Medical Surgical Nursing With Mnemonics

FOCUS!
AND AIM HIGH WITH GOD
Graphics & Edited By:
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
AUTONOMIC NERVOUS SYSTEM

Sympathetic Nervous System Parasympathetic Nervous System
(ADRENERGIC) (CHOLINERGIC, VAGAL, SYMPATHOLYTIC)
- Involved in fight or aggression response. - Involved in fight or withdrawal response.
- Release of Norepinephrine (cathecolamines) - Release of Acetylcholine.
from adrenal glands and causes - vasodilation bronchoconstriction
vasoconstriction.
- Increase all bodily activity except GIT - Decreases all bodily activities except GIT.
EFFECTS OF SNS EFFECTS OF PNS

- Dilation of pupils(mydriasis) in order to be aware. - Constriction of pupils (meiosis).
- Dry mouth (thickened saliva). - Increase salivation.
- Increase BP and Heart Rate. - Decrease BP and Heart Rate.
- Bronchodilation, Increase RR - Bronchoconstriction, Decrease RR.
- Constipation. - Diarrhea
- Urinary Retention. FLUID VOLUME EXCESS - Urinary frequency. FLUID VOLUME DEF.
- Increase blood supply to brain, heart and skeletal - antihypertension
muscles.
- SNS
I. Adrenergic Agents I. Cholinergic Agents

- Give Epinephrine. [ADRENALIN] - Mestinon, Neostigmine.
Signs and Symptoms: Side Effects
- SNS - PNS
Contraindication:
- Contraindicated to patients suffering from COPD
(Broncholitis, Bronchoectasis, Emphysema, Asthma).
II. Anti-cholinergic Agents II. Beta-adrenergic Blocking Agents

- To counter cholinergic agents. - Also called Beta-blockers.
- Atropine Sulfate – decreased mucus production - All ending with ―lol‖
Side Effects - Propranolol [Inderal], Atenelol, Metoprolol.
- SNS
Antipsychotics: Effects of Beta-blockers
 Haloperidol [Haldol], chlorpromazine B – roncho spasm
 Thorazine, etc. E – licits a decrease in myocardial contraction.
Side effect of THORAZINE: atopic T – reats hypertension.
dermatitis and foul smelling odor. A – V conduction slows down.
Side effect of all antipsychotic: signs of  Should be given to patients with Angina
PARKINSON‘S DISEASE, therefore Pectoris, Myocardial Infarction, and
antipsychotic are given together with Hypertension.
antiparkinson drugs
Anti-parkinson drugs: ANTI- HYPERTENSIVE AGENTS
 C.A.P.A.B.L.E.S 1. Beta-blockers – ―lol‖
2. Ace Inhibitors – Angiotensin, ―pril‖ (Captopril,
Enalapril)
3. Calcium Antagonist – Nifedipine (Calcibloc)
 In chronic cases of arrhythmia give
Lidocaine(Xylocaine)
CENTRAL NERVOUS SYSTEM
Brain and Spinal Cord.
[Spinal cord terminates at L1 to L2 therefore a LUMBAR TAP is performed at L3 , L4 or L5 no risk for
spinal cord damage]
I. CELLS
A. NEURONS
Basic cells for nerve impulse and conduction.
PROPERTIES
Excitability – ability of neuron to be affected by changes in external environment.
Conductivity – ability of neuron to transmit a wave of excitation from one cell to another.
Permanent Cell – once destroyed not capable of regeneration.
TYPES OF CELLS BASED ON REGENERATIVE CAPACITY

1. Labile
Capable of regeneration.
Epidermal cells, GIT cells, GUT cells, cells of lungs.
2. Stable
Capable of regeneration with limited time, survival period.
Kidney cells, Liver cells, salivary cells, pancreas.
3. Permanent
Not capable of regeneration.
Myocardial cells, Neurons, Bone cells, Osteocytes, Retinal Cells.
B. NEUROGLIA
 Support and protection of neurons.
TYPES
1. Astrocytes – maintains blood brain barrier semi-permeable.
 Majority of brain tumors (90%) arises from called astrocytoma.
2. Oligodendria Produces myelin sheath in CNS. Act as insulator and facilitates rapid nerve impulse transmission
3. Microglia
4. Epindymal
SUBSTANCES THAT CAN PASS THE BLOOD-BRAIN BARRIER

1. Ammonia
 Cerebral toxin
 Hepatic Encephalopathy (Liver Cirrhosis)
 Ascites
 Esophageal Varices
Early Signs of Hepatic Encephalopathy
 asterixis (flapping hand tremors).
Late Signs of Hepatic Encephalopathy
 Headache
 Dizziness
 Confusion
 Fetor hepaticus (ammonia like breath)
 Decrease LOC [hepatic coma]
[AIRWAY FOR HEPATIC COMA]
2. Carbon Monoxide and Lead Poisoning
 Can lead to Parkinson’s disease.
[PILL ROLLING TREMORS]
 Epilepsy
 Treat with ANTIDOTE: Calcium EDTA
For Lead poisoning
Hyperbaric oxygenation (100% O2)
For carbon monoxide poisoning
PATHOGNOMONIC SIGNS
1. PTB - Low-grade afternoon fever.
2. PNEUMONIA - Rusty sputum.

3. ASTHMA - Wheezing on expiration.
4. EMPHYSEMA - Barrel chest.
5. KAWASAKI DISEASE - Strawberry tongue.
6. PERNICIOUS ANEMIA - Red beefy tongue.
7. DOWN SYNDROME - Protruding tongue / semian crease on palm
8. CHOLERA - Rice watery stool.
9. MALARIA - Stepladder like fever and chills.
10. TYPHOID - Rose spots in abdomen.

11. DIPTHERIA - pseudo membrane formation (pharynx, tonsils, nasal)
12. MEASLES - Koplik’s spots.
13. SLE - Butterfly rashes.
14. LIVER CIRRHOSIS - spider angioma, due to esophageal varices

15. LEPROSY - lioning face
16. BULIMIA NERVOSA - Chipmunk face. Parotid gland swelling
17. APPENDICITIS. - rebound tenderness
18. DENGUE - petechiae or (+) Herman’s sign
19. MENINGITIS - Kernig’s sign (leg pain), Brudzinski sign (neck pain).
20. TETANY - HYPOCALCEMIA (+) Trousseau’s sign/carpopedal spasm; Chvostek sign (facial spasm).
21. TETANUS - risus sardonicus.
22. PANCREATITIS - Cullen’s sign (ecchymosis of umbilicus); (+) Grey turners spots.
23. PYLORIC STENOSIS - olive SHAPE mass on the abdomen

24. PDA - machine like murmur
25. ADDISON’S DISEASE - Bronze like skin pigmentation.
26. CUSHING’S SYNDROME - Moon face appearance and buffalo hump.
27. HYPERTHYROIDISM/GRAVE’S DISEASE - Exopthalmus
28. INTUSSUSCEPTION - sausage shaped mass
29. PARKINSON’S DISEASE - Pill rolling tremors
30. HEPATITIS - Jaundice

31. THROMBOPHEBITIS - Homan’s sign
32. CATARACT - Hazy vision / loss of central vision
33. GLAUCOMA - Tunnel vision / loss of peripheral vision

34. RETINAL DETACHMENT - Curtain veil-like vision / flashes and floaters
35. CHOLECYSTITIS - Murphy’s sign (pain on deep inspiration, a inflammation of the gallbladder
36. ANGINA PECTORIS - Levine’s sign [hand clutching in the chest]

37. MYASTHENIA GRAVIS - Ptosis [drooping of the upper eyelid]
38. TETRALOGY OF FALLOT - Clubbing of fingers
3. Type 1 DM (IDDM) [KETONES]

 Causes diabetic ketoacidosis.
 And increases breakdown of fats.
 And free fatty acids
 Resulting to cholesterol and (+) to Ketones (CNS depressant).
 Resulting to acetone breath odor/fruity odor.
 KUSSMAUL’S respiration, a rapid shallow respiration.
 This may lead to diabetic coma.
4. Hepatitis
 Signs of jaundice (icteric sclerae).
 Caused by bilirubin (yellow pigment)
5. Bilirubin
 Increase bilirubin in brain (Kernicterus).
 Causing irreversible brain damage.
DEMYELINATING DISORDERS
1. ALZHEIMER’S DISEASE
 Atrophy of brain tissues. Progressive, irreversible, degenerative neurologic disease characterized by
gradual losses of cognitive fx. And disturbances in behavior and affect.
Sign and Symptoms
4 A’s of Alzheimer
a. Amnesia – partial or total loss of memory.
b. Agnosia – no recognition of inanimate objects.
c. Apraxia – no recognition of objects function.
d. Aphasia – no speech (nodding).
*Expressive aphasia (Broca‘s Aphasia) frontal lobe
 ―motor speech center‖
 Nursing mgt. provide PICTURE BOARD
*Receptive aphasia (Wernicke‘s Aphasia) temporal lobe
 Inability to understand spoken words.
 Irrational thoughts/illogical
 General Knowing Gnostic Area or General Interpretative Area.
DRUG OF CHOICE: ARICEPT (taken at bedtime) and COGNEX. [increasing acetylcholine]
2. MULTIPLE SCLEROSIS [Autoimmune process]

 Chronic intermittent disorder of CNS characterized by white patches of demyelination in brain and spinal cord.
 Characterized by remission and exacerbation.
 Women ages 15-35 are prone
 Unknown Cause
 Slow growing virus
 Autoimmune disorders
 Pernicious anemia
 Myasthenia gravis
 Lupus
 Hypothyroidism
 GBS
Ig G – only antibody that pass placental

circulation causing passive immunity.
- Short term protection.
- Immediate action.
Ig A – present in all bodily secretions
(tears, saliva, colostrums).
Ig M – acute in inflammation.
Ig E – for allergic reaction.
Ig D – for chronic inflammation.
* Give palliative or supportive care.

Signs and Symptoms
1. Visual disturbances
 blurring of vision (primary)
 Diplopia (double vision)
 scotomas (blind spots)
2. Impaired sensation
 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
Intentional tremors Nystagmus
6. Urinary retention/incontinence
7. Constipation
8. Decrease sexual capacity
DIAGNOSTIC PROCEDURE
 CSF analysis (increase in IgG and Protein).
 MRI (reveals site and extent of demyelination).
 (+) Lhermitte’s sign a continuous and increase contraction of spinal column/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.)
NEURO TRANSMITTER DECREASE INCREASE

Acethylcholine Myasthenia Gravis Bi-polar Disorder
Dopamine Parkinson’s Disease Schizophrenia
3. MIDBRAIN/ MESENCEPHALON
 acts as relay station for sight and hearing.
 size of pupil is 2 – 3 mm.
 equal size of pupil is isocoria.
 unequal size of pupil is anisocoria.
 hearing acuity is 30 – 40 dB.
 positive PERRLA [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
Monroe Kellie Hypothesis
Skull is a closed container
Any alteration or increase in one of the intracranial components
Increase intra-cranial pressure

(normal ICP is 0 – 15 mmHg)
Cervical 1 – also known as ATLAS.

Cervical 2 – also known as AXIS.
Foramen Magnum
Medulla Oblongata
Brain Herniation
Increase intra cranial pressure

* Alternate hot and cold compress to prevent HEMATOMA
 CSF cushions brain (shock absorber)
 Obstruction of flow of CSF will lead to enlargement of skull posteriorly called hydrocephalus.
 Early closure of posterior fontanels causes posterior enlargement of skull in hydrocephalus.
NEUROLOGIC DISORDERS
INCREASE INTRACRANIAL PRESSURE – increase in intra-cranial bulk brought about by an increase in one of the 3
major intra cranial components. 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.
7. Administer medications like:

a. Osmotic diuretic (Mannitol)
for cerebral diuresis
Nursing Management
monitor vital signs especially BP (hypotension).
monitor strictly input and output every 1 hour notify physician if output is less 30 cc/hr.
administered via side drip
Regulated fast drip to prevent crystal formation.
b. Loop diuretic (Lasix, Furosemide)
 Drug of choice for CHF (pulmonary edema)
 Loop of Henle in kidneys.
Nursing Management
 Monitor vital signs especially BP (hypotension).
 monitor strictly input and output every 1 hour notify physician if output is less 30 cc/hr.
 Administered IV push or oral.
 given early morning
 Immediate effect of 10 – 15 minutes.
 maximum effect of 6 hours. [monitor for potassium depletion]
c. Corticosteroids
 Dexamethasone (Decadron)
 Hydrocortisone
 Prednisone (to reduce edema that may lead to increase ICP)
 Mild Analgesics (Codeine Sulfate for respiratory depression)
 Anti Convulsants (Dilantin, Phenytoin)
*CONGESTIVE HEART FAILURE

Signs and Symptoms
 dyspnea
 orthopnea
 paroxysmal nocturnal dyspnea
 productive cough
 frothy salivation
 cyanosis
 rales/crackles
 bronchial wheezing
 pulsus alternans
 anorexia and general body malaise
 PMI (point of maximum impulse/apical pulse rate) is displaced laterally
 S3 (ventricular gallop)
 Predisposing Factors/Mitral Valve
 RHD
 Aging
TREATMENT
Morphine Sulfate
Aminophelline
Digoxin
Diuretics
Oxygen
Gases, blood monitor
RIGHT CONGESTIVE HEART FAILURE (Venous congestion)

Signs and Symptoms
 jugular vein distention (neck)
 ascites
 pitting edema
 weight gain
 hepatosplenomegaly
 jaundice
 pruritus
 esophageal varices
 anorexia and general body malaise
Signs and Symptoms of Lasix in terms of electrolyte imbalances

1. Hypokalemia
 decrease potassium level
 normal value is 3.4 – 5.5 meq/L
Sign and Symptoms
 weakness and fatigue
 constipation
 positive U wave on ECG tracing
Nursing Management
 administer potassium supplements as ordered (Kalium Durule, Oral Potassium Chloride)
 increase intake of foods rich in potassium
FRUITS VEGETABLES
Apple Asparagus
Banana Brocolli
Cantalope Carrots
Oranges Spinach
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
Magnesium Sulfate toxicity [B.U.R.P]

S/S
BP
Urine output DECREASE
Respiratory rate
Patellar relfex absent
3. Hyponatremia
 decrease sodium level
 normal value is 135 – 145 meq/L
Signs and Symptoms
 hypotension
 dehydration signs (Initial sign in adult is THIRST, in infant TACHYCARDIA)
 agitation
 dry mucous membrane
 poor skin turgor
 weakness and fatigue
Nursing Management
 force fluids
 administer isotonic fluid solution as ordered
4. Hyperglycemia
 normal FBS is 80 – 100 mg/dl
Signs and Symptoms - 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)
PARKINSON’S DISEASE/ PARKINSONISM

 Chronic progressive disorder of CNS
characterized by degeneration of dopamine producing cells in the
SUBSTANCIA NIGRA of the midbrain and basal ganglia.
Predisposing Factors
1. Poisoning (lead and carbon monoxide)
2. Arteriosclerosis
3. Hypoxia
4. Encephalitis
5. Increase dosage of the following drugs:
a. Reserpine(Serpasil)
b. Methyldopa(Aldomet) AntihypertensiveS
c. Haloperidol(Haldol)
d. Phenothiazine AntipsychoticS
SIDE EFFECTS RESERPINE  Major depression leading to suicide
Aloneness
Multiple loss
causes suicide
Loss of spouse Loss of Job
 direct approach towards the client

 close surveillance is a nursing priority
 time to commit suicide is on weekends early morning
Signs and Symptoms for Parkinson’s

 pill rolling tremors of extremities especially the hands.
 bradykinesia (slowness of movement)
 rigidity (cogwheel type)
 stooped posture
 shuffling and propulsive gait
 over fatigue
 mask like facial expression with decrease blinking of the eyes.
 difficulty rising from sitting position.
 Dysphonia – soft slurred Monotone type speech
 mood lability (in state of depression)
 Micrographia-shrinking slow handwriting
 increase salivation (drooling type)
 autonomic changes
a. increase sweating
b. increase lacrimation
c. seborrhea
d. constipation
e. decrease sexual capacity
Nursing Management
Anti Parkinsonian agents
 Levodopa (L-dopa) short acting
 Amantadine Hydrochloride (Symmetrel)
 Carbidopa (Sinemet)
Mechanism of Action
 increase level of dopamine
Side Effects
 GIT irritation (should be taken with meals
 orthostatic hypotension (CBQ)
 arrhythmia
 hallucinations
Contraindications
 clients with narrow angle closure glaucoma
 clients taking MAOI‘s (no foods with tryptophan and thiamine: cheese, beer, avocado, wine)
 urine and stool may be darkened
 no Vitamin B6 (Pyridoxine) reverses the therapeutic effects of Levodopa
* Increase Vitamin B when taking INH (Isoniazid), Isonicotinic Acid Hydrazide

