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FOCUS!

AND AIM HIGH WITH GOD

Graphics & Edited By:

J. F. ADORABLE, RN.
Text from Pentagon Review Center

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

AUTONOMIC NERVOUS SYSTEM


Sympathetic Nervous System
(ADRENERGIC)
- Involved in fight or aggression response.
- Release of Norepinephrine (cathecolamines)
from adrenal glands and causes
vasoconstriction.
- Increase all bodily activity except GIT
EFFECTS OF SNS

Parasympathetic Nervous System


(CHOLINERGIC, VAGAL, SYMPATHOLYTIC)
- Involved in fight or withdrawal response.
- Release of Acetylcholine.
- vasodilation bronchoconstriction

- Dilation of pupils(mydriasis) in order to be aware.


- Dry mouth (thickened saliva).
- Increase BP and Heart Rate.
- Bronchodilation, Increase RR
- Constipation.
- Urinary Retention. FLUID VOLUME EXCESS
- Increase blood supply to brain, heart and skeletal
muscles.
- SNS
I. Adrenergic Agents

- Constriction of pupils (meiosis).


- Increase salivation.
- Decrease BP and Heart Rate.
- Bronchoconstriction, Decrease RR.
- Diarrhea
- Urinary frequency. FLUID VOLUME DEF.
- antihypertension

- Give Epinephrine. [ADRENALIN]


Signs and Symptoms:
- SNS
Contraindication:
- Contraindicated to patients suffering from COPD
(Broncholitis, Bronchoectasis, Emphysema, Asthma).
II. Anti-cholinergic Agents

- Mestinon, Neostigmine.
Side Effects
- PNS

- To counter cholinergic agents.


- Atropine Sulfate decreased mucus production
Side Effects
- SNS
Antipsychotics:

Haloperidol [Haldol], chlorpromazine

Thorazine, etc.
Side effect of THORAZINE: atopic
dermatitis and foul smelling odor.
Side effect of all antipsychotic: signs of
PARKINSONS DISEASE, therefore
antipsychotic are given together with
antiparkinson drugs
Anti-parkinson drugs:

C.A.P.A.B.L.E.S

- Also called Beta-blockers.


- All ending with lol
- Propranolol [Inderal], Atenelol, Metoprolol.

- Decreases all bodily activities except GIT.


EFFECTS OF PNS

I. Cholinergic Agents

II. Beta-adrenergic Blocking Agents

Effects of Beta-blockers
B roncho spasm
E licits a decrease in myocardial contraction.
T reats hypertension.
A V conduction slows down.

Should be given to patients with Angina

Pectoris, Myocardial Infarction, and


Hypertension.
ANTI- HYPERTENSIVE AGENTS
1. Beta-blockers lol
2. Ace Inhibitors Angiotensin, pril (Captopril,
Enalapril)
3. Calcium Antagonist Nifedipine (Calcibloc)

In chronic cases of arrhythmia give

Lidocaine(Xylocaine)

CENTRAL NERVOUS SYSTEM


Brain and Spinal Cord.
[Spinal cord terminates at L1 to L2 therefore a LUMBAR TAP is performed at L3 , L4 or L5 no risk for
spinal cord damage]
I. CELLS
A. NEURONS
Basic cells for nerve impulse and conduction.
PROPERTIES
Excitability ability of neuron to be affected by changes in external environment.
Conductivity ability of neuron to transmit a wave of excitation from one cell to another.
Permanent Cell once destroyed not capable of regeneration.

TYPES OF CELLS BASED ON REGENERATIVE CAPACITY


1. Labile
Capable of regeneration.
Epidermal cells, GIT cells, GUT cells, cells of lungs.
2. Stable
Capable of regeneration with limited time, survival period.
Kidney cells, Liver cells, salivary cells, pancreas.
3. Permanent
Not capable of regeneration.
Myocardial cells, Neurons, Bone cells, Osteocytes, Retinal Cells.

B. NEUROGLIA
rstuv
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Support and protection of neurons.
TYPES
0 Astrocytes maintains blood brain barrier semi-permeable.
0.0 Majority of brain tumors (90%) arises from called astrocytoma.
2. Oligodendria Produces myelin sheath in CNS. Act as insulator and facilitates rapid nerve
0 Microglia
1 Epindymal
SUBSTANCES THAT CAN PASS THE BLOOD-BRAIN BARRIER
1. Ammonia
0
1

Cerebral toxin
Hepatic Encephalopathy (Liver Cirrhosis)

impulse transmission

Ascites

Esophageal Varices

Early Signs of Hepatic Encephalopathy


5888
asterixis (flapping hand tremors).
Late Signs of Hepatic Encephalopathy
23 Headache
24

Dizziness

25

Confusion

26

Fetor hepaticus (ammonia like breath)

27

Decrease LOC [hepatic coma]

[AIRWAY FOR HEPATIC COMA]


2. Carbon Monoxide and Lead Poisoning
5888Can lead to Parkinsons disease.
[PILL ROLLING TREMORS]

5889Epilepsy

5890Treat with ANTIDOTE: Calcium EDTA

For Lead poisoning


Hyperbaric oxygenation (100% O2)
For carbon monoxide poisoning

PATHOGNOMONIC SIGNS
1. PTB

Low-grade afternoon fever.

2. PNEUMONIA

Rusty sputum.

3. ASTHMA

Wheezing on expiration.

4. EMPHYSEMA

Barrel chest.

5. KAWASAKI DISEASE

Strawberry tongue.

6. PERNICIOUS ANEMIA

Red beefy tongue.

7. DOWN SYNDROME

- Protruding tongue / semian crease on palm

8. CHOLERA

9. MALARIA

- Stepladder like fever and chills.

10. TYPHOID

- Rose spots in abdomen.

11. DIPTHERIA

- pseudo membrane formation (pharynx, tonsils, nasal)

12. MEASLES

Kopliks spots.

13. SLE

Butterfly rashes.

14. LIVER CIRRHOSIS

- spider angioma, due to esophageal varices

15. LEPROSY

16. BULIMIA NERVOSA

- Chipmunk face. Parotid gland swelling

17. APPENDICITIS.

18. DENGUE

- petechiae or (+) Hermans sign

19. MENINGITIS

- Kernigs sign (leg pain), Brudzinski sign (neck pain).

20. TETANY

- HYPOCALCEMIA (+) Trousseaus sign/carpopedal spasm; Chvostek sign (facial spasm).

21. TETANUS

22. PANCREATITIS

- Cullens sign (ecchymosis of umbilicus); (+) Grey turners spots.

23. PYLORIC STENOSIS

- olive SHAPE mass on the abdomen

24. PDA

25. ADDISONS DISEASE

- Bronze like skin pigmentation.

26. CUSHINGS SYNDROME

- Moon face appearance and buffalo hump.

27. HYPERTHYROIDISM/GRAVES DISEASE

Exopthalmus

28. INTUSSUSCEPTION

sausage shaped mass

29. PARKINSONS DISEASE

Pill rolling tremors

30. HEPATITIS

Jaundice

31. THROMBOPHEBITIS

Homans sign

32. CATARACT

- Hazy vision / loss of central vision

33. GLAUCOMA

- Tunnel vision / loss of peripheral vision

34. RETINAL DETACHMENT

35. CHOLECYSTITIS

- Murphys sign (pain on deep inspiration, a inflammation of the gallbladder

36. ANGINA PECTORIS

- Levines sign [hand clutching in the chest]

37. MYASTHENIA GRAVIS

- Ptosis [drooping of the upper eyelid]

38. TETRALOGY OF FALLOT

23

24

Rice watery stool.

lioning face

rebound tenderness

risus sardonicus.

machine like murmur

Curtain veil-like vision / flashes and floaters

Clubbing of fingers

Type 1 DM (IDDM) [KETONES]


23 Causes diabetic ketoacidosis.
24

And increases breakdown of fats.

25

And free fatty acids

26

Resulting to cholesterol and (+) to Ketones (CNS depressant).

27

Resulting to acetone breath odor/fruity odor.

28

KUSSMAULS respiration, a rapid shallow respiration.

29

This may lead to diabetic coma.

Hepatitis
23 Signs of jaundice (icteric sclerae).
24

Caused by bilirubin (yellow pigment)

5. Bilirubin
23 Increase bilirubin in brain (Kernicterus).
24

Causing irreversible brain damage.

DEMYELINATING DISORDERS
1. ALZHEIMERS DISEASE
5888
Atrophy of brain tissues.
characterized by

Progressive, irreversible, degenerative neurologic disease

gradual losses of cognitive fx. And disturbances in behavior and affect.


Sign and Symptoms
4 As of Alzheimer
23

Amnesia partial or total loss of memory.

24

Agnosia no recognition of inanimate objects.

25

Apraxia no recognition of objects function.

26

Aphasia no speech (nodding).

*Expressive aphasia (Brocas Aphasia) frontal lobe


5888
motor speech center
5889Nursing mgt. provide PICTURE BOARD

*Receptive aphasia (Wernickes Aphasia) temporal lobe


5890
Inability to understand spoken words.
5891 Irrational thoughts/illogical
5892General Knowing Gnostic Area or General Interpretative Area.

DRUG OF CHOICE: ARICEPT (taken at bedtime) and COGNEX. [increasing acetylcholine]


23

MULTIPLE SCLEROSIS [Autoimmune process]


23 Chronic intermittent disorder of CNS characterized by white patches of demyelination in brain and spinal cord.
24

Characterized by remission and exacerbation.

25

Women ages 15-35 are prone

26

Unknown Cause

27

Slow growing virus

28

Autoimmune disorders

29

Pernicious anemia

30

Myasthenia gravis

31

Lupus

32

Hypothyroidism

33

GBS

Ig G only antibody that pass placental


circulation causing passive immunity.
5888

Short term protection.

5889

Immediate action.

Ig A present in all bodily secretions


(tears, saliva, colostrums).
Ig M acute in inflammation.
Ig E for allergic reaction.

Ig D for chronic inflammation.


* Give palliative or supportive care.
Signs and Symptoms
23
23

Visual disturbances
blurring of vision (primary)

24

Diplopia (double vision)

25

scotomas (blind spots)

23

Impaired sensation
Pain, pressure, heat and cold. [do not give hot packs bcoz of dec. sensation to heat which can lead to burns.]

24

tingling sensation

25

paresthesia

26

numbness

24

5888 Mood swings


5888
euphoria (sense of well being)
5889 Impaired motor function
5888
weakness
5889spasticity
5890paralysis

5890 Impaired cerebral function


5888
scanning speech
TRIAD SIGNS OF MS
Ataxia
(Unsteady gait, (+) Rombergs test)

CHARCOTS TRIAD
ANI

Intentional tremors

Nystagmus

0 Urinary retention/incontinence
1 Constipation
2 Decrease sexual capacity
DIAGNOSTIC PROCEDURE
0
CSF analysis (increase in IgG and Protein).
1

MRI (reveals site and extent of demyelination).

(+) Lhermittes sign a continuous and increase contraction of spinal column/cord following laminotomy.

NURSING MANAGEMENT
23

Administer medications as ordered


23

ACTH (Adreno Corticotropic Hormone)/ Steroids for acute exacerbation to reduce edema

at site of demyelination to prevent paralysis. [Best given in Morning to mimic body normal rhythm]
24

Baclofen (Dioresal)/ Dantrolene Sodium (Dantrene) muscle relaxants.

25

Interferons alter immune response.

26

Immunosupresants

24

Maintain side rails to prevent injury related to falls.

25

Institute stress management techniques.


23

Deep breathing exercises

24

Yoga

26

Increase fluid intake and increase fiber to prevent constipation.

27

Catheterization to prevent retention.


23

Diuretics

24

Bethanicol Chloride (Urecholine) treat urinary retention

Nursing Management
5888 Only given subcutaneous.
5889Monitor side effects bronchospasm and wheezing.

5890 Monitor breath sounds 1 hour


administration. c. For Urinary Incontinence

after

subcutaneous

Anti spasmodic agent


a. Prophantheline Bromide (Probanthine) antispasmodic drug to treat urinary incontinence
5888
Acid ash diet like cranberry juice, plums, prunes, pineapple, vitamin C and orange.
5889To acidify urine and prevent bacterial multiplication.

COMMON CAUSE OF UTI


Female
0

short urethra (3-5 cm, 1-1 inches)

poor perineal hygiene

vaginal environment is moist

Nursing Management
0 avoid bubble bath (can alter Ph of vagina).
1

avoid use of tissue papers

avoid using talcum powder and perfume.

Male
0 Urethra (20 cm, 8 inches)
1 urinate after intercourse

MICROGLIA
0stationary cells that carry on phagocytosis (engulfing of bacteria or cellular debris, eating), pinocytosis (cell
drinking).
MACROPHAGE

ORGAN

Microglia
Monocytes

Brain
Blood

Kupffers cells

Kidney

Histiocytes

Skin

Alveolar

Lung

Macrophage
EPINDYMAL CELLS
23 Secretes a glue called chemo attractants that concentrate the bacteria.
COMPOSITION OF BRAIN
23 80% brain mass

24

24

10% blood

25

10% CSF

Brain Mass

PARTS OF THE BRAIN


1. CEREBRUM
23 largest part
24

Composed of the Right Cerebral Hemisphere and Left Cerebral Hemisphere enclosed in the Corpus

Callosum.
Functions of Cerebrum
5888
integrative
5889sensory
5890motor

Lobes of Cerebrum
1. Frontal
0.0

higher cortical thinking

0.1 controls personality


0.2 controls motor activity
0.3 Brocas Area (motor speech area) when damaged results to garbled speech.

1 Temporal
1.0

hearing

1.1 short term memory

2 Parietal
2.0

for appreciation

2.1 Discrimination of sensory impulses to pain, touch, pressure, heat, cold, numbness.

3 Occipital
3.0

for vision

Insula (Island of Reil)


0 Visceral function activities of internal organ like gastric motility.
Limbic System (Rhinencephalon)
0
controls smell and if damaged results to Anosmia (absence of smell).
1

controls libido [the true sense of sexual arousal is when you smelled the fumes of the natural body]

controls long term memory

2. BASAL GAGLIA
23 areas of grey matter located deep within each cerebral hemisphere.
24

release dopamine (controls gross voluntary movement.)

NEURO TRANSMITTER

DECREASE

INCREASE

Acethylcholine

Myasthenia Gravis

Bi-polar Disorder

Dopamine

Parkinsons Disease

Schizophrenia

3. MIDBRAIN/ MESENCEPHALON
5888acts as relay station for sight and hearing.
5889size of pupil is 2 3 mm.
5890equal size of pupil is isocoria.
5891unequal size of pupil is anisocoria.
5892hearing acuity is 30 40 dB.
5893positive PERRLA [Pupils equal, round, reactive to light and accommodation]

4. INTERBRAIN/ DIENCEPHALON
Parts of Diencephalon
23 Thalamus
23

Acts as relay station for sensation.

24 Hypothalamus
23 Controls temperature (thermoregulatory center).
24

controls blood pressure

25

controls thirst

26

appetite/satiety

27

sleep and wakefulness

28

Controls some emotional responses like fear, anxiety and excitement.

29

controls pituitary functions

30

Androgenic hormones promote secondary sex characteristics.

31

early sign for males are testicular and penile enlargement

32

late sign is deepening of voice.

33

early sign for females telarche and late sign is menarche.

5. BRAIN STEM
4 located at lowest part of brain
Parts of Brain Stem
1. Pons
23 pneumotaxic center controls the rate, rhythm and depth of respiration.
1025

Medulla Oblongata
23 Controls respiration, heart rate, and swallowing, vomiting, hiccup, vasomotor center (dilation and
constriction of bronchioles).
[damage to medulla is most life threatening]

1026

Cerebellum
23 Smallest part of the brain.
24

Lesser brain.

25

Controls balance, equilibrium, posture and gait.

INTRA CRANIAL PRESSURE


Monroe Kellie Hypothesis
Skull is a closed container
Any alteration or increase in one of the intracranial components

Increase intra-cranial pressure


(normal ICP is 0 15 mmHg)
Cervical 1 also known as ATLAS.
Cervical 2 also known as AXIS.
Foramen Magnum
Medulla Oblongata
Brain Herniation
Increase intra cranial pressure
23

Alternate hot and cold compress to prevent HEMATOMA

23CSF cushions brain (shock absorber)


24Obstruction of flow of CSF will lead to enlargement of skull posteriorly called hydrocephalus.
25Early closure of posterior fontanels causes posterior enlargement of skull in hydrocephalus.

NEUROLOGIC DISORDERS
INCREASE INTRACRANIAL PRESSURE increase in intra-cranial bulk brought about by an increase in one of the 3
major intra cranial components. NORMAL ICP: 0-15 mmhg
Causes:

head trauma/injury

inflammatory condition (stroke)

localized abscess

hydrocephalus

cerebral edema

tumor (rarely)

hemorrhage

lethargy/stupor
coma

Signs and Symptoms (Early)

decrease LOC
restlessness/agitation

irritability

Signs and Symptoms (Late)


5888changes in vital signs
5889Blood pressure (systolic blood pressure increases but diastolic remains the same).
5890Widening of pulse pressure is neurologic in nature (if narrow cardiac in nature).
5891heart rate decrease
5892respiratory rate decrease
5893Temperature increase directly proportional to blood pressure.
5894projective vomiting
5895headache
5896papilledema (edema of optic disc)
5897abnormal posturing, [may positive to babinski reflex]
5898Decorticate posturing (damage to cortex and spinal cord).
5899decerebrate

posturing (damage to upper brain stem


that includes pons, cerebellum and midbrain).
5900unilateral dilation of pupils called uncal herniation
5901bilateral dilation of pupils called tentorial herniation
5902resulting to mild headache
5903possible seizure activity

Nursing Management
0 Maintain patent and adequate ventilation by:
a.
Prevention
of
hypoxia
hypercarbia Early signs of hypoxia
0
Restlessness
1

Agitation

Tachycardia

and

Late signs of hypoxia


0Bradycardia
1Extreme restlessness
2Dyspnea
3Cyanosis

HYPERCARBIA
23 Increase CO2 (most powerful respiratory stimulant) retention.
24

In chronic respiratory distress syndrome decrease O2 stimulates respiration.

24Before and after suctioning hyper oxygenate client 100% and done 10 15 seconds only.
25

Assist in mechanical ventilation

4 Elevate bed of client 30 35o angle with neck in neutral position unless contraindicated to promote venous drainage.
5 Limit fluid intake to 1200 1500 ml/day (in force fluids 2000 3000 ml/day).
6 Monitor strictly input and output and neuro check
7 Prevent complications of
8 Prevent further increase ICP by:

23

provide an comfortable and quite environment.

24

avoid use of restraints.

25

maintain side rails.

26

instruct client to avoid forms of valsalva maneuver like:


straining stool
excessive vomiting (use anti emetics)
excessive coughing (use anti tussive like
dextromethorphan) avoid stooping/bending
avoid lifting heavy objects

23
23

avoid clustering of nursing activity together.

Administer medications like:


23

Osmotic diuretic (Mannitol)


for cerebral diuresis
Nursing Management
monitor vital signs especially BP (hypotension).
monitor strictly input and output every 1 hour notify physician if output is less 30 cc/hr.
administered via side drip
Regulated fast drip to prevent crystal formation.

23

Loop diuretic (Lasix, Furosemide)


23 Drug of choice for CHF (pulmonary edema)
23 Loop of Henle in kidneys.

Nursing Management
24 Monitor vital signs especially BP (hypotension).
25

monitor strictly input and output every 1 hour notify physician if output is less 30 cc/hr.

26

Administered IV push or oral.

5888given

early morning

5889Immediate effect of 10 15 minutes.


