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MEDICAL-SURGICAL NURSING  Myocardial cells, Neurons, Bone cells, Osteocytes, Retinal Cells.
By: Anthony T. Villegas R.N.
Overview of structures and functions:  Support and protection of neurons.
 The functional unit of the nervous system is the nerve cells or TYPES
neurons 1. Astrocytes
 The nervous system is composed of the ff:  maintains blood brain barrier semi-permiable.
Central Nervous System  majority of brain tumors (90%) arises from called astrocytoma.
 Brain  integrity of blood brain barrier.
 Spinal Cord – serves as a connecting link between the brain & the 2. Oligodendria
periphery.  produces myelin sheath in CNS.
Peripheral Nervous System  act as insulator and facilitates rapid nerve impulse transmission.
 Cranial Nerves –12 pairs; carry impulses to & from the brain. 3. Microglia
 Spinal Nerves – 31 pairs; carry impulses to & from spinal cord.  stationary cells that carry on phagocytosis (engulfing of bacteria
Autonomic Nervous System or cellular debris, eating), pinocytosis (cell drinking).
 subdivision of the PNS that automatically controls body function such 4. Epindymal
as breathing & heart beat.  secretes a glue called chemo attractants that concentrate the
 Special senses of vision and hearing are also covered in this section bacteria.

 Sympathetic nervous system – generally accelerate some body

functions in response to stress.
Microglia Brain
 Parasympathetic nervous system – controls normal body functioning.
Monocytes Blood
Kupffers Kidney
CELLS Histiocytes Skin
A. NEURONS Alveolar Macrophage Lung
 Primary component of nervous system
 Composed of cell body (gray matter), axon, and dendrites
Central Nervous System
 Basic cells for nerve impulse and conduction.

Composition Of Brain
 80% brain mass
 Elongated process or fiber extending from the cell body
 10% blood
 Transmits impulses (messages) away from the cell body to dendrites
 10% CSF
or directly to the cell bodies of other neurons
Brain Mass
 Neurons usually has only one axon
Parts Of The Brain
1. Cerebrum
 Short, blanching fibers that receives impulses and conducts them
 largest part of the brain
toward the nerve cell body.
 outermost area (cerebral cortex) is gray matter
 Neurons may have many dendrites.
 deeper area is composed of white matter
 function of cerebrum: integration, sensory, motor
 Junction between neurons where an impulse is transmitted
 composed of two hemisphere the Right Cerebral Hemisphere
and Left Cerebral Hemisphere enclosed in the Corpus Callosum.
 Chemical agent (ex. Acetylcholine, norepinephrine) involved in the
 Each hemisphere divided into four lobes; many of the functional
transmission of impulse across synapse.
areas of the cerebrum have been located in these lobes:
Myelin Sheath
 A wrapping of myelin (whitish, fatty material) that protects and
Lobes of Cerebrum
insulates nerve fibers and enhances the speed of impulse
1. Frontal Lobe
 controls personality, behavior
o Both axons and dendrites may or may not have a myelin
 higher cortical thinking, intellectual functioning
sheath (myelinated/unmyelinated)
 precentral gyrus: controls motor function
o Most axons leaving the CNS are heavily myelinated by
 Broca’s Area: specialized motor speech area - when damaged
schwann cells
results to garbled speech.
2. Temporal Lobe
Functional Classification
 hearing, taste, smell
1. Afferent (sensory) neurons
 short term memory
 Transmit impulses from peripheral receptors to the CNS
 Wernicke’s area: sensory speech area
2. Efferent (motor) neurons
(understanding/formulation of language)
 Conduct impulses from CNS to muscle and glands
3. Pareital Lobe
3. Internuncial neurons (interneurons)
 for appreciation
 Connecting links between afferent and efferent neurons
 integrates sensory information
 discrimination of sensory impulses to pain, touch, pressure,
1. Excitability – ability of neuron to be affected by changes in external
heat, cold, numbness.
 Postcentral gyrus: registered general sensation (ex. Touch,
2. Conductility – ability of neuron to transmit a wave of excitetation
from one cell to another.
4. Occipital Lobe
3. Permanent Cell – once destroyed not capable of regeneration.
 for vision


Insula (Island of Reil)
1. Labile
 visceral function activities of internal organ like gastric motility.
 Capable of regeneration.
Limbic System (Rhinencephalon)
 Epidermal cells, GIT cells, GUT cells, cells of lungs.
 controls smell - if damaged results to anosmia (absence of
2. Stable
 Capable of regeneration with limited time, survival period.
 controls libido
 Kidney cells, Liver cells, Salivary cells, pancreas.
 controls long term memory
3. Permanent
Corpus Callosum
 Not capable of regeneration.
 large fiber tract that connects the two cerebral hemisphere


Basal Ganglia  In thoracic region, contain cells giving rise to autonomic

 island of gray matter within white matter of cerebrum fibers of sympathetic nervous system
 regulate & integrate motor activity originating in the cerebral
cortex White Matter
 part of extrapyramidal system 1. Ascending Tracts (sensory pathways)
 area of gray matter located deep within each cerebral a. Posterior Column
hemisphere.  Carry impulses concerned with touch,
 release dopamine (controls gross voluntary movement). pressure, vibration, & position sense
b. Spinocerebellar
2. Diencephalon/interbrain  Carry impulses concerned with muscle
 Connecting part of the brain, between the cerebrum & the brain tension & position sense to cerebellum
 Contains several small structures: the thalamus & hypothalamus c. Lateral Spinothalamic
are most important  Carry impulses resulting in pain &
Thalamus temperature sensations
 acts as relay station for discrimination of sensory signals (ex. d. Anterior Spinothlamic
Pain, temperature, touch)  Carry impulses concerned with crude touch
 controls primitive emotional responses (ex. Rage, fear) & pressure
Hypothalamus 2. Descending Tracts (motor pathways)
 found immediately beneath the thalamus a. Corticospinal (pyramidal, upper motor neurons)
 plays a major role in regulation/controls of vital function: blood  Conduct motor impulses from motor cortex
pressure, thirst, appetite, sleep & wakefulness, temperature to anterior horn cells (cross in the medulla)
(thermoregulatory center) b. Extrapyramidal
 acts as controls center for pituitary gland and affects both  Help to maintain muscle tone & to control
divisions of the autonomic nervous system. body movement, especially gross automatic
 controls some emotional responses like fear, anxiety and movements such as walking
 androgenic hormones promotes secondary sex characteristics. Reflex Arc

 early sign for males are testicular and penile enlargement  Reflex consists of an involuntary response to a stimulus

 late sign is deepening of voice. occurring over a neural pathway called a reflex arc.

 early sign for females telarch and late sign is menarch.  Not relayed to & from brain: take place at cord levels

3. Mesencephalon/Midbrain Components

 acts as relay station for sight and hearing. a. Sensory Receptors

 size of pupil is 2 – 3 mm.  Receives/reacts to stimulus

 equal size of pupil is isocoria. b. Afferent Pathways

 unequal size of pupil is anisocoria.  Transmits impulses to spinal cord

 hearing acuity is 30 – 40 dB. c. Interneurons

 positive PERRLA  Synapses with a motor neuron (anterior horn cell)

d. Efferent Pathways

4. Brain Stem  Transmits impulses from motor neuron to effector

 located at lowest part of brain. e. Effectors

 contains midbrain, pons, medulla oblongata.  Muscle or organ that responds to stimulus

 extends from the cerebral hemispheres to the foramen magnum

at the base of the skull. Supporting Structures

 contains nuclei of the cranial nerves and the long ascending and 1. Skull

descending tracts connecting the cerebrum and the spinal cord.  Rigid; numerous bones fused together

 contains vital center of respiratory, vasomotor, and cardiac  Protects & support the brain

functions. 2. Spinal Column

 Consists of 7 cervical, 12 thoracic, & 5 lumbar vertebrae as well

Pons as sacrum & coccyx

 pneumotaxic center controls the rate, rhythm and depth of  Supports the head & protect the spinal cord

respiration. 3. Meninges

Medulla Oblongata  Membranes between the skull & brain & the vertebral column &

 controls respiration, heart rate, swallowing, vomiting, hiccup, spinal cord

vasomotor center (dilation and constriction of bronchioles).  3 fold membrane that covers brain and spinal cord.
 For support and protection; for nourishment; blood supply

5. Cerebellum  Area between arachnoid & pia mater is called subarachnoid

 smallest part of the brain, lesser brain. space: CSF aspiration is done

 coordinates muscle tone and movements and maintains position  Subdural space between the dura and arachnoid

in space (equilibrium)  Layers:

 controls balance, equilibrium, posture and gait. Dura Mater

 outermost layer, tough, leathery

Spinal Cord Arachnoid Mater

 serves as a connecting link between the brain and periphery  middle layer, weblike

 extends from foramen magnum to second lumbar vertebra Pia Mater

 H-shaped gray matter in the center (cell bodies) surrounded by  innermost layer, delicate, clings to surface of brain

white matter (nerve tract and fibers) 4. Ventricles

 Four fluid-filled cavities connecting with one another &

Gray Matter spinal canal

1. Anterior Horns  Produce & circulate cerebrospinal fluid

 Contains cell bodies giving rise to efferent (motor) fibers 5. Cerebrospinal Fluid (CSF)

2. Posterior Horns  Surrounds brain & spinal cord

 Contains cell bodies connecting with afferent (sensory)  Offer protection by functioning as a shock absorber

fibers from dorsal root ganglion  Allows fluid shifts from the cranial cavity to the spinal cavity
3. Lateral Horns  Carries nutrient to & waste product away from nerve cells


 Component of CSF: CHON, WBC, Glucose 4 out of 6 extraocular movement.

6. Vascular Supply Trochlear : CN IV Motor: muscles for downward, inward,
 Two internal carotid arteries anteriorly movement of the eye
 Two vertebral arteries leading to basilar artery posteriorly Trigeminal : CN V Mixed: impulses from face, surface of
 These arteries communicate at the base of the brain through eyes (corneal reflex); muscle
the circle of willis Controlling mastication.
 Anterior, middle, & posterior cerebral arteries are the main Abducens : CN VI Motor: muscles for lateral deviation of
arteries for distributing blood to each hemisphere of the brain eye
 Brain stem & cerebellum are supplied by branches of the Facial : CN VII Mixed: impulses for taste from anterior
vertebral & basilar arteries tongue; muscles for facial
 Venous blood drains into dural sinuses & then into jugular veins Movement.

7. Blood-Brain-Barrier (BBB) Acoustic : CN VIII Sensory: impulses for hearing (cochlear

 Protective barrier preventing harmful agents from entering the division) & balance (vestibular

capillaries of the CNS; protect brain & spinal cord Division).

Glossopharyngeal : CN IX Mixed: impulses for sensation to posterior

Substance That Can Pass Blood-Brain Barrier tongue & pharynx; muscle

1. Amonia For movement of pharynx

 Cerebral toxin (elevation) & swallowing.

 Hepatic Encephalopathy (Liver Cirrhosis) Vagus : CN X Mixed: impulses for sensation to lower

 Ascites pharynx & larynx; muscle for

 Esophageal Varices Movement of soft palate, pharynx,

Early Signs of Hepatic Encephalopathy & larynx.

 Asterexis (flapping hand tremors). Spinal Accessory : CN XI Motor: movement of sternomastoid

Late Signs of Hepatic Encephalopathy muscles & upper part of trapezius

 Headache Muscles.

 Dizziness Hypoglossal : CN XII Motor: movement of tongue.

 Confusion
 Fetor hepaticus (amonia like breath) Autonomic Nervous System
 Part of the peripheral nervous system
 decrease LOC
 Include those peripheral nerves (both cranial & spinal) that regulates
2. Carbon Monoxide and Lead Poisoning
smooth muscles, cardiac muscles, & glands.
 Can lead to Parkinson’s Disease.
 Component:
 Epilepsy
1. Sympathetic Nervous System
 Treated with calcium EDTA.
 Generally accelerates some body function in response to
3. Type 1 DM (IDDM)
 Causes diabetic ketoacidosis.
2. Parasympathetic Nervous System
 And increases breakdown of fats.
 Controls normal body functioning
 And free fatty acids
 Resulting to cholesterol and positive to ketones (CNS
Sympathetic Nervous System Parasympathetic Nervous System
 Resulting to acetone breath odor/fruity odor.
(Adrenergic) Effect (Cholinergic) Effect, Vagal,
 And kusshmauls respiration a rapid shallow respiration. Sympatholytic
 Which may lead to diabetic coma. - Involved in fight or aggression - Involved in flight or withdrawal
4. Hepatitis response. response.
 Signs of jaundice (icteric sclerae). - Release of Norepinephrine - Release of Acetylcholine.
 Caused by bilirubin (yellow pigment) (cathecolamines) from adrenal - Decreases all bodily activities except
5. Bilirubin glands and causes vasoconstriction. GIT.

 Increase bilirubin in brain (kernicterus). - Increase all bodily activity except

 Causing irreversible brain damage. GIT

EFFECTS OF SNS - Constriction of pupils (miosis).
- Dilation of pupils (mydriasis) in - Increase salivation.

Peripheral Nervous System order to be aware. - Decrease BP and Heart Rate.

- Dry mouth (thickened saliva). - Bronchoconstriction, Decrease RR.

Spinal Nerves - Increase BP and Heart Rate. - Diarrhea

 31 pairs: carry impulses to & from spinal cord - Bronchodilation, Increase RR - Urinary frequency.

 Each segment of the spinal cord contains a pair of spinal nerves (one - Constipation.

of each side of the body) - Urinary Retention.

 Each nerve is attached to the spinal by two roots: - Increase blood supply to brain,

1. Dorsal (posterior) roots heart and skeletal muscles.

 contains afferent (sensory) nerve whose cell body is in - SNS I. Cholinergic Agents

the dorsal roots ganglion - Mestinon, Neostignin.

2. Ventral (anterior) roots I. Adrenergic Agents SE:

 Contains efferent (motor) nerve whose nerve fibers - Give Epinephrine. - PNS effect

originate in the anterior horn cell of the spinal cord SE:

(lower motor neuron) - SNS effect


Cranial Nerves - Contraindicated to patients

 12 pairs: carry impulses to & from the brain. suffering from COPD (Broncholitis, II. Anti-cholinergic Agents

 May have sensory, motor, or mixed functions. Bronchoectasis, Emphysema, - To counter cholinergic agents.
Asthma). - Atrophine Sulfate

Name & Number Function

Olfactory : CN I Sensory: carries impulses for sense of II. Beta-adrenergic Blocking Agents SE:

smell. - Also called Beta-blockers. - SNS effect

Optic : CN II Sensory: carries impulses for vision. - all ending with “lol”

Oculomotor : CN III Motor: muscles for papillary constriction, - Propranolol, Atenelol, Metoprolol.

elevation of upper eyelid; Effect of Beta-blockers


B – broncho spasm  Decerebrate Posturing: back arched, rigid extension of all

E – elicits a decrease in myocardial four extremities with hyperpronation of arms & plantar
contraction. flexion of feet: (damage to upper brain stem, midbrain, or
T – treats hypertension. pons)
A – AV conduction slows down.
- Should be given to patients with 2. Glasgow Coma Scale
Angina, Myocardial Infarction,  Objective measurement of LOC sometimes called as the quick
Hypertension neuro check
 Objective evaluation of LOC, motor / verbal response
ANTI- HYPERTENSIVE AGENTS  A standardized system for assessing the degree of neurologic
1. Beta-blockers – “lol” impairment in critically ill client
2. Ace Inhibitors – Angiotensin “pril”
(Captopril, Enalapril) Components
3. Calcium Antagonist – Nifedipine 1. Eye opening
(Calcibloc) 2. Verbal response
- In chronic cases of arrhythmia give 3. Motor response
Lidocane, Xylocane.
GCS Grading / Scoring
Effectors :Sympathetic (Adrenergic) Effect Parasympathetic (Cholinergic)
1. Conscious 15 – 14
2. Lethargy 13 – 11
3. Stupor 10 – 8
Eye dilate pupil (mydriasis) constrict pupil
4. Coma 7
5. Deep Coma 3

Gland of Head
3. Pupillary Reaction & Eye Movement
Lacrimal no effect stimulate
a. Observe size, shape, & equality of pupil (note size in millimeter)
b. Reaction to light: pupillary constriction
Salivary scanty thick, viscous secretions copious thin watery secretions
c. Corneal reflex: blink reflex in response to light stroking of
Dry mouth
d. Oculocephalic reflex (doll’s eyes): present in unconscious client
Heart increase rate & force of contraction decrease rate
with intact brainstem
4. Motor Function
a. Movement of extremities (paralysis)
Blood Vessel constrict smooth muscles of the skin, no effect
b. Muscle strength
Abdominal blood vessels, and
5. Vital Signs: respiratory patterns (may help localize possible lesion)
Cutaneous blood vessels
a. Cheyne-Stokes Respiration: regular rhythmic alternating
Dilates smooth muscles of bronchioles,
between hyperventilation & apnea; may be caused by structural
Blood vessels of the heart & skeletal muscles
cerebral dysfunction or by metabolic problems such as diabetic
Lungs bronchodilation bronchoconstriction
b. Central Neurogenic Hyperventilation: sustained, rapid, regular
respiration (rate of 25/min) with normal O2 level; usually due to
brainstem dysfunction
GI Tract decrease motility increase motility
c. Apneustic Breathing: prolonged inspiratory phase, followed by a
Constrict sphincters relaxed sphincters
2-to-3 sec pause; usually indicates dysfunction respiratory
Possibly inhibits secretions stimulate secretions
center in pons
Inhibits activity of gallbladder & ducts stimulate activity of gallbladder&
d. Cluster Breathing: cluster of irregular breathing, irregularly
followed by periods of apnea; usually caused by a lesion in
Inhibits glycogenolysis in liver
upper medulla & lower pons
e. Ataxic Breathing: breathing pattern completely irregular;
Adrenal Gland stimulates secretion of epinephrine & no effect
indicates damage to respiratory center of the medulla

Neurologic Exam
Urinary Tract relaxes detrusor muscles contract
1. Mental status and speech (Cerebral Function)
detrusor muscles
a. General appearance & behavior
Contract trigone sphincter (prevent voiding) relaxes trigone
b. LOC
sphincter (allows voiding)
c. Intellectual Function: memory (recent & remote), attention
span, cognitive skills
d. Emotional status
Acethylcholine Myesthenia Gravis Bi-polar Disorder
Dopamine Parkinson’s Disease Schizophrenia e. Thought content
f. Language / speech
Physical Examination
2. Cranial nerve assessment
Comprehensive Neuro Exam
3. Cerebellar Function: posture, gait, balance, coordination
Neuro Check
a. Romberg’s Test: 2 nurses, positive for ataxia
1. Level of Consciousness (LOC)
b. Finger to Nose Test: positive result mean dimetria (inability of
a. Orientation to time, place, person
body to stop movement at desired point)
b. Speech: clear, garbled, rambling
4. Sensory Function: light touch, superficial pain, temperature,
c. Ability to follow command
vibration & position sense
d. If does not respond to verbal stimuli, apply a painful stimulus
5. Motor Function: muscle size, tone, strength; abnormal or involuntary
(ex. Pressure on the nailbeds, squeeze trapezius muscle); note
response to pain
6. Reflexes
 Appropriate: withdrawal, moaning
a. Deep tendon reflex: grade from 0 (no response); to 4
 Inappropriate: non-purposeful (hyperactive); 2 (normal)
e. Abnormal posturing (may occur spontaneously or in response to b. Superficial
stimulus) c. Pathologic: babinski reflex (dorsiflexion of the great toe with
 Decorticate Posturing: extension of leg, internal rotation & fanning of toes): indicates damage to corticospinal tracts
abduction of arms with flexion of elbows, wrist, & finger:
(damage to corticospinal tract; cerebral hemisphere)


Level Of Consciouness (LOC)  20/200 indicates blindness

1. Conscious: awake  20/20 visual acuity if client is able to read letters above the red
2. Lethargy: lethargic (drowsy, sleepy, obtunded) line.
3. Stupor 2. Test of visual field or peripheral vision
 Stuporous: (awakened by vigorous stimulation) a. Superiorly
 Generalized body weakness b. Bitemporaly
 Decrease body reflex c. Nasally
4. Coma d. Inferiorly
 Comatose
 light coma: positive to all forms of painful stimulus CRANIAL NERVE III, IV, VI: OCULOMOTOR, TROCHLEAR, ABDUCENS
 deep coma: negative to all forms of painful stimulus  Controls or innervates the movement of extrinsic ocular muscle
Different Painful Stimulation  6 muscles:
1. Deep sternal stimulation / deep sternal pressure Superior Rectus Superior Oblique
2. Orbital pressure
3. Pressure on great toes
4. Corneal or blinking reflex
 Conscious Client: use a wisp of cotton
 Unconscious Client: place 1 drop of saline solution
Lateral Rectus Medial Rectus

Test of Memory
1. Short term memory
 Ask most recent activity
Inferior Oblique Inferior Rectus
 Positive result mean anterograde amnesia and damage to
 Trochlear: controls superior oblique
temporal lobe
 Abducens: controls lateral rectus
2. Long term memory
 Oculomotor: controls the 4 remaining EOM
 Ask for birthday and validate on profile sheet
 Positive result mean retrograde amnesia and damage to limbic
 Controls the size and response of pupil
 Consider educational background
 Normal pupil size is 2 – 3 mm
 Equal size of pupil: Isocoria
Level of Orientation
 Unequal size of pupil: Anisocoria
1. Time: first asked
 Normal response: positive PERRLA
2. Person: second asked
3. Place: third asked
 Largest cranial nerve
Cranial Nerves
 Consists of ophthalmic, maxillary, mandibular
Cranial Nerves Function
1. Olfactory S  Sensory: controls sensation of face, mucous membrane, teeth, soft
2. Optic S palate and corneal reflex
3. Oculomotor M
4. Trochlear M (smallest)  Motor: controls the muscle of mastication or chewing
5. Trigeminal B (largest)  Damage to CN V leads to Trigeminal Neuralgia / Tic Douloureux
6. Abducens M
7. Facial B  Medication: Carbamezapine (Tegretol)
8. Acoustic S
9. Glossopharengeal B
10. Vagus B (longest) CRANIAL NERVE VII: FACIAL
11. Spinal Accessory M  Sensory: controls taste, anterior 2/3 of tongue
12. Hypoglossal M
 Pinch of sugar and cotton applicator placed on tip of tongue
CRANIAL NERVE I: OLFACTORY  Motor: controls muscle of facial expression
 Sensory function for smell  Instruct client to smile, frown and if results are negative there is
Material Used facial paralysis or Bell’s Palsy and the primary cause is forcep
 Don’t use alcohol, ammonia, perfume because it is irritating and delivery.
highly diffusible.
 Use coffee granules, vinegar, bar of soap, cigarette CRANIAL NERVE VIII: ACOUSTIC, VESTIBULOCOCHLEAR
Procedure  Controls balance particularly kinesthesia or position sense, refers to
 Test each nostril by occluding each nostril movement and orientation of the body in space.
Abnormal Findings
1. Hyposnia: decrease sensitivity to smell CRANIAL NERVE IX, X: GLOSOPHARENGEAL, VAGUS
2. Dysosmia: distorted sense of smell  Glosopharenageal: controls taste, posterior 1/3 of tongue
3. Anosmia: absence of smell  Vagus: controls gag reflex
Either of the 3 may indicate head injury damaging the cribriform plate of  Uvula should be midline and if not indicative of damage to cerebral
ethmoid bone where olfactory cells are located may indicate inflammatory hemisphere
conditions (sinusitis)  Effects of vagal stimulation is PNS
CRANIAL NERVE II: OPTIC  Innervates with sternocleidomastoid (neck) and trapezius (shoulder)
 Sensory function for vision or sight
1. Test visual acuity or central vision or distance  Controls the movement of tongue
 Use Snellen’s Chart  Let client protrude tongue and it should be midline and if unable to
 Snellen’s Alphabet chart: for literate client do indicative of damage to cerebral hemisphere and/or has short
 Snellen’s E chart: for illiterate client frenulum.
 Snellen’s Animal chart: for pediatric client
 Normal visual acuity 20/20 Pathognomonic Signs:
 Numerator: is constant, it is the distance of person from the 1. PTB – low grade afternoon fever
chart (6-7 m, 20 feet) 2. PNEUMONIA – rusty sputum.
 Denominator: changes, indicates distance by which the person 3. ASTHMA – wheezing on expiration.
normally can see letter in the chart. 4. EMPHYSEMA – barrel chest.


5. KAWASAKI SYNDROME – strawberry tongue

6. PERNICIOUS ANEMIA – red beefy tongue S/sx
7. DOWN SYNDROME – protruding tongue 1. Visual disturbances
8. CHOLERA – rice watery stool.  blurring of vision (primary)
9. MALARIA – step ladder like fever with chills.  diplopia (double vision)
10. TYPHOID – rose spots in abdomen.  scotomas (blind spots)
11. DIPTHERIA – pseudo membrane. 2. Impaired sensation
12. MEASLES – koplick’s spots  touch, pain, pressure, temperature, or position sense
13. SLE – butterfly rashes.  paresthesia such as tingling sensation, numbness
14. LIVER CIRRHOSIS – spider like varices 3. Mood swings or euphoria (sense of elation)
15. LEPROSY – lioning face 4. Impaired motor function
16. BOLIMIA – chipmunk face.  weakness
17. APPENDICITIS – rebound tenderness  spasticity
18. DENGUE – petichae or positive herman’s sign.  paralysis
19. MENINGITIS – kernig’s sign (leg pain), brudzinski sign (neck pain). 5. Impaired cerebral function
20. TETANY – hypocalcemia (+) trousseu’s sign or carpopedal spasm/  scanning speech
(+) chvostek sign (facial spasm).  ataxic gait
21. TETANUS – risus sardonicus  nystagmus
22. PANCREATITIS – cullen’s sign (echymosis of umbilicus) / (+) grey  dysarthria
turners spots.  intentional tremor
23. PYLORIC STENOSIS – olive like mass. 6. Bladder
24. PDA – machine like murmur  Urinary retention or incontinence
25. ADDISON’S DISEASE – bronze like skin pigmentation. 7. Constipation
26. CUSHING’S SYNDROME – moon face appearance and buffalo hump. 8. Sexual impotence in male / decrease sexual capacity


Alzheimer’s disease (unsteady gait,

 Atrophy of brain tissue due to deficiency of acetylcholine. positive romberg’s test)

4 A’s of Alzheimer
a. Amnesia – loss of memory.
b. Agnosia – unable to recognized inanimate/familiar objects.
c. Apraxia – unable to determine purpose/ function of objects.
d. Aphasia – no speech (nodding).
Intentional tremors

*Expressive aphasia Nystagmus

 “motor speech center” unable to speak

 Broca’s Aphasia Dx

*Receptive aphasia 1. CSF Analysis: increase in IgG and Protein.

 inability to understand spoken words. 2. MRI: reveals site and extent of demyelination.

 Common to Alzheimer’s 3. CT Scan: increase density of white matter.

4. Visual Evoked Response (VER) determine by EEG: maybe delayed
 Wernike’s Aphasia
5. Positive Lhermittes Sign: a continuous and increase contraction of
 General Knowing Gnostic Area or General Interpretative
spinal column.

Nursing Intervention
1. Assess the client for specific deficit related to location of
 Aricept (taken at bedtime)
 Cognex
2. Promote optimum mobility
a. Muscles stretching & strengthening exercises
b. Walking exercises to improve gait: use wide-base gait
1. Palliative & supportive
c. Assistive devices: canes, walker, rails, wheelchair as necessary
3. Administer medications as ordered
a. ACTH (adreno chorticotropic hormone), Corticosteroids
Multiple Sclerosis (MS)
(prednisone) for acute exacerbations: to reduce edema at site
 Chronic intermittently progressive disorder of CNS
of demyelination to prevent paralysis.
characterized by scattered white patches of demyelination
b. Baclofen (Lioresal), Dantrolene (Dantrium), Diazepam (Valium) -
in brain and spinal cord.
muscle relaxants: for spacity
 Characterized by remission and exacerbation.
c. Beta Interferons - Immunosuppresants: alter immune response.
 S/sx are varied & multiple, reflecting the location of
4. Encourage independence in self-care activities
demyelination within the CNS.
5. Prevent complications of immobility
 Cause unknown: maybe a slow growing virus or possibly
6. Institute bowel program
autoimmune disorders.
7. Maintain side rails to prevent injury related to falls.
 Incident: Affects women more than men ages 20-40 are
8. Institute stress management techniques.
prone & more frequent in cool or temperate climate.
a. Deep breathing exercises
b. Yoga
 Ig G - only antibody that pass placental circulation causing passive
9. Increase fluid intake and increase fiber to prevent constipation.
immunity, short term protection
10. Maintain urinary elimination
 Ig A - present in all bodily secretions (tears, saliva, colostrums).
1. Urinary Retention
 Ig M - acute in inflammation.
a. perform intermittent catheterization as ordered: to prevent
 Ig E - for allergic reaction
 Ig D - for chronic inflammation.
b. Bethanecol Chloride (Urecholine) as ordered
Nursing Management
* Give palliative or supportive care.


 only given subcutaneous.  CSF cushions brain (shock absorber)

 monitor side effects bronchospasm and wheezing.  Obstruction of flow of CSF will lead to enlargement of skull
 monitor breath sounds 1 hour after subcutaneous posteriorly called hydrocephalus.
administration.  Early closure of posterior fontanels causes posterior enlargement of
2. Urinary Incontinence skull in hydrocephalus.
a. Establish voiding schedule
b. Anti spasmodic agent Prophantheline Bromide (Pro- DISORDERS
banthine) if ordered Increase Intracranial Pressure (IICP)
3. Force fluid to 3000 ml/day.  Increase in intracranial bulk brought due to an increase in any of the
4. Promote use of acid ash diet like cranberry juice, plums, prunes, 3 major intracranial components: Brain Tissue, CSF, Blood.
pineapple, vitamin C and orange: to acidify urine and prevent  Untreated increase ICP can lead to displacement of brain tissue
bacterial multiplication. (herniation).
11. Prevent injury related to sensory problems.  Present life threatening situation because of pressure on vital
a. Test bath water with thermometer. structures in the brain stem, nerve tracts & cranial nerve.
b. Avoid heating pads, hot water bottles.  Increase ICP may be caused:
c. Inspect body parts frequently for injury.  head trauma/injury
d. Make frequent position changes.  localized abscess
12. Prepare client for plasma exchange if indicated: to remove  cerebral edema
antibodies  hemorrhage
13. Provide psychologic support to client/significant others.  inflammatory condition (stroke)
a. Encourage positive attitude & assist client in setting realistic  hydrocephalus
goals.  tumor (rarely)
b. Provide compassion in helping client adapt to changes in body
image & self-concept. S/sx
c. Do not encourage false hope during remission. (Early signs)
d. Refer to MS societies & community agencies. 1. Decrease LOC
14. Provide client teaching & discharge planning concerning: 2. Irritability / agitation
a. General measures to ensure optimum health. 3. Progresses from restlessness to confusion & disorientation to
 Balance between activity & rest lethargy & coma
 Regular exercise such as walking, swimming, biking in
mild case. (Late signs)
 Use energy conservation techniques 1. Changes in Vital Signs (may be a late signs)
 Well-balance diet a. Systolic blood pressure increases while diastolic pressure
 Fresh air & sunshine remains the same (widening pulse pressure)
 Avoiding fatigue, overheating or chilling, stress, b. Pulse rate decrease
infection. c. Abnormal respiratory patterns (cheyne-stokes respiration)
b. Use of medication & side effects. d. temperature increase directly proportional to blood
c. Alternative methods for sexual counseling if indicated. pressure.
2. Pupillary Changes
COMMON CAUSE OF UTI a. Ipsilateral (same side) dilatation of pupil with sluggish
Female reaction to light from compression of cranial nerve III
- short urethra (3-5 cm, 1-1 ½ inches) b. unilateral dilation of pupils called uncal herniation
- poor perineal hygiene c. bilateral dilation of pupils called tentorial herniation
- vaginal environment is moist d. Pupil eventually becomes fixed & dilated
Nursing Management 3. Motor Abnormalities
- avoid bubble bath (can alter Ph of vagina). a. Contralateral (opposite side) hemiparesis from
- avoid use of tissue papers compression of corticospinal tract
- avoid using talcum powder and perfume. b. abnormal posturing
Male c. decorticate posturing (damage to cortex and spinal
- urethra (20 cm, 8 inches) cord).
- do not urinate after intercourse d. decerebrate posturing (damage to upper brain stem
that includes pons, cerebellum and midbrain).
5. Projective Vomiting
Monroe Kelly Hypothesis 6. Papilledema (edema of optic disc)
7. Possible seizure activity
Skull is a closed container
Nursing Intervention
Any alteration or increase in one of the intracranial components 1. Maintain patent airway and adequate ventilation by:
a. Prevention of hypoxia (decrease O2) and hypercarbia
Increase intracranial pressure (increase CO2) important:
(normal ICP is 0 – 15 mmHg)  Hypoxia may cause brain swelling which increase ICP
 Early signs of hypoxia:
Cervical 1 – also known as atlas.  Restlessness
Cervical 2 – also known as axis.  Tachycardia
 Agitation
Foramen Magnum  Late signs of hypoxia:
 Extreme restlessness
Medulla Oblongata  Bradycardia
 Dyspnea
Brain Herniation  Cyanosis
 Hypercarbia may cause cerebral vasodilation which
Increase intra cranial pressure increase ICP
Nursing Intervention  Hypercabia
1. alternate hot and cold compress to prevent hematoma  Increase CO2 (most powerful respiratory stimulant)


 In chronic respiratory distress syndrome decrease  Check insertion site for signs of infection; monitor
O2 stimulates respiration. temperature.
b. Before and after suctioning hyperventilate the client with  Assess system for CSF leakage, loose connections, air
resuscitator bag connected to 100% O2 & limit suctioning bubbles in he line, & occluded tubing.
to 10 – 15 seconds only. 9. Provide intensive nursing care for clients treated with barbiturates
c. Assist with mechanical hyperventilation as indicated: therapy or administration of paralyzing agents.
produces hypocarbia (decease CO2) causing cerebral a. Intravenous administration of barbiturates may be ordered: to
constriction & decrease ICP. induce coma artificially in the client who has not responded to
2. Monitor V/S, input and output & neuro check frequently to detect conventional treatment.
increase in ICP b. Paralytic agents such as [vercuronium bromide (Norcuron)]:
3. Maintain fluid balance: fluid restriction to 1200-1500 ml/day may be may be administered to paralyzed the client
ordered c. Reduces metabolic demand that may protect the brain from
4. Position the client with head of bed elevated to 30-45o angle with further injury.
neck in neutral position unless contraindicated to improve venous d. Constant monitoring of the client’s ICP, arterial blood gas,
drainage from brain. serum barbiturates level, & ECG is necessary.
5. Prevent further increase ICP by: e. EEG monitoring as necessary
a. Provide comfortable and quite environment. f. Provide appropriate nursing care for the client on a ventilator
b. Avoid use of restraints. 10. Observe for hyperthermia secondary to hypothalamus damage.
c. Maintain side rails.
d. Instruct client to avoid forms of valsalva maneuver like:
 Straining stool: administer stool softener & mild
laxatives as ordered (Dulcolax, Duphalac)
 Excessive vomiting: administer anti-emetics as ordered *CONGESTIVE HEART FAILURE
(Plasil - Phil only, Phenergan) Signs and Symptoms
 Excessive coughing: administer anti-tussive - dyspnea
(dextromethorphan) - orthopnea
 Avoid stooping/bending - paroxysmal nocturnal dyspnea
 Avoid lifting heavy objects - productive cough
e. Avoid clustering of nursing care activity together. - frothy salivation
6. Prevent complications of immobility. - cyanosis
7. Administer medications as ordered: - rales/crackles
a. Hyperosmotic agent / Osmotic Diuretic [Mannitol (Osmitrol)]: to - bronchial wheezing
reduce cerebral edema - pulsus alternans
Nursing Management - anorexia and general body malaise
 Monitor V/S especially BP: SE hypotension. - PMI (point of maximum impulse/apical pulse rate) is displaced
 Monitor strictly input and output every hour: (output should laterally
increase): notify physician if output is less 30 cc/hr. - S3 (ventricular gallop)
 Administered via side drip - Predisposing Factors/Mitral Valve
 Regulate fast drip to prevent crystal formation. o RHD
b. Loop Diuretics [Furosemide, (Lasix)]: to reduce cerebral edema o Aging
 drug of choice for CHF (pulmonary edema)
 loop of henle in kidneys. Treatment
Nursing Management Morphine Sulfate
 Monitor V/S especially BP: SE hypotension. Aminophelline
 Monitor strictly input and output every hour: (output should Digoxin
increase): notify physician if output is less 30 cc/hr. Diuretics
 Administered IV push or oral. Oxygen
 Given early morning Gases, blood monitor
 Immediate effect of 10-15 minutes.
 Maximum effect of 6 hours. RIGHT CONGESTIVE HEART FAILURE (venous congestion)
c. Corticosteroids [Dexamethasone (Decadron)]: anti-inflammatory Signs and Symptoms
effect reduces cerebral edema - jugular vein distention (neck)
d. Analgesics for headache as needed: - ascites
 Small dose of Codein SO4 - pitting edema
 Strong opiates may be contraindicated since they potentiate - weight gain
respiratory depression, alter LOC, & cause papillary - hepatosplenomegaly
changes. - jaundice
e. Anti-convulsants [Phenytoin (Dilantin)]: to prevent seizures. - pruritus
8. Assist with ICP monitoring when indicated: - esophageal varices
a. ICP monitoring records the pressure exerted within the cranial - anorexia and general body malaise
cavity by the brain, cerebral blood, & CSF
b. Types of monitoring devices:
 Intraventricular Catheter: inserted in lateral ventricle to give
direct measurement of ICP; also allows for drainage of CSF
if needed.
 Subarachnoid screw (bolt): inserted through the skull &
dura matter into subarachnoid space.
 Epidural Sensor: least invasive method; placed in space
between skull & dura matter for indirect measurement of
c. Monitor ICP pressure readings frequently & prevent
 Normal ICP reading is 0-15 mmHg; a sustained increase
above 15 mmHg is considered abnormal.
 Use strict aseptic technique when handling any part of the Signs and Symptoms of Lasix in terms of electrolyte imbalances
monitoring system. 1. Hypokalemia


