. The overproduced IL-6 might play a crucial role in the enhanced production of anti-
platelet or anti-endothelial cell autoantibodies, elevated levels of tPA, as well as a deficiency in coagulation.
Capillary leakage is triggered by the dengue virus itself or by antibodies to its antigens. This
immunopathogenesis of DHF/DSS can account for specific characteristics of clinical, pathologic, and
epidemiological observations in dengue virus infection.

2. What is the explanation of bradycardia to patient with hemorrhagic fever ?

Dengue hemorrhagic fever obviously manifest fever rising quickly as high as 104 F (40 C), the heart rate then
is inappropriately slow for the degree of fever which causes bradycardia.

3. Discuss the management of geriatric patients

 Determine the length of time care in the home of the geriatric person is going to be needed. For example,
an elderly person may only need short term care if he is recovering from an illness or accident; in cases
where there is chronic illness or disability, long term care may be required.

 Convene a family meeting with the senior in order to plan and prepare for care at home. Gain input from
everyone in terms of how the needs of the elderly person will be met. In some cases a primary care giver
will be selected from the family with the others acting in a supporting role. The family may also need to
decide if a full or part-time nurse or aide will be needed.

 Gather important information from the geriatric patient to facilitate situations in which the data may be
needed. Keep a log with the patient's social security number, health insurance information, list of
medications, names and phone numbers of physicians and pharmacies.

 Keep a record of all doctor and therapy visits. Log the date of each visit, what was accomplished, any
new prescriptions and follow-up appointment information. Keep all x-rays and test results in this record as

 Set up the house to facilitate geriatric care. Depending on the situation you may need to install a
wheelchair ramp, a hospital bed, oxygen tanks or bathroom safety products such as a shower chair. Ask
medical professionals for recommendations to what might be needed.

 Gain knowledge regarding all the geriatric person's health problems so you can give them the best care
possible. This information can be helpful in letting you know what to expect with certain conditions, and it
can clue you in to current research and new medications which may be available.

 Take a look at financial resources. Determine what funds the elderly person has available for medical
care and what the family in general can contribute. You may need to seek out financial help from
community resources. Schedule an appointment with your local social service office to find out what is
 Communicate extensively with the geriatric patient. It is common for caregivers to forget the patient has
her own opinions and ideas. This can happen due to the focus on meeting physical needs. Remember
that the senior's mental and emotional health is essential to her well being.