NCMB316 LECTURE:
12
BSN 3RD YEAR 2ND SEMESTER MIDTERM 2023
Bachelor of Science in Nursing 3YB
Professor: Dr. Potenciana A. Maroma
Midterm Topics:
• Diabetes
• DI, SIADH, Thyroid disorders
• Adrenal and parathyroid gland disorders
• Introduction to nervous system
• Increased ICP, Head injury, CVA, SCI and Seizures
DIABETES MELLITUS
Pancreas
- Islets of Langerhans (containing beta cells, which produce
insulin. While alpha cells secrete glucagon)
• Alpha cells
- Glucagon –  glucose levels (it function with
gluconeogenesis)
- Pag mababa ang blood sugar, glucagon will be released
by alpha cells and it will raise glucose levels.
• Beta cells
- Insulin -  glucose levels by:
o Transcellular membrane transport of glucose
o Inhibits breakdown of fats & CHON
- Requires Na+ for transport of CHON
- Requires K+ for production
• Delta cells
- Somatostatin – inhibits action of growth hormone
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Exam Week
Diabetes Mellitus
- A chronic metabolic disease characterized by
hyperglycemia due to disorder of carbohydrate, fat and
protein metabolism.
- Once u have it, sayo na yan lifetime (sanaol ung DM hindi
ka na iniiwan, pero ung jowa d lifetime hays)
- Predisposing Factors:
• Heredity – strongly associated with Type II DM
• Obesity – Adipose tissues are resistant to insulin,
therefore glucose uptake by the cells is poor
• Stress – Stimulates secretion of epinephrine, nor-
epinephrine, glucocorticoids  increased serum
carbohydrates
• Viral infection – increase risk to autoimmune disorders
• Autoimmune Disorders – more associated with Type I
DM
• Multigravida Women with large babies
Types of Diabetes Mellitus
1) Type I
2) Type II
3) Gestational Diabetes
4) Diabetes associated with other conditions or syndromes
- Pancreatic disease, Cushing’s syndrome
- Use of certain drugs:
o Steroids
o Thiazide diuretics
o Oral contraceptives
Type I (IDDM) Insulin Dependent Diabetes Mellitus
- Juvenile – onset, Brittle DM, Unstable DM
- Onset is less than 30 years
- Common in children or in non-obese adults
- NO insulin production (there is destruction on pancreas,
therefore there’s no insulin production at all)
- Prone for DKA (Diabetic Ketone Acidosis, because there is
absolute deficiency of insulin, the body will burn protein
and fat reserves) DKA develops when your body doesn't
have enough insulin to allow blood sugar into your cells for
use as energy. Instead, your liver breaks down fat for fuel, a
process that produces acids called ketones.
- Management:
• Diet
• Exercise
• Insulin lifetime
Type II (NIDDM) Non-Insulin Dependent Diabetes Mellitus
- Maturity – onset, Stable DM, Ketosis – resistant DM
- Onset is 40 years
- Common in obese adults
- Inadequate insulin production or cells do not respond to
insulin. (Meron pero konti lng)
 NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER MIDTERM 2023

- Prone for HHNKS (Hyperosmolar Hyperglycemic

Nonketotic Syndrome – high BP) mataas ang bp pero hindi
necessarily mataas ang ketone bodies because there is
still circulating insulin.
- Pwede rin sila magkaroon ng DKA, pero bihira lng.
Magkakaroon lng sila kapag may severely stress.
- Management:
• Diet
• Exercise
• OHA (Oral Hypoglycaemic Agents), Insulin in
STRESSFUL situation
Pathophysiology

- Pag kumain or nag ingest ng food ang patient dito na

papasok yung functioning ng mga absorption ng mga
nutrients galing sa food
- Isa ang pancreas sa mag se secrete ng mga chemicals at
yung isa doon is beta cells na nag p produce ng insulin.
- Ang insulin mag bi bind yan sa mga receptor nya para ma
decrease yung dami ng glucose sa katawan or ma balance
- Once na mag malfunction ang pancreas or magka problem
ang organ either hindi sya magpo produce ng insulin or
yung mga receptor is hindi mag fu function leading to
glucose will stay in the blood and result as diabetes either
type 1 or 2.
- Hyperglycemia: 3P’s
1) Polyuria
2) Polydipsia
3) Polyphagia

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 NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER MIDTERM 2023
- Ketones act as CNS depressants and may decrease brain
pH leading to coma.
Protein metabolism
- Due to increased blood viscosity
• Sluggish circulation
• Proliferation of microorganisms
- Infections, Periodontal, UTI, Vasculitis, Cellulitis,
Vaginitis, Furuncles, Carbuncles, Retarded Wound
Healing
- MUST: thoroughly inspect your feet daily and keep
them clean and dry
Complications
• Macroangiopathy (malalaking blood vessels)
- Brain – Cerebrovascular accident
- Heart – Myocardial infarction
- Peripheral arteries – Peripheral vascular disease
• Microangiopathy (maliliit na blood vessels)
- Kindeys – Renal failure due to nephropathy
- Eyes – Cataract due to retinopathy
• Neuropathy
- Spinal Cord/ ANS
- Peripheral neuropathy – Involves damage to the PNS,
Affect movement, sensation, and bodily functions
(numbness/ tingling)
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- Paralysis
- Gastroparesis (delayed gastric emptying)
- Neurogenic bladder (bladder does not empty properly)
- Decreased Libido, impotence.
Diagnostic Test
• Random Blood Sugar (RBS)
- Blood specimen is drawn without preplanning.
(Kinukuhanan ng dugo agad ang pasyente without
preplanning)
- ≥ 200mg/dl + symptoms is suggestive of DM
• Fasting Blood Sugar (FBS)
- Blood specimen after 8 hours of fasting
- Normal (70-100 mg/dl), pre-diabetes (101 but < 126mg/
dl)
- DM – > 126 mg/dl
• Postprandial Blood Sugar
- Blood sample is taken 2 hrs after a high CHO meal
- No DM (70-140mg/dl), prediabetes (≥140 but <200
mg/dl)
• Oral Glucose Tolerance Test (OGTT)
- Diet high in CHO is eaten for 3 days.
- Client then fast for 8 hours. A baseline blood sample is
drawn & a urine specimen is collected.
- An oral glucose solution is given, and time of ingestion
recorded.
- Blood is drawn at 30 minutes & 1, 2, and 3 hours after
the ingestion of glucose solution. Urine is collected.
o No DM (glucose returns to normal in 2-3 hours &
urine is negative for glucose)
o DM (blood glucose returns to normal slowly; urine is
positive for glucose)
• Glycosylated hemoglobin (HbA1c)
- Single sample of venous blood is withdrawn.
- The amount of glucose stored by the hemoglobin is
elevated above 7% in the newly diagnosed client with
DM, in one who is noncompliant, or in one who is
inadequately treated.
- HbA1c is something that's made when the glucose
(sugar) in your body sticks to your red blood cells. Your
body can't use the sugar properly, so more of it sticks to
your blood cells and builds up in your blood.
Management
• Diet
- Low caloric diet specially if obese
- Diet should be in proportion.
o 20% CHON
 NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER MIDTERM 2023

o 30% Fats
o 50% CHO
• Consume complex CHO and HIGH fiber diet.
- inhibits glucose absorption in the intestines.
• Exercise
- This should be regularly
- Increases CHO uptake by the cells.
- Decreases insulin requirements.
- Maintains ideal body weight, serum carbohydrates &
serum lipids.
- Guidelines:
o Allow additional sources of CHO like snacks during
exercises. Oral Hypoglycemic Agents (OHA)
o Exercise is done 1-2hours after eating to prevent - for Type II
hypoglycemia. - Sulfonylureas
o Exercise must be regular pattern rather than - Nonsufonylureas
sporadic to maintain stable serum carbohydrate • Biguanides
levels. • Alpha-glucosidase inhibitors
• Thiazolidinediones
Medications • Meglitinides
Insulin
- Used for Type I diabetes Nursing Responsibilities in Insulin Therapy
- Used in Type II diabetes (client in stressful situation or • Route: Subcutaneous
hospitalized) - Slow absorption, less painful, 90° (thin) 45° obese
- Insulin preparations can consist of a mixture of: clients, no need to aspirate, do not massage site of
• beef and pork insulin injection
• Pure beef - IV insulin: given in emergency cases (DKA)
• Pure pork • Administer insulin at room temperature
• Human insulin - purest insulin and has the lowest - Cold insulin can cause lipodystrophy.
incidence of hypersensitivity o Lipoatrophy – loss of subcutaneous fat usually
- Human insulin is recommended for: caused by the utilization of animal insulin.
• All newly diagnosed Type I diabetics o Lipohypertrophy – development of fibrofatty masses,
• Type II diabetics who need short-term insulin therapy usually caused by repeated use of injection site.
• Pregnant client • Store vial of insulin in current use at Room
• Diabetic clients with insulin allergy or severe insulin Temperature
resistance - Insulin can be stored at RT for 1 month
- Other vials should be refrigerated
Insulin Onset Peak Duration
- In use – at room temperature
Rapid acting (clear) - Not in use – in refrigerator
5 30 mins
- Lispro (Humalog) 2 to 4 hrs • Rotate the site of injection
minutes - 1hr
- Aspart (Novalog) - To prevent lipodystrophy
Short acting (clear) - Lipodystrophy inhibits insulin absorption
Regular (Humulin R) 30 min 2 t0 4 • Gently roll vial in between the palms to redistribute
6 to 8 hrs insulin particles
(Novolin R) (Iletin II to 1 hr hrs
regular) • DO NOT Shake
- bubbles make it difficult to aspirate exact amount
Intermediate (cloudy)
- NPH
1-2 hrs 6 -12 hrs 18 to 24 hrs • Observe for side effects of insulin therapy
1-2 hrs 8 -12 hrs 18 to 24 hrs - Localized: Induration or Redness, Swelling, Lesion at
- Humulin N
1-2 hrs 8 -12 hrs 18 to 28 hrs the site, Lipodystrophy
Lente, Humulin L
- Generalized:
Long acting 5 to 8 14 to 20 o Edema – due to sudden resolution of hyperglycemia
30 to 36 hrs
- Ultralente hrs hrs
rs o Hypoglycemia
Glargine (Lantus) UK UK
o Somogyi phenomenon

