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J. F. ADORABLE, RN.
Text from Pentagon Review Center
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
35. CHOLECYSTITIS - Murphy’s sign (pain on deep inspiration, a inflammation of the gallbladder
2. Impaired sensation
Pain, pressure, heat and cold. [do not give hot packs b‘coz of dec. sensation to heat which can lead to burns.]
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)
CHARCOTS TRIAD
ANI
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/cord following laminotomy.
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. [Best given in Morning to mimic body normal rhythm]
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) – treat urinary retention
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 (Probanthine) – antispasmodic drug to treat urinary incontinence
Acid ash diet like cranberry juice, plums, prunes, pineapple, vitamin C and orange.
To acidify urine and prevent bacterial multiplication.
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 Brain
Monocytes Blood
Kupffers cells Kidney
Histiocytes Skin
Alveolar Lung
Macrophage
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 [the true sense of sexual arousal is when you smelled the fumes of the natural body]
controls long term memory
2. BASAL GAGLIA
areas of grey matter located deep within each cerebral hemisphere.
release dopamine (controls gross voluntary movement.)
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 [Pupils equal, round, reactive to light and accommodation]
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 promote 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, and swallowing, vomiting, hiccup, vasomotor center (dilation and
constriction of bronchioles).
[damage to medulla is most life threatening]
3. Cerebellum
Smallest part of the brain.
Lesser brain.
Controls balance, equilibrium, posture and gait.
INTRA CRANIAL PRESSURE
Medulla Oblongata
Brain Herniation
NEUROLOGIC DISORDERS
INCREASE INTRACRANIAL PRESSURE – increase in intra-cranial bulk brought about by an increase in one of the 3
major intra cranial components. NORMAL ICP: 0-15 mmhg
Causes:
head trauma/injury inflammatory condition (stroke)
localized abscess hydrocephalus
cerebral edema tumor (rarely)
hemorrhage
Signs and Symptoms (Early)
decrease LOC lethargy/stupor
restlessness/agitation coma
irritability
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, [may positive to babinski reflex]
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
o
2. Elevate bed of client 30 – 35 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.
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)
2. Hypocalcemia/ Tetany
decrease calcium level
normal value is 8.5 – 10.5 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
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 - 3 P’s
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)
Aloneness
Multiple loss
causes suicide
1. Digitalis Toxicity
Signs and Symptoms
nausea and vomiting / anorexia
diarrhea
confusion / fatigue / depression / malaise
photophobia
changes in color perception (yellowish or green halo around lights or ―snowy‖ vision)
Antidote: Digibind – digoxin immune FAB
2. Lithium Toxicity – anti-manic agent/ mood stabilizing agent
Signs and Symptoms
anorexia
nausea and vomiting
diarrhea
dehydration causing fine tremors
hypothyroidism (cretinism – the only endocrine disorder that can lead to mental retardation)
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
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 at 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 Acetylcholine
Signs and Symptoms
initial sign is ptosis a clinical parameter to determine ptosis is palpebral fissure. (drooping of eyelid)
diplipia
mask like facial expression
dysphagia
hoarseness of voice [dysphonia-voice impairment]
respiratory muscle weakness that may lead to respiratory arrest (tracheostomy at bed side)
extreme muscle weakness especially during activity or exertion
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. Immobility
* 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) – pyridostigmine bromide
b. Anti Cholenisterase (Prostigmin) – neostigmine bromide
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: Cause:
under medication over medication
stress (disease exacerbation, high temp.) Signs and Symptoms
infection PNS
Signs and Symptoms Tensilon test doesn‘t improve MG
The client is unable to see, swallow, speak,
breathe Treatment
Treatment Administer anti cholinergic agents (Atropine
administer cholinergic agents as ordered 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
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, generalized 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 Puncture. [note all surgery procedure explain by the doctor, diagnostic procedure is by the nurse]
1. Secure informed consent and explain procedure.
2. Empty bladder and bowel to promote comfort.
3. Encourage to arch back to clearly visualize L3-L4. (fetal position)
Post Lumbar Puncture
o
1. Place flat on bed 12 – 24
2. Force fluids
3. Check punctured site for any discoloration, drainage and leakage to tissues.
4. Assess for movement and sensation of extremities.
CSF analysis reveals
1. Increase CHON and WBC
2. Decrease glucose
3. Increase CSF opening pressure (normal pressure is 50 – 100 mmHg)
4. (+) cultured microorganism (confirms meningitis)
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.
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
7. Administer medications as ordered
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)
9. Prevent complications
a. Arrythmia
b. Paralysis or respiratory muscles / Respiratory arrest
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)
C. Diagnostic Procedures
1. CT Scan – reveals brain lesions
2. EEG – reveals hyper activity of electrical brain waves
D. Nursing Management
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
3. Administer medications as ordered
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
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
CRANIAL NERVES M
IV. TROCHLEAR
(Smallest)
C. Diagnostic Procedures
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
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) – dilating 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
A. Predisposing Factors
1. Post Lens Extraction
2. Myopia (near sightedness)
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)
CRANIAL NERVE III, IV, VI: OCULOMOTOR, TROCHLEAR, ABDUCENS A. normal retina
B. ―wet‖ macular degeneration
Controls or innervates the movement of extrinsic ocular muscle (EOM) c. ―dry‖ macular degeneration
6 muscles
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
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 Anterior pituitary Posterior pituitary
ADH GH
2. Antidiuretic Hormone OXYTOCIN ACTH
A. Predisposing Factors
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.
C. Diagnostic Procedure
1. Urine specific gravity is increased
2. Serum Sodium is decreased (hyponatremia 135 mg/dl)
D. Nursing Management
1. Restrict fluid
2. Administer medications as ordered
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
6. Prevent complications
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.
THYROID DISORDERS
SIMPLE GOITER
o enlargement of thyroid gland due to iodine deficiency
A. Predisposing Factors
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 d. Cobalt
c. PASA (Aspirin) e. Phenylbutazones (NSAIDs) - if goiter is caused by
B. Signs and Symptoms
1. Enlarged thyroid gland
2. Mild dysphagia
3. Mild restlessness
C. Diagnostic Procedures
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)
D. Nursing Management
1. Enforce complete bed rest
2. Administer medications as ordered
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
A. Predisposing Factors
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)
C. Diagnostic Procedures
1. Serum T3 and T4 is decreased
2. Serum Cholesterol is increased
3. RAIU (Radio Active Iodine Uptake) is decreased
D. Nursing Management
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 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
4. Administer medications as ordered
Thyroid Hormones
a. Levothyroxine
b. Leothyronine
c. Thyroid Extracts
5. Provide dietary intake that is low in calories – due to wt. gain
6. Provide comfortable and warm environment – due to cold intolerance
7. Provide meticulous skin care
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 – grave‘s disease or thyroid toxicosis (everything is up except wt. and mens.
o increase in T3 and T4
o Grave’s Disease or Thyrotoxicosis
o developed by Robert Graves
A. Predisposing Factors
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 of TG (increase size)
C. Diagnostic Procedures
1. Serum T3 and T4 is increased
2. RAIU (Radio Active Iodine Uptake) is increased
3. Thyroid Scan- reveals an enlarged thyroid gland
D. Nursing Management
1. Monitor strictly vital signs and intake and output - determine thyroid storm or most feared complication:
Thyrotoxicosis
2. Administer medications as ordered
Anti Thyroid Agent
a. Prophythioracill (PTU)
b. Methymazole (Tapazole)
Most toxic Side Effects Agranulocytosis
o increase lymphocytes and monocytes
o fever and chills
o sore throat (throat swab/culture)
o leukocytosis (CBC)
