MEDICAL SURGICAL Abby Tabuena

Overview of the Structures & Functions of Nervous System Central NS PNS ANS Brain & spinal cord 3 spinal & cranial sy!pathetic NS Parasypathatic NS So!atic NS C" # T" $ %" & S" & C" ANS 'or adrener(ic of parasy!patholitic response) SNS involved in fi(ht or a((ression response .elease of norepinephrine 'adrenaline - cathecola!ine) Adrenal !edulla 'potent vasoconstrictor) /ncreases body activities 0S 1 /ncrease 34cept 5/T - decrease 5/T!otility 8 9hy 5/T is not increased 1 5/T is not i!portant: /ncrease blood flow to s6eletal !uscles; brain & heart+ Effects of SNS (anti"choliner(ic*adrener(ic) + ,ilate pupil - to aware of surroundin(s " !edriasis $+ ,ry !outh 3+ BP & 2.1 increased bronchioles dilated to ta6e !ore o4y(en 7+ .. increased &+ Constipation & urinary retention

/+ Adrener(ic A(ents - 3pinephrine 'adrenaline) S3< SNS effect //+ PNS< Beta adrener(ic bloc6in( a(ents 'opposite of adrener(ic a(ents) 'all end in -=lol>) " Bloc6s release of norepinephrine+ " ,ecrease body activities e4cept 5/T 'diarrhea) 34+ Propanolol; ?etopanolol S3< B - broncho spas! 'bronchoconstriction) 3 - elicits a decrease in !yocardial contraction T - treats 2PN A - A0 conduction slows down 5iven to an(ina & ?/ - beta"bloc6ers to rest heart Anti 2PN a(ents< + Beta bloc6ers '"lol) $+ Ace inhibitors '"pril) e4 3NA%AP./%; CAPTOP./% 3+ Calciu! anta(onist e4 CA%C/B%OC or N3F3,/P/N3 Peripheral nervous syste!< choliner(ic* va(al or sy!patholitic response " /nvolved in fly or withdrawal response " .elease of acetylcholine 'ACT2) " ,ecrease all bodily activities e4cept 5/T 'diarrhea) / Choliner(ic a(ents e4 + ?estinon Antidote - anti choliner(ic a(ents Atropine Sulfate - S*3 - SNS S*3" of anti"hpn dru(s< + orthostatic hpn Effect of PNS: (choliner(ic) + ?eiosis - contraction of pupils $+ /ncrease salivation 3+ BP & 2. decreased 7+ .. decrease - broncho constriction &+ ,iarrhea - increased 5/ !otility @+ Arinary freBuency

transient headache & diCCiness+ "?(t+ .ise slowly+ Assist in a!bulation+ CNS (brain s!ina" cor#$ /+ Cells - A+ neurons Properties and characteristics a+ 34citability - ability of neuron to be affected in e4ternal environ!ent+ b+ Conductivity - ability of neuron to trans!it a wave of e4citation fro! one cell to another c+ Per!anent cells - once destroyed; cant re(enerate 'e4+ heart; retina; brain; osteocytes) .e(enerative capacity A+ %abile - once destroyed cant re(enerate " 3pider!al cells; 5/T cells; resp 'lun( cells)+ 5AT B+ Stable - capable of re(eneration BAT li!ited ti!e only e4 salivary (land; pancreas cells cell of liver; 6idney cells C+ Per!anent cells - retina; brain; heart; osteocytes can>t re(enerate+ 3+) Neuro(lia - attached to neurons+ Supports neurons+ 9here brain tu!ors are found+ Types< + Astrocyte $+ Oli(odendria Astrocyto!a - DE - D&F brain tu!or fro! astrocyte+ ?ost brain tu!ors are found at astrocyte+ Astrocyte - !aintains inte(rity of blood brain barrier 'BBB)+ BBB - se!i per!eable * selective "To4ic substance that destroys astrocyte & destroy BBB+ To4ins that can pass in BBB< + A!!onia"liver cirrhosis+ $+ $+ Carbon ?ono4ide - seiCure & par6insons+ 3+ 3+ Bilirubin" Gaundice; hepatitis; 6ernicterus*hyperbilirubenia+ 7+ 7+ Hetones -,?+ O%/5O,3N,./A - Produces !yelin sheath - wraps around a neuron - acts as insulator facilitates rapid nerve i!pulse trans!ission+ No !yelin sheath - de(enerates neurons ,a!a(e to !yelin sheath - de!yellenatin( disorders ,3?I3%%3NAT/N5 ,S3 +)AL%&EIMER'S DISEASE- atrophy of brain tissue due to a deficiency of acetylcholine+ S&S4< A - a!nesia - loss of !e!ory A - apra4ia - unable to deter!ine function & purpose of obGect A - a(nosia - unable to reco(niCe fa!iliar obGect A - aphasia " 34pressive - brocca>s aphasia - unable to spea6 " .eceptive - wernic6es aphasia - unable to understand spo6en words Co!!on to AlChei!er - receptive aphasia ,ru( of choice - A./C3PT 'ta6en at bedti!e) & CO5N3J+ ?(t< Supportive & palliative+

$+

?icro(lia - stationary cells; en(ulfs bacteria; en(ulfs cellular debris+ //+ Co!positions of Cord & Spinal cord #EF " brain !ass EF " CSF EF " blood ?ON.O3 H3%%I 2IPOT23S/S< The s6ull is a closed vault+ Any increase in one co!ponent will increase /CP+ Nor!al /CP< E" &!!2( Brain !ass

Connects . & % cerebral he!isphere " Corpus collusu! .t cerebral he!isphere; %t cerebral he!isphere Function< + Sensory $+ ?otor 3+ /nte(rative %obes +) Frontal a+ Controls !otor activity b+ Controls personality develop!ent c+ 9here pri!itive refle4es are inhibited d+ Site of develop!ent of sense of u!or e+ Brocca>s area - speech center ,a!a(e " e4pressive aphasia $+) Te!poral a+ 2earin( b+ Short ter! !e!ory c+ 9ernic6es area - (en interpretative or 6nowin( 5nostic area ,a!a(e - receptive aphasia 3+) Parietal lobe - appreciation & discri!ation of sensory i!p " Pain; touch; pressure; heat & cold 7+) Occipital " vision &+) /nsula*island of reil* Central lobe" controls visceral f4 Function< " activities of internal or(an @+) .hinencephalon* %i!bec " S!ell; libido; lon("ter! !e!ory Basal 5an(lia - areas of (ray !atte located deep within a cerebral he!isphere " 34tra pyra!idal tract " .eleases dopa!ine" " Controls (ross voluntary unit ,ecrease dopa!ine - 'Par6inson>s) pin rollin( of e4tre!ities & 2untin(ton>s ,se+ ,ecrease acetylcholine - ?yasthenia 5ravis & AlChei!er>s /ncreased neurotrans!itter 1 psychiatric disorder /ncrease dopa!ine - schiCo /ncrease acetylcholine - bipolar ?/, B.A/N - relay station for si(ht & hearin( Controls siCe & reaction of pupil $ - 3 !! Controls hearin( acuity CN 3 - 7 /socoria - nor!al siCe 'eBual) Anisocoria - uneven siCe - da!a(e to !id brain P3..%A - nor!al reaction ,/3NC3P2A%ON" between brain Thala!us - acts as a relay station for sensation 2ypothala!us - 'ther!ore(ulatin( center of te!p; sleep & wa6efulness; thirst; appetite* satiety center; e!otional responses; controls pituitary function+ B.A/N ST3?" a+ Pons - or pneu!ota4ic center - controls respiration Cranial & - # CNS ?3,A%%A OB%ON5ATA" controls heart rate; respiratory rate; swallowin(; vo!itin(; hiccups* sin(utus 0aso!otor center; spinal decuissation ter!ination; CN D; E; ; $ C3.3B3%%A? - lesser brain " Controls posture; (ait; balance; eBuilibriu!

+ Cerebru! - lar(est "

Cerebellar Tests< a+) . - .o!ber(>s test" needs $ .Ns to assist " Nor!al anato!ical position & - E !in 'K) .o!ber(>s test - 'K) ata4ia or unsteady (ait or drun6en li6e !ove!ent with loss of balance+ b+) Fin(er to nose test 'K) To FTNT - dy!etria - inability to stop a !ove!ent at a desired point c+) Alternate pronation & supination Pal! up & down + 'K) To alternate pronation & supination or da!a(e to cerebellu! - dy!entriu! Co!position of brain " based on ?onroe Hellie 2ypothesis " S6ull is a closed container+ Any alteration in of 3 intracranial co!ponents 1 increase in /CP Nor!al /CP - E - & !!2( Fora!en ?a(nu! C - atlas C$ - a4is 'K) ProGectile vo!itin( 1 increase /CP Observe for $7 " 7# hrs CSF - cushions the brain; shoc6 absorber Obstruction of flow of CSF 1 increase /CP 2ydrocephalus - posteriorly due to closure of posterior fontanel C0A - partial* total obstruction of blood supply

INCREASED ICP - increase /CP is due to increase in of the /ntra Cranial co!ponents+
Predisposin( factors< +) 2ead inGury $+) Tu!or 3+) %ocaliCed abscess 7+) 2e!orrha(e 'stro6e) &+) Cerebral ede!a @+) 2ydrocephalus L+) /nfla!!atory conditions " ?enin(itis; encephalitis B+ S S( chan(e in 0S 1 always late sy!pto!s 3arliest S4< a+) Chan(e or decrease %OC - .estlessness to confusion 9ide pulse pressure< /ncreased /CP " ,isorientation to lethar(y Narrow pp< Cardiac disorder; shoc6 " Stupor to co!a %ate si(n - chan(e in 0*S + BP increase 'systolic increase; diastole" sa!e) $+ 9idenin( pulse pressure Nor!al adult BP $E*#E $E - #E 1 7E 'nor!al pulse pressure) /ncrease /CP 1 BP 7E*#E 1 7E - #E1 @E PP 'wide) 3+ .. is decreased 'Cheyne"Sto6es 1 bet period of apnea or hyperpnea with periods of apnea) 7+ Te!p increase /ncreased /CP< /ncrease BP Shoc6 - decrease BP ,ecrease 2. /ncrease 2. CAS2/N5S 3FF3CT ,ecrease .. /ncrease .. /ncrease Te!p ,ecrease te!p b+) 2eadache ProGectile vo!itin( Papilledi!a 'ede!a of optic dis6 - outer surface of retina) ,ecorticate 'abnor!al fle4ion) 1 ,a!a(e to cortico spinal tract * ,ecerebrate 'abnor!al e4tension) 1 ,a!a(e to upper brain ste!"pons* c+) Ancal herniation - unilateral dilation of pupil+ 'Bilateral dilation of pupil - tentorial herniation+) d+) Possible seiCure+

Nursin( priority< +) ?aintain patent a*w & adeBuate ventilation a+ Prevention of hypo4ia - 'decrease tissue o4y(enation) & hypercarbia 'increase in CO$ retention)+ 2ypo4ia - cerebral ede!a " increase /CP 2ypo4ia - inadeBuate tissue o4y(enation %ate sy!pto!s of hypo4ia - B - bradycardia 3 - e4tre!e restlessness , - dyspnea C - cyanosis 3arly sy!pto!s - . - restlessness A - a(itation T - tachycardia /ncrease CO$ retention* hypercarbia - cerebral vasodilatation 1 increase /CP ?ost powerful respiratory sti!ulant increase in C)* 2yperventilate decrease CO$ - e4crete CO$ .espiratory ,istress Syndro!e '.,S) - decrease O4y(en Suctionin( - E" & seconds; !a4 & seconds+ Suction upon re!oval of suction cap+ A!bu ba( - pu!p upon inspiration c+ Assist in !echanical ventilation + ?aintain patent a*w $+ ?onitor 0S & /&O 3+ 3levate head of bed 3E - 7& de(rees an(le nec6 in neutral position unless contra indicated to pro!ote venous draina(e 7+ %i!it fluid inta6e ;$EE - ;&EE !l*day 'FO.C3 F%A/, !eans</ncrease fluid inta6e*day - $;EEE - 3;EEE !l*day)" not for inc /CP+ &+ Prevent co!plications of i!!obility @+ Prevent increase /CP by< a+ ?aintain Buiet & co!fy environ!ent b+ Avoid use of restraints - lead to fractures c+ Siderails up d+ /nstruct patient to avoid the ff< "0alsalva !aneuver or bearin( down; avoid strainin( of stool '(ive la4atives* stool softener ,ulcola4* ,uphalac) " 34cessive cou(h - antitussive ,e4tro!etorpha! "34cessive vo!itin( - anti e!etic 'Plasil - Phil only)* Phener(an " %iftin( of heavy obGects " Bendin( & stoopin( e+ Avoid clusterin( of nursin( activities L+ Ad!inister me#s as ordered< +) Os!otic diuretic - ?annitol+*Os!itrol pro!otes cerebral diuresis by deco!pressin( brain tissue Nursin( considerations< Mannito" + ?onitor BP - S3 of hypotension $+ ?onitor /&O every hr+ report if M 3Ecc out put 3+ Ad!inister via side drip 7+ .e(ulate fast drip - to prevent for!ation of crystals or precipitate $+) %oop diuretic " %asi4 'Furose!ide) Nursin( ?(t< Lasi( Sa!e as ?annitol e4cept " %asi4 is (iven via /0 push 'e4pect urine after E" &!ins) should be in the !ornin(+ /f (iven at La!+ Pt will urinate at L< & /!!ediate effect of %asi4 within & !inutes+ ?a4 effect - @ hrs due 'La! - p!)

&

S*3 of %asi4

&y!o+a"emia 'nor!al H"3+& - &+& !e(*%)

+ $+ 3+ S&S4 9ea6ness & fati(ue Constipation 'K) NAO wave in 3C5 tracin(

Nursin( ?(t< +) Ad!inister H supple!ents - e4 Haliu! ,urule; H chloride Potassiu! .ich food< ABC>s of H 0e(etables Fruits A " aspara(us A - apple B - broccoli 'hi(hest) B - banana - (reen C - carrots C - cantalope* !elon O - oran(e 'hi(hest) -for di(italis to4icity also+ 0it A - sBuash; carrots yellow ve(etables & fruits; spinach; chesa /ron - raisins; Food appropriate for toddler - spa(hetti: Not !il6 - increase bronchial secretions ,on>t (ive (rapes - !ay cho6e S*3 of %asi4< +) 2ypo6ale!ia

$+) &y!oca"cemia 'Nor!al level Ca 1 #+& -

!(* EE!l) or ,etany< S&S4 wea6ness Paresthesia 'K) Trousseau si(n - patho(no!onic - or carpopedal spas!+ Put bp cuff on ar!1hand spas!+ 'K) Chevoste6>s si(n Arrhyth!ia %aryn(ospas! Ad!inister - Ca (luconate - /0 slowly

Ca -"uconate to(icity< S4 - seiCure - ad!inister ?( SO7

M- S). to(cicity- ad!inister Ca (luconate / - BP decrease U - urine output decrease R - .. decrease P - patellar refle4es absent

3+) &y!onatremia - Nor!al Na level 1 3& - 7& !e(*%

2ypotension Si(ns of ,ehydration< dry s6in; poor s6in tur(or; (en body !alaise+ 3arly si(ns - Adult< thirst and a(itation * Child< tachycardia ?(t< force fluid Ad!inister isotonic fluid sol 7+) &y!er-"ycemia - increase blood su(ar level P - polyuria P - polypha(ia P - polydipsia Ns( ?(t< a+ ?onitor FBS 'N1#E - $E !(*dl) &+) &y!erurecemia - increase seru! uric acid+ Tophi" urate crystals in Goint+ S*S4 -

Gouty art0ritis

+i#ney stones" renal colic 'pain)

Cool !oist s6in S4 Goint pain & swellin( usually at (reat toe+ Ns( ?(t of Gouty Art0ritis a+) Cheese 'not sardines; anchovies; or(an !eat) 'Not (ood if pt ta6in( ?AO) b+) Force fluid c+) Ad!inister !eds - Allopurinol* Pylopri! - inhibits synthesis of uric acid - dru( of choice for (out Colchicene - e4cretes uric acid+ Acute (out dru( of choice+ 1i#ney stones - renal colic 'pain)+ Cool !oist s6in ?(t< +) Force fluid $+) ?eds - narcotic anal(esic ?orphine SO7 S3 of Mor!0ine S). to(icity .espiratory depression 'chec6 .. st) Antidote for !orphine SO7 to4icity -Narcan 'NA%OJON3) Nalo4one to4icity - tre!ors /ncrease /CP !eds< 3+) Corticosteroids " ,e4a!ethsone - decrease cerebral ede!a ',ecadrone) 7+) ?ild anal(esic - codeine SO7+ For headache+ &+) Anti consultants - ,ilantin 'Phenytoin) Question< /ncrease /CP what is the i!!ediate ns( actionR a+ Ad!inister ?annitol as ordered b+ 3levate head 3E - 7& de(rees c+ .estrict fluid d+ Avoid use of restraints Ns( Priority - ABC & safety Pt sufferin( fro! epi(lotitis+ 9hat is ns( priorityR a+ Ad!inister steroids - least priority b+ Assist in 3T - te!p; a*w c+ Assist in tracheoto!y - per!anent 'Answer) d+ Apply war! !oist pac6R %east priority .ationale< 9ont need to pass laryn4 due to laryn4 is infla!ed+ 3T can>t pass+ Need tracheosto!y only" Ma-ic *'s of #ru- monitorinDru, - di(o4in % " lithiu! A - a!inophylline , - ,ilantin A - aceta!inophen N ran-e +& - +& !eB*% +@ - +$ !eB*% E - D !(* EE!l E " D !(* EE !l E - 3E !(* EE!l ,o(icity $ $ $E $E $EE C"assification cardiac (lycosides anti!anic bronchodilator anticonvulsant narcotic anal(esic In#ication C2F bipolar COP, seiCures osteoarthritis

Di-ita"is - increase cardiac contraction 1 increase CO

Nursin( ?(t + Chec6 P.; 2. 'if 2. below @Ebp!; don>t (ive,i(o4in) ,i(italis to4icity - antidote " ,i(ivine a+ Anore4ia "initial s4+ b+ n*v 5/T c+ ,iarrhea d+ Confusion e+ Photophobia

f+

Chan(es in color perception - yellow spots

'O6 to (ive to pts with renal failure+ ,i(o4in is !etaboliCed in liver not in 6idney+) L 2 "it0ium ("it0ane$ decrease levels of norepinephrine; serotonine; acetylcholine
Anti!anic a(ent %ithiu! to4icity S*S4 " Anore4ia n*s ,iarrhea ,ehydration - force fluid; !aintain Na inta6e 7 - E( daily 2ypothyroidis! 'C.3T/N/S?- the only endocrine disorder that can lead to !ental retardation)

a+) b+) c+) d+) e+)

A 2 amino!0y"ine (t0eo!0y""ine$ 2 dilates bronchioles+

Ta6e bp before (ivin( a!inophylline+ S*S4 < A!inophylline to4icity< + Tachycardia $+ 2yperactivity - restlessness; a(itation; tre!ors a+ b+ c+ d+ Question< Avoid (ivin( food with A!inophylline Cheese*butterfood rich in tyra!ine; avoided only if pt is (iven ?AO/ Beer* wine " 2ot chocolate & tea - caffeine - CNS sti!ulant tachycardia Or(an !eat* bo4 cereals - anti par6insonian

?AO/ - antidepressant ! A. plan n A. dil can lead to C0A or hypertensive crisis p A. nate 3 - 7 wee6s " before ?AO/ will ta6e effect Anti Par6insonian a(ents - 0it B@ Pyrido4ine reverses effect of %evodopa

D 2 #i"atin (P0enytoin$ - anti convulsant*seiCure

Nursin( ?(t< + ?i4ed with plain NSS or +D NaCl to prevent for!ation of crystals or precipitate " ,o sandwich !ethod " 5ive NSS then ,ilantin; then NSS: $+ /nstruct the pt to avoid alcohol - bec alcohol K dilantin can lead to severe CNS depression ,ilantin to4icity< S*S4< 5 - (in(ival hyperplasia - swollen (u!s i+ Oral hy(iene - soft toothbrush ii+ ?assa(e (u!s 2 - hairy ton(ue A " ata4ia N - nysta(!us - abnor!al !ove!ent of eyeballs A - aceta!inophen* Tylenol - non"opoid anal(esic & antipyretic - febrile pts Aceta!inophen to4icity < + 2epato to4icity $+ ?onitor liver enCy!es S5PT 'A%T) - Seru! 5luta!ic Piruvate Tyranase S5OT" Seru! 5luta!ic Acetate Tyranase 3+ ?onitor BAN ' E - $E) Crea '+#" ) Aceta!inophen to4icity can lead to hypo(lyce!ia T - tre!ors; Tachycardia

/ - irritability . - restlessness 3 - e4tre!e fati(ue , - depression 'ni(ht!ares) ; ,iaphoresis Antidote for aceta!inophen to4icity - Acetylcesteine 1 causes outporin( of secretions+ Suction+ Prepare suctionin( apparatus+ Question< The followin( are sy!pto!s of hypo(lyce!ia e4cept< a+ Ni(ht!ares b+ 34tre!e thirst - hyper(lyce!ia sy!pto!s c+ 9ea6ness d+ ,iaphoresis

PAR1INS)NS DSE 'par6insonis!) " chronic; pro(ressive disease of CNS char by de(eneration of dopa!ine
producin( cells in substancia ni(ra at !id brain & basal (an(lia " Palliative; Supportive Function of dopa!ine< controls (ross voluntary !otors+ Predisposin( Factors< + Poisonin( 'lead & carbon !ono4ide)+ Antidote for lead 1 Calciu! 3,TA $+ 2ypo4ia 3+ Arteriosclerosis 7+ 3ncephalitis 2i(h doses of the ff< a+ .eserpine 'serpasil) anti 2PN; S3 - +) depression " suicidal $+) breast cancer b+ ?ethyldopa 'aldo!et) " pro!ote safety c+ 2aloperidol '2aldol)" anti psychotic d+ PhenothiaCide " anti psychotic S3 of anti psychotic dru(s - E(tra Pyrami#a" Sym!tom Over !eds of anti psychotic dru(s - neuroleptic !ali(nant syndro!e char by tre!ors 'severe) S*S4< Par6insonis! + Pill rollin( tre!ors of e4tre!ities - early si(n $+ Brady6inesia - slow !ove!ent 3+ Over fati(ue 7+ .i(idity 'co(wheel type) a+ Stooped posture b+ Shufflin( - !ost co!!on c+ Propulsive (ait &+ ?as6 li6e facial e4pression with decrease blin6in( eyes @+ ?onotone speech L+ ,ifficulty risin( fro! sittin( position #+ ?ood labilety - always depressed - suicide Ns( priority< Pro!ote safety D+ /ncrease salivation - droolin( type E+ Autono!ic si(ns< " /ncrease sweatin( " /ncrease lacri!ation " Seborrhea 'increase sebaceous (land) " Constipation " ,ecrease se4ual activity Ns( ?(t +) Anti par6insonian a(ents " %evodopa '%",opa); Carbidopa 'Sine!et); A!antadine 2cl 'Sy!!etrel) ?echanis! of action /ncrease levels of dopa - relievin( tre!ors & brady6inesia S*3 of anti par6insonian " Anore4ia " n*v " Confusion " Orthostatic hypotension " 2allucination

" Arrhyth!ia Contraindication< + Narrow an(led closure (lauco!a $+ Pt ta6in( ?AO/ 'Parnate; ?arplan; Nardil) Ns( ?(t when (ivin( anti"par6insonian + Ta6e with !eals - to decrease 5/T irritation $+ /nfor! pt - urine* stool !ay be dar6ened 3+ /nstruct pt" don>t ta6e food 0it B@ 'Pyrido4ine) cereals; or(an !eats; (reen leafy ve( " Cause B@ reverses therapeutic effects of levodopa 5ive /N2 '/soniaCide"/sonicotene acid hydraCide+) S3"Peripheral neuritis+ $+) Anti choliner(ic a(ents - relieves tre!ors Artane !ech - inhibits acetylcholine Co(entin action ; S*3 " SNS 3+) Antihista!ine - ,iphenhydra!ine 2cl 'Benadryl) - ta6e at bedti!e S*3< adult- drowsiness;- avoid drivin( & operatin( heavy eBuipt+ Ta6e at bedti!e+ Child - hyperactivity CNS e4cite!ent for 6ids+ 7+) ,opa!ine a(onist Bro!otriptine 2cl 'Parlodel) - respiratory depression+ ?onitor ..+ Ns( ?(t - Par6inson +) ?aintain siderails $+) Prevent co!plications of i!!obility " Turn pt every $h Turn pt every h - elderly 3+) Assist in passive .O? e4ercises to prevent contractures 7+) ?aintain (ood nutrition C2ON - in a! C2ON - in p! - to induce sleep - due Tryptopan - A!ino Acid &+) /ncrease fluid in ta6e; hi(h fiber diet to prevent constipation @+) Assist in sur(ery - Sterota4ic Thala!oto!y Co!plications in sterota4ic thal!oto!y" +) Subarachnoid he!orrha(e $+) aneuris! 3+) encephalitis

