Ca1: Medical-Surgical Nursing: "O Lord Grant Us Success." - Psalm 118:25

 Leslie S. Anicete  CA1: MEDICAL-SURGICAL NURSING “O Lord grant us success.
” – Psalm 118:25
☺ INFLAMMATION ☺ There is less new collagen formation but NURSING INTERVENTIONS
increased organization of the collagen fibers and Proper position (fowlers).
“Inflammatio”
stronger bonds between them. Provide rest.
Part of the complex biological response of body
Tension becomes important because new Monitor VS.
tissues to harmful stimuli, such as pathogens,
collagen must orient along the lines of stress to Monitor LOC.
damaged cells or irritants and is a protective
best accommodate the loads required for Monitor I&O
response involving immune cells, blood vessels and
function. Increase fluid intake.
molecular mediators.
PURPOSE The end of tissues remodeling is unknown and Hot and cold modalities.
may take months to years for completion. DRUGS
Eliminate the initial cause of cell injury.
PATHOPHYSIOLOGY NSAIDS
Clear-out necrotic cells and tissues damaged from
Disruption of tissue integrity SURGERY
the original insult and the inflammatory process and
*Injury DISARTICULATION – Cutting of joint
to initiate tissue repair.
CAUSE *Ischemic damage Incision and drainage – NSS
PHYSICAL *Immune reaction AMPUTATION – cutting of the bone
INFLAMMATORY RESPONSE THORACENTESIS – Pleural
Burns
VASCULAR CHANGES PERICARDIOCENTESIS – removal of fluid in the
Frostbite
Vasodilation heart.
Physical injury blunt or penetrating.
Capillary permeability PARACENTSIS – removal of fluid in the abdomen.
Foreign bodies, including splinters, dirt and debris.
Blood flow DEBRIDEMENT
Trauma
Ionizing radiation
Local tissue congestion ☺ PAIN ☺
CELLULAR CHANGES
BIOLOGICAL An unpleasant sensory and emotionally “suffering”.
Phagocytosis
Infection by pathogens Universal, complex experience.
Leukocytes
Immune reaction due to hypersensitivity. Warning.
Release of chemical mediators
Stress Cardinal sign of inflammation.
BODY RESPONSE
CHEMICAL 5th vital signs – assess is the patient is having pain.
LOCAL EFFECTS
Chemical irritants TYPES OF PAIN
Redness
Toxins Onset
Warmth
Alcohol Intensity
PHYSIOLOGICAL Swelling
Duration
Pain
Embarrassment SOURCE
Loss of function
Excitement Nociceptive pain
SYSTEMATIC EFFECTS
STAGES Visceral pain
Fever
PHASE 1: INFLAMMATORY RESPONSE Somatic pain – superficial “cutaneous pain”; deep
Leukocytosis
Healing of acute injury beginning with the acute somatic pain.
Malaise
vascular inflammatory response. ACUTE PAIN
Anorexia
The purpose of vascular changes is to increase Results from acute injury, disease or surgery, usually
Sepsis
blood flow to the local area, mobilize and transport temporary, sudden onset and easily localized (post-
STAGES
cells to the area to initiate healing. op, trauma, burns, procedural obstetric, tooth
VASCULAR RESPONSE
The damaged cells are removed and the body extraction, blood extraction, hemodialysis).
CELLULAR RESPONSE
begins to put new collagen in the area of injury. Acts of warning signals (activates “fight or flight”
1. Fluid exudation
This phase is initiated immediately after injury and reaction).
a. Margination
lasts 3 -5 days. Increase HR, BP, RR, mydriasis sweating.
SIGN & SYMPTOMS b. Emigration – exit WBC
CHRONIC PAIN
c. Chemotaxis – WBC attracted to injured cells.
Pain Slow onset - > 6mos.
d. Phagocytosis
Warmth Chronic cancer pain/ malignant:
REPARATIVE RESPONSE
Swelling Tumor – cause pain in nerve endings.
a. Regeneration – cells
Palpable tenderness Metastasis – spread to distant organ; neighboring
b. Scar formation – fibrous
Limitation in joint or muscle range of motion. tissue; lymphnodes.
TYPES OF EXUDATES
TREATMENT Nonceptive visceral
CATARRHAL/MUCOID
Decrease pain and swelling Effects of drugs – chemotherapy; radiotherapy;
Allergic rhinitis
Prevent chronic inflammation administer slowly.
SEROUS
Maintain immobility Tumor cause obstruction – stage 1 painless; tumor is
Serum/ clear
Strength in adjacent. too small.
SANGUINEOUS
PHASE 2: REPAIR & REGENERATION Chronic non-cancer pain/ non-malignant:
Pink – red
Characterized by new collagen formation. Low back pain; arthritis
Increase RBC
New collagen fibers are laid down is disorganized PAIN PATHWAY
Hemothorax
manner in the form of a scar and there are weak NOCICEPTIVE PAIN
PURULENT
links between cach fiber. Point of cellular injury (Noxious stimuli)  (release
Green
New tissue is weak and susceptible to disruption by mediators)  peripheral nerve sensory  spinal
Thick
overly aggressive activity. cord  thalamus  cerebral cortex  parietal lobe
Foul smell
This phase lasts from 2 days – 8 wks. SUBDIVIDED: Somatic & Visceral pain
Dead cell
SIGN & SYMPTOMS SOMATIC PAIN
Less warmth & swelling Dead WBC (Phagocytosis)
Caused by:
Palpable tenderness decreases. Eosinophils – allergy Mechanical, chemical, thermal, electrical injuries, d/o
Pain felt with tissue resistance or stretch of the PLEURISY: affecting bones, joints, muscle, skin.
tissue. Inflammation of the lungs. SUPERFICIAL “CUTANEOUS” SOMATIC PAIN
TREATMENT Pleural effusion Ex: insect bite, paper cut ”sharp” or “burning”
Range of motion exercises Floral fluid (15-50ml) – lubricant discomfort.
Joint mobilization DIAGNOSTIC EXAM DEEP SOMATIC PAIN
Scar mobilization to produce a mobile scar. X-ray Ex: trauma (fracture)
Light loads to promote tissue remodel. CBC Localized sharp, throbbing and intense sensations.
PHASE 3: REMODELLING AND MATURATION (Pyuria-puss) NEUROPATHIC PAIN
As healing progress, the tissue continuous to urinalysis Results from damage to the pain pathways or pain
remodel, strengthen and improve its cellular processing centers in the brain.
organization.
“I can do all things through Christ who strengthens me.” – Philippians 4:13 1 | 26
 Leslie S. Anicete  CA1: MEDICAL-SURGICAL NURSING “O Lord grant us success.” – Psalm 118:25
Ex: phantom limb pain, spinal cord injuries, stroke, PHANTOM PAIN – painful perception perceived PHYSICAL MEASURES/NON-DRUG
diabetes, herpes zoster. in a missing body part or in a body part INTERVENTIONS
Description of nerve pain: paralyzed from a spinal cord injury. Cutaneous stimulation:
Burning PHANTOM SENSATION – feeling that missing TENS (Transcutaneous electrical nerve stimulation)
Stabbing body part is still present. PENS (Percutaneous electrical nerve stimulation)
Electric shock-like HYPERALGESIA – excessive sensitivity to pain. A combination of acupuncture needles with TENS.
Description of muscle pain: PAIN THRESHOLD “PAIN SENSATION” – the 30 mins 3x a week for 3 weeks.
Tenderness amount of pain stimulation a person requires in Thermal therapy (hot & cold)
Itchiness order to feel pain. Therapeutic touch – Massage; vibration
Stiffness PAIN TOLERANCE – maximum amount and COGNITIVE-BEHAVIORAL MEASURES
Physiological dimensions of pain: duration of pain, that an individual is willing to Effectiveness of these measures reflect the
Transduction endure. premises of the gate control theory.
Transmission NOCICEPTORS – pain receptors. Distraction
Perception PAIN PERCEPTION – the point which the Relaxation
Modulation person becomes aware of the pain. Music therapy
TRANSDUCTION DRUG THERAPY Aromatherapy
Conversion of chemical information to electrical Gold standard form of pain control. Prayer and meditation.
impulses. 3 groups of medication: INVASIVE TECHNIQUES
Chemical mediators: Prostaglandin, bradykinin, Non-opioids/ non-narcotic analgesics Intractable pain, severely debilitating
histamine, subsP Opioids/ narcotics Used when chronic or persistent pain can no longer
Stimulates free nerve endings “nociceptors”. Adjuvants – potentiators or enhancer. be adequately controlled with drugs or other pain-
Impulses are carried by nerve fibers, A-deltafibers W.H.O ANALGESIC LADDER reducing methods.
and C-fibers. MILD – MODERATE PAIN Nerve block – temporary, ablation.
TRANSMISSION Lasting 3 -4 hrs. Spinal cord stimulation
Peripheral nerve fibers form synapses with neurons Start with low doses of non-opioid drugs. Surgical procedures
in the spinal cord. INTERMEDIATE PAIN ☺ FLUID & ELECTROLYTES ☺
It will ascend to RAS, limbic system, thalamus, Pain not well controlled with non-opioid.
FLUIDS
cerebral cortex. Combine non-opioid with low dose of opioid.
50 – 70% of body weight is water.
PERCEPTION SEVERE PAIN
60% average.
Pain threshold: Add a higher dose of opioid to the non-opioid, or
LOCATION
The point at which the pain-transmitting use a drug that potentiates its analgesics effect
Intracellular (within the cells) – 40% fluid
neurochemicals reach the brain, causing conscious like antihistamine.
Extracellular (outside the cells) – 20% fluid
awareness (same among healthy persons). NON-OPIOIDS/ NON-NARCOTIC
Interstitial – 15% fluid
Pain tolerance: ANALGESICS
Intravascular – 5% fluid
Amount of pain a person endures once the threshold Mild to moderate pain.
transcellular fluid – CSF, pleural, peritoneal, synovial
has been reaches. Relieve pain by altering neurotransmission at the
fluids.
MODULATION peripheral level (site of injury).
Last phase of pain impulse transmission, during ASA, acetaminophen, NSAIDS – ketorolac, The volume of fluid in each location varies with age
which the brain interacts with the spinal cord. parecoxib, celecoxib. & sex.
THEORETICAL BASES FOR PAIN OPIOIDS/ NARCOTICS Infants have higher fluid turn-over due to immature
GATE CONTROL THEORY Mainstay in the management of all types of pain. kidney and rapid RR water content of the body
Explains the relationship between pain and emotion. Work centrally by blocking the release of decreases with age.
Results to a conclusion that pain is not just a neurotransmitters in the spinal cord. Infants have higher proportion of body water than
physiologic response, that psychological variables Morphine, Nubain, tramadol, meperidine adults.
(behaviors & emotions) also influence the perception (Demerol)/ PERCENT OF WATER IN HUMAN BODY
of pain. Antidotes: Naloxone (Narcan) Fetus – 100%
In this theory: “a gating mechanism” occurs in the ADJUVANTS Baby at birth – 80%
spinal cord. Potentiators or enhancers. Normal adult – 70%
Similar gating mechanisms exist in the nerve fibers Antihistamines, antiemetic, sedative agent + Elderly person – 50%
descending form the thalamus and cerebral cortex Demerol =enhanced opioids effects. FLUID INTAKE
(areas that regulates thoughts and emotions, beliefs PATIENTS-CONTROLLED ANALGESICS Average oral fluid intake in a healthy adult
and values). (PCA) 2,500ml/day (1,500 – 3,000ml/day)
When pain occurs, a person’s thoughts and Allows client to self-administer their own narcotic DAILY FLUID INTAKE
emotions can modify perceptual phenomena as they analgesic by means of an intravenous pump Standard formula
reach the LOC awareness. system. x 100ml/ kg for the 1st 10kg of weight +
Significance of gate control theory: Dose and time intervals between doses are x 50ml/ kg for the next 10kg of weight +
Recognition of holistic nature of pain. programmed into the device to prevent x 15ml/ kg per remaining kg of weight +
Development of many cognitive = behavioral accidental over dosage. SOURCES OF BODY FLUIDS
therapies (imagery & distraction) to relieve pain. INTRASPINAL ANALGESIA Liquids
CNS PROCESSING Infused into the subarachnoid or epidural space Food
THALAMUS: of the spinal cord through a catheter inserted by Other sources: IVF, TPN, blood products.
Relay station for sensory input from spinothalamic a physician. FLUID OUTPUTS
tract of spinal cord. Nurses do not administer intraspinal analgesia. Average fluid loss amounts to 2,500ml/day counter
MIDBRAIN: NURSING MANAGEMENT (MEDICATIONS) balancing the input to maintain equilibrium.
Signals the cortex to increase awareness of the Monitor for and implements measure for Routes:
stimuli. managing side effects of the drugs used: Urination – 1,500ml/day or at least 30 – 50ml/hr
CORTEX: Risk for impaired gas exchange r/t respiratory Bowel elimination – 200ml
Discrimination and interpretation of pain experience. depression. Perspiration
TERMS USED IN THE CONTEXT OF PAIN Constipation. Breathing
RADIATING PAIN – perceived at the source of the Risk for injury r/t drowsiness and unsteady gait. Sensible loss
pain and extends to the nearby tissues. Risk for imbalanced nutrition r/t anorexia and Insensible loss – unnoticeable immeasurable.
REFFERED PAIN – pain is perceived in an area nausea. AVERAGE DAILY FLUID OF AN ADULT
distant from the site of painful stimuli. Risk for deficient fluid volume r/t reduced oral ROUTE AMOUNT (ml)
INTRACTABLE PAIN – pain that is highly resistant intake. Urine 1,400 – 1,500
to relief. Insensible loss:
Lungs 350 – 400 RAAS Facilitated diffusion
Skin 350 – 400 ANp Require assistance from a carrier molecule to pass
Sweat 100 Specialized neurons in the hypothalamus. through a semi-permeable membrane.
Feces 100 – 200 Highly sensitive to serum osmolality. Ex: insulin-glucose
TOTAL: 2,300 – 2,600 Increased osmolality: Active transport
FUNCTIONS OF THE BODY FLUIDS Osmoreceptors stimulates hypothalamus to Uphill movement
Transport of nutrients. synthesize ADH. Movement of solute from lower concentration to
Medium or milieu for metabolic processes. Decreased osmolality: higher concentration using energy (ATP).
Body temperature regulation. ADH is inhibited. Ex: Na-K pump.
Lubricant of musculoskeletal joints. Triggers thirst promoting increased fluid intake. SODIUM (Na+)
Insulator and shock absorber. Thirsty when ECF volume decreases by approx. RR: 135 – 145 mEq/L
COMPOSITION OF BODY FLUIDS 700ml (2% of body weight). IV: 135 – 145 mmol/L
Composed of solute, solvents, electrolytes. OSMORECEPTORS 1 tsp of table salt = 200 mg
The major Intracellular fluid electrolytes are K+, A decrease in BV by 10%. 1 tsp of soy sauce = 1029 mg
Phosphorus & Magnesium. Systolic BP falls below 90 mmHg. Average dietary intake of sodium is about 6 – 14g/
The major Extracellular fluid electrolytes are Sodium, RA is underfilled – ADH release. day.
Bicarbonate & Chloride. ADH is suppressed when BV, BP increases and Major cation in ECF.
TRANSLOCATION RA is overfilled. Major contributor of plasma osmolality.
Movement back and forth of fluid and exchange of Neurons in the hypothalamus stimulated by ECF Na+ level determines whether water is retained,
chemicals from one location to another. messages from Osmoreceptors. excreted or translocated.
A continuous process in and among all areas where Pituitary gland made to produce ADH. Regulate by kidney (Aldosterone, ADH, NP).
water is located. Spinal cord carries messages from body to Increase serum Na = (-) aldosterone, (+) ADH & NP.
Chemicals involved. hypothalamus. Decrease Na = (+) aldosterone, (-) ADH & NP.
Electrolytes: substances that when dissolved in RENIN ANGIOTENSIN – ALDOSTERONE FUNCTIONS
fluid carry an electrical charge. SYSTEM (RAAS) Maintenance of plasma and interstitial osmolarity.
Acids: substances that release hydrogen into fluid. Decrease ECF (BV) Generation and transmission of action potentials.
Bases: substances that bind with hydrogen. Decrease BP Maintenance of acid-base balance.
THE DELICATE THE BALANCE OF FLUID, NATRIURETIC PEPTIDES Maintenance of electroneutrality.
ELECTROLYTES, ACIDS AND BASES IS Hormone like substances that act in. Skeletal/ heart muscle contraction, nerve impulse
ENSURED BY AN: Opposition to the RAAS. transmission, normal ECF osmolality, normal ECF
Adequate intake of water and nutrients. 2 types: volumes.
Physiologic mechanisms that regulate fluid volume. Atrial NP – hearts atrial muscle. POTASSIUM (K-)
Chemical processes that buffer the blood to keep its Brain NP – ventricles of the heart. Rr: 3.5 – 5.0 mEq/L
pH nearly neutral. Overstretching (atrial and ventricular walls)  IV: 3.5 – 5.0 mmol/L
TONICITY OF BODY FLUIDS ANP & BNP are released. SOURCE
Refers to the concentration of particles in a solution. ANP & BNP inhibit the release of Renin, Avocado 1 medium = 1097 mg.
Body fluids are isotonic comparable with 0.9% NaCl. Aldosterone and ADH = Decrease blood Banana 1 medium = 451 mg
HYPERTONIC: pressure. FUNCTIONS
Fluids have a higher or greater concentration of Potent diuretic Regulation of intracellular osmolarity.
solutes (sodium) compare with plasma. Na – wasting Maintenance of electrical membrane excitability.
Ex: 0.3% NaCl. (-) thirst Maintenance of plasma acid-base balance.
HYPOTONIC: GASTRO INTESTINAL REGULATION Glucose use and storage, maintains action potentials
Fluids have lesser or lower solute concentration than The GIT digest food and absorbs water. in excitable membranes.
plasma. Passive and active transport of with water and Contributes heavily to resting membrane potential
Ex: 0.45%, 0.33% NaCl solution. solutions, maintain the fluid balance in the body. and interacts with muscle contraction and myocardial
The normal tonicity or osmolarity of body fluids is FLUIDS AND ELECTROLYTES MOVE AMONG membrane responsiveness.
270 – 300 mosm/L. CELLS, COMPARTMENTS, TISSUE SPACES Maintain intracellular osmolality.
SOLUTIONS Osmolarity pH Calories Tonicity AND PLASMA BY THE PROCESS OF: CALCIUM (Ca2+)
(mOsm/L) (kcal) Osmosis RR: 9.0 – 10.5 mg/dL
Filtration IV: 2.25 – 2.75 mmol/L
0.9% saline 308 5 0 Isotonic Diffusion 2 forms: bound & unbound (Ionized)
0.45% saline 154 5 0 Hypotonic Active transport BOUND – attached to CHON (albumin)
5% dextrose 272 3.5 170 Isotonic + OSMOSIS IONIZED – “free calcium”; active form; ECF
in water to Movement of water/ liquid/ solvent across a FUNCTIONS
(D5W) 6.5 semi-permeable membrane from lesser Maintenance of plasma acid-base balance.
10% 500 3.5 340 Hypertonic concentration to a higher concentration. Maintenance of plasma electroneutrality.
dextrose in to
water 6.5
Osmotic pressure: Formation of hydrochloric acid.
(D10W) The power of a solution to draw water toward an Bone strength and density, skeletal/ cardiac muscle
5% Dextrose 560 3.5 170 Hypertonic area of greater concentration. contraction, nerve impulse transmission, blood
in 0.9% to Colloidal osmotic pressure: clotting.
saline 6.5 The osmotic pull exerted by plasma proteins like Regulated by – vitamin D, PTH, Thyrocalcitonin.
5% Dextrose 406 4 170 Hypertonic
in 0.45%
albumin. MAGNESIUM (Mg2+)
saline 180L of fluid the blood is filtered by kidney each RR: 1.3 – 2.1 mEq/L
5% Dextrose 321 4 170 Isotonic day. IV: 0.66 – 1.07 mmol/L
in 0.225% DIFFUSION FUNCTIONS
saline Movement of particles, solutes, molecules from Excitable membrane stabilizer.
Ringer’s 273 6.5 9 isotonic
Lactate
an area of higher concentration to an area of a Essential element in cardiac, skeletal and smooth
5% Dextrose 525 4 179 hypertonic lower concentration through a semi-permeable muscle contraction.
in Ringer’s to membrane. Co-factor in blood-clotting cascade.
Lactate 6.5 Factors affecting rate of diffusion: Co-factor in carbohydrate metabolism.
FLUID & ELECTROLYTES REGULATION Concentration of solution – wide difference in Co-factor in DNA & Protein synthesis.
Under normal conditions, the following mechanisms concentration has a faster rate of diffusion. ICF: Skeletal muscle contraction, Vit. V-complex
regulates normal fluid volume and electrolytes Temperature – increase in temp = increase rate activation.
concentrations. of diffusion. ECF: Skeletal muscle contractility.
OSMORECEPTORS Regulated by the kidney and GIT.
PHOSPHORUS (P) ETIOLOGY MANIFESTATION:
RR: 3.0 – 4.5 mg/dL Excessive oral intake. Mental confusion, personality changes.
IV: 0.97 – 1.45 mmol/L Rapid IV infusion. Muscular weakness
Major anion (-) ICF (80% is in bone) Heart failure. Anorexia, restlessness.
Source: Spinach Kidney disease. Tachycardia, nausea & vomiting.
FUNCTIONS Excessive salt intake. Severe: convulsions and coma.
Activation of B complex, vitamins. Adrenal gland dysfunction. MANAGEMENT:
Formation of adrenosine triphosphate and other high Administration of corticosteroids (prednisolone). Underlying cause is corrected.
energy substances. OVERHYDRATION Mild deficits: oral administration of Na+
Co-factor in carbohydrates, protein and lipid Isotonic Overhydration – expansion of ECF Severe deficits: IV solutions.
metabolism. space only. SODIUM: HYPERNATREMIA
Activating B-complex vitamins, calcium homeostasis; Hypotonic Overhydration – expansion of both CAUSE:
balanced and reciprocal/ relationship with Ca+. ECF & ICF compartments. Profuse watery diarrhea.
Regulated by: PTH Hypertonic Overhydration – expansion of the Excessive salt intake without sufficient water intake.
Increase PTH = decrease Phosphorus ECF and contraction of ICF. Decreased water intake; elderly, debilitated,
Decrease PTH = increase Phosphorus PATHOPHYSIOLOGY unconscious clients.
CHLORIDE (Cl) Circulatory overload, comprises cardiopulmonary Excessive administration of solutions containing Na+
98 – 106 mEq/L / mmol/L function. Excessive water loss without accompanying loss of
Major ECF anion (-) The heart compensates increase BP, increase sodium.