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 NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER MIDTERM 2023
Insulin Therapy: Insulin Pumps
- a computerized device that delivers insulin to patients
automatically throughout the day
- Dosage instruction are entered into the pump small
computer and the appropriate amount of insulin is then
injected into the body in a calculated controlled manner
- closely mimic normal pancreatic functioning
- It contain a 3 ml syringe attached to a long (42-inch),
narrow-lumen tube with a needle or Teflon catheter at the
end
- The needle or Teflon catheter is inserted into the
subcutaneous tissue (usually on the abdomen) and
secured with tape or a transparent dressing
- The needle or catheter is changed at least every 3 days
- The pump is worn either on a belt or in a pocket
- The pump uses only regular insulin
- Insulin can be administered via the basal rate (usually 0.5-
2.0 units/hr) and by a bolus dose (which is activated by a
series of button pushes) prior to each meal
Management
Sulfonylureas “insulin releasers”
- Stimulate the beta cells to secrete more insulin.
- Increases the ability of insulin cell receptors to bind insulin.
- SE: weight gain, hypoglycemia, secondary failure of
pancreas due to overstimulation
• Tolbutamide (Orinase)
• Acetohexamide (Dymelor)
• Tolazamide (Tolinase)
• Chlorpropamide (Diabenese)
• Glipizide (Glucotrol)
• Glyburide (micronase, Glynase)
• Glimepiride (Amaryl)
Nonsulfonylureas
• Biguanides
o Metformin (Glucophage)
- Help tissues use available insulin more efficiently
- “insulin sensitizers”
- SE: Stomach upset, flatulence, diarrhea
- no weight gain, no hypoglycemia unlike
sulfonylureas
- it will increase the sensitivity of insulin receptors.
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• Alpha-glucosidase inhibitors
o Miglitol (Glyset), Acarbose (Precose)
- Alpha-glucosidase is an intestinal enzyme that
breaks down carbohydrates into glucose, when this
enzyme is inhibited, the process of forming glucose
is slowed and glucose is absorbed more slowly from
the small intestine.
- Taken 15 minutes before meal.
- It will decrease the absorption of glucose in the
small intestine.
• Thiazolidinediones (TZDs)
o Rosiglitazone (Avandia), Pioglitazone (Actos)
- Help tissues use available insulin more efficiently.
- “insulin sensitizers”
- SE: weight gain, edema & liver damage (kaya
imonitor ang SGPT – Serum Glutamic Pyruvic
Transaminase, a blood test performed to measure
the enzyme created in the liver called Alanine
Transaminase (ALT).
• Meglitinides
o Repaglinide (Prandin)
- An “insulin releaser”
- SE: same as with sulfonylureas
OHA
- Stress importance of taking the drug regularly
- Avoid alcohol intake while on medication
• Sulfonylureas can precipitate extreme vomiting if given
with alcohol
General Nursing Interventions
• Monitor urine sugar and acetone (freshly voided specimen)
• Perform finger sticks to monitor blood glucose levels as
ordered (more accurate than urine tests)
• Observe for signs of hypo and hyperglycemia
• Provide meticulous skin care and prevent injury
• Maintain intake and output; weigh daily
• Provide emotional support; assist client in adapting to
change in life-style and body image
• Observe for chronic complications and plan care
accordingly
• Provide client teaching and discharge planning concerning:
- Disease process
- Diet
- Insulin - insulin at RT, gently roll vial between palms of
hands, Draw up insulin using sterile technique, If mixing
insulin, draw up clear insulin before cloudy insulin
• Provide many opportunities for return demonstration for
proper and correct insulin administration
• Perform good oral hygiene and have regular dental exams
• Regular checkup every 3 mos
• Have regular eye exams
• Care for the diabetics under stress
- Do not omit insulin or oral hypoglycemic agents if taking
antibiotics since infection causes increased blood
sugar
 NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER MIDTERM 2023

Hypoglycemia Diabetic Ketoacidosis (DKA)

- Causes: Overdose of insulin, omission of meals, Strenuous - Acute complication of DM characterized by:
exercise, G.I. upset (N&V) • Hyperglycemia
- Sign and symptoms: • Accumulation of ketones in the body; causes metabolic
• Shaking acidosis
• Sweating • Frequently occurs in DM Type I (IDDM)
• Anxious - Precipitating factors:
• Dizziness • Undiagnosed diabetes
• Hunger • Neglect of treatment
• Fast heartbeat • Infection, cardiovascular disorder
• Impaired vision • Other physical or emotional stress
• Weakness, fatigue - Assessment Findings:
• Headache • 3 P’s
• Irritable • N&V, abdominal pain
- Assessment: <60 mg/dl • Warm, dry, flushed skin
- Management: Simple Sugars p.o. • Dry mucous membranes; soft eyeballs
• 3-4 oz regular soft-drink • Kussmaul’s respirations or tachypnea; acetone breath
• 8 oz fruit juice or fruity breath
• 5-7 pcs lifesaver’s candies • Altered LOC, Hypotension
• 3-4 pcs hard candies • Tachycardia
• 1 tbsp sugar • Sobrang taas ng blood sugar, mataas ang osmotic
• 5 ml pure honey/ karo syrup pressure, ihi ng ihi ang pasyente kaya magkakaroon ng
• 10-15 gm CHO severe dehydration, metabolic acidosis – cns
• D50 W 20-50 ml IV push ( if unconscious) or 1 mg depressant
glucagon - Diagnostic Test:
• Monitor BS (blood sugar) • Serum glucose (up to 600 mg/dL) and ketones elevated
(positive urine ketones)
Hyperglycemia • BUN, Creatinine, Hematocrit are elevated (due to
- Causes: Stress (infection, surgery), Overeating, under dose dehydration)
of insulin • Serum sodium decreased, potassium (elevated due to
- Sign and symptoms: the acidosis)
• Extreme thirst • ABGs: metabolic acidosis with compensatory
• Frequent urination respiratory alkalosis
• Dry skin • Metabolic acidosis compatible with hyperkalemia
• hunger - Management:
• Blurred vision • Maintain a patent airway.
• Drowsiness • Maintain F&E balance.
• Nausea • Administer IV therapy as ordered.
- Assessment: o Normal saline (0.9% NaCl), then hypotonic (0.45%
• 3P’s (polyphagia if insulin is absent) NaCl) sodium chloride
• Warm flushed dry skin, Soft eyeballs o When blood sugar drops to 250 mg/dl, may add 5%
• Tachycardia, N&V, Abdominal pain dextrose to IV
• Kussmaul’s breathing, Fruity odor of breath o Potassium will be added when the urine output is
adequate.
• Urine (+) glucose & Ketones
• Observe for fluid and electrolyte imbalances, especially
• Altered LOC
fluid overload, hypokalemia & hyperkalemia
- Management:
• Administer insulin as ordered.
• Patent airway
o ONLY Regular insulin is given IV (drip or push) and/or
• O2 therapy
subcutaneously (SC).
• NSS + regular insulin IV
o If given IV drip, give with small amounts of albumin
• D10W once glucose reaches 250 mg/dl level
since insulin adheres to IV tubing
• KCI / Slow IV drip, once urine output is adequate o Monitor blood glucose levels frequently.
• Monitor blood sugar • Check urine output every hour
• Monitor vital signs
• Assist client with self-care
• Provide care for the unconscious client if in a coma

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 NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER MIDTERM 2023
• Discuss with client the reasons ketosis developed and
provide additional diabetic teaching if indicated
Hyperosmolar Hyperglycemic Nonketotic Syndrome
(HHNKS)
- A complication of DM characterized by:
• Hyperglycemia
• Hyperosmolar state without ketosis
- Occurs in Type II DM
- Precipitating factors are:
• Undiagnosed diabetes
• Infections, major burns, other stress
• certain medications (Dilantin, Thiazide diuretics)
• Dialysis, Hyper-alimentation, pancreatic disease
- Assessment Findings:
• Similar to ketoacidosis but without Kussmaul
respirations and acetone breath
- Laboratory tests:
• Blood glucose level extremely elevated
• BUN, creatinine, Hct elevated (due to dehydration)
• Urine positive for glucose
- Nursing interventions:
• Treatment and nursing care is similar to DKA, excluding
measures to treat ketosis and metabolic acidosis
DI, SIADH, AND THYROID DISORDERS
SIADH
Brain Regulation
- Disorder of sodium and water balance is a common
complication following neurosurgery.
- Neuroscience patients must be continually assessed and
monitored for their response to therapy.
- Early detection is critical to the protection and integrity of
the brain.
Normal Brain Regulation
1) TBW accounts for 60% of body weight
- 20% ECF
- 40% ICF
2) Fluid shifts can occur depending on concentrations of
solutes in ICF and ECF
3) Na and K are principal determinants in fluid shifts
4) Osmolarity: amount of solute in fluid (urine, blood)
- Normal Serum Osmolarity: 270-295 mOsm/L
5) Serum Osmo above 295 mOsm/L = water deficit
- Concentration is too great OR
- Water concentration is too little
6) Serum Osmo below 270 mOsm/L = water excess
- Amount of particles or solute is too small in proportion
to the amount of water OR
- Too much water for the amount of solute
To maintain plasma or serum osmo within range, free
water intake and excretion must balance
• Antidiuretic Hormone (ADH): balances Na and water in
body and controls water conservation
• Changes in pressure of ECF triggers release of ADH from
pituitary gland
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• Release is coordinated with activity of the thirst center-
regulates intake
• ADH binds with receptor sites of the collecting duct in
kidney resulting in increased free-water resorption
• ADH causes vasoconstriction
- Presence of ADH- renal tubule permeability to water is
increased and water is reabsorbed
- Absence of ADH- renal tubule permeability to water is
decreased – renal excretion to fluids
• Plasma osmolality = Primary regulatory mechanism for the
release of ADH
• Receptors in the brain are sensitive to changes in
osmolality
• Receptors that trigger thirst mechanism are close to those
that control ADH release
• Serum osmo greater than 295 mOsm/L triggers thirst
ADH Feedback Loop
Syndrome of Inappropriate Antidiuretic Hormone
• SIADH: Persistent abnormally high (inappropriate) levels of
ADH in the absence of stimuli with normal renal function
- No longer regulated by plasma osmo and volume
- Imbalance of fluid and electrolytes
• Feedback system is impaired and posterior pituitary
continues to release ADH
• Renal tubules continue to reabsorb free water regardless
of the serum osmolality
• Excessive activity of the neurohypophyseal system r/t brain
disease
Risk Factors
• Post-Operative with pituitary surgery
• Acute head injury
• Pulmonary infections (Pneumonia)
• Nervous system infections (meningitis)
Conditions
• Fluid status with accurate I&O
• Confusion
 NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER MIDTERM 2023

• Dyspnea Diabetes Insipidus (DI)