MUL,IPLE SCLER)SIS (MS$

Chronic inter!ittent disorder of CNS - white patches of de!yelenation in brain & spinal cord+ " .e!ission & e4acerbation " Co!!on - wo!en; & - 3& yo cause - un6nown Predisposin( factor< + Slow (rowin( virus $+ Autoi!!une - 'supportive & palliative treat!ent only) Nor!al .esident Antibodies< /( 5 - can pass placenta - passive i!!unity+ Short actin(+ /( A - body secretions - saliva; tears; colostru!s; sweat /( ? - acute infla!!ation /( 3 - aller(ic reactions /(, - chronic infla!!ation S & S4 of ?S< 'everythin( down) + 0isual disturbances a+ Blurrin( of vision b+ ,iplopia* double vision c+ Scoto!as 'blind spots) - initial s4 $+ /!paired sensation to touch; pain; pressure; heat; cold a+ Nu!bness b+ Tin(lin( c+ Paresthesia 3+ ?ood swin(s - euphoria 'sense of elation ) 7+ /!paired !otor function<

a+ 9ea6ness b+ Spasiticity -N ti(asO c+ Paralysis -!aGor proble! &+ /!paired cerebellar function Triad S4 of ?S / - intentional tre!ors N - nysta(!us - abnor!al rotation of eyes Charcots triad A - Ata4ia & Scannin( speech @+ Arinary retention or incontinence L+ Constipation #+ ,ecrease se4ual ability ,4 - ?S + CSF analysis thru lu!bar puncture " .eveals increase C2ON & /(5 $+ ?./ - reveals site & e4tent of de!yelination 3+ %her!itte>s response is 'K)+ /ntroduce electricity at the bac6+ Theres spas! & paralysis at spinal cord+ Ns( ?(t ?S " Supportive !(t +) ?eds a+ Acute e4acerbation ACT2 - adenocorticotopic Steroids - to reduce ede!a at the site of de!yelination to prevent paralysis S!ina" Cor# In3ury Ad!inister dru( to prevent paralysis due to ede!a a+ 5ive ACT2 - steroids b+ Baclopen '%ioresol) or ,antrolene Na ',antrene) To decrease !uscle spasticity c+ /nterferone - to alter i!!une response d+ /!!unosuppresants $+ ?aintain siderails 3+ Assist passive .O?e4ercises - pro!ote proper body ali(n!ent 7+ Prevent co!plications of i!!obility &+ 3ncoura(e fluid inta6e & increase fiber diet - to prevent constipation @+ Provide catheteriCation die urinary retention L+ 5ive diuretics Arinary incontinence - (ive Prophantheline bro!ide 'probanthene) Antispas!odic anti choliner(ic #+ 5ive stress reducin( activity+ ,eep breathin( e4ercises; biofeedbac6; yo(a techniBues+ D+ Provide acid"ash diet - to acidify urine & prevent bacteria !ultiplication 5rape; Cranberry; Oran(e Guice; 0it C

M4AS,&ENIA GRA5IS (MG$ - disturbance in trans!ission of i!pulses fro! nerve to !uscle cell at neuro !uscular
Gunction+ Co!!on in 9o!en; $E - 7E yo; un6nown cause or idiopathic Autoi!!une - release of cholenesterase - enCy!e Cholinesterase destroys AC2 'acetylcholine) 1 ,ecrease acetylcholine ,escendin( !uscle wea6ness 'Ascendin( !uscle wea6ness - 5uillain Barre Syndro!e) Ns( priority< ) a*w $) aspiration 3) i!!obility S* S4< +) Ptosis - droopin( of upper lid ' initial si(n) Chec6 Palpebral fissure - openin( of upper & lower lids 1 to 6now if 'K) of ?5+ $+) ,iplopia - double vision 3+) ?as6 li6e facial e4pression

7+) ,yspha(ia - ris6 for aspiration: &+) 9ea6enin( of laryn(eal !uscles - hoarseness of voice @+) .esp !uscle wea6ness - lead respiratory arrest+ Prepare at bedside tracheosto!y set L+) 34tre!e !uscle wea6ness durin( activity especially in the !ornin(+ ,4 test + Tensilon test '3drophoniu! 2cl) - te!porarily stren(thens !uscles for & - E !ins+ Short ter!" choliner(ic+ PNS effect+ Ns( ?(t + ?aintain patent a*w & adeBuate vent by< a+) Assist in !echanical vent - attach to ventilator b+) ?onitor pul!onary function test+ ,ecrease vital lun( capacity+ $+ ?onitor 0S; /&O neuro chec6; !uscle stren(th or !otor (radin( scale '7*&; &*&; etc) 3+ Siderails 7+ Prevent co!plications of i!!obility+ Adult"every $ hrs+ 3lderly" every hr+ &+ N5T feedin( Ad!inister !eds a+) Choliner(ics or anticholinesterase a(ents ?estinon 'Pyridosti(!ine) Neosti(nine 'prosti(!in) - %on( ter! " /ncrease acetylcholine s*e - PNS b+) Corticosteroids - to suppress i!!une resp ,ecadron 'de4a!ethasone) ?onitor for $ types of Crisis< ?yastinic crisis A cause - + Ander !edication $+ Stress 3+ /nfection B S&S4 + Anable to see - Ptosis & diplopia $+ ,yspha(ia" unable to swallow+ 3+ Anable to breath C ?(t - ad! choliner(ic a(ents Choliner(ic crisis Cause< over !eds S*S4 " PNS

?(t+ ad! anti"choliner(ic " Atropine SO7 " SNS - dry !outh L+ Assist in sur(ical proc - thy!ecto!y+ .e!oval of thy!us (land+ Thy!us secretes auto i!!une antibody+ #+ Assist in plas!aparesis - filter blood D+ Prevent co!plication - respiratory arrest Prepare tracheosto!y set at bedside+

G/S - Gui""ain /arre Syn#rome

" ,isorder of CNS " Bilateral sy!!etrical polyneuritis " Ascendin( paralysis Cause - un6nown; idiopathic " Auto i!!une " r*t antecedent viral infection " /!!uniCations S&S4 /nitial < + Clu!siness $+ Ascendin( !uscle wea6ness - lead to paralysis 3+ ,yspha(ia 7+ ,ecrease or di!inished ,T. 'deep tendon refle4es) " Paralysis &+ Alternate 2PN to hypotension - lead to arrhyth!ia " co!plication @+ Autono!ic chan(es increase sweatin(; increase salivation+ /ncrease lacri!ation Constipation

,4 !ost i!portant< CSF analysis thru lu!bar puncture reveals increase in < /(5 & C2ON 'sa!e with ?S) Ns( ?(t + ?aintain patent a*w & adeBuate vent a+ Assist in !echanical vent b+ ?onitor pul!onary function test $+ ?onitor vs+; /&O neuro chec6; 3C5 tracin( due to arrhyth!ia 3+ Siderails 7+ Prevent co!pl - i!!obility &+ Assist in passive .O? e4ercises @+ /nstitute N5T feedin( - due dyspha(ia L+ Ad! !eds '5BS) as ordered< - + Anti choliner(ic - atropine SO7 $+ Corticosteroids - to suppress i!!une response 3+ Anti arrhyth!ic a(ents a+) %idocaine *Jylocaine -S3 confusion 1 0Tach b+) Bretylliu! c+) Quinines*Quinidine - anti !alarial a(ent+ 5ive with !eals+ " To4ic effect - cinchonis! Quinidine to4icity S*3 - anore4ia; n*v; headache; verti(o; visual disturbances #+ Assist in plas!aparesis '?5+ 5BS) D+ Prevent co!p - arrhyth!ias; respiratory arrest Prepare tracheosto!y set at bedside+ /NF% CON,/TONS OF B.A/N ?enin(es - 3"fold !e!brane - cover brain & spinal cord F4< Protection & support Nourish!ent Blood supply 3 layers + ,ura!ater sub dural space $+ Arach!oid !atter 3+ Pia !atter sub arachnoid space

where CSF flows %3 & %7+ Site for lu!bar puncture+

MENINGI,IS - infla!!ation of !enin(itis & spinal cord

3tiolo(y - ?enin(ococcus Pneu!ococcus 2e!ophilous influenCa - child Streptococcus - adult !enin(itis ?OT - direct trans!ission via droplet nuclei S&S4 " Stiff nec6 or nuchal ri(idity 'initial si(n) " 2eadache " ProGectile vo!itin( - due to increase /CP " Photophobia " Fever chills; anore4ia " 5en body !alaise " 9t loss " ,ecorticate*decerebration - abnor!al posturin( " Possible seiCure S4 of !enin(eal irritation - nuchal ri(idity or stiffness Opisthotonus" ri(id archin( of bac6 Patho(no!onic si(n - 'K) Herni(>s & BrudCins6i si(n

%e( pain

nec6 pain

,4< + Lumbar !uncture - lu!bar* spinal tap - use of hallow spinal needle - sub arachnoid space %3 & %7 or %7 & %& Aspirate CSF for lu!bar puncture+ Ns( ?(t for lu!bar puncture - invasive + Consent * e4plain procedure to pt " .N - d4 procedure 'lab) " ?, - operation procedure $+ 3!pty bladder; bowel - pro!ote co!fort 3+ Arch bac6 - to clearly visualiCe %3; %7 Ns( N(t post lu!bar + Flat on bed - $ - $7 h to prevent spinal headache & lea6 of CSF $+ Force fluid 3+ Chec6 punctured site for draina(e; discoloration & lea6a(e to tissue 7+ Assess for !ove!ent & sensation of e4tre!eties .esult + CSF analysis< a+ increase C2ON & 9BC Content of CS6< Chon; wbc; (lucose b+ ,ecrease (lucose Confir!s !enin(itis c+ increase CSF openin( pressure N &E - @E !!2( d+ 'K) Culture !icroor(anis! $+ Co!plete blood count CBC - reveals increase 9BC ?(t< + Ad! !eds a+) Broad"spectru! antibiotic penicillin S*3 + 5/T irritation - ta6e with food $+ 2epatoto4icity; nephroto4cicity 3+ Aller(ic reaction 7+ Super infection - alteration in nor!al bacterial flora " N flora throat - streptococcus " N flora intestine - e coli S4 of superinfection of penicillin 1 diarrhea b+) Antipyretic c+) ?ild anal(esic $+ Strict resp isolation $7h after start of antibiotic therapy A - Cushin(>s synd - reverse isolation " due to increased corticosteroid in body+ B - Aplastic ane!ia - reverse isolation " due to bone !arrow depression+ C - Cancer anytype - reverse isolation - i!!unoco!pro!ised+ , - Post liver transplant - reverse isolation - ta6es steroids lifeti!e+ 3 - Prolon(ed use steroids - reverse isolation F - ?enin(itis - strict respiratory isolation - safe after $7h of antibiotic therapy 5 - Asth!a - not to be isolated 3+ 7+ &+ @+ L+ Co!fy & dar6 roo! - due to photophobia & seiCure Prevent co!plications of i!!obility ?aintain F & 3 balance ?onitor vs; /&O ; neuro chec6 Provide client health teachin( & dischar(e plan a+ Nutrition - increase cal & C2O; C2ON"for tissue repair+ S!all freB feedin( b+ Prevent co!plication hydrocephalus; hearin( loss or nerve deafness+ #+ Prevent seiCure+ 9here to brin( $ yo post !enin(itis

" Audiolo(ist due to da!a(e to hearin(" post repair !yelo!enin(ocele " Arolo(ist ",a!a(e to sacral area - spina bifida - controls urination D+ .ehab for neurolo(ical deficit+ Can lead to !ental retardation or a delay in psycho!otor develop!ent+

CERE/R) 5ASCULAR ACCIDEN, - stro6e; brain attac6 or cerebral thro!bosis; apople4y

" " " Partial or co!plete disruption in the brains blood supply $ lar(est & co!!on artery in stro6e ?iddle cerebral artery /nternal carotid artery Co!!on to !ale - $ - 34 hi(h ris6

Predisposin( factor< + Thro!bosis - clot 'attached) $+ 3!bolis! - dislod(ed clot - pul!o e!bolis! S*S4< !u"mo embo"ism Sudden sharp chest pain Ane4plained dyspnea; SOB Tachycardia; palpitations; diaphoresis & !ild restlessness S*S4< cerebra" embo"ism 2eadache; disorientation; confusion & decrease in %OC Fe!ur fracture - co!plications< fat e!bolis! - !ost feared co!plication w*in $7hrs Iellow bone !arrow - produces fat cells at !eduallary cavity of lon( bone .ed bone !arrow - provides 9BC; platelets; .BC found at epiphisis $+) 2e!orrha(e 3+) Co!part!ent syndro!e - co!pression of nerves* arteries .is6 factors of C0A< 2PN; ,?; ?/; artherosclerosis; valvular heart dse " Post heart sur(ery - !itral valve replace!ent %ifestyle< + S!o6in( - nicotine - potent vasoconstrictor $+ Sedentary lifestyle 3+ 2yperlipide!ia - (enetic 7+ Prolon(ed use of oral contraceptives " ?acro pill - has lar(e a!t estro(en " ?ini pill - has lar(e a!t of pro(estin " Pro!ote lipolysis 'brea6down of lipids*fats) - artherosclerosis - 2PN " stro6e &+ Type A personality a+ ,eadline driven person b+ $ - & thin(s at the sa!e ti!e c+ 5uilty when not don( anythin( @+ ,iet - increase saturated fats L+ 3!otional & physical stress #+ Obesity

S & S4 + T/A" warnin( si(ns of i!pendin( stro6e attac6s " 2eadache 'initial s4); diCCiness* verti(o; nu!bness; tinnitus; visual & speech disturbances; paresis or ple(ia '!onople(ia e4tre!e) /ncrease /CP $+ Stro6e in evolution - pro(ression of S & S4 of stro6e 3+ Co!plete stro6e - resolution of stro6e a+) 2eadache b+) Cheyne"Sto6es .esp c+) Anore4ia; n*v d+) ,yspha(ia e+) /ncrease BP f+) 'K) Herni(>s & BrudCins6i - s4 of he!orrha(ic stro6e

&

(+) Focal & neurolo(ical deficit + Phle(ia $+ ,ysarthria - inability to vocaliCe; articulate words 3+ Aphasia 7+ A(raphia diff writin( &+ Alesia - diff readin( @+ 2o!oninous he!ianopsia - loss of half of field of vision %eft sided he!ianopsia - approach .i(ht side of pt - the unaffected side ,4 + CT Scan - reveals brain lesion $+ Cerebral arterio(raphy - site & e4tent of !al occlusion " /nvasive procedure due to inGect dye " Aller(y test All - (raphy - invasive due to iodine dye Post +) Force fluid - to e4crete dye is nephroto4ic $+) Chec6 peripheral pulses " distal Ns( ?(t + ?aintain patent a*w & adeBuate vent " Assist !echanical ventilation " Ad!inister O$ $+ .estrict fluids - prevent cerebral ede!a 3+ 3levate head of bed 3E"7& de(rees an(le+ Avoid valsalva !aneuver+ 7+ ?onitor vs+; /&O; neuro chec6 &+ Prevent co!pl of i!!obility by< a+ Turn client B$h 3lderly B h " To prevent decubitus ulcer " To prevent hypostatic pneu!onia - after prolon(ed i!!obility+ b+ 3(( crate !attress or 2$O bed c+ Sand ba( or foot board" prevent foot drop @+ N5T feedin( - if pt can>t swallow L+ Passive .O? e4ercise B7h #+ Alternative !eans of co!!unication " Non"verbal cues " ?a(ic slate+ Not paper and pen+ Tirin( for pt+ " 'K) To he!ianopsia - approach on unaffected side D+ ?eds Os!otic diuretics - ?annitol %oop diuretics - %asi4* Furose!ide Corticosteroids - de4ta!ethaCone ?ild anal(esic Thro!bolytic* fibrolitic a(ents - tunaw clot+ S3"Articaria; pruritus"caused by forei(n subs+ Strepto6inase Aro6inase Tissue plas!ino(en activatin( ?onitor bleedin( ti!e Anticoa(ulants - 2eparin & Cou!adinO sabayO Cou!adin will ta6e effect after 3 days 2eparin - !onitor PTT partial thro!boplastin ti!e if prolon(ed - bleedin( (ive Prota!ine SO7" antidote+ Cou!adin -%on( ter!+ !onitor PT prothro!bin ti!e if prolon(ed" bleedin( (ive 0it H - ABua!ephyton" antidote+ Antiplatelet - PASA - aspirin paraane!o aspirin; don>t (ive to den(ue; ulcer; and un6nown headache+ 2ealth Teachin( + Avoidance !odifiable lifestyle " ,iet; s!o6in( $+ ,ietary !odification " Avoid caffeine; decrease Na & saturated fats Co!plications<

Subarachnoid he!orrha(e .ehab for focal neurolo(ical deficit - physical therapy + ?ental retardation $+ ,elay in psycho!otor develop!ent

C)N5ULSI5E Disor#er (C)N5ULSI)NS$" disorder of the CNS char+ by paro4ys!al seiCures with or without loss of
consciousness; abnor!al !otor activity; alteration in sensation & perception & chan(e in behavior+ Can you out(row febrile seiCureR Febrile seiCure Nor!al if M & yo Patholo(ic if S & yo ,ifference between< SeiCure" st convulsive attac6 3pilepsy - $nd and with history of seiCure

Predisposin( Factor 2ead inGury due birth trau!a To4icity of carbon !ono4ide Brain tu!or 5enetics Nutritional & !etabolic deficit Physical stress Sudden withdrawal to anticonvulsants will brin( about status epilepticus Status epilepticus - dru( of choice< ,iaCepa! & (lucose S & S4 /+ 5eneraliCed SeiCure a+) 5rand !al * tonic clonic seiCures 9ith or without aura - warnin( sy!pto!s of i!pendin( seiCure attac6" 3pi(astric pain" associated with olfactory; tactile; visual; auditory sensory e4perience " 3pileptic cry - fall " %oss of consciousness 3 - & !in " Tonic clonic contractions " ,irect sy!!etrical e4tension of e4tre!ities"TON/C+ Contractions"C%ON/C " Post ictal sleep "state of lethar(y or drowsiness " unrespondin( sleep after tonic clonic b+) Peti!al seiCure - 'sa!e as daydrea!in(:) or absent seiCure+ " Blan6 stare " ,ecrease blin6in( eye " Twitchin( of !outh " %oss of consciousness - & - E secs 'Buic6 & short) //+ %ocaliCed*partial seiCure a+) Tac6sonian seiCure or focal seiCure - tin(lin(*Ger6y !ove!ent of inde4 fin(er*thu!b & spreads to shoulder & sideof the body with Gan6sonian !arch b+) Psycho!otor* focal !otor " seiCure "Auto!atis! - stereotype repetitive & non"purposive behavior " Cloudin( of consciousness - not in control with environ!ent " ?ild hallucinatory sensory e4perience + $+ 3+ 2A%%AC/NAT/ONS Auditory - schitCo - paranoid type 0isual - 6orsa6offs psychosis - chronic alcoholis! Tactile - addict - substance abuse

///+ Status epilecticus - continuous; uninterrupted seiCure activity; if untreated; lead to hyperpre4ia - co!a - death SeiCure< inc electrical firin( in brain1increased !etabolic activity in brain1brain usin( (lucose and O$1dec (lucose; dec O$+ T4<,iaCepa! 'dru( of choice); (lucose ,4"Convulsion" (et health history: + CT scan - brain lesion $+ 335 electroencephalo(raphy

" 2yperactivity brain waves Ns( ?(t Priority - Airway & safety + ?aintain patent a*w & pro!ote safety Before seiCure< + .e!ove blunt*sharp obGects $+ %oosen clothin( 3+ Avoid restraints 7+ ?aintain siderails &+ Turn head to side to prevent aspiration @+ Ton(ue (uard or !outh piece to prevent bitin( of ton(ue"B3FO.3 S3/PA.3 ON%I: Can use spoon at ho!e+ L+ Avoid precipitatin( sti!ulus - bri(ht (larin( li(hts & noises #+ Ad!inister !eds a+ ,ilantin 'Phenytoin) -' to4icity level - $E ) S3 5in(uial hyperplasia 2"hairy ton(ue A"ata4ia N"nysta(!us A"aceta!inophen" febrile pt ?i4 with NSS " ,on>t (ive alcohol - lead to CNS depression b+ 'Te(retol) Carba!asene" (iven also to Tri(e!inal Neural(ia+ S3< arryth!ia c+ Phenobarbital '%u!inal)" S3< hallucinations $+ /nstitute seiCure & safety precaution+ Post seiCure< Ad!inister O$+ Suction apparatus ready at bedside 3+ ?onitor onset & duration " Type of seiCure " ,uration of post ictal sleep+ The lon(er the duration of post ictal sleep; the hi(her chance of havin( status epilepticus: 7+ Assist in sur(ical procedure+ Cortical resection &+ Co!plications< Subarachnoid he!orrha(e and encephalitis Question< yo (rand !al - i!!ediate nursin( action 1 a*w & safety a+ ?outhpiece - yr old - little teeth only b+ Ad! o$ inhalation - post: c+ 5ive pillow - safety 'answer) d+ Prepare suction Neurolo(ical assess!ent< + Co!prehensive neuro e4a! $+ 5CS " G"as-o7 coma sca"e - obG !easure!ent of %OC or Buic6 neuro chec6 3 co!ponents of 3CS ? - !otor @ 0 - verbal resp & 3 - eye openin( 7 & & - 7 - conscious 3- lethar(y E - # - stupor L - co!a 3 - deep co!a - lowest score Survey of !ental status & speech 'Co!prehensice Neuro 34a!) +) %OC & test of !e!ory $+) %evels of orientation 3+) CN assess!ent 7+) ?otor assess!ent

&+) @+) L+) #+)

Sensory assess!ent Cerebral test - .o!hber(; fin(er to nose ,T. Autono!ics

%evels of consciousness '%OC) + Conscious 'conscious) - awa6e - levels of wa6efulness $+ %ethar(y 'lethar(ic) - drowsy; sleepy; obtunded 3+ Stupor 'stuporous) - awa6ened by vi(orous sti!ulation Pt has (en body wea6ness; decrease body refle4 7+ Co!a 'Co!atose) li(ht - 'K) all for!s of painful sti!ulations ,eep - '") to painful sti!ulation Question< Describe a conscious pt ? a+ Alert - not all pt are alert & oriented to ti!e & place b+ Coherent c+ A7a+e8 answer d+ Aware ,ifferent types of pain sti!ulation " Don't !ric+ + ,eep sternal sti!ulation* pressure 34- fist 6nuc6le 9ith response - li(ht co!a 9ithout response - deep co!a $+ Pressure on (reat toe - 34 3+ Orbital pressure - pressure on orbits only - below eye 7+ Corneal refle4* blin6in( refle4 9isp of cotton - used to illicit blin6in( refle4 a!on( conscious patients /nstill "drop saline solution - unconscious pt if '") response pt is in deep co!a &+ Test of !e!ory - considered educational bac6(round a+) Short ter! !e!ory " 9hat did you eat for brea6fastR ,a!a(e to te!poral lobe - 'K) antero (rade a!nesia b+) %on( ter! !e!ory 'K) .etro(rade a!nesia - da!a(e to li!bic syste! @+ %evels of orientation Ti!e Place Person 5raphesthesia" can identify nu!bers or letters written on pal! with a blunt obGect+ A(raphesthesia - cant identify nu!bers or letters written on pal! with a blunt obGect+

CN assessment:
/// /// /0 00/ 0// 0/// /J JJ/J// Olfactory Optic Oculo!otor Trocheal Tri(e!inal Abducens Facial Acustic*auditory 5lassopharyn(eal 0a(us Spinal accessory 2ypo(lossal s s ! ! b ! b s b b ! !

s!allest CN lar(est CN

lon(est CN

/+ )"factory - don>t use a!!onia; alcohol; colo(ne irritatin( to !ucosa - use coffee; bar soap; vine(ar; ci(arette tar " 2ypos!ia - decrease sensitivity to s!ell " ,ipos!ia - distorted sense of s!ell " Anos!ia - absence of sense of s!ell 3ither of 3 !i(ht indicate head inGury - da!a(e to cribrifor! plate of eth!oid bone where olfactory cells are located or indicate infla!!ation condition - sinusitis

// o!tic" test of visual acuity - Snellens chart - central or distance vision Snellens 3 chart - used for illiterate chart N $E*$E vision distance by w*c person can see letters" $E ft Nu!erator - distance to snellens chart ,eno!inator - distance the person can see the letters O, - .t eye $E*$E $E*$EE - blindness - cant read 3 - bi((est OS - left eye $E*$E OA - both eye $E*$E $+ a+ b+ c+ d+ Test of peripheral vision* visual field Superiority Bite!porally /nferiorly Nasally