Work with Na+ to maintain osmotic pressure of ECF. force of contraction. RESULTS IN:
Important in the formation of HCl in the stomach. Pitting edema develops if there is 3L excess in Thirst
FLUID IMBALANCE IV volume. Dry, sticky mucous membrane
Hypovolemia ASSESSMENT FINDINGS Decreased urine output
Hypervolemia Early signs weight gain, elevated BP, increase Fever
Third spacing breathing effort. Rough dry tongue
HYPOVOLEMIA dependent edema (feet, ankles, sacrum, Lethargy
FLUID VOLUME DEFICIT buttocks). Coma if severe
Decrease volume of ECF. Rings, shoes and stockings leave marks in the TREATMENT:
Dehydration – decrease body fluid volume in both skin. Depends on the cause.
ECF & ICF Prominent jugular vein when sitting. Oral administration of plain water.
ETIOLOGY Rales and crackles. IV administration of hypotonic solutions.
Inadequate fluid intake. DIAGNOSTIC FINDINGS POTASSIUM: HYPOKALEMIA
Prolonged vomiting and diarrhea. Hemodilution: CAUSES:
Hemorrhage. Decrease blood cell count Potassium – wasting diuretics; Furosemide (Lasix).
Wound loss (burn/injury) Decrease hematocrit Severe vomiting
Profuse urination/ perspiration Low urine specific gravity. Diarrhea
Translocation of fluids (abdominal cavity). CVF (>10cm H2O); (<4cm H2O in FVD) Draining intestinal fistula
DEHYDRATION MANAGEMENT Prolonged suctioning
Isotonic dehydration – contraction of the ECF space Treat the underlying cause. Large dose of corticosteroids.
only. Restriction of oral and parenteral fluid intake. IV administration of insulin and glucose.
Hypotonic dehydration – contraction of the ECF and NURSING MANAGEMENT Severe dieting.
expansion of ICF. Implements prescribed interventions (limiting MANIFESTATIONS:
Hypertonic dehydration – expansion of the ECF and Na+ water intake). Fatigue
contraction of ICF. Administering ordered medications. Weakness
PATHOPHYSIOLOGY Elevates client head, legs, change position q2. Anorexia
Increase HR to maintain adequate carbon dioxide. THIRD SPACING Nausea & vomiting
Decrease BP with postural changes or it may Translocation of fluid from the IV or intracellular Cardiac dysrhythmias
become severely lowered when blood is rapidly lost. space to tissue compartments and becomes Muscle weakness
Hemoconcentration occurs: trapped and useless. Paresthesias
Increase potential for blood clots, urinary stones Associated with: loss of colloids Severe: hypotension, flaccid paralysis, death
(comprises kidney’s function to excrete nitrogenous (hypoalbuminemia) severe allergic reaction that (cardiac arrest, respiratory distress)
waste). alter capillary and cellular membrane ECG CHANGES:
Eventually it depletes ICF which can affect cellular permeability. ST – segment depression
functions. It can lead to hypotension, shock and circulatory Flat/ inverted T wave
Change in LOC. failure. Increased U wave
ASSESSMENT FINDINGS ASSESSMENTS FINDINGS TREATMENT:
Thirst: one of the earliest symptoms. Signs and symptoms of hypovolemia except Elimination of the cause.
Weight loss: ≥ 2 lbs/ 24 hr. weight loss. Substitute potassium wasting with potassium sparing
Decrease BP, increase temp., rapid & weak thready Enlargement of organ cavities (ascites). diuretics: Spironolactone (Aldactone).
pulse, rapid & shallow respiration, scant & dark, Management: Increase oral intake of potassium rich foods/
yellow urine, dry & small volume stool, warm & Restoration of colloidal osmotic pressure potassium supplement (mild cases).
flushed dry skin, poor skin turgor “tents”, sunken (albumin), then diuretics. KCl (severe cases); IV incorporation, not bolus
eyes, clear lungs, effortless breathing, weakness, Nursing care combines the assessments (death).
flat jugular veins, reduced cognition, sleepy. techniques for detecting both hypovolemia and NURSING MANAGEMENT:
MEDICAL MANAGEMENT hypervolemia. Assess clients for conditions with the potential to
Fluid deficit is restored by: ☺ ELECTROLYES IMBALANCES ☺ cause potassium imbalances.
Treating its etiology/ causes. SODIUM: HYPONATREMIA Identifies signs and symptoms.
Increases the volume of oral intake. CAUSE Monitor laboratory findings.
Administering IVF replacement. Profuse diaphoresis Administer medication:
Controlling fluid loss. Excessive ingestion of plain water. KCL – diluted in an IV solution and administered at a
HYPERVOLEMIA Administration of electrolyte – free solution. rate below 10 mEq/hr
FLUID VOLUME EXCESS Prolonged vomiting, GI suctioning. POTASSIUM: HYPERKALEMIA
Overhydration Addison’s disease CAUSES:
Increase volume of water in the IV compartment. Chronic renal failure Renal failure
Severe burns
Administration of potassium sparing diuretics. Diuretics (furosemide (Lasix)). Aspirin over dosage, profuse diarrhea, intestinal
Overuse of potassium supplements. Oral phosphate. wound drainage (HCO3 is lost).
Crushing injuries. Calcitonin (Cibacalcin) Decreased BP
Addison’s disease Corticosteroids or plicamycin (Mithracin) – used Altered tissue perfusion
Rapid administration of parenteral KCl. for malignant disease. Epinephrine
MANIFESTATIONS: Encouraged increased fluid intake. Sodium bicarbonate
Diarrhea Limit food sourced of Ca+ Very common in type 1 DM
Nausea Ambulation as tolerated Indication of dialysis
Muscle weakness Provide assistance: avoid falls. ASSESSMENT FINDINGS:
Paresthesias MAGNESIUM: HYPOMAGNESEMIA Kussmaul’s breathing (deep & rapid breathing)
Cardiac dysrhythmias: peak T waves; prolonged PR CAUSES: Tachypnea
intervals; flat/absent P wave; wide QRS complex. Chronic alcoholism. Anorexia, N&V, headache, confusion, flushing,
TREATMENT: Renal disease, polyuric phase. lethargy, malaise, drowsiness, abdominal pain or
Depends on the cause and severity. Severe malnutrition. discomfort, weakness.
Decreased potassium rich food intake. Intestinal malabsorptions syndromes. Cardiac dysrhythmias can develop force of cardiac
Decreased oral potassium replacement. Excessive diuresis (drug induced). contraction can be weakened.
Administration of cation – exchange resin like Prolonged gastric suction. Stupor & coma (severe cases).
sodium polystyrene sulfonate (kayexalate) or MANIFESTATIONS: ABG: decreased Ph. Decrease HCO3 (Na to
combination of IV regular insulin and glucose Tachycardia and other dysrhythmias. decrease PaCO2).
(severe cases). Increased neuromuscular irritability. Anion gap (>16mEq/L indicates metabolic acid)
Peritoneal dialysis/ hemodialysis. Paresthesias of the extremities. (Na + K) – (Cl +HCO3).
CALCIUM: HYPOCALCEMIA Leg & foot cramps. Stimulation of respiratory center.
CAUSES: Mental changes Increase respiratory rate, increase breathing.
Vitamin D deficiency. (+) Chvostek’s & Trousseau’s sign. CNS depression
Hypoparathyroidism Seizures Decrease cardiac contraction.
Acute pancreatitis. MANAGEMENT: Hyperventilate.
Corticosteroids. Oral magnesium salts/ magnesium rich foods. MEDICAL MANAGEMENT:
Intestinal malabsorption. IV magnesium sulfate. Treating the cause and replacing fluid 7 electrolytes
Accidental removal of parathyroid gland. MAGNESIUM: HYPERMAGNESEMIA that may have been lost.
MANIFESTATIONS: CAUSES: IV bicarbonate (severe cases).
Tingling sensations – extremities; around the mouth. Renal failure Renal failure: dialysis
Muscle and abdominal cramps. Excessive use of antacids/ laxatives. Bicarbonate – 2 mEq/L (IV bolus).
Carpopedal spasms – Trousseau’s signs. MANIFESTATIONS: METABOLIC ALKALOSIS
Spasm of facial muscle – Chvostek’s signs Flushing There is increased bicarbonate or decreased
Laryngeal spasms Warmth hydrogen ion concentration.
Tetany – muscle twitching Hypotension Excessive oral or parenteral use of bicarbonate
Seizures Lethargy containing drugs or alkaline salts.
Bleeding Drowsiness Rapid decrease in ECF (diuretic therapy).
Cardiac dysrhythmias – palmar flexion (+) Bradycardia CAUSES:
Trousseau’s sign. Muscle weakness Diuretics: the loss of hydrogen ions and chloride
TREATMENT: Depressed respirations from diuresis causes a compensatory increase in the
Administration of oral Ca+ and vitamin D (mild Coma amount of bicarbonate in the blood.
cases). MANAGEMENT: Excessive vomiting or gastrointestinal suctioning:
IV administration of Ca+ salts calcium gluconate Decreased oral magnesium intake. leads to an excessive loss of hydrochloric acid.
(severe cases). Discontinue parenteral replacement Hyperaldosteronism: increased renal tubular
NURSING MANAGEMENT: Hemodialysis (severe cases) reabsorption of sodium occurs, with the resultant
Closely monitor for neurologic manifestations – ☺ ACID-BASE BALANCE ☺ loss of hydrogen ions.
tetany, seizures, spasms. Ingestion or infusion of excess sodium bicarbonate:
Seizure precautions pH 7.35 – 7.45 causes an increase in the amount of base in the
Provide bed rest for comfort, avoid falls. PaCO2 35 – 45 mmHg blood.
Cardiac dysrhythmias and airway obstruction. HCO3 22 – 26 mEq/L or Massive transfusion of whole blood: the citrate
Check for signs of bruising/ bleeding. mmol/L anticoagulant used for the storage of blood is
CALCIUM: HYPERCALCEMIA PaO2 80 – 100 mmHg metabolized to bicarbonate.
ASSOCIATED WITH: Base excess -2 to +2 mEq/L MANIFESTATIONS:
Parathyroid gland tumors. O2 saturation 95 – 98% Drowsiness
Multiple fractures ACID BASE IMBALANCE Dizziness
Hyperparathyroidism pH HCO3 PaCO2 Nervousness
Excessive doses of vitamin D. Metabolic Confusion
Prolonged immobilization. Acidosis Tachycardia
Certain malignant disease – multiple myeloma, acute Metabolic Dysrhythmias (related to hypokalemia from
leukemia, lymphomas. Alkalosis compensation)
MANIFESTATIONS: Respiratory Anorexia
Deep bone pain Acidosis N&V
Constipation Respiratory Tremors
Anorexia Alkalosis Hypertonic muscles
Nausea and vomiting METABOLIC ACIDOSIS Muscle cramps
Thirst There is increased organic acids (other than Tetany
Mental changes – decrease memory and attention carbonic acid) or decreased bicarbonate. Tingling extremities
span. CAUSE: Seizures
Kidney stones Anaerobic metabolism (form n of by product Hypoventilation (compensatory action by the lungs).
MANAGEMENT: lactic acid) = shock and cardiac arrest. MANAGEMENT:
Determining and correcting the cause. Starvation, diabetic ketoacidosis = fatty acids Monitor signs of respiratory distress.
Increase fluid intake and limiting Ca+ consumption accumulation. Monitor ABGs and potassium and calcium levels.
(mild cases). Kidney failure (cannot reabsorptions of HCO3). Institute safety precautions.
0.45% or 0.9 % NaCl (acute cases). Prepare to replace potassium as prescribed.
Prepare to administer medications and interventions Encourage hydration to thin secretions. Large or extensive burns:
fluids as prescribed to promote the kidney excretion RESPIRATORY ALKALOSIS Major or extensive burns consist of 25% or more of
of bicarbonate. A deficit of carbonic acid and a decrease in the total body surface area for an adult and 10% or
Treat the underlying cause of the alkalosis. hydrogen ion concentration that results from the more of the total body surface for a child.
RESPIRATORY ACIDOSIS accumulation of base or from a loss of acid The response of the body to the injury is systemic.
The total concentration of buffer base is lower than without a comparable loss of base in the body The burn affects all major systems of the body.
normal, with a relative increase in hydrogen ion fluids. Electrical burns often have surface injury that is small
concentration; thus a greater number of hydrogen CAUSES: but internal injuries may be extensive.
ions in circulating in the blood than can be absorbed Fever: causes increased metabolism, resulting ESTIMATING THE EXTENT OF INJURY
by the buffer system. in overstimulation of the respiratory system.
CAUSES: Hyperventilation: rapid respirations cause the
Asthma: spasms resulting from allergens, irritants or blowing off of carbon dioxide (CO2), leading to a
emotions cause the smooth muscles of the decrease in carbonic acid.
bronchioles to constrict, resulting in effective gas Hypoxia: stimulates the respiratory center in the
exchange. brainstem, which causes an increase in the
Atelectasis: excessive mucus collection, with the respiratory rate in order to increase oxygen; this
collapse of alveolar sacs caused by mucous plugs, causes hyperventilation, which results in a
infectious drainage. decrease in the CO2 level.
Brain trauma: Excessive pressure on the Hysteria: often is neurogenic and related to a
respiratory center or medulla, oblongata, depresses psychoneurosis; this condition leads to vigorous
respirations. breathing and excessive exhaling of CO2.
Bronchiectasis: bronchi become dilated as a result Overventilation by mechanical ventilators:
of inflammation, and destructive changes and the administration of O2 and the depletion of BURN DEPTH
weakness in the walls of the bronchi occur. CO2 can occur from mechanical ventilation, SUPERFICIAL-THICKNESS BURN
Bronchitis: inflammation causes airway obstruction, causing the client to be hyperventilated. Involves injury to the epidermis; the blood supply to
resulting in inadequate gas exchange. Pain: overstimulation of the respiratory center in the dermis is still intact.
Central nervous system depressants: the brainstem results in a carbonic acid deficit. Mild to severe erythema (pink to red) is present but
depressants such as sedatives opioids and MANIFESTATIONS: no blisters.
anesthetics depress the respiratory center leading to Lethargy Skin blanches with pressure.
hypoventilation (excessive sedation from Lightheadedness Burn is painful, with tingling sensation, and the pain is
medications may require reversal by opioid Confusion eased by cooling.
antagonist medications); carbon dioxide (CO2) is Tachycardia Discomfort lasts about 48 hours; healing occurs in
retained and the hydrogen ion concentration Dysrhythmias (related to hypokalemia from about 3 to 6 days.
increases. compensation) No scarring occurs and skin grafts are not required.
Emphysema and COPD: loss of elasticity of Nausea SUPERFICIAL-PARTIAL-THICKNESS BURN
alveolar sacs restricts air flow in and out, primarily Vomiting Involves injury deeper into the dermis; the blood
out, leading to an increased CO2 level. Epigastric pain supply is reduced.
Administering high oxygen level per nasal cannula to Tetany Large blisters may cover an extensive area.
clients who are CO2 retainers (emphysema & Numbness Edema is present.
COPD). Tingling of extremities Mottled pink to red base and broken epidermis, with a
Hypoventilation: carbon dioxide is retained and the Hyporeflexion wet, shiny and weeping surface, are characteristics.
hydrogen ion concentration increases, leading to the Seizures Burn is painful and sensitive to cold air.
acidotic state; carbonic acid is retained and the pH. Hyperventilation (lungs are unable to Heals in 10 to 21 days with no scarring, but some
decreases. compensate when there is a respiratory minor pigment changes may occur.
Pneumonia: excess mucus production and lung problem) Grafts may be used if the healing process is
congestion cause airway obstruction, resulting in Circumoral Paresthesias, sweating, panic, dry prolonged.
inadequate gas exchange. mouth DEEP PARTIAL-THICKNESS BURN
Pulmonary edema: extracellular accumulation of ABG: increase pH. Decrease PaCO2 (N to Extends deeper into the skin dermis.
fluid in pulmonary tissue causes disturbances in decrease HCO3) Blister formation usually does not occur because the
alveolar diffusion and perfusion. MANAGEMENT: dead tissue layer is thick and sticks to underlying
Pulmonary emboli: emboli cause obstruction in a Monitors signs of respiratory distress. viable dermis.
pulmonary artery resulting in airway obstruction and Provide emotional support and reassurance to Wound surface is red and dry with white areas in
inadequate gas exchange. the patient. deeper parts.
MANIFESTATIONS: Encourage appropriate breathing patterns. May or may not blanch and edema is moderate.
Breath slowly or irregularly or stop breathing Assist with breathing techniques and breathing Can convert to full-thickness burn if tissue damage
Decrease RR aids as prescribed. increases with infection, hypoxia or ischemia.
Decreased expiratory volumes Provide use of a rebreathing mask as Generally, heals in 3 to 6 weeks, but scar formation
Tachycardia (dysrhythmias), cyanosis prescribed. results and skin grafting may be necessary.
Behavioral changes – mental cloudiness, confusion, Provide CO2 breaths as prescribed (rebreathing FULL-THICKNESS BURN
disorientation, hallucinations (accumulation of CO2). into a paper bag). Involves injury and destruction of the epidermis and
Tremors, muscle twitching, flushed skin, headache, Provide cautions care with ventilator clients so the dermis; the wound will not heal by
weakness, stupor, coma that they are not forced to take breaths too reepithelialization and grafting may be required.
ABG: decrease pH., increase PaCO2 (N to increase deeply or rapidly. Appears as a dry, hard, leathery eschar (burn crust or
HCO3) Monitor electrolyte values, particularly potassium dead tissue must slough off or be removed from the
MANAGEMENT: and calcium levels; monitor ABG levels. wound before healing can occur).
Treatment is individualized depending on the cause Prepare to administer calcium gluconate for Appears waxy white, deep red, yellow, brown, or
of imbalance. tetany as prescribed. black.
Mechanical ventilation (may be necessary to support ☺ BURN ☺ Injured surfaces appear dry.
respiratory function). Edema is present under the eschar.
IV NaHCO3 if ventilation efforts do not adequately Cell destruction of the layers of the skin caused Sensation is reduced or absent because of nerve
restore a balanced pH. by heat, friction, electricity, radiation or ending destruction.
Bronchodilators, antibiotics, airway suctioning. chemicals. Healing make take weeks to months and depends on
Place patient in a semi-fowler’s position. BURN SIZE establishing an adequate blood supply.
Encourage and assist the patient to turn, cough, and Small burns: The response of the body to injury Burn requires removal of eschar and split-or full
deep breath. is localized to the injured area. thickening akin grafting.
Scarring and wound contractures are likely to Provides wound Causes more blood E. coli is the most common causative bacterial
develop. debridement during loss with removal. organism.
DEEP FULL-THICKNESS BURN dressing removal. Can interfere with  ACUTE PYELONEPHRITIS 
Injury extends beyond the skin into underlying fascia Keep skin fold circulation if tightly Acute pyelonephritis occurs as a new infection or
and tissues and muscle, bone and tendons are separated. applied. recurs as a relapse of a previous infection.
damaged. Reduces pain during It can progress to bacteremia or chronic
Injured area appears black and sensation is position changes. pyelonephritis.
completely absent. Open method (exposure method) – abandoned MANIFESTATIONS:
Eschar is hard an inelastic. already (except in face and perineum); cradle Fever and chills.
There is lack of pain because nerve endings have nursing. Tachycardia and tachypnea
been destroyed. Closed method – current preferred method; Nausea
Healing takes months and grafts are required. covered first with nonadherent and absorbent Flank pain on the affected side.
AGE AND GENERAL HEALTH dressings (gauze impregnated with petroleum Costovertebral angel tenderness.
Mortality rates are higher for children younger than 4 jelly or ointment based antimicrobials); occlusive Headache
years old, particularly for children from birth 1 y/o or semi occlusive dressing made of polyvinyl Dysuria
and for patients older than 65 y/o. polyethylene, polyurethane and hydrocolloid Frequency and urgency
Debilitating disorders, such as cardiac, respiratory, materials as final dressing. Cloudy, bloody or foul-smelling urine.
endocrine, and renal disorders, negatively influence ANTIMICROBIAL THERAPY Increased WBC’s in the urine.
the patient’s response to injury and treatment. Topical antibiotic  CHRONIC PYELONEPHRITIS 
Mortality rate is higher when the patient has a pre- Silver sulfadiazine (Silvadene) 1% ointment. A slow, progressive disease usually associated with
existing disorder at the time of the burn injury. Mafenide (Sulfamylon) recurrent acute attacks.
MEDICAL MANAGEMENT Silver nitrate (AgNO3) 0.5% solution. Causes contraction of the kidney and dysfunction of
INITIAL 1ST AID SURGICAL MANAGEMENT the nephrons, which are replaced by scar tissue.
Prevent further injury (at the scene of the fire). Debridement Causes the ureter to become fibrotic and narrowed
Observed closely for respiratory difficulty (inhalation Skin grafting by strictures.
injury) during transport. Application of a skin substitute Can lead to AKI or CKD.
Oxygen is administered, IV fluid. Application of cultured skin MANIFESTATIONS:
ACUTE CARE DEBRIDEMENT Frequently diagnosed incidentally when a patient is
Quick assessment (extent of burn injury additional Removal of necrotic tissue. being evaluated for hypertension.
trauma – fractures, head injuries, lacerations). Done in one of four ways. Inability to conserve sodium.
Maintain adequate ventilation: Natural – tissue sloughs away. Pyuria
Bronchoscopy (assess internal airway). Mechanical – tissue adheres to dressing or Azotemia
Warmed humidified O2. detached during cleansing. Proteinuria
ET should be available for insertion. Enzymatic – application of topical enzyme. MANAGEMENT:
Eschar (a hard leathery crust of dehydrated skin) in Surgical – use of forceps & scissors. Monitor vital signs, especially for elevated
the neck area = tracheostomy. SKIN GRAFTING temperature.
(1) Mechanical ventilation Necessary for deep partial-thickness and full- Encourage fluid intake up to 3000ml/day to reduce
(2) Initiating fluid resuscitation: restore IVF thickness burns. fever and prevent dehydration.
Lactated ringers PURPOSE: Monitor I&O (ensure that output is a minimum of
(3) Pain: Morphine – DOC Lessen the potential for infection. 1500 ml/ 24hr).
If respiratory depression occurs: Epinephrine Minimize fluid loss by evaporation. Monitor weight.
(emergency/ bedside); Naloxone (Narcan). Hasten recovery Encourage adequate rest.
(4) Tetanus immunization is also administered Reduced scarring Instruct the patient about a high-calorie, low-protein
(active); antitetanus serum. Prevent loss of function. diet.
