NERVOUS SYSTEM
Overview of structures and functions:
Central Nervous System
Brain
Spinal Cord
Peripheral Nervous System
Cranial Nerves
Spinal Nerves
Autonomic Nervous System
Sympathetic nervous system
Parasympathetic nervous system
Lidocaine(Xylocaine)
B. NEUROGLIA
Support and protection of neurons.
TYPES
1. Astrocytes – maintains blood brain barrier semi-permeable.
Majority of brain tumors (90%) arises from called
astrocytoma.
2. Oligodendria
3. Microglia
4. Epindymal
2
2. Carbon Monoxide and Lead Poisoning
Can lead to Parkinson’s Disease.
DEMYELINATING DISORDERS
1. ALZHEIMER’S DISEASE
Atrophy of brain tissues.
Sign and Symptoms
4 A’s of Alzheimer
a. Amnesia – loss of memory.
b. Agnosia – no recognition of inanimate objects.
c. Apraxia – no recognition of objects function.
d. Aphasia – no speech (nodding).
*Expressive aphasia
“motor speech center”
Broca’s Aphasia
*Receptive aphasia
2
inability to understand spoken words.
Wernicke’s Aphasia
2. MULTIPLE SCLEROSIS
Chronic intermittent disorder of CNS characterized by white patches of
demyelination in brain and spinal cord.
Characterized by remission and exacerbation.
Women ages 15-35 are prone
Unknown Cause
Slow growing virus
Autoimmune disorders
Pernicious anemia
Myasthenia gravis
Lupus
Hypothyroidism
GBS
2. Impaired sensation
2
to touch, pain, pressure, heat and cold.
tingling sensation
CHARCOTS
TRIAD
IAN
6. Urinary retention/incontinence
7. Constipation
8. Decrease sexual capacity
DIAGNOSTIC PROCEDURE
CSF analysis (increase in IgG and Protein).
MRI (reveals site and extent of demyelination).
(+) Lhermitte’s sign a continuous and increase contraction of spinal
column.
NURSING MANAGEMENT
2
1. Administer medications as ordered
MICROGLIA
stationary cells that carry on phagocytosis (engulfing of bacteria
or cellular debris, eating), pinocytosis (cell drinking).
MACROPHAGE ORGAN
Microglia Brain
Monocytes Blood
Kupffers cells Kidney
Histiocytes Skin
Alveolar Lung
Macrophage
EPINDYMAL CELLS
Secretes a glue called chemo attractants that concentrate the
bacteria.
COMPOSITION OF BRAIN
80% brain mass
10% blood
10% CSF
I. Brain Mass
PARTS OF THE BRAIN
1. CEREBRUM
largest part
composed of the Right Cerebral Hemisphere and Left Cerebral
Hemisphere enclosed in the Corpus Callosum.
Functions of Cerebrum
integrative
sensory
motor
Lobes of Cerebrum
1. Frontal
2
higher cortical thinking
controls personality
2. Temporal
hearing
short term memory
3. Parietal
for appreciation
discrimination of sensory impulses to pain, touch, pressure, heat,
cold, numbness.
4. Occipital
for vision
Insula (Island of Reil)
visceral function activities of internal organ like gastric motility.
Limbic System (Rhinencephalon)
controls smell and if damaged results to Anosmia (absence of
smell).
controls libido
controls long term memory
2. BASAL GAGLIA
areas of grey matter located deep within each cerebral
hemisphere.
release dopamine (controls gross voluntary movement.
3. MIDBRAIN/ MESENCEPHALON
acts as relay station for sight and hearing.
size of pupil is 2 – 3 mm.
2
equal size of pupil is isocoria.
unequal size of pupil is anisocoria.
4. INTERBRAIN/ DIENCEPHALON
Parts of Diencephalon
A. Thalamus
acts as relay station for sensation.
B. Hypothalamus
controls temperature (thermoregulatory center).
controls blood pressure
controls thirst
appetite/satiety
sleep and wakefulness
controls some emotional responses like fear, anxiety and
excitement.
controls pituitary functions
androgenic hormones promotes secondary sex characteristics.
early sign for males are testicular and penile enlargement
late sign is deepening of voice.
early sign for females telarche and late sign is menarche.
5. BRAIN STEM
located at lowest part of brain
Parts of Brain Stem
1. Pons
pneumotaxic center controls the rate, rhythm and depth of
respiration.
2. Medulla Oblongata
controls respiration, heart rate, swallowing, vomiting, hiccup,
vasomotor center (dilation and constriction of bronchioles).
3. Cerebellum
2
smallest part of the brain.
lesser brain.
Medulla Oblongata
Brain Herniation
NEUROLOGIC DISORDERS
INCREASE INTRACRANIAL PRESSURE – increase in intra-cranial bulk
brought about by an increase in one of the 3 major intra cranial components.
2
Causes:
head trauma/injury localized abscess
Nursing Management
1. Maintain patent and adequate ventilation by:
a. Prevention of hypoxia and hypercarbia
Early signs of hypoxia
restlessness
2
agitation
tachycardia
2. Hypocalcemia/ Tetany
decrease calcium level
normal value is 8.5 – 11 mg/100 ml
Signs and Symptoms
tingling sensation
paresthesia
numbness
(+) Trousseau’s sign/ Carpopedal spasm
(+) Chvostek’s sign
Complications
Arrhythmia
Seizures
Nursing Management
Calcium Gluconate per IV slowly as ordered
* Calcium Gluconate toxicity – results to SEIZURE
Magnesium Sulfate
Nursing Management
force fluids
administer isotonic fluid solution as ordered
4. Hyperglycemia
normal FBS is 80 – 100 mg/dl
Signs and Symptoms
polyuria
polydypsia
polyphagia
Nursing Management
monitor FBS
5. Hyperuricemia
increase uric acid (purine metabolism)
foods high in uric acid (sardines, organ meats and anchovies)
*Increase in tophi deposit leads to Gouty arthritis.