o Most feared complication : Thrombosis – stroke CVS
3. Provide dietary intake that is increased in calories.
4. Provide meticulous skin care
5. Comfortable and cold environment
6. Maintain side rails - due to agitation/restlessness
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
TRIAD SIGNS
Hyperthermia Tachycardia
o administer medications as ordered
a. Anti Pyretics
b. Beta-blockers – tachycardia
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 (secretes parathormone) 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
Ca gluconate toxicity – antidote – MgSO4
3. Watch out for accidental Laryngeal (voice box) damage which may lead to hoarseness of voice
Nursing Management
o encourage client to talk/speak immediately after operation and notify physician
PARATHYROID GLAND
o A pair of small nodules behind the thyroid gland
o Secretes parathormone
o Promotes calcium reabsorption
o Thyrocalcitonin – antagonises secretion of parathyroid hormone
o Hypoparathyroidism
o Hyperparathyroidism
HYPOPARATHYROIDISM
o Decrease secretion of parathormone leading to hypocalcemia (tetany)
o Resulting to Hyperphosphatemia
[If Ca decreases, phosphate increases]
A. Predisposing Factors
1. Following subtotal thyroidectomy
2. Atrophy of parathyroid gland due to:
a. inflammation
b. tumor
c. trauma
B. Signs and Symptoms
1. Acute tetany
a. tingling sensation
b. paresthesia
c. numbness
d. dysphagia
e. positive trousseau’s sign/carpopedal spasm
f. positive chvostek sign
g. laryngospasms / 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 (irritable)
C. Diagnostic Procedures
1. Serum Calcium is decreased (normal value: 8.5 – 10.5 mg/100 ml)
2. Serum Phosphate is increased (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
D. Nursing Management
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
VIT. D
(CHOLECALCEFEROL)
d. Phosphate binder
Aluminum Hydroxide Gel (Ampogel)
Side effect: constipation
ANTACID
A.A.C MAD
▼ ▼
Aluminum Containing Magnesium Containing
Antacids Antacids
▼ ▼
Aluminum Ex. Milk of magnesia
Hydroxide
Gel (Maalox – magnesium & aluminum - Less s/e)
▼
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 (decreased phosphorus)
a. anchovies - increase Ca, decrease phosphorus + inc uric acid. Tuna & green turnips- Inc Ca.
b. salmon
c. green turnips
Don„t give milk – due to increase phosphorus
4. Institute seizure and safety precaution
5. Encourage client to breathe using paper bag to produce mild respiratory acidosis result.
6. Prepare trachea set at bedside for presence of laryngospasm
7. Prevent complications
8. Hormonal replacement therapy for lifetime
9. Importance of follow up care.
HYPERPARATHYROIDISM
o Decrease parathormone
o Hypercalcemia: bone demineralization leading to bone fracture (calcium is stored 99% in bone and 1% blood)
o Kidney stones
(parathormone pullout the Ca in from the bone to the blood)
A. Predisposing Factors
1. Hyperplasia of parathyroid gland
2. over compensation of parathyroid gland due to vitamin D deficiency
a. Children: Rickets - the bone do not hardened
b. Adults: Osteomalacia - softening of the bone
B. Signs and Symptoms
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
C. Diagnostic Procedures
1. Serum Calcium is increased
2. Serum Phosphate is decreased
3. X-ray of long bones reveals bone demineralization
D. Nursing Management
1. Force fluids to prevent kidney stones
2. Strain all the urine using gauze pad for stone analysis
3. Provide warm sitz bath
4. Administer medications as ordered
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) most feared renal failure
10. Assist in surgical procedure known as parathyroidectomy
11. Hormonal replacement therapy for lifetime
12. Importance of follow up care
ADRENAL GLAND
o Located atop of each kidney
o 2 layers of adrenal gland
a. Adrenal Cortex – outermost
b. Adrenal Medulla – innermost (secretes catecholamine’s a power hormone)
2 Types of Catecholamines
o Epinephrine and Norepinephrine (vasoconstrictor) increased BP
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
I love Sex!!!
- Sex
3. Zona Glumerulosa
- secretes mineralocorticoids (aldosterone)
- function: promotes sodium and water reabsorption and excretion of potassium
- Salt
s
o Hyposecretion of adreno cortical hormone leading to
ex – secondary sex disturbances / decreased libido
ugar - metabolic disturbance / hypoglycemia
alt – fluid & electrolytes imbalance
A. Predisposing Factors
1. Related to atrophy of adrenal glands
2. Fungal infections
C. Diagnostic Procedures
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)
D. Nursing Management
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
2. Administer isotonic fluid solution as ordered
3. Force fluids
4. Administer medications as ordered
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)
3. Monitor side effects
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
6. Provide meticulous skin care
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 Cushing’s syndrome.
A. Client prior to syndrome.
c. hormonal replacement for lifetime B. Client 4 months after diagnosis of syndrome.
A. Predisposing Factors
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
5. Dexamethasone suppression test
C. Nursing Management
1. Monitor strictly vital signs and intake and output
2. Weigh patient daily and assess for pitting edema
3. Measure abdominal girth daily and notify physician
4. Restrict sodium intake
5. Provide meticulous skin care
6. Administer medications as ordered
a. Spinarolactone – potassium sparring diuretics
7. Prevent complications (DM) Best example of CUSHING SYNDROME is
8. Assist in surgical procedure (bilateral adrenoraphy) no other than
JOLLIBEE – moon face & big body with
9. Hormonal replacement for lifetime thin extremities
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
DIABETES MELLITUS
- Metabolic disorder characterized by non utilization of carbohydrates, protein and fat metabolism
MAIN
ANABOLISM CATABOLISM
FOODSTUFF
HYPERGLYCEMIA
Increase osmotic diuresis
Glycosuria Polyuria
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
A. Predisposing Factors
1. Hyperglycemia
2. Stress – number one precipitating factor
3. Infection
C. Diagnostic Procedures
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
D. Nursing Management
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
4. Administer medications as ordered
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
B. Nursing Management
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
4. Administer medications as ordered
a. Insulin therapy (regular acting insulin peak action of 2 – 4 hours)
- for DKA use rapid acting insulin
b. Antibiotics to prevent infection
Types of Insulin Color & consistency Peak
Rapid Clear 2-4
INSULIN THERAPY
Intermediate Cloudy 6-12
A. Sources of Insulin
Long acting Cloudy 12-24
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
C. Nursing Management
1. Monitor for peak action of insulin and OHA and notify physician
2. Administer insulin and OHA therapy as ordered
3. Monitor strictly vital signs, intake and output and blood sugar levels
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
EYES KIDNEY
glucose is rising
-PREMATURE CATARACT -RECURRENT PYELONEPHRITIS
7. Monitor signs for complications - Blindness - Renal failure
a. Atherosclerosis (HPN, MI, CVA)
b. Microangiopathy (affects small minute blood vessels of eyes and kidneys)
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
Overview only:
PANCREATITIS - acute inflammation of pancreas leading to pancreatic edema, hemorrhage & necrosis due to
Autodigestion – self-digestion
Cause: unknown/idiopathic
alcoholism
Pathognomonic sign- (+) Cullen‘s sign - Ecchymosis of umbilicus (bluish color)- pasa
(+) Grey turner‗s sign – ecchymosis of flank area
HEMATOLOGICAL SYSTEM
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 Marrow
1. Albumin
2. Globulins
3. 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)
3
- normal value: 4 – 6 million/mm
- 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)
3
- normal value: 5000 – 10000/mm
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
HIV
- 6 months – 5 years incubation period
- 6 months window period
- western blot opportunistic
- ELISA
- drug of choice AZT (Zidon Retrovir)
3. Platelets (THROMBOCYTES)
3
- Normal value: 150,000 – 450,000/mm
- 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
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
B. Predisposing Factors
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
C. Signs and Symptoms
1. Usually asymptomatic
2. Weakness and fatigue (initial signs)
3. Headache and dizziness
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
E. Nursing Management
1. Monitor for signs of bleeding of all hema test including urine, stool and GIT
2. Enforce CBR so as not to over tire client
3. Instruct client to take foods rich in iron
a. Organ meat
b. Egg (yolk)
c. Raisin
d. Sweet potatoes
e. Dried fruits
f. Legumes
g. Nuts
4. Instruct the client to avoid taking tea and coffee because it contains tannates which impairs iron absorption
5. Administer medications as ordered
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
3. Monitor side effects
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)
A. Predisposing Factors
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
C. Diagnostic Procedure
Schilling’s Test – reveals inadequate/decrease absorption of Vitamin B12
D. Nursing Management
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
A. Predisposing Factors
1. Chemicals (Benzine and its derivatives)
2. Related to irradiation/exposure to x-ray
When all of the blood elements
3. Immunologic injury are depressed, the term
―pancytopenia‖ is used. ―Pan‖
4. Drugs
meaning everything.