(5) Support GI infection. SOURCE FOR SKIN GRAFT: Provide warm, moist compresses to the flank area to
(6) Provide psychosocial support. Autograft – patient’s own skin. help relieve-pain.
WOUND MANAGEMENT Allograft/ homograft – from human cadaver; Encourage the patient to take warm baths for pain
Wear powder-free sterile gloves temporarily covers large areas of tissues (slough relief.
Body hair around the parameter of the burn is away approx. 1 week); short supply, it could be a Administer analgesics, antipyretics, antibiotics,
shaved. source of other pathogens. urinary antiseptics and antiemetics as prescribed.
Clean the burned areas to remove debris. Heterograft/ xenograft – from animal; Monitor for signs of AKI or CKD.
Open method (Cradle nursing) – wound is left temporary; rejected in days to weeks & must be Encourage follow-up urine culture.
uncovered. removed & replaced at that time.
Closed method (with dressing) – wound is covered.  GLOMERULONEPHRITIS 
☺ RENAL DISORDER ☺ Glomerulonephritis refers to a group of kidney
OPEN METHOD
ADVANTAGES DISADVANTAGES KIDNEY disorders characterized by inflammatory injury in the
Reduces labor – Contributes to wound Regulate fluid volume & electrolytes. glomerulus, most of which are caused by an
intensive care. desiccation (dryness). Secretes waste product of metabolism. immunological reaction.
Causes less pain during Promotes loss of water Regulate BP through RAAS. CAUSES:
wound care. and body heat. Regulate acid-base balance. Immunological diseases
Facilitates inspection. Exposes wound to Activation of Vitamin D. Autoimmune diseases
Decreases expense. pathogens (severe Functional unit of kidney NEPHRONS (1m Antecedent group a B-hemolytic streptococcal
isolation). each). infection of the pharynx or skin.
Contributes to pain Maintain BP renal artery. TYPES:
during repositioning. 5L – 1L/min (20% of blood). ACUTE: Occurs 2 – 3 weeks after a streptococcal
Compromises modesty.  PYELONEPHRITIS  infection.
CLOSED METHOD An inflammation of the renal pelvis and the CHRONIC: May occur after the acute phase or
parenchyma, commonly caused by bacterial slowly over time.
ADVANTAGES DISADVANTAGES
invasion. COMPLICATIONS:
Maintains moist wound. Requires more time.
Acute pyelonephritis often occurs after bacterial Kidney failure
Promotes maintenance Add to expense.
contamination of the urethra or following an Hypertensive encephalopathy
of body temperature. Enhances growth of
invasive procedure of the urinary tract. Pulmonary edema
Decreases cross pathogens beneath
Chronic pyelonephritis most commonly occurs Heart failure
contamination of wound. dressings.
following chronic urinary flow obstruction with MANIFESTATIONS:
Interferes with wound
reflux. Periorbital and facial edema that is more prominent
assessment.
in the morning.
Anorexia MANIFESTATIONS: Decrease urine specific gravity (prerenal causes) or
Decreased urinary output. Renal colic, which originates in the lumbar normal (intrarenal causes).
Cloudy, smoky, brown-colored urine (hematuria). region and radiates around the side and down to Decreased glomerular filtration rate (GFR) and
Pallor, irritability, lethargy. the testicles in men and to the bladder in creatinine clearance.
In an older child: headache, abdominal or flank pain, women. Hyperkalemia
dysuria. Ureteral colic, which radiates toward the Normal or decreased sodium level.
Hypertension genitalia and thighs. Hypervolemia
Proteinuria that produces a persistent and excessive Sharp, severe pain of sudden onset. Hypocalcemia
foam in the urine. Dull, aching pain in the kidney. Hyperphosphatemia
Azotemia Nausea and vomiting, pallor and diaphoresis INTERVENTIONS:
Increased blood urea nitrogen and creatinine levels. during acute pain. Restrict fluid intake; if hypertension is present.
Increased anti-streptolysin O titer (used to diagnose Urinary frequency, with alternating retention. 3. DIURETIC
disorders caused by streptococcal infections). Signs of UTI. Gradual decline in BUN and serum creatinine levels,
MANAGEMENT: Low-grade fever. but still elevated.
Assess airway patency, vital signs and weight (same High numbers of RBC, WBCs and bacteria noted Continued low creatinine clearance with improving
time of day, same scale same clothing). in the urinalysis report. GFR.
Assess for bounding, increased pulse. Gross hematuria. Hypokalemia
Assess for distended hand and neck veins. MANAGEMENT: Hyponatremia
Assess for elevated central venous pressure (CVP) Monitor vital signs, especially temperature for Hypovolemia
and for dysrhythmias. signs of infection. INTERVENTIONS:
Notify physician and carry out prescriptions, Monitor I&O. Administer IV fluids as prescribed, which may
including water and sodium restrictions and Assess for fever, chills and infection. contain electrolytes to replace losses.
administration of diuretics. Monitor for nausea, vomiting and diarrhea. 4. RECOVERY PHASE (Convalescent)
Diet restrictions of sodium. Encourage fluid intake up to 3000 ml/day, unless Increased GFR
Initiate seizure precautions and administer contraindicated, to facilitate the passage of the Stabilization or continual decline BUN and serum
anticonvulsants. stone and prevent infection; monitor for creatinine levels toward normal.
 NEPHROTIC SYNDROME  obstruction. Complete recovery (may take 1 – 2 yrs).
Nephrotic syndrome is a kidney disorder Administer fluids IV as prescribed if unable to MANAGEMENT:
characterized by massive proteinuria, take fluids orally or in adequate amounts to Monitor vital signs, especially for signs of
hypoalbuminemia (hypoproteinemia) and edema. increase the flow of urine and facilitate passage hypertension, tachycardia, tachypnea and irregular
MANIFESTATIONS: of the stone. heart rate.
Massive proteinuria (>3.5g in 24hr) Provide warm baths and heat to the flank area Monitor urine and I&O hourly and urine color and
Hypoalbuminemia (>3g/dl) (massage therapy should be avoided). characteristics.
Renal insufficiency Administer analgesics at regularly scheduled Monitor daily weight (same scale, same clothes,
Weight gain intervals as prescribed to relieve pain. same time of day), noting that an increase of ½ to
Periorbital and facial most prominent in the morning. Assess the patient’s response to pain 1lb/day (0.25 – 0.50 kg/day) indicates fluid retention.
Leg, ankle, labial or scrotal edema. medication. Monitor for changes in the BUN, serum, creatinine
Urine output decreases; urine dark and frothy. Assist the patient in performing relaxation and serum electrolytes levels.
Ascites (fluid in the abdominal cavity). techniques to assist in relieving pain. Monitor for acidosis (may need to be treated with
Blood pressure normal or slightly decreased. Encourage patient ambulation, if stable, to sodium bicarbonate).
Lethargy, anorexia and pallor. promote the passage of the stone. Monitor urinalysis for protein level, hematuria, casts
Decreased serum protein. Turn and reposition the immobilized patient to and specific gravity.
Elevated serum lipids levels. promote passage of the stone. Monitor for altered LOC caused by uremia.
MANAGEMENT: Instruct the patient in the diet restriction specific Monitor for signs of infection because the client may
Monitor vital signs, I&O and daily weights. to the stone composition if prescribed. not exhibit an elevated temperature or an increased
Monitor urine for specific gravity and protein. Prepare the patient for surgical procedure if WBC count.
Monitor for edema. prescribed. Monitor the lungs for wheezes and rhonchi and
A regular diet without added salt may be prescribed,  ACUTE KIDNEY INJURY  monitor for edema. Which can indicate fluid
sodium restricted, fluid restricted. Acute kidney injury (AKI) is the rapid loss of overload.
Corticosteroids therapy is prescribed. kidney function from renal cell damage. Administer the prescribed diet, which is usually a
Immunosuppressant therapy as prescribed. Occurs abruptly and can be reversible. low-to moderate protein (to decrease the workload
Diuretics may be prescribed to reduce edema. CAUSES: on the kidneys) and high carbohydrate diet, ill clients
1. PRE-RENAL may require nutritional support with supplements,
 RENAL CALCULI 
Outside the kidney; caused by intravascular enteral feedings or parenteral feedings.
Calculi are stones that can form anywhere in the Restrict potassium and sodium intake as prescribed
urinary tract, however, the most frequent site is the volume depletion such as with blood loss
associated with trauma or surgery, dehydration, based on the electrolyte levels.
kidney. Administer medications as prescribed.
Problems resulting from calculi are severe decrease cardiac output (as with cardiogenic
shock), decreased peripheral vascular Be alert to the physician adjustment of medications
intermittent pain, obstruction, tissue trauma, dosages for kidney injury.
secondary hemorrhage and infection. resistance, decreased renovascular blood flow
and prerenal infection or obstruction. Prepare for dialysis of prescribed.
Urolithiasis refers to the formation of urinary calculi;
2. INTRARENAL  CHRONIC KIDNEY DISEASE
there from in the ureters.
Nephrolithiasis refers to the formation of kidney Within the parenchyma of the kidney; caused by CKD is a slow, progressive, irreversible loss in
calculi; these form in the renal parenchyma. tubular necrosis, prolonged prerenal ischemia, kidney function with a GFR less than or equal to
CAUSES: intrarenal infection or obstruction, and 60ml/min for 3 mos. or longer.
Family history of stone formation. nephrotoxicity. PRIMARY CAUSES:
Diet high in calcium, vitamin D, protein, oxalate, 3. POSTRENAL May follow AKI.
purines or alkali. Between the kidney and urethral meatus, such Diabetes mellitus and other metabolic disorders.
Obstruction and urinary stasis. as bladder neck obstruction, bladder cancer, Hypertension.
Dehydration calculi and postrenal infection. Chronic urinary obstruction.
Use of diuretics, which can cause volume depletion. PHASES OF AKI: Recurrent infections.
UTIs and prolonged urinary catheterization. 1.ONSET Renal artery occlusion.
Immobilization. Begins with precipitating event. Autoimmune disorders.
Hypercalcemia and hyperparathyroidism. 2. OLIGURIC PHASE MANIFESTATIONS:
Elevated uric acid level, such as in gout. Elevated blood urine nitrogen and serum 1. INITIAL PHASE
creatinine levels. Acute decreased GFR
Urine output ,400ml/ 24hrs PHYSIOLOGY OF RESPIRATORY DIFFUSION
Increased BUN 1.There is adequate O2 in ambient air Movement of air from higher to lower pressure
2. MAINTENANCE PHASE Composition of air Air pushes from higher to lower pressure (oxygen).
GFR Nitrogen - 78.6 MECHANISM OF EXHALATION
Increased BUN Crea O2 – 20.8 Respiratory muscle RELAX
Increased Urine output CO2 - 0.04 Diaphragm ⬆
3. RECOVERY PHASE Water vapor – 0.05 Thorax ⬇ in size
Urine output 400 ml/24hrs Other gases – 0.51 Intrapleural pressure ⬆ 757mmHg
Increased BUN Sea level pressure 760mmHg Lungs ⬇ in size
PATTERN OF PROGRESSION: 2. Airway is patent Intrapulmonic pressure ⬆ 763mmHg
1. DIMINISHED RENAL RESERVE 3.Respiratory muscle and ribcage is functioning Air pushes from higher to lower pressure (carbon
GFR reduced to 50% of normal well dioxide).
Asymptomatic DIAPHRAGM VENTILATION – Movement of air in and out of the
BUN slightly elevated Major muscle of respiration lungs.
2. RENAL INSUFFICIENCY PHRENIC NERVE – nerve supply POTASSIUM – Has direct effect in nerve and
GFR is reduced to 75% of normal. C3-C5 Cervical cord muscles.
Azotemia (elevated serum BUN and creatinine) 4. (-) Intrapleural pressure PLEURISY – Pleural effusion is the complication.
Mild anemia and hypertension PLEURA ATELECTASIS – Lung collapse.
Nocturia (frequent voiding at night) Parietal – outer OXYGENATION – Transportation of gases; Oxygen
3. RENAL DISEASE Visceral – inner and carbon dioxide.
Reduction in GFR to less than 20% of normal. PLEURAL FLUID
 HEART 
Azotemia, acidosis, severe anemia, impaired urine -10-15ml
FUNCTION:
dilution, fluid and electrolyte imbalances. -Lubricant during respiration
Patient may exhibit overt uremia with cardiovascular, Intrapulmonic pressure Like a fist
gastrointestinal, and neurologic complications. Intrapleural pressure Pumps blood:
4. END-STAGE RENAL DISEASE 5. Diffusion between alveoli and pulmonary To right ventricle – Respiratory
Reduction in GFR to less than 10% of normal. capillary effective To aorta – left ventricle
Represents the terminal stage of uremia. Matched ventilation perfusion ratio Stroke volume – 60ml/beat
MANAGEMENT: PERFUSION – amount of blood flow to capillary Cardiac output – 5L/min
Administer a prescribed diet, which is usually a bed. Without oxygen:
Moderate-protein (to decrease the workload on the 6. Heart is an effective pump Brain cells – 4-6mins (brain dead)
kidneys) and high carbohydrate, low potassium and Decrease cardiac output Heart – 20-30mins before infarction
low phosphorus diet. LHF – congestion in lungs Kidney - <8hrs
Provide oral care to prevent stomatitis and reduce RVF – systemic circulation PERICARDIUM:
discomfort from mouth sore. 7. Hemoglobin, RBC is adequate Protects/ covers heart
Dopamine (Intropin), hemodialysis, peritoneal dialysis. Anemia. Parietal pericardium:
Kayexalate, IV infusion of insulin & glucose for 8. Blood vessels are patent and elastic Outermost layer
hyperkalemia. BLOOD VESSELS Visceral pericardium:
Na bicarbonate for acid-base imbalance. Constrict pressure Innermost layer
Dilate – blood pass Pericardial cavity:
☺ DISTURBANCES IN Potential space
HPN
OXYGENATION ☺ 9. Tissue utilize O2 *50ml pericardial tamponade
External respiration – air from environment LAYERS OF CARDIAC MUSCLE:
COMPONENTS INVOLVED IN OXYGENATION MYOCARDIAL WALL
Heart Internal respiration – between blood and cell
VENTILATION-PERFUSION MISMATCHED Epicardium – outermost layer
Lungs Myocardium – middle layer
RBC SHUNTED UNIT
(-) ventilation Endocardium – innermost layer
Blood vessels ANAPHY:
LUNGS: RESPIRATORY SYSTEM (-) perfusion
To the lungs:
ORGANS Air partially obstructed
Hemothorax Right side of the heart: Thinner myocardium and low
Nose pressure
Pharynx Pneumothorax
To aorta:
Larynx Air embolism
Pleural effusion Left ventricle: thicker muscle and higher pressure
Trachea Right ventricle – pulmonary artery
Bronchi Mucus
DEATH SPACE UNIT Perfusion – blood reaches alveoli
Bronchioles 4 CHAMBERS
Alveoli Normal ventilation
w/o gas exchange Left and Right ATRIA/ ATRIUM:
MUCUS – 100ml (Clear) Receiving chambers
FUNCTION (-) perfusion
(-) blood supply Left and Right VENTRICLE:
Diffuses oxygen into the blood Ejecting chambers
Expels CO2 Thrombus
ELECTROPHYSIOLOGIC PROPERTIES
Filters and humidifies air Pulmonary embolism
Pulmonary infarction AUTOMATICITY
Normally clear airway through coughing and Ability to initiate an electrical impulse
sneezing (Protective reflex) Thrombosis
SILENT UNIT Repetitively
AIRWAY OBSTRUCTION Spontaneously
Accumulation of secretion (-) ventilation
(-) perfusion EXCITABILITY/ DEPOLARIZATION
Electrolyte imbalance Ability to respond to an electrical impulse
Laryngospasm/ Bronchospasm Incompatible with life
Drugs: THROMBOLYTICS CONDUCTIVITY
Tumor Ability to transmit an electrical impulse from one cell
Foreign bodies MECHANISM OF INHALATION
Respiratory muscle contract. to another
Aspiration CONTRACTILITY
ARTIFICIAL AIRWAY: Diaphragm decrease
Thorax increase in size Force generated by the contracting myocardium
Oral REFRACTORINESS
Endotracheal tube Intrapleural pressure decrease 755mmHg
Lungs increase in size Protects the heart from sustained contraction
Tracheal tube (Permanent) (tetany) which would result in sudden cardiac death.
Intrapulmonic pressure decrease 759mmHg
ELASTICITY ☺ DISTURBANCES IN CARDINAL SIGNS:
Ability to stretch Fever
RHYTHMICITY OXYGEN TRANSPORT Night sweats
Ability to contract and relax at regular rate and MECHANISM ☺ Muscle and joint pain
pattern. INTERVENTIONS:
BLOOD CIRCULATION INFECTIOUS DISORDERS: Antibiotic: DOC: Penicillin
Superior & Inferior vena cava ➡ Right atrium ➡ Pericarditis Aspirin – control blood clot formation
Myocarditis Steroids – suppresses inflammation
Tricuspid valve ➡ Right ventricle ➡ Pulmonary Endocarditis Antipyretics
artery ➡ LUNGS ➡ Left atrium ➡ Mitral valve ➡ CORONARY ARTERY DISEASE: Antibiotic prophylaxis – prevent reaccurance
Left ventricle ➡ Aorta ➡ SYSTEMIC Atherosclerosis Bed rest
VENTRICULAR CONTRACTION Angina pectoris Assess for progression or improvement
SA node (60-100/min) ➡ AV node (40-60/min) ➡ Myocardial infarction  CORONARY ARTERY DISEASE 
Bundle of his (30-40/min) ➡ Bundle branches ➡ CONGESTIVE HEART FAILURE
PULMONARY EDEMA  ATHEROSCLEROSIS 
Purkinje fibers (20-40/min) ➡ VENTRICULAR
 INFECTIOUS DISORDERS  ARTERIOSCLEROSIS – Thickening or hardening of
CONTRACTION
arterial wall
SA NODE  PERICARDITIS  ATHEROSCLEROSIS – A type of arteriosclerosis
Pacemaker of the heart Inflammation of pericardium caused by formation of PLAQUE (cholesterol)
MECHANICAL PROPERTIES Thickening of pericardium ASSESSMENT:
CARDIAC OUTPUT – 5L/min CAUSE: BP/ HPN
STROKE VOLUME: Viral, bacterial, tuberculous, fungal Elevated cholesterol and triglycerides
Amount of blood ejected from the ventricle MI, Renal failure Obesity
PRELOAD – Just before contraction Rheumatic fever, drug induced Elevated FBS
AFTERLOAD – Overcome to eject blood CARDINAL SIGNS: INTERVENTIONS:
Contractility Pain Cholesterol screening
EVENTS DURING CARDIAC CYCLE Shallow rapid respiration Diet
SYSTOLE – Contraction; Emptying Dyspnea, tachycardia Stop smoking
DIASTOLE – Relaxation; Filling DIAGNOSTIC TEST: Exercise
DIGITALIS: ECG, CT SCAN – reveals thickening of Drug therapy
DOC for Congestive heart failure pericardium Antihyperlipedemia “STATINS”
Increase FORCE (+) Inotropic effect XRAY – Cardiomegaly
Decrease HR (-) Dromotropic effect  ANGINA PECTORIS 
Atrial fibrillation
 CARDIOVASCULAR DISEASE (CVD)  INTERVENTIONS: ASSESSMENT:
NSAIDS Chest pain – Levine’s sign
RISK FACTOR
Corticosteroids PRECIPITATING FACTORS:
CIGARETTE SMOKING
Antibiotic Exertion (physical)
Obesity
Monitor for complication Eating
Stress
PERICARDIAL EFFUSION Extreme temperature
CARDINAL SIGN
Excitement (strong emotion)
Chest pain – decrease O2 Pericardial drainage
Pericardiocentesis Cigarette smoking
Dyspnea - orthopnea
Sexual activities
Fatigue – altered tissue perfusion  MYOCARDITIS  TYPES:
Palpitations Inflammation of myocardium 1. STABLE
Weight gain – best indicator of fluid retention CAUSE: 75% coronary occlusion
Syncope – loss of consciousness Viral, bacterial, fungal and parasitic infection Chest pain less than 15mins
Extremity pain – ischemia and venous insufficiency Alcohol and cocaine abuse Exertion
Edema Autoimmune disorders Relieved by rest or nitroglycerin
RADIOGRAPHIC EXAMINATIONS CARDINAL SIGNS: 2. UNSTABLE
CHEST RADIOGRAPHY Redness 90% coronary occlusion
To determine the size and position of heart. Swelling Pain even at rest
ANGIOGRAPHY (ARTERIOGRAPHY) Loss of function Chest pain 20-30mins
Invasive procedure involving fluoroscopy and the Decrease pumping action of the heart 3. VARIANT/ PRINZMETAL’S
use of contrast. Decrease cardiac output Arterial spasm
Through Blood vessels Cardiogenic shock Chest pain occurs at rest (bet. 12and 8am)
Radio opaque dye (ask for allergy to seafood) Cardiomegaly – enlargement of the heart Sporadic 3-6mos
Crea 0.7-1.1 INTERVENTIONS: Contraction
Increase fluid intake Treatment of underlying cause (antibiotic) INTERVENTIONS:
ELECTROCARDIOGRAPHY (ECG) Promote bed rest, Sodium restricted diet, 1. VASODILATORS
Gold standard test DIGITALIS: *SHORT ACTING*
Resting ECG Monitor cardiopulmonary status and Nitroglycerine – sublingual
Ambulatory ECG - Holter monitoring – worn on waist complications (CHF, Dysrhythmias) don’t swallow, don’t drink
24hrs Monitor VS 3-5mins to relieve pain 3 doses
Exercise ECG: Position pt. in semi fowlers Dilates blood vessels
Stress test Corticosteroids MOA: Dilation of coronary artery
NPO 4hour prior  ENDOCARDITIS  Increase blood supply, decrease demand for O2.