5890maximum effect of 6 hours. [monitor for potassium depletion]

5889

Corticosteroids
5888Dexamethasone (Decadron)
5889Hydrocortisone
5890Prednisone (to reduce edema that may lead to increase ICP)
5891Mild Analgesics (Codeine Sulfate for respiratory depression)
5892Anti Convulsants (Dilantin, Phenytoin)

*CONGESTIVE HEART FAILURE


Signs and Symptoms
0 dyspnea
1

orthopnea

paroxysmal nocturnal dyspnea

productive cough

frothy salivation

cyanosis

rales/crackles

bronchial wheezing

pulsus alternans

anorexia and general body malaise

10

PMI (point of maximum impulse/apical pulse rate) is displaced laterally

11

S3 (ventricular gallop)

12

Predisposing Factors/Mitral Valve


12.0 RHD
12.1 Aging

TREATMENT
Morphine Sulfate
Aminophelline
Digoxin
Diuretics
Oxygen
Gases, blood monitor
RIGHT CONGESTIVE HEART FAILURE (Venous congestion)
Signs and Symptoms
0 jugular vein distention (neck)
1

ascites

pitting edema

weight gain

hepatosplenomegaly

jaundice

pruritus

esophageal varices

anorexia and general body malaise

Signs and Symptoms of Lasix in terms of electrolyte imbalances


1. Hypokalemia
0
decrease potassium level
1

normal value is 3.4 5.5 meq/L

Sign and Symptoms


2
weakness and fatigue

constipation

positive U wave on ECG tracing

Nursing Management
2

administer potassium supplements as ordered (Kalium Durule, Oral Potassium Chloride)

increase intake of foods rich in potassium

FRUITS
Apple

VEGETABLES
Asparagus

Banana

Brocolli

Cantalope

Carrots

Oranges

Spinach

2. Hypocalcemia/ Tetany
23 decrease calcium level
24

normal value is 8.5 10.5 mg/100 ml

Signs and Symptoms


25 tingling sensation
26

paresthesia

27

numbness

28

(+) Trousseaus sign/ Carpopedal spasm

29

(+) Chvosteks sign

Complications
Arrhythmia

Seizures

Nursing Management
23 Calcium Gluconate per IV slowly as ordered
5889

Calcium Gluconate toxicity results to SEIZURE

Magnesium Sulfate
Magnesium Sulfate toxicity [B.U.R.P]
S/S
BP
Urine output

DECREASE

Respiratory rate
Patellar relfex absent
3. Hyponatremia
3
decrease sodium level
4

normal value is 135 145 meq/L

Signs and Symptoms


5
hypotension
6

dehydration signs (Initial sign in adult is THIRST, in infant TACHYCARDIA)

agitation

dry mucous membrane

poor skin turgor

10

weakness and fatigue

Nursing Management
0
force fluids
1

administer isotonic fluid solution as ordered

4. Hyperglycemia

normal FBS is 80 100 mg/dl

Signs and Symptoms - 3 Ps

polyuria

polydypsia

polyphagia

Nursing Management
3 monitor FBS
5. Hyperuricemia
3.0 increase uric acid (purine metabolism)
3.1 foods high in uric acid (sardines, organ meats and anchovies)
3.2 *Increase in tophi deposit leads to Gouty arthritis.

Signs and Symptoms


0 joint pain (great toes)
1

swelling

Nursing Management
0
force fluids
1

administer medications as ordered

1 Allopurinol (Zyloprim)
0
Drug of choice for gout.
1

Mechanism of action: inhibits synthesis of uric acid.

2 Colchecine
0
Acute gout
1

Mechanism of action: promotes excretion of uric acid.

KIDNEY STONES
Signs and Symptoms
0 renal colic
1

Cool moist skin

Nursing Management
0
fluids
1
as ordered

force

administer medications

1 Narcotic Analgesic
0
orphine Sulfate

1 ANTIDOTE:
Naloxone (Narcan) toxicity leads
to tremors.

2 Allopurinol (Zyloprim)
Side Effects
0
Respiratory depression (check for RR)

PARKINSONS DISEASE/ PARKINSONISM


0 Chronic progressive disorder of CNS
characterized by degeneration of dopamine producing cells in the

SUBSTANCIA NIGRA of the midbrain and basal ganglia.


Predisposing Factors
23

Poisoning (lead and carbon monoxide)

24

Arteriosclerosis

25

Hypoxia

26

Encephalitis

27

Increase dosage of the following drugs:


a. Reserpine(Serpasil)
b. Methyldopa(Aldomet)

AntihypertensiveS

c. Haloperidol(Haldol)
d. Phenothiazine

AntipsychoticS

SIDE EFFECTS RESERPINE

Major depression leading to suicide


Aloneness

Multiple
loss causes
suicide

Loss of spouse

Loss of Job

23 direct approach towards the client


24

close surveillance is a nursing priority

25

time to commit suicide is on weekends early morning

Signs and Symptoms for Parkinsons


23 pill rolling tremors of extremities especially the hands.
24

bradykinesia (slowness of movement)

25

rigidity (cogwheel type)

26

stooped posture

27

shuffling and propulsive gait

28

over fatigue

29

mask like facial expression with decrease blinking of the eyes.

30

difficulty rising from sitting position.

31

Dysphonia soft slurred Monotone type speech

32

mood lability (in state of depression)

33

Micrographia-shrinking slow handwriting

34

increase salivation (drooling type)

35

autonomic changes

23

increase sweating

24

increase lacrimation

25

seborrhea

26

constipation

27

decrease sexual capacity

Nursing Management
1. Administer medications as ordered
Anti Parkinsonian agents
5888
Levodopa (L-dopa) short acting
5889Amantadine Hydrochloride (Symmetrel)
5890Carbidopa (Sinemet)

Mechanism of Action
0 increase level of dopamine
Side Effects
23 GIT irritation (should be taken with meals
24 orthostatic hypotension (CBQ)
25

arrhythmia

26

hallucinations

Contraindications
5888clients with narrow angle closure glaucoma
5889clients taking MAOIs (no foods with tryptophan and thiamine: cheese, beer, avocado, wine)
5890urine and stool may be darkened
5891no Vitamin B6 (Pyridoxine) reverses the therapeutic effects of Levodopa

5889

Increase Vitamin B when taking INH (Isoniazid), Isonicotinic Acid Hydrazide

Anti Cholinergic Agents (ARTANE and COGENTIN) - to relieve tremors


Mechanism of Action
23 inhibits action of acethylcholine
Side Effects
5888

SNS

Anti Histamine (Dipenhydramine Hydrochloride)


Side Effects
Adult: drowsiness
Children: CNS excitement (hyperactivity) because blood brain barrier is not yet fully developed.
Dopamine Agonist - relieves tremor rigidity
Bromocriptene Hydrochloride (Parlodel)
Side Effects
23 Respiratory depression

24

Maintain side rails to prevent injury

25

Prevent complications of immobility

26

Decrease protein in morning and increase protein in afternoon to induce sleep

27

Encourage increase fluid intake and fiber.

28

Assist/supervise in ambulation

29

Assist in Stereotaxic Thalamotomy a portion of thalamus is destroyed to reduce tremors

MAGIC 2s IN DRUG MONITORING [D.L.A.D.A]


DRUG

NORMAL RANGE

TOXICITY
LEVEL

INDICATION

CLASSIFICATION

.5 1.5 meq/L

CHF

Cardiac Glycoside

.6 1.2 meq/L

Bipolar

Anti-Manic Agents

10 19 mg/100 ml

20

COPD

Bronchodilators

Dilantin/ Phenytoin

10 19 mg/100 ml

20

Seizures

Anti-Convulsant

Acetaminophen/Tylenol

10 30 mg/100 ml

200

Osteoarthritis

Non-narcotic
Analgesic

Digoxin/ Lanoxin
(Increase force of
cardiac output)
Lithium/ Lithane
(Decrease level of
Ach/NE/Serotonin)
Aminophylline
(Dilates bronchial tree)

1. Digitalis Toxicity
Signs and Symptoms
5888nausea and vomiting / anorexia
5889diarrhea
5890confusion / fatigue / depression / malaise
5891photophobia
5892changes in color perception (yellowish or green halo around lights or snowy vision)

Antidote: Digibind digoxin immune FAB


2. Lithium Toxicity anti-manic agent/ mood stabilizing agent
Signs and Symptoms
23 anorexia
24

nausea and vomiting

25

diarrhea

26

dehydration causing fine tremors

27

hypothyroidism (cretinism the only endocrine disorder that can lead to mental retardation)

Nursing Management
5888force fluids
5889increase sodium intake to 4 10 g% daily

3. Aminophylline Toxicity
Signs and Symptoms
0 tachycardia
1

palpitations

CNS excitement (tremors, irritability, agitation and restlessness)

Nursing Management
0.0 Only mixed with plain NSS or 0.9 NaCl to prevent development of crystals or precipitate.
0.1 administered sandwich method
0.2 avoid taking alcohol because it can lead to severe CNS depression
0.3 avoid caffeine

1 Dilantin phenytoin Toxicity


Signs and Symptoms
0 gingival hyperplasia (swollen & tender gums)
1 hairy tongue
2 ataxia
3 nystagmus

Nursing Management
0
provide oral care
1

massage gums

1 Acetaminophen Toxicity
Signs and Symptoms
0
hepatotoxicity (monitor for liver enzymes)
1

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 at bedside.

MYASTHENIA GRAVIS
0

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
0 unknown
1

Autoimmune: it involves release of cholinesterase an enzyme that destroys Acetylcholine

Signs and Symptoms


0 initial sign is ptosis a clinical parameter to determine ptosis is palpebral fissure. (drooping of eyelid)
1

diplipia

mask like facial expression

dysphagia

hoarseness of voice[dysphonia-voice

respiratory muscle weakness that may lead to respiratory arrest (tracheostomy at bed side)

extreme muscle weakness especially during activity or exertion

impairment]

Diagnostic Procedure
0 Tensilon test (Edrophonium Hydrochloride) provides temporary relief of signs and symptoms for about 5
10 minutes and a maximum of 15 minutes.
1 if there is no effect there is damage to occipital lobe and midbrain and is negative for M.G.

Nursing Management
1. Airway
2. Aspiration

maintain patent airway and adequate ventilation

3. Immobility
0 assist in mechanical ventilation and monitor pulmonary function test
1 monitor strictly vital signs, input and output and neuro check
2 monitor strength or motor grading scale
0 Maintain side rails to prevent injury related to falls
1 Institute NGT feeding
2 Administer medications as ordered
0 Cholinergic (Mestinon) pyridostigmine bromide
1 Anti Cholenisterase (Prostigmin) neostigmine bromide
Mechanism of Action
0
increase level of Ach
Side Effects
1
PNS
2

Cortocosteroids suppress immune response

monitor for 2 types of crisis:

MYASTHENIC CRISIS
Causes:
under medication
stress (disease exacerbation, high temp.)
infection
Signs and Symptoms
The client is unable to see, swallow, speak,
breathe
Treatment
administer cholinergic agents as ordered

CHOLINERGIC CRISIS
Cause:
over medication
Signs and Symptoms
PNS
Tensilon test doesnt improve MG
Treatment
Administer anti cholinergic agents (Atropine
Sulfate)

0 Assist in surgical procedure known as thymectomy because it is believed that the thymus gland is responsible for M.G.
1 Assist in plasma paresis and removing auto immune anti bodies
2 Prevent complications

INFLAMMATORY CONDITIONS OF THE BRAIN


MENINGITIS
Meninges
5888

3 fold membrane that covers brain and spinal cord.

5889for support and protection


5890for nourishment
5891blood supply

LAYERS OF THE MENINGES


0 Dura matter outer layer
1 Arachnoid middle layer
2 Pia matter inner layer
0
subdural space between the dura and arachnoid
1

Subarachnoid space between the arachnoid and pia, CSF aspiration is done.

A. Etiology
0 Meningococcus most dangerous
1 Pneumococcus
2 Streptococcus - causes adult meningitis
3 Hemophilus Influenzae causes pediatric meningitis
0 Mode of transmission
0 airborne transmission (droplet nuclei)

0 Signs and Symptoms


0 headache
1

photophobia

projectile vomiting

fever & chills, anorexia, generalized body malaise and weight loss

Possible increase in ICP and seizure activity

Abnormal posturing (decorticate and decerebrate)

Signs of meningeal irritation

0 Nuchal rigidity or stiff neck


1 Opisthotonus (arching of back)
2 (+) Kernigs sign (leg pain)
3 (+) Brudzinski sign (neck pain)
1 Diagnostic Procedures
0

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. [note all surgery procedure explain by the doctor, diagnostic procedure is by the nurse]
0 Secure informed consent and explain procedure.
1 Empty bladder and bowel to promote comfort.
2 Encourage to arch back to clearly visualize L3-L4. (fetal position)
Post Lumbar Puncture
0
Place flat on bed 12 24 o
1
Force fluids
2
Check punctured site for any discoloration, drainage and leakage to tissues.
3
Assess for movement and sensation of extremities.
CSF analysis reveals
0 Increase CHON and WBC
1 Decrease glucose
2 Increase CSF opening pressure (normal pressure is 50 100 mmHg)
3 (+) cultured microorganism (confirms meningitis)
CBC reveals
1. Increase wbc

notes on hematology:

E. Nursing Management

1. Enforce complete bed rest


0

INCREASED

DECREASED

RBC

Polycythemia

Anemia

WBC

Leukocytosis

Leukopenia

PLATELETS

Thrombocytosis

Thrombocytopenia

Administer medications as ordered


0Broad spectrum antibiotics (Penicillin, Tetracycline)
1Mild analgesics
2Anti pyretics

Institute strict respiratory isolation 24 hours after initiation of anti biotic therapy

Elevate head 30-45o

Monitor strictly V/S, input and output and neuro check

Institute measures to prevent increase ICP and seizure.

Provide a comfortable and darkened environment.

Maintain fluid and electrolyte balance.

Provide client health care and discharge planning concerning:


0Maintain good diet of increase CHO, CHON, calories with small frequent feedings.
1Prevent complications
0 most feared is hydrocephalus
1 hearing loss/nerve deafness is second complication
2 consult audiologist

2Rehabilitation for neurological deficit


0 mental retardation
1 delayed psychomotor development

CVA (STROKE/BRAIN ATTACK/ ADOPLEXY/ CEREBRAL THROMBOSIS)


0 a partial or complete disruption in the brains blood supply.
1

2 most common cerebral artery affected by stroke

1 Mid Cerebral Artery


2 Internal Cerebral Artery the 2 largest artery
1 Incidence Rate
0 men are 2-3 times high risk
2 Predisposing Factors
0 thrombus (attached)
1

embolus (detached and most dangerous because it can go to the lungs and cause pulmonary
embolism or the brain and cause cerebral embolism.

Signs and Symptoms of Pulmonary Embolism


0 Sudden sharp chest pain
1

Unexplained dyspnea

Tachycardia

Palpitations

Diaphoresis

Mild restlessness

Signs and Symptoms of Cerebral Embolism


0.1024
Headache and dizziness
0.1025
Confusion
0.1026
Restlessness
0.1027
Decrease LOC

1
femur fracture.

Fat embolism is the most feared complications after

produces
2
fat cells.

Yellow bone marrow are produced from the medullary cavity of the long bones and

in
3
the circulation.

If there is bone fracture there is hemorrhage and there would be escape of the fat cells

Compartment syndrome (compression of arteries and nerves)

C. Risk Factors
5888 Hypertension, Diabetes Mellitus, Myocardial Infarction, Atherosclerosis, Valvular Heart Disease, Post Cardiac
Surgery (mitral valve replacement)
5889

Lifestyle (smoking), sedentary lifestyle

5890

Obesity (increase 20% ideal body weight)

5891

Hyperlipidemia more on genetics/genes that binds to cholesterol

5892

Type A personality
5888

deadline driven

5889

can do multiple tasks

5890

usually fells guilty when not doing anything

5893

Related to diet: increase intake of saturated fats like whole milk

5894

Related stress physical and emotional

5895 Prolong use of oral contraceptives promotes lypolysis (breakdown of lipids) leading to atherosclerosis that will
lead to hypertension and eventually CVA.
D. Signs and Symptoms
dependent on stages of development
1. TIA
Initial sign of stroke or warning sign
Signs and Symptoms
headache and dizziness
tinnitus
visual and speech disturbances
paresis to plegia
possible increase ICP

Stroke in evolution
-progression of signs and symptoms of stroke
3. Complete stroke
resolution phase characterized by:
Signs and Symptoms
headache and dizziness
Cheyne Stokes Respiration
anorexia, nausea and vomiting
dysphagia

(+) Kernigs sign and Brudzinski sign


which may lead to hemorrhagic stroke

focal neurological deficits


phlegia
aphasia

dysarthria (inability to articulate words)


alexia (difficulty reading)
agraphia (difficulty writing)
homonymous hemianopsia (loss of half of visual field)
Diagnostic Procedure
CT Scan reveals brain lesions
Cerebral Arteriography
reveals the site and extent of malocclusion
uses dye for visualization
most of dye are iodine based
check for shellfish allergy
after diagnostic exam force fluids to release dye because it is nephro toxic
check for distal pulse (femoral)
check for hematoma formation

Notes:
Plegia paralysis
Ex: Hemiplegia paralysis of one
side of the body.
Paresis weakness
Ex: Hemiparesis - weakness of one
side of the body.

F. Nursing Management
Maintain patent airway and adequate ventilation by:
assist in mechanical ventilation
administrate O2 inhalation
Restrict fluids to prevent cerebral edema that might increase ICP
Elevate head 30 45o
Monitor strictly vitals signs, I & O and neuro check
Prevent complications of immobility by:
turn client to side
provide egg crate mattresses or water bed
provide sand bag or foot board.
Assist in passive ROM exercise every 4 hours to promote proper bodily alignment and prevent contractures
Institute NGT feeding
Provide alternative means of communication
non verbal cues
magic slate
If positive to hemianopsia approach client on unaffected side
Administer medications as ordered
Osmotic Diuretics (Mannitol)
Loop Diuretics (Lasix, Furosemide)
Cortecosteroids
Mild Analgesics
Thrombolytic/Fibrinolytic Agents dissolves thrombus
Streptokinase
Side Effect: Allergic Reaction

Urokinase
Tissue Plasminogen Activating Factor
Side Effect: Chest Pain

Anti Coagulants
Heparin (short acting)
check for partial thromboplastin time if prolonged there is a risk for bleeding.
give Protamine Sulfate

Comadin/ Warfarin (long acting)


give simultaneously because Coumadin will take effect after 3 days
check for prothrombin time if prolonged there is a risk for bleeding
give Vit. K (Aqua Mephyton)

Anti Platelet

PASA (Aspirin)
Contraindicated for dengue, ulcer and unknown cause of headache because it may potentiate
bleeding

Provide client health teachings and discharge planning concerning


avoidance of modifiable risk factors (diet, exercise, smoking)
prevent complication (subarachnoid hemorrhage is the most feared complication)
dietary modification (decrease salt, saturated fats and caffeine)
importance of follow up care

GUILLAIN BARRE SYNDROME (Acute Ediopathic Polyneuropathy)


a disorder of the CNS characterized by bilateral symmetrical polyneuritis leading to ascending muscle
paralysis/weakness.
Predisposing Factors
Autoimmune
Antecedent viral infections such as LRT infections

B. Signs and Symptoms


Clumsiness (initial sign)
Dysphagia
Ascending muscle weakness leading to paralysis
Decreased of diminished deep tendon reflex
Alternate hypotension to hypertension
** ARRYTHMIA (most feared complication)
Autonomic symptoms that includes
increase salivation
increase sweating
constipation
C. Diagnostic Procedures
1. CSF analysis reveals increase in IgG and protein
D. Nursing Management
Maintain patent airway and adequate ventilation by:
assist in mechanical ventilation
monitor pulmonary function test
Monitor strictly the following
vital signs
intake and output
neuro check
ECG
Maintain side rails to prevent injury related to fall
Prevent complications of immobility by turning the client every 2 hours
Institute NGT feeding to prevent aspiration
Assist in passive ROM exercise
Administer medications as ordered
Corticosteroids suppress immune response
Anti Cholinergic Agents Atrophine Sulfate
Anti Arrythmic Agents
Lidocaine, Zylocaine
Bretylium blocks release of norepinephrine to prevent increase of BP

Assist in plasma pharesis (filtering of blood to remove autoimmune anti-bodies)


Prevent complications
Arrythmia
Paralysis or respiratory muscles / Respiratory arrest
Sengstaken Blakemore Tube
for liver cirrhosis
to decompress bleeding esophageal verices (prepare scissor to cut tube incase of difficulty in breathing to
release air in the balloon
for hemodialysis prepare bulldog clips to prevent air embolism.