Anti Cholinergic Agents (ARTANE and COGENTIN) - to relieve tremors
Mechanism of Action
 inhibits action of acethylcholine
Side Effects
 SNS
Anti Histamine (Dipenhydramine Hydrochloride)

Side Effects
Adult: drowsiness
Children: CNS excitement (hyperactivity) because blood brain barrier is not yet fully developed.
Dopamine Agonist - relieves tremor rigidity
Bromocriptene Hydrochloride (Parlodel)
Side Effects
 Respiratory depression
2. Maintain side rails to prevent injury
3. Prevent complications of immobility
4. Decrease protein in morning and increase protein in afternoon to induce sleep
5. Encourage increase fluid intake and fiber.
6. Assist/supervise in ambulation
7. Assist in Stereotaxic Thalamotomy –a portion of thalamus is destroyed to reduce tremors
MAGIC 2’s IN DRUG MONITORING [D.L.A.D.A]

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
Non-narcotic
Acetaminophen/Tylenol 10 – 30 mg/100 ml 200 Osteoarthritis
Analgesic
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
4. Dilantin phenytoin Toxicity

Signs and Symptoms
 gingival hyperplasia (swollen & tender gums)
 hairy tongue
 ataxia
 nystagmus
Nursing Management
 provide oral care
 massage gums
5. Acetaminophen Toxicity
Signs and Symptoms
 hepatotoxicity (monitor for liver enzymes)
 SGPT/ALT (Serum Glutamic Pyruvate Transaminace)
 SGOT/AST (Serum Glutamic Oxalo-Acetil Transaminace)
 nephrotoxicity monitor BUN (10 – 20) and Creatinine (.8 – 1)
 hypoglycemia
Tremors, tachycardia
Irritability
Restlessness
Extreme fatigue
Diaphoresis, depression
Antidote: Acetylcisteine (mucomyst) prepare suction apparatus 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
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
INFLAMMATORY CONDITIONS OF THE BRAIN

MENINGITIS
Meninges
 3 fold membrane that covers brain and spinal cord.
 for support and protection
 for nourishment
 blood supply
LAYERS OF THE MENINGES
1. Dura matter – outer layer
2. Arachnoid – middle layer
3. Pia matter – inner layer
 subdural space between the dura and arachnoid
 Subarachnoid space between the arachnoid and pia, CSF aspiration is done.
A. Etiology
1. Meningococcus – most dangerous
2. Pneumococcus
3. Streptococcus - causes adult meningitis
4. Hemophilus Influenzae – causes pediatric meningitis
B. Mode of transmission
 airborne transmission (droplet nuclei)
C. Signs and Symptoms
 headache
 photophobia
 projectile vomiting
 fever & chills, anorexia, 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)
CBC reveals notes on hematology: INCREASED DECREASED

1. Increase wbc RBC Polycythemia Anemia
WBC Leukocytosis Leukopenia

E. Nursing Management
PLATELETS Thrombocytosis Thrombocytopenia
1. Enforce complete bed rest
a. Broad spectrum antibiotics (Penicillin, Tetracycline)
b. Mild analgesics
c. Anti pyretics
3. Institute strict respiratory isolation 24 hours after initiation of anti biotic therapy
o
4. Elevate head 30-45
5. Monitor strictly V/S, input and output and neuro check
6. Institute measures to prevent increase ICP and seizure.
7. Provide a comfortable and darkened environment.
8. Maintain fluid and electrolyte balance.
9. Provide client health care and discharge planning concerning:
a. Maintain good diet of increase CHO, CHON, calories with small frequent feedings.
b. Prevent complications
 most feared is hydrocephalus
 hearing loss/nerve deafness is second complication
 consult audiologist
c. Rehabilitation for neurological deficit
 mental retardation
 delayed psychomotor development
CVA (STROKE/BRAIN ATTACK/ ADOPLEXY/ CEREBRAL THROMBOSIS)
 a partial or complete disruption in the brains blood supply.
 2 most common cerebral artery affected by stroke
a. Mid Cerebral Artery
b. Internal Cerebral Artery – the 2 largest artery
A. Incidence Rate
 men are 2-3 times high risk
B. Predisposing Factors
 thrombus (attached)
 embolus (detached and most dangerous because it can go to the lungs and cause pulmonary
embolism or the brain and cause cerebral embolism.
Signs and Symptoms of Pulmonary Embolism

 Sudden sharp chest pain
 Unexplained dyspnea
 Tachycardia
 Palpitations
 Diaphoresis
 Mild restlessness
Signs and Symptoms of Cerebral Embolism
 Headache and dizziness
 Confusion
 Restlessness
 Decrease LOC
 Fat embolism is the most feared complications after femur fracture.

 Yellow bone marrow are produced from the medullary cavity of the long bones and produces fat cells.
 If there is bone fracture there is hemorrhage and there would be escape of the fat cells in the circulation.
 Compartment syndrome (compression of arteries and nerves)
C. Risk Factors
1. Hypertension, Diabetes Mellitus, Myocardial Infarction, Atherosclerosis, Valvular Heart Disease, Post Cardiac Surgery
(mitral valve replacement)
2. Lifestyle (smoking), sedentary lifestyle
3. Obesity (increase 20% ideal body weight)
4. Hyperlipidemia more on genetics/genes that binds to cholesterol
5. Type A personality
a. deadline driven
b. can do multiple tasks
c. usually fells guilty when not doing anything
6. Related to diet: increase intake of saturated fats like whole milk
7. Related stress physical and emotional
8. Prolong use of oral contraceptives promotes lypolysis (breakdown of lipids) leading to atherosclerosis that will lead to
hypertension and eventually CVA.
D. Signs and Symptoms

 dependent on stages of development
1. TIA
 Initial sign of stroke or warning sign
Signs and Symptoms
 headache and dizziness
 tinnitus
 visual and speech disturbances
 paresis to plegia
 possible increase ICP
2. Stroke in evolution
-progression of signs and symptoms of stroke
3. Complete stroke
 resolution phase characterized by:
Signs and Symptoms
 headache and dizziness
 Cheyne Stokes Respiration
 anorexia, nausea and vomiting
 dysphagia
 (+) Kernig’s sign and Brudzinski sign
which may lead to hemorrhagic stroke
 focal neurological deficits Notes:
“Plegia” – paralysis
a. phlegia
Ex: Hemiplegia – paralysis of one side of
b. aphasia the body.
c. dysarthria (inability to articulate words) “Paresis” – weakness
d. alexia (difficulty reading) Ex: Hemiparesis - weakness of one side
of the body.
e. agraphia (difficulty writing)
f. homonymous hemianopsia (loss of half of visual field)
E. Diagnostic Procedure
1. CT Scan – reveals brain lesions
2. Cerebral Arteriography
 reveals the site and extent of malocclusion
 uses dye for visualization
 most of dye are iodine based
 check for shellfish allergy
 after diagnostic exam force fluids to release dye because it is nephro toxic
 check for distal pulse (femoral)
 check for hematoma formation
F. Nursing Management
1. Maintain patent airway and adequate ventilation by:
a. assist in mechanical ventilation
b. administrate O2 inhalation
2. Restrict fluids to prevent cerebral edema that might increase ICP
o
3. Elevate head 30 – 45
4. Monitor strictly vitals signs, I & O and neuro check
5. Prevent complications of immobility by:
a. turn client to side
b. provide egg crate mattresses or water bed
c. provide sand bag or foot board.
6. Assist in passive ROM exercise every 4 hours to promote proper bodily alignment and prevent contractures
7. Institute NGT feeding
8. Provide alternative means of communication
a. non verbal cues
b. magic slate
9. If positive to hemianopsia approach client on unaffected side
a. Osmotic Diuretics (Mannitol)
b. Loop Diuretics (Lasix, Furosemide)
c. Cortecosteroids
d. Mild Analgesics
e. Thrombolytic/Fibrinolytic Agents – dissolves thrombus
 Streptokinase
 Side Effect: Allergic Reaction
 Urokinase
 Tissue Plasminogen Activating Factor
 Side Effect: Chest Pain
f. Anti Coagulants
 Heparin (short acting)
 check for partial thromboplastin time if prolonged there is a risk for bleeding.
 give Protamine Sulfate
 Comadin/ Warfarin (long acting)
 give simultaneously because Coumadin will take effect after 3 days
 check for prothrombin time if prolonged there is a risk for bleeding
 give Vit. K (Aqua Mephyton)
g. Anti Platelet
 PASA (Aspirin)
 Contraindicated for dengue, ulcer and unknown cause of headache because it may potentiate
bleeding
11. Provide client health teachings and discharge planning concerning
a. avoidance of modifiable risk factors (diet, exercise, smoking)
b. prevent complication (subarachnoid hemorrhage is the most feared complication)
c. dietary modification (decrease salt, saturated fats and caffeine)
d. importance of follow up care
GUILLAIN BARRE SYNDROME (Acute Ediopathic Polyneuropathy)

 a disorder of the CNS characterized by bilateral symmetrical polyneuritis leading to ascending muscle
paralysis/weakness.
A. Predisposing Factors
1. Autoimmune
2. Antecedent viral infections such as LRT infections
B. Signs and Symptoms
1. Clumsiness (initial sign)
2. Dysphagia
3. Ascending muscle weakness leading to paralysis
4. Decreased of diminished deep tendon reflex
5. Alternate hypotension to hypertension
** ARRYTHMIA (most feared complication)
6. Autonomic symptoms that includes
a. increase salivation
b. increase sweating
c. constipation
C. Diagnostic Procedures
1. CSF analysis reveals increase in IgG and protein
D. Nursing Management
1. Maintain patent airway and adequate ventilation by:
a. assist in mechanical ventilation
b. monitor pulmonary function test
2. Monitor strictly the following
a. vital signs
b. intake and output
c. neuro check
d. ECG
3. Maintain side rails to prevent injury related to fall
4. Prevent complications of immobility by turning the client every 2 hours
5. Institute NGT feeding to prevent aspiration
6. Assist in passive ROM exercise
a. Corticosteroids – suppress immune response
b. Anti Cholinergic Agents – Atrophine Sulfate
c. Anti Arrythmic Agents
 Lidocaine, Zylocaine
 Bretylium – blocks release of norepinephrine to prevent increase of BP
8. Assist in plasma pharesis (filtering of blood to remove autoimmune anti-bodies)
a. Arrythmia
b. Paralysis or respiratory muscles / Respiratory arrest
* Sengstaken Blakemore Tube

 for liver cirrhosis
 to decompress bleeding esophageal verices (prepare scissor to cut tube incase of difficulty in breathing
to release air in the balloon
 for hemodialysis prepare bulldog clips to prevent air embolism.
CONVULSIVE DISORDER/ CONVULSION

 Disorder of CNS characterized by paroxysmal seizure with or without loss of consciousness abnormal
motor activity alternation in sensation and perception and changes in behavior.
 Seizure – first convulsive attack
 Epilepsy – second or series of attacks
 Febrile seizure – normal in children age below 5 years
1. Head injury due to birth trauma
2. Genetics
3. Presence of brain tumor
4. Toxicity from
a. lead
b carbon monoxide
5. Nutritional and Metabolic deficiencies
6. Physical and emotional stress
7. Sudden withdrawal to anti convulsant drug is predisposing factor for status epilepticus (drug of choice is Diazepam,
Valium)

 Dependent on stages of development or types of seizure
I. Generalized Seizure
1. Grand mal Seizure (tonic-clonic seizure)
a. Signs or aura with auditory, olfactory, visual, tactile, sensory experience
b. Epileptic cry – is characterized by fall and loss of consciousness for 3 – 5 minutes
c. Tonic contractions - direct symmetrical extension of extremities
Clonic contractions - contraction of extremities
d. Post ictal sleep – unresponsive sleep
2. Petit mal Seizure – absence of seizure common among pediatric clients characterized by
a. blank stare
b. decrease blinking of eyes
c. twitching of mouth
d. loss of consciousness (5 – 10 seconds)
II. Partial or Localized Seizure

1. Jacksonian Seizure (focal seizure)
 Characterized by tingling and jerky movement of index finger and thumb that spreads to the shoulder and other side
of the body.
2. Psychomotor Seizure (focal motor seizure)
a. automatism – stereotype repetitive and non propulsive behavior
b. clouding of consciousness – not in contact with environment
c. mild hallucinatory sensory experience
III. Status Epilepticus

 A continuous uninterrupted seizure activity, if left untreated can lead to hyperpyrexia and lead to coma
and eventually death.
 Drug of choice: Diazepam, Valium and Glucose
1. CT Scan – reveals brain lesions
2. EEG – reveals hyper activity of electrical brain waves
1. Maintain patent airway and promote safety before seizure activity
a. clear the site of blunt or sharp objects
b. loosen clothing of client
c. maintain side rails
d. avoid use of restrains
e. turn clients head to side to prevent aspiration
f. place mouth piece of tongue guard to prevent biting or tongue
2. Avoid precipitating stimulus such as bright/glaring lights and noise
a. Anti convulsants (Dilantin, Phenytoin)
b. Diazepam, Valium
c. Carbamazepine (Tegretol) – Trigeminal neuralgia
d. Phenobarbital, Luminal
4. Institute seizure and safety precaution post seizure attack
a. administer O2 inhalation
b. provide suction apparatus
5. Document and monitor the following
a. onset and duration
b. types of seizures
c. duration of post ictal sleep may lead to status epilepticus
d. assist in surgical procedure cortical resection
COMPREHENSIVE NEURO EXAM

GLASGOW COMA SCALE
 objective measurement of LOC sometimes called as the quick neuro check
Components
Conscious 15 – 14
1. Motor response
Lethargy 13 – 11
2. Verbal response
Stupor 10 – 8
3. Eye opening
Coma 7
Deep Coma 3
 Survey of mental status and speech

a. LOC
b. Test of memory
 Levels of orientation
 Cranial nerve assessment
 Sensory nerve assessment
 Motor nerve assessment
 Deep tendon reflex
 Autonimics
 Cerebellar test
a, Romberg‘s test – 2 nurses, positive for ataxia
b. Finger to nose test – positive result mean dimetria
(inability of body to stop movement at desired point)
c. Alternate supination and pronation – positive result mean dimetria
I. LEVEL OF CONSCIOUSNESS
1. Conscious - awake
2. Lethargy – lethargic (drowsy, sleepy, obtunded)
3. Stupor
 stuporous (awakened by vigorous stimulation)
 generalized body weakness
 decrease body reflex
4. Coma
 comatose
 light coma (positive to all forms of painful stimulus)
 deep coma (negative to all forms of painful stimulus)
DIFFERENT PAINFUL STIMULATION
1. Deep sternal stimulation/ deep sternal pressure
2. Orbital pressure
3. Pressure on great toes
4. Corneal or blinking reflex
 Conscious client use a wisp of cotton
 Unconscious client place 1 drop of saline solution
II. TEST OF MEMORY