Signs and Symptoms
joint pain (great toes)
swelling
Nursing Management
2
force fluids
administer medications as ordered
Aloneness
Multiple loss
causes
suicide
3. Aminophylline Toxicity
Signs and Symptoms
tachycardia
palpitations
CNS excitement (tremors, irritability, agitation and restlessness)
Nursing Management
only mixed with plain NSS or 0.9 NaCl to prevent development of
crystals or precipitate.
administered sandwich method
2
avoid taking alcohol because it can lead to severe CNS depression
avoid caffeine
5. Acetaminophen Toxicity
Signs and Symptoms
hepatotoxicity (monitor for liver enzymes)
SGPT/ALT (Serum Glutamic Pyruvate Transaminace)
SGOT/AST (Serum Glutamic Oxalo-Acetil Transaminace)
nephrotoxicity monitor BUN (10 – 20) and Creatinine (.8 – 1)
hypoglycemia
Tremors, tachycardia
Irritability
Restlessness
Extreme fatigue
Diaphoresis, depression
Antidote: Acetylcisteine (mucomyst) prepare suction apparatus as bedside.
MYASTHENIA GRAVIS
neuromuscular disorder characterized by a disturbance in the
transmission of impulses from nerve to muscle cells at the
neuromuscular junction leading to descending muscle weakness.
Incidence rate: women 20 – 40 years old
Predisposing factors
unknown
autoimmune: it involves release of cholinesterase an enzyme that
destroys Ach.
2
Signs and Symptoms
A. Etiology
1. Meningococcus – most dangerous
2. Pneumococcus
3. Streptococcus - causes adult meningitis
2
4. Hemophilus Influenzae – causes pediatric meningitis
D. Diagnostic Procedures
Lumbar puncture: a hollow spinal needle is inserted in the
subarachnoid space between the L3 – L4 to L5.
Nursing Management for LP
Before Lumbar Puncture
1. Secure informed consent and explain procedure.
2. Empty bladder and bowel to promote comfort.
3. Encourage to arch back to clearly visualize L3-L4.
Post Lumbar Puncture
1. Place flat on bed 12 – 24 o
2. Force fluids
3. Check punctured site for any discoloration, drainage and leakage to tissues.
4. Assess for movement and sensation of extremities.
CSF analysis reveals
1. Increase CHON and WBC
2. Decrease glucose
3. Increase CSF opening pressure (normal pressure is 50 – 100 mmHg)
4. (+) cultured microorganism (confirms meningitis)
CBC reveals
1. Increase wbc
2
E. Nursing Management
B. Predisposing Factors
thrombus (attached)
2
C. Risk Factors
1. Hypertension, Diabetes Mellitus, Myocardial Infarction, Atherosclerosis,
Valvular Heart Disease, Post Cardiac Surgery (mitral valve replacement)
2. Lifestyle (smoking), sedentary lifestyle
3. Obesity (increase 20% ideal body weight)
4. Hyperlipidemia more on genetics/genes that binds to cholesterol
5. Type A personality
a. deadline driven
b. can do multiple tasks 2
c. usually fells guilty when not doing anything
F. Nursing Management
1. Maintain patent airway and adequate ventilation by:
a. assist in mechanical ventilation
b. administrate O2 inhalation
2. Restrict fluids to prevent cerebral edema that might increase ICP
3. Elevate head 30 – 45o
4. Monitor strictly vitals signs, I & O and neuro check
5. Prevent complications of immobility by:
a. turn client to side
b. provide egg crate mattresses or water bed
c. provide sand bag or food board.
6. Assist in passive ROM exercise every 4 hours to promote proper bodily
alignment and prevent contractures
7. Institute NGT feeding
8. Provide alternative means of communication
a. non verbal cues
b. magic slate
9. If positive to hemianopsia approach client on unaffected side
10. Administer medications as ordered
a. Osmotic Diuretics (Mannitol)
b. Loop Diuretics (Lasix, Furosemide)
c. Cortecosteroids
d. Mild Analgesics
2
e. Thrombolytic/Fibrinolytic Agents – dissolves thrombus
Streptokinase
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
2
b. Anti Cholinergic Agents – Atrophine Sulfate
c. Anti Arrythmic Agents
A. Predisposing Factors
1. Head injury due to birth trauma
2. Genetics
3. Presence of brain tumor
4. Toxicity from
a. lead
b carbon monoxide
5. Nutritional and Metabolic deficiencies
6. Physical and emotional stress
2
7. Sudden withdrawal to anti convulsant drug is predisposing factor for status
epilepticus (drug of choice is Diazepam, Valium)
2
C. Diagnostic Procedures
1. CT Scan – reveals brain lesions
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
Conscious 15 – 14
Lethargy 13 – 11
Stupor 10 – 8
Coma Compilation
7 of MS Notes | Karl Gerald C. Manalili, UASN 2010
Deep Coma 3
Survey of mental status and speech
a. LOC
b. Test of memory
Levels of orientation
Cranial nerve assessment
Sensory nerve assessment
Motor nerve assessment
Deep tendon reflex
Autonimics
Cerebellar test
a, Romberg’s test – 2 nurses, positive for ataxia
b. Finger to nose test – positive result mean dimetria
(inability of body to stop movement at
desired point)
c. Alternate supination and pronation – positive result mean
dimetria
I. LEVEL OF CONSCIOUSNESS
1. Conscious - awake
2. Lethargy – lethargic (drowsy, sleepy, obtunded)
3. Stupor
stuporous (awakened by vigorous stimulation)
generalized body weakness
decrease body reflex
4. Coma
comatose
2
light coma (positive to all forms of painful stimulus)
deep coma (negative to all forms of painful stimulus)
CRANIAL NERVES
I. OLFACTORY S
II. OPTIC S
III OCCULOMOTOR M
IV. TROCHLEAR M
(Smallest)
V. TRIGEMINAL B 2
(Largest)
VI. ABDUCENSE M
C. Diagnostic Procedures
1. Tonometry
2. Perimetry
3. Gonioscopy
2
D. Treatment
1. Miotics – constricts pupil
E. Surgical Procedures
1. TRABECULECTOMY (Peripheral Indectomy) – drain aqueous humor
2. Cataract
Decrease opacity of lens
A. Predisposing Factor
1. Aging 65 years and above
2. Related to congenital
3. Diabetes Mellitus
4. Prolonged exposure to UV rays