CONVULSIVE DISORDER/ CONVULSION


Disorder of CNS characterized by paroxysmal seizure with or without loss of consciousness abnormal motor
activity alternation in sensation and perception and changes in behavior.
Seizure first convulsive attack
Epilepsy second or series of attacks
Febrile seizure normal in children age below 5 years

A. Predisposing Factors
Head injury due to birth trauma
Genetics
Presence of brain tumor
Toxicity from
a. lead
b carbon monoxide
Nutritional and Metabolic deficiencies
Physical and emotional stress
Sudden withdrawal to anti convulsant drug is predisposing factor for status epilepticus (drug of choice is Diazepam,
Valium)
B. Signs and Symptoms
Dependent on stages of development or types of seizure
I. Generalized Seizure
Grand mal Seizure (tonic-clonic seizure)
Signs or aura with auditory, olfactory, visual, tactile, sensory experience
Epileptic cry is characterized by fall and loss of consciousness for 3 5 minutes
Tonic contractions - direct symmetrical extension of extremities
Clonic contractions - contraction of extremities
Post ictal sleep unresponsive sleep
Petit mal Seizure absence of seizure common among pediatric clients characterized by
blank stare
decrease blinking of eyes
twitching of mouth
loss of consciousness (5 10 seconds)
II. Partial or Localized Seizure
Jacksonian Seizure (focal seizure)
Characterized by tingling and jerky movement of index finger and thumb that spreads to the shoulder and other side of
the body.
Psychomotor Seizure (focal motor seizure)
automatism stereotype repetitive and non propulsive behavior
clouding of consciousness not in contact with environment
mild hallucinatory sensory experience
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
Diagnostic Procedures
CT Scan reveals brain lesions
EEG reveals hyper activity of electrical brain waves
D. Nursing Management
Maintain patent airway and promote safety before seizure activity
clear the site of blunt or sharp objects
loosen clothing of client
maintain side rails
avoid use of restrains
turn clients head to side to prevent aspiration
place mouth piece of tongue guard to prevent biting or tongue

Avoid precipitating stimulus such as bright/glaring lights and noise


Administer medications as ordered
Anti convulsants (Dilantin, Phenytoin)
Diazepam, Valium
Carbamazepine (Tegretol) Trigeminal neuralgia
Phenobarbital, Luminal
Institute seizure and safety precaution post seizure attack
administer O2 inhalation
provide suction apparatus
Document and monitor the following
onset and duration
types of seizures
duration of post ictal sleep may lead to status epilepticus
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

Conscious

15 14

2. Verbal response

Lethargy

13 11

3. Eye opening

Stupor

10 8

Coma
Deep Coma

7
3

Survey of mental status and speech


LOC
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)
Alternate supination and pronation positive result mean dimetria

LEVEL OF CONSCIOUSNESS
Conscious - awake
Lethargy lethargic (drowsy, sleepy, obtunded)
Stupor
stuporous (awakened by vigorous stimulation)

generalized body weakness

decrease body reflex

4. Coma
comatose
light coma (positive to all forms of painful stimulus)
deep coma (negative to all forms of painful stimulus)

DIFFERENT PAINFUL STIMULATION


Deep sternal stimulation/ deep sternal pressure
Orbital pressure
Pressure on great toes
Corneal or blinking reflex
Conscious client use a wisp of cotton
Unconscious client place 1 drop of saline solution

II. TEST OF MEMORY


Short term memory
ask most recent activity
positive result mean anterograde amnesia and damage to temporal lobe

Long term memory


ask for birthday and validate on profile sheet
positive result mean retrograde amnesia and damage to limbic system
consider educational background

III. LEVELS OF ORIENTATION

CRANIAL NERVES

FUNCTION

1. Time first asked


2. Person second asked

I. OLFACTORY

3. Place third asked

II. OPTIC

III OCCULOMOTOR

IV. TROCHLEAR

CRANIAL NERVES

(Smallest)
CRANIAL NERVE I: OLFACTORY

B
(Largest)

sensory function for smell


VI. ABDUCENSE

dont use alcohol, ammonia, perfume because it is irritating

VII. FACIAL

and highly diffusible.

VIII. ACOUSTIC

IX. GLOSSOPHARYNGEAL

Material Used

V. TRIGEMINAL

use coffee granules, vinegar, bar of soap, cigarette

Procedure

X. VAGUS

B
(Longest)

test each nostril by occluding each nostril


Abnormal Findings

XI. SPINAL ACCESSORY

1. Hyposnia decrease sensitivity to smell

XII. HYPOGLOSSAL

Dysosmia distorted sense of smell


Anosmia absence of smell
Indicative of
head injury damaging the cribriform plate of ethmoid bone where olfactory cells are located
may indicate inflammatory conditions (sinusitis)
CRANIAL NERVE II: OPTIC
sensory function for vision or sight
Functions
Test visual acuity or central vision or distance
use Snellens Chart
Snellens Alphabet chart: for literate clients
Snellens E chart: for illiterate clients
Snellens Animal chart: for pediatric clients
normal visual acuity 20/20
numerator is constant, it is the distance of person from the chart (6 7 m, 20 feet)
denominator changes, indicates distance by which the person normally can see letter in the chart.
- 20/200 indicates blindness
20/20 visual acuity if client is able to read letters above the red line.

Test of visual field or peripheral vision

Superiorly
Bitemporaly
Nasally
Inferiorly
COMMON VISUAL DISORDERS
1. Glaucoma
increase IOP
normal IOP is 12 21 mmHg
preventable but not curable

Predisposing Factors
Common among 40 years old and above
Hereditary
Hypertension
Obesity

Signs and Symptoms


Loss of peripheral vision
pathognomonic sign is tunnel vision
Headache, nausea, vomiting, eye pain (halos around light)
steamy cornea
may lead to blindness

C. Diagnostic Procedures
Tonometry
Perimetry
Gonioscopy
D. Treatment
Miotics constricts pupil
Pilocarpine Sodium, Carbachol
Epinephrine eyedrops decrease formation of aqueous humor
Carbonic Anhydrase Inhibitors
Acetazolamide (Diamox) promotes increase outflow of aqueous humor or drainage

Timoptics (Timolol Maleate)


E. Surgical Procedures
1. TRABECULECTOMY (Peripheral Indectomy) drain aqueous humor

2. CATARACT
Decrease opacity of lens
Predisposing Factor
Aging 65 years and above
Related to congenital
Diabetes Mellitus
Prolonged exposure to UV rays
Signs and Symptoms
1. Loss of central vision

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
Mydriatics (Mydriacyl) dilating pupils
Cyclopegics (Cyclogyl) paralyses cilliary muscle
F. Surgical Procedure
Extra

Intra

Capsular

Capsular

Cataract

Cataract

Lens

Lens

Extraction

Extraction

- Partial removal
- Total removal of cataract with its surrounding capsules
Most feared complication post op is RETINAL DETACHMENT

3. Retinal Detachment
Separation of epithelial surface of retina
Predisposing Factors
Post Lens Extraction
Myopia (near sightedness)
B. Signs and Symptoms
Curtain veil like vision
Floaters
C. Surgical Procedures
Scleral Buckling
Cryosurgery cold application
Diathermy heat application

4. Macular Degeneration
Degeneration of the macula lutea (yellowish spot at the center of retina)
Signs and Symptoms
1. Black Spots
CRANIAL NERVE III, IV, VI: OCULOMOTOR, TROCHLEAR, ABDUCENS

Controls or innervates the movement of extrinsic ocular muscle (EOM)

6 muscles

Superior Rectus

Superior Oblique

Lateral Rectus

Medial Rectus

Inferior Oblique

Inferior Rectus

A. normal retina
B. wet macular
degeneration

c. dry macular
degeneration

trochlear controls superior oblique


abducens controls lateral rectus
oculomotor controls the 4 remaining EOM

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

CRANIAL NERVE V: TRIGEMINAL


largest cranial nerve
consists of ophthalmic, maxillary, mandibular
sensory: controls sensation of face, mucous membrane, teeth, soft palate and corneal reflex)
motor: controls the muscle of mastication or chewing
damage to CN V leads to trigeminal neuralgia/tic douloureux (nerve pain)
medication: Carbamezapine(Tegretol) - anticonvulsant

CRANIAL NERVE VII: FACIAL


Sensory: controls taste, anterior 2/3 of tongue
pinch of sugar and cotton applicator placed on tip of tongue
Motor: controls muscle of facial expression

Instruct client to smile, frown and if results are negative there is facial paralysis or Bells palsy and the primary
cause is forceps delivery.
CRANIAL NERVE VIII: ACOUSTIC/VESTIBULOCOCHLEAR
Controls balance particularly kinesthesia or position sense, refers to movement and orientation of the
body in space.
Parts of the Ear
Outer Ear
Pinna
Eardrum

Middle Ear

Hammer
Anvil

Malleus
Incus

Stirrup

Stapes

Inner Ear
Vestibule: Meineres Disease
Cochlea
Mastoid Cells
Endolymph and Perilymph

COCHLEA: controls hearing, contains the Organ of Corti (the true organ of hearing)
Let client repeat words uttered

CRANIAL NERVE IX, X: GLOSOPHARYNGEAL, VAGUS NERVE


Glosopharyngeal: controls taste, posterior 1/3 of tongue
Vagus: controls gag reflex
Uvula should be midline and if not indicative of damage to cerebral hemisphere
Effects of vagal stimulation is PNS

CRANIAL NERVE XI: SPINAL ACCESSORY


Innervates with sternocleidomastoid (neck) and trapezius (shoulder)
CRANIAL NERVE XII: HYPOGLOSSAL

Controls the movement of tongue


Let client protrude tongue and it should be midline and if unable to do indicative of damage to cerebral
hemisphere and/or has short frenulum.

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
called as adenohypophysis
Posterior Pituitary Gland
called as neurohypophysis
o

secretes hormones oxytocin -promotes uterine contractions preventing bleeding/ hemorrhage

o
o

administrate oxytocin immediately after delivery to prevent uterine atony.


initiates milk let down reflex with help of hormone prolactin
Anterior pituitary

2. Antidiuretic Hormone
o
Pitressin (Vasopressin)

ADH
OXYTOCIN

Posterior pituitary
GH
ACTH
TSH
FSH & LH

o
o

Function: prevents urination thereby conserving water


Diabetes Insipidus/ Syndrome of Inappropriate Anti Diuretic
Hormone

DIABETES INSIPIDUS (Dalas Ihi)


Decrease production of anti diuretic hormone
Predisposing Factor
Related to pituitary surgery
o

Trauma

Inflammation

Presence of tumor
Signs and Symptoms
Polyuria
Signs of dehydration
Adult: thirst
Agitation
Poor Skin turgor
Dry mucous membrane
Weakness and fatigue
Hypotension
Weight loss (payat)
If left untreated results to hypovolemic shock (sign is anuria)
C. Diagnostic Procedures
1. Urine Specific Gravity
o

Normal value: 1.015 1.030

Ph 4 8
Serum Sodium
Increase resulting to hypernatremia
D. Nursing Management
Force fluids
Monitor strictly vital signs and intake and output
Administer medications as ordered
a. Pitressin (Vasopresin Tannate) administered IM Z-tract
Prevent complilcations HYPOVOLEMIC SHOCK is the most feared complication

PROLACTIN
MSH

SIADH lunod sa tubig


o

hypersecretion of antidiuretic hormone

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.

Signs and Symptoms


Fluid retention
Hypertension
Edema
Weight gain (mataba)
Water intoxication may lead to cerebral edema and lead to increase ICP may lead to seizure activity
C. Diagnostic Procedure
Urine specific gravity is increased
Serum Sodium is decreased (hyponatremia 135 mg/dl)
D. Nursing Management
Restrict fluid
Administer medications as ordered
Loop diuretics (Lasix)
Osmotic diuretics (Mannitol)
Monitor strictly vital signs, intake and output and neuro check
Weigh patient daily and assess for pitting edema
Provide meticulous skin care
Prevent complications
ANTERIOR PITUITARY GLAND
o

also called ADENOHYPOPHYSIS secretes

Growth hormones (somatotropic hormone)


o

Promotes elongation of long bones

o Hyposecretion of GH among children results to


Dwarfism o Hypersecretion of GH results to Gigantism
o Hypersecretion of GH among adults results to Acromegaly (square
face) o Drug of choice: Ocreotide (Sandostatin)
Melanocyte Stimulating hormone
o

for skin pigmentation

Hyposecretion of MSH results to Albinism

Most feared complications of albinism


Lead to blindness due to severe photophobia
Prone to skin cancer
Hypersecretion of MSH results to Vitiligo
Adrenochorticotropic hormone (ACTH)
promotes development of adrenal cortex
Lactogenic homone (Prolactin)
promotes development of mammary gland
o

with help of oxytocin it initiates milk let down reflex

5. Leutinizing hormone
secretes estrogen
Follicle stimulating hormone
secretes progesterone
PINEAL GLAND
o secretes melatonin
o inhibits LH secretion
o

it controls/regulates circadian rhythm (body clock)

THYROID GLAND
located anterior to the neck
Hormones secreted
T3 (Tri iodothyronine) - 3 molecules of iodine (more potent)
T4 (tetra iodothyronine, Thyroxine)
T3 and T4 are metabolic or calorigenic hormone
promotes cerebration (thinking)
Thyrocalcitonin antagonizes the effects of parathormone to promote calcium resorption.
HYPOTHYROIDISM thyroid deficiency
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

menorrhagia or amenorrhea

cold intolerance

constipation

can lead to Myxedema

extreme fatigue

o babagsak sa exam (mental proc. Decreased)


o weight gain
o

hypothermic

HYPERTHYROIDISM
o

all are increase except weight and menstruation

Signs and Symptoms


o
o

increase appetite but there is weight loss

Pharmacologic therapy

Myxedema coma

amenorrhea

for hypothyroidism

exophthalmos

Tachycardia, palpitations
insomnia

Synthetic levothyroxine
(syndroid or levothroid)

Severe hypothyroidism
- Increased
lethargic
- Hypothermic
- Stupor
- coma

restlessness agitation

Heat intolerance

HPN

THYROID DISORDERS
SIMPLE GOITER
enlargement of thyroid gland due to iodine deficiency
Predisposing Factors
Goiter belt area
places far from sea
Mountainous regions
Increase intake of goitrogenic foods
o

contains pro-goitrin an anti thyroid agent that has no iodine.

cabbage, turnips, radish, strawberry, carrots, sweet potato, broccoli, all nuts

soil erosion washes away iodine

goitrogenic drugs
Anti Thyroid Agent Prophylthiuracil (PTU)
b. Lithium Carbonate
c. PASA (Aspirin)

d. Cobalt
e. Phenylbutazones (NSAIDs) - if goiter is caused by

B. Signs and Symptoms


1. Enlarged thyroid gland
2. Mild dysphagia
3. Mild restlessness
C. Diagnostic Procedures

Serum T3 and T4 reveals normal or below normal


Thyroid Scan reveals enlarged thyroid gland.
Serum Thyroid Stimulating Hormone (TSH)
is increased (confirmatory diagnostic test)

D. Nursing Management
Enforce complete bed rest
Administer medications as ordered
a. Lugols Solution/SSKI ( Saturated Solution of Potassium Iodine)
o

color purple or violet and administered via straw to prevent staining of teeth.

4 Medications to be taken via straw: Lugols, Iron, Tetracycline, Nitrofurantoin (drug of choice for
pyelonephritis)
b. Thyroid Hormones
Levothyroxine (Synthroid)
o Liothyronine (Cytomel)
o Thyroid Extracts
Nursing Management when giving Thyroid Hormones
Instruct client to take in the morning to prevent insomnia
Monitor vital signs especially heart rate because drug causes tachycardia and palpitations
Monitor side effects
o

insomnia

tachycardia and palpitations

hypertension

heat intolerance
Increase dietary intake of foods rich in iodine
seaweeds
seafoods like oyster, crabs, clams and lobster but not shrimps because it contains lesser amount of iodine.
iodized salt, best taken raw because it it is easily destroyed by heat
Assist in surgical procedure of subtotal thyroidectomy
HYPOTHYROIDISM
o

hyposecretion of thyroid hormone

adults: MYXEDEMA non pitting edema

children: CRETINISM the only endocrine disorder that can lead to mental retardation
Predisposing Factors
Iatrogenic Cause disease caused by medical intervention such as surgery
Related to atrophy of thyroid gland due to trauma, presence of tumor, inflammation
Iodine deficiency

Autoimmune (Hashimotos Disease)


B. Signs and Symptoms
(Early Signs)
Weakness and fatigue
Loss of appetite but with weight gain which promotes lipolysis leading to atherosclerosis and MI
Dry skin
Cold intolerance
Constipation
(Late Signs)
Brittleness of hair and nails
Non pitting edema (Myxedema)
Hoarseness of voice
Decrease libido
Decrease in all vital signs hypotension, bradycardia, bradypnea, hypothermia
CNS changes
o

lethargy

memory impairment (forgetfulness)

psychosis

menorrhagia
Diagnostic Procedures
Serum T3 and T4 is decreased
Serum Cholesterol is increased
RAIU (Radio Active Iodine Uptake) is decreased
Nursing Management
Monitor strictly vital signs and intake and output to determine presence of
Myxedema coma is a complication of hypothyroidism and an emergency case 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

Force fluids
Administer isotonic fluid solution as ordered
Administer medications as ordered
Thyroid Hormones
Levothyroxine
Leothyronine
Thyroid Extracts
Provide dietary intake that is low in calories due to wt. gain
Provide comfortable and warm environment due to cold intolerance
Provide meticulous skin care
Provide client health teaching and discharge planning concerning a.
Avoid precipitating factors leading to myxedema coma

stress

infection

cold intolerance

use of anesthetics, narcotics, and sedatives

o prevent complications (myxedema coma, hypovolemic


shock o hormonal replacement therapy for lifetime
o

importance of follow up care

HYPERTHYROIDISM graves disease or thyroid toxicosis (everything is up except wt. and mens.
o

increase in T3 and T4

Graves Disease or Thyrotoxicosis

developed by Robert Graves


Predisposing Factors
Autoimmune it involves release of long acting thyroid stimulator causing exopthalmus (protrusion of eyeballs)
enopthalmus (late sign of dehydration among infants)
Excessive iodine intake
Related to hyperplasia of TG (increase size)
Signs and Symptoms
Increase appetite (hyperphagia) but there is weight loss due to increased metabolism
Moist skin
Heat intolerance
Diarrhea
All vital signs are increased
CNS involvement
Irritability and agitation
Restlessness
Tremors
Insomnia
Hallucinations
Goiter
Exopthalmus (Pathognomonic sign)
Amenorrhea
Diagnostic Procedures
Serum T3 and T4 is increased
RAIU (Radio Active Iodine Uptake) is increased
Thyroid Scan- reveals an enlarged thyroid gland
Nursing Management
Monitor strictly vital signs and intake and output - determine thyroid storm or most feared complication:
Thyrotoxicosis
Administer medications as ordered
Anti Thyroid Agent
Prophythioracill (PTU)
Methymazole (Tapazole)
Most toxic Side Effects Agranulocytosis
o increase lymphocytes and monocytes
o fever and chills
o sore throat (throat swab/culture)
o leukocytosis (CBC)
Most feared complication : Thrombosis stroke CVS
Provide dietary intake that is increased in calories.
Provide meticulous skin care
Comfortable and cold environment
Maintain side rails - due to agitation/restlessness
Provide bilateral eye patch to prevent drying of the eyes.
Assist in surgical procedures known as subtotal thyroidectomy
Before thyroidectomy administer Lugols Solution (SSKI) to decrease vascularity of the thyroid
gland to prevent bleeding and hemorrhage.

POST OPERATIVELY,
1. Watch out for signs of thyroid storm/ thyrotoxicosis
Agitation

TRIAD SIGNS

Hyperthermia

Tachycardia

administer medications as ordered


Anti Pyretics
Beta-blockers tachycardia
o Monitor strictly vital signs, input and output and neuro check.
o maintain side rails
o

offer TSB

Watch out for accidental removal of parathyroid gland (secretes parathormone) that may lead to
Hypocalcemia (tetany)
Signs and Symptoms
o (+) trousseaus sign
o (+) chvostek sign
o

Watch out for arrhythmia, seizure give Calcium Gluconate IV slowly as ordered
Ca gluconate toxicity antidote MgSO4

3. Watch out for accidental Laryngeal (voice box) damage which may lead to hoarseness of voice
Nursing Management
o

encourage client to talk/speak immediately after operation and notify physician

4. Signs of bleeding (feeling of fullness at incisional site)


Nursing Management
o

Check the soiled dressings at the back or nape area.