Co!!on ,isorders - see pa(e #&"#L for !ore info on (lauco!a; etc+ + 5lauco!a - Nor!al $ - $ !!2( pressure " /ncrease /OP " %oss of peripheral vision - Ntunnel visionO $+ Cataract - opacity of lens " %oss of central vision; NBlurrin( or haCy visionO 3+ .etinal detach!ent - curtain veil - li6e vision & floaters 7+ ?acular de(eneration - blac6 spots ///; /0; 0/ - tested si!ultaneously " /nnervates the !ove!entt of e4trinsic ocular !uscle @ cardinal (aCe 3O? .t eye /O %. S. 3 - 7 3O? /0 - sup obliBue 0/ - lateral rectus Nor!al response - P3..%A 'isocoria - eBual pupil) Anisocoria - uneBual pupil Oculo!otor + .aisin( of eyelid - Ptosis $+ Controls pupil siCe $ "3 c! or +& - $ !! 0 - ,ri-emina" - %ar(est - consists of " ophthal!ic; !a4illary; !andibular Sensory - controls sensation of the face; !ucus !e!braneU teeth & cornea refle4 Anconscious - instill drop of saline solution ?otor - controls !uscles of chewin(* !uscles of !astication Tri(e!inal neural(ia - diff chewin( & swallowin( - e4tre!e food te!p is not reco!!ended Question< Tri(e!inal neural(ia; .N should (ive a+ 2ot !il6; butter; raisins b+ Cereals c+ 5elatin; toast; potato - all correct but d+ Potato; salad; (elatin - salad easier to chew 0/ 6acia"< Sensory - controls taste - ant $*3 of ton(ue test cotton applicator put su(ar+ "Put applicator with su(ar to tip to ton(ue+ "Start of taste insensitivity< A(e (roup - 7E yrs old ?otor" controls !uscles of facial e4pression; s!ile frown; raise eyebrow SO ?. N O S 3 left eye

$E

,a!a(e - Bells palsy - facial paralysis Cause - bells palsy pedia - .*T forcep delivery Te!porary only ?ost evident clinical si(n of facial sy!!etry< Nasolabial folds 0/// Acoustic* vestibule cochlear 'controls hearin() - controls balance '6enesthesia or position sense) " ?ove!ent & orientation of body in space " Or(an of Corti - for hearin( - true sense or(an of hearin( Outer - ty!panic !e!brane; pinna; oricle 'i!pacted ceru!en); ceru!en ?iddle - ha!!er; anvil; stirrup or !elleus; incus; staples+ ?id otitis !edia 3ustachean ear /nner ear" !eniere dse; sensory hearin( loss 'research parts: & dse) .e!ove vestibule - !eniere>s dse - disease inner ear

"

Archi!edes law - buoyancy 'pre(nancy - fetus) ,altons law - partial pressure of (ases /nertia - law of !otion 'diCCiness; verti(o) +) Pt with !ultiple stab wound " chest " ?ove!ent of air in & out of lun(s is carried by what principleR " ,iffusion - ,alton>s law $+) Pre(nant - chec6 up - ultrasound reveals fetus is carried by a!niotic fluid " Archi!edes 3+) Severe verti(o due" /nertia Test for acoustic nerve< " .epeat words uttered /J - G"osso!0aryn-ea" - controls taste - posterior *3 of ton(ue J - 5a-us - controls (a( refle4 Test D - E Pt say ah - chec6 uvula - should be !idline ,a!a(e cerebral he!isphere is % or . 5a( refle4 - place ton(ue depression post part of ton(ue ,on>t touch uvula J/ - S!ina" Accessory " controls sternocleido!astoid 'nec6) & trapeCius 'shoulders and bac6) " Shru( shoulders; put pressure+ Pt should resist pressure+ Paresis or phle(ia J// - &y!o-"ossa" - controls !ove!ent of ton(ue - say NahO+ Assess ton(ue position1!idline % or . deviation " Push ton(ue a(ainst chee6 " Short frenulu! lin(ue Ton(ue tied - NbulolO

END)CRINE F4 of endocrine - ductless (land ?ain (land - Pituitary (land - located at base of brain of Stella Turcica ?aster (land of body ?aster cloc6 of body Anterior pituitary (land - adenohypophysis Posterior pituitary (land - neurohypophysis Posterior pituitary<

+) O4ytocin - a+) Pro!otes uterine contraction preventin( bleedin(* he!orrha(e+ " 5ive after placental delivery to prevent uterine atony+ b+) ?il6 letdown refle4 with help of prolactin+ $+) A,2 - antidiuretic hor!one - 'vasopressin) "Prevents urination - conserve 2$O

A9 DIA/E,IS INSIPIDUS ',/" dalas ihi) - hyposecretion of A,2

Cause< idiopathic* un6nown Predisposin( factor< + Pituitary sur(ery $+ Trau!a* head inGury 3+ Tu!or 7+ /nfla!!ation 8 alcohol inhibits release of A,2 S & S4< + Polyuria $+ S4 of dehydration " 34cessive thirst 'adult) " A(itation " Poor s6in tur(or " ,ry !ucus !e!brane 3+ 9ea6ness & fati(ue 7+ 2ypotension - if left untreated " &+ 2ypovole!ic shoc6 Anuria - late si(n hypovole!ic shoc6 '
st

s4 of dehydration in children"tachycardia)

,4 Proc< + ,ecrease urine specific (ravity" concentrated urine N1 +E & - +E3& $+ Seru! Na 1 increase 'N1 3& " 7& !eB*%) 2ypernatre!ia ?(t< + $+ 3+ 7+ Force fluid $;EEE - 3;EEE!l*day Ad!inister /0 fluid replace!ent as ordered ?onitor 0S; /&O Ad!inister !eds as ordered a+) Pitresin 'vasopressin) /? &+ Prevent co!plications ?ost feared co!plication - 2ypovole!ic shoc6

B+) SIAD& 8 Syn#rome of Ina!!ro!riate Anti8Diuretic &ormone

" /ncrease A,2 " /diopathic* un6nown Predisposin( factor + 2ead inGury $+ .elated to Broncho(enic cancer or lun( caner" 3arly Si(n of %un( Ca " Cou(h - + non productive $+ productive 3+ 2yperplasia of Pit (land /ncrease siCe of or(an S&S4 + $+ 3+ Fluid retention /ncrease BP - 2PN 3de!a

$$

7+ &+

9t (ain ,an(er of 2$O into4ication -Co!plications< + cerebral ede!a - increase /CP - $+ seiCure

,4 Proc< + Arine specific (ravity increase - diluted urine $+ 2yponatre!ia - ,ecreased Na

Ns( ?(t< + .estrict fluid $+ Ad!inister !eds as ordered e(+ ,iuretics< %oop and Os!otic 3+ ?onitorstrictly 0*S; /&O; neuro chec6 - increase /CP 7+ 9ei(h daily &+ Assess for presence ede!a @+ Provide !eticulous s6in care L+ Prevent co!plications - increase /CP & seiCures activity Anterior Pituitary 5land - adeno + 5rowth hor!one '52) 'So!atotropic hor!one) F4< 3lon(ation of lon( bones ,ecrease 52 - dwarfis! children /ncrease 52 - (i(antis! /ncrease 52 - acro!e(aly - adult Puberty D yo - $ yo 3piphyseal plate closes at $ yo SBuare face SBuare Gaw ,ru( of choice in acro!e(aly< Ocreotide 'Sandostatin) S3 diCCiness So!atostatin 2or!one - anta(oniCes the release of of 52 ?elanocytes sti!ulatin( hor!one " ?S2 S6in pi(!entation Prolactin*luteotrpic hor!one* lacto(enic hor!one " Pro!otes develop!ent of !a!!ary (land 'O4ytocin"/nitiates !il6 letdown refle4) 7+ Adrenocorticotropic hor!one - ACT2 " ,evelop!ent & !aturation of adrenal corte4 &+ %uteiniCin( hor!one - produces pro(esterone+ @+ FS2" produces estro(en " $+ " 3+ PINEAL GLAND + Secretes ?elatonin - inhibits luteniCin( hor!one '%2) secretion ,&4R)ID GLAND 'T5) Question< Nor!al physical findin( on T5< a+ 9ith tenderness - thyroid never tender b9 :it0 no#u"ar consistency8 answer c+ ?ar6ed asy!!etry - only T5 d+ Palpable upon swallowin( " Nor!al T5 never palpable unless with (oiter T5 hor!ones< T3 " Triodothyronine " 3 !olecules of iodine

T7 "Tetraiodothyronine* Tyro4ine " 7 !olecules of iodine

Thyrocalcitonin FJ - anta(oniCes effects of parathor!one

?etabolic hor!one /ncrease !etabolis! brain -inc cerebration; inc v*s all v*s down; constipation

$3

2ypo T3 T7 " lethar(y & !e!ory i!pair!ent 2yper T3 T7 " a(itation; restlessness; and hallucination L+ /ncrease 0S; increase !otility 2IPOT2I.O/,/S? - all decreased e4cept wt & !enstruation; loss of appetite but with wt (ain !enorrha(ia - increase in !ens 2IP3.T2I.O/,/S? " /ncrease appetite - wt loss; a!enorrhea

SIMPLE G)I,ER - enlar(ed thyroid (land " iodine deficiency

Predisposin( factors + 5oiter belt area " Place far fro! sea - no iodine+ Seafood>s rich in iodine $+ ?ountainous area - increase inta6e of (oitro(enic foods 'AS< ?idwest; N3; Salt %a6e) Cabba(e - has pro(oitrin - an anti thyroid a(ent with no iodine 34a!ple< Turnips 'sin(6a!as); radish; peas; strawberries; potato; beans; 6a!ote; cassava 'root crops); all nuts+ 3+ 5oitro(enic dru(s< Anti thyroid a(ents <'PTA) prephyl thiupil %ithiu! carbonate; Aspirin PASA Cobalt; Phenyl butasone 3nde!ic (oiter - cause V Sporadic (oiter - caused by V$ & 3 S & S4 - enlar(ed T5 ?ild restlessness ?ild dyspha(ia ,4 Proc+ + Thyroid scan - reveals enlar(ed T5 $+ Seru! TS2 - increase 'confir!atory) 3+ Seru! T3; T7 - N or below N Ns( ?(t< + Ad!inister !eds a+) /odine solution - %o(ol>s solution or saturated sol of H iodide SSH/ Ns( ?(t %u(ol>s sol - violet color + use straw - prevent stainin( teeth $+ Prophyla4is $ "3 drops Treat!ent - & to @ drops Ase straw - to prevernt stainin( of teeth + %u(ol>s sol+; $+ tetracycline 3+ nitrofurantin '!acrodantin)"urinary anticeptic"pyelonephritis+ 7+ /ron solution+ B+ Thyroid h * A(ents + %evothyro4ine 'Synthroid) $+ %iothyronine 'cyto!el) 3+ Thyroid e4tract Ns( ?(t< for T2*a(ents + ?onitor vs+ - 2. due tachycardia & palpitation $+ Ta6e it early A? - S3 inso!nia 3+ ?onitor s*e Tachycardia; palpitations Si(ns of inso!nia 2yperthyroidis! restlessness a(itation 2eat intolerance 2PN

$7

3+

3ncoura(e increase inta6e iodine - iodine is e4tracted fro! seaweeds ':) Seafood" hi(hest iodine content oysters; cla!s; crabs; lobster %owest iodine - shri!ps /odiCed salt -easily destroyed by heat ta6e it raw not coo6ed Assist sur(ery" Sub total thyroidecto!y" Co!plication< + Tetany $+ laryn(eal nerve da!a(e 3+2e!orrha(e"feelin( of fullness at incision site+Chec6 nape for wet blood+ 7+%aryn(eal spas! - ,OB; SOB - trache set ready at bedside+

7+

$+)

&4P),&4R)IDISM - decrease secretion of T3; T7 - can lead to ?/ * Atherosclerosis

Adult - !y4ede!a Child" cretinis! - only endocrine dis lead to !ental retardation Predisposin( factor< + W/atro(enic causes - caused by sur(ery $+ Atrophy of T5 due to< a+ /rradiation b+ Trau!a c+ Tu!or; infla!!ation 3+ /odine def 7+ Autoi!!une - 2ashi!oto disease S&S4 everythin( decreased e4cept wt (ain & !ens increase) 3arly si(ns - wea6ness and fati(ue %oss of appetite - increased lypolysis - brea6down of fats causin( atherosclerosis 1 ?/ 9t (ain Cold intolerance - !y4ede!a " co!a Constipation %ate S4 - brittle hair* nails Non pittin( ede!a due increase accu!ulation of !ucopolysacharide in SQ tissue "?y4ede!a 2orseness voice ,ecrease libido ,ecrease 0S - hypotension bradycardia; bradypnea; and hypother!ia %ethar(y ?e!ory i!pair!ent leadin( to psychosis"for(etfulness ?enorrha(ia ,4< + $+ 3+ Seru! T3 T7 decrease Seru! cholesterol increase - can lead to ?/ .A /A - radio iodine upta6e - decrease

Ns( ?(t< + ?onitor strictly 0*S+ /&O - to deter!ine presence of !y4ede!a co!a: My(e#ema Coma " Severe for! of hypothyroidis! 2ypotension; hypoventilation; bradycardia; bradypnea; hyponatre!ia; hypo(lyce!ia; hypother!ia ?i(ht lead to pro(ressive stupor & co!a /!pt !(t for ?y4ede!a co!a + Assist !ech vent - priority a*w $+ Ad! thyroid hor!one 3+ Ad! /0F replace!ent - force fluid ?(t !y4ede!a co!a + ?onitor 0S; /&O $+ Provide dietary inta6e low in calories - due to wt (ain 3+ S6in care due to dry s6in 7+ Co!fortable & war! environ!ent due to cold intolerance &+ Ad!inister /0F replace!ents

$&

@+ L+

#+

Force fluid Ad!inister !eds - ta6e A? - S3 inso!ia+ ?onitor 2.+ Thyroid hor!ones %evothyro4ine'Synthroid); %iothyronine 'cyto!el) Thyroid e4tracts 2ealth teachin( & dischar(e plan a+ Avoidance precipitatin( factors leadin( to !y4ede!a co!a< + 34posure to cold environ!ent $+ Stress 3+ /nfection 7+ Ase of sedative; narcotics; anesthetics not allowed - CNS depressants 0*S already down

Co!plications< D+ 2ypovole!ic shoc6; !y4ede!a co!a E+ 2or!onal replace!ent therapy " lifeti!e + /!portance of follow up care

&4PER,&4R)IDISM " 5raves dse or thyroto4icosis ' everythin( up e4cept wt and !ens)
"/ncreased T3 & T7 Predisposin( factors< + Autoi!!une disease - release of lon( actin( thyroid sti!ulator '%ATS) 34opthal!os 3nopthal!os - severe dehydration depressed eye $+ 34cessive iodine inta6e 3+ 2yperplasia of T5 S&S4< + $+ 3+ 7+ &+ @+ #+ L+ #+ D+ ,4< + $+ 3+ Seru! T3 & T7 " increased .adio iodine upta6e - increase Thyroid scan - reveals enlar(ed T5 /ncrease in appetite - hyperpha(ia - wt loss due to increase !etabolis! S6in is !oist " perspiration 2eat intolerance ,iarrhea - increase !otility All 0S increase 1 2PN; tachycardia; tachypnea; hyperther!ia CNS chan(es /rritability & a(itation; restlessness; tre!ors; inso!nia; hallucinations 5oiter 34opthal!os - patho(no!onic s4 A!enorrhea

Ns( ?(t< + ?onitor 0S & / & O - deter!ine presence of thyroid stor! or !ost feared co!plication< Thyroto4icosis $+ Ad!inister !eds a+ Antithyroid a(ents + Prophylthiuracil 'PTA) $+ ?ethy!aCole 'TapaCole) ?ost to4ic s*e a(ranulocytosis" fever; sore throat; leu6ocytosis1inc wbc< chec6 cbc and throat swab culture ?ost feared co!plication < Thro!bosis - stro6e C0S 3+ 7+ &+ @+ L+ #+ ,iet - increase calorie - to correct wt loss S6in care Co!fy & cool environ!ent ?aintain siderails" due a(itation*restlessness Provide bilateral eye patch - to prevent dryin( of eyes" e4opthal!os Assist in sur(ery - subtotal thyroidecto!y

$@

Ns( ?(t< pre"op Ad! %u(ol>s solution 'SSH/) H iodide D+ To decrease vascularity of T5 E+ To prevent bleedin( & he!orrha(e ?(t post op< Co!plication< + 9atch out for si(ns of thyroid stor! or thyroto4icosis ,ria# si-ns of t0yroi#stormU a+ Tachycardia *palpitation b+ 2yperther!ia c+ A(itation + $+ 3+ Ns( ?(t Thyroid Stor!< ?onitor 0S & neuro chec6 A(itated !i(ht decrease %OC Antipyretic - fever Tachycardia " bloc6ers '"lol) Siderails - a(itated

Co!p $+ 9atch for inadvertent 'accidental) re!oval of parathyroid (land Secretes Para hor!one /f re!oved; hypocalce!ia " classic si(n tetany - + +'K) Trousseau si(n* $+ Chvostec6>s si(n Ns( ?(t< Ad! calciu! (luconate slowly - to prevent arrhyth!ia Ca (luconate to4icity - antidote - ?(SO7

3+%aryn(eal 'voice bo4) nerve da!a(e 'accidental)

S4< hoarseness of voice 8883ncoura(e pt to tal6 or spea6 post operatively asap to deter!ine laryn(eal nerve da!a(e Notify physician:

7+ Si(ns of bleedin( post subtotal thyroidecto!y

" NFeelin( of fullnessO at incision site Ns( !(t< Chec6 soiled dressin( at nape area

&+ Si(ns of laryn(eal spas!

a+ ,OB b+ SOB Prepare at bedside tracheosto!y

@+ 2or!onal replace!ent therapy " lifeti!e L+ /!portance of follow up care

'%iver cirrhosis - bedside scissor - if pt co!plaints of ,OB) 'Cut cystachean tube to deflate balloon)

Parat0yroi# -"an# - pair of s!all nodules located behind the T5 + Secrets parathyroid hor!one - pro!otes Ca reabsorption Thyrocalcitonin - anta(onises secretion of parathyroid hor!one + $+ 2ypoparthroidis! - decrease of parathyroid hor!one 2yperparathroids!

$L

&4P)PARA,&4R)IDISM - decreased parathor!one

2ypocalce!ia 'Or tetany) X/f Ca decreases; phosphate increasesY A+ Predisposin(; factors< + Followin( subtotal thyroidecto!y $+ Atrophy of parathyroid (land due to a+ /rradiation b+ Trau!a S&S4< + Acute tetany a+ Tin(lin( sensation b+ Paresthesia c+ ,yspha(ia d+ %aryn(ospas! e+ Bronchospas! Patho(no!onic Si(n of tetany< a+ 'K) Trousseau>s or carpopedial spas! b+ 'K) Chvostec6>s si(n f+ SeiCure (+ Arrhyth!ia $+ !ost feared co!plication 2yperphosphate!ia

Chronic tetany a+ %oss of tooth ena!el b+ Photophobia & cataract for!ation c+ 5/T chan(es - anore4ia; n*v; (eneral body !alaise d+ CNS chan(es - !e!ory i!pair!ent; irritability Seru! calciu! - decrease 'N #+& !(* EE!l) Seru! phosphate increase 'N $+& - 7+& !(* EE!l) J"ray of lon( bone - decrease bone density CT Scan - reveals de(eneration of basal (an(lia

,4< + $+ 3+ 7+

Ns( ?(t< + Ad!inistration of !eds< a+) Acute tetany Ca (luconate - /0; slowly b+) Chronic tetany + Oral Ca supple!ents 34+ Ca (luconate Ca carbonate Ca lactate 0it , 'Cholecalceferol) ,ru( diet sunli(ht

$#

Cholecalceferol

calcidiol

calcitriol

La! - Da!

$+ Phosphate binder Alu!!inu! ,2 (el 'a!pho (el) S3 constipation Antacid AAC ?A, Alu!inu! containin( acids ?( containin( antacids 34+ ?il6 or !a(nesia Alu!inu! O2 (el ,iarrhea Constipation ?aalo4 - !a(nesiu! & alu!inu! " %ess s*e $+ Avoid precipitatin( sti!ulus such as bri(ht li(hts & noise< photophobia leadin( to seiCure 3+ ,iet - increase Ca & decrease phosphorus " ,on>t (ive !il6 - due to increase phosphorus 5ood 1 anchovies - increase Ca; decrease phosphorus K inc uric acid+ Tuna & (reen turnips" /nc Ca+ 7+ Bedside - tracheosto!y set -due to laryn(ospas! &+ 3ncoura(e to breath with paper ba( in order to produce !ild respiratory acidosis - to pro!ote increase ioniCed Ca levels @+ ?ost feared co!plication < SeiCure & arrhyth!ia L+ 2or!onal replace!ent therapy " lifeti!e #+ /!portant fallow up care

&4PERPARA,&4R)IDISM " increase parathor!one+ Co!plication< .enal failure

2ypercalce!ia can lead to 2ypophosphate!ia Bone dse " ?ineraliCation %eadin( to bone fracture Ca - DDF bones F seru! blood Predisposin( Factors< + 2yperplasia parathyroid (land 'PT5) $+ Over co!pensation of PT5 due to 0it , deficiency Children - .ic6ets 0it , Adults - Osteo!alacia deficiency Sippy>s diet - 0it , diet - not (ood for pt with ulcer $ "7 cups of !il6 & butter Harrel>s diet - 0it , diet - not (ood for pt with ulcer @ cups of !il6 & whole crea! Food rich in C2ON - e((no( - co!bination of e(( & !il6 S*S4< Bone fracture + Bone pain 'especially at bac6); bone fracture $+ Hidney stone a+ .enal colic b+ Cool !oist s6in 3+ 5/T chan(es - anore4ia; n*v; ulcerations 7+ CNS involve!ent- irritability; !e!ory i!pair!ent ,4 Proc< + Seru! Ca increase 6idney stones

$D

$+ 3+

Seru! phosphorus decreases J"ray lon( bones - reveals bone de!ineraliCation

Ns( ?(t< 1i#ney Stone + $+ 3+ 7+ &+ @+ Force fluids - $;EEE - 3;EEE*day or $"3%*day /sotonic solution 9ar! sitC bath - for co!fort Strain all urine with (auCe pad Acid ash diet - cranberry; plu!; (rapefruit; vit C; cala!ansi - to acidify urine Ad! !eds a+ Narcotic anal(esic - ?orphine SO7; ,e!erol '?eperidine 2cl) S*3 - resp depression+ ?onitor ..) Narcan* Nalo4one - antidote Nalo4one to4icity - tre!ors Siderails Assist in a!bulation ,iet - low in Ca; increase phosphorus lean !eat Prevent co!plication ?ost feared - renal failure Assist sur(ical procedure - parathyroidecto!y /!pt ff up care 2or!onal replace!ent" lifeti!e

L+ #+ D+ E+ + $+ 3+

A,.3NA% 5%AN, $+ Atop of Z 6idney 3+ $ parts Adrenal corte4 - outer!ost layer Adrenal !edulla " inner!ost layer 7+ Secrets cathecola!ines a+) 3pinephrine * Norephinephrine - potent vasoconstrictor - adrenaline1/ncrease BP Adrenal ?edulla>s only disease<

P&E)C&R)M)C4,)MA8 presence of tu!or at adrenal !edulla

"increase nor*epinephrine "with 2PN and resistant to dru(s "dru( of choice< beta bloc6ers "co!plication< 2PN crisis 1 lead to stro6e "no valsalva !aneuver

Adrenal Corte4 -

+ $+

Pona fasiculata - secrets (lucocorticoids 34+ Cortisol " Controls (lucose !etabolis! 'SA5A.) Pona reticularis - secrets traces of (lucocorticoids & andro(enic hor!ones ? - testosterone F - estro(en & pro(esterone F4 - pro!otes develop!ent of secondary se4ual characteristics 34+ Aldosterone F4< pro!otes Na & 2$O reabsorption & e4cretion of potassiu! 'SA%T)

3+ Pona (lo!erulosa " secretes !ineralcortisone

ADDIS)N'S DISEASE - Steroids"lifeti!e

,ecreased adrenocortical hor!ones leadin( to<

3E

a+) ?etabolic disturbances 'su(ar) b+) F&3 i!balances" Na; 2$O; H c+) ,eficiency of neuro!uscular function 'salt & se4) Predisposin( Factors< + Atrophy of adrenal (land $+ Fun(al infections 3+ Tubercular infections S*S4< + Decrease su-ar - 2ypo(lyce!ia - ,ecreased (lucocorticoids " cortisol T - tre!ors; tachycardia / " irritability . " restlessness 3 - e4tre!e fati(ue , - diaphoresis; depression *9 Decrease !"asma cortiso" ,ecrease tolerance to stress - lead to Addisonian>s crisis

