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Circulatory system includes a pump (the heart), interconnected tubes (blood vessels or vascular system), and
extracellular fluid and cells (blood)
Chambers of heart
Right atrium: collecting chamber for incoming systemic venous system
Right ventricle: propels blood into pulmonary system
Left atrium: collects blood from pulmonary venous system
Left ventricle: largest thick-walled muscle that acts as a high-pressure pump which propels
blood into the systemic arterial system
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The Blood supply of the heart comes from the Coronary arteries
- Right coronary artery
- Left coronary artery
Blood supply for the heart:
Coronary arteries supply blood to myocardium
Coronary blood flow blood flowing through the coronary arteries
Coronary sinus drainage area for the blood; empties into right atrium
The main functions of this system are:
- to transport oxygen, hormones and nutrients to the tissues
- and to transport waste products to the lungs and kidneys for excretion
The CONDUCTING SYSTEM OF THE HEART
Consists of the
1. SA node- the pacemaker
2. AV node- slowest conduction
3. Bundle of His branches into the Right and the Left bundle branch
4. Purkinje fibers- fastest conduction
The Heart sounds
1. S1- due to closure of the AV valves
2. S2- due to the closure of the semi-lunar valves
3. S3- due to increased ventricular filling
4. S4- due to forceful atrial contraction
Heart rate
- Normal range is 60-100 beats per minute
- Tachycardia is greater than 100 bpm
- Bradycardia is less than 60 bpm
Page 2
Vascular System
- The vascular system consists of the arteries, veins and capillaries
- The arteries are vessels that carry blood away from the heart to the periphery
- The veins are the vessels that carry blood to the heart
- The capillaries are lined with squamos cells, they connect the veins and arteries
- The lymphatic system also is part of the vascular system and the function of this system is to collect the extravasated
fluid from the tissues and returns it to the blood
Cardiac Assessment
1. Health History
- Obtain description of present illness and the chief complaint
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Page 4
CVP
ECG
Holter monitoring
Exercise ECG
Page 5
ELECTROCARDIOGRAM (ECG)
- A non-invasive procedure that evaluates the electrical activity of the heart
- Electrodes and wires are attached to the patient
- Tell the patient that there is no risk of electrocution
- Avoid muscular contraction/movement
Holter Monitoring
- A non-invasive test in which the client wears a Holter monitor and an ECG tracing recorded continuously over a period
of 24 hours
- Instruct the client to resume normal activities and maintain a diary of activities and any symptoms that may develop
Echocardiogram
Non-invasive test that studies the structural and functional changes of the heart with the use of ultrasound
No special preparation is needed
Page 6
Stress Test
A non-invasive test that studies the heart during activity and detects and evaluates CAD
Exercise test, pharmacologic test and emotional test
Treadmill testing is the most commonly used stress test
Used to determine CAD, Chest pain causes, drug effects and dysrhythmias in exercise
Pre-test: consent may be required, adequate rest , eat a light meal or fast for 4 hours and avoid smoking, alcohol and
caffeine
Post-test: instruct client to notify the physician if any chest pain, dizziness or shortness of breath
Instruct client to avoid taking a hot shower for 10-12 hours after the test
Pharmacological stress test
! Use of dipyridamole
! Maximally dilates coronary artery
! Side-effect: flushing of face
! Pre-test: 4 hours fasting, avoid alcohol, caffeine
! Post test: report symptoms of chest pain
Cardiac Catheterization
Insertion of a catheter into the heart and surrounding vessels
Obtains information about the structure and performance of the heart valves and surrounding vessels
Used to diagnose CAD, assess coronary artery patency and determine extent of atherosclerosis
PRE PROCEDURE
# Ensure Consent
# assess for allergy to seafood and iodine
# Withhold solid food 6-8 hours and liquids for 4 hours
# document weight and height, baseline VS, blood tests and document the peripheral pulses
# inform client that a local anesthetic will be administered before insertion
# Client may feel fatigued because of the need to lie for 2 hours
# Prepare IV line if prescribed
# Prepare insertion site by shaving and cleaning with an antiseptic solution if prescribed
# Administer pre medication
INTRATEST
# inform patient of a fluttery feeling as the catheter passes through the heart
# inform the patient that a feeling of warmth and metallic taste may occur when dye is administered.
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POST TEST
# Monitor VS and cardiac rhythm
# Monitor dysrrhytmia and chest pain
# Monitor peripheral pulses, color and warmth and sensation of the extremity distal to insertion site
# Apply sandbag or compression device to insertion site if required to maintain pressure
# Maintain strict bed rest for 6-12 hours
# Client may turn from side to side but bed should not be elevated more than 15 degrees
# Notify physician if client complains of tingling, cool, pale, cyanosis and loss of peripheral pulses
# Keep the leg straight to prevent occlusion
# Monitor for bleeding and hematoma formation
# Encourage fluid intake to flush out the dye
# Immobilize the arm if the antecubital vein is used
# Monitor for dye allergy
# Encourage fluid intake to promote renal excretion of dye
# Monitor nausea, vomiting, rash and other sign of HPS rxn
CVP
The CVP is the pressure within the SVC
Reflects the pressure under which blood is returned to the SVC and right atrium
is measured with a central venous line in the SVC and balloon flotation catheter in the pulmonary artery
Normal CVP is 3 to 8 mmHg/ 4-10 cm H2O
Increased CVP
1. increase in blood volume as a result of Na and water retention, excessive IVF or heart/renal failure
Decreased CVP
2. May indicate decrease in circulating blood volume and may be to hypovolemia, hemorrhage and severe vasodilatation
Measuring CVP
1. Position the client supine with bed elevated at 45 degrees (CBQ)
2. Position the zero point of the CVP line at the level of the right atrium. Usually this is at the MAL, 4th ICS
3. Instruct the client to be relaxed and avoid coughing and straining.
! note disease that activity that increases intra-thoracic pressure such as coughing and straining
! If the client is on the ventilator reading should be taken at the point of end expiration
Page 8
Cardiac Implementation
Implementation
1. Assess the cardio-pulmonary status
- VS, BP, Cardiac assessment
2. Enhance cardiac output
- Establish IV line to administer fluids
3. Promote gas exchange
- Administer O2
- Position client in SEMI-Fowlers
- Encourage coughing and deep breathing exercises
4. Increase client activity tolerance
- Balance rest and activity periods
- Assist in daily activities
- Provide strict bed rest if indicated
- Soft foods
- Assistance in self-care
5. Promote client comfort
- Assess the clients description of pain and chest discomfort
- Administer medication as prescribed
! Morphine for MI
! Nitroglycerine for Angina
! Diuretics to relieve congestion (CHF)
6. Promote adequate sleep
7. Prevent infection
- Monitor skin integrity of lower extremities
- Assess skin site for edema, redness and warmth
- Monitor for fever
- Change position frequently
8. Minimize patient anxiety
Encourage verbalization of feelings, fears and concerns
Answer client questions. Provide information about procedures and medications
CARDIOVASCULAR DISORDERS
Cardiac Diseases
$ Coronary Artery Disease
$ Myocardial Infarction
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- results from the focal narrowing of the large and medium-sized coronary arteries due to deposition of atheromatous
plaque in the vessel wall
Risk Factors
1. Age above 45/55 and Sex- Males and post-menopausal females
2. Family History
3. Hypertension
4. DM
5. Smoking
6. Obesity
7. Sedentary lifestyle
8. Hyperlipedimia
Most important MODIFIABLE factors:
- Smoking
- Hypertension
- Diabetes
- Cholesterol abnormalities
Pathophysiology
- There is decreased perfusion of myocardial tissue and inadequate myocardial oxygen supply
- If 50% of the left coronary arterial lumen is reduced or 75% of the other coronary artery, this becomes significant
- Potential for Thrombosis and embolism
Artery walls have three layers.
1. The inner layer provides a slippery surface.
2. The middle layer is strong, elastic and muscular.
3. The outer, fibrous, layer adds strength and contains tiny blood vessels that supply blood to the arteries themselves.
Narrowing or obstruction of the coronary arteries is the main cause of a group of disorders known as ischaemic heart
disease.
- Acute Coronary Syndrome (ACS) is the phrase used when referring to any cardiac condition involving the coronary
arteries.
- Angina is a feeling of tightness or pain across the chest that may spread outwards to the shoulders, upper arms and
back.
Page 10
May occur with exercise or strong emotion and can be worse after a meal or in cold weather. Symptoms usually disappear
after 1-2 minutes rest.
- Heart attack (myocardial infarction or MI)
MI is when part of the heart muscle dies. This is usually caused by a blood clot
(coronary thrombosis), which has blocked one of the coronary arteries supplying the heart and depriving the tissues of
oxygen.
C. A. B. G.
- Veins and sometimes arteries are grafted from the aorta to a point on the coronary artery beyond the area of disease.
This enables an adequate blood supply to reach those parts of the heart suffering from ischaemia
Valve Replacements
- Aortic Valve Replacement (AVR)
- Mitral Valve Replacement (MVR)
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Angina Pectoris
2.
3.
-
Cardiac catheterization
Provides the MOST DEFINITIVE source of diagnosis by showing the presence of the atherosclerotic lesions
Decreased cardiac output
Impaired gas exchange
Activity intolerance
- Anxiety
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Nursing Management
1. Administer prescribed medications
! Nitrates- to dilate the venous vessels decreasing venous return and to some extent dilate the coronary arteries
! Aspirin- to prevent thrombus formation
! Beta-blockers- to reduce BP and HR
! Calcium-channel blockers- to dilate coronary artery and reduce vasospasm
2. Teach the patient management of anginal attacks
! Advise patient to stop all activities
! Put one nitroglycerin tablet under the tongue
! Wait for 5 minutes
! If not relieved, take another tablet and wait for 5 minutes
! Another tablet can be taken (third tablet)
! If unrelieved after THREE tablets% seek medical attention
3. Obtain a 12-lead ECG
4. Promote myocardial perfusion
! Instruct patient to maintain bed rest
! Administer O2 @ 3 lpm
! Advise to avoid valsalva maneuvers
! Provide laxatives or high fiber diet to lessen constipation
! Encourage to avoid increased physical activities
5. Assist in possible treatment modalities
! PTCA- percutaneous transluminal coronary angioplasty
! To compress the plaque against the vessel wall, increasing the arterial lumen
! CABG- coronary artery bypass graft
! To improve the blood flow to the myocardial tissue
6. Provide information to family members to minimize anxiety and promote family cooperation
7. Assist client to identify risk factors that can be modified
8. Refer patient to proper agencies
Myocardial infarction
- Death of myocardial tissue in regions of the heart with abrupt interruption of coronary blood supply
FIGURE 13-1 Different degrees of damage occur to the heart muscle after a myocardial infarction. The diagram
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Page 14
Nursing Intevention
1. Provide Oxygen at 2 lpm, Semi-fowlers
2. Administer medications
- Morphine to relieve pain
- Nitrates, thrombolytics, aspirin and anticoagulants
- Stool softener and hypolipidemics
3. Minimize patient anxiety
- Provide information as to procedures and drug therapy
- Allow verbalization of feelings
- Morphine can be administered
4. Provide adequate rest periods
- Bed rest during acute stage
5. Minimize metabolic demands
- Provide soft diet
- Provide a low-sodium, low cholesterol and low fat diet
6. Assist in treatment modalities such as PTCA and CABG
7. Monitor for complications of MI- especially dysrhythmias, since ventricular tachycardia can happen in the first few
hours after MI
8. Provide client teaching
Medical Management
1. Analgesic
- The choice is MORPHINE
- It reduces pain and anxiety
- Relaxes bronchioles to enhance oxygenation
2. ACE inhibitors
- Prevents formation of angiotensin II
- Limits the area of infarction
3. Thrombolytic therapy
Page 15
- Streptokinase, Alteplase
- Dissolve clots in the coronary artery allowing blood to flow
Nursing Interventions After Acute Episode
1. Maintain bed rest for the first 3 days
2. Provide passive ROM exercises
3. Progress with dangling of the feet at side of bed
4. Proceed with sitting out of bed, on the chair for 30 minutes TID
5. Proceed with ambulation in the room % toilet % hallway TID
6. Cardiac rehabilitation
- To extend and improve quality of life
- Physical conditioning
- Patients who are able to walk 3-4 mph are usually ready to resume sexual activities
Infective endocarditis
- Infection of the heart valves and the endothelial surface of the heart
Can be acute, sub-acute or chronic
Etiologic factors
1. Bacteria- Organism depends on several factors
2. Fungi
Risk factors
1.
2.
3.
4.
5.
Prosthetic valves
Congenital malformation
Cardiomyopathy
IV drug users
Valvular dysfunctions
Assessment findings
1. Intermittent high grade fever
2. anorexia, weight loss
3. cough, back pain and joint pain
4. splinter hemorrhages under nails
5. Oslers nodes- painful nodules on fingerpads
6. Roths spots- pale hemorrhages in the retina
7. Heart murmurs
8. Heart failure= usually acute heart failure
Prevention
- Antibiotic prophylaxis if patient is undergoing procedures like dental extractions, bronchoscopy, surgery, etc.
- Any invasive procedure that is associated with transient bacteremia may cause the microrganism to lodge in the
damaged, irregular valves
Laboratory Exam
- Blood Cultures to determine the exact organism
! Usually, 3 culture specimens are obtained and antibiotic sensitivity done
Nursing management
1. Regular monitoring of temperature, heart sounds
2. Manage infection
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- A syndrome of congestion of both pulmonary and systemic circulation caused by inadequate cardiac function and
inadequate cardiac output to meet the metabolic demands of tissues
- Inability of the heart to pump sufficiently
- The heart is unable to maintain adequate circulation to meet the metabolic needs of the body
Page 17
PATHOPHYSIOLOGY
LEFT Ventricular pump failure
Pulmonary manifestations
LEFT ventricular failure
peripheral edema
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5.
6.
7.
8.
9.
Ascites
Body weakness
Anorexia, nausea
Pulsus alternans
Nocturia= urination at night at frequent intervals as the blood moves from interstitial space to the intravascular
space and is excreted
Laboratory Findings
1. CXR may reveal cardiomegaly
2. ECG may identify Cardiac hypertrophy
3. Echocardiogram may show hypokinetic heart
4. ABG and Pulse oximetry may show decreased O2 saturation
5. PCWP is increased in LEFT sided CHF and CVP is increased in RIGHT sided CHF
Nursing Interventions
1. Assess patient's cardio-pulmonary status
2. Assess VS, CVP and PCWP. Weigh patient daily to monitor fluid retention
3. Administer medications- usually cardiac glycosides are given- DIGOXIN or DIGITOXIN, Diuretics, vasodilators and
hypolipidemics are prescribed
Cardiotonics
Diuretics
Low Sodium Diet
Hypolipidemics
CARDIAC TAMPONADE
Page 19
- A condition where the heart is unable to pump blood due to accumulation of fluid in the pericardial sac (pericardial
effusion)
- This condition restricts ventricular filling resulting to decreased cardiac output
- Acute tamponade may happen when there is a sudden accumulation of more than 50 ml fluid in the pericardial sac
Causative factors
1. Cardiac trauma
2. Complication of Myocardial infarction
3. Pericarditis
4. Cancer metastasis
Assessment Findings
1. BECKs Triad- Jugular vein distention, hypotension and distant/muffled heart sound
2. Pulsus paradoxus
3. Increased CVP
4. decreased cardiac output
5. Syncope
6. anxiety
7. dyspnea
8. Percussion- Flatness across the anterior chest
Laboratory Findings
1. Echocardiogram= shows accumulate fluid in the pericardial sac
2. Chest X-ray
Nursing Interventions
1. Assist in PERICARDIOCENTESIS
2. Administer IVF
3. Monitor ECG, urine output and BP
4. Monitor for recurrence of tamponade
Pericardiocentesis
- Patient is monitored by ECG
- Maintain emergency equipments
- Elevate head of bed 45-60 degrees
- Monitor for complications- coronary artery rupture, dysrhythmias, pleural laceration and myocardial trauma
Vascular Diseases
General Measures to Improve Peripheral Circulation
1. Implement Regular Physical Activity to facilitate movement of venous blood
2. Eliminate cigarette smoking- to prevent vasoconstriction
3. Control hyperlipidemia and cholesterol levels- to prevent the progression of atherosclerosis
4. Avoid cold environmental temperature
5. Teach clients to assess fingers and toes daily for circulatory adequacy: Check the peripheral pulses, capillary refill and
temp
6. Report break in the skin
Hypertension
- A systolic BP greater than 140 mmHg and a diastolic pressure greater than 90 mmHg over a sustained period, based on
two or more BP measurements.
Types of Hypertension
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1.
2.
-
Primary or Essential
Most common type
Secondary
Due to other conditions like Pheochromocytoma, renovascular hypertension, Cushings, Conns , SIADH
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Page 22
Aneurysm
Page 23
Assessment Findings
1. INTERMITTENT CLAUDICATION- the hallmark of PAOD
- This is PAIN described as aching, cramping or fatiguing discomfort consistently reproduced with the same degree of
exercise or activity
- This pain is RELIEVED by REST
- This commonly affects the muscle group below the arterial occlusion
2. Progressive pain on the extremity as the disease advances
3. Sensation of cold and numbness of the extremities
4. Skin is pale when elevated and cyanotic and ruddy when placed on a dependent position
5. Muscle atrophy, leg ulceration and gangrene
Diagnostic Findings
1. Unequal pulses between the extremities
2. Duplex ultrasonography
3. Doppler flow studies
Medical Management
1. Drug therapy
- Pentoxyfylline (Trental) reduces blood viscosity and improves supply of O2 blood to muscles
- Cilostazol (Pletaal) inhibits platelet aggregation and increases vasodilatation
2. Surgery- Bypass graft and anastomoses
Nursing Interventions
1. Maintain Circulation to the extremity
- Evaluate regularly peripheral pulses, temperature, sensation, motor function and capillary refill time
- Administer post-operative care to patient who underwent surgery
- Administer heat modalities to the leg cautiously to promote vasodilatation
2. Monitor and manage complications
- Note for bleeding, hematoma, and decreased urine output
- Elevate the legs to diminish edema
- Encourage exercise of the extremity while on bed
- Teach patient to avoid leg-crossing
3. Promote Home management
- Encourage lifestyle changes
- Instruct to AVOID smoking
- Instruct to avoid leg crossing
BUERGERS DISEASE
Thromboangiitis obliterans
- A disease characterized by recurring inflammation of the medium and small arteries and veins of the lower
extremities
- Occurs in MEN ages 20-35
- RISK FACTOR: SMOKING!
Pathophysiology
Pathophysiology
- Cause is UNKNOWN
- Probably an Autoimmune disease
- Inflammation of the arteries and veins% thrombus formation % occlusion of the vessel
Assessment Findings
1. Leg PAIN
- Foot cramps in the arch
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Raynauds Disease
- A form of intermittent arteriolar VASOCONSTRICTION that results in coldness, pain and pallor of the fingertips or toes
- Cause : UNKNOWN
- Most commonly affects WOMEN, 16- 40 years old
Assessment Findings
1. Raynauds phenomenon
- A localized episode of vasoconstriction of the small arteries of the hands and feet that causes color and temperature
changes
W-B-R is the acronym for the color change
- Pallor- due to vasoconstriction, then %
- Blue- due to pooling of Deoxygenated blood
- Red- due to exaggerated reflow or hyperemia
2. Tingling sensation
3. Burning pain on the hands and feet
Medical management
- Drug therapy with the use of CALCIUM channel blockers
! To prevent vasospasms
Nursing Interventions
1. Instruct patient to avoid situations that may be stressful
2. Instruct to avoid exposure to cold and remain indoors when the climate is cold
3. Instruct to avoid all kinds of nicotine
4. Instruct about safety. Careful handling of sharp objects
Venous diseases
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Varicose Veins
Predisposing Factors
! Pregnancy
! Prolonged standing or sitting
! Incompetent venous valves
Pathophysiology
Factors % venous stasis %increased hydrostatic pressure% edema
Assessment findings
- Tortuous superficial veins on the legs
- Leg pain and Heaviness
- Dependent edema
Laboratory findings
- Venography
- Duplex scan pletysmography
Medical management
- Pharmacological therapy
- Leg vein stripping and ligation
- Anti-embolic stockings
Nursing management
1. Advise patient to elevate the legs with pillow to increase venous return
2. Caution patient to avoid prolonged standing or sitting
3. Provide high-fiber foods to prevent constipation
4. Teach simple exercise to promote venous return
5. Caution patient to avoid constrictive clothing
6. Apply anti-embolic stockings as directed
7. Avoid massage on the affected area
- Inflammation of the deep veins of the lower extremities and the pelvic veins
- The inflammation results to formation of blood clots in the area
Predisposing factors
- Prolonged immobility
- Varicosities
- Traumatic procedures
- Increased age
- Malignancy
- Estrogen therapy
- Smoking
Complication
- PULMONARY thromboembolism
Assessment findings
- Leg tenderness
- Leg pain and edema
- Positive HOMANs SIGN
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HOMANs SIGN
The foot is FLEXED upward (dorsiflexed) , there is a sharp pain felt in the calf of the leg% indicative of venous
inflammation
Laboratory findings
- Venography
- Duplex scan
Medical management
- Antiplatelets- aspirin
- Anticoagulants
- Vein stripping and grafting
- Anti-embolic stockings
Nursing management
1. Provide measures to avoid prolonged immobility
- Repositioning Q2
- Provide passive ROM
- Early ambulation
2. Provide skin care to prevent the complication of leg ulcers
3. Provide anti-embolic stockings
4. Administer anticoagulants as prescribed
5. Monitor for signs of pulmonary embolism% sudden respiratory distress
Blood disorders
$Anemia
$Nutritional anemia
$Hemolytic anemia
$Aplastic anemia
$Sickle cell anemia
Anemia
Hypoproliferative Anemia
Iron Deficiency Anemia
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2. Mal-absorption
3. Malnutrition
4. Alcoholism
Pathophysiology
- The body stores of iron decrease, leading to depletion of hemoglobin synthesis
- The oxygen carrying capacity of hemoglobin is reduced% tissue hypoxia
Assessment Findings
1. Pallor of the skin and mucous membrane
2. Weakness and fatigue
3. General malaise
4. Pica
5. Brittle nails
6. Smooth and sore tongue
7. Angular cheilosis
Laboratory findings
1. CBC- Low levels of Hct, Hgb and RBC count
2. Low serum iron, low ferritin
3. Bone marrow aspiration- MOST definitive
Medical management
1. Hematinics
2. Blood transfusion
Nursing Management
1. Provide iron rich-foods
- Organ meats (liver)
- Beans
- Leafy green vegetables
- Raisins and molasses
2.
-
Administer iron
Oral preparations tablets- Fe fumarate, sulfate and gluconate
Advise to take iron ONE hour before meals
Take it with vitamin C
Continue taking it for several months
Oral preparations- liquid
It stains teeth
Drink it with a straw
Stool may turn blackish- dark in color
Advise to eat high-fiber diet to counteract constipation
IM preparation
Administer DEEP IM using the Z-track method
Avoid vigorous rubbing
Can cause local pain and staining
Aplastic Anemia
Causative Factors
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1.
2.
3.
4.
Pathophysiology
Toxins cause a direct bone marrow depression
Megaloblastic Anemias
- Anemias characterized by abnormally large RBC secondary to impaired DNA synthesis due to deficiency of Folic acid
and/or vitamin B12
Folic Acid deficiency
Causative factors
1. Alcoholism
2. Mal-absorption
3. Diet deficient in uncooked vegetables
Impaired RBC development, impaired nuclear maturation but CYTOplasmic maturation continues
large size
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Causative factors
1. Strict vegetarian diet
2. Gastrointestinal mal-absorption
3. Crohn's disease
4. Gastrectomy
Vitamin B12 deficiency: Pernicious Anemia
- Due to the absence of intrinsic factor secreted by the parietal cells
- Intrinsic factor binds with Vit. B12 to promote absorption
Assessment findings
1. weakness
2. fatigue
3. listless
4. neurologic manifestations are present only in Vit. B12 deficiency
Assessment findings
Pernicious Anemia
- Beefy, red, swollen tongue
- Mild diarrhea
- Extreme pallor
- Paresthesias in the extremities
Laboratory findings
1. Peripheral blood smear- shows giant RBCs, WBCs with giant hyper-segmented nuclei
2. Very high MCV
3. Schillings test
4. Intrinsic factor antibody test
Medical Management
1. Vitamin supplementation
2. Folic acid 1 mg daily
3. Diet supplementation
4. Vegetarians should have vitamin intake
5. Lifetime monthly injection of IM Vit B12
Nursing Management
1. Monitor patient
2. Provide assistance in ambulation
3. Oral care for tongue sore
4. Explain the need for lifetime IM injection of vit B12
- A severe chronic incurable hemolytic anemia that results from heritance of the sickle hemoglobin gene.
Causative factor
- Genetic inheritance of the sickle gene- HbS gene
Pathophysiology
Decreased O2, Cold, Vasoconstriction can precipitate sickling process
Factors % cause defective hemoglobin to acquire a rigid, crystal-like C-shaped configuration % Sickled RBCs will adhere to
endothelium % pile up and plug the vessels % ischemia results% pain, swelling and fever
Assessment Findings
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Polycythemia
Primary Polycythemia
- A proliferative disorder in which the myeloid stem cells become uncontrolled
Causative factor
- unknown
Pathophysiology
- The stem cells grow uncontrollably
- The bone marrow becomes HYPERcellular and all the blood cells are increased in number
Page 31
Page 32
C.
II.
The lower respiratory system enables the exchange of gases to regulate serum PaO2, PaCO2 and Ph.
Upper Respiratory
A.
Nose and sinuses
1. Filters, warms and humidifies air
2. First defense against foreign particles
3. Inhalation for deep breathing is to be done via nose
4. Exhalation is done through the mouth
B.
Pharynx
1. Behind oral and nasal cavities
2. Nasopharynx
a.
behind nose
b.
soft palate, adenoids and eustachian tube
3. Oropharynx
a.
from soft palate to base of tongue
b.
palatine tonsils
4. Laryngopharynx
a.
base of tongue to esophagus
b.
where food and fluids are separated from air
c.
bifurcation of larynx and esophagus
C.
Larynx
1. Between trachea and pharynx
2. Commonly called the voice box
3. Thyroid cartilage - Adam's apple
4. Cricoid cartilage
a.
contains vocal cords
b.
the only complete ring in the airway
5. Glottis - opening between vocal cords
6. Epiglottis - covers airway during swallowing
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III.
A.
B.
C.
D.
E.
Trachea
1. Anterior neck in front of esophagus
2. Carries air to lungs
Mainstem bronchi
1. Right and left
2. Right is more vertical, so right middle lobe is more likely to receive aspirate into it with the result
of aspiraton pneumonia, which is more commonly found in elderly populations
Conducting airways
1. Lobar bronchi
a.
surrounded by blood vessels, lymphatics, nerves
b.
lined with ciliated, columnar epithelial cell
c.
cilia move mucus or foreign substances up to larger airways
2. Bronchioles
a.
no cartilage; collapse more easily
b.
no cilia
c.
do not participate in gas exchange
Alveolar ducts and alveoli
1. Lungs contain approximately 300 million alveoli
2. Alveoli surrounded by capillary network
3. Gas exchange area (blood takes O2, gives off CO2)
4. Gas exchange happens at alveolar-capillary membrane (al-cap memb)
5. Held open by surfactant which decreases surface tension to minimize alveolar collapse
Accessory muscles of respiration
Page 34
1.
2.
3.
4.
IV.
Physiology
A.
Basic gas-exchange unit of the respiratory system is the alveoli.
B.
Alveolar stretch receptors respond to inspiration by sending signals to inhibit inspiratory neurons in the
brain stem to prevent lung over distention.
C.
During expiration stretch receptors stop sending signals to inspiratory neurons and inspiration is ready to
start again.
D.
Oxygen and carbon dioxide are exchanged across the alveolar capillary membrane by process of diffusion.
E.
Neural control of respirations is located in the medulla. The respiratory center in the medulla is stimulated
by the concentration of carbon dioxide in the blood.
F.
Chemoreceptors, a secondary feedback system, located in the carotid arteries and aortic arch respond to
hypoxemia. These chemoreceptors also stimulate the medulla.
G.
Ph regulation
1. Blood Ph (partial pressure of hydrogen in blood): a decrease in blood Ph stimulates respiration
hyperventilation, both through the neurons of the brain's respiratory center and through the
chemoreceptors in carotid arteries and aortic arch.