Sign of laryngeal spasm DOB, SOB (tracheostomy at bed side)

Hormonal replacement therapy for lifetime


Importance of follow up care
PARATHYROID GLAND
o A pair of small nodules behind the thyroid gland
o Secretes parathormone
o

Promotes calcium reabsorption

Thyrocalcitonin antagonises secretion of parathyroid hormone

Hypoparathyroidism

Hyperparathyroidism

HYPOPARATHYROIDISM
o Decrease secretion of parathormone leading to hypocalcemia (tetany)
o Resulting to Hyperphosphatemia
[If Ca decreases, phosphate increases]
A. Predisposing Factors
Following subtotal thyroidectomy
Atrophy of parathyroid gland due to:
a. inflammation

tumor
trauma
B. Signs and Symptoms
1. Acute tetany

tingling sensation
paresthesia
numbness
dysphagia
positive trousseaus sign/carpopedal spasm
positive chvostek sign
laryngospasms / broncospasm
seizurefeared complications
arrhythmia
Chronic tetany
photophobia and cataract formation
loss of tooth enamel
anorexia, nausea and vomiting
agitation and memory impairment (irritable)
C. Diagnostic Procedures
Serum Calcium is decreased (normal value: 8.5 10.5 mg/100 ml)
Serum Phosphate is increased (normal value: 2.5 4.5 mg/100 ml)
X-ray of long bones reveals a decrease in bone density
CT Scan reveals degeneration of basal ganglia
D. Nursing Management
Administer medications as ordered such as:
Acute Tetany
Calcium Gluconate IV slowly
Chronic Tetany
Oral Calcium supplements
Calcium Gluconate
Calcium Lactate
Calcium Carbonate

Vitamin D (Cholecalciferol) for absorption of calcium


VIT. D
(CHOLECALCEFEROL)

DRUG

DIET

Cholecalceferol

SUNLIGHT

calcidiol

calcitriol

7am 9am

d. Phosphate binder
Aluminum Hydroxide Gel (Ampogel)
Side effect: constipation

ANTACID
A.A.C

Aluminum Containing
Antacids

Aluminum
Hydroxide
Gel

Less s/e)

Side Effect: Constipation

MAD

Magnesium Containing

Antacids

Ex. Milk of magnesia


(Maalox magnesium & aluminum Side Effect: Diarrhea

Avoid precipitating stimulus such as glaring lights and noise


Encourage increase intake of foods rich in calcium (decreased phosphorus)
anchovies - increase Ca, decrease phosphorus + inc uric acid. Tuna & green turnips- Inc Ca.
salmon
green turnips
Dont give milk due to increase phosphorus
Institute seizure and safety precaution
Encourage client to breathe using paper bag to produce mild respiratory acidosis result.
Prepare trachea set at bedside for presence of laryngospasm
Prevent complications
Hormonal replacement therapy for lifetime
Importance of follow up care.
HYPERPARATHYROIDISM
o

Decrease parathormone

o Hypercalcemia: bone demineralization leading to bone fracture (calcium is stored 99% in bone and 1% blood)
o Kidney stones
(parathormone pullout the Ca in from the bone to the blood)
A. Predisposing Factors
Hyperplasia of parathyroid gland
over compensation of parathyroid gland due to vitamin D deficiency
Children: Rickets - the bone do not hardened
Adults: Osteomalacia - softening of the bone
B. Signs and Symptoms
Bone pain especially at back (bone fracture)
Kidney stones
renal cholic
cool moist skin
Anorexia, nausea and vomiting
Agitation and memory impairment
C. Diagnostic Procedures
Serum Calcium is increased
Serum Phosphate is decreased
X-ray of long bones reveals bone demineralization
D. Nursing Management
Force fluids to prevent kidney stones
Strain all the urine using gauze pad for stone analysis
Provide warm sitz bath
Administer medications as ordered a.
Morphine Sulfate (Demerol)
Encourage increase intake of foods rich in phosphate but decrease in calcium
Provide acid ash in the diet to acidify urine and prevent bacterial growth
Assist/supervise in ambulation
Maintain side rails
Prevent complications (seizure and arrhythmia) most feared renal failure
Assist in surgical procedure known as parathyroidectomy
Hormonal replacement therapy for lifetime
Importance of follow up care

ADRENAL GLAND
o Located atop of each kidney
o 2 layers of adrenal gland

Adrenal Cortex outermost

function:
controls
glucose
metabolism
Sugar
2. Zona
Reticularis
secretes
traces
of
glucocortico
ids
and
androgenic
hormones
function:
promotes
secondary
sex
characteristi
cs
Sex
3. Zona
Glumerulos
a
secretes
mineralocor
ticoids
(aldosteron
e)
function:
promotes
sodium and
water
reabsorptio
n
and
excretion of
potassium
Salt

Adrenal Medulla innermost (secretes catecholamines a power hormone)


2 Types of Catecholamines
o

Epinephrine and Norepinephrine (vasoconstrictor) increased BP

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

PHEOCHROMOCYTOMA- presence of tumor at adrenal medulla


Increase norepinephrine. HPN with pounding headache.
with HPN and resistant to drugs
drug of choice: beta blockers
complication: HPN crisis = lead to stroke
no valsalva maneuver. Dont smoke. No caffeine.
ADRENAL CORTEX
3 Zones/Layers
1. Zona Fasciculata
secretes glucocortocoids (cortisol)

I love
Sex!!!
ADDISONS DISEASE - payat
o

Hyposecretion of adreno cortical hormone leading to

ex
ugar
alt

A. Predisposing Factors
Related to atrophy of adrenal glands
Fungal infections
B. Signs and Symptoms
Hypoglycemia TIRED
Decrease tolerance to stress
Hyponatremia
hypotension
signs of dehydration
weight loss
Hyperkalemia
agitation
diarrhea
arrhythmia
Decrease libido
Loss of pubic and axillary hair
Bronze like skin pigmentation

Addisonian crisis:
Cyanosis
Classic sign of circulatory shock:
pallor, apprehension, rapid weak
pulse, rapid RR, low BP

Hydrocortisone (Solu-Cortef)
admin. IV, followed w/ 5% D5NS.

C. Diagnostic Procedures
FBS is decreased (normal value: 80 100 mg/dl)
Plasma Cortisol is decreased
Serum Sodium is decrease (normal value: 135 145 meq/L)
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 addisons
disease)
Addisonian crisis results from acute exacerbation of addisons disease characterized by
severe hypotension
hypovolemic shock
hyponatremia leading to progressive stupor and coma
Nursing Management for Addisonian Crisis
1. Assist in mechanical ventilation,
administer steroids as ordered
force fluids
Administer isotonic fluid solution as ordered
Force fluids
Administer medications as ordered

Corticosteroids
Dexamethasone (Decadrone)
Prednisone
Hydrocortisone (Cortison)
Nursing Management when giving steroids
Instruct client to take 2/3 dose in the morning and 1/3 dose in the afternoon to mimic the normal diurnal rhythm

Taper dose (withdraw gradually from drug)


Monitor side effects
hypertension
edema
hirsutism
increase susceptibility to infection
moon face appearance
Mineralocorticoids (Flourocortisone)
Provide dietary intake, increase calories, carbohydrates, protein but decrease in potassium
Provide meticulous skin care
Provide client health teaching and discharge planning
avoid precipitating factor leading to addisonian crisis leading to
stress
infection
sudden withdrawal to steroids
b. prevent complications
addisonian crisis
hypovolemic shock
hormonal replacement for lifetime
importance of follow up care

CUSHING SYNDROME - mataba


o

Hypersecretion of adenocortical hormones

A. Predisposing Factors
1 Related to hyperplasia of adrenal gland
Increase susceptibility to infections
Hypernatremia
hypertension
edema
weight gain
moon face appearance and buffalo hump

obese trunk
pendulous abdomen
thin extremities
Hypokalemia
weakness and fatigue
constipation
U wave upon ECG (T wave hyperkalemia)
Hirsutism
Acne and striae
Easy bruising
Increase masculinity among females
B. Diagnostic Procedures
FBS is increased
Plasma Cortisol is increased

Cushings syndrome.
Client prior to syndrome.
Client 4 months after diagnosis of syndrome.

Serum Sodium is increased


Serum Potassium is decreased
Dexamethasone suppression test
C. Nursing Management
Monitor strictly vital signs and intake and output
Weigh patient daily and assess for pitting edema
Measure abdominal girth daily and notify physician
Restrict sodium intake
Provide meticulous skin care
Administer medications as ordered
a. Spinarolactone potassium sparring diuretics
7. Prevent complications (DM)

Best example of CUSHING SYNDROME


is
no other than
JOLLIBEE moon face & big body with
thin extremities

8. Assist in surgical procedure (bilateral adrenoraphy)


9. Hormonal replacement for lifetime
10. Importance of follow up care
PANCREAS
Located behind the stomach
Mixed gland (exocrine and endocrine)

Consist of acinar cells which secretes pancreatic juices that aids in digestion thus it is an exocrine gland
Type 1 (IDDM)
- Juvenile onset type
- Brittle disease

Type 2 (NIDDM)
- Adult onset
- Maturity onset type
- Obese over 40 years old

A. Incidence Rate

A. Incidence Rate

- 10% general population has type 1 DM

- 90% of general population has type 2 DM

B. Predisposing Factors

B. Predisposing Factors

1. Hereditary (total destruction of pancreatic cells)

1. Obesity because obese persons lack insulin

2. Related to viruses

receptor binding sites

3. Drugs
a. Lasix

C. Signs and Symptoms

b. Steroids

1. Usually asymptomatic

4. Related to carbon tetrachloride toxicity

2. Polyuria
3. Polydypsia

C. Signs and Symptoms

4. Polyphagia

1. Polyuria

5. Glucosuria

2. Polydypsia

6. Weight gain

Polyphagia
Glycosuria
Weight loss
6. Anorexia, nausea and vomiting
7. Blurring of vision

D. Treatment
1. Oral Hypoglycemic agents

8. Increase susceptibility to infection

2. Diet

9. Delayed/poor wound healing

3. Exercise

D. Treatment
1. Insulin therapy

E. Complications

2. Diet

1. Hyper

3. Exercise

2. Osmolar
3. Non

E. Complication

4. Ketotic

1. Diabetic Ketoacidosis

5. Coma

Consist of islets of langerhans


Has alpha cells that secretes glucagons (function: hyperglycemia)
Beta cells secretes insulin (function: hypoglycemia)
Delta cells secretes somatostatin (function: antagonizes the effects of growth hormones)
3 Main Disorders of Pancreas
Pancreatic Tumor/Cancer
Diabetes Mellitus
Pancreatitis
DIABETES MELLITUS
- Metabolic disorder characterized by non utilization of carbohydrates, protein and fat metabolism
MAIN
FOODSTUFF

ANABOLISM

CATABOLISM

1. Carbohydrates

Glucose

Glycogen

2. Protein

Amino Acids

Nitrogen

3. Fats

Fatty Acids

Free Fatty Acids


- Cholesterol
- Ketones

HYPERGLYCEMIA
Increase osmotic diuresis
Glycosuria
Cellular starvation weight loss
Stimulates the appetite/satiety center

Polyuria
Cellular dehydration
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

Hypertension

Diabetic Keto Acidosis


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
Hyperglycemia
Stress number one precipitating factor
Infection
B. Signs and Symptoms
Polyuria
Polydypsia
Polyphagia
Glucosuria
Weight loss
Anorexia, nausea and vomiting
Blurring of vision
Acetone breath odor
Kussmauls Respiration (rapid shallow breathing)
CNS depression leading to coma
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
Nursing Management
Assist in mechanical ventilation
Administer 0.9 NaCl followed by .45 NaCl (hypotonic solutions) to counteract dehydration and shock
Monitor strictly vital signs, intake and output and blood sugar levels
Administer medications as ordered
Insulin therapy (regular acting insulin/rapid acting insulin peak action of 2 4 hours)
Sodium Bicarbonate to counteract acidosis
Antibiotics to prevent infection
HYPER OSMOLAR NON KETOTIC COMA
Hyperosmolar: increase osmolarity (severe dehydration)
Non ketotic: absence of lypolysis (no ketones)
A. Signs and Symptoms
Headache and dizziness
Restlessness
Seizure activity
Decrease LOC diabetic coma
B. Nursing Management
Assist in mechanical ventilation
Administer 0.9 NaCl followed by .45 NaCl
(hypotonic solutions) to counteract dehydration and shock
Monitor strictly vital signs, intake and output and blood sugar levels
Administer medications as ordered
Insulin therapy (regular acting insulin peak action of 2 4 hours)
for DKA use rapid acting insulin
Antibiotics to prevent infection

Sources of Insulin 1.

Rapid
Intermediate

Clear
Cloudy

Pea
k
2-4
6-12

Animal sources

Long acting

Cloudy

12-24

Types of Insulin Color & consistency

INSULIN THERAPY A.

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
Administer at room temperature to prevent development of lipodystrophy (atrophy, hypertrophy of subcutaneous tissues)
Place in refrigerator once opened
Avoid shaking insulin vial vigorously instead gently roll vial between palms to prevent formation of bubbles
Use gauge 25 26 needle
Administer insulin either 45o 90o depending on amount of clients tissue deposit
No need to aspirate upon injection
Rotate insulin injection sites to prevent development of lipodystrophy
Most accessible route is abdomen
When mixing 2 types of insulin aspirate first the clear insulin before cloudy to prevent contaminating the clear insulin
and promote proper calibration.
Monitor for signs of local complications such as
Allergic reactions
Lipodystrophy
Somogyi Phenomenon rebound effect of insulin characterized by hypoglycemia to hyperglycemia
ORAL HYPOGLYCEMIC AGENTS - OHA
- Stimulates the pancreas to secrete insulin
A. Classsification
First Generation Sulfonylureas
Chlorpropamide (Diabenase)
Tolbutamide (Orinase)
Tolamazide (Tolinase)
Second Generation Sulfonylureas
Glipzide (Glucotrol)
Diabeta (Micronase)
Nursing Management when giving OHA
Instruct the client to take it with meals to lessen GIT irritation and prevent hypoglycemia
Instruct the client to avoid taking alcohol because it can lead to severe hypoglycemia reaction or Disulfiram (Antabuse)
toxicity symptoms

B. Diagnostic Procedures for DM


1. FBS is increased (3 consecutive times with signs or
polyuria, polydypsia, polyphagia and glucosuria confirmatory for DM)

Random Blood Sugar is increased


Oral glucose tolerance test is increased most sensitive test
Alpha Glycosylated Hemoglobin is increased
C. Nursing Management
Monitor for peak action of insulin and OHA and notify physician
Administer insulin and OHA therapy as ordered
Monitor strictly vital signs, intake and output and blood sugar levels
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)
Provide nutritional intake of diabetic diet that includes: carbohydrates 50%, protein 30% and fats 20% or offer alternative
food substitutes
Instruct client to exercise best after meals when blood
glucose is rising
7. Monitor signs for complications

EYES
-PREMATURE CATARACT
- Blindness

KIDNEY
-RECURRENT PYELONEPHRITIS
- Renal failure

Atherosclerosis (HPN, MI, CVA)


Microangiopathy (affects small minute blood vessels of eyes and kidneys)
HPN and DM major cause of renal failure
Gangrene formation
Shock due to dehydration
peripheral neuropathy
diarrhea/constipation
sexual impotence
Institute foot care management
instruct client to avoid walking barefooted
instruct client to cut toenails straight
instruct client to avoid wearing constrictive garments
encourage client to apply lanolin lotion to
prevent skin breakdown
e. assist in surgical wound debriment
(give analgesics 15 30 mins prior)

Instruct client to have an annual eye and kidney exam


Monitor for signs of DKA and HONKC
Assist in surgical procedure

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
Overview only:

PANCREATITIS - acute inflammation of pancreas leading to pancreatic edema, hemorrhage & necrosis due to
Autodigestion self-digestion
Cause: unknown/idiopathic
alcoholism

Pathognomonic sign- (+) Cullens sign - Ecchymosis of umbilicus (bluish color)- pasa
(+) Grey turners sign ecchymosis of flank area

HEMATOLOGICAL SYSTEM

I. Blood
55% Plasma

45% Formed

Serum

II. Blood Vessels


1. Arteries

III. Blood Forming Organs


1. Liver

2. Veins

3. Spleen
4. Lymphoid Organ
5. Lymph Nodes
6. Bone Marrow

Plasma CHON
(formed in liver)
Albumin
Globulins
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
anti-bodies and immunoglobulins
prothrombin and fibrinogen clotting factors
FORMED ELEMENTS
1. RBC (ERYTHROCYTES)
normal value: 4 6 million/mm3
only unnucleated cell
biconcave discs
consist of molecules of hgb (red pigment) bilirubin (yellow pigment) biliverdin (green pigment) hemosiderin (golden
brown pigment)
transports and carries oxygen to tissues
hemoglobin: normal value female 12 14 gms% male 14 16 gms%
hematocrit red cell percentage in wholeblood
normal value: female 36 42% male 42 48%
substances needed for maturation of RBC
folic acid
iron
vitamin c
vitamin b12 (cyanocobalamin)
vitamin b6 (pyridoxine)
intrinsic factor
Normal life span of RBC is 80 120 days and is killed in red pulp of spleen
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

B-cell
T-cell
- bone marrow
- thymus
for immunity

Natural killer cell


- anti viral and anti tumor property

HIV
6 months 5 years incubation period
6 months window period
western blot opportunistic
ELISA
drug of choice AZT (Zidon Retrovir)
2 Common fungal opportunistic infection in AIDS
Kaposis Sarcoma
Pneumocystis Carinii Pneumonia
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
Signs of Platelet Dysfunction
Petechiae
Echhymosis
Oozing of blood from venipunctured site

BLOOD DISORDERS
Iron Deficiency Anemia
- A chronic microcytic anemia resulting from inadequate absorption of iron leading to hypoxemic tissue injury

A. Incidence Rate
Common among developed countries
Common among tropical zones
Common among women 15 35 years old
Related to poor nutrition
B. Predisposing Factors
Chronic blood loss due to trauma
Heavy menstruation
Related to GIT bleeding resulting to hematemesis and melena (sign for upper GIT bleeding)
fresh blood per rectum is called hematochezia
Inadequate intake of iron due to
Chronic diarrhea
Related to malabsorption syndrome
High cereal intake with low animal protein digestion
Subtotal gastrectomy
4. Related to improper cooking of foods
C. Signs and Symptoms
Usually asymptomatic
Weakness and fatigue (initial signs)

Headache and dizziness


Pallor and cold sensitivity
Dyspnea
Palpitations
Brittleness of hair and spoon shape nails (koilonychias)
Atropic Glossitis (inflammation of tongue)
- Stomatitis

PLUMBER VINSONS SYNDROME

- Dysphagia
9. PICA (abnormal appetite or craving for non edible foods
Diagnostic Procedures
1. RBC is decreased
2. Hgb is decreased
3. Hct is deceased
4. Iron is decreased
5. Reticulocyte is decreased
6. Ferritin is decreased
Nursing Management
Monitor for signs of bleeding of all hema test including urine, stool and GIT
Enforce CBR so as not to over tire client
Instruct client to take foods rich in iron
Organ meat
Egg (yolk)
Raisin
Sweet potatoes
Dried fruits
Legumes
Nuts
Instruct the client to avoid taking tea and coffee because it contains tannates which impairs iron absorption
Administer medications as ordered
Oral Iron Preparations
Ferrous Sulfate
Ferrous Fumarate
Ferrous Gluconate 300 mg/day

Nursing Management when taking oral iron preparations


1. Instruct client to take with meals to lessen GIT irritation
2. When diluting it in liquid iron preparations administer with straw to prevent staining of teeth
Medications administered via straw
Lugols solution
Iron
Tetracycline
Nitrofurantoin (Macrodentin)
3. Administer with Vitamin C or orange juice for absorption
4. Monitor and inform client of side effects
Anorexia
Nausea and vomiting
Abdominal pain
Diarrhea/constipation
Melena
If client cant tolerate/no compliance administer parenteral iron preparation
Iron Dextran (IM, IV)
Sorbitex (IM)
Nursing Management when giving parenteral iron preparations
Administer Z tract technique to prevent discomfort, discoloration and leakage to tissues
Avoid massaging the injection site instead encourage to ambulate to facilitate absorption
Monitor side effects

Pain at injection site


Localized abscess
Lymphadenopathy
Fever and chills
Skin rashes
Pruritus/orticaria
Hypotension (anaphylactic shock)

PERNICIOUS ANEMIA
- Chronic anemia characterized by a deficiency of intrinsic factor leading to hypochlorhydria (decrease hydrochloric
acid secretion)
A. Predisposing Factors
Subtotal gastrectomy
Hereditary factors
Inflammatory disorders of the ileum
Autoimmune
Strictly vegetarian diet

STOMACH

Pareital cells/ Argentaffin or Oxyntic cells


Produces intrinsic factors

Secretes hydrochloric acid

Promotes reabsorption of Vit B12

Aids in digestion

Promotes maturation of RBC


B. Signs and Symptoms
Weakness and fatigue
Headache and dizziness
Pallor and cold sensitivity
Dyspnea and palpitations as part of compensation
GIT changes that includes
mouth sore
red beefy tongue
indigestion/dyspepsia
weight loss
jaundice
CNS changes
tingling sensation
numbness
paresthesia
positive to Rombergs test damage to cerebellum resulting to ataxia
result to psychosis
C. Diagnostic Procedure
Schillings Test reveals inadequate/decrease absorption of Vitamin B12
D. Nursing Management
1. Enforce CBR

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
Provide a dietary intake that is high in carbohydrates, protein, vitamin c and iron
Instruct client to avoid irritating mouth washes instead use soft bristled toothbrush
Avoid heat application to prevent burns

APLASTIC ANEMIA
- Stem cell disorder leading to bone marrow depression leading to pancytopenia
PANCYTOPENIA
Decrease RBC

Decrease WBC

Decrease Platelet

(anemia)
A. Predisposing Factors

(leucopenia)

(thrombocytopenia)

1. Chemicals (Benzine and its derivatives)


2. Related to irradiation/exposure to x-ray

When all of the blood elements

3. Immunologic injury
4. Drugs

are depressed, the term


pancytopenia is used. Pan
meaning everything.

