MEDICAL SURGICAL

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 Effects of SNS (anti-cholinergic/adrenergic)

1. Dilate pupil - to aware of surroundings
Release of norepinephrine (adrenaline - cathecolamine) - medriasis
Adrenal medulla (potent vasoconstrictor) 2. Dry mouth
Increases body activities VS = Increase 3. BP & HR= increased
Except GIT - decrease GITmotility bronchioles dilated to take more oxygen
4. RR increased
* Why GIT is not increased = GIT is not important! 5. Constipation & urinary retention
Increase blood flow to skeletal muscles, brain & heart.

I. Adrenergic Agents - Epinephrine (adrenaline)

SE: SNS effect
II. PNS: Beta adrenergic blocking agents (opposite of adrenergic agents) (all end in -‘lol')
 Blocks release of norepinephrine.
 Decrease body activities except GIT (diarrhea)
Ex. Propanolol, Metopanolol

SE:
B - broncho spasm (bronchoconstriction)
E - elicits a decrease in myocardial contraction
T - treats HPN
A - AV conduction slows down

Given to angina & MI - beta-blockers to rest heart

Anti HPN agents:
1. Beta blockers (-lol)
2. Ace inhibitors (-pril) ex ENALAPRIL, CAPTOPRIL
3. Calcium antagonist
ex CALCIBLOC or NEFEDIPINE

Peripheral nervous system: cholinergic/ vagal or sympatholitic response Effect of PNS: (cholinergic)
 Involved in fly or withdrawal response 1. Meiosis - contraction of pupils
 Release of acetylcholine (ACTH) 2. Increase salivation
 Decrease all bodily activities except GIT (diarrhea) 3. BP & HR decreased
4. RR decrease - broncho constriction
I Cholinergic agents 5. Diarrhea - increased GI motility
ex 1. Mestinon 6. Urinary frequency
Antidote - anti cholinergic agents Atropine Sulfate - S/E - SNS

S/E- of anti-hpn drugs:

 1. orthostatic hpn
2. transient headache & dizziness.
-Mgt. Rise slowly. Assist in ambulation.
CNS (brain & spinal cord)
I. Cells - A. neurons
Properties and characteristics
a. Excitability - ability of neuron to be affected in external environment.
b. Conductivity - ability of neuron to transmit a wave of excitation from one cell to another
c. Permanent cells - once destroyed, cant regenerate (ex. heart, retina, brain, osteocytes)
Regenerative capacity
A. Labile - once destroyed cant regenerate
- Epidermal cells, GIT cells, resp (lung cells). GUT
B. Stable - capable of regeneration BUT limited time only ex salivary gland, pancreas cells cell of liver, kidney cells
C. Permanent cells - retina, brain, heart, osteocytes can't regenerate.

3.) Neuroglia - attached to neurons. Supports neurons. Where brain tumors are found.
Types:
1. Astrocyte
2. Oligodendria

Astrocytoma - 90 - 95% brain tumor from astrocyte. Most brain tumors are found at astrocyte.
Astrocyte - maintains integrity of blood brain barrier (BBB).
BBB - semi permeable / selective
-Toxic substance that destroys astrocyte & destroy BBB.
Toxins that can pass in BBB:
1. Ammonia-liver cirrhosis.
2. 2. Carbon Monoxide - seizure & parkinsons.
3. 3. Bilirubin- jaundice, hepatitis, kernicterus/hyperbilirubenia.
4. 4. Ketones -DM.

OLIGODENDRIA - Produces myelin sheath - wraps around a neuron - acts as insulator facilitates rapid nerve impulse transmission.
No myelin sheath - degenerates neurons

Damage to myelin sheath - demyellenating disorders

DEMYELLENATING DSE
1.)ALZHEIMER'S DISEASE- atrophy of brain tissue due to a deficiency of acetylcholine.

S&Sx:
A - amnesia - loss of memory
A - apraxia - unable to determine function & purpose of object
A - agnosia - unable to recognize familiar object
A - aphasia -
- Expressive - brocca's aphasia - unable to speakO
Drug of choice - ARICEPT (taken at bedtime) & COGNEX.
Mgt: Supportive & palliative.

Microglia - stationary cells, engulfs bacteria, engulfs cellular debris.

II. Compositions of Cord & Spinal cord

80% - brain mass
10% - CSF
10% - blood
MONROE KELLY HYPOTHESIS: The skull is a closed vault. Any increase in one component will increase ICP.
Normal ICP: 0-15mmHg
Brain mass
 1. Cerebrum - largest - Connects R & L cerebral hemisphere
- Corpus collusum
Rt cerebral hemisphere, Lt cerebral hemisphere
Function:
1. Sensory
2. Motor
3. Integrative
Lobes
1.) Frontal
a. Controls motor activity
b. Controls personality development
c. Where primitive reflexes are inhibited
d. Site of development of sense of umor
e. Brocca's area - speech center
Damage - expressive aphasia
2.) Temporal -
a. Hearing
b. Short term memory
c. Wernickes area - gen interpretative or knowing Gnostic area
Damage - receptive aphasia
3.) Parietal lobe - appreciation & discrimation of sensory imp
- Pain, touch, pressure, heat & cold
4.) Occipital - vision
5.) Insula/island of reil/ Central lobe- controls visceral fx
Function: - activities of internal organ
6.) Rhinencephalon/ Limbec
- Smell, libido, long-term memory

Basal Ganglia - areas of gray matte located deep within a cerebral hemisphere
 Extra pyramidal tract
 Releases dopamine-
 Controls gross voluntary unit

Decrease dopamine - (Parkinson's) pin rolling of extremities & Huntington's Dse.

Decrease acetylcholine - Myasthenia Gravis & Alzheimer's
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 - Romberg's test- needs 2 RNs to assist
- Normal anatomical position 5 - 10 min
(+) Romberg's 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

Normal ICP - 0 - 15 mmHg

Foramen Magnum
C1 - atlas
C2 - axis

(+) Projectile vomiting = increase ICP

Observe for 24 - 48 hrs
CSF - cushions the brain, shock absorber
Obstruction of flow of CSF = increase ICP
Hydrocephalus - posteriorly due to closure of posterior fontanel
CVA - partial/ total obstruction of blood supply

INCREASED ICP - increase ICP is due to increase in 1 of the Intra Cranial components.
Predisposing factors:
1. Head injury
2. Tumor
3. Localized abscess
4. Hemorrhage (stroke)
5. Cerebral edema
6. Hydrocephalus
7. Inflammatory conditions - Meningitis, encephalitis

B. S&Sx change in VS = always late symptoms

Earliest Sx:
a.) Change or decrease LOC - Restlessness to confusion Wide pulse pressure: Increased ICP
- Disorientation to lethargy Narrow pp: Cardiac disorder, shock
- Stupor to coma
Late sign - change in V/S
1. BP increase (systolic increase, diastole- same)
2. Widening pulse pressure
Normal adult BP 120/80 120 - 80 = 40 (normal pulse pressure)
Increase ICP = BP 140/80 = 140 - 80= 60 PP (wide)
3. RR is decreased (Cheyne-Stokes = bet period of apnea or hyperpnea with periods of apnea)
4. Temp increase
Increased ICP: Increase BP Shock - decrease BP -
Decrease HR Increase HR CUSHINGS EFFECT
Decrease RR Increase RR
Increase Temp Decrease temp
b.) Headache
Projectile vomiting
Papilledima (edema of optic disk - outer surface of retina)
Decorticate (abnormal flexion) = Damage to cortico spinal tract /
Decerebrate (abnormal extension) = Damage to upper brain stem-pons/

c.) Uncal herniation - unilateral dilation of pupil. (Bilateral dilation of pupil - tentorial herniation.)
d.) Possible seizure.
 Nursing priority:
1.) Maintain patent a/w & adequate ventilation
a. Prevention of hypoxia - (decrease tissue oxygenation) & hypercarbia (increase in CO2 retention).

Hypoxia - cerebral edema - increase ICP

Hypoxia - inadequate tissue oxygenation
Late symptoms of hypoxia - B - bradycardia
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

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

2.) Loop diuretic - Lasix (Furosemide)

Nursing Mgt: Lasix
Same as Mannitol except
- Lasix is given via IV push (expect urine after 10-15mins) should be in the
morning. If given at 7am. Pt will urinate at 7:15
Immediate effect of Lasix within 15 minutes. Max effect - 6 hrs due (7am - 1pm)
 S/E of Lasix
Hypokalemia (normal K-3.5 - 5.5 meg/L)
S&Sx
Weakness & fatigue
Constipation
(+) "U" wave in ECG tracing

Nursing Mgt:
Administer K supplements - ex Kalium Durule, K chloride
Potassium Rich food:
ABC's of K
Vegetables Fruits
A - asparagus A - apple
B - broccoli (highest) B - banana - green
C - carrots 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
Don't give grapes - may choke

S/E of Lasix:
Hypokalemia
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.
(+) Chevostek's sign
Arrhythmia
Laryngospasm
Administer - Ca gluconate - IV slowly

Ca gluconate toxicity: Sx - seizure - administer Mg SO4

Mg SO4 toxcicity- administer Ca gluconate
B - BP decrease
U - urine output decrease
R - RR decrease
P - patellar reflexes absent

Hyponatremia - Normal Na level = 135 - 145 meg/L

S/Sx - 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

4.) Hyperglycemia - increase blood sugar level

P - polyuria
P - polyphagia
P - polydipsia

Nsg Mgt:
Monitor FBS (N=80 - 120 mg/dl)
5.) Hyperurecemia - increase serum uric acid. Tophi- urate crystals in joint.

Gouty arthritis kidney stones- renal colic (pain)

Cool moist skin
Sx joint pain & swelling usually at great toe.
 Nsg Mgt of Gouty Arthritis
a.) Cheese (not sardines, anchovies, organ meat)
(Not good if pt taking MAO)
b.) Force fluid
c.) Administer meds - Allopurinol/ Zyloprim - inhibits synthesis of uric acid - drug of choice for gout
Colchicene - excretes uric acid. Acute gout drug of choice.
Kidney stones - renal colic (pain). Cool moist skin
Mgt:
Force fluid
Meds - narcotic analgesic
Morphine SO4

SE of Morphine SO4 toxicity

Respiratory depression (check RR 1st)
Antidote for morphine SO4 toxicity -Narcan (NALOXONE)
Naloxone toxicity - tremors

Increase ICP meds:

3.) Corticosteroids - Dexamethsone - decrease cerebral edema (Decadrone)
4.) Mild analgesic - codeine SO4. For headache.
5.) Anti consultants - Dilantin (Phenytoin)

Question: Increase ICP what is the immediate nsg action?

Administer Mannitol as ordered
Elevate head 30 - 45 degrees
Restrict fluid
Avoid use of restraints

Nsg Priority - ABC & safety

Pt suffering from epiglotitis. What is nsg priority?

Administer steroids - least priority
Assist in ET - temp, a/w
Assist in tracheotomy - permanent (Answer)
Apply warm moist pack? Least priority
Rationale: Wont need to pass larynx due to larynx is inflamed. ET can't pass. Need tracheostomy only-

Magic 2's of drug monitoring

Drug N range Toxicity Classification Indication

D - digoxin .5 - 1.5 meq/L 2 cardiac glycosides CHF
L - lithium .6 - 1.2 meq/L 2 antimanic bipolar
A - aminophylline 10 - 19 mg/100ml 20 bronchodilator COPD
D - Dilantin 10 -19 mg/100 ml 20 anticonvulsant seizures
A - acetaminophen 10 - 30 mg/100ml 200 narcotic analgesic osteoarthritis

Digitalis - increase cardiac contraction = increase CO

Nursing Mgt
Check PR, HR (if HR below 60bpm, don't giveDigoxin)
Digitalis toxicity - antidote - Digivine nclex-immune fab
Anorexia -initial sx.
n/v GIT
Diarrhea
Confusion
Photophobia
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 -
Anorexia
n/s
Diarrhea
Dehydration - force fluid, maintain Na intake 4 - 10g daily
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:
Tachycardia
Hyperactivity - restlessness, agitation, tremors

Question: Avoid giving food with Aminophylline

Cheese/butter- food rich in tyramine, avoided only if pt is given MAOI
Beer/ wine -
Hot chocolate & tea - caffeine - CNS stimulant tachycardia
Organ meat/ box cereals - anti parkinsonian

MAOI - antidepressant
m AR plan
n AR dil can lead to CVA or hypertensive crisis
p AR nate
3 - 4 weeks - before MAOI will take effect
Anti Parkinsonian agents - Vit B6 Pyridoxine reverses effect of Levodopa

D - dilatin (Phenytoin) - anti convulsant/seizure- it decrease hyperactivity of brain waves.

Nursing Mgt:
Mixed with plain NSS or .9 NaCl to prevent formation of crystals or precipitate
 Do sandwich method
 Give NSS then Dilantin, then NSS!
Instruct the pt to avoid alcohol - bec alcohol + dilantin can lead to severe CNS depression

Dilantin toxicity:
S/Sx:
G - gingival hyperplasia - swollen gums
Oral hygiene - soft toothbrush
Massage gums
H - hairy tongue
A - ataxia (+) rombergs test
N - nystagmus - abnormal movement of eyeballs
A - acetaminophen/ Tylenol - non-opoid analgesic & antipyretic - febrile pts
Acetaminophen toxicity : it inhibits prostaglandin synthesis
Hepato toxicity
Monitor liver enzymes
SGPT (ALT) - Serum Glutamic Piruvate Tyranase
SGOT- Serum Glutamic Acetate Tyranase
Monitor BUN (10 - 20)
Crea (.8-1)
Acetaminophen toxicity can lead to hypoglycemia
T - tremors, Tachycardia
I - irritability
R - restlessness
 E - extreme fatigue
D - depression (nightmares) , Diaphoresis
Antidote for acetaminophen toxicity - Acetylcesteine = causes outporing of secretions. Suction.
Prepare suctioning apparatus.
Question: The following are symptoms of hypoglycemia except:
Nightmares
Extreme thirst - hyperglycemia symptoms
Weakness d. Diaphoresis

PARKINSONS DSE (parkinsonism) - chronic, progressive disease of CNS char by degeneration of dopamine
producing cells in substancia nigra at mid brain & basal ganglia
 Palliative, Supportive
Function of dopamine: controls gross voluntary motors.
Predisposing Factors:
1. Poisoning (lead & carbon monoxide). Antidote for lead = Calcium EDTA
2. Hypoxia
3. Arteriosclerosis-hardening of blood vessel
4. Encephalitis
Triad cause suicidal
High doses of the ff:
a. Reserpine (serpasil) anti HPN, SE - 1.) depression - suicidal 1. Loss of spouse 100% 2.) breast cancer
b. Methyldopa (aldomet) - promote safety 2.loss of job 95%
c. Haloperidol (Haldol)- anti psychotic 3. Aloneness 90%
d. Phenothiazide - anti psychotic

SE of anti psychotic drugs - Extra Pyramidal Symptom

Over meds of anti psychotic drugs - neuroleptic malignant syndrome char by tremors (severe)
S/Sx: Parkinsonism -
Pill rolling tremors of extremities - early sign Stages parkinson
Bradykinesia - slow movement 1, unilateral flexionnn of upper extrimities
Over fatigue 2. Shiffling gait
Rigidity (cogwheel type) 3.progressive diffucuty ambultng
Stooped posture 4. Progressive weakness
Shuffling - most common
Propulsive gait
Mask like facial expression with decrease blinking eyes
Monotone speech
Difficulty rising from sitting position
Mood labilety - always depressed - suicide
Nsg priority: Promote safety
Increase salivation - drooling type
Autonomic signs:
 Increase sweating
 Increase lacrimation
 Seborrhea (increase sebaceous gland)
 Constipation
 Decrease sexual activity
Nsg Mgt
Anti parkinsonian agents
 Levodopa (L-Dopa), Carbidopa (Sinemet), Amantadine Hcl (Symmetrel)
Mechanism of action
Increase levels of dopa - relieving tremors & bradykinesia
S/E of anti parkinsonian
 Anorexia
 n/v
 Confusion
Orthostatic hypotension
 Hallucination
 Arrhythmia
Contraindication:
 Narrow angled closure glaucoma
Pt taking MAOI (Parnate, Marplan, Nardil)

Nsg Mgt when giving anti-parkinsonian

Take with meals - to decrease GIT irritation
Inform pt - urine/ stool may be darkened
Instruct pt- don't take food Vit B6 (Pyridoxine) cereals, organ meats, green leafy veg
Cause B6 reverses therapeutic effects of levodopa
Give INH (Isoniazide-Isonicotene acid hydrazide.) SE-Peripheral neuritis.
Anti cholinergic agents - relieves tremors
Artane mech - inhibits acetylcholine
Cogentin action , S/E - SNS

Antihistamine - Diphenhydramine Hcl (Benadryl) - take at bedtime

S/E: adult- drowsiness,- avoid driving & operating heavy equipt. Take at bedtime.
Child - hyperactivity CNS excitement for kids.
4.) Dopamine agonist
Bromocriptine Hcl (Parlodel) - relieve tremors. respiratory depression. Monitor RR.

Nsg Mgt - Parkinson

1.) Maintain siderails
2.) Prevent complications of immobility
- Turn pt every 2h
Turn pt every 1 h - elderly
3.) Assist in passive ROM exercises to prevent contractures
4.) Maintain good nutrition
CHON - in am
CHON - in pm - to induce sleep - due Tryptopan - Amino Acid
5.) Increase fluid in take, high fiber diet to prevent constipation
6.) Assist in surgery - Sterotaxic Thalamotomy
Complications in sterotaxic thalmotomy- 1.) Subarachnoid hemorrhage 2.) aneurism 3.) encephalitis

MULTIPLE SCLEROSIS (MS)

Chronic intermittent disorder of CNS - white patches of demyelenation in brain & spinal cord.
 Remission & exacerbation
 Common - women, 15 - 35 yo cause - unknown
Predisposing factor:
Ediophatic /unknown.Slow growing virus
Autoimmune - (supportive & palliative treatment only)
Normal Resident Antibodies:
Ig G - can pass placenta - passive immunity. Short acting.
Ig A - body secretions - saliva, tears, colostrums, sweat
Ig M - acute inflammation
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. Lhermitte's 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

MYASTHENIA GRAVIS (MG) - disturbance in transmission of impulses from nerve to muscle cell at neuro muscular
junction. Leading descending muscle weakness.
Common in Women, 20 - 40 yo, unknown cause or idiopathic
Autoimmune- self destruction of self killing - release of cholenesterase - enzyme
Cholinesterase destroys ACH (acetylcholine) = Decrease acetylcholine
Descending muscle weakness( unable to see, swallow,speak, breath)
(Ascending muscle weakness - Guillain Barre Syndrome)
Nsg priority:
a/w
aspiration
immobility
S/ Sx:
Ptosis - drooping of upper lid ‘kirat'( initial sign)
Check Palpebral fissure - opening of upper & lower lids = to know if (+) of MG.
Diplopia - double vision
Mask like facial expression
Dysphagia - risk for aspiration!
Weakening of laryngeal muscles - hoarseness of voice
 Resp muscle weakness - lead respiratory arrest. Prepare at bedside tracheostomy set
Extreme muscle weakness during activity especially in the morning.
Dx test
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 -
Cholinergics or anticholinesterase agents
Mestinon (Pyridostigmine)
Neostignine (prostigmin) - Long term
- Increase acetylcholine
s/e - PNS
Corticosteroids - to suppress immune resp
Decadron (dexamethasone)

Monitor for 2 types of Crisis:

Myastinic crisis Cholinergic crisis
A cause - 1. Under medication Cause: 1 over meds
2. Stress S/Sx - PNS
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 Mgt. adm anti-cholinergic
 Atropine SO4
 SNS - dry mouth
7. Assist in surgical proc - thymectomy. Removal of thymus gland. Thymus secretes auto immune antibody.
8. Assist in plasmaparesis - filter blood
9. Prevent complication - respiratory arrest
Prepare tracheostomy set at bedside.