2. Blood PaCO2 (partial pressure of carbon dioxide in arterial blood): an increase in the PaCO2 results
in decreased blood Ph, and stimulates respiration.
3. Blood PaO2 (partial pressure of oxygen in arterial blood): a decrease in the PaO2 results in a
decreased blood Ph, stimulating respiration.
4. When arterial Ph rises or the arterial PaCO2 falls, hypoventilation occurs.
FUNCTION
A. Primary functions of the respiratory system
1. Provides oxygen for metabolism in the tissues
2. Removes carbon dioxide, the waste product of metabolism
B. Secondary functions of the respiratory system
1. Facilitates sense of smell
2. Produces speech
3. Maintains acid-base balance
4. Maintains body water levels
5. Maintains heat balance
ASSESSMENT OF RESPIRATORY FUNCTION
A. DIAGNOSTIC STUDIES
"
Page 35
"
"
"
b. Assess the client's ability to inhale and hold his or her breath.
c. Question women regarding pregnancy or the possibility of pregnancy.
Sputum specimen
> Specimen obtained by expectoration or tracheal suctioning to assist in the identification of organisms or
abnormal cells
Preprocedure
a. Determine specific purpose of collection
b. Obtain an early morning sterile specimen
c. Instruct the client to rinse the mouth with water before collection.
d. Obtain 15 mL of sputum.
e. Instruct the client to take several deep breaths and then deeply to obtain sputum.
f. Always collect the specimen before the client begins antibiotic therapy.
3. Postprocedure
a. If a culture of sputum is prescribed, transport the specimen to the laboratory immediately.
b. Assist the client with mouth care.
Bronchoscopy
> Direct visual examination of the larynx, trachea, and bronchi with a fiberoptic bronchoscope
Preprocedure
a. Obtain informed consent.
b. NPO post midnight
c. Obtain vital signs.
d. Remove dentures or eyeglasses.
e. Prepare suction equipment.
Postprocedure
a. Monitor vital signs.
b. Maintain the client in a semi-Fowler's position.
c. Assess for the return of the gag reflex.
d. Maintain NPO status until the gag reflex returns.
e. Have an emesis basin readily available for the client to expectorate sputum.
f. Monitor for bloody sputum.
g. Monitor respiratory status
h. Monitor for complications
i. Notify the physician if fever, difficulty in breathing, or other signs of complications occur following the
procedure.
Pulmonary angiography
> An invasive fluoroscopic procedure in which a catheter is inserted through the antecubital or femoral
vein into the pulmonary artery or one of its branches
> Involves an injection of iodine or radiopaque contrast material
Preprocedure
a. Obtain informed consent.
b. Assess for allergies to iodine, seafood, or other radiopaque dyes.
c. NPO for 8 hours before the procedure.
d. Monitor vital signs.
e. Assess results of coagulation studies.
f. Establish an intravenous access.
g. Administer sedation as prescribed.
h. Instruct the client to lie still during the procedure.
i. Instruct the client that he or she may feel an urge to cough, flushing, nausea, or a salty taste following
injection of the dye.
j. Have emergency resuscitation equipment available.
Postprocedure
a. Monitor vital signs.
Page 36
"
"
"
"
"
"
"
"
"
"
"
"
"
"
b. Avoid taking blood pressures for 24 hours in the extremity used for the injection.
c. Monitor peripheral neurovascular status of the affected extremity.
d. Assess insertion site for bleeding.
e. Monitor for delayed reaction to the dye.
Thoracentesis
> Removal of fluid or air from the pleural space via a transthoracic aspiration
Preprocedure
a. Obtain informed consent.
b. Obtain vital signs.
c. Assess results of coagulation studies.
d. Place client in sitting position, with the arms and shoulders supported by a table at the bedside during
the procedure.
e. If the client cannot sit up, the client is placed lying in bed toward the unaffected side, with the head of
the bed elevated.
f. Instruct the client not to cough, breath deeply, or move during the procedure.
Postprocedure
a. Monitor vital signs.
b. Monitor respiratory status.
c. Apply a pressure dressing, and assess the puncture site for bleeding and crepitus.
d. Monitor for signs of pneumothorax, air embolism, and pulmonary edema.
Lung biopsy
> A percutaneous lung biopsy is performed to obtain tissue for analysis by culture or cytological
examination.
Preprocedure
a. Obtain informed consent.
b. Maintain NPO status of the client before the procedure.
c. Inform the client that a local anesthetic will be
d. Administer analgesics and sedatives as prescribed.
Postprocedure
a. Monitor vital signs.
b. Apply a dressing to the biopsy site and monitor for drainage or bleeding.
c. Monitor for signs of respiratory distress.
d. Monitor for signs of pneumothorax and air emboli, and notify the physician if they occur.
Pulse Oximetry
& measures oxygen saturation of hemoglobin
& 90-100%
Arterial Blood Gas Analysis
& measures concentrations of blood gases and identifies acid base balance of the body
& use of arterial blood
Pulmonary Function Test
& Measures lung volumes and capacity
& Done by respiratory therapists; painless; client will breath into a machine
Tidal volume (VT)- volume of inhaled and exhaled during normal and quiet breathing
Inspiratory reserve volume (IRV)- maximum amount of air that can be inhaled over and above the normal
breath
Expiratory reserve volume maximum amount of air that can be exhaled following a normal exhalation
Residual volume (RV)- amount of air remaining in the lungs after maximal exhalation
Total lung capacity (TLC)- total volume of lungs at maximum inflation; VT + IRV + ERV + RV
Vital capacity (VC)- total amount of air that can be exhaled after a maximal inspiration; VT+ IRV + ERV
Inspiratory capacity- total amount of air that can be inhaled following normal quiet respiration; VT + IRV
Functional residual capacity (FRC)- volume left in the lungs after normal exhalation; ERV +RV
Minute volume (MV)- total amount of air breathed in one minute
Page 37
"
"
"
"
"
"
"
"
"
"
"
"
"
"
"
"
Cough
& Most common sign of respiratory disease
& Caused by irritation of mucous membranes
& Chief protection against accumulation of secretions and foreign body
Chest pain: may indicate hypoxia or damage to lungs
Cyanosis and Clubbing of fingers: indicates hypoxia
Hemoptysis: blood expectorated from the respiratory tract; caused by trauma or break in the continuity of
respiratory tract
Effort in breathing: Dyspnea or Orthopnea
Sputum production
Reaction of lungs to constantly recurring irritation
Thoracic sounds
Crackles: loud, low pitched bubbling sound; results from air passing through fluid
Wheezes: musical sound; caused by air passing through narrowed airways
Stridor: loud, high pitched crowing sound
Friction rub: grating, loud harsh sound
Ronchi: sounds likes snores or moans
Chest Configuration- AP: L= 1:2
Barrel chest- increase in AP diameter
Pigeon chest- increase in AP diameter; results from sternal displacement
Funnel chest- depression of lower portion of sternum
C. HISTORY:
1. Current respiratory problems:
" Changes in breathing pattern
" Activities that may cause symptoms
" How many pillows used at night
2. History of respiratory disease
" Any respiratory diseases or infections
" Frequency of occurrence
" Exposure to pollutants
3. Lifestyle
" Smoking history
" Exposure to smoke and other respiratory irritants
" Alcohol use
" Exercise pattern
4. Presence of cough
" How often
" When does it occur
" Productive or dry
5. Description of sputum
" When it is produced
" Amount, color, thickness, odor
" Presence of blood
6. Presence of chest pain
" Location
" Description
" Does it occur with inspiration or expiration
" How long does it affect breathing
Page 38
Cause:
pollen, flowers, grasses and occur in spring/fall; last several weeks while allergens are high.
.
Signs/Symptoms:
Treatment:
Page 39
used when referring to an upper respiratory tract infection that is self-limited and caused
by a virus (viral rhinitis).
Cause:
Virus that invades the upper respiratory tract. Is the most prevalent infectious disease in
the world and is spread by airborne droplets.
Signs/Symptoms:
malaise
fever/chills
headache
nasal discomfort
dry, sore throat
cough (either productive or nonproductive)
mild leukocytosis
*Complications:
Treatment:
INFLUENZA
Definition:
Flu
Cause:
Three groups of viruses (A, B & C, though C has little pathogenic effects)
Signs/Symptoms:
Abrupt onset of cough, fever, and myalgia often accompanied by headache and sore
throat. Symptoms of uncomplicated flu usually subside within 7 days. Some experience
weakness and lassitude, hyperactive airways and chronic cough that may persist for weeks
(older adults, especially).
PNEUMONIA is the most common complication of flu.
Diagnostic Tests:
Treatment:
Vaccine is 70 to 90% effective in preventing flu when given in the fall (mid-Oct) before
exposure occurs.
Treatment is primarily symptomatic
Acetaminophen is given for fever, headache, and myalgia
Rest and increase fluid intake
Page 40
Inflammation of the bronchi in the lower respiratory tract usually due to infection.
Cause:
Signs/Symptoms:
Chilliness
Malaise
Soreness and constriction behind the sternum-worse patient cough
Slight fever
Cough, at first dry and painful; later, green or yellowish sputum with pus cells
Persistent cough following an acute upper airway infection (rhinitis/pharyngitis)
Diagnosis:
When symptoms are severe, chest x-rays can differentiate acute bronchitis from
pneumonia (acute bronchitis has no evidence of consolidation or infiltrates).
Treatment:
Fluids
Rest
Anti-inflammatory agents
Antiviral medications
PNEUMONIA
Definition:
An acute inflammation of the lung parenchyma that commonly impairs gas exchange.
Cause:
Page 41
As alveolocapillary membrane breaks down, alveoli fill with blood and exudate,
resulting in atelectasis (lung collapse)
Viral pneumonia:
The virus first attacks bronchiolar epithelial cells, which causes interstitial
inflammation and desquamation.
The virus also invades bronchial mucous glands and goblet cells.
Aspiration pneumonia:
Acidic gastric juices may damage the airways and alveoli. Particles containing
aspirated gastric juices may obstruct the airways and reduce airflow, leading to
secondary bacterial pneumonia.
A lower respiratory tract infection of the lung parenchyma with onset in the
community or during the first 2 days of hospitalization.
Risk for HAP in mechanically ventilated patients is 6 to 20 times higher than other
patients.
Inpatient mortality rates much higher than mortality for CAP (1-5% vs. 12%)
Aspiration Pneumonia
The sequelae occurring from abnormal entry of secretions or substances into the
lower airway. Usually follows aspiration of material from the mouth or stomach
into the trachea and subsequently the lungs.
Opportunistic Pneumonia
Page 42
Gives rise to latent infections and reactivation with virus shedding. May
be mild or can be fulminant and produce pulmonary insufficiency leading
to death. In pneumonia, may be combined with other bacteria and fungi.
Treat with Cytovene.
Signs/Symptoms:
Diagnosis:
Chest x-ray
Sputum cultures
Blood tests
Treatment:
Supportive measures:
Viral pneumonia
Page 43
Flu vaccine
Pneumococcal vaccine
Nutritional therapy
Role of Nurse:
Goals
No signs of hypoxia
No
complications
related
to
pneumonia
TUBERCULOSIS
Definition:
Cause:
Homeless people
Foreign-born people
Older adults
Institutionalized people
Page 44
Socioeconomically disadvantaged
TB is not highly infectious and transmission usually requires close, frequent or prolonged
exposure.
Signs/Symptoms:
Diagnosis:
Tuberculin Skin Testing
o
o
o
Page 45
Who recently immigrated from (in past 5 years) from areas of high
prevalence
o
o
o
Chest X-ray
Bacteriologic Studies
o
o
True diagnosis can only be made by demonstrating the presence of tubercle bacilli.
Stained sputum smear for acid-fast bacilli is usually the first bacteriologic evidence
of infection.
o
Drug Therapy
o
Active Disease
o
o
Isoniazid (INH)
'
'
Rifampin (Rifamate)
Pyrazinamide
'
'
Streptomycin
Ethambutol (Myambutol)
o
o
o
Vaccine
o
Page 46
o
o
Interventions:
o
o
o
Use a negative pressure isolation room that offers six or more exchanges
per hour to isolate patient.
Teach patient to cover the nose and mouth with paper tissue every time he or she
coughs, sneezes or produces sputum. The tissues should be burned, flushed down
the toilet or thrown into a paper bag and disposed of with the trash.
Instruct the patient about certain factors that could reactivate TB such as
immunosuppressive therapy, malignancy and prolonged debilitation.
Emphysema (COPD)
ASTHMA
Definition:
Cause:
Allergens
Exaggerated allergic response (IgE) to environmental factors (dust, pollen, grass, mites,
roaches, mold, dander, etc.).
Exercise
Exercise-Induced Asthma
Page 47
Respiratory Infections
Drug Allergies
o
Food Allergies
o
Avoid vitamins
Emotional Stress
Panic and anxiety during an attack may exacerbate and prolong the attack
Signs/Symptoms:
Page 48
Early-Phase Response
'
bronchospasm
'
inflammatory response.
'
'
Late-Phase Response
'
Characterized by inflammation,
inflammation constriction of bronchioles and excess mucus.
mucus
'
Late-phase response peaks 5 to 6 hours after exposure and may last for days.
'
WBC infiltration
'
This activity increases airway reactivity which worsens the symptoms of future attacks, and
makes them easier to trigger.
'
'
airway remodeling.
Person may sit upright or slightly bent forward using the accessory muscles of respiration
to try to get enough air.
Page 49
* Status Asthmaticus
The longer it lasts, the worse it gets and the worse it gets, the longer it lasts.
Symptoms same as asthma, but more severe and more prolonged with extreme anxiety,
fear of suffocation, diaphoresis and severely increased work of breathing.
Chest X-Ray
Diagnosis:
Treatment:
Acute Episode:
Status Asthmaticus:
o
Same interventions as for acute asthma (above), but may need to increase the
frequency and dose of inhaled bronchodilators to 2 to 6 puffs every 5 to 20
minutes (depending upon medication).
Page 50
Even after bronchospasm resolves, inflammation, edema, and viscous mucus plugs
remain for several days.
Drug classifications
o
Two categories:
'
'
Role of Nurse:
Coricosteroids (anti-inflammatory)
Bronchodilators
o
B2-agonists (albuterol)
Anticholinergics (Atrovent)
Interventions
Administer oxygen
Administer bronchodilators
Decrease the patients sense of panic; encourage slow breathing using pursed lips for
prolonged exhalation
Group of diseases with the major characteristic of airflow obstruction and hyper-reactivity of
airway. Symptoms include difficulty with exhalation caused by airway obstruction from edema
or excessive mucus production. Lung hyperinflation causes alveolar air trapping and leads to
frequent pulmonary infections. Symptoms are usually progressive and irreversible.
Emphysema:
Emphysema an abnormal, permanent enlargement of the airspaces distal to the terminal
bronchioles, accompanied by destruction of their walls and without obvious fibrosis.
Chronic Bronchitis:
Bronchitis the presence of a chronic productive cough for 3 months in each of 2
successive years in a patient in whom other causes of chronic cough have been excluded.
Page 51
Cause:
Cigarette Smoking.
Infection
Heredity
Aging
Signs/Symptoms: Emphysema:
Emphysema
Page 52
Centrilobular
'
'
Panlobular
'
'
'
Barrel chest;
Underweight
Chronic Bronchitis
Disappearance of cilia
Page 53
Symptoms
Diagnosis:
H & P; chest x-ray; pulmonary function tests; sputum specimens for culturing; ABGs; EKGs;
exercise testing with oximetry; cardiac nuclear scans
Treatment:
Goals:
Improve ventilation
Page 54
Stop smoking
Drug therapy:
MDI or nebulizer
Oxygen therapy
o
Complications of O2 Therapy
'
Combustion
'
'
'
Respiratory Therapy
Chest physiotherapy
Nutritional Therapy
Maintain weight
Eat five to six small meals (avoid bloating which puts pressure on diaphragm)
Page 55
Fluid intake should be at least 3 L per day unless contraindicated, and between meals
rather than with meals
Scope
Physiology
Disorders
PITUITARY DISEASES
ADH DISEASES
ADRENAL GLANDS DISEASES
THYROID DISEASES
PARATHYROID DISEASES
PANCREAS DISEASES
Page 56
The Sequence
Hypothalamus
Pituitary
Anterior
Posterior
Target
Gland
or
Hypophysis
Adenohypophysis
Neurohypophysis
or
or
Glands
APG
Adenohypophysis
- TSH - target % thyroid gland
- ACTH - target % adrenal gland
- ICSH - target % testes (maturation of spermatozoa)
- GH - target % epiphyseal plate (bone growth)
- FSH target % ovary-estrogen (maturation of graafian follicles to release mature ovum)
- LH target % graafian follicle (formation of corpus luteum to maturation of ova)
- MSH skin (pigmentation)
- PROLACTIN (maturation of mammary gland and production of milk)
PPG
Neurohypophysis
- ADH
target
(H2O reabsorption)
- OXYTOCIN uterine contraction and ejection of milk
kidney
tubules
Page 57
Target Glands
Thyroid
Adrenal
Mammary
Skin
Bone plates
Ovaries
Testes
Kidney tubules
Uterus
Thyroid and Parathyroid
The THYROID gland
Anatomy
- Located in the anterior neck lateral to the trachea
- Contains two lobes connected by the isthmus
- Microscopically composed of thyroid follicles where the hormones are produced and stored
The Physiology
Parathyroid Hormone is released
in HYPOCALCEMIA
- calcium level
Parathyroid hormone is NOT
secreted in HYPERCALCEMIA
Calcitonin
is
stimulated
HYPERCALCEMIA
-calcium level
Calcitonin
is
inhibited
HYPOCALCEMIA
by
by
Page 58
Cortex
! Mineralocorticoid:Aldosterone -Na & water reabsorption, K loss
! Glucocorticoid: Cortisol - blood glucose regulation
! Androgen: DHEA - sex hormones testosterone
Medulla (catecholamines)
! stress or sympathetic effect
! Epinephrine and Nor-epinephrine
- neurotransmitters
The GONADS
Anatomy
Ovaries
These two almond-shaped glands are found in the pelvic cavity attached to the uterus by the ovarian ligament
Testes
These two oval-shaped glands are found in the scrotum
Physiology
Ovary
estrogen
affects
devt
of
female
sex
organs
and
secondary
sexual
- progesterone- influences menstrual cycle, stimulates the growth of uterine wall, and maintains pregnancy
Testes
- testosterone- affects the devt of male sex organs and secondary sexual characteristics
Pineal
characteristics
Gland
Melatonin (dec skin pigmentation, inhibit gonadotropic hormone)
The Pancreas
- This retroperitoneal organ has both endocrine and exocrine functions
Anatomy
- The endocrine function resides in the ISLETS of Langerhans
- The islets have three types of cells- alpha, beta and delta cells
Physiology
- The ALPHA cells secrete GLUCAGON
- The BETA cells secrete INSULIN
- The DELTA cells secrete SOMATOSTATIN
Page 59
Placenta
- HCG- maintains pregnancy
- estrogen, progesterone, human placental lactogen
! Pancreas:
Islet
of
langerhans
Alpha- glucagon- blood sugar (hyperglycemia) by stimulating glycogenolysis & gluconeogenesis
! Beta- insulin - blood sugar (hypoglycemia) by facilitating transport of glucose across cell membranes of muscle, liver,
adipose tissue, inhibits breakdown of proteins
Assessment Findings
- Retarded physical growth due to decreased GH% dwarfism
- Low intellectual development
- poor development of secondary sexual characteristics
Page 60
Management:
- Surgical removal of tumor
- Radiation
- HRT hormonal replacement therapy
Pituitary Tumors
- Usually benign
- 3 Types
! Eosinophilic Tumors
! Basophilic Tumors
! Chromophobic Tumors (most common)
Eosinophilic Tumors
- Gigantism (before puberty)
- Acromegaly (after puberty)
- Visual disturbance (compression from tumor)
Hyperpituitarism
- hyper-secretion of the gland
- ACROMEGALY-after 15-16 yo
- Gigantism-before 15-16 yo
Causes: tumor, congenital disorder
Page 61
Assessment Findings
1. Increased growth% Gigantism or Acromegaly
2. large and thick hands and feet
3. Visual disturbances
4. Hypertension, hyperglycemia
5. Organomegaly
Pituitary Tumors
Basophilic Tumors
- Cushings Syndrome
- Musculinization and amenorrhea (female)
Chromophobic Tumors (COMMON)
- Destroy the rest of the pituitary gland
- No hormones except for prolactin (galactorrhea)
- Blindness
- Increased ICP
Diagnostic:
- CT scan
- MRI
- Assessment Findings
Management:
- Drug
Bromocriptine (Parlodel) to lower GH and Prolactin
- Radiation
- Surgery
(transsphenoidal
Octreotide (Sandostatin) = preop drug to reduce tumor
hypophysectomy)
Page 62
water
output
urine
ASSESSMENT findings
- Signs of Hypervolemia
1. Mental status changes
2. Abnormal weight gain
3. DISORDERS OF the PITUITARY GLAND: Posterior gland
4. ASSESSMENT findings
5. Hypertension
6. Anorexia, Nausea and Vomiting
7. HYPOnatremia
Diagnostic Test
- Urine specific gravity is increased (concentrated)
- Hyponatremia
- CBC shows hemodilution
- SIADH
Management:
- FVE intervention
- Stop vasopressin
- Surgery (tumor excision)
Critical conditions:
- Pulmonary edema
Page 63
Cerebral edema
Heart failure
Hypertension
Renal Failure
Nursing Interventions
1. Monitor VS and neurologic status
2. Provide safe environment
3. Restrict fluid intake (less than 500cc/day)
4. Monitor I and O and daily weight
5. Administer Diuretics and IVF carefully
6. Administer prescribed Demeclocycline to inhibit action of ADH in the kidney
DI Diabetes Insipidus
- Decreased ADH secretion
- Decreased
tubular
reabsorption
of
=
decreased
blood
(high Hct, hyperosmolality, thrombosis)
- Increased
urine
= diluted urine (low S.G., clear urine)
- Watch out for manifestations of Fluid Volume Deficit
- Cause: trauma or injury to pituitary gland, resection of hypophysis, insensitivity of kidney to ADH
water
volume
output
Assessment findings
1. Polyuria of more than 4 liters of urine/day
2. Polydipsia
3. Signs of Dehydration
4. Muscle pain and weakness
5. Postural hypotension and tachycardia
Diagnostic Test
1. Urinary Specific gravity % very low, 1.006 or less
2. Serum Sodium levels % high
Management:
- FVD intervention
- Synthetic ADH administration (vasopressin)
- Desmopressin (DDAVP) spray intranasal OD or BID
- Vasopressin tannate in oil = IM OD or every 4 days
Critical conditions:
- Thrombosis thromboembolism pulmonary embolism
- Ischemia
- Infarction
- Necrosis (CVA, MI, RF)
Nursing Interventions
1. Monitor VS, neurologic status and cardiovascular status
2. Monitor Intake and Output
3. Monitor urine specific gravity
4. Provide adequate fluids
5. Administer Chlorpropamide or Clofibrate as prescribed to increase the action of ADH if decreased
6. Administer VASOPRESIN. Desmopressin or Lypressin are given intranasal. Pitressin is given IM
Abnormalities of Adrenal Gland
Page 64
$Conns
$Cushings Disease
$Cushings Syndrome
$Addisons Disease
$Pheochromocytoma
of
Exaggerated functions
HYPERGLYCEMIA
Page 65
2. Protein breakdown
OSTEOPOROSISS,
delayed wound healing
Purplish striae , Bleeding
Muscle wasting
THIN extremity, Truncal
deposition
IMMUNOSUPPRESSION
3. Fat breakdown
4. Decreased WBC
Functions
Mineralocorticoids
1. Sodium Retention
of
Exaggerated functions
Hypernatremia
2.Secondary
water
retention
3. Potassium excretion
HypervolemaHypertension
HYPOKALEMIA
Function of
Hair growth
HIRSUTISM
androgen:
Assessment
1. Generalized muscle weakness and wasting
2. Truncal obesity
3. Moon-face
4. Buffalo hump
5. Easy bruisability
9. Hyperglycemia
10. Osteoporosis
11. Amenorrhea
Page 66
Management:
! Diet: Low Sodium, High Potassium
! FVE intervention
! Replace potassium
! Insulin administration
! Hypertension
! Surgery is adrenalectomy
Critical conditions:
! Arrhythmias due to hypoK
! Hypertensive crisis
! Fluid overload
! Hyperglycemia
Cushings Syndrome (Secondary)
- Pituitary gland disorder
- Same with Cushings Disease
- Surgery is hypophysectomy
Addisons Disease
- Adrenal cortex disorder/ tumor, idiopathic
- Hyposecretion of:
! Mineralocorticoid: Aldosterone=Na and H2O excretion (hyponatremia, hypovolemia, hypotension), K reabsorption
(hyperkalemia)
! Glucocorticoid=hypoglycemia
! Androgen=decreased libido
MSH=bronzing of the skin (primary)
Management
- FVD intervention
- Increase potassium excretion
- Glucagon or simple sugar administration
- Steroid medication
Nursing Interventions
- Monitor VS especially BP
- Monitor weight and I and O
- Monitor blood glucose level and K
- Administer hormonal agents as prescribed
- Observe for ADDISONIAN crisis
- Educate the client regarding lifelong treatment, avoidance of strenuous activities, stress and seeking prompt consult
during illness
- Provide a high-protein, high carbohydrate and increased sodium intake
Addisonian crisis
- A life-threatening disorders caused by acute severe adrenal insufficiency
Page 67
Causes:
- Severe stress
- infection
- trauma or surgery
Pathophysiology
- Overwhelming stimuli % mobilize body defense % decreased stress hormones % inadequate coping
ASSESSMENT Findings for Addisonian Crisis= severe lahat
- Severe headache
- Severe pain
- Severe weakness
- Severe hypotension
- Signs of Shock
- Addisons Disease
Critical Conditions:
- Addisonian crisis cyanosis, with signs of circulatory shock: pallor, apprehension, rapid and weak pulse,
- RR, and acute hypotension
- Dehydration
- Arrhythmias due to hyperkalemia
- Hypoglycemia
- Same with DI
Nursing Interventions
- Administer IV glucocorticoids, usually hydrocortisone
- Monitor VS frequently
- Monitor I and O, neurological status, electrolyte imbalances and blood glucose
- Administer IVF
- Maintain bed rest
- Administer prescribed antibiotics
Steroid
- Dose is variable
- Best time to give between 7-8 AM (active gland) to prevent side effects
- Steroid-induced adrenal insufficiency = TAPERING the DOSE
- Pituitary adrenal suppresion = DOSAGE CONTROL
-
Steroid
Hypertension, thromboembolism
Prone to infection
Glaucoma, corneal ulceration
Muscle wasting, poor wound healing
Osteoporosis,
Hyperglycemia
Weight gain, moon face, trunkal obesity, buffalo hump
Acne
MEDIC-ALERT CARD
Addisons Disease
Critical Conditions
- Dehydration
- Arrhythmias due to hyperK
- Hypovolemic shock
- Hypoglycemia
- Same with DI
- inc ACTH, inc cortisol = pituitary problem (benign tumor)
- normal ACTH, inc cortisol = adrenal problem (benign tumor)
- dec ACTH, dec cortisol = atrophy of the pituitary gland
- normal ACTH, dec cortisol = atrophy of the adrenal gland
Pheochromocytoma
- Hyperfunction of adrenal medulla
- Cause: Tumor usually benign
- catecholamines (nor E and E)
Sign and Symptoms:
- 5 H: HPN, Headache, Hypermetabolism
- Hyperglycemia, Hyperhidrosis(sweat),, n&v, anorexia, dilated pupils, weight loss, tremors, cold extremities, CHF and
cerebral bleeding.