Broad Spectrum Antibiotics
a. Chloramphenicol (Sulfonamides)
Chemotherapeutic Agents
a. Methotrexate (Alkylating Agent)
b. Vincristine (Plant Alkaloid)
c. Nitrogen Mustard (Antimetabolite)
Phenylbutazones (NSAIDS)
D. Nursing Management
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 Heplock
9. Instruct client to use electric razor when shaving
10. Administer medications as ordered
a. Corticosteroids – caused by immunologic injury
b. Immunosuppressants
A. Predisposing Factors
1. Related to rapid blood transfusion
2. Massive burns
3. Massive trauma
4. Anaphylaxis
5. Septicemia
6. Neoplasia (new growth of tissue)
7. Pregnancy
C. Diagnostic Procedures
1. CBC reveals decreased platelets
2. Stool occult blood positive
3. ABG analysis reveals metabolic acidosis
4. Opthamoscopic exam reveals sub retinal hemorrhages
D. Nursing Management
1. Monitor for signs of bleeding of all hema test including stool and GIT
2. Administer isotonic fluid solution as ordered
3. Administer oxygen inhalation
4. Force fluids
5. Administer medications as ordered
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
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 space filled w/ fluid
which is 10 – 30 cc lubricates the surface to reduces
friction during systole.
- 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
C. Valves
- To promote unidimensional flow or prevent backflow
3. Bundle of His
- Right Main Bundle of His
- Left Main Bundle of His
- Located at the interventricular septum
Cardiac electrical activity is the result of the movement of ions (charged particles such as SODIUM, POTASSIUM,
AND CALCIUM) across the cell membrane.
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 - hardening of artery, thicken
- lipid or fat deposits (plaques) - calcium and protein deposits
- tunica intima - tunica media
A. Predisposing Factors
1. Sex – male
2. Race – black
3. Smoking
4. Obesity
5. Hyperlipidemia
6. Sedentary lifestyle
7. Diabetes Mellitus
8. Hypothyroidism
9. Diet – increased saturated fats
10. Type A personality
C. Treatment
Percutaneous Transluminal Coronary Angioplasty
Objectives of PTCA
1. Revascularize myocardium
2. To prevent angina
3. 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
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
D. Diagnostic Procedure
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
E. Nursing Management
1. Enforce complete bed rest
2. Administer medications as ordered
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 persists 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
Orthostatic hypotension
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 during defibrillation as it may lead to burns (most important
thing to remember)
b. Beta-blockers
- (lol)
- Propanolol - side effects PNS - broncho constriction, vasodilation
- Not given to COPD cases because it causes Bronchospasm
c. ACE Inhibitors
- (pril)
- Enalapril, captopril, april jane dolo
d. Calcium Antagonist
- calciblock
- Nifedipine, diltiazem
MYOCARDIAL INFARCTION – areas in myocardial cells in the heart are permanently destroyed.
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
C. Predisposing Factors
1. Sex – male
2. Race – black
3. Smoking
4. Obesity
5. Hyperlipidemia
6. Sedentary lifestyle
7. Diabetes Mellitus
8. Hypothyroidism
9. Diet – increased saturated fats
10. Type A personality
E. Diagnostic Procedure
1. Cardiac Enzymes
a. CPK – MB
- Creatinine phosphokinase is increased
- Heart only, 12 – 24 hours
b. LDH – Lactic 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 (protein in myocardial)
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
F. Nursing Management
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 fowler‘s position
6. Monitor strictly vital signs, intake and output and ECG tracing
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, Isordil) sublingual
d. ACE Inhibitors
- (-pril)
e. Calcium Antagonist
- amlodipine, verapamil, diltiazem
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
A. Predisposing Factors
1. 90% is mitral valve stenosis due to
a. RHD – inflammation of mitral valve due to invasion of Group A beta-hemolytic streptococcus
- Formation of aschoff bodies in the mitral valve
- Common among children (throat infection)
- ASO Titer (Anti streptolysin O titer)
- Penicillin
- Aspirin
b. Aging
2. Myocardial Infarction
3. Ischemic heart disease
4. Hypertension
5. Aortic valve stenosis
B. Signs and Symptoms
1. Dyspnea
2. Paroxysmal nocturnal dyspnea – client awakened at night due to DOB (sudden attacks of Orthopnea at night)
3. Orthopnea – use 2 – 3 pillows when sleeping or place in high fowlers
4. Productive cough with blood tinged sputum (severe pulmonary edema)
5. Frothy salivation
6. Cyanosis
7. Rales/Crackles (bi-basilar lobes that do not clear w/ coughing)
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
13. Oliguria – blood flow to the kidney decreases, causing decreased perfusion and reduce urine output. (Daytime)
14. Nocturia – sleeping cardiac workload decreased, improving renal perfusion, which then leads to frequent urination at
Night.
C. Diagnostic Procedure
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. Echocardiography – enlarged heart chamber (cardiomyopathy), dependent on extent of heart failure
4. ABG – reveals PO2 is decreased (hypoxemia), PCO 2 is increased (respiratory acidosis)
C. Diagnostic Procedures
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 Trendelenburg position to promote ventricular filling and prevent pulmonary
embolism
D. Nursing Management
Goal: increase cardiac contractility thereby increasing cardiac output (3 – 6 L/min)
1. Enforce CBR
2. Administer medications as ordered
a. Cardiac glycosides B. dilated cardiomyopathy
- Digoxin (Lanoxin) (increases cardiac contraction but lowers the pulse rate)
- Increase force of cardiac contraction
- If heart rate is decreased do not give
b. Loop Diuretics
- Lasix (Furosemide) peak 1-2 hrs, duration 6-8 hrs (monitor for hyperkalemia)
c. Bronchodilators aminophylline
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 fowler‘s position
5. Monitor strictly vital signs, intake and output and ECG tracing
6. Measure abdominal girth daily and notify physician
7. Provide a dietary intake of low sodium, cholesterol and caffeine
8. Provide meticulous skin care
9. Assist in bloodless phlebotomy – rotating tourniquet, rotated clockwise every 15 minutes to promote decrease venous
return
10. Provide client health teaching and discharge planning
a. Prevent complications
- Arrhythmia
- Shock
- Right ventricular hypertrophy
- MI
- Thrombophlebitis
b. Dietary modification
c. Strict compliance to medications
PERIPHERAL VASCULAR DISORDER
Arterial Ulcer
I. ThromboAngIitis Obliterans (BUERGER’S DISEASE)
Burger’s Disease - male/ feet
Reynaud’s Disease - female/ hands
Venous Ulcer
1. Varicose Veins
2. Thrombophlebitis (deep vein thrombosis)
A. Predisposing Factors
1. High risk groups – men 30 years old and above
2. Smoking
3. Thrombus formation and occlusion of the vessels
4. Age 20-35 yrs
C. Diagnostic Procedures
1. Oscillometry – decrease in peripheral pulses
2. Doppler UTZ – decrease blood flow to the affected extremity
3. Angiography – reveals site and extent of malocclusion
4. Segmental limb blood pressure (alternation of tourniquet)
A. Predisposing Factors
1. High risk group – female 16-40 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
5. Cold climates and during winter
C. Diagnostic Procedures
1. Doppler UTZ – decrease blood flow to the affected extremity
2. Angiography – reveals site and extent of malocclusion
D. Nursing Management
1. Administer medications as ordered
a. Analgesics
b. Vasodilators (calcium channel blockers: nifedipine)
2. Encourage to wear gloves
3. Instruct client on importance of cessation of smoking and exposure to cold environment
VARICOSITIES
Dilated, tortuous, superficial veins caused by incompetent venous valves
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
A. Predisposing Factors
1. Hereditary
2. Congenital weakness of veins
3. Thrombophlebitis
4. Cardiac disorder
5. Pregnancy
6. Obesity
7. Prolonged standing or sitting
8. Tortuous veins (saphenous veins)
B. Signs and Symptoms
1. Pain after prolonged standing
2. Dilated tortuous skin veins
3. Warm to touch
4. Heaviness in legs
C. Diagnostic Procedure
1. Venography
2. Trendelenburg‘s Test - veins distends quickly in less than 35 seconds
D. Nursing Management
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
4. Administer medications as ordered
a. Analgesics
5. Assist in surgical procedure
a. Vein stripping and ligation (most effective)
b. Sclerotherapy – can recur and only done small/ spider web varicosities and danger of thrombosis (2 – 3 years
for embolism)
- sclerosing agent is injected into the vein, irritating the venous endothelium and producing
localized phlebitis and fibrousis, thereby obliterating the lumen of the vein.
