5074406 medical surgical nursing review notes

MEDICAL-SURGICAL NURSING

NERVOUS SYSTEM

Overview of structures and functions:

Central Nervous System

Brain

Spinal Cord

Peripheral Nervous System

Cranial Nerves

Spinal Nerves

Autonomic Nervous System

Sympathetic nervous system

Parasympathetic nervous system

AUTONOMIC NERVOUS SYSTEM

Sympathetic Nervous System(ADRENERGIC)

Parasympathetic Nervous System(CHOLINERGIC, VAGAL, SYMPATHOLYTIC)

- Involved in fight or aggression response.- Release of Norepinephrine (cathecolamines) from adrenal glands and causes vasoconstriction.- Increase all bodily activity except GIT

EFFECTS OF SNS- Dilation of pupils(mydriasis) in order to be aware.- Dry mouth (thickened saliva).- Increase BP and Heart Rate.- Bronchodilation, Increase RR - Constipation.- Urinary Retention.- Increase blood supply to brain, heart and skeletal muscles.- SNS

I. Adrenergic Agents- Give Epinephrine.Signs and Symptoms:- SNSContraindication: - Contraindicated to patients suffering from COPD (Broncholitis, Bronchoectasis, Emphysema, Asthma).

II. Beta-adrenergic Blocking Agents- Also called Beta-blockers.- All ending with “lol”- Propranolol, Atenelol, Metoprolol. Effects of Beta-blockersB – roncho spasmE – licits a decrease in myocardial contraction.T – reats hypertension.A – V conduction slows down. Should be given to patients with Angina Pectoris,

Myocardial Infarction, Hypertension.

ANTI- HYPERTENSIVE AGENTS1. Beta-blockers – “lol”2. Ace Inhibitors – Angiotensin, “pril” (Captopril, Enalapril)3. Calcium Antagonist – Nifedipine (Calcibloc) In chronic cases of arrhythmia give

Lidocaine(Xylocaine)

- Involved in fight or withdrawal response.- Release of Acetylcholine.

- Decreases all bodily activities except GIT.

EFFECTS OF PNS- Constriction of pupils (meiosis).- Increase salivation.- Decrease BP and Heart Rate.- Bronchoconstriction, Decrease RR.- Diarrhea- Urinary frequency.

I. Cholinergic Agents- Mestinon, Neostigmine.Side Effects- PNS

II. Anti-cholinergic Agents- To counter cholinergic agents.- Atropine SulfateSide Effects- SNS

CENTRAL NERVOUS SYSTEM

Brain and Spinal Cord.

I. CELLS

A. NEURONS

Basic cells for nerve impulse and conduction.

PROPERTIES

Excitability – ability of neuron to be affected by changes in external environment.

Conductivity – ability of neuron to transmit a wave of excitation from one cell to another.

Permanent Cell – once destroyed not capable of regeneration.

TYPES OF CELLS BASED ON REGENERATIVE CAPACITY

1. Labile

Capable of regeneration.

Epidermal cells, GIT cells, GUT cells, cells of lungs.

2. Stable

Capable of regeneration with limited time, survival period.

Kidney cells, Liver cells, Salivary cells, pancreas.

3. Permanent

Not capable of regeneration.

Myocardial cells, Neurons, Bone cells, Osteocytes, Retinal Cells.

B. NEUROGLIA

Support and protection of neurons.

TYPES

1. Astrocytes – maintains blood brain barrier semi-permeable.

Majority of brain tumors (90%) arises from called astrocytoma.

2. Oligodendria

3. Microglia

4. Epindymal

SUBSTANCES THAT CAN PASS THE BLOOD-BRAIN BARRIER

1. Ammonia

Cerebral toxin

Hepatic Encephalopathy (Liver Cirrhosis)

Ascites

Esophageal Varices

Early Signs of Hepatic Encephalopathy

asterixis (flapping hand tremors).

Late Signs of Hepatic Encephalopathy

Headache

Dizziness

Confusion

Fetor hepaticus (ammonia like breath)

Decrease LOC

PATHOGNOMONIC SIGNS

1. PTB – low-grade afternoon fever.

2. PNEUMONIA – rusty sputum.

3. ASTHMA – wheezing on expiration.

4. EMPHYSEMA – barrel chest.

5. KAWASAKI SYNDROME – strawberry tongue.

6. PERNICIOUS ANEMIA – red beefy tongue.

7. DOWN SYNDROME – protruding tongue.

8. CHOLERA – rice watery stool.

9. MALARIA – stepladder like fever with chills.

10. TYPHOID – rose spots in abdomen.

11. DIPTHERIA – pseudo membrane formation

12. MEASLES – koplik’s spots.

13. SLE – butterfly rashes.

14. LIVER CIRRHOSIS – spider like varices.

15. LEPROSY – lioning face.

16. BULIMIA – chipmunk face.

17. APPENDICITIS – rebound tenderness.

18. DENGUE – petechiae or (+) Herman’s sign.

19. MENINGITIS – Kernig’s sign (leg pain), Brudzinski sign (neck pain).

20. TETANY – HYPOCALCEMIA (+) Trousseau’s sign/carpopedal spasm; Chvostek sign (facial spasm).

21. TETANUS – risus sardonicus.

22. PANCREATITIS – Cullen’s sign (ecchymosis of umbilicus); (+) Grey turners spots.

23. PYLORIC STENOSIS – olive like mass.

24. PDA – machine like murmur.

25. ADDISON’S DISEASE – bronze like skin pigmentation.

26. CUSHING’S SYNDROME – moon face appearance and buffalo hump.

27. HYPERTHYROIDISM/GRAVE’S DISEASE – exopthalmus.

28. INTUSSUSCEPTION – sausage shaped mass

2. Carbon Monoxide and Lead Poisoning

Can lead to Parkinson’s Disease.

Epilepsy

Treat with ANTIDOTE: Calcium EDTA.

3. Type 1 DM (IDDM)

Causes diabetic ketoacidosis.

And increases breakdown of fats.

And free fatty acids

Resulting to cholesterol and (+) to Ketones (CNS depressant).

Resulting to acetone breath odor/fruity odor.

KUSSMAUL’S respiration, a rapid shallow respiration.

Which may lead to diabetic coma.

4. Hepatitis

Signs of jaundice (icteric sclerae).

Caused by bilirubin (yellow pigment)

5. Bilirubin

Increase bilirubin in brain (Kernicterus).

Causing irreversible brain damage.

Astrocites

Maintains integrity of blood brain barrier.

Oligodendria

Produces myelin sheath in CNS

Act as insulator and facilitates rapid nerve impulse transmission.

DEMYELINATING DISORDERS

1. ALZHEIMER’S DISEASE

Atrophy of brain tissues.

Sign and Symptoms

4 A’s of Alzheimer

a. Amnesia – loss of memory.

b. Agnosia – no recognition of inanimate objects.

c. Apraxia – no recognition of objects function.

d. Aphasia – no speech (nodding).

*Expressive aphasia

“motor speech center”

Broca’s Aphasia

*Receptive aphasia

inability to understand spoken words.

Wernicke’s Aphasia

General Knowing Gnostic Area or General Interpretative Area.

DRUG OF CHOICE: ARICEPT (taken at bedtime) and COGNEX.

2. MULTIPLE SCLEROSIS

Chronic intermittent disorder of CNS characterized by white patches of demyelination in brain and

spinal cord.

Characterized by remission and exacerbation.

Women ages 15-35 are prone

Unknown Cause

Slow growing virus

Autoimmune disorders

Pernicious anemia

Myasthenia gravis

Lupus

Hypothyroidism

GBS

Ig G – only antibody that pass placental circulation causing passive immunity.

- short term protection.

- Immediate action.

Ig A – present in all bodily secretions (tears, saliva, colostrums).

Ig M – acute in inflammation.

Ig E – for allergic reaction.

Ig D – for chronic inflammation.

* Give palliative or supportive care.

Signs and Symptoms

1. Visual disturbances

blurring of vision (primary)

diplopia (double vision)

scotomas (blind spots)

2. Impaired sensation

to touch, pain, pressure, heat and cold.

tingling sensation

paresthesia

numbness

3. Mood swings

euphoria (sense of well being)

4. Impaired motor function

weakness

spasticity

paralysis

5. Impaired cerebral function

scanning speech

TRIAD SIGNS OF MS

Ataxia

(Unsteady gait, (+) Romberg’s test)

Intentional tremors Nystagmus

6. Urinary retention/incontinence

7. Constipation

8. Decrease sexual capacity

DIAGNOSTIC PROCEDURE

CSF analysis (increase in IgG and Protein).

MRI (reveals site and extent of demyelination).

(+) Lhermitte’s sign a continuous and increase contraction of spinal column.

NURSING MANAGEMENT

1. Administer medications as ordered

a. ACTH (Adreno Corticotropic Hormone)/ Steroids for acute exacerbation to reduce edema at site

of demyelination to prevent paralysis.

b. Baclofen (Dioresal)/ Dantrolene Sodium (Dantrene) – muscle relaxants.

c. Interferons – alter immune response.

d. Immunosupresants

2. Maintain side rails to prevent injury related to falls.

3. Institute stress management techniques.

a. Deep breathing exercises

b. Yoga

4. Increase fluid intake and increase fiber to prevent constipation.

5. Catheterization to prevent retention.

a. Diuretics

b. Bethanicol Chloride (Urecholine)

Nursing Management

Only given subcutaneous.

Monitor side effects bronchospasm and wheezing.

Monitor breath sounds 1 hour after subcutaneous administration.

c. For Urinary Incontinence

Anti spasmodic agent

a. Prophantheline Bromide (Promanthene)

Acid ash diet like cranberry juice, plums, prunes, pineapple, vitamin C and orange.

To acidify urine and prevent bacterial multiplication.

CHARCOTS TRIAD

IAN

COMMON CAUSE OF UTI

Female

short urethra (3-5 cm, 1-1 ½ inches)

poor perineal hygiene

vaginal environment is moist

Nursing Management

avoid bubble bath (can alter Ph of vagina).

avoid use of tissue papers

avoid using talcum powder and perfume.

Male

Urethra (20 cm, 8 inches)

urinate after intercourse

MICROGLIA

stationary cells that carry on phagocytosis (engulfing of bacteria or cellular debris,

eating), pinocytosis (cell drinking).

MACROPHAGE ORGAN

Microglia

Monocytes

Kupffers cells

Histiocytes

Alveolar

Macrophage

Brain

Blood

Kidney

Skin

Lung

EPINDYMAL CELLS

Secretes a glue called chemo attractants that concentrate the bacteria.

COMPOSITION OF BRAIN

80% brain mass

10% blood

10% CSF

I. Brain Mass

PARTS OF THE BRAIN

1. CEREBRUM

largest part

composed of the Right Cerebral Hemisphere and Left Cerebral Hemisphere enclosed in the

Corpus Callosum.

Functions of Cerebrum

integrative

sensory

motor

Lobes of Cerebrum

1. Frontal

higher cortical thinking

controls personality

controls motor activity

Broca’s Area (motor speech area) when damaged results to garbled speech.

2. Temporal

hearing

short term memory

3. Parietal

for appreciation

discrimination of sensory impulses to pain, touch, pressure, heat, cold, numbness.

4. Occipital

for vision

Insula (Island of Reil)

visceral function activities of internal organ like gastric motility.

Limbic System (Rhinencephalon)

controls smell and if damaged results to Anosmia (absence of smell).

controls libido

controls long term memory

2. BASAL GAGLIA

areas of grey matter located deep within each cerebral hemisphere.

release dopamine (controls gross voluntary movement.

NEURO TRANSMITTER DECREASE INCREASE

Acethylcholine Myasthenia Gravis Bi-polar Disorder

Dopamine Parkinson’s Disease Schizophrenia

3. MIDBRAIN/ MESENCEPHALON

acts as relay station for sight and hearing.

size of pupil is 2 – 3 mm.

equal size of pupil is isocoria.

unequal size of pupil is anisocoria.

hearing acuity is 30 – 40 dB.

positive PERRLA

4. INTERBRAIN/ DIENCEPHALON

Parts of Diencephalon

A. Thalamus

acts as relay station for sensation.

B. Hypothalamus

controls temperature (thermoregulatory center).

controls blood pressure

controls thirst

appetite/satiety

sleep and wakefulness

controls some emotional responses like fear, anxiety and excitement.

controls pituitary functions

androgenic hormones promotes secondary sex characteristics.

early sign for males are testicular and penile enlargement

late sign is deepening of voice.

early sign for females telarche and late sign is menarche.

5. BRAIN STEM

located at lowest part of brain

Parts of Brain Stem

1. Pons

pneumotaxic center controls the rate, rhythm and depth of respiration.

2. Medulla Oblongata

controls respiration, heart rate, swallowing, vomiting, hiccup, vasomotor center (dilation and

constriction of bronchioles).

3. Cerebellum

smallest part of the brain.

lesser brain.

controls balance, equilibrium, posture and gait.

INTRA CRANIAL PRESSURE

Monroe Kellie Hypothesis

Skull is a closed container

Any alteration or increase in one of the intracranial components

Increase intra-cranial pressure

(normal ICP is 0 – 15 mmHg)

Cervical 1 – also known as ATLAS.

Cervical 2 – also known as AXIS.

Foramen Magnum

Medulla Oblongata

Brain Herniation

Increase intra cranial pressure

* Alternate hot and cold compress to prevent HEMATOMA

CSF cushions brain (shock absorber)

Obstruction of flow of CSF will lead to enlargement of skull posteriorly called hydrocephalus.

Early closure of posterior fontanels causes posterior enlargement of skull in hydrocephalus.

NEUROLOGIC DISORDERS

INCREASE INTRACRANIAL PRESSURE – increase in intra-cranial bulk brought about by an increase in one

of the 3 major intra cranial components.

Causes:

head trauma/injury

localized abscess

cerebral edema

hemorrhage

inflammatory condition (stroke)

hydrocephalus

tumor (rarely)

Signs and Symptoms (Early)

decrease LOC

restlessness/agitation

irritability

lethargy/stupor

coma

Signs and Symptoms (Late)

changes in vital signs

blood pressure (systolic blood pressure increases but diastolic remains the same).

widening of pulse pressure is neurologic in nature (if narrow cardiac in nature).

heart rate decrease

respiratory rate decrease

temperature increase directly proportional to blood pressure.

projective vomiting

headache

papilledema (edema of optic disc)

abnormal posturing

decorticate posturing (damage to cortex and spinal cord).

decerebrate posturing (damage to upper brain stem that includes pons, cerebellum and

midbrain).

unilateral dilation of pupils called uncal herniation

bilateral dilation of pupils called tentorial herniation

resulting to mild headache

possible seizure activity

Nursing Management

1. Maintain patent and adequate ventilation by:

a. Prevention of hypoxia and hypercarbia

Early signs of hypoxia

restlessness

agitation

tachycardia

Late signs of hypoxia

Bradycardia

Extreme restlessness

Dyspnea

Cyanosis

HYPERCARBIA

Increase CO2 (most powerful respiratory stimulant) retention.

In chronic respiratory distress syndrome decrease O2 stimulates respiration.

b. Before and after suctioning hyper oxygenate client 100% and done 10 – 15 seconds only.

c. Assist in mechanical ventilation

2. Elevate bed of client 30 – 35o angle with neck in neutral position unless contraindicated to promote venous

drainage.

