MedicalSurgical Nursing Review

MEDICAL SURGICAL
Overview oI the Structures & Functions oI Nervous System

Central NS PNS ANS
Brain & spinal cord 31 spinal & cranial sympathetic NS
Parasypathatic NS
Somatic NS
C- 8
T- 12
L- 5
S- 5
C- 1
ANS (or adrenergic oI parasympatholitic response)
SNS involved in Iight or aggression response Effects of SNS (anti-cholinergic/adrenergic)
1. Dilate pupil to aware oI surroundings
Release oI norepinephrine (adrenaline cathecolamine) - medriasis
Adrenal medulla (potent vasoconstrictor) 2. Dry mouth
Increases body activities VS Increase 3. BP & HR increased
Except GIT decrease GITmotility bronchioles dilated to take more oxygen
4. RR increased
* Why GIT is not increased GIT is not important! 5. Constipation & urinary retention
Increase blood Ilow to skeletal muscles, brain & heart.
I. Adrenergic Agents Epinephrine (adrenaline)
SE: SNS eIIect
II. PNS: Beta adrenergic blocking agents (opposite oI adrenergic agents) (all end in lol`)
- Blocks release oI norepinephrine.
- Decrease body activities except GIT (diarrhea)
Ex. Propanolol, Metopanolol
SE:
B broncho spasm (bronchoconstriction)
E elicits a decrease in myocardial contraction
T treats HPN
A AV conduction slows down
Given to angina & MI beta-blockers to rest heart
Anti HPN agents:
1. Beta blockers (-lol)
2. Ace inhibitors (-pril) ex ENALAPRIL, CAPTOPRIL
3. Calcium antagonist
ex CALCIBLOC or NEFEDIPINE
Peripheral nervous system: cholinergic/ vagal or sympatholitic response Effect of PNS: (cholinergic)
- Involved in Ily or withdrawal response 1. Meiosis contraction oI pupils
- Release oI acetylcholine (ACTH) 2. Increase salivation
- Decrease all bodily activities except GIT (diarrhea) 3. BP & HR decreased
4. RR decrease broncho constriction
I Cholinergic agents 5. Diarrhea increased GI motility
ex 1. Mestinon 6. Urinary Irequency
Antidote anti cholinergic agents Atropine SulIate S/E SNS

S/E- oI anti-hpn drugs:
1. orthostatic hpn
1
2. transient headache & dizziness.
-Mgt. Rise slowly. Assist in ambulation.
CNS (brain & spinal cord)
I. Cells A. neurons
Properties and characteristics
a. Excitability ability oI neuron to be aIIected in external environment.
b. Conductivity ability oI neuron to transmit a wave oI excitation Irom one cell to another
c. Permanent cells once destroyed, cant regenerate (ex. heart, retina, brain, osteocytes)
Regenerative capacity
A. Labile once destroyed cant regenerate
- Epidermal cells, GIT cells, resp (lung cells). GUT
B. Stable capable oI regeneration BUT limited time only ex salivary gland, pancreas cells cell oI liver, kidney cells
C. Permanent cells retina, brain, heart, osteocytes can`t regenerate.
3.) Neuroglia attached to neurons. Supports neurons. Where brain tumors are Iound.
Types:
1. Astrocyte
2. Oligodendria
Astrocytoma 90 95 brain tumor Irom astrocyte. Most brain tumors are Iound at astrocyte.
Astrocyte maintains integrity oI blood brain barrier (BBB).
BBB semi permeable / selective
-Toxic substance that destroys astrocyte & destroy BBB.
Toxins that can pass in BBB:
1. Ammonia-liver cirrhosis.
2. 2. Carbon Monoxide seizure & parkinsons.
3. 3. Bilirubin- jaundice, hepatitis, kernicterus/hyperbilirubenia.
4. 4. Ketones DM.
OLIGODENDRIA Produces myelin sheath wraps around a neuron acts as insulator Iacilitates rapid nerve impulse transmission.
No myelin sheath degenerates neurons
Damage to myelin sheath demyellenating disorders
DEMYELLENATING DSE
1.)ALZHEIMER`S DISEASE atrophy oI brain tissue due to a deIiciency oI acetylcholine.
S&Sx:
A amnesia loss oI memory
A apraxia unable to determine Iunction & purpose oI object
A agnosia unable to recognize Iamiliar object
A aphasia
- Expressive brocca`s aphasia unable to speak
- Receptive wernickes aphasia unable to understand spoken words
Common to Alzheimer receptive aphasia
Drug oI choice ARICEPT (taken at bedtime) & COGNEX.
Mgt: Supportive & palliative.
Microglia stationary cells, engulIs bacteria, engulIs cellular debris.
II. Compositions oI Cord & Spinal cord
80 - brain mass
10 - CSF
10 - blood
MONROE KELLY HYPOTHESIS: The skull is a closed vault. Any increase in one component will increase ICP.
Normal ICP: 0-15mmHg
Brain mass
2
1. Cerebrum largest - Connects R & L cerebral hemisphere
- Corpus collusum
Rt cerebral hemisphere, Lt cerebral hemisphere
Function:
1. Sensory
2. Motor
3. Integrative
Lobes
1.) Frontal
a. Controls motor activity
b. Controls personality development
c. Where primitive reIlexes are inhibited
d. Site oI development oI sense oI umor
e. Brocca`s area speech center
Damage - expressive aphasia
2.) Temporal
a. Hearing
b. Short term memory
c. Wernickes area gen interpretative or knowing Gnostic area
Damage receptive aphasia
3.) Parietal lobe appreciation & discrimation oI sensory imp
- Pain, touch, pressure, heat & cold
4.) Occipital - vision
5.) Insula/island oI reil/ Central lobe- controls visceral Ix
Function: - activities oI internal organ
6.) Rhinencephalon/ Limbec
- Smell, libido, long-term memory
Basal Ganglia areas oI gray matte located deep within a cerebral hemisphere
- Extra pyramidal tract
- Releases dopamine-
- Controls gross voluntary unit
Decrease dopamine (Parkinson`s) pin rolling oI extremities & Huntington`s Dse.
Decrease acetylcholine Myasthenia Gravis & Alzheimer`s
Increased neurotransmitter psychiatric disorder Increase dopamine schizo
Increase acetylcholine bipolar
MID BRAIN relay station Ior sight & hearing
Controls size & reaction oI pupil 2 3 mm
Controls hearing acuity
CN 3 4
Isocoria normal size (equal)
Anisocoria uneven size damage to mid brain
PERRLA normal reaction
DIENCEPHALON- between brain
Thalamus acts as a relay station Ior sensation
Hypothalamus (thermoregulating center oI temp, sleep & wakeIulness, thirst, appetite/ satiety center, emotional responses,
controls pituitary Iunction.
BRAIN STEM- a. Pons or pneumotaxic center controls respiration
Cranial 5 8 CNS
MEDULLA OBLONGATA- controls heart rate, respiratory rate, swallowing, vomiting, hiccups/ singutus
Vasomotor center, spinal decuissation termination , CN 9, 10, 11, 12
CEREBELLUM lesser brain
- Controls posture, gait, balance, equilibrium
3
Cerebellar Tests:
a.) R Romberg`s test- needs 2 RNs to assist
- Normal anatomical position 5 10 min
() Romberg`s test () ataxia or unsteady gait or drunken like movement with loss oI balance.
b.) Finger to nose test
() To FTNT dymetria inability to stop a movement at a desired point
c.) Alternate pronation & supination
Palm up & down . () To alternate pronation & supination or damage to cerebellum dymentrium
Composition oI brain - based on Monroe Kellie Hypothesis
- Skull is a closed container. Any alteration in 1 oI 3 intracranial components increase in ICP
Normal ICP 0 15 mmHg
Foramen Magnum
C1 atlas
C2 axis
() Projectile vomiting increase ICP
Observe Ior 24 - 48 hrs
CSF cushions the brain, shock absorber
Obstruction oI Ilow oI CSF increase ICP
Hydrocephalus posteriorly due to closure oI posterior Iontanel
CVA partial/ total obstruction oI blood supply
INCREASED ICP increase ICP is due to increase in 1 oI the Intra Cranial components.
Predisposing Iactors:
1.) Head injury
2.) Tumor
3.) Localized abscess
4.) Hemorrhage (stroke)
5.) Cerebral edema
6.) Hydrocephalus
7.) InIlammatory conditions - Meningitis, encephalitis
B. S&Sx change in VS always late symptoms
Earliest Sx:
a.) Change or decrease LOC Restlessness to conIusion Wide pulse pressure: Increased ICP
- Disorientation to lethargy Narrow pp: Cardiac disorder, shock
- Stupor to coma
Late sign change in V/S
1. BP increase (systolic increase, diastole- same)
2. Widening pulse pressure
Normal adult BP 120/80 120 80 40 (normal pulse pressure)
Increase ICP BP 140/80 140 80 60 PP (wide)
3. RR is decreased (Cheyne-Stokes bet period oI apnea or hyperpnea with periods oI apnea)
4. Temp increase
Increased ICP: Increase BP Shock decrease BP
Decrease HR Increase HR CUSHINGS EFFECT
Decrease RR Increase RR
Increase Temp Decrease temp
b.) Headache
Projectile vomiting
Papilledima (edema oI optic disk outer surIace oI retina)
Decorticate (abnormal Ilexion) Damage to cortico spinal tract /
Decerebrate (abnormal extension) Damage to upper brain stem-pons/
c.) Uncal herniation unilateral dilation oI pupil. (Bilateral dilation oI pupil tentorial herniation.)
d.) Possible seizure.
4
Nursing priority:
1.) Maintain patent a/w & adequate ventilation
a. Prevention oI hypoxia (decrease tissue oxygenation) & hypercarbia (increase in CO2 retention).
Hypoxia cerebral edema - increase ICP
Hypoxia inadequate tissue oxygenation
Late symptoms oI hypoxia B bradycardia
E extreme restlessness
D dyspnea
C cyanosis
Early symptoms R restlessness
A agitation
T tachycardia
Increase CO2 retention/ hypercarbia cerebral vasodilatation increase ICP
Most powerIul respiratory stimulant increase in CO2
Hyperventilate decrease CO2 excrete CO2
Respiratory Distress Syndrome (RDS) decrease Oxygen
Suctioning 10-15 seconds, max 15 seconds. Suction upon removal oI suction cap.
Ambu bag pump upon inspiration
c. Assist in mechanical ventilation
1. Maintain patent a/w
2. Monitor VS & I&O
3. Elevate head oI bed 30 45 degrees angle neck in neutral position unless contra indicated to promote venous
drainage
4. Limit Iluid intake 1,200 1,500 ml/day
(FORCE FLUID means:Increase Iluid intake/day 2,000 3,000 ml/day)- not Ior inc ICP.
