Medical Management
Labs
Based on s/s
Electrocardiogram, echocardiogram, cardiac catheterization, and
angiocardiography
CBC leukocytosis during acute stage.
Erythrocytes and hemoglobin slight decrease.
Platelet count increased during second to fourth week of illness.
IgM, IgA, IgG, and IgF transiently elevated.
Treatment
Immunoglobulin
Methotrexate or cyclophosphamide: In IVIG-resistant cases
Aspirin
Prognosis
With prompt treatment, the prognosis is good.
HEPATITIS B
Imaging studies
Definition: Hepatitis B is an infectious disease caused by the hepatitis B virus Abdominal ultrasonography
(HBV) which affects the liver. Abdominal computed tomography (CT) scanning
Abdominal magnetic resonance imaging (MRI)
Anatomy and physiology Treatment
Alpha interferon
Tenofovir (Nucleos(t)ide reverse transcriptase inhibitors)
Entecavir
Prophylaxis
Hepa B vaccine
Immunoglobulin
Prognosis
Patients who have lost the hepatitis B e antigen (HBeAg) and in whom
hepatitis B virus (HBV) DNA is undetectable have an improved clinical
outcome, as characterized by the following:
Slower rate of disease progression
Prolonged survival without complications
Reduced rate of HCC and cirrhosis
R hypochondriac region Clinical and biochemical improvement after decompensation
Largest internal organ Complications: Hepatocellular carcinoma and cirrhosis
Produce proteins and blood clotting factors, bile
Stores Nursing Diagnosis
vitamin B12, 1. Imbalanced Nutrition, Less Than Body Requirements relate to:
folic acid, discomfort in the right upper quadrant
iron required to make red blood cells, 2. Acute pain related to: swelling of the liver, the inflamed liver and
vitamin A for vision, portal vein dam.
vitamin D for calcium absorption, and 3. Hyperthermia related to: invasion agent in blood circulation
vitamin K to help blood to clot properly. secondary to liver inflammation
Etiology 4. Fatigue related to: chronic inflammatory process secondary to
HBV, bodily fluids, sexual intercourse, IV drug abuse hepatitis
5. Risk for skin integrity and tissue damage related to: pruritus
Symptomatology secondary to the accumulation of the pigment bilirubin in the bile
Icteric Hepatitis salts
Anorexia
Nausea Nursing management
Vomiting 1. Monitor I&O, compare with periodic weight. Note enteric losses: vomiting
Low-grade fever and diarrhea. Provides information about replacement needs and
Myalgia effects of therapy.
Fatigability
fulminant and subfulminant hepatitis 2. Assess vital signs, peripheral pulses, capillary refill, skin turgor, and
Hepatic encephalopathy mucous membranes. Indicators of circulating volume and perfusion.
Jaundice
Somnolence 3. Check for ascites or edema formation. Measure abdominal girth as
indicated. Useful in monitoring progression and resolution of fluid
Mental confusion
shifts.
Coma
Ascites 4. Observe for signs of bleeding: hematuria, melena, ecchymosis, oozing
Gastrointestinal bleeding from gums, puncture sites Prothrombin levels are reduced and
Laboratories coagulation times prolonged when vitamin K absorption is altered in GI
Alanine aminotransferase and/or aspartate aminotransferase tract and synthesis of prothrombin is decreased in affected liver.
levels
Alkaline phosphatase levels 5. Monitor periodic laboratory values: Hb/Hct, Na, albumin, and clotting
Gamma-glutamyl transpeptidase levels times. Reflects hydration and identifies sodium
Total and direct serum bilirubin levels retention/protein deficits, which may lead to edema formation. Deficits in
Albumin level clotting potentiate risk of bleeding and hemorrhage.
Hematologic and coagulation studies (eg, platelet count, complete
blood count [CBC], international normalized ratio) 6. Administer antidiarrheal agents: diphenoxylate with atropine (Lomotil).
Ammonia levels Reduces fluid and electrolyte loss from GI tract.
Erythrocyte sedimentation rate
Serologic tests 7. Provide IV fluids (usually glucose), electrolytes. Protein hydrolysates.
