MEDICAL-SURGICAL NURSING Myocardial cells, Neurons, Bone cells, Osteocytes, Retinal Cells.
By: Anthony T. Villegas R.N.
B. NEUROGLIA
Overview of structures and functions: Support and protection of neurons.
NERVOUS SYSTEM
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.
Composition Of Brain
Axon
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
Dendrites
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
Synapse
function of cerebrum: integration, sensory, motor
Junction between neurons where an impulse is transmitted
composed of two hemisphere the Right Cerebral Hemisphere
Neurotransmitter
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
conduction.
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
Properties
discrimination of sensory impulses to pain, touch, pressure,
1. Excitability – ability of neuron to be affected by changes in external
heat, cold, numbness.
environment.
Postcentral gyrus: registered general sensation (ex. Touch,
2. Conductility – ability of neuron to transmit a wave of excitetation
pressure)
from one cell to another.
4. Occipital Lobe
3. Permanent Cell – once destroyed not capable of regeneration.
for vision
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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
contains midbrain, pons, medulla oblongata. Muscle or organ that responds to stimulus
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
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 &
vasomotor center (dilation and constriction of bronchioles). 3 fold membrane that covers brain and spinal cord.
For support and protection; for nourishment; blood supply
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
serves as a connecting link between the brain and periphery middle layer, weblike
H-shaped gray matter in the center (cell bodies) surrounded by innermost layer, delicate, clings to surface of brain
Contains cell bodies giving rise to efferent (motor) fibers 5. Cerebrospinal Fluid (CSF)
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
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Protective barrier preventing harmful agents from entering the division) & balance (vestibular
Substance That Can Pass Blood-Brain Barrier tongue & pharynx; muscle
Hepatic Encephalopathy (Liver Cirrhosis) Vagus : CN X Mixed: impulses for sensation to lower
Headache Muscles.
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)
stress.
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
depressant).
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.
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.
Each nerve is attached to the spinal by two roots: - Increase blood supply to brain,
contains afferent (sensory) nerve whose cell body is in - SNS I. Cholinergic Agents
Contains efferent (motor) nerve whose nerve fibers - Give Epinephrine. - PNS effect
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
Optic : CN II Sensory: carries impulses for vision. - all ending with “lol”
Oculomotor : CN III Motor: muscles for papillary constriction, - Propranolol, Atenelol, Metoprolol.
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Gland of Head
3. Pupillary Reaction & Eye Movement
Lacrimal no effect stimulate
a. Observe size, shape, & equality of pupil (note size in millimeter)
secretions
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
cornea
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
coma
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
ducts
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
Norepinephrine
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
NEURO TRANSMITTER Decrease Increase
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
movements
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)
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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
Oculomotor
system
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
CRANIAL NERVE V: TRIGEMINAL
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 XI: SPINAL ACCESSORY
CRANIAL NERVE II: OPTIC Innervates with sternocleidomastoid (neck) and trapezius (shoulder)
Sensory function for vision or sight
Functions CRANIAL NERVE XII: HYPOGLOSSAL
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.
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DEMYELINATING DISORDERS
Ataxia
S/sx
CHARCOTS TRIAD
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
inability to understand spoken words. 2. MRI: reveals site and extent of demyelination.
Nursing Intervention
DOC
1. Assess the client for specific deficit related to location of
Aricept (taken at bedtime)
demyelination
Cognex
2. Promote optimum mobility
a. Muscles stretching & strengthening exercises
Management
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
retention.
Ig D - for chronic inflammation.
b. Bethanecol Chloride (Urecholine) as ordered
Nursing Management
* Give palliative or supportive care.
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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
ICP.
c. Monitor ICP pressure readings frequently & prevent
complications:
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
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Pathophysiology
Magnesium Sulfate toxicity
Disorder causes degeneration of dopamine producing neurons in the
S/S
substantia nigra in the midbrain
BP
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
Aloneness
- 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
S/sx
- 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
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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
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
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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
Begins in focal area of brain & symptoms are related to a a. Choroid: highly vascular layer, nourishes retina; located
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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
membrane
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
Otosclerosis
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
Cause
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
S/sx
2. Use bilateral eye patches as ordered; elevate side rails to prevent
1. Progressive hearing loss
injury
2. Tinnitus
3. Identify yourself when entering the room
4. Orient the client frequently to time of date & surroundings; explain
Dx
procedures
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
graft)
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
coughing
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
membrane
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
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3. Surgery: Lactation
a. Surgical destruction of labyrinth causing loss of vestibular & Posterior lobe : ADH : regulates H2O
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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)
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Bradycardia tachycardia
Hypoglycemia hormone
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
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:
c. Need in additional protection in cold weather a. Assign a private room away from excessive activity
e. Avoid precipitating factors leading to myxedema coma & 4. Provide comfortable and cold environment
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 &
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 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:
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Thyroid Storm
Uncontrolled & potentially life-threatening hyperthyroidism caused
by sudden & excessive release of thyroid hormone into the
bloodstream Hyperthermia
Tachycardia
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
check.