GBS - Guillain Barre Syndrome

 Disorder of CNS
 Bilateral symmetrical polyneuritis
Ascending paralysis
Cause - unknown, idiopathic
 Auto immune
 r/t antecedent viral infection
 Immunizations
Common ; men 30 above
S&Sx
Initial :
Clumsiness
Ascending muscle weakness - lead to paralysis
Dysphagia
Decrease or diminished DTR (deep tendon reflexes)
 Paralysis
Alternate HPN to hypotension - lead to arrhythmia - complication (cardiac monitor)
Autonomic changes - increase sweating, increase salivation.
Increase lacrimation
Constipation
Dx most important: CSF analysis thru lumbar puncture reveals increase in : IgG & CHON (same with MS)
Nsg Mgt
1. Maintain patent a/w & adequate vent
a. Assist in mechanical vent
b. Monitor pulmonary function test
2. Monitor vs., I&O neuro check, ECG tracing due to arrhythmia
3. Siderails
4. Prevent compl - immobility
5. Assist in passive ROM exercises
6. Institute NGT feeding - due dysphagia

7. Adm meds (GBS) as ordered: - 1. Anti cholinergic - atropine SO4

2. Corticosteroids - to suppress immune response
3. Anti arrhythmic agents
a.) Lidocaine /Xylocaine -SE confusion = VTach
b.) Bretyllium-hypotension black the release of n.e
c.) Quinines/Quinidine - anti malarial agent. Give with meals.
- Toxic effect - cinchonism
Quinidine toxicity
S/E - anorexia, n/v, headache, vertigo, visual disturbances
Assist in plasmaparesis (MG. GBS) filtering of blood
Prevent comp - arrhythmias, respiratory arrest
Prepare tracheostomy set at bedside.

INFL CONDITONS OF BRAIN

Meninges - 3-fold membrane - cover brain & spinal cord
Fx:
Protection & support
Nourishment
Blood supply
3 layers
1. Duramater sub dural space
2. Arachmoid matter
3. Pia matter sub arachnoid space where CSF flows L3 & L4. Site for lumbar puncture.

MENINGITIS - inflammation of meningitis & spinal cord

Etiology - Meningococcus
Pneumococcus
Hemophilous influenza - child
Streptococcus - adult meningitis
MOT - direct transmission via droplet nuclei

S&Sx
 Stiff neck or nuchal rigidity (initial sign)
 Headache
 Projectile vomiting - due to increase ICP
 Photophobia
 Fever chills, anorexia
 Gen body malaise
 Wt loss
 Decorticate/decerebration - abnormal posturing
 Possible seizure
Sx of meningeal irritation - nuchal rigidity or stiffness
Opisthotonus- rigid arching of back

Pathognomonic sign - (+) Kernig's & Brudzinski sign

Leg pain 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
Consent / explain procedure to pt
 RN - dx procedure (lab)
 MD - operation procedure
Empty bladder, bowel - promote comfort
Arch back - to clearly visualize L3, L4

Nsg Ngt post lumbar

Flat on bed - 12 - 24 h to prevent spinal headache & leak of CSF
Force fluid
Check punctured site for drainage, discoloration & leakage to tissue
Assess for movement & sensation of extremeties

Result
1. CSF analysis: a. increase CHON & WBC Content of CSF: Chon, wbc, glucose
b. Decrease glucose
Confirms meningitis c. increase CSF opening pressure
N 50 - 160 mmHg
d. (+) Culture microorganism
2. Complete blood count CBC - reveals increase WBC
Mgt:
1. Adm meds
a.) Broad-spectrum antibiotic penicillin
S/E
GIT irritation - take with food
Hepatotoxicity, nephrotoxcicity
Allergic reaction
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 - Cushing's 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. Comfy & dark room - due to photophobia & seizure

4. Prevent complications of immobility
5. Maintain F & E balance
6. Monitor vs, I&O , neuro check
7. Provide client health teaching & discharge plan
a. Nutrition - increase cal & CHO, CHON-for tissue repair. Small freq feeding
b. Prevent complication hydrocephalus, hearing loss or nerve deafness.
8. Prevent seizure.
Where to bring 2 yo post meningitis
 Audiologist due to damage to hearing- post repair myelomeningocele
 Urologist -Damage to sacral area - spina bifida - controls urination
9. Rehab for neurological deficit. Can lead to mental retardation or a delay in psychomotor development.

CEREBRO VASCULAR ACCIDENT - stroke, brain attack or cerebral thrombosis, apoplexy

 Partial or complete disruption in the brains blood supply
 2 largest & common artery in stroke
Middle cerebral artery
Internal carotid artery
 Common to male - 2 - 3x high risk

Predisposing factor:
Thrombosis - clot (attached)
Embolism - dislodged clot - pulmo embolism
S/Sx: pulmo embolism
Sudden sharp chest pain
Unexplained dyspnea, SOB
Tachycardia, palpitations, diaphoresis & mild restlessness

S/Sx: cerebral embolism

Headache, disorientation, confusion & decrease in LOC

Femur fracture - complications: fat embolism - most feared complication w/in 24hrs
Yellow bone marrow - produces fat cells at meduallary cavity of long bone
Red bone marrow - provides WBC, platelets, RBC found at epiphisis
2.) Hemorrhage
3.) Compartment syndrome - compression of nerves/ arteries

Risk factors of CVA: HPN, DM, MI, artherosclerosis, valvular heart dse - Post heart surgery - mitral valve replacement

Lifestyle: 1. Smoking - nicotine - potent vasoconstrictor

2. Sedentary lifestyle
3. Hyperlipidemia - genetic
4. Prolonged use of oral contraceptives
- Macro pill - has large amt estrogen
- Mini pill - has large amt of progestin
- Promote lipolysis (breakdown of lipids/fats) - artherosclerosis - HPN - stroke
5. Type A personality
a. Deadline driven person
b. 2 - 5 things at the same time
c. Guilty when not dong anything
6. Diet - increase saturated fats
7. Emotional & physical stress
8. Obesity
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.) (+) Kernig's & 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. Alexia - diff reading
6. Homoninous hemianopsia - loss of half of field of vision
Left sided hemianopsia - approach Right side of pt - the unaffected side

Dx
CT Scan - reveals brain lesion
Cerebral arteriography - site & extent of mal occlusion
Invasive procedure due to inject dye
Allergy test -seafood
All - graphy - invasive due to iodine dye. Fluid volume deficit
Post
Force fluid - to excrete dye is nephrotoxic
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.
4. Monitor vs., I&O, neuro check
5. Prevent compl of immobility by:
a. Turn client q2h on affected extremity every 30mins.
Elderly q1h
 To prevent decubitus ulcer
 To prevent hypostatic pneumonia - after prolonged immobility.
b. Egg crate mattress or H2O bed
c. Sand bag or foot board- prevent foot drop
6. NGT feeding - if pt can't swallow
7. Passive ROM exercise q4h
8. Alternative means of communication
- Non-verbal cues
- Magic slate. Not paper and pen. Tiring for pt.
- (+) To hemianopsia - approach on unaffected side
9. Meds
Osmotic diuretics - Mannitol (osmitrol)- sidedrip check bp before I&O
Loop diuretics - Lasix/ Furosemide
Corticosteroids - dextamethazone(decadron)
Mild analgesic(codeine sulfate)
Thrombolytic/ fibrolitic agents - tunaw clot. SE-Urticaria, pruritus-caused by foreign subs.
Streptokinase-s/e: allergic reaction, anaphylactic reaction
Urokinase-s/e: hypertension
Tissue plasminogen activating
Monitor bleeding time
Anticoagulants - Heparin - short acting & Coumadin-long acting" sabay"
Coumadin will take effect after 3 days
Heparin - "parenteral' monitor PTT partial thromboplastin time if prolonged - bleeding give Protamine SO4-
antidote.
Coumadin - "oral"Long term. monitor PT prothrombin time if prolonged- bleeding give Vit K - Aquamephyton-
antidote.
Antiplatelet - PASA - aspirin para aminosalisylic acid.aspirin, don't give to dengue, ulcer, and unknown headache.
S/E aspirin: heartburn,indegistion or dipepsia, hemolyctic anemia.
Health Teaching
1. Avoidance modifiable lifestyle
- Diet, smoking,exercise
2. Dietary modification
- Avoid caffeine, decrease Na & saturated fats
Complications:
 1.Subarachnoid hemorrhage
Rehab for focal neurological deficit - physical therapy
A, Mental retardation
B Delay in psychomotor development
2.brain herniation

CONVULSIVE Disorder (CONVULSIONS)- disorder of the CNS char. by paroxysmal seizures with or without loss of
consciousness, abnormal motor activity, alteration in sensation & perception & change in behavior.

Can you outgrow febrile seizure? Difference between: Seizure- 1st convulsive attack
Febrile seizure Normal if < 5 yo Epilepsy - 2nd and with history of seizure
Pathologic if > 5 yo

Predisposing Factor
Head injury due birth trauma
Toxicity of carbon monoxide
Brain tumor
Genetics
Nutritional & metabolic deficit
Physical stress
Sudden withdrawal to anticonvulsants will bring about status epilepticus
Status epilepticus - drug of choice: Diazepam & glucose

S & Sx
I. Generalized Seizure -
a.) Grand mal / tonic clonic seizures
With or without aura - warning symptoms of impending seizure attack- Epigastric pain- associated with
olfactory, tactile, visual, auditory sensory experience
 Epileptic cry - fall
 Loss of consciousness 3 - 5 min
Tonic clonic contractions
 Direct symmetrical extension of extremities-TONIC. Contractions-CLONIC
 Post ictal sleep -state of lethargy or drowsiness - unresponding sleep after tonic clonic
b.) Petimal seizure - (same as daydreaming!) or absent seizure.
- Blank stare
- Decrease blinking eye
- Twitching of mouth
- Loss of consciousness - 5 - 10 secs (quick & short)

II. Localized/partial seizure

Jacksonian seizure or focal seizure - tingling/jerky movement of index finger/thumb & spreads to shoulder & 1 sideof
the body with janksonian march
Psychomotor/ focal motor - seizure
-Automatism - stereotype repetitive & non-purposive behavior
- Clouding of consciousness - not in control with environment
- Mild hallucinatory sensory experience

HALLUCINATIONS
Auditory - schitzo - paranoid type
Visual - korsakoffs psychosis - chronic alcoholism
Tactile - addict - substance abuse

III. Status epilecticus - continuous, uninterrupted seizure activity, if untreated, lead to hyperprexia - coma - death
Seizure: inc electrical firing in brain=increased metabolic activity in brain=brain using glucose and O2=dec glucose, dec O2.
Tx:Diazepam (drug of choice), glucose
Dx-Convulsion- get health history!
CT scan - brain lesion
 EEG electroencephalography
 Hyperactivity brain waves
Nsg Mgt
Priority - Airway & safety
Maintain patent a/w & promote safety
Before seizure:
Remove blunt/sharp objects
Loosen clothing
Avoid restraints
Maintain siderails
Turn head to side to prevent aspiration
Tongue guard or mouth piece to prevent biting of tongue-BEFORE SEIZURE ONLY! Can use spoon at home.
Avoid precipitating stimulus - bright glaring lights & noises
Administer meds
Dilantin (Phenytoin) -( toxicity level - 20 )

SE Ginguial hyperplasia
H-hairy tongue
A-ataxia
N-nystagmus
A-acetaminophen- febrile pt
Mix with NSS
- Don't give alcohol - lead to CNS depression
b. (Tegretol) Carbamasene- given also to Trigeminal Neuralgia. SE: arrythmia
c. Phenobarbital (Luminal)- SE: hallucinations

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:
Comprehensive neuro exam
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 (1)
13 - 11 - lethargy (2)
10 - 8 - stupor
7 - coma
3 - deep coma - lowest score

Survey of mental status & speech (Comprehensice Neuro Exam)

LOC & test of memory
Levels of orientation
CN assessment
 Motor assessment
Sensory assessment
Cerebellar test - Romhberg, finger to nose
DeepTendonReflex
Autonomics

Levels of consciousness (LOC) -

Conscious (conscious) - awake - levels of wakefulness
Lethargy (lethargic) - drowsy, sleepy, obtunded
Stupor (stuporous) - awakened by vigorous stimulation
Pt has gen body weakness, decrease body reflex
Coma (Comatose) light - (+) all forms of painful stimulations
Deep - (-) to painful stimulation
Question: Describe a conscious pt ?
Alert - not all pt are alert & oriented to time & place
Coherent
Awake- answer
Aware

Different types of pain stimulation

Don't prick
Deep sternal stimulation/ pressure 3x- fist knuckle
With response - light coma
Without response - deep coma
Pressure on great toe - 3x
Orbital pressure - pressure on orbits only - below eye
Corneal reflex/ blinking reflex
Wisp of cotton - used to illicit blinking reflex among conscious patients
Instill 1-drop saline solution - unconscious pt if (-) response pt is in deep coma
Test of memory - considered educational background
Short term memory -
 What did you eat for breakfast?
Damage to temporal lobe - (+) antero grade amnesia
Long term memory
(+) Retrograde amnesia - damage to limbic system
Levels of orientation
Time Place Person

Graphesthesia- can identify numbers or letters written on palm with a blunt object.
Agraphesthesia - cant identify numbers or letters written on palm with a blunt object.

CN assessment:
I- Olfactory s
II - Optic s
III - Oculomotor m
IV - Trocheal m smallest CN
V- Trigeminal b largest CN
VI - Abducens m
VII - Facial b
VIII - Acustic/auditory s
IX - Glassopharyngeal b
X- Vagus b longest CN
XI- Spinal accessory m
XII - Hypoglossal m

I. Olfactory - don't 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 optic- 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 20/20 20/200 - blindness - cant read E - biggest
OS - left eye 20/20
OU - both eye 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 N left eye

IO SO O
S
LR MR E
SR

3 - 4 EOM
IV - sup oblique
VI - lateral rectus
Normal response - PERRLA (isocoria - equal pupil)
Anisocoria - unequal pupil

Oculomotor
Raising of eyelid - Ptosis
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

Hot milk, butter, raisins
Cereals
Gelatin, toast, potato - all correct but
Potato, salad, gelatin - salad easier to chew

VI 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
Cause - bells palsy pedia - R/T forcep delivery
Temporary only
Most evident clinical sign of facial symmetry: Nasolabial folds

VIII Acoustic/ vestibule cochlear (controls hearing) - controls balance (kenesthesia or position sense)
 Movement & orientation of body in space
 Organ of Corti - for hearing - true sense organ of hearing

Outer - tympanic membrane, pinna, oricle (impacted cerumen), cerumen

Middle - hammer, anvil, stirrup or melleus, incus, staples. Mid otitis media
 Eustachean ear
Inner ear- meniere dse, sensory hearing loss (research parts! & dse)
Remove vestibule - meniere's dse - disease inner ear

Archimedes law - buoyancy (pregnancy - fetus)

Daltons law - partial pressure of gases
Inertia - law of motion (dizziness, vertigo)

1.) Pt with multiple stab wound - chest

- Movement of air in & out of lungs is carried by what principle?
- Diffusion - Dalton's law
2.) Pregnant - check up - ultrasound reveals fetus is carried by amniotic fluid
- Archimedes
3.) Severe vertigo due- Inertia

Test for acoustic nerve:

 Repeat words uttered

IX - Glossopharyngeal - controls taste - posterior 1/3 of tongue

X - Vagus - controls gag reflex

Test 9 - 10
Pt say ah - check uvula - should be midline
Damage cerebral hemisphere is L or R
Gag reflex - place tongue depression post part of tongue
Don't touch uvula

XI - Spinal Accessory - controls sternocleidomastoid (neck) & trapezius (shoulders and back)
 Shrug shoulders, put pressure. Pt should resist pressure. Paresis or phlegia
XII - Hypoglossal - controls movement of tongue - say "ah". Assess tongue position=midline
L or R deviation
- Push tongue against cheek
- Short frenulum lingue -
Tongue tied - "bulol"

ENDOCRINE

Fx of endocrine - ductless gland

Main gland - Pituitary gland - located at base of brain of Stella Turcica
Master gland of body
Master clock of body

Anterior pituitary gland - adenohypophysis

Posterior pituitary gland - neurohypophysis
Posterior pituitary:
1.) Oxytocin - a.) Promotes uterine contraction preventing bleeding/ hemorrhage.
- Give after placental delivery to prevent uterine atony.
b.) Milk letdown reflex with help of prolactin.
2.) ADH - antidiuretic hormone - (vasopressin) -Prevents urination - conserve H2O

A. DIABETIS INSIPIDUS (DI- dalas ihi) - hyposecretion of ADH

Cause: idiopathic/ unknown
Predisposing factor:
Pituitary surgery
Trauma/ head injury
Tumor
Inflammation

* alcohol inhibits release of ADH

S & Sx:
1. Polyuria
2. Sx of dehydration (1st sx of dehydration in children-tachycardia)
- Excessive thirst (adult)
- Agitation
- Poor skin turgor
- Dry mucus membrane
3. Weakness & fatigue
4. Hypotension - if left untreated -
5. Hypovolemic shock
Anuria - late sign hypovolemic shock

Dx Proc:
Decrease urine specific gravity- concentrated urine
N= 1.015 - 1.035
Serum Na = increase (N=135 -145 meq/L) Hypernatremia

Mgt:
Force fluid 2,000 - 3,000ml/day
Administer IV fluid replacement as ordered
Monitor VS, I&O
Administer meds as ordered
a.) Pitresin (vasopressin) IM
5. Prevent complications
Most feared complication - Hypovolemic shock

B.) SIADH - Syndrome of Inappropriate Anti-Diuretic Hormone

- Increase ADH
- Idiopathic/ unknown

Predisposing factor
Head injury
Related to Bronchogenic cancer or lung caner-
Early Sign of Lung Ca - Cough -1. non productive 2. productive
3. Hyperplasia of Pit gland
Increase size of organ

S&Sx
Fluid retention
Increase BP - HPN
 Edema
Wt gain
Danger of H2O intoxication -Complications: 1. cerebral edema - increase ICP - 2. seizure

Dx Proc:
Urine specific gravity increase - diluted urine
Hyponatremia - Decreased Na

Nsg Mgt:
Restrict fluid
Administer meds as ordered eg. Diuretics: Loop and Osmotic
Monitorstrictly V/S, I&O, neuro check - increase ICP
Weigh daily
Assess for presence edema
Provide meticulous skin care
Prevent complications - increase ICP & seizures activity

Anterior Pituitary Gland - adeno

Growth hormone (GH) (Somatotropic hormone)
Fx: Elongation of long bones
Decrease GH - dwarfism children
Increase GH - gigantism
Increase GH - acromegaly - adult
Puberty 9 yo - 21 yo
Epiphyseal plate closes at 21 yo

Square face
Square jaw

Drug of choice in acromegaly: Ocreotide (Sandostatin) SE dizziness

Somatostatin Hormone - antagonizes the release of of GH
Melanocytes stimulating hormone - MSH
 Skin pigmentation
Prolactin/luteotrpic hormone/ lactogenic hormone - Promotes development of mammary gland
(Oxytocin-Initiates milk letdown reflex)
Adrenocorticotropic hormone - ACTH - Development & maturation of adrenal cortex
Luteinizing hormone - produces progesterone.
FSH- produces estrogen

PINEAL GLAND
Secretes Melatonin - inhibits lutenizing hormone (LH) secretion

THYROID GLAND (TG)

Question: Normal physical finding on TG:
a. With tenderness - thyroid never tender
b. With nodular consistency- answer
c. Marked asymmetry - only 1 TG
d. Palpable upon swallowing - Normal TG never palpable unless with goiter

TG hormones:
T3 T4 Thyrocalcitonin
- Triodothyronine -Tetraiodothyronine/ Tyroxine FX - antagonizes effects of parathormone

- 3 molecules of iodine - 4 molecules of iodine

Metabolic hormone
 Increase metabolism brain -inc cerebration, inc v/s all v/s down, constipation

Hypo T3 T4 - lethargy & memory impairment -

Hyper T3 T4 - agitation, restlessness, and hallucination
Increase VS, increase motility

HYPOTHYROIDISM - all decreased except wt & menstruation, loss of appetite but with wt gain
menorrhagia - increase in mens
HYPERTHYROIDISM - Increase appetite - wt loss, amenorrhea

SIMPLE GOITER - enlarged thyroid gland - iodine deficiency

Predisposing factors
Goiter belt area - Place far from sea - no iodine. Seafood's rich in iodine
Mountainous area - increase intake of goitrogenic foods (US: Midwest, NE, Salt Lake)
Cabbage - has progoitrin - an anti thyroid agent with no iodine
Example: Turnips (singkamas), radish, peas, strawberries, potato, beans, kamote, cassava (root crops), all nuts.
3. Goitrogenic drugs:
Anti thyroid agents :(PTU) prephyl thiupil
Lithium carbonate, Aspirin PASA
Cobalt, Phenyl butasone
Endemic goiter - cause # 1
Sporadic goiter - caused by #2 & 3

S & Sx - enlarged TG
Mild restlessness
Mild dysphagia

Dx Proc.
Thyroid scan - reveals enlarged TG
Serum TSH - increase (confirmatory)
Serum T3, T4 - N or below N

Nsg Mgt:
1. Administer meds
a.) Iodine solution - Logol's solution or saturated sol of K iodide SSKI

Nsg Mgt Lugol's sol - violet color

use straw - prevent staining teeth
Prophylaxis 2 -3 drops Treatment - 5 to 6 drops
Use straw - to prevernt staining of teeth
1. Lugol's sol., 2. tetracycline 3. nitrofurantin (macrodantin)-urinary anticeptic-pyelonephritis. 4. Iron solution.