1. Short term memory
 ask most recent activity
 positive result mean anterograde amnesia and damage to temporal lobe
2. Long term memory
 ask for birthday and validate on profile sheet
 positive result mean retrograde amnesia and damage to limbic system
 consider educational background
CRANIAL NERVES FUNCTION

III. LEVELS OF ORIENTATION
1. Time – first asked
I. OLFACTORY S
2. Person – second asked
II. OPTIC S
3. Place – third asked
III OCCULOMOTOR M
CRANIAL NERVES M
IV. TROCHLEAR
(Smallest)
CRANIAL NERVE I: OLFACTORY B

V. TRIGEMINAL
 sensory function for smell (Largest)
Material Used VI. ABDUCENSE M
 don‘t use alcohol, ammonia, perfume because it is irritating VII. FACIAL B
and highly diffusible. VIII. ACOUSTIC S

 use coffee granules, vinegar, bar of soap, cigarette IX. GLOSSOPHARYNGEAL B
Procedure B
X. VAGUS
 test each nostril by occluding each nostril (Longest)
Abnormal Findings XI. SPINAL ACCESSORY M
1. Hyposnia – decrease sensitivity to smell XII. HYPOGLOSSAL M
2. Dysosmia – distorted sense of smell
3. Anosmia – absence of smell
Indicative of
1. head injury damaging the cribriform plate of ethmoid bone where olfactory cells are located
2. may indicate inflammatory conditions (sinusitis)
CRANIAL NERVE II: OPTIC

 sensory function for vision or sight
Functions
1. Test visual acuity or central vision or distance
 use Snellen’s Chart
 Snellen‘s Alphabet chart: for literate clients
 Snellen‘s E chart: for illiterate clients
 Snellen‘s Animal chart: for pediatric clients
 normal visual acuity 20/20
 numerator is constant, it is the distance of person from the chart (6 – 7 m, 20 feet)
 denominator changes, indicates distance by which the person normally can see letter in the chart.
 - 20/200 indicates blindness
 20/20 visual acuity if client is able to read letters above the red line.
2. Test of visual field or peripheral vision
a. Superiorly
b. Bitemporaly
c. Nasally
d. Inferiorly
COMMON VISUAL DISORDERS

1. Glaucoma
 increase IOP
 normal IOP is 12 – 21 mmHg
 preventable but not curable
 Common among 40 years old and above
 Hereditary
 Hypertension
 Obesity
1. Loss of peripheral vision
 pathognomonic sign is tunnel vision
2. Headache, nausea, vomiting, eye pain (halos around light)
 steamy cornea
 may lead to blindness
1. Tonometry
2. Perimetry
3. Gonioscopy
D. Treatment
1. Miotics – constricts pupil
a. Pilocarpine Sodium, Carbachol
2. Epinephrine eyedrops – decrease formation of aqueous humor
3. Carbonic Anhydrase Inhibitors
a. Acetazolamide (Diamox) – promotes increase outflow of aqueous humor or drainage
4. Timoptics (Timolol Maleate)
E. Surgical Procedures
1. TRABECULECTOMY (Peripheral Indectomy) – drain aqueous humor
2. CATARACT
 Decrease opacity of lens
A. Predisposing Factor
1. Aging 65 years and above
2. Related to congenital
3. Diabetes Mellitus
4. Prolonged exposure to UV rays

1. Loss of central vision
C. Pathognomonic Signs
1. Blurring or hazy vision
2. Milky white appearance at center of pupils
3. Decrease perception to colors
 Complication is blindness
D. Diagnostic Procedure
1. Opthalmoscopic exam
E. Treatment
1. Mydriatics (Mydriacyl) – 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
1. Post Lens Extraction
2. Myopia (near sightedness)

1. Curtain veil like vision
2. Floaters
C. Surgical Procedures
1. Scleral Buckling
2. Cryosurgery – cold application
3. Diathermy – heat application
4. Macular Degeneration
 Degeneration of the macula lutea (yellowish spot at the center of retina)
A. Signs and Symptoms

1. Black Spots
CRANIAL NERVE III, IV, VI: OCULOMOTOR, TROCHLEAR, ABDUCENS A. normal retina
B. ―wet‖ macular degeneration
 Controls or innervates the movement of extrinsic ocular muscle (EOM) c. ―dry‖ macular degeneration
 6 muscles
Superior Rectus Superior Oblique
Lateral Rectus Medial Rectus
Inferior Oblique Inferior Rectus

 trochlear controls superior oblique
 abducens controls lateral rectus
 oculomotor controls the 4 remaining EOM
Oculomotor
 controls the size and response of pupil
 normal pupil size is 2 – 3 mm
 equal size of pupil: Isocoria
 Unequal size of pupil: Anisocoria
 Normal response: positive PERRLA
CRANIAL NERVE V: TRIGEMINAL

 largest cranial nerve
 consists of ophthalmic, maxillary, mandibular
 sensory: controls sensation of face, mucous membrane, teeth, soft palate and corneal reflex)
 motor: controls the muscle of mastication or chewing
 damage to CN V leads to trigeminal neuralgia/tic douloureux (nerve pain)
 medication: Carbamezapine(Tegretol) - anticonvulsant
CRANIAL NERVE VII: FACIAL

 Sensory: controls taste, anterior 2/3 of tongue
 pinch of sugar and cotton applicator placed on tip of tongue
 Motor: controls muscle of facial expression
 Instruct client to smile, frown and if results are negative there is facial paralysis or Bell‘s palsy and the
primary cause is forceps delivery.
CRANIAL NERVE VIII: ACOUSTIC/VESTIBULOCOCHLEAR

 Controls balance particularly kinesthesia or position sense, refers to movement and orientation of the
body in space.
Parts of the Ear
1. Outer Ear
 Pinna
 Eardrum
2. Middle Ear
 Hammer Malleus
 Anvil Incus
 Stirrup Stapes
3. Inner Ear
 Vestibule: Meinere’s Disease
 Cochlea
 Mastoid Cells
 Endolymph and Perilymph
 COCHLEA: controls hearing, contains the Organ of Corti (the true organ of hearing)
 Let client repeat words uttered
CRANIAL NERVE IX, X: GLOSOPHARYNGEAL, VAGUS NERVE

 Glosopharyngeal: controls taste, posterior 1/3 of tongue
 Vagus: controls gag reflex
 Uvula should be midline and if not indicative of damage to cerebral hemisphere
 Effects of vagal stimulation is PNS
CRANIAL NERVE XI: SPINAL ACCESSORY

 Innervates with sternocleidomastoid (neck) and trapezius (shoulder)
CRANIAL NERVE XII: HYPOGLOSSAL
 Controls the movement of tongue
 Let client protrude tongue and it should be midline and if unable to do indicative of damage to cerebral
hemisphere and/or has short frenulum.
ENDOCRINE SYSTEM
Overview of the structures and functions
1. Pituitary Gland (Hypophysis Cerebri)
o Located at base of brain particularly at sella turcica
o Master gland or master clock
o Controls all metabolic function of body
PARTS OF THE PITUITARY GLAND
1. Anterior Pituitary Gland
o called as adenohypophysis
2. Posterior Pituitary Gland
o called as neurohypophysis
o secretes hormones oxytocin -promotes uterine contractions preventing bleeding/ hemorrhage
o administrate oxytocin immediately after delivery to prevent uterine atony.
o initiates milk let down reflex with help of hormone prolactin Anterior pituitary Posterior pituitary
ADH GH
2. Antidiuretic Hormone OXYTOCIN ACTH
o Pitressin (Vasopressin) TSH

FSH & LH
o Function: prevents urination thereby conserving water PROLACTIN
MSH
o Diabetes Insipidus/ Syndrome of Inappropriate Anti Diuretic
Hormone
DIABETES INSIPIDUS (Dalas Ihi)

o Decrease production of anti diuretic hormone
A. Predisposing Factor
o Related to pituitary surgery
o Trauma
o Inflammation
o Presence of tumor
1. Polyuria
2. Signs of dehydration
a. Adult: thirst
b. Agitation
c. Poor Skin turgor
d. Dry mucous membrane
3. Weakness and fatigue
4. Hypotension
5. Weight loss (payat)
6. If left untreated results to hypovolemic shock (sign is anuria)
1. Urine Specific Gravity
o Normal value: 1.015 – 1.030
o Ph 4 – 8
2. Serum Sodium
o Increase resulting to hypernatremia
1. Force fluids
2. Monitor strictly vital signs and intake and output
a. Pitressin (Vasopresin Tannate) – administered IM Z-tract
4. Prevent complilcations – HYPOVOLEMIC SHOCK is the most feared complication
SIADH – lunod sa tubig
o hypersecretion of antidiuretic hormone
1. Head injury
2. Related to presence of bronchogenic cancer
o initial sign of lung cancer is non productive cough
o non invasive procedure is chest x-ray
3. Related to hyperplasia (increase size of organ brought about by increase of number of cells) of pituitary gland.

1. Fluid retention
a. Hypertension
b. Edema
c. Weight gain (mataba)
2. Water intoxication may lead to cerebral edema and lead to increase ICP – may lead to seizure activity
C. Diagnostic Procedure
1. Urine specific gravity is increased
2. Serum Sodium is decreased (hyponatremia 135 mg/dl)
1. Restrict fluid
a. Loop diuretics (Lasix)
b. Osmotic diuretics (Mannitol)
3. Monitor strictly vital signs, intake and output and neuro check
4. Weigh patient daily and assess for pitting edema
5. Provide meticulous skin care
ANTERIOR PITUITARY GLAND

o also called ADENOHYPOPHYSIS secretes
1. Growth hormones (somatotropic hormone)
o Promotes elongation of long bones
o Hyposecretion of GH among children results to Dwarfism
o Hypersecretion of GH results to Gigantism
o Hypersecretion of GH among adults results to Acromegaly (square face)
o Drug of choice: Ocreotide (Sandostatin)
2. Melanocyte Stimulating hormone

o for skin pigmentation
o Hyposecretion of MSH results to Albinism
o Most feared complications of albinism
a. Lead to blindness due to severe photophobia
b. Prone to skin cancer
o Hypersecretion of MSH results to Vitiligo
3. Adrenochorticotropic hormone (ACTH)

o promotes development of adrenal cortex
4. Lactogenic homone (Prolactin)

o promotes development of mammary gland
o with help of oxytocin it initiates milk let down reflex
5. Leutinizing hormone
o secretes estrogen
6. Follicle stimulating hormone
o secretes progesterone
PINEAL GLAND
o secretes melatonin
o inhibits LH secretion
o it controls/regulates circadian rhythm (body clock)
THYROID GLAND
o located anterior to the neck
3 Hormones secreted
1. T3 (Tri iodothyronine) - 3 molecules of iodine (more potent)
2. T4 (tetra iodothyronine, Thyroxine)
o T3 and T4 are metabolic or calorigenic hormone
o promotes cerebration (thinking)
3. Thyrocalcitonin – antagonizes the effects of parathormone to promote calcium resorption.
HYPOTHYROIDISM – thyroid deficiency

o all are decrease except weight and menstruation
o memory impairment
Signs and Symptoms
o there is loss of appetite but there is weight gain
o menorrhagia or amenorrhea
o cold intolerance
o constipation
o can lead to Myxedema
o extreme fatigue
o babagsak sa exam (mental proc. Decreased)
o weight gain
o hypothermic
HYPERTHYROIDISM
o all are increase except weight and menstruation
Signs and Symptoms
o increase appetite but there is weight loss Pharmacologic therapy Myxedema coma
o amenorrhea for hypothyroidism Severe hypothyroidism
- Increased
o exophthalmos Synthetic levothyroxine lethargic
(syndroid or levothroid) - Hypothermic
o Tachycardia, palpitations - Stupor
- coma
o insomnia
o restlessness agitation
o Heat intolerance
o HPN
THYROID DISORDERS
SIMPLE GOITER
o enlargement of thyroid gland due to iodine deficiency
1. Goiter belt area
a. places far from sea
b. Mountainous regions
2. Increase intake of goitrogenic foods
o contains pro-goitrin an anti thyroid agent that has no iodine.
o cabbage, turnips, radish, strawberry, carrots, sweet potato, broccoli, all nuts
o soil erosion washes away iodine
o goitrogenic drugs
a. Anti Thyroid Agent – Prophylthiuracil (PTU)
b. Lithium Carbonate d. Cobalt
c. PASA (Aspirin) e. Phenylbutazones (NSAIDs) - if goiter is caused by
1. Enlarged thyroid gland
2. Mild dysphagia
3. Mild restlessness
1. Serum T3 and T4 – reveals normal or below normal
2. Thyroid Scan – reveals enlarged thyroid gland.
3. Serum Thyroid Stimulating Hormone (TSH) –
is increased (confirmatory diagnostic test)
a. Lugol’s Solution/SSKI ( Saturated Solution of Potassium Iodine)
o color purple or violet and administered via straw to prevent staining of teeth.
o 4 Medications to be taken via straw: Lugol‘s, Iron, Tetracycline, Nitrofurantoin (drug of choice for
pyelonephritis)
b. Thyroid Hormones
o Levothyroxine (Synthroid)
o Liothyronine (Cytomel)
o Thyroid Extracts
Nursing Management when giving Thyroid Hormones
1. Instruct client to take in the morning to prevent insomnia
2. Monitor vital signs especially heart rate because drug causes tachycardia and palpitations
3. Monitor side effects
o insomnia
o tachycardia and palpitations
o hypertension
o heat intolerance
4. Increase dietary intake of foods rich in iodine
o seaweeds
o seafood‘s like oyster, crabs, clams and lobster but not shrimps because it contains lesser amount of
iodine.
o iodized salt, best taken raw because it it is easily destroyed by heat
5. Assist in surgical procedure of subtotal thyroidectomy
HYPOTHYROIDISM
o hyposecretion of thyroid hormone
o adults: MYXEDEMA non pitting edema
o children: CRETINISM the only endocrine disorder that can lead to mental retardation
1. Iatrogenic Cause – disease caused by medical intervention such as surgery
2. Related to atrophy of thyroid gland due to trauma, presence of tumor, inflammation
3. Iodine deficiency
4. Autoimmune (Hashimotos Disease)

(Early Signs)
2. Loss of appetite but with weight gain which promotes lipolysis leading to atherosclerosis and MI
3. Dry skin
4. Cold intolerance
5. Constipation
(Late Signs)
1. Brittleness of hair and nails
2. Non pitting edema (Myxedema)
3. Hoarseness of voice
4. Decrease libido
5. Decrease in all vital signs – hypotension, bradycardia, bradypnea, hypothermia
6. CNS changes
o lethargy
o memory impairment (forgetfulness)
o psychosis
o menorrhagia
1. Serum T3 and T4 is decreased
2. Serum Cholesterol is increased
3. RAIU (Radio Active Iodine Uptake) is decreased
1. Monitor strictly vital signs and intake and output to determine presence of
o Myxedema coma is a complication of hypothyroidism and an emergency case a severe form of
hypothyroidism is characterized by severe hypotension, bradycardia, bradypnea, hypoventilation,
hyponatremia, hypoglycemia, hypothermia leading to pregressive stupor and coma.
Nursing Management for Myxedema Coma
 Assist in mechanical ventilation
 Administer thyroid hormones as ordered
 Force fluids
2. Force fluids
3. Administer isotonic fluid solution as ordered
Thyroid Hormones
a. Levothyroxine
b. Leothyronine
c. Thyroid Extracts
5. Provide dietary intake that is low in calories – due to wt. gain
6. Provide comfortable and warm environment – due to cold intolerance
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
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)