• Headache - Disordered regulation of water balance due to impaired
• Fatigue urinary concentrating ability secondary to inadequate
• Weakness secretion of ADH or resistance to ADH.
• Change in LOC - Four Types of DI:
• Lethargy 1) Central/Neurogenic (CDI)
• Vomiting 2) Nephrogenic (NDI)
3) Dipsogenic
• Muscle weakness and cramping
4) Gestational
• Muscle twitching
• Seizures
Pathophysiology of DI
Laboratory Diagnosis
• Central/Neurogenic
Serum Sodium Less than 135 mEq/L - Inadequate secretion of ADH due to loss or malfunction
of neurosecretory neurons that make up the posterior
Urine Sodium Greater than 20 mEq/L
pituitary.
Urine Osmolality Higher than serum - Vasopressin Sensitive
• Nephrogenic
Serum Osmolality Less than 275 mOsm/L - Inadequate response by the kidneys to ADH.
BUN/Creat WNL - A disorder of renal tubular function resulting in the
inability to respond to ADH in absorption of water.
Urine Specific Gravity Greater than 1.005 - Vasopressin Resistant
• Dipsogenic
Adrenal/threshold WNL
- Suppression of ADH secondary a defect or damage to
Serum Potassium Less than 3.5 mEq/L the thirst mechanism located in the hypothalamus
resulting in increased fluid intake or psychogenic
Treatment
causes
• Correct underlying cause Clinical Sign
• Fluid restriction 500-1000 ml/day • Dehydration! Excessive loss of water from body tissue and
• Severe hyponatremia: 3% NSS may be given imbalance of essential electrolytes (Na, K, Cl)
• Lasix may be given (watch K level) • Polydipsia (excessive thirst)
Nursing Management
• Polyuria (excessive amount of urine)
• Frequent Neuro assessment: Mental status and LOC
• Low specific gravity (1.001 to 1.005)
• Pulmonary assessment: s/s fluid overload
• Serum hyperosmolality and hypernatremia
• Cardiac assessment: Dysrhythmias and BP abnormalities Causes
• Monitor for seizure activity: Seizure precautions • Head Trauma
• Accurate I&O • Post-operative (hypophysectomy, pituitary tumor)
• Daily Weights: Same time each day, same scale, same • Brain Tumors
clothes
• CNS Infection (meningitis, abcess)
• Oral hygiene • Increased ICP
• Reduce stress, pain, discomfort
• Idiopathic
Correlation of Decreasing Sodium Levels and Symptoms
• ICH
Serum Sodium Level Symptoms • Stroke
Normal concentration, no • Hypoxia
145-135 mEq/L • Medications (Dilantin, clonidine, alcohol)
symptoms
• Damage to hypothalamus or posterior pituitary
135-120 mEq/L Generally no changes Investigate the following for DI
• Unquenchable thirst
HA, apathy, lethargy, weakness,
• Polydipsia
120-110 mEq/L disorientation, thirst, fatigue,
• Polyuria (hourly urine output > 200 mls)
seizures
• Unexplained weight loss
Confusion, hostility, lethargy, • Urinary frequency
110-100 mEq/L N/V, abdominal cramps, muscle • Dry skin/poor skin turgor
twitching • Tachycardia and hypotension
• Inability to respond to the increased thirst stimulus and
Delirium, convulsions, coma,
compensate for the excessive polyuria
100-95 mEq/L hypothermia, areflexia, Cheyne-
Stokes respirations, death

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 NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER MIDTERM 2023

• Hypernatremia that becomes severe and is manifested by- • After assessing fluid status and serum sodium level, treat
confusion, irritability, stupor, coma and neuromuscular both dehydration and hypernatremia
hyperactivity progressing to seizures. • For chronic neurogenic DI- require hormonal replacement
• Unconscious/intubated therapy: DDAVP (nasal vasopressin)
Labs and Diagnostics • Consultation with an endocrinologist is strongly
• Serum calcium recommended
• Glucose Removal of the underlying cause/offending drug
• Creatinine • DDAVP usually ineffective
• Potassium • Thiazide diuretic (HCTZ) is first line treatment
• Urea level • Adequate hydration
• The following may also be indicated: • Low-sodium diet + thiazide diuretics to induce mild sodium
- 24hr urine collection to quantitative polyuria depletion.
- CT/MRI - rule out pituitary causes, metastases, • Indomethacin may also be useful to reduce urine volume.
hemorrhage, neuronal damage, cerebral tumors. Nursing Management
- Radioimmunoassy: to measure circulating ADH • Hourly Neuro Checks
concentrations • Frequent Vital Signs
Lab Value Result • Evaluate for s/s of hypovolemic shock
• Strict I&O
Serum Sodium Above 145 mEq/L • Rehydrate for symptoms of extreme thirst
Serum Osmolality Above 290 mOsm/kg • Measure and record weight using the same scales at the
same time and with the patient wearing the same clothing
Urine Specific Gravity of the Below 1.005 • Assess mucous membranes and skin turgor and monitor
first morning voiding for symptoms of dehydration
• Provide rest
Urine Sodium Above 145 mEq/L
• Safety measures to prevent injury secondary to dizziness
Urine Osmolality Below 300 mOsm/L and fatigue
Diagnosis of DI should be considered in any person producing • Alert the health care team of problems of urinary frequency
large volumes of dilute urine and extreme thirst that interferes with sleep and activities.
Water Deprivation Test SIADH vs DI Lab Values
- After baseline measurement of: weight, ADH, plasma Finding SIADH DI
sodium, and urine/plasma osmolality, the patient is
deprived of fluids under strict medical supervision Less than 200 mls Greater than
Urine Output
- Frequent (q2h) monitoring of plasma and urine osmolality x 2hrs 250 mls x 2hrs
follows. Below 135 mEq/L Above 145
- The test is generally terminated when plasma osmolality is Serum Sodium
mEq/L
>295 mOsm/kg or the patient loses ≥3.5% of initial body
weight. Urine Sodium Below 25-30 mEq/L Decreased
- DI is confirmed if the plasma osmolality is >295 mOsm/kg
Urine Above 900 Below 400
and the urine osmolality is <500 mOsm/kg.
Osmolality mOsm/kg mOsm/kg
Nephrogenic DI vs Neurogenic DI
• DDAVP Challenge Plasma Below 275 Above 295
- Check urine osmolality 1-2hrs after 1mcg SQ DDAVP Osmolality mOsm/L mOsm/L
- If little or no change: likely NDI or dipsogenic DI
- If significant increase in urine osmolality, likely CDI Blood Pressure Normotension Hypotension
• 5 units vasopressin IV Fluid Status No Dehydration Dehydration
- Measure osmolality
- A significant increase (>50%) in urine osmolality after Confusion, Seizures, coma
Neuro
administration of ADH is indicative of CDI delirium, coma
Symptoms
Treatment with low Na
Correct the underlying cause and maintain adequate fluid
replacement. Complications to treatments of DI and SIADH
• DI Therapy varies with the degree and type of DI present or • Cerebral Edema!
suspected. • Central Pontine Myelinolysis: brain cell dysfunction caused
• IVF may be necessary to correct hypernatremia; avoid by destruction of the myelin sheath covering nerve cells in
rapid replacement brainstem
• Free water restriction • Na levels rise too fast or corrected too quickly
• s/s: (not necessarily immediate)
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 NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER MIDTERM 2023

- Acute paralysis • FNB (Fine Needle Biopsy)

- Dysphagia - Cytology (detection of malignant cells)
- Dysarthria • BMR (Basal Metabolic Rate)
Most Important Nursing Intervention for DI and SIADH - Measures O2 consumption at the lowest cellular activity
• Frequent Labs - Oxygen uptake is measured as an indirect
- We have severe electrolyte abnormalities measurement of metabolic rate
- Careful not to correct too quickly!! - increased utilization O2 (hyperthyroid)
- Na should not rise more than 0.5mEq/L/hr and 10 • Reflex Testing (Kinemometry)
mmol/L/24 hrs - Tendon of Achilles Reflex (TAR)
• Frequent neuro assessment • Goiter
- The nurse can pick up abnormal behavior and signs and - Enlargement of the thyroid gland associated with
symptoms first. Note any changes from baseline hyperthyroidism, hypothyroidism or euthyroidism
Thyroid Gland Disorder - A hyperthyroid goiter is called toxic goiter
- Secretes the following hormones
• T3 (Triidothyronine) Hyperthyroidism (Thyrotoxicosis)
 Metabolism and growth • Grave’s Disorder
• T4 (Thyroxine, tetraiodothyronine) • Basedow’s Disorder
 Catabolism and body heat production • Exophthalmic Goiter
• Thyrocalcitonin • Diffuse Toxic Goiter
 regulates serum Ca++ levels - Common in female, below 40 y/o
 bring down the blood Ca++ level - Causes:
Diagnostic Tests • Severe emotional stress
• T3/ T4 levels • Autoimmune Disorder
-  level: hyperthyroidism • Thyroid inflammation
-  level: hypothyroidism
• PBI (Protein-bound Iodine)
- Preparation: No foods, drugs, test dyes with iodine 7-10
days before the test
• RAIU (Radioactive Iodine Uptake)
- Tracer dose of I131 is used P.O. & at 2°, 6°, and 24° 
exposure to scintillation camera is done
- No foods, drugs, test dyes with iodine 7-10 days before
the test, temporarily discontinue contraceptive pills
(these may metabolic rate)
- Result:
o  iodine uptake: hyperthyroidism
o  iodine uptake: hypothyroidism
Hyperthyroidism: Key concepts
- What are the hormones produced by the thyroid gland?
• T3
• T4
• Calcitonin
- 3 BASIC CONCEPTS:
•  T3 =  metabolic rate
•  T4 =  body heat production
•  Thyrocalcitonin =  calcium
• Thyroid Scan Assessment Findings
- Radioisotope Iodine is injected IV • Restlessness, nervousness, irritability, agitation, fine
- Exposure to scintillation camera tremors, tachycardia, hypertension, voracious appetite to
eat, weight loss, diaphoresis, diarrhea, heat intolerance,
amenorrhea, fine silky hair, pliable nails
• Exophthalmos
- Due to accumulation of fluids, mucopolysaccharides at
the fat-pads behind the eyeballs
- It can lead to corneal ulceration,
• Von Graefe’s sign (LID LAG)
- Long and deep palpebral fissure is still evident when
one looks down
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 NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER MIDTERM 2023