Confirm heart disease Infection of innermost layer of the heart. *LONG ACTING*
Evaluate treatment effectiveness CAUSES: Maintain dilation
Cardiac rehab program: Bacteria, viral, fungal Nitrobid patch – salonpas
Exercise cardiac rehab program Most common direct contact Isordil oral
NURSING CARE Left atrium first affected 2. BETA BLOCKERS
Position pt. in supine or low fowler’s Vegetation Blocks sympathetic stimulation of the heart
Avoid talking and movement Result of phagocytosis ⬆ BP, ⬇ HR, ⬇ demand of O2
No metals Valvular stenosis Metropolol, Atenolol, Propanolol
Inquire cardiac meds Scar formation in the heart 3. CALCIUM CHANNEL BLOCKERS
Assess ability to lie still Valvulitis – inflammation of the valve (Acquired) Blocks influx of calcium ions into myocardial cells
⬇ BP, ⬇ HR 2. CABG (Coronary Artery Bypass Graft) – Lasix
Amlodipine, Nifedipine Coronary artery are replaced by arteries or vein Oxygen
4. ANTIPLATELET AGGREGATION (Leg). Aminophylline
Aspirin, clopidogrel, Plavix 3. Coronary angiography – Repair of coronary Digoxin
5. OHA – DM artery.  PULMONARY EDEMA 
Metformin:  CONGESTIVE HEART FAILURE  Fluid accumulation in the lungs
Bed rest semi fowlers Pump failure Complication of LSHF
O2 therapy Inability to pump blood Fatal/ life threatening
 MYOCARDIAL INFARCTION  Inability of the heart to perform its function CAUSES:
Cells are permanently destroying. TYPES: Cardiogenic – LSHF
Heart attack Left sided heart failure Noncardiogenic –not related to heart
End point of CAD Right sided heart failure Pulmonary embolism
CAUSES: CAUSES: Air embolism
ATHEROSCLEROSIS 1. Inflow of blood to the heart is greatly increase. Thrombosis
CIGARETTE SMOKING Condition: Inhalation injury
Obesity Renal failure ASSESSMENT:
Hypertension Hypervolemia Wheezing
Elevated cholesterol SIADH Orthopnea
Stress Cushing’s Cyanosis
ASSESSMENT: Polycythemia Tachycardia
Pain – Levine sign 2. Inflow of blood to the heart is greatly Metabolic acidosis
Severe and long duration decrease. Altered cerebral perfusion
Unrelieved by nitroglycerine Condition: Altered LOC
Dyspnea Hypovolemia ⬇PH, ⬇PaO2 50mmHg ⬆PaCO2 50mmHg
Syncope DI (Diabetes Insipidus) MEDICAL MANAGEMENT:
Tachycardia Addison’s Inotropic drugs
TYPES: 3. Outflow of blood from the heart is difficult/ Digitalis
1. SUBENDOCARDIAL MI obstructed. Dopamine
Partial thickness Condition: Dobutamine
HPN, Tachycardia Valvular defects/ stenosis Diuretics – IV Furosemide
2. TRANSMURAL MI HPN Vasodilators
Full thickness 4. Damage to the myocardium. Morphine
Cardiogenic shock 5. Increase metabolic states. Supplemental O2
Altered LOC Hyperthyroidism NURSING MANAGEMENT:
Anxiety, apprehension, cold clammy skin. Epinephrine Similar for pt. experiencing CHF
INTRAMURAL MI Mineralocorticoids Establish IV line for meds
Patches, small portion of the heart affected RSHF: Monitor therapeutic and adverse effect of meds.
INTERVENTIONS: Hepatomegaly Swangan’s catheter
PAIN MANAGEMENT: MONA Edema Monitor ECG
Morphine 2-10mg IV q15 (Antidote: Naloxone) Ascites
☺ DISTURBANCES IN OXYGEN
Oxygen – 2-4L/min Distended neck vein
Nitroglycerine – vasodilation LSHF: EXCHANGE UTILIZATION ☺
Aspirin – anti platelet, Plavix Cough CHRONIC AIRFLOW LIMITATIONS (CAL)
Positioning – semi fowler’s Hemoptysis A group of chronic lung disease that includes:
Diet NPO 6-8hrs – Liquid diet Orthopnea Bronchial asthma
Avoid straining Pulmonary congestion Bronchitis
With Foley catheter – Urine output q 1hr, 30cc/hr LEFT SIDED HEART FAILURE: Emphysema
Creatinine and BUN – Renal failure/ Pre; To test Can lead to pulmonary edema Bronchiectasis
complication BACKWARD FAILURE: COPD:
Atypical DOB Pneumonia
DIAGNOSTICS: Productive cough Pleural effusion
Cardiac enzymes Pink frothy sputum Fractured ribs/ sternum
MYOGLOBULIN Cyanosis Pneumothorax
CKMV FORWARD FAILURE: Hemothorax
ECG – inverted P wave Altered LOC Pneumohemothorax
TROPONIN – most reliable Chest pain
 BRONCHIAL ASTHMA 
Typical – long duration Oliguria/ anuria
Assess for chest pain RIGHT SIDED HEART FAILURE: Intermittent and reversible airflow obstruction
affecting the lower airway
MEDICATION: RSHF ➡ Ineffective RV contractility ➡ reduced
COLACE – stool softener Obstruction is due to:
RV pumping ability ➡ decrease CO ➡ blood Inflammation
Nitrates
back up into RA & peripheral circulation ➡ wt. Bronchospasm
Beta blockers
gain, peripheral edema, engorgement of organs. Increase mucus
Calcium channel blockers
FINDINGS: Bronchial edema
No pain – Thrombolytics/ Fibrinolytic: TPA,
Chest X-ray - Reveals cardiomegaly Lightening of muscle/ bronchial muscle
Plasminogen, Streptokinase
ECG – abnormal (ventricular hypertrophy) CAUSES:
Increase fiber diet
Echocardiography – cardiac Valvular changes. Allergens:
Increase fluid intake
Multigated angiographic (MUGA) – scar, info *Inhalance
ANTICOAGULANT:
about ejection fraction. *Ingestance
Heparin: (ANTIDOTE) Protamine sulfate COMPENSATORY MECHANISMS:
Coumadin: (ANTIDOTE) Vitamin K Cold air
Ventricular hypertrophy Dry air
SURGERY:
Ventricular dilation Airborne particles
1. PTCA (Percutaneous Transluminal Coronary
SNS – increase HR Microorganism
Angioplasty) – Coronary artery is dilated by a
INTERVENTIONS: Aspirin – inflammation
balloon catheter.
Upright position Exercise induce asthma
Nitrates
Upper Respi. Illness CAUSES: Antibiotics
Stress induce asthma 1. SMOKING: Bronchodilators
Unknown reason- bronchospasm Damaged air sacs Mucolytics
ASSESSMENT: Cigarettes contains hazardous substances that Humidification
Audible wheezing damage the lungs when inhaled NURSING MANAGEMENT:
Dyspnea, cough, barrel chest 2. ALPHA1-ANTITRYPSIN DEFICIENCY (ATT): Instruct pt. in postural drainage techniques
Cyanosis, poor O2 sat. Genetic CPT (Chest Physio Therapy)
Change of LOC, Tachycardia Protective in nature  PNEUMONIA 
LAB. ASSESSMENT: ATT is made by the liver and is normally present An inflammatory process affecting the bronchioles
ABG, Elevated eosinophils, IgE in the lungs. Elastase and unelastase and alveoli.
Tidal volume 500ml Regulates proteases from working on lung Most common cause of death.
Total lung capacity 6000 (inhale) deep breathing. structures CAUSES:
Vital capacity 4800 (exhale) ATT deficient COPD develop Infection
Residual vol. 1200 PATHOPHYSIOLOGY: Bacterial pneumonia
INTERVENTIONS: Loss of elasticity ➡ Air trapping ➡ impaired gas “TYPICAL PNEUMONIA” – S. Pneumonia, P. Carinii,
Improve airflow exchange ➡ s/s S. Aureus.
Relieve symptoms ATYPICAL PNEUMONIA – Mycoplasma pneumonia,
Loss of elasticity ➡ Air trapping ➡ Bullae/blebs
Prevent episodes
CLIENT EDUCATION: (air in alveolar) ➡ Pneumothorax chlamydia pneumoniae
CLASSIFICATION: Radiation therapy
Avoid factors that triggers asthma attack. Radiation Pneumonia
DRUG THERAPY: Panlobar or panacinar
Centrilobular or centriacinar Damage to normal lung mucosa during radiation
1. BRONCHODILATORS therapy.
B2 agonist Paraseptal or distal acinar
ASSESSMENT: Chemical Ingestion or inhalation
~ Direct bronchodilator Chemical pneumonia
~ Albuterol, bitolterol DOB upon exertion.
Chronic productive cough with mucopurulent Ingestion of kerosene, gasoline
Methylxanthines Aspiration of foreign bodies or gastric contents.
~ Aminophylline IV sputum.
Decreased breath sounds, wheezing, crackles. Aspiration pneumonia
~ increase BP, Tachycardia Inhalation of foreign objects during vomiting.
Cholinergic antagonist Barrel-shaped chest.
Hypoxemia with respiratory acidosis. ASSESSMENT:
~ blocks para sympathetic stimulation RR
~ bronchodilation Altered LOC
EMPHYSEMA – Pink puffer Fever and chills
~ Ipratropium Productive purulent cough
2. ANTI INFLAMMATORY CHRONIC BRONCHITIS – Blue bloater
MEDICAL MANAGEMENT: Chest pain due to pleural irritation
~ indirect bronchodilator Rust sputum
Corticosteroids Bronchodilator, mucolytics, antibiotics,
corticosteroids. Wheezing high pitched sound heard
~ Oral – Prednisone DIAGNOSTIC FINDINGS:
~ Inhaler – Budesonide NURSING MANAGEMENT:
Administer O2 via nasal cannula 3L/min Wheezing, crackles, decreased breath sounds.
Mast cell stabilizer Cyanosis
~ Comolyn sodium prevent atopic attacks Teach abdominal breathing
Pursed-lip breathing Sputum culture reveals infectious microorganism.
EXERCISE/ACTIVITY: Chest X-Ray shows areas of infiltrates and
Aerobic exercise COPD
consolidation.
~ Swimming General appearance MEDICAL MANAGEMENT:
OXYGEN THERAPY RR of 40-50 breaths/min Antibiotic
 BRONCHITIS  Presence of barrel chest Hydration to thin secretions
Cyanosis, clubbing fingers
 ACUTE BRONCHITIS  Supplemental O2
Manifestation of RSHF Fever, dehydration & inadequate nutrition.
Typically begins as on URTI (viruses, bacteria) PSYCHOSOCIAL:
H. Influenza, S. Pneumonia, M. Pneumonia NURSING MANAGEMENT:
Socialization may be reduced. Auscultate lung sounds
Chemical irritants LAB. ASSESSMENT:
ASSESSMENT: Check O2 sat and monitor ABG’s
Abnormal ABG (hypoxemia, Hypercarbia), Position in semi fowler’s
Fever, chills, malaise, headache, dry irritating non- Sputum culture, Hgb, Hct,
productive cough (initial) – mucopurulent sputum ⬆ fluid intake
Pulmonary function test Monitor I&O, skin turgor
MEDICAL MANAGEMENT: INTERVENTIONS:
Usually self-limiting Antipyretics as indicated
Airway maintenance – semi fowler’s
Bed rest, antipyretics expectorants, antitussives,  PLEURAL EFFUSION 
Monitoring – color, I&O, ABG, VS, LOC
increase fluid humidifiers, antibiotics Drug therapy – bronchodilators, antibiotic, Abnormal collection of fluid between the visceral and
 CHRONIC BRONCHITIS  antitussive, mucolytics parietal pleurae as a complication of:
Chronic cough O2 therapy – decrease flow of oxygen Pneumonia
Most days of the months, 3 months in a year, for 2 Chest physiotherapy and postural drainage Lung cancer
consecutive years. PNEUMONIA – Most common complication of TB
SMOKING SENSATION COPD. Pulmonary embolism
ASSESSMENT: COMPLICATIONS: CHF
Chronic productive cough Hypoxemia and acidosis GENERAL CLASSIFICATION:
Thick white mucus Respiratory infections Transudative Effusion:
MEDICAL MANAGEMENT: Cardiac dysrhythmias Protein poor, cell poor
Bronchodilators, increase fluid intake. Coronary pulmonale Hydrothorax – accumulation water.
NURSING MANAGEMENT: Exudative Effusion:
 BRONCHIECTASIS 
Stop smoking Protein rich fluid
An abnormal and permanent dilation of bronchi Pyothorax or Empyema – accumulation of pus.
Prevent infection
and bronchioles. Hemothorax – accumulation of blood
Immunization,
ASSESSMENT: Chylothorax – accumulation of lymph and lipoprotein
Monitor sputum
Chronic cough – blood streak sputum. ASSESSMENT:
 EMPHYSEMA  CXR & bronchoscopy – reveals increased size of
Most common cause of COPD. Fever
bronchioles, Atelectasis. Pain
Chronic disease characterized by loss of lung MEDICAL MANAGEMENT: Dyspnea
elasticity and hyperinflation of the lung and alveoli. Drainage of purulent material from bronchi. Friction rub (Pleurisy)
Dullness over involved area during chest percussion Analgesics ☺ DISTURBANCES IN
Absent breath sound Artificial airway
Chest X-ray and CT scan – shows fluid Antibiotics – prevent infxn OXYGENATION CARRYING
accumulation. ET intubation keep patent MECHANISM ☺
MEDICAL MANAGEMENT: NURSING MANAGEMENT:
Antibiotics Apply immobilize device.  COMPONENTS OF BLOOD 
Analgesics Deep breathing exercise. Plasma (55%)
Cardiotonic drugs Asses, monitor the pt. for signs of respiratory WBC and Platelets (<1%)
Thoracentesis distress, infection and increase pain. RBC (45%)
Insertion of CTT (closed tube Thoracostomy).  PNEUMOTHORAX   BONE MARROW PRODUCES 
Surgery if cause by cancer Accumulation of air in the pleural space. WBC – fight infection
THORACENTESIS It can lead to partial or complete collapse of the RBC – carry oxygen
Syringe on catheter removing fluid from around the lung (ATELECTASIS). Platelets – control clotting
lungs. TYPES:  NORMAL VALUES 
Explain the procedure to the pt. 1. Spontaneous pneumothorax: RBC COUNT
Reassure the pt. that he/she will receive local Common type of closed pneumothorax. Females: 4.2-5.4 million/uL
anesthesia. 2. Open pneumothorax: Male: 4.7-6.1 million/uL
Assist pt. to an appropriate position (sitting with arms Stabbing or gunshot wound. HEMOGLOBIN
and head on padded table or in side lying position on Mediastinal flutter – movement. Female: 12-16 g/dL
unaffected side). Emergency interventions: Male: 14-18 g/dL
Provide comfort to pt. ~ Covers with gauze or anything HEMATOCRIT
Monitor asepsis ~ To prevent open pneumothorax Female: 37-47%
Monitor VS ~ Decrease sounds Male: 42-52%
Apply small sterile pressure dressing on the site after ~ Hyperresonanse on palpitation WBC COUNT
procedure. No antecedent trauma to thorax 5,000-10,000/ uL
Position pt. on the unaffected side. Instruct to stay Emphysema PLATELETS
for at least 1hr. 3. Tension pneumothorax: 150,000-400,000mm3
NURSING MANAGEMENT: Complication of open pneumothorax. BILIRUBIN – end product of RBC destruction
(Pleural Effusion) Pressure in the pleural space is POSITIVE
CTT – monitor the function of the drainage system,  ANEMIA
throughout Respi cycle.
the amount and nature of drainage. Deficiency of RBC, Hgb, Hct.
Causes increase intrathoracic pressure.
Put at least 300ml of water CAUSES:
Mediastinal shift to unaffected side of
PRINCIPLE OF DIFFUSION: Excessive blood loss.
mediastinal structure from side to side.
Gravity Most serious. ⬇ production of RBC.
Suctioning Emergency interventions: Faulty production of RBC.
Small positive pressure ~ Remove cover during exhalation Excessive destruction of RBC.
ONE WAY BOTTLE – Drainage/ water seal ~ Chest tightness
NURSING DIAGNOSIS:
2 WAY BOTTLE – (1) Drainage; (2) Water seal. Activity Intolerance
 HEMOTHORAX 
3 WAY BOTTLE – (1) Drainage; (2) Water seal; (3) Objective: Fatigue, pallor, body weakness
Suction. Accumulation of blood in the pleural space. HEMORRHAGIC ANEMIA
Monitor chest tube drainage. Frequently found with an open pneumothorax in ~ Excessive blood loss.
Check tube for blockage or kinks. a hemopneumothorax. HYPO-PROLIFERATIVE ANEMIA
Check chest drainage system for air leaks. Chest trauma ~ ⬇ production of RBC.
~ Bubbling in the water seal or air leaks meter Hypovolemic shock HEMOLYTIC ANEMIA
indicates presence of air leaks. DIAGNOSTIC TESTS: ~ Excessive destruction of RBC.
Chest X-ray
Maintain the chest tube to water seal dry.  IRON DEFICIENCY ANEMIA 
~ Prevents air from entering the chest tube when BT
Microcytic, Hypochromic anemia.
client inhales. CBC
NORMAL:
~ Have pt. take several deep breaths to fully inflate Blood typing/ cross matching
Size- NOMOCYTIC
the lungs.  PNEUMOHEMOTHORAX  Color- NORMOCHROMIC
Care of dislodged chest tube. ASSESSMENT: CAUSES:
~ Cover immediately with petroleum gauze. Pain, dyspnea Inadequate intake of iron/ less intake.
~ Apply pressure to prevent negative inspiratory Absent breath sound on affected side. ⬇ absorption of iron GIT/ malabsorption.
pressure. Hyper-resonance on percussion. Excessive loss of iron (excessive bleeding or blood
 FRACTURED RIBS/ STERNUM  Tracheal shift to the opposite side. loss).
Common injury resulting from hard fall or a blow to Mediastinal shift. ASSESSMENT:
the chest. DIAGNOSTIC TESTS: Reduced energy, fatigue, cold sensitivity.
~ Motor vehicular accident (most frequent). Chest X-ray – reveals area and degree of ⬆ HR even at rest.
~ Secondary to fall injury. pneumothorax. ⬇ CBC, Hgb, Hct, serum Fe.
~ Sharp end of the broken rib may tear the lung. ABG (+) pressure, hypoxemia with respiratory Blood smear reveals microcytic and Hypochromic
~ FLAIL CHEST more than 1 rib. acidosis. RBC.
PARADOXIC MOVEMENT OF CHEST: PaCO2 ⬆ NURSING MANAGEMENT:
The chest is pulled INWARD during INSPIRATION. PaO2 ⬇ 1. Oral iron supplements for mild iron losses.
The chest bulges OUTWARD during EXPIRATION. NURSING MANAGEMENT: Prophylactic: 300-325mg
ASSESSMENT: ET TUBE suctioning. Therapeutic: 600-1200mg daily in divided dose.
Severe pain Assist with thoracentesis. 2. Take Fe with or immediately after meal to avoid GI
Shortness of breath Assist with the insertion of CTT. upset.
Hypotension Regain back the (-) Intrapleural pressure, Take with orange juice of vit. C (⬆ absorption)
Respiratory acidosis with hypoxemia. (-) fluctuation. Use STRAW (elixir prep) to prevent straining of
Chest x-ray confirms diagnosis. Valsalva maneuver. teeth.
MEDICAL MANAGEMENT: Air tight dressing. Expect iron to COLOR STOOL DARK GREEN OR
Immobilize fractured ribs. Insert 8-10inches of the Tube. BLACK (most certain)
Rib belt/ Elastic bandage Provide relief/control pain. Causes constipation.
Pulmonary complication PNEUMONIA & Administer analgesics as order. Parenteral (SEVERE) IM.
ATELECTASIS Position in high fowlers.
Use Z-TRACK technique to prevent leakage into Absence of neurologic problems in FADA. 2. HEREDITARY
tissue. Folic acid is need for RBC MATURATION Children
Change aspirating needle to prevent straining of the CAUSES: Hereditary spherocytosis G6PD deficiency, sickle
tissue. 1. Poor nutrition cell anemia, thalassemia
NO MASSAGE. 2. Malabsorption ASSESSMENT:
2. Provide dietary teaching regarding foods high in Crohn’s disease – Ulcerative colitis Dyspnea, pallor, fatigue, Jaundice (chronic), chills,
Iron 3. Drugs fever, Irritability
Liver (pork & lamb) Anti convulsant, oral contraceptives – prevent Abdominal pain,
Res meat, organ meats absorption Splenomegaly, hepatomegaly, cholelithiasis
Kidney beans ASSESSMENT: (gallstones).
Whole wheat breads Sore & beefy red tongue LAB. TESTS:
Leafy green vegetables ⬇ Hgb, Hct, serum Fe ⬇ Hgb/Hct
Carrots, egg yolk, raisins SCHILLING TEST ⬆ Reticulocyte count
3. ⬆ fluid intake to prevent constipation if oral iron MEDICAL MANAGEMENT: Coombs’ test (direct) (+) if autoimmune is presence.
prep is being taken. Folic acid supplements Bilirubin (indirect) ⬆ unconjugated fraction
 PERNICIOUS ANEMIA  Well balanced diet MEDICAL MANAGEMENT:
Malabsorption of Vitamin B12 NURSING MANAGEMENT: Eliminate the cause
Deficiency of INTRINSIC FACTOR Eat ⬆folic acid foods Administration of corticosteroids
INTRINSIC FACTOR is necessary for absorption if Oral hygiene, bed rest BT
VITAMIN 12  APLASTIC ANEMIA  Splenectomy (fails to respond to treatment)
VITAMIN B12 is needed for the MATURATION Deficiency of circulating RBCs usually NURSING MANAGEMENT:
ERYTHROCYTES (RBC) accompanied by leukopenia & Monitor s/s of hypoxia
Without Vitamin B12 thrombocytopenia. HEMOSTASIS/ BLOOD CLOTTING:
⬆ in size: MEGALOBLASTIC or MACROCYTIC PANCYTOPENIA in aplastic anemia. Blood clotting mechanism involves 3 sequential
CELLS CAUSES: process:
PARESTHESIA: vitamin B12 is needed for normal Failure of bone marrow to produce cells 1. Platelet aggregation with formation of a platelet
nerve function (Pluripotent stem cell injury). plug
Chronic gastritis Secondary to drugs and chemical. 2. Blood clotting cascade
Surgery – cancer in the stomach Viral infection 3. Formation of complete fibrin clot
Peptic ulcer disease Autoimmune Platelet plug formation triggers the blood clotting
ASSESSMENT: 50% cases UNKNOWN cascade mechanism
STOMATITIS (inflammation or oral mucosa) ASSESSMENT: Intrinsic pathway - direct in the blood
GLOSSITIS (beefy red tongue) Weakness& fatigue Extrinsic pathway – outside the blood; trauma.
Pallor, fatigue CBC – macrocytic anemia, leukopenia,  IDIOPATHIC/ AUTOIMMUNE
NEURO SYMPTOMS thrombocytopenia. THROMBOCYTOPENIC PURPURA 
Paresthesia, Paralysis Bone marrow/ biopsy – replacement of cells by Destruction of platelets causing slow blood clotting
Difficulty with gait or balance fats. process.
Numbness & tingling in arms and legs NURSING DIAGNOSIS: CAUSES:
SEVERE: Jaundice 1. Activity intolerance 1.Autoimmune
NURSING DIAGNOSIS: Fatigue, weakness, pallor Antibodies directed towards own platelets.