3. Limit fluid intake to 1200 – 1500 ml/day (in force fluids 2000 – 3000 ml/day).

4. Monitor strictly input and output and neuro check

5. Prevent complications of

6. Prevent further increase ICP by:

a. provide an comfortable and quite environment.

b. avoid use of restraints.

c. maintain side rails.

d. instruct client to avoid forms of valsalva maneuver like:

straining stool

excessive vomiting (use anti emetics)

excessive coughing (use anti tussive like dextromethorphan)

avoid stooping/bending

avoid lifting heavy objects

e. avoid clustering of nursing activity together.

7. Administer medications like:

a. Osmotic diuretic (Mannitol)

for cerebral diuresis

Nursing Management

monitor vital signs especially BP (hypotension).

monitor strictly input and output every 1 hour notify physician if output is less 30 cc/hr.

administered via side drip

regulated fast drip to prevent crystal formation.

b. Loop diuretic (Lasix, Furosemide)

Drug of choice for CHF (pulmonary edema)

Loop of Henle in kidneys.

Nursing Management

Monitor vital signs especially BP (hypotension).

monitor strictly input and output every 1 hour notify physician if output is less 30 cc/hr.

administered IV push or oral.

given early morning

immediate effect of 10 – 15 minutes.

maximum effect of 6 hours.

c. Corticosteroids

Dexamethasone (Decadron)

Hydrocortisone

Prednisone (to reduce edema that may lead to increase ICP)

Mild Analgesics (Codeine Sulfate for respiratory depression)

Anti Convulsants (Dilantin, Phenytoin)

*CONGESTIVE HEART FAILURE

Signs and Symptoms

dyspnea

orthopnea

paroxysmal nocturnal dyspnea

productive cough

frothy salivation

cyanosis

rales/crackles

bronchial wheezing

pulsus alternans

anorexia and general body malaise

PMI (point of maximum impulse/apical pulse rate) is displaced laterally

S3 (ventricular gallop)

Predisposing Factors/Mitral Valve

RHD

Aging

TREATMENT

Morphine Sulfate

Aminophelline

Digoxin

Diuretics

Oxygen

Gases, blood monitor

RIGHT CONGESTIVE HEART FAILURE (Venous congestion)

Signs and Symptoms

jugular vein distention (neck)

ascites

pitting edema

weight gain

hepatosplenomegaly

jaundice

pruritus

esophageal varices

anorexia and general body malaise

Signs and Symptoms of Lasix in terms of electrolyte imbalances

1. Hypokalemia

decrease potassium level

normal value is 3.4 – 5.5 meq/L

Sign and Symptoms

weakness and fatigue

constipation

positive U wave on ECG tracing

Nursing Management

administer potassium supplements as ordered (Kalium Durule, Oral Potassium Chloride)

increase intake of foods rich in potassium

FRUITS VEGETABLES

Apple

Banana

Cantalope

Oranges

Asparagus

Brocolli

Carrots

Spinach

2. Hypocalcemia/ Tetany

decrease calcium level

normal value is 8.5 – 11 mg/100 ml

Signs and Symptoms

tingling sensation

paresthesia

numbness

(+) Trousseau’s sign/ Carpopedal spasm

(+) Chvostek’s sign

Complications

Arrhythmia

Seizures

Nursing Management

Calcium Gluconate per IV slowly as ordered

* Calcium Gluconate toxicity – results to SEIZURE

Magnesium Sulfate

Magnesium Sulfate toxicity

S/S

BP

Urine output DECREASE

Respiratory rate

Patellar relfex absent

3. Hyponatremia

decrease sodium level

normal value is 135 – 145 meq/L

Signs and Symptoms

hypotension

dehydration signs (Initial sign in adult is THIRST, in infant TACHYCARDIA)

agitation

dry mucous membrane

poor skin turgor

weakness and fatigue

Nursing Management

force fluids

administer isotonic fluid solution as ordered

4. Hyperglycemia

normal FBS is 80 – 100 mg/dl

Signs and Symptoms

polyuria

polydypsia

polyphagia

Nursing Management

monitor FBS

5. Hyperuricemia

increase uric acid (purine metabolism)

foods high in uric acid (sardines, organ meats and anchovies)

*Increase in tophi deposit leads to Gouty arthritis.

Signs and Symptoms

joint pain (great toes)

swelling

Nursing Management

force fluids

administer medications as ordered

a. Allopurinol (Zyloprim)

Drug of choice for gout.

Mechanism of action : inhibits synthesis of uric acid.

b. Colchecine

Acute gout

Mechanism of action : promotes excretion of uric acid.

* KIDNEY STONES

Signs and Symptoms

renal colic

Cool moist skin

Nursing Management

force fluids

administer medications as ordered

a. Narcotic Analgesic

Morphine Sulfate

ANTIDOTE: Naloxone (Narcan) toxicity leads to tremors.

b. Allopurinol (Zyloprim)

Side Effects

Respiratory depression (check for RR)

Multiple loss causes suicide

PARKINSON’S DISEASE/ PARKINSONISM

Chronic progressive disorder of CNS characterized by degeneration of dopamine producing

cells in the SUBSTANCIA NIGRA of the midbrain and basal ganglia.

Predisposing Factors

1. Poisoning (lead and carbon monoxide)

2. Arteriosclerosis

3. Hypoxia

4. Encephalitis

5. Increase dosage of the following drugs:

a. Reserpine(Serpasil)

b. Methyldopa(Aldomet) AntihypertensiveS

c. Haloperidol(Haldol)

d. Phenothiazine AntipsychoticS

SIDE EFFECTS RESERPINE Major depression leading to suicide

Aloneness

Loss of spouse Loss of Job

direct approach towards the client

close surveillance is a nursing priority

time to commit suicide is on weekends early morning

Signs and Symptoms for Parkinson’s

pill rolling tremors of extremities especially the hands.

bradykinesia (slowness of movement)

rigidity (cogwheel type)

stooped posture

shuffling and propulsive gait

over fatigue

mask like facial expression with decrease blinking of the eyes.

difficulty rising from sitting position.

Monotone type speech

mood lability (in state of depression)

increase salivation (drooling type)

autonomic changes

a. increase sweating

b. increase lacrimation

c. seborrhea

d. constipation

e. decrease sexual capacity

Nursing Management


Anti Parkinsonian agents

Levodopa (L-dopa) short acting

Amantadine Hydrochloride (Symmetrel)

Carbidopa (Sinemet)

Mechanism of Action

increase level of dopamine

Side Effects

GIT irritation (should be taken with meals

orthostatic hypotension

arrhythmia

hallucinations

Contraindications

clients with narrow angle closure glaucoma

clients taking MAOI’s (no foods with triptophan and thiamine)

urine and stool may be darkened

no Vitamin B6 (Pyridoxine) reverses the therapeutic effects of Levodopa

* Increase Vitamin B when taking INH (Isoniazid), Isonicotinic Acid Hydrazide

Anti Cholinergic Agents (ARTANE and COGENTIN) - to relieve tremors

Mechanism of Action

inhibits action of acethylcholine

Side Effects

SNS

Anti Histamine (Dipenhydramine Hydrochloride)

Side Effects

Adult: drowsiness

Children: CNS excitement (hyperactivity) because blood brain barrier is not yet fully developed.

Dopamine Agonist - relieves tremor rigidity

Bromocriptene Hydrochloride (Parlodel)

Side Effects

Respiratory depression

2. Maintain side rails to prevent injury

3. Prevent complications of immobility

4. Decrease protein in morning and increase protein in afternoon to induce sleep

5. Encourage increase fluid intake and fiber.

6. Assist/supervise in ambulation

7. Assist in Stereotaxic Thalamotomy

MAGIC 2’s IN DRUG MONITORING

DRUG NORMAL RANGE TOXICITYLEVEL

INDICATION CLASSIFICATION

Digoxin/ Lanoxin (Increase force of cardiac output)

.5 – 1.5 meq/L 2 CHF Cardiac Glycoside

Lithium/ Lithane (Decrease level of Ach/NE/Serotonin)

.6 – 1.2 meq/L 2 Bipolar Anti-Manic Agents

Aminophylline (Dilates bronchial tree)

10 – 19 mg/100 ml 20 COPD Bronchodilators

Dilantin/ Phenytoin 10 – 19 mg/100 ml 20 Seizures Anti-ConvulsantAcetaminophen/Tylenol 10 – 30 mg/100 ml 200 Osteo

ArthritisNon-narcotic Analgesic

1. Digitalis Toxicity

Signs and Symptoms

nausea and vomiting

diarrhea

confusion

photophobia

changes in color perception (yellowish spots)

Antidote: Digibind

2. Lithium Toxicity

Signs and Symptoms

anorexia

nausea and vomiting

diarrhea

dehydration causing fine tremors

hypothyroidism

Nursing Management

force fluids

increase sodium intake to 4 – 10 g% daily

3. Aminophylline Toxicity

Signs and Symptoms

tachycardia

palpitations

CNS excitement (tremors, irritability, agitation and restlessness)

Nursing Management

only mixed with plain NSS or 0.9 NaCl to prevent development of crystals or precipitate.

administered sandwich method

avoid taking alcohol because it can lead to severe CNS depression

avoid caffeine

4. Dilantin Toxicity

Signs and Symptoms

gingival hyperplasia (swollen gums)

hairy tongue

ataxia

nystagmus

Nursing Management

provide oral care

massage gums

5. Acetaminophen Toxicity

Signs and Symptoms

hepatotoxicity (monitor for liver enzymes)

SGPT/ALT (Serum Glutamic Pyruvate Transaminace)

SGOT/AST (Serum Glutamic Oxalo-Acetil Transaminace)

nephrotoxicity monitor BUN (10 – 20) and Creatinine (.8 – 1)

hypoglycemia

Tremors, tachycardia

Irritability

Restlessness

Extreme fatigue

Diaphoresis, depression

Antidote: Acetylcisteine (mucomyst) prepare suction apparatus as bedside.

MYASTHENIA GRAVIS

neuromuscular disorder characterized by a disturbance in the transmission of impulses from

nerve to muscle cells at the neuromuscular junction leading to descending muscle weakness.

Incidence rate: women 20 – 40 years old

Predisposing factors

unknown

autoimmune: it involves release of cholinesterase an enzyme that destroys Ach.

Signs and Symptoms

initial sign is ptosis a clinical parameter to determine ptosis is palpebral fissure.

diplipia

mask like facial expression

dysphagia

hoarseness of voice

respiratory muscle weakness that may lead to respiratory arrest

extreme muscle weakness especially during exertion and morning

Diagnostic Procedure

Tensilon test (Edrophonium Hydrochloride) provides temporary relief of signs and symptoms

for about 5 – 10 minutes and a maximum of 15 minutes.

if there is no effect there is damage to occipital lobe and midbrain and is negative for

M.G.

Nursing Management

1. airway

2. aspiration maintain patent airway and adequate ventilation

3. mmobility

* assist in mechanical ventilation and monitor pulmonary function test

* monitor strictly vital signs, input and output and neuro check

* monitor strength or motor grading scale

4. maintain side rails to prevent injury related to falls

5. institute NGT feeding

6. administer medications as ordered

a. Cholinergic (Mestinon)

b. Anti Cholenisterase (Neostegmin)

Mechanism of Action

increase level of Ach

Side Effects

PNS

Cortocosteroids suppress immune response

monitor for 2 types of crisis:

MYASTHENIC CRISIS CHOLINERGIC CRISIS

Causes:- under medication- stress- infectionSigns and Symptoms- The client is unable to see, swallow, speak, breatheTreatment- administer cholinergic agents as ordered

Cause:- over medication

Signs and Symptoms- PNS

Treatment- Administer anti cholinergic agents (Atropine Sulfate)

7. Assist in surgical procedure known as thymectomy because it is believed that the thymus gland is

responsible for M.G.

8. Assist in plasma paresis and removing auto immune anti bodies

9. Prevent complications

INFLAMMATORY CONDITIONS OF THE BRAIN

MENINGITIS

Meninges

3 fold membrane that covers brain and spinal cord.

for support and protection

for nourishment

blood supply

LAYERS OF THE MENINGES

1. Dura matter – outer layer

2. Arachnoid – middle layer

3. Pia matter – inner layer

subdural space between the dura and arachnoid

subarachnoid space between the arachnoid and pia, CSF aspiration is done.

A. Etiology

1. Meningococcus – most dangerous

2. Pneumococcus

3. Streptococcus - causes adult meningitis

4. Hemophilus Influenzae – causes pediatric meningitis

B. Mode of transmission

airborne transmission (droplet nuclei)

C. Signs and Symptoms

headache

photophobia

projectile vomiting

fever, chills, anorexia, general body malaise and weight loss

Possible increase in ICP and seizure activity

Abnormal posturing (decorticate and decerebrate)

Signs of meningeal irritation

a. Nuchal rigidity or stiff neck

b. Opisthotonus (arching of back)

c. (+) Kernig’s sign (leg pain)

d. (+) Brudzinski sign (neck pain)

D. Diagnostic Procedures

Lumbar puncture: a hollow spinal needle is inserted in the subarachnoid space between the

L3 – L4 to L5.

Nursing Management for LP

Before Lumbar Puncture1. Secure informed consent and explain procedure.2. Empty bladder and bowel to promote comfort.3. Encourage to arch back to clearly visualize L3-L4. Post Lumbar Puncture1. Place flat on bed 12 – 24 o

2. Force fluids3. Check punctured site for any discoloration, drainage and leakage to tissues.4. Assess for movement and sensation of extremities.CSF analysis reveals1. Increase CHON and WBC2. Decrease glucose3. Increase CSF opening pressure (normal pressure is 50 – 100 mmHg)4. (+) cultured microorganism (confirms meningitis)

CBC reveals

1. Increase wbc

E. Nursing Management

1. Enforce complete bed rest


a. Broad spectrum antibiotics (Penicillin, Tetracycline)

b. Mild analgesics

c. Anti pyretics

3. Institute strict respiratory isolation 24 hours after initiation of anti biotic therapy

4. Elevate head 30-45o

5. Monitor strictly V/S, input and output and neuro check

6. Institute measures to prevent increase ICP and seizure.

7. Provide a comfortable and darkened environment.

8. Maintain fluid and electrolyte balance.

9. Provide client health care and discharge planning concerning:

a. Maintain good diet of increase CHO, CHON, calories with small frequent feedings.

b. Prevent complications

most feared is hydrocephalus

hearing loss/nerve deafness is second complication

consult audiologist

c. Rehabilitation for neurological deficit

mental retardation

delayed psychomotor development

CVA (STROKE/BRAIN ATTACK/ ADOPLEXY/ CEREBRAL THROMBOSIS)

a partial or complete disruption in the brains blood supply.

2 most common cerebral artery affected by stroke

a. Mid Cerebral Artery

b. Internal Cerebral Artery – the 2 largest artery

A. Incidence Rate

men are 2-3 times high risk

B. Predisposing Factors

thrombus (attached)

embolus (detached and most dangerous because it can go to the lungs and cause

pulmonary embolism or the brain and cause cerebral embolism.