• Jeffrey’s sign – Forehead remains smooth when one looks • Pre-op Care
up o Promote euthyroid state
• Dalyrimple’s sign (Thyroid stare) - Control of thyroid disturbance
- Bright-eyed stare, infrequent blinking - Stable VS
• Dermopathy o Administer Iodides as ordered – To reduce the size &
- Warm, flushed sweaty skin vascularity of thyroid gland, thereby prevent post-op
- Thickened hyper-pigmented skin at the pretibial area hemorrhage and thyroid crisis
Management o ECG – Heart failure/ cardiac damage results from HPN/
• Rest (non-stimulating cool environment) tachycardia
• Diet o Position : Semi-fowler’s with head, neck & shoulder
- HIGH Calorie, HIGH protein; vitamin and mineral erect
supplement o Prevent Hemorrhage: ice collar over the neck
- Increased fluid intake (if with diarrhea) o Keep tracheostomy set available for the first 48° post-
- Replace F&E losses op
- Avoid stimulants like coffee, tea and nicotine o Ask the patient to speak every hour (to assess for
• Promote safety recurrent laryngeal nerve damage)
• Protect the eyes o Keep Ca++ gluconate readily available – Tetany occurs if
- Artificial tears at regular intervals hypocalcemia is present. This may be secondary to the
- Wear dark sunglasses when going out under the sun accidental removal of the parathyroid gland
Management: Pharmacotherapy o Monitor Body Temperature: hyperthermia is an initial
• ß-blockers: Propranolol sign of thyroid crisis
o Monitor BP (hypertension may be a manifestation of
• Ca++ channel blockers
thyroid storm)
- These drugs are given to control tachycardia and HPN
o assess for Trousseau’s sign (hypocalcemia)
• Iodides: Lugol’s solution
o Steam inhalation to soothe irritated airways
- SSKI (Saturated Solution of Potassium Iodide)
o Advise to support neck with interlaced fingers when
- Are given to inhibit release of thyroid hormone
getting up from bed
- Mix with fruit juice with ice or glass of water to improve
o Observe for signs and symptoms of potential
its palatability
complications
- Provide drinking straw to prevent permanent staining of
- Hemorrhage
teeth
- Airway obstruction
- Side effects: Allergic reaction, Increased salivation,
- Tetany
colds
- Recurrent laryngeal nerve damage
• Thioamides
- Thyroid crisis / storm / thyrotoxicosis
- PTU (Propylthiouracil) & Tapazole (Methimazole)
- Myxedema
- These are given to inhibit synthesis of thyroid hormones
• Client Teaching
- Side effects of PTU
o ROM exercises of the neck 3 to 4 days after discharge
o AGRANULOCYTOSIS / NEUTROPENIA This is
o Massage incision site with cocoa butter lotion to
manifested by unexplained Fever, Sore throat, Skin
minimize scarring
rashes
o Regular follow – up care
o The nurse must elicit these symptoms and if present,
the physician must be alerte
Thyroid crisis/ storm
• Paracetamol for fever
- Sudden, life-threatening exacerbation of hyperthyroidism/
- Aspirin must be avoided because it can displace the
thyrotoxicosis
T3/T4 from the albumin in the plasma causing increased
- Causes: Stress, Infection, Unprepared thyroid surgery
manifestations
Assessment
• Dexamethasone
• Initial sign: Elevated temperature
- inhibit the action of thyroid hormones
• Tachycardia
- Steroids are given to prevent the conversion of T4 to T3 in
the peripheral tissues • Dysrhythmias
• Tremors, apprehension, restlessness
• Radiation therapy (Iodine)
- Need isolation for few days; body secretions are • Delirium, psychotic state, coma
radioactive contaminated • Elevated BP
- NOT recommended in pregnant women because of Management
potential teratogenic effects. Pregnancy should be • Monitor the following every hour
delayed for 6 months after therapy - Temperature
Surgery - Intake and output
• Subtotal Thyroidectomy- Usually about 5/6 of the gland is - Neurologic status
removed - Cardiovascular status

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 NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER MIDTERM 2023

• Administer increasing doses of oral PTU • Irregular menstruation (menorrhagia, amenorrhea)

- (200 to 300 mg q 6 hrs) as ordered, following a loading • Husky, hoarse voice
dose of 800 to 1,200 mg. p.o as ordered • Extreme fatigue
• Administer iodide preparation as ordered • Slow speech
• Administer dexamethasone to help inhibit the release of • Enlarged tongue
thyroid hormone • Increased sensitivity to sedatives, narcotics, and
• Administer propranolol to control hypertension and anesthetics
tachycardia
• Implement measures to lower fever
- cooling devices
- cold baths
- acetaminophen (avoid aspirin)
• Administer oxygen as needed
• Maintain quiet, calm, cool, private environment until crisis
is over

Hypothyroidism
- results from deficiency of thyroid hormones

- What are the hormones produced by the thyroid gland?

• T3
• T4
• Calcitonin Management
- 3 BASIC CONCEPTS: • Monitor vital signs
•  T3 =  metabolic rate • Be alert for signs and symptoms of cardiovascular
•  T4 =  body heat production disorders
•  Thyrocalcitonin =  calcium • Monitor the weight daily
- Causes • Diet: LOW Calorie, High fiber (constipation)
• Autoimmune – Hashimoto’s disease or chronic • Provide warm environment during cold climate
lymphocytic thyroiditis - an autoimmune disorder in Pharmacotherapy
which your immune system inappropriately attacks your • Thyroid hormonal replacement
thyroid gland causing an inflammation - Proloid (Thyroglobulin)
• after surgery (thyroidectomy) - Synthroid (Levothyroxine)
• after radiation therapy (radioactive iodine) - Dessicated Thyroid Extract
• antithyroid drugs - Cytomel (Liothyronine)
Assessment o Before administration, the nurse should monitor BP
• Slowed physical, mental reactions, apathy & PR
• Dull, expressionless, mask-like face o Start with low dose and gradually increase
• Anorexia Myxedema Coma
• Obesity - Extreme, severe stage of hypothyroidism, in which the
• Bradycardia client is hypothermic and unconscious
• Hyperlipidemia & atherosclerosis - Management includes:
• Cold intolerance, subnormal temperature • IV thyroid hormones
• Constipation • Correction of hypothermia
• Coarse, dry, sparse hair • Maintenance of vital function
• Brittle nails • Treat precipitating factors

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 NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER MIDTERM 2023

ADRENAL AND PARATHYROID GLAND DISORDERS - Mineralocorticoids (Aldosterone)

Adrenal Gland Diseases
- Adrenal gland – also known as suprarenal gland, small
triangular shapes gland located on the top of the both
kidneys. 4-5 grams in weight.
- Consists of:
• Zona glomerulosa is the outermost region of the adrenal
cortex and is the only zone of the adrenal gland that
contains the enzyme aldosterone synthase (CYP11B2).
• Zona fasciculata, the middle zone of the adrenal cortex
secretes glucocorticoids which are important for
carbohydrate, protein and lipid metabolism. (Regulates
blood sugar)
• Zona reticularis produces androgens (sex hormones)
• Promotes Na & H2O reabsorption & K+ excretion.
- Glucocorticoids (Cortisol)
• Affects CHO, CHON, Fat metabolism.
- Body’s response to STRESS
• Emotion stability
• Immune Function
- Sex Hormones
• Major source of androgen in women
Assessment
• Fatigue, muscle weakness
• Anorexia, N&V, abdominal pain, weight loss
• Frequent hypoglycemic reactions
• Hypotension, weak pulse
• Bronze like pigmentation of the skin
- Due to MSH (Melanocyte-stimulating hormone) 2° to
loss of adrenal-hypothalamic-pituitary feedback system
• Decreased capacity to deal with stress.

Addison’s Disease
- Hypofunction of the adrenal cortex resulting to a
decreased secretion of the
• Mineralocorticoids
• Glucocorticoids
• Sex hormones
- Causes:
• Idiopathic atrophy of the adrenal cortex possibly due to Diagnostic Tests
an autoimmune process • Low cortisol levels
• Destruction of the gland secondary to tuberculosis or • Hyponatremia
fungal infection • Hypovolemia
• Tumor (not secreting adequate hormone – • Hyperkalemia
hypopituitarism) • Acidosis
- Key Concept: Know the functions of the hormones and • Hypoglycemia
you will know the signs & symptoms.

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 NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER MIDTERM 2023

Nursing Intervention Assessment Findings

• Administer HRT as ordered. (kung kulang ng hormone, edi • Muscle weakness, fatigue
bigyan ng hormone, HRT – Hormonal Replacement • Obese trunk with thin arms and legs, muscle wasting
Therapy) (pendulous abdomen)
- Glucocorticoids (Cortisone, Hydrocortisone) – simulate • Irritability, depression, frequent mood swings
diurnal rhythm of cortisol release, give 2/3 of dose in • Moon face, buffalo hump
early morning and 1/3 of dose in afternoon. • Purple striae on trunk, acne, thin skin
- Mineralocorticoids (Fludrocortisone acetate) • Signs of masculinization in women; menstrual dysfunction,
• Monitor VS decreased libido
• Decrease stress in the environment. • Osteoporosis, decreased resistance to infection
• Provide rest periods; prevent fatigue. • Hypertension, edema
• Prevent exposure to infection. Diagnostic test
• Monitor I&O, weigh daily. • cortisol levels
• Provide proper nutrition in small, frequent feedings of diet • slight hypernatremia
high in Sugar (carbohydrate), Salt (sodium) and Protein
• hypokalemia
• Provide client teaching and D/C planning concerning:
• hyperglycemia
- Use of prescribed medications for lifelong replacement
When cushing’s is suspected, a blood sample will be
therapy; never omit medications.
taken for laboratory analysis.
- Need to avoid stress, trauma, and infections, and to
1) ACTH- 7.2- 52 pg/ml
notify physician if these occur as medication dosage
2) Plasma cortisol - 10-20mcg/dl
may need to be adjusted
- It decreases in the evening- during early phase of
- Stress management techniques
sleep
- Diet modification
3) Dexamethasone suppression test (Confirmatory test)
- Use of salt tablets (if prescribed) or ingestion of salty
- Measures the response of adrenal glands to ACTH.
foods (potato chips) if experiencing increased sweating.
Dexamethasone 1mg is given oral at 11pm.
- Importance of alternating regular exercise with rest
- Plasma cortisol is obtained at 8am…>50% reduction in
periods, avoidance of strenuous exercise especially in
plasma cortisol
hot weather
4) MRI/ CT scan
• Emergency condition: Addisonian crisis is a life-
Medical Management
threatening situation that results in low blood pressure,
low blood levels of sugar and high blood levels of • Mitotane- [Lysodren] to decrease production of
potassium. (circulatory failure or shock, it could be cause glucocorticoids
by a sudden withdrawal of corticosteroids on patient who • Korlym [Mifepristone]- Cortisol Receptor blocker
has having high dose of corticosteroids) • Ketoconazole
Cushing Syndrome • Metyrapone [Metopirone]
- Hyperfunction of the adrenal cortex resulting to an • Insulin
excessive secretion of the: Nursing Intervention
• Mineralocorticoids • Maintain muscle tone (Provide ROM exercises, assist with
• Glucocorticoids ambulation) there is instability because of muscle
• Sex hormones weakness
- Causes: • Prevent accidents or falls and provide adequate rest
• Overproduction of ACTH- hyperpituitarism • Protect client from exposure to infection
• Benign or malignant tumors • Maintain skin integrity.
• Prolonged corticosteroids therapy • Provide meticulous skin care.
• Exogenous • Prevent tearing of skin: use paper tape if necessary.
- Key Concept: Know the functions of the hormones and • Minimize stress in the environment
you will know the signs & symptoms • Monitor VS: observe for hypertension, edema
- Mineralocorticoids (Aldosterone) • Measure I&O and daily weights
• Promotes Na & H2O reabsorption & K+ excretion • Provide diet that is:
- Glucocorticoids (Cortisol) - low in calories and sodium
• Affects CHO, CHON, Fat metabolism - high in protein, K+, Ca++
• Body’s response to STRESS - vitamin supplements
• Emotion stability • Monitor urine for glucose and acetone; administer insulin if
• Immune Function ordered
- Sex Hormones • Provide psychological support and acceptance.
• Major source of androgen in women • Prepare client for hypophysectomy or radiation if condition
is caused by a pituitary tumor.