- decrease potassium level - force fluids

- normal value is 3.4 – 5.5 meq/L - administer medications as ordered
Sign and Symptoms a. Allopurinol (Zylopril)
- weakness and fatigue - drug of choice for gout.
- constipation - mechanism of action: inhibits synthesis of uric acid.
- positive U wave on ECG tracing b. Colchesine
Nursing Management - acute gout
- administer potassium supplements as ordered (Kalium Durule, Oral - mechanism of action: promotes excretion of uric acid.
Potassium Chloride)
- increase intake of foods rich in potassium * Kidney stones
Signs and Symptoms
- renal cholic
- cool moist skin
FRUITS VEGETABLES Nursing Management
Apple Asparagus - force fluids
Banana Brocolli - administer medications as ordered
Cantalope Carrots a. Narcotic Analgesic
Oranges Spinach - Morphine Sulfate
- antidote: Naloxone (Narcan) toxicity leads to tremors.
2. Hypocalcemia/Tetany
b. Allopurinol (Zylopril)
- decrease calcium level
Side Effects
- normal value is 8.5 – 11 mg/100 ml
- respiratory depression (check for RR)
Signs and Symptoms
- tingling sensation
Parkinson’s Disease/ Parkinsonism
- paresthesia
 Chronic progressive disorder of CNS characterized by degeneration
- numbness
of dopamine producing cells in the substantia nigra of the midbrain
- (+) Trousseus sign/Carpopedal spasm
and basal ganglia.
- (+) Chvostek’s sign
 Progressive disorder with degeneration of the nerve cell in the basal
ganglia resulting in generalized decline in muscular function
- arrythmia
 Disorder of the extrapyramidal system
- seizures
 Usually occurs in the older population
Nursing Management
 Cause Unknown: predominantly idiopathic, but sometimes disorder is
- Calcium Glutamate per IV slowly as ordered
postencephalitic, toxic, arteriosclerotic, traumatic, or drug induced
* Calcium Glutamate toxicity – results to seizure
(reserpine, methyldopa (aldomet) haloperidol (haldol),
Magnesium Sulfate

Magnesium Sulfate toxicity
 Disorder causes degeneration of dopamine producing neurons in the
substantia nigra in the midbrain
 Dopamine: influences purposeful movement
Urine output DECREASE
 Depletion of dopamine results in degeneration of the basal ganglia
Respiratory rate
Patellar relfex absent
Predisposing Factors
1. Poisoning (lead and carbon monoxide)
3. Hyponatremia
2. Arteriosclerosis
- decrease sodium level
3. Hypoxia
- normal value is 135 – 145 meq/L
4. Encephalitis
Signs and Symptoms
5. Increase dosage of the following drugs:
- hypotension
a. Reserpine (Serpasil)
- dehydration signs (initial sign in adult is thirst, in infant tachycardia)
b. Methyldopa (Aldomet) Antihypertensive
- agitation
c. Haloperidol (Haldol) _______
- dry mucous membrane
d. Phenothiazine ___________________ Antipsychotic
- poor skin turgor
- weakness and fatigue
Side Effects Reserpine: Major depression lead to suicide
Nursing Management
- force fluids
- administer isotonic fluid solution as ordered

4. Hyperglycemia
Multiple loss
- normal FBS is 80 – 100 mg/dl
causes suicide
Signs and Symptoms
- polyuria
Loss of spouse Loss of Job
- polydypsia
Nursing Intervention for Suicide
- polyphagia
 direct approach towards the client
Nursing Management
 close surveillance is a nursing priority
- monitor FBS
 time to commit suicide is on weekends early morning

5. Hyperuricemia
- increase uric acid (purine metabolism)
1. Tremor: mainly of the upper limbs “pill rolling tremors” of extremities
- foods high in uric acid (sardines, organ meats and anchovies)
especially the hands; resting tremor: most common initial symptoms
2. Bradykinesia: slowness of movement
*Increase in tophi deposit leads to gouty arthritis.
3. Rigidity: cogwheel type
Signs and Symptoms
4. Stooped posture: shuffling, propulsive gait
- joint pain (great toes)
5. Fatigue
- swelling
6. Mask like facial expression with decrease blinking of the eyes.
7. Difficulty rising from sitting position.
Nursing Management


8. Quite, monotone speech  do not rush the client

9. Emotional lability: state of depression 5. Improve communication abilities:
10. Increase salivation: drooling type  Instruct the client to practice reading a loud
11. Cramped, small handwriting  Listen to own voice & enunciate each syllable clearly
12. Autonomic Symptoms 6. Refer for speech therapy when indicated.
a. excessive sweating 7. Maintain adequate nutrition.
b. increase lacrimation  Cut food into bite-size pieces
c. seborrhea  Provide small frequent feeding
d. constipation  Allow sufficient time for meals, use warming tray
e. decrease sexual capacity 8. Avoid constipation & maintain adequate bowel elimination
9. Provide significant support to client/ significant others:
Nursing Intervention  Depression is common due to changes in body image & self-
1. Administer medications as ordered concept
Anti-Parkinson Drug 10. Provide client teaching & discharge planning concerning:
a. Levodopa (L-dopa) short acting a. Nature of the disease
 MOA: Increase level of dopamine in the brain; relieves b. Use prescribed medications & side effects
tremors; rigidity; bradykinesia c. Importance of daily exercise as tolerated: balanced activity &
 SE: GIT irritation (should be taken with meal); anorexia; rest
N/V; postural hypotension; mental changes: confusion,  walking
agitation, hallucination; cardiac arrhythmias; dyskinesias.  swimming
 CI: narrow-angled glaucoma; client taking MAOI inhibitor;  gardening
reserpine; guanethidine; methyldopa; antipsychotic; acute d. Activities/ methods to limit postural deformities:
psychoses  Firm mattress with small pillow
 Avoid multi-vitamins preparation containing vitamin B6 &  Keep head & neck as erected as possible
food rich in vitamin B6 (Pyridoxine): reverses the  Use broad-based gait
therapeutic effects of Levodopa  Raise feet while walking
 Urine and stool may be darkened e. Promotion of active participation in self-care activities.
 Be aware of any worsening of symptoms with prolonged * Increase Vitamin B when taking INH (Isoniazid), Isonicotinic Acid Hydrazide
high-dose therapy: “on-off” syndrome. * Dopamine Agonist relieves tremor rigidity
b. Carbidopa-levodopa (Sinemet)
 Prevents breakdown of dopamine in the periphery & causes MAGIC 2’s IN DRUG MONITORING
c. Amantadine Hydrochloride (Symmetrel) LEVEL
 Used in mild cases or in combination with L-dopa to reduce Digoxin/Lanoxin .5 – 1.5 meq/L 2 CHF Cardiac

rigidity, tremors, & bradykinesia (increase force of

cardiac output)
Lithium/Lithane .6 – 1.2 meq/L 2 Bipolar Anti-Man
Anti-Cholinergic Drug
(decrease level of
a. Benztropine Mesylate (Cogentin)
b. Procyclidine (Kemadrine) Aminophelline 10 – 19 mg/100 ml 20 COPD Broncho
c. Trihexyphenidyl (Artane) (dilates bronchial tree)
 MOA: inhinit the action of acetylcholine; used in mild cases Dilantin/Phenytoin 10 – 19 mg/100 ml 20 Seizures Anti-Con
Acetaminophen/Tylenol 10 – 30 mg/100 ml 200 Osteo Non-nar
or in combination with L-dopa; relived tremors & rigidity
Arthritis Analgesi
 SE: dry mouth; blurred vision; constipation; urinary
retention; confusion; hallucination; tachycardia 1. Digitalis Toxicity
Anti-Histamines Drug Signs and Symptoms
a. Diphenhydramine (benadryl) - nausea and vomiting
 MOA: decrease tremors & anxiety - diarrhea
 SE: Adult: drowsiness Children: CNS excitement - confusion
(hyperactivity) because blood brain barrier is not yet fully - photophobia
developed. - changes in color perception (yellowish spots)
b. Bromocriptine (Parlodel) Antidote: Digibind
 MOA: stimulate release of dopamine in the substantia nigra 2. Lithium Toxicity
 Often employed when L-dopa loses effectiveness Signs and Symptoms
- anorexia
MAOI Inhibitor - nausea and vomiting
a. Eldepryl (Selegilene) - diarrhea
 MOA: inhibit dopamine breakdown & slow progression of - dehydration causing fine tremors
disease - hypothyroidism

Anti-Depressant Drug Nursing Management

a. Tricyclic - force fluids
 MOA: given to treat depression commonly seen in - increase sodium intake to 4 – 10 g% daily
Parkinson’s disease 3. Aminophelline Toxicity
2. Provide safe environment Signs and Symptoms
 Side rails on bed - tachycardia
 Rails & handlebars in the toilet, bathtub, & hallways - palpitations
 No scattered rugs - CNS excitement (tremors, irritability, agitation and restlessness)
 Hard-back or spring-loaded chair to make getting up easier Nursing Management
3. Provide measures to increase mobility - only mixed with plain NSS or 0.9 NaCl to prevent development of crystals of
 Physical Therapy: active & passive ROM exercise; stretching precipitate.
exercise; warm baths - administered sandwich method
 Assistive devices - avoid taking alcohol because it can lead to severe CNS depression
 If client “freezes” suggest thinking of something to walk over - avoid caffeine
4. Encourage independence in self-care activities: 4. Dilantin Toxicity
 alter clothing for ease in dressing Signs and Symptoms
 use assistive device - gingival hyperplasia (swollen gums)


- hairy tongue a. Surgical removal of thymus gland: thought to be involve in the

- ataxia production of acetylcholine receptor antibodies.
- nystagmus b. May cause remission in some clients especially if performed
Nursing Management early in the disease.
- provide oral care 3. Plasma Exchange (Plasmapheresis)
- massage gums a. Removes circulating acetylcholine receptor antibodies.
5. Acetaminophen Toxicity b. Use in clients who do not respond to other types of therapy.
Signs and Symptoms
- hepatotoxicity (monitor for liver enzymes) Nursing Interventions
- SGPT/ALT (Serum Glutamic Pyruvate Transaminace) 1. Administer anti-cholinesterase drugs as ordered:
- SGOT/AST (Serum Glutamic Oxalo-Acetil Transaminace) a. Give medication exactly on time.
- nephrotoxicity monitor BUN (10 – 20) and Creatinine (.8 – 1) b. Give with milk & crackers to decrease GI upset
- hypoglycemia c. Monitor effectiveness of drugs: assess muscle strength & vital
Tremors, tachycardia capacity before & after medication.
Irritability d. Avoid use of the ff drugs:
Restlessness  Morphine SO4 & Strong Sedatives: respiratory
Extreme fatigue depressant effects
Diaphoresis, depression  Quinine, Curare, Procainamide, Neomycin,
Antidote: Acetylceisteine (mucomyst) prepare suction apparatus as bedside. Streptomycine, Kanamycine & other aminoglycosides:
skeletal muscle blocking effect
MYASTHENIA GRAVIS (MG) e. Observe for side effects
 neuromuscular disorder characterized by a disturbance in the 2. Promote optimal nutrition:
transmission of impulses from nerve to muscle cells at the a. Mealtime should coincide with the peak effect of the drugs: give
neuromuscular junction leading to descending muscle weakness. medication 30 minutes before meals.
 Incidence rate: b. Check gag reflex & swallowing ability before feeding.
 highest between 15 & 35 years old for women, over 40 for men. c. Provide mechanical soft diet.
 Affects women more than men d. If the client has difficulty in chewing & swallowing, do not leave
 Cause: alone at mealtime; keep emergency airway & suctioning
 Unknown/ idiopathic equipment nearby.
 Thought to be autoimmune disorder whereby antibodies destroy 3. Monitor respiratory status frequently: Rate, Depth, Vital Capacity;
acetylcholine receptor sites on the postsynaptic membrane of ability to deep breathe & cough
the neuromuscular junction. 4. Assess muscle strength frequently; plan activity to take advantage of
 Voluntary muscles are affected, especially those muscles innervated energy peaks & provide frequent rest periods.
by the cranial nerve. 5. Observe for signs of myasthenic or cholinergic crisis.
 Abrupt onset of severe, generalized muscle  Symptoms similar to myasthenic c
weakness with inability to swallow, speak, or addition the side effect of anti-cho
 Autoimmune = Release of Cholinesterase Enzymes = Cholinesterase
maintain respirations. drugs (excessive salivation & swe
destroy Acetylcholine (ACH) = Decrease of Acetylcholine (ACH)
 Symptoms will improve temporarily with abdominal carmp, N/V, diarrhea,
 Acetylcholine: activate muscle contraction
tensilon test.  Symptoms worsen with tensilon te
 Autoimmune: it involves release of cholinesterase an enzyme that
Atropine Sulfate & emergency equ
destroys Ach
 Cholinesterase: an enzyme that destroys ACH
Causes: Cause:
 under medication  over medication with the choliner
 physical or emotional stress (anti-cholinesterase)
1. Initial sign is ptosis a clinical parameter to determine ptosis is
 infection
palpebral fissure: cracked or cleft in the lining or membrane of the
Signs and Symptoms Signs and Symptoms
 the client is unable to see, swallow, speak,  PNS
2. Diplopia
3. Dysphagia
Treatment Treatment
4. Mask like facial expression
 administer cholinergic agents as ordered  administer anti-cholinergic agents
5. Hoarseness of voice, weakness of voice
6. Respiratory muscle weakness that may lead to respiratory arrest
7. Extreme muscle weakness especially during exertion and morning; Nursing Care in Crisis:
increase activity & reduced with rest. a. Maintain tracheostomy set or endotracheal tube with mechanical
ventilation as indicated.
Dx b. Monitor ABG & Vital Capacity
1. Tensilon Test (Edrophonium Hydrochloride): IV injection of tensilon c. Administer medication as ordered:
provides temporary relief of S/sx for about 5-10 minutes and a  Myasthenic Crisis: increase doses of anti-cholinesterase
maximum of 15 minutes. drug as ordered.
 If there is no effect there is no damage to occipital lobe and
 Cholinergic Crisis: discontinue anti-cholinesterase drugs
midbrain and is negative for M.G.
as ordered until the client recovers.
2. Electromyography (EMG): amplitudes of evoked potentials decrease d. Established method of communication
e. Provide support & reassurance.
3. Presence of anti-acetlycholine receptors antibodies in the serum. 6. Provide nursing care for the client with thymectomy.
Medical Management
7. Provide client teaching & discharge planning concerning:
1. Drug Therapy a. Nature of the disease
a. Anti-cholinesterase Drugs: [Ambenonium (Mytelase),
b. Use of prescribe medications their side effects & sign of toxicity
Neostigmine (Prostigmin), Pyridostigmine (Mestinon)] c. Importance of checking with physician before taking any new
 MOA: block the action of cholinesterase & increase the level
medication including OTC drugs
of acetylcholine at the neuromuscular junction. d. Importance of planning activities to take advantage of energy
 SE: excessive salivation & sweating, abdominal cramps, N/V, peaks & of scheduling frequent rest period
diarrhea, fasciculations (muscle twitching). e. Need o avoid fatigue, stress, people with upper respiratory
b. Corticosteroids: Prednisone infection
 MOA: suppress autoimmune response f. Use of eye patch for diplopia (alternate eyes)
 Used if other drugs are not effective g. Need to wear medic-alert bracelet
2. Surgery (Thymectomy) h. Myasthenia Gravis foundation & other community agencies


9. Promote optimum nutrition:

Guillain-Barre Syndrome a. Check gag reflex before feeding
 a disorder of the CNS characterized by bilateral, symmetrical, b. Start with pureed food
peripheral polyneuritis characterized by ascending muscle paralysis. c. Assess need for NGT feeding: if unable to swallow; to prevent
 Can occur at any age; affects women and men equally aspiration
 Progression of disease is highly individual; 90% of clients stop 10. Administer medications as ordered
progression in 4 weeks; recovery is usually from 3-6 months; may a. Corticosteroids: suppress immune response
have residual deficits. b. Anti Cholinergic Agents:
Causes:  Atrophine Sulfate
1. Unknown / idiopathic c. Anti Arrythmic Agents:
2. May be autoimmune process  Lidocaine (Xylocaine)
 Bretylium: blocks release of norepinephrine; to prevent
Predisposing Factors increase of BP
1. Immunization 11. Assist in plasmapheresis (filtering of blood to remove autoimmune
2. Antecedent viral infections such as LRT infections anti-bodies)
12. Prevent complications:
S/sx a. Arrythmia
1. Mild Sensory Changes: in some clients severe misinterpretation of b. Paralysis of respiratory muscles / respiratory arrest
sensory stimuli resulting to extreme discomfort 13. Provide psychologic support & encouragement to client / significant
2. Clumsiness (initial sign) others
3. Progressive motor weakness in more than one limb (classically is 14. Refer for rehabilitation to regain strength & treat any residual
ascending & symmetrical) deficits.
4. Dysphagia: cranial nerve involvement
5. Ascending muscle weakness leading to paralysis INFLAMMATORY CONDITIONS OF THE BRAIN
6. Ventilatory insufficiency if paralysis ascends to respiratory muscles
7. Absence or decreased deep tendon reflex Meningitis
8. Alternate hypotension to hypertension  Inflammation of the meninges of the brain & spinal cord.
9. Arrythmia (most feared complication)  Cause by bacteria, viruses, & other M.O.
10. Autonomic disfunction: symptoms that includes
a. increase salivation Etiology / Most Common M.O.
b. increase sweating 1. Meningococcus: most dangerous
c. constipation 2. Pneumococcus
3. Streptococcus: cause of adult meningitis
Dx 4. Hemophilus Influenzae: cause of pediatric meningitis
1. CSF analysis: reveals increased in IgG and protein
2. EMG: slowed nerve conduction Mode of transmission
1. Airborne transmission (droplet nuclei)
Medical Management 2. Via blood, CSF, lymph
1. Mechanical Ventilation: if respiratory problems present 3. By direct extension from adjacent cranial structures (nasal, sinuses,
2. Plasmapheresis: to reduce circulating antibodies mastoid bone, ear, skull fracture)
3. Continuous ECG monitoring to detect alteration in heart rate & 4. By oral or nasopharyngeal route
4. Propranolol: to prevent tachycardia Signs and Symptoms
5. Atropine SO4: may be given to prevent episodes of bradycardia 2. Headache, photophobia, general body malaise, irritability,
during endotracheal suctioning & physical therapy 3. Projectile vomiting: due to increase ICP
4. Fever & chills
Nursing Intervention 5. Anorexia & weight loss
1. Maintain patent airway & adequate ventilation: 6. Possible seizure activity & decrease LOC
a. Monitor rate & depth of respiration; serial vital capacity 7. Abnormal posturing: (decorticate and decerebrate)
b. Observe for ventilatory insufficiency 8. Signs of Meningeal Irritation:
c. Maintain mechanical ventilation as needed a. Nuchal rigidity or stiff neck: initial sign
d. Keep airway free of secretions & prevent pneumonia b. Opisthotonos (arching of back): head & heels bent backward &
2. Check individual muscle groups every 2 hrs in acute phase to check body arched forward
progression of muscle weakness c. PS: Kernig’s sign (leg pain): contraction or pain in the hamstring
3. Assess cranial nerve function: muscles when attempting to extend the leg when the hip is
a. Check gag reflex flexed
b. Swallowing ability d. PS: Brudzinski sign (neck pain): flexion at the hip & knee in
c. Ability to handle secretion response to forward flexion of the neck
d. Voice
4. Monitor strictly the following:
a. Vital signs Dx
b. Input and output 1. Lumbar Puncture:
c. Neuro check  Measurement & analysis of CSF shows increased pressure,
d. ECG: due to arrhythmia elevated WBC & CHON, decrease glucose & culture positive for
e. Observe signs of autonomic dysfunction: acute period of specific M.O.
hypertension fluctuating with hypotension  A hollow spinal needle is inserted in the subarachnoid space
f. Tachycardia between the L3-L4 or L4-L5.
g. Arrhythmias
5. Maintain side rails to prevent injury related to fall Nursing Management Before Lumbar Puncture
6. Prevent complications of immobility: turning the client every 2 hrs 1. Secure informed consent and explain procedure.
7. Assist in passive ROM exercise 2. Empty bladder and bowel to promote comfort.
8. Promote comfort (especially in clients with sensory changes): 3. Encourage to arch back to clearly visualize L3-L4.
a. Foot cradle
b. Sheepskin Nursing Management Post Lumbar Puncture
c. Guided imagery 1. Place flat on bed 12 – 24 o

d. Relaxation techniques 2. Force fluids


3. Check punctured site for any discoloration, drainage and 1. Fat embolism is the most feared complications w/in 24 hrs
leakage to tissues. after a femur fracture.
4. Assess for movement and sensation of extremities.  Yellow bone marrow are produced from the medullary
cavity of the long bones and produces fat cells.
CSF analysis reveals  If there is bone fracture there is hemorrhage and there
1. Increase CHON and WBC would be escape of the fat cells in the circulation.
2. Decrease glucose
3. Increase CSF opening pressure (normal pressure is 50 – 100 Risk Factors
mmHg) Disease:
4. (+) cultured microorganism (confirms meningitis) 1. Hypertension
2. Diabetes Mellitus
CBC reveals 3. Atherosclerosis / Arteriosclerosis
1. Increase WBC 4. Myocardial Infarction
5. Mitral valve replacement
Nursing Management 6. Valvular Disease / replacement
1. Administer large doses of antibiotic IV as ordered: 7. Chronic atrial Fibrillation
a. Broad spectrum antibiotics (Penicillin, Tetracycline) 8. Post Cardiac Surgery
b. Mild analgesics: for headaches
c. Antipyretics: for fever Lifestyle:
2. Enforced strict respiratory isolation 24 hours after initiation of anti 1. Smoking
biotic therapy (for some type of meningitis) 2. Sedentary lifestyle
3. Provide nursing care for increase ICP, seizure & hyperthermia if they 3. Obesity (increase 20% ideal body weight)
occur 4. Hyperlipidemia more on genetics/genes that binds to cholesterol
4. Provide nursing care for delirious or unconscious client as needed 5. Type A personality
5. Enforce complete bed rest a. Deadline driven
6. Keep room quiet & dark: if the client has headache & photophobia b. Can do multiple tasks
7. Monitor strictly V/S, I & O & neuro check c. Usually fells guilty when not doing anything
8. Maintain fluid & electrolyte balance 6. Related to diet: increase intake of saturated fats like whole milk
9. Prevent complication of immobility 7. Related stress physical and emotional
10. Provide client teaching & discharge planning concerning: 8. Prolong use of oral contraceptives: promotes lypolysis (breakdown of
a. Importance of good diet: high CHON, high calories with small lipids) leading to atherosclerosis that will lead to hypertension &
frequent feedings. eventually CVA.
b. Rehabilitation program for residual deficit
 mental retardation Pathophysiology
 delayed psychomotor development 1. Interruption of cerebral blood flow for 5 min or more causes death
c. Prevent complications of neurons in affected area with irreversible loss of function.
 most feared is hydrocephalus 2. Modifying Factors:
 hearing loss/nerve deafness is second complication a. Cerebral Edema:
 consult audiologist  Develops around affected area causing further impairment
b. Vasospasm:
Cerebrovascular Accident (CVA) (Stroke/Brain Attack/Apoplexy/Cerebral  Constriction of cerebral blood vessel may occur, causing
Thrombosis) further decrease in blood flow
 Destruction (infarction) of brain cells caused by a reduction in c. Collateral Circulation:
cerebral blood flow and oxygen  May help to maintain cerebral blood flow when there is
 A partial or complete disruption in the brains blood supply. compromise of main blood supply
 2 largest & most common cerebral artery affected by stroke:
a. Mid Cerebral Artery Stages of Development
b. Internal Cerebral Artery 1. Transient Ischemic Attack (TIA)
 Incidence Rate: a. Initial / warning signs of impending CVA / stroke
a. Affects men more than women; Men are 2-3 times high risk; b. Brief period of neurologic deficit:
Incidence increase with age  Visual loss / Visual disturbance
 Causes:  Hemiparesis
a. Thrombosis (attached)  Slurred Speech / Speech disturbance
b. Embolism (detached): most dangerous because it can go to the  Vertigo
lungs & cause pulmonary embolism or the brain & cause  Aphasia
cerebral embolism.  Headache: initial sign
c. Hemorrhage  Dizziness
d. Compartment Syndrome: compression of nerves & arteries  Tinnitus
 Possible Increase ICP
S/sx Pulmonary Embolism c. May last less than 30 sec, but no more than 24 hrs with
1. Sudden sharp chest pain complete resolution of symptoms
2. Unexplained dyspnea 2. Stroke in Evolution
3. SOB  Progressive development of stroke symptoms over a period of
4. Tachycardia hours to days
5. Palpitations 3. Complete Stroke
6. Diaphoresis  Neurologic deficit remains unchanged for 2-3-days period
7. Mild restlessness
S/sx of Cerebral Embolism 1. Headache
1. Headache 2. Generalized Signs:
2. disorientation  Vomiting
3. Confusion  Seizure
4. Decrease LOC  Confusion
 Disorientation
S/sx Compartment syndrome  Decrease LOC
 Nuchal Rigidity


 Fever  Check for Partial Thromboplastin Time (PTT): if

 Hypertension prolonged there is a risk for bleeding
 Slow Bounding Pulse  Antidote: Protamine SO4
 Cheyne-Strokes Respiration  Warfarin (Comadin): long acting / long term therapy
 (+) Kernig’s & Brudzinski sign: may lead to hemorrhagic stroke  Give simultaneously with Heparin cause Warfarin
3. Focal Signs (related to site of infarction): (Coumadin) will take effect after 3 days
 Hemiplegia  Check for Prothrombin Time (PT): if prolonged there is
 Homonymous hemianopsia: loss of half of visual field a risk for bleeding
 Sensory loss  Antidote: Vitamin K (Aqua Mephyton)
 Aphasia  Anti Platelet: to inhibit platelet aggregation in treating TIA’s
 Dysarthia: inability to articulate words  PASA (Aspirin)
 Alexia: difficulty reading  Contraindicated for dengue, ulcer and unknown cause
 Agraphia: difficulty writing of headache because it may potentiate bleeding
e. Antihypertensive: if indicated for elevated BP
Dx f. Mild Analgesics: for pain
1. CT & Brain Scan: reveals brain lesions 12. Provide client health teachings and discharge planning concerning
2. EEG: abnormal changes a. Avoid modifiable risk factors (diet, exercise, smoking)
3. Cerebral Arteriography: invasive procedure due to injection of dye b. Prevent complication (subarachnoid hemorrhage is the
(iodine based); Uses dye for visualization most feared complication)
 May show occlusion or malformation of blood vessels c. Dietary modification (decrease salt, saturated fats and
 Reveals the site and extent of malocclusion caffeine)
d. Importance of follow up care
Nursing Management Post Cerebral Arteriography
 Allergy Test (shellfish) Nursing Intervention: Rehabiltation
 Force fluids to release dye because it is nephro toxic 1. Hemiplegia: results from injury to cell in the cerebral motor cortex or
 Check for peripheral pulse: distal (femoral) to corticospinal tract (causes contralateral hemiplegia since tracts
 Check for hematoma formation crosses medulla)
a. Turn every 2 hrs (20 min only on affected side)
Nursing Intervention: Acute Stage b. Use proper positioning & repositioning to prevent deformities
1. Maintain patent airway and adequate ventilation by: (foot drop, external rotation of hips, flexion of fingers, wrist
a. Assist in mechanical ventilation drop, abduction of shoulder & arms)
b. Administer O2 inhalation c. Support paralyzed arm on pillow or use sling while out of bed to
2. Monitor strictly V/S, I & O, neuro check & observe signs of increase prevent subluxation of shoulders
ICP, shock, hyperthermia, & seizure d. Elevate extremities to prevent dependent edema
3. Provide CBR as ordered e. Provide active & passive ROM exercises every 4 hrs
4. Maintain fluid & electrolyte balance & ensure adequate nutrition: 2. Susceptibility to hazard
a. IV therapy for the first few days a. Keep side rails up at all times
b. NGT for feeding the client who is unable to swallow b. Institute safety measures
c. Fluid restriction as ordered: to decrease cerebral edema & might c. Inspect body parts frequently for signs of injury
also increase ICP 3. Dysphagia: difficulty of swallowing
5. Maintain proper positioning & body alignment: a. Check for gag reflex before feeding client
a. Elevate head 30-45 degree to decrease ICP b. Maintain a calm, unhurried approach
b. Turn & reposition every 2 hrs (20 min only on the affected side) c. Place client in upright position
c. Passive ROM exercise every 4 hrs: prevent contractures; d. Place food in unaffected side of the mouth
promote body alignment e. Offer soft foods
6. Promote optimum skin integrity: turn client & apply lotion every 2 f. Give mouth care before & after meals
hrs 4. Homonymous Hemianopsia: loss of right or left half of each visual
7. Prevent complications of immobility by: field
a. Turn client to side a. Approach the client on unaffected side
b. Provide egg crate mattresses or water bed b. Place personal belongings, food etc., on unaffected side
c. Provide sand bag or food board. c. Gradually teach the client to compensate by scanning (ex.
8. Maintain adequate elimination: Turning the head to see things on affected side)
a. Offer bed pan or urinal every 2 hrs; catheterized only if 5. Emotional Lability: mood swings, frustrations
necessary a. Create a quiet, restful environment with a reduction in excessive
b. Administer stool softener & suppositories as ordered: to prevent sensory stimuli
constipation & fecal impaction b. Maintain a calm, non-threatening manner
9. Provide quiet, restful environment c. Explain to family that client’s behavior is not purposeful
10. Provide alternative means of communication to the client: 6. Aphasia: most common in right hemiplegics; may be receptive /
a. Non verbal cues expressive
b. Magic slate: not paper & pen tiring for client a. Receptive Aphasia
c. If positive to hemianopsia: approach client on unaffected side  Give simple, slow directions
11. Administer medications as ordered:  Give one command at a time; gradually shift topics
a. Hyperosmotic agent: to decrease cerebral edema  Use non-verbal techniques of communication (ex.
 Osmotic Diuretics (Mannitol) Pantomime, demonstration)
 Loop Diuretics Furosemide (Lasix) b. Expressive Aphasia
 Corticosteroids (Dexamethazone)  Listen & watch very carefully when the client attempts to
b. Anti-convulsants: to prevent or treat seizures speak
c. Thrombolytic / Fibrinolytic Agents: given to dissolve clot  Anticipate client’s needs to decrease frustrations & feeling
(hemorrhage must be ruled out) of helplessness
 Tissue Plasminogen Activating Factor (tPA, Alteplase): SE:  Allow sufficient time for client to answer
allergic Reaction 7. Sensory / Perceptual Deficit: more common in left hemiplegics;
 Streptokinase, Urokinase: SE: chest pain characterized by impulsiveness unawareness of disabilities, visual
d. Anticoagulants: for stroke in evolution or embolic stroke neglect (neglect of affected side & visual space on affected side)
(hemorrhage must be ruled out) a. Assist with self-care
 Heparin: short acting b. Provide safety measures
c. Initially arrange objects in environment on unaffected side


d. Gradually teach client to take care of the affected & turn a. Jacksonian Seizure (focal seizure)
frequently & look at affected side  characterized by tingling and jerky movement of index
8. Apraxia: loss of ability to perform purposeful, skilled acts finger and thumb that spreads to the shoulder and other
a. Guide client through intended movement (ex. Take object such side of the body.
as wash cloth & guide client through movement of washing) b. Psychomotor Seizure (focal motor seizure)
b. Keep repeating the movement  May follow trauma, hypoxia, drug use
9. Generalizations about the clients with left hemiplegia vs. right  Purposeful but inappropriate repetitive motor acts
hemiplegia & nursing care  Aura is present: daydreaming like
a. Left Hemiplegia  Automatism: stereotype repetitive and non propulsive
 Perceptual, sensory deficits: quick & impulsive behavior behavior
 Use safety measures, verbal cues, simplicity in all area of  Clouding of consciousness: not in contact with environment
care  Mild hallucinatory sensory experience
b. Right Hemiplegia
 Speech-language deficits: slow & cautious behavior 3. Status Epilepticus
 Use pantomime & demonstration  Usually refers to generalized grand mal seizure
 Seizure is prolong (or there are repeated seizures without
CONVULSIVE DISORDER/CONVULSION regaining consciousness) & unresponsive to treatment
 disorder of CNS characterized by paroxysmal seizure with or without  Can result in decrease in O2 supply & possible cardiac arrest
loss of consciousness abnormal motor activity alternation in  A continuous uninterrupted seizure activity
sensation and perception and changes in behavior.  If left untreated can lead to hyperpyrexia and lead to coma and
 Seizure: first convulsive attack eventually death.
 Epilepsy: second or series of attacks  DOC: Diazepam (Valium) & Glucose
 Febrile seizure: normal in children age below 5 years
C. Diagnostic Procedures
Predisposing Factors 1. CT Scan – reveals brain lesions
1. Head injury due to birth trauma 2. EEG – reveals hyper activity of electrical brain waves
2. Genetics
3. Presence of brain tumor D. Nursing Management
4. Toxicity from the ff: 1. Maintain patent airway and promote safety before seizure activity
a. Lead a. clear the site of blunt or sharp objects
b. Carbon monoxide b. loosen clothing of client
5. Nutritional and Metabolic deficiencies c. maintain side rails
6. Physical and emotional stress d. avoid use of restrains
7. Sudden withdrawal to anti-convulsant drug: is predisposing factor for e. turn clients head to side to prevent aspiration
status epilepticus: DOC: Diazepam (Valium) & Glucose f. place mouth piece of tongue guard to prevent biting or tongue
2. Avoid precipitating stimulus such as bright/glaring lights and noise
S/sx 3. Administer medications as ordered
 Dependent on stages of development or types of seizure a. Anti convulsants (Dilantin, Phenytoin)
1. Generalized Seizure b. Diazepam, Valium
 Initial onset in both hemisphere, usually involves loss of c. Carbamazepine (Tegnetol) – trigeminal neuralgia
consciousness & bilateral motor activity. d. Phenobarbital, Luminal
a. Major Motor Seizure (Grand mal Seizure): tonic-clonic seizure 4. Institute seizure and safety precaution post seizure attack
 Signs or aura with auditory, olfactory, visual, tactile, a. administer O2 inhalation
sensory experience b. provide suction apparatus
 Epileptic cry: is characterized by fall and loss of 5. Document and monitor the following
consciousness for 3-5 minutes a. onset and duration
 Tonic Phase: b. types of seizures
 Limbs contract or stiffens c. duration of post ictal sleep may lead to status epilepticus
 Pupils dilated & eye roll up to one side d. assist in surgical procedure cortical resection
 Glottis closes: causing noise on exhalation
 May be incontinent Overview Anatomy & Physiology of the Eye
 Occurs at same time as loss of consciousness last 20-
40 sec External Structure of Eye
 Tonic contractions: direct symmetrical extension of a. Eyelids (Palpebrae) & Eyelashes: protect the eye from foreign
extremities particles
 Clonic Phase: b. Conjunctiva:
 repetitive movement  Palpebral Conjunctiva: pink; lines inner surface of eyelids
 increase mucus production  Bulbar Conjunctiva: white with small blood vessels, covers
 slowly tapers anterior sclera
 Clonic contractions: contraction of extremities c. Lacrimal Apparatus (lacrimal gland & its ducts & passage): produces
 Postictal sleep: unresponsive sleep tears to lubricate the eye & moisten the cornea; tears drain into the
 Seizure ends with postictal period of confusion, drowsiness nasolacrimal duct, which empties into nasal cavity
b. Absence Seizure (Petit mal Seizure): d. The movement of the eye is controlled by 6 extraocular muscles
 Usually non-organic brain damage present (EOM)
 Must be differentiated from daydreaming
 Sudden onset with twitching & rolling of eyes that last 20-40 sec Internal Structure of Eye
 Common among pediatric clients characterized by: A. 3 layers of the eyeball
 Blank stare 1. Outer Layer
 Decrease blinking of eyes a. Sclera: tough, white connective tissue (“white of the eye”);
 Twitching of mouth located anteriorly & posteriorly

 Loss of consciousness (5 – 10 seconds) b. Cornea: transparent tissue through which light enters the
eye; located anteriorly

2. Partial or Localized Seizure 2. Middle Layer

 Begins in focal area of brain & symptoms are related to a a. Choroid: highly vascular layer, nourishes retina; located

dysfunction of that area posteriorly

 May progress into a generalized seizure


b. Ciliary Body: anterior to choroid, secrets aqueous humor; Glaucoma

muscle change shape of lens  Characterized by increase intraocular pressure resulting in
c. Iris: pigmented membrane behind cornea, gives color to progressive loss of vision
eye; located anteriorly  May cause blindness if not recognized & treated
d. Pupil: is circular opening in the middle of the iris that  Early detection is very important
constrict or dilates to regulate amount of light entering the  preventable but not curable
eye  Regular eye exam including tonometry for person over age 40 is
3. Inner Layer recommended
a. Light-sensitive layer composed of rods & cones (visual cell)
 Cones: specialized for fine discrimination & color Predisposing Factors
vision; (daylight / colored vision) 1. Common among 40 years old and above
 Rods: more sensitive to light than cones, aid in 2. Hereditary
peripheral vision; (night twilight vision) 3. Hypertension
b. Optic Disk: area in retina for entrance of optic nerve, has 4. Obesity
no photoreceptors 5. History of previous eye surgery, trauma, inflammation