B. Thyroid h / Agents
1. Levothyroxine (Synthroid)
2. Liothyronine (cytomel)
3. Thyroid extract

Nsg Mgt: for TH/agents

Monitor vs. - HR due tachycardia & palpitation
Take it early AM - SE insomnia
Monitor s/e
Tachycardia, palpitations
Signs of insomnia
Hyperthyroidism restlessness agitation
Heat intolerance
HPN
 Encourage increase intake iodine - iodine is extracted from seaweeds (!)
Seafood- highest iodine content oysters, clams, crabs, lobster
Lowest iodine - shrimps
Iodized salt -easily destroyed by heat take it raw not cooked

Assist surgery- Sub total thyroidectomy-

Complication: 1. Tetany 2. laryngeal nerve damage 3.Hemorrhage-feeling of fullness at incision site.Check nape for
wet blood. 4.Laryngeal spasm - DOB, SOB - trache set ready at bedside.

2.) HYPOTHYROIDISM - decrease secretion of T3, T4 - can lead to MI / Atherosclerosis

Adult - myxedema
Child- cretinism - only endocrine dis lead to mental retardation
Predisposing factor:
`Iatrogenic causes - caused by surgery
Atrophy of TG due to:
Irradiation
Trauma
Tumor, inflammation
Iodine def
Autoimmune - Hashimoto disease

S&Sx everything decreased except wt gain & mens increase)

Early signs - weakness and fatigue
Loss of appetite - increased lypolysis - breakdown of fats causing atherosclerosis = MI
Wt gain
Cold intolerance - myxedema - coma
Constipation
Late Sx - brittle hair/ nails
Non pitting edema due increase accumulation of mucopolysacharide in SQ tissue -Myxedema
Horseness voice
Decrease libido
Decrease VS - hypotension bradycardia, bradypnea, and hypothermia
Lethargy
Memory impairment leading to psychosis-forgetfulness
Menorrhagia

Dx:
Serum T3 T4 decrease
Serum cholesterol increase - can lead to MI
RA IU - radio iodine uptake - decrease

Nsg Mgt:
Monitor strictly V/S. I&O - to determine presence of myxedema coma!
Myxedema Coma - Severe form of hypothyroidism
Hypotension, hypoventilation, bradycardia, bradypnea, hyponatremia, hypoglycemia, hypothermia
Might lead to progressive stupor & coma
Impt mgt for Myxedema coma
Assist mech vent - priority a/w
Adm thyroid hormone
Adm IVF replacement - force fluid

Mgt myxedema coma

Monitor VS, I&O
Provide dietary intake low in calories - due to wt gain
Skin care due to dry skin
Comfortable & warm environment due to cold intolerance
 Administer IVF replacements
Force fluid
Administer meds - take AM - SE insomia. Monitor HR.
Thyroid hormones
Levothyroxine(Synthroid), Liothyronine (cytomel)
Thyroid extracts
Health teaching & discharge plan
Avoidance precipitating factors leading to myxedema coma:
Exposure to cold environment
Stress 3. Infection
4. Use of sedative, narcotics, anesthetics not allowed - CNS depressants V/S already down

Complications:
Hypovolemic shock, myxedema coma
Hormonal replacement therapy - lifetime
Importance of follow up care

HYPERTHYROIDISM - Graves dse or thyrotoxicosis ( everything up except wt and mens)

-Increased T3 & T4
Predisposing factors:
Autoimmune disease - release of long acting thyroid stimulator (LATS)
Exopthalmos
Enopthalmos - severe dehydration depressed eye
Excessive iodine intake
Hyperplasia of TG

S&Sx:
Increase in appetite - hyperphagia - wt loss due to increase metabolism
Skin is moist - perspiration
Heat intolerance
Diarrhea - increase motility
All VS increase = HPN, tachycardia, tachypnea, hyperthermia
CNS changes
Irritability & agitation, restlessness, tremors, insomnia, hallucinations
Goiter
Exopthalmos - pathognomonic sx
Amenorrhea

Dx:
Serum T3 & T4 - increased
Radio iodine uptake - increase
Thyroid scan - reveals enlarged TG

Nsg Mgt:
1. Monitor VS & I & O - determine presence of thyroid storm or most feared complication: Thyrotoxicosis
Administer meds
Antithyroid agents
Prophylthiuracil (PTU)
Methymazole (Tapazole)
Most toxic s/e agranulocytosis- fever, sore throat, leukocytosis=inc wbc: check cbc and throat swab culture
Most feared complication : Thrombosis - stroke CVS

Diet - increase calorie - to correct wt loss

Skin care -
Comfy & cool environment
Maintain siderails- due agitation/restlessness
Provide bilateral eye patch - to prevent drying of eyes- exopthalmos
Assist in surgery - subtotal thyroidectomy
 Nsg Mgt: pre-op
Adm Lugol's solution (SSKI) K iodide -purple violet color
To decrease vascularity of TG
To prevent bleeding & hemorrhage
Mgt post op:
Complication: 1. Watch out for signs of thyroid storm or thyrotoxicosis
Triad signs of thyroidstorm;
Tachycardia /palpitation
Hyperthermia
Agitation

Nsg Mgt Thyroid Storm:

Monitor VS & neuro check
Agitated might decrease LOC
Antipyretic - fever
Tachycardia - b blockers (-lol)
Siderails - agitated

Comp 2. Watch for inadvertent (accidental) removal of parathyroid gland

Secretes Para hormone

If removed, hypocalcemia - classic sign tetany - 1. .(+) Trousseau sign/ 2. Chvosteck's sign
Nsg Mgt:
Adm calcium gluconate slowly - to prevent arrhythmia
Ca gluconate toxicity - antidote - MgSO4
3.Laryngeal (voice box) nerve damage (accidental)
Sx: hoarseness of voice
***Encourage pt to talk or speak post operatively asap to determine laryngeal nerve damage
Notify physician!

4. Signs of bleeding post subtotal thyroidectomy

- "Feeling of fullness" at incision site
Nsg mgt:
Check soiled dressing at nape area

5. Signs of laryngeal spasm

a. DOB
b. SOB
Prepare at bedside tracheostomy

6. Hormonal replacement therapy - lifetime

7. Importance of follow up care
(Liver cirrhosis - bedside scissor - if pt complaints of DOB)

(Cut cystachean tube to deflate balloon)

Parathyroid gland - pair of small nodules located behind the TG

Secrets parathyroid hormone - promotes Ca reabsorption

Thyrocalcitonin - antagonises secretion of parathyroid hormone

Hypoparthroidism - decrease of parathyroid hormone

Hyperparathroidsm
HYPOPARATHYROIDISM - decreased parathormone

Hypocalcemia Hyperphosphatemia
(Or tetany)dec calcium inc phosphate

[If Ca decreases, phosphate increases]

A. Predisposing, factors:
1. Following subtotal thyroidectomy
2. Atrophy of parathyroid gland due to
a. Irradiation
b. Trauma

S&Sx:
Acute tetany
Tingling sensation
Paresthesia
Dysphagia
Laryngospasm
Bronchospasm

Pathognomonic Sign of tetany:

(+) Trousseau's or carpopedial spasm
(+) Chvosteck's sign

f. Seizure most feared complication

g. Arrhythmia

Chronic tetany
Loss of tooth enamel
Photophobia & cataract formation
GIT changes - anorexia, n/v, general body malaise
CNS changes - memory impairment, irritability

Dx:
Serum calcium - decrease (N 8.5 - 11 mg/100ml)
Serum phosphate increase (N 2.5 - 4.5 mg/100ml)
X-ray of long bone - decrease bone density
CT Scan - reveals degeneration of basal ganglia

Nsg Mgt:
Administration of meds:
Acute tetany -
Ca gluconate - IV, slowly
Chronic tetany
Oral Ca supplements
Ex. Ca gluconate
Ca carbonate
Ca lactate

Vit D (Cholecalceferol)

Drug diet sunlight

Cholecalceferol calcidiol calcitriol 7am - 9am

Phosphate binder
Alumminum DH gel (ampho gel)
SE constipation
Antacid
AAC MAD
Aluminum containing acids Mg containing antacids
Ex. Milk or magnesia
Aluminum OH gel Diarrhea

Constipation Maalox - magnesium & aluminum - Less s/e

2. Avoid precipitating stimulus such as bright lights & noise: photophobia leading to seizure
3. Diet - increase Ca & decrease phosphorus
- Don't give milk - due to increase phosphorus
Good = anchovies - increase Ca, decrease phosphorus + inc uric acid. Tuna & green turnips- Inc Ca.
4. Bedside - tracheostomy set -due to laryngospasm
5. Encourage to breath with paper bag in order to produce mild respiratory acidosis - to promote increase ionized Ca levels
6. Most feared complication : Seizure & arrhythmia
7. Hormonal replacement therapy - lifetime
8. Important fallow up care

HYPERPARATHYROIDISM - increase parathormone. Complication: Renal failure

Hypercalcemia can lead to Hypophosphatemia

Bone dse - kidney stones

Mineralization

Leading to bone fracture

Ca - 99% bones
1% serum blood

Predisposing Factors:
Hyperplasia parathyroid gland (PTG)
Over compensation of PTG due to Vit D deficiency
Children - Rickets Vit D
Adults - Osteomalacia deficiency

Sippy's diet - Vit D diet - not good for pt with ulcer

2 -4 cups of milk & butter
Karrel's diet - Vit D diet - not good for pt with ulcer
6 cups of milk & whole cream

Food rich in CHON - eggnog - combination of egg & milk

S/Sx:
Bone fracture
Bone pain (especially at back), bone fracture
Kidney stone -
Renal colic- flank area pain
Cool moist skin
GIT changes - anorexia, n/v, ulcerations
CNS involvement- irritability, memory impairment

Dx Proc:
 Serum Ca increase
Serum phosphorus decreases
X-ray long bones - reveals bone demineralization

Nsg Mgt: Kidney Stone

Force fluids - 2,000 - 3,000/day or 2-3L/day

Isotonic solution
Warm sitz bath - for comfort
Strain all urine with gauze pad
Acid ash diet - cranberry, plum, grapefruit, vit C, calamansi - to acidify urine
Adm meds
Narcotic analgesic - Morphine SO4, Demerol (Meperidine Hcl)
S/E - resp depression. Monitor RR)
Narcan/ Naloxone - antidote
Naloxone toxicity - tremors
Siderails
Assist in ambulation
Diet - low in Ca, increase phosphorus lean meat
Prevent complication
Most feared - renal failure
Assist surgical procedure - parathyroidectomy
Impt ff up care
Hormonal replacement- lifetime

ADRENAL GLAND
Atop of @ kidney
2 parts
Adrenal cortex - outermost layer
Adrenal medulla - innermost layer
Secrets cathecolamines
Epinephrine / Norephinephrine - potent vasoconstrictor - adrenaline=Increase BP

Adrenal Medulla's only disease:

PHEOCHROMOCYTOMA- presence of tumor at adrenal medulla surgery: adrenalectomy1.unilateral a. 6-12mos rep.
-increase nor/epinephrine 2. Bilateral a. ifetime rep.
-with HPN and resistant to drugs
-drug of choice: beta blockers
-complication: HPN crisis = lead to stroke
-no valsalva maneuver

Adrenal Cortex -
Zona fasiculata - secrets glucocorticoids
Ex. Cortisol - Controls glucose metabolism (SUGAR)
Zona reticularis - secrets traces of glucocorticoids & androgenic hormones
M - testosterone
F - estrogen & progesterone
Fx - promotes development of secondary sexual characteristics
3. Zona glomerulosa - secretes mineralcortisone
Ex. Aldosterone
Fx: promotes Na & H2O reabsorption & excretion of potassium (SALT)

ADDISON'S DISEASE - Steroids-lifetime

Decreased adrenocortical hormones leading to:
 Metabolic disturbances (sugar)
F&E imbalances- Na, H2O, K
Deficiency of neuromuscular function (salt & sex)

Predisposing Factors:
Atrophy of adrenal gland
Fungal infections
Tubercular infections

S/Sx:
Decrease sugar - Hypoglycemia - Decreased glucocorticoids - cortisol

T - tremors, tachycardia
I - irritability
R - restlessness
E - extreme fatigue
D - diaphoresis, depression

Decrease plasma cortisol

Decrease tolerance to stress - lead to Addisonian's crisis

Decrease salt - Hyponatermia - Decreased mineralocorticoids - Aldosterone

Hypovolemia
Hypotension
Signs of dehydration - extreme thirst, agitation
Wt loss
Hyperkalemia
Irritability
Diarrhea
Arrhythmia
Decrease sexual urge or libido- Decreased Androgen
Loss of pubic and axillary hair

To Prevent STD Local - practice monogamous relationship

CGFNS/NCLEX - condom
Pathognomonic sign- bronze like skin pigmentation due to decrease cortisol will stimulate pituitary gland to release melanocyte
stimulating hormone.

Dx Proc:
FBS - decrease FBS (N 80 - 120 mg/dL)
Plasma cortisol - decreased
Serum Na - decreased (N 135 - 145 meg/L)
Serum K - increased (N 3.5 - 5.5 meg/L)

Nsg Mgt:
Monitor VS, I&O - to determine presence of Addisonian crisis
Complication of Addison's dse : Addisonian crisis
Results the acute exacerbation of Addison's dse characterized by :
Hypotension, hypovolemia, hyponatremia, wt loss, arrhythmia
Lead to progressive stupor & coma

Nsg Mgt Addisonian Crisis (Coma)

Assist in mechanical ventilation
Adm steroids
Force fluids

Administer meds
a.) Corticosteroids - (Decadron) or Dexamethazone
- Hydrocortisone (cortisone)- Prednisone

Nsg Mgt with Steroids

 Adm 2/3 dose in AM & 1/3 dose in PM in order to mimic the normal diurnal rhythm.
Taper the dose (w/draw, gradually from drug) - sudden withdrawal can lead to addisonian crisis
Monitor S/E (Cushing's syndrome S/Sx)
HPN
Hirsutism
Edema
Moon face & buffalo hump
Increase susceptibility to infection sue to steroids- reverse isolation

b.) Mineralocorticoids ex. Flourocortisone

Diet - increase calorie or CHO

Increase Na, Increase CHON, Decrease K
Force fluid
Administer isotonic fluid as ordered
Meticulous skin care - due to bronze like
HT & discharge planning
a) Avoid precipitating factors leading to Addisonian crisis
Sudden withdrawal crisis
Stress
Infection
Prevent complications
Addisonian crisis & Hypovolemic shock
Hormonal replacement therapy - lifetime
Important: follow up care

CUSHING'S SYNDROME - increase secretion of adrenocortical hormone

Predisposing Factors:
Hyperplasia of adrenal gland
Tubercular infection - milliary TB
S/Sx
Increase sugar - Hyperglycemia
3 P's
1. Polyuria
2. Polydipsia - increase thirst
3. Polyphagia - increase appetite
Classic Sx of DM - 3 P's & glycosuria + wt loss
Increase susceptibility to infection - due to increased corticosteroid
Hypernatrermia
HPN
Edema
Wt gain
Moon face
Buffalo hump
Obese trunk classic signs
Pendulous abdomen
Thin extremities
Hypokalemia
Weakness & fatigue
Constipation
ECG - (+) "U" wave
Hirsutism - increase sex
Acne & striae
Increase muscularity of female
Dx:
FBS – increase↑ (N: 80-120mg/dL)
Plasma cortisol increase
Na – increase (135-145 meq/L)
K- decrease (3.5-5.5 meq/L)
Nsg Mgt:
Monitor VS, I&O
Administer meds
a. K- sparing diuretics (Aldactone) Spironolactone
- promotes excretion of NA while conserving potassium

Not lasix due to S/E hypoK & Hyperglycemia!

Restrict Na
Provide Dietary intake - low in CHO, low in Na & fats
High in CHON & K
Weigh pt daily & assess presence of edema- measure abdominal girth- notify doc.
Reverse isolation
Skin care - due acne & striae
Prevent complication
- Most feared - arrhythmia & DM
(Endocrine disorder lead to MI - Hypothyroidism & DM)
Surgical bilateral Adrenolectomy
Hormonal replacement therapy - lifetime due to adrenal gland removal- no more corticosteroid!

PANCREAS - behind the stomach, mixed gland - both endocrine and exocrine gland
Acinar cells (exocrine gland) Islets of Langerhans (endocrine gland ductless)

Secrete pancreatic juices at pancreatic ducts. a cells

Aids in digestion (in stomach) secrets glucagon

Fxn: hyperglycemia (high glucose)

b Cells

Secrets insulin

Fxn: hypoglycemia

Delta Cells

Secrets somatostatin

Fxn: antagonizes growth hormone

3 disorders of the Pancreas

DM
Pancreatic Cancer
Pancreatitis

Overview only: alcoholic wag kmain bgo matulog.

PANCREATITIS (check page 72)- acute inflammation of pancreas leading to pancreatic edema, hemorrhage & necrosis due to
Autodigestion - self-digestion
Cause: unknown/idiopathic
Or alcoholism
Pathognomonic sign- (+) Cullen's sign - Ecchymosis of umbilicus (bluish color)- pasa
(+) Grey turner's sign - ecchymosis of flank area

Both sx means hemorrhage

CHRONIC HEMORRHAGIC PANCREATITIS- "bangugot"

Predisposing factors - unknown
Risk factor:
History of hepatobiliary disorder
Alcohol
Drugs - thiazide diuretics, oral contraceptives, aspirin, penthan
Obesity
Hyperlipidemia
Hyperthyroidism
High intake of fatty food - saturated fats

DIABETES MELLITUS - metabolic disorder characterized by non utilization of CHO, CHON,& fat metabolism
Classification:
Type I DM (IDDM) - "Juvenile " onset, common in children, non-obese "brittle dse"
-Insulin dependent diabetes mellitus
Incidence rate
10% of population with DM have Type I
Predisposing Factor:
90% hereditary - total destruction of pancreatic dells
Virus
Toxicity to carbon tetrachloride
Drugs - Steroids both cause hyperglycemia
Lasix - loop diuretics

S/Sx:
3 P'S + G
1.) Polyuria
2.) Poydipsia
3.) Polyphagia
4.) Glycosuria
5.) Weight loss
6.) Anorexia
7.) N/V
8.) Blurring of vision
9.) Increase susceptibility to infection
10.) Delayed/ poor wound healing

Mgt:
Insulin Therapy
Diet - CHO 50% CHON30% FATS20%
Exercise

Complications - Diabetic Ketoacidosis (DKA)

Diabetic Ketoacidosis (DKA) - due to increase fat catabolism or breakdown of fats

DKA -(+) fruity or acetone breath odor

Kassmaul's respiration - rapid, shallow breathing

Diabetic coma (needs oxygen)

 Type II DM - (NIDDM)
Adult/ maturity onset type - age 40 & above, obese OBESE- lack insulin receptor for binding site
Incidence Rate
90% of pop with DM have Type II
Mid 1980's marked increase in type II because of increase proliferation of fast food chains!