Risk for fall injury 2. Risk for bleeding injury r/t ⬇ platelet count ASSESSMENT:
Activity intolerance BONE MARROW ASPIRATION: Bruises, petechial rashes on arms, legs.
Pallor Most definite test Mucosal bleeding
Fatigue MEDICAL MANAGEMENT: Significant blood loss
Body weakness 1. BLOOD TRANSFUSION Intracranial bleed induced stroke (very rare).
HYPOCHLORHYDRIA - ⬇ in hydrochloric acid Whole blood DIAGNOSTIC FINDINGS:
ACHLORHYDRIA – Absence of hydrochloric acid MAINSTAY of Treatment. ⬇ Platelet count, Hgb, Hct
DIAGNOSTIC FINDINGS: Discontinued if pt.’s own marrow begins to Megakaryocytes in the bone marrow.
SCHILLING TEST produce blood cells. Presence of antiplatelet antibodies.
Collect 24 URINE 2. Antibiotic – for infection MEDICAL MANAGEMENT:
Definitive test for pernicious anemia 3. Corticosteroids – immunosuppressant Corticosteroids and Azathioprine (Imuran)
Radioactive B12 ingested ➡Injection of 4. BONE MARROW TRANSPLANT – definite Immunosuppressant
nonradioactive B12 given ➡ Urine samples are Treatment. Platelet transfusion
collected. Identification and withdrawal of offending drug. Maintain safe environment
MEDICAL MANAGEMENT: Antiviral NURSING MANAGEMENT:
Donor bone marrow cells repopulate recipient
Administration of Vitamin B12 IM: Daily ➡ weekly ➡ Control bleeding
bone marrow. Administer platelet transfusion as ordered
monthly (parenteral) ➡ LIFETIME NURSING MANAGEMENT:
NURSING MANAGEMENT: Apply pressure to bleeding sites as needed
Administer BT as ordered Position bleeding part above heart level as possible
Provide vitamin B12 rich diet Provide nursing care for pt with BM
Liver, organ meats, green leafy, citrus fruit Prevent bruising
Transplantation. Provide support to pt and be sensitive to change in
Avoid highly seasoned coarse or very hot foods if pt. Administer meds as ordered.
has stomatitis and glossitis body image
Implement reverse isolation. Measure normal circumference of extremities for
Bed rest ⬆ protein and vitamin diet to help reduce
Provide safety when ambulating (carrying hot items) baseline.
incidence of infection. Administer medications, orally, rectally, or IV rather
Provide pt teaching and discharge planning Oral hygiene.
Dietary instruction than IM: HOLD PRESSURE ON SITE FOR 5mins.
Avoid IM injection. Administer analgesics (ACETAMINOPHEN) as
Importance of lifelong vitamin B12 therapy Check for occult blood in urine an stool.
Rehabilitation and physical therapy for neurologic ordered avoid ASPIRIN.
 HEMOLYTIC ANEMIA   DISSEMINATED INTRAVASCULAR
deficits.
⬆ destruction of RBC COAGULATION (DIC) 
 FOLIC ACID DEFICIENCY ANEMIA 
120 days’ life span of RBC
Can cause MEGALOBLASTIC ANEMIA DIFFUSE FIBRIN DEPOSITION
CAUSES:
Similar manifestation in Vitamin B12 deficiency Widespread coagulation
1. ACQUIRED
EXCEPT FOR NERVOUS SYSTEM (FOLIC ACID Depletion of clotting factor
Cardiopulmonary bypass surgery, malarial infection,
DOES NOT AFFECT NERVE FUNCTION) hazardous chemicals, transfusion reaction.
HEMORRHAGE – kidneys, brain, adrenals, heart.
CAUSES: INTERVENTIONS: DM, hyperlipidemia, cigarette smoking
UNKNOWN – release of thromboplastic. 1. LIFESTYLE MODIFICATIONS ASSESSMENT:
Cancer Sodium restrictions Intermittent claudication
Thromboplastic substances in blood Weight reduction Rest pain
MORTALITY RATE IS HIGH Moderation of alcohol intake Inflow disease – discomfort in lower back
PATHOPHYSIOLOGY: Exercise Outflow disease – burning or cramping of feet, ankle,
Release of thromboplastic subs to promote blood STOP SMOKING toes.
clot ➡ RBCs trapped in fibrin strands and are 2. DRUG THERAPY Thickened toenails
hemolysed, platelets, prothrombin destroyed ➡ Diuretics Cold extremity and cyanotic
Excessing clotting activates fibrinolytic system w/c Calcium channel blockers Most sensitive and specific indicator of arterial
inhibits platelets function causing BLEEDING. ACE inhibitors (pril) function is the quality of the posterior tibial pulse
ASSESSMENT: Angiotensin II receptor blockers (Losartan) (NOT PALPABLE).
Petechiae, ecchymosis on the skin, mucous Aldosterone receptor antagonist Ulcer formation
membranes, heart, lungs Beta blocker DOC DIAGNOSTIC TESTS:
Prolonged bleeding COMPLICATION: Arteriography- not commonly performed.
Severe and uncontrolled bleeding Cardiomegaly Segmental systolic BP measurements – Ankle-
LAB. FINDINGS: Heart failure Brachial Index.
PT/ PTT/ Thrombin prolonged Arrhythmias Exercise Tolerance Testing – Using treadmill
Factor assays (II, V, VII) depressed. Hemorrhage (muscle pain).
MEDICAL MANAGEMENT: CVA INTERVENTIONS:
BT Renal failure 1. POSITIONING
HEPARIN administration  ANEURYSM (ABDOMINAL AORTIC Elevate the leg
Controversial ANEURYSM/ AAA)  Avoid crossing the leg
2. EXERCISE
☺ BLOOD VESSELS Permanent localized dilation on an artery which
To improve arterial blood flow
enlarges the artery to at least 2 times its normal
DISTURBANCES ☺ diameter.
3. PROMOTE VASODILATION
Provide warmth
ARTERIOSCLEROSIS – Thickening or hardening of Forms when the middle layer of artery is
STOP SMOKING
the arterial wall. weakened.
DRUG THERAPY:
ATHEROSCLEROSIS – Formation of plaque within Rupture increases
1. HEMORHEOLOGIC AGENT – Trental, decrease
arterial wall. TYPES:
blood viscosity by inhibiting platelet aggregation and
PATHOPHYSIOLOGY: 1. FUSIFORM – diffuse dilation affecting the
decrease fibrinogen thus increasing blood flow to the
Vascular damage: INFLAMMATION --> Fatty steak entire artery.
extremities.
formation --> PLAQUE. 2. SACCULAR – an out-pouching affecting only
Antiplatelet agent
 HYPERTENSION  a distinct portion of artery.
Plavix
A SYSTOLIC BP >135mmHg CAUSES:
SURGICAL MANAGEMENT:
A DIASTOLIC BP >85mmHg Unknown
Percutaneous transluminal angioplasty
ATHEROSCLEROSIS – common cause
NORMAL ADULT BP (2003) Bypass procedure; grafts preferred are saphenous –
<120mmHg systolic Hypertension
Femoral Artery Bypass Grafting.
<80mmHg diastolic CIGARETTE SMOKING
Pulsatile abdominal mass  BURGER’S DISEASE 
PREHYPERTENSION (120-139/80-89mmHg)
Pulsating – most telling sign “Thromboangitis”
STAGE 1 HYPERTENSION (140-159/90-99mmHg)
Bruit CAUSES:
STAGE 2 HYPERTENSION (>160/>100mmHg)
ASSESSMENT: Unknown
CAUSES:
Asymptomatic Identified in young adult men who smoke.
1. ESSENTIAL (PRIMARY):
Abdominal flank or back pain ASSESSMENT:
UKNOWN
S/S of hypovolemic shock Claudication
Risk factors:
DIAGNOSTIC FINDINGS: ⬆ sensitivity to cold, numbness
Family hx
X-ray reveals EGGSHELL appearance in cases Diminished pulse
SMOKING
of AAA INTERVENTION:
Stress
Serial abdominal UTZ STOP SMOKING
Obesity
Series of UTZ Treatment similar to PAD
>60y/o
2. SECONDARY: INTERVENTIONS:  RAYNAUD’S PHENOMENON/ DISEASE 
Crohn’s disease Nonsurgical management Caused by VASOSPASM of arteries
Cushing syndrome Maintenance of BP at a normal level Common in women
Pregnant Surgical management CAUSES:
Medications Abdominal aortic aneurysm resection UNKNOWN
Brain tumors  PERIPHERAL VASCULAR DISEASE  Cold and stress
⬆ fluid volume Disorders that alter the natural flow of blood ASSESSMENT:
⬆ peripheral vascular resistance through the arteries and veins of the peripheral Blanching of the extremities
Sympathetic nervous system circulation. Numbness, coldness, pain, swelling, ulcers.
ASSESSMENT: Most frequently affected are the LOWER Pallor, cyanotic, redness.
Headaches, dizziness, fainting EXTREMITIES. MANAGEMENT:
Orthostatic hypotension  PERIPHERAL ARTERIAL DISEASE  Calcium beta blocker
Tachycardia, sweating, pallor, pheochromocytoma, Chronic partial or total arterial occlusion resulting  VENOUS THROMBOEMBOLISM 
adrenal medulla tumor from systemic atherosclerosis leading to 1. Thrombus
Assess for stressor, job related. deprivation of o2 & nutrients. Blood clot usually as result of:
DIAGNOSTIC ASSESSMENT: “Lower extremity arterial disease”. (Virchow’s Triad)
NO LABORATORY TESTS ARE DIAGNOSTIC OF CLASSIFICATION: - Endothelial Injury
ESSENTIAL HPN 1. Inflow obstruction – Located above the - Hyper Coagulability
Presence of CHON, RBCs, ⬆BUN & CREA inguinal ligament. - Venous Stasis
Chest X-ray reveals cardiomegaly 2. Outflow obstruction – Below the superficial 2. Embolus – Blood clot/ air/ fat
BP monitoring 24hr femoral artery. 3. Thrombophlebitis – Thrombus associated with
CAUSES: inflammation.
Atherosclerosis – most common cause 4. Phlebothrombosis – Thrombus without inflammation.
 DEEP VEIN THROMBOPHLEBITIS/ DIAGNOSTIC TEST: ENDOSCOPIC THERAPIES:
THROMBOSIS (DVT)  Upper endoscopy – check for inflammation. 1. STRETTA PROCEDURE – the physician applies
Affects the Deep Vein of the Lower Extremities. Blood tests – Pernicious anemia radio frequency energy through needles placed near
CAUSES: Fecal occult blood test (stool test) – presence of gastroesophageal junction inhibiting the vagus nerve
Clot formation blood in your stool, a possible sign of gastritis. thus reducing the discomfort of the client.
NURSING CARE: 2. ENTERYX PROCEDURE – physician injects a
Undergone hip surgery or total knee replacement.
Invasive procedure such IV therapy. 1. If the patient is vomiting, give antiemetics. soft, spongy permanent implant made of liquid
SLE, polycythemia Vera 2. Administer I.V. fluids as ordered to maintain polymeric material into the LES muscle tightening
Trauma fluid and electrolyte imbalance. the LES.
ASSESSMENT: 3. When the patient can tolerate oral feedings, SURGICAL MANAGEMENT:
Calf or groin tenderness and pain. provide a bland diet that takes into account his 1. Laparoscopic Nissen Fundoplication- GOLD
Checking of HOMAN’S SIGN is not advised (pain in food preference. Restart feedings slowly. STANDARD PROCEDURE
the calf on dorsiflexion of the foot). 4. Offer smaller, more frequent servings to DRUG THERAPY:
Localized edema reduce the amount of irritating gastric secretions. 1. ANTACIDS: neutralizes HCL and deactivating
Contrast venography (GOLD STANDARD) 5. Help patient identify specific foods that cause pepsin.
MANAGEMENT: gastric upset and eliminate them from his diet. Aluminum hydroxide, magnesium hydroxide, Maalox,
Rest (do not massage on affected extremities) 6. Administer antacids and other prescribed Mylanta.
DRUG THERAPY: medications as ordered. 2. HISTAMINE2 (H2) RECEPTOR ANTAGONIST-
ANTICOAGULANT –DOC  GERD (GastroEsophageal Reflux decreases acid production of parietal cells.
Warfarin therapy Disorder)  Famotidine, Ranitidine (Zantac), Cimetidine
Thrombolytic therapy (Tagament), Nizatidine.
Backward flow (reflux) of stomach contents into
3. PROTON PUMP INHIBITORS (PPI'S): main
 VARICOSE VEINS (VARICOSITIES)  the esophagus resulting to inflammatory
treatment for GERD.
Dilated tortuous veins changes of the esophageal mucosa.
Inhibition of proton pump of the parietal cell thereby
Saphenous les veins – commonly affected. Hallmark of GERD: Reflux esophagitis (acute
decreases acid secretion.
Rectum symptoms of inflammation).
Omeprazole, Lansoprazole, Rabeprazole,
Hemorrhoids CAUSES:
Pantoprazole, Esomeprazole
Esophagus Inappropriate relaxation of the LES (lower
4. METOCLOPRAMIDE (REGLAN)
Esophageal varices esophageal sphincter).
Increase gastric emptying have EPS side effects.
CAUSES: Gastric volume or intra-abdominal pressure is
NURSING CARE:
Familial tendency elevated.
1. Diet therapy
Incompetent valves Delayed gastric emptying
Limit or eliminate foods that decreases LES pressure
Constricts or interferes with venous return. Abnormal esophageal clearance
(tobacco, chocolate, fatty food, caffeinated
Thrombophlebitis Irritation from reflux material
beverages such as coffee, tea, and cola,
ASSESSMENT: ASSESSMENT FINDINGS:
peppermints, alcohol).
Legs feel heavy and tired 1. Heartburn/Pyrosis
Restrict spicy and acidic foods (orange juice,
Distended and tortuous seen under skin Substernal or retrosternal burning sensation.
tomatoes).
Snakelike elevations Pain radiate to the neck, jaw, back (mimic
Carbonated beverages increase pressure in the
DIAGNOSTIC FINDINGS: ANGINA or MI).
stomach.
Bredie-Trendelenburg test – incompetent valves. 2. Regurgitation
2. Lifestyle changes
Ultrasonography Warm fluid traveling up the throat (sour or bitter
Sleep in the left lateral (side-lying) position to
Venography taste).
minimize the nighttime episodes of reflux.
MEDICAL MANAGEMENT: Danger for aspiration (note for crackles in the
lungs).  PEPTIC ULCER DISEASE 
MILD VARICOSE – Wearing elastic support
stockings. 3. Hypersalivation- "water brash" Peptic ulcer is an open sore that occurs in the
SEVERE VARICOSE – Surgery: Vein Ligation, Vein 4. Dysphagia- difficulty of swallowing protective lining of the Stomach (gastric ulcer),
Stripping. 5. Odynophagia- painful swallowing duodenum (duodenal), or esophagus (esophageal).
6. Barrett's epithelium: Peptic ulcers are more likely occur in the
☺ GASTROINTESTINAL ☺ Change of the normal squamous cell epithelium DUODENUM than in the stomach.
 GASTRITIS  to columnar epithelium. CAUSES:
Gastritis is an inflammation, irritation, or erosion of More resistant to acid as a result of healing 1. H. PYLORI BACTERIA
the lining of the stomach. It can occur suddenly process brought about by inflammation. Colonization of H. Pylori responses to increased
(acute) or gradually (chronic). Considered pre-malignant (high risk of gastrin, the increase in acid can contribute to erosion
CAUSES: esophageal cancer) in the clients with prolonged of the mucosa and therefore ulcer formation.
1. HELICOBACTER PYLORI (H. PYLORI) - GERD. 2. NSAIDs - Such as Ibuprofen and Aspirin
Bacteria that lives in the mucous lining of the 7. Chronic cough especially at night (due to 3. Diet – Dietary factor such as spice consumption
stomach; without treatment, the infection can lead to position), asthma. 4. Cigarette smoking
ulcers, and in some people, stomach cancer. 8. Eructation (belching) 5. Chronic anxiety
2. BILE REFLUX - A backflow of bile into the 9. Flatulence (gas) CLASSIFICATION:
stomach from the bile tract (that connects to the liver 10. Bloating after eating 1. DUODENAL ULCER
and gallbladder), 11. Nausea and vomiting Occur in the duodenum
3. If gastritis is left untreated, it can lead to a severe DIAGNOSTIC TEST: Pain relieved by meal
loss of blood and may increase the risk of 1. 24- hour ambulatory pH. monitoring: Most Epigastric pain 2-3hrs after meal
developing stomach cancer. accurate method Can cause melena
ASSESSMENT FINDINGS: Small catheter is placed through the nose into Heartburn, chest discomfort is less common but may
Nausea or recurrent upset stomach the distal esophagus, pH is continuously be seen.
Abdominal bloating monitored and recorded. Pain may awaken patient during the night.
Abdominal pain 2. Endoscopy (esophagogastro- 2. GASTRIC ULCER
Vomiting duodenoscopy) Occur in the stomach
Indigestion 3. Esophageal manometry- "motility testing" Pain increased by meal
Burning or gnawing feeling in the stomach between Water-filled catheters are inserted via the client's Epigastric pain 1hr after meal
meals or at night nose or mouth and slowly withdrawn while Can cause hematemesis
Hiccups instruments of LES and peristalsis are recorded; Heartburn, chest discomfort, early satiety is
Loss of appetite not specific enough to establish a diagnosis of commonly seen.
Vomiting blood or coffee ground-like material. GERD. Can cause gastric carcinoma (mostly in the elderly).
Black, tarry stools
ASSESSMENT FINDINGS: 2. Place patient in high fowlers position to FEVER, low grade (38-38.5)
Abdominal pain promote chest expansion. Teach patient to splint HIGH GRADE FEVER = RUPTURED
Bloating and abdominal fullness high upper abdominal incision before turning, DIAGNOSTIC TESTS:
Nausea and vomiting coughing and deep breathing. ⬆ WBC (10,000-15,000mm3)
Loss of appetite 3. Promote adequate nutrition. After removal of Elevated acetone in urine
Hematemesis (vomiting of blood) NGT, provide clear liquids with gradual Ultrasound & abdominal x-ray (detection of Fecalith).
COMPLICATIONS: introduction of small amounts of bland foods at Laparoscopy – A diagnostic laparoscopy may be
1. GASTROINTESTINAL BLEEDING frequent intervals. Instruct patient to eat smaller used to rule out acute appendicitis in equivocal
Most common and most serious complication. amounts of food at a lower pace. cases.
Hematemesis usually indicates GI Bleeding 4. Monitor weight daily. C-reactive protein – Protein produced by the liver
Coffee ground blood 5. Provide client teaching and discharge when bacterial infections occur and rapidly increases
2. PERFORATION planning within the first 12 hours.
A hole in the wall of the GI tract 6. Gradually increasing food intake until able to SIGNS OF RUPTURED APPENDICITIS:
Surgical EMERGENCY tolerate 3-meals/ day ⬆ in temperature.
Gastroduodenal contents leak into the surrounding 7. Avoid spicy food Change in pulse and blood pressure
abdomen. 8. Avoid Caffeinated drinks Generalized pain throughout the abdomen.
Sharp pain, client becomes apprehensive assuming 9. Daily weight monitoring Rigid and board-like abdomen
knee-chest position, chemical peritonitis occurs, 10. Need to report signs of complications to NURSING DIAGNOSIS:
bacterial septicemia and HYPOVOLEMIC SHOCK physician Acute pain related to inflammation.
follows. 11. Smoking cessation Risk for deficient fluid volume r/t vomiting.
DIAGNOSTIC TEST:  APPENDICITIS  Risk for infection r/t rupture of appendix.
1. Endoscopy – Reveals ulceration Inflammation of the appendix. MEDICAL MANAGEMENT:
2. Biopsy – Usually done to detect to detect H. It is a medical emergency, and if left untreated, 1. IV fluids – To correct fluid and electrolyte
Pylori infection and rule out malignancy. may rupture and cause a potentially fatal imbalance and dehydration, IV fluids are
3. CBC – Decrease Hemoglobin and Hematocrit infection. administered prior to surgery.
indicates bleeding CAUSES: 2. Antibiotic therapy – To prevent sepsis,
4. (+) occult blood in stool specimen Fecalith antibiotics are administered until surgery is
5. Gastric analysis – Normal gastric acidity in Lymphoid obstruction performed.
gastric ulcer (increase in duodenal ulcer). Infection 3. Drainage – When perforation of the appendix
MEDICAL MANAGEMENT: PREDISPOSING FACTOR: occurs, an abscess may form and patient is initially
DRUG THERAPY 1. OBSTRUCTIVE AGENTS treated with antibiotics and the surgeon may place a
1. ANTACIDS: Magnesium, Aluminum HCL, Sodium a. Foreign bodies: drain in the abscess.
Bicarbonate Parasites: thread worms, round worms SURGICAL MANAGEMENT:
2. H2 RECEPTOR ANTAGONIST: Cimetidine, Vegetables: seeds, date stones Immediate surgery is typically indicated if
Ranitidine, Nizatidine Mineral: Fecalith = common cause appendicitis is diagnosed.
3. PROTON PUMP INHIBITOR: Omeprazole Sub mucous lymphoid tissue hyperplasia leads APPENDECTOMY – Appendectomy or the surgical
4. ANTICHOLINERGICS: Atropine (Decrease to obstruction. removal of the appendix is performed as soon as it is
gastric juice secretions) 2. INFECTIVE AGENTS possible to decrease the risk of perforation.
5. ANTIBIOTICS: Metronidazole, Tetracycline (For a. Primary infection: leading to lymphoid LAPAROTOMY AND LAPAROSCOPY – Both of
H. Pylori infection). hyperplasia. these procedures are safe and effective in the
SURGICAL MANAGEMENT: b. Secondary infection: caused by pressure of treatment of appendicitis with perforation.
Surgery performed when PUD does not respond to an obstructed agent that leads to erosion and NURSING CARE:
medical management. bacteria gain access to the wall. Assess the level of pain.
