A disorder of the CNS characterized by bilateral symmetrical polyneuritis leading to ascending muscle paralysis.
A. Predisposing Factors
1. Autoimmune 2. Antecedent viral infections such as LRT infections
C. Diagnostic Procedures
1. CSF analysis reveals increase in IgG and protein.
D. Nursing Management
1. Maintain patent airway and adequate ventilation by: a. assist in mechanical ventilation b. monitor pulmonary function test 2. Monitor strictly the following a. vital signs b. intake and output c. neuro check d. ECG 3. Maintain side rails to prevent injury related to fall 4. Prevent complications of immobility by turning the client every 2 hours 5. Institute NGT feeding to prevent aspiration 6. Assist in passive ROM exercise
7. Administer medications as ordered a. Corticosteroids suppress immune response b. Anti Cholinergic Agents Atrophine Sulfate c. Anti Arrythmic Agents Lidocaine, Zylocaine Bretylium blocks release of norepinephrine to prevent increase of BP 8. Assist in plasma pharesis(filtering of blood to remove autoimmune anti-bodies) 9. Prevent complications a. Arrythmia b. Paralysis or respiratory muscles/Respiratory arrest * Sengstaken Blakemore Tube for liver cirrhosis to decompress bleeding esophageal varices (prepare scissor to cut tube in case of difficulty in breathing to release air in the balloon for hemodialysis prepare bulldog clips to prevent air embolism.
A. Predisposing Factors
1. Head injury due to birth trauma 2. Genetics 3. Presence of brain tumor
III. Status Epilepticus A continuous uninterrupted seizure activity, if left untreated can lead to hyperpyrexia and lead to coma and eventually death. Drug of choice : Diazepam, Valium and Glucose
C. Diagnostic Procedures
1. CT Scan reveals brain lesions 2. EEG reveals hyper activity of electrical brain waves
D. Nursing Management
1. Maintain patent airway and promote safety before seizure activity a. clear the site of blunt or sharp objects b. loosen clothing of client c. maintain side rails d. avoid use of restrains e. turn clients head to side to prevent aspiration f. place mouth piece of tongue guard to prevent biting or tongue 2. Avoid precipitating stimulus such as bright/glaring lights and noise 3. Administer medications as ordered a. Anti convulsants (Dilantin, Phenytoin) b. Diazepam, Valium c. Carbamazepine (Tegretol) Trigeminal neuralgia d. Phenobarbital, Luminal 4. Institute seizure and safety precaution post seizure attack a. administer O2 inhalation b. provide suction apparatus 5. Document and monitor the following a. onset and duration b. types of seizures c. duration of post ictal sleep may lead to status epilepticus d. assist in surgical procedure cortical resection
COMPREHENSIVE NEURO EXAM GLASGOW COMA SCALE -objective measurement of LOC sometimes called as the quick neuro check Components 1. Motor response 2. Verbal response 3. Eye opening Survey of mental status and speech a. LOC b. Test of memory Levels of orientation Cranial nerve assessment Sensory nerve assessment Motor nerve assessment Deep tendon reflex Autonimics Cerebellar test a. Rombergs test 2 nurses, positive for ataxia b. Finger to nose test positive result mean dimetria (inability of body to stop movement at desired point) c. Alternate supination and pronation positive result mean dimetria Conscious 15 14 Lethargy 13 11 Stupor 10 8 Coma 7 Deep Coma 3
MAIN FOODSTUFF Anabolism/ Catabolism 1. Carbohydrates 2. Protein 3. Fats, Glucose, Amino Acids, Fatty Acids, Glycogen, Nitrogen, Free Fatty AcidsCholesterol- Ketones HYPERGLYCEMIA - increase osmotic diuresis Glycosuria, Polyuria and Cellular starvation- weight loss. Cellular dehydration. Stimulates the appetite/satiety center Stimulates the thirst center (Hypothalamus) (Hypothalamus) Polyphagia/Polydypsia* Liver has glycogen that undergo glycogenesis/
glycogenolysis GLUCONEOGENESIS
Formation of glucose from non-CHO sources Increase protein formation Negative Nitrogen balance Tissue wasting (Cachexia) INCREASE FAT CATABOLISM Free fatty acids Cholesterol Ketones Atherosclerosis, Diabetic KetoAcidosis