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 NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER MIDTERM 2023

• Prepare client for an adrenalectomy if condition is caused Diagnostic tests

by an adrenal tumor or hyperplasia.
• Provide client teaching D/C planning concerning:
- Diet modifications
- Importance of adequate rest
- Need to avoid stress and infection
- Change in medication regimen (alternate day therapy or
reduced dosage) if cause of the condition is prolonged
corticosteroid therapy.
Conn’s Syndrome (Hyperaldosteronism)
- Excessive aldosterone secretion from the adrenal cortex
- Seen more frequently in women (30-50 y/o)
- Cause by a tumor or hyperplasia of adrenal gland
- Key Concept: Mineralocorticoids (Aldosterone) –
Promotes Na+ & H2O reabsorption & K+ excretion
Assessment findings
• Headache
• Hypertension
• Muscle weakness
• Polyuria, polydipsia
• Metabolic alkalosis
• Cardiac arrhythmias (due to hypokalemia)
Diagnostic tests
•  Serum K+
• Alkalosis
• Urinary aldosterone levels elevated
Laboratory Test
• Plasma aldosterone- in supine position with normal
sodium diet
• 2-9 ng/dl or 55-250 pmol/L, with upright /standing position
or seated for at least 2hrs is 2-5x supine value
• Urine aldosterone - 14-56 nmol/24 hrs
Nursing Interventions
• Monitor VS, I&O, daily weigh
• Maintain sodium restriction as ordered
• Administer spironolactone (Aldactone) and potassium
supplements as ordered
• Prepare the client for an adrenalectomy if indicated
• Provide client teaching and discharge planning concerning:
- Use and side effects of medication if the client is being
maintained on spironolactone therapy
- Signs of symptoms of hypo/ hyperaldosteronism
- Need for frequent blood pressure checks and follow-up
care
Pheochromocytoma
- A condition of hyper-functioning tumor of the adrenal
medulla resulting to excessive secretion of epinephrine &
norepinephrine
- Occurs most commonly between ages 25-50, hereditary in
some cases
Assessment findings
• Severe headache, apprehension, palpitations, profuse
sweating, nausea
• Hypertension, tachycardia, vomiting, hyperglycemia,
dilation of pupils, cold extremities
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• Increased plasma levels of catecholamines
• Elevated blood sugar
• Glycosuria
• Elevated urinary catecholamines and urinary
vanillylmandelic acid (VMA) levels
• Presence of tumor on x-ray
Laboratory Test
• Serum epinephrine – 0-140 pg/ml [764.3 pmol/L
• Norepinephrine – 70- 1700pg/ml or 413.8- 10048.7pmol/L
• Catecholamine test uses a sample of blood or urine to
measure levels of some adrenal hormones.
• Normetanephrine – 18- 111 pg/ml
• Metanephrine – 12-60 pg/ml
• Urine catecholamines – 14-110mcg/24 hrs
• VMA – Vanillyl Mandelic Acid is produced in the liver and
is a major product of epinephrine and norepinephrine
metabolism which is excreted in the urine.
- Preparation: No food and fluid with coffee, tea, cocoa,
chocolate for 48 hours before the test
- Normal level 2-7 mg/24 hours
Nursing interventions
• Monitor vital signs, especially blood pressure.
• Administer medications as ordered to control hypertension.
• Promote rest; decrease stressful stimuli.
• Monitor urine tests for glucose and acetone
• Provide high-calorie, well-balanced diet; avoid stimulants
such as coffee, tea.
• Provide care for the client with an adrenalectomy as
ordered; observe post adrenalectomy client carefully for
shock due to drastic drop in catecholamine level.
• Provide client teaching and discharge planning: same as
for adrenalectomy.
Parathyroid Gland
- Produces parathyroid hormone (PTH) or parathormone
which regulates calcium and phosphorous balance.
• Hyperparathyroidism – Hypercalcemia
• Hypoparathyroidism – Hypocalcemia
Hyperparathyroidism
- Characterized by excessive secretion of the PTH
- Causes:
• parathyroid adenoma
• congenital hyperparathyroidism
 NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER MIDTERM 2023

• multiple endocrine neo plasia- a group of disorders that - Serum phosphate- 2.5-4.5 mg/dl
affect the body’s network of hormones producing - Alkaline phosphatase- 44- 147 IU/L
glands Medical Management
• Secondary hyperparathyroidism can occur due to • Surgery to remove the adenoma
o rickets (softening of the bone) • Increased fluids to force diuresis
o vitamin D deficiency • Dietary restrictions of calcium
o chronic renal failure • Medications – Furosemide and ethacrynic acid, oral
o phenytoin and laxative abuse calcitonin, oral potassium phosphate
Pathophysiology Nursing Interventions
- Record I&O accurately
- Strain all urine to check for stones
- Monitor electrolyte levels (Na+, K+, Mg++)
- Be alert for pulmonary edema if IVF therapy is initiated
- Prevent injury due to fracture: Provide a safe environment
to ensure against complications related to potential
osteoporosis and joint and bone pain
- Monitor for cardiac arrhythmias and decreased cardiac
output
- Increase fluids, 2-3 L, cranberry juice
- Encourage mobility
Assessment
Hypoparathyroidism
- Deficiency of PTH, that leads to hypocalcemia and
produces neuromuscular symptoms ranging from
paresthesia to tetany
- Causes:
• Congenital absence, autoimmune disease
• Removal of the parathyroid glands
• Post-thyroidectomy
• Massive thyroid radiation therapy
Clinical Manifestations
• Positive Chvostek’s and Trousseau’s sign
• Tetany, paresthesia
• CNS – psychomotor and personality disturbances, loss of
• INCREASED neuromuscular irritability,  DTR
memory, depression, psychosis, confusion, disorientation,
• Psychosis
stupor and coma
• Dysphagia, abdominal pain
• GI – abdominal pain, anorexia, nausea, vomiting,
• Arrhythmias, bronchospasm, laryngospasm
dyspepsia and constipation
• Cataracts
• Neuromuscular – fatigue, marked muscle weakness and
atrophy • Hair loss, brittle nails, dry skin
• Renal – nephrolithiasis, renal insufficiency • Weakened tooth enamel
• Skeletal – chronic lower back pain, fractures, bone Diagnostic Test
tenderness and joint pain - PTH
• Vision impairment – scleritis/ red eye keratopathy, - serum calcium
asymptomatic conjunctival - serum phosphate
• Calcification and conjunctivitis - X-ray reveals increased bone density
- ECG- prolonged QT intervals and QRS complex and ST
Diagnostic test
segment changes
• Increased serum calcium, with decreased level of
Medical Management
phosphate
• X-rays will show diffuse demineralization of bones, bone • Therapy includes vitamin D supplements, and
cysts, erosions supplemental calcium like Calcium Citrate, Caltrate Plus,
Calcium carbonate, given with meals bec. It requires
• Elevated urine and serum calcium
stomach acid to dissolve and absorb it.
• Increased alkaline phosphatase levels
- Life-threatening hypocalcemia is managed by IV
• UTZ, MRI
calcium gluconate to raise calcium levels.
• Normal Values
• Sedatives and anti-convulsant are used to prevent seizures
- PTH- 10-55 pg/ml
- Serum Calcium- 8.6- 10 mg/dl
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 NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER MIDTERM 2023
Nursing interventions
• Maintain a patent IV line & keep calcium gluconate 10%
solution available
• Administer prescribed sedatives, anticonvulsants &
calcium gluconate (slow IV)
• Institute seizure precaution
• Keep a tracheostomy set and endotracheal tube available
• Watch out for cardiac arrhythmias and decreased cardiac
output
• Encourage to take high calcium and low phosphate diet
early in the disease process
• Creams and lotions can be used to sooth dry skin
INTRO TO NERVOUS SYSTEM
Assessment of the Nervous System
Health History
- An important aspect of the neurologic assessment is the
history of the present illness.
- The initial interview provides an excellent opportunity to
systematically explore the patient’s current condition and
related events while simultaneously observing overall
appearance, mental status, posture, movement, and affect.
- Neurologic disease may be stable or progressive,
characterized by symptom-free periods as well as
fluctuations in symptoms.
- The health history therefore includes details about the:
• Onset, character, severity, location, duration, and
frequency of signs and symptoms
• Associated complaints.
• Precipitating, aggravating, and relieving factors
• Progression, remission, and exacerbation; and
• The presence or absence of similar symptoms among
family members.
- Common signs and symptoms associated with
neurologic disease:
• Pain
• Seizures
• Dizziness & vertigo
• Visual disturbances
• Muscle weakness
• Abnormal sensation
- Past Health, Family, and Social History
• The nurse may inquire about any family history of
genetic diseases.
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• A review of the medical history, including a system-by-
system evaluation, is part of the health history.
• The nurse should be aware of any history of trauma or
falls that may have involved the head or spinal cord.
• Questions regarding the use of alcohol, medications,
and il- licit drugs are also relevant.
- The history-taking portion of the neurologic assessment is
critical and, in many cases of neurologic disease, leads to
an accurate diagnosis.
Physical Assessment
- 5 Components of Neurologic Assessment:
consciousness and cognition, cranial nerves, motor
system, sensory system, and reflexes.
Diagnostic tests
Radiographic examinations
1) X-ray Examinations of the Skull and Spine
- used to determine
- bony fractures
- curvatures
- bone erosion
- bone dislocation
- possible calcification of soft tissue w/c can damage the
nervous system
• you will be asked to lie on the x-ray table or sit in a
chair
• your head may be placed in a number of positions
• several views are taken: anteroposterior, lateral,
oblique & when necessary, special views of the
facial bones
- Nursing responsibilities before:
• Explain that it is similar to that for a chest x-ray
procedure
• Need to remain still during the procedure
• Exposure to radiation is minimal
• Remove hairpins, glasses, hearing aids
• Patient in traction & no portable x-ray= accompany
patient to assist in positioning
• Patient who cannot walk & transfer fr wheelchair to
x-ray table = stretcher
- Nursing responsibilities after: follow up care is not
required
2) Cerebral Angiography (Arteriography/ Arteriogram)
- used to visualize cerebral vessels & detect tumors,
aneurysms, occlusions, hematomas, abscesses
- injection of radiopaque substance into the cerebral
circulation via carotid, vertebral, femoral, brachial
artery followed by x-rays
- DSA – Digital Subtraction Angiography
• x-ray images of the area are obtained b4 and after
the injection of the contrast agent
• images obtained before contrast injection are
digitized and subtracted from post - contract images,
thus removing bones and other background
structures from the final digital images
- Nursing responsibilities before:
• signed consent (after explaining the procedure,
usually the radiologist)
 NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER MIDTERM 2023
• check for allergy to iodinated contrast agents
o =infreq. pt may have an immediate or delayed
allergic rxn to the iodine contained in the
contrast agent
o Manifestations: dyspnea, n&v, sweating,
tachycardia & numbness of extremities
o Int: report to physician at once
o Tx: adm of epinephrine, antihistamines, or
corticosteroids
o Addtnal risks: vessel injury, bleeding & CVA
• necessity for not moving during the procedure
• NPO 4-6 hours before the test – well hydrated, clear
liquids permitted up to the time of regular
angiography
• remove hairpins & jewelries
• record neuro & v/s
• empty bladder
- Nursing responsibilities after:
• v/s, neuro signs & neurovascular checks as ordered;
compare with pre-angiography signs
• restricted to bedrest for several hours
• monitor VS & neuro checks
• extremity used is kept straight & immobilized for the
duration of the bedrest – if w/ hematoma, (localized
collection of blood), ice bag may be applied,
intermittently to the puncture site
• check for the extremity’s skin color & temp, pulses
distal to the injection site, capillary refill
• inspect injection site for evidence of bleeding
• increase oral or IV fluids if not contraindicated
3) Computed Tomography/ Computed Axial Tomography
(CT/ CAT scan)
- used to detect intracranial & spinal cord lesions
- used to monitor effects of surgery or other therapy
- uses ionizing radiation
- skull & spinal cord are scanned in successive layers by
a narrow beam of x-rays
- computer construct a picture of the internal structure of
the brain
- contrast media may or may not be used
- Nursing responsibilities before:
• signed consent
• if w/ contrast agent: notify physician if client has risk
factor & food is withheld for 4-6 hours; fluids are
generally not withheld
• patients must remove all metallic materials (may be
required to change into a hospital gown)
• remove hairpins, hairpieces or wigs
• to provide clear images: patients must remain as
still as possible
• the technician is able to see the patient and
communicate through an intercom system
throughout the procedure
- Nursing responsibilities after: If w/ contrast agent:
• check for delayed allergic response to contrast
medium if used
• increase fluid intake if contrast medium was used
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• check I & O, resultant diuresis may require
replacement of fluids
4) Positron Emission Tomography (PET)
- provides information about the function of the brain
- specifically glucose, O2 metabolism and cerebral blood
flow
- it can be used to image what the brain is doing
- A PET scan can show patterns in the brain which aid the
physician in diagnosing and treating Parkinson's
Disease
• Client is placed on a stretcher
• IV line is started to inject isotope (deoxyglucose)
• isotope emits activity in the form of positron which
are scanned & converted into a color image by
computer
• more active a given part of the brain = the greater the
glucose uptake
• client may be blindfolded with earplugs
• client is asked to perform certain mental functions
to activate different areas of the brain
- Nursing responsibilities before:
• signed consent form
• instruct the client to withhold caffeine, alc &
tobacco for 24 hrs (accdg to agency policy)
• NPO for 6-12 hours (if diabetic=no insulin before the
test)
• no glucose solution nor any drugs that alter glucose
metabolism
- Nursing responsibilities after:
• increase fluid intake (radioisotope is eliminated in
the urine)
• ff-up care is not required
5) Single-Photon Emission Computed Tomography
(SPECT)
- limitation of PET may be overcome.
- less expensive than PET but resolution of images is
limited
- particularly useful in studying:
• Cerebral blood flow
• Head trauma
• Stroke
• Seizures
• Dementia
• Persistent Vegetative state
• AIDS
• Brain death
• Amnesia
• Psychiatric disorders
• Neoplasms
- uses a radiopharmaceutical agent that enables
radioisotopes to cross the blood-brain barrier via IV
injection (1hr before the scan)
- positioned on an x-ray table in a quiet dark room
- gamma cameras scan the head
- images are downloaded to a computer
- it is able to provide true 3D information
 NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER MIDTERM 2023
2) Lumbar puncture/ Spinal tap
- Left: SPECT scans of the brain of a three year old male near
drowning patient shown shortly after the accident showing
decreased brain activity. The patient presented in a
persistent vegetative state, and was pronounced blind with
severe spasticity.
- Right: SPECT scans of the same child taken 9 months later
demonstrating increased brain activity and blood flow
following 120 hyperbaric oxygen treatments. The child was
now alert, responsive, laughing, eating and drinking
normally, walking, speaking bi-lingually, and had regained
normal vision.
Other diagnostic tests
1) Magnetic Resonance Imaging (MRI)
- produces images superior to CT scan computer-drawn,
detailed pictures of structures of the brain & body
through the use of large magnet, radio waves
- used to detect intracranial & spinal cord
- abnormalities assoc with disorders such as:
• cerebrovascular diseases
• tumors
• abscesses
• cerebral edema
• hydrocephalus
• multiple sclerosis
- for enhancement of images, may use gadolinium = a
non-iodine-based contrast
- Nursing responsibilities before:
• signed consent form
• remove jewelry, glasses & other metals
• contraindicated to:
o anyone with orthopedic hardware
o IUDs, tattoos
o Pacemaker
o internal surgical clips
o other fixed metallic objects in the body
• warn client of normal audible humming & thumping
noises during the scan = may wear earplugs
• instruct to remain still, lasts for 45-60 mins
• help prevent claustrophobia = offer open MRI
• void before the test
- Nursing responsibilities after:
• Follow-up care is not required.
J.A.K.E 19 of 28
- the insertion of a spinal needle into the subarachnoid
spacebetween the 3rd & 4th (sometimes L4/L5, L5/S1)
lumbar vertebrae
- used to do the ff:
• obtain pressure readings with a manometer.
• Normal: 60-150 mmH2O
• obtain CSF for analysis protein, sugar, cytology, C/S,
color
• significance of CSF findings
• check for spinal blockage attributable to spinal cord
lesion
• inject contrast medium or air for diagnostic study
• inject spinal anesthetics
• inject certain medications
• reduce mild to moderate increased ICP in certain
conditions
- Nursing responsibilities before:
• signed consent form
• void before the test
• position in lateral recumbent with head & neck
flexed onto the chest & knees pulled up; “fetal
position”
• explain the need to remain still during the procedure
- Nursing responsibilities after:
• label specimens
• keep client flat for 4-8 hours or 12-24 hours as
prescribed by physician or as determined by hospital
policy – to prevent CSF leakage
• check puncture site for bleeding or CSF leak
• increase fluid intake (to 3000ml unless
contraindicated) – facilitate CSF production
• assess sensation and movement in lower
extremities
• monitor VS
• analgesics for headache – a ↓ in CSF may cause
severe, throbbing headache =spinal headache
• If LP is done to ↓ ICP, perform rapid neuro check
 NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER MIDTERM 2023