Signs and Symptoms of Pulmonary Embolism

Sudden sharp chest pain

Unexplained dyspnea

Tachycardia

Palpitations

Diaphoresis

Mild restlessness

Signs and Symptoms of Cerebral Embolism

Headache and dizziness

Confusion

Restlessness

Decrease LOC

Fat embolism is the most feared complications after femur fracture.

Yellow bone marrow are produced from the medullary cavity of the long bones and produces fat cells.

If there is bone fracture there is hemorrhage and there would be escape of the fat cells in the circulation.

Compartment syndrome (compression of arteries and nerves)

C. Risk Factors

1. Hypertension, Diabetes Mellitus, Myocardial Infarction, Atherosclerosis, Valvular Heart Disease, Post

Cardiac Surgery (mitral valve replacement)

2. Lifestyle (smoking), sedentary lifestyle

3. Obesity (increase 20% ideal body weight)

4. Hyperlipidemia more on genetics/genes that binds to cholesterol

5. Type A personality

a. deadline driven

b. can do multiple tasks

c. usually fells guilty when not doing anything

6. Related to diet: increase intake of saturated fats like whole milk

7. Related stress physical and emotional

8. Prolong use of oral contraceptives promotes lypolysis (breakdown of lipids) leading to atherosclerosis that

will lead to hypertension and eventually CVA.

D. Signs and Symptoms

dependent on stages of development

1. TIA

Initial sign of stroke or warning sign

Signs and Symptoms

headache and dizziness

tinnitus

visual and speech disturbances

paresis (plegia)

possible increase ICP

2. Stroke in evolution

progression of signs and symptoms of stroke

3. Complete stroke

resolution phase characterized by:

Signs and Symptoms

headache and dizziness

Cheyne Stokes Respiration

anorexia, nausea and vomiting

dysphagia

(+) Kernig’s sign and Brudzinski sign which may lead to hemorrhagic stroke

focal neurological deficits

a. phlegia

b. aphasia

c. dysarthria (inability to articulate words)

d. alexia (difficulty reading)

e. agraphia (difficulty writing)

f. homonymous hemianopsia (loss of half of visual field)

E. Diagnostic Procedure

1. CT Scan – reveals brain lesions

2. Cerebral Arteriography

reveals the site and extent of malocclusion

uses dye for visualization

most of dye are iodine based

check for shellfish allergy

after diagnostic exam force fluids to release dye because it is nephro toxic

check for distal pulse (femoral)

check for hematoma formation

F. Nursing Management

1. Maintain patent airway and adequate ventilation by:

a. assist in mechanical ventilation

b. administrate O2 inhalation

2. Restrict fluids to prevent cerebral edema that might increase ICP

3. Elevate head 30 – 45o

4. Monitor strictly vitals signs, I & O and neuro check

5. Prevent complications of immobility by:

a. turn client to side

b. provide egg crate mattresses or water bed

c. provide sand bag or food board.

6. Assist in passive ROM exercise every 4 hours to promote proper bodily alignment and prevent contractures

7. Institute NGT feeding

8. Provide alternative means of communication

a. non verbal cues

b. magic slate

9. If positive to hemianopsia approach client on unaffected side


a. Osmotic Diuretics (Mannitol)

b. Loop Diuretics (Lasix, Furosemide)

c. Cortecosteroids

d. Mild Analgesics

e. Thrombolytic/Fibrinolytic Agents – dissolves thrombus

Streptokinase

Side Effect: Allergic Reaction

Urokinase

Tissue Plasminogen Activating Factor

Side Effect: Chest Pain

f. Anti Coagulants

Heparin (short acting)

check for partial thromboplastin time if prolonged there is a risk for bleeding.

give Protamine Sulfate

Comadin/ Warfarin (long acting)

give simultaneously because Coumadin will take effect after 3 days

check for prothrombin time if prolonged there is a risk for bleeding

give Vit. K (Aqua Mephyton)

g. Anti Platelet

PASA (Aspirin)

Contraindicated for dengue, ulcer and unknown cause of headache because it may

potentiate bleeding

11. Provide client health teachings and discharge planning concerning

a. avoidance of modifiable risk factors (diet, exercise, smoking)

b. prevent complication (subarachnoid hemorrhage is the most feared complication)

c. dietary modification (decrease salt, saturated fats and caffeine)

d. importance of follow up care

GUILLAIN BARRE SYNDROME

a disorder of the CNS characterized by bilateral symmetrical polyneuritis leading to ascending muscle

paralysis.

A. Predisposing Factors

1. Autoimmune

2. Antecedent viral infections such as LRT infections

B. Signs and Symptoms

1. Clumsiness (initial sign)

2. Dysphagia

3. Ascending muscle weakness leading to paralysis

4. Decreased of diminished deep tendon reflex

5. Alternate hypotension to hypertension

** ARRYTHMIA (most feared complication)

6. Autonomic symptoms that includes

a. increase salivation

b. increase sweating

c. constipation

C. Diagnostic Procedures

1. CSF analysis reveals increase in IgG and protein

D. Nursing Management

1. Maintain patent airway and adequate ventilation by:

a. assist in mechanical ventilation

b. monitor pulmonary function test

2. Monitor strictly the following

a. vital signs

b. intake and output

c. neuro check

d. ECG

3. Maintain side rails to prevent injury related to fall

4. Prevent complications of immobility by turning the client every 2 hours

5. Institute NGT feeding to prevent aspiration

6. Assist in passive ROM exercise


a. Corticosteroids – suppress immune response

b. Anti Cholinergic Agents – Atrophine Sulfate

c. Anti Arrythmic Agents

Lidocaine, Zylocaine

Bretylium – blocks release of norepinephrine to prevent increase of BP

8. Assist in plasma pharesis (filtering of blood to remove autoimmune anti-bodies)


a. Arrythmia

b. Paralysis or respiratory muscles/Respiratory arrest

* Sengstaken Blakemore Tube

for liver cirrhosis

to decompress bleeding esophageal verices (prepare scissor to cut tube incase of difficulty in

breathing to release air in the balloon

for hemodialysis prepare bulldog clips to prevent air embolism.

CONVULSIVE DISORDER/ CONVULSION

disorder of CNS characterized by paroxysmal seizure with or without loss of consciousness

abnormal motor activity alternation in sensation and perception and changes in behavior.

Seizure – first convulsive attack

Epilepsy – second or series of attacks

Febrile seizure – normal in children age below 5 years


1. Head injury due to birth trauma

2. Genetics

3. Presence of brain tumor

4. Toxicity from

a. lead

b carbon monoxide

5. Nutritional and Metabolic deficiencies

6. Physical and emotional stress

7. Sudden withdrawal to anti convulsant drug is predisposing factor for status epilepticus (drug of choice is

Diazepam, Valium)


Dependent on stages of development or types of seizure

I. Generalized Seizure

1. Grand mal Seizure (tonic-clonic seizure)

a. Signs or aura with auditory, olfactory, visual, tactile, sensory experience

b. Epileptic cry – is characterized by fall and loss of consciousness for 3 – 5 minutes

c. Tonic contractions - direct symmetrical extension of extremities

Clonic contractions - contraction of extremities

d. Post ictal sleep – unresponsive sleep

2. Petit mal Seizure – absence of seizure common among pediatric clients characterized by

a. blank stare

b. decrease blinking of eyes

c. twitching of mouth

d. loss of consciousness (5 – 10 seconds)

II. Partial or Localized Seizure

1. Jacksonian Seizure (focal seizure)

Characterized by tingling and jerky movement of index finger and thumb that spreads to the

shoulder and other side of the body.

2. Psychomotor Seizure (focal motor seizure)

a. automatism – stereotype repetitive and non propulsive behavior

b. clouding of consciousness – not in contact with environment

c. mild hallucinatory sensory experience

III. Status Epilepticus

A continuous uninterrupted seizure activity, if left untreated can lead to hyperpyrexia and lead

to coma and eventually death.

Drug of choice: Diazepam, Valium and Glucose


1. CT Scan – reveals brain lesions

2. EEG – reveals hyper activity of electrical brain waves


1. Maintain patent airway and promote safety before seizure activity

a. clear the site of blunt or sharp objects

b. loosen clothing of client

c. maintain side rails

d. avoid use of restrains

e. turn clients head to side to prevent aspiration

f. place mouth piece of tongue guard to prevent biting or tongue

2. Avoid precipitating stimulus such as bright/glaring lights and noise


a. Anti convulsants (Dilantin, Phenytoin)

b. Diazepam, Valium

c. Carbamazepine (Tegretol) – Trigeminal neuralgia

d. Phenobarbital, Luminal

4. Institute seizure and safety precaution post seizure attack

a. administer O2 inhalation

b. provide suction apparatus

5. Document and monitor the following

a. onset and duration

b. types of seizures

c. duration of post ictal sleep may lead to status epilepticus

d. assist in surgical procedure cortical resection

COMPREHENSIVE NEURO EXAM

GLASGOW COMA SCALE

objective measurement of LOC sometimes called as the quick neuro check

Components

1. Motor response

2. Verbal response

3. Eye opening

Survey of mental status and speech

a. LOC

b. Test of memory

Levels of orientation

Cranial nerve assessment

Sensory nerve assessment

Motor nerve assessment

Deep tendon reflex

Autonimics

Cerebellar test

a, Romberg’s test – 2 nurses, positive for ataxia

b. Finger to nose test – positive result mean dimetria

(inability of body to stop movement at desired point)

c. Alternate supination and pronation – positive result mean dimetria

Conscious 15 – 14

Lethargy 13 – 11

Stupor 10 – 8

Coma 7

Deep Coma 3

I. LEVEL OF CONSCIOUSNESS

1. Conscious - awake

2. Lethargy – lethargic (drowsy, sleepy, obtunded)

3. Stupor

stuporous (awakened by vigorous stimulation)

generalized body weakness

decrease body reflex

4. Coma

comatose

light coma (positive to all forms of painful stimulus)

deep coma (negative to all forms of painful stimulus)

DIFFERENT PAINFUL STIMULATION

1. Deep sternal stimulation/ deep sternal pressure

2. Orbital pressure

3. Pressure on great toes

4. Corneal or blinking reflex

Conscious client use a wisp of cotton

Unconscious client place 1 drop of saline solution

II. TEST OF MEMORY

1. Short term memory

ask most recent activity

positive result mean anterograde amnesia and damage to temporal lobe

2. Long term memory

ask for birthday and validate on profile sheet

positive result mean retrograde amnesia and damage to limbic system

consider educational background

III. LEVELS OF ORIENTATION

1. Time – first asked

2. Person – second asked

3. Place – third asked

CRANIAL NERVES

CRANIAL NERVES FUNCTION

I. OLFACTORY S

II. OPTIC S

III OCCULOMOTOR M

IV. TROCHLEAR M

(Smallest)

V. TRIGEMINAL B

(Largest)

VI. ABDUCENSE M

VII. FACIAL B

VIII. ACOUSTIC S

IX. GLOSSOPHARYNGEAL B

X. VAGUS B

(Longest)

XI. SPINAL ACCESSORY M

XII. HYPOGLOSSAL M

CRANIAL NERVE I: OLFACTORY

sensory function for smell

Material Used

don’t use alcohol, ammonia, perfume because it is irritating and highly diffusible.

use coffee granules, vinegar, bar of soap, cigarette

Procedure

test each nostril by occluding each nostril

Abnormal Findings

1. Hyposnia – decrease sensitivity to smell

2. Dysosmia – distorted sense of smell

3. Anosmia – absence of smell

Indicative of

1. head injury damaging the cribriform plate of ethmoid bone where olfactory cells are located

2. may indicate inflammatory conditions (sinusitis)

CRANIAL NERVE II: OPTIC

sensory function for vision or sight

Functions

1. Test visual acuity or central vision or distance

use Snellen’s Chart

Snellen’s Alphabet chart: for literate clients

Snellen’s E chart: for illiterate clients

Snellen’s Animal chart: for pediatric clients

normal visual acuity 20/20

numerator is constant, it is the distance of person from the chart (6 – 7 m, 20 feet)

denominator changes, indicates distance by which the person normally can see letter in the

chart.

- 20/200 indicates blindness

20/20 visual acuity if client is able to read letters above the red line.

2. Test of visual field or peripheral vision

a. Superiorly

b. Bitemporaly

c. Nasally

d. Inferiorly

COMMON VISUAL DISORDERS

1. Glaucoma

increase IOP

normal IOP is 12 – 21 mmHg

preventable but not curable


Common among 40 years old and above

Hereditary

Hypertension

Obesity


1. Loss of peripheral vision

pathognomonic sign is tunnel vision

2. Headache, nausea, vomiting, eye pain (halos around light)

steamy cornea

may lead to blindness


1. Tonometry

2. Perimetry

3. Gonioscopy

D. Treatment

1. Miotics – constricts pupil

a. Pilocarpine Sodium, Carbachol

2. Epinephrine eyedrops – decrease formation of aqueous humor

3. Carbonic Anhydrase Inhibitors

a. Acetazolamide (Diamox) – promotes increase outflow of aqueous humor or drainage

4. Timoptics (Timolol Maleate)

E. Surgical Procedures

1. TRABECULECTOMY (Peripheral Indectomy) – drain aqueous humor

2. Cataract

Decrease opacity of lens

A. Predisposing Factor

1. Aging 65 years and above

2. Related to congenital

3. Diabetes Mellitus

4. Prolonged exposure to UV rays


1. Loss of central vision

C. Pathognomonic Signs

1. Blurring or hazy vision

2. Milky white appearance at center of pupils

3. Decrease perception to colors

Complication is blindness

D. Diagnostic Procedure

1. Opthalmoscopic exam

E. Treatment

1. Mydriatics (Mydriacyl) – constricts pupils

2. Cyclopegics (Cyclogyl) – paralyses cilliary muscle

F. Surgical Procedure

Extra Intra

Capsular Capsular

Cataract Cataract

Lens Lens

Extraction Extraction

- Partial removal - Total removal of cataract with its surrounding capsules

Most feared complication post op is RETINAL DETACHMENT

3. Retinal Detachment

Separation of epithelial surface of retina


1. Post Lens Extraction

2. Myopia (near sightedness)


1. Curtain veil like vision

2. Floaters

C. Surgical Procedures

1. Scleral Buckling

2. Cryosurgery – cold application

3. Diathermy – heat application

4. Macular Degeneration

Degeneration of the macula lutea (yellowish spot at the center of retina)

A. Signs and Symptoms

1. Black Spots

CRANIAL NERVE III, IV, VI: OCULOMOTOR, TROCHLEAR, ABDUCENS

Controls or innervates the movement of extrinsic ocular muscle (EOM)

6 muscles

Superior Rectus Superior Oblique

Lateral Rectus Medial Rectus

Inferior Oblique Inferior Rectus

trochlear controls superior oblique

abducens controls lateral rectus

oculomotor controls the 4 remaining EOM

Oculomotor

controls the size and response of pupil

normal pupil size is 2 – 3 mm

equal size of pupil: Isocoria

Unequal size of pupil: Anisocoria

Normal response: positive PERRLA

CRANIAL NERVE V: TRIGEMINAL

largest cranial nerve

consists of ophthalmic, maxillary, mandibular

sensory: controls sensation of face, mucous membrane, teeth, soft palate and corneal reflex)

motor: controls the muscle of mastication or chewing

damage to CN V leads to trigeminal neuralgia/thickdolorum

medication: Carbamezapine(Tegretol)

CRANIAL NERVE VII: FACIAL

Sensory: controls taste, anterior 2/3 of tongue

pinch of sugar and cotton applicator placed on tip of tongue

Motor: controls muscle of facial expression

instruct client to smile, frown and if results are negative there is facial paralysis or Bell’s Palsy

and the primary cause is forcep delivery.