Hypertension, Acetone Breath, Kussmauls Respiration odor, MI, CVA, Death Diabetic Coma
DIABETIC KETOACIDOSIS
- Acute complication of type 1 DM due to severe hyperglycemia leading to severe CNS depression
A. Predisposing Factors
1. Hyperglycemia 2. Stress number one precipitating factor 3. Infection
C. Diagnostic Procedures
1. FBS is increased 2. BUN (normal value: 10 20) 3. Creatinine (normal value: .8 1) 4. Hct (normal value: female 36 42, male 42 48) due to severe dehydration
D. Nursing Management
1. Assist in mechanical ventilation 2. Administer 0.9 NaCl followed by .45 NaCl (hypotonic solutions) to counteract dehydration and shock 3. Monitor strictly vital signs, intake and output and blood sugar levels 4. Administer medications as ordered a. Insulin therapy (regular acting insulin/rapid acting insulin peak action of 2 4 hours) b. Sodium Bicarbonate to counteract acidosis c. Antibiotics to prevent infection
B. Nursing Management
1. Assist in mechanical ventilation 2. Administer 0.9 NaCl followed by .45 NaCl (hypotonic solutions) to counteract dehydration and shock 3. Monitor strictly vital signs, intake and output and blood sugar levels 4. Administer medications as ordered a. Insulin therapy (regular acting insulin peak action of 2 4 hours)- for DKA use rapid acting insulin b. Antibiotics to prevent infection INSULIN THERAPY A. Sources of Insulin 1. Animal sources - Rarely used because it can cause severe allergic reaction- Derived from beef and pork 2. Human Sources - Frequently used type because it has less antigenicity property thus less allergic reaction 3. Artificially Compound Insulin B. Types of Insulin 1. Rapid Acting Insulin (clear) - Regular acting insulin (IV only)- Peak action is 2 4 hours 2. Intermediate Acting Insulin (cloudy) - Non Protamine Hagedorn Insulin (NPH)- Peak action is 8 16 hours 3. Long Acting Insulin (cloudy) - Ultra Lente- Peak action is 16 24 hours
C. Nursing Management for Insulin Injections 1. Administer at room temperature to prevent development of lipodystrophy
(atrophy, hypertrophy of subcutaneous tissues)
2. Place in refrigerator once opened 3. Avoid shaking insulin vial vigorously instead gently roll vial between palm
to prevent formation of bubbles
6. No need to aspirate upon injection 7. Rotate insulin injection sites to prevent development of lipodystrophy 8. Most accessible route is abdomen 9. When mixing 2 types of insulin aspirate first the clear insulin before 10. Monitor for signs of local complications such as a. Allergic reactions b. Lipodystrophyc.
Somogyi Phenomenon rebound effect of insulin characterized by hypoglycemia tohyperglycemia ORAL HYPOGLYCEMIC AGENTS - Stimulates the pancreas to secrete insulin
A. Classsification1. First Generation Sulfonylureas a. Chlorpropamide (Diabenase) b. Tolbutamide (Orinase) c. Tolamazide (Tolinase) 2. Second Generation Sulfonylureas a. Glipzide (Glucotrol) b. Diabeta (Micronase)
HISTOPLASMOSIS
Acute fungal infection caused by inhalation of contaminated dust or particles with histoplasma capsulatum derived from birds manure.
B. Diagnostic Procedures
1. Histoplasmin Skin Test positive 2. ABG analysis PO2 decrease C. Nursing Management 1. Enforce CBR 2. Administer oxygen inhalation
3. Administer medications as ordered a. Antifungal- Amphotericin B- Fungizone (Nephrotoxicity, check for BUN and Creatinine, Hypokalemia) b. Steroids c. Mucolyticsd. Antipyretics 4. Force fluids to liquefy secretions 5. Nebulize and suction as needed 6. Prevent complications bronchiectasis 7. Prevent the spread of infection by spraying of breeding places
A. Predisposing Factors
1. Smoking 2. Air pollution
C. Diagnostic Procedure
ABG analysis reveals PO2decrease (hypoxemia), PCO2increase, pH decrease
Bronchial Asthma
Reversible inflammatory lung condition due to hypersensitivity to allergens leading to narrowing of smaller airways.