Broad Spectrum Antibiotics


a. Chloramphenicol (Sulfonamides)
Chemotherapeutic Agents
Methotrexate (Alkylating Agent)
Vincristine (Plant Alkaloid)
Nitrogen Mustard (Antimetabolite)
Phenylbutazones (NSAIDS)
B. Signs and Symptoms
Anemia
Weakness and fatigue
Headache and dizziness
Pallor and cold sensitivity
Dyspnea and palpitations
Leukopenia
Increase susceptibility to infection
Thrombocytopenia
Petechiae (multiple petechiae is called purpura)
Ecchymosis
Oozing of blood from venipunctured sites
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
Removal of underlying cause
Institute BT as ordered
Administer oxygen inhalation
Enforce CBR
Institute reverse isolation
Monitor for signs of infection
fever
cough

7. Avoid IM, subcutaneous, venipunctured sites


8 Instead provide Heplock
Instruct client to use electric razor when shaving
Administer medications as ordered
Corticosteroids caused by immunologic injury
Immunosuppressants
Anti Lymphocyte Globulin

Given via central venous catheter

Given 6 days to 3 weeks to achieve


Maximum therapeutic effect of drug

DISSEMINATED INTRAVASCULAR COAGULATION


Acute hemorrhagic syndrome characterized by wide spread bleeding and thrombosis due to a deficiency of prothrombin
and fibrinogen
A. Predisposing Factors
Related to rapid blood transfusion
Massive burns
Massive trauma
Anaphylaxis
Septicemia
Neoplasia (new growth of tissue)
Pregnancy
B. Signs and Symptoms
Petechiae (widespread and systemic) eye, lungs and lower extremities
Ecchymosis
Oozing of blood from punctured sites
Hemoptysis
6. Oliguria (late sign)
C. Diagnostic Procedures
CBC reveals decreased platelets
Stool occult blood positive
ABG analysis reveals metabolic acidosis
Opthamoscopic exam reveals sub retinal hemorrhages
D. Nursing Management
Monitor for signs of bleeding of all hema test including stool and GIT
Administer isotonic fluid solution as ordered
Administer oxygen inhalation
Force fluids
Administer medications as ordered
Vitamin K
Pitressin/ Vasopresin to conserve fluids
Heparin/Coumadin is ineffective
Provide heparin lock
Institute NGT decompression by performing gastric lavage by using ice or cold saline solution of 500 1000 ml
Monitor NGT output
Prevent complication
Hypovolemic shock
Anuria late sign

BLOOD TRANSFUSION
Goals/Objectives
Replace circulating blood volume
Increase the oxygen carrying capacity of blood
Prevent infection in there is a decrease in WBC
Prevent bleeding if there is platelet deficiency
Principles of blood transfusion
Proper refrigeration
Expiration of packed RBC is 3 6 days
Expiration of platelet is 3 5 days
Proper typing and cross matching
Type O universal donor
Type AB universal recipient
85% of population is RH positive
Aseptically assemble all materials needed for BT
Filter set
Gauge 18 19 needle
Isotonic solution (0.9 NaCl/plain NSS) to prevent hemolysis
Instruct another RN to re check the following
Client name
Blood typing and cross matching
Expiration date
Serial number
Check the blood unit for bubbles cloudiness, sediments and darkness in color because it indicates bacterial
contamination
- Never warm blood as it may destroy vital factors in blood.
- Warming is only done during emergency situation and if you have the warming device
- Emergency rapid BT is given after 30 minutes and let natural room temperature warm the blood.
BT should be completed less than 4 hours because blood that is exposed at room temperature more
than 2 hours causes blood deterioration that can lead to BACTERIAL CONTAMINATION
Avoid mixing or administering drugs at BT line to prevent HEMOLYSIS
Regulate BT 10 15 gtts/min or KVO rate or equivalent to 100 cc/hr to prevent circulatory overload
Monitor strictly vital signs before, during and after BT especially every 15 minutes for first hour
because majority of transfusion reaction occurs during this period
Hemolytic reaction
Allergic reaction
Pyrogenic reaction
Circulatory overload
Air embolism
Thrombocytopenia
Cytrate intoxication
Hyperkalemia (caused by expired blood)
Signs and Symptoms of Hemolytic reaction
Headache and dizziness
Dyspnea
Diarrhea/Constipation
Hypotension
Flushed skin
Lumbar/sternal/ Flank pain
Urine is color red/ portwine urine

Nursing Management
Stop BT
Notify physician
Flush with plain NSS
Administer isotonic fluid solution to prevent shock and acute tubular necrosis
Send the blood unit to blood bank for re examination
Obtain urine and blood sample and send to laboratory for re examination
Monitor vital signs and intake and output
SIGNS AND SYMPTOMS OF ALLERGIC REACTION
Fever
Dyspnea
Broncial wheezing
Skin rashes
Urticaria
Laryngospasm and Broncospasm
Nursing Management
Stop BT
Notify physician
Flush with plain NSS
Administer medications as ordered
a. Anti Histamine (Benadryl) - if positive to hypotension, anaphylactic shock treat with Epinephrine
Send the blood unit to blood bank for re examination
Obtain urine and blood sample and send to laboratory for re examination
Monitor vital signs and intake and output
SIGNS AND SYMPTOMS PYROGENIC REACTIONS (FEVER)
Fever and chills
Headache
Tachycardia
Palpitations
Diaphoresis
Dyspnea
Nursing Management
Stop BT
Notify physician
Flush with plain NSS
Administer medications as ordered
Antipyretic
Antibiotic
Send the blood unit to blood bank for re examination
Obtain urine and blood sample and send to laboratory for re examination
Monitor vital signs and intake and output
Render TSB
SIGNS AND SYMPTOMS OF CIRCULATORY REACTION
Orthopnea
Dyspnea
Rales/Crackles upon auscultation
Exertional discomfort
Nursing Management
Stop BT
Notify physician
Administer medications as ordered
a. Loop diuretic (Lasix

CARDIOVASCULAR SYSTEM
OVERVIEW OF THE STRUCTURE AND FUNCTIONS OF THE HEART
HEART
Muscular pumping organ of the body.
Located on the left mediastinum
Resemble like a close fist
Weighs approximately 300 400 grams
Covered by a serous membrane called the pericardium
2 layers of pericardium
Parietal outer layer
Visceral inner layer
In between is the pericardial space filled w/ fluid
which is 10 30 cc lubricates the surface to
reduces friction during systole.
Common among MI, pericarditis, Cardiac tamponade
A. Layers of Heart
Epicardium outer layer
Myocardium middle layer
Endocardium inner layer
- Myocarditis can lead to cardiogenic shock and rheumatic heart disease
B. Chambers of the Heart
Upper Chamber (connecting or receiving)
Atria
Lower Chamber (contracting or pumping)
Ventricles
Left ventricle has increased pressure which is 120 180 mmHg
In order to propel blood to the systemic circulation
Right atrium has decreased pressure which is 60 80 mmHg
C. Valves
- To promote unidimensional flow or prevent backflow
Atrioventricular Valves guards opening between
tricuspid valve
mitral valve
- Closure of AV valves give rise to first heart sound (S 1 lub)
Semi lunar Valves
pulmonic
aortic
- Closure of SV valve give rise to second heart sound (S 2 dub)
Extra Heart Sounds
S3 ventricular gallop usually seen in Left Congestive Heart Failure sound occurring during rapid ventricular filling
S4 atrial gallop usually seen in Myocardial Infarction and Hypertension sound head during atrial contraction (often
heard when the ventricle is enlarged or hypertrophied

D. Coronary Arteries
- Arises from base of the aorta
Types of Coronary Arteries
Right Main Coronary Artery
Left Main Coronary Arterying
Supplies the myocardium
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
Atrio Ventricular Node (AV or Tawara Node)
- Located at the inter atrial septum
- Delay of electrical impulse for about .08 milliseconds to allow ventricular filling
Bundle of His
Right Main Bundle of His
Left Main Bundle of His
Located at the interventricular septum
4. Purkinje Fibers terminal point in the conduction system
(point which the myocardial cells are stimulated causing ventricular contraction)
Located at the walls of the ventricles for ventricular contraction
P WAVE (atrial depolarization) contraction
QRS WAVE (ventricular depolarization)
T WAVE (ventricular repolarization)
Insert pacemaker if there is complete heart block
Most common pacemaker is the metal pacemaker and lasts up to 2 5 years

Cardiac electrical activity is the result of the movement of ions (charged particles such as SODIUM, POTASSIUM,
AND CALCIUM) across the cell membrane.

ABNORMAL ECG TRACING


1. Positive U wave
2. Peak T wave

- Hypokalemia
Hyperkalemia

3. ST segment depression

Angina Pectoris

4. ST segment elevation

Myocardial Infarction

5. T wave inversion

Myocardial Infarction

6. Widening of QRS complexes

Arrhythmias

CARDIAC DISORDERS
Coronary Arterial Disease/ Ischemic Heart Disease
Stages of Development of Coronary Artery Disease
Myocardial Injury - Atherosclerosis
Myocardial Ischemia Angina Pectoris
Myocardial Necrosis Myocardial Infarction

ATHEROSCLEROSIS
ATHEROSCLEROSIS

ARTERIOSCLEROSIS

- narrowing of artery
- lipid or fat deposits (plaques)

- hardening of artery, thicken


- calcium and protein deposits

- tunica intima

- tunica media

A. Predisposing Factors
Sex male
Race black
Smoking
Obesity
Hyperlipidemia
Sedentary lifestyle
Diabetes Mellitus
Hypothyroidism
Diet increased saturated fats
Type A personality

B. Signs and Symptoms


Chest pain
Dyspnea
Tachycardia
Palpitations
Diaphoresis

C. Treatment
Percutaneous Transluminal Coronary Angioplasty

Objectives of PTCA
Revascularize myocardium
To prevent angina
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


3 Complications of CABG
Pneumonia encourage to perform deep breathing, coughing exercise and use of incentive spirometer
Shock
Thrombophlebitis
ANGINA PECTORIS (SYNDROME)
Clinical syndrome characterized by paroxysmal chest pain that is usually relieved by rest or nitroglycerine due to
temporary myocardial ischemia
A. Predisposing Factors
1. Sex male

Angina is usually caused by


ATHEROSCLEROTIC Disease.

2. Race black

- narrowing of artery

3. Smoking

- lipid or fat deposits

4. Obesity

- tunica intima

Hyperlipidemia
Sedentary lifestyle
Diabetes Mellitus
Hypothyroidism
Diet increased saturated fats
Type A personality
Precipitating Factors
4 Es 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
Signs and Symptoms
Levines Sign initial sign that shows the hand clutching the chest
Chest pain characterized by sharp stabbing pain located at sub sterna usually radiates from back, shoulder, arms, axilla
and jaw muscles, usually relieved by rest or taking nitroglycerine
Dyspnea
Tachycardia
Palpitations
Diaphoresis
D. Diagnostic Procedure
History taking and physical exam
ECG tracing reveals ST segment depression
Stress test treadmill test, reveal abnormal ECG
Serum cholesterol and uric acid is increased
E. Nursing Management
Enforce complete bed rest
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 persists 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
Orthostatic hypotension
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

Avoid rotating transdermal patches as it may decrease drug absorption

Avoid placing near microwave ovens or during defibrillation as it may lead to burns ( most important
thing to remember)
Beta-blockers
(lol)
Propanolol - side effects PNS - broncho constriction, vasodilation
Not given to COPD cases because it causes Bronchospasm
c. ACE Inhibitors
(pril)
Enalapril, captopril, april jane dolo
Calcium Antagonist
- calciblock
- Nifedipine, diltiazem
Administer oxygen inhalation
Place client on semi fowlers position
Monitor strictly vital signs, intake and output and ECG tracing
Provide decrease saturated fats sodium and caffeine
Provide client health teachings and discharge planning
Avoidance of 4 Es
Prevent complication (myocardial infarction)
Instruct client to take medication before indulging into physical exertion to achieve the maximum therapeutic
effect of drug
The importance of follow up care

MYOCARDIAL INFARCTION areas in myocardial cells in the heart are permanently destroyed.
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 either right or left coronary artery
B. The Most Critical Period Following Diagnosis of Myocardial Infarction
** 6 8 hours because majority of death occurs due to arrhythmia leading to PVCs
C. Predisposing Factors

Sex male
Race black
Smoking
Obesity
Hyperlipidemia
Sedentary lifestyle
Diabetes Mellitus
Hypothyroidism
Diet increased saturated fats
Type A personality

D. Signs and Symptoms


Chest pain
Excruciating visceral, viselike pain located at substernal and rarely in precordial
Usually radiates from back, shoulder, arms, axilla, jaw and abdominal muscles (abdominal ischemia) and hands
Not usually relieved by rest or by nitroglycerine
Dyspnea
Increase in blood pressure (initial sign)
Hyperthermia
Ashen skin (pale), cool, clammy, diaphoretic
Mild restlessness and apprehension, anxiety
Occasional findings
Pericardial friction rub
Split S1 and S2
Rales/Crackles upon auscultation
S4 or atrial gallop
Diagnostic Procedure 1.
Cardiac Enzymes

CPK MB
Creatinine phosphokinase is increased
Heart only, 12 24 hours
LDH Lactic dehydroginase is increased
SGPT Serum glutamic pyruvate transaminase is increased
SGOT Serum glutamic oxal-acetic transaminase is increased 2.
Troponin Test is increased (protein in myocardial)
3. ECG tracing reveals
ST segment elevation
T wave inversion
Widening of QRS complexes indicates that there is arrhythmia in MI
4. Serum Cholesterol and uric acid are both increased
5. CBC increased WBC
Nursing Management
Goal: Decrease myocardial oxygen demand
1. Decrease myocardial workload (rest heart)
Administer narcotic analgesic/morphine sulfate
Side Effects: respiratory depression
Antidote: Narcan/Naloxone

- Side Effects of Naloxone Toxicity is tremors


Administer oxygen low inflow to prevent respiratory arrest at 2 3 L/min
Enforce CBR without bathroom privileges a.
Using bedside commode
Instruct client to avoid forms of valsalva maneuver
Place client on semi fowlers position
Monitor strictly vital signs, intake and output and ECG tracing
Provide a general liquid to soft diet that is low in saturated fats, sodium and caffeine
Encourage client to take 20 30 cc/week of wine, whisky and brandy to induce vasodilation

Administer medication as ordered : a.


Vasodilators
- Nitroglycerine
- ISD (Isosorbide Dinitrate, Isordil) sublingual
Anti Arrythmic Agents
Lidocaine (Xylocane
Side Effects: confusion and dizziness
Brutylium
Beta-blockers
(-lol)
ACE Inhibitors
(-pril)
Calcium Antagonist
amlodipine, verapamil, diltiazem
Thrombolytics/ Fibrinolytic Agents
Streptokinase
Side Effects: allergic reaction, pruritus
Urokinase
TIPAF (tissue plasminogen activating factor)
Side Effects: chest pain
Monitor for bleeding time
Anti Coagulant
Heparin (check for partial thrombin time)
Antidote: protamine sulfate
Coumadin/ Warfarin Sodium (check for prothrombin time)
Antidote: Vitamin K
Anti Platelet
PASA (Aspirin)
Anti thrombotic effect
Side Effects of Aspirin
Tinnitus
Heartburn
Indigestion/Dyspepsia

Contraindication
Dengue
Peptic Ulcer Disease
Unknown cause of headache

Provide client health teaching and discharge planning concerning


Avoidance of modifiable risk factors

Arrhythmia (caused by premature ventricular contraction)


Cardiogenic shock
late sign is oliguria
Left Congestive Heart Failure
Thrombophlebitis
homans sign
Stroke/CVA
Post MI Syndrome/Dresslers Syndrome
Client is resistant to pharmacological agents; administer 150,000 450,000 units of streptokinase as
ordered
Resumption of ADL particularly sexual intercourse is 4 6 weeks post cardiac rehab, post CABG and instruct
to
make sex as an appetizer rather than dessert
instruct client to assume a non weight bearing position
Client can resume sexual intercourse if can climb staircase
dietary modification
h. Strict compliance to mediation and importance of follow up care
CONGESTIVE HEART FAILURE
Inability of the heart to pump blood towards systemic circulation
Types of Heart Failure
1. LEFT SIDED HEART FAILURE
A. Predisposing Factors
1. 90% is mitral valve stenosis due to
a. RHD inflammation of mitral valve due to invasion of Group A beta-hemolytic streptococcus
- Formation of aschoff bodies in the mitral valve
- Common among children (throat infection)
- ASO Titer (Anti streptolysin O titer)
- Penicillin
- Aspirin
b. Aging

2. Myocardial Infarction
3. Ischemic heart disease
4. Hypertension
5. Aortic valve stenosis
B. Signs and Symptoms
Dyspnea
Paroxysmal nocturnal dyspnea client awakened at night due to DOB (sudden attacks of Orthopnea at night)
Orthopnea use 2 3 pillows when sleeping or place in high fowlers
Productive cough with blood tinged sputum (severe pulmonary edema)
Frothy salivation
Cyanosis
Rales/Crackles (bi-basilar lobes that do not clear w/ coughing)
Bronchial wheezing
Pulsus Alternans weak pulse followed by strong bounding pulse
PMI is displaced laterally due to cardiomegaly
There is anorexia and generalized body malaise
S3 ventricular gallop
Oliguria blood flow to the kidney decreases, causing decreased perfusion and reduce urine output. (Daytime)
Nocturia sleeping cardiac workload decreased, improving renal perfusion, which then leads to frequent urination at
Night.

C. Diagnostic Procedure
Chest x-ray reveals cardiomegaly
PAP (pulmonary arterial pressure) measures pressure in right ventricle or cardiac status PCWP
(pulmonary capillary wedge pressure) measures end systolic and dyastolic pressure

both are increased


done by cardiac catheterization (insertion of swan ganz catheter)
Echocardiography enlarged heart chamber (cardiomyopathy), dependent on extent of heart failure

ABG reveals PO2 is decreased (hypoxemia), PCO2 is increased (respiratory acidosis)

2. RIGHT SIDED HEART FAILURE RIGHT VENT. FAILS.


Predisposing Factors
1. Tricuspid valve stenosis
2. Pulmonary embolism
3. Related to COPD
4. Pulmonic valve stenosis
5. Left sided heart failure

Signs and Symptoms (venous congestion)


Neck/jugular vein distension
Pitting edema (lower extremities)
Ascites
Weight gain
Hepatosplenomegaly
Jaundice
Pruritus (albumin)
Anorexia
Esophageal varices
C. Diagnostic Procedures
Chest x-ray reveals cardiomegaly
Central venous pressure (CVP)
Measure pressure in right atrium (4 10 cm of water)
CVP fluid status measure

If CVP is less than 4 cm of water hypovolemic shock


Do the fluid challenge (increase IV flow rate)
If CVP is more than 10 cm of water hypervolemic shock
Administer loop diuretics as ordered
When reading CVP patient should be flat on bed
Upon insertion place client in Trendelenburg position to promote ventricular filling and prevent pulmonary
embolism

Ecocardiography reveals enlarged heart chambers (cardiomyopathy)


4. Liver enzymes SGPT and SGOT is increased

B. hypertrophic cardiomyopathy

D. Nursing Management
Goal: increase cardiac contractility thereby increasing cardiac output (3 6 L/min)
Enforce CBR
Administer medications as ordered
a. Cardiac glycosides

B. dilated cardiomyopathy

Digoxin (Lanoxin) (increases cardiac contraction but lowers the pulse rate)
Increase force of cardiac contraction
If heart rate is decreased do not give
b. Loop Diuretics
Lasix (Furosemide) peak 1-2 hrs, duration 6-8 hrs (monitor for hyperkalemia)
c. Bronchodilators aminophylline
d. Narcotic analgesics
Morphine Sulfate
e. Vasodilators
- Nitroglycerine
f. Anti Arrhythmic
Lidocaine (Xylocane)
Administer oxygen inhalation with high inflow, 3 4 L/min, delivered via nasal cannula
High fowlers position
Monitor strictly vital signs, intake and output and ECG tracing
Measure abdominal girth daily and notify physician
Provide a dietary intake of low sodium, cholesterol and caffeine
Provide meticulous skin care
Assist in bloodless phlebotomy rotating tourniquet, rotated clockwise every 15 minutes to promote decrease venous
return
Provide client health teaching and discharge planning
Prevent complications
Arrhythmia
Shock
Right ventricular hypertrophy
MI
Thrombophlebitis
Dietary modification
Strict compliance to medications

PERIPHERAL VASCULAR DISORDER


Arterial Ulcer
ThromboAngIitis Obliterans (BUERGERS DISEASE)
Burgers Disease - male/ feet
Reynauds Disease - female/ hands

Venous Ulcer
Varicose Veins
Thrombophlebitis (deep vein thrombosis)

THROMBOANGIITIS OBLITERANS or BUERGERS DISEASE

(MALE FEET) 20-35 yrs old

Acute inflammatory disorder usually affecting the small medium sized arteries and veins of the lower
extremities (Autoimmune disease)
A. Predisposing Factors
High risk groups men 30 years old and above
Smoking
Thrombus formation and occlusion of the vessels
Age 20-35 yrs
B. Signs and Symptoms (pain is the outstanding symptom)
Intermittent claudication leg pain upon walking (foot cramps, especially the arch (instep claudication after exercise)

Cold sensitivity and changes in skin color rubor (reddish blue discoloration, pallor, and cyanosis)
Decreased peripheral pulses
Trophic changes
Ulceration
Gangrene formation
Absence of pedal pulse but with normal femoral pulse and popliteal pulses.
Radial and ulnar artery pulses are absent or diminished.
C. Diagnostic Procedures
Oscillometry decrease in peripheral pulses
Doppler UTZ decrease blood flow to the affected extremity
Angiography reveals site and extent of malocclusion
Segmental limb blood pressure (alternation of tourniquet)

D. Nursing Management
Encourage a slow progressive physical activity

walking 3 4 times a day


out of bed 3 4 times a day
Administer medications as ordered

Lower the extremities below


the level of the heart if the
condition
is
arterial
in
nature
Elevate
the
extremities
above the heart level if the
condition is venous in nature

Analgesics
Vasodilators
Anti coagulants
Institute foot care management
Instruct client to avoid smoking and exposure to cold environment
Assist in surgical procedure bellow knee amputation (elevate the stump for 24 hrs postop to promote venous return and
minimize edema).
Pain is relieve by rest

REYNAUDS DISEASE
Disorder characterized by acute episodes of arterial (small arteries) spasm/vasoconstriction that result in coldness, pain,
and pallor involving the fingers or digits of the hands.
A. Predisposing Factors
High risk group female 16-40 years old and above
Smoking
Collagen diseases
SLE (butterfly rash)
Rheumatoid Arthritis
Direct hand trauma
Piano playing
Excessive typing
Operating chainsaw
Cold climates and during winter
B. Signs and Symptoms
Intermittent claudication leg pain upon walking
Cold sensitivity and changes in skin color (pallor, cyanosis then rubor)
Trophic changes
Ulceration
Gangrene formation
Raynauds phenomenon refer to localized, intermittent episodes of vasoconstriction of small arteries of the hands that
causes changes in color and temperature. (as white, blue, and red)
C. Diagnostic Procedures
Doppler UTZ decrease blood flow to the affected extremity
Angiography reveals site and extent of malocclusion
D. Nursing Management
Administer medications as ordered
Analgesics
Vasodilators (calcium channel blockers: nifedipine)
Encourage to wear gloves
Instruct client on importance of cessation of smoking and exposure to cold environment

VARICOSITIES
Dilated, tortuous, superficial veins caused by incompetent venous valves
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
Hereditary
Congenital weakness of veins
Thrombophlebitis
Cardiac disorder
Pregnancy
Obesity
Prolonged standing or sitting
Tortuous veins (saphenous veins)

B. Signs and Symptoms


Pain after prolonged standing
Dilated tortuous skin veins
Warm to touch
Heaviness in legs

C. Diagnostic Procedure
Venography
Trendelenburgs Test - veins distends quickly in less than 35 seconds
D. Nursing Management
Elevate legs above heart level to promote increased venous return by placing 2 3 pillows under the legs
Measure the circumference of leg muscle to determine if swollen
Wear anti embolic stockings
Administer medications as ordered
Analgesics
Assist in surgical procedure
Vein stripping and ligation (most effective)
Sclerotherapy can recur and only done small/ spider web varicosities and danger of thrombosis (2 3 years for
embolism)
sclerosing agent is injected into the vein, irritating the venous endothelium and producing
localized phlebitis and fibrousis, thereby obliterating the lumen of the vein.