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
level
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
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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
insufficiency
Dx
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
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Pathophysiology
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)
MAIN FOODSTUFF ANABOLISM CATABOLISM
3. Related to viruses
4. Drugs: diuretics (Lasix), Steroids, oral contraceptives
5. Related to carbon tetrachloride toxicity
S/sx
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
Dx
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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
level)
: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 &
Premature Cataracts Purchase properly fitting shoes & break new shoes in
Affects PNS & ANS Inspect foot daily & notify physician: if cut, blister, or
10. Provide client teaching & discharge planning concerning: Undertake regular exercise; avoid sporadic, vigorous
lists before discharge Exercise is best performed after meals when the blood
skip meals
c. Insulin j. Complication
Use insulin at room temp hypoglycemia (cold and clammy skin), for
Gently roll the vial between palms hyperglycemia (dry and warm skin): administer simple
If mixing insulin, draw up clear insulin, before Eat candy or drink orange juice with sugar added for
obese clients) degree angle depending on amount Acute complication of DM characterized by hyperglycemia &
May store current vial of insulin at room temperature; Acute complication of Type I DM: due to severe hyperglycemia
periods of hyperglycemia or rebound effect of insulin. Onset slow: maybe hours to days
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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
insulin
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:
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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
Thymus
(Fluid) cellular elements 3. Capillaries 3. (14-18 g) in men than in women (12-14 g)
Spleen
e. Production
4.
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
gms%
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
inflammation
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
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reaction
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
group
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
contamination;
a. Antigens of systems are labeled A & B
lumbar pain RBC.
b. Absence of both antigens results in type O blood
Multitransfused
c. Presence of both antigen is type AB
Administer
d. Presence of either type A or B results in type A & type B,
client;
respectively
antibiotics prn
e. Type O: universal donor
multiparous
f. Antibodies are automatically formed against ABO antigens not
client
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
Susceptible
not affected, but subsequent pregnancy with an Rh (+) baby,
tachycardia, instead of whole
mother’s antibodies attack baby’s RBC
Client
orthopnea, blood.
Complication of Blood Transfusion
Type Causes Mechanism Occurrence S/sx
cyanosis, anxiety Monitor CVP
Intervention
t
hro
Hemolytic ABO Antibodies in Acute:
ugh
Headache, Stop transfusion.
a
Incompatibility; recipient plasma first 5 min
lumbar or continue saline IV
Rh react w/ antigen after completion separate line.
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Monitor liver fxn Liver also involved in synthesis of clotting factors, synthesis of
_______________________________________________________________ antithrombins.
________________________
Hyperkalemia Potassium level Release of In client with Blood Tranfusion
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:
red cell lysis 4. Cryoprecipitate, Fresh Frozen Plasma, Fresh Whole Blood:
segm a. Large volume can cause difficulty: 12-24 hr for Hgb & Hct
ents) to rise
b. Complications: volume overload, transmission of hepatitis
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
1. Intrinsic System: initiated by contact activation following endothelial a. Provide twice amount of Hgb as an equivalent amount of
a. Factor XII: initiate as contact made between damaged vessel & b. Indicate in cases of blood loss, pre-op & post-op client &
b. Factors VIII, IX & XI activated c. Complication: transfusion reaction (less common than with
a. Initiated by tissue thromboplastins released from injured vessels 3. Fresh Frozen Plasma
b. Factor VII activated b. Can be stored frozen for 12 months; takes 20 minutes to
thaw
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)
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
Clot Resolution: takes place via fibrinolytic system by plasmin & testing may be necessary
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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
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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
(thrombocytopenia)
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
(Sulfonamides)
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)
corrected
Phenylbutazones (NSAIDS)
S/sx
Pathophysiology
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
Dx
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
S/sx
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)
procedure
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
Dx
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
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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”)
Pericardium
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
Endocardium
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
systole
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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
Transmit impulses to the ventricle & provide for depolarization after Tunica intima deposits
S/sx
JLJLJLJJLJLJL 1. Chest pain
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
Objectives
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
Arteries
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
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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
S/sx
1. Intermittent claudication: leg pain upon walking Medical Management
2. Cold sensitivity & changes in skin color 1 white (pallor) changing to
st
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
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
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
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)
1. High risk group: female between the teenage years & age 40 years 1. Elevate legs above heart level: to promote increased venous return
a. Systemic Lupus Erythematosus (SLE): butterfly rash 3. Apply anti-embolic / knee-length stockings
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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
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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)
Causes
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
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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
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
groin
Failure of the immune system to respond & eradicate cancer
vi. Pain in the testicle or in the scrotum
cells
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
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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
cycle.