CRANIAL NERVE VIII: ACOUSTIC/VESTIBULOCOCHLEAR

Controls balance particularly kinesthesia or position sense, refers to movement and

orientation of the body in space.

Parts of the Ear

1. Outer Ear

Pinna

Eardrum

2. Middle Ear

Hammer Malleus

Anvil Incus

Stirrup Stapes

3. Inner Ear

Vestibule: Meinere’s Disease

Cochlea

Mastoid Cells

Endolymph and Perilymph

COCHLEA: controls hearing, contains the Organ of Corti (the true organ of hearing)

Let client repeat words uttered

CRANIAL NERVE IX, X: GLOSOPHARYNGEAL, VAGUS NERVE

Glosopharyngeal: controls taste, posterior 1/3 of tongue

Vagus: controls gag reflex

Uvula should be midline and if not indicative of damage to cerebral hemisphere

Effects of vagal stimulation is PNS

CRANIAL NERVE XI: SPINAL ACCESSORY

Innervates with sternocleidomastoid (neck) and trapezius (shoulder)

CRANIAL NERVE XII: HYPOGLOSSAL

Controls the movement of tongue

Let client protrude tongue and it should be midline and if unable to do indicative of damage to

cerebral hemisphere and/or has short frenulum.

ENDOCRINE SYSTEM

Overview of the structures and functions

1. Pituitary Gland (Hypophysis Cerebri)

o Located at base of brain particularly at sella turcica

o Master gland or master clock

o Controls all metabolic function of body

PARTS OF THE PITUITARY GLAND

1. Anterior Pituitary Gland

o called as adenohypophysis

2. Posterior Pituitary Gland

o called as neurohypophysis

o secretes hormones oxytocin -promotes uterine contractions preventing bleeding/

hemorrhage

o administrate oxytocin immediately after delivery to prevent uterine atony.

o initiates milk let down reflex with help of hormone prolactin

2. Antidiuretic Hormone

o Pitressin (Vasopressin)

o Function: prevents urination thereby conserving water

o Diabetes Insipidus/ Syndrome of Inappropriate Anti Diuretic Hormone

DIABETES INSIPIDUS

o Decrease production of anti diuretic hormone

A. Predisposing Factor

o Related to pituitary surgery

o Trauma

o Inflammation

o Presence of tumor


1. Polyuria

2. Signs of dehydration

a. Adult: thirst

b. Agitation

c. Poor Skin turgor

d. Dry mucous membrane

3. Weakness and fatigue

4. Hypotension

5. Weight loss

6. If left untreated results to hypovolemic shock (sign is anuria)


1. Urine Specific Gravity

o Normal value: 1.015 – 1.030

o Ph 4 – 8

2. Serum Sodium

o Increase resulting to hypernatremia


1. Force fluids

2. Monitor strictly vital signs and intake and output


a. Pitressin (Vasopresin Tannate) – administered IM Z-tract

4. Prevent complilcations – HYPOVOLEMIC SHOCK is the most feared complication

SIADH

o hypersecretion of anti diuretic hormone


1. Head injury

2. Related to presence of bronchogenic cancer

o initial sign of lung cancer is non productive cough

o non invasive procedure is chest x-ray

3. Related to hyperplasia (increase size of organ brought about by increase of number of cells) of pituitary

gland.


1. Fluid retention

a. Hypertension

b. Edema

c. Weight gain

2. Water intoxication may lead to cerebral edema and lead to increase ICP – may lead to seizure activity

C. Diagnostic Procedure

1. Urine specific gravity is increased

2. Serum Sodium is decreased


1. Restrict fluid


a. Loop diuretics (Lasix)

b. Osmotic diuretics (Mannitol)

3. Monitor strictly vital signs, intake and output and neuro check

4. Weigh patient daily and assess for pitting edema

5. Provide meticulous skin care


ANTERIOR PITUITARY GLAND

o also called ADENOHYPOPHYSIS secretes

1. Growth hormones (somatotropic hormone)

o Promotes elongation of long bones

o Hyposecretion of GH among children results to Dwarfism

o Hypersecretion of GH results to Gigantism

o Hypersecretion of GH among adults results to Acromegaly (square face)

o Drug of choice: Ocreotide (Sandostatin)

2. Melanocyte Stimulating hormone

o for skin pigmentation

o Hyposecretion of MSH results to Albinism

o Most feared complications of albinism

a. Lead to blindness due to severe photophobia

b. Prone to skin cancer

o Hypersecretion of MSH results to Vitiligo

3. Adrenochorticotropic hormone (ACTH)

o promotes development of adrenal cortex

4. Lactogenic homone (Prolactin)

o promotes development of mammary gland

o with help of oxytocin it initiates milk let down reflex

5. Leutinizing hormone

o secretes estrogen

6. Follicle stimulating hormone

o secretes progesterone

PINEAL GLAND

o secretes melatonin

o inhibits LH secretion

o it controls/regulates circadian rhythm (body clock)

THYROID GLAND

o located anterior to the neck

3 Hormones secreted

1. T3 (Tri iodothyronine) - 3 molecules of iodine (more potent)

2. T4 (tetra iodothyronine, Thyroxine)

o T3 and T4 are metabolic or calorigenic hormone

o promotes cerebration (thinking)

3. Thyrocalcitonin – antagonizes the effects of parathormone to promote calcium resorption.

HYPOTHYROIDISM

o all are decrease except weight and menstruation

o memory impairment

Signs and Symptoms

o there is loss of appetite but there is weight gain

o menorrhagia

o cold intolerance

o constipation

HYPERTHYROIDISM

o all are increase except weight and menstruation

Signs and Symptoms

o increase appetite but there is weight loss

o amenorrhea

o exophthalmos

THYROID DISORDERS

SIMPLE GOITER

o enlargement of thyroid gland due to iodine deficiency


1. Goiter belt area

a. places far from sea

b. Mountainous regions

2. Increase intake of goitrogenic foods

o contains pro-goitrin an anti thyroid agent that has no iodine.

o cabbage, turnips, radish, strawberry, carrots, sweet potato, broccoli, all nuts

o soil erosion washes away iodine

o goitrogenic drugs

a. Anti Thyroid Agent – Prophylthiuracil (PTU)

b. Lithium Carbonate

c. PASA (Aspirin)

d. Cobalt

e. Phenylbutazones (NSAIDs)

- if goiter is caused by


1. Enlarged thyroid gland

2. Mild dysphagia

3. Mild restlessness


1. Serum T3 and T4 – reveals normal or below normal

2. Thyroid Scan – reveals enlarged thyroid gland.

3. Serum Thyroid Stimulating Hormone (TSH) – is increased (confirmatory diagnostic test)




a. Lugol’s Solution/SSKI ( Saturated Solution of Potassium Iodine)

o color purple or violet and administered via straw to prevent staining of teeth.

o 4 Medications to be taken via straw: Lugol’s, Iron, Tetracycline, Nitrofurantoin (drug of choice

for pyelonephritis)

b. Thyroid Hormones

o Levothyroxine (Synthroid)

o Liothyronine (Cytomel)

o Thyroid Extracts

Nursing Management when giving Thyroid Hormones

1. Instruct client to take in the morning to prevent insomnia

2. Monitor vital signs especially heart rate because drug causes tachycardia and palpitations

3. Monitor side effects

o insomnia

o tachycardia and palpitations

o hypertension

o heat intolerance

4. Increase dietary intake of foods rich in iodine

o seaweeds

o seafood’s like oyster, crabs, clams and lobster but not shrimps because it contains lesser

amount of iodine.

o iodized salt, best taken raw because it it is easily destroyed by heat

5. Assist in surgical procedure of subtotal thyroidectomy

HYPOTHYROIDISM

o hyposecretion of thyroid hormone

o adults : MYXEDEMA non pitting edema

o children : CRETINISM the only endocrine disorder that can lead to mental retardation


1. Iatrogenic Cause – disease caused by medical intervention such as surgery

2. Related to atrophy of thyroid gland due to trauma, presence of tumor, inflammation

3. Iodine deficiency

4. Autoimmune (Hashimotos Disease)


(Early Signs)


2. Loss of appetite but with weight gain which promotes lipolysis leading to atherosclerosis and MI

3. Dry skin

4. Cold intolerance

5. Constipation

(Late Signs)

1. Brittleness of hair and nails

2. Non pitting edema (Myxedema)

3. Hoarseness of voice

4. Decrease libido

5. Decrease in all vital signs – hypotension, bradycardia, bradypnea, hypothermia

6. CNS changes

o lethargy

o memory impairment

o psychosis

o menorrhagia


1. Serum T3 and T4 is decreased

2. Serum Cholesterol is increased

3. RAIU (Radio Active Iodine Uptake) is decreased


1. Monitor strictly vital signs and intake and output to determine presence of

o Myxedema coma is a complication of hypothyroidism and an emergency case

o a severe form of hypothyroidism is characterized by severe hypotension, bradycardia,

bradypnea, hypoventilation, hyponatremia, hypoglycemia, hypothermia leading to pregressive

stupor and coma.

Nursing Management for Myxedema Coma

Assist in mechanical ventilation

Administer thyroid hormones as ordered

Force fluids

2. Force fluids

3. Administer isotonic fluid solution as ordered


Thyroid Hormones

a. Levothyroxine

b. Leothyronine

c. Thyroid Extracts

5. Provide dietary intake that is low in calories

6. Provide comfortable and warm environment


8. Provide client health teaching and discharge planning concerning

a. Avoid precipitating factors leading to myxedema coma

o stress

o infection

o cold intolerance

o use of anesthetics, narcotics, and sedatives

o prevent complications (myxedema coma, hypovolemic shock

o hormonal replacement therapy for lifetime

o importance of follow up care

HYPERTHYROIDISM

o increase in T3 and T4

o Grave’s Disease or Thyrotoxicosis

o developed by Robert Grave


1. Autoimmune – it involves release of long acting thyroid stimulator causing exopthalmus (protrusion

of eyeballs) enopthalmus (late sign of dehydration among infants)

2. Excessive iodine intake

3. Related to hyperplasia (increase size)


1. Increase appetite (hyperphagia) but there is weight loss

2. Moist skin

3. Heat intolerance

4. Diarrhea

5. All vital signs are increased

6. CNS involvement

a. Irritability and agitation

b. Restlessness

c. Tremors

d. Insomnia

e. Hallucinations

7. Goiter

8. Exopthalmus

9. Amenorrhea


1. Serum T3 and T4 is increased

2. RAIU (Radio Active Iodine Uptake) is increased

3. Thyroid Scan- reveals an enlarged thyroid gland




Anti Thyroid Agent

a. Prophythioracill (PTU)

b. Methymazole (Tapazole)

Side Effects of Agranulocytosis

o increase lymphocytes and monocytes

o fever and chills

o sore throat (throat swab/culture)

o leukocytosis (CBC)

3. Provide dietary intake that is increased in calories.


TRIAD SIGNS

5. Comfortable and cold environment

6. Maintain side rails

7. Provide bilateral eye patch to prevent drying of the eyes.

8. Assist in surgical procedures known as subtotal thyroidectomy

** Before thyroidectomy administer Lugol’s Solution (SSKI) to decrease vascularity of the thyroid

gland to prevent bleeding and hemorrhage.

POST OPERATIVELY,

1. Watch out for signs of thyroid storm/ thyrotoxicosis

Agitation

Hyperthermia Tachycardia

o administer medications as ordered

a. Anti Pyretics

b. Beta-blockers

o monitor strictly vital signs, input and output and neuro check.

o maintain side rails

o offer TSB

2. Watch out for accidental removal of parathyroid gland that may lead to

Hypocalcemia (tetany)

Signs and Symptoms

o (+) trousseau’s sign

o (+) chvostek sign

o Watch out for arrhythmia, seizure give Calcium Gluconate IV slowly as ordered

3. Watch out for accidental Laryngeal damage which may lead to hoarseness of voice

Nursing Management

o encourage client to talk/speak immediately after operation and notify physician

4. Signs of bleeding (feeling of fullness at incisional site)

Nursing Management

o Check the soiled dressings at the back or nape area.

5. Hormonal replacement therapy for lifetime

6. Importance of follow up care

PARATHYROID GLAND

o A pair of small nodules behind the thyroid gland

o Secretes parathormone

o Promotes calcium reabsorption

o Hypoparathyroidism

o Hyperparathyroidism

HYPOPARATHYROIDISM

o Decrease secretion of parathormone leading to hypocalcemia

o Resulting to hyperphospatemia


1. Following subtotal thyroidectomy

2. Atrophy of parathyroid gland due to:

a. inflammation

b. tumor

c. trauma


1. Acute tetany

a. tingling sensation

b. paresthesia

c. numbness

d. dysphagia

e. positive trousseu’s sign/carpopedal spasm

f. positive chvostek sign

g. laryngospasm/broncospasm

h. seizure feared complications

i. arrhythmia

2. Chronic tetany

a. photophobia and cataract formation

b. loss of tooth enamel

c. anorexia, nausea and vomiting

d. agitation and memory impairment


1. Serum Calcium is decreased (normal value: 8.5 – 11 mg/100 ml)

2. Serum Phosphate is decreased (normal value: 2.5 – 4.5 mg/100 ml)

3. X-ray of long bones reveals a decrease in bone density

4. CT Scan – reveals degeneration of basal ganglia


1. Administer medications as ordered such as:

a. Acute Tetany

Calcium Gluconate IV slowly

b. Chronic Tetany

Oral Calcium supplements

Calcium Gluconate

Calcium Lactate

Calcium Carbonate

c. Vitamin D (Cholecalciferol) for absorption of calcium

CHOLECALCIFEROL ARE DERIVED FROM

Drug Diet (Calcidiol) Sunlight (Calcitriol)

d. Phosphate binder

Aluminum Hydroxide Gel (Ampogel)

Side effect: constipation

ANTACID

A.A.C MAD ▼ ▼

Aluminum Containing Magnesium Containing Antacids Antacids

▼ ▼Aluminum Hydroxide Gel ▼

Side Effect: Constipation Side Effect: Diarrhea

2. Avoid precipitating stimulus such as glaring lights and noise

3. Encourage increase intake of foods rich in calcium

a. anchovies

b. salmon

c. green turnips

4. Institute seizure and safety precaution

5. Encourage client to breathe using paper bag to produce mild respiratory acidosis result.

6. Prepare trache set at bedside for presence of laryngo spasm



9. Importance of follow up care.

HYPERTHYROIDISM

o Decrease parathormone

o Hypercalcemia: bone demineralization leading to bone fracture (calcium is stored 99% in bone and 1%

blood)

o Kidney stones


1. Hyperplasia of parathyroid gland

2. Over compensation of parathyroid gland due to vitamin D deficiency

a. Children: Ricketts

b. Adults: Osteomalacia


1. Bone pain especially at back (bone fracture)

2. Kidney stones

a. renal cholic

b. cool moist skin

3. Anorexia, nausea and vomiting

4. Agitation and memory impairment


1. Serum Calcium is increased

2. Serum Phosphate is decreased

3. X-ray of long bones reveals bone demineralization


1. Force fluids to prevent kidney stones

2. Strain all the urine using gauze pad for stone analysis

3. Provide warm sitz bath


a. Morphine Sulfate (Demerol)