C. Pathognomonic Signs
1. Blurring or hazy vision
2. Milky white appearance at center of pupils
3. Decrease perception to colors
Complication is blindness
D. Diagnostic Procedure
1. Opthalmoscopic exam
E. Treatment
1. Mydriatics (Mydriacyl) – constricts pupils
2
2. Cyclopegics (Cyclogyl) – paralyses cilliary muscle
3. Retinal Detachment
Separation of epithelial surface of retina
A. Predisposing Factors
1. Post Lens Extraction
2. Myopia (near sightedness)
C. Surgical Procedures
1. Scleral Buckling
2. Cryosurgery – cold application
3. Diathermy – heat application
4. Macular Degeneration
Degeneration of the macula lutea (yellowish spot at the center of
retina)
2
A. Signs and Symptoms
1. Black Spots
Oculomotor
controls the size and response of pupil
normal pupil size is 2 – 3 mm
equal size of pupil: Isocoria
Unequal size of pupil: Anisocoria
Normal response: positive PERRLA
2
CRANIAL NERVE V: TRIGEMINAL
largest cranial nerve
ENDOCRINE SYSTEM
Overview of the structures and functions
1. Pituitary Gland (Hypophysis Cerebri)
o Located at base of brain particularly at sella turcica
o Master gland or master clock
o Controls all metabolic function of body
PARTS OF THE PITUITARY GLAND
1. Anterior Pituitary Gland
o called as adenohypophysis
2. Posterior Pituitary Gland
o called as neurohypophysis 2
2. Antidiuretic Hormone
o Pitressin (Vasopressin)
o Function: prevents urination thereby conserving water
o Diabetes Insipidus/ Syndrome of Inappropriate Anti Diuretic
Hormone
DIABETES INSIPIDUS
o Decrease production of anti diuretic hormone
A. Predisposing Factor
o Related to pituitary surgery
o Trauma
o Inflammation
o Presence of tumor
B. Signs and Symptoms
1. Polyuria
2. Signs of dehydration
a. Adult: thirst
b. Agitation
c. Poor Skin turgor
d. Dry mucous membrane
3. Weakness and fatigue
4. Hypotension
5. Weight loss
6. If left untreated results to hypovolemic shock (sign is anuria)
C. Diagnostic Procedures
2
1. Urine Specific Gravity
o Normal value: 1.015 – 1.030
SIADH
o hypersecretion of anti diuretic hormone
A. Predisposing Factors
1. Head injury
2. Related to presence of bronchogenic cancer
o initial sign of lung cancer is non productive cough
o non invasive procedure is chest x-ray
3. Related to hyperplasia (increase size of organ brought about by increase of
number of cells) of pituitary gland.
C. Diagnostic Procedure
1. Urine specific gravity is increased 2
PINEAL GLAND
o secretes melatonin
o inhibits LH secretion
o it controls/regulates circadian rhythm (body clock)
THYROID GLAND
o located anterior to the neck
3 Hormones secreted
1. T3 (Tri iodothyronine) - 3 molecules of iodine (more potent)
2. T4 (tetra iodothyronine, Thyroxine)
o T3 and T4 are metabolic or calorigenic hormone
o promotes cerebration (thinking)
3. Thyrocalcitonin – antagonizes the effects of parathormone to
promote calcium resorption.
HYPOTHYROIDISM
o all are decrease except weight and menstruation
o memory impairment
Signs and Symptoms
o there is loss of appetite but there is weight gain
o menorrhagia
o cold intolerance
o constipation
HYPERTHYROIDISM
2
o all are increase except weight and menstruation
Signs and Symptoms
THYROID DISORDERS
SIMPLE GOITER
o enlargement of thyroid gland due to iodine deficiency
A. Predisposing Factors
1. Goiter belt area
a. places far from sea
b. Mountainous regions
2. Increase intake of goitrogenic foods
o contains pro-goitrin an anti thyroid agent that has no iodine.
o cabbage, turnips, radish, strawberry, carrots, sweet potato,
broccoli, all nuts
o soil erosion washes away iodine
o goitrogenic drugs
a. Anti Thyroid Agent – Prophylthiuracil (PTU)
b. Lithium Carbonate
c. PASA (Aspirin)
d. Cobalt
e. Phenylbutazones (NSAIDs)
- if goiter is caused by
C. Diagnostic Procedures
1. Serum T3 and T4 – reveals normal or below normal
2. Thyroid Scan – reveals enlarged thyroid gland. 2
D. Nursing Management
1. Enforce complete bed rest
2. Administer medications as ordered
a. Lugol’s Solution/SSKI ( Saturated Solution of Potassium Iodine)
o color purple or violet and administered via straw to prevent staining
of teeth.
o 4 Medications to be taken via straw: Lugol’s, Iron, Tetracycline,
Nitrofurantoin (drug of choice for pyelonephritis)
b. Thyroid Hormones
o Levothyroxine (Synthroid)
o Liothyronine (Cytomel)
o Thyroid Extracts
Nursing Management when giving Thyroid Hormones
1. Instruct client to take in the morning to prevent insomnia
2. Monitor vital signs especially heart rate because drug causes
tachycardia and palpitations
3. Monitor side effects
o insomnia
o tachycardia and palpitations
o hypertension
o heat intolerance
4. Increase dietary intake of foods rich in iodine
o seaweeds
o seafood’s like oyster, crabs, clams and lobster but not shrimps
because it contains lesser amount of iodine.
o iodized salt, best taken raw because it it is easily destroyed by heat
5. Assist in surgical procedure of subtotal thyroidectomy
HYPOTHYROIDISM
2
o hyposecretion of thyroid hormone
o adults: MYXEDEMA non pitting edema
A. Predisposing Factors
1. Iatrogenic Cause – disease caused by medical intervention such as
surgery
2. Related to atrophy of thyroid gland due to trauma, presence of
tumor, inflammation
3. Iodine deficiency
4. Autoimmune (Hashimotos Disease)
C. Diagnostic Procedures
D. Nursing Management
1. Monitor strictly vital signs and intake and output to determine presence
of
o Myxedema coma is a complication of hypothyroidism and an
emergency case
o a severe form of hypothyroidism is characterized by severe
hypotension, bradycardia, bradypnea, hypoventilation,
hyponatremia, hypoglycemia, hypothermia leading to pregressive
stupor and coma.