B. Lens: transparent body that focuses image on retina

C. Fluid of the eye Types of Glaucoma:
1. Aqueous Humor: clear, watery fluid in anterior & posterior 1. Chronic (open-angle) Glaucoma:
chambers in anterior part of eye; serves as refracting medium &  Most common form
provides nutrients to lens & cornea; contribute to maintenance  Due to obstruction of the outflow of aqueous humor, in
of intraocular pressure trabecular meshwork or canal of schlemm
2. Vitreous Humor: clear, gelatinous material that fills posterior 2. Acute (close-angle) Glaucoma:
cavity of eye; maintains transparency & form of eye  Due to forward displacement of the iris against the cornea,
Visual Pathways obstructing the outflow of the aqueous humor
a. Retina (rods & cones) translates light waves into neural impulses  Occurs suddenly & is an emergency situation
that travel over the optic nerves  If untreated it will result to blindness
b. Optic nerves for each eye meet at the optic chiasm 3. Chronic (close-angle) Glaucoma:
 Fibers from median halves of the retinas cross here & travel  similar to acute (close-angle) glaucoma, with the potential for
to the opposite side of the brain an acute attack
 Fibers from lateral halves of retinas remain uncrossed
c. Optic nerves continue from optic chiasm as optic tracts & travels to S/sx
the cerebrum (occipital lobe) where visual impulses are perceived & 1. Chronic (open-angle) Glaucoma: symptoms develops slowly
interpreted  Impaired peripheral vision (PS: tunnel vision)
 Halos around light
 Mild discomfort in the eye
Canal of schlemm: site of aqueous humor drainage  Loss of central vision if unarrested
Meibomian gland: secrets a lubricating fluid inside the eyelid 2. Acute (close-angle) Glaucoma
Maculla lutea: yellow spot center of retina  Severe eye pain
Fovea centralis: area with highest visual acuity or acute vision  Blurred cloudy vision
 Halos around light
2 muscles of iris:  N/V
Circular smooth muscle fiber: Constricts the pupil  Steamy cornea
Radial smooth muscle fiber: Dilates the pupil  Moderate pupillary dilation
3. Chronic (close-angle) Glaucoma
Physiology of vision  Transient blurred vision
4 Physiological processes for vision to occur:  Slight eye pain
1. Refraction of light rays: bending of light rays  Halos around lights
2. Accommodation of lens
3. Constriction & dilation of pupils Dx
4. Convergence of eyes 1. Visual Acuity: reduced
2. Tonometry: reading of 24-32 mmHg suggest glaucoma; may be 50
Unit of measurements of refraction: diopters mmHg of more in acute (close-angle) glaucoma
Normal eye refraction: emmetropia 3. Ophthalmoscopic exam: reveals narrowing of small vessels of optic
Normal IOP: 12-21 mmHg disk, cupping of optic disk
4. Perimetry: reveals defects in visual field
Error of Refraction
5. Gonioscopy: examine angle of anterior chamber
1. Myopia: nearsightedness: Treatment: biconcave lens
2. Hyperopia: farsightedness: Treatment: biconvex lens
Medical Management
3. Astigmatisim: distorted vision: Treatment: cylindrical
1. Chronic (open-angle) Glaucoma
4. Presbyopia: “old sight” inelasticity of lens due to aging: Treatment:
a. Drug Therapy: one or a combination of the following
bifocal lens or double vista
 Miotics eye drops (Pilocarpine): to increase outflow of
aqueous humor
Accommodation of lenses: based on thelmholtz theory of accommodation
 Epinephrine eye drops: to decrease aqueous humor
Near Vision: Ciliary muscle contracts: Lens bulges
production & increase outflow
 Carbonic Anhydrase Inhibitor: Acetazolamide (Diamox): to
Far Vision: ciliary muscle dilates / relaxes: lens is flat
decrease aqueous humor production
 Timolol Maleate (Timoptic): topical beta-adrenergic blocker:
Convergence of the eye: to decrease intraocular pressure (IOP)
Error: b. Surgery (if no improvement with drug)
1. Exotropia:1 eye normal  Filtering procedure (Trabeculectomy / Trephining): to
2. Esophoria: corrected by corrective create artificial openings for the outflow of aqueous humor
eye surgery  Laser Trabeculoplasty: non-invasive procedure performed
3. Strabismus: squint eye with argon laser that can be done on an out-client basis;
4. Amblyopia: prolong squinting procedure similar result as trabeculectomy
2. Acute (close-angle) Glaucoma
Common Visual Disorder


a. Drug Therapy: before surgery  Phacoemulsification: type of extracapsular extraction; a

 Miotics eye drops (Pilocarpine): to cause pupil to contract & hollow needle capable of ultrasonic vibration is inserted into
draw iris away from cornea lens, vibrations emulsify the lens, which is aspirated
 Osmotic Agent (Glycerin oral, Mannitol IV): to decrease  Intracapsular Extraction: lens is totally removed within its
intraocular pressure (IOP) capsules, may be delivered from eye by cryoextraction (lens
 Narcotic Analgesic: for pain is frozen with metal probe & removed); total removal of
b. Surgery lens & surrounding capsules
 Peripheral Iridectomy: portion of the iris is excised to e. Peripheral Iridectomy: may be performed at the time of surgery;
facilitate outflow of aqueous humor small hole cut in iris to prevent development of secondary
 Argon Laser Beam Surgery: non-invasive procedure using glaucoma
laser produces same effect as iridectomy; done in out-client f. Intraocular Lens Implant: often performed at the time of
basis surgery
 Iridectomy: usually performed on second eye later since a 2. Nursing Intervention Pre-op
large number of client have an acute acute attack in the a. Assess vision in the unaffected eye since the affected eye will be
other eye patched post-op
3. Chronic (close-angle) Glaucoma b. Provide pre-op teaching regarding measures to prevent
a. Drug Therapy: intraocular pressure (IOP) post-op
 miotics (pilocarpine) c. Administer medication as ordered:
b. Surgery:  Topical Mydriatics (Mydriacyl) & Cyclopegics (Cyclogyl): to
 bilateral peripheral iridectomy: to prevent acute attacks dilate the pupil
 Topical antibiotics: to prevent infection
Nursing Intervention  Acetazolamide (Diamox) & osmotic agent (Oral Glycerin or
1. Administer medication as ordered Mannitol IV): to decrease intraocular pressure to provide
2. Provide quite, dark environment soft eyeball for surgery
3. Maintain accurate I & O with the use of osmotic agent 3. Nursing Intervention Post-op
4. Prepare client for surgery if indicated a. Reorient the client to surroundings
5. Provide post-op care b. Provide safety measures:
6. Provide client teaching & discharge planning  Elevate side rails
a. Self-administration of eye drops  Provide call bells
b. Need to avoid stooping, heavy lifting or pushing, emotional  Assist with ambulation when fully recovered from
upsets, excessive fluid intake, constrictive clothing around the anesthesia
neck c. Prevent intraocular pressure & stress on the suture line:
c. Need to avoid the use antihistamines or sympathomimetic drugs  Elevate head of the bed 30-40 degree
(found in cold preparation) in close-angle glaucoma since they  Have the client lie on back or unaffected side
may cause mydriasis  Avoid having the client cough, sneeze, bend over, or move
d. Importance of follow-up care head too rapidly
e. Need to wear medic-alert tag  Treat nausea with anti-emetics as ordered: to prevent
Cataract  Give stool softener as ordered: to prevent straining
 Decrease opacity of ocular lens  Observe for & report signs of intraocular pressure (IOP):
 Incidence increases with age  Severe eye pain
 Restlessness
Predisposing Factor  Increased pulse
1. Aging 65 years and above 4. Protect eye from injury:
2. May caused by changes associated with aging (“senile” cataract) a. Dressing usually removed the day after the surgery
3. Related to congenital b. Eyeglasses or eye shield used during the day
4. May develop secondary to trauma, radiation, infection, certain drugs c. Always use eye shield during the night
(corticosteroids) 5. Administer medication as ordered:
5. Diabetes Mellitus a. Topical mydriatics & cycloplegic: to decrease spasm of ciliary
6. Prolonged exposure to UV rays body & relieve pain
b. Topical antibiotics & corticosteroids
S/sx c. Mild analgesic as needed
1. Loss of central vision 6. Provide client teaching & discharge planning concerning:
2. Blurring or hazy vision a. Technique of eyedrop administration
3. Progressive decrease of vision b. Use of eye shield at night
4. Glare in bright lights c. No bending, stooping, or lifting
5. Milky white appearance at center of pupils d. Report signs & symptoms of complication immediately to
6. Decrease perception to colors physician:
 Severe eye pain
Diagnostic Procedure  Decrease vision
1. Ophthalmoscopic exam: confirms presence of cataract  Excessive drainage
 Swelling of eyelid
Nursing Intervention e. Cataract glasses / contact lenses
1. Prepare client for cataract surgery:  If a lens implant has not been performed the client will
a. Performed when client can no longer remain independent need glasses or contact lenses
because of reduced vision  Temporary glasses are worn for 1-4 weeks then permanent
b. Surgery performed on one eye at a time; usually in a same day glasses fitted
surgery unit  Cataract glasses magnify object by 1/3 & distortion
c. Local anesthesia & intravenous sedation usually used peripheral vision
d. Types of cataract surgery:  Have the client practice manual coordination with
 Extracapsular Extraction: lens capsule is excised & the lens assistance until new spatial relationship becomes
is expressed; posterior capsule is left in place (may be used familiar
to support new artificial lens implant); partial removal of  Have client practice walking, using stairs, reaching for
lens articles
 Contact lenses cause less distortion of vision; prescribe at
one month


Middle Ear
Retinal Detachment 1. Ossicles
 Separation of epithelial surface of retina a. 3 small bones: malleus (Hammer) attached to tympanic
 Detachment or the sensory retina from the pigment epithelium of membrane, incus (anvil), stapes (stirrup)
the retina b. Ossicles are set in motion by sound waves from tympanic
Predisposing Factors c. Sound waves are conducted by vibration to the footplate of
1. Trauma the stapes in the oval widow (an opening between the middle
2. Aging process ear & the inner ear)
3. Severe diabetic retinopathy 2. Eustachian Tube: connects nasopharynx & middle ear; bring air
4. Post-cataract extraction into middle ear, thus equalizing pressure on both sides of eardrum
5. Severe myopia (near sightedness)
Inner Ear
Pathophysiology 1. Cochlea
 Tear in the retina allows vitreous humor to seep behind the sensory  Controls hearing
retina & separate it from the pigment epithelium  Contains Organ of Corti (the true organ of hearing): the
receptor end-organ for hearing
S/sx  Transmit sound waves from the oval window & initiates
1. Curtain veil like vision coming across field of vision nerve impulses carried by cranial nerve VIII (acoustic
2. Flashes of light branch) to the brain (temporal lobe of cerebrum)
3. Visual field loss 2. Vestibular Apparatus
4. Floaters  Organ of balance
5. Gradual decrease of central vision  Composed of three semicircular canals & the utricle
3. Endolymph & Perilymph
Dx  For static equilibrium
1. Ophthalmoscopic exam: confirms diagnosis 4. Mastoid air cells
 Air filled spaces in temporal bone in skull

Medical Management
Disorder of the Ear
1. Bed rest with eye patched & detached areas dependent to prevent
further detachment
 Formation of new spongy bone in the labyrinth of the ear
2. Surgery: necessary to repair detachment
causing fixation of the stapes in the oval window
a. Photocoagulation: light beam (argon laser) through dilated pupil
 This prevent transmission of auditory vibration to the inner ear
creates an inflammatory reaction & scarring to heal the area
b. Cryosurgery or diathermy: application of extreme cold or heat to
Predisposing Factor
external globe; inflammatory reaction causes scarring & healing
1. Found more often in women
of area
c. Scleral buckling: shortening of sclera to force pigment
epithelium close to retina
1. Unknown / idiopathic
2. There is familial tendency
Nursing Intervention Pre-op
3. Ear trauma & surgery
1. Maintain bed rest as ordered with head of bed flat & detached area
in a dependent position
2. Use bilateral eye patches as ordered; elevate side rails to prevent
1. Progressive hearing loss
2. Tinnitus
3. Identify yourself when entering the room
4. Orient the client frequently to time of date & surroundings; explain
1. Audiometry: reveals conductive hearing loss
5. Provide diversional activities to provide sensory stimulation
2. Weber’s & Rinne’s Test: show bone conduction is greater than
Nursing Intervention Post-op
air conduction
1. Check orders for positioning & activity level:
a. May be on bed rest for 1-2 days
Medical Management
b. May need to position client so that detached area is in
1. Stapedectomy: procedure of choice
dependent position
 Removal of diseased portion of stapes & replacement with
2. Administer medication as ordered:
prosthesis to conduct vibrations from the middle ear to
a. Topical mydriatics
inner ear
b. Analgesic as needed
 Usually performed under local anesthesia
3. Provide client teaching & discharge planning concerning:
 Used to treat otoscrlerosis
a. Techniques of eyedrop administration
b. Use eye shield at night
Nursing Intervention Pre-op
c. No bending from waist; no heavy work or lifting for 6 weeks
1. Provide general pre-op nursing care, including an explanation of
d. Restriction of reading for 3 weeks or more
post-op expectation
e. May watch TV
2. Explain to the client that hearing may improve during surgery &
f. Need to check to physician regarding combing & shampooing
then decrease due to edema & packing
hair & shaving
g. Need to report complications such as recurrence of detachment
Nursing Intervention Post-op
1. Position the client according to the surgeon’s orders (possibly
Overview of Anatomy & Physiology Of Ear (Hearing)
with operative ear uppermost to prevent displacement of the
External Ear
1. Auricle (Pinna): outer projection of ear composed of cartilage &
2. Have the client deep breathe every 2 hours while in bed, but no
covered by skin; collects sound waves
2. External Auditory Canal: lined with skin; glands secretes cerumen
3. Elevate side rails; assist the client with ambulation & move
(wax), providing protection; transmits sound waves to tympanic
slowly: may have some vertigo
4. Administer medication as ordered:
3. Tympanic Membrane (Eardrum): at end of external canal; vibrates in
 Analgesic
response to sound & transmits vibrations to middle ear
 Antibiotics
 Anti-emetics


 Anti-motion sickness drug: Meclesine Hcl (Bonamine) Nursing Intervention

5. Check for dressing frequently for excessive drainage or bleeding 1. Maintain bed rest in a quiet, darkened room in position of
6. Assess facial nerve function: Ask the client to do the ff: choice; elevate side rails as needed
 Wrinkle forehead 2. Only move the client for essential care (bath may not be
 Close eyelids essential)
 Puff out checks for any asymmetry 3. Provide emesis basin for vomiting
7. Question the client about the ff: report existence to physicians 4. Monitor IV Therapy; maintain accurate I&O
 Pain 5. Assist in ambulation when the attack is over
 Headaches 6. Administer medication as ordered
 Vertigo 7. Prepare client for surgery as indicated (pot-op care includes
 Unusual sensations in the ear using above measures)
8. Provide client teaching & discharge planning concerning: 8. Provide client care & discharge planning concerning:
a. Warning against blowing nose or coughing; sneeze with a. Use of medication & side effects
mouth open b. Low sodium diet & decrease fluid intake
b. Need to keep ear dry in the shower; no shampooing until c. Importance of eliminating smoking
c. No flying for 6 mos. Especially if upper respiratory tract Overview of Anatomy & Physiology of Endocrine System
infection is present
d. Placement of cotton balls in auditory meatus after packing Endocrine System
is removed; change twice daily  Is composed of an interrelated complex of glands (Pituitary G,
Adrenal G, Thyroid G, Parathyroid G, Islets of langerhans of the
Meniere’s Disease pancreas, Ovaries & Testes) that secretes a variety of hormones
 Disease of the inner ear resulting from dilatation of the directly into the bloodstream.
endolymphatic system & increase volume of endolymph  Its major function, together with the nervous system: is to regulate
 Characterized by recurrent & usually progressive triad of symptoms: body function
vertigo, tinnitus, hearing loss
Hormones Regulation
Predisposing Factor 1. Hormones: chemical substance that acts s messenger to specific
1. Incidence highest between ages 30 & 60 cells & organs (target organs), stimulating & inhibiting various
Cause Two Major Categories
2. Unknown / idiopathic a. Local: hormones with specific effect in the area of secretion (ex.
3. Theories include the ff: Secretin, cholecystokinin, panceozymin [CCK-PZ])
a. Allergy b. General: hormones transported in the blood to distant sites
b. Toxicity where they exert their effects (ex. Cortisol)
c. Localized ischemia 2. Negative Feedback Mechanisms: major means of regulating
d. Hemorrhage hormone levels
e. Viral infection a. Decreased concentration of a circulating hormones triggers
f. Edema production of a stimulating hormones from pituitary gland; this
hormones in turn stimulates its target organ to produce
S/sx hormones
1. Sudden attacks of vertigo lasting hours or days; attacks occurs b. Increased concentration of a hormones inhibits production of
several times a year the stimulating hormone, resulting in decreased secretion of the
2. N/V target organ hormone
3. Tinnitus 3. Some hormones are controlled by changing blood levels of specific
4. Progressive hearing loss substances (ex. Calcium, glucose)
5. Nystagmus 4. Certain hormones (ex. Cortisol or female reproductive hormones)
follow rhythmic patterns of secretion
Dx 5. Autonomic & CNS control (pituitary-hypothalamic axis):
1. Audiometry: reveals sensorineural hearing loss hypothalamus controls release of the hormones of the anterior
2. Vestibular Test: reveals decrease function pituitary gland through releasing & inhibiting factors that stimulate
or inhibits hormone secretions
Medical Management
1. Acute: Hormone Function
 Atropine (decreases autonomic nervous system activity) Endocrine G Hormone Functions
 Diazepam (Valium) Pituitary G
 Fentanyl & Droperidol (Innovar)  Anterior lobe : TSH : stimulate thyroid G to
2. Chronic: release thyroid hormones
a. Drug Therapy: : ACTH : stimulate adrenal
 Vasodilators (nicotinic Acid) cortex to produce &
 Diuretics release adrenocoticoids
 Mild sedative or tranquilizers: Diazepam (Valium) : FSH, LH : stimulate growth,
 Antihistamines: Diphenhydramine (Benadryl) maturation, & function of primary
 Meclizine (antivert) & secondary sex organ
b. Diet: : GH, Somatotropin : stimulate growth of
 Low sodium diet body tissues & bones
 Restricted fluid intake : Prolactin or LTH : stimulate

 Restrict caffeine & nicotine development of mammary gland &

3. Surgery: Lactation

a. Surgical destruction of labyrinth causing loss of vestibular &  Posterior lobe : ADH : regulates H2O

cochlear function (if disease is unilateral) metabolism; release during stress

b. Intracranial division of vestibular portion of cranial nerve Or in response to an

VIII increase in plasma osmolality

c. Endolymphatic sac decompression or shunt to equalize To stimulate

pressure in endolymphatic space reabsorption of H2O & decrease



Output (ACTH), thyroid-stimulating H (TSH), follicle-stimulating H

: Oxytocin : stimulate uterine (FSH), luteinizing H (LH)
contractions during delivery & the  ACTH: promotes development of adrenal cortex
Release of milk in  LH: secretes estrogen
lactation  FSH: secretes progesterone
 Intermediate lobe : MSH : affects skin b. Also secretes hormones that have direct effects on tissues:
pigmentation somatotropic or growth H, prolactin
 Somatotropic / GH: promotes elongation of long bones
Adrenal G  Hyposecretion of GH: among children results to
 Adrenal Cortex : Mineralocorticoid : regulate fluid & dwarfism
electrolyte balance; stimulate  Hypersecretion of GH: among children results to
(ex. Aldosterone) reabsoption of sodium, gigantism
chloride, & H2O; stimulate  Hypersecretion of GH: among adults results to
potassium excretion acromegaly (square face)
: Glucocorticoids : increase blood  DOC: Ocreotide (Sandostatin)
glucose level by increasing rate of  Prolactin: promotes development of mammary gland;
(ex. Cortisol, glyconeogenesis; with help of oxytocin it initiates milk let down reflex
increase CHON catabolism; increase c. Regulated by hypothalamic releasing & inhibiting factors & by
corticosterone) mobilization of fatty negative feedback system
acid; promote sodium & H2O 2. Posterior Lobe PG (Neurohypophysis)
retention; anti-inflammatory effect; aid body in coping  Does not produce hormones
with stress  Store & release anti-diuretic hormones (ADH) & oxytocin
: Sex Hormones : influence produced by hypothalamus
development of secondary sex  Secretes hormones oxytocin (promotes uterine contractions
(androgens, estrogens characeristics preventing bleeding or hemorrhage)
progesterones)  Administer oxytocin immediately after delivery to prevent
 Adrenal Medulla : Epinephrine, : function in acute uterine atony.
stress; increase HR, BP; dilates  Initiates milk let down reflex with help of hormone prolactin
Norepinephrine bronchioles; convert 3. Intermediate Lobe PG
glycogen to glucose when  Secretes melanocytes stimulating H (MSH)
Needed by the muscles  MSH: for skin pigmentation
for energy  Hyposecretion of MSH: results to albinism
 Hypersecretion of MSH: results to vitiligo
Thyroid G : T3, T4 : regulate metabolic  2 feared complications of albinism:
rate; CHO, fats, & CHON 1. Lead to blindness due to severe photophobia
Metabolism; aid in 2. Prone to skin cancer
regulating physical & mental
Growth & development Adrenal Glands
: Thyrocalcitonin : lowers serum calcium  Two small glands, one above each kidney; Located at top of
& phosphate levels each kidney

Parathyroid G : PTH : regulates serum 2 Sections of Adrenal Glands

calcium & phosphate levels 1. Adrenal Cortex (outer portion): produces mineralocorticoids,
glucocorticoids, sex hormones
Pancreas (islets of  3 Zones/Layers
Langerhans)  Zona Fasciculata: secretes glucocortocoids (cortisol):
 Beta Cells : Insulin : allows glucose to controls glucose metabolism: Sugar
diffuse across cell membrane;  Zona Reticularis: secretes traces of glucocorticoids &
Converts glucose to androgenic hormones: promotes secondary sex
glycogen characteristics: Sex
 Alpha Cells : Glucagon : increase blood  Zona Glumerulosa: secretes mineralocorticoids
glucose by causing glyconeogenisis (aldosterone): promotes sodium and water reabsorption
& glycogenolysis in the and excretion of potassium: Salt
liver; secreted in 2. Adrenal Medulla (inner portion): produces epinephrine,
response to norepinephrine (secretes catecholamines a power hormone):
low blood sugar vasoconstrictor
 2 Types of Catecholamines:
Ovaries : Estrogen, Progesterone : development of  Epinephrine (vasoconstrictor)
secondary sex characteristics in the  Norepinephrine (vasoconstrictor)
Female, maturation of o Pheochromocytoma (adrenal medulla): Increase
sex organ, sexual functioning secretion of norepinephrine: Leading to hypertension
Maintenance of which is resistant to pharmacological agents leading to
pregnancy CVA: Use beta-blockers
Testes : Testosterone : development of
secondary sex characteristics in the Thyroid Gland
Male maturation of the  Located in anterior portion of the neck
sex organs, sexual functioning  Consist of 2 lobes connected by a narrow isthmus
 Produces thyroxine (T4), triiodothyronine (T3), thyrocalcitonin
Pituitary Gland (Hypophysis)  3 Hormones Secreted:
 Located in sella turcica at the base of brain  T3: 3 molecules of iodine (more potent)
 “Master Gland” or master clock  T4: 4 molecule of iodine
 Controls all metabolic function of body  T3 and T4 are metabolic hormone: increase brain activity;
3 Lobes of Pituitary Gland promotes cerebration (thinking); increase V/S
1. Anterior Lobe PG (Adenohypophysis)  Thyrocalcitonin: antagonizes the effects of parathormone to
a. Secretes tropic hormones (hormones that stimulate target promote calcium reabsorption.
glands to produce their hormones): adrenocorticotropic H


Parathyroid Gland a. Vasopressin (Pitressin) & Vasopressin Tannate (Pitressin

 4 small glands located in pairs behind the thyroid gland Tannate Oil): administered by IM injection
 Produce parathormone (PTH)  Warm to body temperature before giving
 Promotes calcium reabsorption  Shake tannate suspension to ensure uniform dispersion
b. Lypressin (Diapid): nasal spray
Pancreas 4. Prevent complications: hypovolemic shock is the most feared
 Located behind the stomach complication
 Has both endocrine & exocrine function (mixed gland) 5. Provide client teaching & discharge planning concerning:
 Consist of Acinar Cells (exocrine gland): which secretes pancreatic a. Lifelong hormone replacement: Lypressin (Diapid) as needed to
juices: that aids in digestion control polyuria & polydipsia
 Islets of langerhans (alpha & beta cells) involved in endocrine b. Need to wear medic-alert bracelet
 Alpha Cell: produce glucagons: (function: hyperglycemia) Syndrome of Inappropriate Anti-diuretic Hormone Secretion (SIADH)
 Beta Cell: produce insulin: (function: hypoglycemia)  Hypersecretion of anti-diuretic hormone (ADH) from the PPG even
 Delta Cells: produce somatostatin: (function: antagonizes the when the client has abnormal serum osmolality
effects of growth hormones)
Predisposing Factors
Gonads 1. Head injury
 Ovaries: located in pelvic cavity; produce estrogen & progesterone 2. Related to presence of bronchogenic cancer
 Testes: located in scrotum; produces testosterone  Initial sign of lung cancer is non productive cough
 Non invasive procedure is chest x-ray
Pineal Gland 3. Related to hyperplasia of pituitary gland (increase size of organ
 Secretes melatonin brought about by increase of number of cells)
 Inhibits LH secretion
 It controls & regulates circadian rhythm (body clock) S/sx
1. Person with SIADH cannot excrete a dilute urine
2. Fluid retention & Na deficiency
Diabetes Incipidus (DI) a. Hypertension
 DI: dalas-ihi b. Edema
 Decrease of anti-diuretic hormone (ADH) c. Weight gain
 Hyposecretion of ADH 3. Water intoxication: may lead to cerebral edema: lead to increase
 Hypofunction of the posterior pituitary gland (PPG) resulting in ICP; may lead to seizure activity
deficiency of ADH
 Characterized by excessive thirst & urination Dx
1. Urine specific gravity: is increase
2. Serum Sodium: is decreased
Anti-diuretic Hormone: Pitressin (Vasopressin)
Function: prevents urination thereby conserving water Medical Management
 Note: Alcohol inhibits release of ADH 1. Treat underlying cause if possible
2. Diuretics & fluid restriction
Predisposing Factor
1. Related to pituitary surgery Nursing Intervention
2. Trauma 1. Restrict fluid: to promote fluid loss & gradual increase in serum Na
3. Inflammation 2. Administer medications as ordered:
4. Presence of tumor a. Loop diuretics (Lasix)
b. Osmotic diuretics (Mannitol)
S/sx 3. Monitor strictly V/S, I&O & neuro check
1. Severe polyuria with low specific gravity 4. Weigh patient daily and assess for pitting edema
2. Polydipsia (excessive thirst) 5. Monitor serum electrolytes & blood chemistries carefully
3. Fatigue 6. Provide meticulous skin care
4. Muscle weakness 7. Prevent complications
5. Irritability
6. Weight loss
7. Hypotension
8. Signs of dehydration
a. Adult: thirst; Children: tachycardia HYPOTHYROIDISM
b. Agitation - all are decrease except weight and menstruation
c. Poor Skin turgor - memory impairment
d. Dry mucous membrane Signs and Symptoms
9. Tachycardia, eventually shock if fluids is not replaced - there is loss of appetite but there is weight gain
10. If left untreated results to hypovolemic shock (late sign anuria) - menorrhagia
- cold intolerance
Dx - constipation
1. Urine Specific Gravity (NV: 1.015 – 1.030): less than 1.004
2. Serum Na: increase resulting to hypernatremia HYPERTHYROIDISM
3. H2O deprivation test: reveals inability to concentrate urine - all are increase except weight and menstruation
Signs and Symptoms
Nursing Intervention - increase appetite but there is weight loss
1. Maintain F&E balance / Force fluids 2000-3000 ml/day - amenorrhea
a. Keep accurate I&O - exophthalmos
b. Weigh daily
c. Administer IV/oral fluids as ordered to replace fluid loss Thyroid Disorder
2. Monitor strictly V/S & observe for signs of dehydration &
hypovolemia Simple Goiter
3. Administer hormone replacement as ordered:  Enlargement of thyroid gland due to iodine deficiency


 Enlargement of the thyroid gland not caused by inflammation of 2. Increase dietary intake of foods rich in iodine:
neoplasm  Seaweeds
 Low level of thyroid hormones stimulate increased secretion of TSH  Seafood’s like oyster, crabs, clams and lobster but not
by pituitary; under TSH stimulation the thyroid increases in size to shrimps because it contains lesser amount of iodine.
compensate & produce more thyroid hormone  Iodized salt: best taken raw because it is easily destroyed
by heat
Predisposing Factors 3. Assist in surgical procedure of subtotal thyroidectomy
1. Endemic: caused by nutritional iodine deficiency, most common in 4. Provide client teaching & discharge planning concerning:
the “goiter belt” area, areas where soil & H2O are deficient in iodine;  Used of iodized salt in preventing & treating endemic goiter
occurs most frequently during adolescence & pregnancy  Thyroid hormone replacement
 Goiter belt area:
a. Midwest, northwest & great lakes region Hypothyroidism (Myxedema)
b. Places far from sea  Slowing of metabolic processes caused by hypofunction of the
c. Mountainous regions thyroid gland with decreased thyroid hormone secretion
2. Sporadic: caused by  Hyposecretion of thyroid hormone
 Increase intake of goitrogenic foods (contains agent that  Decrease in all V/S except wt & menses
decrease the thyroxine production: pro-goitrin an anti-thyroid  Adults: myxedema non pitting edema
agent that has no iodine). Ex. cabbage, turnips, radish,  Children: cretinism the only endocrine disorder that can lead to
strawberry, carrots, sweet potato, rutabagas, peaches, peas, mental retardation
spinach, broccoli, all nuts  In severe or untreated cases myxedema coma may occur:
 Soil erosion washes away iodine  Characterized by intensification of S/sx of hypothyroidism &
 Goitrogenic drugs: neurologic impairment leading to coma
a. Anti-Thyroid Agent: Propylthiouracil (PTU)  Mortality rate high; prompt recognition & treatment essential
b. Large doses of iodine  Precipitating factors: failure to take prescribed medications;
c. Phenylbutazone infection; trauma; exposure to cold; use of sedatives, narcotics
d. Para-amino salicylic acid or anesthetics
e. Lithium Carbonate
f. PASA (Aspirin) Predisposing Factors
g. Cobalt 1. Primary hypothyroidism: atrophy of the gland possibly caused
3. Genetic defects that prevents synthesis of thyroid hormones by an autoimmune process
2. Secondary hypothyroidism: caused by decreased stimulation
S/sx from pituitary TSH
1. Enlarged thyroid gland 3. Iatrogenic: surgical removal of the gland or over treatment of
2. Dysphagia hyperthyroidism with drugs or radioactive iodine; disease
3. Respiratory distress caused by medical intervention such as surgery
4. Mild restlessness 4. Related to atrophy of thyroid gland due to trauma, presence of
tumor, inflammation
Dx 5. Iodine deficiency
1. Serum T4: reveals normal or below normal 6. Autoimmune (Hashimotos Disease)
2. Thyroid Scan: reveals enlarged thyroid gland. 7. Occurs more often to women ages 30 & 60
3. Serum Thyroid Stimulating Hormone (TSH): is increased
(confirmatory diagnostic test) S/sx
4. RAIU (Radio Active Iodine Uptake): normal or increased 1. Loss of appetite: but there is wt gain
2. Anorexia
Medical Management 3. Weight gain: which promotes lipolysis leading to atherosclerosis
1. Drug Therapy: and MI
 Hormone replacement with levothyroxine (Synthroid) (T4), 4. Constipation
dessicated thyroid, or liothyronine (Cytomel) (T3) 5. Cold intolerance
 Small dose of iodine (Lugol’s or potassium iodide solution): for 6. Dry scaly skin
goiter resulting from iodine deficiency 7. Spares hair
2. Avoidance of goitrogenic food or drugs in sporadic goiter 8. Brittleness of nails
3. Surgery: 9. Decrease in all V/S: except wt gain & menses
 Subtotal thyroidectomy: (if goiter is large) to relieve pressure a. Hypotension
symptoms & for cosmetic reasons b. Bradycardia
c. Bradypnea
Nursing Intervention d. Hypothermia
1. Administer Replacement therapy as ordered: 10. Weakness and fatigue
a. Lugol’s Solution / SSKI (Saturated Solution of Potassium Iodine) 11. Slowed mental processes
 Color purple or violet and administered via straw to prevent 12. Dull look
staining of teeth. 13. Slow clumsy movement
 4 Medications to be taken via straw: Lugol’s, Iron, 14. Lethargy
Tetracycline, Nitrofurantoin (DOC: for pyelonephritis) 15. Generalized interstitial non-pitting edema (Myxedema)
b. Thyroid Hormones: 16. Hoarseness of voice
 Levothyroxine (Synthroid) 17. Decrease libido
 Liothyronine (Cytomel) 18. Memory impairment
 Thyroid Extracts 19. Psychosis
20. Menorrhagia
Nursing Intervention when giving Thyroid Hormones:
1. Instruct client to take in the morning to prevent insomnia Dx
2. Monitor vital signs especially heart rate because drug causes 1. Serum T3 and T4: is decreased
tachycardia and palpitations 2. Serum Cholesterol: is increased
3. Monitor side effects: 3. RAIU (Radio Active Iodine Uptake): is decreased
 Insomnia Medical Management
 Tachycardia and palpitations 1. Drug Therapy:
 Hypertension  Levothyroxine (Synthroid)
 Heat intolerance  Thyroglobulin (Proloid)


 Dessicated thyroid 2. Autoimmune: involves release of long acting thyroid stimulator

 Liothyronine (Cytomel) causing exopthalmus (protrusion of eyeballs) enopthalmus (late
2. Myxedema coma is a medical emergency: sign of dehydration among infants)
 IV thyroid hormones 3. Excessive iodine intake
 Correction of hypothermina 4. Related to hyperplasia (increase size of TG)
 Maintenance of vital function
 Treatment of precipitating cause S/sx
1. Increase appetite (hyperphagia): but there is weight loss
Nursing Intervention 2. Heat intolerance
1. Monitor strictly V/S & I&O, daily weights; observe for edema & 3. Weight loss
signs of cardiovascular complication & to determine presence of 4. Diarrhea: increase motility
myxedema coma 5. Increased in all V/S: except wt & menses
2. Administer thyroid hormone replacement therapy as ordered & a. Tachycardia
monitor effects: b. Increase systolic BP
a. Observe signs of thyrotoxicosis: c. Palpitation
 Tachycardia & palpitation 6. Warm smooth skin
 N/V 7. Fine soft hair
 Diarrhea 8. Pliable nails
 Sweating 9. CNS involvement
 Tremors a. Irritability & agitation
 Agitation b. Restlessness
 Dyspnea c. Tremors
b. Increase dosage gradually, especially in clients with cardiac d. Insomnia
complication e. Hallucinations
3. Provide comfortable and warm environment: due to cold f. Sweating
intolerance g. Hyperactive movement
4. Provide a low calorie diet 10. Goiter
5. Avoid the use of sedatives; reduce the dose of any sedatives, 11. PS: Exopthalmus (protrusion of eyeballs)
narcotics, or anesthetic agent by half as ordered 12. Amenorrhea
6. Provide meticulous skin care: to prevent skin breakdown
7. Increase fluid & food high in fiber: to prevent constipation; Dx
administer stool softener as ordered 1. Serum T3 and T4: is increased
8. Observe for signs of myxedema coma; provide appropriate 2. RAIU (Radio Active Iodine Uptake): is increased
nursing care 3. Thyroid Scan: reveals an enlarged thyroid gland
a. Administer medication as ordered
b. Maintain vital functions: Medical Management
 Correct hypothermia 1. Drug Therap:
 Maintain adequate ventilation a. Anti-thyroid drugs: Propylthiouracil (PTU) & methimazole
9. Myxedema coma: (Tapazole): blocke synthesis of thyroid hormone; toxic
 A complication of hypothyroidism & an emergency case effect include agranulocytosis
 A severe form of hypothyroidism is characterized by: b. Adrenergic Blocking Agent: Propranolol (Inderal): used to

 Severe hypotension decrease sympathetic activity & alleviate symptoms such as

 Bradycardia tachycardia

 Bradypnea 2. Radioactive Iodine Therapy

 Hypoventilation a. Radioactive isotope of iodine (ex. 131I): given to destroy

 Hyponatremia the thyroid gland, thereby decreasing production of thyroid

 Hypoglycemia hormone

 Hypothermia b. Used in middle-aged or older clients who are resistant to, or

 Leading to progressive stupor and coma develop toxicity from drug therapy
c. Hypothyroidism is a potential complication

Nursing Management for Myxedema Coma 3. Surgery: Thyroidectomy performed in younger client for whom

1. Assist in mechanical ventilation drug therapy has not been effective

2. Administer thyroid hormones as ordered

3. Administer IVF replacement isotonic fluid solution as Nursing Intervention

ordered / Force fluids 1. Monitor strictly V/s & I&O, daily weight

10. Provide client health teaching and discharge planning 2. Administer anti-thyroid medications as ordered:

concerning: a. Propylthiouracil (PTU)

a. Thyroid hormone replacement b. Methimazole (Tapazole)

b. Importance of regular follow-up care 3. Provide for period of uninterrupted rest:

c. Need in additional protection in cold weather a. Assign a private room away from excessive activity

d. Measures to prevent constipation b. Administer medication to promote sleep as ordered

e. Avoid precipitating factors leading to myxedema coma & 4. Provide comfortable and cold environment

hypovolemic shock 5. Minimized stress in the environment

f. Stress & infection 6. Encourage quiet, relaxing diversional activities

g. Use of anesthetics, narcotics, and sedatives 7. Provide dietary intake that is high in CHO, CHON, calories,
vitamin & minerals with supplemental feeding between meals &

Hyperthyroidism at bedtime; omit stimulant

 Secretion of excessive amounts of thyroid hormone in the blood 8. Observe for & prevent complication

causes an increase in metabolic process a. Exophthalmos: protects eyes with dark glasses & artificial

 Increase in T3 and T4 tears as ordered

 Grave’s Disease or Thyrotoxicosis b. Thyroid Storm

 Increase in all V/S except wt & menses 9. Provide meticulous skin care
10. Maintain side rails