5. Encourage increase intake of foods rich in phosphate but decrease in calcium

6. Provide acid ash in the diet to acidify urine and prevent bacterial growth

7. Assist/supervise in ambulation

8. Maintain side rails

9. Prevent complications (seizure and arrhythmia)

10. Assist in surgical procedure known as parathyroidectomy



ADRENAL GLAND

o Located atop of each kidney

o 2 layers of adrenal gland

a. Adrenal Cortex – outermost

b. Adrenal Medulla – innermost (secretes catecholamines a power hormone)

2 Types of Catecholamines

o Epinephrine and Norepinephrine (vasoconstrictor)

o Pheochromocytoma (adrenal medulla)

o Increase secretion of norepinephrine

o Leading to hypertension which is resistant to pharmacological agents leading to CVA

o Use beta-blockers

ADRENAL CORTEX

3 Zones/Layers

1. Zona Fasciculata

- secretes glucocortocoids (cortisol)

- function: controls glucose metabolism

- Sugar

2. Zona Reticularis

- secretes traces of glucocorticoids and androgenic hormones

- function: promotes secondary sex characteristics

- Sex

3. Zona Glumerulosa

- secretes mineralocorticoids (aldosterone)

- function: promotes sodium and water reabsorption and excretion of potassium

- Salt

ADDISON’S DISEASE

o Hyposecretion of adreno cortical hormone leading to

a. metabolic disturbance – Sugar

b. fluid and electrolyte imbalance – Salt

c. deficiency of neuromuscular function – Salt/Sex


1. Related to atrophy of adrenal glands

2. Fungal infections


1. Hypoglycemia – TIRED

2. Decrease tolerance to stress

3. Hyponatremia

- hypotension

- signs of dehydration

- weight loss

4. Hyperkalemia

- agitation

- diarrhea

- arrhythmia

5. Decrease libido

6. Loss of pubic and axillary hair

7. Bronze like skin pigmentation


1. FBS is decreased (normal value: 80 – 100 mg/dl)

2. Plasma Cortisol is decreased

3. Serum Sodium is decrease (normal value: 135 – 145 meq/L)

4. Serum Potassium is increased (normal value: 3.5 – 4.5 meq/L)


1. Monitor strictly vital signs, input and output to determine presence of Addisonian crisis (complication of

addison’s disease)

o Addisonian crisis results from acute exacerbation of addison’s disease characterized by

a. severe hypotension

b. hypovolemic shock

c. hyponatremia leading to progressive stupor and coma

Nursing Management for Addisonian Crisis

1. Assist in mechanical ventilation,

- administer steroids as ordered

- force fluids


3. Force fluids


Corticosteroids

a. Dexamethasone (Decadrone)

b. Prednisone

c. Hydrocortisone (Cortison)

Nursing Management when giving steroids

1. Instruct client to take 2/3 dose in the morning and 1/3 dose in the afternoon to mimic the normal diurnal

rhythm

2. Taper dose (withdraw gradually from drug)


a. hypertension

b. edema

c. hirsutism

d. increase susceptibility to infection

e. moon face appearance

4. Mineralocorticoids (Flourocortisone)

5. Provide dietary intake, increase calories, carbohydrates, protein but decrease in potassium


7. Provide client health teaching and discharge planning

a. avoid precipitating factor leading to addisonian crisis leading to

- stress

- infection

- sudden withdrawal to steroids

b. prevent complications

- addisonian crisis

- hypovolemic shock

c. hormonal replacement for lifetime

d. importance of follow up care

CUSHING SYNDROME

o Hypersecretion of adenocortical hormones


1 Related to hyperplasia of adrenal gland

2. Increase susceptibility to infections

3. Hypernatremia

a. hypertension

b. edema

c. weight gain

d. moon face appearance and buffalo hump

e. obese trunk

f. pendulous abdomen

g. thin extremities

4. Hypokalemia

a. weakness and fatigue

b. constipation

c. U wave upon ECG (T wave hyperkalemia)

5. Hirsutism

6. Acne and striae

7. Easy bruising

8. Increase masculinity among females

B. Diagnostic Procedures

1. FBS is increased

2. Plasma Cortisol is increased

3. Serum Sodium is increased

4. Serum Potassium is decreased

C. Nursing Management


2. Weigh patient daily and assess for pitting edema

3. Measure abdominal girth daily and notify physician

4. Restrict sodium intake



a. Spinarolactone – potassium sparring diuretics

7. Prevent complications (DM)

8. Assist in surgical procedure (bilateral adrenoraphy)

9. Hormonal replacement for lifetime


PANCREAS

- Located behind the stomach

- Mixed gland (exocrine and endocrine)

- Consist of acinar cells which secretes pancreatic juices that aids in digestion thus it is an exocrine gland

- Consist of islets of langerhans

- Has alpha cells that secretes glucagons (function: hyperglycemia)

- Beta cells secretes insulin (function: hypoglycemia)

- Delta cells secretes somatostatin (function: antagonizes the effects of growth hormones)

3 Main Disorders of Pancreas

1. Pancreatic Tumor/Cancer


3. Pancreatitis

DIABETES MELLITUS

- metabolic disorder characterized by non utilization of carbohydrates, protein and fat metabolism

CLASSIFICATION OF DM

Type 1 (IDDM)

- Juvenile onset type

- Brittle disease

A. Incidence Rate

- 10% general population has type 1 DM


1. Hereditary (total destruction of pancreatic cells)

2. Related to viruses

3. Drugs

a. Lasix

b. Steroids

4. Related to carbon tetrachloride toxicity


1. Polyuria

2. Polydypsia

3. Polyphagia

4. Glucosuria

5. Weight loss


7. Blurring of vision

8. Increase susceptibility to infection

9. Delayed/poor wound healing

D. Treatment

1. Insulin therapy

2. Diet

3. Exercise

E. Complication

1. Diabetic Ketoacidosis

Type 2 (NIDDM)

- Adult onset

- Maturity onset type

- Obese over 40 years old

A. Incidence Rate

- 90% of general population has type 2 DM


1. Obesity – because obese persons lack insulin

receptor binding sites


1. Usually asymptomatic

2. Polyuria

3. Polydypsia

4. Polyphagia

5. Glucosuria

6. Weight gain

D. Treatment

1. Oral Hypoglycemic agents

2. Diet

3. Exercise

E. Complications

1. Hyper

2. Osmolar

3. Non

4. Ketotic

5. Coma

MAIN

FOODSTUFF

ANABOLISM CATABOLISM

1. Carbohydrates

2. Protein

3. Fats

Glucose

Amino Acids

Fatty Acids

Glycogen

Nitrogen

Free Fatty Acids

- Cholesterol

- Ketones

HYPERGLYCEMIA

Increase osmotic diuresis

Glycosuria Polyuria

Cellular starvation – weight loss Cellular dehydration

Stimulates the appetite/satiety center Stimulates the thirst center

(Hypothalamus) (Hypothalamus)

Polyphagia Polydypsia

* Liver has glycogen that undergo glycogenesis/ glycogenolysis

GLUCONEOGENESIS

Formation of glucose from non-CHO sources

Increase protein formation

▼

Negative Nitrogen balance

▼

Tissue wasting (Cachexia)

▼

INCREASE FAT CATABOLISM

▼

Free fatty acids

Cholesterol Ketones

▼ ▼Atherosclerosis Diabetic Keto Acidosis ▼ Hypertension

Acetone Breath Kussmaul’s Respiration odor

MI CVA

Death Diabetic Coma

DIABETIC KETOACIDOSIS

- Acute complication of type 1 DM due to severe hyperglycemia leading to severe CNS depression


1. Hyperglycemia

2. Stress – number one precipitating factor

3. Infection


1. Polyuria

2. Polydypsia

3. Polyphagia

4. Glucosuria

5. Weight loss


7. Blurring of vision

8. Acetone breath odor

9. Kussmaul’s Respiration (rapid shallow breathing)

10 CNS depression leading to coma


1. FBS is increased

2. BUN (normal value: 10 – 20)

3. Creatinine (normal value: .8 – 1)

4. Hct (normal value: female 36 – 42, male 42 – 48) due to severe dehydration


1. Assist in mechanical ventilation

2. Administer 0.9 NaCl followed by .45 NaCl (hypotonic solutions) to counteract dehydration and shock

3. Monitor strictly vital signs, intake and output and blood sugar levels


a. Insulin therapy (regular acting insulin/rapid acting insulin peak action of 2 – 4 hours)

b. Sodium Bicarbonate to counteract acidosis

c. Antibiotics to prevent infection

HYPER OSMOLAR NON KETOTIC COMA

- Hyperosmolar: increase osmolarity (severe dehydration)

- Non ketotic: absence of lypolysis (no ketones)


1. Headache and dizziness

2. Restlessness

3. Seizure activity

4. Decrease LOC – diabetic coma

B. Nursing Management

1. Assist in mechanical ventilation

2. Administer 0.9 NaCl followed by .45 NaCl (hypotonic solutions) to counteract dehydration and shock



a. Insulin therapy (regular acting insulin peak action of 2 – 4 hours)

- for DKA use rapid acting insulin

b. Antibiotics to prevent infection

INSULIN THERAPY

A. Sources of Insulin

1. Animal sources

- Rarely used because it can cause severe allergic reaction

- Derived from beef and pork

2. Human Sources

- Frequently used type because it has less antigenicity property thus less allergic reaction

3. Artificially Compound Insulin

B. Types of Insulin

1. Rapid Acting Insulin (clear)

- Regular acting insulin (IV only)

- Peak action is 2 – 4 hours

2. Intermediate Acting Insulin (cloudy)

- Non Protamine Hagedorn Insulin (NPH)


3. Long Acting Insulin (cloudy)

- Ultra Lente


C. Nursing Management for Insulin Injections

1. Administer at room temperature to prevent development of lipodystrophy (atrophy, hypertrophy of

subcutaneous tissues)

2. Place in refrigerator once opened

3. Avoid shaking insulin vial vigorously instead gently roll vial between palm to prevent formation of bubbles

4. Use gauge 25 – 26 needle

5. Administer insulin either 45o – 90o depending on amount of clients tissue deposit

6. No need to aspirate upon injection

7. Rotate insulin injection sites to prevent development of lipodystrophy

8. Most accessible route is abdomen

9. When mixing 2 types of insulin aspirate first the clear insulin before cloudy to prevent contaminating the

clear insulin and promote proper calibration.

10. Monitor for signs of local complications such as

a. Allergic reactions

b. Lipodystrophy

c. Somogyis Phenomenon – rebound effect of insulin characterized by hypoglycemia to

hyperglycemia

ORAL HYPOGLYCEMIC AGENTS

- Stimulates the pancreas to secrete insulin

A. Classsification

1. First Generation Sulfonylureas

a. Chlorpropamide (Diabenase)

b. Tolbutamide (Orinase)

c. Tolamazide (Tolinase)

2. Second Generation Sulfonylureas

a. Glipzide (Glucotrol)

b. Diabeta (Micronase)

Nursing Management when giving OHA

1. Instruct the client to take it with meals to lessen GIT irritation and prevent hypoglycemia

2. Instruct the client to avoid taking alcohol because it can lead to severe hypoglycemia reaction or Disulfiram

(Antabuse) toxicity symptoms


1. FBS is increased (3 consecutive times with signs or polyuria, polydypsia, polyphagia and glucosuria

confirmatory for DM)

2. Random Blood Sugar is increased

3. Oral glucose tolerance test is increased – most sensitive test

4. Alpha Glycosylated Hemoglobin is increased


1. Monitor for peak action of insulin and OHA and notify physician

2. Administer insulin and OHA therapy as ordered


4. Monitor for signs of hypoglycemia and hyperglycemia

- administer simple sugars

- for hypoglycemia (cold and clammy skin) give simple sugars

- for hyperglycemia (dry and warm skin)

5. Provide nutritional intake of diabetic diet that includes: carbohydrates 50%, protein 30% and fats 20% or

offer alternative food substitutes

6. Instruct client to exercise best after meals when blood glucose is rising

7. Monitor signs for complications

a. Atherosclerosis (HPN, MI, CVA)

b. Microangiopathy (affects small minute blood vessels of eyes and kidneys)

EYES KIDNEY

-PREMATURE CATARACT

- Blindness

-RECURRENT PYELONEPHRITIS

- Renal failure

c. HPN and DM major cause of renal failure

d. Gangrene formation

e. Shock due to dehydration

- peripheral neuropathy

- diarrhea/constipation

- sexual impotence

8. Institute foot care management

a. instruct client to avoid walking barefooted

b. instruct client to cut toenails straight

c. instruct client to avoid wearing constrictive garments

d. encourage client to apply lanolin lotion to prevent skin breakdown

e. assist in surgical wound debriment (give analgesics 15 – 30 mins prior)

9. Instruct client to have an annual eye and kidney exam

10. Monitor for signs of DKA and HONKC

11. Assist in surgical procedure

HEMATOLOGICAL SYSTEM

I. Blood II. Blood Vessels III. Blood Forming Organs

1. Arteries 1. Liver 55% Plasma 45% Formed 2. Veins 3. Spleen

4. Lymphoid Organ Serum Plasma CHON 5. Lymph Nodes

(formed in liver) 6. Bone Marrow1. Albumin2. Globulins3. Prothrombin and Fibrinogen

ALBUMIN

- Largest and numerous plasma CHON

- Maintains osmotic pressure preventing edema

GLOBULINS

- Alpha globulins - transport steroids, bilirubin and hormones

- Beta globulins – iron and copper

- Gamma globulins

a. anti-bodies and immunoglobulins

b. prothrombin and fibrinogen clotting factors

FORMED ELEMENTS

1. RBC (ERYTHROCYTES)

- normal value: 4 – 6 million/mm3

- only unnucleated cell

- biconcave discs

- consist of molecules of hgb (red pigment) bilirubin (yellow pigment) biliverdin (green pigment) hemosiderin

(golden brown pigment)

- transports and carries oxygen to tissues

- hemoglobin: normal value female 12 – 14 gms% male 14 – 16 gms%

- hematocrit red cell percentage in wholeblood

- normal value: female 36 – 42% male 42 – 48%

- substances needed for maturation of RBC

a. folic acid

b. iron

c. vitamin c

d. vitamin b12 (cyanocobalamin)

e. vitamin b6 (pyridoxine)

f. intrinsic factor

- Normal life span of RBC is 80 – 120 days and is killed in red pulp of spleen

2. WBC (LEUKOCYTES)

- normal value: 5000 – 10000/mm3

A. Granulocytes

1. Polymorpho Neutrophils

- 60 – 70% of WBC

- involved in short term phagocytosis for acute inflammation

2. Polymorphonuclear Basophils

- for parasite infections

- responsible for the release of chemical mediation for inflammation

3. Polymorphonuclear Eosinophils

- for allergic reaction

B. Non Granulocytes

1. Monocytes

- macrophage in blood

- largest WBC

- involved in long term phagocytosis for chronic inflammation

2. Lymphocytes

B-cell T-cell Natural killer cell- bone marrow - thymus - anti viral and anti tumor property

for immunity

HIV

- 6 months – 5 years incubation period

- 6 months window period

- western blot opportunistic

- ELISA

- drug of choice AZT (Zidon Retrovir)