Nursing Management for Myxedema Coma
Assist in mechanical ventilation
Administer thyroid hormones as ordered
Force fluids
2. Force fluids
3. Administer isotonic fluid solution as ordered
4. Administer medications as ordered
Thyroid Hormones
a. Levothyroxine
b. Leothyronine
c. Thyroid Extracts
5. Provide dietary intake that is low in calories
6. Provide comfortable and warm environment
7. Provide meticulous skin care
8. Provide client health teaching and discharge planning concerning
a. Avoid precipitating factors leading to myxedema coma
o stress
o infection
o cold intolerance
o use of anesthetics, narcotics, and sedatives 2
A. Predisposing Factors
1. Autoimmune – it involves release of long acting thyroid stimulator
causing exopthalmus (protrusion of eyeballs) enopthalmus (late sign of
dehydration among infants)
2. Excessive iodine intake
3. Related to hyperplasia (increase size)
C. Diagnostic Procedures
1. Serum T3 and T4 is increased
2. RAIU (Radio Active Iodine Uptake) is increased 2
3. Thyroid Scan- reveals an enlarged thyroid gland
POST OPERATIVELY,
1. Watch out for signs of thyroid storm/ thyrotoxicosis
Agitation
TRIAD SIGNS
PARATHYROID GLAND
o A pair of small nodules behind the thyroid gland
o Secretes parathormone
2
o Promotes calcium reabsorption
o Hypoparathyroidism
HYPOPARATHYROIDISM
o Decrease secretion of parathormone leading to hypocalcemia
o Resulting to hyperphospatemia
A. Predisposing Factors
1. Following subtotal thyroidectomy
2. Atrophy of parathyroid gland due to:
a. inflammation
b. tumor
c. trauma
B. Signs and Symptoms
1. Acute tetany
a. tingling sensation
b. paresthesia
c. numbness
d. dysphagia
e. positive trousseu’s sign/carpopedal spasm
f. positive chvostek sign
g. laryngospasm/broncospasm
h. seizure feared complications
i. arrhythmia
2. Chronic tetany
a. photophobia and cataract formation
b. loss of tooth enamel
c. anorexia, nausea and vomiting
d. agitation and memory impairment
C. Diagnostic Procedures
1. Serum Calcium is decreased (normal value: 8.5 – 11 mg/100 ml)
2. Serum Phosphate is decreased (normal value: 2.5 – 4.5 mg/100 ml)
3. X-ray of long bones reveals a decrease in bone density
2
4. CT Scan – reveals degeneration of basal ganglia
d. Phosphate binder
Aluminum Hydroxide Gel (Ampogel)
Side effect: constipation
ANTACID
A.A.C MAD
▼ ▼
Aluminum Containing Magnesium Containing
Antacids Antacids
▼ ▼
Aluminum
Hydroxide
Gel
▼
Side Effect: Constipation Side Effect:
Diarrhea
2
2. Avoid precipitating stimulus such as glaring lights and noise
3. Encourage increase intake of foods rich in calcium
HYPERTHYROIDISM
o Decrease parathormone
o Hypercalcemia: bone demineralization leading to bone fracture (calcium
is stored 99% in bone and 1% blood)
o Kidney stones
A. Predisposing Factors
1. Hyperplasia of parathyroid gland
2. Over compensation of parathyroid gland due to vitamin D deficiency
a. Children: Ricketts
b. Adults: Osteomalacia
B. Signs and Symptoms
1. Bone pain especially at back (bone fracture)
2. Kidney stones
a. renal cholic
b. cool moist skin
3. Anorexia, nausea and vomiting
4. Agitation and memory impairment
C. Diagnostic Procedures
1. Serum Calcium is increased
2. Serum Phosphate is decreased 2
3. X-ray of long bones reveals bone demineralization
D. Nursing Management
ADRENAL GLAND
o Located atop of each kidney
o 2 layers of adrenal gland
a. Adrenal Cortex – outermost
b. Adrenal Medulla – innermost (secretes catecholamines a power
hormone)
2 Types of Catecholamines
o Epinephrine and Norepinephrine (vasoconstrictor)
o Pheochromocytoma (adrenal medulla)
o Increase secretion of norepinephrine
o Leading to hypertension which is resistant to pharmacological agents
leading to CVA
o Use beta-blockers
2
ADRENAL CORTEX
ADDISON’S DISEASE
o Hyposecretion of adreno cortical hormone leading to
a. metabolic disturbance – Sugar
b. fluid and electrolyte imbalance – Salt
c. deficiency of neuromuscular function – Salt/Sex
A. Predisposing Factors
1. Related to atrophy of adrenal glands
2. Fungal infections
C. Diagnostic Procedures
1. FBS is decreased (normal value: 80 – 100 mg/dl)
2. Plasma Cortisol is decreased
3. Serum Sodium is decrease (normal value: 135 – 145 meq/L)
4. Serum Potassium is increased (normal value: 3.5 – 4.5 meq/L)
D. Nursing Management
1. Monitor strictly vital signs, input and output to determine presence of
Addisonian crisis (complication of addison’s disease)
o Addisonian crisis results from acute exacerbation of addison’s disease
characterized by
a. severe hypotension
b. hypovolemic shock
c. hyponatremia leading to progressive stupor and coma
Nursing Management for Addisonian Crisis
1. Assist in mechanical ventilation,
- administer steroids as ordered
- force fluids
2. Administer isotonic fluid solution as ordered
3. Force fluids
4. Administer medications as ordered
Corticosteroids
a. Dexamethasone (Decadrone)
b. Prednisone
c. Hydrocortisone (Cortison)
Nursing Management when giving steroids
1. Instruct client to take 2/3 dose in the morning and 1/3 dose in the afternoon
to mimic the normal diurnal rhythm
2
2. Taper dose (withdraw gradually from drug)
3. Monitor side effects
CUSHING SYNDROME
o Hypersecretion of adenocortical hormones
A. Predisposing Factors
1 Related to hyperplasia of adrenal gland
2. Increase susceptibility to infections
3. Hypernatremia
a. hypertension
2
b. edema
c. weight gain
B. Diagnostic Procedures
1. FBS is increased
2. Plasma Cortisol is increased
3. Serum Sodium is increased
4. Serum Potassium is decreased