3+ Decrease sa"t - 2yponater!ia - ,ecreased !ineralocorticoids " Aldosterone 2ypovole!ia a+) 2ypotension b+) Si(ns of dehydration - e4tre!e thirst; a(itation c+) 9t loss 7+ 2yper6ale!ia a+) /rritability b+) ,iarrhea c+) Arrhyth!ia &+ ,ecrease se4ual ur(e or libido" ,ecreased Andro(en @+ %oss of pubic and a4illary hair To Prevent ST, Loca" - practice !ono(a!ous relationship CG6NS;NCLE< - condo! L+ Patho(no!onic si(n- bronCe li6e s6in pi(!entation due to decrease cortisol will sti!ulate pituitary (land to release !elanocyte sti!ulatin( hor!one+ ,4 Proc< + FBS - decrease FBS 'N #E - $E !(*d%) $+ Plas!a cortisol - decreased Seru! Na - decreased 'N 3& - 7& !e(*%) 3+ Seru! H - increased 'N 3+& - &+& !e(*%) Ns( ?(t<

+ ?onitor 0S; /&O - to deter!ine presence of Addisonian crisis &+ Co!plication of Addison>s dse < Addisonian crisis @+ .esults the acute e4acerbation of Addison>s dse characteriCed by < 2ypotension; hypovole!ia; hyponatre!ia; wt loss; arrhyth!ia L+ %ead to pro(ressive stupor & co!a
+ $+ 3+ Ns( ?(t A##isonian Crisis 'Co!a) Assist in !echanical ventilation Ad! steroids Force fluids

$+

Ad!inister !eds a+) Corticosteroids " ',ecadron) or ,e4a!ethaCone " 2ydrocortisone 'cortisone)" Prednisone

Ns( ?(t with Steroi#s + Ad! $*3 dose in A? & *3 dose in P? in order to !i!ic the nor!al diurnal rhyth!+ $+ Taper the dose 'w*draw; (radually fro! dru() - sudden withdrawal can lead to addisonian crisis 3+ ?onitor S*3 'Cushin(>s syndro!e S*S4) a+) 2PN b+) 2irsutis! c+) 3de!a d+) ?oon face & buffalo hu!p e+) /ncrease susceptibility to infection sue to steroids" reverse isolation b+) ?ineralocorticoids e4+ Flourocortisone

3+ 7+ &+ @+ L+

,iet - increase calorie or C2O /ncrease Na; /ncrease C2ON; ,ecrease H Force fluid Ad!inister isotonic fluid as ordered ?eticulous s6in care - due to bronCe li6e

2T & dischar(e plannin( a) Avoid precipitatin( factors leadin( to A##isonian crisis + Sudden withdrawal crisis $+ Stress 3+ /nfection b) Prevent co!plications Addisonian crisis & 2ypovole!ic shoc6

#+ D+

2or!onal replace!ent therapy - lifeti!e /!portant< follow up care

CUS&ING'S S4NDR)ME - increase secretion of adrenocortical hor!one

Predisposin( Factors< + 2yperplasia of adrenal (land $+ Tubercular infection - !illiary TB S*S4 + /ncrease su(ar - 2yper(lyce!ia 3 P>s + Polyuria $+ Polydipsia - increase thirst 3+ Polypha(ia - increase appetite Classic S4 of ,? - 3 P>s & (lycosuria K wt loss $+ /ncrease susceptibility to infection - due to increased corticosteroid 3+ 2ypernatrer!ia a+ 2PN b+ 3de!a c+ 9t (ain d+ ?oon face Buffalo hu!p Obese trun6 classic si(ns Pendulous abdo!en Thin e4tre!ities 7+ 2ypo6ale!ia a+ 9ea6ness & fati(ue b+ Constipation c+ 3C5 - 'K) NAO wave &+ 2irsutis! - increase se4 @+ Acne & striae L+ /ncrease !uscularity of fe!ale ,4< + FBS - increase[ 'N< #E" $E!(*d%)

3$

$+ 3+ 7+

Plas!a cortisol increase Na - increase ' 3&" 7& !eB*%) H" decrease '3+&"&+& !eB*%)

Ns( ?(t< + ?onitor 0S; /&O $+ Ad!inister !eds a+ H" sparin( diuretics 'Aldactone) Spironolactone " pro!otes e4cretion of NA while conservin( potassiu! Not lasi4 due to S*3 hypoH & 2yper(lyce!ia: 3+ 7+ .estrict Na Provide ,ietary inta6e - low in C2O; low in Na & fats 2i(h in C2ON & H &+ 9ei(h pt daily & assess presence of ede!a" !easure abdo!inal (irth" notify doc+ @+ .everse isolation L+ S6in care - due acne & striae #+ Prevent co!plication " ?ost feared - arrhyth!ia & ,? '3ndocrine disorder lead to ?/ - 2ypothyroidis! & ,?) D+ Sur(ical bilateral Adrenolecto!y E+ 2or!onal replace!ent therapy - lifeti!e due to adrenal (land re!oval" no !ore corticosteroid:

PANC.3AS - behind the sto!ach; !i4ed (land - both endocrine and e4ocrine (land
Acinar cells 'e4ocrine (land) Secrete pancreatic Guices at pancreatic ducts+ Aids in di(estion 'in sto!ach) /slets of %an(erhans 'endocrine (land ductless) cells secrets (luca(on F4n< hyper(lyce!ia 'hi(h (lucose) Cells Secrets insulin F4n< hypo(lyce!ia ,elta Cells Secrets so!atostatin F4n< anta(oniCes (rowth hor!one

3 disorders of the Pancreas + ,? $+ Pancreatic Cancer 3+ Pancreatitis

Overview only<

33

PANCREA,I,IS (chec6 pa(e L$)- acute infla!!ation of pancreas leadin( to pancreatic ede!a; he!orrha(e & necrosis due to
Autodi(estion - self"di(estion Cause< un6nown*idiopathic #+ Or alcoholis! Patho(no!onic si(n" 'K) Cullen>s si(n " 3cchy!osis of u!bilicus 'bluish color)" pasa 'K) 5rey turner>s si(n - ecchy!osis of flan6 area Both s4 !eans he!orrha(e

C&R)NIC &EM)RR&AGIC PANCREA,I,IS" Nban(u(otO

Predisposin( factors " un6nown .is6 factor< + 2istory of hepatobiliary disorder $+ Alcohol 3+ ,ru(s - thiaCide diuretics; oral contraceptives; aspirin; penthan 7+ Obesity &+ 2yperlipide!ia @+ 2yperthyroidis! L+ 2i(h inta6e of fatty food - saturated fats

DIA/E,ES MELLI,US " !etabolic disorder characteriCed by non utiliCation of C2O; C2ON;& fat !etabolis!
Classification<

/+

,y!e I DM (IDDM) - NTuvenile N onset; co!!on in children; non"obese Nbrittle dseO

"/nsulin dependent diabetes !ellitus /ncidence rate +) EF of population with ,? have Type / Predisposin( Factor< + DEF hereditary - total destruction of pancreatic dells $+ 0irus 3+ To4icity to carbon tetrachloride 7+ ,ru(s - Steroids both cause hyper(lyce!ia %asi4 " loop diuretics S*S4< 3 P>S K 5 +) Polyuria $+) Poydipsia 3+) Polypha(ia 7+) 5lycosuria &+) 9ei(ht loss @+) Anore4ia L+) N*0 #+) Blurrin( of vision D+) /ncrease susceptibility to infection E+) ,elayed* poor wound healin( ?(t< + /nsulin Therapy ,iet 34ercise Co!plications - ,iabetic Hetoacidosis ',HA) ,iabetic Hetoacidosis ',HA) - due to increase fat catabolis! or brea6down of fats

37

,HA -'K) fruity or acetone breath odor Hass!aul>s respiration - rapid; shallow breathin( ,iabetic co!a 'needs o4y(en)

II9 ,y!e II DM 2 (NIDDM$

Adult* !aturity onset type - a(e 7E & above; obese /ncidence .ate + DEF of pop with ,? have Type // ?id D#E>s !ar6ed increase in type // because of increase proliferation of fast food chains: Predisposin( Factor< + Obesity - obese people lac6 insulin receptors bindin( site $+ 2ereditary S*S4< + $+ T4< + $+ 3+ Oral 2ypo(lyce!ic A(ents 'O2A) ,iet 34ercise Asy!pto!atic 3 P>s and 5

Co!plication< 2ONHC 2 - hyper O - os!olar N - non H - 6etotic C - co!a III9 GES,A,I)NAL DM - occurs durin( pre(nancy & ter!inates upon delivery of child Predisposin( Factors< + An6nown* idiopathic $+ /nfluence of !aternal hor!ones S*S4 < Sa!e as type // + Asy!pto!atic $+ 3 P>s & 5 Type of delivery - CS - due to lar(e baby S4 of hypo(lyce!ia on infant + 2i(h pitched shrill cry $+ Poor suc6in( refle4 I59 DM ASS)CIA,ED :I,& ),&ER DIS)RDER a+) Pancreatic tu!or b+) Cancer c+) Cushin(>s syndro!e 3 ?A/N FOO, 5.OAPS Anabolis! + C2ON (lucose $+ C2ON a!ino acids 3+ Fats fatty acids

Catabolis! (lyco(en nitro(en free fatty acids 'FFA) - Cholesterol & Hetones

Pancreas \ (lucose \ ATP '?ain fuel*ener(y of cell )

3&

.eserve (lucose - (lyco(en %iver will under(o - (luco(enesis - synthesis of (luca(ons & 5lyco(enolysis - brea6down of (luca(ons & 5luconeo(enesis - for!ation of (lucose for! C2O sources - C2ON & fats 2yper(lyce!ia - pancreas will not release insulin+ 5lucose can>t (o to cell; stays at circulation causin( hyper(lyce!ia+ increase os!otic diuresis - (lycosuria %ead to cellular starvation %ead to wt loss sti!ulates the appetite* satiety center '2ypothala!us) Polypha(ia Sti!ulates thirst center 'hypothala!us) Polydipsia /ncreased C2ON catabolis! %ead to '") nitro(en balance Tissue wastin( 'cache4ia) polyuria Cellular dehydration

/ncrease fat catabolis! Free fatty acids Cholesterol Atherosclerosis 2PN ?/ stro6e 6etones ,HA co!a death

DIA/E,IC 1E,)ACID)SIS (D1A$

" " Acute co!plication of Type / ,? due to severe hyper(lyce!ia leadin( to CNS depression & Co!a+ Hetones" a CNS depressant

Predisposin( factor< + Stress - between stress and infection; stress causes ,HA !ore+ $+ 2yper(lyce!ia 3+ /nfection S*S4< + $+ 3+ 7+ &+ @+ L+ #+ D+ 3 P>s & 5 Polyuria Polydipsia Polypha(ia 5lycosuria 9t loss Anore4ia; N*0 'K) Acetone breath odor" fruity odor Huss!aul]s resp"rapid shallow respiration CNS depression

patho(no!onic ,HA

3@

E+ Co!a ,4 Proc< + FBS increase; 2ct - increase 'co!pensate due to dehydration) N 1BAN - E "$E !(* EE!l ""increased due to severe dehydration Crea " +# - !(* EE!l 2ct 7$F 'should be 34 hi(h)"nto h(b Ns( ?(t< + Can lead to co!a - assist !echanical ventilation $+ Ad!inister +DNaCl - isotonic solution Followed by +7&NaCl hypotonic solution To counteract dehydration+ 3+ ?onitor 0S; /&O; blood su(ar levels 7+ Ad!inister !eds as ordered< a+) /nsulin therapy - /0 push .e(ular Actin( /nsulin - clear '$"7hrs; pea6 action) b+) To counteract acidosis - Na &C)= c+) Antibiotic to prevent infection /nsulin Therapy A+ Sources< + Ani!al source - beef* por6"rarely used+ Causes severe aller(ic reaction+ $+ 2u!an - has less anti(enecity property Cause less aller(ic reaction+ 2u!ulin 3+ /f 6id is aller(ic to chic6en - don>t (ive !easles vaccine due it co!es fro! chic6en e!bryo+ Artificially co!pound

B+ Types of /nsulin + .apid Actin( /nsulin " 34+ .e(ular actin( / $+ /nter!ediate actin( / " 34+ NP2 'non"prota!ine 2a(edorn /) 3+ %on( actin( / " 34+ Altra lente ,y!es of Insu"in + .apid $+ /nter!ediate 3+ %on( actin( co"or consistency clear cloudy cloudy onset " " " !ea+ #uration $"7h " @" $h " $"$7h "

34+ &a! 2e!o(lucose test '25T) $&E !(*dl Ad! & units of .A / Pea6 L"Da! - !onitor hypo(lyce!ic reaction at this ti!e" T/.3, Ns( ?(t< upon inGection of insulin< +Ad!inister insulin at roo! te!p: - To prevent lipodystrophy 1 atrophy* hypertrophy of SQ tissues $+ /nsulin is only refri(erated once opened: 3+ 5ently roll vial bet pal!s+ Avoid sha6in( to prevent for!ation of bubbles+ 7+ Ase (au(e $& - $@needle - tuberculin syrin(e &+ Ad!inister insulin at either 7&'for s6inny pt) or DE 'taba pt)dependin( on the client tissue deposit+ @+ ,on>t aspirate after inGection L+ .otate inGection site to prevent lipodystrophy #+ ?ost accessible site - abdo!en D+ 9hen !i4in( $ types of insulin; aspirate st re(ular* clear - before cloudy to prevent conta!inatin( clear insulin & to pro!ote accurate calibration+ E+ ?onitor si(ns of co!plications< a+ Aller(ic reactions - lipodystrophy b+ So!o(yi>s pheno!enon - hypo(lyce!ia followed by periods of hyper(lyce!ia or rebound effect of insulin+

3L

!l or cc of tuberculin 1 EE units of insulin

""

cc 1 EE units

" " +&cc 1 &E units " " + cc 1 E units @ units .A ?ost Feared Co!plication of Type // ,? 2yper [ os!olarity 1 severe dehydration Os!olar Non " absence of lipolysis Hetotic " no 6etone for!ation Co!a - S*S4< headache; restlessness; seiCure; decrease %OC 1 co!a Ns( ?(tU " sa!e as ,HA e4cept don>t (ive Na2CO3: +Can lead to co!a - assist !echanical ventilation $+ Ad!inister +DNaCl - isotonic solution Followed by +7&NaCl hypotonic solution To counteract dehydration+ 3+?onitor 0S; /&O; blood su(ar levels 7+Ad!inister !eds a+) /nsulin therapy - /0 b+) Antibiotic to prevent infection T4< O ral 2 ypo(lyce!ic A (ents D+ Sti!ulates pancreas to secrete insulin Classifications of O2A + First (eneration Sulfonylurear a+ Chlorpropa!ide 'diabenase) b+ Tolbuta!ide 'orinase) c+ TolaCa!ide 'tolinase) $+ $nd (eneration sulfonylurear a+ ,iabeta '?icronase) b+ 5lipside '5lucotrol)

Ns( ?(t or O2A + Ad!inister with !eals - to lessen 5/T irritation & prevent hypo(lyce!ia $+ Avoid alcohol 'alcohol K O2A 1 severe hypo(lyce!ic reaction1CNS depression1co!a) Antabuse",isufra! ,4 for ,? + FBS - N #E - $E !(*dl 1 /ncreased for 3 consecutive ti!es K 3 P>s & 5 $+ Oral (lucose tolerance 'O5TT) " ?ost sensitive test 3+ .ando! blood su(ar - increased 7+ Alpha 5lucosylated 2(b - elevated 1confir!s ,?::

3#

Ns( ?(tU + ?onitor for P3AH action of O2A & insulin Notify ,oc $+ ?onitor 0S; /&O; neurochec6; blood su(ar levels+ 3+ Ad!inister insulin & O2A therapy as ordered+ 7+ ?onitor si(ns of hyper & hypo(lyce!ia+ Pt ,? -N hini!atayO $E+ Iou don>t 6now if hypo or hyper(lyce!ia+ 5ive si!ple su(ar 'Brain can tolerate hi(h su(ar; but brain can>t tolerate low su(ar:) Cold; cla!!y s6in - hypo - Oran(e Tuice or si!ple su(ar * war! to touch - hyper - ad! insulin &+ Provide nutritional inta6e of #iabetic #iet< C2O - &EF C2ON - 3EF Fats - $EF "Or offer alternative food products or bevera(e+ "5lass of oran(e Guice+ @+ 34ercise - after !eals when blood (lucose is risin(+ L+ ?onitor co!plications of ,? a+ Atherosclerosis - 2PN; ?/; C0A b+ ?icroan(iopathy - s!all blood vessels 3yes - diabetic retinopathy ; pre!ature cataract & blindness Hidneys - recurrent pyelonephritis & .enal Failure '$ co!!on causes of .enal Failure < ,? & 2PN) c+ 5an(rene for!ation d+ Peripheral neuropathy + ,iarrhea* constipation $+ Se4ual i!potence e+ Shoc6 due to cellular dehydration #+ Foot care !(t a+ Avoid wa6in( barefooted b+ Cut toe nails strai(ht c+ Apply lanolin lotion - prevent s6in brea6down d+ Avoid wearin( constrictive (ar!ents D+ Annual eye & 6idney e4a! E+ ?onitor urinalysis for presence of 6etones Blood or seru! - !ore accurate + Assist in sur(ical wound debride!ent $+ ?onitor si(ns or ,HA & 2ONHC 3+ Assist sur(ical procedure BHA or above 6nee a!putation

)vervie7: 23?ATO%O5/CA% SIST3?S

/ Blood // Blood vessels /// Blood for!in( or(ans + Thy!us - re!oved !yasthenia (ravis $+ %iver - lar(est (land 3+ %y!ph nodes 7+ %y!phoid or(ans - payers patch &+ Bone !arrow @+ Spleen - destroys .BC Blood vessels + 0eins -S0C; /0C; Tu(ular vein - blood towards the heart $+ Artery - carries blood away fro! the $ + Aorta; carotid

3D

3+

Capillaries

Blood 7&F for!ed ele!ents - &&F plas!a - fluid portion of vlood+ Iellow color+ Seru! Plas!a C2ON>s 'Produced in %iver) + Albu!in" lar(est; !ost abundant plas!a ?aintains os!otic pressure preventin( ede!a FJN< pro!otes s6in inte(rity $+ 5lobulins - alpha - transports steroids 2or!ones & bilirubin " Transports iron & copper 5a!!a - transport i!!uno(lobulins or antibodies 3+ Prothro!bin - fibrino(en - clottin( factor to prevent bleedin(

For!ed 3le!ents< + .BC 'erythrocytes) Spleen life span 1 $E days 'N) 3 - @ ?*!!3 " Anucleated " Biconcave discs " 2as !olecules of 2(b 'red cell pi(!ent) Transports & carries O$

SIC1LE CELL ANEMIA -sic6le shaped .BC+ Should be round+ /!paired circulation of .BC+ "i!!ature cells1he!olysis of .BC1decreased h(b
3 Ns( priority + a*w - avoid deo4y(enatin( activities " 2i(h altitude is bad $+ Fluid deficit - pro!ote hydration 3+ Pain & co!fort 2(b ' he!o(lobin) F1 $ - 7 (!s F ? 1 7" @ (!s F 2ct - 34 h(b $ 4 3 1 3@ 'ha!atocrit) F 3@ - .*> 7 4 3 1 7$ ? .* - 7#F Avera(e 7$F " .ed cell percenta(e in whole red Substances needed for !aturation of .BC a+) Folic acid b+) /ron c+) 0it C d+) 0it B $ 'cyanocobala!in) e+) 0it B@ 'Pyrido4ine) f+) /ntrinsic factor Pre(nant< tri!ester" Folic acid - prevent neural tube deficit 3 tri - iron %ife span of rbc - #E - $E days+ ,estroyed at spleen+
rd st

9BC - leucocytes &;EEE - E;EEE*!!3 5.ANA%OCIT3S + Po"ymor!0onuc"earneutro!0i"s ?ost abundant @E"LEF 9BC " f4 - short ter! pha(ocytosis For acute infla!!ation

NON"5.ANA%OCIT3S + Monocytes '!acropha(e) " lar(est 9BC " involved in lon( ter! pha(ocytes " For chronic infla!!ation " Other na!e !acropha(e

7E

$+ PM /aso!0i"s "/nvolved in Parasitic infection " .elease of che!+ ?ediator for infla!!ation Serotonin; hista!ine; prosta(landin; brady6inins 3+ PM eosino!0i"s " Aller(ic reactions

?acropha(e in CNS" !icro(lia ?acropha(e in s6in - 2istiocytes ?acropha(e in lun(s - alveolar !acropha(e ?acropha(e in Hidneys - Hupffer cells $+ Lym!0ocytes B Cell - % - bone !arrow or bursa dependent T cell - dev>t of i!!unity" tar(et site for 2/0 NH cell - natural 6iller cell 2ave both antiviral & anti"tu!or properties 3+P"ate"ets 'thro!bocytes) N" &E;EEE - 7&E; EEE* !!3 it pro!otes he!ostasis - prevention of blood loss by activatin( clottin( " Consists of i!!ature or baby platelets 6nown as !e(a6aryocytes - tar(et of virus den(ue " Nor!al lifespan D - $ days

,ru( of choice for 2/0 Pidovudine 'APT or .etrovir) Standard precaution for 2/0 (loves; (own; (o((les & !as6 ?alaria - ni(ht bitin( !osBuito ,en(ue - day bitin( !osBuito Si(ns of platelet dis function< a+) Petecchiae b+) 3cche!osis* bruises c+) OoCin( or blood fro! venipuncture site

ANEMIA
/ron deficiency Ane!ia - chronic nor!ocytic; hypocro!ic 'pale); !icrocytic ane!ia due to inadeBuate absorption of iron leadin( to hypo4e!ic inGury+ /ncidence rate< + Co!!on - developed country - due to hi(h cereal inta6e ,ue to accidents - co!!on on adults $+ Co!!on - tropical countries - blood suc6in( parasites 3+ 9o!en - & - 3&yo - reproductive yrs 7+ Co!!on a!on( the poor - poor nutritional inta6e Suicide " co!!on in teena(er Poisonin( - co!!on in children 'aspirin) Aspiration - co!!on in infant Accidents - co!!on in adults Cho6in( - co!!on in toddler S/,S - co!!on in infant in AS $$+ Co!!on in tropical Cone - Phil due blood suc6s Predisposin( factor< + Chronic blood loss a+ Trau!a b+ ?ens c+ 5/T bleedin(< i+ 2e!ate!esis" ii+ ?elena - upper 5/T - duodenal cancer iii+ 2e!atocheCia - lower 5/T - lar(e intestine - fresh blood fro! rectu! $+ /nadeBuate inta6e of food rich in iron 3+ /nadeBuate absorption of iron - due to <

a+ Chronic diarrhea b+ ?alabsorption syndro!e -celiac disease"(luten free diet+ Food for celiac pts" sardines c+ 2i(h cereal inta6e with low ani!al C2ON in(estion d+ Subtotal (astrecto!y 7+ /!proper coo6in( of food S*S4< + $+ 3+ 7+ &+ Asy!pto!atic 2eadache; diCCiness; dyspnea; palpitations; cold sensitivity; (en body !alaise; pallor Brittle hair; spoon shaped nails 'HO/%ONIC2/A)1,ec O$1hypo4ia1atrophy of epider!al cells Atropic (lossitis; dyspha(ia; sto!atitis Pica - abnor!al cravin( for non edible food 'caused by hypo4ia1dec tissue perfusion1psychotic behavior)

Brittle hair; spoon shaped nail - atrophy of epider!al cells N 1 capillary refill ti!e M $ secs N 1 shape nails - biconcave shape; #E Atrophy of cells NPlu!!er 0insons Syndro!eO due to cerebral hypo4ia + Atropic (lossiti - infla!!ation of ton(ue due to atrophy of pharyn(eal and ton(ue cells $+ Sto!atitis - !outh sores 3+ ,yspha(ia ,4 Proc< + .BC $+ 2(b 3+ .eticulocyte 7+ 2ct &+ /ron @+ Ferritin Ns( ?(t + ?onitor si(ns of bleedin( of all he!a test includin( urine & stool $+ Co!plete bed rest - don>t overtire pt 1wea6ness and fati(ue1activity intolerance 3+ 3ncoura(e - iron rich food $3+ .aisins; le(u!es; e(( yol6 7+ /nstruct the pt to avoid ta6in( tea " i!pairs iron absorption &+ Ad!inister !eds a+) Oral iron preparation Ferrous SO7 Fe (luconate Fe Fu!arate Ns( ?(t oral iron !eds< + Ad!inister with !eals - to lessen 5/T irritation $+ /f dilutin( in iron liBuid prep -ad! with straw Straw + $+ 3+ 7+ %u(ol>s Tetracycline Oral iron ?acrodantine 3+ 7+ a+ b+ c+ d+ e+ 5ive Oran(e Guice - for iron absorption ?onitor & infor! pts S*3 Anore4ia n*v Abdo!inal pain ,iarrhea or constipation ?elena

/f pt can>t tolerate oral iron prep - ad!inister parenteral iron prep e4a!ple< + /ron de4tran '/0; /?)