2 Common fungal opportunistic infection in AIDS

1. Kaposi’s Sarcoma

2. Pneumocystis Carinii Pneumonia

3. Platelets (THROMBOCYTES)

- Normal value: 150,000 – 450,000/mm3

- Promotes hemostasis (prevention of blood loss)

- Consist of immature or baby platelets or megakaryocytes which is the target of dengue virus

- Normal life span of platelet is 9 – 12 days

Signs of Platelet Dysfunction

1. Petechiae

2. Echhymosis

3. Oozing of blood from venipunctured site

BLOOD DISORDERS

Iron Deficiency Anemia

- A chronic microcytic anemia resulting from inadequate absorption of iron leading to hypoxemic tissue injury

A. Incidence Rate

1. Common among developed countries

2. Common among tropical zones

3. Common among women 15 – 35 years old

4. Related to poor nutrition


1. Chronic blood loss due to trauma

a. Heavy menstruation

b. Related to GIT bleeding resulting to hematemesis and melena (sign for upper GIT bleeding)

c. fresh blood per rectum is called hematochezia

2. Inadequate intake of iron due to

a. Chronic diarrhea

b. Related to malabsorption syndrome

c. High cereal intake with low animal protein digestion

d. Subtotal gastrectomy

4. Related to improper cooking of foods


1. Usually asymptomatic

2. Weakness and fatigue (initial signs)


4. Pallor and cold sensitivity

5. Dyspnea

6. Palpitations

7. Brittleness of hair and spoon shape nails (koilonychias)

8. Atropic Glossitis (inflammation of tongue)

- Stomatitis PLUMBER VINSON’S SYNDROME

- Dysphagia

9. PICA (abnormal appetite or craving for non edible foods

D. Diagnostic Procedures

1. RBC is decreased

2. Hgb is decreased

3. Hct is deceased

4. Iron is decreased

5. Reticulocyte is decreased

6. Ferritin is decreased


1. Monitor for signs of bleeding of all hema test including urinw, stool and GIT

2. Enforce CBR so as not to over tire client

3. Instruct client to take foods rich in iron

a. Organ meatb. Egg (yolk)c. Raisind. Sweet potatoese. Dried fruitsf. Legumesg. Nuts

4. Instruct the client to avoid taking tea and coffee because it contains tannates which impairs iron absorption


Oral Iron Preparations

a. Ferrous Sulfate

b. Ferrous Fumarate

c. Ferrous Gluconate

- 300 mg/day

Nursing Management when taking oral iron preparations

1. Instruct client to take with meals to lessen GIT irritation

2. When diluting it in liquid iron preparations administer with straw to prevent staining of teeth

Medications administered via straw

- Lugol’s solution

- Iron

- Tetracycline

- Nitrofurantoin (Macrodentin)

3. Administer with Vitamin C or orange juice for absorption

4. Monitor and inform client of side effects

a. Anorexia

b. Nausea and vomiting

c. Abdominal pain

d. Diarrhea/constipation

e. Melena

5. If client cant tolerate/no compliance administer parenteral iron preparation

a. Iron Dextran (IM, IV)

b. Sorbitex (IM)

Nursing Management when giving parenteral iron preparations

1. Administer Z tract technique to prevent discomfort, discoloration and leakage to tissues

2. Avoid massaging the injection site instead encourage to ambulate to facilitate absorption


a. Pain at injection site

b. Localized abscess

c. Lymphadenopathy

d. Fever and chills

e. Skin rashes

f. Pruritus/orticaria

g. Hypotension (anaphylactic shock)

PERNICIOUS ANEMIA

- Chronic anemia characterized by a deficiency of intrinsic factor leading to hypochlorhydria (decrease

hydrochloric acid secretion)


1. Subtotal gastrectomy

2. Hereditary factors

3. Inflammatory disorders of the ileum

4. Autoimmune

5. Strictly vegetarian diet

STOMACH▼

Pareital cells/ Argentaffin or Oxyntic cells

Produces intrinsic factors Secretes hydrochloric acid

▼ ▼

Promotes reabsorption of Vit B12 Aids in digestion

▼

Promotes maturation of RBC




3. Pallor and cold sensitivity

4. Dyspnea and palpitations as part of compensation

5. GIT changes that includes

a. mouth sore

b. red beefy tongue

c. indigestion/dyspepsia

d. weight loss

e. jaundice

6. CNS changes

a. tingling sensation

b. numbness

c. paresthesia

d. positive to Romberg’s test – damage to cerebellum resulting to ataxia

e. result to psychosis


Schilling’s Test – reveals inadequate/decrease absorption of Vitamin B12


1. Enforce CBR

2. Administer Vitamin B12 injections at monthly intervals for lifetime as ordered

- Never given orally because there is possibility of developing tolerance

- Site of injection for Vitamin B12 is dorsogluteal and ventrogluteal

- No side effects

3. Provide a dietary intake that is high in carbohydrates, protein, vitamin c and iron

4. Instruct client to avoid irritating mouth washes instead use soft bristled toothbrush

5. Avoid heat application to prevent burns

APLASTIC ANEMIA

- Stem cell disorder leading to bone marrow depression leading to pancytopenia

PANCYTOPENIA

Decrease RBC Decrease WBC Decrease Platelet (anemia) (leucopenia) (thrombocytopenia)


1. Chemicals (Benzine and its derivatives)

2. Related to irradiation/exposure to x-ray

3. Immunologic injury

4. Drugs

Broad Spectrum Antibiotics

a. Chloramphenicol (Sulfonamides)

Chemotherapeutic Agents

a. Methotrexate (Alkylating Agent)

b. Vincristine (Plant Alkaloid)

c. Nitrogen Mustard (Antimetabolite)

Phenylbutazones (NSAIDS)


1. Anemia

a. Weakness and fatigue

b. Headache and dizziness

c. Pallor and cold sensitivity

d. Dyspnea and palpitations

2. Leukopenia

a. Increase susceptibility to infection

3. Thrombocytopenia

a. Petechiae (multiple petechiae is called purpura)

b. Ecchymosis

c. Oozing of blood from venipunctured sites


1. CBC reveals pancytopenia

2. Bone marrow biopsy/aspiration (site is the posterior iliac crest) – reveals fat necrosis in bone marrow


1. Removal of underlying cause

2. Institute BT as ordered

3. Administer oxygen inhalation

4. Enforce CBR

5. Institute reverse isolation

6. Monitor for signs of infection

a. fever

b. cough

7. Avoid IM, subcutaneous, venipunctured sites

8 Instead provide heparin lock

9. Instruct client to use electric razor when shaving


a. Corticosteroids – caused by immunologic injury

b. Immunosuppressants

Anti Lymphocyte Globulin ▼

Given via central venous catheter

▼Given 6 days to 3 weeks to achieve Maximum therapeutic effect of drug

DISSEMINATED INTRAVASCULAR COAGULATION

Acute hemorrhagic syndrome characterized by wide spread bleeding and thrombosis due to a deficiency of

prothrombin and fibrinogen


1. Related to rapid blood transfusion

2. Massive burns

3. Massive trauma

4. Anaphylaxis

5. Septecemia

6. Neoplasia (new growth of tissue)

7. Pregnancy


1. Petechiae (widespread and systemic) eye, lungs and lower extremities

2. Ecchymosis

3. Oozing of blood from punctured sites

4. Hemoptysis

6. Oliguria (late sign)


1. CBC reveals decreased platelets

2. Stool occult blood positive

3. ABG analysis reveals metabolic acidosis

4. Opthamoscopic exam reveals sub retinal hemorrhages


1. Monitor for signs of bleeding of all hema test including stool and GIT



4. Force fluids


a. Vitamin K

b. Pitressin/ Vasopresin to conserve fluids

c. Heparin/Coumadin is ineffective

6. Provide heparin lock

7. Institute NGT decompression by performing gastric lavage by using ice or cold saline solution of 500 – 1000

ml

8. Monitor NGT output

9. Prevent complication

a. Hypovolemic shock

b. Anuria – late sign

BLOOD TRANSFUSION

Goals/Objectives

1. Replace circulating blood volume

2. Increase the oxygen carrying capacity of blood

3. Prevent infection in there is a decrease in WBC

4. Prevent bleeding if there is platelet deficiency

Principles of blood transfusion

1. Proper refrigeration

- Expiration of packed RBC is 3 – 6 days

- Expiration of platelet is 3 – 5 days

2. Proper typing and cross matching

a. Type O – universal donor

b. Type AB – universal recipient

c. 85% of population is RH positive

3. Aseptically assemble all materials needed for BT

a. Filter set

b. Gauge 18 – 19 needle

c. Isotonic solution (0.9 NaCl/plain NSS) to prevent hemolysis

4. Instruct another RN to re check the following

a. Client name

b. Blood typing and cross matching

c. Expiration date

d. Serial number

5. Check the blood unit for bubbles cloudiness, sediments and darkness in color because it indicates

bacterial contamination

- Never warm blood as it may destroy vital factors in blood.

- Warming is only done during emergency situation and if you have the warming device

- Emergency rapid BT is given after 30 minutes and let natural room temperature warm the blood.

6. BT should be completed less than 4 hours because blood that is exposed at room temperature more

than 2 hours causes blood deterioration that can lead to BACTERIAL CONTAMINATION

7. Avoid mixing or administering drugs at BT line to prevent HEMOLYSIS

8. Regulate BT 10 – 15 gtts/min or KVO rate or equivalent to 100 cc/hr to prevent circulatory overload

9. Monitor strictly vital signs before, during and after BT especially every 15 minutes for first hour

because majority of transfusion reaction occurs during this period

a. Hemolytic reaction

b. Allergic reaction

c. Pyrogenic reaction

d. Circulatory overload

e. Air embolism

f. Thrombocytopenia

g. Cytrate intoxication

h. Hyperkalemia (caused by expired blood)

Signs and Symptoms of Hemolytic reaction


2. Dyspnea

3. Diarrhea/Constipation

4. Hypotension

5. Flushed skin

6. Lumbasternal/ Flank pain

7. Urine is color red/ portwine urine

Nursing Management

1. Stop BT

2. Notify physician

3. Flush with plain NSS

4. Administer isotonic fluid solution to prevent shock and acute tubular necrosis

5. Send the blood unit to blood bank for re examination

6. Obtain urine and blood sample and send to laboratory for re examination

7. Monitor vital signs and intake and output

SIGNS AND SYMPTOMS OF ALLERGIC REACTION

1. Fever

2. Dyspnea

3. Broncial wheezing

4. Skin rashes

5. Urticaria

6. Laryngospasm and Broncospasm

Nursing Management

1. Stop BT

2. Notify physician



a. Anti Histamine (Benadryl) - if positive to hypotension, anaphylactic shock treat with Epinephrine




SIGNS AND SYMPTOMS PYROGENIC REACTIONS

1. Fever and chills

2. Headache

3. Tachycardia

4. Palpitations

5. Diaphoresis

6. Dyspnea

Nursing Management

1. Stop BT

2. Notify physician



a. Antipyretic

b. Antibiotic




8. Render TSB

SIGNS AND SYMPTOMS OF CIRCULATORY REACTION

1. Orthopnea

2. Dyspnea

3. Rales/Crackles upon auscultation

4. Exertional discomfort

Nursing Management

1. Stop BT

2. Notify physician


a. Loop diuretic (Lasix)

CARDIOVASCULAR SYSTEM

OVERVIEW OF THE STRUCTURE AND FUNCTIONS OF THE HEART

HEART

- Muscular pumping organ of the body.

- Located on the left mediastinum

- Resemble like a close fist

- Weighs approximately 300 – 400 grams

- Covered by a serous membrane called the pericardium

2 layers of pericardium

a. Parietal – outer layer

b. Visceral – inner layer

- In between is the pericardial fluid which is 10 – 20 cc

- Prevent pericardial friction rub

- Common among MI, pericarditis, Cardiac tamponade

A. Layers of Heart

1. Epicardium – outer layer

2. Myocardium – middle layer

3. Endocardium – inner layer

- Myocarditis can lead to cardiogenic shock and rheumatic heart disease

B. Chambers of the Heart

1. Upper Chamber (connecting or receiving)

a. Atria

2. Lower Chamber (contracting or pumping)

a. Ventricles

- Left ventricle has increased pressure which is 120 – 180 mmHg

- In order to propel blood to the systemic circulation

- Right atrium has decreased pressure which is 60 – 80 mmHg

SA NODE

AV NODE

BUNDLE OF HIS

JLJLJLJJLJLJL

C. Valves

- To promote unidimensional flow or prevent backflow

1. Atrioventricular Valves – guards opening between

a. tricuspid valve

b. mitral valve

- Closure of AV valves give rise to first heart sound (S1 “lub”)

2. Semi – lunar Valves

a. pulmonic

b. aortic

- Closure of SV valve give rise to second heart sound (S2 “dub”)

Extra Heart Sounds

1. S3 – ventricular gallop usually seen in Left Congestive Heart Failure

2. S4 – atrial gallop usually seen in Myocardial Infarction and Hypertension

D. Coronary Arteries

- Arises from base of the aorta

Types of Coronary Arteries

1. Right Main Coronary Artery

2. Left Main Coronary Artery

- Supplies the myocardium

E. Cardiac Conduction System

1. Sino – Atrial Node (SA or Keith Flack Node)

- Located at the junction of superior vena cava and right atrium

- Acts as primary pacemaker of the heart

- Initiates electrical impulse of 60 – 100 bpm

2. Atrio – Ventricular Node (AV or Tawara Node)

- Located at the inter atrial septum

- Delay of electrical impulse for about .08 milliseconds to allow ventricular filling

3. Bundle of His

- Right Main Bundle of His

- Left Main Bundle of His

- Located at the interventricular septum

4. Purkinje Fibers

- Located at the walls of the ventricles for ventricular contraction

PURKINJE FIBERS

- P WAVE (atrial depolarization) contraction

- QRS WAVE (ventricular depolarization)

- T WAVE (ventricular repolarization)