C. Nursing Management
1. Monitor strictly vital signs and intake and output
2. Weigh patient daily and assess for pitting edema
3. Measure abdominal girth daily and notify physician
4. Restrict sodium intake
5. Provide meticulous skin care
6. Administer medications as ordered
a. Spinarolactone – potassium sparring diuretics
7. Prevent complications (DM)
8. Assist in surgical procedure (bilateral adrenoraphy)
9. Hormonal replacement for lifetime
10. Importance of follow up care
PANCREAS
2
- Located behind the stomach
- Mixed gland (exocrine and endocrine)
DIABETES MELLITUS
- metabolic disorder characterized by non utilization of carbohydrates, protein
and fat metabolism
CLASSIFICATION OF DM
Type 1 (IDDM) Type 2 (NIDDM)
- Juvenile onset type - Adult onset
- Brittle disease - Maturity onset type
- Obese over 40 years old
A. Incidence Rate A. Incidence Rate
- 10% general population has type 1 - 90% of general population has type 2
DM DM
B. Predisposing Factors B. Predisposing Factors
1. Hereditary (total destruction of 1. Obesity – because obese persons
pancreatic cells) lack insulin receptor binding sites
2. Related to viruses
3. Drugs
a. Lasix
2
b. Steroids
4. Related to carbon tetrachloride
HYPERGLYCEMIA
Increase osmotic diuresis
Glycosuria Polyuria
GLUCONEOGENESIS
Formation of glucose from non-CHO sources
Increase protein formation
▼
Negative Nitrogen balance
▼
Tissue wasting (Cachexia)
▼
INCREASE FAT CATABOLISM
▼
Free fatty acids
2
Cholesterol Ketones
▼ ▼
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
5. Weight loss
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
2
B. Nursing Management
1. Assist in mechanical ventilation
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
B. Diagnostic Procedures
1. FBS is increased (3 consecutive times with signs or polyuria, polydypsia,
polyphagia and glucosuria confirmatory for DM)
2
2. Random Blood Sugar is increased
3. Oral glucose tolerance test is increased – most sensitive test
C. Nursing Management
1. Monitor for peak action of insulin and OHA and notify physician
2. Administer insulin and OHA therapy as ordered
3. Monitor strictly vital signs, intake and output and blood sugar levels
4. Monitor for signs of hypoglycemia and hyperglycemia
- administer simple sugars
- for hypoglycemia (cold and clammy skin) give simple sugars
- for hyperglycemia (dry and warm skin)
5. Provide nutritional intake of diabetic diet that includes: carbohydrates 50%,
protein 30% and fats 20% or offer alternative food substitutes
6. Instruct client to exercise best after meals when blood glucose is rising
7. Monitor signs for complications
a. Atherosclerosis (HPN, MI, CVA)
b. Microangiopathy (affects small minute blood vessels of eyes and
kidneys)
EYES KIDNEY
-PREMATURE -RECURRENT
CATARACT PYELONEPHRITIS
- Blindness - Renal failure
HEMATOLOGICAL SYSTEM
1. Arteries 1. Liver
55% Plasma 45% Formed 2. Veins 3. Spleen
4. Lymphoid Organ
Serum Plasma CHON 5. Lymph
Nodes
(formed in liver) 6. Bone Marrow
1. Albumin
2. Globulins
3. Prothrombin and Fibrinogen
ALBUMIN
- Largest and numerous plasma CHON
- Maintains osmotic pressure preventing edema
GLOBULINS
- Alpha globulins - transport steroids, bilirubin and hormones
- Beta globulins – iron and copper
- Gamma globulins
a. anti-bodies and immunoglobulins
b. prothrombin and fibrinogen clotting factors
FORMED ELEMENTS
1. RBC (ERYTHROCYTES)
- normal value: 4 – 6 million/mm3
- only unnucleated cell
- biconcave discs 2
2. WBC (LEUKOCYTES)
- normal value: 5000 – 10000/mm3
A. Granulocytes
1. Polymorpho Neutrophils
- 60 – 70% of WBC
- involved in short term phagocytosis for acute inflammation
2. Polymorphonuclear Basophils
- for parasite infections
- responsible for the release of chemical mediation for inflammation
3. Polymorphonuclear Eosinophils
- for allergic reaction
B. Non Granulocytes
1. Monocytes
- macrophage in blood
- largest WBC
- involved in long term phagocytosis for chronic inflammation
2. Lymphocytes
2
HIV
- 6 months – 5 years incubation period
- 6 months window period
- western blot opportunistic
- ELISA
- drug of choice AZT (Zidon Retrovir)
3. Platelets (THROMBOCYTES)
- Normal value: 150,000 – 450,000/mm3
- Promotes hemostasis (prevention of blood loss)
- Consist of immature or baby platelets or megakaryocytes which is the target
of dengue virus
- Normal life span of platelet is 9 – 12 days
BLOOD DISORDERS
Iron Deficiency Anemia
- A chronic microcytic anemia resulting from inadequate absorption of iron
leading to hypoxemic tissue injury
A. Incidence Rate
1. Common among developed countries 2
b. Sorbitex (IM)
PERNICIOUS ANEMIA
- Chronic anemia characterized by a deficiency of intrinsic factor leading to
hypochlorhydria (decrease hydrochloric acid secretion)
A. Predisposing Factors
1. Subtotal gastrectomy
2. Hereditary factors
3. Inflammatory disorders of the ileum
4. Autoimmune
5. Strictly vegetarian diet
STOMACH
▼
Pareital cells/ Argentaffin or Oxyntic cells
digestion
C. Diagnostic Procedure
Schilling’s Test – reveals inadequate/decrease absorption of Vitamin B12
D. Nursing Management
1. Enforce CBR
2. Administer Vitamin B12 injections at monthly intervals for lifetime as ordered
- Never given orally because there is possibility of developing tolerance
- Site of injection for Vitamin B12 is dorsogluteal and ventrogluteal
- No side effects
3. Provide a dietary intake that is high in carbohydrates, protein, vitamin c and
iron
4. Instruct client to avoid irritating mouth washes instead use soft bristled