THROMBOPHLEBITIS
Deep vein thrombosis
Inflammation of the veins with thrombus formation
3 factors known as VIRCHOWS TRIAD believe to play a significant role in its development:
Stasis of the blood (venous
stasis) Vessel wall injury
Altered blood coagulation
A. Predisposing Factors
Obesity
Smoking
Related to pregnancy
Chronic anemia
Prolong use of oral contraceptives promotes lipolysis
Diabetes mellitus
Congestive heart failure
Myocardial infarction
Post op complication
Post cannulation insertion of various cardiac catheter.
Increase in saturated fats in the diet.
Signs and Symptoms
1. Pain at affected extremity
2. Warm to touch
3. Dilated tortuous skin veins
4. Positive Homans Signs pain at the calf or leg muscle upon dorsiflexion of the foot
Diagnostic Procedure
1. Venography

2. Angiography
D. Nursing Management
Elevate legs above heart level to promote increase venous return
Apply warm moist pack to reduce lymphatic congestion
Measure circumference of leg muscle to determine if swollen
Encourage to wear anti embolic stockings or knee elastic stockings
Administer medications as ordered
Analgesics
Anti Coagulant take at the same time each day, usually bet. 8-9 am
Heparin
Note: if any of the ff. sign are appear, report them immediately
Faintness, dizziness, or increased weakness
Severe headaches or abdominal pain
Reddish or brownish urine
Any bleeding nose bleeding, cuts, and unusual
Red black bowel movements
Rash
6. Monitor for signs of complications
Embolism
a. Pulmonary
Sudden sharp chest pain
Unexplained dyspnea
Tachycardia
Palpitations
Diaphoresis
Restlessness
b. Cerebral
Headache
Dizziness
Decrease LOC
MURPHYS SIGN is seen in clients with cholelithiasis, cholecystitis characterized by pain at the right upper
quadrant with tenderness (inflammation of the gall bladder)

RESPIRATORY SYSTEM
OVERVIEW OF THE STRUCTURES AND FUCNTIONS OF THE RESPIRATORY SYSTEM
I. Upper Respiratory System
Filtering of air
Warming and moistening of air
Humidification
A. Nose
Cartillage
Right nostril
Left nostril
Separated by septum
Consist of anastomosis of capillaries known as Kesselbachs 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
II. Lower Respiratory System
For gas exchange
A. Trachea/Windpipe
Consist of cartilaginous rings
Serves as passageway of air going to the lungs
Site of tracheostomy
B. Bronchus
Right main bronchus
Left main bronchus
C. Lungs
Right lung (consist of 3 lobes, 10 segments)
Left lung (consist of 2 lobes, 8 segments)
Serous membranes
Pleural Cavity
Pareital
Pleural fluid
Visceral
With Pleuritic Friction Rub
Pneumonia
Pleural effusion
Hydrothorax (air and blood in pleural space
Alveoli acinar cells
Site of gas exchange (CO2 and O2)
Diffusion (Daltons law of partial pressure of gases)
Respiratory Distress Syndrome
Decrease oxygen stimulates breathing
Increase carbon dioxide is a powerful stimulant for breathing
Ventilation movement of air in & out of lungs
Respiration movement of air into cells
Type II Cells of Alveoli
Secretes surfactant
Decrease surface tension
Prevent collapse of alveoli
Composed of lecithin and spingomyelin
L/S ratio to determine lung maturity
Normal L/S ratio is 2:1
In premature infants 1:2
Give oxygen of less 40% in premature to prevent atelectasis and retrolental fibroplasias

retinopathy/blindness in prematurity

Disorders of Respiratory System


1. PTB/Pulmonary Tuberculosis (Kochs Disease)
Infection of lung tissue caused by invasion of mycobacterium tuberculosis or tubercle bacilli
An acid fast, gram negative, aerobic and easily destroyed by heat or sunlight
A. Precipitating Factors
Malnutrition
Overcrowded places
Alcoholism
Over fatigue
Ingestion of infected cattle with mycobacterium bovis
Virulence (degree of pathogenecity) of microorganism
B. Mode of Transmission
1. Airborne transmission via droplet nuclei
C. Signs and Symptoms
Low grade afternoon fever, night sweats
Productive cough (yellowish sputum)
Anorexia, generalized body malaise
Weight loss
Dyspnea
Chest pain
Hemoptysis (chronic)

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
Positive Mantoux test (previous exposure to tubercle bacilli but without active TB)
2. Sputum Acid Fast Bacillus
- Positive to cultured microorganism
3. Chest X-ray
- Reveals pulmonary infiltrates (chalk thorax)
4. CBC
- Reveals increase WBC
E. Nursing Management
Enforce CBR
Institute strict respiratory isolation
Administer oxygen inhalation
Force fluids to liquefy secretions
Place client on semi fowlers position to promote
expansion of lungs
Encourage deep breathing and coughing exercise
Nebulize and suction when needed
Comfortable and humid environment

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
Side Effect Ethambutol: optic neuritis
b. Standard phase
Injection of streptomycin (aminoglycoside)
Kanamycin
Amikacin
Neomycin
Gentamycin
Side Effect:
Ototoxicity damage to the 8th cranial nerve resulting to tinnitus leading to hearing loss
Nephrotoxicity check for BUN and Creatinine
Give aspirin if there is fever
Side Effect: tinnitus, dyspepsia, heartburn
Provide increase carbohydrates, protein, vitamin C and calories
Provide client health teaching and discharge planning
Avoidance of precipitating factors
Prevent complications (Atelectasis, military tuberculosis)
PTB
Bones (potts)
Meninges
Eyes
Skin
Adrenal gland
Strict compliance to medications
Importance of follow up care

PNEUMONIA
Inflammation of the lung parenchyma leading to pulmonary consolidation as the alveoli is filled with exudates
A. Etiologic Agents
Streptococcus Pneumonae causing pneumococal pneumonia
Hemophylus Influenzae causing broncho pneumonia (children)
Diplococcus Pneumoniae
Klebsella Pneumoniae
Escherichia Pneumoniae
Pseudomonas
B. High Risk Groups
1. Children below 5 years old bec. Of low resistance 2.
Elderly
C. Predisposing Factors

Smoking
Air pollution
Immuno compromised
a. AIDS
- Pneumocystic carini pneumonia
Drug of choice is Retrovir
b. Bronchogenic Cancer
Initial sign is non productive cough to productive cough
Chest x-ray confirms lung cancer
Related to prolonged immobility (CVA clients), causing hypostatic pneumonia
Aspiration of food causing aspiration pneumonia
D. Signs and Symptoms
Productive cough with greenish to rusty sputum
Dyspnea with prolong expiratory grunt
Fever, chills, anorexia and general body malaise
Weight loss
Rales/crackles
Bronchial wheezing
Cyanosis
Pleuritic friction rub
Chest pain
Abdominal distention leading to paralytic ileus (absence of peristalsis)
E. Diagnostic Procedure
Sputum Gram Staining and Culture Sensitivity positive to cultured microorganisms

Chest x-ray reveals pulmonary consolidation


ABG analysis reveals decrease PO2
CBC reveals increase WBC, erythrocyte sedimentation rate is increased
F. Nursing Management
Enforce CBR
Administer oxygen inhalation low inflow
Administer medications as ordered
Broad Spectrum Antibiotic
Penicillin
Tetracycline
Microlides (Zethromax)
Azethromycin (Side Effect: Ototoxicity)
Antipyretics
Mucolytics/Expectorants
Analgesics
Force fluid
Place on semi fowlers position
Institute pulmonary toilet
(tends to promote expectoration)
Deep breathing exercises
Coughing exercises
Chest physiotherapy
Turning and reposition
Nebulize and suction as needed
Assist in postural drainage
Drain uppermost area of lungs
Placed on various position

Nursing Management for Postural Drainage


Best done before meals or 2 4 hours after meals to prevent gastro esophageal reflux
Monitor vital signs
Encourage client deep breathing exercises normal breathe sound bronchovesicular
Administer bronchodilators 15 30 minutes before procedure
Stop if client cannot tolerate procedure
Provide oral care after procedure
Contraindicated with
Unstable vital signs
Hemoptysis
Clients with increase intra ocular pressure (Normal IOP 12 21 mmHg)
Increase ICP
Provide increase carbohydrates, calories, protein and vitamin C
Health teaching and discharge planning
Avoid smoking
Prevent complications
Atelectasis
Meningitis (nerve deafness, hydrocephalus)
Regular adherence to medications
Importance of follow up care

HISTOPLASMOSIS
Acute fungal infection caused by inhalation of contaminated dust or particles with histoplasma capsulatum derived from
birds manure

Signs

and

Symptoms

PTB or Pneumonia like

1. Productive cough
2. Dyspnea
3. Fever, chills, anorexia, general body malaise
4. Cyanosis
5. Hemoptysis
6. Chest and joint pains
Diagnostic Procedures
Histoplasmin Skin Test positive
ABG analysis PO2 decrease
C. Nursing Management
Enforce CBR
Administer oxygen inhalation
Administer medications as ordered
a. Antifungal
Amphotericin B
Fungizone (Nephrotoxicity, check for BUN and Creatinine, Hypokalemia)
b. Steroids
c. Mucolytics
d. Antipyretics
Force fluids to liquefy secretions
Nebulize and suction as needed
Prevent complications bronchiectasis
Prevent the spread of infection by spraying of breeding places

COPD (Chronic Obstructive Pulmonary/Lung Disease)

Chronic Bronchitis
Inflammation of bronchus resulting to hypertrophy or hyperplasia of goblet mucous producing cells leading to narrowing of
smaller airways
Predisposing Factors
1. Smoking
2. Air pollution
Signs and Symptoms
Productive cough (consistent to all COPD)
Dyspnea on exertion
Prolonged expiratory grunt
Anorexia and generalized body malaise
Scattered rales/ronchi
Cyanosis
Pulmonary hypertension
Peripheral edema
Cor Pulmonale (right ventricular hypertrophy)

C. Diagnostic Procedure
ABG analysis reveals PO2 decrease (hypoxemia), PCO2 increase, and pH decrease (resp. acidosis)

Bronchial Asthma
Reversible inflammatory lung condition due to hypersensitivity to allergens leading to narrowing of smaller airways

A. Predisposing Factors (Depending on Types)


1. Extrinsic Asthma (Atopic/ Allergic)
Causes
Pollen
Dust
Fumes
Smoke
Gases
Danders
Furs
Lints

2. Intrinsic Asthma (Non atopic/Non


allergic) Causes
Hereditary
Drugs (aspirin, penicillin, beta blocker)
Foods (seafoods, eggs, milk, chocolates, chicken
Food additives (nitrates)
Sudden change in temperature, air pressure and humidity
Physical and emotional stress

3. Mixed Type

90 95%

B. Signs and Symptoms


Cough that is non productive
Dyspnea
Wheezing on expiration

Cyanosis
Mild Stress/apprehension
Tachycardia, palpitations
Diaphoresis
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
Nursing Management
Enforce CBR
Oxygen inhalation, with low inflow of 2 3 L/min
Administer medications as ordered
Bronchodilators given via inhalation or metered dose inhalaer or MDI for 5 minutes
Steroids decrease inflammation
Mucomysts (acetylceisteine)
Mucolytics/expectorants
Anti histamine
Force fluids
Semi fowlers position
Nebulize and suction when needed
Provide client health teachings and discharge planning concerning
Avoidance of precipitating factor
Prevent complications
Emphysema
Status Asthmaticus (give drug of choice)
Epinephrine
Steroids
Bronchodilators
Regular adherence to medications to prevent development of status asthmaticus
Importance of follow up care

BRONCHIECTASIS
Abnormal permanent dilation of bronchus leading to destruction of muscular and elastic tissues of alveoli

A. Predisposing Factors
Recurrent lower respiratory tract infections
Chest trauma
Congenital defects
Related to presence of tumor
B. Signs and Symptoms
Productive cough
Dyspnea
Cyanosis
Anorexia and generalized body malaise
Hemoptysis (only COPD with sign)

C. Diagnostic Procedure
1. ABG PO2 decrease

2. Bronchoscopy direct visualization of bronchus using fiberscope


Nursing Management PRE Bronchoscopy
Secure inform consent and explain procedure to client
Maintain NPO 6 8 hours prior to procedure
Monitor vital signs and breathe sound
POST Bronchoscopy
Feeding initiated upon return of gag reflex
Avoid talking, coughing and smoking, may cause irritation
Monitor for signs of gross
Monitor for signs of laryngeal spasm prepare tracheostomy set
D. Treatment
Surgery (pneumonectomy, 1 lung is removed and position on affected side)
Segmental Wedge Lobectomy (promote re expansion of lungs)
- Unaffected lobectomy facilitate drainage

EMPHYSEMA
Irreversible terminal stage of COPD characterized by
Inelasticity of alveoli
Air trapping
Maldistribution of gases
Over distention of thoracic cavity (barrel chest)
A. Predisposing Factors
Smoking
Air pollution
Allergy
High risk: elderly
Hereditary it involves deficiency of
ALPHA-1 ANTI TRYPSIN
(needed to form Elastase, for recoil of alveoli)
B. Signs and Symptoms
1. Productive cough
2. Dyspnea at rest
3. Prolong expiratory grunt
4. Anorexia and generalized body malaise
5. Resonance to hyperresonance
6. Decrease tactile fremitus
7. Decrease or diminished breath sounds
8. Rales or ronchi
9. Bronchial wheezing
10. Barrel chest
11. Flaring of alai nares
12. Purse lip breathing to eliminates excess CO2
(compensatory mechanism)
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
Enforce CBR
Administer oxygen inhalation via low inflow
Administer medications as ordered
Bronchodilators
Steroids
Antibiotics
Mucolytics/expectorants
High fowlers position
Force fluids
Institute pulmonary toilet
Nebulize and suction when needed
Institute PEEP (positive end expiratory pressure) in mechanical ventilation promotes maximum alveolar lung expansion

Provide comfortable and humid environment


Provide high carbohydrates, protein, calories, vitamins and minerals
Health teachings and discharge planning concerning
Avoid smoking
Prevent complications
Atelectasis
Cor Pulmonale
CO2 narcosis may lead to coma
Pneumothorax
Strict compliance to medication
Importance of follow up care

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

Open pneumothorax air enters pleural space through an opening in chest wall
-Stab/ gunshot wound
3. Tension Pneumothorax air enters plural space with @ inspiration & cant escape leading to over
distension of thoracic cavity resulting to shifting of mediastinum content to unaffected side.
Eg. Flail chest paradoxical breathing pattern

Predisposing factors:
Chest trauma
Inflammatory lung conditions
Tumor
S/Sx:
Sudden sharp chest pain
unexplained Dyspnea or SOB
Cyanosis
Diminished or decreased breath
sound of affected lung
Cool moist skin- initial sign of shock
Mild restlessness/ apprehension, anxiety
Resonance to hyperresonance
decreased tactile fremitus
Diagnosis:
ABG pO2 decrease
CXR confirms pneumothorax/collapse of
lung Nursing Mgt:
Assist in endotracheal intubation
Assist in thoracenthesis
Administer meds Morphine SO4 due to
pain - Anti microbial agents- due to bacteria
Assist in test tube thoracotomy attached
to H2O sealed drainage system

If client has a tension pneumothorax, the initial treatment of choice is to insert a large-bore needle
into the second intercostal space midclavicular line to relieve pressure. Next, a chest tube system is
placed into the fourth intercostal space.
A small chest tube(28 french) is inserted near the second intercostal space; this space is used
because it is the thinnest part of the chest wall, minimizes the danger of contracting the thoracic
nerve, and leave small scar. If the patient has also hemothorax, a large-diameter chest tube (32
french) or greater is inserted usually in the 4th or 5th interscostal space at the midaxillary line.
Purpose of H2O sealed drainage
Reestablish (-) pressure in the lungs-lung 6-12mm Hg
Promote re-expansion of the lungs
Drain fluid, blood and air
To prevent reflux of blood fluid and air
Nursing Mgt if pt is on CPT attached to H2O drainage
Maintain strict aseptic technique
DBE
At bedside
a.) Petroleum gauze pad if dislodged
Hemostat b.) If with air leakage clamp
c.) Extra bottle
Meds Morphine SO4
Antimicrobial
Monitor & assess for oscillation fluctuations or bubbling
a.) If (+) to intermittent bubbling means normal or intact
H2O rises upon inspiration
H2O goes down upon expiration
b.) If (+) to continuous, remittent bubbling
Check for air leakage
Clamp towards chest tube
Notify MD
c.) If (-) to bubbling
Check for loop, clots, and kink
Milk towards H2O seal
Indicates re-expansion of lungs normal
Auscultate for breath sounds, Xrays
Removal of CTT

When will MD remove chest tube?


If (-) fluctuations
(+) Breath sounds
CXR full expansion of lungs
Nursing Mgt of removal of chest tube
Encourage DBE
Instruct to perform Valsalva maneuver for easy removal, to prevent entry of air in pleural
space.