Hepatitis B surface antigen (HBsAg) Provides fluid and electrolyte replacement in acute toxic state.
Hepatitis B e antigen (HBeAg)
Hepatitis B core antibody (anti-HBc) immunoglobulin M (IgM) 8. Administer medications as indicated: Vitamin K Correction of albumin
anti-HBc IgG and protein deficits can aid in return of fluid from tissues to the circulatory
Hepatitis B e antibody (anti-HBe) system. Because absorption is altered, supplementation may prevent
hepatitis B virus (HBV) deoxyribonucleic acid (DNA) coagulation problems, which may occur if clotting factors and
prothrombin time (PT) is depressed.
Cerebrovascular Accident
Symptomatology
Definition: an ischemic stroke or brain attack, is a sudden loss of brain Sudden numbness or weakness in the face, arm, or leg, especially
function resulting from a disruption of the blood supply to a part of the brain. on one side of the body.
Sudden confusion, trouble speaking, or difficulty understanding
Ischemic stroke. This is the loss of function in the brain as a result speech.
of a disrupted blood supply. Sudden trouble seeing in one or both eyes.
Sudden trouble walking, dizziness, loss of balance, or lack of
Hemorrhagic stroke. Hemorrhagic strokes are caused by bleeding coordination.
into the brain tissue, the ventricles, or the subarachnoid space. Sudden severe headache with no known cause.
Diagnostics/Laboratories
CT scan. Demonstrates structural abnormalities, edema,
hematomas, ischemia, and infarctions
PET scan. Provides data on cerebral metabolism and blood flow
changes.
MRI. Shows areas of infarction, hemorrhage, AV malformations,
and areas of ischemia.
Cerebral angiography. Helps determine specific cause of stroke,
e.g., hemorrhage or obstructed artery, pinpoints site of occlusion or
rupture. Digital subtraction angiography evaluates patency of
cerebral vessels, identifies their position in head and neck, and
detects/evaluates lesions and vascular abnormalities.
Anatomy and physiology
Lumbar puncture. Pressure is usually normal and CSF is clear in
cerebral thrombosis, embolism, and TIA. Pressure elevation and
grossly bloody fluid suggest subarachnoid and intracerebral
hemorrhage. CSF total protein level may be elevated in cases of
thrombosis because of inflammatory process. LP should be
performed if septic embolism from bacterial endocarditis is
suspected.
Transcranial Doppler ultrasonography. Evaluates the velocity of
blood flow through major intracranial vessels; identifies AV
disease, e.g., problems with carotid system (blood flow/presence
of atherosclerotic plaques).
EEG. Identifies problems based on reduced electrical activity in
specific areas of infarction; and can differentiate seizure activity
from CVA damage.
Skull x-ray. May show a shift of pineal gland to the opposite side
from an expanding mass; calcifications of the internal carotid may
be visible in cerebral thrombosis; partial calcification of walls of an
aneurysm may be noted in subarachnoid hemorrhage.
ECG and echocardiography. To rule out cardiac origin as source of
embolus (20% of strokes are the result of blood or vegetative
emboli associated with valvular disease, dysrhythmias, or
endocarditis).
Laboratory studies to rule out systemic causes: CBC, platelet and
clotting studies, VDRL/RPR, erythrocyte sedimentation rate (ESR),
chemistries (glucose, sodium).
Medical Management
Etiology 1. Recombinant tissue plasminogen activator would be prescribed
Nonmodifiable unless contraindicated, and there should be monitoring for
Advanced age (older than 55 years) bleeding.
Gender (Male) 2. Increased ICP. Management of increased ICP includes osmotic
Race (African American) diuretics, maintenance of PaCO2 at 30-35 mmHg, and positioning
Modifiable to avoid hypoxia through elevation of the head of the bed.
Hypertension 3. Endotracheal Tube. There is a possibility of intubation to establish
Atrial brillation patent airway if necessary.
Hyperlipidemia 4. Hemodynamic monitoring. Continuous hemodynamic monitoring
Obesity should be implemented to avoid an increase in blood pressure.