1. VAGOTOMY c. Both aerobic and anaerobic organisms are Assess relevant laboratory findings.
Performed to reduce gastric acid secretion. involved including (coliforms, enterococci, Assess patient’s vital signs in preparation for
Transection of vagus nerve that eliminates the acid- bactericide and other intestinal commensals. surgery.
secreting stimulus to gastric cells and causing a PATHOPHYSIOLOGY: No medical treatment for appendicitis
decrease gastric acid secretion. Obstruction of the appendix lumen (mucosa Prevent perforation of the appendix; don’t give
2. PYLOROPLASTY continues to secret fluids until pressure within enemas or cathartics or use heating pad.
Performed in conjunction with vagotomy to widen the the lumen exceeds venous)  PANCREATITIS 
exit of pylorus to facilitate emptying of stomach ⬇ Pancreatitis is the inflammation of the pancreas
contents. ⬇ blood flow to appendix, mucosal inflammation/ Commonly described as AUTO DIGESTION of the
3. ANTRECTOMY (Gastroduodenostomy; Bilroth I) edema and bacterial proliferation. pancreas
Removal of the lower portion of the antrum of the ⬇ CAUSES:
stomach (which contains the cells that secrete Gangrene develops within 24-36 due to hypoxia 1. Alcoholism/ alcohol abuse
gastrin). ⬇ 2. Biliary tract disease/ biliary obstruction
4. GASTROJEJUNOSTOMY (Bilroth II) Abscess 3. Trauma, viral infection, penetrating duodenal
Removal of the antrum and the distal portion of the ⬇ ulcer, abscesses
stomach and duodenum with anastomosis of the Peritonitis 4. Drugs (antihypertensive, steroids, thiazide
remaining portion of the stomach to the jejunum. ASSESSMENT FINDINGS: diuretics, antimicrobials, immunosuppressive, oral
Creating a passage between the body of the PAIN starts at the epigastric or umbilical region contraceptives
stomach and the jejunum to permits neutralization of and becomes localized in the McBURNEY’s 5. Metabolic disorders (hyperparathyroidism,
gastric acid by regurgitation of alkaline duodenal POINT (midway between the umbilicus and the hyperlipidemia)
contents into the stomach. right anterior superior iliac crest). 6. Unknown/ autoimmune
6. ESOPHAGOJEJUNOSTOMY (TOTAL BLUMBERG SIGN – Rebound tenderness ASSESSMENT FINDINGS:
GASTRECTOMY) PSOAS SIGN – Lateral position with right hip PAIN (Midepigastric/LUQ radiating to back, flank or
Removal of the entire stomach with a loop of flexion. substernal area) accompanied by DOB (shallow
jejunum anastomosed to the esophagus. ROVSING SIGN – Right quadrant pain when the respiration with pain), aggravated by eating fatty
NURSING CARE PREOP: left is palpated. foods.
1. Informed consent OBTURATOR SIGN – Pain on external rotation Nausea and vomiting/ absent bowel sounds
2. NPO of the right thigh. Abdominal tenderness with muscle guarding.
5. GASTROENTEROSTOMY Nausea and vomiting (+) GREY TURNER’S SPOTS (ecchymoses on
3. Medications ANOREXIA, loss of appetite flanks)
NURSING CARE POSTOP: Coated tongue and bad breath (+) CULLEN’S SIGN (ecchymoses of periumbilical
1. Promote adequate pulmonary ventilation. Decreased bowel sounds area)
Tachycardia Inflammation caused by Crohn's disease can Bedrest.
DIAGNOSTIC TESTS: involve different areas of the digestive tract in Keep a record of the number of stools, their
⬆ SERUM AMYLASE (>300 somogyi units) and different people. consistency and color, and presence or absence of
LIPASE Small intestine (60%), colon (20%), or both blood.
⬆ Urinary amylase Terminal ileum: the site most often affected 2. PHARMACOLOGICAL AGENTS:
⬆ blood sugar CAUSES: a. 5 aminosalicylate-based compounds:
⬆ lipids levels UNKNOWN, thought to be autoimmune Sulfasalazine(Azulfidine), Mesalamine (5-ASA,
⬇ serum calcium Mycobacterium paratuberculosis Asacol, Rowasa), and Olsalazine (Dipentum)
CT SCAN: enlargement of the pancreas. Genetic predisposition (1st degree and identical b. Corticosteroid medications: Budesonide (Entocort)
MEDICAL MANAGEMENT: twins). c. Immunosuppressive and immunoregulatory drugs:
DRUG THERAPY PATHOLOGY: 6-mercaptopurine(Purinethol), methotrexate(Folex),
1. MORPHINE – Fentanyl and hydromorphone Deep fissures and ulceration develops  bowel azathioprine (Imuran), Cyclosporine(Sandimmune),
frequently as prescribed to achieve level of pain fistulas, anorectal fissure, and anal abscesses  and Infliximab(Remicade).
acceptable to pt. DIARRHEA and MALABSORPTION 3. INCREASE NUTRITIONAL INTAKE
Act by depressing the CNS and thereby increasing Chronic pathologic changes include thickening of Nutritional deficiencies are the most common
the pt.’s pain threshold. the bowel wall  narrowed lumen and strictures complications of IBD
2. HEPERIDIME (DEMEROL) is AVOIDED because  OBSTRUCTION 4. DIET AND SUPPLEMENTS
it has failed acute pain studies and it possesses ENTEROENTERIC FISTULA: Inc. CHON and calories
toxic metabolites. (Between intestine and intestine) Inc. dietary intake of folate and take Sulfasalazine
3. ANTACIDS to decrease pancreatic stimulation. Leaks that go through to a part of the intestines. between meals.
4. H2 ANTAGONISTS, VASODILATORS, CALCIUM EXTERNAL ENTEROCUTANEOUS: 5. TOTAL PARENTERAL NUTRITION
GLUCONATE. (Between skin and intestine) Indicated when the client has not responded to
Diet modification Enterocutaneous fistula is an abnormal medical intervention, is being prepared for surgery,
NPO usually fir a few days to promote GIT rest. connection between the intestines and the skin. or has undergone intestinal resection
Peritoneal lavage Intestinal or stomach contents can leak through Provides bowel rest by removing all stimulation of
Dialysis if the condition is severe this connection. The contents may leak into secretion and by decreasing fecal bulk.
NURSING INTERVENTIONS another part of the body or outside of the body. NURSING INTERVENTIONS:
1. Administer ANALGESICS (TOP PRIORITY), ASSESSMENT FINDINGS (CHRON’s and UC)
antacids, and anticholinergics as ordered, monitor Abdominal distention, masses, visible peristalsis. Maintain NPO during the active phase.
effects. Diarrhea; less severe than that of ulcerative Monitor for complications like severe bleeding,
2. Withhold food/fluid and eliminate odor and sight of colitis (steatorrhea is common and sometimes dehydration, electrolyte imbalance.
food environment to decrease pancreatic bloody). Monitor bowel sounds, stool and blood studies.
stimulations. Steatorrhea is fat in the stool, with oily and Restrict activities.
3. Maintain NGT and assess for drainage. greasy appearance and foul smell. Administer IVF, electrolytes and TPN if prescribed.
4. Institute non-pharmacologic measures to Anemia, fatigue, and metabolic disturbances. Instruct the patient to AVOID gas-forming foods
decrease pain. Constant abdominal pain (asparagus, broccoli, beans, cabbage, cauliflower,
Assist client to positions of comfort (knee chest, fetal Low-grade fever cucumbers), MILK products, and foods such as
position). Weight loss (80% of clients) whole grains, nuts, raw fruits and vegetables
Teach relaxation techniques and provide a quiet, Be aware to detect clinical manifestations of (Spinach), pepper, alcohol and caffeine.
restful environment. peritonitis, bowel obstruction, and nutritional and Low-fat diet (Butter, margarine, fried foods).
5. Provide client teaching and discharge planning fluid imbalances. Avoid spicy foods, caffeine, and alcohol.
concerning  ULCERATIVE COLITIS  Diet progression- clear liquid LOW residue, high
High CHO, High CHON, low fat diet. Ulcerative and inflammatory condition affecting protein.
Eating small, frequent meals instead of three large only the mucosal lining of the colon or rectum. Administer drugs like anti-inflammatory, antibiotics
ones Usually starts in the rectum and distal colon, (Metronidazole, Ciprofloxacin), steroids, bulk-forming
6. Initially the client with acute pancreatitis isn’t spreading upward (sigmoid and descending agents and vitamin/iron supplements.
permitted food and oral intake. colon). Eat small frequent meals.
7. Avoiding caffeine products Cause is UNKNOWN Drink plenty of liquids.
8. Eliminating ALCOHOL CONSUMPTION ASSESSMENT FINDINGS Crohn’s Ulcerative Colitis
9. Maintaining relaxed atmosphere after meals. Disease
Nausea and vomiting, anorexia
10. Recognition of signs of complications Transmural Characteristic Mucous
Fever ulceration
Continued N&V Weight loss Ileum Rectum/cecum
Abdominal distention with increasing fullness Decreased serum potassium concentration. Unknown Cause Unknown
Persistent wt. loss SEVERE DIARRHEA with rectal bleeding Familial Familial
Severe epigastric or back pain Anemia Environmental Emotional stress
Frothy/foul-smelling bowel movements Dehydration 15 to 40 y/o Age/peak 15 to 25 y/o
11. Irritability, confusion, persistent elevation of temp Colicky abdominal pain and cramping in the incidence 55 to 65 y/o
(2days) lower left quadrant. Less severe; Bleeding Severe; stool
stool with pus with blood, pus,
 INFLAMMATORY BOWEL DISEASE  Abdominal distention in severe ulcerative colitis.
or mucus. and mucus.
Chronic and recurrent DIAGNOSTIC TESTS
Common Fistulas Rare
Can occur in people at any age but usually are Blood test 20% Rectal 100%
diagnosed in young adults between 15 and 30 years Stool sample- involvement
of age. X-ray Rare Malignancy After 10 years
NO KNOWN CURE and NO PREVENTIVE CT scan 5 to 6 soft loose Diarrhea 20 to 30 watery
MEASURES. Treatment is symptomatic. Colonoscopy stool/day stool/day
The only risk factor identified are GENETIC. TOTAL PROCTOCOLECTOMY - surgical (+) Abdominal pain (+)
Cause remains unclear, but it probably involves a removal of the colon, rectum, and anus. Your TPN Intervention Diet, TPN
surgeon will perform it while you’re under Steroids Steroids
combination of genetic predisposition, environmental Azulfidine Azulfidine
conditions, defects in immune regulation. general anesthesia.
(Sulfasalazine) (Sulfasalazine)
 CROHN'S DISEASE  MEDICAL MANAGEMENT Ileostomy Ileostomy
Crohn's disease is an inflammatory bowel disease 1. DECREASE THE DIARRHEA Proctocolectomy.
(IBD). It causes inflammation of the lining of your Fluids, electrolytes, and blood are replaced as (+) Weight loss (+)
digestive tract, which can lead to abdominal pain, needed.
severe diarrhea, fatigue, weight loss and Physical activity should be kept to a minimum
malnutrition. during acute attack.
 PERITONITIS  Provide routine pre and post op care if surgery Sigmoidoscopy, colonoscopy, barium enema, CT
Local or generalized inflammation of part or all of the ordered. scan.
parietal and visceral surfaces of the abdominal  INTESTINAL OBSTRUCTION  SURGICAL MANAGEMENT:
cavity. It is a sort of a block which prevents food or 1. Any damaged parts of your bowel will be repaired
Acute or chronic and can be life threatening. liquids to pass from the small intestine to the or removed. This procedure is called BOWEL
PATHOLOGY large intestine. RESECTION.
1. Initial response It can be partial or complete. 2. If a section is removed, the healthy ends will be
ABDOMINAL PAIN & RIGIDITY CLASSIFIED AS: reconnected with stitches or staples. Sometimes,
Edema, vascular congestion, hypermotility of the 1. MECHANICAL INTESTINAL OBSTRUCTION when part of the intestine is removed, the ends
bowel and outpouring of plasma-like fluid from the Physical blockage of the passage of intestinal cannot be reconnected. If this happens, the surgeon
extracellular, vascular, and intestinal compartments contents with subsequent distention by fluid and will bring one end out through an opening in the
into the peritoneal space. gas. abdominal wall. This may be done using a
2. Later response CAUSES: colostomy, ileostomy, or mucous fistula.
Abdominal Distention leading to respiratory a. ADHESIONS – Bands of granulations & scar 3. Adhesiolysis (Severing of adhesive band(s); done
compromise, hypovolemia results in decreased tissue that develop as a result of an by laparoscopy or laparotomy.
urinary output inflammatory response encircling the intestines NURSING INTERVENTIONS:
Intestinal motility gradually decreases and & constricting its lumen. Monitor F&E imbalance, prevent further imbalance,
progresses to paralytic ileus. b. HERNIAS – Protruding of intestine on a keep client, NPO, and administer IV fluids as
There is NO risk factors because the condition is a weaken part of abdomen. ordered.
result of another problem c. VOLVULUS – Twisting of intestine. Usually on Most clients with an obstruction have at least an
CAUSES sigmoid and cecum. NGT. Accurately measure the drainage from
1. Primary d. INTUSSUSCEPTION – Telescoping of a NG/intestinal tube.
Blood borne organisms segment of the intestine within itself. Put in Fowler's position (alleviate pressure on the
Genital tract organisms e. Inflammatory Bowel Disease, Foreign Bodies, diaphragm).
2. Secondary Structures, Neoplasms & Fecal Impaction. Encourage nasal breathing to minimize swallowing
Perforation and Peritoneal dialysis – Common 2. NON-MECHANICAL INTESTINAL of air and further abdominal distention.
Ruptured appendicitis, Obstruction OBSTRUCTION Institute comfort measures associated with NG
Trauma (Blunt or Penetrating) “paralytic”, “neurogenic” or “a dynamic ileus”. intubation and intestinal decompression.
Ruptured diverticulitis, PUD, UTI Brought about by interference with the nerve PREVENT COMPLICATION:
Pancreatitis, Ischemic Bowel disorders supply to the intestine resulting in decreased or Measure abdominal girth daily to assess increasing
Post-operative complication absent peristalsis. abdominal distention.
Bacterial – E. coli, Klebsiella, S. pneumoniae. CAUSES: Assess for sign & symptoms of peritonitis.
ASSESSMENT FINDINGS a. Handling of the intestine during abdominal Monitor urinary output.
Abdominal pain, dullness to percussion surgery.
Rigid, board-like abdomen b. Thoracic Diseases – Rib fracture, MI &
Blumberg’s Sign – Rebound tenderness in the pneumonia
abdomen. c. Hypokalemia
Decreased peristalsis, abdominal distention, inability d. Peritonitis
to pass flatus or stool, anorexia, nausea and e. Shock
vomiting. f. VASCULAR OBSTRUCTIONS – Interference
High fever and tachycardia, tachypnea, Oliguria, with the blood supply to a portion of the intestine,
Restlessness, Weakness, pallor, Diaphoresis. resulting in intestinal ischemia and gangrene of
Possible compromise in respiratory status. the bowel; caused by an embolus,
DIAGNOSTIC TEST atherosclerosis.
WBC Elevated (20,000/cu mm or Higher) PATHOPHYSIOLOGY
Hct elevated (Hemoconcentration) Obstruction in the intestine
MEDICAL MANAGEMENT ⬇
Maintain fluid & electrolyte balance Blockage
NPO č fluid replacement ⬇
Fluid, electrolyte and colloid replacement, TPN  CHOLECYSTITIS 
Distention of proximal intestine
solutions if prescribed ⬇ Acute or chronic inflammation of the gallbladder.
NGT is inserted to relieve abdominal distention CAUSES:
Pain, increase abdominal girth, increase tension
Peritoneal lavage č warm saline in intestinal wall CBD blockage.
Insertion of drainage tubes Excessive cholesterol in gallbladder, which can
⬇
Control infection happen during pregnancy or after rapid weight loss.
Complications: Tissue Death/ Perforation of
Drug therapy: broad spectrum IV antibiotics to Decreased blood supply to the gallbladder because
Bowel, Infections
combat infection, analgesics for pain ASSESSMENT FINDINGS: of DM.
SURGICAL MANAGEMENT Tumors in liver or pancreas.
High-pitched bowel sound above the level of
Exploratory laparotomy – To remove or repair the Tumors in gallbladder, which are rare.
obstruction.
inflamed or perforated organ. CHOLELITHIASIS:
Decreased or absent bowel sound below the
Colon resection with or without colostomy The formation of gallstones.
level of obstruction.
Draining of Peritoneal fluid following surgery – Use More common in women after age 40 (estrogen
CARDINAL SIGNS:
of Penn-rose Drain therapy) women taking oral contraceptives and
Abdominal distention
NURSING INTERVENTIONS obese.
abdominal pain
Assess Respi. Status for possible distress. PATHOPHYSIOLOGY
vomiting
Assess characteristics of abdominal pain and Metabolic factors obesity, pregnancy, diabetes
obstipation (severe constipation)
changes over time. mellitus, hypothyroidism, statis may all lead to:
weight loss
Administer medications as ordered. Stagnation of bile in gallbladder
DIAGNOSTIC TESTS:
Perform frequent abdominal assessment. Flat-plate & upper right X-rays reveals presence ⬇
Monitor and maintain fluid & electrolytes balance, of gas and fluid. Excessive absorption of water
monitor for signs and septic shock. Increase Hgb/Hct, BUN & Creatinine (indicative ⬇
Maintain patency of NG or intestinal tubes. of dehydration). Precipitation of salts (stones)
Encourage deep breathing exercises. Decrease serum Na, Cl, K. Gallstones are composed primarily of cholesterol
Place client in fowler’s position to localize peritoneal Increase serum venous CO2 concentration & (80%), bile salts, Ca++, bilirubin & CHONs.
contents. other values indicate metabolic acidosis.
ASSESSMENT FINDINGS 4. Resume sexual activity as desired unless  VIRAL HEPATITIS E 
Most patient is asymptomatic. ordered by the physician. Similar to hepatitis A with FECAL OR ORAL
When symptomatic, pain in RUQ and epigastric. 5. Clients having laparoscopy cholecystectomy TRANSMISSION there is no chronic form.
Pain lasting approximately 30 minutes. usually resume normal activity within 2 weeks. The risk of fulminant disease has been described
Fever and leukocytosis (inc.WBC) 6. Recognition and reporting of signs of mainly in pregnant patients.
1. CHARCOT TRIAD complications (fever, jaundice, pain dark urine, ASSESSMENT FINDINGS:
Fever, jaundice, pain in RUQ (ascending cholangitis) pale stools, pruritus). 1. PREICTERIC STAGE (PRODROMAL PHASE)
2. Intolerance for fatty foods – stearrhea, N&V,  HEPATITIS  1 week
sensation of fullness Infectious inflammation of the liver parenchyrna Anorexia (major manifestation)
3. Pruritus, easy bruising, dark amber urine caused by bacteria, viruses and other N&V
DIAGNOSTIC TEST: microorganisms. Fatigue
1. Direct bilirubin transaminase, alkaline phosphate, Widespread inflammation of the liver tissue. Constipation, diarrhea
WBC, amylase, lipase: all increased. Liver cell damage due to hepatic cell Weight loss
2. Oral cholecystogram (gallbladder series) – degeneration and necrosis. RUQ discomfort
Positive for gallstone. Proliferation and enlargement of the Kuepfer Hepatomegaly
NURSING INTERVENTIONS: cells. Splenomegaly
Administer pain medication as ordered and monitor Inflammation of the periportal areas Lymphadenopathy
for effects. causing interruption of the bile flow. 2. ICTERIC STAGE
Administer IV fluids as ordered.
 VIRAL HEPATITIS A  Fatigue
Provide small frequent meals of modified diet, low fat Weight loss
ssRNA VIRUS transmitted via FECAL-ORAL
if oral intake allowed. Light-colored stool
ROUTE.
Provide care to relieve pruritus. Dark urine/ tea color
Poor hygiene or contaminated food and shellfish
Provide care for the client with cholecystectomy or Hepatomegaly č tenderness
increase risk of transmission.
choledochostomy. Lymphadenopathy
Incubation period 15-45days.
Pre-Op Care: Splenomegaly
HIGHLY CONTAGIOUS.
Informed Consent, NPO, Medication Jaundice
Post- Op Care:  VIRAL HEPATITIS B 
Pruritus
1. Provide routine. DNA VIRUS, identified in all body fluids; blood,
3. POSTICTERIC STAGE
2. Position client to semi fowler’s position or side saliva, synovial fluid, breast milk, ascites,
Fatigue but increased sense of well being
lying positions; reposition frequently. cerebral spinal fluid.
HEPATOMEGALY gradually decreasing
3. Splint incision when turning, coughing and deep Transmitted by blood and blood fluids, often from
COLLABORATIVE MANAGEMENT
breathing. contaminated needles among IV drug abusers,
Promotion of REST to relieve fatigue.
4. Maintain/monitor functioning of T-tube ensure that intimate/ sexual contact.
Maintenance of FOOD & FLUID intake; ⬆ CALORIE,
T-tube is connected to closed gravity drainage – 50% of cases of fulminant hepatitis.
⬆ PROTEIN (CHO).
Avoid kinks, clamping, or pulling of the tube. Incubation period is very long 1-6mos.
3,000 ml/day of fluids for fever and vomiting; monitor
5. Measure and record drainage every shift. RISK FACTORS:
I&O, wt.
Expect 300-500ml bile color drainage for the 1st People who share needles
Well balance diet; encourage fruit juices, carbonated
24hours then 200ml/24hours for 3-4days. Health workers who are exposed to infected
beverages.
6. Asses for signs of peritonitis. blood
Fats may need to be restricted.
7. Monitor color of urine and stools (stools will be POSSIBLE SYMPTOMS
Alcoholic beverages should be avoided.
light colored if bile is flowing through T-tube but Pain in the upper right quadrant of abdomen
Prevention of injury.
normal color should be reappear as drainage N&V
Monitor pt (bleeding tendencies): plan so that all
diminishes. Loss of appetite
blood samples are collected at one time to avoid
8. Asses skin around T-tube; cleanse frequently and Jaundice
several punctures.
keep dry. Fatigue
Avoid parenteral injections.
MEDICAL MANAGEMENT: Itching
Apply pressure to injection sites and venipuncture
Supportive treatment: NPO with NG intubation and Hepa B vaccine protects against serious dse
sites for 5mins.
IV fluid. causing inflammation and damage to the liver.
Monitor Hgb/Hct, urine and stools for fresh or old
Diet modification with administration of fat soluble  VIRAL HEPATITIS C  blood; the skin for Petechiae.
vitamins. ssRNA VIRUS generally transmitted Advise client to use soft toothbrush or swabs.
DRUG THERAPY: predominantly by blood products. Administer Vit. K as ordered.
1. Narcotic analgesics (morphine is the drug of Currently the most common hepatitis among IV Provision of comfort measures.
choice) for acute severe pain. drug abusers and in prisons. Relaxing baths, backrubs, fresh linens and quiet
2. The use of Demerol is controversial (Brunner, 90% of transfusion hepatitis in 1990. dark environment.
2010). Incubation: 2wks-6mos. Relieve pruritus through the ff measures.
3. Anticholinergics (atropine) may use for pain High risk of progression to chronic form. Use cool, light, non-restrictive clothing.