THROMBOPHLEBITIS
Deep vein thrombosis
Inflammation of the veins with thrombus formation
3 factors known as VIRCHOW’S TRIAD believe to play a significant role in its development:
Stasis of the blood (venous stasis)
Vessel wall injury
Altered blood coagulation
A. Predisposing Factors
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.
C. Diagnostic Procedure
1. Venography
2. Angiography
D. Nursing Management
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
5. Administer medications as ordered
a. Analgesics
b. Anti Coagulant – take at the same time each day, usually bet. 8-9 am
- Heparin
Note: if any of the ff. sign are appear, report them immediately
Faintness, dizziness, or increased weakness
Severe headaches or abdominal pain
Reddish or brownish urine
Any bleeding – nose bleeding, cuts, and unusual
Red black bowel movements
Rash
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 (inflammation of the gall bladder)
RESPIRATORY SYSTEM
A. Nose
- Cartillage
- Right nostril
- Left nostril
- Separated by septum
- Consist of anastomosis of capillaries known as Kesselbach’s 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
A. Precipitating Factors
1. Malnutrition
2. Overcrowded places
3. Alcoholism
4. Over fatigue
5. Ingestion of infected cattle with mycobacterium bovis
6. Virulence (degree of pathogenecity) of microorganism
B. Mode of Transmission
1. Airborne transmission via droplet nuclei
D. Diagnostic Procedure
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)
3. Chest X-ray
- Reveals pulmonary infiltrates (chalk thorax)
4. CBC
- Reveals increase WBC
E. Nursing Management
1. Enforce CBR
2. Institute strict respiratory isolation
3. Administer oxygen inhalation
4. Force fluids to liquefy secretions
5. Place client on semi fowler‘s 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:
th
- Ototoxicity damage to the 8 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
11. Provide client health teaching and discharge planning
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 (children)
3. Diplococcus Pneumoniae
4. Klebsella Pneumoniae
5. Escherichia Pneumoniae
6. Pseudomonas
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 to 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
D. Signs and Symptoms
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
6. Bronchial wheezing
7. Cyanosis
8. Pleuritic friction rub
9. Chest pain
10. Abdominal distention leading to paralytic ileus (absence of peristalsis)
E. Diagnostic Procedure
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
F. Nursing Management
1. Enforce CBR
2. Administer oxygen inhalation low inflow
3. Administer medications as ordered
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 fowler‘s 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 – 4 hours after meals to prevent gastro esophageal reflux
b. Monitor vital signs
c. Encourage client deep breathing exercises normal breathe sound bronchovesicular
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
b. Prevent complications
- Atelectasis
- Meningitis (nerve deafness, hydrocephalus)
c. Regular adherence to medications
d. Importance of follow up care
HISTOPLASMOSIS
Acute fungal infection caused by inhalation of contaminated dust or particles with histoplasma capsulatum derived from
birds manure
B. Diagnostic Procedures
1. Histoplasmin Skin Test – positive
2. ABG analysis PO2 decrease
C. Nursing Management
1. Enforce CBR
2. Administer oxygen inhalation
3. Administer medications as ordered
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
A. Predisposing Factors
1. Smoking
2. Air pollution
B. Signs and Symptoms
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)
C. Diagnostic Procedure
ABG analysis – reveals PO2 decrease (hypoxemia), PCO2 increase, and pH decrease (resp. acidosis)
Bronchial Asthma
Reversible inflammatory lung condition due to hypersensitivity to allergens leading to narrowing of smaller airways
C. Diagnostic Procedure
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
D. Nursing Management
1. Enforce CBR
2. Oxygen inhalation, with low inflow of 2 – 3 L/min
3. Administer medications as ordered
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 fowler‘s position
6. Nebulize and suction when needed
7. Provide client health teachings and discharge planning concerning
a. Avoidance of precipitating factor
b. Prevent complications
- Emphysema
- Status Asthmaticus (give drug of choice)
- Epinephrine
- Steroids
- Bronchodilators
c. Regular adherence to medications to prevent development of status asthmaticus
d. Importance of follow up care
BRONCHIECTASIS
Abnormal permanent dilation of bronchus leading to destruction of muscular and elastic tissues of alveoli
A. Predisposing Factors
1. Recurrent lower respiratory tract infections
2. Chest trauma
3. Congenital defects
4. Related to presence of tumor
C. Diagnostic Procedure
1. ABG – PO2 decrease
2. Bronchoscopy – direct visualization of bronchus using fiberscope
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)
A. Predisposing Factors
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)
C. Diagnostic Procedure
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
D. Nursing Management
1. Enforce CBR
2. Administer oxygen inhalation via low inflow
3. Administer medications as ordered
a. Bronchodilators
b. Steroids
c. Antibiotics
d. Mucolytics/expectorants
4. High fowlers position
5. Force fluids
6. Institute pulmonary toilet
7. Nebulize and suction when needed
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
b. Prevent complications
- Atelectasis
- Cor Pulmonale
- CO2 narcosis may lead to coma
- Pneumothorax
c. Strict compliance to medication
d. Importance of follow up care
RESTRICTIVE LUNG DISORDER
PNEUMOTHORAX – partial / or complete collapse of lungs due to entry or air in pleural space.
Types:
1. Spontaneous pneumothorax – entry of air in pleural space without obvious cause.
eg. Rupture of bleb (alveoli filled sacs) in pt with inflammed lung conditions
2. Open pneumothorax – air enters pleural space through an opening in chest wall
-Stab/ gunshot wound
3. Tension Pneumothorax – air enters plural space with @ inspiration & can‘t escape leading to over distension of
thoracic cavity resulting to shifting of mediastinum content to unaffected side.
Eg. Flail chest – ―paradoxical breathing pattern‖
Predisposing factors:
1. Chest trauma
2. Inflammatory lung conditions
3. Tumor
S/Sx:
1. Sudden sharp chest pain
2. unexplained Dyspnea or SOB
3. Cyanosis
4. Diminished or decreased breath sound
of affected lung
5. Cool moist skin- initial sign of shock
6. Mild restlessness/ apprehension, anxiety
7. Resonance to hyperresonance
8. decreased tactile fremitus
Diagnosis:
1. ABG – pO2 decrease –
2. CXR – confirms pneumothorax/collapse of lung
Nursing Mgt:
1. Assist in endotracheal intubation
2. Assist in thoracenthesis
3. Administer meds – Morphine SO4 – due to pain
- Anti microbial agents- due to bacteria
4. Assist in test tube thoracotomy attached
to H2O sealed drainage system
If client has a tension pneumothorax, the initial treatment of choice is to insert a large-bore needle into the
second intercostal space midclavicular line to relieve pressure. Next, a chest tube system is placed into the fourth
intercostal space.
A small chest tube(28 french) is inserted near the second intercostal space; this space is used because it is the
thinnest part of the chest wall, minimizes the danger of contracting the thoracic nerve, and leave small scar. If
the patient has also hemothorax, a large-diameter chest tube (32 french) or greater is inserted usually in the 4 th
or 5th interscostal space at the midaxillary line.
I. Salivary Glands
1. Parotid – below & front of ear
2. Sublingual
3. Submaxillary
S/Sx:
1. Fever, chills anorexia, generalized body malaise
2. enlarged parotid gland
3. Swelling of parotid gland
4. Dysphagia
5. Earache – otalgia
Nursing Mgt:
1. CBR
2. Institute a strict respiratory isolation
3. Meds: analgesic
Antipyretic
Antibiotics – to prevent 2 complications
4. Alternate warm & cold compress at affected part (vinegar promotes cooling)
5. General liquid to soft diet
6. Complications
Women – cervicitis, vaginitis, oophoritis
Both sexes – meningitis & encephalitis/ reason why antibiotics is needed
Men – orchitis might lead to sterility if it occurs during / after puberty.