5. Prevent complications oI immobility
6. Prevent increase ICP by:
a. Maintain quiet & comIy environment
b. Avoid use oI restraints lead to Iractures
c. Siderails up
d. Instruct patient to avoid the II:
-Valsalva maneuver or bearing down, avoid straining oI stool
(give laxatives/ stool soItener Dulcolax/ Duphalac)
- Excessive cough antitussive
Dextrometorpham
-Excessive vomiting anti emetic (Plasil Phil only)/ Phenergan
- LiIting oI heavy objects
- Bending & stooping
e. Avoid clustering oI nursing activities
7. Administer meds as ordered:
1.) Osmotic diuretic Mannitol./Osmitrol promotes cerebral diuresis by decompressing brain tissue
Nursing considerations: Mannitol
1. Monitor BP SE oI hypotension
2. Monitor I&O every hr. report iI 30cc out put
3. Administer via side drip
4. Regulate Iast drip to prevent Iormation oI crystals or precipitate
2.) Loop diuretic - Lasix (Furosemide)
Nursing Mgt: Lasix
Same as Mannitol except
- Lasix is given via IV push (expect urine aIter 10-15mins) should be in the
morning. II given at 7am. Pt will urinate at 7:15
Immediate eIIect oI Lasix within 15 minutes. Max eIIect 6 hrs due (7am 1pm)
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S/E oI Lasix
Hypokalemia (normal K-3.5 5.5 meg/L)
S&Sx
1. Weakness & Iatigue
2. Constipation
3. () 'U wave in ECG tracing
Nursing Mgt:
1.) Administer K supplements ex Kalium Durule, K chloride
Potassium Rich Iood:
ABC`s oI K
Vegetables Fruits
A - asparagus A apple
B broccoli (highest) B banana green
C carrots C cantalope/ melon
O orange (highest) Ior digitalis toxicity also.
Vit A squash, carrots yellow vegetables & Iruits, spinach, chesa
Iron raisins,
Food appropriate Ior toddler spaghetti! Not milk increase bronchial secretions
Don`t give grapes may choke
S/E oI Lasix:
1.) Hypokalemia
2.) Hypocalcemia (Normal level Ca 8.5 11mg/100ml) or Tetany:
S&Sx
weakness
Paresthesia
() Trousseau sign pathognomonic or carpopedal spasm. Put bp cuII on armhand spasm.
() Chevostek`s sign
Arrhythmia
Laryngospasm
Administer Ca gluconate IV slowly

Ca gluconate toxicity: Sx seizure administer Mg SO4
Mg SO4 toxcicity administer Ca gluconate
B BP decrease
U urine output decrease
R RR decrease
P patellar reIlexes absent
3.) Hyponatremia Normal Na level 135 145 meg/L
S/Sx Hypotension
Signs oI Dehydration: dry skin, poor skin turgor, gen body malaise.
Early signs Adult: thirst and agitation / Child: tachycardia
Mgt: Iorce Iluid
Administer isotonic Iluid sol
4.) Hyperglycemia increase blood sugar level
P polyuria
P polyphagia
P polydipsia
Nsg Mgt:
a. Monitor FBS (N80 120 mg/dl)
5.) Hyperurecemia increase serum uric acid. Tophi- urate crystals in joint.
6
Gou ty arthritis kidney stones- renal colic (pain)
Cool moist skin
Sx joint pain & swelling usually at great toe.
Nsg Mgt oI Gouty Arthritis
a.) Cheese (not sardines, anchovies, organ meat)
(Not good iI pt taking MAO)
b.) Force Iluid
c.) Administer meds Allopurinol/ Zyloprim inhibits synthesis oI uric acid drug oI choice Ior gout
Colchicene excretes uric acid. Acute gout drug oI choice.
Kidney stones renal colic (pain). Cool moist skin
Mgt:
1.) Force Iluid
2.) Meds narcotic analgesic
Morphine SO4
SE oI Morphine SO4 toxicity
Respiratory depression (check RR 1
st
)
Antidote Ior morphine SO4 toxicity Narcan (NALOXONE)
Naloxone toxicity tremors
Increase ICP meds:
3.) Corticosteroids - Dexamethsone decrease cerebral edema (Decadrone)
4.) Mild analgesic codeine SO4. For headache.
5.) Anti consultants Dilantin (Phenytoin)
Question: Increase ICP what is the immediate nsg action?
a. Administer Mannitol as ordered
b. Elevate head 30 45 degrees
c. Restrict Iluid
d. Avoid use oI restraints
Nsg Priority ABC & saIety
Pt suIIering Irom epiglotitis. What is nsg priority?
a. Administer steroids least priority
b. Assist in ET temp, a/w
c. Assist in tracheotomy permanent (Answer)
d. Apply warm moist pack? Least priority
Rationale: Wont need to pass larynx due to larynx is inIlamed. ET can`t pass. Need tracheostomy only-
Magic 2`s of drug monitoring
Drug N range Toxicity Classification Indication
D digoxin .5 1.5 meq/L 2 cardiac glycosides CHF
L - lithium .6 1.2 meq/L 2 antimanic bipolar
A aminophylline 10 19 mg/100ml 20 bronchodilator COPD
D Dilantin 10 -19 mg/100 ml 20 anticonvulsant seizures
A acetaminophen 10 30 mg/100ml 200 narcotic analgesic osteoarthritis
Digitalis increase cardiac contraction increase CO
Nursing Mgt
1. Check PR, HR (iI HR below 60bpm, don`t giveDigoxin)
Digitalis toxicity antidote - Digivine
a. Anorexia -initial sx.
b. n/v GIT
c. Diarrhea
d. ConIusion
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e. Photophobia
I. Changes in color perception yellow spots
(Ok to give to pts with renal Iailure. Digoxin is metabolized in liver not in kidney.)
L - lithium (lithane) decrease levels oI norepinephrine, serotonine, acetylcholine
Antimanic agent
Lithium toxicity
S/Sx -
a.) Anorexia
b.) n/s
c.) Diarrhea
d.) Dehydration Iorce Iluid, maintain Na intake 4 10g daily
e.) Hypothyroidism
(CRETINISM the only endocrine disorder that can lead to mental retardation)
A - aminophyline (theophylline) - dilates bronchioles.
Take bp beIore giving aminophylline.
S/Sx : Aminophylline toxicity:
1. Tachycardia
2. Hyperactivity restlessness, agitation, tremors
Question: Avoid giving Iood with Aminophylline
a. Cheese/butter Iood rich in tyramine, avoided only iI pt is given MAOI
b. Beer/ wine -
c. Hot chocolate & tea caIIeine CNS stimulant tachycardia
d. Organ meat/ box cereals anti parkinsonian
MAOI antidepressant
m AR plan
n AR dil can lead to CVA or hypertensive crisis
p AR nate
3 4 weeks - beIore MAOI will take eIIect
Anti Parkinsonian agents Vit B6 Pyridoxine reverses eIIect oI Levodopa
D - dilatin (Phenytoin) anti convulsant/seizure
Nursing Mgt:
1. Mixed with plain NSS or .9 NaCl to prevent Iormation oI crystals or precipitate
- Do sandwich method
- Give NSS then Dilantin, then NSS!
2. Instruct the pt to avoid alcohol bec alcohol dilantin can lead to severe CNS depression
Dilantin toxicity:
S/Sx:
G gingival hyperplasia swollen gums
i. Oral hygiene soIt toothbrush
ii. Massage gums
H hairy tongue
A - ataxia
N nystagmus abnormal movement oI eyeballs
A acetaminophen/ Tylenol non-opoid analgesic & antipyretic Iebrile pts
Acetaminophen toxicity :
1. Hepato toxicity
2. Monitor liver enzymes
SGPT (ALT) Serum Glutamic Piruvate Tyranase
SGOT- Serum Glutamic Acetate Tyranase
3. Monitor BUN (10 20)
Crea (.8-1)
Acetaminophen toxicity can lead to hypoglycemia
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T tremors, Tachycardia
I irritability
R restlessness
E extreme Iatigue
D depression (nightmares) , Diaphoresis
Antidote Ior acetaminophen toxicity Acetylcesteine causes outporing oI secretions. Suction.
Prepare suctioning apparatus.
Question: The Iollowing are symptoms oI hypoglycemia except:
a. Nightmares
b. Extreme thirst hyperglycemia symptoms
c. Weakness d. Diaphoresis
PARKINSONS DSE (parkinsonism) - chronic, progressive disease oI CNS char by degeneration oI dopamine
producing cells in substancia nigra at mid brain & basal ganglia
- Palliative, Supportive
Function oI dopamine: controls gross voluntary motors.
Predisposing Factors:
1. Poisoning (lead & carbon monoxide). Antidote Ior lead Calcium EDTA
2. Hypoxia
3. Arteriosclerosis
4. Encephalitis
High doses oI the II:
a. Reserpine (serpasil) anti HPN, SE 1.) depression - suicidal 2.) breast cancer
b. Methyldopa (aldomet) - promote saIety
c. Haloperidol (Haldol)- anti psychotic
d. Phenothiazide - anti psychotic
SE oI anti psychotic drugs Extra Pyramidal Symptom
Over meds oI anti psychotic drugs neuroleptic malignant syndrome char by tremors (severe)
S/Sx: Parkinsonism
1. Pill rolling tremors oI extremities early sign
2. Bradykinesia slow movement
3. Over Iatigue
4. Rigidity (cogwheel type)
a. Stooped posture
b. ShuIIling most common
c. Propulsive gait
5. Mask like Iacial expression with decrease blinking eyes
6. Monotone speech
7. DiIIiculty rising Irom sitting position
8. Mood labilety always depressed suicide
Nsg priority: Promote saIety
9. Increase salivation drooling type
10. Autonomic signs:
- Increase sweating
- Increase lacrimation
- Seborrhea (increase sebaceous gland)
- Constipation
- Decrease sexual activity
Nsg Mgt
1.) Anti parkinsonian agents
- Levodopa (L-Dopa), Carbidopa (Sinemet), Amantadine Hcl (Symmetrel)
Mechanism oI action
Increase levels oI dopa relieving tremors & bradykinesia
S/E oI anti parkinsonian
- Anorexia
- n/v
- ConIusion
- Orthostatic hypotension
9
- Hallucination
- Arrhythmia
Contraindication:
1. Narrow angled closure glaucoma
2. Pt taking MAOI (Parnate, Marplan, Nardil)
Nsg Mgt when giving anti-parkinsonian
1. Take with meals to decrease GIT irritation
2. InIorm pt urine/ stool may be darkened
3. Instruct pt- don`t take Iood Vit B6 (Pyridoxine) cereals, organ meats, green leaIy veg
- Cause B6 reverses therapeutic eIIects oI levodopa
Give INH (Isoniazide-Isonicotene acid hydrazide.) SE-Peripheral neuritis.
2.) Anti cholinergic agents relieves tremors
Artane mech inhibits acetylcholine
Cogentin action , S/E - SNS
3.) Antihistamine Diphenhydramine Hcl (Benadryl) take at bedtime
S/E: adult drowsiness, avoid driving & operating heavy equipt. Take at bedtime.
Child hyperactivity CNS excitement Ior kids.