3) Electroencephalography (EEG) • head position depends on the dye used:

- graphic recording of electrical activity of the brain by o oil-based or water-soluble =elevated
several electrodes placed on the scalp o air =positioned lower than the trunk
- used to: • administer analgesics for headache or backache as
• Detect focus or foci of seizure activity prescribed
• used to quantitatively evaluate level of brain • encourage fluids to help excrete the contrast
function (determine brain death) material
• diagnose sleep disorders (sleep EEG) • monitor I & O to ensure adeq fluid intake, facilitate
- sleep EEG: excretion of contrast material and determine adeq
• You will be placed in a room that encourages urine output – at least 30mL/hr
relaxation
• asked to fall asleep
• while brain's electrical activity is recorded
• last about 2-3 hours / sometimes 6 hours
- Nursing responsibilities before:
• withhold sedatives, tranquilizers, stimulants for 2-3
days
• not to consume caffeine before the test.
• avoid using hair styling products (hairspray or gel) on
the day of the exam
• for sleep EEG, client may be asked to stay awake the
night before the exam
- Nursing responsibilities after:
• remove electrode paste with acetone & shampoo
hair
• any medications withheld are reinstituted
INCREASED ICP, HEAD INJURY, CVA, SCI AND SEIZURES
• may need a nap if sleep deprived
Increased ICP
Radiographic or Non-radiographic?
1) Myelography / Myelogram - means, an ↑ in intracranial bulk due to an ↑ in any of the
- injection of dye or air into the subarachnoid space to intracranial
detect abnormalities of the spinal cord and vertebrae - Components: brain tissue, CSF or blood
• procedure begins with a lumbar puncture radiologist - Causes: trauma, hemorrhage, abscesses, growths or
may remove some of the CSF from the spinal canal tumors, hydrocephalus, edema or inflammation
• next, a portion of contrast dye will be injected into • Can impede circulation to the brain
the spinal canal through the hollow needle • Can impede the absorption of CSF
• the needle will remain in place and will be placed in • Affect functioning of nerve cells
prone position • Lead to brainstem compression
• x-ray table will be tilted in various directions to allow • Death
gravity to move the contrast dye to diff areas of the - To understand intracranial pressure, think of the skull as a
spinal cord (patient is be held in place by a special rigid box.
brace or harness) - After brain injury, the skull may become overfilled with
• more contrast dye will be administered during this swollen brain tissue, blood, or CSF.
process through the secured lumbar puncture - The skull will not stretch like skin to deal with these
needle changes.
• required x-rays or CT scan pictures will be taken - The skull may become too full and increase the pressure
- Nursing responsibilities before: on the brain tissue. This is called increased intracranial
• informed consent pressure.
- ICP is usually measured in the lateral ventricles, with the
• provide hydration for at least 12 hours before the
normal pressure being 0 to 10 mm Hg, and 15 mm Hg being
test
the upper limit of normal (Brunner & Suddarth’s Textbook
• solid foods are avoided
of MS 12th ed)
• assess for allergies to contrast agents, iodine or
shellfish
• if taking phenothiazine: hold medication -lowers the
seizure threshold
• premedicate for sedation as prescribed
- Nursing responsibilities after:
• assess v/s & neuro condn freq as prescribed

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 NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER MIDTERM 2023

Monro-Kellie Principle

- This concept holds that the skull is a rigid compartment

that contains 3 components:
• brain tissue
• blood (arterial & venous)
• CSF
- These components are balanced in a state of dynamic
equilibrium.
- If an increase occurs in the relative volume of one
component, such as brain tissue = the volume of one or
more of the other components must decrease or an
elevation in ICP will result.
Assessment
• Earliest sign: Deterioration in the level of
consciousness
- Early: confusion, restlessness, lethargy, and
disorientation first to time, then to place, and then to
person
- Later: stupor then coma
• Pupillary dysfunction relative to size, shape, and
reaction to light
- Early: gradual dilation, a slightly ovoid shape, and a
sluggish response to light ipsilateral to the lesion
- Later: signs are dilation of the ipsilateral pupil and a
non-reactivity to light (from compression of CNIII)
- Final: bilateral dilation and fixation
• Motor weakness and sensory deficits
- Early: monoparesis, contralateral hemiparesis, and
decreased visual acuity, such as blurred vision &
diplopia
- Later: hemiplegia, decortication or decerebration
(either unilateral or bilateral)
• Headache, possible seizures, projectile vomiting, (+)
Babinski’s reflex
- Late sign: Changes in vital signs
o Hypertension systolic BP rises while diastolic
pressure remains the same (widening pulse
pressure-a difference of more than 50 mm Hg )
o Bradycardia
o abnormal respiratory pattern
o elevated temperature
• Cushing's triad – a very late presentation of brain stem
dysfunction

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 NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER MIDTERM 2023

Nursing interventions Post procedure interventions:

1) Elevate head of bed to 30-40 degrees as prescribed. 1) Position the client supine and turn from the back to the
2) Avoid Trendelenburg’s position. nonoperative side.
3) Prevent flexion of the neck and hips. 2) Monitor for signs of ↑ing ICP resulting from shunt failure.
4) Monitor respiratory status and prevent hypoxia. -leads to 3) Monitor for signs of infection.
brain swelling
5) Avoid the administration of morphine sulfate to prevent the
occurrence of hypoxia.
6) Maintain mechanical ventilation as prescribed.
- PaCO2 at 30-35 mmHg → vasoconstriction of cerebral
blood vessels → ↓ed blood flow = ↓ed ICP
- Hypercarbia=vasodilation= ↑ ICP;
- Hypocarbia=too much vasoconstriction
7) Maintain body temperature.
8) Prevent shivering –can ↑ICP
9) Decrease environmental stimuli.
10) Monitor electrolyte levels and acid-base balance.
11) Monitor I& O.
12) Limit fluid intake to 1200 mL/day.
13) Instruct client to avoid straining activities, such as
coughing and sneezing. Head Injury
14) Instruct the client to avoid Valsalva’s maneuver. - trauma to the skull, resulting in mild to extensive damage
Medications to the brain
1) Anticonvulsants - usually caused by car accident, falls & assaults
- as prophylactic to prevent seizures → ↑metabolic - immediate complications: cerebral bleeding, hematomas,
requirements & cerebral blood flow & volume → ↑ing uncontrolled ↑ed ICP, infections and seizures
ICP - changes in personality or behavior cranial nerve deficits &
- phenytoin (Dilantin) any other residual deficits depend on the area of the brain
2) Antipyretics & Muscle Relaxants damage & the extent of the damage
- prevents temp elevation & shivering
- temp reduction → ↑metabolism, cerebral blood flow +
ICP
- acetaminophen (Tylenol), diazepam (Valium)
Blood Pressure Medications
- to maintain cerebral perfusion at a normal level
- notify physician if BP is <100 or >than 150mmHg systolic
- beta blockers (Propanolol)
3) Corticosteroids
- stabilize the cell membrane & reduce the leakiness in
the blood-brain barrier ↓ cerebral edema
- S/E: ↑gastric secretion (give histamine blocker) ; - Types of head injuries:
adrenal crisis (withdrawn slowly from corticosteroid 1) Open
therapy) • Scalp lacerations
- dexamethasone (Decadron) • Fractures of the skull
4) Hyperosmotic Agents • Interruption of the dura mater
- Mannitol (Osmitrol) is a hyperosmotic agent that 2) Closed
↑intravascular pressure by drawing fluid from the • Concussion
interstitial spaces & from the brain cells • Contusions
- monitor renal function ; -diuresis is expected • Fractures
5) Intravenous Fluids Concussion Contusion
- administered via infusion pump to control the amount
delivered • widespread • localized (coup-contra
- hypertonic IVs are avoided bec of risk of promoting • microscopic coup)
addtnal cerebral edema • jarring of the brain • macroscopic
Surgical Intervention within the skull • bruising type of injury to the
Ventriculoperitoneal Shunt • temporary loss of brain
- shunts CSF from the ventricles into the peritoneum consciousness • noticeable loss of functions

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 NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER MIDTERM 2023

Assessment
- Assessment findings depend on the injury
- Clinical manifestations usually result from ↑ed ICP
• Changes in LOC
• visual disturbances, pupillary changes & papilledema
• airway & breathing pattern changes
• headache, n&v
• weakness & paralysis
• posturing
• v/s changes
- CSF drainage: ears / nose
Fractures Nursing intervention
Types of skull fracture include: 1) Maintain patent airway & ventilation; V/S, neuro checks,
• Linear or hairline: a break in a cranial bone resembling a monitor signs of ↑ICP, seizures, hyperthermia
thin line, without splintering, depression, or distortion of 2) Observe CSF leak
bone - check discharge for glucose (strip test); bloody spot
• Depressed: a break in a cranial bone (or "crushed" portion encircled by watery, pale ring on pillowcase or sheet
of skull) with depression of the bone in toward the brain - never attempt to clean the ears or nose; never use nasal
• Compound: a break in or loss of skin and splintering of the suction unless ordered
bone 3) If a CSF leak is present:
• Comminuted: a fracture of many relatively small fragments - instruct not to blow nose
Hematoma - elevate HOB 30 degrees
• Subdural Hematoma - observe for signs of meningitis, antibiotics as ordered
- occurs under the dura as a result of tears in the veins - place cotton ball on ear to absorb otorrhea
crossing the subdural space - gently place sterile gauze pad at the bottom of the nose
- forms slowly for rhinorrhea
- results from a venous bleed 4) Prevent complications of immobility
• Intracerebral Hematoma 5) Prepare the client for surgery if indicated
- accumulation of blood within the cerebrum - Depressed skull fracture-surgical removal or elevation
of splintered bone; debridement & cleansing; repair of
dural tear
- Epidural / subdural hematoma-evacuation of
hematoma
6) Monitor for signs of infection

Cerebrovascular Accident (CVA)

- Destruction (infarction) of brain cells caused by a
reduction in cerebral blood flow and oxygen
- Affects men more than women; incidence increases with
age
- Caused by thrombosis, embolism, hemorrhage
- Risk factors:
• Hypertension
• diabetes mellitus
• arteriosclerosis/atherosclerosis
• cardiac disease (valvular disease/replacement, chronic
atrial fibrillation, MI)
• life-style (obesity, smoking, inactivity, stress, use of oral
contraceptives)
- A stroke can happen when:
• A blood vessel carrying blood to the brain is blocked by
a blood clot.
• This is called an ischemic stroke.
• A blood vessel breaks open, causing blood to leak into
the brain. This is a hemorrhagic stroke.
• If blood flow is stopped for longer than a few seconds,
the brain cannot get blood and oxygen.

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 NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER MIDTERM 2023
• Brain cells can die, causing permanent damage.
- Pathophysiology: interruption of cerebral blood flow for 5
minutes or more causes death of neurons in affected area
with irreversible loss of function
Stages of development:
1) Transient ischemic attack (TIA)
- warning sign of impending CVA
- brief period of neurologic deficit (visual loss,
hemiparesis, slurred speech, aphasia, vertigo)
- may last less than 30 seconds, but no more than 24
hours with complete resolution of symptoms
2) Stroke in evolution – progressive development of stroke
symptoms over a period of hours to days
3) Completed stroke – neurologic deficit remains unchanged
for a 2- to 3-day period
Assessment
• Headache
• Generalized signs: vomiting, seizures, confusion,
disorientation, decreased LOC, nuchal rigidity, fever,
hypertension, slow bounding pulse, Cheyne-Stokes
respirations
• Focal signs (related to site of infarction): hemiplegia,
sensory loss, aphasia, homonymous hemianopsia
• Diagnostic tests
1) CT and brain scan: reveal lesion
2) EEG: abnormal changes
3) Cerebral arteriography: may show occlusion or
malformation of blood vessels
Nursing interventions
Acute stage:
1) Maintain patent airway and adequate ventilation.
2) Monitor VS, neuro checks, observe for signs of ed ICP,
shock, hyperthermia, and seizures.
3) Provide complete bed rest as ordered.
4) Maintain F& E balance and ensure adequate nutrition.
• IV therapy for the first few days
• NGT feedings - if unable to swallow
• Fluid restriction as ordered - to decrease cerebral
edema
5) Maintain proper positioning and body alignment.
• Head of bed may be elevated 30°-45° to  ICP
• Turn and reposition every 2 hours (only 20 minutes on
the affected side)
• Passive ROM exercises every 4 hours.
6) Promote optimum skin integrity: turn client and apply
lotion every 2 hours
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7) Maintain adequate elimination.
• Offer bedpan or urinal every 2 hours, catheterize only if
absolutely necessary.
• Administer stool softeners and suppositories as
ordered to prevent
constipation and fecal impaction.
8) Provide a quiet, restful environment.
9) Establish a means of communicating with the client.
10) Administer medications as ordered.
• Hyperosmotic agents, corticosteroids to decrease
cerebral edema
• Anticonvulsants to prevent or treat seizures
• Thrombolytics given to dissolve clot (hemorrhage must
be ruled out)
a) tissue plasminogen activator (tPA, Alteplase)
b) streptokinase, urokinase = must be given within 2
hours of episode
• Anticoagulants - stroke in evolution or embolic stroke
a) heparin
b) warfarin (Coumadin) for long-term therapy
c) aspirin and dipyridamole (Persantin) – to inhibit
platelet aggregation in treating TIAs
• Antihypertensives - if indicated for elevated blood
pressure
Rehabilitation
1) Hemiplegia: results from injury to cells in the cerebral
motor cortex or corticospinal pathway
a) Turn every 2 hours (20 minutes only on affected side)
b) Use proper positioning & repositioning to prevent
deformities
c) Support paralyzed arm on pillow or use sling while out
of bed
d) Elevate extremities to prevent dependent edema
e) Provide active & passive ROM exercises every 4 hours
2) Susceptibility to hazards
a) keep side rails up at all times
b) institute safety measures
c) inspect body parts frequently for signs of injury
3) Dysphagia (inability to swallow or difficulty in swallowing)
a) check gag reflex before feeding the patient
b) maintain calm, unhurried approach
c) place in upright position
d) place food in unaffected side of mouth
e) offer soft foods
f) give mouth care before and after meals
4) Homonymous hemianopsia
a) approach client on unaffected side
b) place personal belongings, food on unaffected side
c) teach client by scanning
5) Emotional lability: mood swings, frustration
a) create a quiet, restful environment with a reduction in
excessive sensory stimuli
b) maintain a calm, nonthreatening manner
c) explain to family that the client behavior is not
purposeful
6) Aphasia – most common in R hemiplegics bec. Left-
hemisphere dominance for language
a) Receptive:
 NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER MIDTERM 2023

• give simple, slow directions - Medical management: Immobilization & maintenance of

• give one command at a time; gradually shift topics normal spine alignment – to promote fracture healing
• use nonverbal techniques of communication 1) Horizontal turning frame / Stryker frame
b) Expressive: 2) Skeletal traction
• listen & watch very carefully when client attempts to a) cervical tongs (Crutchfield)
speak b) halo traction
• anticipate clients need to decrease frustration & - Surgery
feelings of helplessness • Decompression laminectomy
• allow sufficient time & client to answer • Spinal fusion
7) Sensory/ perceptual deficits – more common in left Assessment
hemiplegics – characterized by impulsiveness, unaware of 1) Spinal Shock
disabilities, visual neglect - occurs immediately after the injury as a result of the
a) assist with self-care insult to the CNS
b) provide safetty measures - temporary condition lasting from several days to 3
c) initially arrange objects in env of unaffected side months
d) gradually teach clients to take care of the unaffected - characterized by:
side & to turn frequently & look at affected side • Absence of reflexes below the level of lesion
• Flaccid paralysis
Spinal cord injury • Lack of temperature control
- trauma to the spinal cord which causes partial or complete • Hypotension w/ bradycardia
disruption of the nerve tracts & neurons • Retention of urine & feces
- Causes 2) Level of Injury
• traumatic: motor vehicle accidents, diving in shallow a) Quadriplegia
water, falls, industrial accidents, sports injuries, - Cervical injuries (C1-C8) → paralysis of all 4
gunshot or stab wound extremities
• non-traumatic: tumors, hematomas, aneurysms, - respiratory paralysis → lesions above C6 (phrenic
congenital defects nerve at C4-C5 level) =the nerve that governs
- SCI is classified according to: movement of the diaphragm during breathing
• Extent of injury b) Paraplegia
• Level of injury - thoracolumbar injuries (T1-L4) → paralysis of the
o Cervical lower half of the body involving both legs
o Thoracic 3) Extent of Injury
o Lumbar a) Complete Cord Transection
• Mechanism of injury - loss of all voluntary movement and sensation below
o Hyperflexion the level of injury
o Hyperextension b) Incomplete lesions
o Axial loading – force exerted straight up or down - varying degrees of motor or sensory loss between
spinal column (ex: diving) the level of the lesion depending on which
- May affect the vertebral column. neurologic tracts are damaged & which are spared
• Fracture Nursing Interventions
• Dislocation Emergency Care:
- May affect anterior & posterior ligaments 1) Assess ABC
• compression of spinal cord - do not move patient during assessment
- May affect the spinal cord & its roots: - if airway obstruction or inadequate ventilation exists; do
• Concussion not hyperextend neck to open airway, use jaw thrust
• Contusion 2) Perform a quick head to toe assessment; check for LOC,
• Compression or laceration by fracture / dislocation signs of trauma; check for leakage of fluid from ear
• penetrating (ex. GSW, missile) 3) Immobilize client
- Axial Loading 4) Assist in immobilizing head and neck with cervical collar &
• Fall from a height, landing on one's feet is typical of this place on spinal board; avoid flexion of the spinal column
fracture Acute Care:
1) Maintain optimum respiratory function
• axial loading applied to intravertebral disc results in
- observe for weak or labored respirations
increased pressure and stresses
- prevent pneumonia and atelectasis; turn every 2 hours;
• a large central posterior- superior fragment occurs as a
cough and deep breathe
result of these forces
- tracheostomy & mechanical ventilation may be
- Pathophysiology: hemorrhage & edema → ischemia →
necessary
necrosis & destruction of cord