7$

$+

Sorbite4 '/?)

Ns( ?(t parenteral iron prep + Ad!inister of use P tract !ethod to prevent disco!fort; discoloration lea6a(e to tissues+ $+ ,on>t !assa(e inGection site+ A!bulate to facilitate absorption+ 3+ ?onitor S*3< a+) Pain at inGury site b+) %ocaliCed abscess 'NnanaO) c+) %y!phadenopathy d+) Fever* chills e+) Articaria - itchiness f+) 2ypotension - anaphylactic shoc6 Anaphylactic shoc6 - (ive epinephrine

PERNICI)US ANEMIA " !e(aloblastic; chronic ane!ia due to deficiency of intrinsic factor leadin( to
2ypochlorhydria - decrease 2cl acid secretion+ %ifeti!e B $ inGections+ 9ith CNS involve!ent+ Predisposin( factor + Subtotal (astrecto!y - re!oval sto!ach $+ 2ereditary 3+ /nfl dse of ileu! 7+ Autoi!!une &+ Strict ve(etable diet S,)MAC& Parietal or er(entaffen O4yntic cells F4n - produce intrinsic factor For reabsorption of B $ For !aturation of .BC ,iet hi(h caloric or C2O to correct wt loss S*S4< 2eadache diCCiness; dyspnea; palpitations; cold sensitivity; (en body !alaise; pallor 5/T chan(es a+ .ed - beefy ton(ue - PAT2O5NO?ON/C - !outh sores b+ ,yspepsia - indi(estion c+ 9t loss d+ Taundice 3+ CNS ?ost dan(erous ane!ia< pernicious due to neuro(lo(ic involve!ent+ a+ Tin(lin( sensation b+ Paresthesia c+ 'K) .o!ber(>s test Ata4ia d+ Psychosis ,4<" Shillin(>s test Ns( ?(t - Pernicious ane!ia + 3nforce CB. $+ Ad!inister B $ inGections at !onthly intervals for lifeti!e as ordered+ /?" dorso(luteal or ventro(luteal+ Not -iven ora" due pt !i(ht have tolerance to dru( 3+ ,iet - hi(h calorie or C2O+ /ncrease C2ON; iron & 0it C + $+ F4n - secrets 2cl acid F4 aids in di(estion

73

7+ &+

Avoid irritatin( !outhwashes+ Ase of soft bristled toothbrush is encoura(ed+ Avoid applyin( electric heatin( pads - can lead to burns

APLAS,IC ANEMIA - ste! cell disorder due to bone !arrow depression leadin( to pancytopenia - all .BC are decreased
,ecrease .BC Ane!ia /ncrease 9BC leu6ocytocys /ncrease .BC polycythe!ia vera - co!plication stro6e; C0A; thro!bosis Predisposin( factors leadin( to Aplastic Ane!ia + Che!icals - BanCene & its derivatives $+ radiation 3+ /!!unolo(ic inGury 7+ ,ru(s - cause bone !arrow depression a+ Broad spectru! antibiotic " Chlora!penicol " Sulfona!ides - bactri! b+ Che!o therapeutic a(ents ?ethotre4ate - al6ylatin( a(ents Nitro(en !ustard - anti !etabolic 0incristine - plant al6aloid S*S4< + Ane!ia< a+ 9ea6ness & fati(ue b+ 2eadache; diCCiness; dyspnea c+ cold sensitivity; pallor d+ palpitations $+ %eucopenia - increase susceptibility to infection 3+ Thro!bocytopenia a+ Peticchiae b+ OoCin( ofblood fro! venipuncture site c+ ecchy!osis ,4< + CBC - pancytopenia $+ Bone !arrow biopsy* aspiration at post iliac crest - reveals fatty strea6s in bone !arrow Ns( ?(t< + .e!oval of underlyin( cause $+ Blood transfusion as ordered 3+ Co!plete bed rest 7+ O$ inhalation &+ .everse isolation due leu6openia @+ ?onitor si(ns of infection L+ Avoid SQ; /? or any venipuncture site 1 23P%OCH #+ Ase electric raCor when shavin( to prevent bleedin( D+ Ad!inister !eds /!!unosuppresants Anti ly!phocyte (lobulin 'Al() (iven via central venous catheter; @ days - 3 wee6s to achieve !a4 therapeutic effect of dru(+ /L))D ,RANS6USI)N< ObGectives< + To replace circulatin( blood volu!e $+ To increase O$ carryin( capacity of blood 3+ To co!bat infection if there>s decrease 9BC 7+ To prevent bleedin( if there>s platelet deficiency Ns- M-t !rinci!"es in /"oo# ,ransfusion + Proper refri(eration decrease 9BC leu6openia decrease platelets thro!bocytopenia

77

$+

3+

Proper typin( & cross!atchin( Type O - universal donor AB - universal recipient #&F of people is .2 'K) Asceptically asse!ble all !aterials needed< a+) Filter set b+) /sotonic or PNSS or +DNaCl to prevent 2e!olysis 2ypotonic sol - swell or burst 2ypertonic sol - will shrin6 or crenate c+) Needle (au(e # " D or lar(e bore needle to prevent he!olysis+ d+) /nstruct another .N to rechec6 the followin( + Pts na!e; blood typin( & cross typin( e4piration date; serial nu!ber+ e+) Chec6 blood unit for presence of bubbles; cloudiness; dar6 in color & sedi!ents - indicates bacterial conta!ination+ ,on>t dispose+ .eturn to blood ban6+ f+) Never war! blood products - !ay destroy vital factors in blood+ " 9ar!in( is done if with war!in( device - only in 3?3.53NCI: For !ultiple BT+ " 9ithin 3E !ins roo! te!p only: (+) Blood transfusion should be co!pleted ? .0rs because blood that is e4posed at roo! te!p for S $h causes blood deterioration+ h+) Avoid !i4in( or ad!inisterin( dru( at BT line - leads to he!olysis i+) .e(ulate BT E - & (tts*!in H0O or EEcc*hr to prevent circulatory overload G+) ?onitor 0S before; durin( & after BT especially B & !ins'local board) for st hour+ NC%3J"B&!in for st &!in+ " ?aGority of BT reaction occurs within h+

/, reactions S*S4 2e!olytic reaction< 2 - he!olytic .eaction + 2eadache; diCCiness; dyspnea; palpitation; lu!bar* sterna* flan6 pain; A - aller(ic .eaction hypotension; flushed s6in ; 'red) port wine urine+ P - pyro(enic .eaction C - circulatory overload A - air e!bolis! T " thro!bocytopenia C - citrate into4ication - e4pired blood 1hyper6ale!ia 2 - hyper6ale!ia Ns( ?(t< &emo"ytic Reaction: + Stop BT $+ Notify ,oc 3+ Flush with plain NSS 7+ Ad!inister isotonic fluid sol - to prevent acute tubular necrosis & conteract shoc6 &+ Send blood unit to blood ban6 for ree4a!ination @+ Obtain urine & blood sa!ples of pt & send to lab for ree4a!ination L+ ?onitor 0S & Aller(ic .4n

A""er-ic Reaction:
S*S4 + $+ 3+ 7+ &+ Fever* chills Articaria* pruritus ,yspnea %aryn(ospas!* bronchospas! Bronchial wheeCin(

Ns( ?(t< + Stop BT $+ Notify ,oc 3+ Flush with PNSS

7&

7+

Ad!inister antihista!ine - diphenhydra!ine 2cl 'Benadryl)+ 5ive bedti!e+S3"Adult"drowsiness+ Child"hyperactive /f 'K) 2ypotension - anaphylactic shoc6 ad!inister - epinephrine &+ Send blood unit to blood ban6 @+ Obtain urine & blood sa!ples - send to lab L+ ?onitor 0S & /O #+ Ad!+ Antihista!ine as ordered for Aller(ic.4n; if 'K) to hypotension - indicates anaphylactic shoc6 $7+ ad!inister epinephrine D+ Ad! antipyretic & antibiotic for pyro(enic .4n & TSB

Pyro-enic Reaction:
S*S4 a+) Fever* chills b+) 2eadache c+) ,yspnea Ns( ?(t< + $+ 3+ 7+ &+ @+ L+ #+ S4 a+ b+ c+ d+ ,yspnea Orthopnea .ales or crac6les 34ertional disco!fort Stop BT Notify ,oc Flush with PNSS Ad!inister antipyretics; antibiotics Send blood unit to blood ban6 Obtain urine & blood sa!ples - send to lab ?onitor 0S & /O Tepid spon(e bath - offer hypother!ic blan6et d+ tachycardia e+ palpitations f+ diaphoresis

Circu"atory )ver"oa#:

Ns( ?(t< + Stop BT $+ Notify ,oc+ ,on>t flush due pt has circulatory overload+ 3+ Ad!inister diuretics Priority cases< 2e!olytic .4n - st due to hypotension - st priority - attend to destruction of 2(b - O$ brain da!a(e Aller(ic 3rd Pyro(enic 7th Circulatory $nd 2e!olytic Anaphylitic $nd
st priority

DIC 2 DISSEMINA,ED IN,RA5ASCULAR C)AGULA,I)N

$&+ Acute he!orrha(ic syndro!e char by wide spread bleedin( & thro!bosis due to a def of clottin( factors 'Prot0rombin 6ibrino-en$9 Predisposin( factor< + .apid BT $+ ?assive trau!a 3+ ?assive burns 7+ Septice!ia &+ 2e!olytic reaction @+ Anaphyla4is L+ Neoplasia - (rowth of new tissue #+ Pre(nancy

7@

S*S4 + $+ 3+ 7+ &+ @+ Petechiae - widespread & syste!ic 'lun(s; lower & upper trun6) 3cchy!osis - widespread OoCin( of blood fro! venipunctured site 2e!optysis - cou(h blood 2e!orrha(e Oli(uria - late s4

,4 Proc+ CBC - reveals decrease platelets $+ Stool for occult blood 'K) Speci!en - stool 3+ Opthal!oscopic e4a! - sub retinal he!orrha(e 7+ AB5 analysis - !etabolic acidosis !& p2 ph ph ph &C)= PCO$ PCO$ 2CO3 2CO3

. O ? 3

respiratory al6alosis respiratory acidosis !etabolic al6alosis !etabolic acidosis

,iarrhea - !et acidosis 0o!ittin( - !et al6 Pyloric stenosis - !et al6alosis - vo!itin( /leosto!y or intestinal tubin( - !et acidosis Cushin(>s - !et al6 ,? !et acid Chronic bronchitis - resp acid - with hypo4e!ia; cyanosis Ns- M-t DIC ?onitor si(ns of bleedin( - he!a test K urine; stool; 5/T Ad!inister isotonic fluid solution to prevent shoc6+ Ad!inister O$ inhalation Ad!inister !eds 0it H aBua!ephyton Pitressin or vasopressin - to conserve water+ N5T - lava(e " Ase iced saline lava(e @+ ?onitor N5T output L+ Provide heploc6 #+ Prevent co!plication< hypovole!ic shoc6 %ate si(ns of hypovole!ic shoc6 < anuria )nco"o-ic Ns-< Oncolo(y - study of neoplasia -new (rowth Beni(n 'tu!or) ,iff " well differentiated 3ncapulation - 'K) ?etastasis - '") Pro(nosis - (ood Therapeutic !odality sur(ery ?ali(nancy 'cancer) poorly or undifferentiated '") 'K) poor + Che!otherapy plenty S*3 $+ .adiation 3+ Sur(ery !ost preferred treat!ent 7+ Bone !arrow transplant " %eu6e!ia only + $+ 3+ 7+ a+ b+ &+

7L

Pre#is!osin- factors: (carcino-enesis$ 5 - (enetic factors / - i!!unolo(ic factors 0 - viral factors a+ 2u!an papilo!a virus - causin( warts b+ 3pstein barr virus 3 - environ!ental Factors DEF a+ Physical - irradiation; A0 rays; nuclear e4plosion; chronic irritation; direct trau!a b+ Che!ical factors " Food additives 'nitrates " 2ydrocarbon vesicants; al6alies " ,ru(s 'stillbestrol) " Araehane " 2or!ones " S!o6in( ?ale 3+) Prostate cancer " co!!on 7E & above '!iddle a(e & above) BP2 - &E & above +) %un( cancer $+) %iver cancer Fe!ale + Breast cancer - 7E yrs old & up - !a!!o(raphy $+ Cervical cancer - DEF !ulti se4ual partners &F early pre(nancy 3+ Ovarian cancer C"asses of cancer Tissue typin( + $+ 3+ & - $E !ins 'SB3 - L days after !ens)

Carcino!a - arises fro! surface epitheliu! & (landular tissues Sarco!a" fro! connective tissue or bones ?ultiple !yelo!a - fro! bone !arrow Patholo(ical fracture of ribs & bac6 pain 7+ %y!pho!a - fro! ly!ph (lands &+ %eu6e!ia - fro! blood

:arnin- ; Dan-er S( of CA C - chan(e in bowel *bladder habits A - a sore that doesn>t heal A - unusual bleedin(* ,ischar(e T - thic6enin( of lu!p - breast or elsewhere / - indi(estionR ,yspha(ia O - obvious chan(e in wart* !ole N - na((in( cou(h* hoarseness A - une4plained ane!ia A " ane!ia S - sudden wt loss % - loss of wt Therapeutic ?odality<

+ C0emot0era!y - use various che!otherapeutic a(ents that 6ills cancer cells & 6ills nor!al rapidly producin( cells - 5/T;
bone !arrow; and hair follicle+ Classification< a+) Al6ylatin( a(ents b+) Plant al6aloids - vincristine c+) Anti !etabolites - nitro(en !ustard d+) 2or!ones - ,3S Steroids e+) Antineoplastic antibiotics S*3 & !(t

7#

5/T " "Nausea & vo!itin( Ns( ?(t< + Ad!inister anti e!etic 7 - @h before start of che!o Plasil $+ 9ithhold food* fluid before start of che!o 3+ Provide bland diet post che!o $@+ Non irritatin( * non spicy " ,iarrhea + Ad!inister anti diarrheal 7 - @h before start of che!o $+ ?onitor urine; /&O Bh " Sto!atitis* !outh sores + Oral care - offer ice chips* popsic6les $+ /nfor! pt - hair loss - te!porary alopecia 2air will (row bac6 after 7 - @ !onths post che!o+ "Bone !arrow depression - ane!ia + 3nforce CB. $+ O$ inhalation 3+ .everse isolation 7+ ?onitor si(ns of bleedin( .epro or(an - sterility + ,o sper! ban6in( before start of che!o .enal syste! - increase uric acid + Ad!inister allopurinol* 4yloprin '(out) $L+ /nhibits uric acid $#+ Acute (out - colchicines $D+ /ncrease secretion of uric acid Neurolo(ical chan(es - peristalsis - paralytic ileus ?ost feared co!plication ff any abdo!inal sur(ery 0incristine - plant al6aloid causes peripheral neuropathy

*9 Ra#iation t0era!y - involves use of ioniCin( radiation that 6ills cancer cells & inhibit their (rowth & 6ill N rapidly producin(
cells+ Types of ener(y e!itted + Alpha rays - rarely used - doesn>t penetrate s6in tissues $+ Beta rays - internal radiation - !ore penetration 3+ 5a!!a ray - e4ternal radiation - penetrates deeper underlyin( tissues ?ethods of delivery + 34ternal radiation" involves electro !a(netic waves 34+ cobalt therapy $+ /nternal radiation - inGection* i!plantation of radioisotopes pro4i!al to CA site for a specific period of ti!e+ $ types< a+) Sealed i!plant - radioisotope with a container & doesn>t conta!inate body fluid+ b+) Ansealed i!plant - radioisotope without a container & conta!inates body fluid+ 34+ Phosphorus 3$ 3 Factors affectin( e4posure< A+) 2alf life - ti!e period reBuired for half of radioisotopes to decay+ " At end of half life - less e4posure B+) ,istance - the farther the distance - lesser e4posure C+ ) Ti!e - the shorter the ti!e; the lesser e4posure ,+) Shieldin( - rays can be shielded or bloc6ed by usin( rubber (loves - & (a!!a - use thic6 lead on concrete+ S*3 & ?(t< a+) S6in errythe!a; redness; slou(hin( + Assist in battlin( pt $+ Force fluid - $;EEE - 3;EEE !l*day 3+ Avoid lotion or talcu! powder - s6in irritation

7D

7+ Apply cornstarch or olive oil b+) 5/T -nausea * vo!itin( " + Ad!inister antie!etic 7 - @h before start of che!o " Plasil $ 9ithhold food* fluid before start of che!o 3+ Provide bland diet post che!o Non irritatin( * non spicy ,ys(lusia - decrease taste sensitivity "9hen atrophy papilla 'taste buds) - 7E yo Sto!atitis c+) Bone !arrow depression + 3nforce CB. $+ O$ inhalation 3+ .everse isolation 7+ ?onitor si(ns of bleedin(

)vervie7 of function

structure of t0e 0eart

&EAR, " ?uscular; pu!pin( or(an of the body " %eft !ediastinu! " 9ei(h 3EE - 7EE (ra!s " .ese!bles a closed fist " Covered by serous !e!brane - pericardiu! Pericardiu! Parietal layer Pericardial Fluid - prevent Friction rub 0isceral layer

%ayer + 3picardiu! - outer!ost $+ ?yocardiu! - inner - responsible for pu!pin( action* !ost dan(erous layer " cardio(enic shoc6 3+ 3ndocardiu! - inner!ost layer Cha!bers + Apper - collectin(* receivin( cha!ber " Atria $+ %ower - pu!pin(* contractin( cha!ber " 0entricles 0alves + Atrioventricular valves " Tricuspid & !itral valve Closure of A0 valves - (ives rise to st heart sound or S or NlubO $+ Se!i lunar valve a+) Pul!onic b+) Aortic Closure of se!ilunar valve - (ives rise to $nd heart sound or S$ or NdubO 34tra heart Sound S3 - ventricular 5allop - C2F S7 - atrial (allop - ?/; 2PN

2eart conduction syste! + Sino atrial node 'SA node) 'or Heith"Floc6 node) %oc - Gunction of S0C & .t atriu! F4" pri!ary pace !a6er of heart "/nitiates electric i!pulse of @E - EE bp! $+ Atrioventicular node 'A0 node or Tawara node) %oc - inter atrial septu! ,elay of electric i!pulse to allow ventricular fillin( 3+ Bundle of 2is - location interventricular septu! .t !ain Bundle Branch %t !ain Bundle Branch

&E

7+

Pur6enGie Fiber %oc" walls of ventricles"" 0entricular contractions SA node

A0

Pur6enGie Fibers Bundle of 2is Co!plete heart bloc6 - insertion of pace!a6er at Bundle Branch ?etal - Pace ?a6er - chan(e B3 - & yo Prolon(ed P. - atrial fib ST se(!ent depression - an(ina ST - elev - ?/ T wave inversion - ?/ widenin( Q.S - arrhyth!ia

CA, - coronary artery dse or /sche!ic 2eart ,se '/2,) Atherosclerosis - ?yocrdial inGury An(ina Pectoris - ?yocardial ische!ia ?/" !yocardial necrosis AT23.OSC%3.OS/S " 2ardenin( or artery due to fat* lipid deposits at tunica inti!a+ Artery - tunica adventitia - outer " Tunica inti!a - inner!ost " Tunica !edia - !iddle AT23.OSC%3.OS/S Predisposin( Factor + Se4 - !ale $+ Blac6 race 3+ 2yperlipide!ia 7+ S!o6in( &+ 2PN @+ ,? L+ Oral contraceptive" prolon(ed use #+ Sedentary lifestyle D+ Obesity E+ 2ypothyroidis! Si(ns & Sy!pto!s + Chest pain $+ ,yspnea 3+ Tachycardia 7+ Palpitations &+ ,iaphoresis Treat!ent P - percutaneous T - tanslu!inar C - coronary A - an(ioplasty ObG< + To revasculariCe the !yocardiu! A.T3.OSC%3.OS/S " Narrowin( or artery due to calciu! & C2ON deposits at tunica !edia+

&

$+ 3+

To prevent an(ina /ncrease survival rate

PTCA - done to pt with sin(le occluded vessel + ?ultiple occluded vessels C - coronary A - arterial B - bypass A -and 5 - (raft sur(ery Ns( ?(t Before CABA5 + ,eep breathin( cou(h e4ercises $+ Ase of incentive spiro!eter 3+ %e( e4ercises

ANGINA PEC,)RIS8 A clinical syndro!e characteriCed by paro4ys!al chest pain usually relieved by .3ST or N5T
nitro(lycerin; resultin( fr te!p !yocardial ische!ia+ Predisposin( Factor< + se4 - !ale $+ blac6 raise 3+ hyperlipide!ia 7+ s!o6in( &+ 2PN @+ ,? L+ oral contraceptive prolon(ed #+ sedentary lifestyle D+ obesity E+hypothyroidis! Precipitatin( factors 7 3>s + 34cessive physical e4ertion $+ 34posure to cold environ!ent " 0asoconstriction 3+ 34tre!e e!otional response 7+ 34cessive inta6e of food - saturated fats+ Si(ns & Sy!pto!s + /nitial sy!pto!s - %evine>s si(n - hand clutchin( of chest $+ Chest pain - sharp; stabbin( e4cruciatin( pain+ %ocation - substernal "radiates bac6; shoulders; a4illa; ar!s & Gaw !uscles "relieve by rest or N5T 3+ ,yspnea 7+ Tachycardia &+ Palpitation @+diaphoresis ,ia(nosis +2istory ta6in( & P3 $+ 3C5 - ST se(!ent depression 3+ Stress test - tread!ill 1 abnor!al 3C5 7+ Seru! cholesterol & uric acid " increase+ Nursin( ?ana(e!ent +) 3nforce CB. $+) Ad!inister !eds NT5 - s!all doses - venodilator %ar(e dose - vasodilator st dose NT5 - (ive 3 - & !in $nd dose NT5 - 3 - & !in 3rd & last dose - 3 - & !in Still painful after 3rd dose - notify doc+ ?/:

&$

&& yrs old with chest pain< st Buestion to as6 pt< what did you do before you had chest pain+ $nd Buestion< does pain radiateR /f radiate - heart in nature+ /f not radiate - pul!onary ori(in 0enodilator - veins of lower e4t - increase venous poolin( lead to decrease venous return+ ?eds< A+ NT5" Ns( ?(t< + Heep in a dry place+ Avoid !oisture & heat; !ay inactivate the dru(+ $+ ?onitor S*3< orthostatic hypotension - dec bp transient headache diCCiness 3+ .ise slowly fro! sittin( position 7+ Assist in a!bulation+ &+ /f (ivin( NT5 via patch< i+ avoid placin( it near hairy areas"will dec dru( absorption ii+ avoid rotatin( transder!al patches" will dec dru( absorption iii+ avoid placin( near !icrowave oven or durin( defibrillation"will burn pt due alu!inu! foil in patch B+ Beta bloc6ers - propanolol C+ AC3 inhibitors - captopril ,+ Ca anta(onist " nefedipine Ad!inister O$ inhalation Se!i"fowler ,iet" ,ecrease Na and saturated fats ?onitor 0S; /&O; 3C5 2T< ,ischar(e plannin(< a+ Avoid precipitatin( factors - 7 3>s b+ Prevent co!plications - ?/ c+ Ta6e !eds before physical e4ertion"to achieve !a4i!u! therapeutic effect of dru( d+ /!portance of follow"up care+

3+) 7+) &+) @+) L+)

MI 2 M4)CARDIAL IN6ARC,I)N - hear attac6 - ter!inal sta(e of CA,

" Types< + $+ Tras!ural ?/ - !ost dan(erous ?/ - ?al"occlusion of both .&% coronary artery Sub"endocardial ?/ - !al"occlusion of either . & % coronary artery CharacteriCed by necrosis & scarrin( due to per!anent !al"occlusion

?ost critical period upon d4 of ?/ - 7# to L$h " ?aGority of pt suffers fro! P0C pre!ature ventricular contraction+

Predisposin( factors + se4 - !ale $+ blac6 raise 3+ hyperlipide!ia 7+ s!o6in( &+ 2PN @+ ,? L+ oral contraceptive prolon(e d #+ sedentary lifestyle

Si(ns & sy!pto!s + chest pain - e4cruciatin(; vice li6e; visceral pain located substernal or precodial area 'rare) " radiates bac6; ar!; shoulders; a4illa; Gaw & abd !uscles+ " not usually relived by rest r NT5 $+ dyspnea 3+ erther!ia 7+ initial increase in BP &+ !ild restlessness & apprehensions @+ occasional findin(s