4.) Dopamine agonist
Bromotriptine Hcl (Parlodel) respiratory depression. Monitor RR.
Nsg Mgt Parkinson
1.) Maintain siderails
2.) Prevent complications oI immobility
- Turn pt every 2h
Turn pt every 1 h elderly
3.) Assist in passive ROM exercises to prevent contractures
4.) Maintain good nutrition
CHON in am
CHON in pm to induce sleep due Tryptopan Amino Acid
5.) Increase Iluid in take, high Iiber diet to prevent constipation
6.) Assist in surgery Sterotaxic Thalamotomy
Complications in sterotaxic thalmotomy- 1.) Subarachnoid hemorrhage 2.) aneurism 3.) encephalitis
MULTIPLE SCLEROSIS (MS)
Chronic intermittent disorder oI CNS white patches oI demyelenation in brain & spinal cord.
- Remission & exacerbation
- Common women, 15 35 yo cause unknown
Predisposing Iactor:
1. Slow growing virus
2. Autoimmune (supportive & palliative treatment only)
Normal Resident Antibodies:
Ig G can pass placenta passive immunity. Short acting.
Ig A body secretions saliva, tears, colostrums, sweat
Ig M acute inIlammation
Ig E allergic reactions
IgD chronic inIlammation
S & Sx oI MS: (everything down)
1. Visual disturbances
a. Blurring oI vision
b. Diplopia/ double vision
c. Scotomas (blind spots) initial sx
2. Impaired sensation to touch, pain, pressure, heat, cold
a. Numbness
b. Tingling
c. Paresthesia
3. Mood swings euphoria (sense oI elation )
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4. Impaired motor Iunction:
a. Weakness
b. Spasiticity ' tigas
c. Paralysis major problem
5. Impaired cerebellar Iunction
Triad Sx oI MS
I intentional tremors
N nystagmus abnormal rotation oI eyes Charcots triad
A Ataxia
& Scanning speech
6. Urinary retention or incontinence
7. Constipation
8. Decrease sexual ability
Dx MS
1. CSF analysis thru lumbar puncture
- Reveals increase CHON & IgG
2. MRI reveals site & extent oI demyelination
3. Lhermitte`s response is (). Introduce electricity at the back. Theres spasm & paralysis at spinal cord.
Nsg Mgt MS
- Supportive mgt
1.) Meds
a. Acute exacerbation
ACTH adenocorticotopic
Steroids to reduce edema at the site oI demyelination to prevent paralysis
Spinal Cord Injury
Administer drug to prevent paralysis due to edema
a. Give ACTH steroids
b. Baclopen (Lioresol) or Dantrolene Na (Dantrene)
To decrease muscle spasticity
c. InterIerone to alter immune response
d. Immunosuppresants
2. Maintain siderails
3. Assist passive ROMexercises promote proper body alignment
5. Encourage Iluid intake & increase Iiber diet to prevent constipation
6. Provide catheterization die urinary retention
7. Give diuretics
Urinary incontinence give Prophantheline bromide (probanthene)
Antispasmodic anti cholinergic
8. Give stress reducing activity. Deep breathing exercises, bioIeedback, yoga techniques.
9. Provide acid-ash diet to acidiIy urine & prevent bacteria multiplication
Grape, Cranberry, Orange juice, Vit C
MYASTHENIA GRAVIS (MG) disturbance in transmission oI impulses Irom nerve to muscle cell at neuro muscular
junction.
Common in Women, 20 40 yo, unknown cause or idiopathic
Autoimmune release oI cholenesterase enzyme
Cholinesterase destroys ACH (acetylcholine) Decrease acetylcholine
Descending muscle weakness
(Ascending muscle weakness Guillain Barre Syndrome)
Nsg priority:
1) a/w
2) aspiration
3) immobility
S/ Sx:
1.) Ptosis drooping oI upper lid ( initial sign)
Check Palpebral Iissure opening oI upper & lower lids to know iI () oI MG.
2.) Diplopia double vision
11
3.) Mask like Iacial expression
4.) Dysphagia risk Ior aspiration!
5.) Weakening oI laryngeal muscles hoarseness oI voice
6.) Resp muscle weakness lead respiratory arrest. Prepare at bedside tracheostomy set
7.) Extreme muscle weakness during activity especially in the morning.
Dx test
1. Tensilon test (Edrophonium Hcl) temporarily strengthens muscles Ior 5 10 mins. Short term- cholinergic. PNS eIIect.
Nsg Mgt
1. Maintain patent a/w & adequate vent by:
a.) Assist in mechanical vent attach to ventilator
b.) Monitor pulmonary Iunction test. Decrease vital lung capacity.
2. Monitor VS, I&O neuro check, muscle strength or motor grading scale (4/5, 5/5, etc)
3. Siderails
4. Prevent complications oI immobility. Adult-every 2 hrs. Elderly- every 1 hr.
5. NGT Ieeding
Administer meds
a.) Cholinergics or anticholinesterase agents
Mestinon (Pyridostigmine)
Neostignine (prostigmin) Long term
- Increase acetylcholine
s/e PNS
b.) Corticosteroids to suppress immune resp
Decadron (dexamethasone)
Monitor Ior 2 types oI Crisis:
Myastinic crisis Cholinergic crisis
A cause 1. Under medication
2. Stress
3. InIection
B S&Sx 1. Unable to see Ptosis &
diplopia
2. Dysphagia- unable to swallow.
3. Unable to breath
C Mgt adm cholinergic agents
Cause: 1 over meds
S/Sx - PNS
Mgt. adm anti-cholinergic
- Atropine SO4
- SNS dry mouth
7. Assist in surgical proc thymectomy. Removal oI thymus gland. Thymus secretes auto immune antibody.
8. Assist in plasmaparesis Iilter blood
9. Prevent complication respiratory arrest
Prepare tracheostomy set at bedside.
GBS Guillain Barre Syndrome
- Disorder oI CNS
- Bilateral symmetrical polyneuritis
- Ascending paralysis
Cause unknown, idiopathic
- Auto immune
- r/t antecedent viral inIection
- Immunizations
S&Sx
Initial :
1. Clumsiness
2. Ascending muscle weakness lead to paralysis
3. Dysphagia
4. Decrease or diminished DTR (deep tendon reIlexes)
- Paralysis
5. Alternate HPN to hypotension lead to arrhythmia - complication
6. Autonomic changes increase sweating, increase salivation.
Increase lacrimation
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Constipation
Dx most important: CSF analysis thru lumbar puncture reveals increase in : IgG & CHON (same with MS)
Nsg Mgt
1. Maintain patent a/w & adequate vent
a. Assist in mechanical vent
b. Monitor pulmonary Iunction test
2. Monitor vs., I&O neuro check, ECG tracing due to arrhythmia
3. Siderails
4. Prevent compl immobility
5. Assist in passive ROM exercises
6. Institute NGT Ieeding due dysphagia
7. Adm meds (GBS) as ordered: 1. Anti cholinergic atropine SO4
2. Corticosteroids to suppress immune response
3. Anti arrhythmic agents
a.) Lidocaine /Xylocaine SE conIusion VTach
b.) Bretyllium
c.) Quinines/Quinidine anti malarial agent. Give with meals.
- Toxic eIIect cinchonism
Quinidine toxicity
S/E anorexia, n/v, headache, vertigo, visual disturbances
8. Assist in plasmaparesis (MG. GBS)
9. Prevent comp arrhythmias, respiratory arrest
Prepare tracheostomy set at bedside.
INFL CONDITONS OF BRAIN
Meninges 3-Iold membrane cover brain & spinal cord
Fx:
Protection & support
Nourishment
Blood supply
3 layers
1. Duramater sub dural space
2. Arachmoid matter
3. Pia matter sub arachnoid space where CSF Ilows L3 & L4. Site Ior lumbar puncture.
MENINGITIS inIlammation oI meningitis & spinal cord
Etiology Meningococcus
Pneumococcus
Hemophilous inIluenza child
Streptococcus adult meningitis
MOT direct transmission via droplet nuclei
S&Sx
- StiII neck or nuchal rigidity (initial sign)
- Headache
- Projectile vomiting due to increase ICP
- Photophobia
- Fever chills, anorexia
- Gen body malaise
- Wt loss
- Decorticate/decerebration abnormal posturing
- Possible seizure
Sx oI meningeal irritation nuchal rigidity or stiIIness
Opisthotonus- rigid arching oI back
Pathognomonic sign () Kernig`s & Brudzinski sign
13
Leg pain neck pain
Dx:
1. Lumbar puncture lumbar/ spinal tap use oI hallow spinal needle sub arachnoid space L3 & L4 or L4 & L5
Aspirate CSF Ior lumbar puncture.
Nsg Mgt Ior lumbar puncture invasive
1. Consent / explain procedure to pt
- RN dx procedure (lab)
- MD operation procedure
2. Empty bladder, bowel promote comIort
3. Arch back to clearly visualize L3, L4
Nsg Ngt post lumbar
1. Flat on bed 12 24 h to prevent spinal headache & leak oI CSF
2. Force Iluid
3. Check punctured site Ior drainage, discoloration & leakage to tissue
4. Assess Ior movement & sensation oI extremeties
Result
1. CSF analysis: a. increase CHON & WBC Content of CSF: Chon, wbc, glucose
b. Decrease glucose
ConIirms meningitis c. increase CSF opening pressure
N 50 160 mmHg
d. () Culture microorganism
2. Complete blood count CBC reveals increase WBC
Mgt:
1. Adm meds
a.) Broad-spectrum antibiotic penicillin
S/E
1. GIT irritation take with Iood
2. Hepatotoxicity, nephrotoxcicity
3. Allergic reaction
4. Super inIection alteration in normal bacterial Ilora
- N Ilora throat streptococcus
- N Ilora intestine e coli
Sx oI superinIection oI penicillin diarrhea
b.) Antipyretic
c.) Mild analgesic
2. Strict resp isolation 24h aIter start oI antibiotic therapy
A Cushing`s synd reverse isolation - due to increased corticosteroid in body.
B Aplastic anemia reverse isolation - due to bone marrow depression.
C Cancer anytype reverse isolation immunocompromised.
D Post liver transplant reverse isolation takes steroids liIetime.
E Prolonged use steroids reverse isolation
F Meningitis strict respiratory isolation saIe aIter 24h oI antibiotic therapy
G Asthma not to be isolated
3. ComIy & dark room due to photophobia & seizure
5. Maintain F & E balance
6. Monitor vs, I&O , neuro check
7. Provide client health teaching & discharge plan
a. Nutrition increase cal & CHO, CHON-Ior tissue repair. Small Ireq Ieeding
b. Prevent complication hydrocephalus, hearing loss or nerve deaIness.