1. Increase appetite (hyperphagia) but there is weight loss due to increased metabolism
2. Moist skin
3. Heat intolerance
4. Diarrhea
5. All vital signs are increased
6. CNS involvement
a. Irritability and agitation
b. Restlessness
c. Tremors
d. Insomnia
e. Hallucinations
7. Goiter
8. Exopthalmus (Pathognomonic sign)
9. Amenorrhea
1. Serum T3 and T4 is increased
2. RAIU (Radio Active Iodine Uptake) is increased
3. Thyroid Scan- reveals an enlarged thyroid gland
1. Monitor strictly vital signs and intake and output - determine thyroid storm or most feared complication:
Thyrotoxicosis
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.
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
4. Signs of bleeding (feeling of fullness at incisional site)

Nursing Management
o Check the soiled dressings at the back or nape area.
o Sign of laryngeal spasm – DOB, SOB (tracheostomy at bed side)
5. Hormonal replacement therapy for lifetime
6. Importance of follow up care
PARATHYROID GLAND
o A pair of small nodules behind the thyroid gland
o Secretes parathormone
o Promotes calcium reabsorption
o 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]
1. Following subtotal thyroidectomy
2. Atrophy of parathyroid gland due to:
a. inflammation
b. tumor
c. trauma
1. Acute tetany
a. tingling sensation
b. paresthesia
c. numbness
d. dysphagia
e. positive 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)
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
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)
DRUG DIET SUNLIGHT
Cholecalceferol calcidiol calcitriol

7am – 9am
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
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)
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
1. Bone pain especially at back (bone fracture)
2. Kidney stones
a. renal cholic
b. cool moist skin
3. Anorexia, nausea and vomiting
4. Agitation and memory impairment
1. Serum Calcium is increased
2. Serum Phosphate is decreased
3. X-ray of long bones reveals bone demineralization
1. Force fluids to prevent kidney stones
2. Strain all the urine using gauze pad for stone analysis
3. Provide warm sitz bath
a. Morphine Sulfate (Demerol)
5. Encourage increase intake of foods rich in phosphate but decrease in calcium
6. Provide acid ash in the diet to acidify urine and prevent bacterial growth
7. Assist/supervise in ambulation
8. Maintain side rails
9. Prevent complications (seizure and arrhythmia) most feared renal failure
10. Assist in surgical procedure known as parathyroidectomy
ADRENAL GLAND
o Located atop of each kidney
o 2 layers of adrenal gland
a. Adrenal Cortex – outermost
b. Adrenal Medulla – innermost (secretes 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
PHEOCHROMOCYTOMA- presence of tumor at adrenal medulla

Increase norepinephrine. HPN with pounding headache.
with HPN and resistant to drugs
drug of choice: beta blockers
complication: HPN crisis = lead to stroke
no valsalva maneuver. Don‗t smoke. No caffeine.
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
ADDISON’S DISEASE - payat
s
o Hyposecretion of adreno cortical hormone leading to
ex – secondary sex disturbances / decreased libido
ugar - metabolic disturbance / hypoglycemia
alt – fluid & electrolytes imbalance
1. Related to atrophy of adrenal glands
2. Fungal infections

1. Hypoglycemia – TIRED
2. Decrease tolerance to stress
3. Hyponatremia
- hypotension
- signs of dehydration
- weight loss
4. Hyperkalemia
- agitation
- diarrhea
- arrhythmia
5. Decrease libido
6. Loss of pubic and axillary hair
7. Bronze like skin pigmentation
Addisonian crisis:
Cyanosis
Classic sign of circulatory shock: pallor,
apprehension, rapid weak pulse, rapid
RR, low BP
Hydrocortisone (Solu-Cortef) admin. IV, followed

w/ 5% D5NS.
1. FBS is decreased (normal value: 80 – 100 mg/dl)
2. Plasma Cortisol is decreased
3. Serum Sodium is decrease (normal value: 135 – 145 meq/L)
4. Serum Potassium is increased (normal value: 3.5 – 4.5 meq/L)
1. Monitor strictly vital signs, input and output to determine presence of Addisonian crisis (complication of addison‘s
disease)
o Addisonian crisis results from acute exacerbation of addison‘s disease characterized by
a. severe hypotension
b. hypovolemic shock
c. hyponatremia leading to progressive stupor and coma
Nursing Management for Addisonian Crisis
1. Assist in mechanical ventilation,
- administer steroids as ordered
- force fluids
3. Force fluids
Corticosteroids
a. Dexamethasone (Decadrone)
b. Prednisone
c. Hydrocortisone (Cortison)
Nursing Management when giving steroids
1. Instruct client to take 2/3 dose in the morning and 1/3 dose in the afternoon to mimic the normal diurnal rhythm
2. Taper dose (withdraw gradually from drug)
a. hypertension
b. edema
c. hirsutism
d. increase susceptibility to infection
e. moon face appearance
4. Mineralocorticoids (Flourocortisone)
5. Provide dietary intake, increase calories, carbohydrates, protein but decrease in potassium
7. Provide client health teaching and discharge planning
a. avoid precipitating factor leading to addisonian crisis leading to
- stress
- infection
- sudden withdrawal to steroids
b. prevent complications
- addisonian crisis
- hypovolemic shock Cushing’s syndrome.
A. Client prior to syndrome.
c. hormonal replacement for lifetime B. Client 4 months after diagnosis of syndrome.
d. importance of follow up care
CUSHING SYNDROME - mataba

o Hypersecretion of adenocortical hormones
1 Related to hyperplasia of adrenal gland
2. Increase susceptibility to infections
3. Hypernatremia
a. hypertension
b. edema
c. weight gain
d. moon face appearance and buffalo hump
e. obese trunk
f. pendulous abdomen
g. thin extremities
4. Hypokalemia
a. weakness and fatigue
b. constipation
c. U wave upon ECG (T wave hyperkalemia)
5. Hirsutism
6. Acne and striae
7. Easy bruising
8. Increase masculinity among females
B. Diagnostic Procedures
1. FBS is increased
2. Plasma Cortisol is increased
3. Serum Sodium is increased
4. Serum Potassium is decreased
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
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
Type 1 (IDDM) Type 2 (NIDDM)

- Juvenile onset type - Adult onset
- Brittle disease - Maturity onset type
- Obese over 40 years old
A. Incidence Rate A. Incidence Rate
- 10% general population has type 1 DM - 90% of general population has type 2 DM
B. Predisposing Factors B. Predisposing Factors
1. Hereditary (total destruction of pancreatic cells) 1. Obesity – because obese persons lack insulin
2. Related to viruses receptor binding sites
3. Drugs
a. Lasix C. Signs and Symptoms
b. Steroids 1. Usually asymptomatic
4. Related to carbon tetrachloride toxicity 2. Polyuria
3. Polydypsia
C. Signs and Symptoms 4. Polyphagia
1. Polyuria 5. Glucosuria
2. Polydypsia 6. Weight gain
3. Polyphagia
4. Glycosuria
5. Weight loss
6. Anorexia, nausea and vomiting D. Treatment
7. Blurring of vision 1. Oral Hypoglycemic agents
8. Increase susceptibility to infection 2. Diet
9. Delayed/poor wound healing 3. Exercise
D. Treatment
1. Insulin therapy E. Complications
2. Diet 1. Hyper
3. Exercise 2. Osmolar
3. Non
E. Complication 4. Ketotic
1. Diabetic Ketoacidosis 5. Coma
- Consist of islets of langerhans
- Has alpha cells that secretes glucagons (function: hyperglycemia)
- Beta cells secretes insulin (function: hypoglycemia)
- Delta cells secretes somatostatin (function: antagonizes the effects of growth hormones)
3 Main Disorders of Pancreas
1. Pancreatic Tumor/Cancer
3. Pancreatitis
DIABETES MELLITUS
- Metabolic disorder characterized by non utilization of carbohydrates, protein and fat metabolism
MAIN
ANABOLISM CATABOLISM
FOODSTUFF
1. Carbohydrates Glucose Glycogen

2. Protein Amino Acids Nitrogen
3. Fats Fatty Acids Free Fatty Acids
- Cholesterol
- Ketones
HYPERGLYCEMIA
Increase osmotic diuresis
Glycosuria Polyuria
Cellular starvation – weight loss Cellular dehydration
Stimulates the appetite/satiety center Stimulates the thirst center

(Hypothalamus) (Hypothalamus)
Polyphagia Polydypsia
* Liver has glycogen that undergo glycogenesis/ glycogenolysis
GLUCONEOGENESIS
Formation of glucose from non-CHO sources
Increase protein formation
▼
Negative Nitrogen balance
▼
Tissue wasting (Cachexia)
▼
INCREASE FAT CATABOLISM
▼
Free fatty acids
Cholesterol Ketones
▼ ▼
Atherosclerosis Diabetic Keto Acidosis
▼
Hypertension
Acetone Breath Kussmaul‘s Respiration
odor
MI CVA
Death Diabetic Coma

DIABETIC KETOACIDOSIS
- Acute complication of type 1 DM due to severe hyperglycemia leading to severe CNS depression
1. Hyperglycemia
2. Stress – number one precipitating factor
3. Infection

1. Polyuria
2. Polydypsia
3. Polyphagia
4. Glucosuria
5. Weight loss
6. Anorexia, nausea and vomiting
7. Blurring of vision
8. Acetone breath odor
9. Kussmaul’s Respiration (rapid shallow breathing)
10 CNS depression leading to coma
1. FBS is increased
2. BUN (normal value: 10 – 20)
3. Creatinine (normal value: .8 – 1)
4. Hct (normal value: female 36 – 42, male 42 – 48) due to severe dehydration
1. Assist in mechanical ventilation
2. Administer 0.9 NaCl followed by .45 NaCl (hypotonic solutions) to counteract dehydration and shock
3. Monitor strictly vital signs, intake and output and blood sugar levels
a. Insulin therapy (regular acting insulin/rapid acting insulin peak action of 2 – 4 hours)
b. Sodium Bicarbonate to counteract acidosis
c. Antibiotics to prevent infection
HYPER OSMOLAR NON KETOTIC COMA

- Hyperosmolar: increase osmolarity (severe dehydration)
- Non ketotic: absence of lypolysis (no ketones)

1. Headache and dizziness
2. Restlessness
3. Seizure activity
4. Decrease LOC – diabetic coma
B. Nursing Management
1. Assist in mechanical ventilation
2. Administer 0.9 NaCl followed by .45 NaCl
(hypotonic solutions) to counteract dehydration and shock
a. Insulin therapy (regular acting insulin peak action of 2 – 4 hours)
- for DKA use rapid acting insulin
b. Antibiotics to prevent infection
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
1. Rapid Acting Insulin (clear)

- Regular acting insulin (IV only)
- Peak action is 2 – 4 hours
2. Intermediate Acting Insulin (cloudy)
- Non Protamine Hagedorn Insulin (NPH)
3. Long Acting Insulin (cloudy)
- Ultra Lente
C. Nursing Management for Insulin Injections

1. Administer at room temperature to prevent development of lipodystrophy (atrophy, hypertrophy of subcutaneous
tissues)
2. Place in refrigerator once opened
3. Avoid shaking insulin vial vigorously instead gently roll vial between palms to prevent formation of bubbles
4. Use gauge 25 – 26 needle
o o
5. Administer insulin either 45 – 90 depending on amount of clients tissue deposit
6. No need to aspirate upon injection
7. Rotate insulin injection sites to prevent development of lipodystrophy
8. Most accessible route is abdomen
9. When mixing 2 types of insulin aspirate first the clear insulin before cloudy to prevent contaminating the clear
insulin and promote proper calibration.
10. Monitor for signs of local complications such as
a. Allergic reactions
b. Lipodystrophy
c. Somogyi Phenomenon – rebound effect of insulin characterized by hypoglycemia to hyperglycemia
ORAL HYPOGLYCEMIC AGENTS - OHA

- Stimulates the pancreas to secrete insulin
A. Classsification
1. First Generation Sulfonylureas
a. Chlorpropamide (Diabenase)
b. Tolbutamide (Orinase)
c. Tolamazide (Tolinase)
2. Second Generation Sulfonylureas
a. Glipzide (Glucotrol)
b. Diabeta (Micronase)
Nursing Management when giving OHA
1. Instruct the client to take it with meals to lessen GIT irritation and prevent hypoglycemia
2. Instruct the client to avoid taking alcohol because it can lead to severe hypoglycemia reaction or Disulfiram (Antabuse)
toxicity symptoms
B. Diagnostic Procedures for DM
1. FBS is increased (3 consecutive times with signs or
polyuria, polydypsia, polyphagia and glucosuria confirmatory for DM)
2. Random Blood Sugar is increased
3. Oral glucose tolerance test is increased – most sensitive test
4. Alpha Glycosylated Hemoglobin is increased
1. Monitor for peak action of insulin and OHA and notify physician
2. Administer insulin and OHA therapy as ordered
4. Monitor for signs of hypoglycemia and hyperglycemia
- administer simple sugars
- for hypoglycemia (cold and clammy skin) give simple sugars
- for hyperglycemia (dry and warm skin)
5. Provide nutritional intake of diabetic diet that includes: carbohydrates 50%, protein 30% and fats 20% or offer
alternative food substitutes
6. Instruct client to exercise best after meals when blood
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
CHRONIC HEMORRHAGIC PANCREATITIS- ―bangugot

Predisposing factors - unknown
Risk factor:
History of hepatobiliary disorder
Alcohol
Drugs – thiazide diuretics, oral contraceptives, aspirin, penthan
Obesity
Hyperlipidemia
Hyperthyroidism
High intake of fatty food – saturated fats
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
I. Blood II. Blood Vessels III. Blood Forming Organs
1. Arteries 1. Liver
55% Plasma 45% Formed 2. Veins 3. Spleen
4. Lymphoid Organ
Serum Plasma CHON 5. Lymph Nodes
(formed in liver) 6. Bone 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
B-cell T-cell Natural killer cell

- bone marrow - thymus - anti viral and anti tumor property
for immunity
HIV
- 6 months – 5 years incubation period
- 6 months window period
- western blot opportunistic
- ELISA
- drug of choice AZT (Zidon Retrovir)
2 Common fungal opportunistic infection in AIDS

1. Kaposi‘s Sarcoma
2. Pneumocystis Carinii Pneumonia
3. Platelets (THROMBOCYTES)
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
Signs of Platelet Dysfunction

1. Petechiae
2. Echhymosis
3. Oozing of blood from venipunctured site
BLOOD DISORDERS
Iron Deficiency Anemia
- A chronic microcytic anemia resulting from inadequate absorption of iron leading to hypoxemic tissue injury
A. Incidence Rate
1. Common among developed countries
2. Common among tropical zones
3. Common among women 15 – 35 years old
4. Related to poor nutrition
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
1. Usually asymptomatic
2. Weakness and fatigue (initial signs)
4. Pallor and cold sensitivity
5. Dyspnea
6. Palpitations
7. Brittleness of hair and spoon shape nails (koilonychias)
8. Atropic Glossitis (inflammation of tongue)
- Stomatitis PLUMBER VINSON’S SYNDROME
- Dysphagia
9. PICA (abnormal appetite or craving for non edible foods
D. Diagnostic Procedures
1. RBC is decreased
2. Hgb is decreased
3. Hct is deceased
4. Iron is decreased
5. Reticulocyte is decreased
6. Ferritin is decreased
1. Monitor for signs of bleeding of all hema test including 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
Oral Iron Preparations
a. Ferrous Sulfate
b. Ferrous Fumarate
c. Ferrous Gluconate
- 300 mg/day
Nursing Management when taking oral iron preparations
1. Instruct client to take with meals to lessen GIT irritation
2. When diluting it in liquid iron preparations administer with straw to prevent staining of teeth
Medications administered via straw
Lugol‘s solution
Iron
Tetracycline
Nitrofurantoin (Macrodentin)
3. Administer with Vitamin C or orange juice for absorption
4. Monitor and inform client of side effects
a. Anorexia
b. Nausea and vomiting
c. Abdominal pain
d. Diarrhea/constipation
e. Melena
5. If client cant tolerate/no compliance administer parenteral iron preparation
a. Iron Dextran (IM, IV)
b. Sorbitex (IM)
Nursing Management when giving parenteral iron preparations
1. Administer Z tract technique to prevent discomfort, discoloration and leakage to tissues
2. Avoid massaging the injection site instead encourage to ambulate to facilitate absorption
a. Pain at injection site
b. Localized abscess
c. Lymphadenopathy
d. Fever and chills
e. Skin rashes
f. Pruritus/orticaria
g. Hypotension (anaphylactic shock)
PERNICIOUS ANEMIA
- Chronic anemia characterized by a deficiency of intrinsic factor leading to hypochlorhydria (decrease hydrochloric
acid secretion)
1. Subtotal gastrectomy
2. Hereditary factors
3. Inflammatory disorders of the ileum
4. Autoimmune
5. Strictly vegetarian diet
STOMACH
▼
Pareital cells/ Argentaffin or Oxyntic cells
Produces intrinsic factors Secretes hydrochloric acid