,ia(nostic 34a! + cardiac enCy!es a+) CPH - ?B - Creatinine Phospho6inase b+) %,2 - lactic acid dehydro(enase c+) S5PT - 'A%T) - Seru! 5lutanic Pyruvate Transa!inase" increased d+) S5OT 'AST) - Seru! 5luta!ic O4alo" acetic " increased $+ Troponin test - increase 3+ 3C5 tracin( - ST se(!ent increase;

&3

D+ obesity E+ hypothyroidis!

a+) split S & S$ b+) pericardial friction rub c+) rales *crac6les d+) S7 'atrial (allop)

widenin( or Q.S co!ple4es - !eans arrhyth!ia in ?/ indicatin( P0C 7+ seru! cholesterol & uric acid " increase &+ CBC - increase 9BC

Nursin( ?ana(e!ent + Narcotic anal(esics - ?orphine SO7 - to induce vasodilation & decrease levels of an4iety+ $+ Ad!inister O$ inhalation - low inflow 'C2F"increase inflow) 3+ 3nforce CB. without BP a+) Bedside co!!ode 7+ Avoid valsalva !aneuver &+ Se!i fowler @+ 5eneral liBuid to soft diet - decrease Na; saturated fat; caffeine L+ ?onitor 0S; /&O & 3C5 tracin(s #+ Ta6e $E - 3E !l*wee6 - wine; brandy*whis6y to induce vasodilation+ D+ Assist in sur(icalU CABA5 E+ Provide pt 2T a+) Avoid !odifiable ris6 factors b+) Prevent co!plications< + Arrhyth!ias - P0C $+ Shoc6 - cardio(enic shoc6+ %ate si(ns of cardio(enic shoc6 in ?/ - oli(uria 3+ thro!bophlebitis " deep vein 7+ C2F - left sided &+ ,ressler>s syndro!e - post ?/ syndro!e ".esistant to !edications "Ad!inister &E;EEE - 7&E;EEE units of strepto6inase c+) Strict co!pliance to !eds " 0asodilators + NT5 $+ /sordil " Antiarryth!ic + %ydocaine bloc6s release of norepenephrine $+ Brithyliu! " Beta"bloc6ers - NlolO + Propanolol 'inderal) " AC3 inhibitors " pril + Captopril - 'enalapril) " Ca - anta(onist + Nifedipine " Thro!bolitics or fibrinolytics- to dissolve clots* thro!bus S*3 aller(ic reactions* uticaria + Strepto6inase $+ Aro6inase 3+ Tissue plas!ino(en adGustin( factor

?onitor for bleedin(< " Anticoa(ulants + 2eparin PTT /f prolon(ed bleedin( Antidote Prota!ine sulfate " Anti platelet PASA 'aspirin)

$+ Cau!adin - delayed reaction $ - 3 days PT prolon(ed bleedin( antidote 0it H

&7

d+) .esu!e A,% - se4* activity - 7 to @ wee6s Post"cardiac rehab +)Se4 as an appetiCer rather then dessert Before !eals not after; due after !eals increase !etabolis! - heart is pu!pin( hard after !eals+ $+) Position - non"wei(ht bearin( position+ 9hen to resu!e se4* act< 9hen pt can already use staircase; then he can resu!e se4+ e+) ,iet - decrease Na; Saturated fats; and caffeine f+) Follow up care+

C&6 2 C)NGES,I5E &EAR, 6AILURE 8 /nability of heart to pu!p blood towards syste!ic circulation+
" Bac6flow +) Left si#e# 0eart fai"ure: Predisposin( factors< +) DEF !itral valve stenosis - due .2,; a(in( .2, affects !itral valve - streptococcal infection ,4< " Aso titer - anti streptolysine O S 3EE total units " Steroids " Penicillin " Aspirin Co!plication< .S"C2F A(in( - de(eneration * calcification of !itral valve /sche!ic heart disease 2PN; ?/; Aortic stenosis S*S4 Pul!onary con(estion* 3de!a + ,yspnea $+ Orthopnea ',iff of breathin( sittin( pos - platypnea) 3+ Paro4ys!al nocturnal dysnea - PNO" nalulunod 7+ Productive cou(h with blood tin(ed sputu! &+ Frothy salivation 'fro! lun(s) @+ Cyanosis L+ .ales* crac6les - due to fluid #+ Bronchial wheeCin( D+ P?/ - displaced lateral - due cardio!e(aly E+ Pulsus alternons - wea6"stron( pulse + Anore4ia & (eneral body !alaise $+ S3 - ventricular (allop ,4 + $+ CJ. - cardio!e(aly PAP - Pul!onary Arterial Pressure PC9P - Pul!onary Capillary9ed(e Pressure PAP - !easures pressure of . ventricle+ /ndicates cardiac status+ PC9P - !easures end systolic* diastolic pressure PAP & PC9P< Swan - (anC catheteriCation - cardiac catheteriCation is done at bedside at /CA 'Trachesosto!y - bedside) " ,one & - $E !ins - scalpel & trachesosto!y set C0P - indicates fluid or hydration status /ncrease C0P - decrease flow rate of /0 ,ecrease C0P - increase flow rate of /0 3chocardio(raphy - reveals enlar(ed heart cha!ber or cardio!ayopathy AB5 - PCO$ increase; PO$ decrease 1 1 hypo4e!ia 1 resp acidosis

3+ 7+

&&

$+) Ri-0t si#e# &6 Predisposin( factor + DEF " tricuspid stenosis $+ COP, 3+ Pul!onary e!bolis! 7+ Pul!onic stenosis &+ %eft sided heart failure S*S4 0enous con(estion " Nec6 or Gu(ular vein distension " Pittin( ede!a " Ascites " 9t (ain " 2epato!e(alo* spleno!e(aly " Taundice " Pruritus " 3sopha(eal varies " Anore4ia; (en body !alaise ,ia(nosis< + $+ CJ. - cardio!e(aly C0P - !easures the pressure at . atriu! Nor!al< 7 to E c! of water /ncrease C0P S E - hypervole!ia ,ecrease C0P M 7 - hypovole!ia Flat on bed - post of pt when (ivin( C0P Position durin( C0P insertion - Trendelenbur( to prevent pul!onary e!bolis! & pro!ote ventricular fillin(+

3+ 3chocardio(raphy - enlar(ed heart cha!ber * cardio!yopathy .+%iver enCy!e S5PT ' A%T) S5OT AST Ns( !(t< /ncrease force of !yocardial contraction 1 increase CO 3 - @% of CO + Ad!inister !eds< T4 for %S2F< ? - !orphine SO7 to induce vasodilatation A - a!inophylline & decrease an4iety , - di(italis 'di(o4in) , " diuretics O " o4y(en 5 " (ases a+) Cardiac (lycosides /ncrease !yocardial 1 increase CO ,i(o4in '%ano4in)+ Antidote< di(ivine ,i(ito4in< !etaboliCes in liver not in 6idneys not (iven if with 6idney failure+ b+) %oop diuretics< %asi4 - effect with in E" & !in+ ?a4 1 @ hrs c+) Bronchodilators< A!inophillin 'Theophyllin)+ Avoid (ivin( caffeine d+) Narcotic anal(esic< ?orphine SO7 " induce vasodilaton & decrease an4iety e+) 0asodilators - NT5 f+) Anti"arryth!ics - %idocaine $+ Ad!inister O$ inhalation - hi(h: Z 3 "7%*!in via nasal cannula 3+ 2i(h fowlers 7+ .estrict Na:

&@

&+ Provide !eticulous s6in care @+ 9ei(h pt daily+ Assess for pittin( ede!a+ ?easure abdo!inal (irth daily & notify ?, L+ ?onitor 0*S; /&O; breath sounds #+ /nstitute bloodless phleboto!y+ .otatin( tourniBuet or BP cuff rotated cloc6wise B & !ins 1 to pro!ote decrease venous return D+ ,iet - decrease salt; fats & caffeine E+ 2T< a) Co!plications <shoc6 Arrhyth!ia Thro!bophlebitis ?/ Cor Pul!onale - .T ventricular hypertrophy b+) ,ietary !odifications c+) Adherence to !eds

PERIP&ERAL MUSCULAR DISEASE Arterial ulcers + Thro!boan(iitis Obliterans - !ale* feet $+ .eynauds - fe!ale* hands venous ulcer + 0aricose veins $+ Thro!bophlebitis

9$ ,0romboan-iitis ob"iterates; /UERGER DISEASE" Acute infla!!atory disorder affectin( s!all to !ediu! siCed
arteries & veins of lower e4tre!ities+ ?ale* feet Predisposin( factors< " ?ale " S!o6ers

S*S4 + /nter!ittent claudication - le( pain upon wal6in( " .elieved by rest $+ Cold sensitivity & s6in color chan(es 9hite Pallor bluish cyanosis red rubor

3+ ,ecrease or di!inished peripheral pulses " Post tibial; ,orsalis pedis 7+ Tropic chan(es &+ Alcerations @+ 5an(rene for!ation ,4< + $+ 3+ &+ Oscillo!etry - decrease peripheral pulse volu!e+ ,oppler ATP - decrease blood flow to affected e4tre!ities+ An(io(raphy - reveals site & e4tent of !al"occulsion+

Ns( ?(t< + 3ncoura(e a slow pro(ression of physical activity a+) 9al6 3 "7 4 * day

&L

$+

3+

7+ &+

b+) Out of bed $ - 3 4 a * day ?eds a+) Anal(esic b+) 0asodilator c+) Anticoa(ulant Foot care !(t li6e ,? a+) Avoid wal6in( barefoot b+) Cut toe nails strai(ht c+) Apply lanolin lotion - prevent s6in brea6down d+) Avoid wearin( constrictive (ar!ents Avoid s!o6in( & e4posure to cold environ!ent Sur(ery< BHA 'Below the 6nee a!putation)

$+)RE4NAUD'S Predisposin( factors< + $+ 3+

P&EN)MEN)N - acute episodes of arterial spas! affectin( di(its of hands & fin(ers

Fe!ale; 7E yrs S!o6in( Colla(en dse a+) S%3 - patho(no!onic si(n - butterfly rash on face Chip!un6 face - buli!ia nervosa Cherry red s6in - carbon !ono4ide Spider an(io!a - liver cirrhosis Caput !edusae - le( & trun6 %ion face - leprosy b+) .heu!atoid arthritis ,irect hand trau!a - piano playin(; e4cessive typin(; operatin( chainsaw + $+

poisonin( u!bilicus" %iver cirrhosis

7+ S*S4<

/nter!ittent claudication " le( pain upon wal6in( " .elieved by rest Cold sensitivity

Ns( ?(t< a+ Anal(esics b+ 0asodilators c+ 3ncoura(e to wear (loves especially when openin( a refri(erator+ d+ Avoid s!o6in( & e4posure to cold environ!ent

5EN)US ULCERS + 5ARIC)SI,IES ; 5aricose veins " Abnor!al dilation of veins - lower e4t & trun6 " ,ue to< a+) /nco!petent valves leadin( to b+) /ncrease venous poolin( & stasis leadin( to c+) ,ecrease venous return Predisposin( factors< a+ 2ereditary b+ Con(enital wea6ness of veins c+ Thro!bophlebitis d+ 2eart dse e+ Pre(nancy f+ Obesity (+ Prolon(ed i!!obility " Prolon(ed standin( S*S4< + Pain especially after prolon(ed standin( $+ ,ilated tortuous s6in veins

&#

3+ 7+ ,4< + $+

9ar! to touch 2eaviness in le(s

0eno(raphy Trendelenber(>s test - vein distend Buic6ly M 3& secs

Ns( ?(t< + 3levate le(s above heart level - to pro!ote venous return - to $ pillows $+ ?easure circu!ference of le( !uscles to deter!ine if swollen+ 3+ 9ear anti e!bolic or 6nee hi(h stoc6in(s+ 9o!en - panty hose 7+ ?eds< Anal(esics &+ Sur(ery< vein sweepin( & li(ation Sclerotherapy - spider web varicosities S*3 thro!bosis

,&R)M/)P&LE/I,IS 'deep vein thro!bosis) " /nfla!!ation of veins with thro!bus for!ation
Predisposin( factors< + S!o6in( $+ Obesity $+ 2yperlipede!ia 7+ Prolon(ed use of oral contraceptives &+ Chronic ane!ia @+ ,? L+ ?/ #+ C2F D+ Postop co!plications E+ Post cannulation - insertion of various cardiac catheters S*S4< + $+ 3+ ,4< + $+ Ns( ?(t< + 3levate le(s above heart level+ $+ Apply war!; !oist pac6s to decrease ly!phatic con(estion+ 3+ ?easure circu!ference of le( !uscles to detect if swollen+ 7+ Ase anti e!bolic stoc6in(s+ &+ ?eds< Anal(esics+ Anticoa(ulant< 2eparin @+ Co!plication< An(io(raphy ,oppler ATP Pain at affected e4tre!ities Cyanosis 'K) 2o!an>s si(n " Pain at le( !uscles upon dorsifle4ion of foot+

Pu"monary Embo"ism:
" Sudden sharp chest pain " ,yspnea " Tachycardia " Palpitation " ,iaphoresis " ?ild restlessness )5ER5IE: )6 RESPIRA,)R4 S4S,EM: /+ Apper respiratory tract< F4< + Filterin( of air $+ 9ar!in( & !oistenin( 3+ 2u!idification a+ Nose - cartila(e

&D

" Parts< "

.t nostril %t nostril

separated by septu!

Consists of anasto!osis of capillaries Hessel - Bach Ple4us - site of epista4is b+ Pharyn4 'throat) - !uscular passa(eway for air& food Branches< + Oropharyn4 $+ Nasopharyn4 3+ %ayn(opharyn4 c+ %aryn4 - voice bo4 F4< + $+ For phonation Cou(h refle4

5lottis - openin( Opens to allow passa(e of air Closes to allow passa(e of food //+ %ower .t - F4 for (as e4chan(e a+ Trachea - windpipe " has cartilla(enous rin(s " site for per!anent* artificial a*w - tracheosto!y b+ Bronchus - . & % !ain bronchus c+ %un(s - . - 3 lobes 1 E se(!ents % - $ lobes - # se(!ents Post pneu!onecto!y " position affected side to pro!ote e4pansion of lun(s Post se(!ental lobecto!y - position unaffected side to pro!ote draina(e %un(s - covered by pleural cavity; parietal lobe & visceral lobe Alveoli - acinar cells " site of (as e4chan(e 'O$ & CO$) " diffusion< ,altons law of partial pressure of (ases 0entilation - !ove!ent of air in & out of lun(s .espiration - !ove!ent of air into cells Type // cells of alveoli - secrets surfactant Surfactant " decrease surface tension of alveoli %ecithin & spino(o!eter %*S ratio $< - indicator of lun( !aturity /f <$ - ad! O$ " M 7EF Concentration to prevent atelectasis & retinopathy or blindness+

/+ PNEUM)NIA - infla!!ation of lun( parenchy!a leadin( to pul!onary consolidation as alveoli is filled with e4udates+ 3tiolo(ic a(ents< + Streptococcus pneu!oniae 'pne!ococcal pneu!onia) $+ 2e!ophilus pneu!oniae'Bronchopneu!onia) 3+ 3scherichia coli 7+ Hlebsiella P+

@E

&+

,iplococcus P+

2i(h ris6 elderly & children below & yo Predisposin( factors< + S!o6in( $+ Air pollution 3+ /!!uno"co!pro!ised a+ A/,S - P%P b+ Broncho(enic CA " Non"productive to productive cou(h 7+ Prolon(ed i!!obility - C0A" hypostatic pneu!onia &+ Aspiration of food @+ Over fati(ue S*S4< + $+ 3+ 7+ &+ @+ L+ #+ Productive cou(h - patho(no!onic< -reenis0 to rusty s!utum ,yspnea with prolon(ed respiratory (runt Fever; chills; anore4ia; (en body !alaise 9t loss Pleuritic friction rub .ales* crac6les Cyanosis Abdo!inal distension leadin( to paralytic ileus

Sputu! e4a! - could confir! presence of TB & pneu!onia ,4< + Sputu! 5SCS" (ra! stainin( & culture sensitivity " .eveals 'K) cultured !icroor(anis!+ $+ CJ. - pul!o consolidation 3+ CBC - increase 9BC 3rythrocyte sedi!entation rate 7+ AB5 - PO$ decrease Ns( ?(t< 3nforce CB. Strict respiratory isolation ?eds< a+) Broad spectru! antibiotics Penicillin or tetracycline ?acrolides - e4 aCythro!ycin 'Cythro!a4) b+) Anti pyretics c+) ?ucolytics or e4pectorants 7+ Force fluids - $ to 3 %*day &+ /nstitute pul!onary toilet" a+) ,eep breathin( e4ercise b+) Cou(hin( e4ercise c+) Chest physiotherapy - cuppin( d+) Turnin( & reposition " Pro!ote e4pectoration of secretions @+ Se!i"fowler L+ NebuliCe & suction #+ Co!fy & hu!id environ!ent D+ ,iet< increase C2O or calories; C2ON & vit C E+ Postural draina(e " To drain secretions usin( (ravity ?(t for postural draina(e< a+) Best done before !eals or $ - 7 hrs after !eals to prevent 5astroesopha(eal .eflu4 b+) ?onitor 0S & breath sounds Nor!al breath sound - bronchovesicular c+) ,eep breathin( e4ercises d+) Ad! bronchodilators & - 3E !in before procedure e+) Stop if pt can>t tolerate procedure + $+ 3+

f+) Provide oral care - it !ay alter taste sensation (+) C*/ - pt with unstable 0S & he!optysis; increase /CP; increase /OP '(lauco!a) Nor!al /OP - $ - $ !!2( + 2T< a+) Avoidance of precipitatin( factors b+) Co!plication< Atelectacies & !enin(itis c+) Co!pliance to !eds

PULM)NAR4 ,U/ERCUL)SIS (1)C& DSE$ 8 /nfla!!ation of lun( tissue caused by invasion of !ycobacteriu! TB or
tubercle bacilli or acid fast bacilli - (ra! 'K) aerobic; !otile & easily destroyed by heat or sunli(ht+ Predisposin( factors< + ?alnutrition $+ Overcrowdin( 3+ Alcoholis! 7+ /n(estion of infected cattle '!ycobacteriu! BO0/S) &+ 0irulence @+ Over fati(ue S*S4< + $+ 3+ 7+ &+ @+ L+ Productive cou(h - yellowish %ow fever Ni(ht sweats ,yspnea Anore4ia; (eneral body !alaise; wt loss Chest* bac6 pain 2e!potysis

,ia(nosis< + S6in test - !antou4 test - infection of Purified C2ON ,erivative PP, ,O2 - #" E !! induration 92O - E" 7 !! induration .esult within 7# - L$h 'K) ?antou4 test - previous e4posure to tubercle bacilli ?ode of trans!ission - droplet infection $+ Sputu! AFB - 'K) to cultured !icroor(anis! 3+ CJ. - pul!onary infiltrate caseosis necrosis 7+ CBC - increase 9BC Nursin( ?(t< + CB. $+ Strict resp isolation 3+ O$ inhalation 7+ Se!i fowler &+ Force fluid to liBuefy secretions @+ ,BC3 L+ NebuliCe & suction #+ Co!fy & hu!id environ!ent D+ ,iet - increase C2O & calories; C2ON; 0it; !inerals E+ Short course che!otherapy

"

/ntensive phase /N2 - isoniaCide .ifa!picin " (ive before !eals for absorption " (iven within 7 !onths; (iven si!ultaneously to prevent resistance "S*3< peripheral neutitis - vit B@ .ifa!picin "All body secretions turn to red oran(e color urine; stool; saliva; sweat & tears+

@$

PPA - PyraCina!ide - (iven $ !os* after !eals+ S*3< aller(ic r4n; nephroto4icity & hepato4icity Stan#ar# re-imen + /nGection of strepto!ycin - a!ino(lycoside 34+ Hana!ycin; (enta!ycin; neo!ycin S*3< a+) Ototo4icity - da!a(e CN V # - tinnitus - hearin( loss b+) Nephroto4icicity - !onitor BAN & Crea 2T< a+) Avoid pred factors b+) Co!plications< +) Atelectasis $+) ?iliary TB - spread of Tb to other syste! b+) Co!pliance to !eds " .eli(iously ta6e !eds

&IS,)PLASM)SIS" acute fun(al infection caused by inhalation of conta!inated dust with histoplas!a capsulatu! trans!itted
to birds !anure+ S*S4< Sa!e as pneu!onia & PTB - li6e + Productive cou(h $+ ,yspnea 3+ Chest & Goint pains 7+ Cyanosis &+ Anore4ia; (en body !alaise; wt loss @+ 2e!optysis ,4< + $+ 2istoplas!in s6in test 1 'K) AB5 - pO$ decrease

Ns( ?(t< + CB. $+ ?eds< a+) Anti fun(al a(ents A!photericin B 'Fun(iCone) S*3 < a+) Nephroto4cicity chec6 BAN b+) 2ypo6ale!ia b+)Corticosteroids c+) ?ucolytic* or e4pectorants 3+ O$ - force fluids 7+ NebuliCe; suction &+ Co!plications< a+) Atelectasis b+) Bronchiectasis COP, @+ Prevent spread of histoplas!osis< a+) Spray breadin( places or 6ill the bird+

C)PD 2 C0ronic )bstructive Pu"monary Disease

+ $+ 3+ 7+ Chronic bronchitis Bronchial asth!a Bronchiectasis Pul!onary e!physe!a - ter!inal sta(e

@3

C&R)NIC /R)NC&I,IS " called B%A3 B%OAT3.S infla!!ation of bronchus due to hypertrophy or hyperplasia of (oblet
!ucus producin( cells leadin( to narrowin( of s!aller airways+ Predisposin( factors< + S!o6in( - all COP, types $+ Air pollution S*S4< + Prod cou(h $+ ,yspnea on e4ertion 3+ Prolon(ed e4piratory (runt 7+ Scattered rales* rhonchi &+ Cyanosis @+ Pul!o 2PN - a+)%eadin( to peripheral ede!a b+) Cor pul!onary - respiratory in ori(in L+ Anore4ia; (en body !alaise ,4< + AB5 PO$ PCO$ .esp acidosis

2ypo4e!ia - causin( cyanosis Ns( ?(t< 'Sa!e as e!physe!a) $+) /R)NC&IAL AS,&MA" reversible infla!!ation lun( condition due to hyerpsensitivity leadin( to narrowin( of s!aller airway+ Predisposin( factor< + 34trinsic Asth!a - called Atropic* aller(ic asth!a a+) Pallor b+) ,ust c+) 5ases d+) S!o6e e+) ,ander f+) %ints $+ /ntrinsic Asth!a" Cause< 2erediatary ,ru(s - aspirin; penicillin; bloc6ers Food additives - nitrites Foods - seafood; chic6en; e((s; chocolates; !il6 Physical* e!otional stress Sudden chan(e of te!p; hu!idity &air pressure 3+ !i4ed type< co!bi of both e4t & intr+ Asth!a DEF cause of asth!a S*S4< + $+ 3+ 7+ &+ @+ L+ ,4< + $+ Pul!o function test - decrease lun( capacity AB5 - PO$ decrease C - cou(h - non productive to productive , - dyspnea 9 - wheeCin( on e4piration Cyanosis ?ild apprehension & restlessness Tachycardia & palpitation ,iaphoresis

Ns( ?(t<

@7

+ $+

$+ 3+ 7+ &+ @+ " "

CB. - all COP, ?eds" a+) Bronchodilator throu(h inhalation or !etered dose inhaled * pu!p+ 5ive st before corticosteroids b+) Corticosteroids - due infla!!atory+ 5iven E !in after ad! bronchodilator c+) ?ucolytic* e4pectorant d+) ?uco!ist - at bedside put suction !achine+ e+) Antihista!ine Force fluid O$ - all COP, low inflow to prevent resp distress NebuliCe & suction Se!ifowler - all COP, e4cept e!physe!a due late sta(e 2T a+) Avoid pred factors b+) Co!plications< Status ast!aticus" (ive epinephrine & bronchodilators 3!physe!a c+) Adherence to !ed

/R)NC&IEC,ASIS - abnor!al per!anent dilation of bronchus resultin( to destruction of !uscular & elastic tissues of alveoli+
Predisposin( factors< + .ecurrent upper & lower ./ $+ Con(enital ano!alies 3+ Tu!ors 7+ Trau!a S*S4< + Productive cou(h $+ ,yspnea 3+ Anore4ia; (en body !alaise" all ener(y are used to increase respiration+ 7+ Cyanosis &+ 2e!optisis ,4< + $+ AB5 - PO$ decrease Bronchoscopy - direct visualiCation of bronchus usin( fiberscope+ Ns( ?(t< before bronchoscopy + Consent; e4plain procedure - ?,* lab e4plain .N $+ NPO 3+ ?onitor 0S + $+ 3+ 7+ " " Feedin( after return of (a( refle4 /nstruct client to avoid tal6in(; s!o6in( or cou(hin( ?onitor si(ns of fran6 or (ross bleedin( ?onitor of laryn(eal spas! ,OB Prepare at bedside tracheosto!y set