8. Prevent seizure.
14
Where to bring 2 yo post meningitis
- Audiologist due to damage to hearing- post repair myelomeningocele
- Urologist - Damage to sacral area spina biIida controls urination
9. Rehab Ior neurological deIicit. Can lead to mental retardation or a delay in psychomotor development.

CEREBRO VASCULAR ACCIDENT stroke, brain attack or cerebral thrombosis, apoplexy
- Partial or complete disruption in the brains blood supply
- 2 largest & common artery in stroke
Middle cerebral artery
Internal carotid artery
- Common to male 2 3x high risk
1. Thrombosis clot (attached)
2. Embolism dislodged clot pulmo embolism
S/Sx: pulmo embolism
Sudden sharp chest pain
Unexplained dyspnea, SOB
Tachycardia, palpitations, diaphoresis & mild restlessness
S/Sx: cerebral embolism
Headache, disorientation, conIusion & decrease in LOC
Femur Iracture complications: Iat embolism most Ieared complication w/in 24hrs
Yellow bone marrow produces Iat cells at meduallary cavity oI long bone
Red bone marrow provides WBC, platelets, RBC Iound at epiphisis
2.) Hemorrhage
3.) Compartment syndrome compression oI nerves/ arteries
Risk Iactors oI CVA: HPN, DM, MI, artherosclerosis, valvular heart dse - Post heart surgery mitral valve replacement
LiIestyle: 1. Smoking nicotine potent vasoconstrictor
2. Sedentary liIestyle
3. Hyperlipidemia genetic
4. Prolonged use oI oral contraceptives
- Macro pill has large amt estrogen
- Mini pill has large amt oI progestin
- Promote lipolysis (breakdown oI lipids/Iats) artherosclerosis HPN - stroke
5. Type A personality
a. Deadline driven person
b. 2 5 things at the same time
c. Guilty when not dong anything
6. Diet increase saturated Iats
7. Emotional & physical stress
8. Obesity
S & Sx
1. TIA- warning signs oI impending stroke attacks
- Headache (initial sx), dizziness/ vertigo, numbness, tinnitus, visual & speech disturbances, paresis or plegia (monoplegia 1
extreme)
Increase ICP
2. Stroke in evolution progression oI S & Sx oI stroke
3. Complete stroke resolution oI stroke
a.) Headache
b.) Cheyne-Stokes Resp
c.) Anorexia, n/v
d.) Dysphagia
15
e.) Increase BP
I.) () Kernig`s & Brudzinski sx oI hemorrhagic stroke
g.) Focal & neurological deIicit
1. Phlegia
2. Dysarthria inability to vocalize, articulate words
3. Aphasia
4. Agraphia diII writing
5. Alesia diII reading
6. Homoninous hemianopsia loss oI halI oI Iield oI vision
LeIt sided hemianopsia approach Right side oI pt the unaIIected side
Dx
1. CT Scan reveals brain lesion
2. Cerebral arteriography site & extent oI mal occlusion
- Invasive procedure due to inject dye
- Allergy test
All graphy invasive due to iodine dye
Post
1.) Force Iluid to excrete dye is nephrotoxic
2.) Check peripheral pulses - distal
Nsg Mgt
1. Maintain patent a/w & adequate vent
- Assist mechanical ventilation
- Administer O2
2. Restrict Iluids prevent cerebral edema
3. Elevate head oI bed 30-45 degrees angle. Avoid valsalva maneuver.
4. Monitor vs., I&O, neuro check
5. Prevent compl oI immobility by:
a. Turn client q2h
Elderly q1h
- To prevent decubitus ulcer
- To prevent hypostatic pneumonia aIter prolonged immobility.
b. Egg crate mattress or H2O bed
c. Sand bag or Ioot board- prevent Ioot drop
6. NGT Ieeding iI pt can`t swallow
7. Passive ROM exercise q4h
8. Alternative means oI communication
- Non-verbal cues
- Magic slate. Not paper and pen. Tiring Ior pt.
- () To hemianopsia approach on unaIIected side
9. Meds
Osmotic diuretics Mannitol
Loop diuretics Lasix/ Furosemide
Corticosteroids dextamethazone
Mild analgesic
Thrombolytic/ Iibrolitic agents tunaw clot. SE-Urticaria, pruritus-caused by Ioreign subs.
Streptokinase
Urokinase
Tissue plasminogen activating
Monitor bleeding time
Anticoagulants Heparin & Coumadin sabay
Coumadin will take eIIect aIter 3 days
Heparin monitor PTT partial thromboplastin time iI prolonged bleeding give Protamine SO4- antidote.
Coumadin Long term. monitor PT prothrombin time iI prolonged- bleeding give Vit K Aquamephyton- antidote.
Antiplatelet PASA aspirin paraanemo aspirin, don`t give to dengue, ulcer, and unknown headache.
Health Teaching
1. Avoidance modiIiable liIestyle
- Diet, smoking
2. Dietary modiIication
16
- Avoid caIIeine, decrease Na & saturated Iats
Complications:
Subarachnoid hemorrhage
Rehab Ior Iocal neurological deIicit physical therapy
1. Mental retardation
2. Delay in psychomotor development
CONVULSIVE Disorder (CONVULSIONS)- disorder oI the CNS char. by paroxysmal seizures with or without loss oI
consciousness, abnormal motor activity, alteration in sensation & perception & change in behavior.
Can you outgrow Iebrile seizure? DiIIerence between: Seizure- 1
st
convulsive attack
Febrile seizure Normal iI 5 yo Epilepsy 2
nd
and with history oI seizure
Pathologic iI ~ 5 yo
Predisposing Factor
Head injury due birth trauma
Toxicity oI carbon monoxide
Brain tumor
Genetics
Nutritional & metabolic deIicit
Physical stress
Sudden withdrawal to anticonvulsants will bring about status epilepticus
Status epilepticus drug oI choice: Diazepam & glucose
S & Sx
I. Generalized Seizure
a.) Grand mal / tonic clonic seizures
With or without aura warning symptoms oI impending seizure attack- Epigastric pain- associated with
olIactory, tactile, visual, auditory sensory experience
- Epileptic cry Iall
- Loss oI consciousness 3 5 min
- Tonic clonic contractions
- Direct symmetrical extension oI extremities-TONIC. Contractions-CLONIC
- Post ictal sleep -state oI lethargy or drowsiness - unresponding sleep aIter tonic clonic
b.) Petimal seizure (same as daydreaming!) or absent seizure.
- Blank stare
- Decrease blinking eye
- Twitching oI mouth
- Loss oI consciousness 5 10 secs (quick & short)
II. Localized/partial seizure
a.) Jacksonian seizure or Iocal seizure tingling/jerky movement oI index Iinger/thumb & spreads to shoulder &
1 sideoI the body with janksonian march
b.) Psychomotor/ Iocal motor - seizure
-Automatism stereotype repetitive & non-purposive behavior
- Clouding oI consciousness not in control with environment
- Mild hallucinatory sensory experience
HALLUCINATIONS
1. Auditory schitzo paranoid type
2. Visual korsakoIIs psychosis chronic alcoholism
3. Tactile addict substance abuse
III. Status epilecticus continuous, uninterrupted seizure activity, iI untreated, lead to hyperprexia coma death
Seizure: inc electrical Iiring in brainincreased metabolic activity in brainbrain using glucose and O2dec glucose, dec O2.
Tx:Diazepam (drug oI choice), glucose
17
Dx-Convulsion- get health history!
1. CT scan brain lesion
2. EEG electroencephalography
- Hyperactivity brain waves
Nsg Mgt
Priority Airway & saIety
1. Maintain patent a/w & promote saIety
BeIore seizure:
1. Remove blunt/sharp objects
2. Loosen clothing
3. Avoid restraints
5. Turn head to side to prevent aspiration
6. Tongue guard or mouth piece to prevent biting oI tongue-BEFORE SEIZURE ONLY! Can use spoon at home.
7. Avoid precipitating stimulus bright glaring lights & noises
8. Administer meds
a. Dilantin (Phenytoin) ( toxicity level 20 )
SE Ginguial hyperplasia
H-hairy tongue
A-ataxia
N-nystagmus
A-acetaminophen- Iebrile pt
Mix with NSS
- Don`t give alcohol lead to CNS depression
b. (Tegretol) Carbamasene- given also to Trigeminal Neuralgia. SE: arrythmia
c. Phenobarbital (Luminal)- SE: hallucinations
2. Institute seizure & saIety precaution. Post seizure: Administer O2. Suction apparatus ready at bedside
3. Monitor onset & duration
- Type oI seizure
- Duration oI post ictal sleep. The longer the duration oI post ictal sleep, the higher chance oI having status
epilepticus!
4. Assist in surgical procedure. Cortical resection
5. Complications: Subarachnoid hemorrhage and encephalitis
Question: 1 yo grand mal immediate nursing action a/w & saIety
a. Mouthpiece 1 yr old little teeth only
b. Adm o2 inhalation post!
c. Give pillow saIety (answer)
d. Prepare suction
Neurological assessment:
1. Comprehensive neuro exam
2. GCS - Glasgow coma scale obj measurement oI LOC or quick neuro check
3 components oI ECS
M motor 6
V verbal resp 5
E eye opening 4
15
15 14 conscious
13 11 lethargy
10 8 stupor
7 coma
3 deep coma lowest score
Survey oI mental status & speech (Comprehensice Neuro Exam)
1.) LOC & test oI memory
18
2.) Levels oI orientation
3.) CN assessment
4.) Motor assessment
5.) Sensory assessment
6.) Cerebral test Romhberg, Iinger to nose
7.) DTR
8.) Autonomics
Levels oI consciousness (LOC)
1. Conscious (conscious) awake levels oI wakeIulness
2. Lethargy (lethargic) drowsy, sleepy, obtunded
3. Stupor (stuporous) awakened by vigorous stimulation
Pt has gen body weakness, decrease body reIlex
4. Coma (Comatose) light () all Iorms oI painIul stimulations
Deep (-) to painIul stimulation
Question: Describe a conscious pt ?
a. Alert not all pt are alert & oriented to time & place
b. Coherent
c. Awake- answer
d. Aware
DiIIerent types oI pain stimulation
- Don`t prick
1. Deep sternal stimulation/ pressure 3x Iist knuckle
With response light coma
Without response deep coma
2. Pressure on great toe 3x
3. Orbital pressure pressure on orbits only below eye
4. Corneal reIlex/ blinking reIlex
Wisp oI cotton used to illicit blinking reIlex among conscious patients
Instill 1-drop saline solution unconscious pt iI (-) response pt is in deep coma
5. Test oI memory considered educational background
a.) Short term memory
- What did you eat Ior breakIast?
Damage to temporal lobe () antero grade amnesia
b.) Long term memory
() Retrograde amnesia damage to limbic system
6. Levels oI orientation
Time Place Person
Graphesthesia- can identiIy numbers or letters written on palm with a blunt object.
Agraphesthesia cant identiIy numbers or letters written on palm with a blunt object.