▼ ▼
Promotes reabsorption of Vit B12 Aids in digestion
▼
Promotes maturation of RBC

3. Pallor and cold sensitivity
4. Dyspnea and palpitations as part of compensation
5. GIT changes that includes
a. mouth sore
b. red beefy tongue
c. indigestion/dyspepsia
d. weight loss
e. jaundice
6. CNS changes
a. tingling sensation
b. numbness
c. paresthesia
d. positive to Romberg’s test – damage to cerebellum resulting to ataxia
e. result to psychosis
Schilling’s Test – reveals inadequate/decrease absorption of Vitamin B12
1. Enforce CBR
2. Administer Vitamin B12 injections at monthly intervals for lifetime as ordered
- Never given orally because there is possibility of developing tolerance
- Site of injection for Vitamin B12 is dorsogluteal and ventrogluteal
- No side effects
3. Provide a dietary intake that is high in carbohydrates, protein, vitamin c and iron
4. Instruct client to avoid irritating mouth washes instead use soft bristled toothbrush
5. Avoid heat application to prevent burns
APLASTIC ANEMIA
- Stem cell disorder leading to bone marrow depression leading to pancytopenia
PANCYTOPENIA
Decrease RBC Decrease WBC Decrease Platelet

(anemia) (leucopenia) (thrombocytopenia)
1. Chemicals (Benzine and its derivatives)
2. Related to irradiation/exposure to x-ray
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)

1. Anemia
a. Weakness and fatigue
b. Headache and dizziness
c. Pallor and cold sensitivity
d. Dyspnea and palpitations
2. Leukopenia
a. Increase susceptibility to infection
3. Thrombocytopenia
a. Petechiae (multiple petechiae is called purpura)
b. Ecchymosis
c. Oozing of blood from venipunctured sites
1. CBC reveals pancytopenia
2. Bone marrow biopsy/aspiration (site is the posterior iliac crest) – reveals fat necrosis in bone marrow
1. Removal of underlying cause
2. Institute BT as ordered
3. Administer oxygen inhalation
4. Enforce CBR
5. Institute reverse isolation
6. Monitor for signs of infection
a. fever
b. cough
7. Avoid IM, subcutaneous, venipunctured sites
8 Instead provide Heplock
9. Instruct client to use electric razor when shaving
a. Corticosteroids – caused by immunologic injury
b. Immunosuppressants
Anti Lymphocyte Globulin

▼
Given via central venous catheter
▼
Given 6 days to 3 weeks to achieve
Maximum therapeutic effect of drug
DISSEMINATED INTRAVASCULAR COAGULATION

Acute hemorrhagic syndrome characterized by wide spread bleeding and thrombosis due to a deficiency of prothrombin
and fibrinogen
1. Related to rapid blood transfusion
2. Massive burns
3. Massive trauma
4. Anaphylaxis
5. Septicemia
6. Neoplasia (new growth of tissue)
7. Pregnancy

1. Petechiae (widespread and systemic) eye, lungs and lower extremities
2. Ecchymosis
3. Oozing of blood from punctured sites
4. Hemoptysis
6. Oliguria (late sign)
1. CBC reveals decreased platelets
2. Stool occult blood positive
3. ABG analysis reveals metabolic acidosis
4. Opthamoscopic exam reveals sub retinal hemorrhages
1. Monitor for signs of bleeding of all hema test including stool and GIT
4. Force fluids
a. Vitamin K
b. Pitressin/ Vasopresin to conserve fluids
c. Heparin/Coumadin is ineffective
6. Provide heparin lock
7. Institute NGT decompression by performing gastric lavage by using ice or cold saline solution of 500 – 1000 ml
8. Monitor NGT output
9. Prevent complication
a. Hypovolemic shock
b. Anuria – late sign
BLOOD TRANSFUSION
Goals/Objectives
1. Replace circulating blood volume
2. Increase the oxygen carrying capacity of blood
3. Prevent infection in there is a decrease in WBC
4. Prevent bleeding if there is platelet deficiency
Principles of blood transfusion

1. Proper refrigeration
- Expiration of packed RBC is 3 – 6 days
- Expiration of platelet is 3 – 5 days
2. Proper typing and cross matching
a. Type O – universal donor
b. Type AB – universal recipient
c. 85% of population is RH positive
3. Aseptically assemble all materials needed for BT
a. Filter set
b. Gauge 18 – 19 needle
c. Isotonic solution (0.9 NaCl/plain NSS) to prevent hemolysis
4. Instruct another RN to re check the following
a. Client name
b. Blood typing and cross matching
c. Expiration date
d. Serial number
5. Check the blood unit for bubbles cloudiness, sediments and darkness in color because it indicates bacterial
contamination
- Never warm blood as it may destroy vital factors in blood.
- Warming is only done during emergency situation and if you have the warming device
- Emergency rapid BT is given after 30 minutes and let natural room temperature warm the blood.
6. BT should be completed less than 4 hours because blood that is exposed at room temperature more
than 2 hours causes blood deterioration that can lead to BACTERIAL CONTAMINATION
7. Avoid mixing or administering drugs at BT line to prevent HEMOLYSIS
8. Regulate BT 10 – 15 gtts/min or KVO rate or equivalent to 100 cc/hr to prevent circulatory overload
9. Monitor strictly vital signs before, during and after BT especially every 15 minutes for first hour
because majority of transfusion reaction occurs during this period
a. Hemolytic reaction
b. Allergic reaction
c. Pyrogenic reaction
d. Circulatory overload
e. Air embolism
f. Thrombocytopenia
g. Cytrate intoxication
h. Hyperkalemia (caused by expired blood)
Signs and Symptoms of Hemolytic reaction

2. Dyspnea
3. Diarrhea/Constipation
4. Hypotension
5. Flushed skin
6. Lumbar/sternal/ Flank pain
7. Urine is color red/ portwine urine
Nursing Management
1. Stop BT
2. Notify physician
3. Flush with plain NSS
4. Administer isotonic fluid solution to prevent shock and acute tubular necrosis
5. Send the blood unit to blood bank for re examination
6. Obtain urine and blood sample and send to laboratory for re examination
7. Monitor vital signs and intake and output
SIGNS AND SYMPTOMS OF ALLERGIC REACTION

1. Fever
2. Dyspnea
3. Broncial wheezing
4. Skin rashes
5. Urticaria
6. Laryngospasm and Broncospasm
Nursing Management
1. Stop BT
2. Notify physician
a. Anti Histamine (Benadryl) - if positive to hypotension, anaphylactic shock treat with Epinephrine
SIGNS AND SYMPTOMS PYROGENIC REACTIONS (FEVER)

1. Fever and chills
2. Headache
3. Tachycardia
4. Palpitations
5. Diaphoresis
6. Dyspnea
Nursing Management
1. Stop BT
2. Notify physician
a. Antipyretic
b. Antibiotic
8. Render TSB
SIGNS AND SYMPTOMS OF CIRCULATORY REACTION
1. Orthopnea
2. Dyspnea
3. Rales/Crackles upon auscultation
4. Exertional discomfort
Nursing Management
1. Stop BT
2. Notify physician
a. Loop diuretic (Lasix
CARDIOVASCULAR SYSTEM
OVERVIEW OF THE STRUCTURE AND FUNCTIONS OF THE HEART
HEART
- Muscular pumping organ of the body.
- Located on the left mediastinum
- Resemble like a close fist
- Weighs approximately 300 – 400 grams
- Covered by a serous membrane called the pericardium
2 layers of pericardium
a. Parietal – outer layer
b. Visceral – inner layer
- In between is the pericardial 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
B. Chambers of the Heart

1. Upper Chamber (connecting or receiving)
a. Atria
2. Lower Chamber (contracting or pumping)
a. Ventricles
- Left ventricle has increased pressure which is 120 – 180 mmHg
- In order to propel blood to the systemic circulation
- Right atrium has decreased pressure which is 60 – 80 mmHg
C. Valves
- To promote unidimensional flow or prevent backflow
1. Atrioventricular Valves – guards opening between

a. tricuspid valve
b. mitral valve
- Closure of AV valves give rise to first heart sound (S1 “lub”)
2. Semi – lunar Valves

a. pulmonic
b. aortic
- Closure of SV valve give rise to second heart sound (S2 “dub”)
Extra Heart Sounds

1. S3 – ventricular gallop usually seen in Left Congestive Heart Failure sound occurring during rapid ventricular filling
2. S4 – atrial gallop usually seen in Myocardial Infarction and Hypertension sound head during atrial contraction (often
heard when the ventricle is enlarged or hypertrophied
D. Coronary Arteries
- Arises from base of the aorta
Types of Coronary Arteries
1. Right Main Coronary Artery
2. Left Main Coronary Arterying
- Supplies the myocardium
E. Cardiac Conduction System

1. Sino – Atrial Node (SA or Keith Flack Node)
- Located at the junction of superior vena cava and right atrium
- Acts as primary pacemaker of the heart
- Initiates electrical impulse of 60 – 100 bpm
2. Atrio – Ventricular Node (AV or Tawara Node)

- Located at the inter atrial septum
- Delay of electrical impulse for about .08 milliseconds to allow ventricular filling
3. Bundle of His
- Right Main Bundle of His
- Left Main Bundle of His
- Located at the interventricular septum
4. Purkinje Fibers terminal point in the conduction system

(point which the myocardial cells are stimulated causing ventricular contraction)
- Located at the walls of the ventricles for ventricular contraction
- P WAVE (atrial depolarization) contraction
- QRS WAVE (ventricular depolarization)
- T WAVE (ventricular repolarization)
 Insert pacemaker if there is complete heart block
 Most common pacemaker is the metal pacemaker and lasts up to 2 – 5 years
Cardiac electrical activity is the result of the movement of ions (charged particles such as SODIUM, POTASSIUM,
AND CALCIUM) across the cell membrane.
ABNORMAL ECG TRACING

1. Positive U wave - Hypokalemia
2. Peak T wave – Hyperkalemia
3. ST segment depression – Angina Pectoris
4. ST segment elevation – Myocardial Infarction
5. T wave inversion – Myocardial Infarction
6. Widening of QRS complexes – Arrhythmias
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
1. Sex – male
2. Race – black
3. Smoking
4. Obesity
5. Hyperlipidemia
6. Sedentary lifestyle
8. Hypothyroidism
9. Diet – increased saturated fats

1. Chest pain
2. Dyspnea
3. Tachycardia
4. Palpitations
5. Diaphoresis
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
ANGINA PECTORIS (SYNDROME)

Clinical syndrome characterized by paroxysmal chest pain that is usually relieved by rest or nitroglycerine due to
temporary myocardial ischemia
A. Predisposing Factors Angina is usually caused by
1. Sex – male ATHEROSCLEROTIC Disease.
2. Race – black - narrowing of artery
3. Smoking - lipid or fat deposits
4. Obesity - tunica intima
5. Hyperlipidemia
8. Hypothyroidism
B. Precipitating Factors
4 E’s of Angina Pectoris
1. Excessive physical exertion – heavy exercises
2. Exposure to cold environment
3. Extreme emotional response – fear, anxiety, excitement
4. Excessive intake of foods rich in saturated fats – skimmed milk

1. Levine’s Sign – initial sign that shows the hand clutching the chest
2. Chest pain characterized by sharp stabbing pain located at sub sterna usually radiates from back, shoulder, arms, axilla
and jaw muscles, usually relieved by rest or taking nitroglycerine
3. Dyspnea
4. Tachycardia
5. Palpitations
6. Diaphoresis
1. History taking and physical exam
2. ECG tracing reveals ST segment depression
3. Stress test – treadmill test, reveal abnormal ECG
4. Serum cholesterol and uric acid is increased
a. Nitroglycerine (NTG) – when given in small doses will act as venodilator, but in large doses will act as
vasodilator
- Give first dose of NTG (sublingual) 3 – 5 minutes
- Give second dose of NTG if pain persist after giving first dose with interval of 3 - 5 minutes
- Give third and last dose of NTG if pain still 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

4. Place client on semi fowler‘s position
5. Monitor strictly vital signs, intake and output and ECG tracing
6. Provide decrease saturated fats sodium and caffeine
7. Provide client health teachings and discharge planning
a. Avoidance of 4 E‘s
b. Prevent complication (myocardial infarction)
c. Instruct client to take medication before indulging into physical exertion to achieve the maximum therapeutic
effect of drug
d. The importance of follow up care
MYOCARDIAL INFARCTION – 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
B. The Most Critical Period Following Diagnosis of Myocardial Infarction

** 6 – 8 hours because majority of death occurs due to arrhythmia leading to PVC’s
C. Predisposing Factors
1. Sex – male
2. Race – black
3. Smoking
4. Obesity
5. Hyperlipidemia
8. Hypothyroidism

1. Chest pain
- Excruciating visceral, viselike pain located at substernal and rarely in precordial
- Usually radiates from back, shoulder, arms, axilla, jaw and abdominal muscles (abdominal ischemia) and hands
- Not usually relieved by rest or by nitroglycerine
2. Dyspnea
3. Increase in blood pressure (initial sign)
4. Hyperthermia
5. Ashen skin (pale), cool, clammy, diaphoretic
6. Mild restlessness and apprehension, anxiety
7. Occasional findings
a. Pericardial friction rub
b. Split S1 and S2
c. Rales/Crackles upon auscultation
d. S4 or atrial gallop
1. Cardiac Enzymes
a. CPK – MB
- Creatinine phosphokinase is increased
- Heart only, 12 – 24 hours
b. LDH – Lactic 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
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
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
b. Anti Arrythmic Agents

- Lidocaine (Xylocane
- Side Effects: confusion and dizziness
- Brutylium
c. Beta-blockers
- (-lol)
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
10. Provide client health teaching and discharge planning concerning

a. Avoidance of modifiable risk factors
- Arrhythmia (caused by premature ventricular contraction)
b. Cardiogenic shock
- late sign is oliguria
c. Left Congestive Heart Failure
d. Thrombophlebitis
- homan’s sign
e. Stroke/CVA
f. Post MI Syndrome/Dressler’s Syndrome
- Client is resistant to pharmacological agents; administer 150,000 – 450,000 units of streptokinase as
ordered
g. Resumption of ADL particularly sexual intercourse is 4 – 6 weeks post cardiac rehab, post CABG and instruct
to
- make sex as an appetizer rather than dessert
- instruct client to assume a non weight bearing position
Client can resume sexual intercourse if can climb staircase
- dietary modification
h. Strict compliance to mediation and importance of follow up care
CONGESTIVE HEART FAILURE

Inability of the heart to pump blood towards systemic circulation
Types of Heart Failure

1. LEFT SIDED HEART FAILURE
1. 90% is mitral valve stenosis due to
a. RHD – inflammation of mitral valve due to invasion of 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
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.
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)
2. RIGHT SIDED HEART FAILURE – RIGHT VENT. FAILS.