Predisposing Factors 11. Provide bilateral eye patch to prevent drying of the eyes

1. More often seen in women between ages 30 & 50 12. Assist in surgical procedures subtotal Thyroidectomy:
13. Provide client teaching & discharge planning concerning:


a. Need to recognized & report S/sx of agranulocytosis (fever,

sore throat, skin rash): if taking anti-thyroid drugs
b. S/sx of hyperthyroidism & hypothyroidism

Thyroid Storm
 Uncontrolled & potentially life-threatening hyperthyroidism caused
by sudden & excessive release of thyroid hormone into the
bloodstream Hyperthermia
Precipitating Factors  Administer medications as ordered:
1. Stress  Anti Pyretics
2. Infection  Beta-blockers
3. unprepared thyroid surgery  Monitor strictly vital signs, input and output and neuro
S/sx  Maintain side rails
1. Apprehension  Offer TSB
2. Restlessness 8. Administer IV fluids as ordered: until the client is tolerating
3. Extremely high temp (up to 106 F / 40.7 C) fluids by mouth
4. Tahchycardia 9. Administer analgesics as ordered: for incisional pain
5. HF 10. Relieve discomfort from sore throat:
6. Respiratory Distress a. Cool mist humidifier to thin secretions
7. Delirium b. Administer analgesic throat lozenges before meals prn as
8. Coma ordered
11. Encourage coughing & deep breathing every hour
Nursing Intervention 12. Assist the client with ambulation: instruct the client to place the
1. Maintain patent airway & adequate ventilation; administer O2 as hands behind the neck: to decrease stress on suture line if
ordered added support is necessary
2. Administer IV therapy as ordered 13. Hormonal replacement therapy for lifetime
3. Administer medication as ordered: 14. Watch out for accidental laryngeal damage which may lead to
a. Anti-thyroid drugs hoarseness of voice: encourage client to talk/speak immediately
b. Corticosteroids after operation and notify physician
c. Sedatives 15. Provide client teaching& discharge planning concerning:
d. Cardiac Drugs a. S/sx of hyperthyroidism & hypothyroidism
b. Self administration of thyroid hormone: if total
Thyroidectomy thyroidectomy is performed
 Partial or total removal of thyroid gland c. Application of lubricant to the incision once suture is
 Indication: removed
 Subtotal Thyroidectomy: hyperthyroidism d. Perform ROM neck exercise 3-4 times a day
 Total Thyroidectomy: thyroid cancer e. Importance of follow up care with periodic serum calcium
Nursing Intervention Pre-op
1. Ensure that the client is adequately prepared for surgery
a. Cardiac status is normal
b. Weight & nutritional status is normal Hypoparathyroidism
2. Administer anti-thyroid drugs as ordered: to suppressed the  Disorder characterized by hypocalcemia resulting from a deficiency
production of thyroid hormone & to prevent thyroid storm of parathormone (PTH) production
3. Administer iodine preparation Lugol’s Solution (SSKI) or  Decrease secretion of parathormone: leading to hypocalcemia:
Potassium Iodide Solution: to decrease vascularity of the thyroid resulting to hyperphospatemia
gland & to prevent hemorrhage.  If calcium decreases phosphate increases

Nursing Intervention Post-Op Predisposing Factors

1. Monitor V/S & I&O 1. May be hereditary
2. Check dressing for signs of hemorrhage: check for wetness 2. Idiopathic
behind the neck 3. Caused by accidental damage to or removal of parathyroid
3. Place client in semi-fowlers position & support head with pillow gland during thyroidectomy surgery
4. Observe for respiratory distress secondary to hemorrhage, 4. Atrophy of parathyroid gland due to: inflammation, tumor,
edema of glottis, laryngeal nerve damage, or tetany: keep trauma
tracheostomy set, O2 & suction nearby
5. Assess for signs of tetany: due to hypocalcemia: due to S/sx
secondary accidental removal of parathyroid glands: keep 1. Acute hypocalcemia (tetany)
Calcium Gluconate available: a. Paresthesia: tingling sensation of finger & around lip
 Watch out for accidental removal of parathyroid which may b. Muscle spasm
lead to hypocalcemia (tetany) c. laryngospasm/broncospasm
Classic S/sx of Tetany d. Dysphagia
 Positive trousseu’s sign e. Seizure: feared complications
 Positive chvostek sign f. Cardiac arrhythmia: feared complications
 Observe for arrhythmia, seizure: give Calcium Gluconate IV g. Numbness
slowly as ordered h. Positive trousseu’s sign: carpopedal spasm
6. Ecourage clients voice to rest: i. Positive chvostek sign
a. Some hoarseness is common 2. Chronic hypocalcemia (tetany)
b. Check every 30-60 min for extreme hoarseness or any a. Fatigue
accompanying respiratory distress b. Weakness
7. Observe for signs of thyroid storm / thyrotoxicosis: due to c. Muscle cramps
release of excessive amount of thyroid hormone
SIGNS surgery d. Personality changes
e. Irritability
Agitation f. Memory impairment


g. Agitation  Increase secretion of PTH that results in an altered state of calcium,

h. Dry scaly skin phosphate & bone metabolism
i. Hair loss  Decrease parathormone
j. Loss of tooth enamel  Hypercalcemia: bone demineralization leading to bone fracture
k. Tremors (calcium is stored 99% in bone and 1% blood)
l. Cardiac arrhythmias  Kidney stones
m. Cataract formation
n. Photophobia Predisposing Factors
o. Anorexia 1. Most commonly affects women between ages 35 & 65
p. N/V 2. Primary Hyperparathyroidism: caused by tumor & hyperplasia of
parathyroid gland
Diagnostic Procedures 3. Secondary Hyperparathyroidism: cause by compensatory over
1. Serum Calcium level: decreased (normal value: 8.5 – 11 mg/100 secretion of PTH in response to hypocalcemia from:
ml) a. Children: Ricketts
2. Serum Phosphate level: increased (normal value: 2.5 – 4.5 b. Adults: Osteomalacia
mg/100 ml) c. Chronic renal disease
3. Skeletal X-ray of long bones: reveals a increased in bone density d. Malabsorption syndrome
4. CT Scan: reveals degeneration of basal ganglia
Nursing Management 1. Bone pain (especially at back); Bone demineralization;
1. Administer medications as ordered such as: Pathologic fracture
a. Acute Tetany: Calcium Gluconate slow IV drip as ordered 2. Kidney stones; Renal colic; Polyuria; Polydipsia; Cool moist skin
b. Chronic Tetany: 3. Anorexia; N/V; Gastric Ulcer; Constipation
 Oral calcium preparation: Calcium Gluconate, Calcium 4. Muscle weakness; Fatigue
Lactate, Calcium Carbonate (Os-Cal) 5. Irritability / Agitation; Personality changes; Depression; Memory
 Large dose of vitamin D (Calciferol): to help absorption impairment
of calcium 6. Cardiac arrhythmias; HPN


1. Serum Calcium: is increased
Drug Diet (Calcidiol) 2. Serum Phosphate: is decreased
Sunlight (Calcitriol) 3. Skeletal X-ray of long bones: reveals bone demineralization

 Phosphate Binder: Aluminum Hydroxide Gel Nursing Intervention

(Amphogel) or aluminum carbonate gel, basic 1. Administer IV infusions of normal saline solution & give diuretics
(basaljel): to decrease phosphate levels as ordered:
2. Monitor I&O & observe fluid overload & electrolytes imbalance
ANTACID 3. Assist client with self care: Provide careful handling, Moving,
Ambulation: to prevent pathologic fracture
A.A.C 4. Monitor V/S: report irregularities
MAD 5. Force fluids 2000-3000 L/day: to prevent kidney stones
6. Provide acid-ash juices (ex. Cranberry, orange juice): to acidify
Aluminum urine & prevent bacterial growth
Magnesium Containing 7. Strain urine: using gauze pad: for stone analysis
Containing 8. Provide low-calcium & high-phosphorus diet
Antacids 9. Provide warm sitz bath: for comfort
Antacids 10. Administer medications as ordered: Morphine Sulfate (Demerol)
11. Maintain side rails
12. Assist in surgical procedure: Parathyroidectomy
13. Provide client teaching & discharge planning concerning:
a. Need to engage in progressive ambulatory activities
b. Increase fluid intake
c. Use of calcium preparation & importance of high-calcium
Side Effect: Constipation Side
diet following a parathyroidectomy
Effect: Diarrhea
d. Prevent complications: renal failure
2. Institute seizure & safety precaution
e. Hormonal replacement therapy for lifetime
3. Provide quite environment free from excessive stimuli
f. Importance of follow up care
4. Avoid precipitating stimulus such as glaring lights and noise
5. Monitor signs of hoarseness or stridor; check for signs for
Addison’s Disease
Chvostek’s & Trousseau’s sign
 Primary adrenocortical insufficiency; hypofunction of the adrenal
6. Keep emergency equipment (tracheostomy set, injectable
cortex causes decrease secretion of the mineralcorticoids,
Calcium Gluconate) at bedside: for presence of laryngospasm
glucocorticoids, & sex hormones
7. For tetany or generalized muscle cramp: may use rebreathing
 Hyposecretion of adrenocortical hormone leading to:
bag or paper bag to produce mild respiratory acidosis: to
 Metabolic disturbance: Sugar
promote increase ionized Ca levels
 Fluid and electrolyte imbalance: Na, H2O, K
8. Monitor serum calcium & phosphate level
 Deficiency of neuromascular function: Salt, Sex
9. Provide high-calcium & low-phosphorus diet
10. Provide client teaching & discharge planning concerning:
Predisposing Factors
a. Medication regimen: oral calcium preparation & vit D to be
1. Relatively rare disease caused by:
taken with meal to increase absorption
 Idiopathic atrophy of the adrenal cortex: due to an
b. Need to recognized & report S/sx of hypo/hypercalcemia
autoimmune process
c. Importance of follow-up care with periodic serum calcium
 Destruction of the gland secondary to TB or fungal
d. Prevent complications
e. Hormonal replacement therapy for lifetime
1. Fatigue, Muscle weakness


2. Anorexia, N/V, abdominal pain, weight loss h. Avoidance of strenuous exercise especially in hot weather
3. History of hypoglycemic reaction / Hypoglycemia: tremors, i. Avoid precipitating factor: leading to addisonian crisis:
tachycardia, irritability, restlessness, extreme fatigue, stress, infection, sudden withdrawal to steroids
diaphoresis, depression j. Prevent complications: addisonian crisis, hypovolemic shock
4. Hyponatremia: hypotension, signs of dehydration, weight loss, k. Importance of follow up care
weak pulse
5. Decrease tolerance to stress
6. Hyperkalemia: agitation, diarrhea, arrhythmia
7. Decrease libido
8. Loss of pubic and axillary hair Addisonian Crisis
9. Bronze like skin pigmentation  Severe exacerbation of addison’s diseasecaused by acute adrenal
1. FBS: is decreased (normal value: 80 – 100 mg/dl) Predisposing Factors
2. Plasma Cortisol: is decreased 1. Strenuous activity
3. Serum Sodium: is decrease (normal value: 135 – 145 meq/L) 2. Stress
4. Serum Potassium: is increased (normal value: 3.5 – 4.5 meq/L) 3. Trauma
4. Infection
Nursing Intervention 5. Failure to take prescribe medicine
1. Administer hormone replacement therapy as ordered: 6. Iatrogenic:
a. Glucocorticoids: stimulate diurnal rhythm of cortisol release,  Surgery of pituitary gland or adrenal gland
give 2/3 of dose in early morning & 1/3 of dose in  Rapid withdrawal of exogenous steroids in a client on
afternoon long-term steroid therapy
 Corticosteroids: Dexamethasone (Decadrone)
 Hydrocortisone: Cortisone (Prednisone) S/sx
b. Mineralocorticoids: 1. Generalized muscle weakness
 Fludrocortisone Acetate (Florinef) 2. Severe hypotension
3. Hypovolemic shock: vascular collapse
Nursing Management when giving steroids 4. Hyponatremia: leading to progressive stupor and coma
1. Instruct client to take 2/3 dose in the morning and 1/3 dose
in the afternoon to mimic the normal diurnal rhythm Nursing Intervention
2. Taper dose (withdraw gradually from drug) 1. Assist in mechanical ventilation
3. Monitor side effects: 2. Administer IV fluids (5% dextrose in saline, plasma) as
 Hypertension ordered: to treat vascular collapse
 Edema 3. Administer IV glucocorticoids: Hydrocortisone (Solu-Cortef)
 Hirsutism & vasopressors as ordered
 Increase susceptibility to infection 4. Force fluids
 Moon face appearance 5. If crisis precipitate by infection: administer antibiotics as
2. Monitor V/S ordered
3. Decrease stress in the environment 6. Maintain strict bed rest & eliminate all forms of stressful
4. Prevent exposure to infection stimuli
5. Provide rest period: prevent fatigue 7. Monitor V/S, I&O & daily weight
6. Weight daily 8. Protect client from infection
7. Provide small frequent feeding of diet: decrease in K, increase 9. Provide client teaching & discharge planning concerning:
cal, CHO, CHON, Na: to prevent hypoglycemia, & hyponatremia same as addison’s disease
& provide proper nutrition Cushing Syndrome
8. Monitor I&O: to determine presence of addisonian crisis  Condition resulting from excessive secretion of corticosteroids,
(complication of addison’s disease) particularly glucocorticoid cortisol
9. Provide meticulous skin care  Hypersecretion of adrenocortical hormones
10. Provide client teaching & discharge planning concerning:
a. Disease process: signs of adrenal insufficiency Predisposing Factors
b. Use of prescribe medication for lifelong replacement 1. Primary Cushing’s Syndrome: caused by adrenocortical tumors
therapy: never omit medication or hyperplasia
c. Need to avoid stress, trauma & infection: notify the 2. Secondary Cushing’s Syndrome (also called Cushing’s disease):
physician if these occurs as medication dosage may need to caused by functioning pituitary or nonpituitary neoplasm
be adjusted secreting ACTH, causing increase secretion of glucocorticoids
d. Stress management technique 3. Iatrogenic: cause by prolonged use of corticosteroids
e. Diet modification 4. Related to hyperplasia of adrenal gland
f. Use of salt tablet (if prescribe) or ingestion of salty foods 5. Increase susceptibility to infections
(potato chips): if experiencing increase sweating
g. Importance of alternating regular exercise with rest periods S/sx
1. Muscle weakness 14. Signs of masculinization in women: menstrual dysfunction,
2. Fatigue decrease libido
3. Obese trunk with thin arms & legs 15. Osteoporosis
4. Muscle wasting 16. Decrease resistance to infection
5. Irritability 17. Hypertension
6. Depression 18. Edema
7. Frequent mood swings 19. Hypernatremia
8. Moon face 20. Weight gain
9. Buffalo hump 21. Hypokalemia
10. Pendulous abdomen 22. Constipation
11. Purple striae on trunk 23. U wave upon ECG (T wave hyperkalemia)
12. Acne 24. Hirsutis
13. Thin skin 25. Easy bruising
1. FBS: is increased
Dx 2. Plasma Cortisol: is increased


3. Serum Sodium: is increased 1. CHO Glucose Glycogen

4. Serum Potassium: is decreased 2. CHON Amino Acids Nitrogen
3. Fats Fatty Acids Free Fatty Acids
Nursing Intervention : cholesterol
1. Maintain muscle tone : ketones
a. Provide ROM exercise
b. Assist in ambulation
2. Prevent accidents fall & provide adequate rest HYPERGLYCEMIA
3. Protect client from exposure to infection Increase osmotic diuresis
4. Maintain skin integrity
a. Provide meticulous skin care Glycosuria
b. Prevent tearing of the skin: use paper tape if necessary Polyuria
5. Minimize stress in the environment
Cellular starvation: weight loss Cellular
6. Monitor V/S: observe for hypertension & edema
7. Monitor I&O & daily weight: assess for pitting edema: Measure
Stimulates the appetite / satiety center Stimulates
abdominal girth: notify physician
the thirst center
8. Provide diet low in Calorie & Na & high in CHON, K, Ca, Vitamin
9. Monitor urine: for glucose & acetone; administer insulin as
10. Provide psychological support & acceptance
11. Prepare client for hypophysectomy or radiation: if condition is
* liver has glycogen that undergo glycogenesis/glycogenolysis
caused by a pituitary tumor
12. Prepare client for Adrenalectomy: if condition is caused by an
adrenal tumor or hyperplasia
Formation of glucose from non-CHO sources
13. Restrict sodium intake
14. Administer medications as ordered: Spironolactone (Aldactone):
Increase protein formation
potassium sparring diuretics
15. Provide client teaching & discharge planning concerning:
Negative Nitrogen balance
a. Diet modification
b. Importance of adequate rest
Tissue wasting (Cachexia)
c. Need to avoid stress & infection
d. Change in medication regimen (alternate day therapy or
reduce dosage): if caused of condition is prolonged
corticosteroid therapy
Free fatty acids
e. Prevent complications (DM)
f. Hormonal replacement for lifetime: lifetime due to adrenal
gland removal: no more corticosteroid!
g. Importance of follow up care Ketones

Atherosclerosis Diabetic Keto

Diabetes Mellitus (DM)
 Represent a heterogenous group of chronic disorders characterized
by hyperglycemia Hypertension
Acetone Breath
 Hyperglycemia: due to total or partial insulin deficiency or
Kussmaul’s Respiration
insensitivity of the cells to insulin odor
 Characterized by disorder in the metabolism of CHO, fats, CHON, as
well as changes in the structure & function of blood vessels
 Metabolic disorder characterized by non utilization of carbohydrates,
protein and fat metabolism Diabetic Coma

Classification Of DM
Lack of insulin causes hyperglycemia (insulin is necessary for the transport of
1. Type I Insulin-dependent Diabetes Mellitus (IDDM)
glucose across the cell membrane) = Hyperglycemia leads to osmitic diuresis
 Secondary to destruction of beta cells in the islets of langerhans
as large amounts of glucose pass through the kidney result polyuria &
in the pancreas resulting in little of no insulin production
glycosuria = Diuresis leads to cellular dehydration & F & E depletion causing
 Non-obese adults
polydipsia (excessive thirst) = Polyphagia (hunger & increase appetite) result
 Requires insulin injection
from cellular starvation = The body turns to fat & CHON for energy but in the
 Juvenile onset type (Brittle disease)
absence of glucose in the cell fat cannot be completely metabolized & ketones
(intermediate products of fat metabolism) are produced = This leads to
Incidence Rate
ketonemia, ketonuria (contributes to osmotic diuresis) & metabolic acidosis
1. 10% general population has Type I DM
(ketones are acid bodies) = Ketone sacts as CNS depressants & can cause
coma = Excess loss of F & E leads to hypovolemia, hypotension, renal failure
Predisposing Factors
& decease blood flow to the brain resulting in coma & death unless treated.
1. Autoimmune response
2. Genetics / Hereditary (total destruction of pancreatic cells)
3. Related to viruses
4. Drugs: diuretics (Lasix), Steroids, oral contraceptives
5. Related to carbon tetrachloride toxicity

1. Polyuria 7. Anorexia
2. Polydipsia 8. N/V
3. Polyphagia 9. Blurring of vision
4. Glucosuria 10. Increase susceptibility to infection
5. Weight loss 11. Delayed / poor wound healing
6. Fatigue


1. FBS: Incidence Rate

a. A level of 140 mg/dl of greater on at two occasions 1. 90% of general population has Type II DM
confirms DM
b. May be normal in Type II DM Predisposing Factors
2. Postprandial Blood Sugar: elevated 1. Genetics
3. Oral Glucose Tolerance Test (most sensitve test): elevated 2. Obesity: because obese persons lack insulin receptor binding
4. Glycosolated Hemoglobin (hemoglobin A1c): elevated sites

Medical Management S/sx

1. Insulin therapy 1. Usually asymptomatic
2. Exercise 2. Polyuria
3. Diet: 3. Polydypsia
a. Consistency is imperative to avoid hypoglycemia 4. Polyphagia
b. High-fiber, low-fat diet also recommended 5. Glycosuria
4. Drug therapy: 6. Weight gain / Obesity
a. Insulin: 7. Fatigue
 Short Acting: used in treating ketoacidosis; during 8. Blurred Vision
surgery, infection, trauma; management of poorly 9. Increase susceptibility to infection
controlled diabetes; to supplement long-acting insulins 10. Delayed / poor wound healing
 Intermediate: used for maintenance therapy
 Long Acting: used for maintenance therapy in clients Dx
who experience hyperglycemia during the night with 5. FBS:
intermediate-acting insulin c. A level of 140 mg/dl of greater on at two occasions
b. Insulin preparation can consist of mixture of pure pork, confirms DM
pure beef, or human insulin. Human insulin is the purest d. May be normal in Type II DM
insulin & has the lowest antigenic effect 6. Postprandial Blood Sugar: elevated
c. Human Insulin: is recommended for all newly diagnosed 7. Oral Glucose Tolerance Test (most sensitve test): elevated
Type I & Type II DM who need short-term insulin therapy; 8. Glycosolated Hemoglobin (hemoglobin A1c): elevated
the pregnant client & diabetic client with insulin allergy or
severe insulin resistance Medical Management
d. Insulin Pumps: externally worn device that closely mimic 1. Ideally manage by diet & exercise
normal pancreatic functioning 2. Oral Hypoglycemic agents or occasionally insulin: if diet &
5. Exercise: helpful adjunct to therapy as exercise decrease the exercise are not effective in controlling hyperglycemia
body’s need for insulin 3. Insulin is needed in acute stress: ex. Surgery, infection
4. Diet: CHO 50%, CHON 30% & Fats 20%
Characteristics of Insulin Preparation a. Weight loss is important since it decreases insulin
Drug Synonym Appearance Onset Peak resistance
Duration Compatible Mixed b. High-fiber, low-fat diet also recommended
Rapid Acting 5. Drug therapy:
Insulin Injection Regular Ins Clear ½-1 2-4 6-8 a. Occasional use of insulin
All insulin prep b. Oral hypoglycemic agent:
 Used by client who are not controlled by diet &
except lente exercise
 Increase the ability of islet cells of the pancreas to
Insulin, Zinc Semilente Ins Cloudy ½-1 4-6 12-16 secret insulin; may have some effect on cell receptors
Lente prep to decrease resistance to insulin
suspension, 6. Exercise: helpful adjunct to therapy as exercise decrease the
prompt body’s need for insulin

Intermediate Acting Oral Hypoglycemic Agent

Isophane Ins NPH Ins Cloudy 1-1 ½ 8-12 18-24 Drug Onset Peak Duration
Regular Ins Comments
injection Oral Sulfonylureas
injection Acetohexamide (Dymelor) 1 4-6 12-24
Chlorpropamide (Diabinase) 1 4-6 40-60
Insulin Zinc Lente Ins Cloudy 1-1 ½ 8-12 18-24 Glyburide (Micronase, Diabeta) 15 min- 1 hr 2-8 10-24
Regular Ins &
Suspension Oral Biguanides
semilente prep Metformin (Glucophage) 2-2.5 10-16
:Decrease glucose
Long Acting
Insulin Zinc Ultralente Ins Cloudy 4-8 16-20 30-36 production in liver
Regular Ins &
suspension, :Decrease intestinal
semilente prep
extended absorption of glucose &

Complication improves insulin sensitivity

1. Diabetic Ketoacidosis (DKA)
Oral Alpha-glucosidose Inhibitor
2. Type II Non-insulin-dependent Diabetes Mellitus (NIDDM) Acarbose (Precose) Unknown 1 Unknown
 May result to partial deficiency of insulin production &/or an :Delay glucose absorption
insensitivity of the cells to insulin
 Obese adult over 40 years old & digestion of CHO,
 Maturity onset type
lowering blood sugar


Miglitol (Glyset) 2-3  Avoid alcohol intake while on medication: it can lead to
Troglitazone (Rezulin) Rapid 2-3 Unknown severe hypoglycemia reaction
:Reduce plasma glucose &  Instruct the client to take it with meals: to lessen GIT
irritation & prevent hypoglycemia
insulin e. Urine testing (not very accurate reflection of blood glucose
:Potetiates action of insulin  May be satisfactory for Type II diabetics since they are
more stable
in skeletal muscle &  Use clinitest, tes-tape, diastix, for glucose testing
 Perform test before meals & at bedtime
decrease glucose  Use freshly voided specimen
 Be consistent in brand of urine test used
production in liver  Report results in percentage
 Report result to physician if results are greater that
Complications 1%, especially if experiencing symptoms of
1. Hyper Osmolar Non-Ketotic Coma (HONKC) hyperglycemia
 Urine testing for ketones should be done by Type I
Nursing Intervention diabetic clients when there is persistent glycosuria,
1. Administer insulin or oral hypoglycemic agent as ordered: increase blood glucose level or if the client is not
monitor hypoglycemia especially during period of drug peak feeling well (acetest, ketostix)
action f. Blood glucose monitoring
2. Provide special diet as ordered:  Use for Type I diabetic client: since it gives exact blood
a. Ensure that the client is eating all meals glucose level & also detects hypoglycemia
b. If all food is not ingested: provide appropriate substitute  Instruct client in finger stick technique: use of monitor
according to the exchange list or give measured amount of device (if used), & recording & utilization of test results
orange juice to substitute for leftover food; provide snack g. General care
later in the day  Perform good oral hygiene & have regular dental exam
3. Monitor urine sugar & acetone (freshly voided specimen)  Have regular eye exam
4. Perform finger sticks to monitor blood glucose level as ordered  Care for “sick days” (ex. Cold or flu)
(more accurate than urine test)  Do not omit insulin or oral hypoglycemic agent:
5. Observe signs of hypo/hyperglycemia since infection causes increase blood sugar
6. Provide meticulous skin care & prevent injury  Notify physician
7. Maintain I&O; weight daily  Monitor urine or blood glucose level & urine
8. Provide emotional support: assist client in adapting change in ketones frequently
lifestyle & body image  If N/V occurs: sip on clear liquid with simple sugar
9. Observe for chronic complications & plan of care accordingly:
a. Atherosclerosis: leads to CAD, MI, CVA & Peripheral h. Foot care

Vascular Disease  Wash foot with mild soap & water & pat dry

b. Microangiopathy: most commonly affects eyes & kidneys  Apply lanolin lotion to feet: to prevent drying &

c. Kidney Disease cracking

 Recurrent Pyelonephritis  Cut toenail straight across

 Diabetic Nephropathy  Avoid constrictive garments such as garters

d. Ocular Disorder  Wear clean, absorbent socks (cotton or wool)

 Premature Cataracts  Purchase properly fitting shoes & break new shoes in

 Diabetic Retinopathy gradually

e. Peripheral Neuropathy  Never go barefoot

 Affects PNS & ANS  Inspect foot daily & notify physician: if cut, blister, or

 Cause diarrhea, constipation, neurogenic bladder, break in skin occurs

impotence, decrease sweating i. Exercise

10. Provide client teaching & discharge planning concerning:  Undertake regular exercise; avoid sporadic, vigorous

a. Disease process exercise

b. Diet  Food intake may need to be increased before

 Client should be able to plan a meal using exchange exercising

lists before discharge  Exercise is best performed after meals when the blood

 Emphasize importance of regularity of meals; never sugar is rising

skip meals
c. Insulin j. Complication

 How to draw up into syringe  Learn to recognized S/sx of hypo/hyperglycemia: for

 Use insulin at room temp hypoglycemia (cold and clammy skin), for

 Gently roll the vial between palms hyperglycemia (dry and warm skin): administer simple

 Draw up insulin using sterile technique sugars

 If mixing insulin, draw up clear insulin, before  Eat candy or drink orange juice with sugar added for

cloudy insulin insulin reaction (hypoglycemia)

 Injection technique  Monitor signs of DKA & HONKC

 Systematically rotate the site: to prevent k. Need to wear a Medic-Alert bracelet

lipodystrophy: (hypertrophy or atrophy of tissue)

 Insert needle at a 45 (skinny clients) or 90 (fat or Diabetic Ketoacidosis (DKA)

obese clients) degree angle depending on amount  Acute complication of DM characterized by hyperglycemia &

of adipose tissue accumulation of ketones in the body: cause metabolic acidosis

 May store current vial of insulin at room temperature;  Acute complication of Type I DM: due to severe hyperglycemia

refrigerate extra supplies leading to severe CNS depression

 Somogyi’s phenomenon: hypoglycemia followed by  Occurs in insulin-dependent diabetic clients

periods of hyperglycemia or rebound effect of insulin.  Onset slow: maybe hours to days

 Provide many opportunities for return demonstration

d. Oral hypoglycemic agent Predisposing Factors

 Stress importance of taking the drug regularly 1. Undiagnosed DM


2. Neglect to treatment 6. Physical & Emotional Stress: number one precipitating factor
3. Infection
4. cardiovascular disorder S/sx
5. Hyperglycemia
1. Polyuria 10. Dry mucous membrane; soft eyeballs
2. Polydipsia 11. Blurring of vision
3. Polyphagia 12. PS: Acetone breath odor
4. Glucosuria 13. PS: Kussmaul’s Respiration (rapid shallow breathing) or
5. Weight loss tachypnea
6. Anorexia 14. Alteration in LOC
7. N/V 15. Hypotension
8. Abdominal pain 16. Tachycardia
9. Skin warm, dry & flushed 17. CNS depression leading to coma
c. Monitor blood glucose level frequently
Dx 5. Administer medications as ordered:
1. FBS: is increased a. Sodium Bicarbonate: to counteract acidosis
2. Serum glucose & ketones level: elevated b. Antibiotics: to prevent infection
3. BUN (normal value: 10 – 20): elevated: due to dehydration 6. Check urine output every hour
4. Creatinine (normal value: .8 – 1): elevated: due to dehydration 7. Monitor V/S, I&O & blood sugar levels
5. Hct (normal value: female 36 – 42, male 42 – 48): elevated: 8. Assist client with self-care
due to dehydration 9. Provide care for unconscious client if in a coma
6. Serum Na: decrease 10. Discuss with client the reasons ketosis developed & provide
7. Serum K: maybe normal or elevated at first additional diabetic teaching if indicated
8. ABG: metabolic acidosis with compensatory respiratory alkalosis
Hyperglycemic Hyperosmolar Non-Ketotic Coma (HHNKC)
Nursing Intervention  Characterized by hyperglycemia & a hyperosmolar state without
1. Maintain patent airway ketosis
2. Assist in mechanical ventilation  Occurs in non-insulin-dependent diabetic or non-diabetic persons
3. Maintain F&E balance: (typically elderly clients)
a. Administer IV therapy as ordered:  Hyperosmolar: increase osmolarity (severe dehydration)
 Normal saline (0.9% NaCl), followed by hypotonic  Non-ketotic: absence of lypolysis (no ketones)
solutions (.45% NaCl) sodium chloride: to counteract
dehydration & shock Predisposing Factors
 When blood sugar drops to 250 mg/dl: may add 5% 1. Undiagnosed diabetes
dextrose to IV 2. Infection or other stress
 Potassium will be added: when the urine output is 3. Certain medications (ex. dilantin, thiazide, diuretics)
adequate 4. Dialysis
b. Observe for F&E imbalance, especially fluid overload, 5. Hyperalimentation
hyperkalemia & hypokalemia 6. Major burns
4. Administer insulin as ordered: regular acting insulin/rapid acting 7. Pancreatic disease
a. Regular insulin IV (drip or push) & / or subcutaneously (SC) S/sx
b. If given IV drip: give small amount of albumin since insulin
adheres to IV tubing
1. Polyuria 10. Dry mucous membrane; soft eyeballs
2. Polydipsia 11. Blurring of vision
3. Polyphagia 12. Hypotension
4. Glucosuria 13. Tachycardia
5. Weight loss 14. Headache and dizziness
6. Anorexia 15. Restlessness
7. N/V 16. Seizure activity
8. Abdominal pain 17. Alteration / Decrease LOC: diabetic coma
9. Skin warm, dry & flushed
a. Regular insulin IV (drip or push) & / or subcutaneously (SC)
Dx b. If given IV drip: give small amount of albumin since insulin
1. Blood glucose level: extremely elevated adheres to IV tubing
2. BUN: elevated: due to dehydration c. Monitor blood glucose level frequently
3. Creatinine: elevted: due to dehydration 5. Administer medications as ordered:
4. Hct: elevated: due to dehydration a. Antibiotics: to prevent infection
5. Urine: (+) for glucose 6. Check urine output every hour
7. Monitor V/S, I&O & blood sugar levels
Nursing Intervention 8. Assist client with self-care
1. Maintain patent airway 9. Provide care for unconscious client if in a coma
2. Assist in mechanical ventilation 10. Discuss with client the reasons ketosis developed & provide
3. Maintain F&E balance: additional diabetic teaching if indicated
a. Administer IV therapy as ordered:
 Normal saline (0.9% NaCl), followed by hypotonic
solutions (.45% NaCl) sodium chloride: to counteract
dehydration & shock Overview of Anatomy & Physiology of Hematologic System
 When blood sugar drops to 250 mg/dl: may add 5%
dextrose to IV  The structure of the hematological of hematopoietic system includes
 Potassium will be added: when the urine output is the blood, blood vessels, & blood forming organs (bone marrow,
adequate spleen, liver, lymph nodes, & thymus gland).
b. Observe for F&E imbalance, especially fluid overload,  The major function of blood: is to carry necessary materials (O2,
hyperkalemia & hypokalemia nutrients) to cells & remove CO2 & metabolic waste products.
4. Administer insulin as ordered:


 The hematologic system also plays an important role in hormone 3. Fibrinogens, Prothrombin, Plasminogens: clotting factors to
transport, the inflammatory & immune responses, temperature prevent bleeding
regulation, F&E balance & acid-base balance.
Cellular Components or Formed Elements
1. Erythrocytes (RBC)
HEMATOLOGICAL SYSTEM a. Normal value: 4 – 6 million/mm3
b. No nucleus, Biconcave shape discs, Chiefly sac of hemoglobin
c. Call membrane is highly diffusible to O2 & CO2
I. Blood II. Blood Vessels III.
Blood Forming Organs d. Responsible for O2 transport via hemoglobin (Hgb)
 Two portion: iron carried on heme portion; second portion
1. Arteries 1.
Liver is CHON
55% Plasma 45% Formed 2. Veins 2.
 Normal blood contains 12-18 g Hgb/100 ml blood; higher
(Fluid) cellular elements 3. Capillaries 3. (14-18 g) in men than in women (12-14 g)
e. Production
Lymphoid Organ  Start in bone marrow as stem cells, release as reticulocytes
Serum Plasma CHON 5.
(immature cells), mature into erythrocytes
Lymph Nodes
(formed in liver) 6.  Erythropoietin stimulates differentiation; produced by
Bone Marrow
kidneys & stimulated by hypoxia
1. Albumin
2. Globulins  Iron, vitamin B12, folic acid, pyridoxine vitamin B6, & other
3. Prothrombin and Fibrinogen
factors required for erythropoiesis
f. Hemolysis (Destruction)
Bone Marrow  Normal life span of RBC is 80 – 120 days and is killed in red
 Contained inside all bones, occupies interior of spongy bones & pulp of spleen
center of long bones; collectively one of the largest organs in the  Immature RBCs destroyed in either bone marrow or other
body (4-5% of total body weight) reticuloendothelial organs (blood, connective tissue, spleen,
 Primary function is Hematopoiesis: the formation of blood cells liver, lungs and lymph nodes)
 All blood cells start as stem cells in the bone marrow; these mature  Mature cells remove chiefly by liver and spleen
into different, specific types of cells, collectively referred to as  Bilirubin (yellow pigment): by product of Hgb (red pigment)
Formed Elements of Blood or Blood Components: released when RBCs destroyed, excreted in bile
1. Erythrocytes  Biliverdin (green pigment)
2. Leukocytes  Hemosiderin (golden brown pigment)
3. Thrombocytes  Iron: feed from Hgb during bilirubin formation; transported
 Two kinds of Bone Marrow: to bone marrow via transferring and and reclaimed for new
1. Red Marrow Hgb production
 Carries out hematopoiesis; production site of erythroid,  Premature destruction: may be caused by RBC membrane
myeloid, & thrombocytic component of blood; one source of abnormalities, Hgb abnormalities, extrinsic physical factors
lymphocytes & macrophages (such as the enzyme defects found in G6PD)
 Found in the ribs, vertebral column, other flat bones  Normal age RBCs may be destroyed by gross damage as in
2. Yellow Marrow trauma or extravascular hemolysis (in spleen, liver, bone
 Red marrow that has changed to fats; found in long bone; marrow)
does not contribute to hematopoiesis g. Hemoglobin: normal value female 12 – 14 gms% male 14 – 16
Blood h. Hematocrit red cell percentage in wholeblood (normal value:
 Composed of plasma (55%) & cellular components (45%) female 36 – 42% male 42 – 48%)
 Hematocrit i. Substances needed for maturation of RBC:
1. Reflects portion of blood composed of red blood cells a. Folic acid
2. Centrifugation of blood results in separation into top layer of b. Iron
plasma, middle layer of leukocytes & platelets, & bottom layer c. Vitamin c
of erythrocytes d. Vitamin b12 (Cyanocobalamin)
3. Majority of formed elements is erythrocytes; volume of e. Vitamin b6 (Pyridoxine)
leukocytes & platelets is negligible f. Intrinsic factor
 Distribution
1. 1300 ml in pulmonary circulation 2. Leukocytes (WBC)
a. 400 ml arterial a. Normal value: 5000 – 10000/mm3
b. 60 ml capillary b. Granulocytes and mononuclear cells: involved in the protection
c. 840 ml venous from bacteria and other foreign substances
2. 3000 ml in systemic circulation c. Granulocytes:
a. 550 ml arterial  Polymorphonuclear Neutrophils
b. 300 ml capillary - 60 – 70% of WBC
c. 2150 ml venous - Involved in short term phagocytosis for acute
Plasma - Mature neutrophils: polymorphonuclear leukocytes
 Liquid part of the blood; yellow in color because of pigments - Immature neutrophils: band cells (bacterial infection
 Consists of serum (liquid portion of plasma) & fibrinogen usually produces increased numbers of band cells)
 Contains plasma CHON such as albumin, serum, globulins,  Polymorphonuclear Basophils
fibrinogen, prothrombin, plasminogen - For parasite infections
1. Albumin - Responsible for the release of chemical mediation for
 Largest & numerous plasma CHON inflammation
 Involved in regulation of intravascular plasma volume - Involved in prevention of clotting in microcirculation
 Maintains osmotic pressure: preventing edema and allergic reactions
2. Serum Globulins  Polymorphonuclear Eosinophils
a. Alpha: role in transport steroids, lipids, bilirubin & - Involved in phagocytosis and allergic reaction
hormones  Eosinophils & Basophils: are reservoirs of histamine,
b. Beta: role in transport of iron & copper serotonin & heparin
c. Gamma: role in immune response, function of antibodies d. Non Granulocytes
 Mononuclear cells: large nucleated cells


a. Monocytes: Use of dextrose Agglutinated cell chills,

 Involved in long-term phagocytosis for chronic flushing, sample to lab.
inflammation solutions; block capillary Delayed: heat
 Play a role in immune response along vein, Watch for
 Macrophage in blood Wide temp blood flow to days to 2
 Largest WBC restlessness, hemoglobinuria.
 Produced by bone marrow: give rise to histiocytes fluctuation organs. weeks after
(kupffer cells of liver), macrophages & other anemia, jaundice, Treat or prevent
components of reticuloendothelial system Hemolysis (Hgb
b. Lymphocytes: immune cells; produce substances dyspnea, signs shock, DIC, &
against foreign cells; produced primarily in lymph into plasma & of
tissue (B cells) & thymus (T cells) shock, renal renal shutdown
Lymphocytes urine)
shutdown, DIC