2
toothbrush
5. Avoid heat application to prevent burns
PANCYTOPENIA
A. Predisposing Factors
1. Chemicals (Benzine and its derivatives)
2. Related to irradiation/exposure to x-ray
3. Immunologic injury
4. Drugs
Broad Spectrum Antibiotics
a. Chloramphenicol (Sulfonamides)
Chemotherapeutic Agents
a. Methotrexate (Alkylating Agent)
b. Vincristine (Plant Alkaloid)
c. Nitrogen Mustard (Antimetabolite)
Phenylbutazones (NSAIDS)
C. Diagnostic Procedures
1. CBC reveals pancytopenia
2. Bone marrow biopsy/aspiration (site is the posterior iliac crest) – reveals fat
necrosis in bone marrow
D. Nursing Management
1. Removal of underlying cause
2. Institute BT as ordered
3. Administer oxygen inhalation
4. Enforce CBR
5. Institute reverse isolation
6. Monitor for signs of infection
a. fever
b. cough
7. Avoid IM, subcutaneous, venipunctured sites
8 Instead provide heparin lock
9. Instruct client to use electric razor when shaving
10. Administer medications as ordered
a. Corticosteroids – caused by immunologic injury
b. Immunosuppressants
C. Diagnostic Procedures
1. CBC reveals decreased platelets
2. Stool occult blood positive
3. ABG analysis reveals metabolic acidosis
4. Opthamoscopic exam reveals sub retinal hemorrhages
D. Nursing Management
1. Monitor for signs of bleeding of all hema test including stool and GIT
2. Administer isotonic fluid solution as ordered
3. Administer oxygen inhalation
4. Force fluids
5. Administer medications as ordered
a. Vitamin K
b. Pitressin/ Vasopresin to conserve fluids
c. Heparin/Coumadin is ineffective
6. Provide heparin lock
2
7. Institute NGT decompression by performing gastric lavage by using ice or
cold saline solution of 500 – 1000 ml
BLOOD TRANSFUSION
Goals/Objectives
1. Replace circulating blood volume
2. Increase the oxygen carrying capacity of blood
3. Prevent infection in there is a decrease in WBC
4. Prevent bleeding if there is platelet deficiency
A. Layers of Heart
1. Epicardium – outer layer
2. Myocardium – middle layer
3. Endocardium – inner layer
- Myocarditis can lead to cardiogenic shock and rheumatic heart disease
C. Valves
- To promote unidimensional flow or prevent backflow
D. Coronary Arteries
- Arises from base of the aorta
Types of Coronary Arteries
1. Right Main Coronary Artery
2. Left Main Coronary Artery
- Supplies the myocardium
E. Cardiac Conduction System
1. Sino – Atrial Node (SA or Keith Flack Node)
- Located at the junction of superior vena cava and right atrium
- Acts as primary pacemaker of the heart
- Initiates electrical impulse of 60 – 100 bpm
3. Bundle of His
- Right Main Bundle of His
- Left Main Bundle of His
- Located at the interventricular septum
4. Purkinje Fibers
- Located at the walls of the ventricles for ventricular contraction
SA NODE
AV NODE
BUNDLE OF HIS
JLJLJLJJLJLJL
CARDIAC DISORDERS
Coronary Arterial Disease/ Ischemic Heart Disease
Stages of Development of Coronary Artery Disease
1. Myocardial Injury - Atherosclerosis
2
2. Myocardial Ischemia – Angina Pectoris
3. Myocardial Necrosis – Myocardial Infarction
A. Predisposing Factors
1. Sex – male
2. Race – black
3. Smoking
4. Obesity
5. Hyperlipidemia
6. sedentary lifestyle
7. Diabetes Mellitus
8. Hypothyroidism
9. Diet – increased saturated fats
10. Type A personality
C. Treatment
Percutaneous Transluminal Coronary Angioplasty
Objectives of PTCA
1. Revascularize myocardium
2. To prevent angina
3. Increase survival rate
- Done to single occluded vessels
- If there is 2 or more occluded blood vessels CABG is done
Coronary Arterial Bypass And Graft Surgery
2
A. Predisposing Factors
1. Sex – male
2. Race – black
3. Smoking
4. Obesity
5. Hyperlipidemia
6. sedentary lifestyle
7. Diabetes Mellitus
8. Hypothyroidism
9. Diet – increased saturated fats
10. Type A personality
B. Precipitating Factors
4 E’s of Angina Pectoris
1. Excessive physical exertion – heavy exercises
2. Exposure to cold environment
3. Extreme emotional response – fear, anxiety, excitement
4. Excessive intake of foods rich in saturated fats – skimmed milk
D. Diagnostic Procedure
1. History taking and physical exam
2. ECG tracing reveals ST segment depression
3. Stress test – treadmill test, reveal abnormal ECG
4. Serum cholesterol and uric acid is increased
E. Nursing Management
1. Enforce complete bed rest
2. Administer medications as ordered
a. Nitroglycerine (NTG) – when given in small doses will act as
venodilator, but in large doses will act as vasodilator
- Give first dose of NTG (sublingual) 3 – 5 minutes
- Give second dose of NTG if pain persist after giving first dose
with interval of 3 - 5 minutes
- Give third and last dose of NTG if pain still persist at 3 – 5
minutes interval
Nursing Management when giving NTG
- Keep the drug in a dry place, avoid moisture and exposure to sunlight
as it may inactivate the drug
- Monitor side effects
o Orthostatic hypotension
o Transient headache and dizziness
- Instruct the client to rise slowly from sitting position
- Assist or supervise in ambulation
- When giving nitrol or transdermal patch
o Avoid placing near hairy areas as it may decrease drug
absorption
o Avoid rotating transdermal patches as it may decrease drug
absorption 2
b. Beta-blockers
- Propanolol - side effects PNS
- Not given to COPD cases because it causes bronchospasm
c. ACE Inhibitors
- Enalapril
d. Calcium Antagonist
- NIfedipine
MYOCARDIAL INFARCTION
Heart attack
Terminal stage of coronary artery disease characterized by malocclusion,
necrosis and scarring.