1. Tricuspid valve stenosis
2. Pulmonary embolism
3. Related to COPD
4. Pulmonic valve stenosis
5. Left sided heart failure
B. Signs and Symptoms (venous congestion)

1. Neck/jugular vein distension
2. Pitting edema (lower extremities)
3. Ascites
4. Weight gain
5. Hepatosplenomegaly
6. Jaundice
7. Pruritus (albumin)
8. Anorexia
9. Esophageal varices
1. Chest x-ray – reveals cardiomegaly
2. Central venous pressure (CVP)
- Measure pressure in right atrium (4 – 10 cm of water)
- CVP fluid status measure
- If CVP is less than 4 cm of water hypovolemic shock
- Do the fluid challenge (increase IV flow rate)
- If CVP is more than 10 cm of water hypervolemic shock
- Administer loop diuretics as ordered
- When reading CVP patient should be flat on bed
- Upon insertion place client in Trendelenburg position to promote ventricular filling and prevent pulmonary
embolism
3. Ecocardiography – reveals enlarged heart chambers (cardiomyopathy)

4. Liver enzymes – SGPT and SGOT is increased B. hypertrophic cardiomyopathy
Goal: increase cardiac contractility thereby increasing cardiac output (3 – 6 L/min)
1. Enforce CBR
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
6. Measure abdominal girth daily and notify physician
7. Provide a dietary intake of low sodium, cholesterol and caffeine
9. Assist in bloodless phlebotomy – rotating tourniquet, rotated clockwise every 15 minutes to promote decrease venous
return
a. Prevent complications
- 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)
THROMBOANGIITIS OBLITERANS or BUERGER’S DISEASE (MALE FEET) 20-35 yrs old

Acute inflammatory disorder usually affecting the small medium sized arteries and veins of the lower extremities
(Autoimmune disease)
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
B. Signs and Symptoms (pain is the outstanding symptom)

1. Intermittent claudication – leg pain upon walking (foot cramps, especially the arch (instep claudication after exercise)
2. Cold sensitivity and changes in skin color rubor (reddish blue discoloration, pallor, and cyanosis)
3. Decreased peripheral pulses
4. Trophic changes
5. Ulceration
6. Gangrene formation
7. Absence of pedal pulse but with normal femoral pulse and popliteal pulses.
8. Radial and ulnar artery pulses are absent or diminished.
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)
D. Nursing Management Lower the extremities below the

level of the heart – if the
1. Encourage a slow progressive physical activity
condition is arterial in nature
A. walking 3 – 4 times a day
Elevate the extremities above
B. out of bed 3 – 4 times a day
the heart level – if the condition
2. Administer medications as ordered is venous in nature
a. Analgesics
b. Vasodilators
c. Anti coagulants
3. Institute foot care management
4. Instruct client to avoid smoking and exposure to cold environment
5. Assist in surgical procedure – bellow knee amputation (elevate the stump for 24 hrs postop to promote venous return
and minimize edema).
6. Pain is relieve by rest
REYNAUD’S DISEASE
Disorder characterized by acute episodes of arterial (small arteries) spasm/vasoconstriction that result in coldness, pain,
and pallor involving the fingers or digits of the hands.
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

1. Intermittent claudication – leg pain upon walking
2. Cold sensitivity and changes in skin color (pallor, cyanosis then rubor)
3. Trophic changes
4. Ulceration
5. Gangrene formation
6. Raynaud’s phenomenon – refer to localized, intermittent episodes of vasoconstriction of small arteries of the hands
that causes changes in color and temperature. (as white, blue, and red)
1. Doppler UTZ – decrease blood flow to the affected extremity
2. Angiography – reveals site and extent of malocclusion
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
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)
1. Pain after prolonged standing
2. Dilated tortuous skin veins
3. Warm to touch
4. Heaviness in legs
1. Venography
2. Trendelenburg‘s Test - veins distends quickly in less than 35 seconds
1. Elevate legs above heart level to promote increased venous return by placing 2 – 3 pillows under the legs
2. Measure the circumference of leg muscle to determine if swollen
3. Wear anti embolic stockings
a. Analgesics
5. Assist in surgical procedure
a. Vein stripping and ligation (most effective)
b. Sclerotherapy – can recur and only done 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
1. Obesity
2. Smoking
3. Related to pregnancy
4. Chronic anemia
5. Prolong use of oral contraceptives – promotes lipolysis
6. Diabetes mellitus
7. Congestive heart failure
8. Myocardial infarction
9. Post op complication
10. Post cannulation – insertion of various cardiac catheter.
11. Increase in saturated fats in the diet.

1. Pain at affected extremity
2. Warm to touch
3. Dilated tortuous skin veins
4. Positive Homan‘s Signs – pain at the calf or leg muscle upon dorsiflexion of the foot
1. Venography
2. Angiography
1. Elevate legs above heart level to promote increase venous return
2. Apply warm moist pack – to reduce lymphatic congestion
3. Measure circumference of leg muscle to determine if swollen
4. Encourage to wear anti embolic stockings or knee elastic stockings
a. Analgesics
b. Anti Coagulant – 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
6. Monitor for signs of complications

Embolism
a. Pulmonary
- Sudden sharp chest pain
- Unexplained dyspnea
- Tachycardia
- Palpitations
- Diaphoresis
- Restlessness
b. Cerebral
- Headache
- Dizziness
- Decrease LOC
MURPHY’S SIGN is seen in clients with cholelithiasis, cholecystitis characterized by pain at the right upper
quadrant with tenderness (inflammation of the gall bladder)
RESPIRATORY SYSTEM
OVERVIEW OF THE STRUCTURES AND FUCNTIONS OF THE RESPIRATORY SYSTEM

I. Upper Respiratory System
1. Filtering of air
2. Warming and moistening of air
3. Humidification
A. Nose
- Cartillage
- Right nostril
- Left nostril
- Separated by septum
- Consist of anastomosis of capillaries known as 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
II. Lower Respiratory System

- For gas exchange
A. Trachea/Windpipe
- Consist of cartilaginous rings
- Serves as passageway of air going to the lungs
- Site of tracheostomy
B. Bronchus
- Right main bronchus
- Left main bronchus
C. Lungs
- Right lung (consist of 3 lobes, 10 segments)
- Left lung (consist of 2 lobes, 8 segments)
- Serous membranes
Pleural Cavity
a. Pareital
b. Pleural fluid
c. Visceral
With Pleuritic Friction Rub
a. Pneumonia
b. Pleural effusion
c. Hydrothorax (air and blood in pleural space
Alveoli – acinar cells
- Site of gas exchange (CO2 and O2)
- Diffusion (Dalton‘s law of partial pressure of gases)
Respiratory Distress Syndrome

- Decrease oxygen stimulates breathing
- Increase carbon dioxide is a powerful stimulant for breathing
Ventilation – movement of air in & out of lungs
Respiration – movement of air into cells
Type II Cells of Alveoli

- Secretes surfactant
- Decrease surface tension
- Prevent collapse of alveoli
- Composed of lecithin and spingomyelin
- L/S ratio to determine lung maturity
- Normal L/S ratio is 2:1
- In premature infants 1:2
- Give oxygen of less 40% in premature to prevent atelectasis and retrolental fibroplasias
- retinopathy/blindness in prematurity
Disorders of Respiratory System
1. PTB/Pulmonary Tuberculosis (Koch’s Disease)
- Infection of lung tissue caused by invasion of mycobacterium tuberculosis or tubercle bacilli
- An acid fast, gram negative, aerobic and easily destroyed by heat or sunlight
A. Precipitating Factors
1. Malnutrition
2. Overcrowded places
3. Alcoholism
4. Over fatigue
5. Ingestion of infected cattle with mycobacterium bovis
6. Virulence (degree of pathogenecity) of microorganism
B. Mode of Transmission
1. Airborne transmission via droplet nuclei

1. Low grade afternoon fever, night sweats
2. Productive cough (yellowish sputum)
3. Anorexia, generalized body malaise
4. Weight loss
5. Dyspnea
6. Chest pain
7. Hemoptysis (chronic)
1. Mantoux Test (skin test)
- Purified protein derivative
- DOH 8 – 10 mm induration, 48 – 72 hours
- WHO 10 – 14 mm induration, 48 – 72 hours
- Positive Mantoux test (previous exposure to tubercle bacilli but without active TB)
2. Sputum Acid Fast Bacillus

- Positive to cultured microorganism
3. Chest X-ray
- Reveals pulmonary infiltrates (chalk thorax)
4. CBC
- Reveals increase WBC
1. Enforce CBR
2. Institute strict respiratory isolation
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
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
B. High Risk Groups

1. Children below 5 years old bec. Of low resistance
2. Elderly
C. Predisposing Factors
1. Smoking
2. Air pollution
3. Immuno compromised
a. AIDS
- Pneumocystic carini pneumonia
- Drug of choice is Retrovir
b. Bronchogenic Cancer
- Initial sign is non productive cough 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
1. Productive cough with greenish to rusty sputum
2. Dyspnea with prolong expiratory grunt
3. Fever, chills, anorexia and general body malaise
4. Weight loss
5. Rales/crackles
7. Cyanosis
8. Pleuritic friction rub
9. Chest pain
10. Abdominal distention leading to paralytic ileus (absence of peristalsis)
1. Sputum Gram Staining and Culture Sensitivity – positive to cultured microorganisms
2. Chest x-ray – reveals pulmonary consolidation
3. ABG analysis – reveals decrease PO2
4. CBC – reveals increase WBC, erythrocyte sedimentation rate is increased
1. Enforce CBR
2. Administer oxygen inhalation low inflow
Broad Spectrum Antibiotic
a. Penicillin
b. Tetracycline
c. Microlides (Zethromax)
- Azethromycin (Side Effect: Ototoxicity)
- Antipyretics
- Mucolytics/Expectorants
- Analgesics
4. Force fluid
5. Place on semi 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
- Atelectasis
- Meningitis (nerve deafness, hydrocephalus)
c. Regular adherence to medications
HISTOPLASMOSIS
Acute fungal infection caused by inhalation of contaminated dust or particles with histoplasma capsulatum derived from
birds manure

PTB or Pneumonia like
1. Productive cough
2. Dyspnea
3. Fever, chills, anorexia, general body malaise
4. Cyanosis
5. Hemoptysis
6. Chest and joint pains
B. Diagnostic Procedures
1. Histoplasmin Skin Test – positive
2. ABG analysis PO2 decrease
1. Enforce CBR
a. Antifungal
- Amphotericin B
- Fungizone (Nephrotoxicity, check for BUN and Creatinine, Hypokalemia)
b. Steroids
c. Mucolytics
d. Antipyretics
4. Force fluids to liquefy secretions
5. Nebulize and suction as needed
6. Prevent complications – bronchiectasis
7. Prevent the spread of infection by spraying of breeding places
COPD (Chronic Obstructive Pulmonary/Lung Disease)
Chronic Bronchitis
Inflammation of bronchus resulting to hypertrophy or hyperplasia of goblet mucous producing cells leading to narrowing of
smaller airways
1. Smoking
2. Air pollution
1. Productive cough (consistent to all COPD)
2. Dyspnea on exertion
3. Prolonged expiratory grunt
4. Anorexia and generalized body malaise
5. Scattered rales/ronchi
6. Cyanosis
7. Pulmonary hypertension
a. Peripheral edema
b. Cor Pulmonale (right ventricular hypertrophy)
ABG analysis – reveals PO2 decrease (hypoxemia), PCO2 increase, and pH decrease (resp. acidosis)
Bronchial Asthma
Reversible inflammatory lung condition due to hypersensitivity to allergens leading to narrowing of smaller airways
A. Predisposing Factors (Depending on Types)

1. Extrinsic Asthma (Atopic/ Allergic)
Causes
a. Pollen
b. Dust
c. Fumes
d. Smoke
e. Gases
f. Danders
g. Furs
h. Lints
2. Intrinsic Asthma (Non atopic/Non allergic)

Causes
a. Hereditary
b. Drugs (aspirin, penicillin, beta blocker)
c. Foods (seafoods, eggs, milk, chocolates, chicken
d. Food additives (nitrates)
e. Sudden change in temperature, air pressure and humidity
f. Physical and emotional stress
3. Mixed Type  90 – 95%

1. Cough that is non productive
2. Dyspnea
3. Wheezing on expiration
4. Cyanosis
5. Mild Stress/apprehension
6. Tachycardia, palpitations
7. Diaphoresis
1. Pulmonary Function Test
- Incentive spirometer reveals decrease vital lung capacity
2. ABG analysis – PO2 decrease
- Before ABG test for positive Allens Test, apply direct
pressure to ulnar and radial artery to determine presence
of collateral circulation
1. Enforce CBR
2. Oxygen inhalation, with low inflow of 2 – 3 L/min
a. Bronchodilators – given via inhalation or metered dose inhalaer or MDI for 5 minutes
b. Steroids – decrease inflammation
c. Mucomysts (acetylceisteine)
d. Mucolytics/expectorants
e. Anti histamine
4. Force fluids
5. Semi fowler‘s position
7. Provide client health teachings and discharge planning concerning
a. Avoidance of precipitating factor
- Emphysema
- Status Asthmaticus (give drug of choice)
- Epinephrine
- Steroids
- Bronchodilators
c. Regular adherence to medications to prevent development of status asthmaticus
BRONCHIECTASIS
Abnormal permanent dilation of bronchus leading to destruction of muscular and elastic tissues of alveoli
1. Recurrent lower respiratory tract infections
2. Chest trauma
3. Congenital defects
4. Related to presence of tumor

1. Productive cough
2. Dyspnea
3. Cyanosis
5. Hemoptysis (only COPD with sign)
1. ABG – PO2 decrease
2. Bronchoscopy – direct visualization of bronchus using fiberscope
Nursing Management PRE Bronchoscopy

1. Secure inform consent and explain procedure to client
2. Maintain NPO 6 – 8 hours prior to procedure
3. Monitor vital signs and breathe sound
POST Bronchoscopy
1. Feeding initiated upon return of gag reflex
2. Avoid talking, coughing and smoking, may cause irritation
3. Monitor for signs of gross
4. Monitor for signs of laryngeal spasm – prepare tracheostomy set
D. Treatment
1. Surgery (pneumonectomy, 1 lung is removed and position on affected side)
2. Segmental Wedge Lobectomy (promote re expansion of lungs)
- Unaffected lobectomy facilitate drainage
EMPHYSEMA
Irreversible terminal stage of COPD characterized by
a. Inelasticity of alveoli
b. Air trapping
c. Maldistribution of gases
d. Over distention of thoracic cavity (barrel chest)
1. Smoking
2. Air pollution
3. Allergy
4. High risk: elderly
5. Hereditary – it involves deficiency of
ALPHA-1 ANTI TRYPSIN
(needed to form Elastase, for recoil of alveoli)

1. Productive cough
2. Dyspnea at rest
3. Prolong expiratory grunt
5. Resonance to hyperresonance
6. Decrease tactile fremitus
7. Decrease or diminished breath sounds
8. Rales or ronchi
10. Barrel chest
11. Flaring of alai nares
12. Purse lip breathing to eliminates excess CO2
(compensatory mechanism)
1. Pulmonary Function Test – reveals decrease vital lung capacity
2. ABG analysis reveals
a. Panlobular/ centrilobular
- Decrease PO2 (hypoxemia leading to chronic bronchitis, ―Blue Bloaters‖)
- Decrease ph
- Increase PCO2
- Respiratory acidosis
b. Panacinar/ centriacinar
- Increase PO2 (hyperaxemia, ―Pink Puffers‖)
- Decrease PCO2
- Increase ph
- Respiratory alkalosis
1. Enforce CBR
2. Administer oxygen inhalation via low inflow
a. Bronchodilators
b. Steroids
c. Antibiotics
d. Mucolytics/expectorants
4. High fowlers position
5. Force fluids
6. Institute pulmonary toilet
8. Institute PEEP (positive end expiratory pressure) in mechanical ventilation promotes maximum alveolar lung expansion
9. Provide comfortable and humid environment
10. Provide high carbohydrates, protein, calories, vitamins and minerals
11. Health teachings and discharge planning concerning
a. Avoid smoking
- Atelectasis
- Cor Pulmonale
- CO2 narcosis may lead to coma
- Pneumothorax
c. Strict compliance to medication
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.
Purpose of H2O sealed drainage