B-cell T-cell Natural killer cell

- bone marrow - thymus - anti-viral and anti-
tumor property
for immunity
Complication of Blood Transfusion
Type Causes Mechanism Occurrence S/sx
c. Thrombocytes (Platelets)
Allergic Transfer of an Immune Within 30 min
 Normal value: 150,000 – 450,000/mm3
Uticaria, larygeal Stop transfusion.
 Normal life span of platelet is 9 – 12 days
antigen & sensitivity to start of
 Fragments of megakaryocytes formed in bone
edema, wheezing Administer
antibody from foreign serum transfusion
 Production regulated by thrombopoietin
dyspnea, antihistamine &
 Essential factors in coagulation via adhesion,
donor to CHON
aggregation & plug formation
bronchospasm, or epinephrine.
 Release substances involved in coagulation
 Promotes hemostasis (prevention of blood loss)
headache, Treat
 Consist of immature or baby platelets or
Allergic donor
megakaryocytes which is the target of dengue
anaphylaxis life-threatening

Signs of Platelet Dysfunction
1. Petechiae
2. Echhymosis
Pyrogenic Recipient Leukocytes Within 15-90
3. Oozing of blood from venipunctured site
Fever, chills, Stop transfusion.
possesses agglutination min after
Blood Groups
flushing, Treat temp.
 Erythrocytes carry antigens, which determine the different blood
antibodies bacterial initiation of
palpitation, Transfuse with
 Blood-typing system are based on the many possible antigens, but
directed against organism transfusion
the most important are the antigens of the ABO & Rh blood groups
tachycardia, leukocytes-poor
because they are most likely to be involved in transfusion reactions
WBC; bacterial
occasional blood of washed
1. ABO Typing
a. Antigens of systems are labeled A & B
lumbar pain RBC.
b. Absence of both antigens results in type O blood
c. Presence of both antigen is type AB
d. Presence of either type A or B results in type A & type B,
antibiotics prn
e. Type O: universal donor
f. Antibodies are automatically formed against ABO antigens not
on persons own RBC
2. Rh Typing
a. Identifies presence or absence of Rh antigens (Rh + or Rh -)
Circulatory Too rapid Fluid volume During & after
b. Anti-Rh antibodies not automatically formed in Rh (-) persons,
Dyspnea, Slow infusion rate
but if Rh (+) blood is given, antibody formation starts & second
Overload infusion in overload transfusion
exposure to Rh antigen will trigger a transfusion reaction
increase BP, Used packed cells
c. Important for Rh (-) woman carrying Rh (+) baby; 1st pregnancy
not affected, but subsequent pregnancy with an Rh (+) baby,
tachycardia, instead of whole
mother’s antibodies attack baby’s RBC
orthopnea, blood.
Complication of Blood Transfusion
Type Causes Mechanism Occurrence S/sx
cyanosis, anxiety Monitor CVP
Hemolytic ABO Antibodies in Acute:
Headache, Stop transfusion.
Incompatibility; recipient plasma first 5 min
lumbar or continue saline IV
Rh react w/ antigen after completion separate line.

sternal pain, send blood unit & _______________________________________________________________

Incompatibility; in donor cells. of transfusion ________________________

diarrhea, fever, client blood


Air Embolism Blood given Bolus of air Anytime

Dyspnea, Clamp tubing.
under air blocks pulmonary Spleen
increase pulse, Turn client on  Largest Lymphatic Organ: functions as blood filtration system &
pressure artery outflow reservoir
wheezing, chest left side  Vascular bean shape; lies beneath the diaphragm, behind & to the
following severe pain, left of the stomach; composed of fibrous tissue capsule surrounding
decrease BP, a network of fiber
blood loss  Contains two types of pulp:
apprehension a. Red Pulp: located between the fibrous strands, composed of
_______________________________________________________________ RBC, WBC & macrophages
________________________Thrombo- Used of large Platelets b. White Pulp: scattered throughout the red pulp, produces
When large Abnormal Assess for signs lymphocytes & sequesters lymphocytes, macrophages, &
cytopenia amount of deteriorate amount of blood antigens
bleeding of bleeding.  1%-2% of red cell mass or 200 ml blood/minute stored in the
banked blood rapidly in stored given over 24 hr spleen; blood comes via splenic artery to the pulp for cleansing, then
Initiate bleeding passes into splenic venules that are lined with phagocytic cells &
blood finally to the splenic vein to the liver.
precautions.  Important hematopoietic site in fetus; postnatally procedures
lymphocytes & monocytes
Use fresh blood.  Important in phagocytosis; removes misshapen erythrocytes,
_______________________________________________________________ unwanted parts of erythrocytes
________________________  Also involved in antibody production by plasma cells & iron
Citrate Large amount Citrate binds After large metabolism (iron released from Hgb portion of destroyed
Neuromascular Monitor/treat erythrocytes returned to bone marrow)
Intoxication of citrated blood ionic calcium amount of  In the adult functions of the spleen can be taken over by the
irritability hypocalcemia. reticuloendothelial system.
in client with banked blood
Bleeding due to Avoid large Liver
decrease liver  Involved in bile production (via erythrocyte destruction & bilirubin
decrease calcium amounts of production) & erythropoeisis (during fetal life & when bone marrow
function production is insufficient).
citrated blood.  Kupffer cells of liver have reticuloendothelial function as histiocytes;
phagocytic activity & iron storage.

Monitor liver fxn  Liver also involved in synthesis of clotting factors, synthesis of

_______________________________________________________________ antithrombins.

Hyperkalemia Potassium level Release of In client with Blood Tranfusion

Nausea, colic, Administer blood Purpose

increase in potassium into renal 1. RBC: Improve O2 transport

diarrhea, muscle less than 5-7 2. Whole Blood, Plasma, Albumin: volume expansion

stored blood plasma with insufficiency 3. Fresh Frozen Plasma, Albumin, Plasma Protein Fraction:

spasm, ECG days old in client provision of proteins

red cell lysis 4. Cryoprecipitate, Fresh Frozen Plasma, Fresh Whole Blood:

changes (tall with impaired provision of coagulation factors

5. Platelet Concentration, Fresh Whole Blood: provision of platelets

peaked T-waves, potassium

short Blood & Blood Products

Q-T excretion 1. Whole Blood: provides all components

segm a. Large volume can cause difficulty: 12-24 hr for Hgb & Hct

ents) to rise
b. Complications: volume overload, transmission of hepatitis

Blood Coagulation or AIDS, transfusion reacion, infusion of excess potassium

 Conversion of fluid blood into a solid clot to reduce blood loss when & sodium, infusion of anticoagulant (citrate) used to keep

blood vessels are ruptured stored blood from clotting, calcium binding & depletion
(citrate) in massive transfusion therapy

System that Initiating Clotting 2. Red Blood Cell (RBC)

1. Intrinsic System: initiated by contact activation following endothelial a. Provide twice amount of Hgb as an equivalent amount of

injury (“intrinsic” to vessel itself) whole blood

a. Factor XII: initiate as contact made between damaged vessel & b. Indicate in cases of blood loss, pre-op & post-op client &

plasma CHON those with incipient congestive failure

b. Factors VIII, IX & XI activated c. Complication: transfusion reaction (less common than with

2. Extrinsic System: whole blood: due to removal of plasma protein)

a. Initiated by tissue thromboplastins released from injured vessels 3. Fresh Frozen Plasma

(“extrinsic” to vessel) a. Contains all coagulation factors including V & VIII

b. Factor VII activated b. Can be stored frozen for 12 months; takes 20 minutes to

Common Pathways: activated by either intrinsic or extrinsic pathways c. Hang immediately upon arrival to unit (loses its coagulation

1. Platelet factor 3 (PF3) & calcium react with factor X & V factor rapidly)

2. Prothrombin converted to thrombin via thromboplastin 4. Platelets

3. Thrombin acts on fibrinogens, forming soluble fibrin a. Will raise recipient’s platelet count by 10,000/mm3

4. Soluble fibrin polymerized by factor XIII to produce a stable, b. Pooled from 4-8 units of whole blood

insoluble fibrin clot c. Single-donor platelet transfusion may be necessary for

clients who have developed antibodies; compatibilities

Clot Resolution: takes place via fibrinolytic system by plasmin & testing may be necessary

proteolytic enzymes; clots dissolves as tissue repairs.


5. Factor VIII Fractions (Cryoprecipitate): contains factor VIII,

fibrinogens & XIII Nursing Management
6. Granulocytes 1. Stop BT
a. Do not increase WBC: increase marginal pool (at tissue 2. Notify physician
level) rather than circulating pool 3. Flush with plain NSS
b. Premedication with steroids, antihistamine & 4. Administer isotonic fluid solution: to prevent shock and acute
acetaminophen tubular necrosis
c. Respiratory distress with shortness of breath, cyanosis & 5. Send the blood unit to blood bank for re-examination
chest pain may occur; requires cessation of transfusion & 6. Obtain urine & blood sample & send to laboratory for re-
immediate attention examination
d. Shaking chills or rigors common, require brief cessation of 7. Monitor vital signs & I&O
therapy, administration of meperdine IV until rigors are
diminished & resumption of transfusion when symptoms S/sx of Allergic reaction
relieved 1. Fever
7. Volume Expander: albumin; percentage concentration varies 2. Dyspnea
(50-100 ml/unit); hyperosmolar solution should not be used in 3. Broncial wheezing
dehydrated clients 4. Skin rashes
5. Urticaria
Goals / Objectives 6. Laryngospasm & Broncospasm
1. Replace circulating blood volume
2. Increase the O2 carrying capacity of blood Nursing Management
3. Prevent infection: if there is a decrease in WBC 1. Stop BT
4. Prevent bleeding: if there is platelet deficiency 2. Notify physician
3. Flush with plain NSS
Principles of blood transfusion 4. Administer medications as ordered
1. Proper refrigeration a. Anti Histamine (Benadryl): if positive to hypotension,
a. Expiration of packed RBC is 3-6 days anaphylactic shock: treat with Epinephrine
b. Expiration of platelet is 3-5 days 5. Send the blood unit to blood bank for re examination
2. Proper typing and cross matching 6. Obtain urine & blood sample & send to laboratory for re-
a. Type O: universal donor examination
b. Type AB: universal recipient 7. Monitor vital signs and intake and output
c. 85% of population is RH positive
3. Aseptically assemble all materials needed for BT S/sx Pyrogenic reactions
a. Filter set 1. Fever and chills
b. Gauge 18-19 needle 2. Headache
c. Isotonic solution (0.9 NaCl / plain NSS): to prevent 3. Tachycardia
hemolysis 4. Palpitations
4. Instruct another RN to re check the following 5. Diaphoresis
a. Client name 6. Dyspnea
b. Blood typing & cross matching
c. Expiration date Nursing Management
d. Serial number 1. Stop BT
5. Check the blood unit for bubbles cloudiness, sediments and 2. Notify physician
darkness in color because it indicates bacterial contamination 3. Flush with plain NSS
a. Never warm blood: it may destroy vital factors in blood. 4. Administer medications as ordered
b. Warming is only done: during emergency situation & if you a. Antipyretic
have the warming device b. Antibiotic
c. Emergency rapid BT is given after 30 minutes & let natural 5. Send the blood unit to blood bank for re examination
room temperature warm the blood. 6. Obtain urine & blood sample & send to laboratory for re-
6. BT should be completed less than 4 hours because blood that is examination
exposed at room temperature more than 2 hours: causes blood 7. Monitor vital signs & I&O
deterioration that can lead to bacterial contamination 8. Render TSB
7. Avoid mixing or administering drugs at BT line: to prevent
8. Regulate BT 10-15 gtts/min or KVO rate or equivalent to 100 S/sx of Circulatory reaction
cc/hr: to prevent circulatory overload 1. Orthopnea
9. Monitor strictly vital signs before, during & after BT especially 2. Dyspnea
every 15 minutes for first hour because majority of transfusion 3. Rales / Crackles upon auscultation
reaction occurs during this period 4. Exertional discomfort
a. Hemolytic reaction
b. Allergic reaction Nursing Management
c. Pyrogenic reaction 1. Stop BT
d. Circulatory overload 2. Notify physician
e. Air embolism 3. Administer medications as ordered
f. Thrombocytopenia a. Loop diuretic (Lasix)
g. Cytrate intoxication
h. Hyperkalemia (caused by expired blood) Nursing Care
1. Assess client for history of previous blood transfusions & any
S/sx of Hemolytic reaction adverse reaction
1. Headache and dizziness 2. Ensure that the adult client has an 18-19 gauge IV catheter in
2. Dyspnea place
3. Diarrhea / Constipation 3. Use 0.9% sodium chloride
4. Hypotension 4. At least two nurse should verify the ABO group, RH type, client
5. Flushed skin & blood numbers & expiration date
6. Lumbasternal / Flank pain 5. Take baseline V/S before initiating transfusion
7. Urine is color red / portwine urine 6. Start transfusion slowly (2 ml/min)


7. Stay with the client during the first 15 min of the transfusion & b. Dysphagia
take V/S frequently 9. PICA: abnormal appetite or craving for non edible foods
8. Maintain the prescribed transfusion rate:
a. Whole Blood: approximately 3-4 hr Dx
b. RBC: approximately 2-4 hr 1. RBC: small (microcytic) & pale (hypochromic)
c. Fresh Frozen Plasma: as quickly as possible 2. RBC: is decreased
d. Platelet: as quickly as possible 3. Hgb: decreased
e. Cryoprecipitate: rapid infusion 4. Hct: moderately decreased
f. Granulocytes: usually over 2 hr 5. Serum iron: decreased
g. Volume Expander: volume-dependent rate 6. Reticulocyte count: is decreased
9. Monitor for adverse reaction 7. Serum ferritin: is decreased
10. Document the following: 8. Hemosiderin: absent from bone marrow
a. Blood component unit number (apply sticker if available)
b. Date of infusion starts & end Nursing Intervention
c. Type of component & amount transfused 1. Monitor for s/sx of bleeding through hematest of all elimination
d. Client reaction & vital signs including urine, stool & gastrict content
e. Signature of transfusionist 2. Enforce CBR / Provide adequate rest: plan activities so as not to
over tire the client
HIV 3. Provide thorough explanation of all diagnostic exam used to
- 6 months – 5 years incubation period determine sources of possible bleeding: help allay anxiety &
- 6 months window period ensure cooperation
- western blot opportunistic 4. Instruct client to take foods rich in iron
- ELISA a. Organ meat
- drug of choice AZT (Zidon Retrovir) b. Egg yolk
c. Raisin
2 Common fungal opportunistic infection in AIDS d. Sweet potatoes
1. Kaposis Sarcoma e. Dried fruits
2. Pneumocystic Carini Pneumonia f. Legumes
g. Nuts
Blood Disorder 5. Instruct the client to avoid taking tea and coffee: because it
contains tannates which impairs iron absorption
Iron Deficiency Anemia (Anemias) 6. Administer iron preparation as ordered:
 A chronic microcytic anemia resulting from inadequate absorption of a. Oral Iron Preparations: route of choice
iron leading to hypoxemic tissue injury  Ferrous Sulfate
 Chronic microcytic, hypochromic anemia caused by either inadequate  Ferrous Fumarate
absorption or excessive loss of iron  Ferrous Gluconate
 Acute or chronic bleeding principal cause in adults (chiefly from
trauma, dysfunctional uterine bleeding & GI bleeding) Nursing Management when taking oral iron
 May also be caused by inadequate intake of iron-rich foods or by preparations
inadequate absorption of iron  Instruct client to take with meals: to lessen GIT
 In iron-deficiency states, iron stores are depleted first, followed by a irritation
reduction in Hgb formation  Dilute in liquid preparations well & administer using a
straw: to prevent staining of teeth
Incidence Rate  When possible administer with orange juice as vitamin
1. Common among developed countries & tropical zones (blood- C (ascorbic acid): to enhance iron absorption
sucking parasites)  Warn clients that iron preparations will change stool
2. Common among women 15 & 45 years old & children affected color & consistency (dark & tarry) & may cause
more frequently, as are the poor constipation
3. Related to poor nutrition  Antacid ingestion will decrease oral iron effectiveness

Predisposing Factors b. Parenteral: used in clients intolerant to oral preparations,

1. Chronic blood loss due to: who are noncompliant with therapy or who have continuing
a. Trauma blood losses
b. Heavy menstruation
c. Related to GIT bleeding resulting to hematemasis and Nursing Management when giving parenteral iron
melena (sign for upper GIT bleeding) preparation
d. Fresh blood per rectum is called hematochezia  Use one needle to withdraw & another to administer
2. Inadequate intake or absorption of iron due to: iron preparation as tissue staining & irritation are a
a. Chronic diarrhea problem
b. Related to malabsorption syndrome  Use Z-track injection technique: to prevent leakage
c. High cereal intake with low animal CHON digestion into tissue
d. Partial or complete gastrectomy  Do not massage injection site but encourage
e. Pica ambulation as this will enhance absorption; advice
3. Related to improper cooking of foods against vigourous exercise & constricting garments
 Observe for local signs of complication:
S/sx  Pain at the injection site
1. Usually asymptomatic (mild cases)  Development of sterile abscesses
2. Weakness & fatigue (initial signs)  Lymphadenitis
3. Headache & dizziness  Fever & chills
4. Pallor & cold sensitivity  Headache
5. Dyspnea  Urticaria
6. Palpitations  Pruritus
7. Brittleness of hair & nails, spoon shape nails (koilonychias)  Hypotension
8. Atrophic Glossitis (inflammation of tongue)  Skin rashes
a. Stomatitis PLUMBER  Anaphylactic shock


Medications administered via straw b. Numbness

 Lugol’s Solution c. Paresthesias of hands & feet
 Iron d. Paralysis
 Tetracycline e. Depression
 Nitrofurantoin (Macrodentin) f. Psychosis
7. Administer with Vitamin C or orange juice for absorption g. Positive to Romberg’s test: damage to cerebellum resulting
8. Monitor & inform client of side effects to ataxia
a. Anorexia
b. N/V Dx
c. Abdominal pain 1. Erythrocytes count: decrease
d. Diarrhea / constipation 2. Blood Smear: oval, macrocytic erythrocytes with a proportionate
e. Melena amount of Hgb
9. If client can’t tolerate / no compliance administer parenteral iron 3. Bilirubin (indirect): elevated unconjugated fraction
preparation 4. Serum LDH: elevated
a. Iron Dextran (IM, IV) 5. Bone Marrow:
b. Sorbitex (IM) a. Increased megaloblasts (abnormal erythrocytes)
10. Provide dietary teaching regarding food high in iron b. Few normoblasts or maturing erythrocytes
11. Encourage ingestion of roughage & increase fluid intake: to c. Defective leukocytes maturation
prevent constipation if oral iron preparation are being taken 6. Positive Schilling’s Test: reveals inadequate / decrease
absorption of Vitamin B12
Pernicious Anemia a. Measures absorption of radioactive vitamin B12 bothe before
 Chronic progressive, macrocytic anemia caused by a deficiency of & after parenteral administration of intrinsic factor
intrinsic factor; the result is abnormally large erythrocytes & b. Definitive test for pernicious anemia
hypochlorhydria (a deficiency of hydrochloric acid in gastric c. Used to detect lack of intrinsic factor
secretion) d. Fasting client is given radioactive vitamin B12 by mouth &
 Chronic anemia characterized by a deficiency of intrinsic factor non-radioactive vitamin B12 IM to permit some excretion of
leading to hypochlorhydria (decrease hydrochloric acid secretion) radioactive vitamin B12 in the urine if it os absorbed
 Characterized by neurologic & GI symptoms; death usually resuls if e. 24-48 hour urine collection is obtained: client is encourage
untreated to drink fluids
 Lack of intrinsic factor is caused by gastric mucosal atrophy (possibly f. If indicated, second stage schilling test performed 1 week
due to heredity, prolonged iron deficiency, or an autoimmune after first stage. Fasting client is given radioactive vitamin
disorder); can also results in clients who have had a total gastrctomy B12 combined with human intrinsic factor & test is repeated
if vitamin B12 is not administer 7. Gastric Analysis: decrease free hydrochloric acid
8. Large number of reticulocytes in the blood following parenteral
vitamin B12 administration
1. Intrinsic factor is necessary for the absorbtion of vitamin B12 into
small intestines
Medical Management
2. B12 deficiency diminished DNA synthesis, which results in
1. Drug Therapy:
defective maturation of cell (particularly rapidly dividing cells
a. Vitamin B12 injection: monthly maintenance
such as blood cells & GI tract cells)
b. Iron preparation: (if Hgb level inadequate to meet increase
3. B12 deficiency can alter structure & function of peripheral
numbers of erythrocytes)
nerves, spinal cord, & the brain
c. Folic Acid
 Controversial
 Reverses anemia & GI symptoms but may intensify
Pareital cells/Argentaffin or Oxyntic cells
neurologic symptoms
 May be safe if given in small amounts in addition to
Produces intrinsic factors Secretes
vitamin B12
hydrochloric acid
2. Transfusion Therapy
Nursing Intervention
Promotes reabsorption of Vit B12 Aids in
1. Enforce CBR: necessary if anemia is severe
2. Adminster Vitamin B12 injections at monthly intervals for lifetime
as ordered
Promotes maturation of RBC
 Never given orally because there is possibility of developing
Predisposing Factors
 Site of injection for Vitamin B12 is dorsogluteal and
1. Usually occurs in men & women over age of 50 with an increase
in blue-eyed person of Scandinavian decent
 No side effects
2. Subtotal gastrectomy
3. Provide a dietary intake that is high in CHON, vitamin c and iron
3. Hereditary factors
(fish, meat, milk / milk product & eggs)
4. Inflammatory disorders of the ileum
4. Avoid highly seasoned, coursed, or very hot foods: if client has
5. Autoimmune
mouth sore
6. Strictly vegetarian diet
5. Provide safety when ambulating (especially when carrying hot
1. Anemia
6. Instruct client to avoid irritating mouth washes instead use soft
2. Weakness & fatigue
bristled toothbrush
3. Headache and dizziness
7. Avoid heat application to prevent burns
4. Pallor & cold sensitivity
8. Provide client teaching & discharge planning concerning:
5. Dyspnea & palpitations: as part of compensation
a. Dietery instruction
6. GIT S/sx:
b. Importance of lifelong vitamin B12 therapy
a. Mouth sore
c. Rehabilitation & physical therapy for neurologic deficit, as
b. PS: Red beefy tongue
well as instruction regarding safety
c. Indigestion / dyspepsia
d. Weight loss
Aplastic Anemia
e. Constipation / diarrhea
 Stem cell disorder leading to bone marrow depression leading to
f. Jaundice
7. CNS S/sx:
a. Tingling sensation


 Pancytopenia or depression of granulocytes, platelets & erythrocytes 9. Monitor signs of bleeding & provide measures to minimize risk:
production: due to fatty replacement of the bone marrow a. Use soft toothbrush when brushing teeth & electric razor
 Bone marrow destruction may be idiopathic or secondary when shaving: prevent bleeding
b. Avoid IM, subcutaneous, venipunctured sites: Instead
PANCYTOPENIA provide heparin lock
c. Hematest urine & stool
Decrease RBC Decrease WBC d. Observe for oozing from gums, petechiae or ecchymoses
Decrease Platelet
10. Provide client teaching & discharge planning concerning:
(anemia) (leukopenia)
a. Self-care regimen
b. Identification of offending agent & importance of avoiding it
(if possible) in future
Predisposing Factors
1. Chemicals (Benzene and its derivatives)
Disseminated Intravascular Coagulation (DIC)
2. Related to radiation / exposure to x-ray
 Diffuse fibrin deposition within arterioles & capillaries with
3. Immunologic injury
widespread coagulation all over the body & subsequent depletion of
4. Drugs:
clotting factors
a. Broad Spectrum Antibiotics: Chloramphenicol
 Acute hemorrhagic syndrome characterized by wide spread bleeding
and thrombosis due to a deficiency of prothrombin and fibrinogen
b. Cytotoxic agent / Chemotherapeutic Agents:
 Hemorrhage from kidneys, brain, adrenals, heart & other organs
 Methotrexate (Alkylating Agent)
 May be linked with entry of thromboplasic substance into the blood
 Vincristine (Plant Alkaloid)
 Mortality rate is high usually because underlying disease cannot be
 Nitrogen Mustard (Antimetabolite)
 Phenylbutazones (NSAIDS)

1. Anemia
1. Underlying disease (ex. toxemia of pregnancy, cancer) cause
a. Weakness & fatigue
release of thromboplastic substance that promote the deposition
b. Headache & dizziness
of fibrin throughout the microcirculation
c. Pallor & cold sensitivity
2. Microthrombi form in many organs, causing microinfarcts &
d. Dyspnea & palpitations
tissue necrosis
2. Leukopenia
3. RBC are trapped in fibrin strands & are hemolysed
a. Increase susceptibility to infection
4. Platelets, prothrombin & other clotting factors are destroyed,
3. Thrombocytopenia
leading to bleeding
a. Petechiae (multiple petechiae is called purpura)
5. Excessive clotting activates the fibrinolytic system, which inhibits
b. Ecchymosis
platelet function, causing futher bleeding.
c. Oozing of blood from venipunctured sites
Predisposing Factors
1. CBC: reveals pancytopenia
1. Related to rapid blood transfusion
2. Normocytic anemia, granulocytopenia, thrombocytopenia
2. Massive burns
3. Bone marrow biopsy: aspiration (site is the posterior iliac crest):
3. Massive trauma
marrow is fatty & contain very few developing cells; reveals fat
4. Anaphylaxis
necrosis in bone marrow
5. Septecemia
6. Neoplasia (new growth of tissue)
Medical Management
7. Pregnancy
1. Blood transfusion: key to therapy until client’s own marrow
begins to produce blood cells
2. Aggressive treatment of infection
1. Petechiae & Ecchymosis on the skin, mucous membrane, heart,
3. Bone marrow transplantation
eyes, lungs & other organs (widespread and systemic)
4. Drug Therapy:
2. Prolonged bleeding from breaks in the skin: oozing of blood
a. Corticosteroids & / or androgens: to stimulate bone marrow
from punctured sites
function & to increase capillary resistance (effective in
3. Severe & uncontrollable hemorrhage during childbirth or surgical
children but usually not in adults)
b. Estrogen & / or progesterone: to prevent amenorrhea in
4. Hemoptysis
female clients
5. Oliguria & acute renal failure (late sign)
5. Identification & withdrawal of offending agent or drug
6. Convulsion, coma, death

Nursing Intervention
1. Removal of underlying cause
1. PT: prolonged
2. Administer Blood Transfusion as ordered
2. PTT: usually prolonged
3. Administer O2 inhalation
3. Thrombin Time: usually prolonged
4. Enforce CBR
4. Fibrinogen level: usually depressed
5. Institute reverse isolation
5. Fibrin splits products: elevated
6. Provide nursing care for client with bone marrow transplant
6. Protamine Sulfate Test: strongly positive
7. Administer medications as ordered:
7. Factor assay (II, V, VII): depressed
a. Corticosteroids: caused by immunologic injury
8. CBC: reveals decreased platelets
b. Immunosuppressants: Anti Lymphocyte Globulin
9. Stool occult blood: positive
Given via central venous catheter 10. ABG analysis: reveals metabolic acidosis
Given 6 days to 3 weeks to achieve maximum therapeutic 11. Opthamoscopic exam: reveals sub retinal hemorrhages
effect of drug
8. Monitor for signs of infection & provide care to minimize risk: Medical Management
a. Monitor neuropenic precautions 1. Identification & control the underlying disease is key
b. Encourage high CHON, vitamin diet: to help reduce 2. Blood Tranfusions: include whole blood, packed RBC, platelets,
incidence of infection plasma, cryoprecipitites & volume expanders
c. Provide mouth care before & after meals 3. Heparin administration
d. Fever a. Somewhat controversial
e. Cough


b. Inhibits thrombin thus preventing further clot formation,  2 chambers, function as receiving chambers, lies above the
allowing coagulation factors to accumulate ventricles
 Upper Chamber (connecting or receiving)
Nursing Intervention  Right Atrium: receives systemic venous blood through the
1. Monitor blood loss & attemp to quantify superior vena cava, inferior vena cava & coronary sinus
2. Monitor for signs of additional bleeding or thrombus formation  Left Atrium: receives oxygenated blood returning to the heart
3. Monitor all hema test / laboratory data including stool and GIT from the lungs trough the pulmonary veins
4. Prevent further injury Ventricles
a. Avoid IM injection  2 thick-walled chambers; major responsibility for forcing blood out
b. Apply pressure to bleeding site of the heart; lie below the atria
c. Turn & position the client frequently & gently  Lower Chamber (contracting or pumping)
d. Provide frequent nontraumatic mouth care (ex. soft  Right Ventricle: contracts & propels deoxygenated blood into
toothbrush or gauze sponge) pulmonary circulation via the aorta during ventricular systole;
5. Administer isotonic fluid solution as ordered: to prevent shock Right atrium has decreased pressure which is 60 – 80 mmHg
6. Administer oxygen inhalation  Left Ventricle: propels blood into the systemic circulation via
7. Force fluids aortaduring ventricular systole; Left ventricle has increased
8. Administer medications as ordered: pressure which is 120 – 180 mmHg in order to propel blood to
a. Vitamin K the systemic circulation
b. Pitressin / Vasopresin: to conserve fluids
c. Heparin / Comadin is ineffective Valves
9. Provide heparin lock  To promote unidimensional flow or prevent backflow
10. Institute NGT decompression by performing gastric lavage: by Atrioventricular Valve
using ice or cold saline solution of 500-1000 ml  Guards opening between
11. Monitor NGT output  Mitral Valve: located between the left atrium & left ventricle;
12. Prevent complication contains 2 leaflets attached to the chordae tandinae
a. Hypovolemic shock: Anuria (late sign of hypovolemic shock)  Tricuspid Valve: located between the right atrium & right
13. Provide emotional support to client & significant other ventricle; contains 3 leaflets attached to the chordae tandinae
14. Teach client the importance of avoiding aspirin or aspirin-
containing compounds Functions
 Permit unidirectional flow of blood from specific atrium to specific
ventricle during ventricular diastole
Overview of the Structure & Functions of the Heart  Prevent reflux flow during ventricular systole
 Valve leaflets open during ventricular diastole; Closure of AV valves
 Cardiovascular system consists of the heart, arteries, veins & give rise to first heart sound (S1 “lub”)
capillaries. The major function are circulation of blood, delivery of O2 Semi-lunar Valve
& other nutrients to the tissues of the body & removal of CO2 &  Pulmonary Valve
other cellular products metabolism  Located between the left ventricle & pulmonary artery
Heart  Aortic Valve
 Muscular pumping organ that propel blood into the arerial system &  Located between left ventricle & aorta
receive blood from the venous system of the body. Function
 Located on the left mediastinum  Pemit unidirectional flow of the blood from specific ventricle to
 Resemble like a close fist arterial vessel during ventricular diastole
 Weighs approximately 300 – 400 grams  Prevent reflux blood flow during ventricular diastole
 Covered by a serous membrane called the pericardium  Valve open when ventricle contract & close during ventricular
diastole; Closure of SV valve produces second heart sound (S2
Heart Wall / Layers of the Heart “dub”)
 Composed of fibrous (outermost layer) & serous pericardium Extra Heart Sounds
(parietal & visceral); a sac that function to protect the heart from  S3: ventricular gallop usually seen in Left Congestive Heart Failure
friction  S4: atrial gallop usually seen in Myocardial Infarction and
 In between is the pericardial fluid which is 10 – 20 cc: Prevent Hypertension
pericardial friction rub
 2 layers of pericardium Coronary Circulation
 Parietal: outer layer Coronary Arteries
 Visceral: inner layer  Branch off at the base of the aorta & supply blood to the
Epicardium myocardium & the conduction system
 Covers surface of the heart, becomes continuous with visceral layer  Arises from base of the aorta
of serous pericardium  Types of Coronary Arteries
 Outer layer  Right Main Coronary Artery
Myocardium  Left Main Coronary Artery
 Middle muscular layer Coronary Veins
 Myocarditis can lead to cardiogenic shock and rheumatic heart  Return blood from the myocardium back to the right atrium via the
disease coronary sinus
 Thin, inner membrabous layer lining the chamber of the heart Conduction System
 Inner layer Sinoatrial Node (SA node or Keith Flack Node)
Papillary Muscle  Located at the junction of superior vena cava and right atrium
 Arise from the endocardial & myocardial surface of the ventricles &  Acts as primary pacemaker of the heart
attach to the chordae tendinae  Initiates the cardiac impulse which spreads across the atria & into
Chordae Tendinae AV node
 Attach to the tricuspid & mitral valves & prevent eversion during  Initiates electrical impulse of 60-100 bpm

Atrioventricular Node (AV node or Tawara Node)

Chambers of the Heart  Located at the inter atrial septum
Atria  Delays the impulse from the atria while the ventricles fill


 Delay of electrical impulse for about .08 milliseconds to allow deoxygenated blood back to the heart. When the skeletal
ventricular filling surrounding veins contract, the veins are compressed, promoting
movement of blood back to the heart.
Bundle of His
 Arises from the AV node & conduct impulse to the bundle branch
system Cardiac Disorders
 Located at the interventricular septum Coronary Arterial Disease / Ischemic Heart Disease
 Right Bundle Branch: divided into anterior lateral & posterior;
transmits impulses down the right side of the interventricular Stages of Development of Coronary Artery Disease
myocardium 1. Myocardial Injury: Atherosclerosis
 Left Bundle Branch: divided into anterior & posterior 2. Myocardial Ischemia: Angina Pectoris
 Anterior Portion: transmits impulses to the anterior 3. Myocardial Necrosis: Myocardial Infarction
endocardial surface of the left ventricle
 Posterior Portion: transmits impulse over the posterior & ATHEROSCLEROSIS
inferior endocardial surface of the left ventricle ATHEROSCLEROSIS ARTERIOSCLEROSIS
 Narrowing of artery  Hardening of artery

Purkinje Fibers  Lipid or fat deposits  Calcium and protein

 Transmit impulses to the ventricle & provide for depolarization after  Tunica intima deposits

ventricular contraction  Tunica media

 Located at the walls of the ventricles for ventricular contraction

Predisposing Factors
1. Sex: male
2. Race: black
3. Smoking
4. Obesity
5. Hyperlipidemia
6. Sedentary lifestyle
7. Diabetes Mellitus
8. Hypothyroidism
9. Diet: increased saturated fats
10. Type A personality



3. Tachycardia
Electrical activity of heart can be visualize by attaching electrodes to the skin 4. Palpitations
& recording activity by ECG 5. Diaphoresis
Electrocadiography (ECG) Tracing
 P wave (atrail depolarization) contraction Treatment
 QRS wave (ventricular depolarization) P - Percutaneous
 T wave (ventricular repolarization) T - Transluminal
 Insert pacemaker if there is complete heart block C - Coronary
 Most common pacemaker is the metal pacemaker and lasts up to 2 – A – Angioplasty
5 years