S/Sx:
1. Pathognomonic sign: (+) rebound tenderness
2. Low grade fever, anorexia, n/v
3. Diarrhea &/ or constipation
4. Pain at Rt. iliac region-- MCBURNEY‘S point – site of surgical incision
5. Late sign due pain – tachycardia
Rovsing’s sign – elicited by palpating the left lower quadrant; this paradoxically causes pain to be felt in the right
lower quadrant.
Diagnosis:
1. CBC – mild leukocytosis – increase WBC
2. PE – (+) rebound tenderness (flex Rt leg, palpate Rt iliac area – rebound)
3. Urinalysis—(+) acetone in urine
Treatment: - appendectomy 24 – 45
Nursing Mgt:
1. Secure consent
2. Routinely nursing measures:
a.) Skin prep
b.) NPO
c.) Avoid enema/laxatives – lead to rupture of
appendix
3. Meds:
Antipyretic
Antibiotics
*Don’t give analgesic – pre-diagnosis will mask pain
Give analgesic – post diagnosis
- Presence of pain means appendix has not ruptured.
4. Avoid heat application – will rupture appendix.
5. Monitor VS, I&O bowel sound
6. Maintain a patent IV line
Complications:
Peritonitis
Septicemia
PEPTIC ULCER DISEASE – (PUD) – excoriation / erosion of submucosa & mucosal lining due to:
a.) Hyper secretion of acid – pepsin
b.) Decrease resistance to mucosal barrier
Incidence Rate:
1. Men – 40 – 55 yrs old
2. Aggressive persons/ type A personality
3. Hereditary
4. Emotional Stress
Predisposing factors:
1. Hereditary
2. Emotional
3. Smoking – vasoconstriction – GIT ischemia
4. Alcoholism – stimulates release of histamine = Parietal cell release Hcl acid = ulceration
5. Caffeine – tea, soda, chocolate
6. Irregular diet
7. Rapid eating
8. Ulcerogenic drugs – NSAIDS, aspirin, steroids, indomethacin, ibuprofen
Indomethacin - S/E corneal cloudiness. Needs annual eye check up.
NSAID and steroids= gastropathy
Types of ulcers
Ascending to severity
1. Acute – affects submucosal lining
2. Chronic – affects underlying tissues –
heals & forms a scar, deeper
According to location
1. Stress ulcer
2. Gastric ulcer
3. Duodenal ulcer – most common
Hypovolemia
GIT schemia
Ulcerations
Hyperacidity
Ulcerations
Treatment: Vagotomy - done to prevent hemorrhage and shock prior to surgery on the stomach
90-95% is cases of duodenal ulcers - less bicarbonate ions, decrease so increase incidence
Diagnosis:
1. Endoscopic exam
2. Stool from occult blood (+)
3. Gastric analysis – Gastric Ulcer: normal gastric acid secretion
Duodenal: increased gastric acid secretion
4. GI series – confirms presence of ulceration
Nursing Mgt:
1. Diet – bland, non irritating, non spicy
2. Avoid caffeine & milk/ milk products Increase gastric acid secretion
3. Administer meds
a.) Antacids
ACA
Aluminum containing antacids Magnesium containing antacids
Nursing Mgt:
1. Administer antacid & H2 receptor antagonist (Cimetidine) – 1hr apart
-Cemetidine decrease antacid absorption & vise versa
c.) Cytoprotective agents
Ex
1. Sucralfate (Carafate) - Provides a paste like subs that coats mucosal lining of stomach
2. Misoprostol (Cytotec) –SE: menstrual spotting
d.) Sedatives/ Tranquilizers - Valium, lithium
e.) Anticholinergics / Antispasmodic
1. Atropine SO4
2. Prophantheline Bromide (Profanthene)
(Pt has history of hpn crisis with peptic ulcer disease. Rn should not administer alka seltzer- has large amount of Na.
Removal of ½ of stomach & anastomoses of Removal of ½ -3/4 of stomach & duodenal bulb &
gastric stump to the duodenum. anastomostoses of gastric stump to jejunum.
Before surgery for BI or BII - Do vagotomy (severing of vagus nerve) & pyloroplasty (drainage) first.
Nursing Mgt:
1. Monitor NGT output or drainage immediately post op- bright red
a.) Immediately post op should be bright red
b.) Within 36- 48h – output is yellow green
c.) After 48h – output is dark red due to HCl acid
2. Administer meds:
a.) Analgesic
b.) Antibiotic
c.) Antiemetics
3. Maintain patent IV line
4. VS, I&O & bowel sounds
5. Complications:
a.) Hemorrhage – hypovolemic shock
Late signs – anuria
b.) Peritonitis
c.) Paralytic ileus – most feared
d.) Hypokalemia
e.) Thrombophlebitis
f.) Pernicious anemia
g.) Septicemia
Nursing mgt:
1. Avoid fluids in chilled solutions, sweets
(fluids must be taken after meals)
2. Small frequent feedings-6 equally divided feedings
3. Diet – decrease CHO, moderate fats & CHON
4. Flat on bed 15 -30 minutes after q feeding
DIVERTICULITIS/DIVERTICULOSIS
1. Diverticulum- an outpouching of the intestinal mucosa particularly the sigmoid colon
2. Diverticulosis- multiple diverticulum
3. Diverticulitis- inflammation of diverticula
A. Predisposing Factors
1. High Risk Groups- men (40-45yo)
2. Congenital weakness of muscle fibers of the intestine.
3. Low roughage and fiber in the diet
S/S:
1. Intermittent lower left abdominal quadrant pain, particularly in the rectosigmoid area
2. tenderness
3. alternating bouts of constipation or diarrhea with blood or mucous
Dx:
1. Barium enema—reveals inflammatory process
2. CBC reveals: decreased hematocrit and hemoglobin
Nsg Mgt:
1. Administer meds as ordered:
a. antibiotics
b. bulk laxatives
c. stool softeners
d. anti spasmodic agents
2. Instruct clients to take foods high in fiber if there is diverticulosis
3. Monitor for signs of infection
Feared complications: Peritonitis
4. Assists in surgical procedure
Resection of the diseased bowel and creation of a colostomy
Function:
1. Produces bile
Bile – emulsifies fats—H2O and bile salts= cholesterol
Right sided pain: Cholelithiasis- easy bruising
Left sided pain: Pancreatitis
- Composed of H2O & bile salts
-Gives color to urine – urobilin
Stool color – stechobilin
2. Detoxifies drugs
3. Promotes synthesis of vit A, D, E, K - fat soluble vitamins (needs fat for absorption)
LIVER CIRRHOSIS - lost of architectural design of liver leading to fat necrosis & scarring
Laennac Cirrhosis- loss of architectural design of the liver leading to fat necrosis and scarring
Early sign – hepatic encephalopathy – accumulation of ammonia and other toxic substance in the blood
1. Asterixis – flapping hand tremors
Late signs – headache, restlessness, disorientation, decrease LOC – hepatic coma.
Nursing priority – assist in mechanical ventilation
Predisposing factor:
Decrease Laennac‘s cirrhosis – caused by alcoholism
1. Chronic alcoholism- major cause
2. Malnutrition – decreaseVit B, thiamin - primary cause
3. Virus –
4. Toxicity- eg. Carbon tetrachloride (CCL4)
5. Use of hepatotoxic agents
S/Sx:
1. Early signs:
a.) Weakness, fatigue
b.) Anorexia, n/v
c.) Stomatitis
d.) Urine – tea color
Stool – clay color
e.) Amenorrhea
f.) Decrease sexual urge
g.) Loss of pubic, axilla hair
h.) Hepatomegaly
i.) Jaundice
j.) Pruritus or urticaria (palmar erythema)
k.) Decrease bowel sounds
2. Late signs
a.) Hematological changes – all blood cells decrease
Leukopenia- decrease
Thrombocytopenia- bleeding tendencies
Anemia- decrease
b.) Endocrine changes
Spider angiomas, Gynecomastia
Caput medusae, Palmar erythema, loss of tortousity of the umbilicus
Hepatic coma
Diagnosis:
1. Liver enzymes- increase
SGPT (ALT)
SGOT (AST)