1. Reestablish (-) pressure in the lungs-lung 6-12mm Hg
2. Promote re-expansion of the lungs
3. Drain fluid, blood and air
4. To prevent reflux of blood fluid and air
Nursing Mgt if pt is on CPT attached to H2O drainage

1. Maintain strict aseptic technique
2. DBE
3. At bedside
a.) Petroleum gauze pad if dislodged Hemostat
b.) If with air leakage – clamp
c.) Extra bottle
4. Meds – Morphine SO4
Antimicrobial
5. Monitor & assess for oscillation fluctuations or bubbling
a.) If (+) to intermittent bubbling means normal or intact
- H2O rises upon inspiration
- H2O goes down upon expiration
b.) If (+) to continuous, remittent bubbling
1. Check for air leakage
2. Clamp towards chest tube
3. Notify MD
c.) If (-) to bubbling
1. Check for loop, clots, and kink
2. Milk towards H2O seal
3. Indicates re-expansion of lungs normal
4. Auscultate for breath sounds, Xrays
5. Removal of CTT
When will MD remove chest tube?
1. If (-) fluctuations
2. (+) Breath sounds
3. CXR – full expansion of lungs
Nursing Mgt of removal of chest tube

1. Encourage DBE
2. Instruct to perform Valsalva maneuver for easy removal, to prevent entry of air in pleural space.
3. Apply vaselinated air occlusive dressing and pressure dressing
- Maintain dressing dry & intact
4. Prepare: Extra bottle, excellent clamp, petroleum gauze
Gastro Intestinal Tract

I. Upper alimentary canal - function for digestion
a. Mouth
b. Pharynx (throat)
c. Esophagus
d. Stomach- site of digestion
e. 1st half of duodenum
II. Middle Alimentary canal – Function: for absorption

- Complete absorption – large intestine
a. 2nd half of duodenum for absorption
b. Jejunum
c. Ileum
d. 1st half of ascending colon
III. Lower Alimentary Canal – Function: elimination

a. 2nd half of ascending colon for elimination
b. Transverse for complete absorption— L I
c. Descending colon
d. Sigmoid
e. Rectum
IV. Accessory Organ

a. Salivary gland
b. Verniform appendix
c. Liver
d. Pancreas – auto digestion
e. Gallbladder – storage of bile
I. Salivary Glands
1. Parotid – below & front of ear
2. Sublingual
3. Submaxillary
- Produces saliva – for mechanical digestion

- 1,200 -1,500 ml/day - saliva produced
Lacrimal gland- depression on the frontal bone
Lacrimal duct- outer canthus
PAROTITIS – ―mumps‖ – inflammation of parotid gland

-Paramyxovirus
S/Sx:
1. Fever, chills anorexia, generalized body malaise
2. enlarged parotid gland
3. Swelling of parotid gland
4. Dysphagia
5. Earache – otalgia
Mode of transmission: Direct transmission & droplet nuclei

Incubation period: 14 – 21 days
Period of communicability – 1 week before swelling & immediately when swelling begins.
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.
VERNIFORM APPENDIX – Rt. iliac or Rt. inguinal area

- Function – lymphatic organ – produces WBC during fetal life - ceases to function upon birth of baby
APENDICITIS – inflamation of verniform appendix

Predisposing factor:
1. Microbial infection
2. Feacalith – undigested food particles – tomato seeds, guava seeds
3. Intestinal obstruction
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
Nursing Mgt: post op

1. If (+) to Penrose drain – indicates rupture of appendix
Position- affected side to drain
2. Meds: analgesic due post op pain
Antibiotics, Antipyretics PRN
3. Monitor VS, I&O, bowel sound- N- borborygmy sound
4. Maintain patent IV line
5. 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
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
9. Gastrin producing tumor or gastrinoma – Zollinger Ellisons syndrome

10. Microbial invasion – helicobacter pylori. Metronidazole (Flagyl)
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
Stress ulcers – common among critically ill clients

2 types
1. Curling’s ulcer – cause: trauma & Burns
Hypovolemia
GIT schemia
Decrease resistance of mucosal barriers to Hcl acid
Ulcerations
2. Cushing’s ulcer – cause – stroke/CVA/ head injury
Increase vagal stimulation
Hyperacidity
Ulcerations
Treatment: Vagotomy - done to prevent hemorrhage and shock prior to surgery on the stomach
GASTRIC ULCER DUODENAL ULCER

SITE Antrum or lesser curvature Duodenal bulb
PAIN - 30 min – 1 hr after eating - 2-3 hrs after eating
- epigastrium - mid epigastrium
- gaseous & burning - cramping & burning pain
- not usually relieved by food & antacid - usually relieved by food & antacid
- 12 MN – 3am pain
- Eating leads to pain - Eating lessens pain
HYPERSECRETION Normal gastric acid secretion Increased gastric acid secretion
VOMITING common Not common
HEMORRHAGE hematemesis Melena
WT Wt loss Wt gain
COMPLICATIONS a. stomach cancer a. perforation
b. hemorrhage
HIGH RISK 50 or 60 years old and above 20 years old and above
INCIDENCE Male; female = 1:1 Male: Female = 2-3:1
15% of peptic ulcers are gastric 80% of peptic ulcers are duodenal
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
ex. aluminum hydroxide gel ex. milk of magnesia

(Amphogel) S/E diarrhea
S/E constipation
Maalox (fever S/E)
b.) H2 receptor antagonist:

1. Ranitidine (Zantac) SE: fever
2. Cimetidine (Tagamet)—hastens the effect of oral anticoagulants
3. Famotidine (Pepcid) SE: fever
- Avoid smoking – decrease effectiveness of drug
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.
3. Surgery: subtotal gastrectomy - Partial removal of stomach
Billroth I (Gastroduodenostomy) Billroth II (Gastrojejunostomy)
 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
7.) Dumping syndrome – common complication – rapid gastric

emptying of hypertonic food solutions – CHYME leading to hypovolemia.
Sx of Dumping syndrome:
1. Dizziness
2. Diaphoresis
3. Diarrhea
4. Palpitations
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
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
Liver – largest gland

- Occupies most of right hypochondriac region
- Color: scarlet red, brown shiny and transparent
- Covered by a fibrous capsule – Glisson‘s capsule
- Functional unit – liver lobules
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)
Hypervitaminosis – vit D & K

Vit A – retinol (Def Vit A – night blindness)
Vit D – cholecalciferon
- Helps calcium
- Rickets, osteoarthritis
4. It destroys excess estrogen hormone

5. for metabolism
A. CHO –
1. Glycogenesis – synthesis of glycogens
2. Glycogenolysis – breakdown of glycogen
3. Gluconeogenesis – formation of glucose from CHO sources
B. CHON-
1. Promotes synthesis of albumin & globulin
Liver Cirrhosis – decrease albumin; ascites and edema
Albumin – maintains osmotic pressure, prevents edema
2. Promotes synthesis of prothrombin & fibrinogen
3. Promotes conversion of ammonia to urea.
Ammonia like breath – fetor hepaticus – a sweet, slightly fecal odor to the breath presumed 2 be intestinal orig.
C. FATS – promotes synthesis of cholesterol to neutral fats – called triglycerides
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
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
c.) GIT changes

Ascites, bleeding esophageal varices – due to portal HPN
d.) Neurological changes:
hepatic encephalopathy
Hepatic encephalopathy - ammonia (cerebral toxin)

Late signs: Early signs:
Headache and dizziness asterexis - flapping hand tremors
Fetor hepaticus Minor mental changes and motor disturbances
Confusion hyperactive deep tendon reflexes
Restlessness
Hypoactive deep tendon reflexes flaccid
Decrease LOC
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
b.) Bleeding esophageal varices

- Dilation of esophageal veins
1. Meds: Vit K
Pitressin or Vasopressin (IM)
2. NGT decompression- lavage
- Give before lavage – ice or cold saline solution
- Monitor NGT output
3. Assist in mechanical decompression
- Insertion of Sengstaken-Blackemore tube - to decompress veins of esophagus-to prevent
esophageal varices
- 3 lumen typed catheter
- Scissors at bedside to deflate/decompress balloon. Prep scissors when pt complains of DOB
c.) Hepatic encephalopathy –
1. Assist in mechanical ventilation – due coma
2. Monitor VS, neuro check
3. Siderails – due restless
4. Meds – Laxatives – to excrete ammonia (Lactulose)
HEPATITIS - jaundice (icteric sclera)
Bilirubin
Kernicterus/ hyperbilirubinia
Irreversible brain damage
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
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
2. Withold food & fluid – aggravates pain (total NPO)
3. Assist in Total Parenteral Nutrition (TPN) or hyperalimentation

Complications of TPN
1. Infection—maintain a strict aseptic technique
2. Pulmonary Embolism—check all connection to system
3. Hyperglycemia
4. Hyperkalemia
4. Institute stress mgt tech
a.) DBE
b.) Biofeedback
5. Comfy position - Knee chest or fetal lie position
6. If pt can tolerate food, give increase CHO, decrease fats, and moderate CHON
7. Complications: Chronic hemorrhagic pancreatitis, Peritonitis, Septicemia, Shock
GALLBLADDER – storage of bile – made up of cholesterol.
Definition of terms: Biliary

Cholecystitis Inflammation of the gallbladder
Cholelithiasis The presence of calculi in the gallbladder
Cholecystectomy Removal of the gallbladder
Cholecystostomy Opening and drainage of the gallbladder
Choledochotomy Opening into the common duct
Choledocholithiasis Stones in the common duct
Choledocholitholithotomy Incision of common bile duct for removal of stones
Choledochoduodenostomy Anastomosis of common duct to duodenum
Choledochojejunostomy Anastomosis of common duct to jejunum
Lithotripsy Disintegration of gallstones by shock waves
Laparoscopic cholecystectomy Removal of gallbladder through endoscopic
procedure
Laser cholecystectomy Removal of gallbladder using laser rather than
scalpel and traditional surgical instruments
CHOLECYSTITIS / CHOLELITHIASIS – inflammation of gallbladder with gallstone formation.

1. High risk – women 40 years old
2. Post menopausal women – undergoing estrogen therapy
3. Obesity
4. Sedentary lifestyle, prolonged immobility
5. Hyperlipidemia
6. Neoplasm
7. Obstruction
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
Stomach – widest section of alimentary canal

- J shaped structures
1. Anthrum
2. Pylorus
3. Fundus
Valves – prevent GERD
1. cardiac sphincter valve
2. Pyloric sphincter valve- stomach and first half of duodenum
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
Function of the stomach

1. Mechanical digestion
2. Chem.
3. Storage of food
-CHO, CHON- stored 1 -2 hrs. Fats – stored 2 – 3 hrs
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
Thermal - direct contact – flames, hot grease, sunburn.

Electric, – wires
Chemical – direct contact – corrosive materials acids
Smoke – gas / fume inhalation
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)
II Full thickness Burns

th
1. Third & 4 degrees burn
- Affects all layers of skin, muscles, bones
- Cause – electrical
- Less painful
- Dry, thick, leathery wound surface – known as ESCHAR – devitalized or necrotic tissue.
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
Hemolysis muscle spasm
b.) Morphine SO4

c.) Systemic antibiotics
1. Ampicillin
2. Cephalosporin
3. Tetracyclin
4. Topical antibiotic:
1. Silver Sulfadiazene (silvadene)
2. Sulfamylon
3. Silver nitrate
4. Povidone iodine (betadine)
2. Administer isotonic fluid sol & CHON replacements

3. Strict aseptic technique
4. Diet – increase CHO, increase CHON, increase Vit C, and increase K- orange
5. If (+) to burns on head, neck, face - Assist in intubation
6. Assist in hydrotherapy
7. Assist in surgical wound debridement. Administer analgesic 15 – 30 minutes before debridement
8. Complications:
a.) Infection
b.) Shock
c.) Paralytic ileus - due to hypovolemia & hypokalemia
d.) Curling‘s ulcer – H2 receptor antagonist
e.) Septicemia blood poisoning
f.) Surgery: skin grafting
GUT – genito-urinary tract

Function:
1. Promote excretion of nitrogenous waste products
2. Maintain F&E & acid base balance
1. Kidneys – pair of bean shaped organ

- Located retroperitonially (back of peritoneum) on either side of vertebral column. Encased in Bowmans‘s capsule.
Parts:
1. Renal pelvis – Pyelonephritis – inflammation of the renal pelvis
2. Cortex
3. Medulla
Nephrons – basic living unit of the kidneys consisting of glomerulus

Glomerulus – filters blood going to kidneys
Function of kidneys:
1. Urine formation Causes of Transient Incontinence: DIAPPERS
2. Regulation of BP
Urine formation – 25% of total CO (Cardiac Output) is Delirium

received by kidneys (3,000-6,000 ml.)
125ml/ min filtered by the glomerulus > Infection of urinary tract
Glomerular filtration rate
1. Filtration
2. Tubular Reabsorption—124ml of ultra filtered are Atrophic vaginitis, urethritis
reabsorbed in the blood
3. Tubular Secretion- 1 ml is excreted in the urine
Pharmacologic agents (anticholinergic)
Filtration – Normal GFR/ min is 125 ml of blood
Tubular reabsorption – 124ml of ultra infiltrates (H2O & Psychological factors (depression, regression)
electrolytes is for reabsorption)
Tubular secretion – 1 ml is excreted in urine
Excessive urine production (DI, diabetic keto, inc. intake)
Causes of CRF:
1. HPN Restricted activity
2. DM
Regulation of BP:
Predisposing factor: Stool imfaction
Ex CS – Hypovolemia – decrease BP going to kidneys
Activation of RAAS
Release of Renin (hydrolytic enzyme) at juxtaglomerular apparatus
Angiotensin I mild vasoconstrictor
Angiotensin II vasoconstrictor
Adrenal cortex increase CO increase PR
Aldosterone
Increase BP
Increase Na &
H2O reabsorption
Hypervolemia
Ureters – 25 – 35 cm long, passageway of urine to bladder

Bladder – loc behind symphisis pubis. Muscular & elastic tissue that is distensible
- Function – reservoir of urine
1200 – 1800 ml – Normal adult can hold
200 – 500 ml – needed to initiate micturition reflex (voiding)
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
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
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
NEPHROLITHIASIS/ UROLITHIASIS- formation of stones at urinary tract

- calcium , oxalate, uric acid
milk cabbage anchovies

cranberries organ meat
nuts tea nuts
chocolates sardines
1. Diet – increase Ca & oxalate
2. Hereditary – gout
3. Obesity
5. Hyperparathyroidism
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
BENIGN PROSTATIC HYPERTROPHY - enlarged prostate gland leading to

a.) Hydro ureters – dilation of ureters
b.) Hydronephrosis – dilation of renal pelvis
c.) Kidney stones Stone formation-- Renal failure
d.) Renal failure
 encircles the neck of the bladder
 decreased form of urinary stream
 Cause is unknown
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)
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)
Intra-renal cause – involves renal pathology= kidney problem

1. Acute tubular necrosis 3. HPN
2. Pyelonephritis 4. Acute Glom.
Post renal cause – involves mechanical obstruction

Causes:
1. Urinary strictures
2. Urolithiasis
3. BPH
4. Presence of tumors
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
III. CONVALESCENT/RECOVERY PHASE—3-12 months
CHRONIC RF – irreversible loss of kidney function