Page 68
Diagnosis
- VMA vanilly mandelic acid (urine specimen)
- catecholamines (blood specimen)
- blood sugar and glycosuria
- Monitor VS esp BP
- Give antihypertensive drugs:Phentolamine
- Provide high calorie foods
- Prepare pt forSurgical Intervention (adrenalectomy)
Abnormalities
of
the
Thyroid
Gland
GOITER
- Iodine-deficient
- Goitrogenic = cabbage, beans
- Compensatory hypertrophy
- No s/sx, compression of the trachea
- SSKI to suppress pituitarys TSH secretions
- Less than 40 fg/day of iodine = goiter
- Iodized salt = 1:100,000
- PREVENTION = iodized salt
$Hypothyroidism
$Hyperthyroidism
Note:
! inc T3, inc T4, dec TSH = thyroid problem
! inc T3, inc T4, inc TSH = pituitary tumor (benign)
Hypothyroidism
Caused by:
- Autoimmune Disease (Hashimotos Thyroiditis)
- Use of radioactive iodine
- Destruction or removal of thyroid tissue
- Overtreatment of antithyroid drug
Page 69
! MYXEDEMA- Adults
! CRETINISM- Children
3 Basic Concepts:
- Decreased metabolic rate due to hyposecretion of T3
- Decreased body heat production due to hyposecretion of T4
- Hypercalcemia due to hyposecretion of calcitonin
Assessment
1. Lethargy and fatigue
2. Weakness and paresthesia
3. COLD intolerance
4. Weight gain
5. Bradycardia, constipation
6. Dry hair and skin, loss of body hair
7. Generalized puffiness and edema around the eyes and face
Cont of s/sx
- SQ swelling, puffy skin, puffy eyelids
- Thinning of hair, loss of lateral 1/3 of the eyebrow
- Menorrhagia or amenorrhea, decreased libido, abortions
- Myxedema = severe complication leads to coma
Management
- Symptomatic
- Monitor VS and daily weights
- Provide warm environment
- Diet: low calorie, high fiber
- Thyroid hormone replacement
- T4 Synthroid, Levothyroid
- T3 Cytomel
- T3 & T4 Proloid
- T3 given NGT, faster than T4
- T4 given parenterally(S.E. adrenal insuf.)
- Note: 3-12 wks S/Sx must disappear
Hyperthyroidism
Caused by:
! Graves Disease: Autoimmune
! TSAb thyroid stimulating antibody duplicate
Page 70
Manifestations:
! Nervousness, tremors, emotional lability
! Weight loss, emaciated
! Flushed skin, warm and moist
! Increased temp and palpitation to atrial fibrillation
! Heat intolerance
! Hypertension
! Difficulty in sitting quietly
! Thyroid gland may be palpable and a (+) bruit
! Diarrhea
! Bulging eyes (exophthalmus), startled expression
! Amenorrhea, oligomenorrhea, decreased libido
! Delirium, disorientation, extreme nervousness
! Arrhythmias
! Thyroid storm = hyperpyrexia, diarrhea, dehydration,
! tachycardia, arrhythmias, delirium, coma, shock, death
Exophthalmus
Thyroid Scan
Page 71
MANAGEMENT
! Beta blockers- Metoprolol: Inderal
! to control tachycardia and hypertension
! Thiomides- PTU (propylthiouracil) and Tapazole ( Methimazole)
! to inhibit synthesis of thyroid hormone side effects: Agranulocytosis and neutrpenia
! Radioactive Iodine isolation for a few days, body secretions are radioactive contaminated
! Surgery:Thyroidectomy: 5/6 of the gland is removed
! SSKI (Lugols) is given preop to dec thyroid vascularity & to inhibit release of thyroid hormone
! Given with juice to disguise taste
! Given with straw to prevent staining of teeth
! Postop:
! Position: Semi-fowlers, neck at the midline
! Monitor for bleeding, prevent hemorrhage by placing ice collar over the neck
! Monitor blood pressure- to assess for TROUSSEAUS Sign ( hypocalcemia)
! Check for tetany and monitor for signs of hypocalcemia (parathyroid gland is severed)
! give calcium gluconate
! Hoarseness of voice-laryngeal nerve damage- ask the client to speak every hour
! Watchout thyroid crisis
THYROIDECTOMY
! Removal of the thyroid gland
NURSING INTERVENTIONS
1. Provide adequate rest periods in a quiet room
2. Administer anti-thyroid medications that block hormone synthesis- Methimazole and PTU
3. Provide a HIGH-calorie diet, HIGH protein
4. Manage diarrhea
5. Provide a cool and quiet environment
6. Avoid giving stimulants
7. Provide eye care
! Hypoallergenic tape for eyelid closure
8. Administer PROPRANOLOL for tachycardia
9. Administer IODIONE preparation- Lugols solution and SSKI to inhibit the release of T3 and T4
10. Prepare clients for Radioactive iodine therapy
11. Prepare patient for thyroidectomy
12. Manage thyroid storm appropriately
DISORDERS OF the THYROID GLAND
Thyroid storm
! An acute LIFE-threatening condition characterized by excessive thyroid hormone
CAUSE: Manipulation of the thyroid during surgery causing the release of excessive hormones in the blood
ASSESSMENT Findings for Thyroid Storm
1. HIGH fever
2. Tachycardia and Tachypnea
3.
4.
5.
6.
Systolic HYPERtension
Delirium and coma
Severe vomiting and diarrhea
Restlessness, Agitation, confusion and Seizures
NURSING INTERVENTIONS
1. Maintain PATENT airway and adequate ventilation
2. Administer anti-thyroid medications such as Lugols solution, Propranolol, and Glucocorticoids
3. Monitor VS
4. Monitor Cardiac rhythms
Page 72
5.
6.
7.
8.
Administer PARACETAMOL
( not Aspirin) for FEVER
Manage Seizures as required.
Provide a quiet environment
Parathyroid
Gland
Abnormalities
$Hypoparathyroidism
$Hyperparathyroidism
Parathyroid Gland
- produce parathyroid hormone/parathormone which regulates calcium and phosphorus balance
dec serum Ca level
PTH release
serum Ca levels
Therefore: Hyperparathyroidism: Hypercalcemia
Hypoparathyroidism: Hypocalcemia
Hypoparathyroidism
Caused:
- Accidental removal or destruction of parathyroid gland
- Thyroidectomy
- Radical neck dissection
- Idiopathic
- Autoimmune
Diagnostic:
- Decreased PTH
- Decreased serum Ca (7.5 mg/100 ml)
- Increased PO4
Manifestation:
- Hypocalcemia
- Tetany
- Numbness of fingers
- +Chvosteks sign
- +Trousseaus sign
- +Laryngeal spasm
- Severe anxiety and apprehension
- Muscle cramps
- Cardiac dysrhythmias
Page 73
Page 74
Management:
- Treat the cause
- IV calcium gluconate -Syringe and ampule of Ca sol. on bedside
- Oral Ca with Vit. D
Hyperparathyroidism
Caused:
! Primary
! Tumor/adenoma
! hyperplasia
Diagnostic:
- Increased vit D
- Increased PTH
- Increased serum Ca (11 mg/100 ml)
- Decreased PO4
Manifestation:
- Hypercalcemia
- Decalcification of bone
- Fracture
- Deep bone pain
- Depression of neuromuscular function
- Generalized fatigue
- Memory loss
- Dec LOC, stupor coma
Management:
- Treat the cause
- Hydration (IV saline)
- Diuretics (Ca excretion)
- Calcitonin (inhibits bone resorption)
- Dietary Ca restriction
- Avoid thiazide and vit D (may increase Ca)
- Dialysis
- Digitalis is withdrawn (may increase Ca)
Pancreas:
Islet
of
Alpha- glucagon- blood sugar (hyperglycemia) by stimulating glycogenolysis & gluconeogenesis
langerhans
Beta- insulin- blood sugar (hypoglycemia) by facilitating transport of glucose across cell membranes of muscle, liver,
adipose tissue, inhibits breakdown of proteins, requires Na for transport of CHO and requires K for production
Diabetes Mellitus
Page 75
- DM is a disorder of glucose intolerance caused by a deficiency in insulin production and action resulting in
hyperglycemia and abnormal CHO, CHON and fat metabolism.
Types
$Type
no
diseased pancreas (beta cell)
$Type
decreased
inadequate insulin
or
II
IDDM
insulin
NIDDM
insulin
Page 76
! paralysis
! peripheral neuropathy
! numbness/tingling sensation
! neurogenic bladder
Management
- Diet
- Activity/Exercise
- Oral Hypoglycemic Agents
- Insulin- in case of stress, surgery, infection, pregnancy---these conditions trigger stress response and stimulate the
secretion of epi, norepi, glucocorticoids thereby causing hyperglycemia
- DIET- CHO 50%, Fats 30%, CHON 20%
- calorie specially if obese
- ACTIVITY/EXERCISE- CHO uptake by the cells, insulin requirements, maintains ideal body weight
! done 1-2 hours after meals to prevent hypoglycemia
! regular pattern
- MEDICATIONS: Oral Hypoglycemic Agents- indicated only in type II DM
- INSULIN
OHA = oral hypoglycemic agents
- Sulfonylureas - stimulates insulin secretions and increases tissue sensitivity to insulin (Glipizide, Euglucon)
- Biguanides decreases intestinal uptake and hepatic production of glucose and increases tissue sensitivity
(Glucophage) Alpha
- Glucosidase Inhibitor slows CHO carbohydrate absorption (Glucobay)
- Thiazolidinediones insulin sensitizer, increases tissue sensitivity to insulin (Avandia)
TYPES OF INSULIN
Immediate
Acting,
Lispro
Rapid
Acting
clear insulin
Humulin R,
Regular,
Semilente
Actrapid
Intermediate
ActingActingcloudy NPH
Lente,
Humulin N
Monotard
Long Acting
cloudy
UltraLente
ONSET
PEAK
DURATION
5-15 min
3030-90 min
hours
3030-60min
2-4 hours
6-8 hours
1-2 hours
6-8 hours
1818-24 hours
3-4hours
161620hours
3030-36 hours
Page 77
Insulin!
- Hyperinsulinism
tremors,
hunger
and
diaphoresis will manifest
- Somogyi
Phenomenon
rebound
hyperglycemia
after
insulin
administration
(gradual reduction of insulin is the key to manage it)
- Lipodystrophy is a complication if the site of injection is not rotated properly, it can also alter the rate of insulin
absorption.
- Insulin
Pump
external
battery
operated,
needle
is
inserted
SQ
that
delivers
regular insulin (monitor hypokalemia)
Nursing Interventions
- Site
abdomen
(best
site),
upper buttocks- rotate the site of injection
- Route SQ, only REGULAR insulin can be given as IV bolus
(flush the line first it will absorb insulin)
- IV bolus mixed with D5W if hypoglycemic, or PNSS ideal for DKA and HONKS
- Subcutaneous-Pinch or 45 for thin patient, 90 for regular client
- Good site must be supple skin.
- Mixed Insulin regular (clear) first to be drawn followed by NPH (cloudy)
- Administer at room temp- cold insulin leads to lipodystrophy
- Refrigerate after use.
Diagnostic Evaluation
- Fasting Blood Sugar 80-120mg/dl
140 mg/dl for 2 readings
- 2H Postprandial Blood Sugar Test
200 mg/dl
100
gm
of
then check after 2H
- OGTT - 200 mg/dl
blood is withdrawn initially
150-300
gm
of
every hour bloos specimen is taken (1H,2H,3H after)
done when results of FBS and 2H PPBS are borderline
- Random
Blood
200 mg/dl for 2x + 3 Ps blood is withdrawn anytime
- Glycosylated
Hg
can
detect
glucose
level
2-3
months
Adult 2.2%-4.0%
Children 1.8%-4.0%
upper
esp
sugar
CHO/sugar
Sugar
A1C
average
over
(most
in
arms,
case
of
DKA
orally
PO
serum
preceding
reliable)
Page 78
#
#
#
#
!
!
To maintain good health, a balance of fluids and electrolytes, acids and bases must be normally regulated for metabolic
processes to be in working state.
A cell, together with its environment in any part of the body, is primarily composed of FLUID.
Thus fluid and electrolyte balance must be maintained to promote normal function. Potential and actual problems of fluid
and electrolytes happen in all health care settings, in every disorder and with a variety of changes that affect homeostasis.
The nurse therefore needs to FULLY understand the physiology and pathophysiology of fluid and electrolyte alterations so
as to identify or anticipate and intervene appropriately.
Fluids
a solution of solvent and solute
Solvent
a liquid substance where particles can be dissolved
Solute
!
!
Solution
a homogeneous mixture of 2 or more substances of dissimilar molecular structure
usually applied to solids in liquids but applies equally to gasses in liquids
A.
1.
2.
3.
4.
5.
Body Fluids
Function
Transporter of nutrients , wastes, hormones, proteins and etc
Medium or milieu for metabolic processes
Body temperature regulation
Lubricant of musculoskeletal joints
Insulator and shock absorber
Extracellular
Outside cells
Potassium*
Phosphates
Magnesium
Sodium*
Bicarbonates
Chloride
Interstitial
Fluid surrounding
the cells
20%TBW or 2/3
of ECF
Intravascular
Within the blood
vessels
1/3 of ECF Plasma
7.5%
Higher
content
Transcellular
Contained
in
body
cavities
2.5%
Not readily utilized by
the body
CSF,
Pleural
fluid,
Synovial
Fluid
and
peritoneal fluid
Secreted by epithelial
cells
Term
75%
protein
Bound
Bone
and
Cartilage 7.5%
Dense
Connective
tissues 7.5%
25 yrs
60%
50%
45 yrs
55%
47%
65 yrs
50%
45%
Page 79
ECF
ICF
Blood Volume
!
!
!
A.
B.
C.
45%
35%
90-100 ml/kg
40%
35%
85 ml/kg
20%
40%
70 ml/kg
neonates reach adult values by 2 yrs and are about half-way by 3 months
average values ~ 70 ml/100g of lean body mass
percentage of water varies with tissue type,
lean tissues ~ 60-80%
bone ~ 20-25%
fat ~ 10-15%
!
!
!
!
!
!
#
#
K+
0
0
0
0
5
5
5.1
0
0
Ca
0
0
0
0
0
Glu
278
0
0
222
0
6.25
0
0
0
0
0
Osm.
Osm.
253
300
855
282
274
294
293
108
300
pH
5
5.7
5.7
3.5 5-5
6.7
5.5
7.3
6.2
4- 7
Lact
0
0
0
0
28
27
0
0
0
kJ/l
840
0
0
672
37.8
84
0
0
0
Osmole
the weight in grams of a substance producing an osmotic pressure of 22.4 atm. when dissolved in 1.0 litre of solution
(gram molecular weight) / (no. of freely moving particles per molecule)
Osmolality
the number of osmoles of solute per kilogram of solvent
Osmolarity
the number of osmoles of solute per litre of solution
Mole
that number of molecules contained in 0.012 kg of C12, or,
the molecular weight of a substance in grams = Avogadro's number
= 6.023 x 1023
Molality
the number of moles of solute per kilogram of solvent
Molarity
is the number of moles of solute per litre of solution
THE Normal DYNAMICS OF BODY FLUIDS
Page 80
The methods by which electrolytes and other solutes move across biologic membranes are Osmosis, Diffusion, Filtration
and Active Transport. Osmosis, diffusion and filtration are passive processes, while Active transport is an active process.
1.
!
!
!
2.
!
!
!
OSMOSIS
This is the movement of water/liquid/solvent across a semi-permeable membrane from a lesser concentration to a higher
concentration
Osmotic pressure is the power of a solution to draw water across a semi-permeable membrane
Colloid osmotic pressure (also called oncotic pressure) is the osmotic pull exerted by plasma proteins
DIFFUSION
Brownian movement or downhill movement
The movement of particles/solutes/molecules from an area of higher concentration to an area of a lower concentration
This process is affected by:
a. The size of the molecules- larger size moves slower than smaller size
b. The concentration of solution- wide difference in concentration has a faster rate of diffusion
c. The temperature- increase in temperature causes increase rate of diffusion
Facilitated Diffusion is a type of diffusion, which uses a carrier, but no energy is expended. One example is fructose and
amino acid transport process in the intestinal cells. This type of diffusion is saturable.
3. FILTRATION
! This is the movement of BOTH solute and solvent together across a membrane from an area of higher pressure to an area
of lower pressure
! Hydrostatic pressure is the pressure exerted by the fluids within the closed system in the walls of the container
4. ACTIVE TRANSPORT
! Process where substances/solutes move from an area of lower concentration to an area of higher concentration with
utilization of ENERGY
! It is called an uphill movement
! Usually, a carrier is required. An enzyme is utilized also.
a.
!
!
b.
!
!
2. Endocrine Regulation
# The primary regulator of water intake is the thirst mechanism, controlled by the thirst center in the hypothalamus
(anterolateral wall of the third ventricle)
# Anti-diuretic hormone (ADH) is synthesized by the hypothalamus and acts on the collecting ducts of the nephron
Page 81
#
#
#
3. Gastro
Gastro--intestinal regulation
# The GIT digests food and absorbs water
# The hormonal and enzymatic activities involved in digestion, combined with the passive and active transport of electrolyte,
water and solutions, maintain the fluid balance in the body.
B.
#
#
#
#
#
Fluid Intake
Healthy adult ingests fluid as part of the dietary intake.
90% of intake is from the ingested food and water
10% of intake results from the products of cellular metabolism
Usual intake of adult is about 2, 500 ml per day
The other sources of fluid intake are: IVF, TPN, Blood products, and colloids
C.
#
#
#
#
#
Fluid Output
The average fluid losses amounts to 2, 500 ml per day, counterbalancing the input.
The routes of fluid output are the following:
SENSIBLE LOSS- Urine, feces or GI losses, sweat
INSENSIBLE LOSS- though the skin and lungs as water vapor
URINE- is an ultra-filtrate of blood. The normal output is 1,500 ml/day or 30-50 ml per hour or 0.5-1 ml per kilogram per
hour. Urine is formed from the filtration process in the nephron
FECAL loss- usually amounts to about 200 ml in the stool
Insensible loss- occurs in the skin and lungs, which are not noticeable and cannot be accurately measured. Water vapor goes
out of the lungs and skin.
#
#
'
'
Water Metabolism
Daily Balance: turnover ~ 2500 ml
a. Intake
i. drink ~ 1500 ml
ii. food ~ 700 ml
iii. metabolism ~ 300 ml
b. Losses
i. urine ~ 1500 ml
ii. skin ~ 500 ml
insensible losses ~ 400 ml
sweat ~ 100 ml
iii. lungs ~ 400 ml
iv. faeces ~ 100 ml
Minimum daily intake ~ 500 ml with a "normal" diet
Minimum losses ~ 1500 ml/d
Losses are increased with;
a. increased ambient T
b. hyperthermia ~ 13% per C
c. decreased relative humidity
d. increased minute ventilation
e. increased MRO2
Fluid Imbalances
Imbalances
FLUID VOLUME DEFICIT or HYPOVOLEMIA
Page 82
Definition: This is the loss of extra cellular fluid volume that exceeds the intake of fluid. The loss of water and electrolyte is
in equal proportion. It can be called in various terms- vascular, cellular or intracellular dehydration. But the preferred term
is hypovolemia.
# Dehydration refers to loss of WATER alone, with increased solutes concentration and sodium concentration
Pathophysiology of Fluid Volume Deficit
# Etiologic conditions include:
a. Vomiting
b. Diarrhea
c. Prolonged GI suctioning
d. Increased sweating
e. Inability to gain access to fluids
f. Inadequate fluid intake
g. Massive third spacing
#
a.
b.
c.
d.
e.
f.
#
#
#
#
#
#
PATHOPHYSIOLOGY:
Factors
inadequate fluids in the body
decreased blood volume
decreased cellular hydration
cellular shrinkage
weight loss, decreased turgor, oliguria, hypotension, weak pulse, etc.
The Nursing Process in Fluid Volume Deficit
ASSESSMENT:
#
#
#
#
Physical examination
Weight loss, tented skin turgor, dry mucus membrane
Hypotension
Tachycardia
Cool skin, acute weight loss
Flat neck veins
Decreased CVP
Subjective cues
Thirst
Nausea, anorexia
Muscle weakness and cramps
Change in mental state
1.
2.
3.
4.
Laboratory findings
Elevated BUN due to depletion of fluids or decreased renal perfusion
Hemoconcentration
Possible Electrolyte imbalances: Hypokalemia, Hyperkalemia, Hyponatremia, hypernatremia
Urine specific gravity is increased (concentrated urine) above 1.020
#
#
#
#
#
#
NURSING DIAGNOSIS
Page 83
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
!
!
!
1.
2.
3.
4.
5.
6.
7.
Page 84
1. Shortness of breath
2. Change in mental state
Laboratory findings
1. BUN and Creatinine levels are LOW because of dilution
2. Urine sodium and osmolality decreased (urine becomes diluted)
3. CXR may show pulmonary congestion
NURSING DIAGNOSIS
o Fluid Volume excess
IMPLEMENTATION
ASSIST IN MEDICAL INTERVENTION
#
#
#
1.
2.
3.
4.
5.
ELECTROLYTES
Electrolytes are charged ions capable of conducting electricity and are solutes found in all body compartments.
1. Sources of electrolytes
Foods and ingested fluids, medications; IVF and TPN solutions
#
#
#
#
#
#
#
#
2. Functions of Electrolytes
Maintains fluid balance
Regulates acid-base balance
Needed for enzymatic secretion and activation
Needed for proper metabolism and effective processes of muscular contraction, nerve transmission
3. Types of Electrolytes
CATIONS- positively charged ions; examples are sodium, potassium, calcium
ANIONS- negatively charged ions; examples are chloride and phosphates]
The major ICF cation is potassium (K+); the major ICF anion is Phosphates
The major ECF cation is Sodium (Na+); the major ECF anion is Chloride (Cl-)
DYNAMICS OF ELECTROLYTE BALANCE
#
#
#
1. Electrolyte
Electrolyte Distribution
ECF and ICF vary in their electrolyte distribution and concentration
ICF has K+, PO4-, proteins, Mg+, Ca++ and SO4ECF has Na+, Cl-, HCO3-
2. Electrolyte Excretion
These electrolytes are excessively eliminated by abnormal fluid losses
Page 85
Routes can be thru urine, feces, vomiting, surgical drainage, wound drainage and skin excretion
#
#
3. Regulation of Electrolytes
a) Renal Regulation
occurs by the process of glomerular filtration, tubular reabsorption and tubular secretion
b) Endocrine Regulation
Regulation
hormones play a role in this type of regulation:
AldosteroneAldosterone- promotes Na retention and K excretion
ANFANF- promotes Na excretion
PTHPTH- promotes Ca retention and PO4 excretion
CalcitoninCalcitonin- promotes Ca and PO4 excretion
c) GIT Regulation
electrolytes are absorbed and secreted
some are excreted thru the stool
#
#
#
#
#
#
THE CATIONS
SODIUM
The most abundant cation in the ECF
Normal range in the blood is 135-145 mEq/L
A loss or gain of sodium is usually accompanied by a loss or gain of water.
Major contributor of the plasma Osmolality
Sources: Diet, medications, IVF. The minimum daily requirement is 2 grams
Imbalances- Hyponatremia= <135 mEq/L; Hypernatremia= >145 mEq/L
#
#
Functions:
Participates in the Na-K pump
Assists in maintaining blood volume
Assists in nerve transmission and muscle contraction
Primary determinant of ECF concentration.
Controls water distribution throughout the body.
Primary regulator of ECF volume.
Sodium also functions in the establishment of the electrochemical state necessary for muscle contraction and the
transmission of nerve impulses.
8. Regulations: skin, GIT, GUT, Aldosterone increases Na retention in the kidney
1.
2.
3.
4.
5.
6.
7.
#
#
1.
2.
3.
4.
5.
#
1.
#
2.
#
#
Page 86
#
#
#
#
#
#
o
o
o
o
o
o
o
#
1.
2.
3.
4.
5.
#
1.
2.
3.
4.
#
1.
2.
3.
4.
!
!
!
Page 87
Provide continuous assessment by doing an accurate intake and output, daily weights, mental status examination, urinary
sodium levels and GI manifestations. Maintain seizure precaution
2. Detect and control Hyponatremia by encouraging food intake with high sodium content, monitoring patients on lithium
therapy, monitoring input of fluids like IVF, parenteral medication and feedings.
3. Return the Sodium level to Normal by restricting water intake if the primary problem is water retention. Administer sodium
to normovolemic patient and elevate the sodium slowly by using sodium chloride solution
1.
#
#
#
1.
2.
3.
4.
5.
6.
#
1.
2.
3.
4.
!
!
!
!
!
!
#
#
#
#
o
o
#
#
A primary characteristic of hypernatremia is thirst. Thirst is so strong a defender of serum sodium levels in normal people
that hypernatremia never occurs unless the person is unconscious or is denied access to water; unfortunately, ill people may
have an impaired thirst mechanism. Other signs include dry, swollen tongue and sticky mucous membranes. A mild
elevation in body temperature may occur, but on correction of the hypernatremia the body temperature should return to
normal.
#
1.
ASSESSMENT
Physical Examination
Restlessness, elevated body temperature
Page 88
2.
3.
4.
5.
6.
#
1.
2.
3.
#
1.
2.
3.
Disorientation
Dry, swollen tongue and sticky mucous membrane, tented skin turgor
Flushed skin, postural hypotension
Increased muscle tone and deep reflexes
Peripheral and pulmonary edema
Subjective Cues
Delusions and hallucinations
Extreme thirst
Behavioral changes
Laboratory findings
Serum sodium level exceeds 145 mEq/L
Serum osmolality exceeds 295 mOsm/kg
Urine specific gravity and osmolality INCREASED or elevated
IMPLEMENTATION
ASSIST IN THE MEDICAL INTERVENTION
1. Administer hypotonic electrolyte solution slowly as ordered
2. Administer diuretics as ordered
3. Desmopressin is prescribed for diabetes insipidus
1.
2.
3.
4.
5.
6.
#
#
#
#
#
#
#
#
#
1.
2.
3.
4.
5.
a.
#
#
#
#
NURSING MANAGEMENT
Continuously monitor the patient by assessing abnormal loses of water, noting for the thirst and elevated body temperature
and behavioral changes
Prevent hypernatremia by offering fluids regularly and plan with the physician alternative routes if oral route is not
possible. Ensure adequate water for patients with DI. Administer IVF therapy cautiously
Correct the Hypernatremia by monitoring the patients response to the IVF replacement. Administer the hypotonic solution
very slowly to prevent sudden cerebral edema.
Monitor serum sodium level.
Reposition client regularly, keep side-rails up, the bed in low position and the call bell/light within reach.
Provide teaching to avoid over-the counter medications without consultation as they may contain sodium
POTASSIUM
The most abundant cation in the ICF
Potassium is the major intracellular electrolyte; in fact, 98% of the bodys potassium is inside the cells.
The remaining 2% is in the ECF; it is this 2% that is all-important in neuromuscular function.
Potassium is constantly moving in and out of cells according to the bodys needs, under the influence of the sodiumpotassium pump.
Normal range in the blood is 3.5-5 mEq/L
Normal renal function is necessary for maintenance of potassium balance, because 80-90% of the potassium is excreted
daily from the body by way of the kidneys. The other less than 20% is lost through the bowel and sweat glands.
Major electrolyte maintaining ICF balance
Sources- Diet, vegetables, fruits, IVF, medications
Functions:
Maintains ICF Osmolality
Important for nerve conduction and muscle contraction
Maintains acid-base balance
Needed for metabolism of carbohydrates, fats and proteins
Potassium influences both skeletal and cardiac muscle activity.
For example, alterations in its concentration change myocardial irritability and rhythm.
Regulations: renal secretion and excretion, Aldosterone promotes renal excretion acidosis promotes K exchange for
hydrogen
Imbalances:
Hypokalemia= <3.5 mEq/L
Hyperkalemia=> 5.0 mEq/L
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2. Infuse parenteral potassium supplement. Always dilute the K in the IVF solution and administer with a pump. IVF with
potassium should be given no faster than 10-20-mEq/ hour!
3. NEVER administer K by IV bolus or IM
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NURSING MANAGEMENT
Continuously monitor the patient by assessing the cardiac status, ECG monitoring, and digitalis precaution
Prevent hypokalemia by encouraging the patient to eat potassium rich foods like orange juice, bananas, cantaloupe,
peaches, potatoes, dates and apricots.
Correct hypokalemia by administering prescribed IV potassium replacement. The nurse must ensure that the kidney is
functioning properly!
Administer IV potassium no faster than 20 mEq/hour and hook the patient on a cardiac monitor. To EMPHASIZE:
Potassium should NEVER be given IV bolus or IM!!
A concentration greater than 60 mEq/L is not advisable for peripheral veins.
POTASSIUM EXCESS: HYPERKALEMIA
HYPERKALEMIA
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Gastrointestinal manifestations, such as nausea, intermit tent intestinal colic, and diarrhea, may occur in hyperkalemic
patients.
ASSESSMENT
Physical Examination
Diarrhea
Skeletal muscle weakness
Abnormal cardiac rate
Subjective Cues
Nausea
Intestinal pain/colic
Palpitations
Laboratory Findings
Peaked and narrow T waves
ST segment depression and shortened QT interval
Prolonged PR interval
Prolonged QRS complex
Disappearance of P wave
Serum potassium is higher than 5.5 mEq/L
Acidosis
IMPLEMENTATION
ASSIST IN MEDICAL INTERVENTION
1. Monitor the patients cardiac status with cardiac machine
2. Institute emergency therapy to lower potassium level by:
a. Administering IV calcium gluconate- antagonizes action of K on cardiac conduction
b. Administering Insulin with dextrose-causes temporary shift of K into cells
c.