Predisposing Factor:
Obesity - obese people lack insulin receptors binding site
Hereditary

S/Sx:
Asymptomatic
3 P's and 1G

Tx:
Oral Hypoglycemic Agents (OHA)
Diet
Exercise

Complication: HONKC
H - hyper
O - osmolar
N - non
K - ketotic
C - coma

III. GESTATIONAL DM - occurs during pregnancy & terminates upon delivery of child

Predisposing Factors:
Unknown/ idiopathic
Influence of maternal hormones
S/Sx :
Same as type II -
Asymptomatic
3 P's & 1G

Type of delivery - CS - due to large baby

Sx of hypoglycemia on infant
High pitched shrill cry
Poor sucking reflex
IV. DM ASSOCIATED WITH OTHER DISORDER
Pancreatic tumor
Cancer
Cushing's syndrome

3 MAIN FOOD GROUPS

Anabolism Catabolism
1. CHON glucose glycogen
2. CHON amino acids nitrogen
3. Fats fatty acids free fatty acids (FFA) - Cholesterol & Ketones

Pancreas → glucose → ATP (Main fuel/energy of cell )

Reserve glucose – glycogen
Liver will undergo – glucogenesis – synthesis of glucagons
& Glycogenolysis – breakdown of glucagons
& Gluconeogenesis – formation of glucose form CHO sources – CHON & fats
Hyperglycemia - pancreas will not release insulin. Glucose can't go to cell, stays at circulation causing hyperglycemia.
increase osmotic diuresis - glycosuria
Lead to cellular starvation

Lead to wt loss stimulates the appetite/ satiety center polyuria

(Hypothalamus)
Cellular dehydration
Polyphagia
Stimulates thirst center (hypothalamus)

Polydipsia

Increased CHON catabolism

Lead to (-) nitrogen balance

Tissue wasting (cachexia)

Increase fat catabolism

Free fatty acids

Cholesterol ketones DKA

Atherosclerosis coma

HPN death

MI stroke

DIABETIC KETOACIDOSIS (DKA)

 Acute complication of Type I DM due to severe hyperglycemia leading to CNS depression & Coma.
 Ketones- a CNS depressant

Predisposing factor:
Stress - between stress and infection, stress causes DKA more.
Hyperglycemia
Infection

S/Sx: 3 P's & 1G

Polyuria
Polydipsia
Polyphagia
Glycosuria
Wt loss
Anorexia, N/V
(+) Acetone breath odor- fruity odor pathognomonic DKA
Kussmaul's resp-rapid shallow respiration
CNS depression
Coma

Dx Proc:
FBS increase, Hct - increase (compensate due to dehydration)
N =BUN - 10 -20 mg/100ml --increased due to severe dehydration
Crea - .8 - 1 mg/100ml
 Hct 42% (should be 3x high)-nto hgb

Nsg Mgt:
Can lead to coma - assist mechanical ventilation
Administer .9NaCl - isotonic solution
Followed by .45NaCl hypotonic solution
To counteract dehydration.
Monitor VS, I&O, blood sugar levels
Administer meds as ordered:
Insulin therapy - IV push
Regular Acting Insulin - clear (2-4hrs, peak action)
To counteract acidosis - Na HCO3
Antibiotic to prevent infection

Insulin Therapy
Sources:
Animal source - beef/ pork-rarely used. Causes severe allergic reaction.
Human - has less antigenecity property
Cause less allergic reaction. Humulin

If kid is allergic to chicken - don't give measles vaccine due it comes from chicken embryo.
Artificially compound

Types of Insulin
Rapid Acting Insulin - Ex. Regular acting I
Intermediate acting I - Ex. NPH (non-protamine Hagedorn I)
Long acting I - Ex. Ultra lente

Types of Insulin color & consistency onset peak duration

1. Rapid regular humulin clear 2-4h -
2. Intermediate nph cloudy 8-16h -
3. Long acting ultra lente cloudy 16-24h -

Ex. 5am Hemoglucose test (HGT)

250 mg/dl
Adm 5 units of RA I
Peak 7-9am - monitor hypoglycemic reaction at this time- TIRED

Nsg Mgt: upon injection of insulin:

1.Administer insulin at room temp! - To prevent lipodystrophy = atrophy/ hypertrophy of SQ tissues
2. Insulin is only refrigerated once opened!
3. Gently roll vial bet palms. Avoid shaking to prevent formation of bubbles.
4. Use gauge 25 - 26needle - tuberculin syringe
5. Administer insulin at either 45(for skinny pt) or 90° (taba pt)depending on the client tissue deposit.
6. Don't aspirate after injection
7. Rotate injection site to prevent lipodystrophy
8. Most accessible site - abdomen
9. When mixing 2 types of insulin, aspirate
1st regular/ clear - before cloudy to prevent contaminating clear insulin & to promote accurate calibration.
10. Monitor signs of complications:
a. Allergic reactions - lipodystrophy
b. Somogyi's phenomenon - hypoglycemia followed by periods of hyperglycemia or rebound effect of insulin.
11. 1ml or cc of tuberculin = 100 units of insulin
 - - 1 cc = 100 units

- - .5cc = 50 units

- - .1 cc = 10 units

6 units RA

Most Feared Complication of Type II DM

Hyper ↑ osmolarity = severe dehydration
Osmolar
Non - absence of lipolysis
Ketotic - no ketone formation
Coma – S/Sx: headache, restlessness, seizure, decrease LOC = coma

Nsg Mgt; - same as DKA except don't give NaHCO3!

1.Can lead to coma - assist mechanical ventilation

2. Administer .9NaCl - isotonic solution
Followed by .45NaCl hypotonic solution
To counteract dehydration.
3.Monitor VS, I&O, blood sugar levels
4.Administer meds
Insulin therapy - IV
Antibiotic to prevent infection
Tx:
O ral
H ypoglycemic
A gents
Stimulates pancreas to secrete insulin

Classifications of OHA
First generation Sulfonylurear
Chlorpropamide (diabenase)
Tolbutamide (orinase)
Tolazamide (tolinase)

2nd generation sulfonylurear

Diabeta (Micronase)
Glipside (Glucotrol)

Nsg Mgt or OHA

Administer with meals - to lessen GIT irritation & prevent hypoglycemia
Avoid alcohol (alcohol + OHA = severe hypoglycemic reaction=CNS depression=coma) Antabuse-Disufram

Dx for DM
FBS - N 80 - 120 mg/dl = Increased for 3 consecutive times =confirms DM!!
+ 3 P's & 1G
Oral glucose tolerance (OGTT) - Most sensitive test
Random blood sugar - increased
Alpha Glucosylated Hgb - elevated

Nsg Mgt;
Monitor for PEAK action of OHA & insulin
Notify Doc
Monitor VS, I&O, neurocheck, blood sugar levels.
Administer insulin & OHA therapy as ordered.
 Monitor signs of hyper & hypoglycemia.

Pt DM -" hinimatay"
You don't know if hypo or hyperglycemia.
Give simple sugar
(Brain can tolerate high sugar, but brain can't tolerate low sugar!)
Cold, clammy skin - hypo - Orange Juice or simple sugar / warm to touch - hyper - adm insulin
Provide nutritional intake of diabetic diet:
CHO - 50%
CHON - 30%
Fats - 20%
-Or offer alternative food products or beverage.
-Glass of orange juice.
Exercise - after meals when blood glucose is rising.
Monitor complications of DM
Atherosclerosis - HPN, MI, CVA
Microangiopathy - small blood vessels
Eyes - diabetic retinopathy , premature cataract & blindness
Kidneys - recurrent pyelonephritis & Renal Failure
(2 common causes of Renal Failure : DM & HPN)
Gangrene formation
Peripheral neuropathy
Diarrhea/ constipation
Sexual impotence
Shock due to cellular dehydration
Foot care mgt
Avoid waking barefooted
Cut toe nails straight
Apply lanolin lotion - prevent skin breakdown
Avoid wearing constrictive garments

Annual eye & kidney exam

Monitor urinalysis for presence of ketones
Blood or serum - more accurate
Assist in surgical wound debridement
Monitor signs or DKA & HONKC
Assist surgical procedure
BKA or above knee amputation

Overview: HEMATOLOGICAL SYSTEMS

I Blood
II Blood vessels
III Blood forming organs
Thymus - removed myasthenia gravis
Liver - largest gland
Lymph nodes
Lymphoid organs - payers patch
Bone marrow
Spleen - destroys RBC
Blood vessels
Veins -SVC, IVC, Jugular vein - blood towards the heart
Artery - carries blood away from the
Aorta, carotid
Capillaries

Blood 45% formed elements - 55% plasma - fluid portion of vlood. Yellow color.

Serum Plasma CHON's (Produced in Liver)

1. Albumin- largest, most abundant plasma
 Maintains osmotic pressure preventing edema
FXN: promotes skin integrity
2. Globulins - alpha - transports steroids Hormones & bilirubin
b - Transports iron & copper
Gamma - transport immunoglobulins or antibodies
3. Prothrombin - fibrinogen - clotting factor to prevent bleeding
Formed Elements:
1. RBC (erythrocytes) Spleen life span = 120 days
(N) 3 - 6 M/mm3
- Anucleated
- Biconcave discs
- Has molecules of Hgb (red cell pigment)
Transports & carries O2

SICKLE CELL ANEMIA -sickle shaped RBC. Should be round. Impaired circulation of RBC.
-immature cells=hemolysis of RBC=decreased hgb
3 Nsg priority
1. a/w - avoid deoxygenating activities
- High altitude is bad
2. Fluid deficit - promote hydration
3. Pain & comfort

Hgb ( hemoglobin)

F= 12 - 14 gms %
M = 14-16 gms %

Hct - 3x hgb 12 x 3 = 36
(hamatocrit) F 36 - 42% 14 x 3 = 42
M 42 - 48%
Average 42%
- Red cell percentage in whole red

Substances needed for maturation of RBC

Folic acid
Iron
Vit C
Vit B12 (cyanocobalamin)
Vit B6 (Pyridoxine)
Intrinsic factor

Pregnant: 1st trimester- Folic acid - prevent neural tube deficit

3rd tri - iron
Life span of rbc - 80 - 120 days. Destroyed at spleen.

WBC - leucocytes 5,000 - 10,000/mm3

GRANULOCYTES NON-GRANULOCYTES
1. Polymorphonuclearneutrophils 1. Monocytes (macrophage) - largest WBC
Most abundant 60-70% WBC - involved in long term phagocytes
- fx - short term phagocytosis - For chronic inflammation
For acute inflammation - Other name macrophage

2. PM Basophils Macrophage in CNS- microglia

-Involved in Parasitic infection
- Release of chem. Mediator for inflammation
Serotonin, histamine, prostaglandin, bradykinins
3. PM eosinophils
- Allergic reactions
Macrophage in skin - Histiocytes
Macrophage in lungs - alveolar macrophage
Macrophage in Kidneys - Kupffer cells
2. Lymphocytes
B Cell - L - bone marrow or bursa dependent
T cell - dev't of immunity- target site for HIV
NK cell - natural killer cell
Have both antiviral & anti-tumor properties

3.Platelets (thrombocytes)
N- 150,000 - 450, 000/ mm3
it promotes hemostasis - prevention of blood loss by activating clotting
- Consists of immature or baby platelets known as megakaryocytes - target of virus -
dengue
- Normal lifespan 9 - 12 days

Drug of choice for HIV Zidovudine (AZT or Retrovir)

Standard precaution for HIV gloves, gown, goggles & mask

Malaria - night biting mosquito

Dengue - day biting mosquito

Signs of platelet dis function:

Petecchiae
Ecchemosis/ bruises
Oozing or blood from venipuncture site

ANEMIA
Iron deficiency Anemia - chronic normocytic, hypocromic (pale), microcytic anemia due to inadequate absorption of iron leading to
hypoxemic injury.

Incidence rate:
1. Common - developed country - due to high cereal intake
Due to accidents - common on adults
2. Common - tropical countries - blood sucking parasites
3. Women - 15 - 35yo - reproductive yrs
4. Common among the poor - poor nutritional intake

Suicide - common in teenager

Poisoning - common in children (aspirin)
Aspiration - common in infant
Accidents - common in adults
Choking - common in toddler
SIDS - common in infant in US
Common in tropical zone - Phil due blood sucks

Predisposing factor:
Chronic blood loss
Trauma
Mens
GIT bleeding:
 Hematemesis-
Melena - upper GIT - duodenal cancer
Hematochezia - lower GIT - large intestine - fresh blood from rectum
2. Inadequate intake of food rich in iron
3. Inadequate absorption of iron - due to :
a. Chronic diarrhea
b. Malabsorption syndrome -celiac disease-gluten free diet. Food for celiac pts- sardines
c. High cereal intake with low animal CHON ingestion
d. Subtotal gastrectomy
4. Improper cooking of food

S/Sx:
Asymptomatic
Headache, dizziness, dyspnea, palpitations, cold sensitivity, gen body malaise, pallor
Brittle hair, spoon shaped nails (KOILONYCHIA)=Dec O2=hypoxia=atrophy of epidermal cells
Atropic glossitis, dysphagia, stomatitis
Pica - abnormal craving for non edible food (caused by hypoxia=dec tissue perfusion=psychotic behavior)

Brittle hair, spoon shaped nail - atrophy of epidermal cells

N = capillary refill time < 2 secs
N = shape nails - biconcave shape, 180°
Atrophy of cells "Plummer Vinsons Syndrome" due to cerebral hypoxia
1. Atropic glossiti - inflammation of tongue due to atrophy of pharyngeal and tongue cells
2. Stomatitis - mouth sores
3. Dysphagia

Dx Proc:
RBC
Hgb
Reticulocyte
Hct
Iron
Ferritin

Nsg Mgt
Monitor signs of bleeding of all hema test including urine & stool
Complete bed rest - don't overtire pt =weakness and fatigue=activity intolerance
Encourage - iron rich food
Raisins, legumes, egg yolk
Instruct the pt to avoid taking tea - impairs iron absorption
Administer meds
Oral iron preparation
Ferrous SO4
Fe gluconate
Fe Fumarate
Nsg Mgt oral iron meds:
Administer with meals - to lessen GIT irritation
If diluting in iron liquid prep -adm with straw

Straw
Lugol's
Tetracycline
Oral iron
Macrodantine

Give Orange juice - for iron absorption

Monitor & inform pts S/E
Anorexia
n/v
Abdominal pain
 Diarrhea or constipation
Melena

If pt can't tolerate oral iron prep - administer parenteral iron prep example:
Iron dextran (IV, IM)
Sorbitex (IM)

Nsg Mgt parenteral iron prep

Administer of use Z tract method to prevent discomfort, discoloration leakage to tissues.
Don't massage injection site. Ambulate to facilitate absorption.
Monitor S/E:
Pain at injury site
Localized abscess ("nana")
Lymphadenopathy
Fever/ chills
Urticaria - itchiness
Hypotension - anaphylactic shock

Anaphylactic shock - give epinephrine

PERNICIOUS ANEMIA - megaloblastic, chronic anemia due to deficiency of intrinsic factor leading to
Hypochlorhydria - decrease Hcl acid secretion. Lifetime B12 injections. With CNS involvement.

Predisposing factor
Subtotal gastrectomy - removal stomach
Hereditary
Infl dse of ileum
Autoimmune
Strict vegetable diet

STOMACH

Parietal or ergentaffen Oxyntic cells

Fxn - produce intrinsic factor Fxn - secrets Hcl acid

For reabsorption of B12 Fx aids in digestion

For maturation of RBC

Diet high caloric or CHO to correct wt loss

S/Sx:
Headache dizziness, dyspnea, palpitations, cold sensitivity, gen body malaise, pallor
GIT changes
Red - beefy tongue - PATHOGNOMONIC - mouth sores
Dyspepsia - indigestion
Wt loss
Jaundice
CNS -
Most dangerous anemia: pernicious due to neuroglogic involvement.
Tingling sensation
Paresthesia
(+) Romberg's test
Ataxia
Psychosis
Dx:- Shilling's test
Nsg Mgt - Pernicious anemia
Enforce CBR
Administer B12 injections at monthly intervals for lifetime as ordered. IM- dorsogluteal or ventrogluteal. Not given oral - due pt
might have tolerance to drug
Diet - high calorie or CHO. Increase CHON, iron & Vit C
Avoid irritating mouthwashes. Use of soft bristled toothbrush is encouraged.
Avoid applying electric heating pads - can lead to burns

APLASTIC ANEMIA - stem cell disorder due to bone marrow depression leading to pancytopenia - all RBC are decreased

Decrease RBC decrease WBC decrease platelets

Anemia leukopenia thrombocytopenia
Increase WBC leukocytocys
Increase RBC polycythemia vera - complication stroke, CVA, thrombosis

Predisposing factors leading to Aplastic Anemia

Chemicals - Banzene & its derivatives
radiation
Immunologic injury
Drugs - cause bone marrow depression
Broad spectrum antibiotic - Chlorampenicol
- Sulfonamides - bactrim
Chemo therapeutic agents
Methotrexate - alkylating agents
Nitrogen mustard - anti metabolic
Vincristine - plant alkaloid

S/Sx:
1. Anemia:
a. Weakness & fatigue
b. Headache, dizziness, dyspnea
c. cold sensitivity, pallor
d. palpitations
2. Leucopenia - increase susceptibility to infection
3. Thrombocytopenia -
Peticchiae
Oozing ofblood from venipuncture site
ecchymosis
Dx:
CBC - pancytopenia
Bone marrow biopsy/ aspiration at post iliac crest - reveals fatty streaks in bone marrow
Nsg Mgt:
Removal of underlying cause
Blood transfusion as ordered
Complete bed rest
O2 inhalation
Reverse isolation due leukopenia
Monitor signs of infection
Avoid SQ, IM or any venipuncture site = HEPLOCK
Use electric razor when shaving to prevent bleeding
Administer meds
Immunosuppresants
Anti lymphocyte globulin (Alg) given via central venous catheter, 6 days - 3 weeks to achieve max therapeutic effect of
drug.

BLOOD TRANSFUSION:
Objectives:
To replace circulating blood volume
To increase O2 carrying capacity of blood
 To combat infection if there's decrease WBC
To prevent bleeding if there's platelet deficiency

Nsg Mgt & principles in Blood Transfusion

Proper refrigeration
Proper typing & crossmatching
Type O - universal donor
AB - universal recipient
85% of people is RH (+)
Asceptically assemble all materials needed:
Filter set
Isotonic or PNSS or .9NaCl to prevent Hemolysis

Hypotonic sol - swell or burst

Hypertonic sol - will shrink or crenate
Needle gauge 18 - 19 or large bore needle to prevent hemolysis.
Instruct another RN to recheck the following .
Pts name, blood typing & cross typing expiration date, serial number.
e.) Check blood unit for presence of bubbles, cloudiness, dark in color & sediments - indicates bacterial contamination.
Don't dispose. Return to blood bank.
f.) Never warm blood products - may destroy vital factors in blood.
- Warming is done if with warming device - only in EMERGENCY! For multiple BT.
- Within 30 mins room temp only!
g.) Blood transfusion should be completed < 4hrs because blood that is exposed at room temp for > 2h causes blood
deterioration.
h.) Avoid mixing or administering drug at BT line - leads to hemolysis
i.) Regulate BT 10 - 15 gtts/min KVO or 100cc/hr to prevent circulatory overload
j.) Monitor VS before, during & after BT especially q15 mins(local board) for 1st hour. NCLEX-q5min for 1st 15min.
- Majority of BT reaction occurs within 1h.