Apply vaselinated air occlusive dressing and pressure dressing


Maintain dressing dry & intact
4. Prepare: Extra bottle, excellent clamp, petroleum gauze

Gastro Intestinal Tract


Upper alimentary canal - function for digestion
Mouth
Pharynx (throat)
Esophagus
Stomach- site of digestion
1st half of duodenum
II. Middle Alimentary canal Function: for
absorption - Complete absorption large
intestine
a. 2nd half of duodenum for absorption
Jejunum
Ileum
1st half of ascending colon
III. Lower Alimentary Canal Function: elimination
a. 2nd half of ascending
for elimination
colon
b. Transverse
for complete absorption L
I
Descending colon
Sigmoid
Rectum
IV. Accessory Organ
Salivary gland
Verniform appendix
Liver
Pancreas auto digestion
Gallbladder storage of bile
I. Salivary Glands
Parotid below & front of ear
Sublingual
Submaxillary
Produces saliva for mechanical digestion
1,200 -1,500 ml/day - saliva produced
Lacrimal gland- depression on the frontal bone
Lacrimal duct- outer canthus

PAROTITIS mumps inflammation of parotid


gland -Paramyxovirus

S/Sx:
Fever, chills anorexia, generalized body malaise
enlarged parotid gland
Swelling of parotid gland
Dysphagia
Earache 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
Institute a strict respiratory isolation
Meds: analgesic
Antipyretic
Antibiotics to prevent 2 complications
4. Alternate warm & cold compress at affected part (vinegar promotes cooling)

General 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 occurs 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-- MCBURNEYS point site of surgical incision
Late sign due pain tachycardia
Rovsings sign elicited by palpating the left lower quadrant; this paradoxically causes pain to be felt in the right
lower quadrant.
Diagnosis:
CBC mild leukocytosis increase WBC
PE (+) rebound tenderness (flex Rt leg, palpate Rt iliac area rebound)
Urinalysis(+) acetone in urine
Treatment: - appendectomy 24 45
Nursing Mgt:
Secure consent
Routinely nursing measures: a.)
Skin prep
b.) NPO
c.) Avoid enema/laxatives lead to rupture of
appendix
Meds:
Antipyretic
Antibiotics
*Dont give analgesic pre-diagnosis will mask pain
Give analgesic post diagnosis
Presence of pain means appendix has not ruptured.
Avoid heat application will rupture appendix.
Monitor VS, I&O bowel sound
Maintain a patent IV line
Complications:
Peritonitis
Septicemia
Nursing Mgt: post op
If (+) to Penrose 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- N- borborygmy sound
Maintain patent IV line
Complications- peritonitis, septicemia

PEPTIC ULCER DISEASE (PUD) excoriation / erosion of submucosa & mucosal lining due
to: a.) Hyper secretion of acid pepsin
b.) Decrease resistance to mucosal barrier
Incidence Rate:
Men 40 55 yrs old
Aggressive persons/ type A personality
Hereditary
Emotional Stress
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.
NSAID and steroids= gastropathy
Gastrin producing tumor or gastrinoma Zollinger Ellisons syndrome
Microbial invasion helicobacter pylori. Metronidazole (Flagyl)

Types of ulcers
Ascending to severity
Acute affects submucosal lining
Chronic affects underlying tissues
heals & forms a scar, deeper
According to location
Stress ulcer
Gastric ulcer
Duodenal ulcer most common
Stress ulcers common among critically ill
clients 2 types
1. Curlings ulcer cause: trauma & Burns
Hypovolemia
GIT schemia
Decrease resistance of mucosal barriers to Hcl acid
Ulcerations
2. Cushings ulcer cause stroke/CVA/ head injury
Increase vagal stimulation
Hyperacidity
Ulcerations
Treatment: Vagotomy - done to prevent hemorrhage and shock prior to surgery on the stomach
GASTRIC ULCER
SITE
PAIN

HYPERSECRETION
VOMITING
HEMORRHAGE
WT
COMPLICATIONS
HIGH RISK
INCIDENCE

Antrum or lesser curvature


- 30 min 1 hr after eating
- epigastrium
- gaseous & burning
- not usually relieved by food & antacid
- Eating leads to pain
Normal gastric acid secretion
common
hematemesis
Wt loss
a. stomach cancer
b. hemorrhage
50 or 60 years old and above
Male; female = 1:1
15% of peptic ulcers are gastric

DUODENAL ULCER
Duodenal bulb
- 2-3 hrs after eating
- mid epigastrium
- cramping & burning pain
- usually relieved by food & antacid
- 12 MN 3am pain
- Eating lessens pain
Increased gastric acid secretion
Not common
Melena
Wt gain
a. perforation
20 years old and above
Male: Female = 2-3:1
80% of peptic ulcers are duodenal

90-95% is cases of duodenal ulcers - less bicarbonate ions, decrease so increase


incidence Diagnosis:
Endoscopic exam
Stool from occult blood (+)
Gastric analysis Gastric Ulcer: normal gastric acid secretion
Duodenal: increased gastric acid secretion
4. 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

a.) Antacids
ACA
Aluminum containing antacids

Magnesium containing antacids

ex. aluminum hydroxide gel


ex. milk of magnesia
(Amphogel)
S/E diarrhea
S/E constipation
Maalox (fever S/E)
b.) H2 receptor antagonist:
Ranitidine (Zantac) SE: fever
Cimetidine (Tagamet)hastens the effect of oral anticoagulants
Famotidine (Pepcid) SE: fever
Avoid smoking decrease effectiveness of drug
Nursing Mgt:
1. Administer antacid & H2 receptor antagonist (Cimetidine) 1hr apart
-Cemetidine decrease antacid absorption & vise versa
c.) Cytoprotective
agents Ex
Sucralfate (Carafate) - Provides a paste like subs that coats mucosal lining of stomach
Misoprostol (Cytotec) SE: menstrual spotting
d.) Sedatives/ Tranquilizers - Valium, lithium
e.) Anticholinergics / Antispasmodic
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.
3. Surgery: subtotal gastrectomy - Partial removal of stomach

Billroth I (Gastroduodenostomy)
Removal of of stomach & anastomoses of gastric
stump to the duodenum.

Billroth II (Gastrojejunostomy)
Removal of -3/4 of stomach & duodenal bulb &
anastomostoses of gastric stump to jejunum.

Before surgery for BI or BII - Do vagotomy (severing of vagus nerve) & pyloroplasty (drainage) first.
Nursing Mgt:
Monitor NGT output or drainage immediately post op- bright red a.)
Immediately post op should be bright red
b.) Within 36- 48h output is yellow green
c.) After 48h output is dark red due to HCl acid
Administer meds: a.)
Analgesic

b.) Antibiotic c.)


Antiemetics
Maintain patent IV line
VS, I&O & bowel sounds
Complications:
a.) Hemorrhage hypovolemic shock
Late signs anuria
b.) Peritonitis
c.) Paralytic ileus most feared
d.) Hypokalemia
e.) Thrombophlebitis
f.) Pernicious anemia
g.) Septicemia
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, sweets
(fluids must be taken after meals)

Small frequent feedings-6 equally divided feedings


Diet decrease CHO, moderate fats & CHON
Flat on bed 15 -30 minutes after q feeding

DIVERTICULITIS/DIVERTICULOSIS
Diverticulum- an outpouching of the intestinal mucosa particularly the sigmoid colon
Diverticulosis- multiple diverticulum
Diverticulitis- inflammation of diverticula
Predisposing Factors
High Risk Groups- men (40-45yo)
Congenital weakness of muscle fibers of the intestine.
Low roughage and fiber in the diet
S/S:
Intermittent lower left abdominal quadrant pain, particularly in the rectosigmoid area

tenderness
alternating bouts of constipation or diarrhea with blood or mucous

Dx:
Barium enemareveals inflammatory process
CBC reveals: decreased hematocrit and hemoglobin
Nsg Mgt:
Administer meds as ordered:
antibiotics
bulk laxatives
stool softeners
anti spasmodic agents
Instruct clients to take foods high in fiber if there is diverticulosis
Monitor for signs of infection
Feared complications: Peritonitis
4. Assists in surgical procedure
Resection of the diseased bowel and creation of a colostomy

Liver largest gland


Occupies most of right hypochondriac region
Color: scarlet red, brown shiny and transparent
Covered by a fibrous capsule Glissons capsule
Functional unit liver lobules
Function:
Produces bile
Bile emulsifies fatsH2O and bile salts= cholesterol
Right sided pain: Cholelithiasis- easy
bruising Left sided pain: Pancreatitis
- Composed of H2O & bile salts
-Gives color to urine urobilin

Stool color stechobilin


Detoxifies drugs
Promotes synthesis of vit A, D, E, K - fat soluble vitamins (needs fat for absorption)
Hypervitaminosis vit D & K
Vit A retinol (Def Vit A night blindness)
Vit D cholecalciferon
Helps calcium
Rickets, osteoarthritis
It destroys excess estrogen hormone
for metabolism
CHO
Glycogenesis synthesis of glycogens
Glycogenolysis breakdown of glycogen
Gluconeogenesis formation of glucose from CHO sources
CHONPromotes synthesis of albumin & globulin
Liver Cirrhosis decrease albumin; ascites and edema
Albumin maintains osmotic pressure, prevents edema
Promotes synthesis of prothrombin & fibrinogen
Promotes conversion of ammonia to urea.
Ammonia like breath fetor hepaticus a sweet, slightly fecal odor to the breath presumed 2 be intestinal
orig. C. FATS promotes synthesis of cholesterol to neutral fats called triglycerides

LIVER CIRRHOSIS - lost of architectural design of liver leading to fat necrosis & scarring
Cirrhosis- loss of architectural design of the liver leading to fat necrosis and scarring

Laennac

Early sign hepatic encephalopathy accumulation of ammonia and other toxic substance in the
blood 1. Asterixis flapping hand tremors
Late signs headache, restlessness, disorientation, decrease LOC hepatic
coma. Nursing priority assist in mechanical ventilation
Predisposing factor:
Decrease Laennacs cirrhosis caused by alcoholism
Chronic alcoholism- major cause
Malnutrition decreaseVit B, thiamin - primary cause
Virus
Toxicity- eg. Carbon tetrachloride (CCL4)
Use of hepatotoxic agents
S/Sx:
1. Early signs:
a.) Weakness, fatigue
b.) Anorexia, n/v
c.) Stomatitis
d.) Urine tea color
Stool clay color
e.) Amenorrhea
f.) Decrease sexual urge

g.)
h.)
i.)
j.)
k.)

Loss of pubic, axilla hair


Hepatomegaly
Jaundice
Pruritus or urticaria (palmar erythema)
Decrease bowel sounds

2. Late signs
a.) Hematological changes all blood cells
decrease Leukopenia- decrease
Thrombocytopenia- bleeding tendencies
Anemia- decrease
b.) Endocrine changes
Spider angiomas, Gynecomastia
Caput medusae, Palmar erythema, loss of tortousity of the umbilicus
c.) GIT changes
Ascites, bleeding esophageal varices due to portal HPN
d.) Neurological changes:
hepatic encephalopathy

Hepatic encephalopathy - ammonia (cerebral toxin)


Late signs:
Headache and dizziness
Fetor hepaticus
Confusion
Restlessness
Hypoactive deep tendon reflexes
Decrease LOC

Early signs:
asterexis - flapping hand tremors
Minor mental changes and motor disturbances

hyperactive deep tendon reflexes


flaccid

Hepatic coma
Diagnosis:
Liver enzymes- increase
SGPT (ALT)
SGOT (AST)

Serum cholesterol & ammonia increase


Indirect or conjugated bilirubin increase
CBC - pancytopenia
PTT prolonged bleeding
Hepatic ultrasonogram fat necrosis of liver globules
Nursing Mgt
CBR
Restrict Na!
Monitor VS, I&O
Weigh 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 of liver cirrhosis:
a.) Ascites fluid in peritoneal cavity
Nursing Mgt:
Meds: Loop diuretics 10 15 min effect or potassium sparing diuretic
Assist in abdominal paracentesis - aspiration of fluid
Void before paracentesis to prevent accidental puncture of bladder as trochar is inserted

b.) Bleeding esophageal varices


- Dilation of esophageal
veins 1. Meds: Vit K
Pitressin or Vasopressin (IM)
NGT decompression- lavage
Give before lavage ice or cold saline solution
Monitor NGT output
Assist in mechanical decompression
Insertion of Sengstaken-Blackemore tube - to decompress veins of esophagus-to prevent
esophageal varices
3 lumen typed catheter
Scissors at bedside to deflate/decompress balloon. Prep scissors when pt complains of DOB
c.) Hepatic encephalopathy
Assist in mechanical ventilation due coma
Monitor VS, neuro check
Siderails due restless
Meds Laxatives to excrete ammonia (Lactulose)

HEPATITIS - jaundice (icteric sclera)


Bilirubin
Kernicterus/ hyperbilirubinia
Irreversible brain damage

Hepatitis A
Hepatitis A virus (HAV) is a virus that causes liver disease. Incubation is about 30 days, and the virus is excreted in the stool for
about 2 weeks before the illness and about a week after it. The mortality rate is low. Children are typically asymptomatic. Adults
generally have a more severe illness. The disease is not chronic and is not carried : FECAL ORAL

TRANSMISSION

INFECTION CONTROL

Hand hygiene to prevent the spread of HAV.


Vaccine before traveling to places where HAV is endemic.
Standard precautions, when caring for this client.
Contact precautions, for incontinent clients (cannot control bladder/bowel).

Hepatitis B
Hepatitis B (HBV) is one of the five hepatitis viruses that infect the liver. This virus has a complex structure capable of
attacking and destroying liver cells, resulting in illness or disease. Cellular destruction results in architectural changes of
the normal structure, of the liver which leads to a disruption in the flow of blood and bile. Illness can range from mild signs
and symptoms to chronic disease, such as fatal cirrhosis or liver cancer. BLOOD CARRIER

Pancreas mixed gland (exocrine & endocrine gland); found behind the stomach
PANCREATITIS acute or chronic inflammation of pancreas leading to pancreatic edema, hemorrhage & necrosis due to
auto digestion (self-digestion).
Bleeding of pancreas - Cullens sign on umbilical area
Predisposing factors:
Chronic alcoholism
Hepatobilary disease
Obesity
Hyperlipidemia

Hyperparathyroidism
Drugs Thiazide diuretics,aspirin, pills, Pentamidine HCL (Pentam) for clients with AIDS,
Diet increase saturated fats
S/Sx:
Severe Midepigastrium epigastric pain radiates from back & flank area (left upper quadrant) 24-48 hrs. Aggravated by heavy meals/eating, accompanied by DOB
N/V
Tachycardia
Palpitation due to pain (abdominal guarding)
Dyspepsia /indigestion (rigid board like abdomen)
Decrease bowel sounds
7. (+) Cullens sign - ecchymosis of umbilicus
hemorrhage
(+) Grey Turners 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)
Dont give Morphine SO4 will cause spasm of the sphincter of ODDI.
b.) Smooth muscle relaxant/ anticholinergic
- 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
Withold food & fluid aggravates pain (total NPO)
Assist in Total Parenteral Nutrition (TPN) or hyperalimentation
Complications of TPN
Infectionmaintain a strict aseptic technique
Pulmonary Embolismcheck all connection to system
Hyperglycemia
Hyperkalemia
Institute stress mgt tech
a.) DBE
b.) Biofeedback
Comfy position - Knee chest or fetal lie position
If pt can tolerate food, give increase CHO, decrease fats, and moderate CHON
7. Complications:
Chronic hemorrhagic pancreatitis, Peritonitis, Septicemia, Shock

GALLBLADDER storage of bile made up of cholesterol.

Definition of terms: Biliary


Cholecystitis

Inflammation of the gallbladder

Cholelithiasis
Cholecystectomy
Cholecystostomy
Choledochotomy
Choledocholithiasis
Choledocholitholithotomy
Choledochoduodenostomy
Choledochojejunostomy
Lithotripsy
Laparoscopic cholecystectomy

The presence of calculi in the gallbladder


Removal of the gallbladder
Opening and drainage of the gallbladder
Opening into the common duct
Stones in the common duct
Incision of common bile duct for removal of stones
Anastomosis of common duct to duodenum
Anastomosis of common duct to jejunum
Disintegration of gallstones by shock waves
Removal of gallbladder through endoscopic
procedure
Removal of gallbladder using laser rather than
scalpel and traditional surgical instruments

Laser cholecystectomy

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, prolonged immobility
Hyperlipidemia
Neoplasm
Obstruction
S/Sx:
Severe Right abdominal pain (after eating fatty food). Occurring especially at night =
epigastric or right abdominal quadrant after eating a heavy meal
Fat intolerance
Anorexia, n/v, feeling of fullness
Jaundice
Pruritus
Easy bruising
Tea colored urine
Steatorrhea
Diagnosis:
Oral cholecystogram (or gallbladder series) - confirms presence of gall stones
Increased indirect bilirubin
Increased alkaline phosphatase
increased serum and amylase
Nursing Mgt:
1. Meds a.) Narcotic analgesic - Meperdipine Hcl Demerol
b.) Anti cholinergic/Anti-spasmodic - Atropine SO4 c.)
Anti emetic
Phenergan Phenothiazide with anti emetic properties
Broad spectrum antibiotics
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 prevent GERD
cardiac sphincter valve
Pyloric sphincter valve- stomach and first half of duodenum
Cells
1. Chief/ Zymogenic cells secrets
a.) Gastric amylase - digest CHO / sugars
b.) Gastric lipase digest fats
c.) Pepsin CHON
d.) Rennin digests milk products

Parietal / Argentaffin / oxyntic cells


Function:
a.) Produces intrinsic factor promotes reabsorption of vit B12 cyanocobalamin promotes maturation of
RBC
b.) Secrets Hcl acid aids in digestion
Endocrine cells - Secretes gastrin increase Hcl acid secretion
Function of the stomach
1.Mechanical
digestion
2.Chem.
3.Storage of food
-CHO, CHON- stored 1 -2 hrs. Fats stored 2 3 hrs

BURNS
direct tissue injury caused by thermal, electric, chemical & smoke inhaled (TECS)
Nursing Priority infection (all kinds of burns)
Head burn-priority - Airway
2nd priority for 1st & 2nd burn - pain
2nd priority for 3rd burn - Fluid and electrolytes

Thermal - direct contact flames, hot grease, sunburn.


Electric, wires
Chemical direct contact corrosive materials acids
Smoke gas / fume inhalation
Stages:
Emergent phase Removal of pt from cause of burn. Determine source or location of 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
Diuretic/ Fluid remobilization phase - 3 to 5 days. Return of fluid from interstitial to intravascular space
Recovery/ convalescent phase complete diuresis. Wound healing starts immediately after tissue injury.
Class:
I. Partial Burn
1st degree superficial burns
Affects epidermis
Cause: thermal burn
Painful
Redness (erythema) & blanching upon pressure
with no fluid filled vesicles
2nd degree deep burns
Affects epidermis & dermis
Cause chem. burns
very painful
Erythema & fluid filled vesicles (blisters)
II Full thickness Burns
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
Ant chest
Post chest
@ Arm 9+9
@ leg 18+18
Genitalia/ perineum
Total
Nursing Mgt:
1. Meds

= 9%
= 18%
= 18%
= 18%
= 18%
= 1%
100%

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
Ampicillin
Cephalosporin
Tetracyclin
Topical antibiotic:
Silver Sulfadiazene (silvadene)
Sulfamylon
Silver nitrate
Povidone iodine (betadine)
Administer isotonic fluid sol & CHON replacements
Strict aseptic technique
Diet increase CHO, increase CHON, increase Vit C, and increase K- orange
If (+) to burns on head, neck, face - Assist in intubation
Assist in hydrotherapy
Assist in surgical wound debridement. Administer analgesic 15 30 minutes before debridement
Complications:
a.) Infection
b.) Shock
c.) Paralytic ileus - due to hypovolemia & hypokalemia
d.) Curlings 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
Kidneys pair of bean shaped organ
Located retroperitonially (back of peritoneum) on either side of vertebral column. Encased in Bowmanss capsule.
Parts:
Renal pelvis Pyelonephritis inflammation of the renal pelvis
Cortex
Medulla
Nephrons basic living unit of the kidneys consisting of glomerulus
Glomerulus filters blood going to kidneys

Function of kidneys:
Urine formation
Regulation of BP

Causes of Transient Incontinence:


DIAPPERS

Urine formation 25% of total CO (Cardiac Output)


is received by kidneys (3,000-6,000 ml.)
125ml/ min filtered by the glomerulus >
Glomerular filtration rate
Filtration
Tubular Reabsorption124ml of ultra filtered are
reabsorbed in the blood
Tubular Secretion- 1 ml is excreted in the urine
Filtration Normal GFR/ min is 125 ml of blood
Tubular reabsorption 124ml of ultra infiltrates (H2O &

Delirium
Infection of urinary tract
Atrophic vaginitis, urethritis
Pharmacologic agents (anticholinergic)

electrolytes is for reabsorption)


Tubular secretion 1 ml is excreted in urine

Psychological factors (depression, regression)

Causes of CRF:
HPN

Excessive urine production (DI, diabetic keto, inc.


intake)

DM Regulation
of BP: Predisposing
factor:

Restricted activity

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 of urine
1200 1800 ml Normal adult can hold
200 500 ml needed to initiate micturition reflex (voiding)
Color
Odor
Consistency
pH
Specific gravity
WBC/ RBC
Albumin
E coli
Mucus threads
Amorphous urate

amber
aromatic
clear or slightly turbid
4.5 8
1.015 1.030

(-)
(-)
(-)
few
(-)

Urethra extends to external surface of body. Passage of urine, seminal & vaginal fluids.
Women 3 5 cm or 1 to 1
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:
1. Pain flank area
2. Urinary frequency & urgency
3. Burning upon urination

In the older adult, the most


common signs & symptoms of
cystitis or UTI:
1. Fatigue.
2. Change in cognitive status.