Administering sodium bicarbonate-alkalinizes plasma to cause temporary shift
d. Administering Beta-agonists
e. Administering Kayexalate (cation-exchange resin)-draws K+ into the bowel
NURSING MANAGEMENT
Provide continuous monitoring of cardiac status, dysrhythmias, and potassium levels.
Assess for signs of muscular weakness, paresthesias, nausea
Evaluate and verify all HIGH serum K levels
Prevent hyperkalemia by encouraging high risk patient to adhere to proper potassium restriction
Correct hyperkalemia by administering carefully prescribed drugs. Nurses must ensure that clients receiving IVF with
potassium must be always monitored and that the potassium supplement is given correctly
6. Assist in hemodialysis if hyperkalemia cannot be corrected.
7. Provide client teaching. Advise patients at risk to avoid eating potassium rich foods, and to use potassium salts sparingly.
8. Monitor patients for hypokalemia who are receiving potassium-sparing diuretic
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CALCIUM
Majority of calcium is in the bones and teeth
Small amount may be found in the ECF and ICF
Normal serum range is 8.5 10.5 mg/dL
Sources: milk and milk products; diet; IVF and medications
Functions:
1. Needed for formation of bones and teeth
2. For muscular contraction and relaxation
3. For neuronal and cardiac function
4. For enzymatic activation
5. For normal blood clotting
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Regulations:
1. GIT- absorbs Ca+ in the intestine; Vitamin D helps to increase absorption
2. Renal regulation- Ca+ is filtered in the glomerulus and reabsorbed in the tubules:
3. Endocrine regulation:
Parathyroid hormone from the parathyroid glands is
released when Ca+ level is low. PTH causes release of calcium
from bones and increased retention of calcium by the kidney but PO4 is excreted
Calcitonin from the thyroid gland is released when the calcium level is high. This causes excretion of both calcium and PO4
in the kidney and promoted deposition of calcium in the bones.
Imbalances- Hypocalcemia= <8.5 mg/dL; Hypercalcemia= >10.5 mg/dL
THE ANIONS
CHLORIDE
The major Anion of the ECF
Normal range is 95-108 mEq/L
Sources: Diet, especially high salt foods, IVF (like NSS), HCl (in the stomach)
Functions:
1. Major component of gastric juice
2. Regulates serum Osmolality and blood volume
3. Participates in the chloride shift
4. Acts as chemical buffer
Regulations: Renal regulation by absorption and excretion; GIT absorption
Imbalances: Hypochloremia= < 95 mEq/L; Hyperchloremia= >108 mEq/L
PHOSPHATES
The major Anion of the ICF
Normal range is 2.5 to 4.5 mg/dL
Sources: Diet, TPN, Bone reserves
Functions:
1. Component of bones, muscles and nerve tissues
2. Needed by the cells to generate ATP
3. Needed for the metabolism of carbohydrates, fats and proteins
4. Component of DNA and RNA
Regulations: Renal glomerular filtration, endocrinal regulation by PTH-decreases PO4 in the blood by kidney excretion
Imbalances- Hypophosphatemia= <2.5 mg/dL; Hyperphosphatemia >4.5 mg/dL
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BICARBONATES
Present in both ICF and ECF
Regulates acid-base balance together with hydrogen
Normal range is 22-26 mEq/L
Sources: Diet; medications and metabolic by-products of the cells.
Function: Component of the bicarbonate-carbonic acid buffer system
Regulation: Kidney production, absorption and secretion
Imbalances: Metabolic acidosis= <22 mEq/L; Metabolic alkalosis= >26 mEq/
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1. AGE
Infants have higher proportion of body water than adults
Water content of the body decreases with age
Infants have higher fluid turn-over due to immature kidney and rapid respiratory rate
1.
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Metabolic Alkalosis
A base bicarbonate excess
A result of a loss of acid and the
accumulation of bases
S/S - serum pH > 7.45, increased serum
HCO3, serum K level less than 4, tetany, confusion and convulsions
Nursing Interventions - watch for s/s of hypokalemia, LOC and seizure precautions
!
!
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Metabolic Acidosis
A base bicarbonate deficit
Comes from too much acid from metabolism and loss of bicarbonate
S/S - Serum pH <7.35, Increased K+ level, DKA (Kussmauls Respirations), Shock, stupor, coma
Nursing Intervention - Give HCO3/Monitor K+ levels
!
!
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Respiratory Alkalosis
A deficit of carbonic acid caused by hyperventilation
S/S - decreased levels of CO2 and increased levels of pH, HCO3 near normal
Nursing Interventions - monitor for anxiety and observe for signs and symptoms of tetany
Page 95
Respiratory Alkalosis
A carbonic acid excess
Caused by an condition that interferes with the release of CO2 from the lungs (sedatives, COPD, narcotics etc.)
S/S - serum pH < 7.35, increased serum CO2 levels> 45 mm Hg, serum K increased, cyanosis
Nursing Interventions - Provide O2, Semifowlers position, seizure precautions
Interpretation Arterial Blood Gases
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NEURO
Overview of the Structures & Functions of Nervous System
Central NS
PNS
ANS
Brain & spinal cord
31 spinal & cranial
sympathetic NS
Parasypathatic NS
Somatic NS
C- 8
T- 12
L- 5
S- 5
C- 1
ANS (or adrenergic of parasympatholitic response)
SNS involved in fight or aggression response
Release of norepinephrine (adrenaline cathecolamine)
Adrenal medulla (potent vasoconstrictor)
Increases body activities
VS = Increase
Except GIT decrease GITmotility
* Why GIT is not increased = GIT is not important!
Page 96
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3.)
4.)
5.)
6.)
Basal Ganglia areas of gray matte located deep within a cerebral hemisphere
- Extra pyramidal tract
- Releases dopamine- Controls gross voluntary unit
Decrease dopamine (Parkinsons) pin rolling of extremities & Huntingtons Dse.
Decrease acetylcholine Myasthenia Gravis & Alzheimers
Increased neurotransmitter = psychiatric disorder
Increase dopamine schizo
Increase acetylcholine bipolar
MID BRAIN relay station for sight & hearing
Controls size & reaction of pupil 2 3 mm
Controls hearing acuity
CN 3 4
Isocoria normal size (equal)
Anisocoria uneven size damage to mid brain
PERRLA normal reaction
DIENCEPHALON- between brain
Thalamus acts as a relay station for sensation
Hypothalamus (thermoregulating center of temp, sleep & wakefulness, thirst, appetite/ satiety center, emotional
responses, controls pituitary function.
BRAIN STEM- a. Pons or pneumotaxic center controls respiration
Cranial 5 8 CNS
MEDULLA OBLONGATA- controls heart rate, respiratory rate, swallowing, vomiting, hiccups/ singutus
Vasomotor center, spinal decuissation termination, CN 9, 10, 11, 12
CEREBELLUM lesser brain
- Controls posture, gait, balance, equilibrium
Cerebellar Tests:
a.) R Rombergs test- needs 2 RNs to assist
- Normal anatomical position 5 10 min
(+) Rombergs test (+) ataxia or unsteady gait or drunken like movement with loss of balance.
b.) Finger to nose test
(+) To FTNT dymetria inability to stop a movement at a desired point
c.) Alternate pronation & supination
Palm up & down . (+) To alternate pronation & supination or damage to cerebellum dymentrium
Composition of brain - based on Monroe Kellie Hypothesis
- Skull is a closed container. Any alteration in 1 of 3 intracranial components = increase in ICP
Page 99
Page 100
E extreme restlessness
D dyspnea
C cyanosis
Early symptoms R restlessness
A agitation
T tachycardia
Increase CO2 retention/ hypercarbia cerebral vasodilatation = increase ICP
Most powerful respiratory stimulant increase in CO2
Hyperventilate decrease CO2 excrete CO2
Respiratory Distress Syndrome (RDS) decrease Oxygen
Suctioning 10-15 seconds, max 15 seconds. Suction upon removal of suction cap.
Ambu bag pump upon inspiration
c. Assist in mechanical ventilation
1. Maintain patent a/w
2. Monitor VS & I&O
3. Elevate head of bed 30 45 degrees angle neck in neutral position unless contra indicated to promote venous drainage
4. Limit fluid intake 1,200 1,500 ml/day
(FORCE FLUID means:Increase fluid intake/day 2,000 3,000 ml/day)- not for inc ICP.
5. Prevent complications of immobility
6. Prevent increase ICP by:
a. Maintain quiet & comfy environment
b. Avoid use of restraints lead to fractures
c. Siderails up
d. Instruct patient to avoid the ff:
-Valsalva maneuver or bearing down, avoid straining of stool
(give laxatives/ stool softener Dulcolax/ Duphalac)
- Excessive cough antitussive
Dextrometorpham
-Excessive vomiting anti emetic (Plasil Phil only)/ Phenergan
- Lifting of heavy objects
- Bending & stooping
e. Avoid clustering of nursing activities
7. Administer meds as ordered:
1.) Osmotic diuretic Mannitol./Osmitrol promotes cerebral diuresis by decompressing brain tissue
Nursing considerations: Mannitol
1.
2.
3.
4.
Monitor BP SE of hypotension
Monitor I&O every hr. report if < 30cc out put
Administer via side drip
Regulate fast drip to prevent formation of crystals or precipitate
S/E of Lasix
S&Sx
Hypokalemia
Hypokalemia (normal K-3.5 5.5 meg/L)
1.
Page 101
2. Constipation
3. (+) U wave in ECG tracing
Nursing Mgt:
1.) Administer K supplements ex Kalium Durule, K chloride
Potassium Rich food:
ABCs of K
Vegetables
A - asparagus
B broccoli (highest)
C carrots
Fruits
A apple
B banana green
C cantalope/ melon
O orange (highest) for digitalis toxicity also.
Vit A squash, carrots yellow vegetables & fruits, spinach, chesa
Iron raisins,
Food appropriate for toddler spaghetti! Not milk increase bronchial secretions
Dont give grapes may choke
S/E of Lasix:
1.) Hypokalemia
Tetany:
2.) Hypocalcemia (Normal level Ca = 8.5 11mg/100ml) or Tetany
S&Sx
weakness
Paresthesia
(+) Trousseau sign pathognomonic or carpopedal spasm. Put bp cuff on arm=hand spasm.
(+) Chevosteks sign
Arrhythmia
Laryngospasm
Administer Ca gluconate IV slowly
Ca gluconate toxicity:
toxicity Sx seizure administer Mg SO4
Mg SO4 toxcicity
toxcicity administer Ca gluconate
B BP decrease
U urine output decrease
R RR decrease
P patellar reflexes absent
3.) Hyponatremia Normal Na level = 135 145 meg/L
Hypotension
Signs of Dehydration: dry skin, poor skin turgor, gen body malaise.
Early signs Adult: thirst and agitation / Child: tachycardia
Mgt: force fluid
Administer isotonic fluid sol
S/Sx
Page 102
Toxicity
2
2
20
200
Classification
cardiac glycosides
antimanic
bronchodilator
20
anticonvulsant
narcotic analgesic
Indication
CHF
bipolar
COPD
seizures
osteoarthritis
Page 103
e. Photophobia
f. Changes in color perception yellow spots
(Ok to give to pts with renal failure. Digoxin is metabolized in liver not in kidney.)
L lithium (lithane) decrease levels of norepinephrine, serotonine, acetylcholine
Antimanic agent
Lithium toxicity
S/Sx a.) Anorexia
b.) n/s
c.) Diarrhea
d.) Dehydration force fluid, maintain Na intake 4 10g daily
e.) Hypothyroidism
(CRETINISM the only endocrine disorder that can lead to mental retardation)
A aminophyline (theophylline) dilates bronchioles.
Take bp before giving aminophylline.
S/Sx : Aminophylline toxicity:
1. Tachycardia
2. Hyperactivity restlessness, agitation, tremors
Question: Avoid giving food with Aminophylline
a. Cheese/butter food rich in tyramine, avoided only if pt is given
MAOI
b. Beer/ wine c. Hot chocolate & tea caffeine CNS stimulant tachycardia
d. Organ meat/ box cereals anti parkinsonian
MAOI antidepressant
m AR plan
n AR dil
can
lead
to
CVA
p AR nate
3 4 weeks - before MAOI will take effect
Anti Parkinsonian agents Vit B6 Pyridoxine reverses effect of Levodopa
or
hypertensive
crisis
Page 104
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Ig E allergic reactions
IgD chronic inflammation
S & Sx of MS: (everything down)
1. Visual disturbances
a. Blurring of vision
b. Diplopia/ double vision
c. Scotomas (blind spots) initial sx
2. Impaired sensation to touch, pain, pressure, heat, cold
a. Numbness
b. Tingling
c. Paresthesia
3. Mood swings euphoria (sense of elation )
4. Impaired motor function:
a. Weakness
b. Spasiticity tigas
c. Paralysis major problem
5. Impaired cerebellar function
Triad Sx of MS
I intentional tremors
N nystagmus abnormal rotation of eyes
Charcots triad
A Ataxia
& Scanning speech
6. Urinary retention or incontinence
7. Constipation
8. Decrease sexual ability
Dx MS
1. CSF analysis thru lumbar puncture
- Reveals increase CHON & IgG
2. MRI reveals site & extent of demyelination
3. Lhermittes response is (+). Introduce electricity at the back. Theres spasm & paralysis at spinal cord.
Nsg Mgt MS
- Supportive mgt
1.) Meds
a. Acute exacerbation
ACTH adenocorticotopic
Steroids to reduce edema at the site of demyelination to prevent paralysis
Spinal Cord Injury
Administer drug to prevent paralysis due to edema
a. Give ACTH steroids
b. Baclopen (Lioresol) or Dantrolene Na (Dantrene)
To decrease muscle spasticity
c. Interferone to alter immune response
d. Immunosuppresants
2. Maintain siderails
3. Assist passive ROMexercises promote proper body alignment
4. Prevent complications of immobility
5. Encourage fluid intake & increase fiber diet to prevent constipation
6. Provide catheterization die urinary retention
7. Give diuretics
Urinary incontinence give Prophantheline bromide (probanthene)
Antispasmodic anti cholinergic
8. Give stress reducing activity. Deep breathing exercises, biofeedback, yoga techniques.
9. Provide acid-ash diet to acidify urine & prevent bacteria multiplication
Grape, Cranberry, Orange juice, Vit C
Page 107
MYASTHENIA GRAVIS (MG) disturbance in transmission of impulses from nerve to muscle cell at neuro muscular
junction.
Common in Women, 20 40 yo, unknown cause or idiopathic
Autoimmune release of cholenesterase enzyme
Cholinesterase destroys ACH (acetylcholine) = Decrease acetylcholine
Descending muscle weakness
(Ascending muscle weakness Guillain Barre Syndrome)
Nsg priority:
1) a/w
2) aspiration
3) immobility
S/ Sx:
1.) Ptosis drooping of upper lid ( initial sign)
Check Palpebral fissure opening of upper & lower lids = to know if (+) of MG.
2.) Diplopia double vision
3.) Mask like facial expression
4.) Dysphagia risk for aspiration!
5.) Weakening of laryngeal muscles hoarseness of voice
6.) Resp muscle weakness lead respiratory arrest. Prepare at bedside tracheostomy set
7.) Extreme muscle weakness during activity especially in the morning.
Dx test
1. Tensilon test (Edrophonium Hcl) temporarily strengthens muscles for 5 10 mins. Short term- cholinergic. PNS
effect.
Nsg Mgt
1. Maintain patent a/w & adequate vent by:
a.) Assist in mechanical vent attach to ventilator
b.) Monitor pulmonary function test. Decrease vital lung capacity.
2. Monitor VS, I&O neuro check, muscle strength or motor grading scale (4/5, 5/5, etc)
3. Siderails
4. Prevent complications of immobility. Adult-every 2 hrs. Elderly- every 1 hr.
5. NGT feeding
Administer meds
a.) Cholinergics or anticholinesterase agents
Mestinon (Pyridostigmine)
Neostignine (prostigmin) Long term
- Increase acetylcholine
s/e PNS
b.) Corticosteroids to suppress immune resp
Decadron (dexamethasone)
Monitor for 2 types of Crisis:
Myastinic crisis
A cause 1. Under medication
2. Stress
3. Infection
B S&Sx 1. Unable to see Ptosis & diplopia
2. Dysphagia- unable to swallow.
3. Unable to breath
C Mgt adm cholinergic agents
Cholinergic crisis
Cause: 1 over meds
S/Sx - PNS
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3 layers
1. Duramater
2. Arachmoid matter
3. Pia matter
neck pain
Dx:
1. Lumbar puncture lumbar/ spinal tap use of hallow spinal needle sub arachnoid space L3 & L4 or L4 & L5
Aspirate CSF for lumbar puncture.
Nsg Mgt for lumbar puncture invasive
1. Consent / explain procedure to pt
- RN dx procedure (lab)
- MD operation procedure
2. Empty bladder, bowel promote comfort
3. Arch back to clearly visualize L3, L4
Nsg Ngt post lumbar
1. Flat on bed 12 24 h to prevent spinal headache & leak of CSF
2. Force fluid
3. Check punctured site for drainage, discoloration & leakage to tissue
4. Assess for movement & sensation of extremeties
Result
1. CSF analysis:
Content of CSF:
CSF Chon, wbc, glucose
Page 110
S/E
1. GIT irritation take with food
2. Hepatotoxicity, nephrotoxcicity
3. Allergic reaction
4. Super infection alteration in normal bacterial flora
- N flora throat streptococcus
- N flora intestine e coli
Sx of superinfection of penicillin = diarrhea
b.) Antipyretic
c.) Mild analgesic
2. Strict resp isolation 24h after start of antibiotic therapy
A Cushings synd reverse isolation - due to increased corticosteroid in body.
B Aplastic anemia reverse isolation - due to bone marrow depression.
C Cancer anytype reverse isolation immunocompromised.
D Post liver transplant reverse isolation takes steroids lifetime.
E Prolonged use steroids reverse isolation
F Meningitis strict respiratory isolation safe after 24h of antibiotic therapy
G Asthma not to be isolated
3.
4.
5.
6.
7.
Page 111
3.)
Risk factors of CVA: HPN, DM, MI, artherosclerosis, valvular heart dse - Post heart surgery mitral valve replacement
Lifestyle:
S & Sx
1. TIA- warning signs of impending stroke attacks
- Headache (initial sx), dizziness/ vertigo, numbness, tinnitus, visual & speech disturbances, paresis or plegia
(monoplegia 1 extreme)
Increase ICP
2. Stroke in evolution progression of S & Sx of stroke
3. Complete stroke resolution of stroke
a.) Headache
b.) Cheyne-Stokes Resp
c.) Anorexia, n/v
d.) Dysphagia
e.) Increase BP
f.) (+) Kernigs & Brudzinski sx of hemorrhagic stroke
g.) Focal & neurological deficit
1. Phlegia
2. Dysarthria inability to vocalize, articulate words
3. Aphasia
4. Agraphia diff writing
5. Alesia diff reading
6. Homoninous hemianopsia loss of half of field of vision
Left sided hemianopsia approach Right side of pt the unaffected side
Dx
1. CT Scan reveals brain lesion
2. Cerebral arteriography site & extent of mal occlusion
- Invasive procedure due to inject dye
- Allergy test
All graphy invasive due to iodine dye
Post
1.) Force fluid to excrete dye is nephrotoxic
2.) Check peripheral pulses - distal
Nsg Mgt
1. Maintain patent a/w & adequate vent
- Assist mechanical ventilation
- Administer O2
2. Restrict fluids prevent cerebral edema
3. Elevate head of bed 30-45 degrees angle. Avoid valsalva maneuver.
Page 112
Difference between:
Predisposing Factor
Head injury due birth trauma
Toxicity of carbon monoxide
Brain tumor
Genetics
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Ginguial hyperplasia
H-hairy tongue
A-ataxia
N-nystagmus
A-acetaminophen- febrile pt
Mix with NSS
- Dont give alcohol lead to CNS depression
b. (Tegretol) Carbamasene- given also to Trigeminal Neuralgia. SE: arrythmia
c. Phenobarbital (Luminal)- SE: hallucinations
SE
2. Institute seizure & safety precaution. Post seizure: Administer O2. Suction apparatus ready at bedside
3. Monitor onset & duration
- Type of seizure
- Duration of post ictal sleep. The longer the duration of post ictal sleep, the higher chance of having status epilepticus!
4. Assist in surgical procedure. Cortical resection
5. Complications: Subarachnoid hemorrhage and encephalitis
Question: 1 yo grand mal immediate nursing action = a/w & safety
a. Mouthpiece 1 yr old little teeth only
b. Adm o2 inhalation post!
c. Give pillow safety (answer)
d. Prepare suction
Neurological assessment:
1. Comprehensive neuro exam
2. GCS - Glasgow coma scale obj measurement of LOC or quick neuro check
3 components of ECS
M motor
6
V verbal resp 5
E eye opening 4
15
15 14 conscious
13 11 lethargy
10 8 stupor
7 coma
3 deep coma lowest score
Survey of mental status & speech (Comprehensice Neuro Exam)
1.) LOC & test of memory
2.) Levels of orientation
3.) CN assessment
4.) Motor assessment
5.) Sensory assessment
6.) Cerebral test Romhberg, finger to nose
7.) DTR
8.) Autonomics
Levels of consciousness (LOC)
1. Conscious (conscious) awake levels of wakefulness
2. Lethargy (lethargic) drowsy, sleepy, obtunded
3. Stupor (stuporous) awakened by vigorous stimulation
Pt has gen body weakness, decrease body reflex
4. Coma (Comatose) light (+) all forms of painful stimulations
Page 115
Olfactory
Optic
Oculomotor
Trocheal
Trigeminal
Abducens
Facial
Acustic/auditory
Glassopharyngeal
Vagus
Spinal accessory
Hypoglossal
s
s
m
m
b
m
b
s
b
b
m
m
smallest CN
largest CN
longest CN
I. Olfactory dont use ammonia, alcohol, cologne irritating to mucosa use coffee, bar soap, vinegar, cigarette tar
- Hyposmia decrease sensitivity to smell
- Diposmia distorted sense of smell
- Anosmia absence of sense of smell
Either of 3 might indicate head injury damage to cribriform plate of ethmoid bone where olfactory cells are located or
indicate inflammation condition sinusitis
II opticoptic test of visual acuity Snellens chart central or distance vision
Snellens E chart used for illiterate chart
N 20/20 vision distance by w/c person can see letters- 20 ft
Numerator distance to snellens chart
Denominator distance the person can see the letters
OD Rt eye
20/2020/200 blindness cant read E biggest
Page 116
OS left eye
OU both eye
2.
a.
b.
c.
d.
20/20
20/20
Test of peripheral vision/ visual field
Superiority
Bitemporally
Inferiorly
Nasally
Common Disorders see page 85-87 for more info on glaucoma, etc.
1. Glaucoma Normal 12 21 mmHg pressure
- Increase IOP - Loss of peripheral vision tunnel vision
2. Cataract opacity of lens - Loss of central vision, Blurring or hazy vision
3. Retinal detachment curtain veil like vision & floaters
4. Macular degeneration black spots
III, IV, VI tested simultaneously
- Innervates the movementt of extrinsic ocular muscle
6 cardinal gaze EOM
Rt eye
IO
SO
LR
MR
N
O
S
E
left eye
SR
3 4 EOM
IV sup oblique
VI lateral rectus
Normal response PERRLA (isocoria equal pupil)
Anisocoria unequal pupil
Oculomotor
1. Raising of eyelid Ptosis
2. Controls pupil size 2 -3 cm or 1.5 2 mm
V Trigeminal Largest consists of - ophthalmic, maxillary, mandibular
Sensory controls sensation of the face, mucus membrane; teeth & cornea reflex
Unconscious instill drop of saline solution
Motor controls muscles of chewing/ muscles of mastication
Trigeminal neuralgia diff chewing & swallowing extreme food temp is not recommended
Question: Trigeminal neuralgia, RN should give
a. Hot milk, butter, raisins
b. Cereals
c. Gelatin, toast, potato all correct but
d. Potato, salad, gelatin salad easier to chew
VI Facial:
Facial Sensory controls taste ant 2/3 of tongue test cotton applicator put sugar.
-Put applicator with sugar to tip to tongue.
-Start of taste insensitivity: Age group 40 yrs old
Motor- controls muscles of facial expression, smile frown, raise eyebrow
Damage Bells palsy facial paralysis
Page 117
ONCOLOGY NURSING
ONCOLOGY / CANCER NURSING
Page 118
THE CELL
Definition of Related Terms
Cell
- The basic unit of living organism; can reproduce itself
Cancer a disease process whereby cells proliferate abnormally, ignoring growth
regulating signals in the environment surrounding the cells.
Carcinoma
a new growth or malignant tumor that originates from epithelial cells, the skin, GIT, Lungs, Uterus, breast
and other organs.
Benign usually a reference to growths that are encapsulated, remain localized, and are slow growing
Malignant
- terms for growth that is encapsulated but metastasize and grow. These growths are cancerous lesions
having the characteristics of disorderly, uncontrolled proliferation of the cell
Tumor - Abnormal swelling usually from inflammation, or from morbid enlargement.
- They are uncontrolled tissue growth that in which cell rapidly multiplies
Oncology
- The study of cancer
Staging - a method of classifying malignancies based on the presence and extent of the tumor on the body
Metastasis
- the transfer of disease from one organ or apart to another not directly connected to it.
Undifferentiated cells cells that lost the capacity for specialized functions
Carcinogenesis
Carcinogenesis process of transforming normal cells into malignant cells
Carcinogens
- agents that initiate or promote cellular transformation.
Oncogene
- cancer gene that alters the normal cell
Carcinoma
- usually solid tumors arising from epithelial cell
Sarcoma
- from muscle, bone, fat and other connective tissue
Sarcoma
Lymphoma
- malignant tumors in lymphatic system
Leukemia
- cancer of the blood
Nadir - lowest point of WBC depression after therapy that has toxic effects on the bone marrow
Metastasis
- spread of cancer cells from the primary tumor to distant sites.
Review of Anatomy and Physiology: Cell
Centrioles
- self-replicating organelles made of
o nine
bundles of microtubules and
are found only in animal cells
Cilia and Flagella essential for locomotion (singlecelled). Cilia function to move fluid
or materials past an immobile cell as well as moving
a cell
or group of cells.
Endoplasmic Reticulum a network of sacs
that manufactures processes and transports
chemical compounds for use inside and outside of
the
cell.
Provides a pipeline between the nucleus
and
the
Cytoplasm.
Golgi apparatus The distribution and Shipping
department for the cells
chemical products
Lysozymes
- Main function is digestion. Breaks down cellular waste products and debris from outside the cell into
simple compounds, which are transferred to the cytoplasm as new cell-building materials.
Mitochondria - are oblong shaped. The main power generators, converting oxygen and
nutrients into energy
Nucleus - Serves as the information processing and administrative center of the
cell.
- Stores DNA
- Coordinates cell activities
o Growth
o Intermediary metabolism
o Protein synthesis
o Reproduction (cell division)
Page 119
of
Mitosis
Cell division is an elegant process that enables organisms to grow and reproduce. Through a sequence of steps, the
replicated genetic material in a parent cell is equally distributed to two daughter cells. While there are some subtle
differences, mitosis is remarkably similar across organisms.
Before a dividing cell enters mitosis, it undergoes a period of growth called interphase. Interphase is the "holding" stage or
the stage between two successive cell divisions.
In this stage, the cell replicates its genetic material and organelles in preparation for division.
Mitosis
Prophase
is
composed
of
several
stages:
In prophase, the chromatin condenses into discrete chromosomes. The nuclear envelope breaks down and spindles form at
opposite
"poles"
of
the
cell.
Metaphase
In metaphase, the chromosomes are aligned at the metaphase plate (a plane that is equally distant from the two spindle
poles).
Anaphase
In
anaphase,
the
paired
chromosomes
(sister
chromatids)
move
to
opposite
ends
of
the
cell.
Telophase
In this last stage, the chromosomes are cordoned off in distinct new nuclei in the emerging daughter cells. Cytokinesis is
also
occurring
at
this
time.
At the end of mitosis, two distinct cells with identical genetic material are produced.