Ns- M-t after bronc0osco!y

?(t< sa!e as e!physe!a e4cept Sur(ery Pneu!onecto!y - re!oval of affected lun( Se(!ental lobecto!y - position of pt - unaffected side

PULM)NAR4 EMP&4SEMA - irreversible ter!inal sta(e of COP,

" CharacteriCed by inelasticity of alveolar wall leadin( to air trappin(; leadin( to !aldistribution of (ases+ " Body will co!pensate over distension of thoracic cavity " Barrel chest Predisposin( factor<

@&

+ $+ 3+ 7+ &+ S*S4< + $+ 3+ 7+ &+ @+ L+ #+ D+ E+ +

S!o6in( Aller(y Air pollution 2i(h ris6 - elderly 2ereditary " anti trypsin to release elastase for recoil of alveoli+

Productive cou(h ,yspnea at rest - due ter!inal Anore4ia & (en body !alaise .ales* rhonchi Bronchial wheeCin( ,ecrease tactile fre!itus 'should have vibration)- palpation - NDDO+ ,ecreased " with air or fluid .esonance to hyperresonance - percussion ,ecreased or di!inished breath sounds Patho(no!onic< barrel chest - increase post* anterior dia!eter of chest Purse lip breathin( - to eli!inated PCO$ Flarin( of alai nares

,ia(nosis< + Pul!onary function test - decrease vital lun( capacity $+ AB5 a+) Panlobular * centrolobular e!physe!a pCO$ increase pO$ decrease - hypo4e!a resp acidosis Blue bloaters b+) Panacinar* Centracinar pCO$ decrease pO$ increase - hypera4e!ia resp al6alosis Pin6 puffers Nursin( ?(t< + CB. $+ ?eds a+) Bronchodilators b+) Corticosteroids c+) Anti!icrobial a(ents d+) ?ucolytics* e4pectorants 3+ O$ - %ow inflow 7+ Force fluids &+ 2i(h fowlers @+ Neb & suction L+ /nstitute P - posture 3 - end 3 - e4piratory to prevent collapse of alveoli P - pressure #+ 2T a+) Avoid s!o6in( b+) Prevent co!plications +) Cor pul!onary - . ventricular hypertrophy $+) CO$ narcosis - lead to co!a 3+) Atelectasis 7+) Pneu!othora4 - air in pleural space D+ Adherence to !eds

.3ST./CT/03 %AN5 ,/SO.,3. PNEUM),&)RA< - partial * or co!plete collapse of lun(s due to entry or air in pleural space+ Types< + Spontaneous pneu!othora4 - entry of air in pleural space without obvious cause+

@@

$+

3(+ rupture of bleb 'alveoli filled sacs) in pt with infla!!ed lun( conditions 3(+ open pneu!othora4 - air enters pleural space throu(h an openin( in chest wall "Stab* (un shot wound Tension Pneu!othora4 - air enters plural space with Z inspiration & can>t escape leadin( to over distension of thoracic cavity resultin( to shiftin( of !ediastinu! content to unaffected side+ 3(+ flail chest - Nparado4ical breathin(O

Predisposin( factors< +Chest trau!a $+/nfla!!atory lun( conditions 3+Tu!or S*S4< + Sudden sharp chest pain $+ ,yspnea 3+ Cyanosis 7+ ,i!inished breath sound of affected lun( &+ Cool !oist s6in @+ ?ild restlessness* apprehension L+ .esonance to hyper resonance ,ia(nosis< + AB5 - pO$ decrease $+ CJ. - confir!s pneu!othora4 Nursin( ?(t< + 3ndotracheal intubation $+ Thoracenthesis 3+ ?eds - ?orphine SO7 " Anti !icrobial a(ents 7+ Assist in test tube thoracoto!y Nursin( ?(t if pt is on CPT attached to 2$O draina(e + ?aintain strict aseptic techniBue $+ ,B3 3+ At bedside a+) Petroleu! (auCe pad if dislod(ed 2e!ostan b+) /f with air lea6a(e - cla!p c+) 34tra bottle 7+ ?eds - ?orphine SO7 Anti!icrobial &+ ?onitor & assess for oscillation fluctuations or bubblin( a+) /f 'K) to inter!ittent bubblin( !eans nor!al or intact " 2$O rises upon inspiration " 2$o (oes down upon e4piration b+) /f 'K) to continuous; re!ittent bubblin( + Chec6 for air lea6a(e $+ Cla!p towards chest tube 3+ Notify ?, c+) /f '") to bubblin( + Chec6 for loop; clots; and 6in6 $+ ?il6 towards 2$O seal 3+ /ndicates re"e4pansion of lun(s 9hen will ?, re!ove chest tube< + /f '") fluctuations $+ 'K) Breath sounds 3+ CJ. - full e4pansion of lun(s Nursin( ?(t of re!oval of chest tube + ,B3 $+ /nstruct to perfor! 0alsalva !aneuver for easy re!oval; to prevent entry of air in pleural space+ 3+ Apply vaselinated air occlusive dressin( " ?aintain dressin( dry & intact

@L

GI, /+ Apper ali!entary canal " function for di(estion a+ ?outh b+ Pharyn4 'throat) c+ 3sopha(us d+ Sto!ach st e+ half of duodenu! //+ ?iddle Ali!entary canal - Function< for absorption " Co!plete absorption - lar(e intestine a+ $nd half of duodenu! b+ TeGunu! c+ /leu! st d+ half of ascendin( colon ///+ %ower Ali!entary Canal - Function< eli!ination a+ $nd half of ascendin( colon b+ Transverse c+ ,escendin( colon d+ Si(!oid e+ .ectu! /0+ Accessory Or(an a+ Salivary (land b+ 0ernifor! appendi4 c+ %iver d+ Pancreas - auto di(estion e+ 5allbladder - stora(e of bile /+ Salivary 5lands + Parotid - below & front of ear $+ Sublin(ual 3+ Sub!a4illary " " Produces saliva - for !echanical di(estion $EE " &EE !l*day " saliva produced

PAR),I,IS - N!u!psO - infla!!ation of parotid (land

"Para!y4o virus S*S4< + $+ 3+ 7+ Fever; chills anore4ia; (en body !alaise Swellin( of parotid (land ,yspha(ia 3ar ache - otal(ia

?ode of trans!ission< ,irect trans!ission & droplet nuclei /ncubation period< 7 - $ days Period of co!!unicability - wee6 before swellin( & i!!ediately when swellin( be(ins+ Nursin( ?(t< + CB. $+ Strict isolation 3+ ?eds< anal(esic Antipyretic Antibiotics - to prevent $ co!plications 7+ Alternate war! & cold co!press at affected part &+ 5en liBuid to soft diet @+ Co!plications 9o!en - cervicitis; va(initis; oophoritis Both se4es - !enin(itis & encephalitis* reason why antibiotics is needed ?en - orchitis !i(ht lead to sterility if it occur durin( * after puberty+

@#

03.N/FO.? APP3N,/J - .t iliac or .t in(uinal area " Function - ly!phatic or(an - produces 9BC durin( fetal life " ceases to function upon birth of baby

APENDICI,IS - infla!ation of vernifor! appendi4

Predisposin( factor< + ?icrobial infection $+ Feacalith - undi(ested food particles - to!ato seeds; (uava seeds 3+ /ntestinal obstruction S*S4< + $+ 3+ 7+ &+ Patho(no!onic si(n< 'K) rebound tenderness %ow (rade fever; anore4ia; n*v ,iarrhea * & or constipation Pain at .t iliac re(ion %ate si(n due pain - tachycardia

,ia(nosis< + CBC - !ild leu6ocytosis - increase 9BC $+ P3 - 'K) rebound tenderness 'fle4 .t le(; palpate .t iliac area - rebound) 3+ Arinalysis Treat!ent< " appendecto!y $7 - 7& Nursin( ?(t< + Consent $+ .outinary nursin( !easures< a+) S6in prep b+) NPO c+) Avoid ene!a - lead to rupture of appendi4 3+ ?eds< Antipyretic Antibiotics 8,on>t (ive anal(esic - will !as6 pain " Presence of pain !eans appendi4 has not ruptured+ 7+ Avoid heat application - will rupture appendi4+ &+ ?onitor 0S; /&O bowel sound Nursin( ?(t< post op + /f 'K) to Pendrose drain - indicates rupture of appendi4 Position" affected side to drain $+ ?eds< anal(esic due post op pain Antibiotics; Antipyretics P.N 3+ ?onitor 0S; /&O; bowel sound 7+ ?aintain patent /0 line &+ Co!plications" peritonitis; septice!ia %iver - lar(est (land " Occupies !ost of ri(ht hypochondriac re(ion " Color< scarlet red " Covered by a fibrous capsule - 5lisson>s capsule " Functional unit - liver lobules Function< + Produces bile Bile - e!ulsifies fats " Co!posed of 2$O & bile salts "5ives color to urine - urobilin Stool - stircobilin ,eto4ifies dru(s Pro!otes synthesis of vit A; ,; 3; H " fat soluble vita!ins

$+ 3+

@D

2ypevita!inosis - vit , & H 0it A - retinol ,ef 0it A - ni(ht blindness 0it , - cholecalciferon " 2elps calciu! " .ic6ets; osteoarthritis 7+ /t destroys e4cess estro(en hor!one &+ For !etabolis! A+ C2O + 5lyco(enesis - synthesis of (lyco(ens $+ 5lyco(enolysis - brea6down of (lyco(en 3+ 5luconeo(enesis - for!ation of (lucose fro! C2O sources B+ C2ON" + Pro!otes synthesis of albu!in & (lobulin Cirrhosis - decrease albu!in Albu!in - !aintains os!otic pressure; prevents ede!a $+ Pro!otes synthesis of prothro!bin & fibrino(en 3+ Pro!otes conversion of a!!onia to urea+ A!!onia li6e breath - fetor hepaticus C+ FATS - pro!otes synthesis of cholesterol to neutral fats - called tri(lycerides

LI5ER CIRR&)SIS " lost of architectural desi(n of liver leadin( to fat necrosis & scarrin(
3arly si(n - hepatic encephalopathy + Asteri4is - flappin( hand tre!ors %ate si(ns - headache; restlessness; disorientation; decrease %OC - hepatic co!a+ Nursin( priority - assist in !echanical ventilation Predisposin( factor< ,ecrease %aennac>s cirrhosis - caused by alcoholis! + Chronic alcoholis! $+ ?alnutrition - decrease0it B; thia!in " !ain cause 3+ 0irus 7+ To4icity" e(+ Carbon tetrachloride &+ Ase of hepatoto4ic a(ents S*S4< 3arly si(ns< a+) 9ea6ness; fati(ue b+) Anore4ia; n*v c+) Sto!atitis d+) Arine - tea color Stool - clay color e+) A!enorrhea f+) ,ecrease se4ual ur(e (+) %oss of pubic; a4illa hair h+) 2epato!e(aly i+) Taundice G+) Pruritus or urticaria $+ %ate si(ns a+) 2e!atolo(ical chan(es - all blood cells decrease %eu6openia" decrease Thro!bocytopenia" decrease Ane!ia" decrease b+) 3ndocrine chan(es Spider an(io!as; 5yneco!astia Caput !edusate; Pal!ar errythe!a

LE

c+) 5/T chan(es Ascitis; bleedin( esopha(eal varices - due to portal 2PN d+) Neurolo(ical chan(es< &e!atic ence!0a"o!at0y 8 a!!onia 'cerebral to4in) %ate si(ns< 3arly si(ns< 2eadache astere4is Fetor hepaticus 'flappin( hand tre!ors) Confusion .estlessness ,ecrease %OC 2epatic co!a ,ia(nosis< + %iver enCy!es" increase S5PT 'A%T) S5OT 'AST) Seru! cholesterol & a!!onia increase /ndirect bilirubin increase CBC " pancytopenia PTT - prolon(ed 2epatic ultrasono(ra! - fat necrosis of liver lobules

$+ 3+ 7+ &+ @+

Nursin( ?(t + CB. $+ .estrict Na: 3+ ?onitor 0S; /&O 7+ 9ith pt daily & assess pittin( ede!a &+ ?easure abdo!inal (irth daily - notify ?, @+ ?eticulous s6in care L+ ,iet - increase C2O; vit & !inerals+ ?oderate fats+ ,ecrease C2ON 9ell balanced diet #+ Co!plications< a+) Ascites - fluid in peritoneal cavity Nursin( ?(t< + ?eds< %oop diuretics - E - & !in effect $+ Assist in abdo!inal paracentesis " aspiration of fluid " 0oid before paracentesis to prevent accidental puncture of bladder as trochar is inserted b9$ /"ee#in- eso!0a-ea" varices " ,ilation of esopha(eal veins + ?eds< 0it H Pitrisin or 0asopresin '/?) $+ N5T deco!pression" lava(e " 5ive before lava(e - ice or cold saline solution " ?onitor N5T output 3+ Assist in !echanical deco!pression " /nsertion of sen(sta6en"blac6e!ore tube " 3 lu!en typed catheter " Scissors at bedside to deflate balloon+ c+) 2epatic encephalopathy + Assist in !echanical ventilation - due co!a $+ ?onitor 0S; neuro chec6 3+ Siderails - due restless 7+ ?eds - %a4atives - to e4crete a!!onia

&EPA,I,IS" Gaundice 'icteric sclera)

Bilirubin Hernicterus* hyperbilirubinia /rreversible brain da!a(e

Pancreas - !i4ed (land 'e4ocrine & endocrine (land)

PANCREA,I,IS - acute or chronic infla!!ation of pancreas leadin( to pancreatic ede!a; he!orrha(e & necrosis due to auto
di(estion+ Bleedin( of pancreas " Cullen>s si(n at u!bilicus Predisposin( factors< + Chronic alcoholis! $+ 2epatobilary disease 3+ Obesity 7+ 2yperlipide!ia &+ 2yperparathyroidis! @+ ,ru(s - ThiaCide diuretics; pills Penta!idine 2C% 'Penta!) L+ ,iet - increase saturated fats S*S4< + Severe %t epi(astric pain - radiates fro! bac6 &flan6 area " A((ravated by eatin(; with ,OB $+ N*0 3+ Tachycardia 7+ Palpitation due to pain &+ ,yspepsia - indi(estion @+ ,ecrease bowel sounds L+ 'K) Cullen>s si(n " ecchy!osis of u!bilicus he!orrha(e #+ 'K) 5rey Turner>s spots - ecchy!osis of flan6 area D+ 2ypocalce!ia ,ia(nosis< + Seru! a!ylase & lipase - increase $+ Arine lipase - increase 3+ Seru! Ca - decrease Nursin( ?(t< + ?eds a+) Narcotic anal(esic " ?eperidine 2cl ',e!erol) ,on>t (ive ?orphine SO7 -will cause spas! of sphincter+ b+) S!ooth !uscle rela4ant* anti choliner(ic " 34+ Papavarine 2cl Prophantheline Bro!ide 'Profanthene) c+) 0asodilator - NT5 d+) Antacid - ?aalo4 e+) 2$ receptor anta(onist " .anitidin 'Pantac) to decrease pancreatic sti!ulation f+) Ca - (luconate $+ 9ithold food & fluid - a((ravates pain 3+ Assist in ,ota" Parentera" Nutrition (,PN$ or hyperali!entation Co!plications of TPN + /nfection $+ 3!bolis! 3+ 2yper(lyce!ia 7+ /nstitute stress !(t tech a+) ,B3 b+) Biofeedbac6

L$

&+ Co!fy position " Hnee chest or fetal li6e position @+ /f pt can tolerate food; (ive increase C2O; decrease fats; and increase C2ON L+ Co!plications< Chronic he!orrha(ic pancreatitis 5A%%B%A,,3. - stora(e of bile - !ade up of cholesterol+ C&)LEC4S,I,IS; C&)LELI,&IASIS - infla!!ation of (allbladder with (allstone for!ation+ Predisposin( factor< + 2i(h ris6 - wo!en 7E years old $+ Post !enopausal wo!en - under(oin( estro(en therapy 3+ Obesity 7+ Sedentary lifestyle &+ 2yperlipide!ia @+ Neoplas! S*S4< + Severe .i(ht abdo!inal pain 'after eatin( fatty food)+ Occurrin( especially at ni(ht $+ Fatty intolerance 3+ Anore4ia; n*v 7+ Taundice &+ Pruritus @+ 3asy bruisin( L+ Tea colored urine #+ Steatorrhea ,ia(nosis< + Oral cholecysto(ra! 'or (allbladder series)" confir!s presence of stones Nursin( ?(t< + ?eds - a+) Narcotic anal(esic " ?eperdipine 2cl - ,e!erol b+) Anti choliner(ic " Atropine SO7 c+) Anti e!etic Phener(an - PhenothiaCide with anti e!etic properties $+ ,iet - increase C2O; !oderate C2ON; decrease fats 3+ ?eticulous s6in care 7+ Sur(ery< Cholecystecto!y Nursin( ?(t post cholecystecto!y "?aintain patency of T"tube intact & prevent infection Sto!ach - widest section of ali!entary canal " T shaped structures + Anthru! $+ Pylorus 3+ Fundus 0alves + +cardiac sphincter $+ Pyloric sphincter Cells + Chief* Py!o(enic cells - secrets a+) 5astric a!ylase " di(est C2O b+) 5astric lipase - di(est fats c+) Pepsin - C2ON d+) .ennin - di(ests !il6 products Parietal * Ar(entaffin * o4yntic cells Function< a+) Produces intrinsic factor - pro!otes reabsorption of vit B $ cyanocobala!in - pro!otes !aturation of .BC b+) Secrets 2cl acid - aids in di(estion 3ndocrine cells " Secrets (astrin - increase 2cl acid secretion

$+

3+

Function of the sto!ach

L3

+?echanical $+Che!+ ,i(estion 3+Stora(e of food "C2O; C2ON" stored

"$ hrs+ Fats - stored $ - 3 hrs

PEP,IC ULCER DISEASE 2 (PUD) - e4coriation * erosion of sub!ucosa & !ucosal linin( due to<
a+) 2ypercecretion of acid - pepsin b+) ,ecrease resistance to !ucosal barrier /ncidence .ate< + ?en - 7E - && yrs old $+ A((ressive persons Predisposin( factors< + 2ereditary $+ 3!otional 3+ S!o6in( - vasoconstriction - 5/T ische!ia 7+ Alcoholis! - sti!ulates release of hista!ine 1 Parietal cell release 2cl acid 1 ulceration &+ Caffeine - tea; soda; chocolate @+ /rre(ular diet L+ .apid eatin( #+ Alcero(enic dru(s - NSA/,S; aspirin; steroids; indo!ethacin; ibuprofen /ndo!ethacin " S*3 corneal cloudiness+ Needs annual eye chec6 up+ D+ 5astrin producin( tu!or or (astrino!a - Pollin(er 3llisons si(n E+ ?icrobial invasion - helicobacter pylori+ ?etro!idaCole 'Fla(yl) Types of ulcers Ascendin( to severity + Acute - affects sub!ucosal linin( $+ Chronic - affects underlyin( tissue - heals & for!s a scar Accordin( to location + Stress ulcer $+ 5astric ulcer 3+ ,uodenal ulcer - !ost co!!on Stress ulcers - co!!on a!on( eritically ill clients $ types +Curin(>s ulcer - cause< trau!a & birth hypovole!ia 5/T sche!ia ,ecrease resistance of !ucosal barriers to 2cl acid Alcerations $+Cushin(>s ulcer - cause - stro6e*C0A* head inGury /ncrease va(al sti!ulation 2yperacidity Alcerations

L7

S/T3 PA/N

2IP3.S3C.3T/ON 0O?/T/N5 23?O..2A53 9T CO?P%/CAT/ONS

2/52 ./SH ,ia(nosis< + 3ndoscopic e4a! $+ Stool fro! occult blood 3+ 5astric analysis - N - (astric /ncrease - duodenal 7+ 5/ series - confir!s presence of ulceration Nursin( ?(t< + ,iet - bland; non irritatin(; non spicy $+ Avoid caffeine & !il6* !il6 products /ncrease (astric acid secretion 3+ Ad!inister !eds a+) Antacids AAC A"uminum containin- antaci#s 34+ alu!inu! O2 (el 'A!pho"(el) S*3 constipation ?aalo4 'fever S*3) b+) 2$ receptor anta(onist 34 + .anitidine 'Pantac) $+ Ci!etidine 'Ta(a!et) 3+ Ta!otidine 'Pepcid) " Avoid s!o6in( - decrease effectiveness of dru( Nursin( ?(t<

5AST./C A%C3. /ntru! or lesser curvature "3E !in - hr after eatin( " epi(astriu! " (aseous & burnin( " not usually relieved by food & antacid Nor!al (astric acid secretion co!!on he!ate!eis 9t loss a+ sto!ach cause b+ he!orrha(e @E years old

,AO,3NA% A%C3. ,uodenal bulb "$"3 hrs after eatin( " !id epi(astriu! " cra!pin( & burnin( " usually relieved by food & antacid " $ ?N - 3a! pain /ncreased (astric acid secretion Not co!!on ?elena 9t (ain a+ perforation $E years old

?a(nesiu! containin( antacids e4+ !il6 of !a(nesia S*3 diarrhea

Ad!inister antacid & 2$ receptor anta(onist - hr apart "Ce!etidine decrease antacid absorption & vise versa c+) Cytoprotective a(ents 34 + Sucralfate 'Carafate) " Provides a paste li6e subs that coats !ucosal linin( of sto!ach $+ Cytotec d+) Sedatives* TranBuiliCers " 0aliu!; lithiu! e+)Anticholiner(ics + Atropine SO7

L&

$+

Prophantheline Bro!ide 'Profanthene)

'Pt has history of hpn crisis 9ith peptic ulcer disease+ .n should not ad!inister al6a seltCer" has lar(e a!ount of Na+ 7+ Sur(ery< subtotal (astrecto!y " Partial re!oval of sto!ach Billroth / '5astroduodenosto!y) Billroth // '5astroGeGunosto!y) ".e!oval of ^ of sto!ach & anasto!oses of (astric stu!p " re!oval of ^ "3*7 of sto!ach & duodenal bulb & anasto!ostoses of to the duodenu!+ (astric stu!p to GeGunu!+ Before sur(ery for B/ or B// " ,o va(oto!y 'severin( of va(us nerve) & pyloroplasty 'draina(e) first+ Nursin( ?(t< + ?onitor N5T output a+) /!!ediately post op should be bri(ht red b+) 9ithin 3@" 7$h - output is yellow (reen c+) After 7$h - output is dar6 red $+ Ad!inister !eds< a+) Anal(esic b+) Antibiotic c+) Antie!etics 3+ ?aintain patent /0 line 7+ 0S; /&O & bowel sounds &+ Co!plications< a+) 2e!orrha(e - hypovole!ic shoc6 %ate si(ns - anuria b+) Peritonitis c+) Paralytic ileus - !ost feared d+) 2ypo6ale!ia e+) Thro!obphlebitis f+) Pernicious ane!ia L+)Dum!in- syn#rome - co!!on co!plication - rapid (astric e!ptyin( of hypertonic food solutions - C2I?3 leadin( to hypovole!ia+ S4 of ,u!pin( syndro!e< + ,iCCiness $+ ,iaphoresis 3+ ,iarrhea 7+ Palpitations Nursin( !(t< + Avoid fluids in chilled solutions $+ S!all freBuent feedin( s"@ eBually divided feedin(s 3+ ,iet - decrease C2O; !oderate fats & C2ON 7+ Flat on bed & "3E !inutes after B feedin(

/URNS - direct tissue inGury caused by ther!al; electric; che!ical & s!o6e inhaled 'T3CS)
Nursin( Priority - infection 'all 6inds of burns) 2ead burn"priority" a*w $nd priority for st & $nd " pain $nd priority for 3rd " F&3 Ther!al" direct contact - fla!es; hot (rease; sunburn+ 3lectric; - wires Che!+ - direct contact - corrosive !aterials acids S!o6e - (as * fu!e inhalation Sta(es< + 3!er(ent phase - .e!oval of pt fro! cause of burn+ ,eter!ine source or loc or burn $+ Shoc6 phase - 7# " L$+ CharacteriCed by shiftin( of fluids fro! intravascular to interstitial space 12ypovole!ia

L@

S*S4< " " " " " " "

BP decrease Arine output 2. increase 2ct increase Seru! Na decrease Seru! H increase ?et acidosis

3+ ,iuretic* Fluid re!obiliCation phase " 3 to & days+ .eturn of fluid fro! interstitial to intravascular space 7+ .ecovery* convalescent phase - co!plete diuresis+ 9ound healin( starts i!!ediately after tissue inGury+ Class< /+ Partial Burn + st de(ree - superficial burns " Affects epider!is " Cause< ther!al burn " Painful " .edness 'erythe!a) & blanchin( upon pressure with no fluid filled vesicles $+ $nd de(ree - deep burns " Affects epider!is & der!is " Cause -che!+ burns " very painful " 3rythe!a & fluid filled vesicles 'blisters) // Full thic6ness Burns + Third & 7th de(rees burn " Affects all layers of s6in; !uscles; bones " Cause - electrical " %ess painful " ,ry; thic6; leathery wound surface - 6nown as 3SC2A. - devitaliCed or necrotic tissue+ Assess!ent findin(s .ule of nines 2ead & nec6 1 DF Ant chest 1 #F Post chest 1 #F Z Ar! DKD 1 #F Z le( #K # 1 #F 5enitalia* perineu!1 F Total EEF Nursin( ?(t + ?eds a+) Tetanus to4oid" burn surface area is source of anaerobic (rowth - Claustridiu! tetany Tetany Tetanolysin 2e!olysis tetanospas!in !uscle spas!

b+) ?orphine SO7 c+) Syste!ic antibiotics + A!picillin $+ Cephalosporin 3+ Tetracyclin 7+ Topical antibiotic < + Silver SulfadiaCene 'silvadene) $+ Sulfa!ylon 3+ Silver nitrate

LL

7+ Povidone iodine 'betadine) $+ Ad!inister isotonic fluid sol & C2ON replace!ents 3+ Strict aseptic techniBue 7+ ,iet - increase C2O; increase C2ON; increase 0it C; and increase H" oran(e &+ /f 'K) to burns on head; nec6; face " Assist in intubation @+ Assist in hydrotherapy L+ Assist in sur(ical wound debride!ent+ Ad!inister anal(esic & - 3E !inutes before debride!ent #+ Co!plications< a+) /nfection b+) Shoc6 c+) Paralytic ileus " due to hypovole!ia & hypo6ale!ia d+) Curlin(>s ulcer - 2$ receptor anta(onist e+) Septice!ia blood poisonin( f+) Sur(ery< s6in (raftin( GU, - (enito"urinary tract Function< + Pro!ote e4cretion of nitro(enous waste products $+ ?aintain F&3 & acid base balance + Hidneys - pair of bean shaped or(an " .etro peritonially 'bac6 of peritoneu!) on either side of vertebral colu!n+ 3ncased in Bow!ans>s capsule+ Parts< + $+ 3+ .enal pelvis - pyenophritis - infl Corte4 ?edulla

Nephrones - basic livin( unit 5lo!erulus - filters blood (oin( to 6idneys Function of 6idneys< + Arine for!ation $+ .e(ulation of BP Arine for!ation - $&F of total CO 'Cardiac Output) is received by 6idneys + Filtration $+ Tubular .eabsorption 3+ Tubular Secretion Filtration - Nor!al 5F.* !in is $& !l of blood Tubular reabsorption - $7!l of ultra infiltrates '2$O & electrolytes is for reabsorption) Tubular secretion - !l is e4creted in urine .e(ulation of BP< Predisposin( factor< 34 CS - hypovole!ia - decrease BP (oin( to 6idneys Activation of .AAS .elease of .enin 'hydrolytic enCy!e) at Gu4ta(lo!erular apparatus An(iotensin / !ild vasoconstrictor An(iotensin // vasoconstrictor Adrenal corte4 Aldosterone /ncrease BP increase CO increase P.