BT reactions S/Sx Hemolytic reaction:

H - hemolytic Reaction 1. Headache, dizziness, dyspnea, palpitation, lumbar/ sterna/ flank pain,
A - allergic Reaction hypotension, flushed skin , (red) port wine urine.
P - pyrogenic Reaction
C - circulatory overload
A - air embolism
T - thrombocytopenia
C - citrate intoxication - expired blood =hyperkalemia
H - hyperkalemia

Nsg Mgt: Hemolytic Reaction:

Stop BT
Notify Doc
Flush with plain NSS
Administer isotonic fluid sol - to prevent acute tubular necrosis & conteract shock
Send blood unit to blood bank for reexamination
Obtain urine & blood samples of pt & send to lab for reexamination
Monitor VS & Allergic Rxn

Allergic Reaction:
S/Sx
Fever/ chills
Urticaria/ pruritus
Dyspnea
Laryngospasm/ bronchospasm
Bronchial wheezing
Nsg Mgt:
Stop BT
Notify Doc
Flush with PNSS
Administer antihistamine - diphenhydramine Hcl (Benadryl). Give bedtime.SE-Adult-drowsiness. Child-hyperactive
If (+) Hypotension - anaphylactic shock administer - epinephrine
Send blood unit to blood bank
Obtain urine & blood samples - send to lab
Monitor VS & IO
Adm. Antihistamine as ordered for AllergicRxn, if (+) to hypotension - indicates anaphylactic shock
administer epinephrine
9. Adm antipyretic & antibiotic for pyrogenic Rxn & TSB

Pyrogenic Reaction:

S/Sx
Fever/ chills d. tachycardia
Headache e. palpitations
Dyspnea f. diaphoresis

Nsg Mgt:
Stop BT
Notify Doc
Flush with PNSS
Administer antipyretics, antibiotics
Send blood unit to blood bank
Obtain urine & blood samples - send to lab
Monitor VS & IO
Tepid sponge bath - offer hypothermic blanket

Circulatory Overload:
Sx
Dyspnea
Orthopnea
Rales or crackles
Exertional discomfort

Nsg Mgt:
Stop BT
Notify Doc. Don't flush due pt has circulatory overload.
Administer diuretics
Priority cases:
Hemolytic Rxn - 1st due to hypotension - 1st priority - attend to destruction of Hgb - O2 brain damage
Allergic 3rd
Pyrogenic 4th
Circulatory 2nd

Hemolytic 2nd
Anaphylitic 1st priority

DIC - DISSEMINATED INTRAVASCULAR COAGULATION

Acute hemorrhagic syndrome char by wide spread bleeding & thrombosis due to a def of clotting factors (Prothrombin &
Fibrinogen).

Predisposing factor:
Rapid BT
Massive trauma
Massive burns
 Septicemia
Hemolytic reaction
Anaphylaxis
Neoplasia - growth of new tissue
Pregnancy

S/Sx
Petechiae - widespread & systemic (lungs, lower & upper trunk)
Ecchymosis - widespread
Oozing of blood from venipunctured site
Hemoptysis - cough blood
Hemorrhage
Oliguria - late sx

Dx Proc-
CBC - reveals decrease platelets
Stool for occult blood (+)
Specimen - stool
Opthalmoscopic exam - sub retinal hemorrhage
ABG analysis - metabolic acidosis

pH HCO3
R pH PCO2 respiratory alkalosis

O ph PCO2 respiratory acidosis

M ph HCO3 metabolic alkalosis

E ph HCO3 metabolic acidosis

Diarrhea - met acidosis

Vomitting - met alk
Pyloric stenosis - met alkalosis - vomiting
Ileostomy or intestinal tubing - met acidosis
Cushing's - met alk
DM met acid
Chronic bronchitis - resp acid - with hypoxemia, cyanosis

Nsg Mgt DIC

Monitor signs of bleeding - hema test + urine, stool, GIT
Administer isotonic fluid solution to prevent shock.
Administer O2 inhalation
Administer meds
Vit K aquamephyton
Pitressin or vasopressin - to conserve water.
NGT - lavage
- Use iced saline lavage
6. Monitor NGT output
7. Provide heplock
8. Prevent complication: hypovolemic shock
Late signs of hypovolemic shock : anuria
Oncologic Nsg:
Oncology - study of neoplasia -new growth

Benign (tumor) Malignancy (cancer)

Diff - well differentiated poorly or undifferentiated

Encapulation - (+) (-)
Metastasis - (-) (+)
Prognosis - good poor
Therapeutic modality surgery 1. Chemotherapy plenty S/E
2. Radiation
3. Surgery most preferred treatment
4. Bone marrow transplant - Leukemia only
Predisposing factors: (carcinogenesis)
G - genetic factors
I - immunologic factors
V - viral factors
a. Human papiloma virus - causing warts
b. Epstein barr virus
E - environmental Factors 90%
a. Physical - irradiation, UV rays, nuclear explosion, chronic irritation, direct trauma
b. Chemical factors -
- Food additives (nitrates
- Hydrocarbon vesicants, alkalies
- Drugs (stillbestrol)
- Uraehane
- Hormones
- Smoking
Male
3.) Prostate cancer - common 40 & above (middle age & above)
BPH - 50 & above
1.) Lung cancer
2.) Liver cancer

Female
1. Breast cancer - 40 yrs old & up - mammography 15 - 20 mins (SBE - 7 days after mens)
2. Cervical cancer - 90% multi sexual partners
5% early pregnancy
3. Ovarian cancer

Classes of cancer
Tissue typing
Carcinoma - arises from surface epithelium & glandular tissues
Sarcoma- from connective tissue or bones
Multiple myeloma - from bone marrow
Pathological fracture of ribs & back pain
4. Lymphoma - from lymph glands
5. Leukemia - from blood

Warning / Danger Sx of CA
C - change in bowel /bladder habits
A - a sore that doesn't heal
U - unusual bleeding/ Discharge
T - thickening of lump - breast or elsewhere
I - indigestion? Dysphagia
O - obvious change in wart/ mole
N - nagging cough/ hoarseness
U - unexplained anemia A - anemia
S - sudden wt loss L - loss of wt

Therapeutic Modality:
Chemotherapy - use various chemotherapeutic agents that kills cancer cells & kills normal rapidly producing cells - GIT, bone
marrow, and hair follicle.

Classification:
Alkylating agents -
Plant alkaloids - vincristine
Anti metabolites - nitrogen mustard
Hormones - DES
 Steroids
Antineoplastic antibiotics

S/E & mgt

GIT - -Nausea & vomiting
Nsg Mgt:
1. Administer anti emetic 4 - 6h before start of chemo
Plasil
Withhold food/ fluid before start of chemo
Provide bland diet post chemo
Non irritating / non spicy

- Diarrhea
1. Administer anti diarrheal 4 - 6h before start of chemo
2. Monitor urine, I&O qh
- Stomatitis/ mouth sores
1. Oral care - offer ice chips/ popsickles
2. Inform pt - hair loss - temporary alopecia
Hair will grow back after 4 - 6 months post chemo.
-Bone marrow depression - anemia
Enforce CBR
O2 inhalation
Reverse isolation
Monitor signs of bleeding
Repro organ - sterility
Do sperm banking before start of chemo
Renal system - increase uric acid
Administer allopurinol/ xyloprin (gout)
Inhibits uric acid
Acute gout - colchicines
Increase secretion of uric acid
Neurological changes - peristalsis - paralytic ileus
Most feared complication ff any abdominal surgery
Vincristine - plant alkaloid causes peripheral neuropathy

2. Radiation therapy - involves use of ionizing radiation that kills cancer cells & inhibit their growth & kill N rapidly producing
cells.

Types of energy emitted

Alpha rays - rarely used - doesn't penetrate skin tissues
Beta rays - internal radiation - more penetration
Gamma ray - external radiation - penetrates deeper underlying tissues

Methods of delivery
External radiation- involves electro magnetic waves
Ex. cobalt therapy
Internal radiation - injection/ implantation of radioisotopes proximal to CA site for a specific period of time.
2 types:
a.) Sealed implant - radioisotope with a container & doesn't contaminate body fluid.
b.) Unsealed implant - radioisotope without a container & contaminates body fluid.
Ex. Phosphorus 32

3 Factors affecting exposure:

A.) Half life - time period required for half of radioisotopes to decay.
- At end of half life - less exposure
B.) Distance - the farther the distance - lesser exposure
C. ) Time - the shorter the time, the lesser exposure
D.) Shielding - rays can be shielded or blocked by using rubber gloves - a & b gamma - use thick lead on concrete.

S/E & Mgt:

 Skin errythema, redness, sloughing
Assist in battling pt
Force fluid - 2,000 - 3,000 ml/day
Avoid lotion or talcum powder - skin irritation
Apply cornstarch or olive oil
b.) GIT -nausea / vomiting -
1. Administer antiemetic 4 - 6h before start of chemo - Plasil
2 Withhold food/ fluid before start of chemo
Provide bland diet post chemo
Non irritating / non spicy
Dysglusia - decrease taste sensitivity
-When atrophy papilla (taste buds) - 40 yo
Stomatitis
c.) Bone marrow depression
Enforce CBR
O2 inhalation
Reverse isolation
Monitor signs of bleeding

Overview of function & structure of the heart

HEART
Muscular, pumping organ of the body
Left mediastinum
Weigh 300 - 400 grams
Resembles a closed fist
Covered by serous membrane - pericardium
Pericardium

Parietal layer Pericardial Visceral layer

Fluid - prevent
Friction rub

Layer
Epicardium - outermost
Myocardium - inner - responsible for pumping action/ most dangerous layer - cardiogenic shock
Endocardium - innermost layer
Chambers
Upper - collecting/ receiving chamber - Atria
Lower - pumping/ contracting chamber - Ventricles
Valves
Atrioventricular valves - Tricuspid & mitral valve
Closure of AV valves - gives rise to 1st heart sound or S1 or "lub"
Semi lunar valve
Pulmonic
Aortic
Closure of semilunar valve - gives rise to 2nd heart sound or S2 or "dub"
Extra heart Sound
S3 - ventricular Gallop - CHF
S4 - atrial gallop - MI, HPN

Heart conduction system

Sino atrial node (SA node) (or Keith-Flock node)
Loc - junction of SVC & Rt atrium
Fx- primary pace maker of heart
-Initiates electric impulse of 60 - 100 bpm
Atrioventicular node (AV node or Tawara node)
Loc - inter atrial septum
 Delay of electric impulse to allow ventricular filling
Bundle of His - location interventricular septum
Rt main Bundle Branch
Lt main Bundle Branch
Purkenjie Fiber
Loc- walls of ventricles-- Ventricular contractions

SA node

AV

Purkenjie Fibers
Bundle of His

Complete heart block - insertion of pacemaker at Bundle Branch

Metal - Pace Maker - change q3 - 5 yo

Prolonged PR - atrial fib T wave inversion - MI

ST segment depression - angina widening QRS - arrhythmia
ST - elev - MI

CAD - coronary artery dse or Ischemic Heart Dse (IHD)

Atherosclerosis - Myocrdial injury
Angina Pectoris - Myocardial ischemia
MI- myocardial necrosis

ATHEROSCLEROSIS ARTEROSCLEROSIS
- Hardening or artery due to fat/ lipid deposits at tunica intima. - Narrowing or artery due to calcium & CHON deposits at tunica media.

Artery - tunica adventitia - outer

Tunica intima - innermost
Tunica media - middle

ATHEROSCLEROSIS
Predisposing Factor
Sex - male
Black race
Hyperlipidemia
Smoking
HPN
DM
Oral contraceptive- prolonged use
Sedentary lifestyle
Obesity
Hypothyroidism
Signs & Symptoms
Chest pain
Dyspnea
Tachycardia
Palpitations
Diaphoresis
Treatment
P - percutaneous
T - tansluminar
C - coronary
A - angioplasty

Obj:
To revascularize the myocardium
To prevent angina
3. Increase survival rate

PTCA - done to pt with single occluded vessel .

Multiple occluded vessels
C - coronary
A - arterial
B - bypass
A -and
G - graft surgery

Nsg Mgt Before CABAG

Deep breathing cough exercises
Use of incentive spirometer
Leg exercises

ANGINA PECTORIS- A clinical syndrome characterized by paroxysmal chest pain usually relieved by REST or NGT
nitroglycerin, resulting fr temp myocardial ischemia.
Predisposing Factor:
sex - male
black raise
hyperlipidemia
smoking
HPN
DM
oral contraceptive prolonged
sedentary lifestyle
obesity
10.hypothyroidism
Precipitating factors
4 E's
Excessive physical exertion
Exposure to cold environment - Vasoconstriction
Extreme emotional response
4. Excessive intake of food - saturated fats.
Signs & Symptoms
Initial symptoms - Levine's sign - hand clutching of chest
Chest pain - sharp, stabbing excruciating pain. Location - substernal
-radiates back, shoulders, axilla, arms & jaw muscles
-relieve by rest or NGT
Dyspnea
Tachycardia
Palpitation
6.diaphoresis
Diagnosis
1.History taking & PE
2. ECG - ST segment depression
3. Stress test - treadmill = abnormal ECG
4. Serum cholesterol & uric acid - increase.
Nursing Management
1.) Enforce CBR
2.) Administer meds
NTG - small doses - venodilator
Large dose - vasodilator
 1st dose NTG - give 3 - 5 min
2nd dose NTG - 3 - 5 min
3rd & last dose - 3 - 5 min
Still painful after 3rd dose - notify doc. MI!

55 yrs old with chest pain:

1st question to ask pt: what did you do before you had chest pain.
2nd question: does pain radiate? If radiate - heart in nature. If not radiate - pulmonary origin

Venodilator - veins of lower ext - increase venous pooling lead to decrease venous return.

Meds:
A. NTG- Nsg Mgt:
Keep in a dry place. Avoid moisture & heat, may inactivate the drug.
Monitor S/E:
orthostatic hypotension - dec bp
transient headache
dizziness
Rise slowly from sitting position
4. Assist in ambulation.
5. If giving NTG via patch:
avoid placing it near hairy areas-will dec drug absorption
avoid rotating transdermal patches- will dec drug absorption
avoid placing near microwave oven or during defibrillation-will burn pt due aluminum foil in patch

B. Beta blockers - propanolol

C. ACE inhibitors - captopril
D. Ca antagonist - nefedipine
3.) Administer O2 inhalation
4.) Semi-fowler
5.) Diet- Decrease Na and saturated fats
6.) Monitor VS, I&O, ECG
7.) HT: Discharge planning:
Avoid precipitating factors - 4 E's
Prevent complications - MI
Take meds before physical exertion-to achieve maximum therapeutic effect of drug
Importance of follow-up care.

MI - MYOCARDIAL INFARCTION - hear attack - terminal stage of CAD

Characterized by necrosis & scarring due to permanent mal-occlusion

Types:

Trasmural MI - most dangerous MI - Mal-occlusion of both R&L coronary artery

Sub-endocardial MI - mal-occlusion of either R & L coronary artery

Most critical period upon dx of MI - 48 to 72h

Majority of pt suffers from PVC premature ventricular contraction.

Predisposing factors Signs & symptoms Diagnostic Exam

sex - male 1. chest pain - excruciating, vice like, visceral pain located 1. cardiac enzymes
black raise substernal or precodial area (rare) a.) CPK - MB - Creatinine Phosphokinase
hyperlipidemia - radiates back, arm, shoulders, axilla, jaw & abd muscles. b.) LDH - lactic acid dehydrogenase
smoking - not usually relived by rest r NTG c.) SGPT - (ALT) - Serum Glutanic Pyruvate
HPN 2. dyspnea Transaminase- increased
DM 3. erthermia d.) SGOT (AST) - Serum Glutamic Oxalo-
oral contraceptive prolonged 4. initial increase in BP acetic - increased
sedentary lifestyle 5. mild restlessness & apprehensions 2. Troponin test - increase
obesity 6. occasional findings 3. ECG tracing - ST segment increase,
hypothyroidism a.) split S1 & S2 widening or QRS complexes - means
b.) pericardial friction rub arrhythmia in MI indicating PVC
c.) rales /crackles 4. serum cholesterol & uric acid - increase
d.) S4 (atrial gallop) 5. CBC - increase WBC

Nursing Management
1. Narcotic analgesics - Morphine SO4 - to induce vasodilation & decrease levels of anxiety.
2. Administer O2 inhalation - low inflow (CHF-increase inflow)
3. Enforce CBR without BP
a.) Bedside commode
4. Avoid valsalva maneuver
5. Semi fowler
6. General liquid to soft diet - decrease Na, saturated fat, caffeine
7. Monitor VS, I&O & ECG tracings
8. Take 20 - 30 ml/week - wine, brandy/whisky to induce vasodilation.
9. Assist in surgical; CABAG
10. Provide pt HT
a.) Avoid modifiable risk factors
b.) Prevent complications:
1. Arrhythmias - PVC
2. Shock - cardiogenic shock. Late signs of cardiogenic shock in MI - oliguria
3. thrombophlebitis - deep vein
4. CHF - left sided
5. Dressler's syndrome - post MI syndrome
-Resistant to medications
-Administer 150,000 - 450,000 units of streptokinase
c.) Strict compliance to meds
- Vasodilators
1. NTG
2. Isordil
- Antiarrythmic
1. Lydocaine blocks release of norepenephrine
2. Brithylium
- Beta-blockers - "lol"
1. Propanolol (inderal)
- ACE inhibitors - pril
1. Captopril - (enalapril)
- Ca - antagonist
1. Nifedipine
- Thrombolitics or fibrinolytics- to dissolve clots/ thrombus

S/E allergic reactions/ uticaria

1. Streptokinase
2. Urokinase
3. Tissue plasminogen adjusting factor

Monitor for bleeding:

- Anticoagulants
1. Heparin 2. Caumadin - delayed reaction 2 - 3 days

PTT PT

If prolonged bleeding prolonged bleeding

Antidote antidote Vit K

Protamine sulfate
- Anti platelet PASA (aspirin)
d.) Resume ADL - sex/ activity - 4 to 6 weeks
Post-cardiac rehab
1.)Sex as an appetizer rather then dessert -
Before meals not after, due after meals increase metabolism - heart is pumping hard after meals.
2.) Position - non-weight bearing position.

When to resume sex/ act: When pt can already use staircase, then he can resume sex.
e.) Diet - decrease Na, Saturated fats, and caffeine
f.) Follow up care.

CHF - CONGESTIVE HEART FAILURE - Inability of heart to pump blood towards systemic circulation.
- Backflow
1.) Left sided heart failure:

Predisposing factors:
1.) 90% mitral valve stenosis - due RHD, aging
RHD affects mitral valve - streptococcal infection
Dx: - Aso titer - anti streptolysine O > 300 total units
- Steroids
- Penicillin
- Aspirin
Complication: RS-CHF
Aging - degeneration / calcification of mitral valve
Ischemic heart disease
HPN, MI, Aortic stenosis

S/Sx
Pulmonary congestion/ Edema
Dyspnea
Orthopnea (Diff of breathing sitting pos - platypnea)
Paroxysmal nocturnal dysnea - PNO- nalulunod
Productive cough with blood tinged sputum
Frothy salivation (from lungs)
Cyanosis
Rales/ crackles - due to fluid
Bronchial wheezing
PMI - displaced lateral - due cardiomegaly
Pulsus alternons - weak-strong pulse
Anorexia & general body malaise
S3 - ventricular gallop

Dx
CXR - cardiomegaly
PAP - Pulmonary Arterial Pressure
PCWP - Pulmonary CapillaryWedge Pressure

PAP - measures pressure of R ventricle. Indicates cardiac status.