CN assessment:
I OlIactory s
II Optic s
III Oculomotor m
IV Trocheal m smallest CN
V Trigeminal b largest CN
VI Abducens m
VII Facial b
VIII Acustic/auditory s
IX Glassopharyngeal b
X Vagus b longest CN
XI Spinal accessory m
XII Hypoglossal m
I. Olfactory don`t use ammonia, alcohol, cologne irritating to mucosa use coIIee, bar soap, vinegar, cigarette tar
- Hyposmia decrease sensitivity to smell
- Diposmia distorted sense oI smell
19
- Anosmia absence oI sense oI smell
Either oI 3 might indicate head injury damage to cribriIorm plate oI ethmoid bone where olIactory cells are located
or indicate inIlammation condition sinusitis
II optic- test oI visual acuity Snellens chart central or distance vision
Snellens E chart used Ior illiterate chart
N 20/20 vision distance by w/c person can see letters- 20 It
Numerator distance to snellens chart
Denominator distance the person can see the letters
OD Rt eye 20/20 20/200 blindness cant read E biggest
OS leIt eye 20/20
OU both eye 20/20
2. Test oI peripheral vision/ visual Iield
a. Superiority
b. Bitemporally
c. InIeriorly
d. Nasally
Common Disorders see page 85-87 Ior more inIo on glaucoma, etc.
1. Glaucoma Normal 12 21 mmHg pressure
- Increase IOP - Loss oI peripheral vision 'tunnel vision
2. Cataract opacity oI lens - Loss oI central vision, 'Blurring or hazy vision
3. Retinal detachment curtain veil like vision & Iloaters
4. Macular degeneration black spots
III, IV, VI tested simultaneously
- Innervates the movementt oI extrinsic ocular muscle
6 cardinal gaze EOM
Rt eye N leIt eye
IO SO O
S
LR MR E
SR
3 4 EOM
IV sup oblique
VI lateral rectus
Normal response PERRLA (isocoria equal pupil)
Anisocoria unequal pupil
Oculomotor
1. Raising oI eyelid Ptosis
2. Controls pupil size 2 -3 cm or 1.5 2 mm
V Trigeminal Largest consists oI - ophthalmic, maxillary, mandibular
Sensory controls sensation oI the Iace, mucus membrane; teeth & cornea reIlex
Unconscious instill drop oI saline solution
Motor controls muscles oI chewing/ muscles oI mastication
Trigeminal neuralgia diII chewing & swallowing extreme Iood temp is not recommended
Question: Trigeminal neuralgia, RN should give
a. Hot milk, butter, raisins
b. Cereals
c. Gelatin, toast, potato all correct but
d. Potato, salad, gelatin salad easier to chew
20
VI Facial: Sensory controls taste ant 2/3 oI tongue test cotton applicator put sugar.
-Put applicator with sugar to tip to tongue.
-Start oI taste insensitivity: Age group 40 yrs old
Motor- controls muscles oI Iacial expression, smile Irown, raise eyebrow
Damage Bells palsy Iacial paralysis
Cause bells palsy pedia R/T Iorcep delivery
Temporary only
Most evident clinical sign oI Iacial symmetry: Nasolabial Iolds
VIII Acoustic/ vestibule cochlear (controls hearing) controls balance (kenesthesia or position sense)
- Movement & orientation oI body in space
- Organ oI Corti Ior hearing true sense organ oI hearing
Outer tympanic membrane, pinna, oricle (impacted cerumen), cerumen
Middle hammer, anvil, stirrup or melleus, incus, staples. Mid otitis media
- Eustachean ear
Inner ear- meniere dse, sensory hearing loss (research parts! & dse)
Remove vestibule meniere`s dse disease inner ear
Archimedes law buoyancy (pregnancy Ietus)
Daltons law partial pressure oI gases
Inertia law oI motion (dizziness, vertigo)
1.) Pt with multiple stab wound - chest
- Movement oI air in & out oI lungs is carried by what principle?
- DiIIusion Dalton`s law
2.) Pregnant check up ultrasound reveals Ietus is carried by amniotic Iluid
- Archimedes
3.) Severe vertigo due- Inertia
Test Ior acoustic nerve:
- Repeat words uttered
IX Glossopharyngeal controls taste posterior 1/3 oI tongue
X Vagus controls gag reIlex
Test 9 10
Pt say ah check uvula should be midline
Damage cerebral hemisphere is L or R
Gag reIlex place tongue depression post part oI tongue
! Don`t touch uvula
XI Spinal Accessory - controls sternocleidomastoid (neck) & trapezius (shoulders and back)
- Shrug shoulders, put pressure. Pt should resist pressure. Paresis or phlegia
XII Hypoglossal controls movement oI tongue say 'ah. Assess tongue positionmidline
L or R deviation
- Push tongue against cheek
- Short Irenulum lingue
Tongue tied 'bulol
ENDOCRINE
Fx oI endocrine ductless gland
Main gland Pituitary gland located at base oI brain oI Stella Turcica
Master gland oI body
Master clock oI body
21
Anterior pituitary gland adenohypophysis
Posterior pituitary gland neurohypophysis
Posterior pituitary:
1.) Oxytocin a.) Promotes uterine contraction preventing bleeding/ hemorrhage.
- Give aIter placental delivery to prevent uterine atony.
b.) Milk letdown reIlex with help oI prolactin.
2.) ADH antidiuretic hormone (vasopressin) -Prevents urination conserve H2O

A. DIABETIS INSIPIDUS (DI- dalas ihi) hyposecretion oI ADH
Cause: idiopathic/ unknown
1. Pituitary surgery
2. Trauma/ head injury
3. Tumor
4. InIlammation
* alcohol inhibits release oI ADH
S & Sx:
1. Polyuria
2. Sx oI dehydration (1
st
sx oI dehydration in children-tachycardia)
- Excessive thirst (adult)
- Agitation
- Poor skin turgor
- Dry mucus membrane
3. Weakness & Iatigue
4. Hypotension iI leIt untreated -
5. Hypovolemic shock
Anuria late sign hypovolemic shock
Dx Proc:
1. Decrease urine speciIic gravity- concentrated urine
N 1.015 1.035
2. Serum Na increase (N135 -145 meq/L) Hypernatremia
Mgt:
1. Force Iluid 2,000 3,000ml/day
2. Administer IV Iluid replacement as ordered
3. Monitor VS, I&O
4. Administer meds as ordered
a.) Pitresin (vasopressin) IM
5. Prevent complications
Most Ieared complication Hypovolemic shock
B.) SIADH - Syndrome of Inappropriate Anti-Diuretic Hormone
- Increase ADH
- Idiopathic/ unknown
Predisposing Iactor
1. Head injury
2. Related to Bronchogenic cancer or lung caner-
Early Sign oI Lung Ca - Cough 1. non productive 2. productive
3. Hyperplasia oI Pit gland
Increase size oI organ
22
S&Sx
1. Fluid retention
2. Increase BP HPN
3. Edema
4. Wt gain
5. Danger oI H2O intoxication Complications: 1. cerebral edema increase ICP 2. seizure
Dx Proc:
1. Urine speciIic gravity increase diluted urine
2. Hyponatremia Decreased Na
Nsg Mgt:
1. Restrict Iluid
2. Administer meds as ordered eg. Diuretics: Loop and Osmotic
3. Monitorstrictly V/S, I&O, neuro check increase ICP
4. Weigh daily
5. Assess Ior presence edema
6. Provide meticulous skin care
7. Prevent complications increase ICP & seizures activity
Anterior Pituitary Gland adeno
1. Growth hormone (GH) (Somatotropic hormone)
Fx: Elongation oI long bones
Decrease GH dwarIism children
Increase GH gigantism
Increase GH acromegaly adult
Puberty 9 yo 21 yo
Epiphyseal plate closes at 21 yo
Square Iace
Square jaw
Drug oI choice in acromegaly: Ocreotide (Sandostatin) SE dizziness
- Somatostatin Hormone antagonizes the release oI oI GH
2. Melanocytes stimulating hormone - MSH
- Skin pigmentation
3. Prolactin/luteotrpic hormone/ lactogenic hormone - Promotes development oI mammary gland
(Oxytocin-Initiates milk letdown reIlex)
4. Adrenocorticotropic hormone ACTH - Development & maturation oI adrenal cortex
5. Luteinizing hormone produces progesterone.
6. FSH- produces estrogen
PINEAL GLAND
1. Secretes Melatonin inhibits lutenizing hormone (LH) secretion
THYROID GLAND (TG)
Question: Normal physical Iinding on TG:
a. With tenderness thyroid never tender
b. With nodular consistency- answer
c. Marked asymmetry only 1 TG
d. Palpable upon swallowing - Normal TG never palpable unless with goiter
TG hormones:
T3 T4 Thyrocalcitonin
- Triodothyronine -Tetraiodothyronine/ Tyroxine FX antagonizes eIIects oI parathormone
- 3 molecules oI iodine - 4 molecules oI iodine
23
Metabolic hormone
Increase metabolism brain inc cerebration, inc v/s all v/s down, constipation
Hypo T3 T4 - lethargy & memory impairment
Hyper T3 T4 - agitation, restlessness, and hallucination
7. Increase VS, increase motility
HYPOTHYROIDISM all decreased except wt & menstruation, loss oI appetite but with wt gain
menorrhagia increase in mens
HYPERTHYROIDISM - Increase appetite wt loss, amenorrhea
SIMPLE GOITER enlarged thyroid gland - iodine deIiciency
Predisposing Iactors
1. Goiter belt area - Place Iar Irom sea no iodine. SeaIood`s rich in iodine
2. Mountainous area increase intake oI goitrogenic Ioods (US: Midwest, NE, Salt Lake)
Cabbage has progoitrin an anti thyroid agent with no iodine
Example: Turnips (singkamas), radish, peas, strawberries, potato, beans, kamote, cassava (root crops), all nuts.
3. Goitrogenic drugs:
Anti thyroid agents :(PTU) prephyl thiupil
Lithium carbonate, Aspirin PASA
Cobalt, Phenyl butasone
Endemic goiter cause # 1
Sporadic goiter caused by #2 & 3
S & Sx enlarged TG
Mild restlessness
Mild dysphagia
Dx Proc.
1. Thyroid scan reveals enlarged TG
2. Serum TSH increase (conIirmatory)
3. Serum T3, T4 N or below N
Nsg Mgt:
1. Administer meds
a.) Iodine solution Logol`s solution or saturated sol oI K iodide SSKI
Nsg Mgt Lugol`s sol violet color
1. use straw prevent staining teeth
2. Prophylaxis 2 -3 drops Treatment 5 to 6 drops
Use straw to prevernt staining oI teeth
1. Lugol`s sol., 2. tetracycline 3. nitroIurantin (macrodantin)-urinary anticeptic-pyelonephritis. 4. Iron solution.
B. Thyroid h / Agents
1. Levothyroxine (Synthroid)
2. Liothyronine (cytomel)
3. Thyroid extract
Nsg Mgt: Ior TH/agents
1. Monitor vs. HR due tachycardia & palpitation
2. Take it early AM SE insomnia
3. Monitor s/e
24
Tachycardia, palpitations
Signs oI insomnia
Hyperthyroidism restlessness agitation
Heat intolerance
HPN
3. Encourage increase intake iodine iodine is extracted Irom seaweeds (!)
SeaIood- highest iodine content oysters, clams, crabs, lobster
Lowest iodine shrimps
Iodized salt easily destroyed by heat take it raw not cooked
4. Assist surgery- Sub total thyroidectomy-
Complication: 1. Tetany 2. laryngeal nerve damage 3.Hemorrhage-Ieeling oI Iullness at incision site.Check nape Ior
wet blood. 4.Laryngeal spasm DOB, SOB trache set ready at bedside.