Before a dividing cell enters mitosis, it undergoes a period of growth called interphase. Some 90 percent of a cell's time in
the
normal
cellular
cycle
may
be
spent
in
interphase.
Stages of Interphase
G1 phase: The period prior to the synthesis of DNA. In this phase, the cell increases in mass in preparation
for cell division. Note that the G in G1 represents gap and the 1 represents first, so the G1 phase is the first gap
phase.
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G2 phase: The period after DNA synthesis has occurred but prior to the start of prophase. The cell
synthesizes proteins and continues to increase in size. Note that the G in G2 represents gap and the 2 represents
second, so the G2 phase is the second gap phase.
In the latter part of interphase, the cell still has nucleoli present.
The nucleus is bounded by a nuclear envelope and the cell's chromosomes have duplicated but are in the
form of chromatin.
In animal cells, two pair of centrioles formed from the replication of one pair are located outside of the
nucleus.
Pathogenesis of Cancer
Conceptualizes that normal cells may be transformed into cancer cells due to exposure to some
etiologic agents.
Advocates that all individuals possess cancer cells. However, the cancer cells are recognized by the
immune response system. So, the cancer cell undergoes destruction. Failure of the immune response
system leads to inability to destroy the cancer cells.
Page 121
o
o
Dysplasia
Ca of the cervix
Hepatitis B virus
o Liver Ca
Human T cell lymphotropic Virus
o lymphocytic leukemia
o lymphomas
HIV
o Kaposis Sarcoma
Helicobacter pylori (bacteria)
o Gastric Malignancy
B. PHYSICAL AGENTS
a. Exposure to UV rays of the sun
b. Exposure to Ionizing radiation
c. Chronic inflammation or Irritation
d. Tobacco use
C. CHEMICAL AGENTS
- 75 % of all Ca are thought to be related to the environment
- Tobacco smoke single most lethal chemical carcinogen 30% of Ca deaths
- Chemical substances found in workplace (amines, aniline dyes, pesticides and formaldehydes, arsenic,
tars, asbestos, benzene, Cadmiun, Nickel and Zinc ores, PVCs etc.)
- Chemical agents alters DNA structure in body sites distant from chemicalexposure (liver, lungs and
kidneys are most commonly affected)
D. GENETIC & FAMILIAL FACTORS
- genetics, shared environments, cultural or lifestyle factors, chance.
E. DIETARY FACTORS
- Proactive (protective) substances High fiber, cruciferous vegetables, carotenoids,, Vit. E & C, Zinc and
Selenium
- Cacinogenic
Cacinogenic & Co-Carcinogenic substances High fat, Low Fiber, Alcohol, Salt-cured or smoked meats,
foods w/ nitrates & nitrites, High Caloric.
F. HORMONAL AGENTS
- Endogenous vs. Exogenous hormones
- DES (Diethylstilbestrol) vaginal carcinomas
- Oral contraceptives and prolonged estrogen replacement therapy
Predisposing Factors
Age
- Older individuals are more prone to cancer, they have been exposed to carcinogens longer, they may have
developed immune system alteration.
Sex
- Women = more prone to breast, uterus, cervical cancer
Men = more prone to prostate, lung cancer
Residence
- Urban dwellers are more prone to cancer than Rural dwellers.
Geographic distribution
- Japan = cancer of the stomach
- US = cancer of the breast
- Due to influence of environmental factors such as, national diet, ethnic customs, type of pollutions
Occupation
- Chemical factory workers, farmers, radiology department person
Heredity
- Greater risk with positive family history
Stress
- Depression, grief, anger, aggression, despair or life stresses decreases
immunocompetence (affect hypothalamus and pituitary gland)
- immunodeficiency may spur the growth and proliferation of cancer cells
Precancerous lesions
- May undergo transformation into Ca lesions and tumors.
- E.g. pigmented moles, burn scars, senile keratosis, leoukoplakia, benign polyps/adenoma of the colon
or stomach, fibrocystic disease of the breast
Obesity - Studies have linked obesity to breast and colorectal Ca
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Cancer Classification
1. Solid Tumors Associated with the organs from which they develop. Such as breast cancer or lung cancer
2. Hematological Cancer Originate from blood cell-forming tissues, such as the Leukemia sans the Lymphomas
Characteristic
Characteristic of Malignant vs. Benign neoplasm
CHARACTERISTICS
Rate of growth
BENIGN
Usually slow
Mode of growth
Cell characteristics
Metastasis
General effects
Tissue destruction
MALIGNANT
Variable
and
depends
on level
of
differentiation; the more anaplastic the tumor,
the faster its growth
Grows at he periphery and sends out processes
that infiltrate and destroy surrounding tissues
Undifferentiated and often bear little
resemblance to the normal cells of the tissue
from which they arose
Gains access to the blood and lymphatic
channels and metastasizes to other areas of the
body
Often causes generalized effects such as
Anemia, Weakness, and weight loss
Often causes extensive tissue damage as the
tumor outgrows its blood supply or
encroaches on blood flow to the area; may
also produce substances that cause cell damage
Usually causes death unless growth can be
controlled
Staging determines the size of the tumor and the existence of metastasis
TNM system most frequently used system in classifying the extent of disease.
T Extent of Primary Tumor
N Lymph node involvement
M extent of mmetastasis
Primary Tumor (T)
TX Primary tumor cannot be assessed
T0 No evidence of primary tumor
Tis carcinoma in situ
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T1, T2, T3, T4 increasing size and / or local extent of the primary tumor
Regional Lymph Node (N)
NX Regional lymph nodes cannot be assessed
N0 No regional Lymph node metastasis
N1,N2,N3 Increasing involvement of regional lymph nodes
STAGING
Stage 0
Stage I
Stage II
Stage III
Stage IV
Carcinoma in situ
Tumor limited to the tissue of origin; localized tumor growth
Limited local spread
Extensive local and regional spread
Metastasis
Distant Metastasis
Metastasis (M)
MX distant metastasis cannot be assessed
M0 No distant metastasis
M1 Distant metastasis
Cells
Cells
Cells
Cells
seeks to define the type of tissue from which the tumor originated and the degree to which the tumor
cells retain the functional and histologic characteristics of the tissue of origin.
done through Cytology, Biopsy, Surgical Excision.
differ slightly from normal cells and are well differentiated (mild dysplasia)
are more abnormal and are moderately differentiated (moderate dysplasia)
are very abnormal and are poorly differentiated (severe dysplasia)
are immature (anaplasia) and undifferentiated; cell of origin is difficult to determine
Mammography
Papanicolaous (Pap) smear
Stools for occult blood
Sigmoidoscopy: colonoscopy
Breast self-examination
Testicular Self Examination
Skin inspection
DIAGNOSTIC TESTS
TESTS
1. Blood analysis- an unestablished diagnostic test used by some health care
practitioners to determine a course of treatment
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DESCRIPTION
DIAGNOSTIC USES
Analysis of substances found in blood or other Breast, colon, lung, ovarian,
body fluids that are made by the tumor or by testicular, prostate Cancer
the body in response to the tumor.
MRI
Use of magnetic fields and radiofrequency signals Neurologic, pelvic, abdominal,
to create sectioned images of various body thoracic cancers
structures
CT scan
Use of Narrow beam x-ray to scan successive Neurologic, pelvic, skeletal,
layers of tissues for cross-sectional views
abdominal, thoracic cancers
Fluoroscopy
Use of x-rays that identify contrasts in body Abdominal and pelvic cancers
tissue densities; may use contrast agents
Endoscopy
Direct visualization of a body cavity or Bronchial, GI cancer
passageway by insertion of an endoscope into a
body cavity or opening; allowing tissue biopsy,
fluid aspiration and excision of small tumors;
both diagnostic and therapeutic
PET scan
Computed cross-sectional images of increased Lung, colon, liver, pancreas,
concentration of radioisotopes in malignant cells breast,
esophagus
cancer;
provide information about biologic activity of Hodgkins and non-Hodgkins
malignant cells; helps identify if malignant or just lymphoma and Melanoma.
benign
Radioimmunoconjugates
Monoclonal antibodies are labeled with a Colorectal,
breast,
ovarian,
radioisotope and injected intravenously into the head
and
neck
cancers;
patient; antibodies aggregate at the tumor site lymphoma and melanoma
then visualized with scanners
3. Biopsy the definitive means of diagnosing cancer and provides histological proof of malignancy
- involves surgical incision of a small piece of tissue for microscopic examination
marker
Types:
a. Needle
- Aspiration of cells
b. Incisional
- Removal of a wedge of suspected tissue from a larger mass
c. Excisional
- Complete removal of the entire lesion
d. Staging
- Multiple needle or incisional biopsies in tissues where metastasis
is suspected or likely.
***
Instructions
> Obtain an Informed consent
Pathophysiologic Basis of Malignant Neoplasm
Cancer is a disease process that begins when an abnormal cell is transformed by the genetic mutation of the cellular
DNA. This abnormal cell forms a clone and begins to proliferate abnormally, ignoring growth regulating signals in the
environment surrounding the cell. The cells acquire invasive characteristics, and changes occur in surrounding tissues. The
cells infiltrate these tissues and gain access to lymph and blood vessels, which carry the cells to other areas of the body. This
phenomenon is called Metastasis.
Page 125
Cancer is not a single disease with a single cause; rather, it is a group of distinct diseases with different causes,
manifestations, treatments and prognoses.
Proliferative patterns
Hyperplasia
Increase in the number of cells of a tissue; most often associated
with periods of rapid body growth
Metaplasia
conversion of one type of mature cell into another type of cell
Dysplasia
bizarre cell growth resulting in cells that differ in size, shape, or
arrangement from other cells of the same type of tissue.
Anaplasia
cells that lack normal cellular characteristics and differ in shape
and organization with respect to their cells of origin; usually, anaplastic cells are malignant
Neoplasia
Uncontrolled cell growth that follows no physiologic demand.
Carcinogenesis
- a.k.a. Malignant transformation; has three-step cellular process
a. Initiation Carcinogens escape normal enzymatic mechanisms and alter the genetic structure of the cellular DNA
(Permanent cellular mutations)
b. Promotion repeated exposure to co-carcinogens causes the expression of abnormal or mutant genetic
information even after long latency periods.
Cellular oncogenes responsible for the vital cellular functions of growth and
differentiation.
Cellular ProtoProto-oncogenes acts as an ON switch for cellular growth.
Cancer Suppressor genes turn OFF or regulate unneeded cellular proliferation
- when mutated, rearranged, amplified, or lose their regulatory
capabilities, malignant cells reproduce.
P53 gene
- tumor suppressor gene that is frequently mutated in many human
cancers.
- regulates whether cells will repair or die after DNA damage.
c. Progression Cellular changes exhibit increased malignant behavior.
- cells shows propensity to invade adjacent tissues and to
metastasize.
Cellular Aberration
1. Ca Cell Proliferation disrupts normal cell growth and interfere with tissue function
Manifestation:
- Pressure
- Obstruction
- Pain
- Effusion
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Ulceration
Vascular Thrombosis, Embolus, Thrombophlebitis
Approaches:
a.
!
!
!
!
!
TYPES:
Salvage Surgery uses an extensive surgical approach to treat the local recurrence of the cancer after a less
extensive primary approach is used. E.g. mastectomy to treat recurrent breast Ca after primary lumpectomy and
radiation
Electrosurgery makes use of electrical current to destroy the tumor cells
Cryosurgery uses liquid nitrogen to freeze tissue to cause cell destruction
Chemosurgery uses combined topical chemotherapy and layer-by-layer surgical removal of abnormal tissue
Laser surgery makes use of light and energy aimed at an exact tissue location and depth to vaporize cancer cells
Stereotactic Radiosurcegy (SRS) single and highly precise administration of high dose radiation therapy used in
some types of brain and head and neck cancers.
a.
Prophylactic Sx performed in clients with an existing premalignant condition or a known family history that
strongly predisposes the person to the development of cancer
- an attempt is made to remove the tissue or organ at risk and thus prevent the development of cancer
b. Curative Sx all gross and microscopic tumor is removed or destroyed
c. Control (Cytoreductive) Sx a debulking procedure that consist of removing part of the tumor
- Sx decreases the number of cancer cells and increases the chance that other therapies will be successful
d. Palliative Sx performed to improve quality of life during the survival time.
- to reduce pain, relieve airway obstruction, relieve obstructions in
the GI or Urinary tract, relieve pressure on the brain or spinal cord, prevent hemorrhage, remove infected or ulcerated
tumors, or drain abscesses.
e. Reconstructive / Rehabilitative Sx performed to improve quality of life by restoring maximal function and
appearance suh as breast reconstruction after Mastectomy
Side Effects:
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1.
2.
3.
4.
Nursing Management:
!
!
!
!
!
!
Side Effects:
!
!
!
!
destroys cancer cells with minimal exposure of normal cells to the damaging effects of radiation. The
cells damaged die or become unable to divide
effective on tissues directly within the path of the radiation beam.
Types:
Page 128
client does not emit radiation and does not pose a hazard to anyone else
wash area with mild soap and water using hand rather than washcloth
rinse thoroughly and pat dry
do not remove radiation markings from the skin
no powders, ointments, lotions or creams on the areas unless prescribed
avoid sun and heat exposure
monitor for moist desquamation (weeping of the skin)
if moist desquamation occurs, cleanse the area with warm water ad pat dry, apply antibiotic ointment
as prescribed.
Client education:
b. Internal (Brachytherapy) radiation source comes in direct, continuous contact with tumor tissues for a specific time
- radiation source is within the client, for a period of time, client emits radiation and can pose hazard to
everybody
- Sealed vs. Unsealed source
- Unsealed -via ORAL, IV or instillation to body cavities
- eliminated in various excreta which are radioactive and harmful to others
- Sealed
- solid, temporary or permanent, is implanted within the
tumor target tissues
- client emits radiation while the implant is in place, but the excreta are not radioactive
C. CHEMOTHERAPY
Chemotherapy,
Chemotherapy in its most general sense, refers to treatment of disease by chemicals that kill cells, specifically those of
micro-organisms or cancer. In popular usage, it will usually refer to antineoplastic drugs used to treat cancer or the
combination of these drugs into a standardized treatment regimen.
In its non-oncological use, the term may also refer to antibiotics (antibacterial chemotherapy). In that sense, the first
modern chemotherapeutic agent was Paul Ehrlich's arsphenamine, an arsenic compound discovered in 1909 and used to
treat syphilis. This was later followed by sulfonamides discovered by Domagk and penicillin discovered by Alexander
Fleming.
Other uses of cytostatic chemotherapy agents (including the ones mentioned below) are the treatment of autoimmune
diseases such as multiple sclerosis and rheumatoid arthritis and the suppression of transplant rejections
Objectives:
-
To destroy all malignant tumor cells without excessive destruction of normal cells
To control tumor growth if cure is no longer possible
Used as adjuvant therapy
Contraindications:
Infection. The anti-tumor drugs are immunosuppresives
Recent surgery. The drugs may retard healing process
Impaired renal / hepat
hepatic
ic function. The drugs are nephrotoxic & hepatotoxic
Recent Radiation Therapy. Also immunisuppresive
Pregnancy. The drugs may cause congenital defects
Page 129
Bone Marrow Depression. The drugs may aggravate the condition. The WBC level must be within normal
limits.
AntiNeoplastic Medications
- Kills or inhibit the reproduction of neoplastic cells
- Normal cells are also affected
- Cell cycle phase specific medications
o Affects cells only during a certain phase of the reproductive cycle
- Cell cycle phase nonnon-specific medications
medications
o Affects cells in any phase of the reproductive cycle
- Can use combination medications or with other treatment modalities
Side Effects:
1. G.I. System Nausea & Vomiting, Diarrhea, constipation, anorexia
2. Integumentary System
a. Pruritus, urticaria & systemic signs
b. Stomatitis
c. Alopecia
d. Skin pigmentation
e. Nail changes
3. Hematopoetic system
a. Anemia
b. Neutropenia
c. Thrombocytopenia
4. Genito Urinary system
a. Hemorrhagic cystitis
b. Urine color changes
5. Others
a. Pain
b. Malnutrition
c. Memory loss
d. Weight loss or gain
e. Hemorrhage
f. Secondary neoplasms
g. Cardiotoxicity
h. Hepatotoxicity
i. Nephrotoxicity
j. Ototoxicity
k. tumor lysis syndrome
l. post-chemotherapy cognitive impairment("chemo brain")
m. Infertility
Interventions:
-
Page 130
Classifications
Classification
I. ALKYLATING MEDS
Cell cycle
nonspecific
II.ANTI-TUMOR
ANTIBIOTICS
Cell cycle
nonspecific
III. ANTIMETABOLITES
V. HORMONAL MEDS /
ENZYMES
VI. OTHERS
Side effects
Gonadal
Suppression,
Hemorrhagic
cystitis,
Alopecia,
Hematuria
Examples
Nitrogen Mustards Cyclophosphamide (Cytoxan)
Ifosfamide(Ifex)
Nitrosoureas
Streptozocin(Zanosar)
Carmustine(BiCNU)
Alkylating-like
Cisplatine(Platinol)
Thiotepa
(Thioplex)
Bleomycin
Sulfate(Blenoxane)
Daunorubicin
(Cerubidine)
Doxorubicin(Adriamycin)
Plicamycin(Mithracin) Dactinomycin(Actinomycin
D)
Bone
Marrow
depression,
Gonadal
Suppression,
Vesication
Cell cycle Bone
marrow 5-Fluouracil (Adrucil)
6specific (S suppression,
Mercapturine(Purinethol) Methotrexate (Folex)
Phase)
stomatitis,
photosensitivity,
hepatotoxicity
Cell cycle Neurotoxicity,
Vincristine Sulfate(Oncovin) Teniposide(Vamon)
specific (M Leukopenia, Ptosis,
Phase)
Constipation,
Peripheral
Neuropathy
Slows
Leukopenia,
ESTROGEN:Diethylstilbestrol ANTI-ESTROGEN:
growth
gynecomastia, hot Tamoxifen citrate ANDROGENS:Testosterone
rate
of flashes,
sex ANTI-ANDROGENS:Flutamide
tumors
characteristic
PROGESTINS:Medroxyprogesterone(Depoalterations
provera) OTHERS: Asparginase,Mitotane
Immunomodulator agents = Interleukins / Interferon
Colony-stimulating factors = Erythropoietin (Epogen)
CANCER TYPES
BREAST CANCER
Invasive when it penetrates the tissue surrounding the mammary duct &
grows in an irregular patter
Metastasis
Precipitating factors:
1. family History
2. Early menarche / late menopause
3. Previous Ca of Breast, Uterus or ovaries
4. Nulliparity
5. Obesity
Page 131
Monitor v/s
positioning - (Semifowlers ,Back to unaffected side, affected arm elevated above the level of the heart)
Deep breathing and coughing exercise
Monitor operative site for infection/swelling/drainage
No IV, Injection, BP taking, venipuctures in affected arm
diuretics & low salt diet
CERVICAL CANCER
- Pre invasive Ca (Cervical intraepithelial neoplasia)
o I Mild dysplasia
o II Moderate dysplasia
o III severe dysplasia to carcinoma in situ
-
Precipitating factors:
- low social economic groups
- early first marriage
- early & frequent intercourse
- multiple sex partners
- high parity
- poor hygiene
Assessment:
-
Page 132
Diagnosis:
-
Management:
NON-SURGICAL
SURGICAL
-Chemotherapy
- Conization
- Hysterectomy
- External radiation
- Pelvic exenteration
- Internal radiation implants (intracavitary)
- laser therapy
- cryosurgery
OVARIAN CANCER
- Grows rapidly / spreads fast / often bilateral
- Prognosis usually is poor (tumor detected late)
Assessment:
-
Diagnosis:
-
Intervention:
1. External Radiation
2. Chemotherapy (Post-op / for all stages)
3. Intraperitoneal Chemotherapy (abdominal Cavity)
4. Immunotherapy
5. TAHBSO
HODGKINS DISEASE
- (Lymphoma) malignancy of the lymph nodes
- Metastasis to other lymph nodes and eventually nonlymphoid tissues
- Usually affects lymph nodes, spleen and bone marrow
- Distinguishing sign : ReedReed-sternberg cell
Etiology:
- viral infection
- previous exposure to alkylating chemical agents
Assessment:
-
Fever
Malaise, fatigue, weakness
Night sweats
Loss of appetite and significant wt. loss
Enlarged lymph nodes, spleen & liver
Anemia & thrombocytopenia
Page 133
Diagnosis:
-
Blood tests (elevated serum protein, thrombocytopenia, granulocytopenia, elevated uric acid & calcium levels)
Urine exams (presence of Bence-Jones protein)
Intervention:
1. Chemotherapy
2. Supportive care (to control symptoms & prevent complications)
3. Maintain Neutropenic & Bleeding precautions
4. Fluids 3-4 L/day
5. Monitor for signs of Renal Failure
6. Encourage ambulation
7. IV Fluids & diuretics, blood transfusion, analgesics, antibiotics as prescribed
LEUKEMIA
- Leukemia or leukaemia (Greek leukos , "white"; aima , "blood") is a cancer of the blood or bone marrow
and is characterized by an abnormal proliferation (production by multiplication) of blood cells, usually white blood cells
(leukocytes). Leukemia is clinically and pathologically subdivided into several large groups. The first division is between its
acute and chronic forms:
Acute leukemia is characterized by the rapid increase of immature blood cells. This crowding makes the bone
marrow unable to produce healthy blood cells. Acute forms of leukemia can occur in children and young adults. (In
Page 134
fact, it is a more common cause of death for children in the US than any other type of malignant disease).
Immediate treatment is required in acute leukemias due to the rapid progression and accumulation of the malignant
cells, which then spill over into the bloodstream and spread to other organs of the body. Central nervous system
(CNS) involvement is uncommon, although the disease can occasionally cause cranial nerve palsies.
Chronic leukemia is distinguished by the excessive build up of relatively mature, but still abnormal, blood cells.
Typically taking months or years to progress, the cells are produced at a much higher rate than normal cells,
resulting in many abnormal white blood cells in the blood. Chronic leukemia mostly occurs in older people, but
can theoretically occur in any age group. Whereas acute leukemia must be treated immediately, chronic forms are
sometimes monitored for some time before treatment to ensure maximum effectiveness of therapy.
Acute
Lymphocytic
(or "lymphoblastic")
Chronic
Myelogenous
leukemia Acute myelogenous leukemia (AML)
Onset:>50 y.o.
(also "myeloid" or "nonlymphocytic") Onset: 15-39 y.o.
(mostly granulocytes)
Cause:
- Unknown
- Gene damage of cells(suspect)
Risk Factors:
- Genetic
- Viral
- Environmental
- Immunological
- Exposure to Radiation, Chemicals, Medications
Signs / Symptoms:
-
people with leukemia may become bruised, bleed excessively, or develop pinprick bleeds (petechiae).
Immunosuppression
anemia
dyspnea.
Diarrhea
Paleness
Malaise
Diagnosis
Page 135
Diagnosis requires blood tests to look for an abnormal number of white blood cells, and a bone marrow examination
to look for abnormal numbers or forms of cells in the bone marrow.
Management:
- Induction chemotherapy to bring about bone marrow remission.
- Consolidation therapy to eliminate any remaining leukemia cells.
- CNS prophylaxis (preventive therapy) to stop the cancer from spreading to the brain and nervous system.
- Maintenance treatments with chemotherapeutic drugs to prevent disease recurrence once remission has been
achieved.
- Alternatively, allogeneic bone marrow transplantation may be appropriate for high-risk or relapsed
patients.
- Single agent chemotherapy
- Combination Chemotherapy
- Protective isolation
- Bleeding precaution
- Monitor v/s & lab values
- Nutrition
- Radiation Therapy
LIVER CANCER
- Associated with Chronic liver disease / Hepa-B/ Hepa-C / Cirrhosis
Risk Factors:
- Cigarette Smoking
- Alcohol Use
Metastasis:
- Portal Circulation
- Lymphatic changes
- Direct extension
Signs / Symptoms:
- Pain (RUQ/ Epigastrium/ Bask)
- Wt. Loss / Anorexia
- Loss of strength
- Anemia
- Enlarged liver
- Ascites
- Jaundice
Diagnosis:
- Lab Exams
- Increased serum levels of Alpha FetoProtein (AFP)
- X-rays
- Liver scans
- CT Scan
- UTZ
- MRI
- Arteriography
- Laparoscopy
- PET Scans
- BIOPSY
Management:
NON-SURGICAL:
SURGICAL:
- Radiation Therapy
- Hepatic Resection
- Chemotherapy
- Lobectomy
- Immunotherapy
- Cryosurgery
- Percutaneous Billiary Drainage
- Liver Transplantation
Page 136
Laser Hyperthermia
LUNG CANCER
- Can be Primary or Metastatic
- Bronchogenic Carcinoma spreads thru direct extension & lymphatic dissemination
4 major types:
1. Small Cell (Oat cell)
2. Epidermal (Squamous cell)
3. Adenocarcinoma
4. Large cell anaplstic carcinoma
Diagnosis:
- CXR
- Bronchoscopy
- Sputum Studies
Causes:
- Cigarette smoking
- Exposure to Environmental pollutants
- Exposure to Occupational pollutants
Signs / Symptoms:
- Cough
- Dyspnea
- Hoarseness
- Hemoptysis
- Chest pain
- Anorexia / Wt. loss
- Weakness
Interventions:
- Monitor v/s
- Position : High Fowlers position
- Assess for tracheal deviation
- Oxygen with humidifier
- Pulse oximeter
- Meds: Analgesics, Bronchodilators, corticosteroids
- Nutrition: High calorie, protein, vitamins
NON-SURGICAL
SURGICAL
- Radiation therapy
- Laser Therapy
- Chemotherapy
- Thoracentesis / Pleurodesis
- Immunotherapy
- Thoracotomy with pneumonectomy
o Thoracotomy with lobectomy
o Thoracotomy with segmental resection
PROSTATE CANCER
- SLOW GROWING
- Usually androgen dependent type of adenocarcinoma
- Risk = increases in men each decade after 50 y/o
- Metastasis= direct invasion, bloodstream & lymphatics, to bone (a concern)
Diagnosis:
- DRE
- PSAT
- Confirmed if with increased in Serum acid phosphatase
Signs/Symptoms:
- Early stage = asymptomatic
- Hard, peas sized nodule
- Hematuria
- Urinary obstruction
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Intervention:
NON-SURGICAL
SURGICAL
- Hormone manipulation therapy
- orchiectomy(palliative)
- Radiation Therapy
= decreased testosterone
- Chemotherapy (Hormone resistant tumors) - TURP
o Prostatectomy
o Cryosurgical Ablation
BRAIN TUMOR
- LOCALIZED / INTRACRANIAL LESION
- Effects are due to compression & infiltration of tissues
- Primary vs. secondary
o Primary = Originated from cells & structures within the brain
o Secondary = Metastatic / develops from structures outside the brain
Cause:
- Unknown
Risk Factor:
- Exposure to ionizing radiation
- Greater in men than in women
Signs / Sypmtoms:
1. Increased ICP / Cerebral Edema
2. Seizure activity / focal neurologic signs
3. Hydrocephalus
4. Altered pituitary function
Classification:
I.
INTRACEREBRAL TUMORS
a. GLIOMAS infiltrate any portion of the brain; most common type of brain tumors
i. ASTROCYTOMAS
ii. GLIOBLASTOMA MULTIFORME
iii. OLIGODENDROCYTOMA
iv. EPENDYMOMA
v. MEDULLOBLASTOMA
II.
ARISING FROM SUPPORTING STRUCTURES
a. Meningiomas
b. Neuromas
c. Pituitary Adenomas
III.
DEVELOPMENTAL TUMORS
a. Angiomas
b. Dermoid, Epidermoid, Teroma, craniopharyngioma
IV.