Smoking 5. Neurologic assessment to determine if the stroke is evolving and if
Diabetes other acute complications are developing
6. Surgical Management
Asymptomatic carotid stenosis and valvular heart disease (eg,
endocarditis, prosthetic heart valves)
Periodontal disease
Surgical management may include prevention and relief from increased ICP. Discharge
1. Consult an occupational therapist. An occupational therapist may
7. Carotid endarterectomy. This is the removal of atherosclerotic be helpful in assessing the home environment and recommending
plaque or thrombus from the carotid artery to prevent stroke in modifications to help the patient become more independent.
patients with occlusive disease of the extracranial cerebral arteries. 2. Physical therapy. A program of physical therapy may be beneficial,
8. Hemicraniectomy. Hemicraniectomy may be performed for whether it takes place in the home or in an outpatient program.
increased ICP from brain edema in severe cases of stroke. 3. Antidepressant therapy. Depression is a common and serious
Prognosis problem in the patient who has had a stroke.
Weakness and paralysis 4. Support groups. Community-based stroke support groups may
Spacticity allow the patient and the family to learn from others with similar
Difficulty walking problems and to share their experiences.
Changes in sensation 5. Assess caregivers. Nurses should assess caregivers for signs of
Memory depression, as depression is also common among caregivers of
Attention - Survivors may find it hard to choose when they need to stroke survivors.
pay attention and when they dont. Focusing on a task may be
difficult and it may become harder to concentrate, especially on
several tasks at a time.
Depression
Aphasia.
Fatigue
Visual problems
Nursing Diagnosis
1. Impaired physical mobility related to hemiparesis, loss of balance
and coordination, spasticity, and brain injury.
2. Acute pain related to hemiplegia and disuse.
3. Deficient self-care related to stroke sequelae.
4. Disturbed sensory perception related to altered sensory reception,
transmission, and/or integration.
5. Impaired urinary elimination related to flaccid bladder, detrusor
instability, confusion, or difficulty in communicating.
6. Disturbed thought processes related to brain damage.
Nursing management
Etiology
Multiule Sclerosis communicating with body cells is electrical impulses, which are rapid and
specific and causes almost immediate responses.
Definition Three functions:
- Multiple sclerosis is a chronic, degenerative progressive disorder 1. Monitor changes inside and outside the body
ease of the central nervous system characterized by the Changes are called as stimuli
occurrence of small patches of demyelination in the brain and Gathered information is called as sensory input
spinal cord. 2. Processes and interprets sensory input
- Demyelination refers to the destruction of myelin, the fatty and Integration making decision about what should be
protein material that surrounds certain nerve fibers in the brain and done at the moment
spinal cord, which results in impaired transmission of the nerve 3. Effects a response by muscle or gland activation
impulses.
Types Structural Classification
1. Benign 1. Central Nervous System
Nervous system, dysfunction will occur in different - Consists of the brain and the spinal cord, which
episodes, full recovery occurs occupies the dorsal body cavity
2. Relapsing Remitting - Acts as the integrating and command centers of the
Most common nervous system
Neurological exacerbations occur but - Interpret sensory information and issue instructions
improvement can be seen with either complete or based on past/present experiences
partial recovery 2. Peripheral Nervous System
3. Primary Progressive - Spinal nerves (carry impulses to and from the spinal
Sudden loss of neurological function occurs, cord) and cranial nerves (carry impulses to and from the
which may not resolve brain)
Leaves severe functional impairments - Links all body parts of the body by carrying impulses
These may actually worsen over time from the sensory receptors to the CNS and from the
No remission follows CNS to the glands and muscles
4. Secondary Progressive
Starts familiar to relapsing remitting Functional Classification
Changes to a primary progressive form 1. Sensory or Afferent Division
No remission follows - Nerve fibers that convey the impulses to the CNS from
sensory receptors from the body
- Sensory fibers
o Somatic sensory fibers skin, skeletal
muscles and joints
o Visceral sensory fibers visceral organs
2. Motor or Efferent Division
- Carry impulses from the CNS to effector organs,
muscles and glands
- Two subdivisions
o Somatic Nervous System - allows to
consciously and voluntarily control the
skeletal muscles
o Parasympathetic Nervous System
automatic or involuntary
Sympathetic
Parasympathetic
- Microglia
o Dispose debris, including dead brain cells
and bacteria
- Ependymal
o Lines the cavities of the brain and spinal cord
o Helps to circulate the CSF that fills those
Anatomy and Physiology
cavities and forms a protective cushion