2.) HYPOTHYROIDISM decrease secretion oI T3, T4 can lead to MI / Atherosclerosis
Adult myxedema
Child- cretinism only endocrine dis lead to mental retardation
1. `Iatrogenic causes caused by surgery
2. Atrophy oI TG due to:
a. Irradiation
b. Trauma
c. Tumor, inIlammation
3. Iodine deI
4. Autoimmune Hashimoto disease
S&Sx everything decreased except wt gain & mens increase)
Early signs weakness and Iatigue
Loss oI appetite increased lypolysis breakdown oI Iats causing atherosclerosis MI
Wt gain
Cold intolerance myxedema - coma
Constipation
Late Sx brittle hair/ nails
Non pitting edema due increase accumulation oI mucopolysacharide in SQ tissue -Myxedema
Horseness voice
Decrease libido
Decrease VS hypotension bradycardia, bradypnea, and hypothermia
Lethargy
Memory impairment leading to psychosis-IorgetIulness
Menorrhagia
Dx:
1. Serum T3 T4 decrease
2. Serum cholesterol increase can lead to MI
3. RA IU radio iodine uptake decrease
Nsg Mgt:
1. Monitor strictly V/S. I&O to determine presence oI myxedema coma!
Myxedema Coma - Severe Iorm oI hypothyroidism
Hypotension, hypoventilation, bradycardia, bradypnea, hyponatremia, hypoglycemia, hypothermia
Might lead to progressive stupor & coma
Impt mgt Ior Myxedema coma
1. Assist mech vent priority a/w
2. Adm thyroid hormone
3. Adm IVF replacement Iorce Iluid
25
Mgt myxedema coma
1. Monitor VS, I&O
2. Provide dietary intake low in calories due to wt gain
3. Skin care due to dry skin
4. ComIortable & warm environment due to cold intolerance
5. Administer IVF replacements
6. Force Iluid
7. Administer meds take AM SE insomia. Monitor HR.
Thyroid hormones
Levothyroxine(Synthroid), Liothyronine (cytomel)
Thyroid extracts
8. Health teaching & discharge plan
a. Avoidance precipitating Iactors leading to myxedema coma:
1. Exposure to cold environment
2. Stress 3. InIection
4. Use oI sedative, narcotics, anesthetics not allowed CNS depressants V/S already down
Complications:
9. Hypovolemic shock, myxedema coma
10. Hormonal replacement therapy - liIetime
11. Importance oI Iollow up care
HYPERTHYROIDISM - Graves dse or thyrotoxicosis ( everything up except wt and mens)
-Increased T3 & T4
1. Autoimmune disease release oI long acting thyroid stimulator (LATS)
Exopthalmos
Enopthalmos severe dehydration depressed eye
2. Excessive iodine intake
3. Hyperplasia oI TG
S&Sx:
1. Increase in appetite hyperphagia wt loss due to increase metabolism
2. Skin is moist - perspiration
3. Heat intolerance
4. Diarrhea increase motility
5. All VS increase HPN, tachycardia, tachypnea, hyperthermia
6. CNS changes
8. Irritability & agitation, restlessness, tremors, insomnia, hallucinations
7. Goiter
8. Exopthalmos pathognomonic sx
9. Amenorrhea
Dx:
1. Serum T3 & T4 - increased
2. Radio iodine uptake increase
3. Thyroid scan reveals enlarged TG
Nsg Mgt:
1. Monitor VS & I & O determine presence oI thyroid storm or most Ieared complication: Thyrotoxicosis
2. Administer meds
a. Antithyroid agents
1. Prophylthiuracil (PTU)
2. Methymazole (Tapazole)
Most toxic s/e agranulocytosis- Iever, sore throat, leukocytosisinc wbc: check cbc and throat swab culture
Most Ieared complication : Thrombosis stroke CVS
26
3. Diet increase calorie to correct wt loss
4. Skin care
5. ComIy & cool environment
6. Maintain siderails- due agitation/restlessness
7. Provide bilateral eye patch to prevent drying oI eyes- exopthalmos
8. Assist in surgery subtotal thyroidectomy
Nsg Mgt: pre-op
Adm Lugol`s solution (SSKI) K iodide
9. To decrease vascularity oI TG
10. To prevent bleeding & hemorrhage
Mgt post op:
Complication: 1. Watch out Ior signs oI thyroid storm or thyrotoxicosis
Triad signs of thyroidstorm;
a. Tachycardia /palpitation
b. Hyperthermia
c. Agitation
Nsg Mgt Thyroid Storm:
1. Monitor VS & neuro check
Agitated might decrease LOC
2. Antipyretic Iever
Tachycardia - ! blockers (-lol)
3. Siderails agitated
Comp 2. Watch Ior inadvertent (accidental) removal oI parathyroid gland
Secretes Para hormone
II removed, hypocalcemia - classic sign tetany 1. .() Trousseau sign/ 2. Chvosteck`s sign
Nsg Mgt:
Adm calcium gluconate slowly to prevent arrhythmia
Ca gluconate toxicity antidote MgSO4
3.Laryngeal (voice box) nerve damage (accidental)
Sx: hoarseness oI voice
***Encourage pt to talk or speak post operatively asap to determine laryngeal nerve damage
NotiIy physician!
4. Signs oI bleeding post subtotal thyroidectomy
- 'Feeling oI Iullness at incision site
Nsg mgt:
Check soiled dressing at nape area
5. Signs oI laryngeal spasm
a. DOB
b. SOB
Prepare at bedside tracheostomy
7. Importance oI Iollow up care
(Liver cirrhosis bedside scissor iI pt complaints oI DOB)
(Cut cystachean tube to deIlate balloon)
Parathyroid gland pair oI small nodules located behind the TG
27
11. Secrets parathyroid hormone promotes Ca reabsorption
Thyrocalcitonin antagonises secretion oI parathyroid hormone
1. Hypoparthroidism decrease oI parathyroid hormone
2. Hyperparathroidsm
HYPOPARATHYROIDISM decreased parathormone
Hypocalcemia Hyperphosphatemia
(Or tetany)
|II Ca decreases, phosphate increases|
A. Predisposing, Iactors:
1. Following subtotal thyroidectomy
2. Atrophy oI parathyroid gland due to
a. Irradiation
b. Trauma
S&Sx:
1. Acute tetany
a. Tingling sensation
b. Paresthesia
c. Dysphagia
d. Laryngospasm
e. Bronchospasm
Pathognomonic Sign oI tetany:
a. () Trousseau`s or carpopedial spasm
b. () Chvosteck`s sign
I. Seizure most Ieared complication
g. Arrhythmia
2. Chronic tetany
a. Loss oI tooth enamel
b. Photophobia & cataract Iormation
c. GIT changes anorexia, n/v, general body malaise
d. CNS changes memory impairment, irritability
Dx:
1. Serum calcium decrease (N 8.5 11 mg/100ml)
2. Serum phosphate increase (N 2.5 4.5 mg/100ml)
3. X-ray oI long bone decrease bone density
4. CT Scan reveals degeneration oI basal ganglia
Nsg Mgt:
1. Administration oI meds:
a.) Acute tetany
Ca gluconate IV, slowly
b.) Chronic tetany
1. Oral Ca supplements
Ex. Ca gluconate
28
Ca carbonate
Ca lactate
Vit D (CholecalceIerol)
Drug diet sunlight
CholecalceIerol calcidiol calcitriol 7am 9am
2. Phosphate binder
Alumminum DH gel (ampho gel)
SE constipation
Antacid
AAC MAD
Aluminum containing acids Mg containing antacids
Ex. Milk or magnesia
Aluminum OH gel Diarrhea
Constipation Maalox magnesium & aluminum - Less s/e
2. Avoid precipitating stimulus such as bright lights & noise: photophobia leading to seizure
3. Diet increase Ca & decrease phosphorus
- Don`t give milk due to increase phosphorus
Good anchovies increase Ca, decrease phosphorus inc uric acid. Tuna & green turnips- Inc Ca.
4. Bedside tracheostomy set due to laryngospasm
5. Encourage to breath with paper bag in order to produce mild respiratory acidosis to promote increase ionized Ca levels
6. Most Ieared complication : Seizure & arrhythmia
8. Important Iallow up care
HYPERPARATHYROIDISM - increase parathormone. Complication: Renal Iailure
Hypercalcemia can lead to Hypophosphatemia
Bone dse - kidney stones
Mineralization
Leading to bone Iracture
Ca 99 bones
1 serum blood
1. Hyperplasia parathyroid gland (PTG)
2. Over compensation oI PTG due to Vit D deIiciency
Children Rickets Vit D
Adults Osteomalacia deIiciency
Sippy`s diet Vit D diet not good Ior pt with ulcer
2 -4 cups oI milk & butter
Karrel`s diet Vit D diet not good Ior pt with ulcer
6 cups oI milk & whole cream
Food rich in CHON eggnog combination oI egg & milk
S/Sx:
Bone Iracture
1. Bone pain (especially at back), bone Iracture
29
2. Kidney stone
a. Renal colic
b. Cool moist skin
3. GIT changes anorexia, n/v, ulcerations
4. CNS involvement irritability, memory impairment
Dx Proc:
1. Serum Ca increase
2. Serum phosphorus decreases
3. X-ray long bones reveals bone demineralization
Nsg Mgt: Kidney Stone
1. Force Iluids 2,000 3,000/day or 2-3L/day
2. Isotonic solution
3. Warm sitz bath Ior comIort
4. Strain all urine with gauze pad
5. Acid ash diet cranberry, plum, grapeIruit, vit C, calamansi to acidiIy urine
6. Adm meds
a. Narcotic analgesic Morphine SO4, Demerol (Meperidine Hcl)
S/E resp depression. Monitor RR)
Narcan/ Naloxone antidote
Naloxone toxicity tremors
7. Siderails
8. Assist in ambulation
9. Diet low in Ca, increase phosphorus lean meat
10. Prevent complication
Most Ieared renal Iailure
11. Assist surgical procedure parathyroidectomy
12. Impt II up care
13. Hormonal replacement- liIetime
ADRENAL GLAND
12. Atop oI kidney
13. 2 parts
Adrenal cortex outermost layer
Adrenal medulla - innermost layer
14. Secrets cathecolamines
a.) Epinephrine / Norephinephrine potent vasoconstrictor adrenalineIncrease BP
Adrenal Medulla`s only disease:
PHEOCHROMOCYTOMA- presence oI tumor at adrenal medulla
-increase nor/epinephrine
-with HPN and resistant to drugs
-drug oI choice: beta blockers
-complication: HPN crisis lead to stroke
-no valsalva maneuver
Adrenal Cortex
1. Zona Iasiculata secrets glucocorticoids
Ex. Cortisol - Controls glucose metabolism (SUGAR)
2. Zona reticularis secrets traces oI glucocorticoids & androgenic hormones
M testosterone
F estrogen & progesterone
30
Fx promotes development oI secondary sexual characteristics
3. Zona glomerulosa - secretes mineralcortisone
Ex. Aldosterone
Fx: promotes Na & H2O reabsorption & excretion oI potassium (SALT)
ADDISON`S DISEASE Steroids-liIetime
Decreased adrenocortical hormones leading to:
a.) Metabolic disturbances (sugar)
b.) F&E imbalances- Na, H2O, K
c.) DeIiciency oI neuromuscular Iunction (salt & sex)
1. Atrophy oI adrenal gland
2. Fungal inIections
3. Tubercular inIections
S/Sx:
1. Decrease sugar Hypoglycemia Decreased glucocorticoids - cortisol
T tremors, tachycardia
I - irritability
R - restlessness
E extreme Iatigue
D diaphoresis, depression
2. Decrease plasma cortisol
Decrease tolerance to stress lead to Addisonian`s crisis
3. Decrease salt Hyponatermia Decreased mineralocorticoids - Aldosterone
Hypovolemia
a.) Hypotension
b.) Signs oI dehydration extreme thirst, agitation
c.) Wt loss
4. Hyperkalemia
a.) Irritability
b.) Diarrhea
c.) Arrhythmia
5. Decrease sexual urge or libido- Decreased Androgen
6. Loss oI pubic and axillary hair
To Prevent STD Local practice monogamous relationship
CGFNS/NCLEX condom
7. Pathognomonic sign bronze like skin pigmentation due to decrease cortisol will stimulate pituitary gland to release
melanocyte stimulating hormone.