METASTATIC LESIONS
Diagnosis:
- CT SCAN
- MRI
- PET scan
- EEG
- Cytologic Studies
Management:
NON-SURGICAL
- Chemotherapy
- Radiation therapy
SURGICAL
- craniotomy
- Laser / Radiotion (Iodine 131)
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- Gamma Knife
Brachytherapy
Corticosteroids
Photodynamic therapy33699
MUSCULOSKELETAL SYSTEM
The musculo-skeletal system consists of the muscles, tendons, bones and cartilage together with the joints
The primary function of which is to produce skeletal movements
Three types of muscles exist in the body
1. Skeletal Muscles
Voluntary and striated
2. Cardiac muscles
Involuntary and striated
3. Smooth/Visceral muscles
Involuntary and NON-striated
Tendons: Bands of fibrous connective tissue that tie bones to muscles
Ligaments: Strong, dense and flexible bands of fibrous tissue connecting bones to another bone
Bones: Variously classified according to shape, location and size
Functions
1. Locomotion
2. Protection
3. Support and lever
4. Blood production
5. Mineral deposition
Joints: The part of the Skeleton where two or more bones are connected
Cartilages: A dense connective tissue that consists of fibers embedded in a strong gel-like substance
Bursae: Sac containing fluid that are located around the joints to prevent friction
1. BONE MARROW ASPIRATION
Usually involves aspiration of the marrow to diagnose diseases like leukemia, aplastic anemia
2. Arthroscopy
A direct visualization of the joint cavity
Pre-test: consent, explanation of procedure, NPO
Intra-test: Sedative, Anesthesia, incision will be made
Post-test: maintain dressing, ambulation as soon as awake, mild soreness of joint for 2 days, joint rest for a few days, ice
application to relieve discomfort
BONE SCAN
Imaging study with the use of a contrast radioactive material
Pre-test: Painless procedure, IV radioisotope is used, no special preparation, pregnancy is contraindicated
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Intra-test: IV injection, Waiting period of 2 hours before X-ray, Fluids allowed, Supine position for scanning
Post-test: Increase fluid intake to flush out radioactive material
DXA- Dual-energy XRAY absorptiometry
Assesses bone density to diagnose osteoporosis
Uses LOW dose radiation to measure bone density. Painless procedure, non-invasive, no special preparation. Advise to
remove jewelry
PAIN
These can be related to joint inflammation, traction, surgical intervention
1. Assess patients perception of pain
2. Instruct patient alternative pain management like meditation, heat and cold application, TENS and guided imagery
3. Administer analgesics as prescribed
Usually NSAIDS
Meperidine can be given for severe pain
4. Assess the effectiveness of pain measures
IMPAIRED PHYSICAL MOBILITY
1. Instruct patient to perform range of motion exercises, either passive or active
2. Provide support in ambulation with assistive devices
3. Turn and change position every 2 hours
4. Encourage mobility for a short period and provide positive reinforcements for small accomplishments
SELF-CARE DEFICITS
1. Assess functional levels of the patient
2. Provide support for feeding problems
Place patient in Fowlers position
Provide assistive device and supervise mealtime
Offer finger foods that can be handled by patient
Keep suction equipment ready
3. Assist patient with difficulty bathing and hygiene
Assist with bath only when patient has difficulty
Provide ample time for patient to finish activity
Traction
A method of fracture immobilization by applying equipments to align bone fragments
Used for immobilization, bone alignment and relief of muscle spasm
Skin traction- Buck, Bryant
Skeletal traction
Balanced Suspension traction
Running/Straight traction
Pulling force exerted on bones to reduce or immobilize fractures, reduce muscle spasm, correct or prevent deformities
TO decrease muscle spasms
TO reduce, align and immobilize fractures
To correct deformities
Traction: General principles
1. ALWAYS ensure that the weights hang freely and do not touch the floor
2. NEVER remove the weights
3. Maintain proper body alignment
4. Ensure that the pulleys and ropes are properly functioning and fastened by tying square knot
Traction: General principles
5. Observe and prevent foot drop
Provide foot plate
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CAST: types
Long arm, Short arm, Short leg, Long leg, Spica , Body cast
Plaster of Paris
Drying takes 1-3 days
If dry, it is SHINY, WHITE, hard and resistant
Fiberglass
Lightweight and dries in 20-30 minutes
Water resistant
Cast Application:
1. TO immobilize a body part in a specific position
2. TO exert uniform compression to the tissue
3. TO provide early mobilization of UNAFFECTED body part
4. TO correct deformities
5. TO stabilize and support unstable joints
CAST: General Nursing Care
1. Allow the cast to air dry (usually 24-72 hours)
2. Handle a wet cast with the PALMS not the fingertips
3. Keep the casted extremity ELEVATED using a pillow
4. Turn the extremity for equal drying. DO NOT USE DRYER for plaster cast
Encourage mobility and range of motion exercises
5. Petal the edges of the cast to prevent crumbling of the edges
6. Examine the skin for pressure areas and Regularly check the pulses and skin
7. Instruct the patient not to place sticks or small objects inside the cast
8. Monitor for the following: pain, swelling, discoloration, coolness, tingling or lack of sensation and diminished pulses
CAST: General Nursing Care
Hot spots occurring along the cast may indicate infection under the cast
Osteoporosis
A disease of the bone characterized by a decrease in the bone mass and density with a change in bone structure
Normal homeostatic bone turnover is altered rate of bone RESORPTION is greater than bone FORMATION reduction in
total bone mass reduction in bone mineral density prone to FRACTURE
Osteoporosis: TYPES
1. Primary Osteoporosis- advanced age, post-menopausal
2. Secondary osteoporosis- Steroid overuse, Renal failure
RISK factors for the development of Osteoporosis
1. Sedentary lifestyle
2. Age
3. Diet- caffeine, alcohol, low Ca and Vit D
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4. Post-menopausal
5. Genetics- caucasian and asian
6. Immobility
ASSESSMENT FINDINGS
1. Low stature
2. Fracture Femur
3. Bone pain
LABORATORY FINDINGS
1. DEXA-scan
Provides information about bone mineral density
2. X-ray studies
Medical management of Osteoporosis
1. Diet therapy with calcium and Vitamin D
2. Hormone replacement therapy
3. Biphosphonates- Alendronate, risedronate produce increased bone mass by inhibiting the OSTEOCLAST
4. Moderate weight bearing exercises
5. Management of fractures
Osteoporosis Nursing Interventions
1. Promote understanding of osteoporosis and the treatment regimen
Provide adequate dietary supplement of calcium and vitamin D
Instruct to employ a regular program of moderate exercises and physical activity
Manage the constipating side-effect of calcium supplements
Take calcium supplements with meals
Take alendronate with an EMPTY stomach with water
Instruct on intake of Hormonal replacement
2. Relieve the pain: Instruct the patient to rest on a firm mattress. Suggest that knee flexion will cause relaxation of back
muscles. Heat application may provide comfort. Encourage good posture and body mechanics .Instruct to avoid twisting
and heavy lifting
3. Improve bowel elimination. Constipation is a problem of calcium supplements and immobility. Advise intake of HIGH
fiber diet and increased fluids
4. Prevent injury. Instruct to use isometric exercise to strengthen the trunk muscles. AVOID sudden jarring, bending and
strenuous lifting. Provide a safe environment
Juvenile Rheumatoid Arthritis: Definition: AUTO-IMMUNE inflammatory joint disorder of UNKNOWN cause. SYSTEMIC
chronic disorder of connective tissue
Diagnosed BEFORE age 16 years old PATHOPHYSIOLOGY : unknown Affected by stress, climate and genetics. Common in
girls 2-5 and 9-12 y.o.
Systemic JRA: fever, salmon pink rash, five or more joints, anorexia, anemia, and fatigue.
Pauci-articular: Mild joint pain and swelling, iridocyclyitis, less than 4 joints, very good prognosis
POlyarthritis: Moming joint and stiffness and fever. Weight bearing joints, five or more joints, poor prognosis
JRA: Symptoms may decrease as child enters adulthood. With periods of remissions and exacerbation.
Medical Management: Aspirin and NSAIDS - mainstay treatment; slow acting anti rheumatic drugs, corticosteroids
Nsg Management: Encourage normal performance of ADL; Assist child in ROM exercises; Administer Medications;
encourage social and emotional development.
Nsg Management: during acute attact: splint the joints. Neutral positioning, Warm or cold packs.
Osteoarthritis: the most common form of degenerative joint disorder
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Osteoarthritis: Patho: Injury, genetic, obesity, advanced age--> stimulate the chondrocytes to release chemicals-> chemicals
will cause cartilage degeneration reactive inflammation of the synovial lining and bone stiffening
Risk factors: Increased age, obesity, repetitive use of joints with previous joint damage, anatomical deformity, genetic
susceptibility
Assessment Findings: joint pain, joint stiffness, functional joint impairment limitation. The joint involvement is assymetrical.
This is not systemic, there is no fever, no severe swelling. Atrophy of unused muscles. Usual joint are the weight bearing
joints.
Joint Pain: caused by inflamed cartilage and synovium, stretching of the joint capsule. irritation of nerve endings.
Stiffness. Commonly occurs in the morning after awakening. Lasts only for less than 30 minutes. Decreases with movement,
but worsens after increased weight bearing activity. Crepitation may be elicited.
Dx Findings: 1. X-ray: narrowing of the joint space, loss of cartilage, osteophytes. 2. Blood tests will show no evidence of
systemic inflammation and are not useful.
Medical Management: 1. Weight reduction. 2. Use of splinting devices to support joints. 3. Occupational and physical
therapy. 4. Pharmacologic management: use of paracetamol, nsaids, use of glucosamine and chondroitin; topical analgesics,
intra-articular to decrease inflammation
Nsg Intervention: 1. Provide relief of Pain: Administer prescribed analgesics; Application of heat modalities. ICE packs may
be used in the early acute stage. Plan daily activitites when pain is less severe. Pain meds before exercising. 2. Advise pt to
reduce weight: aerobic exercise and walking. 3. Administer prescribed meds: NSAIDS. 4. Position the client to prevent
flexion deformity: Use of foot board, splints, wedges, and pillows.
Rheumatoid Arthritis: A type of chronic systemic inflammatory arthritis and connective tissue disorder affecting more
women ages 35-45 than men.
Factors: Genetics: autoimmune connective tissue disorders. Fatigue, emotional stress, cold, infection.
Patho: Immune reaction in the synovium-- attracts neutrophils -- releases enzymes -- breakdown of collagen -- irritates the
synovial lining -- causing synovial inflammation edema and pannus formation and joint erosions and swelling.
Assessment: Pain; Joint Swelling and stiffness: symmetrical, bilateral; Warthm, erythema and lack of function; Fever, weight
loss, anemia, fatigue; Palpation of joint reveals spongy tissues; hesitancy in joint movement.
Assessment Findings: Joint involvement is symmetrical and bilateral: characteristically beginning in the hands, wrists, and
feet. Joint stiffness occurs early morning last more than 30 minutes, not relieved by movement, dimishes as the day
progresses. Joints are swollen and warm. Painful when moved. Deformities are common in the hands and feet causing
misalignment. Rheumatoid nodules may be found in the subcutaneous tissues.
Dx test: 1. xray shows bony erosion. Blood studies reveal positive rheumatoid factor, elevated ESR and CRP and anti
nuclear antibody. Arthrocentesis shows synovial joint that is cloudy, milky, or dark yellow containing numerous WBC and
inflammatory proteins.
Medical ManagementL: Therapeutic dose of NSAIDS and Aspirin to reduce inflammation. Chemotherapy with
methotrexate, antimalarials, gold therapy, and steroids. For advanced cases - arthroplasty, synovectomy. Nutritional
therapy.
Gold therapy: IM or Oral preparation. takes severals months 3-6 months before effects can be seen. Can damage the
kidney and causes bone marrow depression.
Nsg Management:
1.
Relieve pain and discomfort: use splints to immobilize the affected extremity during acute stage of the disease and
inflammation to reduce deformity. Administer prescribed medications. Suggest application of Cold packs during the
acute phase of pain, then Heat application as the inflammation subsides.
2. Decrease patient fatigue: schedule activity when pain is less severe, provide adequate periods of rests.
3. Promote restorative sleep.
4. Increase pt mobility: advise proper posture and body mechanics. support joint in function position. advise Active
ROM.
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5.
Provide Diet therapy: pts experiences anorexia, nausea and weight loss. Regular diet with caloric restrictions
because steroids may decrease appetite. Supplements of vitamins, iron, and proteins.
6. Increase Mobility and prevent deformity: lie flat on a firm mattress. Lie prone several times to prevent HIp flexion
contractures. Use on pillow under the head because of risk of dorsal kyphosis. No pillow under the joints because
this promotes flexion contractures.
Hot application: use to relieve joint stiffness, pain and muscle spasm. after acute attacks.
COld: use to control inflammation and pain. Acute attacks.
RA: onset is early, chronic systemic disease, involves the synovium, involved joints are symmetrical-fingers, cervical spine;
malaise, fever, anemia.
OA: onset is late. degenerative disease. involves the cartilages. involved joints are unilateral-weight bearing knee, hips,
spine. no other systemic s/sx
Gouty arthritis: A systemic disease caused by deposition of uric acid crystals in the joint and body tissues. Causes: 1. primary
gout: disorder of purine metabolis. 2. Secondary gout: excessive uric acid in the blood like leukemia.
Assessment" Fever low grade occasionaly. Pain on the knees, fingers, ankles, toes. Joints stiff and deformed, and tender to
touch. SKIN appears red, shiny, swollen and hot skin over affected joints. Tophi deposits - urate leaking (advanced) Other:
racing heart, chills, malaise, and tendon inflammation.
Assessment: 1. Severe pain in the involved joints initially the big toel. 2. Swelling and inflammation of the joint. 3. TOPHI yellowish-whitish irregular deposits in the skin that break open and reveal a gritty appearance. 4. PODAGRA- a big toe. 5.
Fever, malaise. 6. Body weakness and headache. 7. Renal stones.
Dx tests: Elevated levels of uric acid in the blood. Uric acid stones in the kidneys. Positive urate crystals in the synovial fluid.
Medical Management: 1. Allupurinol - take it with food. Rash signifies allergic reaction. 2. Colchicine: for acute attack. 3.
Probenecid: for uric acid excretion in the kidney.
Nsg Intervention. 1. Provide a diet with Low Purine: avoid organ meats, age and processed foods. Strict dietary restrictions
is not necessary. 2. Encourage an increased fluid intake (2-3L/day) to prevent stone formation. 3. Instruct the pt to avoid
alcohol. 4. Provide alkaline ash diet to increase urinary pH. 5. Provide bed rest during early attack of gout. 6. Position the
affected extremity in mild flexion. 7. Administer anti gouty meds and analgesics.
Fracture: a break in the continuity of the bone and is defined according to its type and extent.
Severe mechanical stress to bone - - bone fracture. Direct blows. crushing forces. sudden twisting motion. extreme muscle
contraction.
Types: 1. Complete: involves a break across the entire cross section. 2. Incomplete fracture: the break occurs through only a
part of the cross-section.
1. Comminuted: a fracture that involves production of several bone fragments. 2. Simple fracture: a fracture that involves
break of bone into two parts or one.
Assessment: Pain or tenderness over the involved area, loss of function, deformity, shortening, crepitus, swelling, and
discoloration.
PAIN: continuous and increases in severity. Muscle spasm accompanies the fracture is a reaction of the body to immobilize
the fractured bone. 2. Loss of function: abnormal movement and pain can result to this manifestation. 3. Deformity:
displacement, angulation or rotation of fragments causes deformity. 4. Crepitus: a grating sensation produced when the
bone fragments rub each other.
Emergency Management of Fracture: 1. Immobilize any suspected fracture. 2. Support the extremity above and below
when moving the affected part from a vehicle. 3. Suggested temporary splints: hard board, stick, rolled sheets. 4. Apply
sling if forearm fracture is suspected or the suspected fractured arm maybe bandaged to the chest. 5. Open fracture is
managed by covering a clean / sterile gauze to prevent contamination. 6. Do not attempt to reduce the fracture. \
Medical Management: 1. Reduction of fracture either open or closed, immobilization and Restoration of function. 2.
Antibiotics, muscle relaxants and pain medications.
For Closed Fracture: 1. Assist in reduction and immobilization. 2. Administer pain medication and muscle relaxants. 3.
Teach patient to care for the cast. 4. Teach pt about potential complication of fracture and to report infection, poor
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In 1867-1948, Agnes Hunt, referred to as the Florence of Nightingale of Orthopedic Center in Great Britain.
The efforts of Sir Robert Jones and the massive casualties of World War I led to the founding of many orthopedic
training centers in the early 20th century.
In 1840, William Little established the Royal Orthopedic Infirmary in Great Britain.
In 1857, Anthonius Methyson of Holland described the plaster bandage.
In 1866, the New York Orthopedic Dispensary was formed.
A vastly increased knowledge of muscular functions and of the growth and development of bone was gained in the
19th century. Significant advances at this time were the new operation of tenotomy (the cutting of tendons, which made
correcting deformities easier), the surgical correction of clubfoot, the invention of the Thomas splint (which provided better
support for fractures of long bones in the limbs), and the introduction of quick-setting plaster of Paris for use in orthopedic
bandages.
Modern orthopedics has extended beyond the treatment of fractures, broken bones, strained muscles, torn
ligaments and tendons, and other traumatic injuries to deal with a wide range of acquired and congenital skeletal
deformities and with the effects of degenerative diseases such as osteoarthritis. A specialty that originally depended on the
use of heavy braces and splints, orthopedics now utilizes bone grafts and artificial plastic joints for the hip and other bones
damaged by disease, as well artificial limbs special footwear, and braces to return mobility to disabled patients. Orthopedics
uses the techniques of physical medicine and rehabilitation and occupational therapy in addition to those of traditional
medicine and surgery.
History of the Philippine Orthopedic Center
POC started in February 9, 1945 by PCAU General Hospital. The US Army established the hospital in
Mandaluyong, Rizal. It was then called as Mandaluyong Emergency Hospital. Its main purpose is to help take care of the
civilian casualties of war. But its function was not only as emergency basis seeing not only victims of wars but also all cases.
In May 1945, the hospital was turned over to the Phil. Government. In August 1945, the Bureau of Health took
over and only fracture cases and bone joint condition remained.
The hospital kept functioning during those difficult years and it is attributed to the skill, ingenuity, dedication and
foresight of the staff lead by Dr. Jose V. delos Santos.
The hospital finally transferred to its present site in Quezon City.
Review of Structure and Function of the MusculoMusculo-skeletal System
I The Bones
A. The human skeleton consist of two main division:
1. Axial body upright structure
a) Skull
b) vertebral column
2. Appendicular the body appendages
a) Arms
b) hips
c) ribs
c) legs
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c.
Muscles can be long and tapered, short and blunt, triangular, quadrilateral or irregular.
Muscle fiber arrangement varies
1. In some muscles, the fiber runs parallel to the muscles long axis
2. In others, the fibers are oblique and bipennate like the feather of a quill pin
3. Fibers curve cut from a narrow attachment at the muscles and to form a triangle
Main functions
1. Prime mover directly brings about a desired motion
2. Antagonist muscles that directly opposes the movement under consideration
3. Fixation generally stabilizes a joint or its part thereby maintaining position while prime mover acts
V Joints
3 Basic Joint Types
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1.
Fibrous composed of fibrous tissue, tightly, connecting the articular surfaces of two bones
2 types
a) sutures permits no movement
b) syndesmosis permits minimal movement between bones
2. Cartilagenous joints connect two bones with cartilage, allowing only slight movement.
3. Synovial joints, the most common joint type, have the most complex structure and permit maximum mobility.
These joints include the following
a) joint capsule
b) synovial membrane
c)
articular cartilage
d) synovial cavity
FRACTURES
A. Fracture is a break in the continuity of the bone. In adults this break is usually complete in that the periosteum and the
cortical tissue on both sides are completely severed.
In pathology, a break in a bone, caused by stress. Certain normal and pathological conditions may predispose bones to
fracture. Children have relatively weak bones because of incomplete calcification, and older adults, especially women past
menopause, develop osteoporosis, a weakening of bone concomitant with aging. Pathological conditions involving the
skeleton, most commonly the spread of cancer to bones, may also cause weak bones. In such cases very minor stresses may
produce a fracture. Other factors, such as general health, nutrition, and heredity, also have effects on the liability of bones
to fracture and their ability to heal.
An incomplete break or greenstick fracture is mere common in children. Bone broken is bent but securely hinged at one
side.
A complete fracture occurs when periosteum and cortical tissue completely severed on both sides of bone.
B. Fracture bone fragments are labeled according to relationship to the cortex of the body.
1.
2. proximal here to
C. Causes of fracture
1.
In normal bones, fracture occurs when more stress is placed upon a bone that is able to absorb such as:
a) Direct blow or crushing form
b) Twisting force (torsion a severe twisting of a broken bone at a side different from where the force was
actually applied.
c)
Powerful contractions highly developed muscles contract so violently that muscles tear from bone
sometimes pulling a small piece of bone with it.
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Open fracture
2. Closed fracture
Principles of Fracture Treatment
A. Reduction or realignment of bone fragments
B. Maintenance or realignment by immobilization
C. Restoration of function
A. Reduction
Reduction
1.
Closed reduction is accompanied by application of plaster cast after the fracture4 have been aligned with
or without the use of anesthesia, to include the joint above and below the fracture line.
2. Open reduction immobilization is done by nails, screws, pins, wires or rods which are inserted with or
without plates. Such devices stay in the patient indefinitely unless they produce symptoms after healing
takes place.
B. Immobilization
The most important phase in obtaining the union of fracture fragments.
a. Cast
b. Traction
c. Brace
d. Fixation devices
a. Internal fixation devices
b. External fixation devices
CARE OF PATIENT IN CAST
Plaster Cast is temporary immobilization device, which is made of gypsum sulfate, rendered anhydrous by calcification
when mixed with water swells and forms into hard cement.
FUNCTIONS
1.
2.
3.
4.
To immobilize
To prevent or correct deformity
To support, maintain and protect realigned bone
To promote healing and early weight bearing
* Cast can be applied to the extremities, to the trunk and to the extremity and trunk as in spicas.
It can be applied to encase the whole area where it should be applied or it can be applied as a splint or mold.
*Complications of cast
1. Neurovascular compromise
2. Incorrect fracture alignment
3. Cast syndrome, superior mesenteric artery
a. Occurs with body cast
b. Traction on superior mesenteric artery causes decrease in blood supply to bowel
c. Signs and symptoms, abdominal pain, nausea and vomiting
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4. Compartment syndrome is a condition in which increases pressure within limited space, compromises circulation and
function of the tissue within that space.
Principle in application of plaster cast
1.
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Edges that are extremely rough should be trimmed and smoothened very slightly with a knife.
Rough edges can be covered with adhesive petals, especially if there is no stockinet underneath the plaster and wadding
sheet.
Care of the Patient in Cast
The duration of keeping the body or part of it in cast is at least 1 month. Though, it varies among patients. Factors that
influence the duration are
1. Age of the patient
2. Part of the e body affected
3. The degree of injury the affection of the part
*During the
a.
b.
c.
d.
entire period that the patient is in cast, the nurse responsibility is focused on the following:
Neurovascular check
Preservation of the efficiency of the cast
Maintenance and promotion of the integrity of the system of the body
Maintenance of the cleanliness of the cast
A. Neurovascular checks
In all casted patient, COLOR, MOTION, TEMPERATURE AND SENSATION OF TOES/FINGERS should be observed
every 30minutes for several hours. After cast application, longer if there is edema, and then regularly every 3 hours.
Circulatory impairment results in symptoms of coldness, edema, cyanosis, pain and finally numbness in the toes or
fingers. The blanching sign will indicate whether or not there is an adequate circulation. When the nail of the thumb or
great toes is compressed and immediately released, the color should go from white to pink with the same speed/. If not, the
circulation is slow and the toes or fingers need closer observation.
Patients in arm or leg casts should be able to move and feel each toe or finger, because the same nerve does not
innervate each other. All toes and fingers should be checked.
Nerve Function Test
Nerve
Radial
Ulna
Peroneal
Dorsiflex ankle
Tibial
second toe
To relieve patients apprehension and anxieties that crowd their minds with their cast on, the nurse can help the [patient
make a start toward resolving some of the problems by helping them become to remain as independent as possible.
Instruction regarding cast care need to be received and patient can be reminded that frequent rest periods for the entire
body are necessary. Discussing plans with the patient before discharge will make the transition from the hospital to another
facility much smoother and add to her peace of mind.
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What to observe/remarks
Remarks
1. Avoid insertions of foreign bodies in cast
2. Avoid soiling of the cast
3. Report signs of cracks and weakness of the cast
4. Maintain proper alignment of casted extremity
5. Proper support of the cast
Cast of the Lower Extremities
1. Observe for impaired circulation as manifested by
a. Cyanosis or bluish discoloration of the skin
b. coldness of sensation
c. loss of function of the affected extremity
d. numbness
e. absence of pulse
f. marked swelling
2. Nerve damage due to pressure on the nerve as it passes over bony prominences
a. increasing persistent localized pain
b. numbness in the extremity
c. feeling of deep pressure
d. paresthesia
e. motor weakness or paralysis
3. Infections, tissue necrosis due to skin breakdown
a. drainage through casts
b. sudden, unexplained rise in temperature
c. hot spot felt on cast over the lesion
d. pressure on the groins, knee, ankle and metatarsals
Spica Casts
1. Signs of respiratory distress
2. Signs of cast syndrome
a. Prolonged nausea
b. Repeated vomiting
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3.
4.
5.
6.
c. Distention
d. Vague abdominal pain
e. Absence of bowel sounds
Pressure on the jaws, ears, face, clavicle area, anterior superior iliac crest, groin, buttocks, and above the knee.
Urinary and bowel disturbances
Signs of plaster cast
a. itchiness/burning sensation
b. severe pain
c. rise in the body temperature
d. disturb sleep
e. night cries among babies
f. restlessness
Signs of infections and tissue necrosis
A. Supine to lateral
With 2-3 members working together the patient is gently pulled toward the unaffected side. Member remains on this
side to give the patient the sense of security while the other member moves to the opposite side of the bed where the
affected leg is to arrange the pillow along the entire length of the casted leg and back.
B. Supine to prone
One member places his hands on the patient shoulder and hips, while the other support the thighs and extremities. The
member of the opposite side pulls the shoulder and thighs as the patient is gently teased on his front. After the patient has
been turned, observe the following points:
a. Toes should not dips against the mattress
b. Body section of the cast plaster should not press the back, chest and abdomen
c. Heels should be maintained in correct angulations and should be allowed to extend beyond the mattress
In bowel or bladder elimination, the buttocks should be lower than the head and toward the breast. This can be
achieved by:
a.
Elevating the head part slightly and placing a small pillow under the back of the patient.
b. Placing a folded cloth on the posterior aspect of the bedpan. This will absorb moisture and this prevents
spoiling the cast.
Adult patients are usually placed in their good side first. The bedpan is placed so that the buttocks are on the
posterior section of the bedpan. Pillows, blankets are then arranged to support the legs and back so that there
will no be back flow.
If patient can support himself by lifting with the aid of the overhead trapeze, the bedpan is slipped under the
buttocks.
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Bladder and bowel elimination in children with hip spica if placed in headboard frame is not difficult if the
bedpan is kept constantly in the spica under the buttocks.
Instrument for Cast Removal
1. Cast cutter (manual electric)
2. Spreader
3. Trimming knife
4. Bandage scissors
5. Plaster sears
Points to Remember
1. After the cast is removed, support the part with pillow maintaining the same position that existed in the cast.
2. Move the extremity gently.
3. Observe the skin for any abrasions and plaster sore.
4. Wash skin with mild soap followed by application of oil or lanolin.
TRACTION
Traction is the application of a pulling force to a part of the body. It is used to align and immobilize fractured bones, to
relieve muscle spasms and to correct flexion contractures, deformities and dislocations.
For traction to be effective, there must be also a pull in the OPPOSITE DIRECTION (COUNTER TRACTION) by using
the body or by elevating part of the bed toward the traction.
PRINCIPLES OF TRACTION
1. MAINTAIN THE ESTABLISHED LINE OF PULL
Weights should hang freely, not hitting the bed or resting on the floor. The position of the weights should be
rechecked if the level of the bed is altered.
AVOID
1. Bumping against the weights when walking near the bed.
2. Allowing the weights to sway.
Both movements can cause pain for the patient in traction. It is preferred that the weights should not hang over
the patient, if necessary, the nurse should tape the weights so they will not fall on the patient.
2. PREVENT FRICTION
Traction rope should rest in the groove of the pulley and move easily. The rope should not be frayed. The nurse
should TIE securely knots in the traction rope and tape the rope ends. The rope knots should not lodge against the pulley
because this will interfere with the line of pull. For the same reason, the nurse should ensure that the pulley, spreader bar
and footplate do not rest against the foot of the bed.
3. MAINTAIN COUNTER TRACTION
To provide traction, the nurse must ensure that counter traction is maintained. If the weight of the patient body is to
provide the counter traction, HIS BODY should not interfere with the DIRECTION OF PULL. For instance, the feet of the
patient in BUCK traction should not touch the foot of the bed, or if the patient is in cervical traction, his head should not
touch the head of the bed.