PCWP - measures end systolic/ diastolic pressure
PAP & PCWP:
Swan - ganz catheterization - cardiac catheterization is done at bedside at ICU
 (Trachesostomy - bedside) - Done 5 - 20 mins - scalpel & trachesostomy set

CVP - indicates fluid or hydration status

Increase CVP - decrease flow rate of IV
Decrease CVP - increase flow rate of IV
3. Echocardiography - reveals enlarged heart chamber or cardiomayopathy

4. ABG - PCO2 increase, PO2 decrease = = hypoxemia = resp acidosis

2.) Right sided HF

Predisposing factor
90% - tricuspid stenosis
COPD
Pulmonary embolism
Pulmonic stenosis
Left sided heart failure

S/Sx
Venous congestion
Neck or jugular vein distension
Pitting edema
Ascites
Wt gain
Hepatomegalo/ splenomegaly
Jaundice
Pruritus
Esophageal varies
Anorexia, gen body malaise

Diagnosis:
CXR - cardiomegaly
CVP - measures the pressure at R atrium
Normal: 4 to 10 cm of water
Increase CVP > 10 - hypervolemia
Decrease CVP < 4 - hypovolemia
Flat on bed - post of pt when giving CVP
Position during CVP insertion - Trendelenburg to prevent pulmonary embolism & promote ventricular
filling.

3. Echocardiography - enlarged heart chamber / cardiomyopathy

4.Liver enzyme
SGPT ( ALT)
SGOT AST

Nsg mgt: Increase force of myocardial contraction = increase CO

3 - 6L of CO

1. Administer meds:
Tx for LSHF: M - morphine SO4 to induce vasodilatation
A - aminophylline & decrease anxiety
D - digitalis (digoxin)
D - diuretics
O - oxygen
G - gases

a.) Cardiac glycosides

Increase myocardial = increase CO
Digoxin (Lanoxin). Antidote: digivine
 Digitoxin: metabolizes in liver not in kidneys not given if with kidney failure.
b.) Loop diuretics: Lasix - effect with in 10-15 min. Max = 6 hrs
c.) Bronchodilators: Aminophillin (Theophyllin). Avoid giving caffeine
d.) Narcotic analgesic: Morphine SO4 - induce vasodilaton & decrease anxiety
e.) Vasodilators - NTG
f.) Anti-arrythmics - Lidocaine

2. Administer O2 inhalation - high! @ 3 -4L/min via nasal cannula

3. High fowlers
4. Restrict Na!
5. Provide meticulous skin care
6. Weigh pt daily. Assess for pitting edema.
Measure abdominal girth daily & notify MD
7. Monitor V/S, I&O, breath sounds
8. Institute bloodless phlebotomy. Rotating tourniquet or BP cuff rotated clockwise q 15 mins = to promote decrease venous
return
9. Diet - decrease salt, fats & caffeine
10. HT:
a) Complications :shock
Arrhythmia
Thrombophlebitis
MI
Cor Pulmonale - RT ventricular hypertrophy
b.) Dietary modifications
c.) Adherence to meds

PERIPHERAL MUSCULAR DISEASE

Arterial ulcers venous ulcer

1. Thromboangiitis Obliterans - male/ feet 1. Varicose veins
2. Reynauds - female/ hands 2. Thrombophlebitis

1.) Thromboangiitis obliterates/ BUERGER DISEASE- Acute inflammatory disorder affecting small to medium sized
arteries & veins of lower extremities. Male/ feet

Predisposing factors:
Male
Smokers

S/Sx
1. Intermittent claudication - leg pain upon walking - Relieved by rest
2. Cold sensitivity & skin color changes

White bluish red

Pallor cyanosis rubor

3. Decrease or diminished peripheral pulses - Post tibial, Dorsalis pedis

4. Tropic changes
5. Ulcerations
6. Gangrene formation
Dx:
Oscillometry - decrease peripheral pulse volume.
Doppler UTZ - decrease blood flow to affected extremities.
Angiography - reveals site & extent of mal-occulsion.

Nsg Mgt:
Encourage a slow progression of physical activity
Walk 3 -4 x / day
Out of bed 2 - 3 x a / day
Meds
Analgesic
Vasodilator
Anticoagulant
Foot care mgt like DM -
Avoid walking barefoot
Cut toe nails straight
Apply lanolin lotion - prevent skin breakdown
Avoid wearing constrictive garments
Avoid smoking & exposure to cold environment
Surgery: BKA (Below the knee amputation)

2.)REYNAUD'S PHENOMENON - acute episodes of arterial spasm affecting digits of hands & fingers
Predisposing factors:

Female, 40 yrs
Smoking
Collagen dse
SLE - pathognomonic sign - butterfly rash on face
Chipmunk face - bulimia nervosa
Cherry red skin - carbon monoxide poisoning
Spider angioma - liver cirrhosis
Caput medusae - leg & trunk umbilicus- Liver cirrhosis
Lion face - leprosy

Rheumatoid arthritis -
Direct hand trauma - piano playing, excessive typing, operating chainsaw
S/Sx:
Intermittent claudication - leg pain upon walking - Relieved by rest
Cold sensitivity

Nsg Mgt:
Analgesics
Vasodilators
Encourage to wear gloves especially when opening a refrigerator.
Avoid smoking & exposure to cold environment

VENOUS ULCERS
1. VARICOSITIES / Varicose veins - Abnormal dilation of veins - lower ext & trunk
- Due to:
a.) Incompetent valves leading to
b.) Increase venous pooling & stasis leading to
c.) Decrease venous return

Predisposing factors:
Hereditary
 Congenital weakness of veins
Thrombophlebitis
Heart dse
Pregnancy
Obesity
Prolonged immobility - Prolonged standing
S/Sx:
Pain especially after prolonged standing
Dilated tortuous skin veins
Warm to touch
Heaviness in legs

Dx:
Venography
Trendelenberg's test - vein distend quickly < 35 secs

Nsg Mgt:
Elevate legs above heart level - to promote venous return - 1 to 2 pillows
Measure circumference of leg muscles to determine if swollen.
Wear anti embolic or knee high stockings. Women - panty hose
Meds: Analgesics
Surgery: vein sweeping & ligation
Sclerotherapy - spider web varicosities
S/E thrombosis

THROMBOPHLEBITIS (deep vein thrombosis) - Inflammation of veins with thrombus formation

Predisposing factors:
Smoking
2. Obesity
Hyperlipedemia
4. Prolonged use of oral contraceptives
Chronic anemia
DM
MI
CHF
Postop complications
Post cannulation - insertion of various cardiac catheters

S/Sx:
Pain at affected extremities
Cyanosis
(+) Homan's sign - Pain at leg muscles upon dorsiflexion of foot.
Dx:
Angiography
Doppler UTZ
Nsg Mgt:
Elevate legs above heart level.
Apply warm, moist packs to decrease lymphatic congestion.
Measure circumference of leg muscles to detect if swollen.
Use anti embolic stockings.
Meds: Analgesics.
Anticoagulant: Heparin
Complication:
Pulmonary Embolism:
- Sudden sharp chest pain
- Dyspnea
- Tachycardia
- Palpitation
- Diaphoresis
 - Mild restlessness

OVERVIEW OF RESPIRATORY SYSTEM:

I. Upper respiratory tract:
Fx:
Filtering of air
Warming & moistening
Humidification
Nose - cartilage
- Parts: Rt nostril separated by septum
Lt nostril

Consists of anastomosis of capillaries -

Kessel - Bach Plexus - site of epistaxis
b. Pharynx (throat) - muscular passageway for air& food
Branches:
Oropharynx
Nasopharynx
Layngopharynx

c. Larynx - voice box

Fx:
For phonation
Cough reflex

Glottis - opening
Opens to allow passage of air
Closes to allow passage of food

II. Lower Rt - Fx for gas exchange

Trachea - windpipe
- has cartillagenous rings
- site for permanent/ artificial a/w - tracheostomy
b. Bronchus - R & L main bronchus
c. Lungs - R - 3 lobes = 10 segments
L - 2 lobes - 8 segments

Post pneumonectomy - position affected side to promote expansion of lungs

Post segmental lobectomy - position unaffected side to promote drainage

Lungs - covered by pleural cavity, parietal lobe & visceral lobe

Alveoli - acinar cells
site of gas exchange (O2 & CO2)
diffusion: Daltons law of partial pressure of gases

Ventilation - movement of air in & out of lungs

Respiration - movement of air into cells

Type II cells of alveoli - secrets surfactant

Surfactant - decrease surface tension of alveoli

Lecithin & spinogometer

L/S ratio 2:1 - indicator of lung maturity

If 1:2 - adm O2 - < 40% Concentration to prevent atelectasis & retinopathy or blindness.
I. PNEUMONIA - inflammation of lung parenchyma leading to pulmonary consolidation as alveoli is filled with exudates.

Etiologic agents:
Streptococcus pneumoniae (pnemococcal pneumonia)
Hemophilus pneumoniae(Bronchopneumonia)
Escherichia coli
Klebsiella P.
Diplococcus P.

High risk elderly & children below 5 yo

Predisposing factors:
Smoking
Air pollution
Immuno-compromised
AIDS - PLP
Bronchogenic CA - Non-productive to productive cough
4. Prolonged immobility - CVA- hypostatic pneumonia
5. Aspiration of food
6. Over fatigue

S/Sx:
Productive cough - pathognomonic: greenish to rusty sputum
Dyspnea with prolonged respiratory grunt
Fever, chills, anorexia, gen body malaise
Wt loss
Pleuritic friction rub
Rales/ crackles
Cyanosis
Abdominal distension leading to paralytic ileus

Sputum exam - could confirm presence of TB & pneumonia

Dx:
Sputum GSCS- gram staining & culture sensitivity - Reveals (+) cultured microorganism.
CXR - pulmo consolidation
CBC - increase WBC
Erythrocyte sedimentation rate
ABG - PO2 decrease

Nsg Mgt:
Enforce CBR
Strict respiratory isolation
Meds:
Broad spectrum antibiotics
Penicillin or tetracycline
Macrolides - ex azythromycin (zythromax)
Anti pyretics
Mucolytics or expectorants
Force fluids - 2 to 3 L/day
Institute pulmonary toilet-
Deep breathing exercise
Coughing exercise
Chest physiotherapy - cupping
Turning & reposition - Promote expectoration of secretions
6. Semi-fowler
7. Nebulize & suction
8. Comfy & humid environment
 9. Diet: increase CHO or calories, CHON & vit C
10. Postural drainage - To drain secretions using gravity
Mgt for postural drainage:
Best done before meals or 2 - 4 hrs after meals to prevent Gastroesophageal Reflux
Monitor VS & breath sounds
Normal breath sound - bronchovesicular
c.) Deep breathing exercises
d.) Adm bronchodilators 15 - 30 min before procedure
e.) Stop if pt can't tolerate procedure
f.) Provide oral care - it may alter taste sensation
g.) C/I - pt with unstable VS & hemoptysis, increase ICP, increase IOP (glaucoma)
Normal IOP - 12 - 21 mmHg
11. HT:
a.) Avoidance of precipitating factors
b.) Complication: Atelectacies & meningitis
c.) Compliance to meds

PULMONARY TUBERCULOSIS (KOCH DSE) - Inflammation of lung tissue caused by invasion of mycobacterium TB or
tubercle bacilli or acid fast bacilli - gram (+) aerobic, motile & easily destroyed by heat or sunlight.

Predisposing factors:
1. Malnutrition
2. Overcrowding
3. Alcoholism
4. Ingestion of infected cattle (mycobacterium BOVIS)
5. Virulence
Over fatigue

S/Sx:
Productive cough - yellowish
Low fever
Night sweats
Dyspnea
Anorexia, general body malaise, wt loss
Chest/ back pain
Hempotysis

Diagnosis:
Skin test - mantoux test - infection of Purified CHON Derivative PPD
DOH - 8-10 mm induration
WHO - 10-14 mm induration
Result within 48 - 72h
(+) Mantoux test - previous exposure to tubercle bacilli

Mode of transmission - droplet infection

Sputum AFB - (+) to cultured microorganism
CXR - pulmonary infiltrate caseosis necrosis
CBC - increase WBC

Nursing Mgt:
CBR
Strict resp isolation
O2 inhalation
Semi fowler
Force fluid to liquefy secretions
DBCE
Nebulize & suction
Comfy & humid environment
Diet - increase CHO & calories, CHON, Vit, minerals
Short course chemotherapy
 Intensive phase

INH - isoniazide - give before meals for absorption

Rifampicin - given within 4 months, given simultaneously to prevent resistance
-S/E: peripheral neutitis - vit B6
Rifampicin -All body secretions turn to red orange color urine, stool, saliva, sweat & tears.

PZA - Pyrazinamide - given 2 mos/ after meals. S/E: allergic rxn, nephrotoxicity & hepatoxicity

Standard regimen
Injection of streptomycin - aminoglycoside
Ex. Kanamycin, gentamycin, neomycin
S/E:
Ototoxicity - damage CN # 8 - tinnitus - hearing loss
Nephrotoxicicity - monitor BUN & Crea
HT:
Avoid pred factors
Complications:
Atelectasis
Miliary TB - spread of Tb to other system
Compliance to meds
- Religiously take meds

HISTOPLASMOSIS- acute fungal infection caused by inhalation of contaminated dust with histoplasma capsulatum transmitted
to birds manure.
S/Sx: Same as pneumonia & PTB - like
Productive cough
Dyspnea
Chest & joint pains
Cyanosis
Anorexia, gen body malaise, wt loss
Hemoptysis

Dx:
Histoplasmin skin test = (+)
ABG - pO2 decrease

Nsg Mgt:
CBR
Meds:
Anti fungal agents
Amphotericin B (Fungizone)
S/E :
Nephrotoxcicity check BUN
Hypokalemia
b.)Corticosteroids
c.) Mucolytic/ or expectorants
3. O2 - force fluids
4. Nebulize, suction
5. Complications:
a.) Atelectasis
b.) Bronchiectasis COPD
6. Prevent spread of histoplasmosis:
a.) Spray breading places or kill the bird.
COPD - Chronic Obstructive Pulmonary Disease
Chronic bronchitis
Bronchial asthma
Bronchiectasis
Pulmonary emphysema - terminal stage

CHRONIC BRONCHITIS - called BLUE BLOATERS inflammation of bronchus due to hypertrophy or hyperplasia of goblet
mucus producing cells leading to narrowing of smaller airways.

Predisposing factors:
Smoking - all COPD types
Air pollution
S/Sx:
Prod cough
Dyspnea on exertion
Prolonged expiratory grunt
Scattered rales/ rhonchi
Cyanosis
Pulmo HPN - a.)Leading to peripheral edema
b.) Cor pulmonary - respiratory in origin
7. Anorexia, gen body malaise

Dx:
ABG
PO2 PCO2 Resp acidosis

Hypoxemia - causing cyanosis

Nsg Mgt:
(Same as emphysema)

2.) BRONCHIAL ASTHMA- reversible inflammation lung condition due to hyerpsensitivity leading to narrowing of smaller
airway.
Predisposing factor:
Extrinsic Asthma - called Atropic/ allergic asthma
Pallor
Dust
Gases
Smoke
Dander
Lints

Intrinsic Asthma-
Cause:
Herediatary
Drugs - aspirin, penicillin, b blockers
Food additives - nitrites
Foods - seafood, chicken, eggs, chocolates, milk
Physical/ emotional stress
Sudden change of temp, humidity &air pressure
mixed type: combi of both ext & intr. Asthma
90% cause of asthma

S/Sx:
C - cough - non productive to productive
D - dyspnea
W - wheezing on expiration
Cyanosis
 Mild apprehension & restlessness
Tachycardia & palpitation
Diaphoresis
Dx:
Pulmo function test - decrease lung capacity
ABG - PO2 decrease

Nsg Mgt:
CBR - all COPD
Meds-
Bronchodilator through inhalation or metered dose inhaled / pump. Give 1st before corticosteroids
Corticosteroids - due inflammatory. Given 10 min after adm bronchodilator
c.) Mucolytic/ expectorant
d.) Mucomist - at bedside put suction machine.
e.) Antihistamine
Force fluid
O2 - all COPD low inflow to prevent resp distress
Nebulize & suction
Semifowler - all COPD except emphysema due late stage
HT
Avoid pred factors
Complications:
Status astmaticus- give epinephrine & bronchodilators
Emphysema
Adherence to med

BRONCHIECTASIS - abnormal permanent dilation of bronchus resulting to destruction of muscular & elastic tissues of alveoli.
Predisposing factors:
Recurrent upper & lower RI
Congenital anomalies
Tumors
Trauma
S/Sx:
Productive cough
Dyspnea
Anorexia, gen body malaise- all energy are used to increase respiration.
Cyanosis
Hemoptisis

Dx:
ABG - PO2 decrease
Bronchoscopy - direct visualization of bronchus using fiberscope.
Nsg Mgt: before bronchoscopy
Consent, explain procedure - MD/ lab explain RN
NPO
Monitor VS
Nsg Mgt after bronchoscopy
Feeding after return of gag reflex
Instruct client to avoid talking, smoking or coughing
Monitor signs of frank or gross bleeding
Monitor of laryngeal spasm
DOB
Prepare at bedside tracheostomy set

Mgt: same as emphysema except Surgery

Pneumonectomy - removal of affected lung
Segmental lobectomy - position of pt - unaffected side
PULMONARY EMPHYSEMA - irreversible terminal stage of COPD
Characterized by inelasticity of alveolar wall leading to air trapping, leading to maldistribution of gases.
Body will compensate over distension of thoracic cavity
Barrel chest
Predisposing factor:
Smoking
Allergy
Air pollution
High risk - elderly
Hereditary - a 1 anti trypsin to release elastase for recoil of alveoli.