4. Antiemetic Associated with extrahepatic manifestations Use of soft, dry, clean bedding, use warm baths.
SURGERY MANAGEMENT: commonly: mixed cryoglobulinemia and Apply of emollient creams and lotions to dry skin.
CHOLECYSTECTOMY – removal of the bladder polyarteritis nodosa. VIRAL HEPATITIS
with insertion of T- tube into the common bile duct  VIRAL HEPATITIS D  Source Route of Chronic Prevention
exploration is performed. RNA VIRUS that infects either simultaneously of virus transmission infection
CHOLEDOCHOTOMY – opening of common duct with hepatitis B or as a super infection in a A Feces Fecal oral No Pre/post
removal of stone and insertion of T- tube. person with chronic hepatitis B. exposure
LAPAROSCOPIC CHOLECYSTECTOMY – Hepatitis D infection cannot occur unless there is immunization
performed via of under complicated cases when B Blood/ Percutaneous/ Yes Pre/post
current and ongoing replication of the hepatitis B
client has not had previous abdominal surgery. body permucossal exposure
virus. fluids immunization
CHOLECYSTOSTOMY – opening of gallbladder to Overall, this infection carries the highest risk C Blood/ Percutaneous/ Yes Blood donor
remove stones. among acute viral hepatitis for fulminant disease, body permucossal screening
CHOLEDOCHOSTOMY – surgical incision of the the risk is even greater in super infection. fluids risk behavior
common bile duct usually to effect drainage. Predominantly seen in patients exposed to blood modification
NURSING HEALTH TEACHING: products (drug addicts and hemophiliacs). If anti D Blood/ Percutaneous/ Yes Pre/post
1. Adherence to dietary restrictions. HBs antibodies are present, then that person is body permucossal exposure
2. Resumption of ADL. fluids immunization
immune to hepatitis B and D.
3. Avoid heavy lifting for at least 6 weeks. E Feces Fecal oral No Ensure safe
drinking water
 LIVER CIRRHOSIS  2. Stop drinking alcohol. You need to quit Sensation of incomplete evacuation of the rectum.
Chronic, progressive disease characterized by completely. Talk to your doctor about all of the Internal hemorrhoids may prolapse, usually painless.
inflammation, fibrosis, and degeneration of the liver medicines you take, including nonprescription External hemorrhoids are usually painful.
parenchymal cells. drugs such as acetaminophen (for example, SURGICAL MANAGEMENT
Destroyed liver cells are replaced by scar tissue, Tylenol), aspirin, ibuprofen (for example, Advil or Hemorrhoidectomy
resulting in architectural changes & malfunction of Motrin), and naproxen (Aleve). These could Sderotherapy (5% phenol in oil)
the liver. increase the risk of liver damage and bleeding. Cryosurgery
TYPES 3. Get immunized (if you have not already) Rubber band ligation (done only if hemorrhoids are
1. Laennec’s cirrhosis – associated with alcohol against hepatitis A and hepatitis B, influenza, internal)
abuse and malnutrition; characterized by an and pneumococcus. Begin following a low- NURSING MANAGEMENT
accumulation of fat in the liver cells, progressing to sodium diet if you have fluid buildup (ascites). High fiber diet
widespread scar formation. Reducing your sodium intake can help prevent Liberal fluid intake
2. Postnecrotic cirrhosis – results in severe fluid buildup in your belly and chest. Bulk laxatives
inflammation with massive necrosisas a complication NURSING INTERVENTION Hot sitz bath, warm compress, witch hazel cream
of viral hepatitis. 1. Provide bed rest with bathroom privileges. can be applied to decrease size
3. Cardiac cirrhosis – occurs as a consequence of Encourage gradual, progressive, increasing Local anesthetic application – nupercaine
RSHF; manifested by hepatomegaly with some activity with planned rest periods. PRE OP CARE:
fibrosis. Institute measures to relieve pruritus. Low residue diet to reduce the bulk of stool
4. Biliary cirrhosis – associated with biliary 2. Do not use soaps and detergents. Stool softener
obstruction, usually in the common bile duct; results 3. Bathe in tepid water followed by application of POST OP CARE:
in chronic impairment of bile excretion. an emollient lotion. 1. Promotion of comfort
ASSESSMENT 4. Provide cool, light, nonrestrictive clothing. Analgesics as prescribed
1. Early stage: Anorexia, weakness, weight loss 5. Keep nail short to avoid skin excoriation from Post op position: SIDE LYING OR PRONE
(liver is unable to metabolize nutrients and store fat- scratching. POSITION
soluble vitamins) 6. Apply cool, moist compresses to pruritic HOT STZ BATH 12-24Hrs post op to promote
2. Fever (in response to tissue injury) areas. comfort and fasten healing
3. Jaundice, pruritus, tea colored urine (due to 7. Encourage small frequent feedings. 2. Promotion of elimination
increased bilirubin in the blood). 8. Promote a high-calorie, low to moderate Stool softeners are given as prescribed
Remember-bilirubin is conjugated initially before protein, high CHO, low fat diet, with Analgesics before initial defecation
excretion. supplemental vitamin therapy (vitamins A, B Encourage the client to defecate as soon as the urge
4. Increased Bleeding tendencies (liver is unable to complex, C, D, K, and folic acid). occurs
store vit. K. There is also impaired production of 9. Prevent skin breakdown by frequent turning Enema as prescribed, using a small – bore rectal
clotting factors). and skin care. tube
5. Portal HPN 10. Provide reverse isolation for clients with PATIENT TEACHING
CONSEQUENCES OF PORTAL HPN severe leukopenia; pay special attention to hand 1. CLEAN rectal area thoroughly after each
1. Hepatomegaly initially, then the liver shrinks in washing technique. defecation.
size as fibrosis replaces the liver parenchyma. 11. Monitor WBC. 2. SITZ BATH at home especially after defecation
2. Splenomegaly due to increased backpressure of 12. Monitor/prevent bleeding. 3. AVOID CONSTIPATION by adhering to these
the blood. 13. Administer diuretics as ordered. practice:
3. Caput mucosae (dilated veins over the abdomen). 14. Provide client teaching & D/C planning High fiber diet, high fluid intake, regular exercise
4. Spider angioma (telangiectasia/dilated capillaries concerning: Regular time for defecation, use stool softener until
over the face and anterior trunk) = due to increased 15. Avoidance of agents that may be hepatotoxic healing is complete
estrogen (sedatives, opiates, or OTC drugs detoxified by 4. NOTIFY PHYSICIAN for the ff:
5. Palmar erythema this is also due to elevated the liver). Rectal bleeding, suppurative drainage, continued
estrogen level in males. 16. How to assess for weight gain and increased pain on defecation, continued constipation
6. Ascites abdominal girth.  DIVERTICULITIS 
7. Males (increased estrogen) will result to: 17. Avoidance of persons with upper respiratory Acute INFLAMMATION and infection caused by
Decreased libido, impotence, fall of body hair, infections. trapped fecal material and bacteria in the
atrophy of testicles, gynecomastia 18. Avoidance of alcohol. diverticulum that can impede the drainage and lead
8. Females (increased androgen) 19. Avoidance of straining at stool, vigorous to perforation or abscess formation.
Hirsutism blowing of nose and coughing, to decrease the DIVERTICULUM is outpouching of the mucosal
Acne incidence of bleeding. lining of the GI tract commonly in the colon (95% is
Deepening of voice  HEMORRHOIDS  in sigmoid colon).
Virilism (development or premature development of These are dilated blood vessels beneath the DIVERTICULA/ DIVERTICULOSIS are multiple
male secondary sexual characteristics) lining of the skin in the anal canal. outpouchings without inflammation or symptoms.
HEPATIC ENCEPHALOPATHY TYPES ASYMPTOMATIC: unknown.
1. Accumulation of AMMONIA because the liver 1. EXTERNAL HEMORRHOIDS – Occur below At least 10% of pt.’s with diverticulosis have
cannot convert ammonia into urea that can lead to the anal sphincter diverticulitis.
hepatic coma (ammonia is by product of CHON 2. INTERNAL HEMORRHOIDS – Occur above CAUSES
metabolism). the anal sphincter Low fiber diet
2. Initial manifestations: BEHAVIORAL changes and CAUSES Chronic constipation
MENTAL changes Chronic constipation Obesity
3. Other findings in advanced stages are: Pregnancy ASSESSMENT FINDINGS
asterixis-flapping tremors of the hands Obesity Dull, steady, cramp like lower left quadrant
Confusion/disorientation Prolonged sitting or standing abdominal PAIN worsens with movement, coughing
Delirium/hallucination Wearing constricting clothing or straining.
Fetor hepaticus-disagreeable odor from the mouth Disease conditions like liver cirrhosis, RSCHF Low grade FEVER.
Coma ASSESSMENT CHRONIC CONSTIPATION with episodes of
4. PT prolonged Constipation in an effort to prevent pain or diarrhea.
5. Serum albumin decreased bleeding associated with defecation. Nausea and vomiting.
6. Hgb/Hct decreased ANAL PAIN Abdominal distention and tenderness.
7. BSP increased Rectal bleeding (usually bright red- Occult bleeding, rectal bleeding, change bowel
MEDICAL MANAGEMENT hematochezia). movement.
1. Lifestyle Anal itchiness. S/S of PERITONITIS due to development of abscess
Mucous secretions from anus. or perforation.
The symptoms manifested generally result from Onset 40 y/o Slow absorption, less painful, 90 ° (thin) 45° obese
complications: Common in obese adults clients, no need to aspirate, do not massage site of
Abscess Prone for HHNKS injection.
Fistula formation MANAGEMENT 2. Administer insulin at room temperature.
Obstruction Diabetic diet a. Cold insulin can cause lipodystrophy
Perforation OHA Lipoatrophy- loss of subcutaneous fat usually
Peritonitis Exercise caused by the utilization of animal insulin.
Hemorrhage ASSESSMENT Lipohypertrophy – development of fibrofatty masses,
DIAGNOSTIC TEST Polyuria usually caused by repeated use of injection site.
COLONOSCOPY, SIGMOIDOSCOPY – Polydipsia 3. Store vial of insulin in current use at RT
Visualization of diverticula Polyphagia Insulin can be stored at RT for 1 month.
CBC may reveal INCREASED WBC COMPLICATIONS Other vials should be refrigerated
BARIUM ENEMA is NOT usually ordered in cases of 1. MACROANGIOPATHY 4. Rotate the site of injection
ACUTE INFLAMMATION because of possibility of Brain (Cerebrovascular accident) To prevent lipodystrophy
perforation. Heart (Myocardial infarction) Lipodystrophy inhibits insulin absorption
NURSING MANAGEMENT Peripheral Arteries (Peripheral vascular disease) 5. Gently roll vial in between the palms to redistribute
High fiber diet. 2. MICROANGIOPATHY insulin particles.
Increased fluid intake of 2,500-3,000ml/day. Kidneys (Renal failure due to neuropathy) 6. DO NOT SHAKE
AVOID NUTS AND SEEDS which can be trapped in Eyes (Cataract due to retinopathy) Bubbles make it difficult to aspirate exact amount.
the diverticula. 3. NEUROPATHY 7. Observe for side effects of Insulin Therapy
Bulk – forming laxatives are ordered to restore Spinal Cord/ ANS a. Localized: Induration or Redness, welling, Lesion
normal bowel pattern. Peripheral Neuropathy (involved damage to the at the site, Lipodystrophy
IVF and medications PNS/ affect movement, sensation and bodily b. Generalized:
A bulk laxative: PSYLLIUM HYDROPHILIC functions (numbness/ tingling) Edema - Due to sudden resolution of hyperglycemia
MUCILLOID (METAMUCIL) Paralysis Hypoglycemia
During an ACUTE EPISODE Gastroparesis (delayed gastric emptying) Somogyi phenomenon
Bed rest Neurogenic Bladder (bladder does not empty GENERAL NURSING INTERVENTION:
NPO, then clear liquids to rest the bowel. properly) 1. Monitor urine sugar and acetone (freshly voided
AVOID HIGH FIBER foods to prevent further Decreased Libido, Impotence specimen)
irritation of the mucosa. DIAGNOSTIC TESTS 2. Perform finger sticks to monitor blood glucose
Gradually increase the fiber when the infection/ Random blood sugar (RBS) levels as ordered
inflammation subsides. Fasting blood sugar (FBS) 3. Observe for signs of hype and hyperglycemia
 DIABETES MELLITUS  Postprandial blood sugar (PBS) 4. Provide meticulous skin care and prevent injury.
A chronic metabolic disease characterized by Oral glucose tolerance test (OTT) 5. Maintain intake and output; weigh daily.
HYPERGLYCEMIA due to disorder of carbohydrate, MANAGEMENT 6. Provide emotional support, assist client in
fat and protein metabolism. 1. DIET adapting to change in life style and body image.
PREDISPOSING FACTOR Low caloric diet specially if obese 7. Observe for chronic complications and plan care
Hereditary Diet should be in proportion accordingly.
Obesity 20% CHON 8. Provide client teaching and discharge planning
Stress – stimulates secretion of epinephrine, nor- 30% FATS concerning:
epinephrine, glucocorticoids ➡ increased serum 50% CHO a. Disease process
Consume complex CHO and HIGH FIBER DET b. Diet
carbohydrates.
– it inhibits glucose absorption in the intestines c. Insulin – insulin at RT, gently roll vial between
Viral infection – increase risk to autoimmune
2. EXERCISE palms of hands, draw up insulin using sterile
disorders.
Increased CHO uptake by the cells. technique, if missing insulin, draw up clear insulin
Autoimmune disorders – more associated with type
Decreased insulin requirements. before cloudy insulin.
1 DM.
Multi gravida women – with large babies. Maintain ideal body weight, serum CATEGORIES OF INSULIN
TIME AGENT ONSET PEAK DURA- INDICATION
TYPES OF DM carbohydrates and serum lipids COURSE TION
1. Type 1 Guidelines: Rapid Lispro 10-15 1h 2-4 h Used for
allow additional sources of CHO like snacks acting (Humalog) min 40-50 2-4 h rapid
2. Type 2 Aspart 5-15 min 2h reduction of
3. Gestational Diabetes during exercises (Novolog) min 30-0 glucose
4. Diabetes associated with other conditions or exercise is done 1-2 hours after eating to Glulisine 5-15 min level, to treat
(Apidra) min postprandial
syndromes: prevent hypoglycemia hyper
a. Pancreatic dse, Cushing’s exercise must be regular pattern rather than glycemia,
and/or to
b. Use of certain drugs sporadic to maintain stable serum carbohydrate prevent
Steroids levels. nocturnal
hypo
Thiazide diuretics 3. MEDICATIONS glycemia.
Oral contraceptives a. Insulin Short Regular 1 ½- 1h 2-3 h 4-6h Usually
used for type 1 diabetes acting (Humalog administered
 TYPE 1 DM  R., 20-30 min
used in type II diabetes (client in stressful Novolin R, before a
Insulin dependent diabetes mellitus (IDDM)
situation or hospitalized. Iletin II meal; maybe
JUVENILE – onset, brittle DM, Unstable DM Regular) taken alone
pregnant client and diabetic clients with allergy or in
Onset is less than 30y/o
or severe insulin resistance combination
Common in children or in obese adults with longer-
b. Oral Hypoglycemic Agents (OHA) for type II
NO INSULIN PRODUCTION acting
Sulfonylureas insulin.
Prone for DKA Inter- NPH 2-4h 4-12h 16-20h Usually
Nonsulfonylureas
MANAGEMENT: mediate (neutral 3-4h 4-12h 1-20h taken after
Diguanides acting protamine food
Diabetic diet Hagedorn)
Alpha- glucosidase inhibitors
Insulin (Humulin
Thiazolidinediones N., Iletin II
Exercise
Meglitinides Lente,
 TYPE 2 DM  NURSING RESPONSIBILITIES IN INSULIN
Iletin II
NPH,
NON INSULIN DEPENDENT DIABETES MELLITUS THERAPY Novolin N
(NIDDM) 1. Route (NPH)
Very long Glargine 1hr Conti- 24h Used for
MATURITY – onset, stable DM, ketosis- resistant IV insulin: given in emergency cases (DKA). acting (Lantus) nuous basal dose
DM Detemir (no
(Levemir) peak)
☺ ENDOCRINE SYSTEM ☺ ADH (Antidiuretic hormone/ Vasopressin) c. Indwelling catheter will be inserted (to monitor
1. Composed of DUCTLESS GLANDS that releases Causes the renal retention of water (not affecting UO) – DIABETES INSIPIDUS can be a complication
sodium) in the renal tubules of the surgery.
HORMONES directly into bloodstream.
It can also cause vasoconstriction vasopressin. d. Review all pt.’s medication regimen and provide
2. HYPOTHALAMUS
HYPER SECRETION: routine pre op care.
a. Control most of the endocrinal cavity of Pituitary
SIADH – excessive retention of water by the 2. POST OP
Gland.
renal tubules a. Strictly keep the pt on BED rest for 24hr and
PITUITARY GLAND (HYPOPHYSIS)
HYPO SECRETION: encourage ambulation on day 2.
DIVIDED INTO 2 LOBES:
DI – inability of the renal tubules to retain water b. Position the pt fowlers to avoid tension on the
a. ANTERIOR PITUITARY (Adenohypophysis)
Diagnostic test: Water deprivation test suture line and to avoid increased ICP.
70% of the gland.
OXYTOCIN c. Remind the pt not to sneeze, forcefully cough,
Found in the sella turica, a depression in the
Release during child birth to cause uterine bend over and blow the nose for several days to
sphenoid bone at the base of the brain.
contraction avoid disturbing the suture lines.
Secretes: GH, PRL, ACTH, TSH, LH, FSH, MSH.
Responsible for the LET-DOWN REFLEX MILK d. Mild analgesics can be given for headache.
b. POSTERIOR PITUITARY (Neurohypophysis)
EJECTION. e. Anticipate the pt to manifest s/s of DI after
Stores and secretes ADH and OXYTOCIN produced
by the hypothalamus.  ANTERIOR PITUITARY GLAND surgery.
DISORDERS DISORDER  - Be alert for increased thirst and increased UO with
HYPER – When the gland secretes excessive low SG.
 HYPERPITUITARISM  - Replace fluids and administer IV vasopressin as
hormones. Chronic, progressive HYPER-FUNCTION of the
HYPO – When the gland does not secrete enough ordered. DI should resolve in 72 hrs.
anterior pituitary in OVERSECRETION of one or - Report outputs above 900ml/ 2hrs or specific
hormones. more of the anterior pituitary hormones.
CLASSIFICATION gravity below 1.006 DI.
CAUSES f. Arrange for visual field testing because
PRIMARY – When the gland itself is the problem. 1. TUMOR AND HYPERPLASIA (Benign
SECONDARY – When the problem is the pituitary or progressive VISUAL FIELD DEFECTS may indicate
pituitary adenoma, hyperplasia of pituitary BLEEDING.
the hypothalamus. tissue). g. Be alert for potential LEAKAGE OF CSF from the
GROWTH HORMONE (Somatotropin) 2. PROLACTINOMAS (prolactin- secreting operative site.
Growth of body tissues and bone. tumors) account for 60 to 80% of all pituitary
HYPER SECRETION: - If RHINORRHEA is present, test the discharge for
tumors. glucose and if positive, report to the physician of the
Gigantism (Children) 3. 2nd to Prolactinomas: GH-producing CSF leakage.
Acromegaly (Adult) adenomas. h. Provide emotional support to help pt cope with an
HYPO SECRETION: ASSESSMENT FINDINGS altered body image.
Dwarfism 1. ACROMEGALY – Gradual, marked i. Perform range of motion exercises to promote
PROLACTIN (Mammotropic/ Lactotropic enlargement of the bones of the face, jaw, hands
Hormone) maximum joint mobility and prevent injury due to
and feet. There can be diaphoresis, muscle weakness.
Mammary Tissue growth and lactation. hyperglycemia, oily skin and hirsutism. j. Keep skin dry and avoid using oily lotion.
HYPER SECRETION: 2. GIGANTISM – Proportional overgrowth of all k. Provide SAFETY measures because pituitary
Galactorrhea (abnormal breast milk production). body tissues with remarkable height. tumor can cause visual disturbances. Approach the
HYPO SECRETION: 3. NEUROLOGIC MANIFESTATION: pt to the unaffected side if he has Hemianopsia.
Absence of milk during lactation. Headache l. Deal with the mood swings appropriately.
ACTH (Adrenocorticotropic hormone) Somnolence, behavioral changes, seizures. m. Home teaching include: emphasizing that
Stimulates adrenal cortex to secret adrenal S/S of increased ICP. hormone replacement id needed lifetime, wear an
hormones cortisol and aldosterone. Disturbance in appetite, sleep, temperature
HYPER SECRETION: ID, have regular follow-up.
regulation and emotional balance due to 3. HOME CARE:
Cushing’s hypothalamic involvement. a. Explain the need to take the medications as
HYPO SECRETION: Visual disturbances due to the compression of prescribed.
Addison’s the OPTIC CHIASM above the pituitary gland: b. Report progressive visual changes, excessive
TSH (Thyroid stimulating hormone) HEMIANOPSIA OR SCOTOMAS (blind spot in urination.
Stimulates the thyroid gland to secrete T3 and T4. vision). c. Advised pt not to brush the teeth for 2 wks. to
HYPER SECRETION: DIAGNOSTIC TESTS avoid injury to the suture lines.
Hyperthyroidism 1. Skull x-ray, CT scan, MRI (tumor or pituitary
HYPO SECRETION: - Find alternative measures for oral care like
enlargement). mouthwash.
Hypothyroidism 2. Plasma GH levels determination: increased.
GONADOTROPIN (FSH/LH)  HYPOPITUITARISM 
MEDICAL MANAGEMENT
Affect growth, maturity, and functioning of primary Hypo function of pituitary gland cause
1. Surgery
and secondary. DEFICIENCIES in both the pituitary hormones and
Removal of pituitary gland
Sex characteristics the hormones of the target glands.
TRANSPHENOIDAL HYPOPHYSECTOMY
They influence the glands (OVARIES AND TESTES) CLINICAL MANIFESTATION
2. Radiation
to secrete gonadal hormone – estrogen, 1. Observed when 75% of the pituitary gland is
3. Pharmacotherapy
progesterone, testosterone dysfunctional.
BROMOCRIPTINE (PARLODEL) is used to treat
HYPER SECRETION: 2. Metabolic dysfunction
Amenorrhea, a condition in which the menstrual
Precocious puberty 3. Sexual immaturity
period does not occur.
HYPO SECRETION: 4. Growth retardation
Infertility – inability to get pregnant in women.