Insert pacemaker if there is complete heart block

Most common pacemaker is the metal pacemaker and lasts up to 2 – 5 years

ABNORMAL ECG TRACING

1. Positive U wave - Hypokalemia

2. Peak T wave – Hyperkalemia

3. ST segment depression – Angina Pectoris

4. ST segment elevation – Myocardial Infarction

5. T wave inversion – Myocardial Infarction

6. Widening of QRS complexes – Arrythmia

CARDIAC DISORDERS

Coronary Arterial Disease/ Ischemic Heart Disease

Stages of Development of Coronary Artery Disease

1. Myocardial Injury - Atherosclerosis

2. Myocardial Ischemia – Angina Pectoris

3. Myocardial Necrosis – Myocardial Infarction

ATHEROSCLEROSIS

ATHEROSCLEROSIS ARTERIOSCLEROSIS

- narrowing of artery

- lipid or fat deposits

- tunica intima

- hardening of artery

- calcium and protein deposits

- tunica media


1. Sex – male

2. Race – black

3. Smoking

4. Obesity

5. Hyperlipidemia

6. sedentary lifestyle


8. Hypothyroidism

9. Diet – increased saturated fats



1. Chest pain

2. Dyspnea

3. Tachycardia

4. Palpitations

5. Duaphoresis

C. Treatment

Percutaneous Transluminal Coronary Angioplasty

Objectives of PTCA

1. Revascularize myocardium2. To prevent angina3. Increase survival rate

- Done to single occluded vessels

- If there is 2 or more occluded blood vessels CABG is done

Coronary Arterial Bypass And Graft Surgery

3 Complications of CABG

1. Pneumonia – encourage to perform deep breathing, coughing exercise and use of incentive spirometer

2. Shock

3. Thrombophlebitis

ANGINA PECTORIS (SYNDROME)

Clinical syndrome characterized by paroxysmal chest pain that is usually relieved by rest or nitroglycerine due

to temporary myocardial ischemia


1. Sex – male

2. Race – black

3. Smoking

4. Obesity

5. Hyperlipidemia



8. Hypothyroidism



B. Precipitating Factors

4 E’s of Angina Pectoris

1. Excessive physical exertion – heavy exercises

2. Exposure to cold environment

3. Extreme emotional response – fear, anxiety, excitement

4. Excessive intake of foods rich in saturated fats – skimmed milk


1. Levine’s Sign – initial sign that shows the hand clutching the chest

2. Chest pain characterized by sharp stabbing pain located at sub sterna usually radiates from back, shoulder,

arms, axilla and jaw muscles, usually relieved by rest or taking nitroglycerine

3. Dyspnea

4. Tachycardia

5. Palpitations

6. Diaphoresis


1. History taking and physical exam

2. ECG tracing reveals ST segment depression

3. Stress test – treadmill test, reveal abnormal ECG

4. Serum cholesterol and uric acid is increased




a. Nitroglycerine (NTG) – when given in small doses will act as venodilator, but in large doses will

act as vasodilator

- Give first dose of NTG (sublingual) 3 – 5 minutes

- Give second dose of NTG if pain persist after giving first dose with interval of 3 - 5 minutes

- Give third and last dose of NTG if pain still persist at 3 – 5 minutes interval

Nursing Management when giving NTG

- Keep the drug in a dry place, avoid moisture and exposure to sunlight as it may inactivate the drug

- Monitor side effects

o Orthostatic hypotension

o Transient headache and dizziness

- Instruct the client to rise slowly from sitting position

- Assist or supervise in ambulation

- When giving nitrol or transdermal patch

o Avoid placing near hairy areas as it may decrease drug absorption

o Avoid rotating transdermal patches as it may decrease drug absorption

o Avoid placing near microwave ovens or duting defibrillation as it may lead to burns (most

important thing to remember)

b. Beta-blockers

- Propanolol - side effects PNS

- Not given to COPD cases because it causes bronchospasm

c. ACE Inhibitors

- Enalapril

d. Calcium Antagonist

- NIfedipine


4. Place client on semi fowlers position

5. Monitor strictly vital signs, intake and output and ECG tracing

6. Provide decrease saturated fats sodium and caffeine

7. Provide client health teachings and discharge planning

a. Avoidance of 4 E’s

b. Prevent complication (myocardial infarction)

c. Instruct client to take medication before indulging into physical exertion to achieve the maximum

therapeutic effect of drug

d. The importance of follow up care

MYOCARDIAL INFARCTION

Heart attack

Terminal stage of coronary artery disease characterized by malocclusion, necrosis and scarring.

A. Types

1. Transmural Myocardial Infarction – most dangerous type characterized by occlusion of both right and left

coronary artery

2. Subendocardial Myocardial Infarction – characterized by occlusion of either right or left coronary artery

B. The Most Critical Period Following Diagnosis of Myocardial Infarction

** 6 – 8 hours because majority of death occurs due to arrhythmia leading to PVC’s

C. Predisposing Factors

1. Sex – male

2. Race – black

3. Smoking

4. Obesity

5. Hyperlipidemia



8. Hypothyroidism




1. Chest pain

- Excruciating visceral, viselike pain located at substernal and rarely in precordial

- Usually radiates from back, shoulder, arms, axilla, jaw and abdominal muscles (abdominal ischemia)

- Not usually relieved by rest or by nitroglycerine

2. Dyspnea

3. Increase in blood pressure (initial sign)

4. Hyperthermia

5. Ashen skin

6. Mild restlessness and apprehension

7. Occasional findings

a. Pericardial friction rub

b. Split S1 and S2

c. Rales/Crackles upon auscultation

d. S4 or atrial gallop


1. Cardiac Enzymes

a. CPK – MB

- Creatinine phosphokinase is increased

- Heart only, 12 – 24 hours

b. LDH – Lactic acid dehydroginase is increased

c. SGPT – Serum glutamic pyruvate transaminase is increased

d. SGOT – Serum glutamic oxal-acetic transaminase is increased

2. Troponin Test – is increased

3. ECG tracing reveals

a. ST segment elevation

b. T wave inversion

c. Widening of QRS complexes indicates that there is arrhythmia in MI

4. Serum Cholesterol and uric acid are both increased

5. CBC – increased WBC


Goal: Decrease myocardial oxygen demand

1. Decrease myocardial workload (rest heart)

- Administer narcotic analgesic/morphine sulfate

- Side Effects: respiratory depression

- Antidote: Narcan/Naloxone

- Side Effects of Naloxone Toxicity is tremors

2. Administer oxygen low inflow to prevent respiratory arrest at 2 – 3 L/min

3. Enforce CBR without bathroom privileges

a. Using bedside commode

4. Instruct client to avoid forms of valsalva maneuver

5. Place client on semi fowlers position


7. Provide a general liquid to soft diet that is low in saturated fats, sodium and caffeine

8. Encourage client to take 20 – 30 cc/week of wine, whisky and brandy to induce vasodilation

9. Administer medication as ordered

a. Vasodilators

- Nitroglycerine

- ISD (Isosorbide Dinitrate, Isodil) sublingual

b. Anti Arrythmic Agents

- Lidocaine (Xylocane

- Side Effects: confusion and dizziness

- Brutylium

c. Beta-blockers

d. ACE Inhibitors

e. Calcium Antagonist

f. Thrombolytics/ Fibrinolytic Agents

- Streptokinase

- Side Effects: allergic reaction, pruritus

- Urokinase

- TIPAF (tissue plasminogen activating factor)

- Side Effects: chest pain

- Monitor for bleeding time

g. Anti Coagulant

- Heparin (check for partial thrombin time)

- Antidote: protamine sulfate

- Coumadin/ Warfarin Sodium (check for prothrombin time)

- Antidote: Vitamin K

h. Anti Platelet

- PASA (Aspirin)

- Anti thrombotic effect

- Side Effects of Aspirin

Tinnitus

Heartburn

Indigestion/Dyspepsia

- Contraindication

Dengue

Peptic Ulcer Disease

Unknown cause of headache

10. Provide client health teaching and discharge planning concerning

a. Avoidance of modifiable risk factors

- arrhythmia (caused by premature ventricular contraction)

b. Cardiogenic shock

- late sign is oliguria

c. Left Congestive Heart Failure

d. Thrombophlebitis

- homan’s sign

e. Stroke/CVA

f. Post MI Syndrome/Dressler’s Syndrome

- client is resistant to pharmacological agents, administer 150,000 – 450,000 units of

streptokinase as ordered

g. Resumption of ADL particularly sexual intercourse is 4 – 6 weeks post cardiac rehab, post CABG

and instruct to

- make sex as an appetizer rather than dessert

- instruct client to assume a non weight bearing position

- client can resume sexual intercourse if can climb staircase

- dietary modification

h. Strict compliance to mediation and importance of follow up care

CONGESTIVE HEART FAILURE

Inability of the heart to pump blood towards systemic circulation

Types of Heart Failure

1. LEFT SIDED HEART FAILURE


1. 90% is mitral valve stenosis due to

a. RHD – inflammation of mitral valve due to invasion of Grp. A beta-hemolytic streptococcus

- Formation of aschoff bodies in the mitral valve

- Common among children

- ASO Titer (Anti streptolysin O titer)

- Penicillin

- Aspirin

b. Aging

2. Myocardial Infarction

3. Ischemic heart disease

4. Hypertension

5. Aortic valve stenosis


1. Dyspnea

2. Paroxysmal nocturnal dyspnea – client is awakened at night due to difficulty of breathing

3. Orthopnea – use 2 – 3 pillows when sleeping or place in high fowlers

4. Productive cough with blood tinged sputum

5. Frothy salivation

6. Cyanosis

7. Rales/Crackles

8. Bronchial wheezing

9. Pulsus Alternans – weak pulse followed by strong bounding pulse

10. PMI is displaced laterally due to cardiomegaly

11. There is anorexia and generalized body malaise

12. S3 – ventricular gallop


1. Chest x-ray – reveals cardiomegaly

2. PAP (pulmonary arterial pressure) – measures pressure in right ventricle or cardiac status

PCWP (pulmonary capillary wedge pressure) – measures end systolic and dyastolic pressure

- both are increased

- done by cardiac catheterization (insertion of swan ganz catheter)

3. Ecocardiography – enlarged heart chamber (cardiomyopathy), dependent on extent of heart failure

4. ABG – reveals PO2 is decreased (hypoxemia), PCO2 is increased (respiratory acidosis)

2. RIGHT SIDED HEART FAILURE


1. Tricuspid valve stenosis

2. Pulmonary embolism

3. Related to COPD

4. Pulmonic valve stenosis

5. Left sided heart failure

B. Signs and Symptoms (venous congestion)

1. Neck/jugular vein distension

2. Pitting edema

3. Ascites

4. Weight gain

5. Hepatosplenomegaly

6. Jaundice

7. Pruritus

8. Anorexia

9. Esophageal varices


1. Chest x-ray – reveals cardiomegaly

2. Central venous pressure (CVP)

- Measure pressure in right atrium (4 – 10 cm of water)

- CVP fluid status measure

- If CVP is less than 4 cm of water hypovolemic shock

- Do the fluid challenge (increase IV flow rate)

- If CVP is more than 10 cm of water hypervolemic shock

- Administer loop diuretics as ordered

- When reading CVP patient should be flat on bed

- Upon insertion place client in trendelendberg position to promote ventricular filling and prevent

pulmonary embolism

3. Ecocardiography – reveals enlarged heart chambers (cardiomyopathy

4. Liver enzymes – SGPT and SGOT is increased


Goal: increase cardiac contractility thereby increasing cardiac output (3 – 6 L/min)

1. Enforce CBR


a. Cardiac glycosides

- Digoxin (Lanoxin)

- Increase force of cardiac contraction

- If heart rate is decreased do not give

b. Loop Diuretics

- Lasix (Furosemide)

c. Bronchodilators

d. Narcotic analgesics

- Morphine Sulfate

e. Vasodilators

- Nitroglycerine

f. Anti Arrhythmic

- Lidocaine (Xylocane)

3. Administer oxygen inhalation with high inflow, 3 – 4 L/min, delivered via nasal cannula

4. High fowlers position


6. Measure abdominal girth daily and notify physician

7. Provide a dietary intake of low sodium, cholesterol and caffeine


9. Assist in bloodless phlebotomy – rotating tourniquet, rotated clockwise every 15 minutes to promote

decrease venous return


a. Prevent complications

- Arrythmia

- Shock

- Right ventricular hypertrophy

- MI

- Thrombophlebitis

b. Dietary modification

c. Strict compliance to medications

PERIPHERAL VASCULAR DISORDER

Arterial Ulcer

I. Thrombo Angitis Obliterans

Burger’s Disease

Reynaud’s Disease

Venous Ulcer

1. Varicose Veins

2. Thrombophlebitis (deep vein thrombosis)

THROMBOANGITIS OBLITERANS

Acute inflammatory disorder usually affecting the small medium sized arteries and veins of the lower

extremities


1. High risk groups – men 30 years old and above

2. Smoking


1. Intermittent claudication – leg pain upon walking

2. Cold sensitivity and changes in skin color (pallor, cyanosis then rubor)

3. Decreased peripheral pulses

4. Trophic changes

5. Ulceration

6. Gangrene formation


1. Oscillometry – decrease in peripheral pulses

2. Doppler UTZ – decrease blood flow to the affected extremity

3. Angiography – reveals site and extent of malocclusion


1. Encourage a slow progressive physical activity

a. walking 3 – 4 times a day

b. out of bed 3 – 4 times a day


a. Analgesics

b. Vasodilators

c. Anti coagulants

3. Institute foot care management

4. Instruct client to avoid smoking and exposure to cold environment

5. Assist in surgical procedure – bellow knee amputation

REYNAUD’S DISEASE

Disorder characterized by acute episodes of arterial spasm involving the fingers or digits of the hands


1. High risk group – female 40 years old and above

2. Smoking

3. Collagen diseases

a. SLE (butterfly rash)

b. Rheumatoid Arthritis

4. Direct hand trauma

a. Piano playing

b. Excessive typing

c. Operating chainsaw


1. Intermittent claudication – leg pain upon walking

2. Cold sensitivity and changes in skin color (pallor, cyanosis then rubor)

3. Trophic changes

4. Ulceration

5. Gangrene formation


1. Doppler UTZ – decrease blood flow to the affected extremity

2. Angiography – reveals site and extent of malocclusion



a. Analgesics

b. Vasodilators

2. Encourage to wear gloves

3. Instruct client on importance of cessation of smoking and exposure to cold environment

VARICOSITIES

Abnormal dilation of veins of lower extremities and trunks due to

Incompetent valve resulting to

Increased venous pooling resulting to

Venous stasis causing

Decrease venous return


1. Hereditary

2. Congenital weakness of veins

3. Thrombophlebitis

4. Cardiac disorder

5. Pregnancy

6. Obesity

7. Prolonged standing or sitting


1. Pain after prolonged standing

2. Dilated tortuous skin veins

3. Warm to touch

4. Heaviness in legs


1. Venography

2. Trendelenburg’s Test - veins distends quickly in less than 35 seconds


1. Elevate legs above heart level to promote increased venous return by placing 2 – 3 pillows under the legs

2. Measure the circumference of leg muscle to determine if swollen

3. Wear anti embolic stockings


a. Analgesics

5. Assist in surgical procedure

a. Vein stripping and ligation (most effective)

b. Sclerotherapy – can recur and only done in spider web varicosities and danger of thrombosis (2 – 3

years for embolism)