S/Sx:
Productive cough
Dyspnea at rest - due terminal
Anorexia & gen body malaise
Rales/ rhonchi
Bronchial wheezing
Decrease tactile fremitus (should have vibration)- palpation - "99". Decreased - with air or fluid
Resonance to hyperresonance - percussion
Decreased or diminished breath sounds
Pathognomonic: barrel chest - increase post/ anterior diameter of chest
Purse lip breathing - to eliminated PCO2
Flaring of alai nares

Diagnosis:
1. Pulmonary function test - decrease vital lung capacity
2. ABG -
Panlobular / centrolobular emphysema
pCO2 increase
pO2 decrease - hypoxema resp acidosis Blue bloaters
Panacinar/ Centracinar
pCO2 decrease
pO2 increase - hyperaxemia resp alkalosis Pink puffers
Nursing Mgt:
CBR
Meds -
Bronchodilators
Corticosteroids
Antimicrobial agents
Mucolytics/ expectorants
O2 - Low inflow
Force fluids
High fowlers
Neb & suction
Institute
P - posture
E - end
E - expiratory to prevent collapse of alveoli
P - pressure
HT
Avoid smoking
Prevent complications
Cor pulmonary - R ventricular hypertrophy
CO2 narcosis - lead to coma
Atelectasis
Pneumothorax - air in pleural space
Adherence to meds
RESTRICTIVE LUNG DISORDER
PNEUMOTHORAX - partial / or complete collapse of lungs due to entry or air in pleural space.
Types:
Spontaneous pneumothorax - entry of air in pleural space without obvious cause.
Eg. rupture of bleb (alveoli filled sacs) in pt with inflammed lung conditions
Eg. open pneumothorax - air enters pleural space through an opening in chest wall
-Stab/ gun shot wound
Tension Pneumothorax - air enters plural space with @ inspiration & can't escape leading to over distension of thoracic cavity
resulting to shifting of mediastinum content to unaffected side.
Eg. flail chest - "paradoxical breathing"

Predisposing factors:
1.Chest trauma
2.Inflammatory lung conditions
3.Tumor
S/Sx:
Sudden sharp chest pain
Dyspnea
Cyanosis
Diminished breath sound of affected lung
Cool moist skin
Mild restlessness/ apprehension
Resonance to hyper resonance
Diagnosis:
ABG - pO2 decrease -
CXR - confirms pneumothorax
Nursing Mgt:
Endotracheal intubation
Thoracenthesis
Meds - Morphine SO4
Anti microbial agents
Assist in test tube thoracotomy
Nursing Mgt if pt is on CPT attached to H2O drainage
Maintain strict aseptic technique
DBE
At bedside
Petroleum gauze pad if dislodged Hemostan
If with air leakage - clamp
Extra bottle
Meds - Morphine SO4
Antimicrobial
Monitor & assess for oscillation fluctuations or bubbling
If (+) to intermittent bubbling means normal or intact
- H2O rises upon inspiration
- H2o goes down upon expiration
b.) If (+) to continuous, remittent bubbling
1. Check for air leakage
2. Clamp towards chest tube
3. Notify MD
c.) If (-) to bubbling
1. Check for loop, clots, and kink
2. Milk towards H2O seal
3. Indicates re-expansion of lungs
When will MD remove chest tube:
If (-) fluctuations
(+) Breath sounds
 CXR - full expansion of lungs

Nursing Mgt of removal of chest tube

DBE
Instruct to perform Valsalva maneuver for easy removal, to prevent entry of air in pleural space.
Apply vaselinated air occlusive dressing
Maintain dressing dry & intact

GIT
I. Upper alimentary canal - function for digestion
Mouth
Pharynx (throat)
Esophagus
Stomach
1st half of duodenum
II. Middle Alimentary canal - Function: for absorption
- Complete absorption - large intestine
2nd half of duodenum
Jejunum
Ileum
1st half of ascending colon
III. Lower Alimentary Canal - Function: elimination
2nd half of ascending colon
Transverse
Descending colon
Sigmoid
Rectum
IV. Accessory Organ
Salivary gland
Verniform appendix
Liver
Pancreas - auto digestion
Gallbladder - storage of bile

I. Salivary Glands
1. Parotid - below & front of ear
2. Sublingual
3. Submaxillary

Produces saliva - for mechanical digestion

1200 -1500 ml/day - saliva produced

PAROTITIS - "mumps" - inflammation of parotid gland

-Paramyxo virus

S/Sx:
Fever, chills anorexia, gen body malaise
Swelling of parotid gland
Dysphagia
Ear ache - otalgia

Mode of transmission: Direct transmission & droplet nuclei

Incubation period: 14 - 21 days
Period of communicability - 1 week before swelling & immediately when swelling begins.

Nursing Mgt:
CBR
Strict isolation
Meds: analgesic
Antipyretic
 Antibiotics - to prevent 2° complications
Alternate warm & cold compress at affected part
Gen liquid to soft diet
Complications
Women - cervicitis, vaginitis, oophoritis
Both sexes - meningitis & encephalitis/ reason why antibiotics is needed
Men - orchitis might lead to sterility if it occur during / after puberty.

VERNIFORM APPENDIX - Rt iliac or Rt inguinal area

Function - lymphatic organ - produces WBC during fetal life - ceases to function upon birth of baby

APENDICITIS - inflamation of verniform appendix

Predisposing factor:
Microbial infection
Feacalith - undigested food particles - tomato seeds, guava seeds
Intestinal obstruction

S/Sx:
Pathognomonic sign: (+) rebound tenderness
Low grade fever, anorexia, n/v
Diarrhea / & or constipation
Pain at Rt iliac region
Late sign due pain - tachycardia

Diagnosis:
CBC - mild leukocytosis - increase WBC
PE - (+) rebound tenderness (flex Rt leg, palpate Rt iliac area - rebound)
Urinalysis

Treatment: - appendectomy 24 - 45°

Nursing Mgt:
Consent
Routinary nursing measures:
Skin prep
NPO
Avoid enema - lead to rupture of appendix
Meds:
Antipyretic
Antibiotics
*Don't give analgesic - will mask pain
- Presence of pain means appendix has not ruptured.
4. Avoid heat application - will rupture appendix.
5. Monitor VS, I&O bowel sound

Nursing Mgt: post op

If (+) to Pendrose drain - indicates rupture of appendix
Position- affected side to drain
Meds: analgesic due post op pain
Antibiotics, Antipyretics PRN
Monitor VS, I&O, bowel sound
Maintain patent IV line
Complications- peritonitis, septicemia

Liver - largest gland

Occupies most of right hypochondriac region
Color: scarlet red
Covered by a fibrous capsule - Glisson's capsule
Functional unit - liver lobules
Function:
Produces bile
Bile - emulsifies fats
- Composed of H2O & bile salts
-Gives color to urine - urobilin
Stool - stircobilin
Detoxifies drugs
Promotes synthesis of vit A, D, E, K - fat soluble vitamins
Hypevitaminosis - vit D & K
Vit A - retinol
Def Vit A - night blindness
Vit D - cholecalciferon
Helps calcium
Rickets, osteoarthritis

4. It destroys excess estrogen hormone

5. For metabolism
A. CHO -
1. Glycogenesis - synthesis of glycogens
2. Glycogenolysis - breakdown of glycogen
3. Gluconeogenesis - formation of glucose from CHO sources
B. CHON-
1. Promotes synthesis of albumin & globulin
Cirrhosis - decrease albumin
Albumin - maintains osmotic pressure, prevents edema
2. Promotes synthesis of prothrombin & fibrinogen
3. Promotes conversion of ammonia to urea.
Ammonia like breath - fetor hepaticus
C. FATS - promotes synthesis of cholesterol to neutral fats - called triglycerides

LIVER CIRRHOSIS - lost of architectural design of liver leading to fat necrosis & scarring
Early sign - hepatic encephalopathy
Asterixis - flapping hand tremors
Late signs - headache, restlessness, disorientation, decrease LOC - hepatic coma.
Nursing priority - assist in mechanical ventilation

Predisposing factor:
Decrease Laennac's cirrhosis - caused by alcoholism
Chronic alcoholism
Malnutrition - decreaseVit B, thiamin - main cause
Virus -
Toxicity- eg. Carbon tetrachloride
Use of hepatotoxic agents
S/Sx:
Early signs:
Weakness, fatigue
Anorexia, n/v
Stomatitis
Urine - tea color
Stool - clay color
Amenorrhea
Decrease sexual urge
Loss of pubic, axilla hair
Hepatomegaly
Jaundice
Pruritus or urticaria

2. Late signs
 a.) Hematological changes - all blood cells decrease
Leukopenia- decrease
Thrombocytopenia- decrease
Anemia- decrease
b.) Endocrine changes
Spider angiomas, Gynecomastia
Caput medusate, Palmar errythema

c.) GIT changes

Ascitis, bleeding esophageal varices - due to portal HPN
d.) Neurological changes:

Hepatic encephalopathy - ammonia (cerebral toxin)

Late signs: Early signs:
Headache asterexis
Fetor hepaticus (flapping hand tremors)
Confusion
Restlessness
Decrease LOC

Hepatic coma

Diagnosis:
Liver enzymes- increase

SGPT (ALT)
SGOT (AST)
Serum cholesterol & ammonia increase
Indirect bilirubin increase
CBC - pancytopenia
PTT - prolonged
Hepatic ultrasonogram - fat necrosis of liver lobules

Nursing Mgt
CBR
Restrict Na!
Monitor VS, I&O
With pt daily & assess pitting edema
Measure abdominal girth daily - notify MD
Meticulous skin care
Diet - increase CHO, vit & minerals. Moderate fats. Decrease CHON
Well balanced diet
Complications:
Ascites - fluid in peritoneal cavity
Nursing Mgt:
Meds: Loop diuretics - 10 - 15 min effect
Assist in abdominal paracentesis - aspiration of fluid
- Void before paracentesis to prevent accidental puncture of bladder as trochar is inserted

Bleeding esophageal varices

- Dilation of esophageal veins
1. Meds: Vit K
Pitrisin or Vasopresin (IM)
2. NGT decompression- lavage
- Give before lavage - ice or cold saline solution
- Monitor NGT output
3. Assist in mechanical decompression
- Insertion of sengstaken-blackemore tube
- 3 lumen typed catheter
- Scissors at bedside to deflate balloon.
Hepatic encephalopathy -
 Assist in mechanical ventilation - due coma
Monitor VS, neuro check
Siderails - due restless
Meds - Laxatives - to excrete ammonia

HEPATITIS- jaundice (icteric sclera)

Bilirubin

Kernicterus/ hyperbilirubinia

Irreversible brain damage

Pancreas - mixed gland (exocrine & endocrine gland)

PANCREATITIS - acute or chronic inflammation of pancreas leading to pancreatic edema, hemorrhage & necrosis due to auto
digestion.
Bleeding of pancreas - Cullen's sign at umbilicus

Predisposing factors:
Chronic alcoholism
Hepatobilary disease
Obesity
Hyperlipidemia
Hyperparathyroidism
Drugs - Thiazide diuretics, pills Pentamidine HCL (Pentam)
Diet - increase saturated fats
S/Sx:
Severe Lt epigastric pain - radiates from back &flank area
Aggravated by eating, with DOB
N/V
Tachycardia
Palpitation due to pain
Dyspepsia - indigestion
Decrease bowel sounds
(+) Cullen's sign - ecchymosis of umbilicus hemorrhage
(+) Grey Turner's spots - ecchymosis of flank area
Hypocalcemia
Diagnosis:
Serum amylase & lipase - increase
Urine lipase - increase
Serum Ca - decrease
Nursing Mgt:
1. Meds
a.) Narcotic analgesic - Meperidine Hcl (Demerol)
Don't give Morphine SO4 -will cause spasm of sphincter.
b.) Smooth muscle relaxant/ anti cholinergic
- Ex. Papavarine Hcl
Prophantheline Bromide (Profanthene)
c.) Vasodilator - NTG
d.) Antacid - Maalox
e.) H2 receptor antagonist - Ranitidin (Zantac) to decrease pancreatic stimulation
f.) Ca - gluconate

2. Withold food & fluid - aggravates pain

3. Assist in Total Parenteral Nutrition (TPN) or hyperalimentation
 Complications of TPN
Infection
Embolism
Hyperglycemia
4. Institute stress mgt tech
a.) DBE
b.) Biofeedback
5. Comfy position - Knee chest or fetal like position
6. If pt can tolerate food, give increase CHO, decrease fats, and increase CHON
7. Complications: Chronic hemorrhagic pancreatitis

GALLBLADDER - storage of bile - made up of cholesterol.

CHOLECYSTITIS/ CHOLELITHIASIS - inflammation of gallbladder with gallstone formation.
Predisposing factor:
High risk - women 40 years old
Post menopausal women - undergoing estrogen therapy
Obesity
Sedentary lifestyle
Hyperlipidemia
Neoplasm
S/Sx:
Severe Right abdominal pain (after eating fatty food). Occurring especially at night
Fatty intolerance
Anorexia, n/v
Jaundice
Pruritus
Easy bruising
Tea colored urine
Steatorrhea

Diagnosis:
Oral cholecystogram (or gallbladder series)- confirms presence of stones

Nursing Mgt:
Meds - a.) Narcotic analgesic - Meperdipine Hcl - Demerol
b.) Anti cholinergic - Atropine SO4
c.) Anti emetic
Phenergan - Phenothiazide with anti emetic properties
Diet - increase CHO, moderate CHON, decrease fats
Meticulous skin care
Surgery: Cholecystectomy
Nursing Mgt post cholecystectomy
-Maintain patency of T-tube intact & prevent infection

Stomach - widest section of alimentary canal

J shaped structures
Anthrum
Pylorus
Fundus
Valves
1.cardiac sphincter
Pyloric sphincter

Cells
Chief/ Zymogenic cells - secrets
Gastric amylase - digest CHO
Gastric lipase - digest fats
Pepsin - CHON
Rennin - digests milk products
 Parietal / Argentaffin / oxyntic cells
Function:
Produces intrinsic factor - promotes reabsorption of vit B12 cyanocobalamin - promotes maturation of RBC
Secrets Hcl acid - aids in digestion
Endocrine cells - Secrets gastrin - increase Hcl acid secretion

Function of the stomach

1.Mechanical
2.Chem. Digestion
3.Storage of food
-CHO, CHON- stored 1 -2 hrs. Fats - stored 2 - 3 hrs

PEPTIC ULCER DISEASE - (PUD) - excoriation / erosion of submucosa & mucosal lining due to:
Hypercecretion of acid - pepsin
Decrease resistance to mucosal barrier

Incidence Rate:
Men - 40 - 55 yrs old
Aggressive persons

Predisposing factors:
Hereditary
Emotional
Smoking - vasoconstriction - GIT ischemia
Alcoholism - stimulates release of histamine = Parietal cell release Hcl acid = ulceration
Caffeine - tea, soda, chocolate
Irregular diet
Rapid eating
Ulcerogenic drugs - NSAIDS, aspirin, steroids, indomethacin, ibuprofen
Indomethacin - S/E corneal cloudiness. Needs annual eye check up.

Gastrin producing tumor or gastrinoma - Zollinger Ellisons sign

Microbial invasion - helicobacter pylori. Metromidazole (Flagyl)

Types of ulcers
Ascending to severity
Acute - affects submucosal lining
Chronic - affects underlying tissue - heals & forms a scar

According to location
Stress ulcer
Gastric ulcer
Duodenal ulcer - most common

Stress ulcers - common among eritically ill clients

2 types
1.Curing's ulcer - cause: trauma & birth

hypovolemia

GIT schemia

Decrease resistance of mucosal barriers to Hcl acid

Ulcerations

2.Cushing's ulcer - cause - stroke/CVA/ head injury

Increase vagal stimulation

 Hyperacidity

Ulcerations

GASTRIC ULCER DUODENAL ULCER

SITE Intrum or lesser curvature Duodenal bulb
PAIN -30 min - 1 hr after eating -2-3 hrs after eating
- epigastrium - mid epigastrium
- gaseous & burning - cramping & burning
- not usually relieved by food & antacid - usually relieved by food & antacid
- 12 MN - 3am pain

HYPERSECRETION Normal gastric acid secretion Increased gastric acid secretion

VOMITING common Not common
HEMORRHAGE hematemeis Melena
WT Wt loss Wt gain
COMPLICATIONS a. stomach cause a. perforation
b. hemorrhage
HIGH RISK 60 years old 20 years old
Diagnosis:
Endoscopic exam
Stool from occult blood
Gastric analysis - N - gastric
Increase - duodenal
GI series - confirms presence of ulceration

Nursing Mgt:
Diet - bland, non irritating, non spicy
Avoid caffeine & milk/ milk products

Increase gastric acid secretion

Administer meds
Antacids

AAC
Aluminum containing antacids Magnesium containing antacids
Ex. aluminum OH gel ex. milk of magnesia
(Ampho-gel) S/E diarrhea
S/E constipation

Maalox (fever S/E)

H2 receptor antagonist
Ex
Ranitidine (Zantac)
Cimetidine (Tagamet)
Tamotidine (Pepcid)
Avoid smoking - decrease effectiveness of drug

Nursing Mgt:
Administer antacid & H2 receptor antagonist - 1hr apart
 -Cemetidine decrease antacid absorption & vise versa
Cytoprotective agents
Ex
1. Sucralfate (Carafate) - Provides a paste like subs that coats mucosal lining of stomach
2. Cytotec
d.) Sedatives/ Tranquilizers - Valium, lithium
e.)Anticholinergics
Atropine SO4
Prophantheline Bromide (Profanthene)

(Pt has history of hpn crisis With peptic ulcer disease. Rn should not administer alka seltzer- has large amount of Na.

4. Surgery: subtotal gastrectomy - Partial removal of stomach

Billroth I (Gastroduodenostomy) Billroth II (Gastrojejunostomy)
-Removal of ½ of stomach & anastomoses of gastric stump to - removal of ½ -3/4 of stomach & duodenal bulb & anastomostoses of
the duodenum. gastric stump to jejunum.

Before surgery for BI or BII - Do vagotomy (severing of vagus nerve) & pyloroplasty (drainage) first.

Nursing Mgt:
Monitor NGT output
Immediately post op should be bright red
Within 36- 42h - output is yellow green
After 42h - output is dark red
Administer meds:
Analgesic
Antibiotic
Antiemetics
Maintain patent IV line
VS, I&O & bowel sounds
Complications:
Hemorrhage - hypovolemic shock
Late signs - anuria
Peritonitis
Paralytic ileus - most feared
Hypokalemia
Thromobphlebitis
Pernicious anemia

7.)Dumping syndrome - common complication - rapid gastric emptying of hypertonic food solutions - CHYME leading to
hypovolemia.
Sx of Dumping syndrome:
Dizziness
Diaphoresis
Diarrhea
Palpitations

Nursing mgt:
Avoid fluids in chilled solutions
Small frequent feeding s-6 equally divided feedings
Diet - decrease CHO, moderate fats & CHON
Flat on bed 15 -30 minutes after q feeding

BURNS - direct tissue injury caused by thermal, electric, chemical & smoke inhaled (TECS)
Nursing Priority - infection (all kinds of burns)
Head burn-priority- a/w
2nd priority for 1st & 2nd ° - pain
2nd priority for 3rd ° - F&E

Thermal- direct contact - flames, hot grease, sunburn.

Electric, - wires
Chem. - direct contact - corrosive materials acids
Smoke - gas / fume inhalation

Stages:
Emergent phase - Removal of pt from cause of burn. Determine source or loc or burn
Shock phase - 48 - 72°. Characterized by shifting of fluids from intravascular to interstitial space
=Hypovolemia

S/Sx:
BP decrease
Urine output
HR increase
Hct increase
Serum Na decrease
Serum K increase
Met acidosis

3. Diuretic/ Fluid remobilization phase - 3 to 5 days. Return of fluid from interstitial to intravascular space
4. Recovery/ convalescent phase - complete diuresis. Wound healing starts immediately after tissue injury.

Class:
I. Partial Burn
1. 1st degree - superficial burns
- Affects epidermis
- Cause: thermal burn
- Painful
- Redness (erythema) & blanching upon pressure with no fluid filled vesicles
2. 2nd degree - deep burns
- Affects epidermis & dermis
- Cause -chem. burns
- very painful
- Erythema & fluid filled vesicles (blisters)
II Full thickness Burns
1. Third & 4th degrees burn
- Affects all layers of skin, muscles, bones
- Cause - electrical
- Less painful
- Dry, thick, leathery wound surface - known as ESCHAR - devitalized or necrotic tissue.
Assessment findings
Rule of nines
Head & neck = 9%
Ant chest = 18%
Post chest = 18%
@ Arm 9+9 = 18%
@ leg 18+18 = 18%
Genitalia/ perineum= 1%
Total 100%

Nursing Mgt
1. Meds
a.) Tetanus toxoid- burn surface area is source of anaerobic growth - Claustridium tetany

Tetany

Tetanolysin tetanospasmin

Hemolysis muscle spasm

b.) Morphine SO4

c.) Systemic antibiotics
1. Ampicillin
2. Cephalosporin
3. Tetracyclin
4. Topical antibiotic :
1. Silver Sulfadiazene (silvadene)
2. Sulfamylon
3. Silver nitrate
4. Povidone iodine (betadine)
2. Administer isotonic fluid sol & CHON replacements
3. Strict aseptic technique
4. Diet - increase CHO, increase CHON, increase Vit C, and increase K- orange
5. If (+) to burns on head, neck, face - Assist in intubation
6. Assist in hydrotherapy
7. Assist in surgical wound debridement. Administer analgesic 15 - 30 minutes before debridement
8. Complications:
a.) Infection
b.) Shock
c.) Paralytic ileus - due to hypovolemia & hypokalemia
d.) Curling's ulcer - H2 receptor antagonist
e.) Septicemia blood poisoning
f.) Surgery: skin grafting

GUT - genito-urinary tract

Function:
Promote excretion of nitrogenous waste products
Maintain F&E & acid base balance

1. Kidneys - pair of bean shaped organ

Retro peritonially (back of peritoneum) on either side of vertebral column. Encased in Bowmans's capsule.