C - Coronary
Abnormal ECG Tracing A - Arterial
 Positive U wave: Hypokalemia B - Bypass
 Peak T wave: Hyperkalemia A - And
 ST segment depression: Angina Pectoris G - Graft
 ST segment elevation: Myocardial Infarction S - Surgery
 T wave inversion: Myocardial Infarction
 Widening of QRS complexes: Arrythmia
Vascular System 1. Revascularize myocardium
 Major function of the blood vessels isto supply the tissue with blood, 2. To prevent angina
remove wastes, & carry unoxygenated blood back to the heart 3. Increase survival rate
4. Done to single occluded vessels
Types of Blood Vessels 5. If there is 2 or more occluded blood vessels CABG is done
 Elastic-walled vessels that can stretch during systole & recoil during 3 Complications of CABG
diastole; they carry blood away from the heart & distribute 1. Pneumonia: encourage to perform deep breathing, coughing
oxygenated blood throughout the body exercise and use of incentive spirometer
Arterioles 2. Shock
 Small arteries that distribute blood to the capillaries & function in 3. Thrombophlebitis
controlling systemic vascular resistance & therefore arterial pressure
Capilliaries Angina Pectoris
 The following exchanges occurs in the capilliaries  Transient paroxysmal chest pain produced by insufficient blood flow
 O2 & CO2 to the myocardium resulting to myocardial ischemia
 Solutes between the blood & tissue  Clinical syndrome characterized by paroxysmal chest pain that is
 Fluid volume transfer between the plasma & interstitial space usually relieved by rest or nitroglycerine due to temporary
Venules myocardial ischemia
 Small veins that receive blood from capillaries & function as
collecting channels between the capillaries & veins Predisposing Factors
Veins 1. Sex: male
 Low-pressure vessels with thin small & less muscles than arteries; 2. Race: black

most contains valves that prevent retrograde blood flow; they carry 3. Smoking


4. Obesity  Avoid placing near hairy areas as it may decrease drug

5. Hyperlipidemia absorption
6. Sedentary lifestyle  Avoid rotating transdermal patches as it may decrease drug
7. Diabetes Mellitus absorption
8. Hypertension  Avoid placing near microwave ovens or during defibrillation
9. CAD: Atherosclerosis as it may lead to burns (most important thing to remember)
10. Thromboangiitis Obliterans b. Beta-blockers
11. Severe Anemia  Propanolol: side effects PNS
12. Aortic Insufficiency: heart valve that fails to open & close efficiently  Not given to COPD cases: it causes bronchospasm
13. Hypothyroidism c. ACE Inhibitors
14. Diet: increased saturated fats  Enalapril
15. Type A personality d. Calcium Antagonist
 Nefedipine
Precipitating Factors 4. Administer oxygen inhalation
4 E’s of Angina Pectoris 5. Place client on semi-to high fowlers position
1. Excessive physical exertion: heavy exercises, sexual activity 6. Monitor strictly V/S, I&O, status of cardiopulmonary fuction & ECG
2. Exposure to cold environment: vasoconstriction tracing
3. Extreme emotional response: fear, anxiety, excitement, strong 7. Provide decrease saturated fats sodium and caffeine
emotions 8. Provide client health teachings and discharge planning
4. Excessive intake of foods or heavy meal  Avoidance of 4 E’s
 Prevent complication (myocardial infarction)
S/sx  Instruct client to take medication before indulging into physical
1. Levine’s Sign: initial sign that shows the hand clutching the chest exertion to achieve the maximum therapeutic effect of drug
2. Chest pain: characterized by sharp stabbing pain located at sub  Reduce stress & anxiety: relaxation techniques & guided
sterna usually radiates from neck, back, arms, shoulder and jaw imagery
muscles usually relieved by rest or taking nitroglycerine (NTG)  Avoid overexertion & smoking
3. Dyspnea  Avoid extremes of temperature
4. Tachycardia  Dress warmly in cold weather
5. Palpitations  Participate in regular exercise program
6. Diaphoresis  Space exercise periods & allow for rest periods
 The importance of follow up care
9. Instruct the client to notify the physician immediately if pain occurs
Dx & persists despite rest & medication administration
1. History taking and physical exam
2. ECG: may reveals ST segment depression & T wave inversion during Myocardial Infarction
chest pain  Death of myocardial cells from inadequate oxygenation, often
3. Stress test / treadmill test: reveal abnormal ECG during exercise caused by sudden complete blockage of a coronary artery
4. Increase serum lipid levels  Characterized by localized formation of necrosis (tissue destruction)
5. Serum cholesterol & uric acid is increased with subsequent healing by scar formation & fibrosis
 Heart attack
Medical Management  Terminal stage of coronary artery disease characterized by
1. Drug Therapy: if cholesterol is elevated malocclusion, necrosis & scarring.
 Nitrates: Nitroglycerine (NTG)
 Beta-adrenergic blocking agent: Propanolol Types
 Calcium-blocking agent: nefedipine 1. Transmural Myocardial Infarction: most dangerous type
 Ace Inhibitor: Enapril characterized by occlusion of both right and left coronary artery
2. Modification of diet & other risk factors 2. Subendocardial Myocardial Infarction: characterized by occlusion of
3. Surgery: Coronary artery bypass surgery either right or left coronary artery
4. Percutaneuos Transluminal Coronary Angioplasty (PTCA)

The Most Critical Period Following Diagnosis of Myocardial Infarction

Nursing Intervention  6-8 hours because majority of death occurs due to arrhythmia
1. Enforce complete bed rest leading to premature ventricular contractions (PVC)
2. Give prompt pain relievers with nitrates or narcotic analgesic as
ordered Predisposing Factors
3. Administer medications as ordered: 1. Sex: male
a. Nitroglycerine (NTG): when given in small doses will act as 2. Race: black
venodilator, but in large doses will act as vasodilator 3. Smoking
 Give 1 dose of NTG: sublingual 3-5 minutes
4. Obesity
 Give 2 dose of NTG: if pain persist after giving 1 dose
nd st
5. CAD: Atherosclerotic
with interval of 3-5 minutes 6. Thrombus Formation
 Give 3 & last dose of NTG: if pain still persist at 3-5
7. Genetic Predisposition
minutes interval 8. Hyperlipidemia
9. Sedentary lifestyle
Nursing Management when giving NTG 10. Diabetes Mellitus
1. NTG Tablets (sublingual) 11. Hypothyroidism
 Keep the drug in a dry place, avoid moisture and exposure 12. Diet: increased saturated fats
to sunlight as it may inactivate the drug 13. Type A personality
 Relax for 15 minutes after taking a tablet: to prevent
dizziness S/sx
 Monitor side effects: 1. Chest pain
 Orthostatic hypotension  Excruciating visceral, viselike pain with sudden onset located at
 Transient headache & dizziness: frequent side effect substernal & rarely in precordial
 Instruct the client to rise slowly from sitting position  Usually radiates from neck, back, shoulder, arms, jaw &
 Assist or supervise in ambulation abdominal muscles (abdominal ischemia): severe crushing
2. NTG Nitrol or Transdermal patch  Not usually relieved by rest or by nitroglycerine
2. N/V


3. Dyspnea  Antidote: Vitamin K

4. Increase in blood pressure & pulse, with gradual drop in blood  Nursing Intervention: Check for Prothrombin Time (PT)
pressure (initial sign) h. Anti Platelet: PASA (Aspirin): Anti thrombotic effect
5. Hyperthermia: elevated temp  Side Effects: Tinnitus, Heartburn, Indigestion / Dyspepsia
6. Skin: cool, clammy, ashen  Contraindication: Dengue, Peptic Ulcer Disease, Unknown
7. Mild restlessness & apprehension cause of headache
8. Occasional findings: 14. Provide client health teaching & discharge planning concerning:
 Pericardial friction rub a. Effects of MI healing process & treatment regimen
 Split S1 & S2 b. Medication regimen including time name purpose, schedule,
 Rales or Crackles upon auscultation dosage, side effects
 S4 or atrial gallop c. Dietary restrictions: low Na, low cholesterol, avoidance of
Dx d. Encourage client to take 20 – 30 cc/week of wine, whisky and
1. Cardiac Enzymes brandy: to induce vasodilation
 CPK-MB: elevated e. Avoidance of modifiable risk factors
 Creatinine phosphokinase (CPK): elevated f. Prevent Complication
 Heart only, 12 – 24 hours  Arrhythmia: caused by premature ventricular contraction
 Lactic acid dehydrogenase (LDH): is increased  Cardiogenic shock: late sign is oliguria
 Serum glutamic pyruvate transaminase (SGPT): is increased  Left Congestive Heart Failure
 Serum glutamic oxal-acetic transaminase (SGOT): is increased  Thrombophlebitis: homan’s sign
2. Troponin Test: is increased  Stroke / CVA
3. ECG tracing reveals  Dressler’s Syndrome (Post MI Syndrome): client is resistant
 ST segment elevation to pharmacological agents: administer 150,000-450,000
 T wave inversion units of streptokinase as ordered
 Widening of QRS complexes: indicates that there is arrhythmia g. Importance of participation in a progressive activity program
in MI h. Resumption of ADL particularly sexual intercourse: is 4-6 weeks
4. Serum Cholesterol & uric acid: are both increased post cardiac rehab, post CABG & instruct to:
5. CBC: increased WBC  Make sex as an appetizer rather than dessert
 Instruct client to assume a non weight bearing position
Nursing Intervention  Client can resume sexual intercourse: if can climb or use
 Goal: Decrease myocardial oxygen demand the staircase
i. Need to report the ff s/sx:
1. Decrease myocardial workload (rest heart)  Increased persistent chest pain
 Establish a patent IV line  Dyspnea
 Administer narcotic analgesic as ordered: Morphine Sulfate IV:  Weakness
provide pain relief (given IV because after an infarction there is  Fatigue
poor peripheral perfusion & because serum enzyme would be  Persistent palpitation
affected by IM injection as ordered)  Light headedness
 Side Effects: Respiratory Depression j. Enrollment of client in a cardiac rehabilitation program
 Antidote: Naloxone (Narcan) k. Strict compliance to mediation & importance of follow up care
 Side Effects of Naloxone Toxicity: is tremors
2. Administer oxygen low flow 2-3 L / min: to prevent respiratory arrest Congestive Heart Failure
or dyspnea & prevent arrhythmias  Inability of the heart to pump an adequate supply of blood to meet
3. Enforce CBR in semi-fowlers position without bathroom privileges the metabolic needs of the body
(use bedside commode): to decrease cardiac workload  Inability of the heart to pump blood towards systemic circulation
4. Instruct client to avoid forms of valsalva maneuver
5. Place client on semi fowlers position Types of Heart Failure
6. Monitor strictly V/S, I&O, ECG tracing & hemodynamic procedures 1. Left Sided Heart Failure
7. Perform complete lung / cardiovascular assessment 2. Right Sided Heart Failure
8. Monitor urinary output & report output of less than 30 ml / hr: 3. High-Output Failure
indicates decrease cardiac output
9. Provide a full liquid diet with gradual increase to soft diet: low in Left Sided Heart Failure
saturated fats, Na & caffeine  Left ventricular damage causes blood to back up through the left
10. Maintain quiet environment atrium & into the pulmonary veins: Increased pressure causes
11. Administer stool softeners as ordered: to facilitate bowel evacuation transudation into interstitial tissues of the lungs which result
& prevent straining pulmonary congestion.
12. Relieve anxiety associated with coronary care unit (CCU)
environment Predisposing Factors
13. Administer medication as ordered: 1. 90% is mitral valve stenosis due to RHD: inflammation of mitral
a. Vasodilators: Nitroglycirine (NTG), Isosorbide Dinitrate, Isodil valve due to invasion of Group A beta-hemolytic streptococcus
(ISD): sublingual 2. Myocardial Infarction
b. Anti Arrythmic Agents: Lidocaine (Xylocane), Brithylium 3. Ischemic heart disease
 Side Effects: confusion and dizziness 4. Hypertension
c. Beta-blockers: Propanolol (Inderal) 5. Aortic valve stenosis
d. ACE Inhibitors: Captopril (Enalapril)
e. Calcium Antagonist: Nefedipine S/sx
f. Thrombolytics / Fibrinolytic Agents: Streptokinase, Urokinase, 1. Dyspnea
Tissue Plasminogen Activating Factor (TIPAF) 2. Paroxysmal nocturnal dyspnea (PND): client is awakened at night
 Side Effects: allergic reaction, urticaria, pruritus due to difficulty of breathing
 Nursing Intervention: Monitor for bleeding time 3. Orthopnea: use 2-3 pillows when sleeping or place in high fowlers
g. Anti Coagulant 4. Tiredness
 Heparin 5. Muscle Weakness
 Antidote: Protamine Sulfate 6. Productive cough with blood tinged sputum
 Nursing Intervention: Check for Partial Thrombin Time 7. Tachycardia
(PTT) 8. Frothy salivation
 Caumadin (Warfarin) 9. Cyanosis


10. Pallor  D – Diuretics

11. Rales / Crackles  O – O2
12. Bronchial wheezing  G – Gases
13. Pulsus Alternans: weak pulse followed by strong bounding pulse
14. PMI is displaced laterally: due to cardiomegaly Nursing Intervention
15. Possible S3: ventricular gallop Goal: Increase cardiac contractility thereby increasing cardiac output of 3-6
L / min
1. Chest X-ray (CXR): reveals cardiomegaly 1. Monitor respiratory status & provide adequate ventilation (when HF
2. Pulmonary Arterial Pressure (PAP): measures pressure in right progress to pulmonary edema)
ventricle or cardiac status: increased a. Administer O2 therapy: high inflow 3-4 L / min delivered via
3. Pulmonary Capillary Wedge Pressure (PCWP): measures end systolic nasal cannula
and dyastolic pressure: increased b. Maintain client in semi or high fowlers position: maximize
4. Central Venous Pressure (CVP): indicates fluid or hydration status oxygenation by promoting lung expansion
 Increase CVP: decreased flow rate of IV c. Monitor ABG
 Decrease CVP: increased flow rate of IV d. Assess for breath sounds: noting any changes
5. Swan-Ganz catheterization: cardiac catheterization 2. Provide physical & emotional rest
6. Echocardiography: shows increased sized of cardiac chamber a. Constantly assess level of anxiety
(cardiomyopathy): dependent on extent of heart failure b. Maintain bed rest with limited activity
7. ABG: reveals PO2 is decreased (hypoxemia), PCO2 is increased c. Maintain quiet & relaxed environment
(respiratory acidosis) d. Organized nursing care around rest periods
3. Increase cardiac output
Right Sided Heart Failure a. Administer digitalis as ordered & monitor effects
 Weakened right ventricle is unable to pump blood into he pulmonary  Cardiac glycosides: Digoxin (Lanoxin)
system: systemic venous congestion occurs as pressure builds up  Action: Increase force of cardiac contraction
 Contraindication: If heart rate is decreased do not give
Predisposing Factors b. Monitor ECG & hemodynamic monitoring
1. Right ventricular infarction c. Administer vasodilators as ordered
2. Atherosclerotic heart disease  Vasodilators: Nitroglycerine (NTG)
3. Tricuspid valve stenosis d. Monitor V/S
4. Pulmonary embolism 4. Reduce / eliminate edema
5. Related to COPD a. Administer diuretics as ordered
6. Pulmonic valve stenosis  Loop Diuretics: Lasix (Furosemide)
7. Left sided heart failure b. Daily weight
c. Maintain accurate I&O
S/sx d. Assess for peripheral edema
1. Anorexia e. Measure abdominal girth daily
2. Nausea f. Monitor electrolyte levels
3. Weight gain g. Monitor CVP & Swan-Ganz reading
4. Neck / jugular vein distension h. Provide Na restricted diet as ordered
5. Pitting edema i. Provide meticulous skin care
6. Bounding pulse 5. If acute pulmonary edema occurs: For Left Sided Heart Failure only
7. Hepatomegaly / Slenomegaly a. Administer Narcotic Analgesic as ordered
8. Cool extremities  Narcotic analgesic: Morphine SO4
9. Ascites  Action: to allay anxiety & reduce preload & afterload
10. Jaundice b. Administer Bronchodilator as ordered
11. Pruritus  Bronchodilators: Aminophylline IV
12. Esophageal varices  Action: relieve bronchospasm, increase urinary output &
Dx increase cardiac output
1. Chest X-ray (CXR): reveals cardiomegaly c. Administer Anti-arrythmic as ordered
2. Central Venous Pressure (CVP): measure fluid status: elevated  Anti-arrythmic: Lidocaine (Xylocane)
 Measure pressure in right atrium: 4-10 cm of water 6. Assist in bloodless phlebotomy: rotating tourniquet, rotated
 If CVP is less than 4 cm of water: Hypovolemic shock: increase clockwise every 15 minutes: to promote decrease venous return or
IV flow rate reducing preload
 If CVP is more than 10 cm of water: Hypervolemic shock: 7. Provide client teaching & discharge planning concerning:
Administer loop diuretics as ordered a. Need to monitor self daily for S/sx of Heart Failure (pedal
 Nursing Intervention: edema, weight gain, of 1-2 kg in a 2 day period, dyspnea, loss
 When reading CVP patient should be flat on bed of appetite, cough)
 Upon insertion place client in trendelendberg position: to b. Medication regimen including name, purpose, dosage, frequency
promote ventricular filling and prevent pulmonary embolism & side effects (digitalis, diuretics)
3. Echocardiography: reveals increased size of cardiac chambers c. Prescribe diet plan (low Na, cholesterol, caffeine: small frequent
(cardiomyopathy) meals)
4. Liver enzymes: SGPT & SGOT: is increased d. Need to avoid fatigue & plan for rest periods
5. ABG: decreased pO2 e. Prevent complications
 Arrythmia
Medical Management  Shock
1. Determination & elimination / control of underlying cause  Right ventricular hypertrophy
2. Drug therapy: digitalis preparations, diuretics, vasodilators  MI
3. Sodium-restricted diet: to decrease fluid retention  Thrombophlebitis
4. If medical therapies unsuccessful: mechanical assist devices (intra- f. Importance of follow-up care
aortic balloon pump), cardiac transplantation, or mechanical heart
may be employed Peripheral Vascular Disorder
5. Treatment for Left Sided Heart Failure Only:
 M – Morphine SO4 Arterial Ulcer
 A – Aminophylline 1. Thromboangiitis Obliterans (Buerger’s Disease)
 D – Digitalis 2. Raynaud’s Phenomenon


c. Operating chainsaw
Venous Ulcer
1. Varicose Veins S/sx
2. Thrombophlebitis (deep vein thrombosis) 1. Coldness
2. Numbness
Thromboangiitis Obliterans (Buerger’s Disease) 3. Tingling in one or more digits
 Acute inflammatory disorder affecting the small / medium sized 4. Pain: usually precipitated by exposure to cold, Emotional upset &
arteries & veins of the lower extremities Tobacco use
 Occurs as focal, obstructive, process; result in occlusion of a vessel 5. Intermittent color changes: pallor (white), cyanosis (blue), rubor
with a subsequent development of collateral circulation (red)
6. Small ulceration & gangrene a tips of digits (advance)
Predisposing Factors
1. High risk groups - men 25-40 years old Dx
2. High incident among smokers 1. Doppler UTZ: decrease blood flow to the affected extremity
2. Angiography: reveals site & extent of malocclusion
1. Intermittent claudication: leg pain upon walking Medical Management
2. Cold sensitivity & changes in skin color 1 white (pallor) changing to
1. Administer medications as ordered
blue (cyanosis) then red (rubor) a. Catecholamine-depliting antihypertinsive drugs:
3. Decreased or absent peripheral pulses (posterior tibial & dorsalis  Reserpine
pedis)  Guanethidine Monosulfate (Ismelin)
4. Trophic changes b. Vasodilators
5. Ulceration & Gangrene formation (advanced) Nursing Intervention
1. Importance of stop smoking
Dx 2. Need to maintain warmth especially in cold weather
1. Oscillometry: may reveal decrease in peripheral pulse volume 3. Need to wear gloves when handling cold object / opening a freezer
2. Doppler (UTZ): reveals decrease blood flow to the affected extremity or refrigerator door
3. Angiography: reveals location & extent of obstructive process

Medical Management
1. Drug Therapy Varicose Veins
a. Vasodilators: to improve arterial circulation (effectiveness ?)  Dilated veins that occurs most often in the lower extremities & trunk.
 Papaverine As the vessel dilates the valves become stretched & incompetent
 Isoxsuprine HCL (Vasodilan) with result venous pooling / edema
 Nylidrin HCL (Arlidin)  Abnormal dilation of veins of lower extremities and trunks due to
 Nicotinyl Alcohol (Roniacol) incompetent valve resulting to increased venous pooling resulting to
 Cyclandelate (Cyclospasmol) venous stasis causing decrease venous return
 Tolazoline HCL (Priscoline)
b. Analgesic: to relieve ischemic pain Predisposing Factors
c. Anti-coagulant: to prevent thrombus formation 1. Hereditary
2. Surgery 2. Congenital weakness of the veins
a. Bypass Grafting 3. Thrombophlebitis
b. Endarterectomy 4. Cardiac disorder
c. Balloon Catheter Dilation 5. Pregnancy
d. Lumbar Sympathectomy: to increase blood flow 6. Obesity
e. Amputation: may be necessary 7. Prolonged standing or sitting

Nursing Intervention S/sx

1. Encourage a slow progressive physical activity 1. Pain after prolonged standing: relieved by elevation
 Walking at least 2 times / day 2. Swollen dilated tortuous skin veins
 Out of bed at least 3-4 times / day 3. Warm to touch

2. Administer medications as ordered 4. Heaviness in legs

 Analgesics
 Vasodilators Dx

 Anti-coagulants 1. Venography

3. Foot care management: 2. Trendelenburg Test: veins distends quickly in less than 35 seconds

 Need to avoid trauma to the affected extreminty 3. Doppler Ultrasound: decreased or no blood flow heard after calf or

4. Importance of stop smoking thigh compression

5. Need to maintain warmth especially in cold weather

6. Prepare client for surgery: below knee amputation (BKA) Medical Management

7. Importance of follow-up care 1. Vein Ligation: involves ligating the saphenous vein where it joins the
femoral vein & stripping the saphenous vein system fro groin to

Raynaud’s Phenomenon ankles

 Intermittent episodes of arterial spasm most frequently involving the 2. Sclerotherapy: can recur & only done in spider web varicosities &

fingers or digits of the hands danger of thrombosis (2-3 years for embolism)

Predisposing Factors Nursing Intervention

1. High risk group: female between the teenage years & age 40 years 1. Elevate legs above heart level: to promote increased venous return

old & above by placing 2-3 pillows under the legs

2. Smoking 2. Measure the circumference of ankle & calf muscle daily: to

3. Collagen diseases determine if swollen

a. Systemic Lupus Erythematosus (SLE): butterfly rash 3. Apply anti-embolic / knee-length stockings

b. Rheumatoid Arthritis 4. Provide adequate rest

4. Direct hand trauma 5. Administer medications as ordered

a. Piano playing a. Analgesics: for pain

b. Excessive typing 6. Prepare client for vein ligation if necessary


a. Provide routine pre-op care: usually OPD  Diarrhea

b. In addition to routine post-op care:  Stomatitis
 Keep affected extremity elevated above the level of the  Hypersensitivity:
heart: to prevent edema  Dermatitis
 Apply elastic bandage & stockings which should be  Urticaria
removed every 8 hours for short periods & reapplied  Pruritus
 Assist out of bed within 24 hours ensuring the elastic  Fever
stockings is applied  Other:
 Assess for increase of bleeding particularly in groin area  Transient hair loss
7. Provide client teaching & discharge planning  Burning sensation of feet
 Bleeding complication
2. Surgery
Thrombophlebitis (Deep vein thrombosis) a. Vein ligation & stripping
 Inflammation of the vessel wall with formation of clot (thrombus), b. Venous thrombectomy: removal of cloth in the iliofemoral region
may affect superficial or deep veins c. Plication of the inferior vena cava: insertion of an umbrella-like
 Inflammation of the veins with thrombus formation prosthesis into the lumen of the vena cava: to filter incoming
 Most frequent veins affected are the saphenous, femoral & popliteal cloth
 Can result in damage to the surrounding tissue, ischemia & necrosis
Nursing Intervention
Predisposing Factors 1. Elevate legs above heart level: to promote increase venous return &
1. Obesity decreased edema
2. Smoking 2. Apply warm moist pack: to reduce lymphatic congestion
3. Related to pregnancy 3. Administer anti-coagulant as ordered:
4. Severe anemia a. Heparin
5. Prolong use of oral contraceptives: promotes lipolysis  Monitor PTT: dosage should be adjusted to keep PTT
6. Prolonged immobility between 1.5-2.5 times normal control level
7. Trauma  Use infusion pump to administer heparin
8. Dehydration  Ensure proper injection technique
9. Sepsis  Use 26 or 27 gauge syringe with ½-5/8 inch needle,
10. Congestive heart failure inject into fatty layer of abdomen above iliac crest
11. Myocardial infarction  Avoid injecting within 2 inches of umbilicus
12. Post-op complication: surgery  Insert needle at 45-90o to skin
13. Venous cannulation: insertion of various cardiac catheter  Do not withdraw plunger to assess blood return
14. Increase in saturated fats in the diet.  Apply gentle pressure after removal of needle: avoid
S/sx  Assess for increased bleeding tendencies (hematuria,
1. Pain in the affected extremity hematemesis, bleeding gums, petechiae of soft palate,
2. Superficial vein: Tenderness, redness induration along course of the conjunctiva retina, ecchymoses, epistaxis, bloody spumtum,
vein melena) & instruct the client to observe for & report these
3. Deep vein:  Have antidote (Protamine Sulfate) available
 Swelling  Instruct the client to avoid aspirin, antihistamines 7 cough
 Venous distention of limb preparations containing glyceryl guaiacolate & obtain MD
 Tenderness over involved vein permission before using other OTC drugs
 Positive homan’s sign: pain at the calf or leg muscle upon dorsi b. Warfarin (Coumadin)
flexion of the foot  Assess PT daily: dosage should be adjusted to maintain PT
 Cyanosis at 1.5-2.5 times normal control level; INR of 2
 Obtain careful medication history (there are many drug-
Dx drug interaction)
1. Venography (Phlebography): increased uptake of radioactive  Advise client to withhold dose & notify MD immediately if
material bleeding occur
2. Doppler ultrasonography: impairment of blood flow ahead of  Have antidote (Vitamin K) available
thrombus  Alert client to factors that may affect the anticoagulant
3. Venous pressure measurement: high in affected limb until collateral response (high-fat diet or sudden increased in vit. K-rich
circulation is developed food)
 Instruct the client to wear medic-alert bracelet
Medical Management 4. Assess V/S every 4 hours
1. Anti-coagulant therapy 5. Monitor chest pain or shortness of breath: possible pulmonary
a. Heparin embolism
 Action: block conversion of prothrombin to thrombin & 6. Measure thigh, calves, ankles & instep every morning
reduces formation or extension of thrombus 7. Provide client teaching & discharge planning
 Side effects: a. Need to avoid standing, sitting for long period, constrictive
 Spontaneous bleeding clothing, crossing legs at the knee, smoking, oral contraceptives
 Injection site reaction b. Importance of adequate hydration: to prevent hypercoagubility
 Ecchymoses c. Use elastic stockings when ambulatory
 Tissue irritation & sloughing d. Importance of planned rest periods with elevation of the feet
 Reversible transient alopecia e. Drug regimen
 Cyanosis f. Plan for exercise / activity
 Pan in the arms or legs  Begin with dorsiflexion of the feet while sitting or lying
 Thrombocytopenia down
b. Warfarin (Coumadin)  Swim several times weekly
 Action: block prothrombin synthesis by interfering with vit.  Gradually increased walking distance
K synthesis g. Importance of weight reduction: if obese
 Side effects: h. Monitor for signs of complications
 GI: a. Pulmonary Embolism
 Anorexia  Sudden sharp chest pain
 N/V  Unexplained dyspnea


 Tachycardia  Divides into the upper & lower lobar bronchi to supply the left
 Palpitations lobes
 Diaphoresis
 Restlessness Bronchioles
 In the bronchioles, airway patency is primarily dependent upon
Overview of Anatomy & Physiology of the Respiratory System elastic recoil formed by network of smooth muscles
 The tracheobronchial tree ends at the terminal bronchials. Distal to
Upper Respiratory System the terminal bronchioles the major function is no longer air
 Structure of the respiratory system, primarily an air conduction conduction but gas exchange between blood & alveolar air
system, include the nose, pharynx & larynx. Air is filtered warmed &  The respiratory bronchioles serves as the transition to the alveolar
humidified in the upper airway before passing to lower airway. epithelium

Nose Lungs
1. External nose is a frame work of bone & cartilage , internally divided  Right lung (consist of 3 lobes, 10 segments)
into two passages or nares (nasal cavity) by the septum: air enters  Left lung (consist of 2 lobes, 8 segments)
the system through the nares  Main organ of respiration, lie within the thoracic cavity on either side
2. The septum is covered with mucous membrane, where the olfactory of the heart
receptors are located. Turbinates, located internally, assist in  Broad area of lungs resting on diaphragm is called the base & the
warming & moistening the air narrow superior portion called the apex
3. The major function of the nose are warming, moistening & filtering
air. Pleura
4. Consist of anastomosis of capillaries known as Keissel Rach Plexus:  Serous membranes covering the lungs, continuous with the parietal
the site of nose bleeding pleura that lines the chest wall

Pharynx Parietal Pleura

1. A muscular passageway commonly called the throat  Lines the chest walls & secretes small amounts of lubricating fluid
2. Air passes through the nose to the pharynx into the intrapleural space (space between the parietal pleura &
3. Serves as a muscular passageway for both food and air visceral pleura) this fluid holds the lungs & chest wall together as a
single unit while allowing them to move separately
Composed of three section
1. Nasopharynx: located above the soft palate of the mouth, contains Chest Wall
the adenoids & opening to the eustachian tubes  Includes the ribs cage, intercostal muscles & diaphragm
2. Oropharynx: located directly behind the mouth & tongue, contains  Chest is a C shaped & supported by 12 pairs of ribs & costal
the palatine tonsils; air & food enter the body through oropharynx cartilages, the ribs have several attached muscles
3. Laryngopharynx: extends from the epiglotitis to the sixth cervical  Contraction of the external intercostal muscles raises the ribs
level cage during inspiration & helps increase the size of the thoracic
Larynx  The internal intercoastal muscles tends to pull ribs down & in &
1. Sometimes called “voice Box” connects upper & lower airways play a role in forced expiration
2. Framework is formed by the hyoid bone, epiglotitis & thyroid, cricoid
& arytenoids cartilages Diaphragm
3. Larynx opens to allow respiration & closes to prevent aspiration  A major muscle of ventilation (the exchange of air between the
when food passes through the pharynx atmosphere & the alveoli).
4. Vocal cords of larynx permit speech & are involved in the cough
reflex Alveoli
5. For phonation (voice production)  Are functional cellular unit of the lungs; about half arise directly from
Glottis alveolar ducts & are responsible for about 35% of alveolar gas
1. Opening of larynx exchange
2. Opens to allow passage of air  Produces surfactants
3. Closes to allow passage of food going to the esophagus  Site of gas exchange (CO2 and O2)
4. The initial sign of complete airway obstruction is the inability to  Diffusion (Dalton’s law of partial pressure of gases)
Lower Respiratory System  A phospholipids substance found in the fluid lining the alveolar
 Consist of trachea, bronchi & branches, & the lungs & associated epithelium
structures  Reduces surface tension & increase stability of the alveoli & prevents
 For gas exchange their collapse

Trachea Alveolar Ducts

 AKA “Windpipe”  Arises from the respiratory bronchioles & lead to the alveoli
 Air move from the pharynx to larynx to trachea (length 11-13 cm,
diameter 1.5-2.5 cm in adult) Alveolar Sac
 Extend from the larynx to the second costal cartilage, where it  Form the last part of the airway
bifurcates & is supported by 16-20 C-shaped cartilage rings  Functionally the same as the alveolar ducts they are surrounded by
 The area where the trachea divides into two branches is called the alveoli & are responsible for the 65% of the alveolar gas exchange
carina Type II Cells of Alveoli
 Consist of cartilaginous rings  Secretes surfactant
 Serves as passageway of air going to the lungs  Decrease surface tension
 Site of tracheostomy  Prevent collapse of alveoli
 Composed of lecithin and spingomyelin
Bronchi  Lecitin / Spingomyelin ratio: to determine lung maturity
 Right main bronchus  Normal Lecitin / Spingomyelin ratio: is 2:1
 Larger & straighter than the left  In premature infants: 1:2
 Divided into three lobar branches (upper, middle & lower  Give oxygen of less 40% in premature: to prevent atelectasis
bronchi) to supply the three lobes of right lung and retrolental fibroplasias
 Left main bronchus  Retinopathy & blindness: in premature


 Deep breathing & coughing exercise: tends to promote

Pulmonary Circulation expectoration
 Provides for reoxygenation of blood & release of CO2  Tracheobronchial suctioning as needed
 Gas transfers occurs in the pulmonary capillary bed  Administer Mucolytic or Expectorant as ordered
 Aerosol treatment via nebulizer
Respiratory Distress Syndrome  Humidification of inhaled air
 Decrease oxygen stimulates breathing  Chest physiotherapy (Postural Drainage): tends to promote
 Increase carbon dioxide is a powerful stimulant for breathing expectoration
3. Observe color characteristics of sputum & report any changes:
Pneumonia encourage client to perform good oral hygiene after expectoration
 Inflammation of the alveolar spaces of the lungs, resulting in 4. Provide adequate rest & relief control of pain
consolidation of lung tissue as the alveoli fill with exudates  Enforce CBR with limited activity
 Inflammation of the lung parenchyma leading to pulmonary  Limit visits & minimized conversation
consolidation as the alveoli is filled with exudates  Plan for uninterrupted rest periods
 Maintain pleasant & restful environment
Etiologic Agents 5. Administer antibiotic as ordered: monitor effects & possible toxicity
1. Streptococcus Pneumonae: causing pneumococal pneumonia  Broad Spectrum Antibiotic
2. Hemophylus Influenzae: causing broncho pneumonia  Penicillin
3. Diplococcus Pneumoniae  Tetracycline
4. Klebsella Pneumoniae  Microlides (Zethromax)
5. Escherichia Pneumoniae  Azethromycin: Side Effect: Ototoxicity
6. Pseudomonas 6. Prevent transmission: respiratory isolation client with staphylococcal
High Risk Groups 7. Control fever & chills:
1. Children below 5 years old  Monitor temperature A
2. Elderly  Administer antipyretic as ordered
 Increased fluid intake
Predisposing Factors  Provide frequent clothing & linen changing
1. Smoking 8. Assist in postural drainage: uses gravity & various position to
2. Air pollution stimulate the movement of secretions
3. Immuno compromised
4. Related to prolonged immobility (CVA clients): causing hypostatic Nursing Management for Postural Drainage
pneumonia a. Best done before meals or 2-3 hours: to prevent gastro
5. Aspiration of food: causing aspiration pneumonia esophageal reflux
b. Monitor vital signs
S/sx c. Encourage client deep breathing exercises
1. Productive cough with greenish to rusty sputum d. Administer bronchodilators 20-30 minutes before procedure
2. Rapid shallow respiration with expiratory grunt e. Stop if client cannot tolerate procedure
3. Nasal flaring f. Provide oral care after procedure
4. Intercostal rib retraction g. Contraindicated with
5. Use of accessory muscles of respiration  Unstable V/S
6. Dullness to flatness upon auscultation  Hemoptysis
7. Possible pleural friction rub  Clients with increase intra ocular pressure (Normal IOP 12 –
8. High-pitched bronchial breath sound 21 mmHg)
9. Rales / crackles (early) progressing to coarse (later)  Increase ICP
10. Fever 9. Provide increase CHO, calories, CHON & vitamin C
11. Chills 10. Provide client teaching & discharge planning
12. Anorexia a. Medication regimen / antibiotic therapy
13. General body malaise b. Need for adequate rest, limited activity, good nutrition, with
14. Weight loss adequate fluid intake & good ventilation
15. Bronchial wheezing c. Need to continue deep breathing & coughing exercise for at
16. Cyanosis least 6-8 weeks after discharge
17. Chest pain d. Availability of vaccines
18. Abdominal distention leading to paralytic ileus (absence of e. Need to report S/sx of respiratory infection
peristalsis)  Persistent or recurrent fever
 Changes in characteristics color of sputum
Dx  Chills
1. Sputum Gram Staining & Culture Sensitivity: positive to cultured  Increased pain
microorganisms  Difficulty in breathing
2. Chest x-ray: reveals pulmonary consolidation over affected area  Weight loss
3. ABG analysis: reveals decrease PO2  Persistent fatigue
4. CBC: reveals increase WBC, erythrocyte sedimentation rate is f. Avoid smoking
increased g. Prevent complications
 Atelectasis
Nursing Intervention  Meningitis
1. Facilitate adequate ventilation h. Importance of follow up care
 Administer O2 as needed & assess its effectiveness: low inflow
 Place client semi fowlers position Histoplasmosis
 Turn & reposition frequently client who are immobilized  Systemic fungal disease caused by inhalation of dust contaminated
 Administer analgesic as ordered: DOC: codeine: to relieve pain by histoplasma capsulatum which is transmitted to bird manure
associated with breathing  Acute fungal infection caused by inhalation of contaminated dust or
 Auscultate breath sound every 2-4 hour particles with histoplasma capsulatum derived from birds manure
 Monitor ABG
2. Facilitate removal of secretions S/sx
 General hydration 1. Similar to PTB or Pneumonia
2. Productive cough


3. Fever, chills, anorexia, general body malaise Spasm of the smooth muscle of bronchi & bronchioles, Accumulation
4. Chest and joint pains of tenacious secretions
5. Dyspnea  Reversible inflammatory lung condition due to hypersensitivity to
6. Cyanosis allergens leading to narrowing of smaller airways
7. Hemoptysis
8. Sometimes asymptomatic Predisposing Factors (Depending on Types)
1. Extrinsic Asthma (Atopic / Allergic)
Dx Causes
1. Chest X-ray: often appears similar to PTB  Pollen
2. Histoplasmin Skin Test: positive  Dust
3. ABG analysis: PO2 decrease  Fumes
 Smoke
Medical Management  Gases
1. Anti-fungal Agent: Amphotericin B (Fungizone)  Danders
 Very toxic: toxicity includes anorexia, chills, fever, headaches &  Furs
renal failure  Lints
 Acetaminophen, Benadryl & Steroids is given with Amphotericin
B: to prevent reaction 2. Intrinsic Asthma (Non atopic / Non allergic)
Nursing Intervention  Hereditary
1. Monitor respiratory status  Drugs (aspirin, penicillin, beta blocker)
2. Enforce CBR  Foods (seafoods, eggs, milk, chocolates, chicken)
3. Administer oxygen inhalation  Food additives (nitrates)
4. Administer medications as ordered  Sudden change in temperature, air pressure and humidity
a. Antifungal: Amphotericin B (Fungizone)  Physical and emotional stress
 Observe severe side effects:
 Fever: acetaminophen given prophylactically 3. Mixed Type: 90 – 95%
 Anaphylactic reaction: Benadryl & Steroids given
prophylactically S/sx
 Abnormal renal function with hypokalemia & azotemia: 1. Cough that is non productive
Nephrotoxicity, check for BUN and Creatinine, 2. Dyspnea
Hypokalemia 3. Wheezing on expiration
5. Force fluids to liquefy secretions 4. Cyanosis
6. Nebulize & suction as needed 5. Mild Stress or apprehension
7. Prevent complications: bronchiectasis 6. Tachycardia, palpitations
8. Prevent the spread of infection by spraying of breeding places 7. Diaphoresis