Dx Proc:
1. FBS decrease FBS (N 80 120 mg/dL)
2. Plasma cortisol decreased
Serum Na decreased (N 135 145 meg/L)
3. Serum K increased (N 3.5 5.5 meg/L)
Nsg Mgt:
1. Monitor VS, I&O to determine presence oI Addisonian crisis
15. Complication oI Addison`s dse : Addisonian crisis
16. Results the acute exacerbation oI Addison`s dse characterized by :
Hypotension, hypovolemia, hyponatremia, wt loss, arrhythmia
31
17. Lead to progressive stupor & coma
Nsg Mgt Addisonian Crisis (Coma)
1. Assist in mechanical ventilation
2. Adm steroids
3. Force Iluids
2. Administer meds
a.) Corticosteroids - (Decadron) or Dexamethazone
- Hydrocortisone (cortisone)- Prednisone
Nsg Mgt with Steroids
1. Adm 2/3 dose in AM & 1/3 dose in PM in order to mimic the normal diurnal rhythm.
2. Taper the dose (w/draw, gradually Irom drug) sudden withdrawal can lead to addisonian crisis
3. Monitor S/E (Cushing`s syndrome S/Sx)
a.) HPN
b.) Hirsutism
c.) Edema
d.) Moon Iace & buIIalo hump
e.) Increase susceptibility to inIection sue to steroids- reverse isolation
b.) Mineralocorticoids ex. Flourocortisone
3. Diet increase calorie or CHO
Increase Na, Increase CHON, Decrease K
4. Force Iluid
5. Administer isotonic Iluid as ordered
6. Meticulous skin care due to bronze like
7. HT & discharge planning
a) Avoid precipitating Iactors leading to Addisonian crisis
1. Sudden withdrawal crisis
2. Stress
3. InIection
b) Prevent complications
Addisonian crisis & Hypovolemic shock
8. Hormonal replacement therapy liIetime
9. Important: Iollow up care
CUSHING`S SYNDROME increase secretion oI adrenocortical hormone
1. Hyperplasia oI adrenal gland
2. Tubercular inIection milliary TB
S/Sx
1. Increase sugar Hyperglycemia
3 P`s
1. Polyuria
2. Polydipsia increase thirst
3. Polyphagia increase appetite
Classic Sx oI DM 3 P`s & glycosuria wt loss
2. Increase susceptibility to inIection due to increased corticosteroid
3. Hypernatrermia
a. HPN
b. Edema
c. Wt gain
d. Moon Iace
BuIIalo hump
32
Obese trunk classic signs
Pendulous abdomen
Thin extremities
4. Hypokalemia
a. Weakness & Iatigue
b. Constipation
c. ECG () 'U wave
5. Hirsutism increase sex
6. Acne & striae
7. Increase muscularity oI Iemale
Dx:
1. FBS increase (N: 80-120mg/dL)
2. Plasma cortisol increase
3. Na increase (135-145 meq/L)
4. K- decrease (3.5-5.5 meq/L)
Nsg Mgt:
1. Monitor VS, I&O
2. Administer meds
a. K- sparing diuretics (Aldactone) Spironolactone
- promotes excretion oI NA while conserving potassium
Not lasix due to S/E hypoK & Hyperglycemia!
3. Restrict Na
4. Provide Dietary intake low in CHO, low in Na & Iats
High in CHON & K
5. Weigh pt daily & assess presence oI edema- measure abdominal girth- notiIy doc.
6. Reverse isolation
7. Skin care due acne & striae
8. Prevent complication
- Most Ieared arrhythmia & DM
(Endocrine disorder lead to MI Hypothyroidism & DM)
9. Surgical bilateral Adrenolectomy
10. Hormonal replacement therapy liIetime due to adrenal gland removal- no more corticosteroid!
PANCREAS behind the stomach, mixed gland both endocrine and exocrine gland
Acinar cells (exocrine gland) Islets oI Langerhans (endocrine gland ductless)
Secrete pancreatic juices at pancreatic ducts. " cells
Aids in digestion (in stomach) secrets glucagon
Fxn: hyperglycemia (high glucose)
! Cells
Secrets insulin
Fxn: hypoglycemia
Delta Cells
33
Secrets somatostatin
Fxn: antagonizes growth hormone
3 disorders oI the Pancreas
1. DM
2. Pancreatic Cancer
3. Pancreatitis
Overview only:
PANCREATITIS (check page 72) acute inIlammation oI pancreas leading to pancreatic edema, hemorrhage & necrosis due to
Autodigestion selI-digestion
Cause: unknown/idiopathic
18. Or alcoholism
Pathognomonic sign- () Cullen`s sign - Ecchymosis oI umbilicus (bluish color)- pasa
() Grey turner`s sign ecchymosis oI Ilank area
Both sx means hemorrhage
CHRONIC HEMORRHAGIC PANCREATITIS- 'bangugot
Predisposing Iactors - unknown
Risk Iactor:
1. History oI hepatobiliary disorder
2. Alcohol
3. Drugs thiazide diuretics, oral contraceptives, aspirin, penthan
4. Obesity
5. Hyperlipidemia
6. Hyperthyroidism
7. High intake oI Iatty Iood saturated Iats
DIABETES MELLITUS - metabolic disorder characterized by non utilization oI CHO, CHON,& Iat metabolism
ClassiIication:
I. Type I DM (IDDM) 'Juvenile ' onset, common in children, non-obese 'brittle dse
-Insulin dependent diabetes mellitus
Incidence rate
1.) 10 oI population with DM have Type I
Predisposing Factor:
1. 90 hereditary total destruction oI pancreatic dells
2. Virus
3. Toxicity to carbon tetrachloride
4. Drugs Steroids both cause hyperglycemia
Lasix - loop diuretics
S/Sx:
3 P`S G
1.) Polyuria
2.) Poydipsia
3.) Polyphagia
4.) Glycosuria
5.) Weight loss
34
6.) Anorexia
7.) N/V
8.) Blurring oI vision
9.) Increase susceptibility to inIection
10.) Delayed/ poor wound healing
Mgt:
1. Insulin Therapy
Diet
Exercise
Complications Diabetic Ketoacidosis (DKA)
Diabetic Ketoacidosis (DKA) due to increase Iat catabolism or breakdown oI Iats
DKA () Iruity or acetone breath odor
Kassmaul`s respiration rapid, shallow breathing
Diabetic coma (needs oxygen)
II. Type II DM - (NIDDM)
Adult/ maturity onset type age 40 & above, obese
Incidence Rate
1. 90 oI pop with DM have Type II
Mid 1980`s marked increase in type II because oI increase proliIeration oI Iast Iood chains!
1. Obesity obese people lack insulin receptors binding site
2. Hereditary
S/Sx:
1. Asymptomatic
2. 3 P`s and 1G
Tx:
1. Oral Hypoglycemic Agents (OHA)
2. Diet
3. Exercise
Complication: HONKC
H hyper
O osmolar
N non
K ketotic
C coma
III. GESTATIONAL DM occurs during pregnancy & terminates upon delivery oI child
1. Unknown/ idiopathic
2. InIluence oI maternal hormones
S/Sx :
Same as type II
1. Asymptomatic
2. 3 P`s & 1G
Type oI delivery CS due to large baby
Sx oI hypoglycemia on inIant
1. High pitched shrill cry
35
2. Poor sucking reIlex
IV. DM ASSOCIATED WITH OTHER DISORDER
a.) Pancreatic tumor
b.) Cancer
c.) Cushing`s syndrome
3 MAIN FOOD GROUPS
Anabolism Catabolism
1. CHON glucose glycogen
2. CHON amino acids nitrogen
3. Fats Iatty acids Iree Iatty acids (FFA) Cholesterol & Ketones
Pancreas glucose ATP (Main Iuel/energy oI cell )
Reserve glucose glycogen
Liver will undergo glucogenesis synthesis oI glucagons
& Glycogenolysis breakdown oI glucagons
& Gluconeogenesis Iormation oI glucose Iorm CHO sources CHON & Iats
Hyperglycemia pancreas will not release insulin. Glucose can`t go to cell, stays at circulation causing hyperglycemia.
increase osmotic diuresis glycosuria
Lead to cellular starvation
Lead to wt loss stimulates the appetite/ satiety center polyuria
(Hypothalamus)
Cellular dehydration
Polyphagia
Stimulates thirst center (hypothalamus)
Polydipsia
Increased CHON catabolism
Lead to (-) nitrogen balance
Tissue wasting (cachexia)
Increase Iat catabolism
Free Iatty acids
Cholesterol ketones DKA
Atherosclerosis coma
HPN death
MI stroke
DIABETIC KETOACIDOSIS (DKA)
- Acute complication oI Type I DM due to severe hyperglycemia leading to CNS depression & Coma.
- Ketones- a CNS depressant
36
1. Stress between stress and inIection, stress causes DKA more.
2. Hyperglycemia
3. InIection
S/Sx: 3 P`s & 1G
1. Polyuria
2. Polydipsia
3. Polyphagia
4. Glycosuria
5. Wt loss
6. Anorexia, N/V
7. () Acetone breath odor- Iruity odor pathognomonic DKA
8. Kussmaul's resp-rapid shallow respiration
9. CNS depression
10. Coma
Dx Proc:
1. FBS increase, Hct increase (compensate due to dehydration)
N BUN 10 -20 mg/100ml --increased due to severe dehydration
Crea - .8 1 mg/100ml

Hct 42 (should be 3x high)-nto hgb
Nsg Mgt:
1. Can lead to coma assist mechanical ventilation
2. Administer .9NaCl isotonic solution
Followed by .45NaCl hypotonic solution
To counteract dehydration.