C. Diagnostic Procedure
1. Pulmonary Function Test- Incentive spirometer reveals decrease vital lung capacity 2. ABG analysis PO2 decrease- Before ABG test for positive Allens Test, apply direct pressure to ulnar and radial artery to determine presence of collateral circulation
D. Nursing Management
1. Enforce CBR 2. Oxygen inhalation, with low inflow of 2 3 L/min 3. Administer medications as ordered a. Bronchodilators given via inhalation or metered dose inhaler or MDI for 5 minutes. b. Steroids decrease inflammation
c. Mucomysts (acetylceisteine) d. Mucolytics/expectorants e. Anti histamine 4. Force fluids 5. Semi fowlers position 6. Nebulize and suction when needed 7. Provide client health teachings and discharge planning concerning a. Avoidance of precipitating factor b. Prevent complications- Emphysema- Status Asthmaticus (give drug of choice)- Epinephrine- Steroids- Bronchodilators c. Regular adherence to medications to prevent development of status asthmaticus d. Importance of follow up care
BRONCHIECTASIS
Abnormal permanent dilation of bronchus leading to destruction of muscular and elastic tissues of alveoli
A. Predisposing Factors
1. Recurrent lower respiratory tract infections 2. Chest trauma 3. Congenital defects 4. Related to presence of tumor
C. Diagnostic Procedure
1. ABG PO2 decrease 2. Bronchoscopy direct visualization of bronchus using fiberscope Nursing Management PRE Bronchoscopy 1. Secure inform consent and explain procedure to client 2. Maintain NPO 6 8 hours prior to procedure 3. Monitor vital signs and breath sound POST Bronchoscopy 1. Feeding initiated upon return of gag reflex 2. Avoid talking, coughing and smoking, may cause irritation 3. Monitor for signs of gross 4. Monitor for signs of laryngeal spasm prepare tracheostomy set
D. Treatment
1. Surgery (pneumonectomy , 1 lung is removed and position on affected side) 2. Segmental Wedge Lobectomy (promote re expansion of lungs)- Unaffected lobectomy facilitate drainage
EMPHYSEMA
Irreversible terminal stage of COPD characterized by a. Inelasticity of alveoli b. Air trapping c. Maldistribution of gases d. Over distention of thoracic cavity (barrel chest)
A. Predisposing Factors
1. Smoking 2. Air pollution 3. Allergy 4. High risk: elderly 5. Hereditary it involves deficiency of ALPHA-1 ANTI TRYPSIN (needed to form Elastase, for recoil of alveoli)
C. Diagnostic Procedure
1. Pulmonary Function Test reveals decrease vital lung capacity 2. ABG analysis reveals a. Panlobular/ centrilobular - Decrease PO2 (hypoxemia leading to chronic bronchitis, Blue Bloaters)- Decrease ph- Increase PCO2- Respiratory acidosis b. Panacinar/ centriacinar - Increase PO2 (hyperaxemia, Pink Puffers) Decrease PCO2 - Increase ph- Respiratory alkalosis
D. Nursing Management
1. Enforce CBR 2. Administer oxygen inhalation via low inflow 3. Administer medications as ordered a. Bronchodilators b. Steroids c. Antibiotics d. Mucolytics /expectorants 4. High fowlers position 5. Force fluids 6. Institute pulmonary toilet 7. Nebulize and suction when needed 8. Institute PEEP (positive end expiratory pressure) in mechanical ventilation promotes maximum alveolar lung expansion 9. Provide comfortable and humid environment 10. Provide high carbohydrates, protein, calories, vitamins and minerals 11. Health teachings and discharge planning concerning a. Avoid smoking b. Prevent complications- Atelectasis- Cor Pulmonale- CO2 narcosis may lead to coma- Pneumothorax c. Strict compliance to medication d. Importance of follow up care