1. DM
2. HPN
3. Recurrent UTI/ nephritis/ pyelonephritis
4. Exposure to renal toxins
Stages of CRF
1. Diminished Reserve Volume – asymptomatic
Normal BUN & Crea, GFR < 10 – 30%
2. Renal Insufficiency
3. End Stage Renal disease
S/Sx:
1.) Urinary System 2.) Metabolic disturbances

a.) polyuria a.) azotemia (increase BUN & Crea)
b.) nocturia b.) hyperglycemia
c.) hematuria c.) hyperinulinemia
d.) Dysuria
e.) oliguria
3.) CNS 4.) GIT
a.) headache a.) n/v
b.) lethargy b.) stomatitis
c.) disorientation c.) uremic breath
d.) restlessness d.) diarrhea/ constipation
e.) memory impairment
5.) Respiratory 6.) hematological
a.) Kassmaul’s resp a.) Normocytic anemia
b.) decrease cough reflex bleeding tendencies
c.) crackles
7.) Fluid & Electrolytes 8.) Integumentary
a.) hyperkalemia a.) itchiness/ pruritus
b.) hypernatermia b.) uremic frost
c.) hypermagnesemia 9.) Cardiovascular changes
d.) hyperposphatemia a. HPN
e.) hypocalcemia b. CHF
f.) met acidosis c. Pericarditis
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
Meibomean gland – secrets a lubricating fluid inside eyelid

b.) Stye/ sty or Hordeolum- inflamed Meibomean gland
5. Conjunctiva
6. Lacrimal apparatus – tears
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
II. Uveal tract – nutritive care

Uveitis – infl of uveal tract
Consist of:
a.) Iris – colored muscular ring of eye
2 muscles of iris:
1. Circular smooth muscle fiber - Constricts the pupil
2.radial smooth muscle fiber - Dilates the pupil
2 chambers of the eye

1. Anterior
a.) Vitreous Humor – maintains spherical shape of the eye
b.) Aqueous Humor – maintains intrinsic ocular pressure
Normal IOP= 12-21 mmHg
II. Retina (innermost layer)

i. Optic discs or blind spot – nerve fibers only
No auto receptors
cones (daylight/ colored vision) rods – night twilight vision
phototopic vision ―scotopic vision‖ = vit A deficiency – rods insufficient
ii. Maculla lutea – yellow spot center of retina

iii. Fovea centralis – area with highest visual acuity or acute vision
Physiology of vision
4 Physiological processes for vision to occur:
1. Refraction of light rays – bending of light rays
2. Accommodation of lens
3. Constriction & dilation of pupils
4. Convergence of eyes
Unit of measurements of refraction – diopters

Normal eye refraction – emmetropia
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
Near vision = far vision=

Ciliary muscle contracts= ciliary muscle dilates / relaxes=
Lens bulges lens is flat
Convergence of the eye:

Error:
1. Exotropia – 1 eye n.
2. Esophoria – corrected by corrective eye surgery
3. Strabismus- squint
4. Amblyopia – prolong squinting
GLAUCOMA – increase IOP – if untreated, atrophy of optic nerve disc – blindness
1. High risk group – 40 & above (nearsightedness)
2. HPN
3. DM
4. Hereditary
5. Obesity
6. Recent eye trauma, infl, surgery
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)
Nursing Mgt pre op- all types surgery

1. Apply eye patch on unaffected eye to force weaker eye to become stronger.
Nursing Mgt post op – all types of surgery

1. Position unaffected/ unoperated side - to prevent tension on suture line.
2. Avoid valsalva maneuver
3. Monitor for symptoms of IOP
a.) Headache
b.) n/v
c.) Eye discomfort
d.) Tachycardia
4. Eye patch – both eyes - post op
CATARACT – partial/ complete opacity of lens

1. 90-95% - aging (degenerative/ senile cataract)
2. Congenital
3. Prolonged exposure to UV rays
4. DM
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
Diagnosis: Opthalmoscopic exam – (+) opacity of lens
Nsg Mgt:
1. Reorient pt to environment – due opacity

2. Side rails
3. Meds: a.) Mydriatics – dilate pupil – not lifetime (SNS)
Ex. Mydriacyl
c.) Cyslopegics – paralyzes ciliary muscle. Ex. Cyclogye
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:
1. Position unaffected/ unoperated side - to prevent tension on suture line.

2. Avoid valsalva maneuver
3. Monitor symptoms of IOP

a.) Headache
b.) n/v
c.) Eye discomfort
d.) Tachycardia
4. Eye patch – both eyes - post op
RETINAL DETACHMENT- separation of 2 layers of retina

1. Severe myopia – nearsightedness
2. Diabetic Retinopathy
3. Trauma
4. Following lens extraction
5. HPN
S/Sx:
1. ―Curtain –veil‖ like vision
2. Flashes of lights
3. Floaters
4. Gradual decrease in central vision
5. Headache
6. Cobwebs
Diagnosis: ophthalmoscopic exam

Nursing Mgt:
1. Side rails (all visual disease)
2. Surgery:
a.) Cryosurgery – cold application
(Diathermy – heat application)
b.) Scleral buckling
EAR
1. Hearing
2. Balance (Kinesthesia or position sense)
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
Disorders of outer ear

Entry of insects – put flashlight to give route of exit
Foreign objects – beans (bring to MD)
H2O - drain
2. Middle ear
a.) Ear osssicle
1. Hammer -malleus
2. Anvil -Incus for bone conduction disorder conductive hearing loss
3. Stirrups -stapes
b. Eustachian tube - Opens to allow equalization of pressure on both ears

- Yawn, chew, and swallow
Children – straight, wide, short
c.) Otitis media
Adult – long, narrow & slanted
c. Muscles
1. Stapedius
2. Tensor tympani
3. Inner ear
a. Bony labyrinth – for balance, vestibule
Utricle & succule
Otolithe or ear stone – has Ca carbonate
Movement of head = Righting reflex = Kinesthesia

b. Membranous Labyrinth
1. Cochlea – ( function for hearing) has organ of corti
2. Endolymph & perilymph – for static equilibrium
3. Mastoid air cells – air filled spaces in temporal bone in skull
Complications of Mastoditis – meningitis
Types of hearing loss:

1. Conductive hearing loss – transmission hearing loss
Causes:
a.) Impacted cerumen – tinnitus & conduction hearing loss- assist in ear irrigation
b.) Immobility of stapes – OTOSCLEROSIS
d.) Middle ear disease char by formation of spongy bone in the inner ear causing fixation or immobility of stapes
e.) Stapes can‘t transmit sound waves
Surgery
Stapedectomy – removal of stapes, spongy bone & implantation of graft/ ear prosthesis
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
SENSORY NEURAL HEARING LOSS/ NERVE DEAFNESS

Cause:
1. Tumor on cocheal
2. Loud noises (gun shot)
3. Presbycusis – bilateral progressive hearing loss especially at high frequencies – elderly
Face elderly to promote lip reading
4. Meniere’s disease – endolymphatic hydrops
f.) Inner ear disease char by dilation of endolympathic system leading to increase volume of endolin
Predisposing factor of MENIERE’S DISEASE

 Smoking
 Hyperlipidemia
 30 years old
 Obesity – (+) chosesteatoma
 Allergy
 Ear trauma & infection
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
Opened bottles must be used in 8 hours

HepLock- flush with NSS
KCl < 80meq/L

Epinephrine 1:10,000
Lidocaine- 4 mg /ml (1g/250ml)
COMPATIBLE WITH PNSS ONLY

o Phenytoin
o Vit K
o Vit B6
o Vit C
o Hydralazine
o Furosemide
COMPATIBLE WITH D5W ONLY

o Epinephrine
o Norepinephrine
o Ephedrine
o Dopamine
o Dobutamine
o Nitroprusside
o NaHCO3
Not to be diluted in LR
Penicillin G
Ampicillin
Cephalosporin
NaHCO3
PRBC—to be infused within 2-4hours

FFP—1-1.
5 hours
Platelet concentrates—infuses immediately and quickly
Autoimmune diseases Apparatus needed at bedside
Acetaminophen toxicity- Prepare suction apparatus-

Multiple Sclerosis Acetylcisteine acetylcysteine causes outpouring of
Hypothyroidism secretions
Acute Glomerulonephritis Myasthenia Gravis tracheostomy set. For respiratory
Myasthenia Gravis arrest
Hyperthyroidism Hemodyalisis bulldog clip
GBS Senkstaken tube scissors to deflate balloon
Pernicious Anemia Guillain Barre Syndrome tracheostomy set. For respiratory
arrest
Convulsion- suction apparatus Increased secretions
Hyperthyroidism tracheostomy set. For laryngeal
spasm post subtotal thyroidectomy
complication
Goiter tracheostomy set. For laryngeal
spasm post subtotal thyroidectomy
complication
Hypoparathyroidism tracheostomy set. For laryngeal
spasm
NEURO TRANSMITTER DECREASE INCREASE

Myasthenia Gravis /
Acethylcholine Bi-polar Disorder
Alzheimer
Dopamine Parkinson’s Disease Schizophrenia
Jerome Adorable, RN 2010

PATHOGNOMONIC SIGNS
1. PTB - Low-grade afternoon fever.
2. PNEUMONIA - Rusty sputum.
3. ASTHMA - Wheezing on expiration.
4. EMPHYSEMA - Barrel chest.

5. KAWASAKI DISEASE - Strawberry tongue.
6. PERNICIOUS ANEMIA - Red beefy tongue.
7. DOWN SYNDROME - Protruding tongue / semian crease on palm
8. CHOLERA - Rice watery stool.
9. MALARIA - Stepladder like fever and chills.
10. TYPHOID - Rose spots in abdomen.

11. DIPTHERIA - pseudo membrane formation (pharynx, tonsils, nasal)
12. MEASLES - Koplik’s spots.
13. SLE - Butterfly rashes.
14. LIVER CIRRHOSIS - spider angioma, due to esophageal varices

15. LEPROSY - lioning face
16. BULIMIA NERVOSA - Chipmunk face. Parotid gland swelling
17. APPENDICITIS. - rebound tenderness
18. DENGUE - petechiae or (+) Herman’s sign
19. MENINGITIS - Kernig’s sign (leg pain), Brudzinski sign (neck pain).
20. TETANY - HYPOCALCEMIA (+) Trousseau’s sign/carpopedal spasm; Chvostek sign (facial spasm).
21. TETANUS - risus sardonicus.
22. PANCREATITIS - Cullen’s sign (ecchymosis of umbilicus); (+) Grey turners spots.
23. PYLORIC STENOSIS - olive SHAPE mass on the abdomen

24. PDA - machine like murmur
25. ADDISON’S DISEASE - Bronze like skin pigmentation.
26. CUSHING’S SYNDROME - Moon face appearance and buffalo hump.
27. HYPERTHYROIDISM/GRAVE’S DISEASE - Exopthalmus
28. INTUSSUSCEPTION - sausage shaped mass
29. PARKINSON’S DISEASE - Pill rolling tremors
30. HEPATITIS - Jaundice
31. THROMBOPHEBITIS - Homan’s sign
32. CATARACT - Hazy vision / loss of central vision
33. GLAUCOMA - Tunnel vision / loss of peripheral vision
34. RETINAL DETACHMENT - Curtain veil-like vision / flashes and floaters
35. CHOLECYSTITIS - Murphy’s sign (pain on deep inspiration, a inflammation of the gallbladder
36. ANGINA PECTORIS - Levine’s sign [hand clutching in the chest]
37. MYASTHENIA GRAVIS - Ptosis [drooping of the upper eyelid]

38. TETRALOGY OF FALLOT - Clubbing of fingers

GASTRIC ULCER DUODENAL ULCER
SITE Antrum or lesser curvature Duodenal bulb

- 30 min – 1 hr after eating - 2-3 hrs after eating
- epigastrium - mid epigastrium
- gaseous & burning - cramping & burning pain
PAIN - not usually relieved by food & antacid - usually relieved by food & antacid
- 12 MN – 3am pain
- Eating leads to pain - Eating lessens pain
HYPERSECRETION Normal gastric acid secretion Increased gastric acid secretion
VOMITING common Not common
HEMORRHAGE hematemesis Melena
WT Wt loss Wt gain
a. stomach cancer a. perforation
COMPLICATIONS
b. hemorrhage
HIGH RISK 50 or 60 years old and above 20 years old and above
Male; female = 1:1 Male: Female = 2-3:1
INCIDENCE
15% of peptic ulcers are gastric 80% of peptic ulcers are duodenal
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.

“Happiness is only real, when it shared” CSLRM

Medical Surgical Nursing With Mnemonics

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AND AIM HIGH WITH GOD

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AUTONOMIC NERVOUS SYSTEM

EFFECTS OF SNS EFFECTS OF PNS

I. Adrenergic Agents I. Cholinergic Agents

II. Anti-cholinergic Agents II. Beta-adrenergic Blocking Agents

TYPES OF CELLS BASED ON REGENERATIVE CAPACITY

SUBSTANCES THAT CAN PASS THE BLOOD-BRAIN BARRIER

2. PNEUMONIA - Rusty sputum.

10. TYPHOID - Rose spots in abdomen.

14. LIVER CIRRHOSIS - spider angioma, due to esophageal varices

23. PYLORIC STENOSIS - olive SHAPE mass on the abdomen

30. HEPATITIS - Jaundice

32. CATARACT - Hazy vision / loss of central vision

33. GLAUCOMA - Tunnel vision / loss of peripheral vision

36. ANGINA PECTORIS - Levine’s sign [hand clutching in the chest]

3. Type 1 DM (IDDM) [KETONES]

2. MULTIPLE SCLEROSIS [Autoimmune process]

Ig G – only antibody that pass placental

* Give palliative or supportive care.

Intentional tremors Nystagmus

NEURO TRANSMITTER DECREASE INCREASE

Monroe Kellie Hypothesis

Skull is a closed container

Any alteration or increase in one of the intracranial components

Increase intra-cranial pressure

Cervical 1 – also known as ATLAS.

Increase intra cranial pressure

7. Administer medications like:

*CONGESTIVE HEART FAILURE

RIGHT CONGESTIVE HEART FAILURE (Venous congestion)

Signs and Symptoms of Lasix in terms of electrolyte imbalances

Magnesium Sulfate toxicity [B.U.R.P]

PARKINSON’S DISEASE/ PARKINSONISM

Loss of spouse Loss of Job

 direct approach towards the client

Signs and Symptoms for Parkinson’s

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

Anti Histamine (Dipenhydramine Hydrochloride)

MAGIC 2’s IN DRUG MONITORING [D.L.A.D.A]

4. Dilantin phenytoin Toxicity

INFLAMMATORY CONDITIONS OF THE BRAIN

CBC reveals notes on hematology: INCREASED DECREASED

WBC Leukocytosis Leukopenia

Signs and Symptoms of Pulmonary Embolism

 Fat embolism is the most feared complications after femur fracture.

D. Signs and Symptoms

GUILLAIN BARRE SYNDROME (Acute Ediopathic Polyneuropathy)

* Sengstaken Blakemore Tube

CONVULSIVE DISORDER/ CONVULSION

B. Signs and Symptoms

II. Partial or Localized Seizure

III. Status Epilepticus

COMPREHENSIVE NEURO EXAM

 Survey of mental status and speech

II. TEST OF MEMORY

CRANIAL NERVES FUNCTION

CRANIAL NERVE I: OLFACTORY B

Material Used VI. ABDUCENSE M

 don‘t use alcohol, ammonia, perfume because it is irritating VII. FACIAL B

and highly diffusible. VIII. ACOUSTIC S

CRANIAL NERVE II: OPTIC