2. Serum cholesterol & ammonia increase
3. Indirect or conjugated bilirubin increase
4. CBC - pancytopenia
5. PTT – prolonged bleeding
6. Hepatic ultrasonogram – fat necrosis of liver globules
Nursing Mgt
1. CBR
2. Restrict Na!
3. Monitor VS, I&O
4. Weigh pt daily & assess pitting edema
5. Measure abdominal girth daily – notify MD
6. Meticulous skin care
7. Diet – increase CHO, vit & minerals. Moderate fats. Decrease CHON
Well balanced diet
8. Complications of liver cirrhosis:
a.) Ascites – fluid in peritoneal cavity
Nursing Mgt:
1. Meds: Loop diuretics – 10 – 15 min effect or potassium sparing diuretic
2. Assist in abdominal paracentesis - aspiration of fluid
- Void before paracentesis to prevent accidental puncture of bladder as trochar is inserted
Kernicterus/ hyperbilirubinia
Hepatitis A
Hepatitis A virus (HAV) is a virus that causes liver disease. Incubation is about 30 days, and the virus is excreted in the
stool for about 2 weeks before the illness and about a week after it. The mortality rate is low. Children are typically
asymptomatic. Adults generally have a more severe illness. The disease is not chronic and is not ―carried‖: FECAL ORAL
TRANSMISSION
INFECTION CONTROL
Hand hygiene to prevent the spread of HAV.
Vaccine before traveling to places where HAV is endemic.
Standard precautions, when caring for this client.
Contact precautions, for incontinent clients (cannot control bladder/bowel).
Hepatitis B
Hepatitis B (HBV) is one of the five hepatitis viruses that infect the liver. This virus has a complex structure capable of
attacking and destroying liver cells, resulting in illness or disease. Cellular destruction results in architectural changes of
the normal structure, of the liver which leads to a disruption in the flow of blood and bile. Illness can range from mild signs
and symptoms to chronic disease, such as fatal cirrhosis or liver cancer. BLOOD CARRIER
Pancreas – mixed gland (exocrine & endocrine gland); found behind the stomach
PANCREATITIS – acute or chronic inflammation of pancreas leading to pancreatic edema, hemorrhage & necrosis due to
auto digestion (self-digestion).
Bleeding of pancreas - Cullen’s sign on umbilical area
Predisposing factors:
1. Chronic alcoholism
2. Hepatobilary disease
3. Obesity
4. Hyperlipidemia
5. Hyperparathyroidism
6. Drugs – Thiazide diuretics,aspirin, pills, Pentamidine HCL (Pentam) for clients with AIDS,
7. Diet – increase saturated fats
S/Sx:
1. Severe Midepigastrium epigastric pain – radiates from back & flank area (left upper quadrant)
- 24-48 hrs. Aggravated by heavy meals/eating, accompanied by DOB
2. N/V
3. Tachycardia
4. Palpitation due to pain (abdominal guarding)
5. Dyspepsia /indigestion (rigid board like abdomen)
6. Decrease bowel sounds
7. (+) Cullen’s sign - ecchymosis of umbilicus hemorrhage
8. (+) Grey Turner’s spots – ecchymosis of flank area
9. Hypocalcemia
Diagnosis:
1. Serum amylase & lipase – increase
2. Urine lipase – increase
3. Serum Ca – decrease
Nursing Mgt:
1. Meds
a.) Narcotic analgesic - Meperidine Hcl (Demerol)
Don‘t give Morphine SO4 –will cause spasm of the sphincter of ODDI.
b.) Smooth muscle relaxant/ anticholinergic
- Ex. Papavarine Hcl
Prophantheline Bromide (Profanthene)
c.) Vasodilator – NTG
d.) Antacid – Maalox
e.) H2 receptor antagonist - Ranitidin (Zantac) to decrease pancreatic stimulation
f.) Ca – gluconate
S/Sx:
1. Severe Right abdominal pain (after eating fatty food). Occurring especially at night
= epigastric or right abdominal quadrant after eating a heavy meal
2. Fat intolerance
3. Anorexia, n/v, feeling of fullness
4. Jaundice
5. Pruritus
6. Easy bruising
7. Tea colored urine
8. Steatorrhea
Diagnosis:
1. Oral cholecystogram (or gallbladder series) - confirms presence of gall stones
2. Increased indirect bilirubin
3. Increased alkaline phosphatase
4. increased serum and amylase
Nursing Mgt:
1. Meds – a.) Narcotic analgesic - Meperdipine Hcl – Demerol
b.) Anti cholinergic/Anti-spasmodic - Atropine SO4
c.) Anti emetic
Phenergan – Phenothiazide with anti emetic properties
d) Broad spectrum antibiotics
2. Diet – increase CHO, moderate CHON, decrease fats
3. Meticulous skin care
4. Surgery: Cholecystectomy
Nursing Mgt post cholecystectomy
-Maintain patency of T-tube intact & prevent infection
Cells
1. Chief/ Zymogenic cells – secrets
a.) Gastric amylase - digest CHO / sugars
b.) Gastric lipase – digest fats
c.) Pepsin – CHON
d.) Rennin – digests milk products
2. Parietal / Argentaffin / oxyntic cells
Function:
a.) Produces intrinsic factor – promotes reabsorption of vit B12 cyanocobalamin – promotes maturation of
RBC
b.) Secrets Hcl acid – aids in digestion
3. Endocrine cells - Secretes gastrin – increase Hcl acid secretion
BURNS – direct tissue injury caused by thermal, electric, chemical & smoke inhaled (TECS)
Nursing Priority – infection (all kinds of burns)
Head burn-priority - Airway
nd st nd
2 priority for 1 & 2 burn - pain
nd rd
2 priority for 3 burn - Fluid and electrolytes
Stages:
Emergent phase – Removal of pt from cause of burn. Determine source or location of burn
Shock phase – 48 - 72 . Characterized by shifting of fluids from intravascular to interstitial space (Hypovolemia)
S/Sx:
- BP decrease
- Urine output
- HR increase
- Hct. increase
- Serum Na decrease
- Serum K increase
- Met acidosis
Diuretic/ Fluid remobilization phase - 3 to 5 days. Return of fluid from interstitial to intravascular space
Recovery/ convalescent phase – complete diuresis. Wound healing starts immediately after tissue injury.
Class:
I. Partial Burn
st
1. 1 degree – superficial burns
- Affects epidermis
- Cause: thermal burn
- Painful
- Redness (erythema) & blanching upon pressure
with no fluid filled vesicles
nd
2. 2 degree – deep burns
- Affects epidermis & dermis
- Cause –chem. burns
- very painful
- Erythema & fluid filled vesicles (blisters)
Assessment findings:
Rule of nines
Head & neck = 9%
Ant chest = 18%
Post chest = 18%
@ Arm 9+9 = 18%
@ leg 18+18 = 18%
Genitalia/ perineum = 1%
Total 100%
Nursing Mgt:
1. Meds
a.) Tetanus toxoid- burn surface area is source of anaerobic growth – Claustridium tetany
Tetany
Tetanolysin tetanospasmin
Parts:
1. Renal pelvis – Pyelonephritis – inflammation of the renal pelvis
2. Cortex
3. Medulla
Angiotensin II vasoconstrictor
Aldosterone
Increase BP
Increase Na &
H2O reabsorption
Hypervolemia
Color amber
Odor aromatic
Consistency clear or slightly turbid
pH 4.5 – 8
Specific gravity 1.015 – 1.030
WBC/ RBC (-)
Albumin (-)
E coli (-)
Mucus threads few
Amorphous urate (-)
Urethra – extends to external surface of body. Passage of urine, seminal & vaginal fluids.