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 NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER MIDTERM 2023
2) Maintain optimal cardiovascular function
- monitor vital signs: observe for bradycardia, arrythmias,
hypotension
- apply thigh-high elastic stockings
- change position slowly & gradually elevate the head of
the bed to prevent postural hypotension
- observe for signs of DVT
3) Maintain fluid & electrolyte balance & nutrition
- NGT may be inserted until bowel sounds return
- maintain IV therapy as ordered
- check bowel sounds before feeding
- progress slowly from clear liquid to regular diet
- provide diet high in protein, CHO, calories
4) Maintain immobilization & spinal alignment always
- turn every hour on turning frame
- maintain cervical traction at all times if indicated
5) Prevent complications of immobility
6) Maintain urinary elimination
- provide intermittent catheterization or indwelling
catheter
- increase fluids to 3000ml/day
- provide acid-ash foods/ fluids to urine = a diet
consisting largely of meat or fish, eggs, and cereals with
a minimal quantity of milk, fruit, and vegetables, that
when catabolized leaves an acid residue to be excreted
in the urine.
7) Maintain bowel elimination
8) Monitor temperature control
9) Observe for & prevent infection
10) Observe for & prevent stress ulcers
Chronic care
1) Nonreflexive/ Areflexive or lower motor neuron bladder
/ LMN bladder
- spinal shock: when reflex arc is not functioning due to
initial trauma
- no reflex activity of the bladder occurs, resulting in
urine retention with overflow
- Failure to Empty
- lesion: Complete destruction of Sacral Micturition
Center (S2–S4) at S2 or below
- Management:
• intermittent catheterization every 6 hours
• Crede’s maneuver or rectal stretch
• regulate intake to 1800-2000 ml/day → to prevent
overdistention of bladder
2) Reflex or upper motor neuron bladder / UMN bladder
- reflex activity of the bladder may occur after spinal
shock resolves
- bladder is unable to store urine very long and empties
voluntarily
- Failure to Store (Incontinence)
- lesion: Above Sacral Micturition Center (above S2)
- Management:
• intermittent catheterization every 4 hours and
gradually progresses to every 6 hours
• regulate fluid intake to 1800-2000 ml/day
• bladder taps → to cause reflex emptying of the
bladder
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Autonomic Dysreflexia
- rise in blood pressure, sometimes to fatal levels
- reflex response to stimulation of the sympathetic nervous
system
- occurs in clients with cord lesions above T6
- most commonly in clients with cervical injuries
- stimulus: overdistended bladder or bowel, decubitus ulcer,
chilling, pressure from bedclothes
- Symptoms: severe headache, hypertension, bradycardia,
sweating, goose bumps, nasal congestion, blurred vision,
convulsions
- Interventions:
• raise client to sitting position to decrease BP.
• check for source of stimulus (bladder, bowel, skin)
• remove offending stimulus (e.g. reposition client
catheterize client, digitally remove impacted feces,)
• monitor BP
• administer antihypertensives (e.g. hydralazine HCl
[Apresoline]) as ordered
Medications
1) Dexamethasone (Decadron)
- used for its anti-inflamm & edema reducing effects
- may interfere with healing
2) Dextran (plasma expander)
- used to increase capillary blood flow within the spinal
cord and to prevent / treat hypotension
3) Dantrolene (Dantrium), Baclofen (Lioresal)
- used for clients with upper motor neuron injuries to
control muscle spasticity
Seizures
- An abnormal, sudden, excessive, uncontrolled electrical
discharge of neurons within the brain that may result in
alteration of consciousness, motor or sensory ability,
and/or behavior
- Epilepsy – a chronic disorder characterized by recurrent,
unprovoked seizure activity. Cause unknown in 75% of
epilepsy cases.
- THEREFORE: Seizure is a symptom of epilepsy
Pathophysiology
- Normally neurons send out messages in electrical
impulses periodically, and the firing of individual neurons is
regulated by an inhibitory feedback loop mechanism.
- With seizures, many more neurons than normal fire in a
synchronous fashion in a particular area of the brain; the
energy generated overcomes the inhibitory feedback
mechanism.
 NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER MIDTERM 2023

Type of Seizure Clinical Findings - Begins in focal area (anterior

temporal lobe) but spreads to both
I. Generalized seizures Complex partial
hemispheres.
seizure
- May be preceded by aura - Impairs consciousness.
- tonic and clonic phases - May be preceded by aura.
- Tonic phase: limbs contract or
stiffen; pupils dilate and eyes roll up
and to one side; glottis closes,
causing noise on exhalation; may be
Major motor
incontinent; occurs at same time as
seizure (grand
loss of consciousness; lasts 20–40
mal)
seconds.
- Clonic phase: repetitive
movements, increased mucus
production; slowly tapers.
- Seizure ends with postictal period of
confusion, drowsiness.
- Related to organic brain damage.
Akinetic seizure Sudden brief loss of postural tone,
(atonic) and temporary loss of
consciousness.
- Associated with brain damage, may
be precipitated by tactile or visual
sensations.
- May be generalized or local.
Myoclonic
Brief flexor muscle spasm; may
seizure
have arm extension, trunk flexion.
Medical management (Drug therapy)
- Single group of muscles affected;
1) Phenytoin (Dilantin)
involuntary muscle contractions =
- It is one of the drugs of choice for :
myoclonic jerks.
• Generalized tonic-clonic seizures
- Usually nonorganic brain damage
• Partial seizures
present; must be differentiated from
Absence seizure - Phenytoin should not be used to treat absence seizures
daydreaming.
(petit mal) or myoclonic seizures.
- Sudden onset, with twitching or
- Serum blood level determinations may be necessary for
rolling of eyes; lasts a few seconds.
optimal dosage
- Common in 5% of population under
- adjustments – the clinically effective serum level is
5, familial, nonprogressive; does not
usually 10-20 mcg/mL
generally result in brain damage.
- Common side effects of phenytoin include:
Febrile seizure Typically tonic-clonic.
- Seizure occurs only when fever is • swollen, tender gums – gum hyperplasia
rising. • growth of facial and body hair
- EEG is normal 2 weeks after seizure. • enlarged or rough facial features
Status epilepticus • acne
- Usually refers to generalized grand mal seizures. • skin rash
- Seizure is prolonged (there are repeated seizures without - Serum phenytoin level
regaining consciousness) and unresponsive to treatment. • The therapeutic range is 10-20 mcg/mL.
- Can result in decreased oxygen supply and possible • Plasma levels (mcg/mL) have an association with
cardiac arrest. acute neurological symptoms.
II. Partial seizures o Lower than 10 - Rare
- Seizure confined to one hemisphere o Between 10 and 20 - Occasional mild nystagmus
of brain. o Between 20 and 30 - Nystagmus
Simple partial - No loss of consciousness. o Between 30 and 40 - Ataxia, slurred speech,
seizure - May be motor, sensory, or nausea, and vomiting
autonomic symptoms. o Between 40 and 50 - Lethargy and confusion
o Higher than 50 - Coma and seizures
- Considerations:
• Phenytoin may decrease the effectiveness of
hormonal contraceptives (birth control pills, patches,

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rings, injections, implants, or intrauterine devices). b) Keep airway open.

Use another form of birth control while taking • place in side-lying position.
Phenytoin. • suction excess mucous.
• Phenytoin is listed in Pregnancy Category D. This c) Observe and record seizure.
means that there is a risk to the baby, but the • note any preictal aura.
benefits may outweigh the risk for some women. - affective signs: fear, anxiety
• Often used with Phenobarbital for its potentiating - psychosensory signs: hallucinations
effect. - cognitive signs: "déjà-vu" symptoms
a) elevates the seizure • note nature of the ictal phase.
b) threshold and inhibits the - symmetry of movement
c) spread of electrical discharge - response to stimuli; LOC
2) Carbamazepine - respiratory pattern
- It is used alone or in combination with other • note postictal response: amount of time it takes to
medications to treat certain types of seizures in orient to time and place; sleepiness
patients with epilepsy.
- It is also used to treat trigeminal neuralgia (a condition
that causes facial nerve pain).
- It works by reducing abnormal excitement in the brain.
- Common side-effects:
• fatigue
• dizziness GOOD LUCK EVERYONE!!
• nausea & vomiting
- Carbamazepine can lower the white blood cells.
- Serious side effects:
• Fever
• sore throat
• headache with a severe blistering, peeling & red skin
rash
• pale skin
• easy bruising or bleeding
• jaundice (yellowing of the skin or eyes
3) Valium
- It slows the central nervous system and is used to treat
anxiety related disorders and conditions that cause
severe muscle spasms and convulsions.
- Valium is administered rectally. Liquid Valium is
absorbed fast from the rectum.
- The effect should take place 5-15 minutes after the
injection.
- Valium should not be used on a daily basis because it
can cause withdrawal.
Surgery
- to remove the tumor, hematoma, or epileptic focus
Diagnostic tests
• Blood studies to rule out lead poisoning, hypoglycemia,
infection, or electrolyte imbalances
• Lumbar puncture to rule out infection or trauma
• Skull x-rays, CT scan, or ultrasound of the head, brain scan,
arteriogram to detect any pathologic defects
• EEG may detect abnormal wave patterns characteristic of
different types of seizures
Nursing interventions (During seizure activity)
a) Protect from injury.
• prevent falling, gently support head.
• decrease external stimuli; do not restrain.
• do not use tongue blades (they add additional stimuli).
• loosen tight clothing.

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