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 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
lips.
alpha, generally emitted from radioactive isotopes, used for internal
o Advice client to suck on Popsicles or ice chips to provide
source.
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.
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
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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
Isolate from those with known infection. Articular cartilage covers the ends of the bones
Encourage high CHON diet. Capsule is lined with synovial membrane that secretes synovial
direct tissue injury caused by thermal, electric, chemical & smoke Maintain posture
Provide site for storage of calcium & phosphorus 4. Play a role in society (work)
1. Types of Bones
Long Bones Predisposing factors
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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
become effective 1. Most important factor in development is aging (wear & tear on
Proteinuria
Mouth ulcers S/sx
Skin rash 1. Pain: (aggravated by use & relieved by rest) & stiffness of joints
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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
nuclei.
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
involvement.
Systemic Lupus Erythematosus (SLE) 5. Provide psychologic support to client / significant others.
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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
intestine
Bone grafting: after repeated infections
Major function: digestion & absorption of the end product of
Leg amputation
digestion
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
FRACTURES
Crypts of Lieberkuhn: produce secretions containing digestive
A. General information
enzymes
1.
Brunner’s Gland: found in the submucosaof the duodenum,
B. Medical management
secretes mucus
C. Assessment findings
D. Nursing interventions
2nd half of duodenum
Jejunum
Overview of Anatomy & Physiology Gastro Intestinal Track System
Ileum
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:
Mouth
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
mastication
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
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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
nd
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
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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
antacids
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
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8. Hyperlipidemia day)
9. Hyperparathyroidism
10. Drugs: Thiazide, steroids, diuretics, oral contraceptives Apendicitis
Inflammation of the appendix that prevents mucus from passing into
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
5. Dyspepsia: indigestion
6. Decrease bowel sounds Predisposing factor:
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
Dx
1. Serum amylase & lipase: increase S/Sx:
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
Dx
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Antibiotics: for infection Keep nail short: to avoid skin excoriation from scratching
Antipyretics: for fever (PRN) Apply cool, moist compresses to pruritic area
6. Complications: Peritonitis, Septicemia Prevent skin breakdown: by turning & skin care
Provide reverse isolation for client with severe leukopenia: handwashing
Destroyed liver cell are replaced by scar tissue, resulting in architectural Small frequent meals
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
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
viral hepatitis How to assess weight gain & increase abdominal girth
Occurs as a consequence of right sided heart failure Reporting signs of reccuring illness (liver tenderness, increase jaundice,
Associated with biliary obstruction usually in the common bile duct Avoid straining stool vigorous blowing of nose & coughing: to decrease
Fatigue
Anorexia Nursing Intervention
Peripheral edema
Hepatomegaly: pain located in the right upper quadrant Nursing Intervention
Increased abdominal girth Give before lavage: ice or cold saline solution
Decrease of pubic & axilla hair in males Scissors at bedside to deflate balloon.
Amenorrhea in female
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Hepatic encephalopathy
Urethra
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
Cortex
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:
Ca
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)
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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
Cephalosporin
Regulation of BP: Aminoglycosides
Sulfonamides
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
S/sx:
UTI Acute Pyelonephritis
CYSTITIS Severe flank pain or dull ache
Inflammation of bladder due to bacterial infection Costovertibral angle pain / tenderness
Fever
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
Hematuria
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
Acute
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
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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
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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
urine
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
Atelectesis
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
Hyperkalemia
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
S/Sx:
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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
Paresthes
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
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