A. Types
1. Transmural Myocardial Infarction – most dangerous type characterized by
occlusion of both right and left coronary artery
2. Subendocardial Myocardial Infarction – characterized by occlusion of
2
either right or left coronary artery
C. Predisposing Factors
1. Sex – male
2. Race – black
3. Smoking
4. Obesity
5. Hyperlipidemia
6. sedentary lifestyle
7. Diabetes Mellitus
8. Hypothyroidism
9. Diet – increased saturated fats
10. Type A personality
F. Nursing Management
Goal: Decrease myocardial oxygen demand
d. ACE Inhibitors
e. Calcium Antagonist
g. Anti Coagulant
- Heparin (check for partial thrombin time)
- Antidote: protamine sulfate
- Coumadin/ Warfarin Sodium (check for prothrombin time)
- Antidote: Vitamin K
h. Anti Platelet
- PASA (Aspirin)
- Anti thrombotic effect
- Side Effects of Aspirin
2
Tinnitus
Heartburn
A. Predisposing Factors 2
D. Nursing Management
Goal: increase cardiac contractility thereby increasing cardiac output (3 – 6
L/min)
1. Enforce CBR
2. Administer medications as ordered
a. Cardiac glycosides
- Digoxin (Lanoxin)
- Increase force of cardiac contraction
- If heart rate is decreased do not give
b. Loop Diuretics
- Lasix (Furosemide)
c. Bronchodilators
d. Narcotic analgesics
- Morphine Sulfate
e. Vasodilators
- Nitroglycerine
f. Anti Arrhythmic
- Lidocaine (Xylocane)
Venous Ulcer
1. Varicose Veins
2. Thrombophlebitis (deep vein thrombosis)
THROMBOANGITIS OBLITERANS
Acute inflammatory disorder usually affecting the small medium sized arteries
and veins of the lower extremities
A. Predisposing Factors
1. High risk groups – men 30 years old and above
2. Smoking
C. Diagnostic Procedures
D. Nursing Management
1. Encourage a slow progressive physical activity
a. walking 3 – 4 times a day
b. out of bed 3 – 4 times a day
2. Administer medications as ordered
a. Analgesics
b. Vasodilators
c. Anti coagulants
3. Institute foot care management
4. Instruct client to avoid smoking and exposure to cold environment
5. Assist in surgical procedure – bellow knee amputation
REYNAUD’S DISEASE
Disorder characterized by acute episodes of arterial spasm involving the
fingers or digits of the hands
A. Predisposing Factors
1. High risk group – female 40 years old and above
2. Smoking
3. Collagen diseases
a. SLE (butterfly rash)
b. Rheumatoid Arthritis
4. Direct hand trauma
a. Piano playing
b. Excessive typing
c. Operating chainsaw
2
B. Signs and Symptoms
1. Intermittent claudication – leg pain upon walking
C. Diagnostic Procedures
1. Doppler UTZ – decrease blood flow to the affected extremity
2. Angiography – reveals site and extent of malocclusion
D. Nursing Management
1. Administer medications as ordered
a. Analgesics
b. Vasodilators
2. Encourage to wear gloves
3. Instruct client on importance of cessation of smoking and exposure to cold
environment
VARICOSITIES
Abnormal dilation of veins of lower extremities and trunks due to
Incompetent valve resulting to
Increased venous pooling resulting to
Venous stasis causing
Decrease venous return
A. Predisposing Factors
1. Hereditary
2. Congenital weakness of veins
3. Thrombophlebitis
4. Cardiac disorder
5. Pregnancy
6. Obesity
7. Prolonged standing or sitting
2
B. Signs and Symptoms
1. Pain after prolonged standing
D. Nursing Management
1. Elevate legs above heart level to promote increased venous return by
placing 2 – 3 pillows under the legs
2. Measure the circumference of leg muscle to determine if swollen
3. Wear anti embolic stockings
4. Administer medications as ordered
a. Analgesics
5. Assist in surgical procedure
a. Vein stripping and ligation (most effective)
b. Sclerotherapy – can recur and only done in spider web varicosities
and danger of thrombosis (2 – 3 years for embolism)
THROMBOPHLEBITIS
Deep vein thrombosis
Inflammation of the veins with thrombus formation
A. Predisposing Factors
1. Obesity
2. Smoking
3. Related to pregnancy
4. Chronic anemia
5. Prolong use of oral contraceptives – promotes lipolysis
6. Diabetes mellitus
7. Congestive heart failure
8. Myocardial infarction
2
9. Post op complication
10. Post cannulation – insertion of various cardiac catheter
C. Diagnostic Procedure
1. Venography
2. Angiography
D. Nursing Management
1. Elevate legs above heart level to promote increase venous return
2. Apply warm moist pack – to reduce lymphatic congestion
3. Measure circumference of leg muscle to determine if swollen
4. Encourage to wear anti embolic stockings or knee elastic stockings
5. Administer medications as ordered
a. Analgesics
b. Anti Coagulant
- Heparin
6. Monitor for signs of complications
Embolism
a. Pulmonary
- Sudden sharp chest pain
- Unexplained dyspnea
- Tachycardia
- Palpitations
- Diaphoresis
- Restlessness
b. Cerebral
2
- Headache
- Dizziness
RESPIRATORY SYSTEM
OVERVIEW OF THE STRUCTURES AND FUCNTIONS OF THE
RESPIRATORY SYSTEM
I. Upper Respiratory System
1. Filtering of air
2. Warming and moistening of air
3. Humidification
A. Nose
- Cartillage
- Right nostril
- Left nostril
- Separated by septum
- Consist of anastomosis of capillaries known as Keissel Rach Plexus (the