Chronic Obstructive Pulmonary Disease (COPD) Dx

1. Pulmonary Function Test Incentive spirometer: reveals decrease vital
Chronic Bronchitis lung capacity
 Excessive production of mucus in the bronchi with accompanying 2. ABG analysis: PO2 decrease
persistent cough 3. Before ABG test for positive Allens Test, apply direct pressure to
 Characteristic include hypertrophy / hyperplasia of the mucus ulnar & radial artery to determine presence of collateral circulation
secreting gland in the bronchi, decreased ciliary activity, chronic
inflammation & narrowing of the airway Medical Management
 Inflammation of bronchus resulting to hypertrophy or hyperplasia of 1. Drug Therapy
goblet mucous producing cells leading to narrowing of smaller a. Bronchodilators: given via inhalation or metered dose inhaler or
airways MDI for 5 minutes
 AKA “Blue Bloaters” b. Steroids: decrease inflammation: given 10 min after
Predisposing Factors c. Mucomysts (acetylceisteine): at bed side put suction machine
1. Smoking d. Mucolytics / expectorants
2. Air pollution e. Anti histamine
2. Physical Therapy
S/sx 3. Hyposensitization
1. Productive copious cough (consistent to all COPD) 4. Execise
2. Dyspnea on exertion Nursing Intervention
3. Use of accessory muscle of respiration 1. Enforce CBR
4. Scattered rales / rhonchi 2. O2 inhalation: low flow 2-3 L/min: to prevent respiratory distress
5. Feeling of gastric fullness 3. Administer medications as ordered
6. Slight Cyanosis 4. Force fluids 2-3 L/day
7. Distended neck veins 5. Semi fowlers position: to promote lung expansion
8. Ankle edema 6. Nebulize & suction when needed
9. Prolonged expiratory grunt 7. Provide client health teachings and discharge planning concerning
10. Anorexia and generalized body malaise a. Avoidance of precipitating factor
11. Pulmonary hypertension b. Prevent complications
a. Leading to peripheral edema  Emphysema
b. Cor Pulmonale (right ventricular hypertrophy)  Status Asthmaticus: severe attack of asthma which cause
poor controlled asthma
Dx  DOC: Epinephrine
1. ABG analysis: reveals PO2 decrease (hypoxemia): causing cyanosis, PCO2  Steroids
increase  Bronchodilators
c. Regular adherence to medications: to prevent development of
Bronchial Asthma status asthmaticus
 Immunologic / allergic reaction results in histamine release which d. Importance of follow up care
produces three mainairway response: Edema of mucus membrane,


Bronchiectasis 9. Decrease respiratory excursion

 Permanent abnormal dilation of the bronchi with destruction of 10. Resonance to hyper resonance
muscular & elastic structure of the bronchial wall 11. Decrease or diminished breath sounds with prolong expiration
 Abnormal permanent dilation of bronchus leading to destruction of 12. Decrease tactile fremitus
muscular and elastic tissues of alveoli 13. Prolong expiratory grunt
14. Rales or rhonchi
Predisposing Factors 15. Bronchial wheezing
1. Caused by bacterial infection 16. Barrel chest
2. Recurrent lower respiratory tract infections 17. Purse lip breathing: to eliminates excess CO2 (compensatory
3. Chest trauma mechanism)
4. Congenital defects (altered bronchial structure)
5. Related to presence of tumor (lung tumor) Dx
6. Thick tenacious secretion 1. Pulmonary Function Test: reveals decrease vital lung capacity
2. ABG analysis: reveals
Sx  Panlobular/centrilobular
1. Productive cough with mucopurulent sputum  Decrease PO2 (hypoxemia leading to chronic bronchitis,
2. Dyspnea in exertion “Blue Bloaters”)
3. Cyanosis  Decrease ph
4. Anorexia & generalized body malaise  Increase PCO2
5. Hemoptysis (only COPD with sign)  Respiratory acidosis
6. Wheezing  Panacinar/centriacinar
7. Weight loss  Increase PO2 (hyperaxemia, “Pink Puffers”)
 Decrease PCO2
Dx  Increase ph
1. CBC: elevation in WBC  Respiratory alkalosis
2. ABG: PO2 decrease
3. Bronchoscopy: reveals sources & sites of secretion: direct Nursing Intervention
visualization of bronchus using fiberscope 1. Enforce CBR
2. Administer oxygen inhalation via low inflow
Nursing Management before Bronchoscopy 3. Administer medications as ordered
1. Secure inform consent and explain procedure to client a. Bronchodilators: used to treat bronchospam
2. Maintain NPO 6-8 hours prior to procedure  Aminophylline
3. Monitor vital signs & breath sound  Isoproterenol (Isuprel)
 Terbutalin (Brethine)
Post Bronchoscopy  Metaproterenol (Alupent)
1. Feeding initiated upon return of gag reflex  Theophylline
2. Avoid talking, coughing and smoking, may cause irritation  Isoetharine (Bronkosol)
3. Monitor for signs of gross b. Corticosteroids:
4. Monitor for signs of laryngeal spasm: prepare tracheostomy set  Prednisone
c. Anti-microbial / Antibiotics: to treat bacterial infection
Medical Management  Tetracycline
1. Surgery  Ampicilline
 Pneumonectomy: 1 lung is removed & position on affected side d. Mucolytics / expectorants
 Segmental Wedge Lobectomy: promote re-expansion of lungs 4. Facilitate removal of secretions:
 Unaffected lobectomy: facilitate drainage a. Force fluids at least 3 L/day
b. Provide chest physiotherapy, coughing & deep breathing
Emphysema c. Nebulize & suction when needed
 Enlargement & destruction of the alveolar, bronchial & bronchiolar d. Provide oral hygiene after expectoration of sputum
tissue with resultant loss of recoil, air tapping, thoracic 5. Improve ventilation
overdistension, sputum accumulation & loss of diaphragmatic muscle a. Position client to semi or high fowlers
tone b. Instruct the client diaphragmatic muscles to breathe
 These changes cause a state of CO2 retention, hypoxia & respiratory c. Encourage productive cough after all treatment (splint abdomen
acidosis to help produce more expulsive cough)
 Irreversible terminal stage of COPD characterized by d. Employ pursed-lip breathing techniques (prolonged slow relaxed
 Inelasticity of alveoli expiration against pursed lips)
 Air trapping e. Institute pulmonary toilet
 Maldistribution of gases 6. Institute PEEP (positive end expiratory pressure) in mechanical
 Overdistention of thoracic cavity (barrel chest) ventilation promotes maximum alveolar lung expansion
7. Provide comfortable & humid environment
Predisposing Factors 8. Provide high carbohydrates, protein, calories, vitamins and minerals
1. Smoking 9. Provide client teachings and discharge planning concerning
2. Inhaled irritants: air pollution a. Prevention of recurrent infection
3. Allergy or allergic factor  Avoid crowds & individual with known infection
4. High risk: elderly  Adhere to high CHON, CHO & increased vit C diet
5. Hereditary: it involves deficiency of Alpha 1 anti-trypsin: to release  Received immunization for influenza & pneumonia
elastase for recoil of alveoli  Report changes in characteristic & color of sputum
S/sx  Report of worsening of symptoms (increased tightness of
1. Productive cough chest, fatigue, increased dyspnea)
2. Sputum production b. Control of environment
3. Anorexia & generalized body malaise  Use home humidifier at 30-50%
4. Weight loss  Wear scarf over nose & mouth in cold weather: to prevent
5. Flaring of nostrils (alai nares) bronchospasm
6. Use of accessory muscles  Avoid smoking & contact with environmental smoke
7. Dyspnea at rest  Avoid abrupt change in temperature
8. Increased rate & depth of breathing c. Avoidance of inhaled irritants


 Stay indoor: if pollution level is high  Chemical

 Use air conditioner with efficiency particulate air filter: to  Nitrates, & food additives, polycyclic
remove particles from air hydrocarbons, dyes, alkylating agents
d. Increase activity tolerance  Drugs: arsenicals, stilbestol, urethane
 Start with mild exercise: such as walking & gradual increase  Cigarette smoke
in amount & duration  hormones
 Used breathing techniques: (pursed lip, diaphragmatic) Classification of Cancer
during activities / exercise: to control breathing Tissue Typing:
 Have O2 available as needed to assist with activities  Carcinoma – arises from surface, glandular, or parenchymal
 Plan activities that require low amount of energy epithelium
 Plan rest period before & after activities 1. Squamous Cell Carcinoma – surface epithelium
e. Prevent complications 2. Adenocarcinoma – glandular or parenchymal tissue
 Atelectasis  Sarcoma – arises from connective tissue
 Cor Pulmonale: R ventricular hypertrophy  Leukemia – from blood
 CO2 narcosis: may lead to coma  Lymphoma – from lymph glands
 Pneumothorax: air in the pleural space  Multiple Myeloma – from bone marrow
f. Strict compliance to medication Stages of Tumor Growth
g. Importance of follow up care A. Staging System:
 TNM System: uses letters & numbers to designate the extent of
Oncology Nursing tumors
Pathophysiology & Etiology of Cancer o T– stands for primary growth; 1-4 with increasing size; T1S

Evolution of Cancer Cells indicates carcinoma in situ

 All cells constantly change through growth, degeneration, repair, & o N – stands for lymph nodes involvement: 0-4 indicates
adaptation. Normal cells must divide & multiply to meet the needs of progressively advancing nodal disease
the organism as a whole, & this cycle of cell growth & destruction is o M – stands for metastasis; 0 indicates no distant
an integral part of life processes. The activities of the normal cell in metastases, 1 indicates presence of metastases
the human body are all coordinated to meet the needs of the  Stages 0 – IV: all cancers divided into five stages incorporating size,
organism as a whole, but when the regulatory control mechanisms nodal involvement & spread
of normal fail, & growth continues in excess of the body needs,
neoplasia results. B. Cytologic Diagnosis of Cancer
 The term neoplasia refers to both benign & malignant growths, but 1. Involves in the study of shed cells (ex. Pap smear)
malignant cells behave very differently from normal cells & have 2. Classified by degree of cellular abnormality
special features characteristics of the cancer process.  Normal
 Since the growth control mechanism of normal cells is not  Probably normal (slight changes)
entirely understood, it is not clear what allows the  Doubtful (more severe changes)
uncontrolled growth, therefore no definitive cure has been  Probably cancer or precancerous
found.  Definitely cancer
Client Factors

Characteristics of Malignant Cells 1. Seven warning signs of cancer

 Cancer cells are mutated stem cells that have undergone structural 2. BSE – breast self – examination

changes so that they are unable to perform the normal functions of 3. Importance of retal exam for those over age 40

specialized tissues. 4. Hazards of smoking

 They may function is a disorderly way to crease normal function 5. Oral self – examination as well as annual exam of mouth &

completely, only functioning for their own survival & growth. teeth

 The most undifferentiated cells are also called anaplastic. 6. Hazards of excess sun exposure
7. Importance of pap smear
8. P.E. with lab work – up: every 3 years ages 20-40; yearly for
Rate of Growth
age 40 & over
 Cancer cells have uncontrolled growth or cell division
9. TSE – testicular self – examination
 Rate at which a tumor grows involves both increased cell division &
 Testicular Cancer
increased survival time of cells.
i. Most common cancer in men between the age
 Malignant cells do not form orderly layers, but pile on top of each
of 15 & 34
other to eventually form tumors.
 Warning signs that men should look for:
i. Painless swelling
Pre-disposing Factors
ii. Feeling of heaviness
 G – Genetics
iii. Hard lump (size of a pea)
 Some cancers shows familial pattern
iv. Sudden collection fluid in the scrotum
 Maybe caused by inherited genetics defects
v. Dull ache in the lower abdomen or in the
 I – Immunologic
 Failure of the immune system to respond & eradicate cancer
vi. Pain in the testicle or in the scrotum
vii. Enlargement or tenderness of the breasts
 Immunosuppressed individuals are more susceptible to cancer
 V – Viral 7 Warning Signs of Cancer
o Viruses have been shown to be the cause of certain tumors
C: change in bowel or bladder habits
in animals
A: a sore that doesn’t heal
o Viruses ( HTLV-I, Epstein Barr Virus, Human Papilloma
U: unusual bleeding or discharge
Virus) linked to human tumors
T: thickening of lump in breast or elsewhere
o Oncovirus (RNA – Type Viruses) thought to be culprit
I: indigestion or dysphagia
 E – Environmental
O: obvious change in wart or mole
o Majority (over 80%) of human cancer related to
N: nagging cough or hoarseness
environmental carcinogens
o Types:
Treatment of Cancer
 Physical Therapeutic Modality
 Radiation: X – ray, radium, nuclear
explosion & waste, UV Chemotherapy
 Trauma or chronic irritation


 Ability of the drug to kill cancer cells; normal cells may also be
damaged, producing side effects.
 Different drug act on tumor cell in different stages of the cell growth C. Integumentary System
 Alopecia
Types of Chemotherapeutic Drugs o Explain that hair loss is not permanent
o Offer support & encouragement
1. Antimetabolites o Scalp tourniquets or scalp hypothermia via ice pack may be
o Foster cancer cell death by interfering with cellular ordered to minimize hair loss with some agent
metabolic process. o Advice client to obtain wig before initiating treatment
2. Alkylating Agent
o act with DNA to hinder cell growth & division. D. Renal System
3. Plant Alkaloids
o obtained from periwinkle plant.  Encourage fluid & frequent voiding to prevent accumulation of
o makes the host’s body a less favorable environment for the metabolites in bladder; R: may cause direct damage to kidney by
growth of cancer cells. excretion of metabolites.
4. Antitumor Antibiotics  Increased excretion of uric acid may damage kidney
o affect RNA to make environment less favorable for cancer  Administer allopurinol (Zyloprim) as ordered; R: to prevent uric acid
growth. formation; encourage fluids when administering allopurinol
5. Steroids & Sex Hormones
o alter the endocrine environment to make it less conducive E. Reproductive System
to growth of cancer cells.
 Damage may occur to both men & women resulting infertility &/or
Major Side Effects & Nursing Intervention mutagenic damage to chromosomes
 Banking sperm often recommended for men before chemotherapy
A. GI System  Clients & partners advised to use reliable methods of contraception
during chemotherapy
 Nausea & Vomiting
o Administer antiemetics routinely q 4-6 hrs as well as F. Neurologic System
prophylactically before chemotherapy is initiated.
o Withhold food/fluid 4-6 hrs before chemotherapy  Plant alkaloids (vincristine) cause neurologic damage with repeated

o Provide bland food in small amounts after treatment doses

 Peripheral neuropathies, hearing loss, loss of deep tendon reflex, &

 Diarrhea paralytic ileus may occur.

o Administer antidiarrheals.
Radiation Therapy
o Maintain good perineal care.
 Uses ionizing radiation to kill or limit the growth of cancer cells,
o Give clear liquids as tolerated.
maybe internal or external.
o Monitor K, Na, Cl levels.
 It not only injured cell membrane but destroy & alter DNA so that
the cell cannot reproduce.
 Stomatitis (mouth sore)
 Effects cannot be limited to cancer cells only; all exposed cells
o Provide & teach the client good oral hygiene, including
including normal cells will be injured causing side effects.
avoidance of commercial mouthwashes.
 Localized effects are related to the area of the body being treated;
o Rinse with viscous lidocaine before meals to provide
generalized effects maybe related to cellular breakdown products.
analgesic effect.
o Perform a cleansing rinse with plain H2O or dilute a H2O
Types of Energy Emitted
soluble lubricant such as hydrogen peroxide after meal.
 Alpha – particles cannot passed through skin, rarely used.
o Apply H2O lubricant such as K-Y jelly to lubricate cracked
 Beta – particle cannot passed through skin, more penetrating than
alpha, generally emitted from radioactive isotopes, used for internal
o Advice client to suck on Popsicles or ice chips to provide
moisture.  Gamma – penetrate more deeper areas of the body, most common
form of external radiotherapy (ex. Electromagnetic or X-ray)
B. Hematologic System

Methods of Delivery
 Thrombocytopenia  External Radiation Therapy – beams high energy rays directly to the
o Avoid bumping or bruising the skin. affected area. Ex. Cobalt therapy
o Protect client from physical injury.  Internal Radiation Therapy – radioactive material is injected or
o Avoid aspirin or aspirin products. implanted in the client’s body for designated period of time.
o Avoid giving IM injections. o Sealed Implants – a radioisotope enclosed in a container so
o Monitor blood counts carefully. it does not circulate in the body; client’s body fluids should
o Assess for signs of increase bleeding tendencies (epistaxis, not be contaminated.

petechiae, ecchymoses) o Unsealed source – a radioisotope that is not encased in a

container & does circulate in the body & contaminate body
 Leukopenia fluids.
o Use careful handwashing technique.
o Maintain reverse isolation if WBC count drops below Factors Controlling Exposure

1000/mm  Half-life – time required for half of radioactive atoms to decay.

o Assess for signs of respiratory infection 1. Each radioisotope has different half-life.
2. At the end of half-life the danger from exposure decreases.
o Avoid crowds/persons with known infection
 Time – the shorter the duration the less the exposure.
 Distance – the greater the distance from the radiation source the
 Anemia
less the exposure.
o Provide adequate rest period
 Shielding – all radiation can be blocked; rubber gloves for alpha &
o Monitor hemoglobin & hematocrit
usually beta rays; thick lead or concrete stop gamma rays.
o Protect client from injury
o Administer O2 if needed
Side Effects of Radiation Therapy & Nursing Intervention


A. Skin - itching, redness, burning, oozing, sloughing.  Central shaft (diaphysis) made of compact bone & two end
 Keep skin free from foreign substances. (epiphyses) composed of cancellous bones (ex. Femur &
 Avoid use of medicated solution, ointment, or powders that contain humerus)
heavy metals such as zinc oxide.  Short Bones
 Avoid pressure, trauma, infection to skin; use bed cradle.  Cancellous bones covered by thin layer of compact bone
 Wash affected areas with plain H2O & pat dry; avoid soap. (ex. Carpals & tarsals)
 Use cornstarch, olive oil for itching; avoid talcum powder.  Flat Bones
 If sloughing occurs, use sterile dressing with micropore tape  Two layers of compact bone separated by a layer of
 Avoid exposing skin to heat, cold, or sunlight & avoid constricting cancellous bone (ex. Skull & ribs)
irritating clothing.  Irregular Bones
B. Anorexia, N/V  Sizes and shapes vary (ex. Vertebrae & mandible)
 Arrange meal time so they do not directly precede or follow
therapy. Joints
 Encourage bland foods.  Articulation of bones occurs at joints
 Provide small attractive meals.  Movable joints provide stabilization and permit a variety of
 Avoid extreme temperature. movements
 Administer antiemetics as ordered before meals.
C. Diarrhea Classification
 Encourage low residue, bland, high CHON food. 1. Synarthroses: immovable joints
 Administer antidiarrheal as ordered. 2. Amphiarthroses: partially movable joints
 Provide good perineal care. 3. Diarthroses (synovial): freely movable joints

 Monitor electrolytes particularly Na, K, Cl  Have a joint cavity (synovial cavity) between the articulating

D. Anemia, Leukopenia, Thrombocytopenia bone surfaces

 Isolate from those with known infection.  Articular cartilage covers the ends of the bones

 Provide frequent rest period.  A fibrous capsule encloses the joint

 Encourage high CHON diet.  Capsule is lined with synovial membrane that secretes synovial

 Avoid injury. fluid to lubricate the joint and reduce friction.

 Assess for bleeding. Muscles

 Monitor CBC, WBC, & platelets.  Functions of Muscles

 Provide shape to the body

Burns  Protect the bones

 direct tissue injury caused by thermal, electric, chemical & smoke  Maintain posture

inhaled (TECS)  Cause movement of body parts by contraction

Type:  Types of Muscles

1. Thermal  Cardiac: involuntary; found only in heart
2. Smoke Inhalation  Smooth: involuntary; found in walls of hollow structures (e.g.
3. Chemical intestines)
4. Electrical  Striated (skeletal): voluntary

Classification 1. Characteristics of skeletal muscles

 Partial Thickness  Muscles are attached to the skeleton at the point of origin
1. st
Superficial partial thickness (1 degree) and to bones at the point of insertion.
 Depth: epidermis only  Have properties of contraction and extension, as well as
 Causes: sunburn, splashes of hot liquid elasticity, to permit isotonic (shortening and thickening of
 Sensation: painful the muscle) and isometric (increased muscle tension)
 Characteristics: erythema, blanching on pressure, movement.
no vesicles  Contraction is innervated by nerve stimulation.
2. Deep Partial Thickness (2nd degree)
 Depth: epidermis & dermis Cartilage
 Causes: flash, scalding, or flame burn  A form of connective tissue
 Sensation: very painful  Major functions are to cushion bony prominences and offer
 Characteristics: fluid filled vesicles; red, shinny, protection where resiliency is required
wet after vesicles ruptures
 Full Thickness (3 rd & 4th
degree) Tendons and Ligaments
1. Depth: all skin layers & nerve endings; may involve  Composed of dense, fibrous connective tissue
muscles, tendons & bones  Functions
2. Causes: flames, chemicals, scalding, electric current 1. Ligaments attach bone to bone
3. Sensation: little or no pain 2. Tendons attach muscle to bone
4. Characteristics: wound is dry, white, leathery, or hard
Rheumatoid Arthritis (RA)
Overview Of Anatomy & Physiology Of Musculoskeletal System  Chronic systemic disease characterized by inflammatory changes in
 Consist of bones, muscles, joints, cartilages, tendons, ligaments, joints and related structures.
bursae  Joint distribution is symmetric (bilateral): most commonly affects
 To provide a structural framework for the body smaller peripheral joints of hands & also commonly involves wrists,
 To provide a means for movement elbows, shoulders, knees, hips, ankles and jaw.
 If unarrested, affected joints progress through four stages of
Bones deterioration: synovitis, pannus formation, fibrous ankylosis, and
 Function of Bones bony ankylosis.
 Provide support to skeletal framework Cause
 Assist in movement by acting as levers for muscles 1. Cause unknown or idiopathic
 Protect vital organ & soft tissue 2. Maybe an autoimmune process
 Manufacture RBC in the red bone marrow (hematopoiesis) 3. Genetic factors

 Provide site for storage of calcium & phosphorus 4. Play a role in society (work)

1. Types of Bones
 Long Bones Predisposing factors


1. Occurs in women more often than men (3:1) between the ages 35- 3. Change position frequently: alternate sitting, standing & lying.
45. 4. Promote comfort & relief / control of pain.
2. Fatigue a. Ensure balance between activity & rest.
3. Cold b. Provide 1-2 scheduled rest periods throughout day.
4. Emotional stress c. Rest & support inflamed joints: if splints used: remove 1-2
5. Infection times/day for gentle ROM exercises.
5. Ensure bed rest if ordered for acute exacerbations.
S/sx a. Provide firm mattress.
1. Fatigue b. Maintain proper body alignment.
2. Anorexia & body malaise c. Have client lie prone for ½ hour twice a day.
3. Weight loss d. Avoid pillows under knees.
4. Slight elevation in temperature e. Keep joints mainly in extension, not flexion.
5. Joints are painful: warm, swollen, limited in motion, stiff in morning f. Prevent complications of immobility.
& after a period of inactivity & may show crippling deformity in long- 6. Provide heat treatments: warm bath, shower or whirlpool; warm,
standing disease. moist compresses; paraffin dips as ordered.
6. Muscle weakness secondary to inactivity a. May be more effective in chronic pain.
7. History of remissions and exacerbations b. Reduce stiffness, pain & muscle spasm.
8. Some clients have additional extra-articular manifestations: 7. Provide cold treatments as ordered: most effective during acute
subcutaneous nodules; eye, vascular, lung, or cardiac problems. episodes.
8. Provide psychologic support and encourage client to express
Dx feelings.
1. X-rays: shows various stages of joint disease 9. Assists clients in setting realistic goals; focus on client strengths.
2. CBC: anemia is common 10. Provide client teaching & discharge planning & concerning.
3. ESR: elevated a. Use of prescribed medications & side effects
4. Rheumatoid factor positive b. Self-help devices to assist in ADL and to increase independence
5. ANA: may be positive c. Importance of maintaining a balance between activity & rest
6. C-reactive protein: elevated d. Energy conservation methods
e. Performance of ROM, isometric & prescribed exercises
Medical Management f. Maintenance of well-balanced diet
1. Drug therapy g. Application of resting splints as ordered
a. Aspirin: mainstay of treatment: has both analgesic and anti- h. Avoidance of undue physical or emotional stress
inflammatory effect. i. Importance of follow-up care
b. Nonsteroidal anti-inflammatory drugs (NSAIDs): relieve pain and
inflammation by inhibiting the synthesis of prostaglandins. Osteoarthritis
 Ibuprofen (Motrin)  Chronic non-systemic disorder of joints characterized by
 Indomethacin (Indocin) degeneration of articular cartilage
 Fenoprofen (Nalfon)  Weight-bearing joints (spine, knees and hips) & terminal
 Mefenamic acid (Ponstel) interphalangeal joints of fingers most commonly affected
 Phenylbutazone (Butazolidin)
 Piroxicam (Feldene) Incident Rate

 Naproxen (Naprosyn) 1. Women & men affected equally

 Sulindac (Clinoril) 2. Incidence increases with age

c. Gold compounds (Chrysotherapy)

 Injectable form: given IM once a week; take 3-6 months to Predisposing Factors

become effective 1. Most important factor in development is aging (wear & tear on

 Sodium thiomalate (Myochrysine) joints)

 Aurothioglucose (Solganal) 2. Obesity

 SI: monitor blood studies & urinalysis frequently 3. Joint trauma

 Proteinuria
 Mouth ulcers S/sx

 Skin rash 1. Pain: (aggravated by use & relieved by rest) & stiffness of joints

 Aplastic anemia. 2. Heberden’s nodes: bony overgrowths at terminal interphalangeal

 Oral form: smaller doses are effective; take 3-6 months to
3. Decreased ROM with possible crepitation (grating sound when
become effective
moving joints)
 Auranofin (Ridaura)
 SI: blood & urine studies should be monitored.
 Diarrhea
1. X-rays: show joint deformity as disease progresses
d. Corticosteroids
2. ESR: may be slightly elevated when disease is inflammatory
 Intra-articular injections: temporarily suppress inflammation
in specific joints.
Nursing Interventions
 Systemic administration: used only when client does not
1. Assess joints for pain & ROM.
respond to less potent anti-inflammatory drugs.
2. Relieve strain & prevent further trauma to joints.
e. Methotrexate: given to suppress immune response
a. Encourage rest periods throughout day.
 Cytoxan
b. Use cane or walker when indicated.
 SI: bone marrow suppression.
c. Ensure proper posture & body mechanics.
2. Physical therapy: to minimize joint deformities.
d. Promote weight reduction: if obese
3. Surgery: to remove severely damaged joints (e.g. total hip
e. Avoid excessive weight-bearing activities & continuous standing.
replacement; knee replacement).
3. Maintain joint mobility and muscle strength.
a. Provide ROM & isometric exercises.
Nursing Interventions
b. Ensure proper body alignment.
1. Assess joints for pain, swelling, tenderness & limitation of motion.
c. Change client’s position frequently.
2. Promote maintenance of joint mobility and muscle strength.
4. Promote comfort / relief of pain.
a. Perform ROM exercises several times a day: use of heat prior to
a. Administer medications as ordered:
exercise may decrease discomfort; stop exercise at the point of
 Aspirin & NSAID: most commonly used
b. Use isometric or other exercise to strengthen muscles.


 Corticosteroids (Intra-articular injections): to relieve pain &  Chronic connective tissue disease involving multiple organ systems
improve mobility.
b. Apply heat or ice as ordered (e.g. warm baths, compresses, hot Incident Rate
packs): to reduce pain. 1. Occurs most frequently in young women
5. Prepare client for joint replacement surgery if necessary.
6. Provide client teaching and discharge planning concerning Predisposing Factors
a. Used of prescribed medications and side effects 1. Cause unknown
b. Importance of rest periods 2. Immune
c. Measures to relieve strain on joints 3. Genetic & viral factors have all been suggested
d. ROM and isometric exercises
e. Maintenance of a well-balanced diet Pathophysiology
f. Use of heat/ice as ordered. 1. A defect in body’s immunologic mechanisms produces autoantibodies
in the serum directed against components of the client’s own cell
Gout 2. Affects cells throughout the body resulting in involvement of many
 A disorder of purine metabolism; causes high levels of uric acid in organs, including joints, skin, kidney, CNS & cardiopulmonary
the blood & the precipitation of urate crystals in the joints system.
 Inflammation of the joints caused by deposition of urate crystals in
articular tissue S/sx
1. Fatigue
Incident Rate 2. Fever
1. Occurs most often in males 3. Anorexia
2. Familial tendency 4. Weight loss
5. Malaise
S/sx 6. History of remissions & exacerbations
1. Joint pain 7. Joint pain
2. Redness 8. Morning stiffness
3. Heat 9. Skin lesions
4. Swelling  Erythematous rash on face, neck or extremities may occur
5. Joints of foot (especially great toe) & ankle most commonly affected  Butterfly rash over bridge of nose & cheeks
(acute gouty arthritis stage)  Photosensitivity with rash in areas exposed to sun
6. Headache 10. Oral or nasopharyngeal ulcerations
7. Malaise 11. Alopecia
8. Anorexia 12. Renal system involvement
9. Tachycardia  Proteinuria
10. Fever  Hematuria
11. Tophi in outer ear, hands & feet (chronic tophaceous stage)  Renal failure
13. CNS involvement
Dx  Peripheral neuritis
1. CBC: uric acid elevated  Seizures
 Organic brain syndrome
Medical Management  Psychosis
1. Drug therapy 14. Cardiopulmonary system involvement
a. Acute attack:  Pericarditis
 Colchicine IV or PO: discontinue if diarrhea occurs  Pleurisy
 NSAID: Indomethacin (Indocin) 15. Increase susceptibility to infection
 Naproxen (Naprosyn)
 Phenylbutazone (Butazolidin) Dx
b. Prevention of attacks 1. ESR: elevated
 Uricosuric agents: increase renal excretion of uric acid 2. CBC: RBC anemia, WBC & platelet counts decreased
 Probenecid (Benemid) 3. Anti-nuclear antibody test (ANA): positive
 Sulfinpyrazone (Anturanel) 4. Lupus Erythematosus (LE prep): positive
 Allopurinal (Zyloprim): inhibits uric acid formation 5. Anti-DNA: positive
2. Low-purine diet may be recommended 6. Chronic false-positive test for syphilis
3. Joint rest & protection
4. Heat or cold therapy Medical Management
1. Drug therapy
Nursing Interventions a. Aspirin & NSAID: to relieve mild symptoms such as fever &
1. Assess joints for pain, motion & appearance. arthritis
2. Provide bed rest & joint immobilization as ordered. b. Corticosteroids: to suppress the inflammatory response in acute
3. Administer anti-gout medications as ordered. exacerbations or severe disease
4. Administer analgesics as ordered: for pain c. Immunosuppressive agents: to suppress the immune response
5. Increased fluid intake to 2000-3000 ml/day: to prevent formation of when client unresponsive to more conservative therapy
renal calculi.  Azathioprine (Imuran)
6. Apply local heat or cold as ordered: to reduce pain  Cyclophosphamide (Cytoxan)
7. Apply bed cradle: to keep pressure of sheets off joints. 2. Plasma exchange: to provide temporary reduction in amount of
8. Provide client teaching and discharge planning concerning circulating antibodies.
a. Medications & their side effects 3. Supportive therapy: as organ systems become involved.
b. Modifications for low-purine diet: avoidance of shellfish, liver,
kidney, brains, sweetbreads, sardines, anchovies Nursing Interventions
c. Limitation of alcohol use 1. Assess symptoms to determine systems involved.
d. Increased in fluid intake 2. Monitor vital signs, I&O, daily weights.
e. Weight reduction if necessary 3. Administer medications as ordered.
f. Importance of regular exercise 4. Institute seizure precautions & safety measures: with CNS
Systemic Lupus Erythematosus (SLE) 5. Provide psychologic support to client / significant others.


6. Provide client teaching & discharge planning concerning  Pharynx: aids in swallowing & functions in ingestion by
a. Disease process & relationship to symptoms providing a route for food to pass from the mouth to the
b. Medication regimen & side effects. esophagus
c. Importance of adequate rest.
d. Use of daily heat & exercises as prescribed: for arthritis. Esophagus
e. Need to avoid physical or emotional stress  Muscular tube that receives foods from the pharynx & propels it into
f. Maintenance of a well-balanced diet the stomach by peristalsis
g. Need to avoid direct exposure to sunlight: wear hat & other
protective clothing Stomach
h. Need to avoid exposure to persons with infections  Located on the left side of the abdominal cavity occupying the
i. Importance of regular medical follow-up hypochondriac, epigastric & umbilical regions
j. Availability of community agencies  Stores & mixes food with gastric juices & mucus producing chemical
& mechanical changes in the bolus of food
 The secretion of digestive juice is stimulated by smelling, tasting
Osteomyelitis & chewing food which is known as cephalic phase of digestion
 Infection of the bone and surrounding soft tissues, most commonly  The gastric phase is stimulated by the presence of food in the
caused by S. aureus. stomach & regulated by neural stimulation via PNS & hormonal
 Infection may reach bone through open wound (compound fracture stimulation through secretion of gastrin by the gastric mucosa
or surgery), through the bloodstream, or by direct extension from  After processing in the stomach the food bolus called chyme is
infected adjacent structures. released into the small intestine through the duodenum
 Infections can be acute or chronic; both cause bone destruction.  Two sphincters control the rate of food passage
 Cardiac Sphincter: located at the opening between the
S/sx esophagus & stomach
1. Malaise  Pyloric Sphincter: located between the stomach & duodenum
2. Fever  Three anatomic division
3. Pain & tenderness of bone  Fundus
4. Redness & swelling over bone  Body
5. Difficulty with weight-bearing  Antrum
6. Drainage from wound site may be present.  Gastric Secretions:
 Pepsinogen: secreted by the chief cells located in the fundus aid
Dx in CHON digestion
1. CBC: WBC elevated  Hydrocholoric Acid: secreted by parietal cells, function in CHON
2. Blood cultures: may be positive digestion & released in response to gastrin
3. ESR: may be elevated  Intrinsic Factor: secreted by parietal cell, promotes absorption
of Vit B12
Nursing Interventions  Mucoid Secretion: coat stomach wall & prevent auto digestion
1. Administer analgesics & antibiotics as ordered.
2. Use sterile techniques during dressing changes. 1st half of duodenum
3. Maintain proper body alignment & change position frequently: to
prevent deformities. Middle Alimentary canal: Function for absorption; Complete absorption: large
4. Provide immobilization of affected part as ordered. intestine
5. Provide psychologic support & diversional activities (depression may Small Intestines
result from prolonged hospitalization)  Composed of the duodenum, jejunum & ileum
6. Prepare client for surgery if indicated.
 Extends from the pylorus to the ileocecal valve which regulates flow
 Incision & drainage: of bone abscess
into the large intestines to prevent reflux to the into the small
 Sequestrectomy: removal of dead, infected bone & cartilage
 Bone grafting: after repeated infections
 Major function: digestion & absorption of the end product of
 Leg amputation
7. Provide client teaching and discharge planning concerning
 Structural Features:
 Use of prescribed oral antibiotic therapy & side effects
 Villi (functional unit of the small intestines): finger like
 Importance of recognizing & reporting signs & complications
projections located in the mucous membrane; containing goblet
(deformity, fracture) or recurrence
cells that secrets mucus & absorptive cells that absorb digested
food stuff
 Crypts of Lieberkuhn: produce secretions containing digestive
A. General information
 Brunner’s Gland: found in the submucosaof the duodenum,
B. Medical management
secretes mucus
C. Assessment findings
D. Nursing interventions
2nd half of duodenum
Overview of Anatomy & Physiology Gastro Intestinal Track System
 The primary function of GIT are the movement of food, digestion,
1st half of ascending colon
absorption, elimination & provision of a continuous supply of the
nutrients electrolytes & H2O.
Lower Alimentary Canal: Function: elimination
Large Intestine
Upper alimentary canal: function for digestion
 Divided into four parts:
 Cecum (with appendix)
 Consist of lips & oral cavity
 Colon (ascending, transverse, descending, sigmoid)
 Provides entrance & initial processing for nutrients & sensory data
 Rectum
such as taste, texture & temperature
 Anus
 Oral Cavity: contains the teeth used for mastication & the
 Serves as a reservoir for fecal material until defecation occurs
tongue which assists in deglutition & the taste sensation &
 Function: to absorb water & electrolytes
 MO present in the large intestine: are responsible for small amount
 Salivary gland: located in the mouth produce secretion
of further breakdown & also make some vitamins
containing pyalin for starch digestion & mucus for lubrication
 Amino Acids: deaminated by bacteria resulting in ammonia
which is converted to urea in the liver


 Bacteria in the large intestine: aid in the synthesis of vitamin K secretin, pancreas releases bicarbonate to neutralized acid
& some of the vitamin B groups chyme
 Feces (solid waste): leave the body via rectum & anus  Cholecystokinin & Pancreozymin (CCKPZ)
 Anus: contains internal sphincter (under involuntary control) &  Are produced by the duodenal mucosa
external sphincter (voluntary control)  Stimulate contraction of the gallbladder along with
 Fecal matter: usually 75% water & 25% solid wastes relaxation of the sphincter of oddi (to allow bile flow
(roughage, dead bacteria, fats, CHON, inorganic matter) from common bile duct into the duodenum) &
a. 2 half of ascending colon
stimulate release of the pancreatic enzymes
b. Transverse Salivary Glands
c. Descending colon 1. Parotid – below & front of ear
d. Sigmoid 2. Sublingual
e. Rectum 3. Submaxillary