Parts:
Renal pelvis - pyenophritis - infl
Cortex
Medulla

Nephrones - basic living unit

Glomerulus - filters blood going to kidneys

Function of kidneys:
Urine formation
Regulation of BP

Urine formation - 25% of total CO (Cardiac Output) is received by kidneys

Filtration
Tubular Reabsorption
Tubular Secretion

Filtration - Normal GFR/ min is 125 ml of blood

Tubular reabsorption - 124ml of ultra infiltrates (H2O & electrolytes is for reabsorption)
Tubular secretion - 1 ml is excreted in urine

Regulation of BP:

Predisposing factor:
Ex CS - hypovolemia - decrease BP going to kidneys
Activation of RAAS

Release of Renin (hydrolytic enzyme) at juxtaglomerular apparatus

Angiotensin I mild vasoconstrictor

 Angiotensin II vasoconstrictor

Adrenal cortex increase CO increase PR

Aldosterone
Increase BP
Increase Na &
H2O reabsorption

Hypervolemia

Ureters - 25 - 35 cm long, passageway of urine to bladder

Bladder - loc behind symphisis pubis. Muscular & elastic tissue that is distensible
- Function - reservoir or urine
1200 - 1800 ml - Normal adult can hold
200 - 500 ml - needed to initiate micturition reflex

Color - amber
Odor - aromatic
Consistency - clear or slightly turbid
pH - 4.5 - 8
Specific gravity - 1.015 - 1.030
WBC/ RBC - (-)
Albumin - (-)
E coli - (-)
Mucus thread - few
Amorphous urate (-)

Urethra - extends to external surface of body. Passage of urine, seminal & vaginal fluids.
Women 3 - 5 cm or 1 to 1 ½ "
Male - 20cm or 8"

UTI
CYSTITIS - inflammation of bladder
Predisposing factors:
Microbial invasion - E. coli
High risk - women
Obstruction
Urinary retention
Increase estrogen levels
Sexual intercourse
S/Sx:
Pain - flank area
Urinary frequency & urgency
Burning upon urination
Dysuria & hematuria
Fever, chills, anorexia, gen body malaise
Diagnosis:
Urine culture & sensitivity - (+) to E. coli
Nursing Mgt:
Force fluid - 2000 ml
Warm sitz bath - to promote comfort
Monitor & assess for gross hematuria
Acid ash diet - cranberry, vit C -OJ to acidify urine & prevent bacterial multiplication
Meds: systemic antibiotics
Ampicillin
Cephalosporin
Sulfonamides - cotrimaxazole (Bactrim)
 - Gantrism (ganthanol)
Urinary antiseptics - Mitropurantoin (Macrodantin)
Urinary analgesic- Pyridum
6. Ht
a.) Importance of Hydration
b.) Void after sex
c.) Female - avoids cleaning back & front
Bubble bath, Tissue paper, Powder, perfume
d.) Complications:
Pyelonephritis

PYELONEPHRITIS - acute/ chronic infl of 1 or 2 renal pelvis of kidneys leading to tubular destruction, interstitial abscess
formation.
Lead to Renal Failure

Predisposing factor:
Microbial invasion
E. Coli
Streptococcus
Urinary retention /obstruction
Pregnancy
DM
Exposure to renal toxins
S/Sx:
Acute pyelonephritis
Costovertibral angle pain, tenderness
Fever, anorexia, gen body malaise
Urinary frequency, urgency
Nocturia, dsyuria, hematuria
Burning on urination

Chronic Pyelonephritis
Fatigue, wt loss
Polyuuria, polydypsia
HPN

Diagnosis:
Urine culture & sensitivity - (+) E. coli & streptococcus
Urinalysis
Increase WBC, CHON & pus cells
Cystoscopic exam - urinary obstruction

Nursing Mgt:
Provide CBR - acute phase
Force fluid
Acid ash diet
Meds:
Urinary antiseptic - nitrofurantoin (macrodantin)
SE: peripheral neuropathy
GI irritation
Hemolytic anemia
Staining of teeth
Urinary analgesic - Peridium
Complication- Renal Failure

NEPHROLITHIASIS/ UROLITHIASIS- formation of stones at urinary tract

- calcium , oxalate, uric acid
 milk cabbage anchovies
cranberries organ meat
nuts tea nuts
chocolates sardines

Predisposing factors:
Diet - increase Ca & oxalate
Hereditary - gout
Obesity
Sedentary lifestyle
Hyperparathyroidism

S/Sx:
Renal colic
Cool moist skin (shock)
Burning upon urination
Hematuria
Anorexia, n/v
Diagnosis:
IVP - intravenous pyelography. Reveals location of stone
KUB - reveals location of stone
Cytoscopic exam- urinary obstruction
Stone analysis - composition & type of stone
Urinalysis - increase EBC, increase CHON
Nursing Mgt:
1.Force fluid
2.Strain urine using gauze pad
3.Warm sitz bath - for comfort
4.Alternate warm compress at flank area
5. a.) Narcotic analgesic- Morphine SO4
b.) Allopurinol (Zyeoprim)
c.) Patent IV line
d.) Diet - if + Ca stones - acid ash diet
If + oxalate stone - alkaline ash diet - (Ex milk/ milk products)
If + uric acid stones - decrease organ meat / anchovies sardines
Surgery
Nephectomy - removal of affected kidney
Litholapoxy - removal of 1/3 of stones- Stones will recur. Not advised for pt with big stones
Extracorporeal shock wave lithotripsy
- Non - invasive
- Dissolve stones by shock wave
Complications: Renal Failure

BENIGN PROSTATIC HYPERTROPHY - enlarged prostate gland leading to

Hydro ureters - dilation of ureters
Hydronephrosis - dilation of renal pelvis
Kidney stones
Renal failure

Predisposing factor:
High risk - 50 years old & above
60 - 70 - (3 to 4 x at risk)
Influence of male hormone
S/Sx:
1.Decrease force of urinary stream
2.Dysuria
3.Hematuria
4.Burning upon urination
5.Terminal bubbling
6.Backache
 7.Sciatica
Diagnosis:
Digital rectal exam - enlarged prostate gland
KUB - urinary obstruction
Cystoscopic exam - obstruction
Urinalysis - increase WBC, CHON

Nursing Mgt:
Prostatic message - promotes evacuation of prostatic fluid
Limit fluid intake
Provide catheterization
Meds:
Terazozine (hytrin) - Relaxes bladder sphincter
Fenasteride (Proscar) - Atrophy of Prostate Gland
5. Surgery: Prostatectomy - TURP- Transurethral resection of Prostate- No incision
-Assist in cystoclysis or continuous bladder irrigation.
Nursing mgt:
Monitor symptoms of infection
Monitor symptoms gross/ flank bleeding. Normal bleeding within 24h.
3. Maintain irrigation or tube patent to flush out clots - to prevent bladder spasm & distention

ACUTE RENAL FAILURE - sudden immobility of kidneys to excrete nitrogenous waste products & maintain F&E balance
due to a decrease in GFR. (N 125 ml/min)

Predisposing factor:
Pre renal cause- decrease blood flow
Causes:
Septic shock
Hypovolemia
Hypotension decrease flow to kidneys
CHF
Hemorrhage
Dehydration

Intra-renal cause - involves renal pathology= kidney problem

Acute tubular necrosis-
Pyelonephritis
HPN
Acute GN

Post renal cause - involves mechanical obstruction

Stricture
Urolithiasis
BPH

CHRONIC RF - irreversible loss of kidney function

Predisposing factors:
DM
HPN
Recurrent UTI/ nephritis
Exposure to renal toxins

Stages of CRF
Diminished Reserve Volume - asymptomatic
Normal BUN & Crea, GFR < 10 - 30%
2. Renal Insufficiency
3. End Stage Renal disease
 S/Sx:
1.) Urinary System 2.) Metabolic disturbances
a.) polyuria a.) azotemia (increase BUN & Crea)
b.) nocturia b.) hyperglycemia
c.) hematuria c.) hyperinulinemia
d.) Dysuria
e.) oliguria
3.) CNS 4.) GIT
a.) headache a.) n/v
b.) lethargy b.) stomatitis
c.) disorientation c.) uremic breath
d.) restlessness d.) diarrhea/ constipation
e.) memory impairment
5.) Respiratory 6.) hematological
a.) Kassmaul's resp a.) Normocytic anemia
b.) decrease cough reflex bleeding tendencies

7.) Fluid & Electrolytes 8.) Integumentary

a.) hyperkalemia a.) itchiness/ pruritus
b.) hypernatermia b.) uremic frost
c.) hypermagnesemia
d.) hyperposphatemia
e.) hypocalcemia
f.) met acidosis
Nursing Mgt:
Enforce CBR
Monitor VS, I&O
Meticulous skin care. Uremic frost - assist in bathing pt
4. Meds:
a.) Na HCO3 - due Hyperkalemia
b.) Kagexelate enema
c.) Anti HPN - hydralazine
d.) Vit & minerals
e.) Phosphate binder
(Amphogel) Al OH gel - S/E constipation
f.) Decrease Ca - Ca gluconate
5. Assist in hemodialysis
Consent/ explain procedure
Obtain baseline data & monitor VS, I&O, wt, blood exam
Strict aseptic technique
Monitor for signs of complications:
B - bleeding
E - embolism
D - disequilibrium syndrome
S - septicemia
S - shock - decrease in tissue perfusion
Disequilibrium syndrome - from rapid removal of urea & nitrogenous waste prod leading to:
n/v
HPN
Leg cramps
Disorientation
Paresthesia

Avoid BP taking, blood extraction, IV, at side of shunt or fistula. Can lead to compression of fistula.
Maintain patency of shunt by:
Palpate for thrills & auscultate for bruits if (+) patent shunt!
Bedside- bulldog clip
- If with accidental removal of fistula to prevent embolism.
- Infersole (diastole) - common dialisate used
7. Complication
 - Peritonitis
- Shock

8. Assist in surgery:
Renal transplantation : Complication - rejection. Reverse isolation

EYES
External parts
Orbital cavity - made up of connective tissue protects eye form trauma.
EOM - extrinsic ocular muscles - involuntary muscles of eye needed for gazing movement.
Eyelashes/ eyebrows - esthetic purposes
Eyelids - palpebral fissure - opening upper & lower lid. Protects eye from direct sunlight

Meibomean gland - secrets a lubricating fluid inside eyelid

Stye/ sty or Hordeolum- inflamed Meibomean gland
Conjunctiva
Lacrimal apparatus - tears

Process of grieving
Denial
Anger
Bargaining
Depression
Acceptance
Intrinsic coat
I. sclerotic coat - outer most
a.) Sclera - white. Occupies ¾ post of eye. Refracts light rays
b.) Canal of schlera - site of aqueous humor drainage
c.) Cornea - transparent structure of eye

II/ Uveal tract - nutritive care

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

2 chambers of the eye

1. Anterior
a.) Vitereous Humor - maintains spherical shape of the eye
b.) Aqueous Humor - maintains intrinsic ocular pressure
Normal IOP= 12-21 mmHg

II. Retina (innermost layer)

Optic discs or blind spot - nerve fibers only

No auto receptors

cones (daylight/ colored vision) rods - night twilight vision

phototopic vision "scotopic vision" = vit A deficiency - rods insufficient

 Maculla lutea - yellow spot center of retina
Fovea centralis - area with highest visual acuity oracute vision

Physiology of vision
4 Physiological processes for vision to occur:
1. Refraction of light rays - bending of light rays
2. Accommodation of lens
3. Constriction & dilation of pupils
4. Convergence of eyes

Unit of measurements of refraction - diopters

Normal eye refraction - emmetropia

ERROR of refraction
Myopia - near sightedness - Treatment: biconcave lens
Hyperopia/ or farsightedness - Treatment: biconvex lens
Astigmatisim - distorted vision - Treatment: cylindrical
Prebyopia - "old slight" - inelasticity of lens due to aging - Treatment: bifocal lens or double vista
Accommodation of lenses - based on thelmholtz theory of accommodation

Near vision = far vision=

Ciliary muscle contracts= ciliary muscle dilates / relaxes=
Lens bulges lens is flat

Convergence of the eye:

Error:
Exotropia - 1 eye normal
Esophoria - corrected by corrective eye surgery
Strabismus- squint eye
Amblyopia - prolong squinting

GLAUCOMA - increase IOP - if untreated, atrophy of optic nerve disc - blindness

Predisposing factors:
High risk group - 40 & above
HPN
DM
Hereditary
Obesity
Recent eye trauma, infl, surgery

Type:
Chronic - (open angle G.) - most common type
Obstruct in flow of aqueous humor at trabecular meshwork of canal of schlema
Acute (close angle G.) - Most dangerous type
Forward displacement of iris to cornea leading to blindness.
Chronic (closed - angle) - Precipitated by acute attack

S/Sx:
1. Loss of peripheral vision - tunnel vision
2. Halos around lights
3. Headache
4. n/v
5. Steamy cornea
6. Eye discomfort
7. If untreated - gradual loss of central vision - blindness

Diagnosis:
1. Tonometry - increase IOP >12- 21 mmHg
2. Perimetry - decrease peripheral vision
3. Gonioscopy - abstruction in anterior chamber

Nursing mgt:
Enforce CBR
Maintain siderails
Administer meds
Miotics - lifetime - contracts ciliary muscles & constricts pupil. Ex Pilocarpine Na (Carbachol)
Epinephrine eye drops - decrease secretion of aqueous humor
Carbonic anhydrase inhibitors. Ex. acetapolamide (Diamox)
- Promotes increase out flow of aquaeous humor
d.) Temoptics (Timolol maleate)- Increase outflow of aquaous humor
Surgery:
Invasive:
Trabeculectomy - eyetrephining - removal of trabelar meshwork of canal or schlera to drain aqueous humor
Peripheral Iridectomy - portion of iris is excised to drain aqueous humor

Non-invasive:
Trabeculoctomy (eye laser surgery)

Nursing Mgt pre op- all types surgery

Apply eye patch on unaffected eye to force weaker eye to become stronger.

Nursing Mgt post op - all types of surgery

Position unaffected/ unoperated side - to prevent tension on suture line.
Avoid valsalva maneuver
Monitor symptoms of IOP
Headache
n/v
Eye discomfort
Tachycardia
Eye patch - both eyes - post op

CATARACT - partial/ complete opacity of lens

Predisposing factor:
90-95% - aging (degenerative/ senile cataract)
Congenital
Prolonged exposure to UV rays
DM-

S/Sx:
Loss of central vision - "Hazy or blurring of vision"
Painless
Milky white appearance at center of pupil
Decrease perception of colors

Diagnosis: Opthalmoscopic exam - (+) opacity of lens

Nsg Mgt:
Reorient pt to environment - due opacity
Siderails
Meds - a.) Mydriatics - dilate pupil - not lifetime
Ex. Mydriacyl
Cyslopegics - paralyzes ciliary muscle. Ex. Cyclogye
Surgery

E - extra
C - capsular
 C - cataract partial removal of lens
L - lens
E - extraction

I - intra
C - capsular
C - cataract total removal of lens & surrounding capsules
L - lens
E - extraction

Nursing Mgt:

1.Position unaffected/ unoperated side - to prevent tension on suture line.

2.Avoid valsalva maneuver

3.Monitor symptoms of IOP

Headache
n/v
Eye discomfort
Tachycardia
4.Eye patch - both eyes - post op

RETINAL DETACHMENT- separation of 2 layers of retina

Predisposing factors:
Severe myopia - nearsightedness
Diabetic Retinopathy
Trauma
Following lens extraction
HPN

S/Sx:
"Curtain -veil" like vision
Flashes of lights
Floaters
Gradual decrease in central vision
Headache

Diagnosis- opthaloscopic exam

Nursing Mgt:
Siderails (all visual disease)
Surgery:
Cryosurgery
Scleral buckling

EAR -
Hearing
Balance (Kinesthesia or position sense)

Parts:
Outer-
Pinna/ auricle - protects ear from direct trauma
Ext. auditory meatus - has ceruminous gland. Cerumen
Tympanic membrane - transmits sound waves to middle ear

Disorders of outer ear

Entry of insects - put flashlight to give route of exit
Foreign objects - beans (bring to MD)
H2O - drain
2. Middle ear
a.) Ear osssicle

1. Hammer -malleus
2. Anvil -Incus for bone conduction disorder conductive hearing loss
3. Stirrups -stapes

b. Eustachian tube - Opens to allow equalization of pressure on both ears

- Yawn, chew, and swallow
Children - straight, wide, short
Otitis media
Adult - long, narrow & slanted

c. Muscles
1. Stapedius
2. Tensor tympani
3. Inner ear
a. Bony labyrinth - for balance, vestibule

Utricle & succule

Otolithe or ear stone - has Ca carbonate

Movement of head = Righting reflex = Kinesthesia

b. Membranous Labyrinth
Cochlea - ( function for hearing) has organ of corti
Endolymph & perilymph - for static equilibrium
Mastoid air cells - air filled spaces in temporal bone in skull

Complications of Mastoditis - meningitis

Types of hearing loss:

Conductive hearing loss - transmission hearing loss
Causes:
Impacted cerumen - tinnitus & conduction hearing loss- assist in ear irrigaton
Immobility of stapes - OTOSCLEROSIS
Middle ear disease char by formation of spongy bone in the inner ear causing fixation or immobility of stapes
Stapes can't transmit sound waves

Surgery
Stapedectomy - removal of stapes, spongy bone & implantation of graft/ ear prosthesis

Predisposing factor:
Familiar tendency
Ear trauma & surgery

S/Sx:
Tinnitus
Conductive hearing loss

Diagnosis:
Audiometry - various sound stimulates (+) conductive hearing loss
Weber's test - Normal AC> BC
result BC > AC

Stapedectomy
Nursing Mgt post op
Position pt unaffected side
DBE
No coughing & blowing of nose
- Night lead to removal of graft
 Meds:
Analgesic
Antiemetic
Antimotion sickness agent. Ex. meclesine Hcl (Bonamine)
Assess - motor function - facial nerve - (Smile, frown, raise eyebrow)
Avoid shampoo hair for 1 to 2 weeks. Use shower cap

SENSORY NEURAL HEARING LOSS/ NERVE DEAFNESS

Cause:
Tumor on cocheal
Loud noises (gun shot)
Presbycusis - bilateral progressive hearing loss especially at high frequencies - elderly
Face elderly to promote lip reading
Meniere's disease - endolymphatic hydrops
Inner ear disease char by dilation of endo - lympathic system leading to increase volume of endolin

Predisposing factor of MENIERE'S DISEASE

Smoking
Hyperlipidemia
30 years old
Obesity - (+) chosesteatoma
Allergy
Ear trauma & infection

S/Sx:
TRIAD symptoms of Meniere's disease
Tinnitus
Vertigo
Sensory neural hearing loss
Nystagmus
n/v
Mild apprehension, anxiety
Tachycardia
Palpitations
Diaphoresis

Diagnosis:
Audiometry - (+) sensory hearing loss

Nursing mgt:
Comfy & darkened environment
Siderails
Emetic basin
Meds:
Diuretics -to remove endolymph
Vasodilator
Antihistamine
Antiemetic
Antimotion sickness agent
Sedatives/ tranquilizers

Restrict Na
Limit fluid intake
Avoid smoking
Surgery - endolymphatic sac decompression- Shunt