L#

/ncrease Na & 2$O reabsorption 2ypervole!ia Areters - $& - 3& c! lon(; passa(eway of urine to bladder Bladder - loc behind sy!phisis pubis+ ?uscular & elastic tissue that is distensible " Function - reservoir or urine $EE - #EE !l - Nor!al adult can hold $EE - &EE !l - needed to initiate !icturition refle4 Color a!ber Odor aro!atic Consistency clear or sli(htly turbid p2 7+& - # Specific (ravity - +E & - +E3E 9BC* .BC '") Albu!in '") 3 coli '") ?ucus thread - few A!orphous urate '") Arethra - e4tends to e4ternal surface of body+ Passa(e of urine; se!inal & va(inal fluids+ " 9o!en 3 - & c! or to ^ N " ?ale - $Ec! or #O AT/

C4S,I,IS - infla!!ation of bladder

Predisposin( factors< + ?icrobial invasion - 3+ coli $+ 2i(h ris6 - wo!en 3+ Obstruction 7+ Arinary retention &+ /ncrease estro(en levels @+ Se4ual intercourse S*S4< + Pain - flan6 area $+ Arinary freBuency & ur(ency 3+ Burnin( upon urination 7+ ,ysuria & he!aturia &+ Fever; chills; anore4ia; (en body !alaise ,ia(nosis< + Arine culture & sensitivity " 'K) to 3+ coli Nursin( ?(t< + Force fluid - $EEE !l $+ 9ar! sitC bath - to pro!ote co!fort 3+ ?onitor & assess for (ross he!aturia 7+ Acid ash diet - cranberry; vit C "OT to acidify urine & prevent bacterial !ultiplication &+ ?eds< syste!ic antibiotics A!picillin Cephalosporin Sulfona!ides - cotri!a4aCole 'Bactri!) " 5antris! '(anthanol) Arinary antiseptics - ?itropurantoin '?acrodantin) Arinary anal(esic" Pyridu! @+ 2t a+) /!portance of 2ydration b+) 0oid after se4 c+) Fe!ale - avoids cleanin( bac6 & front Bubble bath; Tissue paper; Powder; perfu!e

LD

d+) Co!plications< Pyelonephritis

P4EL)NEP&RI,IS - acute* chronic infl of or $ renal pelvis of 6idneys leadin( to tubular destruction; interstitial abscess
for!ation+ " %ead to .enal Failure Predisposin( factor< + ?icrobial invasion a+) 3+ Coli b+) Streptococcus $+ Arinary retention *obstruction 3+ Pre(nancy 7+ ,? &+ 34posure to renal to4ins S*S4< Acute pyelonephritis a+) Costovertibral an(le pain; tenderness b+) Fever; anore4ia; (en body !alaise c+) Arinary freBuency; ur(ency d+) Nocturia; dsyuria; he!aturia e+) Burnin( on urination Chronic Pyelonephritis a+) Fati(ue; wt loss b+) Polyuuria; polydypsia c+) 2PN ,ia(nosis< + Arine culture & sensitivity - 'K) 3+ coli & streptococcus $+ Arinalysis /ncrease 9BC; C2ON & pus cells 3+ Cystoscopic e4a! - urinary obstruction Nursin( ?(t< + Provide CB. - acute phase $+ Force fluid 3+ Acid ash diet 7+ ?eds< a+) Arinary antiseptic - nitrofurantoin '!acrodantin) S3< peripheral neuropathy 5/ irritation 2e!olytic ane!ia Stainin( of teeth b+) Arinary anal(esic - Peridiu! $+ Co!plication" .enal Failure

NEP&R)LI,&IASIS; UR)LI,&IASIS" for!ation of stones at urinary tract

" calciu! ; !il6 o4alate; cabba(e cranberries nuts tea chocolates uric acid anchovies or(an !eat nuts sardines

Predisposin( factors< + ,iet - increase Ca & o4alate $+ 2ereditary - (out

#E

3+ 7+ &+ S*S4<

Obesity Sedentary lifestyle 2yperparathyroidis!

+ .enal colic $+ Cool !oist s6in 'shoc6) 3+ Burnin( upon urination 7+ 2e!aturia &+ Anore4ia; n*v ,ia(nosis< + /0P - intravenous pyelo(raphy+ .eveals location of stone $+ HAB - reveals location of stone 3+ Cytoscopic e4a!" urinary obstruction 7+ Stone analysis - co!position & type of stone &+ Arinalysis - increase 3BC; increase C2ON Nursin( ?(t< +Force fluid $+Strain urine usin( (auCe pad 3+9ar! sitC bath - for co!fort 7+Alternate war! co!press at flan6 area &+ a+) Narcotic anal(esic" ?orphine SO7 b+) Allopurinol 'Pyeopri!) c+) Patent /0 line d+) ,iet - if K Ca stones - acid ash diet /f K o4alate stone - al6aline ash diet " '34 !il6* !il6 products) /f K uric acid stones - decrease or(an !eat * anchovies sardines @+ Sur(ery a+) Nephecto!y - re!oval of affected 6idney %itholapo4y - re!oval of *3 of stones" Stones will recur+ Not advised for pt with bi( stones b+) 34tracorporeal shoc6 wave lithotripsy " Non " invasive " ,issolve stones by shoc6 wave L+ Co!plications< .enal Failure

/ENIGN PR)S,A,IC &4PER,R)P&4 " enlar(ed prostate (land leadin( to

a+) b+) c+) d+) 2ydro ureters - dilation of ureters 2ydronephrosis - dilation of renal pelvis Hidney stones .enal failure

Predisposin( factor< + 2i(h ris6 - &E years old & above @E - LE - '3 to 7 4 at ris6) $+ /nfluence of !ale hor!one S*S4< +,ecrease force of urinary strea! $+,ysuria 3+2e!aturia 7+Burnin( upon urination &+Ter!inal bubblin( @+Bac6ache L+Sciatica ,ia(nosis< + ,i(ital rectal e4a! - enlar(ed prostate (land $+ HAB - urinary obstruction 3+ Cystoscopic e4a! - obstruction 7+ Arinalysis - increase 9BC; C2ON Nursin( ?(t<

Prostatic !essa(e - pro!otes evacuation of prostatic fluid %i!it fluid inta6e Provide catheteriCation ?eds< a+ TeraCoCine 'hytrin) " .ela4es bladder sphincter b+ Fenasteride 'Proscar) " Atrophy of Prostate 5land &+ Sur(ery< Prostatecto!y - TA.P" Transurethral resection of Prostate" No incision "Assist in cystoclysis or continuous bladder irri(ation+ Nursin( !(t< c+ ?onitor sy!pto!s of infection d+ ?onitor sy!pto!s (ross* flan6 bleedin(+ Nor!al bleedin( within $7h+ 3+ ?aintain irri(ation or tube patent to flush out clots " to prevent bladder spas! & distention

+ $+ 3+ 7+

ACU,E RENAL 6AILURE - sudden i!!obility of 6idneys to e4crete nitro(enous waste products & !aintain F&3 balance
due to a decrease in 5F.+ 'N $& !l*!in) Predisposin( factor< Pre renal cause" decrease blood flow Causes< + Septic shoc6 $+ 2ypovole!ia 3+ 2ypotension decrease flow to 6idneys 7+ C2F &+ 2e!orrha(e @+ ,ehydration /ntra"renal cause - involves renal patholo(y1 6idney proble! + Acute tubular necrosis" $+ Pyelonephritis 3+ 2PN 7+ Acute 5N Post renal cause - involves !echanical obstruction + Stricture $+ Arolithiasis 3+ BP2

C&R)NIC R6 - irreversible loss of 6idney function

Predisposin( factors< + ,? $+ 2PN 3+ .ecurrent AT/* nephritis 7+ 34posure to renal to4ins Sta(es of C.F + ,i!inished .eserve 0olu!e - asy!pto!atic Nor!al BAN & Crea; 5F. M E - 3EF $+ .enal /nsufficiency 3+ 3nd Sta(e .enal disease S*S4< +) Arinary Syste! a+) polyuria b+) nocturia c+) he!aturia d+) ,ysuria e+) oli(uria 3+) CNS $+) ?etabolic disturbances a+) aCote!ia 'increase BAN & Crea) b+) hyper(lyce!ia c+) hyperinuline!ia 7+) 5/T

#$

a+) headache a+) n*v b+) lethar(y b+) sto!atitis c+) disorientation c+) ure!ic breath d+) restlessness d+) diarrhea* constipation e+) !e!ory i!pair!ent &+) .espiratory @+) he!atolo(ical a+) Hass!aul>s resp a+) Nor!ocytic ane!ia b+) decrease cou(h bleedin( tendencies refle4 L+) Fluid & 3lectrolytes #+) /nte(u!entary a+) hyper6ale!ia a+) itchiness* pruritus b+) hypernater!ia b+) ure!ic frost c+) hyper!a(nese!ia d+) hyperposphate!ia e+) hypocalce!ia f+) !et acidosis Nursin( ?(t< + 3nforce CB. $+ ?onitor 0S; /&O 3+ ?eticulous s6in care+ Are!ic frost - assist in bathin( pt 7+ ?eds< a+) Na 2CO3 - due 2yper6ale!ia b+) Ha(e4elate ene!a c+) Anti 2PN - hydralaCine d+) 0it & !inerals e+) Phosphate binder 'A!pho(el) Al O2 (el " S*3 constipation f+) ,ecrease Ca - Ca (luconate &+ Assist in he!odialysis +) Consent* e4plain procedure $+) Obtain baseline data & !onitor 0S; /&O; wt; blood e4a! 3+) Strict aseptic techniBue 7+) ?onitor for si(ns of co!plications< B - bleedin( 3 - e!bolis! , - diseBuilibriu! syndro!e S - septice!ia S - shoc6 - decrease in tissue perfusion ,iseBuilibriu! syndro!e - fro! rapid re!oval of urea & nitro(enous waste prod leadin( to< a+) n*v b+) 2PN c+) %e( cra!ps d+) ,isorientation e+) Paresthesia Avoid BP ta6in(; blood e4traction; /0; at side of shunt or fistula+ Can lead to co!pression of fistula+ ?aintain patency of shunt by< i+ Palpate for thrills & auscultate for bruits if 'K) patent shunt: ii+ Bedside" bulldo( clip " /f with accidental re!oval of fistula to prevent e!bolis!+ " /nfersole 'diastole) - co!!on dialisate used L+ Co!plication " Peritonitis " Shoc6 #+ Assist in sur(ery< .enal transplantation < Co!plication - reGection+ .everse isolation $+ 3+

#3

E4ES
34ternal parts + Orbital cavity - !ade up of connective tissue protects eye for! trau!a+ $+ 3O? - e4trinsic ocular !uscles - involuntary !uscles of eye needed for (aCin( !ove!ent+ 3+ 3yelashes* eyebrows - esthetic purposes 7+ 3yelids - palpebral fissure - openin( upper & lower lid+ Protects eye fro! direct sunli(ht ?eibo!ean (land - secrets a lubricatin( fluid inside eyelid b+) Stye* sty or 2ordeolu!" infla!ed ?eibo!ean (land &+ ConGunctiva @+ %acri!al apparatus - tears Process of -rievina+ ,enial b+ An(er c+ Bar(ainin( d+ ,epression e+ Acceptance $+ /ntrinsic coat /+ sclerotic coat - outer !ost a+) Sclera - white+ Occupies _ post of eye+ .efracts li(ht rays b+) Canal of schlera - site of aBueous hu!or draina(e c+) Cornea - transparent structure of eye //* Aveal tract - nutritive care Aveitis - infl of uveal tract Consist of< a+) /ris - colored !uscular rin( of eye $ !uscles of iris< + Circular s!ooth !uscle fiber " Constricts the pupil $+radial s!ooth !uscle fiber " ,ilates the pupil $ cha!bers of the eye + Anterior a+) 0itereous 2u!or - !aintains spherical shape of the eye b+) ABueous 2u!or - !aintains intrinsic ocular pressure Nor!al /OP1 $"$ !!2( //+ .etina 'inner!ost layer) i+ Optic discs or blind spot - nerve fibers only No auto receptors cones 'dayli(ht* colored vision) phototopic vision rods - ni(ht twili(ht vision Nscotopic visionO 1 vit A deficiency - rods insufficient ii+ ?aculla lutea - yellow spot center of retina iii+ Fovea centralis - area with hi(hest visual acuity oracute vision Physiolo(y of vision 7 Physiolo(ical processes for vision to occur< + .efraction of li(ht rays - bendin( of li(ht rays $+ Acco!!odation of lens 3+ Constriction & dilation of pupils 7+ Conver(ence of eyes

#7

Anit of !easure!ents of refraction - diopters Nor!al eye refraction - e!!etropia 3..O. of refraction + ?yopia - near si(htedness - Treat!ent< biconcave lens $+ 2yperopia* or farsi(htedness - Treat!ent< biconve4 lens 3+ Asti(!atisi! - distorted vision - Treat!ent< cylindrical 7+ Prebyopia - Nold sli(htO - inelasticity of lens due to a(in( - Treat!ent< bifocal lens or double vista Acco!!odation of lenses - based on thel!holtC theory of acco!!odation Near vision 1 Ciliary !uscle contracts1 %ens bul(es Conver(ence of the eye< 3rror< + 34otropia - eye nor!al $+ 3sophoria 3+ Strabis!us" sBuint eye 7+ A!blyopia - prolon( sBuintin( far vision1 ciliary !uscle dilates * rela4es1 lens is flat

corrected by corrective eye sur(ery

GLAUC)MA - increase /OP - if untreated; atrophy of optic nerve disc - blindness

Predisposin( factors< + 2i(h ris6 (roup - 7E & above $+ 2PN 3+ ,? 7+ 2ereditary &+ Obesity @+ .ecent eye trau!a; infl; sur(ery Type< + $+ 3+ S*S4< + $+ 3+ 7+ &+ @+ L+ %oss of peripheral vision - tunnel vision 2alos around li(hts 2eadache n*v Stea!y cornea 3ye disco!fort /f untreated - (radual loss of central vision - blindness Chronic - 'open an(le 5+) - !ost co!!on type Obstruct in flow of aBueous hu!or at trabecular !eshwor6 of canal of schle!a Acute 'close an(le 5+) - ?ost dan(erous type Forward displace!ent of iris to cornea leadin( to blindness+ Chronic 'closed - an(le) " Precipitated by acute attac6

,ia(nosis< + Tono!etry - increase /OP S $" $ !!2( $+ Peri!etry - decrease peripheral vision 3+ 5onioscopy - abstruction in anterior cha!ber Nursin( !(t< + 3nforce CB. $+ ?aintain siderails 3+ Ad!inister !eds a+) ?iotics - lifeti!e " contracts ciliary !uscles & constricts pupil+ 34 Pilocarpine Na 'Carbachol) b+) 3pinephrine eye drops - decrease secretion of aBueous hu!or

#&

c+) Carbonic anhydrase inhibitors+ 34+ acetapola!ide ',ia!o4) " Pro!otes increase out flow of aBuaeous hu!or d+) Te!optics 'Ti!olol !aleate)" /ncrease outflow of aBuaous hu!or $+ Sur(ery< /nvasive< a+) Trabeculecto!y - eyetrephinin( - re!oval of trabelar !eshwor6 of canal or schlera to drain aBueous hu!or b+) Peripheral /ridecto!y - portion of iris is e4cised to drain aBueous hu!or Non"invasive< Trabeculocto!y 'eye laser sur(ery)

Nursin( ?(t pre op" all types sur(ery + Apply eye patch on unaffected eye to force wea6er eye to beco!e stron(er+ Nursin( ?(t post op - all types of sur(ery + Position unaffected* unoperated side " to prevent tension on suture line+ $+ Avoid valsalva !aneuver 3+ ?onitor sym!toms of I)P a+) 2eadache b+) n*v c+) 3ye disco!fort d+) Tachycardia $+ 3ye patch - both eyes " post op

CA,ARAC, - partial* co!plete opacity of lens

Predisposin( factor< + DE"D&F " a(in( 'de(enerative* senile cataract) $+ Con(enital 3+ Prolon(ed e4posure to A0 rays 7+ ,?" S*S4< + $+ 3+ 7+ %oss of central vision " N2aCy or blurrin( of visionO Painless ?il6y white appearance at center of pupil ,ecrease perception of colors

,ia(nosis< Opthal!oscopic e4a! - 'K) opacity of lens Ns( ?(t< + .eorient pt to environ!ent - due opacity $+ Siderails 3+ ?eds - a+) ?ydriatics - dilate pupil - not lifeti!e 34+ ?ydriacyl c+) Cyslope(ics - paralyCes ciliary !uscle+ 34+ Cyclo(ye 7+ Sur(ery 3 - e4tra C " capsular C - cataract % " lens 3 - e4traction / " intra C " capsular C - cataract % " lens 3 - e4traction

partial re!oval of lens

total re!oval of lens & surroundin( capsules

#@

Nursin( ?(t< +Position unaffected* unoperated side " to prevent tension on suture line+ $+Avoid valsalva !aneuver 3+?onitor sym!toms of I)P a+) 2eadache b+) n*v c+) 3ye disco!fort d+) Tachycardia 7+3ye patch - both eyes " post op

RE,INAL DE,AC&MEN," separation of $ layers of retina

Predisposin( factors< + $+ 3+ 7+ &+ S*S4< + $+ 3+ 7+ &+ NCurtain -veilO li6e vision Flashes of li(hts Floaters 5radual decrease in central vision 2eadache Severe !yopia - nearsi(htedness ,iabetic .etinopathy Trau!a Followin( lens e4traction 2PN

,ia(nosis" opthaloscopic e4a! Nursin( ?(t< + Siderails 'all visual disease) $+ Sur(ery< a+) Cryosur(ery b+) Scleral buc6lin( 3A. + 2earin( $+ Balance 'Hinesthesia or position sense) Parts< + Outer" a+) Pinna* auricle - protects ear fro! direct trau!a b+) 34t+ auditory !eatus - has ceru!inous (land+ Ceru!en c+) Ty!panic !e!brane - trans!its sound waves to !iddle ear

Disor#ers of outer ear

3ntry of insects - put flashli(ht to (ive route of e4it Forei(n obGects - beans 'brin( to ?,) 2$O " drain $+ ?iddle ear a+) 3ar osssicle + 2a!!er "!alleus $+ Anvil "/ncus 3+ Stirrups "stapes for bone conduction disorder conductive hearin( loss

b+ 3ustachian tube " Opens to allow eBualiCation of pressure on both ears " Iawn; chew; and swallow

#L

Children - strai(ht; wide; short c+) Otitis !edia Adult - lon(; narrow & slanted c+ ?uscles + Stapedius $+ Tensor ty!pani 3+ /nner ear a+ Bony labyrinth - for balance; vestibule Atricle & succule Otolithe or ear stone - has Ca carbonate ?ove!ent of head 1 .i(htin( refle4 1 Hinesthesia b+ ?e!branous %abyrinth + Cochlea - ' function for hearin() has or(an of corti $+ 3ndoly!ph & perily!ph - for static eBuilibriu! 3+ ?astoid air cells - air filled spaces in te!poral bone in s6ull Co!plications of ?astoditis - !enin(itis Types of hearin( loss< + Conductive hearin( loss - trans!ission hearin( loss Causes< a+) /!pacted ceru!en - tinnitus & conduction hearin( loss" assist in ear irri(aton b+) /!!obility of stapes - OTOSC%3.OS/S d+) ?iddle ear disease char by for!ation of spon(y bone in the inner ear causin( fi4ation or i!!obility of stapes e+) Stapes can>t trans!it sound waves Sur(ery Stapedecto!y - re!oval of stapes; spon(y bone & i!plantation of (raft* ear prosthesis Predisposin( factor< + Fa!iliar tendency $+ 3ar trau!a & sur(ery S*S4< + $+ Tinnitus Conductive hearin( loss

,ia(nosis< + Audio!etry - various sound sti!ulates 'K) conductive hearin( loss $+ 9eber>s test - Nor!al ACS BC result BC S AC Sta!e#ectomy Nursin( ?(t post op + Position pt unaffected side $+ ,B3 No cou(hin( & blowin( of nose " Ni(ht lead to re!oval of (raft 3+ ?eds< a+) Anal(esic b+) Antie!etic c+) Anti!otion sic6ness a(ent+ 34+ !eclesine 2cl 'Bona!ine) 7+ Assess - !otor function - facial nerve " 'S!ile; frown; raise eyebrow) &+ Avoid sha!poo hair for to $ wee6s+ Ase shower cap

##

SENS)R4 NEURAL &EARING L)SS; NER5E DEA6NESS

Cause< + Tu!or on cocheal $+ %oud noises '(un shot) 3+ Presbycusis - bilateral pro(ressive hearin( loss especially at hi(h freBuencies - elderly Face elderly to pro!ote lip readin( 7+ ?eniere>s disease - endoly!phatic hydrops f+) /nner ear disease char by dilation of endo - ly!pathic syste! leadin( to increase volu!e of endolin Predisposin( factor of MENIERE'S DISEASE S!o6in( 2yperlipide!ia 3E years old Obesity - 'K) chosesteato!a Aller(y 3ar trau!a & infection S*S4< + T./A, sy!pto!s of ?eniere>s disease a+) Tinnitus b+) 0erti(o c+) Sensory neural hearin( loss Nysta(!us n*v ?ild apprehension; an4iety Tachycardia Palpitations ,iaphoresis

$+ 3+ 7+ &+ @+ L+

,ia(nosis< + Audio!etry - 'K) sensory hearin( loss + $+ 3+ 7+ Nursin( !(t< Co!fy & dar6ened environ!ent Siderails 3!etic basin ?eds< a+) ,iuretics -to re!ove endoly!ph b+) 0asodilator c+) Antihista!ine d+) Antie!etic e+) Anti!otion sic6ness a(ent f+) Sedatives* tranBuiliCers .estrict Na %i!it fluid inta6e Avoid s!o6in( Sur(ery - endoly!phatic sac deco!pression" Shunt

&+ @+ L+ #+

#D