Nervous System
- Oligodendrocytes
Is the master and communicating system of the body. Every thought, action
and emotion reflects its activity. Its signaling device or means of
o Wrap the flat extensions tightly around the L later reaction ta viral infection
nerve fibers, producing fatty insulating T Trauma
coverings called as the myelin sheaths I Infection (viral)
- Schwann Cells The virus Epstein Barr is the most consistently linked to
o Form the myelin sheaths around nerve fibers MS, a virus that causes mononucleosis
found in the PNS P Pregnant
- Satellite Cells Symptoms decrease during pregnancy and increase
o Protective and cushioning cells after delivery
2. Neurons Disabling effects makes it difficult for the mother to carry
- Transmits messages from one part of the body to the pregnancy
another Increases likelihood for falls
- *Axons transmit nerve impulses away from the cell Worsen fatigue
body. When these impulses reach the axon terminals, Increases risk for infection
they stimulate the release of neurotransmitters into the L Loss of energy
extracellular space. E Emotional stress
- Cell body
o Metabolic center of the neuron Symptomatology
o Contains the usual organelles MS course assume different patterns
- Neurofibril A Ataxia or impaired coordination of movements
o Intermediate filaments that are important in Due to involvement of the cerebellum or basal ganglia
maintaining cell shape
M Muscle spasticity and muscle weakness
- Processes or fibers
Due to involvement of the main motor pathways of the spinal cord
o Convey incoming messages toward the cell
U Unusual reflexes (positive Babinski)
body
L Loss of energy (fatigue) COMMON SYMPTOM
- Dendrites
o Generate nerve impulses and conduct them T Tremors
away from the cell body T Two visions (diplopia) EARLIEST SIGN
- Axons Due to lesions in the optic nerves or their connections
o Each neuron has only one axon I Incontinence in urinary and bowel
o Arises from the axon hillock Secondary complications of MS
- Axon terminals P Paresthesia and pain
o Contain the chemicals called as Due to disruption of the sensory axons
neurotransmitters L Less perception to pain, touch and temperature
Axon Terminal E Emotional changes (apathy, euphoria)
- Separated from the next neuron by a tiny gap called D Depression
synaptic cleft Due to frontal or parietal lobe involvement
- Such a functional junction is called as synapse
- Very close, but never actually touch other neuron Laboratory Tests
- Covered with a white, fatty material called as myelin MRI
o Protects and insulates the fibers and - Test that produces clear pictures of the human body without
increases the transmission rate of the nerve the use of x rays
impulses - Uses large magnets, radio waves and a computer to produce
- Axons outside the CNS are myelinated by Schwann images
cells, specialized supporting that wrap themselves - To visualize small plaques and to evaluate the course of the
tightly around the axon disease and effect of the treatment
- After the wrapping process, a tight coil of wrapped Spinal Tap or Lumbar Puncture
membranes, myelin sheaths, encloses the axons - A procedure used to remove and test CSF to diagnose brain
- Since the myelin sheath is formed by many Schwann and spinal cord disorders including multiple sclerosis
Cells, it has gaps or indentations called as the Nodes of - CSF studies help define the extent of the disease process and
Ranvier monitor changes
Evoked Potential Tests
Neurons - Tests that measure the electrical activity of the brain caused
- Myelinated fibers are also found in the central nervous by light, sound and touch
system, however, it is oligodendrocytes that for the CNS - Detects problems along the cranial and spinal nerves
myelin sheaths
- Although the myelin sheaths formed by the Medications
oligodendrocytes and those formed by the Schwann Corticosteroids (prednisone and methylprednisolone) and ACTH
cells are similar, the CNS sheaths lacks a neurilemma o Used as anti inflammatory agents that may improve nerve
o Neurilemma remains intact when a conduction
peripheral nerve fiber is damaged Immunosuppressive agents like cyclosporine and glatiramer
o Plays an important role in fiber regeneration acetate
o Reduce the rate at which the disease progresses and
Etiology decrease the frequency and severity of exacerbations
M More common in women Interferons beta 1b (Betaseron and Avonex)
Women produce more protein called as S1PR2 which o Used in relapsing remitting MS and significantly reduces the
controls the permeability of the blood brain barrier area of demyelination in the brain tissue
Hormones may also play a significant role of the Baclofen
susceptibility to MS o An antispasmodic agent, choice for spasticity
U Usually occurs between ages 20 to 40 years old Beta adrenergic blockers, anticonvulsants, and benzodiazepines
o Used to treat ataxia Prognosis
Ascorbic acid Prognosis for people with MS is encouraging. Studies show that
o To acidify urine, making bacterial growth less likely majority of MS patient will experience a normal (or almost normal) life span.