site of nose bleeding)
B. Pharynx/Throat
- Serves as a muscular passageway for both food and air
C. Larynx
- For phonation (voice production)
- For cough reflex
Glottis
- Opening of larynx
- Opens to allow passage of air
- Closes to allow passage of food going to the esophagus
- The initial sign of complete airway obstruction is the inability to cough
A. Precipitating Factors
1. Malnutrition
2. Overcrowded places
3. Alcoholism
4. Over fatigue
5. Ingestion of an infected cattle with mycobacterium bovis
6. Virulence (degree of pathogenecity) of microorganism
B. Mode of Transmission
1. Airborne transmission via droplet nuclei
D. Diagnostic Procedure
1. Mantoux Test (skin test)
- Purified protein derivative
- DOH 8 – 10 mm induration, 48 – 72 hours
- WHO 10 – 14 mm induration, 48 – 72 hours
2
- Positive Mantoux test (previous exposure to tubercle bacilli but without active
TB)
3. Chest X-ray
- Reveals pulmonary infiltrates
4. CBC
- Reveals increase WBC
E. Nursing Management
1. Enforce CBR
2. Institute strict respiratory isolation
3. Administer oxygen inhalation
4. Force fluids to liquefy secretions
5. Place client on semi fowlers position to promote expansion of lungs
6. Encourage deep breathing and coughing exercise
7. Nebulize and suction when needed
8. Comfortable and humid environment
9. Institute short course chemotherapy
a. Intensive phase
- INH (Isonicotinic Acid Hydrazide)
- Rifampicin (Rifampin)
- PZA (Pyrazinamide)
- Given everyday simultaneously to prevent resistance
- INH and Rifampicin is given for 4 months, taken before meals to
facilitate absorption
- PZA is given for 2 months, taken after meals to facilitate absorption
- Side Effect INH: peripheral neuritis/neuropathy (increase intake of
Vitamin B6/Pyridoxine)
- Side Effect Rifampicin: all bodily secretions turn to red orange color
- Side Effect PZA: allergic reaction, hepatotoxicity, nephrotoxicity
- PZA can be replaced by Ethambutol
2
- Side Effect Ethambutol: optic neuritis
PNEUMONIA
Inflammation of the lung parenchyma leading to pulmonary consolidation as
the alveoli is filled with exudates
A. Etiologic Agents
1. Streptococcus Pneumonae – causing pneumococal pneumonia
2. Hemophylus Influenzae – causing broncho pneumonia
3. Diplococcus Pneumoniae
2
4. Klebsella Pneumoniae
5. Escherichia Pneumoniae
C. Predisposing Factors
1. Smoking
2. Air pollution
3. Immuno compromised
a. AIDS
- Pneumocystic carini pneumonia
- Drug of choice is Retrovir
b. Bronchogenic Cancer
- Initial sign is non productive cough
- Chest x-ray confirms lung cancer
4. Related to prolonged immobility (CVA clients), causing hypostatic
pneumonia
5. Aspiration of food causing aspiration pneumonia
F. Nursing Management
1. Enforce CBR
2. Administer oxygen inhalation low inflow
3. Administer medications as ordered
Broad Spectrum Antibiotic
a. Penicillin
b. Tetracycline
c. Microlides (Zethromax)
- Azethromycin (Side Effect: Ototoxicity)
- Antipyretics
- Mucolytics/Expectorants
- Analgesics
4. Force fluid
5. Place on semi fowlers position
6. Institute pulmonary toilet (tends to promote expectoration)
- Deep breathing exercises
- Coughing exercises
- Chest physiotherapy
- Turning and reposition
7. Nebulize and suction as needed
8. Assist in postural drainage
- Drain uppermost area of lungs
- Placed on various position
Nursing Management for Postural Drainage
a. Best done before meals or 2 – 3 hours to prevent gastro esophageal
reflux
2
b. Monitor vital signs
c. Encourage client deep breathing exercises
HISTOPLASMOSIS
Acute fungal infection caused by inhalation of contaminated dust or particles
with histoplasma capsulatum derived from birds manure
B. Diagnostic Procedures
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. Mucolytics
d. Antipyretics
4. Force fluids to liquefy secretions
5. Nebulize and suction as needed
6. Prevent complications – bronchiectasis
7. Prevent the spread of infection by spraying of breeding places
A. Predisposing Factors
1. Smoking
2. Air pollution
B. Signs and Symptoms
1. Productive cough (consistent to all COPD)
2. Dyspnea on exertion
3. Prolonged expiratory grunt
4. Anorexia and generalized body malaise
5. Scattered rales/ronchi
2
6. Cyanosis
7. Pulmonary hypertension
Bronchial Asthma
Reversible inflammatory lung condition due to hypersensitivity to allergens
leading to narrowing of smaller airways
2
B. Signs and Symptoms
1. Cough that is non productive
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 inhalaer 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
2
- Steroids
- Bronchodilators
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
POST Bronchoscopy
1. Feeding initiated upon return of gag reflex
2. Avoid talking, coughing and smoking, may cause irritation
2
3. Monitor for signs of gross
4. Monitor for signs of laryngeal spasm – prepare tracheostomy set
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
2
9. Provide comfortable and humid environment
10. Provide high carbohydrates, protein, calories, vitamins and minerals