- Women 3 – 5 cm or 1 to 1 ½ ―
- Male – 20cm or 8‖
UTI
CYSTITIS – inflammation of bladder
Predisposing factors:
1. Microbial invasion – E. coli
2. High risk – women
3. Obstruction
4. Urinary retention
5. Increase estrogen levels
6. Sexual intercourse
S/Sx: In the older adult, the most
1. Pain – flank area common signs & symptoms of
2. Urinary frequency & urgency cystitis or UTI:
1. Fatigue.
3. Burning upon urination 2. Change in cognitive status.
4. Dysuria & hematuria
5. Fever, chills, anorexia, gen body malaise
6. Nocturia
Diagnosis: Urine culture & sensitivity - 80% of the cases are (+) to E. coli
Nursing Mgt:
1. Force fluid – 2000 ml= to prevent bacterial multiplication
2. Warm sitz bath – to promote comfort
3. Monitor & assess for gross hematuria
4. Monitor and assess urine for color, odor, and bleeding N pH: 4.8
5. Acid ash diet – cranberry, vit C -OJ to acidify urine & prevent bacterial multiplication
6. Meds: systemic antibiotics
Ampicillin
Cephalosporin
Sulfonamides – cotrimoxazole (Bactrim)
- Gantrism (ganthanol)
Aminoglycosides: Gentamycin
Urinary antiseptics – Nitrofurantoin (Macrodantin)
Urinary analgesic- Pyridum
7. Ht
a.) Importance of Hydration
b.) Void after sex (male and female)
c.) Female – avoids cleaning back & front
Bubble bath, Tissue paper, Powder, perfume
d.) Complications: Pyelonephritis
PYELONEPHRITIS – acute/ chronic inflammation of 1 or 2 renal pelvis of kidneys leading to tubular destruction,
interstitial abscess formation.
- Lead to Renal Failure
Predisposing factor:
1. Microbial invasion (Bacterial)
a.) E. Coli
b.) Streptococcus
2. Urinary retention /obstruction
3. Pregnancy
4. DM
5. Exposure to renal toxins or nephrotoxic agents
S/Sx:
Acute pyelonephritis
a.) Costovertibral angle pain, tenderness
b.) Fever, anorexia, gen body malaise
c.) Urinary frequency, urgency
d.) Nocturia, dysuria, hematuria
e.) Burning upon urination
f.) FLANK PAIN
g.) Enlarged kidney
Chronic Pyelonephritis
a.) Fatigue, wt loss, weakness
b.) Polyuria, polydypsia
c.) HPN
Diagnosis:
1. Urine culture & sensitivity – (+) E. coli & streptococcus
2. Urinalysis
(+) WBC, (+)RBC, (+) Pus cells
3. Cystoscopic exam – urinary obstruction
Nursing Mgt:
1. Provide CBR – especially during acute phase
2. Force fluid
3. Acid ash diet
4. Provide a warm sitz bath for comfort
5. Meds:
a.) Urinary antiseptic – nitrofurantoin (macrodantin)
SE: peripheral neuropathy
GI irritation
Hemolytic anemia
Staining of teeth
b.) Urinary analgesic – Pyridium
6. Complication - Renal Failure
S/Sx:
1. Renal colic
2. Cool moist skin (shock)
3. Burning upon urination
4. Hematuria
5. Anorexia, n/v
Diagnosis:
1. IVP – intravenous pyelography. Reveals location of stone
2. KUB – reveals location of stone
3. Cytoscopic exam- urinary obstruction
4. Stone analysis – composition & type of stone
5. Urinalysis – increase EBC, increase CHON
6. X-ray
Nursing Mgt:
1. Force fluid
2. Strain urine using gauze pad
3. Warm sitz bath – for comfort
4. Alternate warm compress at flank area
5. a.) Narcotic analgesic- Morphine SO4
b.) Allopurinol (Zyeoprim)
c.) Patent IV line
d.) Diet – if + Ca stones – acid ash diet
If + oxalate stone – alkaline ash diet - (Ex milk/ milk products)
If + uric acid stones – decrease organ meat / anchovies sardines
6. Surgery
a.) Nephectomy – removal of affected kidney
Litholapoxy – removal of 1/3 of stones- Stones will recur. Not advised for pt with big stones
b.) Extracorporeal shock wave lithotripsy
- Non - invasive
- Dissolve stones by shock wave
7. Complications: Renal Failure
Predisposing factor:
1. High risk – 50 years old & above
60 – 70 – (3 to 4 x at risk)
Prostate cancer: 40 years old & above
2. Influence of male hormone
S/Sx:
1. Decrease force of and amount of urinary stream
2. Dysuria
3. Hematuria
4. Burning upon urination
5. Terminal dribbling—early sign of BPH
6. Backache
7. Sciatica
8. Hesitancy
Diagnosis:
1. Digital rectal exam – enlarged prostate gland
2. KUB – urinary obstruction
3. Cystoscopic exam – obstruction
4. Urinalysis – increase WBC, CHON, RBC
Nursing Mgt:
1. Prostatic message – promotes evacuation of prostatic fluid
2. Limit fluid intake
3. Provide catheterization
4. Provide a warm sitz bath for comfort
5. Meds:
a. Terazozine (hytrin) - Relaxes bladder sphincter, relaxes the smooth muscle of urinary sphincter
S/E: HA, hypotension
b. Fenasteride (Proscar) - Atrophy of Prostate Gland (given after meals)
S/E: N&V, Anorexia
5. Surgery: Prostatectomy – TURP- Transurethral resection of Prostate- No incision
Without incision: for debilitated clients
-Assist in cystoclysis or continuous bladder irrigation.
Complication:
1. Hemorrhage
2. Urinary obstruction
3. Penile dysfunction
Nursing mgt:
c. Monitor signs and symptoms of infection
d. Monitor symptoms gross/ frank bleeding. Normal bleeding within 24h.
3. Maintain irrigation or tube patent to flush out clots - to prevent bladder spasm & distention
ACUTE RENAL FAILURE – sudden immobility of kidneys to excrete nitrogenous waste products & maintain F&E
balance due to a decrease in GFR. (N 125 ml/min)
Predisposing factors:
Pre renal cause- decrease blood flow
Causes:
1. Septic shock
2. Hypovolemia
3. Hypotension decrease blood flow to the kidneys
4. CHF
5. Hemorrhage
6. Dehydration (chronic diarrhea)
Stages: Initiation period begins with the initial insult and ends when oliguria develops.
I. OLIGURIC STAGE (1-2 weeks)
- involves passage of urine < 400ml/day Increased serum concentration:
- S/S: Urea
Creatinine
a. Hyperkalemia- arrhythmia Uric acid
b. Hypernatremia Organic acids
c. Hyperphosphatemia Intra cellular cations
d. Hypocalcemia Potassium
e. High BUN 10-20 and creatinine .8-1 Magnesium
f. Metabolic acidosis 1-2wks
II. DIURETIC PHASE 2-3 weeks Increased amount of urine
a. Hypokalemia
b. Hyponatremia
c. Metabolic Acidosis
d. Increased Creatinine and BUN
Stages of CRF
1. Diminished Reserve Volume – asymptomatic
Normal BUN & Crea, GFR < 10 – 30%
2. Renal Insufficiency
3. End Stage Renal disease
S/Sx:
Nursing Mgt:
1. Enforce CBR, reverse isolation
2. Monitor strictly VS, I&O, neurocheck, monitor for signs of hypocalcemia (increased phosphate)
3. Meticulous skin care. Uremic frost – assist in bathing pt
4. Meds:
a.) Na HCO3 – due Hyperkalemia
b.) Kayexelate enema
c.) Anti HPN – Hydralazine (Apresoline)
d.) Vit & minerals (Multivitamins)
e.) Phosphate binder
(Amphogel) Al OH gel - S/E constipation
f.) Decrease Ca – Ca gluconate
5. Assist in hemodialysis
1.) Consent/ explain procedure
2.) Weigh patient
3.) Obtain baseline data & monitor VS before and during q30mins, I&O, wt, blood exam
4.) Encourage patient to void
5.) Strict aseptic technique
6.) Monitor for signs of complications:
B – bleeding (due to heparin)
E – embolism
D – disequilibrium syndrome
S – septicemia
S – shock – decrease in tissue perfusion
Disequilibrium syndrome – from rapid removal of urea & nitrogenous waste product leading to:
a.) n/v
b.) HPN
c.) Leg cramps
d.) Disorientation
e.) Paresthesia
5. Avoid BP taking, blood extraction, IV, at side of shunt or fistula. Can lead to compression of fistula.
6. Maintain patency of shunt by:
i. Palpate for thrills & auscultate for bruits if (+) patent shunt!
ii. Bedside- bulldog clip
If with accidental removal of fistula to prevent embolism.