People with MS tend to die from many of the same conditions that people
Treatments and Surgery without MS die form, like cancer and heart disease.
No cure is available, supportive care should be maintained Prognosis for longevity is good except in cases of sever MS. Symptoms cause
Maximum support to client and family is usually needed pain, discomfort and inconvenience, even though patients will never become
Safety precautions severely disabled. Some patient will need crutches or cane to remain
Promoting physical mobility ambulatory, however.
Preventing injury
Enhancing bladder and bowel control
Managing speech and swallowing difficulties
Improving sensory and cognitive function
Improving self care abilities
Promoting sexual functioning
Medication
Immediate gentle irrigation with water or a dilute water povidone-
iodine solution
Wound cleansing is especially important in rabies prevention since,
in animal studies, thorough wound cleansing alone without other
postexposure prophylaxis has been shown to markedly reduce the
likelihood of rabies.
Tetanus shot if you have not been immunized in ten years
Nursing Diagnosis
1. Impaired skin integrity r/t break in the skin
2. Ineffective breathing pattern related to asphyxia
3. Imbalanced Nutrition: less than body requirements related to
decreased swallowing reflexes
4. Hyperthermia related to viremia
5. Risk for injury related to seizures and weakness
Nursing Management
1. Isolate the patient.
2. Give emotional and spiritual support.
3. Provide optimum comfort.
Signs and Symptoms
4. Darken the room and provide a quiet environment.
Prodromal/Invasion Phase
5. Patient should not be bathed and there should not be any running
o Fever, headache, and general weakness or discomfort
water in the room or within the hearing distance of the patient.
Excitement or neurological phase 6. If IV fluid has to be given it should be wrapped and needle should
o Characterized by marked excitation, and apprehension. be securely anchored in the vein to avoid dislodging in times of
Terror may even occur restlessness.
o Delirium associated with nuchal rigidity, involuntary 7. Concurrent and terminal disinfection should be carried out
twitching or generalized convulsions 8. Providing public education, especially among children, in avoiding
Terminal/paralytic phase and reporting all animals that appear sick.
o The patient becomes quiet and unconscious. Death
occurs due to respiratory paralysis, circulatory collapse, Prognosis
or heart failure About 60,000 people die every year of rabies, mostly in Asia and
Note: disease progression Africa.
o Insomnia, anxiety, confusion, slight or partial paralysis, In the U.S., one to three people die from rabies each year.
excitation, hallucinations, agitation, hypersalivation Every year, more than 15 million people worldwide receive a post-
(increase in saliva), difficulty swallowing, and bite vaccination to prevent the disease; this is estimated to prevent
hydrophobia (fear of water) hundreds of thousands of rabies deaths annually.
Etiology Rhabdovirus
ORAL REVALIDA NCM1O5 JMCD
SYSTEMIC LUTHUS ERYTHIMATOUS
Etiology
Idiopathic
Risk Factors
Genetics
Hormones
Environmental Factors
UV
Drugs
Infection (EBV)
Medical Management
>Labs
-ANA test
-Complement test (low)
-CBC
-Erythrocyte sedimentation rate (high)
-C-reactive protein (high)
>Medication
-Corticosteroids (Prednisone)
-Anti-malarial (Plaquenil)
-Immunosuppresant (Benlysta)
-NSAIDs (Ibuprofen)
-Sunblock (SPF > 55)
>Surgical
-None