4. MAINTAIN CORRECT BODY ALIGNMENT
The patient should have correct BODY alignment while lying centered in the bed. The nurse must ensure that the
patient does not angle his body or lean off the side of the bed because the line of traction pull would then be changed or
interrupted.
Types of Traction
1.
SKIN TRACTION
Skin traction is accomplished by weights that pull on tape, sponge rubber or plastic materials attached to the skin.
TRACTION on the SKIN, TRANSMITS traction to the musculoskeletal structures.
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Forms
1.
Buck Extension
A form of skin traction in which the pull is exerted in one plane when partial or temporary
immobilization is desirable. In Bucks extension, strips of adhesive, moleskin or perforated flex foam are
applied smoothly to each side of the affected extremity and attached to a spreader block at the foot. The
extremity is wrapped with elastic bandage to improve adherence of the tape to the skin and prevent
slipping. A traction rope is attached to the spreader block then over the pulley, thence to a weight hung
over the side of the bed.
2. Russells Traction
The knee sling should be smooth and its edges must not cause pressure on the soft tissue over the
peroneal nerve.
2. The heel of the foot in traction should just clear the bed.
Firm pillows should support the thigh and the calf along the
entire length, leaving the heel free of the bed.
3. The popliteal space must be watched for ridging and skin denudation. Elevation of the backrest is
permitted and few difficulties are encountered in giving nursing care because the fractured leg is not at
the mercy of the gravity and will not be altered in position.
4. Encourage active dorsiflexion and plantar flexion of the feet.
Important features
1.
A piece of felt should be inserted between the sling and the patients skin to prevent wrinkling of the
sling under the popliteal area. This will assist in eliminating pressure sores that sometimes form at this
point.
2. The heel should clear the bed. The ideal position for the heels of the patient in Russell traction is that
of a person standing with his heels four inches apart. Abduction is to be avoided.
3. Two pillows are usually placed under the limb in traction. One under the thigh to maintain the
desired angle and the other under the calf down and including the Achilles tendon.
2. SKELETAL TRACTION
Method of traction used most frequently in the treatment of fracture of the femur, humerus and the tibia. The traction
is applied directly to the bones by use of a metal pin or wire (Kirschnerwire, Steimann pin), inserted into and through a
bone distal to the fracture. Usually the skin is made under local anesthesia. The pin or wire is sterilized with all the aseptic
precaution of an operation. Following insertion of pins, the wound is covered with a small gauze squares. If the wire or pin
extends back to the caliper, a cork placed over the end of the pin prevents the tearing of lines and other more serious
accidents.
Skeletal traction is applied by weights and pulleys as described for skin traction. The Thomas Splint with the Pearson
attachment is usually used with skeletal traction in fractures of the femur. It may be used with skin traction and other
balanced suspension apparatus. Because upward traction is required for these fractures, the patient is placed on a fracture
bed.
Inasmuch as fracture occurs under varying circumstances and involves individuals of different ages, weights and body
builds, NO TWO FRACTURES ARE ALIKE and every fractured patient require individual treatment. By same token, traction
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may be modified in many ways to meet a variety of special requirements, as exemplified by so called BALANCED
SUSPENSION TRACTION and the RUNNING TRACTION.
3. MANUAL TRACTION
Means the application of traction to a part of the body by the hands of the operator. When assisting with the
application of traction or a cast, the nurse may be asked to apply a manual traction. This calls a firm smooth grip on the
extremity and the avoidance of sudden jerking movements.
BALANCED SUSPENSION
Balanced suspension traction is used primarily for femoral fractures in adults by means of the Thomas splint with a
Pearson attachment. Balanced suspension provides counter traction by its own system of weights and pulleys. Therefore
when the patient lifts, the splint should also lift so that traction is maintained.
The Thomas splint has a sling that supports the thigh. The nurse should check for irritation from the ring to the groin,
inner thigh and ischium. The Pearson attachment is connected to the splint by the knee and supports the calf in a position
parallel to and above the bed. A Steimann pin or Kirschner wire is inserted through the distal end of the femur or through
the proximal or distal end of the tibia.
The nurse teaches the patient and family that the tractions main purpose is to provide sling, this allows the leg to rest
comfortably and provides freedom to move without disrupting traction pull or alignment.
By using the overhead trapeze, the patient can lift the shoulders and upper body. This movement allows for change of
linen from the top to the bottom of the bed. Similarly, the nurse can apply lotion to the patients back because the
individual is not allowed to turn for back care.
UPPER EXTREMITY TRACTION
Skin/Skeletal
Sidearm traction is used to immobilized fracture of the humerus and may be applied either a skin or skeletal traction. There
is outward pull on the upper arm and an upward pull on the forearm. For this reason, two separate set-ups of adhesive
strips and elastic bone wraps are needed. In addition, if skeletal traction is used, a Kirschnerwire is usually inserted trough
the olecranon.
If the traction equipment is attached to the bed frame under the mattress, elevating the head of the bed will not disrupt
the traction pull. However, if the frame is attached so that it moves when the bed position changes, the nurse should keep
the head of the bed flat. Placing a folded blanket under the mattress near the traction frame can provide COUNTER
TRACTION.
Skeletal
Overhead 90-90 traction, there is an upward pull on the upper arm, which is at a 90degree to the body. The elbow is
flexed at a 90degree that the forearm is suspended in a sling and rest above and across the body. Weight is attached to the
sling and to the Kirschner wire that is usually inserted through the olecranon.
Because the arm is elevated, the patient should have less edema. This will be the case as long as the nurse ensures the
patient keeps the involved hand supported in the sling and does not allow it to hang freely.
CERVICAL TRACTION
Skin Cervical Halter
Skin traction is frequently used for patients with sprains or strains to the cervical spine and ruptured cervical discs. It is
applied to the cervical spine by a halter with straps that go under the chin and around the head of the base of the skull.
After the halter is placed, the spreader bar and attached weights are connected. The patient may have small pillow under
his head and should rest the back against the bed. Because cervical traction is usually ordered intermittently for a specified
period, the nurse should teach the patient how to remove and reapply it. This information is especially important for the
patient because there may be the need to remove the halter if vomiting or choking occurs. Any severe headache or pain in
the area of the traction should be reported.
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Types
1. Pelvic belt is primarily for relief of lower back pain to the lumbar spine
whereas the pelvic sling is used to treat a pelvic fracture.
Pelvic belt traction is applied to the lumbar spine by a pelvic belt with straps attached to weights. It is used to
reduce muscle spasms and in the conservative management of low back pain and herniated lumbar disc. This traction
may be ordered for intermittent periods. However, patients cooperation is crucial to success.
The nurse should place the patient in Williams position, in which both the hips and knees are flexed at a 30degree
angle and the head of the bed is slightly elevated. This position relieves pressure from the lower back by decreasing the
lumbar curve. It also provides counter traction. If traction increases pain to the back or legs, the nurse should report this
to the physician.
2. Pelvic sling
It is used continuously to stabilize and immobilize fractures of the pelvis. A
large canvas sling attached to weights suspends the patients buttocks just off
the bed. The pelvic sling may also be used to compress the entire pelvis (by
applying pressure along each side), if there is a pelvic ring separation.
Compression is achieved when the physician repositions the rods from the
attachment edges of the sling to grooves that are closer together toward the
patients midline.
Strict immobilization is required to maintain the traction force. The nurse
should give back care every 4 hours by sliding her hands between the sling
and the patients back. However, it is difficult to reach the buttocks for skin
care and bathing and the patient may generally uncomfortable. For these
reasons an external fixator may be inserted into each iliac crest to stabilize
unstable fractures of the pelvis. External fixation can reduce the patients pain,
allow for his early ambulation and facilitate nursing care.
NURSING PRIORITIES FOR PATIENTS IN TRACTION
1. Frequently inspection of the fracture dressing in the first 24hours after application. A bandage that appears loose
when applied may in a very few hours cause constriction which if not relieved may lead to gangrene of the
extremity.
2. Dressing is applied in such a way as to leave the tips of the fingers and toes exposed. Any cyanosis, loss of
temperature, tingling sensation in these parts should warn the nurse that the dressings are too tight. If the condition
is caused by a single turn of the bandage, the turn may be divided with scissors, but it is usually advisable to notify
the surgeon.
3. After the first 24 hours, the fracture dressing should be inspected at least 3-4 times daily. Evidences of constriction
should be noted and pressure points checked heel on the bedclothes resting on toes.
4. It is also important to ask the patient if there are any painful areas.
5. If traction is in used, the apparatus should be checked to see the ropes are in the wheel of the groove of the pulleys
that the supporting apparatus is free of the pulleys, that the weights hang freely and that the patient has not slipped
down in the bed.
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6. The foot must be in natural position; rotation outward or inward should be reported. FOOT DROP is to be
avoided and the patients foot must be maintained in the neutral position supported by appropriate orthopedic
devices. The rope sometimes frays; therefore, it too must be inspected at least daily.
7. Weights are necessary to provide constant force and may be ordinary metal traction weights or bags of water, hot
or cold. It is especially important that the knots on the traction rope be tied securely. Enough weight is applied at
first to overcome shortening tendency of the injured limb, but is gradually lessened as the fracture becomes more
fixed. Weights should never be removed from a patient with fracture unless a life-threatening situation arises.
Weight and pulley is applied to secure constant corrective extension.
8. WHEN THERE IS PULL IN ONE DIRECTION, THERE MUST BE AN EQUAL PULL IN THE OPPOSITE DIRECTION.
Counter traction is supplied by either the patients body and friction against the bed (fracture of the upper
extremity) or by elevating the foot of the bed (fracture of the lower extremity).
9. When traction frames are used, a trapeze may be suspended overhead within easy reach of the patient. This
apparatus is of great help in assisting the patient to move in bed and on and off the bedpans.
NURSING CARE OF PATIENT IN TRACTION
Nursing principles and implications
implications
The purposes of traction regardless how it is achieved are
1. To reduce and to immobilize a fracture
2. To lessen or to eliminate muscle spasms
3. To prevent fracture deformity
An eye is a round-shaped organ that works with the brain to provide us with vision. The shape of the eye is
maintained by the pressure of the aqueous humor.
The main function of the eye is to work with the brain to provide us with vision. The eye and brain translate light
waves into a sensation we call vision.
External Structures of the Eye
Ocular Adnexa
! Are the accessory structures of the eyes that support and protect it.
Ocular Muscles
! Eyeball is moved by 6 ocular muscles, which are attached to the surface of the globe.
! 4 Rectus muscles move eyes vertically & horizontally
(medial, lateral, superior, inferior)
! 2 Oblique muscles rotate the eye in circular movements (superior, inferior)
Eyelids
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B.
1. OUTER LAYER
- fibrous coat that supports the eye
SCLERAE
- Tough, white connective tissue white of the eye
- located anteriorly & posteriorly
CORNEA
- Transparent tissue through which light enters the
eye.
- Located anteriorly.
2. MIDDLE LAYER
- second layer of the eyeball
- vascular & highly pigmented
CHOROID
- a dark brown membrane located between the
sclera & the retina
- it lines most of the sclera & is attached to the
retina but can easily detach from the sclera
- contains blood vessels that nourishes the retina
- located posteriorly.
CILIARY BODY
- connects the choroid with the iris
- secretes aqueous humor that helps give the eye its
Shape.
IRIS
- the colored portion of the eye
- located in front of the lens
- it has a central opening called the pupil.
3. INNER LAYER (RETINA)
- a thin, delicate structure in which the fibers of the optic nerve
are distributed
- bordered externally by the choroid & sclera and internally by the
vitreous
- contains blood vessels & photoreceptors (cones & rods)
- light sensitive layer.
CONTAINS THE FOLLOWING STRUCTURES
1. CONES
- Specialized for fine discrimination, central vision & color
vision
- Functions at bright levels of illumination
2. RODS
RODS
- More sensitive to light than cones
- Aid in peripheral vision
- Functions at reduced levels of illumination.
AQUEOUS HUMOR
- Clear, watery fluid that fills the anterior &
posterior chambers of the eye
- produced by the ciliary processes, & the fluid
drains in the Canal of Sclemm
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PARASYMPATHOLYTIC DRUGS
- used pre-op or for eye examinations to produce mydriasis
- C/I in clients with glaucoma because of the risk of increased IOP
Classification
MYDRIATICS
- dilate the pupils (mydriasis)
CYCLOPLEGIA
- relax the ciliary muscles
ANTICHOLINERGICS
- block responses of the sphincter muscle in the
ciliary body, producing mydriasis
Example:
Atropine sulfate (Isopto-Atropine, Ocu-Tropine, Atropair, Atropisol)
Scopolamine hydrobromide (Isopto-Hyoscine)
Cyclopentolate hydrochloride (Cyclogyl, AK-Pentolate, Pentolair)
Homotropine hydrobromide (Isopto Homatrine, AK-Homatropine,
Spectro-Homatrine)
Tropicamide (Mydriacyl, I-Picamide, Tropicacyl)
Phenylephrine hydrochloride (AK-Dilate, Dilatair, Mydfrin, Ocu-Phrin)
Nursing
Nursing care:
Assess for constipation & urinary retention
Instruct the client that a burning sensation may occur
on installation
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PARASYMPATHOMIMETIC
Miotics
- reduce IOP by constricting the pupil & contracting the ciliary muscle,
thereby increasing the blood flow to the retina & decreasing retinal
damage & loss of vision
-open the anterior chamber angle & increase the outflow of aqueous
humor
- used for chronic open-angle glaucoma or acute & chronic closed-angle
Glaucoma
Example of miotic drugs
Acethylcholine Cl (Miochol)
Carbachol (Miostat)
Pilocarpine HCl (Isopto Carpine, Pilocar)
Pilocarpine nitrate (Pilofrin, Liquifilm, Pilagan)
Echothiophate iodide (Phospholine iodide)
Demecarium bromide (Humorsol)
Isoflurophate (Floropr
Nursing Care:
affecting
accommodation
or
EXAMPLES
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Metipranolol (Optipranolol))
Timolol maleate (Timoptic)
Nursing Care
If the pulse is below 60 or if systolic BP is below 90 mm Hg, withhold the
medication & contact MD
Instruct to change positions slowly to avoid orthostatic hypotension
ADRENERGIC EYE MEDICATIONS
ADRENERGIC MEDICATIONS
ACETAZOLAMIDE ( DIAMOX)
Mannitol (Osmitrol)
Urea (Ureaphil)
EYE LUBRICANTS
- Replace tears or add moisture to the eyes
- Moisten contact lenses or an artificial eye
- Protect the eyes during surgery or diagnostic procedures
- Used for keratitis, during anesthesia or in a disorder that results in
unconsciousness or decreased blinking
EXAMPLES
Hydroxypropyl methylcellulose
methylcellulose (Lacril, Isopto Plain)
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Note that the medications should not be given to the client for home use & are not to be self-administered by the
client
Note that the blink reflex is temporarily lost & that the corneal epithelium needs to be protected
Provide an eye patch to protect the eye from injury until the corneal reflex returns
ANTIANTI-INFLAMMATORY EYE MEDICATIONS
EXAMPLES
Dexamethasone (Maxidex)
Diclofenac (Voltaren)
Flurbiprofen Na (Ocufen)
Suprofen (Profenal)
Rimaxolone (Vexol
ANTIANTI-INFECTIVE EYE MEDICATIONS
ANTIBACTERIAL
Erythromycin (Ilotycin)
Norfloxacin (Chibroxin)
Silver nitrate 1%
ANTIFUNGAL
Idoxuridine (Herplex(Herplex-Liquifilm)
Trifluridine (Viroptic)
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When ambulating, allow the client to grasp the nurses arm at the
Elbow the nurse keeps his or her arm close to the body so that the client
can detect the direction of movement
Instruct the client to remain one step behind the nurse when
ambulating.
People may use talking thermometers, enlarged or marked oven dials, talking watches, talking clocks, talking
scales, talking calculators, talking compasses and other talking equipment.
Immediately after operative, the patiet must keep still the head still and try to avoid coughing,
vomiting, sneezing or moving suddently
The patient should lie with unoperated side down to prevent pressure on the operated eye and to
prevent possible contamination of the dressing with vomiting
A burning sensation about one hour after surgery usually means that the anesthethic is wearing off
The patient is instructed to avoid lifting the head or hips, straining at stolol or squeezing the eyelid
o If sneezing or coughinh occurs, the patient should follow through with open mouth
o If vomiting occurs, the eyelids should be kept open
o Cough medicines and antiemetics can be givenb for cough and vomiting, stool softener
and laxatives for constipation
To prevent stress on the suturebline, bending forward is avoided
o Sudden jerky movement may result in hemorrhage into the hyphema
Side rails are placed on the bed immediately postoperatively and are kept on while both eyes are
covered or as long as necessary for protection
The bedside table should be placed on the side of the unoperated eye so that the patient can see it
without excessive movement of the head
Care is taken that the dressing is not looased or removed
o Bleeding and serous fluid should be minimal
o Edema of the eyelids subside within 3 to 4 days
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The feeling of something in the eye 4 to 5 days post op usually is because of sutures and
is normal
o Sensation of pressure within the eye ad sharp pain are quickly reported to the surgeon.
These indicate bleeding
Supervision and assistance on ambulation should be given by the nurse to avoiding sustain injury
The patient is advised not to bend,or lift objects for several weeks post op, to prevent increasing
intraocular pressure
o
B.
CATARACT
- an opacity of the lens that distorts the image projected onto the
retina & that can progress to blindness.
- Intervention is indicated when visual acuity has been reduced to
a level that the client finds to be unacceptable or adversely
affecting lifestyle
Risk Factors
# Normal aging (90%)
# long-term exposure to ultraviolet light, exposure to radiation
# exposure to infrared radiation such as glassblowers, microwave radiation
# Drugs Coticosteroids, Haloperidol, Miotics
$ Denatured proteins can exhibit a wide range of characteristics, from loss of solubility to communal aggregation.
Types of cataracts;
1. Senile Cataracts: age-related begin around age of 50 years
Classified into three:
a. Cortical
-opacification found in the periphery of the lens
-progree slowly, infrequenly involve the visual axis, often do not cause severe loss of vision
b. Nuclear sclerotic cataracts- progressive and hardening of the central lens
c. Posterior subcapsular cataracts- occur centrally on the posterior lens capsule and cause visual loss early in their
development because they lie directly on the visual axis
2. Traumatic: those associated with injury
3. Congenital; Those associated at birth
4. Secondary: Those which occur following other eye or systemioc diseases
ASSESSMENT
# Opaque or cloudy white pupil
# Gradual loss of vision
# Blurred vision or hazy
hazy vision
# Decreased color perception
# Vision that is better in dim light with pupil dilation
# Photophobia
# Absence of red reflex - reddish-orange reflection from
the eye's retina that is observed when using an
ophthalmoscope.
MEDICAL MANAGEMENT
! No known medical treatment that either prevents or reduces cataract formation.
! OBJECTIVE: To remove the opacified lens.
EXTRACAPSULAR EXTRACTION ECCE
# removing the lens & anterior portion of lens capsule, the posterior lens capsule is left intact.
# allow insertion of lens implant w/ fewer post-op complication.
INTRACAPSULAR EXTRACTION ICCE
# removing the lens including the lens capsule.
PHACOEMULSION 2 to 3 mm
- the lens is broken up by ultrasonic vibrations & extracted.
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Cryoextraction: The cataract is lifted from the eye by a small probe that has been cooled to a temperature below zero and
Cryoextraction
adheres to the wet surface of the cataract
PREPRE-OP NURSING CARE
Wipe excess drainage or tearing with a sterile wet cotton ball from
the inner to the outward canthus
Contact lenses
Contact lenses provide sharp visual acuity and must have the manual dexterity to
handlethe lenses, cleaning, insertion of lenses, replacement of lenses and the dasnger of
corneal abrasion
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Cataract glasses act as magnifying glasses & replace central vision only
GLAUCOMA
Ocular condtions characterized by optic nerve damage that will lead to irreversible blindness
blindness related to
increased IOP due to congestion of aquuenous humor in the eye
Glaucoma is the second leading cause of blindness in the world, according to the World Health
Organization.
Aquenous Humor
Flows in the anterior and posterior chamber of the eyes, nourishing the cornea and lens
90% of fluid flows out the anterior chamber, draining through the spongy trabecular meshwork into the
canal of schlemn and the episcleral veins
10% of fluids exits through the ciliary body into the suprachoridalspace and then drains into the venous
circulation of the ciliary body, choroid and sclera
Outflow of aquenous humor depends on an intact drainage system and an open angle ( 45 degrees)
between the iris and the cornea.
IOP
NormalNormal- 1010-21 mmhg
When A.H is inhibited from flowing out, the pressure builds up within the eye ( Increase IOP)
Increase IOP----damages the optic nerve---blindness
Two theories regarding how IOP damages the optic nerve
Direct mechanicasl theory
' High IOP damages the retinal layer as it passess through the optic nerve head
Indirect ischemic theory
' High IOP compresses the microcirculation in the optic nerve head, resulting in cell injury
and death
STAGES in the development of Glaucoma
1. Initiating events
PF= illness, emotional stress, congenital narrow angles, long term corticosteroid,
mydriatics
2. Structural altrertaion in the aquenous outflow system
`
Tissue and cellular changes
3.Functional alterations: :conditions such as increased IOP or impaired blood flow create functional changes
4. Optic nerve damage: atrophy of the optic nerve is characterized by loss of nerve fibers and blood supply
5. Visual loss: progressive loss of vision is characterized by visual field effect
Classification
Terms:
Primary and secondary glaucoma refer whether the cause is the disease alone or another condition
Acute and chronic refer to the onset and duration of the disorder
Open ( wide) and closed ( narrow- describe the width of the angle between cornea and the iris .Narrower angle places the
iris closer to the trabecular meshwork =impeded the outflow of A.H
Types of glaucoma:
I.
Primary OpenOpen-Angle Glaucoma POAG
! Often referred to as thief in the night.
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The pressure in the eye slowly rises and the cornea adapts without swelling
is the most common type of glaucoma.
slow damage to the nerve in the back of the eye (optic nerve) causes gradual loss of eyesight.
has been called simple glaucoma
glaucoma, chronic glaucoma,
glaucoma and widewide-angle glaucoma..
glaucoma.
The most common cause is degenerative change in the trabecular meshwork, rresulting
esulting in decrease outflow of
aqueous humor.
! IOP= 3030-50 mmhg
Risk Factors:
a. Age. The risk for glaucoma increases rapidly after age 40.
b. Race. Blacks are 4 times more likely than whites to have glaucoma.
c. Family history of glaucoma
d. Prior loss of vision in one eye from glaucoma
e. Diabetes. People with diabetes are also at risk for a type of secondary glaucoma where new blood vessels grow
into and block the drainage angle of the eye (trabecular meshwork).
!
!
!
!
!
II.Close
II.Close angle glaucoma
An acute attack can develop only in an eye in which the anterior chamber angle is
anatomically narrow.
Attack occurs due to sudden blockage of the anterior angle by the base of the iris.
When Aqueous flow is obstructed >>> IOP becomes markedly elevated >>> severe
pain & blurred vision >>> Blindness
This sudden rise in pressure can occur within a matter of hours and become very
painful. If the pressure rises high enough, the pain may become so intense that it can
cause nausea and vomiting.
The eye becomes red,
clouds, and the patient may see haloes
red the cornea swells and clouds
around lights and experience blurred vision.
IOP= 50-70 mmhg
Risk Factors:
a. Race. People from East Asia or with East Asian ancestry, as well as Canadian, Alaskan
b. Age. People over age 40 are at increased risk for closed-angle glaucoma.
c. Sex. Older women are more likely than older men to develop closed-angle glaucoma.
d. Birth defects - born with narrow drainage angles in the eyes.
e. Physical injuries. Severe trauma, such as being hit in the eye, can result in increased eye pressure. Injury can also
dislocate the lens, closing the drainage angle.
f. Farsightedness, Family history, Having closed-angle glaucoma in one eye .
III.
!
!
!
!
!
Congenital glaucoma
is a rare form of glaucoma that is present in babies at birth.
often caused by a birth defect
defect that can cause abnormal development of structures in the eye.
usually diagnosed by the end of the first year of life.
Glaucoma that develops between birth and age 3 is called infantile glaucoma
glaucoma.
People between the ages of 3 and young adulthood can develop another type of developmental glaucoma called
juvenile glaucoma.
glaucoma.
Symptoms:
# Watery eyes, sensitivity to light
# eyes that look cloudy
# Eyes look larger than normal
# Rubbing the eyes or keeping the eyes closed much of the time.
IV.
LowLow-Tension Glaucoma
Resembles Primary Open-Angle Glaucoma
The angle is normal, optic nerves are cupped, & show peripheral vision deficits.
IOP is within normal range.
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V.
Treatment is indicated to lower the pressure even further, to avoid progressive optic nerve damage and visual field
loss.
Secondary Glaucoma
Glaucoma may develop after an eye injury, after eye surgery, from the growth of an eye tumor, or as a
complication of a medical condition such as diabetes - cause new blood vessels to grow into the drainage angle
of the eye.
Certain medicines : corticosteroids
Pigmentary glaucoma - is a form of secondary glaucoma caused by pigment granules being released from the
back of the iris. These granules can block the drainage of aqueous humor.
Phacomorphic glaucoma - Cataract that causes swelling of the lens can cause glaucoma.
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To do the test, you sit and look inside a bowl-shaped instrument called a perimeter. While you stare at the center
of the bowl, lights flash. You press a button each time you see a flash. A computer records the spot of each flash
and if you pressed the button when the light flashed in that spot.
At the end of the test, a printout shows if there are areas of your vision where you did not see the flashes of light.
o Pharmocologic therapy
Topical Miotics Pilocarpine hydrochloride
o causes pupillary constriction to open canal of schlemm
o constricts pupil & increase outflow
Topical epinephrine also increase outflow
Topical beta-blockers or alpha-adrenergics Timolol Maleate
o Decreases production of aqueous humor
Oral carbonic anhydrase inhibitors acetazolamide/Diamox
o Inhibits production of aqueous humor
$
Surgical Management:
Laser Trabeculoplasty
! Laser is used to create an opening in the trabecular meshwork to allow increased outflow of aqueous.
! IOP is reduced in about 80% of cases.
! Effect of laser treatment decreases over time & procedure may need to be repeated.
! Tx with medications is usually continued.
Filtering Procedures
! Goal is to create an outflow channel from the anterior chamber into the subconjunctival space.
Example:
Trabeculectomy-remove
the part of trabecular meshwrok to allow drainage of aqueous humor into the conjuctival
Trabeculectomy
spaces
SclerotomySclerotomy surgical incision of sclera
Iridectomyridectomy portion of the iris is excised to facilitate outflow of aquenuos humor
*25% of cases, the opening closes because of scar formation
Ways to prevent scar tissue formation
o Topical corticosteroid used post op antiinflammtory action inhibits proliferation of fibroblast at the
surgical site
o Injection subconjunctival of 5-FU, mitomycin and other anti-metabolites
Cyclodestructive Procedure
Procedure- destroying part of ciliary by
cyclocryotherapy ( application of freezing tip) or
cyclophotocoagulation
Medical Management: Close ANGLE GLAUCOMA
Treat as medical emergency
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D.
!
!
!
TYPES
! PARTIAL RETINAL DETACHMENT
DETACHMENT
- becomes complete if left untreated
! COMPLETE RETINAL DETACHMENT
- when detachment is complete, blindness may occur.
$ there is a hole or a tear in the retina. Fluid that normally fills the inside of the eye can go through these retinal
holes or tears and get behind the retina. This separates the retina from the back of the eye, causing a detachment.
$ Retina is separated from the choroid >>> avascular necrosis >>> interrupts the transmission of visual images
from retina to the brain >>> progressive loss of vision >>> COMPLETE BLINDNESS.
Clinical Manifestations:
# Shadow or curtain falling across the field of vision-part of detachment in the retina
# Painless onset is usually sudden
# Black spots/Floaters- these are blood and retinal cells that are freed at the time of the tear and cast shadows on the
retina as they seem to drift about the eye
# Flashes of light the light that enters the yes is not absorbed by the detached melanin epithelial pigment
Ep the patient
Diagnostic Tests:
Ophthalmoscopy
o used to evaluate the extent and source of detachment.
o Areas of detachment appears bluish gray.
gray
Immediate nursing care: to prevent further detachment
Provide bedrest
The head is positioned so that the retinal hole is in the lowest part of the eye ( dependent position)
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Diathermy
! The use of electrode needle and heat through the sclera stimulate an inflammatory response leading to adhesions
Laser therapy
! To stimulate an inflammatriy response to seal small retinal tears before detachment occurs
Sceral Buckling
! Used to splint and hold the retina & choroid together.