MALE: impotence, decrease production of 5. Absence of all pituitary secretions
Abnormal discharge of milk from the breast
spermatozoa. a. Panhypopituitarism (Simmond’s dse)
Hypogonadism
FEMALE: no ovulation, no menstruation, infertility. 6. POSTPARTUM PITUITARY NECROSIS
Parkinson’s dse
MSH (Melanocyte stimulating hormone) a. Severe bleeding, hypovolemia and hypotension at
Inhibit the synthesis of GROWTH HORMONE
Stimulates the skin melanocytes to produce the the time of delivery
(ACROMEGALY) and PROLACTIN
pigment melanin. b. Sheehan’s syndrome
NURSING MANAGEMENT
HYPER SECRETION: CAUSE
1. PRE OP (Health teaching)
Bronze appearance of the skin (hyperpigmentation). Trauma
a. Explain to the pt that this surgery will remove
HYPO SECRETION: TUMOR
the tumor from the pituitary gland.
Albinism (hypopigmentation) Vascular lesion
b. A nasal catheter and nasal packing are
Surgery/ radiation of pituitary gland
expected in the nasal cavity for a day.
Congenital
ASSESSMENT FINDINGS may be prescribed; these are used when the Increased calorigenesis.
1. Hemianopsia/ headache (if due to tumor). ADH deficiency is SEVERE or CHRONIC. Altered CHON, Fat, CHO (due to increased
2. Wt. loss, emaciation Instruct the pt in the administration of metabolism).
3. Varying sighs of hormonal disturbances medications as prescribed; DDAVP may be Stimulation of bone and BM function (bone
depending on which hormones are being under- administered by injection, intranasally, or orally. resorption of calcium).
secreted: Instruct the pt to wear a medic-alert bracelet. Sympathetic activity and CNS function.
a. Menstrual dysfunction  SYNDROME OF INAPPROPRIATE Altered reproductive function.
b. Hypometabolism ANTIDIURETIC HORMONE (SIADH)  BASIC CONCEPTS
c. Adrenal insufficiency
Increased ADH ⬆ T3 = ⬆ metabolic rate
d. Growth retardation
EXCESS ADH is released, but not in response ⬆ T4 = ⬆ body heat production
DIAGNOSTIC TESTS ⬆ Thyrocalcitonin = ⬇ calcium
to the body’ s need for it.
Skull x ray, CT scan, MRI (reveal pituitary tumor) HALLMARKS
The syndrome result in WATER INTOXICATION
Blood examination – Increased plasma hormone Goiter
and HYPONATREMIA.
levels (depending on specific hormones under- CAUSES Exophthalmos
secreted). Hyperthyroidism
Trauma
COLLABORATIVE MANAGEMENT ASSESSMENT FINDINGS
Stroke
1. Specific treatment depends on cause.
Malignancies (lungs or pancreas) 1. VON GRAEFE’s sign (LID LAG) – Long and
a. Tumor: SURGICAL REMOVAL or irradiation of the deep palpebral fissure is still evident when one looks
Medications
gland. down.
Stress
b. Regardless of cause, treatment will include ASSESSMENT FINDINGS 2. JEFFREY’S SIGN – Forehead remains smooth
REPLACEMENT OF DEFICIENT HORMONE when one looks up.
Signs of FLUID VOLUME OVERLOAD
(HRT).
Change in LOC 3. DALYRIMPLE’s sign (THYROID STARE) –
-Corticosteroids Bright-eyed stare, infrequent blinking
WEIGHT GAIN
-Thyroid hormone
Hypertension 4. DERMOPATHY – Warm, flushed sweaty skin;
-Sex hormones, gonadotropins Thickened hyper pigmented skin at the pretibial
Tachycardia
Hormone Hyper secretion Hypo secretion Anorexia n&v area.
GH Gigantism (child) Dwarfism (child) INTERVENTIONS MANAGEMENT
Acromegaly Lethargy, Monitor vs, cardiac and neurologic status. 1. Rest (non-stimulating cool environment)
(adult) premature aging Provide a safe environment, particularly for the 2. Diet
ACTH Cushing’s Addison’s Disease pt with change in LOC. a. High calorie, high protein, vitamin and mineral
Disease Monitor I&O and obtain wt. daily. supplement.
TSH Goiter, increased Decreased BMR, Monitor fluid and electrolyte balance. b. Increased fluid intake (if with diarrhea)
BMR, HR, BP HR, CO, BP Monitor serum and urine osmolality. c. Replace fluid and electrolytes losses
Graves’ disease Cretinism RESTRICT FLUID INTAKE as prescribed. d. Avoid stimulants like coffee, tea and nicotine
(children) Administer diuretics and IV fluids (NSS or 3. Promote safety
Prolactin Amenorrhea Too little milk hypertonic saline) as prescribed; monitor IV 4. Protect the eyes
FSH Late puberty, fluids carefully because of the RISK FOR FLUID a. Artificial tears at regular intervals
infertility VOLUME OVERLOAD (IV solutions containing b. Wear dark sunglasses when going out under the
LH Menstrual cycle Amenorrhea, water are contraindicated because of the risk of sun.
disturbance impotence water intoxication). DRUG THERAPY
1. BETA BLOCKERS: PROPRANOLOL
 POSTERIOR PITUITARY GLAND DRUG THERAPY
DEMECLOCYLINE (Declomycin) – Inhibits ADH- 2. CALCIUM CHANNEL BLOCKERS:
DISORDER  a. These drugs are given to control tachycardia and
induced water reabsorption and produces
 DIABETES INSIPIDUS  HPN.
WATER DIURESIS.
Decrease ADH 3. IODIDES: Lugol’s solution
 THYROID GLAND DISORDER 
Hyposecretion of ADH caused by strokes or trauma a. SSKI (Saturated Solution of Potassium Iodide
or may be idiopathic. Secrets the ff hormones: b. Are given to inhibit release of thyroid hormone
ASSESSMENT FINDINGS T3 (TRIIODOTHYRONINE) – Metabolism and c. Mix with fruit juice with ice or glass of water to
POLYURIA growth. improve its palatability.
POLYDIPSIA T4 (THYROXINE, TETRAIODOTHYRONINE) – d. Provide drinking straw to prevent permanent
DEHYDRATION Catabolism and body heat production. staining of teeth
Decreased skin turgor and dry mucous membrane. THYROCALCITONIN e. SIDE EFFECTS: Allergic reaction, increased
Inability to concentrate urine -Regulates Serum Ca++ levels salivation, colds
Low urine specific gravity -Bring down the blood Ca++ level 4. THIOAMIDES
Fatigue, muscle pain and weakness; headache. EUTHYROIDISM – The thyroid gland is a. PTU (propylthouracil) Tapazole (Methimazole)
Postural hypotension that may progress to vascular functioning normally -These are given to inhibit synthesis of thyroid
collapse without rehydration. HYPERTHYROIDISM – Increased secretion of hormones
Tachycardia the thyroid glands hormone b. SIDE EFFECTS OF PTU: AGRANULOCYTOSIS/
INTERVENTIONS HYPOTHYROIDISM – Decreased secretion of NEUTROPENIA
Monitor vs and neurological and cardiovascular thyroid glands hormone 5. PARACETAMOL
status. GOITER – Enlargement of the thyroid gland a. For fever
PROVIDE SAFE ENVIRONMENT particularly for the  HYPERTHYROIDISM  b. Aspirin must be avoided be because it can
pt with postural hypotension. 1. THYROTOXICOSIS displace the T3/ T4 from the albumin in the plasma
Monitor electrolyte values and for signs of a. Grave’s disorder causing increased manifestations
dehydration. b. Parry’s disorder 6. DEXAMETHASONE
Maintain the intake adequate fluids. c. Basedow’s disorder a. Inhibit the action of thyroid hormones
Monitor I&O, wt., serum osmolality, and specific d. Exophthalmic goiter b. Steroids are given to prevent the conversion of
gravity of urine. e. Toxic diffuse goiter T3/ T4 in the peripheral tissues
Instruct the pt to avoid foods or liquids that produce 2. Common in FEMALE, below 40y/o SURGICAL MANAGEMENT
diuresis. CAUSES 1. SUBTOTAL THYROIDECTOMY
CHLOPROPAMIDE (diabetes) may be prescribed for 1. Severe emotional stress a. Usually about 5/6 of the gland is removed
MILD DI. 2. Autoimmune disorder NURSING MANAGEMENT
VASOPRESSIN TANNATE (pitressin) or 3. Thyroid inflammation 1. PRE OP CARE
DESMOPRESSIN ACETATE (DDDAVP, Stimate) Increased Thyroid hormones a. Promote euthyroid state
Metabolic rate O2 consumption -Control thyroid disturbance
-Stable VS CAUSES ASSESSMENT
a. Administer Iodides as ordered 1. AUTOIMMUNE a. CNS
b. ECG a. HASHIMOTO’s dse or CHRONIC - Psychomotor and personality disturbances, loss of
-Heart failure/ cardiac damage results from HPN/ LYMPHOCYTIC THYROIDITIS memory, depression, psychosis, stupor and coma.
tachycardia. - An autoimmune disorder in which your immune b. GI
2. POST OP CARE system inappropriately attacks your thyroid gland - Abdominal pain, anorexia, N&V, dyspepsia and
a. POSITION causing inflammation. CONSTIPATION.
- Semi fowlers with head in neutral position. b. After surgery (thyroidectomy) c. NEUROMUSCULAR
b. Prevent hemorrhage: ICE COLLAR over the neck c. After radiation therapy (Radioactive iodine). - Fatigue, marked muscle weakness and atrophy.
c. Keep TRACHEOSTOMY set available for the first d. Anti-thyroid drugs d. RENAL
48hrs post op. ASSESSMENT - Nephrolithiasis, renal insufficiency
d. Ask the pt to SPEAK EVERY HOUR (to assess for a. Slowed physical, mental reactions, apathy. e. SKELETAL
recurrent laryngeal nerve damage). b. Dull, expressionless, mask like face - Chronic lower back pain, fractures, bone
e. Keep CALCIUM GLUCONATE readily available c. Anorexia tenderness and joint pain.
- Tetany occurs if hypocalcemia is present. This may d. Obesity f. Vision impairment
be secondary to the removal of the parathyroid e. Bradycardia g. Subcutaneous calcification
gland. f. Hyperlipidemia and atherosclerosis DIAGNOSTIC TEST
f. Monitor body temp: hyperthermia is an initial sign g. Cold intolerance, subnormal temperature a. Increased serum assay in IRA
of thyroid crisis. h. Constipation b. Increased serum calcium with decreased level of
g. Monitor BP (hypertension may be manifestation of j. Coarse, dry, sparse hair phosphate
thyroid storm). k. Brittle nails c. X-rays will show diffuse demineralization of bones,
h. Assess for TROUSSEAU’s sign (hypocalcemia). l. Irregular menstruation (menorrhagia, bone cysts, erosions
i. Steam inhalation to soothe irritate airways. amenorrhea) d. Elevated urine and serum calcium
j. Advise to support neck with interlaced fingers m. Husky hoarse voice e. Increased alkaline phosphate levels
when getting up from bed n. Extreme fatigue MEDICAL MANAGEMENT
k. Observe for s/s of potential complications o. Slow speech a. SURGERY to remove the adenoma
- Hemorrhage p. Enlarged tongue b. Increased fluids to force diuresis
- Airway obstruction q. Increased sensitivity to sedatives, narcotics, c. Dietary restrictions of calcium
- Tetany and anesthetics d. MEDICATIONS:
- Recurrent laryngeal nerve damage MANAGEMENT - Furosemide
- Thyroid crisis/ storm/ thyrotoxicosis a. Monitor VS - Ethacrynic acid
- Myxedema b. Be alert for s/s of cardiovascular disorders - Oral calcitonin
l. Client teaching c. Monitor wt. gain - Oral potassium phosphate
- ROM exercises of the neck 3-4 days after d. Diet - Gallium nitrate (Ganite) - An anti-hypercalcemic
discharge. - Low calorie drug.
- Massage incision site with cocoa butter lotion to - High fiber (constipation) NURSING INTERVENTIONS
minimize scarring. e. Provide WARM environment during cold a. Record I&O accurately
- Regular follow-up care climate b. Strain all urine to check for stones
“THYROID CRISIS/STORM” DRUG THERAPY c. Monitor electrolytes levels (Na, K, Mg)
a. Exacerbation of hyperthyroidism/ thyrotoxicosis 1. Thyroid hormonal replacement d. Be alert for pulmonary edema if IVF therapy is
CAUSES a. PROLOID (Thyroglobulin) initiated
a. Stress b. SYNTHYROID (Levothyroxine) e. Prevent injury due to fracture
b. Infection c. Desiccated Thyroid Extract f. Provide a safe environment to ensure against
c. Unprepared thyroid surgery d. CYTOMEL (Levothyroxine) complications related to potential osteoporosis and
ASSESSMENT - Before administration, the nurse should monitor joint and bone pain
a. Initial sign: ELEVATED TEMPERATURE BP & PR. g. Monitor for cardiac arrhythmias and decreased
b. Tachycardia - Start with low dose and gradually increase cardiac output.
c. Dysrhythmias MYXEDEMIC COMA  HYPOPARATHYROIDISM
d. Tremors, apprehension, restlessness a. Extreme sever stage of hypothyroidism, in Deficiency of PTH that leads to hypocalcemia and
e. Delirium, psychotic state, coma which the client is hypothermic and unconscious. produces neuromuscular symptoms ranging from
f. Elevated BP b. Management includes paresthesia to tetany.
MANAGEMENT - IV thyroid hormones CAUSES
a. Monitor temp, I&O, neurologic status, - Correction of hypothermia a. Congenital absence, autoimmune disease
cardiovascular q1. - Maintenance of vital function removal of the parathyroid glands
b. Administer increasing doses of oral PTU. - Treat precipitating factors b. Post-thyroidectomy
c. Administer IODIDE preparation as ordered.  PARATHYROID GLAND  c. Massive thyroid radiation therapy
d. Administer DEXAMETHASONE to help inhibit the PARATHYROID GLAND MANIFESTATION OF HYPOCALCEMIA
release of thyroid hormone. a. Produces parathyroid hormone (PTH) or a. Positive Chvostek’s and Trousseaus’, tetany,
e. Administer PROPRANOLOL to control HPN and parathormone which regulates calcium and paresthesia
tachycardia. phosphorous balance. b. Neuromuscular irritability
f. Implement measures to lower fever. b. HYPERPARATHYROIDISM – Hypercalcemia c. Psychosis
- Cooling devices c. HYPOPARATHYROIDISM – Hypocalcemia d. Dysphagia, abdominal pain
- Cold baths
 HYPERPARATHYROIDISM  e. Arrhythmias
g. Administer OXYGEN as needed f. Cataracts
Characterized by excessive secretion of the
h. Maintain quiet, calm, cool, private environment g. Hair loss, brittle nails, dry skin
PTH.
until crisis is over. h. Weakened tooth enamel
CAUSES
 HYPOTHYROIDISM  a. Parathyroid adenoma DIAGNOSTIC TEST
a. Results from deficiency of thyroid hormones. b. Congenital hyperparathyroidism a. ⬇ PTH
b. MYXEDEMA (adult) c. Multiple endocrine neoplasia b. ⬇ serum calcium
c. CRETINISM (children) d. Secondary hyperthyroidism can occur due to: c. ⬆ serum phosphate
d. Hormones: T3, T4, Calcitonin - Rickets (softening of the bone) d. X-ray reveals increased bone density
BASIC CONCEPTS - Vitamin D deficiency e. ECG – prolonged QT intervals and QRS complex
a. ⬇T3 = ⬇ metabolic rate - Chronic renal failure and ST segment changes
b. ⬇ T4 = ⬇ body heat production - Phenytoin and laxative abuse
c. ⬇ Thyrocalcitonin = ⬆ calcium
MEDICAL MANAGEMENT NURSING INTERVENTIONS  ADRENAL MEDULLA 
a. Therapy includes VIT D SUPPLEMENTS AND a. Administer HRT as ordered 1. ADRENAL MEDULLA – is the middle portion of
CALCIUM SUPPLEMENTS b. GLUCOCORTICOIDS (Cortisone, adrenal gland secreting catecholamines
b. Life threatening hypocalcemia is managed by IV Hydrocortisone) (epinephrine, norepinephrine)
calcium gluconate to raise calcium levels - Simulate diurnal rhythm of cortisol release p, 2. CATECHOLAMINES – help to prepare the
c. Sedatives and anti-convulsant are used to prevent give 2/3 of dose in early morning and 1/3 of dose individual to deal with emergency situations. The
seizures in afternoon. major disorder of the adrenal medulla is
NURSING INTERVENTIONS c. MINERALOCORTICOIDS (Fludrocortisone pheochromocytoma.
a. Maintain a patent IV line & keep calcium acetate) 3. PHEOCHROMOCYTOMA
gluconate solution available d. Monitor VS - Pheochromocytoma (PCC) is a rare tumor that can
b. Administer prescribed sedatives, anticonvulsants e. Decrease stress in the environment form in cells in the middle of the adrenal glands
and calcium gluconate (slow IV) f. Provide rest periods; prevent fatigue which is the adrenal medulla.
c. Institute seizure precaution g. Prevent exposure to infection - In the case of PCC, a tumor can cause the adrenal
d. Keep a calcium gluconate and endotracheal tube h. Monitor I&O, Weigh daily glands to make too much of the hormones
available i. Provide proper nutrition in small, frequent norepinephrine (noradrenaline) and epinephrine
e. WO for cardiac arrhythmias and decrease cardiac feedings of diet high in (adrenaline).
output j. Sugar (carbohydrate), Salt (sodium) and - Increased levels of these hormones can put the
f. Encourage to take high calcium and low Protein body into a stress-response state, causing blood
phosphate diet early in the dse process  CUSHING’S SYNDROME  pressure to increase.
g. Creams and lotions can be used to sooth dry skin HYPERFUNCTION of the adrenal cortex - Tumor that form on the outside of the adrenal
 ADRENAL GLAND  resulting to an excessive secretion of the glands are called paragangliomas. Both
Adrenal glands secrete hormones which help Mineralocorticoids pheochromocytoma and paragangliomas can also
regulate chemical balance, regulate metabolism and GLUCOCORTICOIDS impact the adrenal glands production of adrenal
supplement the glands. Sex hormones hormones called catecholamines.
a. ADRENAL CORTEX CAUSES ASSESSMENT FINDINGS OF
- Glucocorticoids a. Overproduction of ACTH PHEOCHROMOCYTOMA
- Cortisol b. Benign or malignant tumors a. Episodic and sudden onset of severe headaches
- Mineralocorticoids c. Prolonged corticosteroids therapy b. Sweating
- Aldosterone ASSESSMENT FINDINGS c. Abdominal pain
- Sex hormones a. Muscle weakness, fatigue d. High blood pressure that may be resistant to
- Testosterone b. Obese trunk with the arms and legs, muscle conventional medications
b. ADRENAL MEDULLA wasting e. Rapid heart rate
- Epinephrine c. Irritability, depression, frequent mood swings f. Irritability and anxiety
- Norepinephrine d. Moon face DIAGNOSTIC TEST
ADRENAL CORTEX e. Purple striae on trunk, acne, thin skin a. MRI
 ADDISON’S DISEASE  f. Signs os masculinization, menstrual b. PET imaging
a. Hypo-function of the adrenal cortex resulting to a dysfunction, decreased libido c. Laboratory test to assess hormone levels
decreased secretion of the DIAGNOSTIC TEST d. Blood plasma test for catecholamine and
- Mineralocorticoids a. ⬆ cortisol levels metanephrine levels.
- Glucocorticoids b. Slight hypernatremia e. Urine metanephrines test for catecholamine and
- Sex hormones c. Hypokalemia metanephrine level.
CAUSES d. Hyperglycemia NURSING MANAGEMENT
a. Idiopathic atrophy of the adrenal cortex possibly NURSING INTERVENTIONS a. Monitor vital signs, especially BP changes
due to an AUTOIMMUNE process a. Maintain muscle tone (provide ROM b. Promote rest and decrease stressful stimuli
b. Destruction of the gland secondary to tuberculosis exercises, assist with ambulation) c. Provide high-calorie, well balanced diet
or fungal infection b. Prevent accidents or falls and provide d. Instruct patient to avoid smoking and stimulants
c. Tumor adequate rest like coffee and tea
MINERALOCORTICOIDS c. Protect client from exposure to infection COMPLICATION
a. Promotes Na and H2O reabsorption and K d. Maintain skin integrity a. High blood pressure crisis
excretion. - Provide meticulous skin care b. Irregular heart beat
GLUCOCORTICOIDS (Cortisol) - Prevent tearing of skin: use paper tape if c. Heart attack
a. Affects CHO, CHON, fat metabolism necessary d. Multiple organs of the body begin to fail
b. Body’s response to STRESS e. Minimize stress in the environment MEDICATION
c. Emotion stability f. Monitor VS: observe for hypertension, edema a. ALPHA BLOCKERS
d. Immune function g. Measure I&O and daily weights - Prevent noradrenaline from stimulating the muscles
SEX HORMONES h. Provide diet that is in the walls of smaller arteries and veins.
a. Major source of androgen in women - Low in calories and sodium b. BETA BLOCKERS
ASSESSMENT - High in protein, K, Ca - Result in the heart beating more slowly and with
a. Fatigue, muscle weakness - Vitamin supplements less force. Beta blockers also help keep blood
b. Anorexia, N&V, abdominal pain, wt loss i. Monitor urine for glucose and acetone; vessels open and relaxed by slowing the release of a
c. Frequent hypoglycemic reactions administer insulin if ordered particular enzyme from the kidney.
d. HYPOTENSION, weak pulse j. Provide psychological support and acceptance
e. BRONZELIKE PIGMENTATION of the skin k. Prepare pt for hypophysectomy or radiation if
f. Due to increase MSH secondary to loss of adrenal- condition is caused by a pituitary tumor
hypothalamic pituitary feedback system l. Prepare client for an adrenalectomy if condition
g. Decreased capacity to deal with stress is caused by an adrenal tumor or hyperplasia
DIAGNOSTIC TEST m. Provide pt teaching
a. Low cortisol levels - Diet modifications
b. Hyponatremia - Importance of adequate rest
c. Hypovolemia - Need to avoid stress and infection
d. Hyperkalemia - Change in medication regimen (alternate day
e. Acidosis therapy or reduced dosage) if cause of the
f. Hypoglycemia condition is prolonged corticosteroid therapy.

Ca1: Medical-Surgical Nursing: "O Lord Grant Us Success." - Psalm 118:25

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Ca1: Medical-Surgical Nursing: "O Lord Grant Us Success." - Psalm 118:25

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 Leslie S. Anicete  CA1: MEDICAL-SURGICAL NURSING “O Lord grant us success.

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