THROMBOPHLEBITIS

Deep vein thrombosis

Inflammation of the veins with thrombus formation


1. Obesity

2. Smoking

3. Related to pregnancy

4. Chronic anemia

5. Prolong use of oral contraceptives – promotes lipolysis

6. Diabetes mellitus

7. Congestive heart failure

8. Myocardial infarction

9. Post op complication

10. Post cannulation – insertion of various cardiac catheter

11. Increase in saturated fats in the diet.


1. Pain at affected extremity

2. Warm to touch

3. Dilated tortuous skin veins

4. Positive Hpman’s Signs – pain at the calf or leg muscle upon dorsi flexion of the foot


1. Venography

2. Angiography


1. Elevate legs above heart level to promote increase venous return

2. Apply warm moist pack – to reduce lymphatic congestion

3. Measure circumference of leg muscle to determine if swollen

4. Encourage to wear anti embolic stockings or knee elastic stockings


a. Analgesics

b. Anti Coagulant

- Heparin

6. Monitor for signs of complications

Embolism

a. Pulmonary

- Sudden sharp chest pain

- Unexplained dyspnea

- Tachycardia

- Palpitations

- Diaphoresis

- Restlessness

b. Cerebral

- Headache

- Dizziness

- Decrease LOC

MURPHY’S SIGN is seen in clients with cholelithiasis, cholecystitis characterized by pain at the

right upper quadrant with tenderness

RESPIRATORY SYSTEM

OVERVIEW OF THE STRUCTURES AND FUCNTIONS OF THE RESPIRATORY SYSTEM

I. Upper Respiratory System

1. Filtering of air

2. Warming and moistening of air

3. Humidification

A. Nose

- Cartillage

- Right nostril

- Left nostril

- Separated by septum

- Consist of anastomosis of capillaries known as Keissel Rach Plexus (the site of nose bleeding)

B. Pharynx/Throat

- Serves as a muscular passageway for both food and air

C. Larynx

- For phonation (voice production)

- For cough reflex

Glottis

- Opening of larynx

- Opens to allow passage of air

- Closes to allow passage of food going to the esophagus

- The initial sign of complete airway obstruction is the inability to cough

II. Lower Respiratory System

- For gas exchange

A. Trachea/Windpipe

- Consist of cartilaginous rings

- Serves as passageway of air going to the lungs

- Site of tracheostomy

B. Bronchus

- Right main bronchus

- Left main bronchus

C. Lungs

- Right lung (consist of 3 lobes, 10 segments)

- Left lung (consist of 2 lobes, 8 segments)

- Serous membranes

Pleural Cavity

a. Pareital

b. Pleural fluid

c. Visceral

With Pleuritic Friction Rub

a. Pneumonia

b. Pleural effusion

c. Hydrothorax (air and blood in pleural space

Alveoli

- Site of gas exchange (CO2 and O2)

- Diffusion (Dalton’s law of partial pressure of gases)

Respiratory Distress Syndrome

- Decrease oxygen stimulates breathing

- Increase carbon dioxide is a powerful stimulant for breathing

Type II Cells of Alveoli

- Secretes surfactant

- Decrease surface tension

- Prevent collapse of alveoli

- Composed of lecithin and spingomyelin

- L/S ratio to determine lung maturity

- Normal L/S ratio is 2:1

- In premature infants 1:2

- Give oxygen of less 40% in premature to prevent atelectasis and retrolental fibroplasias

- retinopathy/blindness in prematurity

Disorders of Respiratory System

1. PTB/Pulmonary Tuberculosis (Koch’s Disease)

- Infection of lung tissue caused by invasion of mycobacterium tuberculosis or tubercle bacilli

- An acid fast, gram negative, aerobic and easily destroyed by heat or sunlight

A. Precipitating Factors

1. Malnutrition

2. Overcrowded places

3. Alcoholism

4. Over fatigue

5. Ingestion of an infected cattle with mycobacterium bovis

6. Virulence (degree of pathogenecity) of microorganism

B. Mode of Transmission

1. Airborne transmission via droplet nuclei


1. Low grade afternoon fever, night sweats

2. Productive cough (yellowish sputum)

3. Anorexia, generalized body malaise

4. Weight loss

5. Dyspnea

6. Chest pain

7. Hemoptysis (chronic)


1. Mantoux Test (skin test)

- Purified protein derivative

- DOH 8 – 10 mm induration, 48 – 72 hours

- WHO 10 – 14 mm induration, 48 – 72 hours

- Positive Mantoux test (previous exposure to tubercle bacilli but without active TB)

2. Sputum Acid Fast Bacillus

- Positive to cultured microorganism

3. Chest X-ray

- Reveals pulmonary infiltrates

4. CBC

- Reveals increase WBC


1. Enforce CBR

2. Institute strict respiratory isolation


4. Force fluids to liquefy secretions

5. Place client on semi fowlers position to promote expansion of lungs

6. Encourage deep breathing and coughing exercise

7. Nebulize and suction when needed

8. Comfortable and humid environment

9. Institute short course chemotherapy

a. Intensive phase

- INH (Isonicotinic Acid Hydrazide)

- Rifampicin (Rifampin)

- PZA (Pyrazinamide)

- Given everyday simultaneously to prevent resistance

- INH and Rifampicin is given for 4 months, taken before meals to facilitate absorption

- PZA is given for 2 months, taken after meals to facilitate absorption

- Side Effect INH: peripheral neuritis/neuropathy (increase intake of Vitamin B6/Pyridoxine)

- Side Effect Rifampicin: all bodily secretions turn to red orange color

- Side Effect PZA: allergic reaction, hepatotoxicity, nephrotoxicity

- PZA can be replaced by Ethambutol

- Side Effect Ethambutol: optic neuritis

b. Standard phase

- Injection of streptomycin (aminoglycoside)

- Kanamycin

- Amikacin

- Neomycin

- Gentamycin

- Side Effect:

- Ototoxicity damage to the 8th cranial nerve resulting to tinnitus leading to hearing loss

- Nephrotoxicity check for BUN and Creatinine

- Give aspirin if there is fever

- Side Effect: tinnitus, dyspepsia, heartburn

10. Provide increase carbohydrates, protein, vitamin C and calories


a. Avoidance of precipitating factors

b. Prevent complications (atelectasis, military tuberculosis)

PTB

- Bones (potts)

- Meninges

- Eyes

- Skin

- Adrenal gland

c. Strict compliance to medications

d. Importance of follow up care

PNEUMONIA

Inflammation of the lung parenchyma leading to pulmonary consolidation as the alveoli is filled with exudates

A. Etiologic Agents

1. Streptococcus Pneumonae – causing pneumococal pneumonia

2. Hemophylus Influenzae – causing broncho pneumonia

3. Diplococcus Pneumoniae

4. Klebsella Pneumoniae

5. Escherichia Pneumoniae

6. Pseudomonas

B. High Risk Groups

1. Children below 5 years old

2. Elderly

C. Predisposing Factors

1. Smoking

2. Air pollution

3. Immuno compromised

a. AIDS

- Pneumocystic carini pneumonia

- Drug of choice is Retrovir

b. Bronchogenic Cancer

- Initial sign is non productive cough

- Chest x-ray confirms lung cancer

4. Related to prolonged immobility (CVA clients), causing hypostatic pneumonia

5. Aspiration of food causing aspiration pneumonia


1. Productive cough with greenish to rusty sputum

2. Dyspnea with prolong expiratory grunt

3. Fever, chills, anorexia and general body malaise

4. Weight loss

5. Rales/crackles


7. Cyanosis

8. Pleuritic friction rub

9. Chest pain

10. Abdominal distention leading to paralytic ileus (absence of peristalsis)


1. Sputum Gram Staining and Culture Sensitivity – positive to cultured microorganisms

2. Chest x-ray – reveals pulmonary consolidation

3. ABG analysis – reveals decrease PO2

4. CBC – reveals increase WBC, erythrocyte sedimentation rate is increased


1. Enforce CBR

2. Administer oxygen inhalation low inflow


Broad Spectrum Antibiotic

a. Penicillin

b. Tetracycline

c. Microlides (Zethromax)

- Azethromycin (Side Effect: Ototoxicity)

- Antipyretics

- Mucolytics/Expectorants

- Analgesics

4. Force fluid

5. Place on semi fowlers position

6. Institute pulmonary toilet (tends to promote expectoration)

- Deep breathing exercises

- Coughing exercises

- Chest physiotherapy

- Turning and reposition

7. Nebulize and suction as needed

8. Assist in postural drainage

- Drain uppermost area of lungs

- Placed on various position

Nursing Management for Postural Drainage

a. Best done before meals or 2 – 3 hours to prevent gastro esophageal reflux

b. Monitor vital signs

c. Encourage client deep breathing exercises

d. Administer bronchodilators 15 – 30 minutes before procedure

e. Stop if client cannot tolerate procedure

f. Provide oral care after procedure

g. Contraindicated with

- Unstable vital signs

- Hemoptysis

- Clients with increase intra ocular pressure (Normal IOP 12 – 21 mmHg)

- Increase ICP

9. Provide increase carbohydrates, calories, protein and vitamin C

10. Health teaching and discharge planning

a. Avoid smoking


- Atelectasis

- Meningitis (nerve deafness, hydrocephalus)

c. Regular adherence to medications


HISTOPLASMOSIS

Acute fungal infection caused by inhalation of contaminated dust or particles with histoplasma capsulatum

derived from birds manure


PTB or Pneumonia like

1. Productive cough

2. Dyspnea

3. Fever, chills, anorexia, general body malaise

4. Cyanosis

5. Hemoptysis

6. Chest and joint pains


1. Histoplasmin Skin Test – positive

2. ABG analysis PO2 decrease


1. Enforce CBR



a. Antifungal

- Amphotericin B

- Fungizone (Nephrotoxicity, check for BUN and Creatinine, Hypokalemia)

b. Steroids

c. Mucolytics

d. Antipyretics

4. Force fluids to liquefy secretions

5. Nebulize and suction as needed

6. Prevent complications – bronchiectasis

7. Prevent the spread of infection by spraying of breeding places

COPD (Chronic Obstructive Pulmonary/Lung Disease)

Chronic Bronchitis

Inflammation of bronchus resulting to hypertrophy or hyperplasia of goblet mucous producing cells leading to

narrowing of smaller airways


1. Smoking

2. Air pollution


1. Productive cough (consistent to all COPD)

2. Dyspnea on exertion

3. Prolonged expiratory grunt

4. Anorexia and generalized body malaise

5. Scattered rales/ronchi

6. Cyanosis

7. Pulmonary hypertension

a. Peripheral edema

b. Cor Pulmonale (right ventricular hypertrophy)


ABG analysis – reveals PO2 decrease (hypoxemia), PCO2 increase, pH decrease

Bronchial Asthma

Reversible inflammatory lung condition due to hypersensitivity to allergens leading to narrowing of smaller

airways

A. Predisposing Factors (Depending on Types)

1. Extrinsic Asthma ( Atopic/ Allergic )

Causes

a. Pollen

b. Dust

c. Fumes

d. Smoke

e. Gases

f. Danders

g. Furs

h. Lints

2. Intrinsic Asthma (Non atopic/Non allergic)

Causes

a. Hereditary

b. Drugs (aspirin, penicillin, beta blocker)

c. Foods (seafoods, eggs, milk, chocolates, chicken

d. Food additives (nitrates)

e. Sudden change in temperature, air pressure and humidity

f. Physical and emotional stress

3. Mixed Type 90 – 95%


1. Cough that is non productive

2. Dyspnea

3. Wheezing on expiration

4. Cyanosis

5. Mild Stress/apprehension

6. Tachycardia, palpitations

7. Diaphoresis


1. Pulmonary Function Test

- Incentive spirometer reveals decrease vital lung capacity

2. ABG analysis – PO2 decrease

- Before ABG test for positive Allens Test, apply direct pressure to ulnar and radial artery to determine

presence of collateral circulation


1. Enforce CBR

2. Oxygen inhalation, with low inflow of 2 – 3 L/min


a. Bronchodilators – given via inhalation or metered dose inhalaer or MDI for 5 minutes

b. Steroids – decrease inflammation

c. Mucomysts (acetylceisteine)

d. Mucolytics/expectorants

e. Anti histamine

4. Force fluids

5. Semi fowlers position


7. Provide client health teachings and discharge planning concerning

a. Avoidance of precipitating factor


- Emphysema

- Status Asthmaticus (give drug of choice)

- Epinephrine

- Steroids

- Bronchodilators

c. Regular adherence to medications to prevent development of status asthmaticus


BRONCHIECTASIS

Abnormal permanent dilation of bronchus leading to destruction of muscular and elastic tissues of alveoli


1. Recurrent lower respiratory tract infections

2. Chest trauma

3. Congenital defects

4. Related to presence of tumor


1. Productive cough

2. Dyspnea

3. Cyanosis


5. Hemoptysis (only COPD with sign)


1. ABG – PO2 decrease

2. Bronchoscopy – direct visualization of bronchus using fiberscope

Nursing Management PRE Bronchoscopy

1. Secure inform consent and explain procedure to client

2. Maintain NPO 6 – 8 hours prior to procedure

3. Monitor vital signs and breath sound

POST Bronchoscopy

1. Feeding initiated upon return of gag reflex

2. Avoid talking, coughing and smoking, may cause irritation

3. Monitor for signs of gross

4. Monitor for signs of laryngeal spasm – prepare tracheostomy set

D. Treatment

1. Surgery (pneumonectomy , 1 lung is removed and position on affected side)

2. Segmental Wedge Lobectomy (promote re expansion of lungs)

- Unaffected lobectomy facilitate drainage

EMPHYSEMA

Irreversible terminal stage of COPD characterized by

a. Inelasticity of alveoli

b. Air trapping

c. Maldistribution of gases

d. Over distention of thoracic cavity (barrel chest)


1. Smoking

2. Air pollution

3. Allergy

4. High risk: elderly

5. Hereditary – it involves deficiency of ALPHA-1 ANTI TRYPSIN (needed to form Elastase, for recoil of

alveoli)


1. Productive cough

2. Dyspnea at rest

3. Prolong expiratory grunt


5. Resonance to hyperresonance

6. Decrease tactile fremitus

7. Decrease or diminished breath sounds

8. Rales or ronchi


10. Barrel chest

11. Flaring of alai nares

12. Purse lip breathing to eliminates excess CO2 (compensatory mechanism)


1. Pulmonary Function Test – reveals decrease vital lung capacity

2. ABG analysis reveals

a. Panlobular/ centrilobular

- Decrease PO2 (hypoxemia leading to chronic bronchitis, “Blue Bloaters”)

- Decrease ph

- Increase PCO2

- Respiratory acidosis

b. Panacinar/ centriacinar

- Increase PO2 (hyperaxemia, “Pink Puffers”)

- Decrease PCO2

- Increase ph

- Respiratory alkalosis


1. Enforce CBR

2. Administer oxygen inhalation via low inflow


a. Bronchodilators

b. Steroids

c. Antibiotics

d. Mucolytics/expectorants

4. High fowlers position

5. Force fluids

6. Institute pulmonary toilet


8. Institute PEEP (positive end expiratory pressure) in mechanical ventilation promotes maximum alveolar lung

expansion

9. Provide comfortable and humid environment

10. Provide high carbohydrates, protein, calories, vitamins and minerals

11. Health teachings and discharge planning concerning

a. Avoid smoking


- Atelectasis

- Cor Pulmonale

- CO2 narcosis may lead to coma

- Pneumothorax

c. Strict compliance to medication


5074406 medical surgical nursing review notes

Documents

central nervous

weigh patient

maintain patent

maintain side

s3 ventricular

deep breathing

rapid acting

urine specific