4. Dysuria & hematuria


5. Fever, chills, anorexia, gen body malaise
6. Nocturia

Diagnosis:
Urine culture & sensitivity - 80% of the cases are (+) to E. coli
Nursing Mgt:
Force fluid 2000 ml= to prevent bacterial multiplication
Warm sitz bath to promote comfort
Monitor & assess for gross hematuria
Monitor and assess urine for color, odor, and bleeding N pH: 4.8
Acid ash diet cranberry, vit C -OJ to acidify urine & prevent bacterial multiplication
Meds: systemic antibiotics
Ampicillin
Cephalosporin

Sulfonamides cotrimoxazole (Bactrim)


- Gantrism (ganthanol)
Aminoglycosides: Gentamycin
Urinary antiseptics Nitrofurantoin (Macrodantin)
Urinary analgesic- Pyridum

7. Ht
a.) Importance of Hydration
b.) Void after sex (male and female)
c.) Female avoids cleaning back & front
Bubble bath, Tissue paper, Powder, perfume
d.) Complications: Pyelonephritis

PYELONEPHRITIS acute/ chronic inflammation of 1 or 2 renal pelvis of kidneys leading to tubular destruction,
interstitial abscess formation.

Lead to Renal Failure

Predisposing factor:
Microbial invasion (Bacterial) a.)
E. Coli
b.) Streptococcus
Urinary retention /obstruction
Pregnancy
DM
Exposure to renal toxins or nephrotoxic agents
S/Sx:
Acute pyelonephritis
a.) Costovertibral angle pain, tenderness
b.) Fever, anorexia, gen body malaise c.)
Urinary frequency, urgency
d.) Nocturia, dysuria, hematuria
e.) Burning upon urination
f.) FLANK PAIN g.)
Enlarged kidney
Chronic Pyelonephritis
a.) Fatigue, wt loss, weakness
b.) Polyuria, polydypsia
c.) HPN
Diagnosis:
Urine culture & sensitivity (+) E. coli & streptococcus
Urinalysis
(+) WBC, (+)RBC, (+) Pus cells
Cystoscopic exam urinary obstruction
Nursing Mgt:
Provide CBR especially during acute phase
Force fluid
Acid ash diet
Provide a warm sitz bath for comfort
Meds:
a.) Urinary antiseptic nitrofurantoin (macrodantin)
SE: peripheral neuropathy
GI irritation
Hemolytic anemia
Staining of teeth

b.) Urinary analgesic Pyridium


6. Complication - Renal Failure

NEPHROLITHIASIS/ UROLITHIASIS - formation of stones at urinary tract


- calcium ,
milk

oxalate,
cabbage

uric acid
anchovies

cranberries
nuts tea
chocolates

organ meat
nuts
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
X-ray
Nursing Mgt:
Force fluid
Strain urine using gauze pad
Warm sitz bath for comfort
Alternate warm compress at flank area
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
a.) Nephectomy removal of affected kidney
Litholapoxy removal of 1/3 of stones- Stones will recur. Not advised for pt with big stones
b.) Extracorporeal shock wave lithotripsy
Non - invasive
Dissolve stones by shock wave
Complications: Renal Failure

BENIGN PROSTATIC HYPERTROPHY - enlarged prostate gland leading to


a.)
b.)
c.)
d.)

Hydro ureters dilation of ureters


Hydronephrosis dilation of renal pelvis

Kidney stones Stone formation-- Renal failure


Renal failure

encircles the neck of the bladder


decreased form of urinary stream
Cause is unknown

Predisposing factor:
1. High risk 50 years old & above
60 70 (3 to 4 x at risk)
Prostate cancer: 40 years old &
above 2. Influence of male hormone
S/Sx:
Decrease force of and amount of urinary stream
Dysuria
Hematuria
Burning upon urination
Terminal dribblingearly sign of BPH
Backache
Sciatica
Hesitancy
Diagnosis:
Digital rectal exam enlarged prostate gland
KUB urinary obstruction
Cystoscopic exam obstruction
Urinalysis increase WBC, CHON, RBC
Nursing Mgt:
Prostatic message promotes evacuation of prostatic fluid
Limit fluid intake
Provide catheterization
Provide a warm sitz bath for comfort
Meds:
a. Terazozine (hytrin) - Relaxes bladder sphincter, relaxes the smooth muscle of urinary sphincter
S/E: HA, hypotension
b. Fenasteride (Proscar) - Atrophy of Prostate Gland (given after meals)
S/E: N&V, Anorexia

5. Surgery: Prostatectomy TURP- Transurethral resection of Prostate- No incision


Without incision: for debilitated clients

Urea

In
cr

Creatinine
Uric acid
anic
acids
Intra

-Assist in cystoclysis or continuous bladder


irrigation. Complication:
Hemorrhage
Urinary obstruction
Penile dysfunction
Nursing mgt:
Monitor signs and symptoms of infection
Monitor symptoms gross/ frank 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 factors:
Pre renal cause- decrease blood flow
Causes:
Septic shock
Hypovolemia
3. Hypotension
CHF
Hemorrhage
Dehydration (chronic diarrhea)

decrease blood flow to the kidneys

Intra-renal cause involves renal pathology= kidney problem


1. Acute tubular necrosis
3.HPN
2. Pyelonephritis
4.Acute Glom.
Post renal cause involves mechanical obstruction

Causes:
Urinary strictures
Urolithiasis
BPH
Presence of tumors
Stages: Initiation period begins with the initial insult and ends when oliguria develops.
I. OLIGURIC STAGE (1-2 weeks)
- involves passage of urine < 400ml/day S/S:
a. Hyperkalemia- arrhythmia
b. Hypernatremia
c. Hyperphosphatemia
d. Hypocalcemia
e. High BUN 10-20 and creatinine .8-1
Metabolic acidosis 1-2wks

DIURETIC PHASE 2-3 weeks Increased amount of urine


Hypokalemia
Hyponatremia
Metabolic Acidosis
Increased Creatinine and BUN
III. CONVALESCENT/RECOVERY PHASE3-12 months

CHRONIC RF irreversible loss of kidney function


Predisposing factors:
DM
HPN
Recurrent UTI/ nephritis/ pyelonephritis
Exposure to renal toxins
Stages of CRF
Diminished Reserve Volume asymptomatic
Normal BUN & Crea, GFR < 10 30%

Renal Insufficiency
End Stage Renal disease

S/Sx:
1.) Urinary System
a.) polyuria
b.) nocturia
c.) hematuria
d.) Dysuria
e.) oliguria

2.) Metabolic disturbances


a.) azotemia (increase BUN & Crea)
b.) hyperglycemia
c.) hyperinulinemia

3.) CNS
a.) headache
b.) lethargy
c.) disorientation
d.) restlessness
e.) memory impairment
5.) Respiratory
a.) Kassmauls resp
b.) decrease cough reflex
c.) crackles
7.) Fluid & Electrolytes
a.) hyperkalemia
b.) hypernatermia
c.) hypermagnesemia
d.) hyperposphatemia
e.) hypocalcemia
f.) met acidosis

4.) GIT
a.) n/v
b.) stomatitis
c.) uremic breath
d.) diarrhea/ constipation
6.) hematological
a.) Normocytic anemia
bleeding tendencies
8.) Integumentary
a.) itchiness/ pruritus
b.) uremic frost
9.) Cardiovascular changes
a. HPN
b. CHF
c. Pericarditis

Nursing Mgt:
Enforce CBR, reverse isolation
Monitor strictly VS, I&O, neurocheck, monitor for signs of hypocalcemia (increased phosphate)

Meticulous skin care. Uremic frost assist in bathing pt


Meds:
a.) Na HCO3 due Hyperkalemia
b.) Kayexelate enema
c.) Anti HPN Hydralazine (Apresoline)
d.) Vit & minerals (Multivitamins)

e.) Phosphate binder


(Amphogel) Al OH gel - S/E constipation
f.) Decrease Ca Ca gluconate
5. Assist in hemodialysis
1.) Consent/ explain procedure
2.) Weigh patient
3.) Obtain baseline data & monitor VS before and during q30mins, I&O, wt, blood exam
4.) Encourage patient to void
5.) Strict aseptic technique
6.) Monitor for signs of complications:
B bleeding (due to heparin)

E embolism
D disequilibrium
syndrome S septicemia
S shock decrease in tissue perfusion

Disequilibrium syndrome from rapid removal of urea & nitrogenous waste product leading to:
a.) n/v
b.) HPN
c.) Leg cramps
d.) Disorientation
e.) 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
Complication
Peritonitis (most feared)
Shock
Inflow time: 10-20mins
Indwelling time: 30-45 mins
8. Assist in surgery:
Renal transplantation: Complication rejection (feared complication). Reverse
isolation Rejection time in acute6mos to 1 year
Rejection time in chronic5-10 years

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
b.) 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 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.) Vitreous Humor maintains spherical shape of the eye
b.) Aqueous Humor maintains intrinsic ocular pressure

Normal IOP= 12-21 mmHg

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 or acute vision
Physiology of vision
4 Physiological processes for vision to occur:
Refraction of light rays bending of light rays
Accommodation of lens
Constriction & dilation of pupils
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
Presbyopia old slight inelasticity of lens due to aging Treatment: bifocal lens or double vista
Accommodation of lenses based on Helmholtz theory of accommodation
Near vision =
Ciliary muscle contracts=
Lens bulges
Convergence of the eye:
Error:
1. Exotropia 1 eye n.
2. Esophoria
Strabismus- squint
Amblyopia prolong squinting

far vision=
ciliary muscle dilates / relaxes=
lens is flat

corrected by corrective eye surgery

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


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

(nearsightedness)

Type:
1. Chronic (open angle G.) most common type Obstruct in flow of aqueous humor at trabecular meshwork of
canal of schlema
2. Acute (close angle G.) Most dangerous type Forward displacement of iris to cornea leading to blindness. 3.
Chronic (closed angle) - Precipitated by acute attack
S/Sx:
Loss of peripheral vision tunnel vision
Halos around lights
Headache
n/v
Steamy cornea
Eye discomfort
If untreated gradual loss of central vision blindness
Diagnosis:
1. Tonometry increase IOP >12- 21 mmHg
Perimetry decrease peripheral vision
Gonioscopy abstruction in anterior chamber

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

Nursing Mgt pre op- all types surgery


1. 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 for symptoms of IOP
a.) Headache
b.) n/v
c.) Eye discomfort
d.) Tachycardia
4. 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 blurry vision

Milky white appearance at center of pupil


Decrease perception of colors
Diplopia
Diagnosis:

Opthalmoscopic exam (+) opacity of lens

Nsg Mgt:
Reorient pt to environment due opacity
Side rails
Meds: a.) Mydriatics dilate pupil not lifetime (SNS)
Ex. Mydriacyl
c.) Cyslopegics paralyzes ciliary muscle. Ex. Cyclogye
4. Surgery
E extra
C - capsular
C cataract
L - lens
E extraction

partial removal of lens

I - intra
C - capsular
C cataract total removal of lens & surrounding capsules L lens
E extraction
Nursing Mgt:
Position unaffected/ unoperated side - to prevent tension on suture line.
Avoid valsalva maneuver
Monitor symptoms of IOP
a.) Headache
b.) n/v
c.) Eye discomfort
d.) 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
Cobwebs
Diagnosis: ophthalmoscopic exam
Nursing Mgt:
Side rails (all visual disease)
Surgery:
a.) Cryosurgery cold application
(Diathermy heat application)

b.) Scleral buckling

EAR
Hearing
Balance (Kinesthesia or position sense)

Parts:
1. Outera.) Pinna / auricle protects ear from direct trauma
b.) Ext. auditory meatus has ceruminous gland. Cerumen
c.) 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
Stirrups -stapes

for bone conduction

disorder conductive hearing loss

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


- Yawn, chew, and swallow
Children straight, wide, short
c.) Otitis media
Adult long, narrow & slanted
Muscles
Stapedius
Tensor tympani
Inner ear
a. Bony labyrinth for balance, vestibule
Utricle & succule
Otolithe or ear stone has Ca carbonate
Movement of head = Righting reflex = Kinesthesia
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:
1. Conductive hearing loss transmission hearing loss
Causes:
a.) Impacted cerumen tinnitus & conduction hearing loss- assist in ear irrigation
b.) Immobility of stapes OTOSCLEROSIS
d.) Middle ear disease char by formation of spongy bone in the inner ear causing fixation or immobility of stapes
e.) Stapes cant 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
Webers 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:
a.) Analgesic
b.) Antiemetic
c.) 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
4. Menieres disease endolymphatic hydrops
f.) Inner ear disease char by dilation of endolympathic system leading to increase volume of endolin
Predisposing factor of MENIERES DISEASE
Smoking
Hyperlipidemia
30 years old
Obesity (+) chosesteatoma
Allergy
Ear trauma & infection

S/Sx:
TRIAD symptoms of Menieres disease a.)
Tinnitus
b.) Vertigo
c.) Sensory neural hearing loss
Nystagmus
n/v
Mild apprehension, anxiety
Tachycardia
Palpitations
Diaphoresis
Diagnosis:
1. Audiometry (+) sensory hearing loss
Nursing mgt:
Comfy & darkened environment
Siderails
Emetic basin
Meds:
a.) Diuretics to remove endolymph
b.) Vasodilator
c.) Antihistamine
d.) Antiemetic
e.) Antimotion sickness agent
f.) Sedatives/ tranquilizers
Restrict Na
Limit fluid intake
Avoid smoking
Surgery endolymphatic sac decompression - Shunt

OTITIS MEDIA Inflammation of the middle ear. (last less than 6 wks)
Sign and symptoms:
Pain
Temporary hearing loss
Tugging at the affected ear
Difficulty sleeping
Draining fluid / pus
Frequent pulling of the ear
(children) Fever
Nursing management:
Usually self limiting and resolved spontaneously
Antibiotic
Drainage (lean on the affected side to facilitate drainage)
Complication:
Hearing loss
Mastoiditis
Delayed speech and language development
Perforation of the TM

OTHER MNEMONICS

IV NOTES
Clindamycin, KCl===NOT for IV pushit may cause arrhythmia
Chloramphenicol===NOT for IM

Procaine, Penicillin, Benzatine, Pen G, Vancomycin HCl, Acyclovir (Zovirax) ===NOT for IV

Opened bottles must be used in 8 hours


HepLock- flush with NSS
KCl < 80meq/L
Epinephrine 1:10,000
Lidocaine- 4 mg /ml (1g/250ml)
COMPATIBLE WITH PNSS ONLY
o Phenytoin
o Vit K
o Vit B6
o Vit C
o Hydralazine
o Furosemide
COMPATIBLE WITH D5W ONLY
o Epinephrine
o Norepinephrine
o Ephedrine
o Dopamine
o Dobutamine
o Nitroprusside
o NaHCO3
Not to be diluted in LR
Penicillin G
Ampicillin
Cephalosporin
NaHCO3
PRBCto be infused within 24hours FFP1-1.
5 hours
Platelet concentratesinfuses immediately and quickly

Autoimmune diseases

Multiple Sclerosis
Hypothyroidism
Acute Glomerulonephritis
Myasthenia Gravis
Hyperthyroidism
GBS
Pernicious Anemia

Apparatus needed at bedside


Acetaminophen toxicityAcetylcisteine
Myasthenia Gravis
Hemodyalisis
Senkstaken tube
Guillain Barre Syndrome
Convulsion- suction apparatus
Hyperthyroidism
Goiter
Hypoparathyroidism

Prepare suction apparatusacetylcysteine causes outpouring of


secretions
tracheostomy set. For respiratory
arrest
bulldog clip
scissors to deflate balloon
tracheostomy set. For respiratory
arrest
Increased secretions
tracheostomy set. For laryngeal
spasm post subtotal thyroidectomy
complication
tracheostomy set. For laryngeal
spasm post subtotal thyroidectomy
complication
tracheostomy set. For laryngeal
spasm

NEURO TRANSMITTER

DECREASE

INCREASE

Acethylcholine

Myasthenia Gravis /
Alzheimer

Bi-polar Disorder

Dopamine

Parkinsons Disease

Schizophrenia

Jerome Adorable, RN 2010

PATHOGNOMONIC SIGNS
1. PTB

Low-grade afternoon fever.

2. PNEUMONIA

Rusty sputum.

3. ASTHMA

Wheezing on expiration.

4. EMPHYSEMA

Barrel chest.

5. KAWASAKI DISEASE

Strawberry tongue.

6. PERNICIOUS ANEMIA

Red beefy tongue.

7. DOWN SYNDROME

Protruding tongue / semian crease on palm

8. CHOLERA

Rice watery stool.

9. MALARIA

- Stepladder like fever and chills.

10. TYPHOID

Rose spots in abdomen.

11. DIPTHERIA

pseudo membrane formation (pharynx, tonsils, nasal)

12. MEASLES

Kopliks spots.

13. SLE

Butterfly rashes.

14. LIVER CIRRHOSIS

spider angioma, due to esophageal varices

15. LEPROSY

lioning face

16. BULIMIA NERVOSA

Chipmunk face. Parotid gland swelling

17. APPENDICITIS.

rebound tenderness

18. DENGUE

petechiae or (+) Hermans sign

19. MENINGITIS

Kernigs sign (leg pain), Brudzinski sign (neck pain).

20. TETANY

HYPOCALCEMIA (+) Trousseaus sign/carpopedal spasm; Chvostek sign (facial spasm).

21. TETANUS

risus sardonicus.

22. PANCREATITIS

Cullens sign (ecchymosis of umbilicus); (+) Grey turners spots.

23. PYLORIC STENOSIS

olive SHAPE mass on the abdomen

24. PDA

machine like murmur

25. ADDISONS DISEASE

Bronze like skin pigmentation.

26. CUSHINGS SYNDROME

Moon face appearance and buffalo hump.

27. HYPERTHYROIDISM/GRAVES DISEASE

Exopthalmus

28. INTUSSUSCEPTION

sausage shaped mass

29. PARKINSONS DISEASE

Pill rolling tremors

30. HEPATITIS

Jaundice

31. THROMBOPHEBITIS

Homans sign

32. CATARACT

- Hazy vision / loss of central vision

33. GLAUCOMA

Tunnel vision / loss of peripheral vision

34. RETINAL DETACHMENT

Curtain veil-like vision / flashes and floaters

35. CHOLECYSTITIS

- Murphys sign (pain on deep inspiration, a inflammation of the gallbladder

36. ANGINA PECTORIS

Levines sign [hand clutching in the chest]

37. MYASTHENIA GRAVIS

Ptosis [drooping of the upper eyelid]

38. TETRALOGY OF FALLOT

Clubbing of fingers

Jerome Adorable, RN 2010

GASTRIC ULCER
SITE

DUODENAL ULCER

Antrum or lesser curvature


- 30 min 1 hr after eating
- epigastrium
- gaseous & burning
- not usually relieved by food & antacid

PAIN

Duodenal bulb
- 2-3 hrs after eating
- mid epigastrium
- cramping & burning pain
- usually relieved by food & antacid
- 12 MN 3am pain
- Eating lessens pain
Increased gastric acid secretion
Not common
Melena
Wt gain
a. perforation

- Eating leads to pain


Normal gastric acid secretion
common
hematemesis
Wt loss
a. stomach cancer
b. hemorrhage
50 or 60 years old and above
Male; female = 1:1
15% of peptic ulcers are gastric

HYPERSECRETION
VOMITING
HEMORRHAGE
WT
COMPLICATIONS
HIGH RISK
INCIDENCE

20 years old and above


Male: Female = 2-3:1
80% of peptic ulcers are duodenal

ATHEROSCLEROSIS

ARTERIOSCLEROSIS

- narrowing of artery
- lipid or fat deposits (plaques)

- hardening of artery, thicken


- calcium and protein deposits

- tunica intima

- tunica media

THE 5 MOST COMMON DRUG GIVEN IN BOARD EXAM: D.L.A.D.A MAJIC 2s


NORMAL RANGE

TOXICITY
LEVEL

INDICATION

CLASSIFICATION

.5 1.5 meq/L

CHF

Cardiac Glycoside

.6 1.2 meq/L

Bipolar

Anti-Manic Agents

10 19 mg/100 ml

20

COPD

Bronchodilators

Dilantin/ Phenytoin

10 19 mg/100 ml

20

Seizures

Anti-Convulsant

Acetaminophen/Tylenol

10 30 mg/100 ml

200

Osteoarthritis

Non-narcotic Analgesic

DRUG
Digoxin/ Lanoxin
(Increase force of
cardiac output)
Lithium/ Lithane
(Decrease level of
Ach/NE/Serotonin)
Aminophylline
(Dilates bronchial tree)

PITUITARY SECRETIONS
Anterior pituitary
ADH

Posterior pituitary
GH

OXYTOCIN

ACTH
TSH
FSH & LH
PROLACTIN
MSH

Happiness is only real, when it shared

JESUS
EVERY TIME JESUS
I SAY
I wish to offer to GOD
the infinite
merits of Jesus
passi a
Christ, His
on
n
d
death, with all
being al
the masses
said
l
over the world

for:
(a) The glory of GOD, (b) my own intentions, (c) the peace of the World.

Jerome Adorable, RN 2010


CSLRM

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