Accessory Organ - Produces saliva – for mechanical digestion

Liver - 1200 -1500 ml/day - saliva produced
 Largest internal organ: located in the right hypochondriac &
epigastric regions of the abdomen Disorder of the GIT
 Liver Loobules: functional unit of the liver composed of hepatic cells Peptic Ulcer Disease (PUD)
 Hepatic Sinusoids (capillaries): are lined with kupffer cells which Gastric Ulcer
carry out the process of phagocytosis  Ulceration of the mucosal lining of the stomach
 Portal circulation brings blood to the liver from the stomach, spleen,  Most commonly found in the antrum
pancreas & intestines  Excoriation / erosion of submucosa & mucosal lining due to:
 Function:  Hypersecretion of acid: pepsin
 Metabolism of fats, CHO & CHON: oxidizes these nutrient for  Decrease resistance to mucosal barrier
energy & produces compounds that can be stored  Caused by bacterial infection: Helicobacter Pylori
 Production of bile
 Conjugation & excretion (in the form of glycogen, fatty acids, Doudenal Ulcer
minerals, fat-soluble & water-soluble vitamins) of bilirubin  Most commonly found in the first 2 cm of the duodenum
 Storage of vitamins A, D, B12 & iron  Characterized by gastric hyperacidity & a significant rate of gastric
 Synthesis of coagulation factors emptying
 Detoxification of many drugs & conjugation of sex hormones
Predisposing factor
Salivary gland  Smoking: vasoconstriction: effect GIT ischemia
Verniform appendix  Alcohol Abuse: stimulates release of histamine: Parietal cell release
Liver Hcl acid = Ulceration
Pancreas: auto digestion  Emotional Stress
Gallbladder: storage of bile  Drugs:
 Salicylates (Aspirin)
Biliary System  Steroids
 Consist of the gallbladder & associated ductal system (bile ducts)  Butazolidin
 Gallbladder: lies under the surface of the liver
 Function: to concentrate & store bile S/sx
 Ductal System: provides a route for bile to reach the intestines Gastric Ulcer
 Bile: is formed in the liver & excreted into hepatic duct Duodenal Ulcer
 Hepatic Duct: joins with the cystic duct (which drains the Site Antrum or lesser Duodenal bulb
gallbladder) to form the common bile duct curvature
 If the sphincter of oddi is relaxed: bile enters the duodenum, if  Pain  30 min-1 hr  2-3 hrs after
contracted: bile is stored in gallbladder after eating eating
 Left epigastrium  Mid
Pancreas  Gaseous & epigastrium
 Positioned transversely in the upper abdominal cavity burning  Cramping &
 Consist of head, body & tail along with a pancreatic duct which  Not usually burning
extends along the gland & enters the duodenum via the common relieved by food  Usually relieved
bile duct & antacid by food &
 Has both exocrine & endocrine function antacid
 Function in GI system: is exocrine  12 MN – 3am
 Exocrine cells in the pancreas secretes: pain
 Hypersecretion  Normal gastric  Increased
 Trypsinogen & Chymotrypsin: for protein digestion
acid secretion gastric acid
 Amylase: breakdown starch to disacchardes
 Lipase: for fat digestion  Vomiting  Common  Not common
 Endocrine function related to islets of langerhas  Hemorrhage  Hematemeis  Melena
 Weight  Weight loss  Weight gain
 Complications  Stomach cause  Perforation
Physiology of Digestion & Absorption  Hemorrhage
 Digestion: physical & chemical breakdown of food into absorptive  High Risk  60 years old  20 years old
 Hgb & Hct: decrease (if anemic)
 Initiate in the mouth where the food mixes with saliva & starch
 Endoscopy: reveals ulceration & differentiate ulceration from gastric
is broken down
 Food then passes into the esophagus where it is propelled into
 Gastric Analysis: normal gastric acidity
the stomach
 Upper GI series: presence of ulcer confirm
 In the stomach food is processed by gastric secretions into a
substance called chyme
Medical Management
 In the small intestines CHO are hydrolyzed to monosaccharides,
1. Supportive:
fats to glycerol & fatty acid & CHON to amino acid to complete
 Rest
the digestive process
 Bland diet
 When chymes enters the duodenum, mucus is secreted to
 Stress management
neutralized hydrocholoric acid, in response to release


2. Drug Therapy: 3. Avoid caffeine & milk / milk products: Increase gastric acid secretion
 Antacids: neutralizes gastric acid 4. Provide client teaching & discharge planning
 Aluminum hydroxide: binds phosphate in the GIT & a. Medical Regimen
neutralized gastric acid & inactivates pepsin  Take medication at prescribe time
 Magnesium & aluminum salt: neutralized gastric acid &  Have antacid available at all times
inactivate pepsin if pH is raised to >=4  Recognized situation that would increase the need for
Aluminum containing Antacids Magnesium containing  Avoid ulcerogenic drugs: salicylates, steroids
Antacids  Know proper dosage, action & SE
Ex. Aluminum OH gel (Amphojel) Ex. Milk of Magnesia b. Proper Diet
SE: Constipation SE: Diarrhea  Bland diet consist of six meals / day
 Eat slowly
 Avoid acid producing substance: caffeine, alcohol, highly
seasoned food
Maalox  Avoid stressfull situation at mealtime
SE: fever  Plan rest period after meal
 Avoid late bedtime snacks
 Histamines (H2) receptor antagonist: inhibits gastric acid c. Avoidance of stress-producing situation & development of stress
secretion of parietal cells production methods
 Ranitidine (Zantac): has some antibacterial action against  Relaxation techniques
H. pylori  Exercise
 Cimetidine (Tagamet)  Biofeedback
 Famotidine (Pepcid)
 Anticholinergic: Dumping syndrome
 Atropine SO4: inhibit the action of acetylcholine at post  Abrupt emptying of stomach content into the intestine
ganglionic site (secretory glands) results decreases GI  Rapid gastric emptying of hypertonic food solutions
secretions  Common complication of gastric surgery
 Propantheline: inhibit muscarinic action of acetylcholine  Appears 15-20 min after meal & last for 20-60 min
resulting decrease GI secretions  Associated with hyperosmolar CHYME in the jejunum which draws
 Proton Pump Inhibitor: inhibit gastric acid secretion regardless fluid by osmosis from the extracellular fluid into the bowel.
of acetylcholine or histamine release Decreased plasma volume & distension of the bowel stimulates
 Omeprazole (Prilosec): diminished the accumulation of acid increased intestinal motility
in the gastric lumen & healing of duodenal ulcer
 Pepsin Inhibitor: reacts with acid to form a paste that binds to S/sx
ulcerated tissue to prevent further destruction by digestive 1. Weakness
enzyme pepsin 2. Faintness
 Sucralfate (Carafate): provides a paste like subs that coats 3. Feeling of fullness
mucosal lining of stomach 4. Dizziness
 Metronidazole & Amoxacillin: for ulcer caused by Helicobacter 5. Diaphoresis
Pylori 6. Diarrhea
3. Surgery: 7. Palpitations
 Gastric Resection
 Anastomosis: joining of 2 or more hollow organ Nursing Intervention
 Subtotal Gastrectomy: Partial removal of stomach 1. Avoid fluids in chilled solutions
 Before surgery for BI or BII 2. Small frequent feeding: six equally divided feedings
 Do Vagotomy (severing or cutting of vagus nerve) & 3. Diet: decrease CHO, moderate fats & CHON
Pyloroplasty (drainage) first 4. Flat on bed 15-30 min after q feeding

Billroth I (Gastroduodenostomy) Billroth II (Gastrojejunostomy) Disorders of the Gallbladder

 Removal of ½ of stomach  Removal of ½ -3/4 of Cholecystitis / Cholelithiasis
& anastomoses of gastric stomach & duodenal bulb &  Cholecystitis:
stump to the duodenum. anastomostoses of gastric  Acute or chronic inflammation of the gallbladder
stump to jejunum.  Most commonly associated with gallstones
 Inflammation occurs within the walls of the gallbladder &
Nursing Intervention Post op
creates thickening accompanied by edema
1. Monitor NGT output
 Consequently there is impaired circulation, ischemia &
 Immediately post op should be bright red
eventually necrosis
 Within 36-42 hrs: output is yellow green
 Cholelithiasis:
 After 42 hrs: output is dark red
 Formation of gallstones & cholesterol stones
2. Administer medication
 Inflammation of gallbladder with gallstone formation.
 Analgesic
 Antibiotic
Predisposing Factor:
 Antiemetics
1. High risk: women 40 years old
3. Maintain patent IV line
2. Post menopausal women: undergoing estrogen therapy
4. Monitor V/S, I&O & bowel sounds
3. Obesity
5. Complications:
4. Sedentary lifestyle
 Hemorrhage: Hypovolemic shock: Late signs: anuria
5. Hyperlipidemia
 Peritonitis
6. Neoplasm
 Paralytic ileus: most feared
 Hypokalemia S/sx:
 Thromobphlebitis 1. Severe Right abdominal pain (after eating fatty food): Occurring
 Pernicious anemia especially at night
2. Intolerance of fatty food
Nursing Intervention 3. Anorexia
1. Administer medication as ordered 4. N/V
2. Diet: bland, non irritating, non spicy 5. Jaundice


6. Pruritus 1. Drug Therapy

7. Easy bruising  Narcotic Analgesic: for pain
8. Tea colored urine  Meperidine Hcl (Demerol)
9. Steatorrhea  Don’t give Morphine SO4: will cause spasm of Sphincter of
Dx  Smooth muscle relaxant: to relieve pain
1. Direct Bilirubin Transaminase: increase  Papaverine Hcl
2. Alkaline Phosphatase: increase  Anticholinergic: to decrease pancreatic stimulation
3. WBC: increase  Atrophine SO4
4. Amylase: increase  Propantheline Bromide (Profanthene)
5. Lipase: increase  Antacids: to decrease pancreatic stimulation
6. Oral cholecystogram (or gallbladder series): confirms presence of  Maalox
stones  H2 Antagonist: to decrease pancreatic stimulation
Medical Management  Ranitidin (Zantac)
1. Supportive Treatment: NPO with NGT & IV fluids  Vasodilators: to decrease pancreatic stimulation
2. Diet modification with administration of fat soluble vitamins  Nitroglycerine (NTG)
3. Drug Therapy  Ca Gluconate: to decrease pancreatic stimulation
 Narcotic analgesic: DOC: Meperdipine Hcl (Demerol): for pain 2. Diet Modification
 (Morpine SO4: is contraindicated because it causes spasm 3. NPO (usually)
of the Sphincter of Oddi) 4. Peritoneal Lavage
 Antocholinergic: (Atrophine SO4): for pain 5. Dialysis
 (Anticholinergic: relax smooth muscles & open bile ducts)
 Antiemetics: Phenothiazide (Phenergan): with anti emetic Nursing Intervention
properties 1. Administer medication as ordered
4. Surgery: Cholecystectomy / Choledochostomy 2. Withhold food & fluid & eliminate odor: to decrease pancreatic
stimulation / aggravates pain
Nursing Intervention 3. Assist in Total Parenteral Nutrition (TPN) or hyperalimentation
1. Administer pain medication as ordered & monitor effects  Complication of TPN
2. Administer IV fluids as ordered  Infection
3. Diet: increase CHO, moderate CHON, decrease fats  Embolism
4. Meticulous skin care: to relieved priritus  Hyperglycemia
4. Institute non-pharmacological measures: to decrease pain
Disorders of the Pancreas
 Assist client to comfortable position: Knee chest or fetal like
 An inflammatory process with varying degrees of pancreatic edema,
 Teach relaxation techniques & provide quiet, restful
fat necrosis or hemorrhage
 Proteolytic & lipolytic pancreatic enzymes are activated in the
5. Provide client teaching & discharge planning
pancreas rather than in the duodenum resulting in tissue damage &
 Dietary regimen when oral intake permitted
auto digestion of pancreas
 High CHO, CHON & decrease fats
 Acute or chronic inflammation of pancreas leading to pancreatic
 Eat small frequent meal instead of three large ones
edema, hemorrhage & necrosis due to auto digestion
 Avoid caffeine products
 Bleeding of Pancreas: Cullen’s sign at umbilicus
 Eliminate alcohol consumption
 Maintain relaxed atmosphere after meals
Predisposing factors:
 Report signs of complication
1. Chronic alcoholism
 Continued N/V
2. Hepatobilary disease
 Abdominal distension with feeling of fullness
3. Trauma
4. Viral infection  Persistent weight loss

5. Penetrating duodenal ulcer  Severe epigastric or back pain

6. Abscesses  Frothy foul smelling bowel movement

7. Obesity  Irritability, confusion, persistent elevation of temperature (2

8. Hyperlipidemia day)

9. Hyperparathyroidism
10. Drugs: Thiazide, steroids, diuretics, oral contraceptives Apendicitis
 Inflammation of the appendix that prevents mucus from passing into

S/Sx: the cecum

1. Severe left upper epigastric pain radiates from back & flank area:  Inflammation of verniform appendix

aggravated by eating with DOB  If untreated: ischemia, gangrene, rupture & peritonitis

2. N/V  May cause by mechanical obstruction (fecalith, intestinal parasites)

3. Tachycardia or anatomic defect

4. Palpitation: due to pain  May be related to decrease fiber in the diet

5. Dyspepsia: indigestion
6. Decrease bowel sounds Predisposing factor:

7. (+) Cullen’s sign: ecchymosis of umbilicus Hemorrhage 1. Microbial infection

8. (+) Grey Turner’s spots: ecchymosis of flank area 2. Feacalith: undigested food particles like tomato seeds, guava seeds

9. Hypocalcemia etc.
3. Intestinal obstruction

1. Serum amylase & lipase: increase S/Sx:

2. Urinary amylase: increase 1. Pathognomonic sign: (+) rebound tenderness

3. Blood Sugar: increase 2. Low grade fever

4. Lipids Level: increase 3. N/V

5. Serum Ca: decrease 4. Decrease bowel sound

6. CT Scan: shows enlargement of the pancreas 5. Diffuse pain at lower Right iliac region
6. Late sign: tachycardia: due to pain

Medical Management


1. CBC: mild leukocytosis: increase WBC Jaundice

2. PE: (+) rebound tenderness (flex Right leg, palpate Right iliac area: Pruritus or urticaria
rebound) Easy bruising
3. Urinalysis: elevated acetone in urine Spider angiomas on nose, cheeks, upper thorax & shoulder
Palmar erythema
Medical Management Muscle atrophy
 Surgery: Appendectomy 24-45 hrs
Nursing Intervention Liver enzymes: increase
1. Administer antibiotics / antipyretic as ordered SGPT (ALT)
2. Routinary pre-op nursing measures: SGOT (AST)
 Skin prep LDH Alkaline Phosphate
 NPO Serum cholesterol & ammonia: increase
 Avoid enema, cathartics: lead to rupture of appendix Indirect bilirubin: increase
3. Don’t give analgesic: will mask pain CBC: pancytopenia
 Presence of pain means appendix has not ruptured PT: prolonged
4. Avoid heat application: will rupture appendix Hepatic Ultrasonogram: fat necrosis of liver lobules
5. Monitor VS, I&O bowel sound
Nursing Intervention
Nursing Intervention post op CBR with bathroom privileges
1. If (+) Pendrose drain (rubber drain inserted at surgical wound for Encourage gradual, progressive, increasing activity with planned rest
drainage of blood, pus etc): indicates rupture of appendix period
2. Position the client semi-fowlers or side lying on right: to facilitate Institute measure to relieve pruritus
drainage Do not use soap & detergent
3. Administer Meds: Bathe with tepid water followed by application of emollient lotion
 Analgesic: due post op pain Provide cool, light, non-constrictive clothing

 Antibiotics: for infection Keep nail short: to avoid skin excoriation from scratching

 Antipyretics: for fever (PRN) Apply cool, moist compresses to pruritic area

4. Monitor VS, I&O, bowel sound Monitor VS, I & O

5. Maintain patent IV line Prevent Infection

6. Complications: Peritonitis, Septicemia Prevent skin breakdown: by turning & skin care
Provide reverse isolation for client with severe leukopenia: handwashing

Liver Cirrhosis technique

Chronic progressive disease characterized by inflammation, fibrosis & Monitor WBC

degeneration of the liver parenchymal cell Diet:

Destroyed liver cell are replaced by scar tissue, resulting in architectural Small frequent meals

changes & malfunction of the liver Restrict Na!

Lost of architectural design of liver leading to fat necrosis & scarring High calorie, low to moderate CHON, high CHO, low fats with
supplemental Vit A, B-complex, C, D, K & folic acid

Types Monitor / prevent bleeding

Laennec’s Cirrhosis: Measure abdominal girth daily: notify MD

Associated with alcohol abuse & malnutrition With pt daily & assess pitting edema

Characterized by an accumulation of fat in the liver cell progressing to Administer diuretics as ordered

widespread scar formation Provide client teaching & discharge planning

Postnecrotic Cirrhosis Avoidance of hepatotoxicity drug: sedative, opiates or OTC drugs

Result in severe inflammation with massive necrosis as a complication of detoxified by liver

viral hepatitis How to assess weight gain & increase abdominal girth

Cardiac Cirrhosis Avoid person with upper respiratory infection

Occurs as a consequence of right sided heart failure Reporting signs of reccuring illness (liver tenderness, increase jaundice,

Manifested by hepatomegaly with some fibrosis increase fatigue, anorexia)

Biliary Cirrhosis Avoid all alcohol

Associated with biliary obstruction usually in the common bile duct Avoid straining stool vigorous blowing of nose & coughing: to decrease

Results in chronic impairment of bile excretion incidence of bleeding


S/sx Ascites: accumolation of free fluid in abdominal cavity

Anorexia Nursing Intervention

N/V Meds: Loop diuretics: 10-15 min effect

Dyspepsia: Indigestion Assist in abdominal paracentesis: aspiration of fluid

Weight loss Void before paracentesis: to prevent accidental puncture of bladder

Flatulence as trochar is inserted

Change (Irregular) bowel habit

Ascites Bleeding esophageal varices: Dilation of esophageal veins

Peripheral edema
Hepatomegaly: pain located in the right upper quadrant Nursing Intervention

Atrophy of the liver Administer meds:

Fetor hepaticus: fruity, musty odor of chronic liver disease Vit K

Aterixis: flapping of hands & tremores Pitrisin or Vasopresin (IM)

Hard nodular liver upon palpation NGT decompression: lavage

Increased abdominal girth Give before lavage: ice or cold saline solution

Changes in moods Monitor NGT output

Alertness & mental ability Assist in mechanical decompression

Sensory deficits Insertion of sengstaken-blackemore tube

Gynecomastia 3 lumen typed catheter

Decrease of pubic & axilla hair in males Scissors at bedside to deflate balloon.

Amenorrhea in female


Hepatic encephalopathy
Nursing Intervention Small tube that extends from the bladder to the exterior of the body
Assist in mechanical ventilation: due coma Passage of urine, seminal & vaginal fluids.
Monitor VS, neuro check Females: located behind the symphisis pubis & anterior vagina &
Siderails: due restless approximately 3-5 cm
Administer meds Males: extend the entire length of the penis & approximately 20 cm
Laxatives: to excrete ammonia
Function of kidneys
Overview of Anatomy & Physiology Of GUT System Kidneys remove nitrogenous waste & regulates F & E balance &
acid base balance
GUT: Genito-urinary tract Urine is the end product
GUT includes the kidneys, ureters, urinary bladder, urethra & the male &
female genitalia Urine formation: 25 % of total cardiac output is received by kidneys
Function: Glomerular Filtration
Promote excretion of nitrogenous waste products Ultrafiltration of blood by the glomerulus, beginning of urine
Maintain F&E & acid base balance formation
Requires hydrostatic pressure & sufficient circulating volume
Kidneys Pressure in bowman’s capsule opposes hydrostatic pressure & filtration
Two of bean shaped organ that lie in the retroperitonial space If glomerular pressure insufficient to force substance out of the blood into the
on either side of the vertebral column tubules filtrate formation stops
Retroperitonially (back of peritoneum) on either side of vertebral Glomerular Filtration Rate (GFR)
column Amount of blood filtered by the glomeruli in a given time
Adrenal gland is on top of each kidneys Normal: 125 ml / min
Encased in Bowmans’s capsule Filtrate formed has essentially same composition as blood plasma
without the CHON; blood cells & CHON are usually too large to
Renal Parenchyma pass the glomerular membrane
Outermost layer Tubular Function
Site of glomeruli & proximal & distal tubules of nephron Tubules & collecting ducts carry out the function of
Medulla reabsorption, secretion & excretion
Middle layer Reabsorption of H2O & electrolytes is controlled by anitdiuretics
Formed by collecting tubules & ducts hormones (ADH) released by the pituitary & aldosterone
secreted by the adrenal glands
Renal Sinus & Pelvis Proximal Convoluted Tubule
Papillae Reabsorb the ff:
Projection of renal tissues located at the tip of the renal pyramids 80% of F & E
Calices H2O
Minor Calyx: collects urine flow from collecting ducts Glucose
Major Calyx: directs urine from renal sinus to renal pelvis Amino acids
Urine flows from renal pelvis to ureters Bicarbonate
Secretes the ff:
Nephron Organic substance
Functional unit of the kidney Waste
Basic living unit Loop of Henli
Reabsorb the ff:
Renal Corpuscle (vascular system of nephron) Na & Chloride in the ascending limb
Bowman’s Capsule: H2O in the descending limb
Portion of the proximal tubule surrounds the glomerulus Concentrate / dilutes urine
Glomerulus: Distal Convoluted Tubule
Capillary network permeable to water, electrolytes, nutrients & Secretes the ff:
waste Potassium
Impermeable to large CHON molecules Hydrogen ions
Filters blood going to kidneys Ammonia
Renal Tubule Reabsorb the ff:
Divided into proximal convoluted tubule, descending loop of H2O
Henle, acending loop of Henle, distal convoluted tubule & Bicarbonate
collecting ducts Regulate the ff:
Ureters Phosphate concentration
Two tubes approximately 25-35 cm long Collecting Ducts
Extend from the renal pelvis to the pelvic cavity where they enter the Received urine from distal convoluted tubules & reabsorb H2O (regulated
bladder, convey urine from the kidney to the bladder by ADH)
Passageway of urine to bladder
Ureterovesical valve: prevent backflow of urine into ureters Normal Adult: produces 1 L /day of urine

Bladder Regulation of BP
Located behind the symphisis pubis Through maintenance of volume (formation / excretion of urine)
Composed of muscular elastic tissue that makes it distensible Rennin-angiotensin system is the kidneys controlled mechanism that can
Serve s as reservoir of urine (capable of holding 1000-1800 ml & 500 ml contribute to rise the BP
moderately full) When the BP drops the cells of the glomerulus release rennin which then
Internal & external urethral sphincter controls the flow of urine activates angiotensin to cause vasoconstriction.
Urge to void stimulated by passage of urine past the internal sphincter
(involuntary) to the upper urethra
Relaxation of external sphincter (voluntary) produces emptying of the Filtration – Normal GFR/ min is 125 ml of blood
bladder (voiding)


Tubular reabsorption – 124ml of ultra infiltrates (H2O & electrolytes is for Administer Medication as ordered:
reabsorption) Systemic Antibiotics
Tubular secretion – 1 ml is excreted in urine Ampicillin
Regulation of BP: Aminoglycosides
Predisposing factor: Co-trimaxazole (Bactrim)
Ex CS – hypovolemia – decrease BP going to kidneys Gantrism (Gantanol)
Activation of RAAS Antibacterial
Nitrofurantoin (Macrodantin)
Release of Renin (hydrolytic enzyme) at juxtaglomerular Methenamine Mandelate (Mandelamine)
apparatus Nalixidic Acid (NegGram)
Urinary Tract Anagesic
Angiotensin I mild vasoconstrictor Urinary antiseptics: Mitropurantoin (Macrodantin)
Urinary analgesic: Pyridium
Angiotensin II vasoconstrictor Provide client teachings & discharge planning
Importance of Hydration
Void after sex: to avoid stagnation
Adrenal cortex increase CO increase PR Female: avoids cleaning back & front (should be front to back)
Bubble bath, Tissue paper, Powder, perfume
Aldosterone Complications: Pyelonephritis
Increase BP
Increase Na & Pyelonephritis
H2O reabsorption Acute / chronic inflammation of 1 or 2 renal pelvis of kidneys
leading to tubular destruction & interstitial abscess
Hypervolemia formation
Acute: infection usually ascends from lower urinary tract
Chronic: a combination of structural alteration along with
infection major cause is ureterovesical reflux with infected
urine backing up into ureters & renal pelvis
Recurrent infection will lead to renal parenchymal deterioration
Color – amber & Renal Failure
Odor – aromatic
Consistency – clear or slightly turbid Predisposing factor:
pH – 4.5 – 8 Microbial invasion
Specific gravity – 1.015 – 1.030 E. Coli
WBC/ RBC – (-) Streptococcus
Albumin – (-) Urinary retention /obstruction
E coli – (-) Pregnancy
Mucus thread – few DM
Amorphous urate (-) Exposure to renal toxins

UTI Acute Pyelonephritis
CYSTITIS Severe flank pain or dull ache
Inflammation of bladder due to bacterial infection Costovertibral angle pain / tenderness
Predisposing factors: Chills
Microbial invasion: E. coli N/V
High risk: women Anorexia
Obstruction Gen body malaise
Urinary retention Urinary frequency & urgency
Increase estrogen levels Nocturia
Sexual intercourse Dsyuria
S/Sx: Burning sensation on urination
Pain: flank area
Urinary frequency & urgency Chronic Pyelonephritis: client usually not aware of disease
Burning pain upon urination Bladder irritability
Dysuria Slight dull ache over the kidney
Hematuria Chronic Fatigue
Nocturia Weight loss
Fever Polyuria
Chills Polydypsia
Anorexia HPN
Gen body malaise Atrophy of the kidney

Dx Medical Management
Urine culture & sensitivity: (+) to E. coli Urinary analgesic: Peridium
Nursing Intervention Antibiotics
Force fluid: 3000 ml Antispasmodic
Warm sitz bath: to promote comfort Surgery: removal of any obstruction
Monitor & assess urine for gross odor, hematuria & sediments Chronic
Acid Ash Diet: cranberry, vit C: OJ: to acidify urine & prevent bacterial Antibiotics
multiplication Urinary Antiseptics


Nitrofurantoin (macrodantin) Strain urine using gauze pad: to detect stones & crush all cloths
SE: peripheral neuropathy Encourage ambulation: to prevent stasis
GI irritation Warm sitz bath: for comfort
Hemolytic anemia Administer narcotic analgesic as ordered: Morphine SO4: to relieve pain
Staining of teeth Application warm compress at flank area: to relieve pain
Surgery: correction of structural abnormality if possible Monitor I & O
Provide modified diet depending upon the stone consistency
Dx Calcium Stones
Urine culture & sensitivity: (+) E. coli & streptococcus Limit milk & dairy products
Urinalysis: increase WBC, CHON & pus cells Provide acid ash diet (cranberry or prune juice, meat, fish, eggs,
Cystoscopic exam: urinary obstruction poultry, grapes, whole grains): to acidify urine
Take vitamin C
Nursing Intervention Oxalate Stone
Provide CBR: acute phase Avoid excess intake of food / fluids high in oxalate (tea,
Monitor I & O chocolate, rhubarb, spinach)
Force fluid Maintain alkaline-ash diet (milk, vegetable, fruits except
Acid ash diet cranberry, plums & prune): to alkalinize urine
Administer medication as ordered Uric Acid Stone
Chronic: possibility of dialysis & transplant if has renal deterioration Reduce food high in purine (liver, brain, kidney, venison,
Complication: Renal Failure shellfish, meat soup, gravies, legumes)
Maintain alkaline urine
Nephrolithiasis / Urolithiasis Administer Allopurinol (Zyloprim) as ordered: to decrease uric acid
Presence of stone anywhere in the urinary tract production: push fluids when giving allopurinol
Formation of stones at urinary tract Provide client teaching & discharge planning
Frequent composition of stones Prevention of urinary stasis: increase fluid intake especially during hot
Calcium weather & illness
Oxalate Mobility
Uric acid Voiding whenever the urge is felt & at least twice during night
Adherence to prescribe diet
Calcium Oxalate Uric Acid Complications: Renal Failure

Milk Cabbage Anchovies Benign Prostatic Hypertrophy (BPH)

Cranberries Organ meat Mild to moderate glandular enlargement, hyperplsia & over growth
Nuts tea Nuts of the smooth muscles & connective tissue
Chocolates Sardines As the gland enlarges it compresses the urethra: resulting to urinary
Predisposing factors: Enlarged prostate gland leading to
Diet: increase Ca & oxalate Hydroureters: dilation of urethers
Increase uric acid level Hydronephrosis: dilation of renal pelvis
Hereditary: gout or calculi Kidney stones
Immobility Renal failure
Sedentary lifestyle
Hyperparathyroidism Predisposing factor:
High risk: 50 years old & above & 60-70 (3-4x at risk)
S/sx Influence of male hormone
Abdominal or flank pain
Renal colic S/sx
Cool moist skin (shock) Urgency, frequency & hesitancy
Burning sensation upon urination Nocturia
Hematuria Enlargement of prostate gland upon palpation by digital rectal
Anorexia exam
N/V Decrease force & amount of urinary stream
Dx Hematuria
Intravenous Pyelography (IVP): identifies site of obstruction & presence Burning sensation upon urination
of non-radiopaque stones Terminal bubbling
KUB: reveals location, number & size of stone Backache
Cytoscopic Exam: urinary obstruction Sciatica: severe pain in the lower back & down the back of thigh
Stone Analysis: composition & type of stone & leg
Urinalysis: indicates presence of bacteria, increase WBC, RBC & CHON
Medical Management Digital rectal exam: enlarged prostate gland
Surgery KUB: urinary obstruction
Percutaneous Nephrostomy: Cystoscopic Exam: reveals enlargement of prostate gland &
Tube is inserted through skin & underlying tissue into renal pelvis to obstruction of urine flow
remove calculi Urinalysis: alkalinity increase
Percutaneous Nephrostolithotomy Specific Gravity: normal or elevated
Delivers ultrasound wave through a probe placed on the calculus BUN & Creatinine: elevated (if longstanding BPH)
Extracorporeal Shockwave Lithotripsy: Prostate-specific Antigen: elevated (normal is < 4 ng /ml)
Delivers shockwaves from outside of the body to the stone causing Nursing Intervention
pulverization Prostate message: promotes evacuation of prostatic fluid
Pain management & diet modification Force fluid intake: 2000-3000 ml unless contraindicated
Provide catheterization
Nursing Intervention Administer medication as ordered:
Force fluid: 3000-4000 ml / day


Terazosine (Hytrin): relaxes bladder sphincter & make it easier Diuresis may occur (output 3-5 L / day): due to partially regenerated
to urinate tubules inability to concentrate urine
Finasteride (Proscar): shrink enlarge prostate gland Duration: 2-3 weeks
Surgery: Prostatectomy S/sx
Transurethral Resection of Prostate (TURP): insertion of a resectoscope Hyponatremia
into urethra to excise prostatic tissue Hypokalemia
Assist in cystoclysis or continuous bladder irrigation. Hypovolemia
Nursing Intervention Dx
Monitor symptoms of infection BUN & Creatinine: elevated
Monitor symptoms gross / flank bleeding. Normal bleeding Recovery or Covalescent Phase: renal function stabilized with gradual
within 24h improvement over next 3-12 mos
Maintain irrigation or tube patent to flush out clots: to prevent
bladder spasm & distention Nursing Intervention
Monitor / maintain F&E balance
Obtain baseline data on usual appearance & amount of client’s
Acute Renal Failure Measure I&O every hour: note excessive losses
Sudden inability of the kidney to regulate fluid & electrolyte balance & Administer IV F&E supplements as ordered
remove toxic products from the body Weight daily
Sudden immobility of kidneys to excrete nitrogenous waste products & Monitor lab values: assess / treat F&E & acid base imbalance as
maintain F&E balance due to a decrease in GFR (N 125 ml/min) needed
Monitor alteration in fluid volume
Causes Monitor V/S. PAP, PCWP, CVP as needed
Pre-renal cause: interfering with perfusion & resulting in decreased blood Monitor I&O strictly
flow & glomerular filtrate Assess every hour fro hypervolemia
Inter-renal cause: condiion that cause damage to the nephrons Maintain ventilation
Post-renal cause: mechanical obstruction anywhere from the tubules to Decrease fluid intake as ordered
the urethra Administer diuretics, cardiac glycosides & hypertensive
agent as ordered
Pre renal cause: decrease blood flow & glomerular filtrate Assess every hour for hypovolemia: replace fluid as ordered
Ischemia & oliguria Monitor ECG
Cardiogenic shock Check urine serum osmolality / osmolarity & urine specific
Acute vasoconstriction gravity as ordered
Septicemia Promote optimal nutrition
Hypovolemia Decrease flow to Administer TPN as ordered
kidneys Restrict CHON intake
Hypotension Prevent complication from impaired mobility
CHF Pulmonary Embolism
Hemorrhage Skin breakdown
Dehydration Contractures
Intra-renal cause: involves renal pathology: kidney problem Prevent infection / fever
Acute tubular necrosis Assess sign of infection
Endocarditis Use strict aseptic technique for wound & catheter care
DM Take temperature via rectal
Tumors Administer antipyretics as ordered & cooling blankets
Pyelonephritis Support clients / significant others: reduce level of anxiety
Malignant HPN Provide care for client receiving dialysis
Acute Glomerulonephritis Provide client teaching & discharge planning
Blood transfision reaction Adherence to prescribed dietary regime
Hypercalemia S/sx of recurrent renal disease
Nephrotoxin (certain antibiotics, X-ray, dyes, pesticides, Importance of planned rest period
anesthesia) Use of prescribe drugs only
S/sx of UTI or respiratory infection: report to MD
Post renal cause: involves mechanical obstruction
Tumors Chronic Renal Failure
Stricture Progressive, irreversible destruction of the kidneys that continues until
Blood cloths nephrons are replaced by scar tissue
Urolithiasis Loss of renal function gradual
BPH Irreversible loss of kidney function
Anatomic malformation
Predisposing factors:
S/sx DM
Oliguric Phase: caused by reduction in glomerular filtration rate HPN
Urine output less than 400 ml / 24 hrs; duration 1-2 weeks Recurrent UTI/ nephritis
S/sx Urinary Tract obstruction
Hypernatremia Exposure to renal toxins
Hyperphosphotemia Stages of CRF
Hypermagnesemia Diminished Reserve Volume – asymptomatic
Hypocalcemia Normal BUN & Crea, GFR < 10 – 30%
Metabolic acidosis 2. Renal Insufficiency
Dx 3. End Stage Renal disease
BUN & Creatinine: elevated
Diuretic Phase: slow gradual increase in daily urine output


N/V Paresthesias
Diarrhea / constipation Muscle cramps
Decreased urinary output Seizures
Dyspnea Abnormal reflex
Stomatitis Maintenance of skin integrity
Hypotension (early) Provide care for pruritus
Hypertension (late) Monitor uremic frost (urea crystallization on the skin): bathe in plain
Lethargy water
Convulsion Monitor for bleeding complication & prevent injury to client
Memory impairment Monitor Hgb, Hct, platelets, RBC
Pericardial Friction Rub Hematest all secretions
HF Administer hematinics as ordered
Avoid IM injections
Maintain maximal cardiovascular function
Urinary System Metabolic Disturbance Monitor BP
Polyuria Azotemia (increase BUN & Auscultate for pericardial friction rub
Nocturia Creatinine) Perform circulation check routinely
Hematuria Hyperglycemia Administer diuretics as ordered & monitor I&O
Dysuria Hyperinsulinemia Modify digitalis dose as ordered (digitalis is excreted in kidneys)
Oliguria Provide care for client receiving dialysis
CNS GIT Disequilibrium syndrome: from rapid removal of urea & nitrogenous
Headache N/V waste prod leading to:
Lethargy Stomatitis N/V
Disorientation Uremic breath HPN
Restlessness Diarrhea / constipation Leg cramps
Memory impairment Disorientation
Respiratory Hematological
Kassmaul’s resp Normocytic anemia
Enforce CBR
Decrease cough reflex Bleeding tendencies
Monitor VS, I&O

Fluid & Electrolytes Integumentary Meticulous skin care. Uremic frost – assist in bathing pt

Hyperkalemia Itchiness / pruritus 4. Meds:

Hypernatermia Uremic frost a.) Na HCO3 – due Hyperkalemia

Hypermagnesemia b.) Kagexelate enema

Hyperposphatemia c.) Anti HPN – hydralazine

Hypocalcemia d.) Vit & minerals

Metabolic acidosis e.) Phosphate binder

(Amphogel) Al OH gel - S/E constipation
f.) Decrease Ca – Ca gluconate
Dx 5. Assist in hemodialysis
Urinalysis: CHON, Na & WBC: elevated Consent/ explain procedure
Specific gravity: decrease Obtain baseline data & monitor VS, I&O, wt, blood
Platelets: decrease exam
Ca: decrease Strict aseptic technique
Monitor for signs of complications:
Medical Management B – bleeding
Diet restriction E – embolism
Multivitamins D – disequilibrium syndrome
Hematinics S – septicemia
Aluminum Hydroxide Gels S – shock – decrease in tissue perfusion
Antihypertensive Disequilibrium syndrome – from rapid removal of urea & nitrogenous waste
prod leading to:
Nursing Intervention n/v
Prevent neurologic complication HPN
Monitor for signs of uremia Leg cramps
Fatigue Disorientation
Loss of appetite Paresthesia
Decreased urine output
Apathy Avoid BP taking, blood extraction, IV, at side of shunt or fistula.
Confusion Can lead to compression of fistula.
Elevated BP Maintain patency of shunt by:
Edema of face & feet Palpate for thrills & auscultate for bruits if (+) patent
Itchy skin shunt!
Restlessness Bedside- bulldog clip
Seizures - If with accidental removal of fistula to prevent
Monitor for changes in mental functioning embolism.
Orient confused client to time, place, date & person - Infersole (diastole) – common dialisate used
Institute safety measures to protect the client from falling out of 7. Complication
bed - Peritonitis
Monitor serum electrolytes, BUN & creatinine as ordered - Shock
Promote optimal GI function
Provide care for stomatitis 8. Assist in surgery:
Monitor N/V & anorexia: administer antiemetics as ordered Renal transplantation : Complication – rejection. Reverse
Monitor signs of GI bleeding isolation
Monitor & prevent alteration in F&E balance
Monitor for hyperphosphatemia: administer aluminum hydroxides gel
(amphojel, alternagel) as ordered