Infersole (diastole) – common dialisate used
7. Complication
- Peritonitis (most feared)
- Shock
Inflow time: 10-20mins
Indwelling time: 30-45 mins
8. Assist in surgery:
Renal transplantation: Complication – rejection (feared complication). Reverse isolation
Rejection time in acute—6mos to 1 year
Rejection time in chronic—5-10 years
EYES
External parts
1. Orbital cavity – made up of connective tissue protects eye form trauma.
2. EOM – extrinsic ocular muscles – involuntary muscles of eye needed for gazing movement.
3. Eyelashes/ eyebrows – esthetic purposes
4. Eyelids – palpebral fissure – opening upper & lower lid. Protects eye from direct sunlight
Process of grieving
a. Denial
b. Anger
c. Bargaining
d. Depression
e. Acceptance
Intrinsic coat
I. sclerotic coat – outer most
a.) Sclera – white. Occupies ¾ post of eye. Refracts light rays
b.) Canal of schlera – site of aqueous humor drainage
c.) Cornea – transparent structure of eye
No auto receptors
ERROR of refraction
1. Myopia – near sightedness – Treatment: biconcave lens
2. Hyperopia/ or farsightedness – Treatment: biconvex lens
3. Astigmatisim – distorted vision – Treatment: cylindrical
4. Presbyopia – ―old slight‖ – inelasticity of lens due to aging – Treatment: bifocal lens or double vista
Accommodation of lenses – based on Helmholtz theory of accommodation
Type:
1. Chronic – (open angle G.) – most common type Obstruct in flow of aqueous humor at trabecular meshwork of
canal of schlema
2. Acute (close angle G.) – Most dangerous type Forward displacement of iris to cornea leading to blindness.
3. Chronic (closed – angle) - Precipitated by acute attack
S/Sx:
1. Loss of peripheral vision – tunnel vision
2. Halos around lights
3. Headache
4. n/v
5. Steamy cornea
6. Eye discomfort
7. If untreated – gradual loss of central vision – blindness
Diagnosis:
1. Tonometry – increase IOP >12- 21 mmHg
2. Perimetry – decrease peripheral vision
3. Gonioscopy – abstruction in anterior chamber
Nursing mgt:
1. Enforce CBR
2. Maintain siderails
3. Administer meds
a.) Miotics – lifetime - contracts ciliary muscles & constricts pupil. Ex Pilocarpine Na (Carbachol)
b.) Epinephrine eye drops – decrease secretion of aqueous humor
c.) Carbonic anhydrase inhibitors. Ex. Acetazolamide (Diamox)
- Promotes increase out flow of aquaeous humor
d.) Temoptics (Timolol maleate)- Increase outflow of aquaous humor
4. Surgery:
Invasive:
a.) Trabeculectomy – eyetrephining – removal of trabelar meshwork of canal or schlera to drain aqueous
humor
b.) Peripheral Iridectomy – portion of iris is excised to drain aqueous humor
Non-invasive:
Trabeculoctomy (eye laser surgery)
S/Sx:
1. Loss of central vision - ―Hazy or blurring of vision‖
2. Painless blurry vision
3. Milky white appearance at center of pupil
4. Decrease perception of colors
5. Diplopia
Nsg Mgt:
4. Surgery
E – extra
C - capsular
C – cataract partial removal of lens
L - lens
E – extraction
I - intra
C - capsular
C – cataract total removal of lens & surrounding capsules
L - lens
E – extraction
Nursing Mgt:
S/Sx:
1. ―Curtain –veil‖ like vision
2. Flashes of lights
3. Floaters
4. Gradual decrease in central vision
5. Headache
6. Cobwebs
Parts:
1. Outer-
a.) Pinna / auricle – protects ear from direct trauma
b.) Ext. auditory meatus – has ceruminous gland. Cerumen
c.) Tympanic membrane – transmits sound waves to middle ear
1. Hammer -malleus
2. Anvil -Incus for bone conduction disorder conductive hearing loss
3. Stirrups -stapes
c. Muscles
1. Stapedius
2. Tensor tympani
3. Inner ear
a. Bony labyrinth – for balance, vestibule
Surgery
Stapedectomy – removal of stapes, spongy bone & implantation of graft/ ear prosthesis
Predisposing factor:
1. Familiar tendency
2. Ear trauma & surgery
S/Sx:
1. Tinnitus
2. Conductive hearing loss
Diagnosis:
1. Audiometry – various sound stimulates (+) conductive hearing loss
2. Weber‘s test – Normal AC> BC
result BC > AC
Stapedectomy
Nursing Mgt post op
1. Position pt unaffected side
2. DBE
No coughing & blowing of nose
- Night lead to removal of graft
3. Meds:
a.) Analgesic
b.) Antiemetic
c.) Antimotion sickness agent. Ex. meclesine Hcl (Bonamine)
4. Assess – motor function – facial nerve - (Smile, frown, raise eyebrow)
5. Avoid shampoo hair for 1 to 2 weeks. Use shower cap
S/Sx:
1. TRIAD symptoms of Meniere’s disease
a.) Tinnitus
b.) Vertigo
c.) Sensory neural hearing loss
2. Nystagmus
3. n/v
4. Mild apprehension, anxiety
5. Tachycardia
6. Palpitations
7. Diaphoresis
Diagnosis:
1. Audiometry – (+) sensory hearing loss
Nursing mgt:
1. Comfy & darkened environment
2. Siderails
3. Emetic basin
4. Meds:
a.) Diuretics –to remove endolymph
b.) Vasodilator
c.) Antihistamine
d.) Antiemetic
e.) Antimotion sickness agent
f.) Sedatives/ tranquilizers
5. Restrict Na
6. Limit fluid intake
7. Avoid smoking
8. Surgery – endolymphatic sac decompression - Shunt
OTITIS MEDIA – Inflammation of the middle ear. (last less than 6 wks)
Sign and symptoms:
Pain
Temporary hearing loss
Tugging at the affected ear
Difficulty sleeping
Draining fluid / pus
Frequent pulling of the ear (children)
Fever
Nursing management:
Usually self limiting and resolved spontaneously
Antibiotic
Drainage (lean on the affected side to facilitate drainage)
Complication:
Hearing loss
Mastoiditis
Delayed speech and language development
Perforation of the TM
OTHER MNEMONICS
IV NOTES
Clindamycin, KCl===NOT for IV push—it may cause arrhythmia
Chloramphenicol===NOT for IM
Procaine, Penicillin, Benzatine, Pen G, Vancomycin HCl, Acyclovir (Zovirax) ===NOT for IV
Not to be diluted in LR
Penicillin G
Ampicillin
Cephalosporin
NaHCO3
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.
35. CHOLECYSTITIS - Murphy’s sign (pain on deep inspiration, a inflammation of the gallbladder
ATHEROSCLEROSIS ARTERIOSCLEROSIS
- narrowing of artery - hardening of artery, thicken
- lipid or fat deposits (plaques) - calcium and protein deposits
- tunica intima - tunica media
THE 5 MOST COMMON DRUG GIVEN IN BOARD EXAM: D.L.A.D.A MAJIC 2’s
TOXICITY
DRUG NORMAL RANGE INDICATION CLASSIFICATION
LEVEL
Digoxin/ Lanoxin
(Increase force of .5 – 1.5 meq/L 2 CHF Cardiac Glycoside
cardiac output)
Lithium/ Lithane
(Decrease level of .6 – 1.2 meq/L 2 Bipolar Anti-Manic Agents
Ach/NE/Serotonin)
Aminophylline
10 – 19 mg/100 ml 20 COPD Bronchodilators
(Dilates bronchial tree)
Dilantin/ Phenytoin 10 – 19 mg/100 ml 20 Seizures Anti-Convulsant
Acetaminophen/Tylenol 10 – 30 mg/100 ml 200 Osteoarthritis Non-narcotic Analgesic
PITUITARY SECRETIONS
Anterior pituitary Posterior pituitary
ADH GH
OXYTOCIN ACTH
TSH
FSH & LH
PROLACTIN
MSH JESUS
EVERY TIME I SAY JESUS
I wish to offer to GOD the infinite
merits of Jesus Christ, His passion and
death, with all the masses being said all
over the world for:
(a) The glory of GOD, (b) my own
intentions, (c) the peace of the World.