! A silicone sponge implant is placed over the tear and held in place with an encircling band.
Pre op Nsg. Care:
# Place on activity restrictions based on the size & location of detachment.
# General anesthesia is used & pupil must be dilated before the operation.
Post op Nsg. Care:
# Observe eye patch for any drainage.
# Narcotics needed during first 24 hours.
# Nausea & vomiting may require management.
# IOP monitoring for first 24 hours.
# Resume regular diet & fluids as tolerated.
# Antibiotic-steroid combination drop
# Cycloplegic agents
# Redness & swelling of lids & conjunctiva should be expected.
# Clean eyes with warm tap water & clean wash cloth.
# Glasses worn during the day & eye shield should be worn at night.
# Avoid vigorous activities and heavy lifting.
# Healing takes place over weeks & months, vision may improve gradually. (Warm & cold compress for comfort).
E.
Macular Degeneration
Is an atrophic degenerative process that affects the macula and surrounding tissues, resulting in central visual
deficits.
Found in most adults over age 65. Incidence increases with each decade over 50.
It may also be hereditary.
There is no known medical treatment or prevention for age-related macular degeneration.
Client may notice blurred scotoma or decreased central visual acuity.
Amsler Grid
! a simple device to test the early and progressive effects of age-related macular degeneration.
! patients can test their own vision by posting the grid on the refrigerator or somewhere else at home.
! Then patients can report any changes they detect.
F.
Diabetic Retinopathy
A progressive disorder of the retina characterized by microscopic damage to the retinal vessels.
As a result of inadequate blood supply , sections of the retina deteriorate & vision is permanently lost.
All diabetics are prone to develop retinopathy.
Clients who have had diabetes for 15-20 years have an 80-90% chance of developing retinopathy.
Clinical Manifestations:
# Gradual or sudden loss of vision
# Floaters or shadows
Management:
# tight control of diabetes.
# tight control of diabetes.
# avoiding smoking,
# keeping regular appointments with your doctor and the eye specialist.
# Community referrals for rehabilitation & low vision aids.
Eye infection
Conjunctivitis
$ Conjunctivitis is an inflammation or infection of the conjunctiva.
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Three types:
A. Infectious commonly known as Pink eye.
B. Allergic
C. Chemical
Clinical manifestation:
o Hyperemia redness
o Tearing & exudation
o Psuedoptosis drooping of the upper lid
o Sandy or scratchy feeling in the eyes
o Blurred vision
It is important to prevent spreading conjunctivitis. If contagious, measures can be taken to prevent spreading conjunctivitis
to others.
# Keep your hands away from your eyes;
# Thoroughly wash hands before and after applying eye medications;
# Do not share towels, washcloths, cosmetics or eye drops with others;
# Seek treatment promptly.
Infectious conjunctivitis
# treated with antibiotic eye drops and/or ointment.
Allergic conjunctivitis
# avoid contact with any animal if it causes an allergic reaction.
Chemical conjunctivitis
# Wear swimming goggles if chlorinated water irritates your eyes.
Blepharitis
! Is a common chronic bilateral inflammation of the eyelid margins.
! Signs & Symptoms:
itching & burning of the eyes.
red eyelid margins,
scales or granulations along lashes.
lashes.
In view of the longlong-term nature of the condition, strict lid hygiene is necessary. The following regimen may be useful:
# Fill a small glass with warm water.
# Add three drops of baby shampoo.
# Take a clean cotton ball and soak it in the solution.
# While th
the
e eyes are closed, gently scrub both eyelids for two minutes .
# Rinse with cool tap water.
# Gently dry with a clean towel.
# Use medications as directed.
$ Infected blepharitis may be treated with antibiotic ophthalmic ointment.
Hordeolum
! Stye is an infection
infection of the glands of the eyelids.
! Caused by staphylococcus infections.
! Signs & Symptoms:
redness & pain; localized swelling; may be filled with purulent material.
! Management:
Warm compress
Antibiotics
Incision & drainage as indicated.
Chalazion
! Is a sterile chronic granulomatous inflammation of a meibomian gland.
! Meibomian Cysts
! Usually characterized by painless localized swelling along the lid margin without redness.
! If large enough to distort vision or to be a cosmetic blemish, it may be surgically
surgically excised.
Extraocular Muscle Disorrders
Strabismus : called SQUINT EYE or LAZY EYE
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Instruct the parents regarding patching (occlusion therapy) of the good eye
- to strengthen the weak eye
Prepare for botulinum toxin (Botox) injection into the eye muscle
- produces temporary paralysis
- allows muscles opposite the paralyzed muscle to strengthen the eye
Inform the parents that the injection of botulinum toxin wears off in about 2
months & if successful, correction will occur
Have the client look upward, expose the lower lid, wet a cotton-
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tipped applicator with sterile NSS & gently twist the swab over
the particle & remove it
Flush the eyes at the site of injury with water for at least 15-20 mins
The solution is directed across the cornea & toward the lateral canthus
Presbyopia
' old sight
' Lessening of the effective powers of accommodation, occurs because of hardening of the lens due
to aging process
' Blurring of near object or visual fatigue when doing
doing close eye work
' Convex reading glasses are recommended
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Astigmatism
' distorted vison
' Caused by variation in refractive power along different meridians of the eye
' Optical distortion is most often caused by irregular caorneal curvature which prevents clear
clear focus
of light from any point
Monitor V/S
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Orient
Orient the client frequently
Instruct the client in how to apply the patch & eye shield
Instruct the client to wear the eye shield at night for 1 month &
whenever around
around small children or pets
GRAFT REJECTION
Can occur at anytime
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Gastric
Pre-test: Clear liquid diet and laxatives, NPO post-midnight, cleansing enema prior to the test
Lower GIT study: barium enema
Post-test: Laxative is ordered, increase patient fluid intake, instruct that stools will turn white, monitor for
obstruction -(inform MD if bowel movement doe not occur in 2days.)
analysis
Aspiration of gastric juice to measure pH, appearance, volume and contents
HOW?
Insertion of nasogastric tube to examine fasting gastric contents for acidity & volume.
o CONT
PRETEST:
KEEP NPO 6-8 HOURS PRETEST
ADVICE CLIENT ABOUT NO SMOKING, ANTICHOLINERGIC MEDICATION, ANTACIDS FOR 24 HOURS
BEFORE THE TEST.
INFORM CLIENT THAT TUBE WILL BE INSERTED INTO THE STOMACH VIA THE NOSE, & INSTRUCT TO
EXPECTORATE SALIVA TO PREVENT BUFFERING OF SECRETIONS.
POSTTEST:
PROVIDE FREQUENT MOUTH CARE.
EGD
(esophagogastroduodenoscopy
! Visualization of the upper GIT by endoscope
! Pre-test: ensure consent, NPO 8 hours, pre-medications like atropine and anxiolytics
! Intra-test: position : RIGHT lateral to facilitate salivary drainage and easy access
! Post-test:
! NPO until the gag reflex return
! Sims position until the client awakens.
! Monitor for signs of perforation (bleeding, pain, unusual difficulty swallowing , elevated temp.
! Maintain bedrest for the sedated client until alert.
! Lozenges, saline gargles, or oral analgesics can relieve minor sore throat , after the gag reflex returns.
Lower GI- scopy
! Use of endoscope to visualize the anus, rectum, sigmoid and colon
! Pre-test: consent, clear liquid diet at noon before the test, NPO 8 hours, cleansing enema until return is clear
!
!
!
Cholecystography
! Examination of the gallbladder to detect stones, its ability to concentrate, store and release the bile
! Pre-test: ensure consent, ask allergies to iodine, seafood and dyes; contrast medium is administered the night prior,
NPO after contrast administration
!
!
Post-test: Advise that dysuria is common as the dye is excreted in the urine, resume normal activities.
A normal diet may be resumed( fatty meal may enhance excretion of the contrast agent.)
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Paracentesis
Removal of peritoneal fluid for analysis & for the relief of difficulty of breathing (ascitis)
Pre-test: ensure consent, instruct to VOID and empty bladder, measure abdominal girth
Intra-test: Upright on the edge of the bed, back supported and feet resting on a foot stool
POSTPROCEDURE:
1. MONITOR THE VS
2. MEASURE ABDOMINAL GIRTH & WEIGHT
3. MONITOR FOR HYPOVOLEMIA, ELECTROLYTE LOSS, MENTAL STAUS CHANGES & ENCEPHALOPATHY
4. MONITOR FOR HEMATURIA CAUSED BY BLADDER TRAUMA.
5. EVALUATE EFFECTIVENESS BY: ABDOMINAL GIRTH, WEIGHT, RESPIRATORY RATE.
Liver biopsy
Pretest: Consent, NPO, Check for the bleeding parameters (platelet count, PT, PTT)
Intratest Position: Semi fowlers LEFT lateral to expose right side of abdomen or supine.
Post-test: position on RIGHT lateral with pillow underneath, monitor VS and complications like bleeding, perforation.
Instruct to avoid lifting objects for 1 week
1. Mucosal transport
2. Myoelectric activity
3. Process of
of defecation
NURSING INTERVENTIONS
1. Assist physician in treating the underlying cause of constipation
2. Encourage to eat HIGH fiber diet to increase the bulk
3. Increase fluid intake
4. Administer prescribed laxatives, stool softeners
5. Assist in relieving stress
DIARRHEA- Abnormal fluidity of the stool excessively frequent passage of stools
Multiple causes
Gastrointestinal Diseases
Hyperthyroidism
Food poisoning
Drugs
Food intolerance
Infectious organisms
Nursing Interventions
1. Increase fluid intake- ORESOL is the most important treatment! (water is not sufficient)
2. Determine and manage the cause (antibiotics if bacteria is the cause)
3. Anti-diarrheal drugs ( not initially used if bacteria is the cause)
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4. Avoid carbonated, caffeinated, and high-sugar drinks (osmotic pull) increases diarrhea ---NCLEX
5. Diet should progress, as tolerated. As the symptoms begin to subside, bland foods (cream soups, crackers, toast, rice,
yogurt, custards) can be introduced into the diet. Spicy foods, dairy products, vegetables, fruits, high-sugar foods, and
alcohol should be avoided for the first 2 to 3 days
6. Check VS, Monitor for shock due to dehydration.
DUMPING SYNDROME
A condition of rapid emptying of the gastric contents into the small intestine usually after a gastric surgery
Symptoms occur 30 minutes after eating
ASSESSMENT FINDINGS: early symptoms
1. Nausea and Vomiting
2. Abdominal fullness
3. Abdominal cramping
4. Palpitation
5. Diaphoresis
6. Drowsiness
7. Weakness and Dizziness
8. Hypoglycemia
DOS NURSING INTERVENTIONS
1. Advise patient to eat LOW-carbohydrate HIGH-fat and HIGH-protein diet
2. Instruct to eat SMALL frequent meals, include MORE dry items.
3. Instruct to AVOID consuming FLUIDS with meals
4. Administer anti-spasmodic medications to delay gastric emptying
PERNICIOUS ANEMIA
Results from Deficiency of vitamin B12 due to autoimmune destruction of the parietal cells, lack of INTRINSIC
FACTOR or total removal of the stomach
PERNICIOUS ANEMIA ASSESSMENT
Signs and Symptoms
Severe pallor
Fatigue
Weight loss
SMOOTH BEEFY-RED TONGUE
Mild jaundice
Paresthesia of extremities
Balance disturbance
Diagnostic test:
Schillings test:
test: measures the absorption of radioactive vitB12 both before & after parenteral administration of intrinsic
factor.
Fasting client is given radioactive vit B12 by mouth & non radioactive vit B12 IM to saturate tissue binding sites & to permit
some excretion of radioactive vitamin B12 in the urine if it is absorbed.
24 hour urine collection is obtained.
8%-40% is excreted in 24 hours is normal.
More than 40% indicates pernicious anemia.
NURSING INTERVENTION for Pernicious Anemia Lifetime injection of Vitamin B 12 weekly initially, then MONTHLY
Check up twice a year is recommended. Why? Prone to gastric cancer
STOMATITIS
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Stomatitis is an inflammation of the mucous membranes of the mouth, involving the cheeks, gums, tongue, lips, and roof or
floor of the mouth, and affecting all age groups. The two primary types of stomatitis are aphthous (also called a canker
sore) and herpes simplex virus type 1 (also called a cold sore).
CAUSES
TRAUMA TO MUCOUS MEMBRANES
IRRITATION
HERPES SIMPLEX VIRUS
Signs and symptoms
PAIN
ULCERATIONS, LESIONS
SWOLLEN LYMPH NODES
TREATMENT:
1. Practice good oral hygiene.
2. Appropriate dental care. ( soft bristled toothbrush, toothettes, poorly fitting dentures should be corrected.)
3. Avoid irritating beverages & spicy foods. Avoid hot food & drinks. No to tortilla chips & nuts.
4. Topical anesthetics can be used to decrease pain. ( lidocaine mouthwash.)
5. Oral meds may be prescribed: acyclovir ( herpes), tetracycline, corticosteriods, Nystatin ( fungal)
HIATAL HERNIA
Portion of your stomach herniates to the weakened esophageal hiatus of your diaphragm.
Two types- Sliding hiatal hernia
( most common) and Axial hiatal hernia
CAUSES
MALFORMATIONS
MUSCLE WEAKNESS OF THE ESOPHAGEAL HIATUS
ESOPHAGEAL SHORTENING
OBESITY
ASSESSMENT Findings in Hiatal hernia
1. Heartburn
2. Regurgitation
3. Dysphagia
4. 50%- without symptoms
DIAGNOSTIC TEST
Barium swallow and fluoroscopy
NURSING INTERVENTIONS
1. Provide small frequent feedings (bland)
2. AVOID supine position for 1 hour after eating
3. Elevate the head of the bed on 8-inch block
4. Provide pre-op and post-op care
5. Avoid carbonated beverages & anticholinergic drugs.- CBQ
6. Avoid heavy lifting- CBQ
7. Avoid tight constricted clothing.- CBQ
8. Importance of treating persistent cough.
9. Adherence to weight reduction plan.
Esophageal Varices
Dilation and tortuosity of the submucosal veins in the distal esophagus
ETIOLOGY: commonly caused by PORTAL hypertension secondary to liver cirrhosis
This is an Emergency condition!
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!
!
!
!
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F
Female
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Fat
Forty
Fertile
Fair
NURSING INTERVENTIONS
1. Maintain NPO in the active phase
2. Maintain NGT decompression
NURSING INTERVENTIONS
3. Administer prescribed medications to relieve pain. Usually Demerol (MEPERIDINE)
Codeine and Morphine may cause spasm of the Sphincter% increased pain. Morphine cause MORE PAIN
4. Instruct patient to AVOID HIGH- fat diet and GAS-forming foods
5. Assist in surgical and non-surgical measures
6. Surgical procedures- Cholecystectomy, Choledochotomy, laparoscopy
CONDITION OF THE GALLBLADDER
PHARMACOLOGIC THERAPY
Analgesic- Meperidine
Chenodeoxycholic acid= to dissolve the gallstones
Antacids
Anti-emetics
Post-operative nursing interventions
1. Monitor for surgical complications
2. Post-operative position after recovery from anesthesia- LOW FOWLERs
Post-operative nursing interventions
3. Encourage early ambulation
4. Administer medication before coughing and deep breathing exercises
5. Advise client to splint the abdomen to prevent discomfort during coughing
Post-operative nursing interventions
6. Administer analgesics, antiemetics, antacids
7. Care of the biliary drainageor T-tube drainage
8. Fat restriction is only limited to 4-6 weeks. Normal diet is resumed
Pancreatitis
Inflammation of the pancreas
Can be acute or chronic
Pancreatitis
Etiology and predisposing factors
Alcoholism
Hypercalcemia
Trauma
Hyperlipidemia
Etiology and predisposing factors
Biliary tract disease
- cholelithiasis
Bacterial disease
PUD
Mumps
ASSESSMENT findings
1. Abdominal pain- acute onset, occurring after a heavy meal or alcohol intake
2. Abdominal guarding
3. Bruising on the umbilicus (cullen sign), Bruising on the flanks ( grey turners spots)---CGFNS!!!
4. N/V, jaundice
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ROUTES OF INFECTION
1.Ascending (up the urethra)= transurethral (fecal contamination)
-sexual intercourse/ massaging of urethra forces the bacteria up in bladder
2.Hematogenous
3. Direct extension( (+) fistula from intestine)
CLINICAL MANIFESTATION
LOWER UTI: over 50% with bacteruria have no symptoms
- others: frequent pain & burning sensation on urination; urgency, increase in frequency,
nocturia,incontinence & suprapubic or pelvic pain, hematuria, backpain
UPPER UTI: fever, chills, flank and low back pain
Nausea and vomiting, painful urination
(+) tenderness @ cortovertebral angle (+)kidney punch
ASSESMENT AND DIAGNOSTIC FINDING
TEST: colony count
Cellular studies
Urine culture
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COMPLICATIONS
-End Stage Renal Disease
- Hypertension , \formation of Kidney stones
MANAGEMENT
- Antimicrobial drugs, Teaching patient on bladder emptying, Perineal hygiene
ACUTE GLOMERULONEPHRITIS
- Inflammation of the glomerullar capillaries
- Primarily a disease of older children 2 years or at any age
CAUSATIVE AGENTS; Group A Beta Hemolytic Streptococcos infection of the throat
Infection of the skin Impetigo ( Staphylococcos). Viral, Mumps
Chickenpox, EVB virus, HepB, HIV/AIDS
CLINICAL MANIFESTATIONS:
-primary presenting features : hematuria (micro/gross, cola-colored urine)
Proteinuria
Increased BUN and creatinine as urine output decreased
Anemia
Edema
HPN( Hypertension)
Flank pain
ASSESSMENT & DIAGNOSTIC FINDINGS
-Elevated ASO titer: kidneys are swollen, enlarged & congested
COMPLICATIONS:
-Hypertensive encephalopathy, heart failure, pulmonary edema, End stage renal disease
MANAGEMENT:
-Treat symptoms, preserve kidney function, treat complications
-pharma
pharma drugs depend on causative agent : Penicillin for streptococcal infection
Steroids for inflammation & edema
Diuretics
Anti-hypertensive
Diet:
Diet Decrease dietary protein when BUN is elevated
Sodium restriction when with HPN, Edema & heart failure
CHRONIC GLUMERULONEPHRITIS
-Due to repeated episodes of AGN, hypertensive nephrosclerosis, hyperlipidemia, chronic
injury
-the kidney is reduced to as little as 1/5 of its normal size
tubulointerstitial
CLINICAL MANIFESTATIONS:
Signs and symptoms of renal insufficiency= periorbital edema
anemia
HPN
Retinal findings
Cardiopulmonary findings
ASSESSMENT & DIAGNOSTIC FINDINGS:
-Falling
Falling GFR below 50ml/min. (normal GFR= 100-200ml/min.)
-Hyperkalemia
Hyperkalemia due to decrease potassium excretion
-Metabolic
Metabolic acidosis due to decrease acid secretion of kidney
-Anemia
Anemia due to decrease erythropoeisis
-Hypoalbuminemia
Hypoalbuminemia with edema due to protein loss through the damaged glumerular membrane
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NEPHROTIC SYNDROMES
-Primarily a Glumerular disease characterized by:
Proteinuria (increased protein in urine)- markedly
Hypoalbuminimia
Edema
Hyperlipidemia (high serum cholesterol & low density lipoprotein)
CAUSE:
-Any intrinsic renal disease or systemic disease that affect glumerulus (DM)
-Generally considered a disease of childhood, may also occur at any age
-Causes includes CGN, DM, SLE
CLINICAL MANIFESTATIONS:
Edema (periorbital, sacrum, ankles,hand, ascitis)
Malaise
Headache
Irritability
DIAGNOSTIC FINDINGS:
Proteinuria greater than 3.5g/day
Increased WBC
COMPLICATIONS:
-Accelerated atherosclerosis due to hyperlipidemia
-infection due to deficient immune (proteinuria)
MEDICAL MANAGEMENT:
-The objective is to preserve renal function
-diuretics
-ACE inhibitor- reduce degree of proteinuria
-coticosteroids
-antineoplastic agents
Diet: protein 0.85/kg/day with emphasis on high biologic protein such as dairy products,
meats
Low in saturated fats
egg &
excreted by
the kidney
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CLINICAL MANIFESTATIONS
Lethargy, appears very ill, nausea, vomiting, diarrhea , dry mucous membrane
Uremic factor , CNS s/sx
Management
Identify cause and damage--- treat accordingly
PHARMA: hyperkalemiatreated by cation exchange resin
( kayexalate)kayexalate work by exchanging Na to K in the GIT
(sorbitol)(sorbitol)- induce diarrhea type or water Loss effect
-- RETENTION ENEMA by rectal catheter (kayexalate)
CHRONIC RENAL FAILURE
(ESRD)- progressive, irreversible deterioration in renal function in which the kidney s ability to maintain fluid and
electrolyte falls results to uremia or acoismia (retention of urea and nitrogen waste product in the blood)
Cause: DM, GN, Hypertensive vascular disease, Polycystic kidney
Clinical Manifestations: CVD signs and symptoms, Dermatologic signs, GIT s/sx, CNS s/sx
Assessment: GFR. Electrolyte analysis, Anemia
Management; Pharmacologic
SURGERY: kidney transplant
Nrsg. MNGT: pre op/ intra-op, and during post- operative period
IMMUNOSUPRESSIVE TREATMENT
- the survival of transplanted kidney depends on the ability to BLOCK THE BODYS immune response for the transplanted
kidney and to overcome or minimize bodys defense mechanism, immunosuppresive agents such as,immuran, azathiopine,
cyclosporan are administered
OTHER URINARY SYSTEM DISORDER
UROLITHIASIS ( gravel,sand) bladder stone
--refer to stones (calculi) in urinary tract
--formed when urinary concentration of substances are increased ( due to stasis/obstruction/inability to excrete.
-- ( calcium oxalate, calcium phosphate, uric acid.
OTHER CONDITIONS: excessive intake of vit.D, milk and alkali, Hyperthyroidism, Calcium
CLINICAL MANIFESTATIONS: S/SX of obstruction, infection, edema (RF)
DIAGNOSIS: by X-ray of KUB or Ultrsound
MANAGEMENT: Pain mgt. (NSAID)= hot bath apply to the flank
Surgical: by cystoscopy and by ESWL.
URINARY TRACT CANCER
(Ca.of the Bladder) = predominant cause cigarette smoking.
=metastasis-colon, rectum
=50-70 yrs. Old
= painless visible hematuria, alteration in voiding
NEPROSCLEROSIS
= hardening or sclerosis of the arteries of the kidney due to prolonged Hypertension
= decreased blood flow---glumeruli destruction
URETHRITISinflammation of urethra --- ascending infection-- Gonoccocal or Non-gonoccocal Uritritis or due Sexually
transmitted disease
ASSESSMENT OF RENAL AND URINARY TRACT FUNCTION
Summarized and lecture by Dr. G. Flores
Urinary System Comprises: Kidneys, ureters, bladder and urethra
Structures of which precisely maintain the internal chemical environment of the body perform various
excretory, regulatory and secretory functions.
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KIDNEYS
Pain located retroperitoneally (behind and outside the peritoneal cavity) on the posterior wall of the
abdomen from 12th thoracic vertebrae to 3rd lumbar vertebrae (adult)
Wt. 120-170gram: right kidney lower the left
size : 12 X 6 X 2.5cm
protected by ribs, muscle, fascia, perirenal fat and renal capsule
Region:
o Parenchyma divided into:
' cortex contain the glomeruli tubules collecting ducts peritubular capillaries
' Medulla contain the pyramid which drain into calices renal pelvis
o Renal pelvis
Each contain about 1 million nephrons - cortical nephron (located at the cortex)
- juxtemedulla nephron (located at the medulla)
Glumerulus compose of three filtering layers:
1. Capillary endothelium filters fluid and small molecules, limit
passages of large molecules such as blood (RBC) and albumin
(protein)
2. Basement membrane
3. Epithelium
Function decreases at a rate of 1% each year by age 30 years old.
URETERS
- fibromuscular tube that connects kidney and bladder
- passage of urine
-24-30 cm long; originate to renal pelvis and ends in the bladder wall; left slightly shorter
Three narrowed areas in the ureter:
1. Uretero pelvic junction
2. Sacroiliac junction
3. Ureterovesical junction the angling provides antegrade or downward movement
- prevents vesicourethral reflux or retrograde, backward movement of urine
URINARY BLADDER
A muscular hollow sac behind the pubic bone (true pelvis)
Capacity (adult): 300-600mL
Has 2 inlets (ureters) and 1 outlet (urethrovesical junction)
4 layers of Urinary Bladder:
1. Adventitia (outermost)
2. Detrusor smooth muscle
3. Lamina propia (smooth muscle)
4. Urothelium (innermost) specialized transitional cell epithelium, containing a membrane that is
impermeable to water (prevent reabsorption of urine stored in bladder)
Bladder neck contain: portion of internal sphincter (involuntary smooth muscle) urethral sphincter and
external sphincter under voluntary control at the anterior urethral
URETHRA
Arises from the base of the bladder
Male: it passes to the penis
Female: it open just anterior to the vagina
In male the prostate gland which lies just below the bladder neck, surround the urethra posteriorly and laterally.
Function of the Urinary System
Urine Formation
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Of the 180L/day (45 gallon) of filtrate that the kidney produce each day, 99% is reabsorb in the bloodstream
resulting to 1000-1100 urine each day
Reabsorption and secretion frequently involve passive and active transport and may require use of energy.
Filtrates in the collecting ducts become concentrated under the influence of ADH and becomes urine and enters the
renal pelvis.
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Can store urine 2-4hrs at a time during the day = 6-8hrs at night due to the release ADH (vasoregulator) due to
less intake = concentrated urine
BLADDER EMPTYING
! MICTURATION : Normal: approximately 8xaday
! Normal residual urine : less than 50mL (middle age adult)
50 100mL (older adult)
ASSESSMENT FOR GUT DYSFUNCTION
! Unexplained anemia, manifested by fatigue, SOB, exercise intolerance
! Pain due to obstructed urine flow, inflammation and swelling of tissue
! Changes in voiding, frequency, urgency, dysuria, hesitancy, incontinence, eneuresis, polyuria, oliguria, hematuria
! GIT symptoms: occur because of shared autonomic and sensory innervation
: Nausea/Vomiting/Diarrhea, abdominal pain/ discomfort/distention
PHYSICAL EXAMINATION
(Head-to-toe assessment)
Emphasis in abdomen, suprapubic region, genitalia, lower back and lower extremities
! Direct palpation of kidney: determines size and mobility
! Tenderness of the costovertebral angle
! Auscultation for bruits (low pitch murmurs that indicate renal artery stenosis or an aortic aneurism)
! Presence of peritoneal fluid
! Percussion of bladder and residual urine (from midline umbilicus downward)
! DRE for BPH (yearly exam to men greater than 50yrs old = PSH level
! Inguinal area palpated = (+) enlarged nodes/ hernia/ varicocoele
! Look/papate:: Urethrocoele (bulging of anterior vaginal wall into urethra)
: Cystocoele ( herniation of the bladder wall into vaginal vault)
: Pelvic prolapsed (Cervix bulging in the vaginal vault)
: Enterocoele (hernation bowel into the posterior vaginal wall)
: Rectocoele (herniation of rectum into the vaginal wall)
! Edema/ change in body weight (face independent part of the body, ankle, scrotum)
! 1kg increase= 1000mL of fluid retension
DIAGNOSTIC EXAMINATION
! Urinalysis (+) hematuria (+) pyuria, (+) bacteriuria
! Urine culture
! Renal function test: serum creatinine, BUN, creatinine clearance
! X-ray (KUB delinate size, shape, position of the kidney, abnormalities and calculi
! Ultrasound
! CT/MRI provide cross section views of kidney, urinary function
Example: nephrolithiasis,metastatic disease
! Nuclear scan use to evaluate acute renal function, renal masses, pre and post-renal transplant
! Urography, cystography
! Biopsy
DYSFUNCTIONS OF URINARY TRACT: Management
1.Urinary
Urinary Incontenence
a. Risk Factor: Pregnancy/vaginal delivery/ episiotomy
:stroke, age-related change in urinary tract, medication,diuretic,immobility,sedation
Management: anti cholinergic agent: Oxybutymin; Tx is according to the underlying
cause
Dicycloverine
Treatment : fluid management
Standard voiding frequency
:time and voiding
:habit retraining
:bladder retraining (drill)
:PME (Kegels exercise)
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