3. Monitor VS, I&O, blood sugar levels
4. Administer meds as ordered:
a.) Insulin therapy IV push
Regular Acting Insulin clear (2-4hrs, peak action)
b.) To counteract acidosis Na HCO3
c.) Antibiotic to prevent inIection
Insulin Therapy
A. Sources:
1. Animal source beeI/ pork-rarely used. Causes severe allergic reaction.
2. Human has less antigenecity property
Cause less allergic reaction. Humulin
II kid is allergic to chicken don`t give measles vaccine due it comes Irom chicken embryo.
3. ArtiIicially compound
B. Types oI Insulin
1. Rapid Acting Insulin - Ex. Regular acting I
2. Intermediate acting I - Ex. NPH (non-protamine Hagedorn I)
3. Long acting I - Ex. Ultra lente
Types of Insulin color & consistency onset peak duration
1. Rapid clear - 2-4h -
2. Intermediate cloudy - 6-12h -
3. Long acting cloudy - 12-24h -
Ex. 5am Hemoglucose test (HGT)
250 mg/dl
Adm 5 units oI RA I
37
Peak 7-9am monitor hypoglycemic reaction at this time- TIRED
Nsg Mgt: upon injection oI insulin:
1.Administer insulin at room temp! To prevent lipodystrophy atrophy/ hypertrophy oI SQ tissues
2. Insulin is only reIrigerated once opened!
3. Gently roll vial bet palms. Avoid shaking to prevent Iormation oI bubbles.
4. Use gauge 25 26needle tuberculin syringe
5. Administer insulin at either 45(Ior skinny pt) or 90 (taba pt)depending on the client tissue deposit.
6. Don`t aspirate aIter injection
7. Rotate injection site to prevent lipodystrophy
8. Most accessible site abdomen
9. When mixing 2 types oI insulin, aspirate
1
st
regular/ clear beIore cloudy to prevent contaminating clear insulin & to promote accurate calibration.
10. Monitor signs oI complications:
a. Allergic reactions lipodystrophy
b. Somogyi`s phenomenon hypoglycemia Iollowed by periods oI hyperglycemia or rebound eIIect oI insulin.
11. 1ml or cc oI tuberculin 100 units oI insulin
- - 1 cc 100 units

- - .5cc 50 units
- - .1 cc 10 units

6 units RA
Most Feared Complication oI Type II DM
Hyper osmolarity severe dehydration
Osmolar
Non - absence oI lipolysis
Ketotic - no ketone Iormation
Coma S/Sx: headache, restlessness, seizure, decrease LOC coma
Nsg Mgt; - same as DKA except don`t give NaHCO3!
1.Can lead to coma assist mechanical ventilation
2. Administer .9NaCl isotonic solution
Followed by .45NaCl hypotonic solution
To counteract dehydration.
3.Monitor VS, I&O, blood sugar levels
4.Administer meds
a.) Insulin therapy IV
b.) Antibiotic to prevent inIection
Tx:
O ral
H ypoglycemic
A gents
19. Stimulates pancreas to secrete insulin
ClassiIications oI OHA
1. First generation SulIonylurear
a. Chlorpropamide (diabenase)
b. Tolbutamide (orinase)
c. Tolazamide (tolinase)
38
2. 2
nd
generation sulIonylurear
a. Diabeta (Micronase)
b. Glipside (Glucotrol)
Nsg Mgt or OHA
1. Administer with meals to lessen GIT irritation & prevent hypoglycemia
2. Avoid alcohol (alcohol OHA severe hypoglycemic reactionCNS depressioncoma) Antabuse-DisuIram
Dx Ior DM
1. FBS N 80 120 mg/dl Increased Ior 3 consecutive times conIirms DM!!
3 P`s & 1G
2. Oral glucose tolerance (OGTT) - Most sensitive test
3. Random blood sugar increased
4. Alpha Glucosylated Hgb elevated
Nsg Mgt;
1. Monitor Ior PEAK action oI OHA & insulin
NotiIy Doc
2. Monitor VS, I&O, neurocheck, blood sugar levels.
3. Administer insulin & OHA therapy as ordered.
4. Monitor signs oI hyper & hypoglycemia.
Pt DM ' hinimatay
20. You don`t know iI hypo or hyperglycemia.
Give simple sugar
(Brain can tolerate high sugar, but brain can`t tolerate low sugar!)
Cold, clammy skin hypo Orange Juice or simple sugar / warm to touch hyper adm insulin
5. Provide nutritional intake oI diabetic diet:
CHO 50
CHON 30
Fats 20
-Or oIIer alternative Iood products or beverage.
-Glass oI orange juice.
6. Exercise aIter meals when blood glucose is rising.
7. Monitor complications oI DM
a. Atherosclerosis HPN, MI, CVA
b. Microangiopathy small blood vessels
Eyes diabetic retinopathy , premature cataract & blindness
Kidneys recurrent pyelonephritis & Renal Failure
(2 common causes oI Renal Failure : DM & HPN)
c. Gangrene Iormation
d. Peripheral neuropathy
1. Diarrhea/ constipation
2. Sexual impotence
e. Shock due to cellular dehydration
8. Foot care mgt
a. Avoid waking bareIooted
b. Cut toe nails straight
c. Apply lanolin lotion prevent skin breakdown
d. Avoid wearing constrictive garments
9. Annual eye & kidney exam
10. Monitor urinalysis Ior presence oI ketones
Blood or serum more accurate
11. Assist in surgical wound debridement
12. Monitor signs or DKA & HONKC
13. Assist surgical procedure
39
BKA or above knee amputation
Overview: HEMATOLOGICAL SYSTEMS
I Blood
II Blood vessels
III Blood Iorming organs
1. Thymus removed myasthenia gravis
2. Liver largest gland
3. Lymph nodes
4. Lymphoid organs payers patch
5. Bone marrow
6. Spleen destroys RBC
Blood vessels
1. Veins SVC, IVC, Jugular vein blood towards the heart
2. Artery carries blood away Irom the
21. Aorta, carotid
3. Capillaries
Blood 45 Iormed elements 55 plasma Iluid portion oI vlood. Yellow color.
Serum Plasma CHON`s (Produced in Liver)
1. Albumin- largest, most abundant plasma
Maintains osmotic pressure preventing edema
FXN: promotes skin integrity
2. Globulins alpha transports steroids Hormones & bilirubin
! - Transports iron & copper
Gamma transport immunoglobulins or antibodies
3. Prothrombin Iibrinogen clotting Iactor to prevent bleeding
Formed Elements:
1. RBC (erythrocytes) Spleen liIe span 120 days
(N) 3 6 M/mm3
- Anucleated
- Biconcave discs
- Has molecules oI Hgb (red cell pigment)
Transports & carries O2
SICKLE CELL ANEMIA sickle shaped RBC. Should be round. Impaired circulation oI RBC.
-immature cellshemolysis oI RBCdecreased hgb
3 Nsg priority
1. a/w avoid deoxygenating activities
- High altitude is bad
2. Fluid deIicit promote hydration
3. Pain & comIort
Hgb ( hemoglobin)
F 12 14 gms
M 14-16 gms
Hct 3x hgb 12 x 3 36
(hamatocrit) F 36 42 14 x 3 42
M 42 48
Average 42
- Red cell percentage in whole red
40
Substances needed Ior maturation oI RBC
a.) Folic acid
b.) Iron
c.) Vit C
d.) Vit B12 (cyanocobalamin)
e.) Vit B6 (Pyridoxine)
I.) Intrinsic Iactor
Pregnant: 1
st
trimester- Folic acid prevent neural tube deIicit
3
rd
tri iron
LiIe span oI rbc 80 120 days. Destroyed at spleen.
WBC leucocytes 5,000 10,000/mm3
GRANULOCYTES
1. Polymorphonuclearneutrophils
Most abundant 60-70 WBC
- Ix short term phagocytosis
For acute inIlammation
2. PM Basophils
-Involved in Parasitic inIection
- Release oI chem. Mediator Ior inIlammation
Serotonin, histamine, prostaglandin,
bradykinins
3. PM eosinophils
- Allergic reactions
NON-GRANULOCYTES
1. Monocytes (macrophage) - largest WBC
- involved in long term phagocytes
- For chronic inIlammation
- Other name macrophage
Macrophage in CNS- microglia
Macrophage in skin Histiocytes
Macrophage in lungs alveolar macrophage
Macrophage in Kidneys KupIIer cells
2. Lymphocytes
B Cell L bone marrow or bursa dependent
T cell dev`t oI immunity- target site Ior HIV
NK cell natural killer cell
Have both antiviral & anti-tumor properties
3.Platelets (thrombocytes)
N- 150,000 450, 000/ mm3
it promotes hemostasis prevention oI blood loss by activating clotting
- Consists oI immature or baby platelets known as megakaryocytes target oI virus
dengue
- Normal liIespan 9 12 days
Drug oI choice Ior HIV Zidovudine (AZT or Retrovir)
Standard precaution Ior HIV gloves, gown, goggles & mask
Malaria night biting mosquito
Dengue day biting mosquito
Signs oI platelet dis Iunction:
a.) Petecchiae
b.) Ecchemosis/ bruises
c.) Oozing or blood Irom venipuncture site
ANEMIA
Iron deIiciency Anemia chronic normocytic, hypocromic (pale), microcytic anemia due to inadequate absorption oI iron leading to
hypoxemic injury.
Incidence rate:
1. Common developed country due to high cereal intake
Due to accidents common on adults
2. Common tropical countries blood sucking parasites
3. Women 15 35yo reproductive yrs
4. Common among the poor poor nutritional intake
41
Suicide - common in teenager
Poisoning common in children (aspirin)
Aspiration common in inIant
Accidents common in adults
Choking common in toddler
SIDS common in inIant in US
22. Common in tropical zone Phil due blood sucks
1. Chronic blood loss
a. Trauma
b. Mens
c. GIT bleeding:
i. Hematemesis-
ii. Melena upper GIT duodenal cancer
iii. Hematochezia lower GIT large intestine Iresh blood Irom rectum
2. Inadequate intake oI Iood rich in iron
3. Inadequate absorption oI iron due to :
a. Chronic diarrhea
b. Malabsorption syndrome celiac disease-gluten Iree diet. Food Ior celiac pts- sardines
c. High cereal intake with low animal CHON ingestion
d. Subtotal gastrectomy
4. Improper cooking oI Iood
S/Sx:
1. Asymptomatic
2. Headache, dizziness, dyspnea, palpitations, cold sensitivity, gen body malaise, pallor
3. Brittle hair, spoon shaped nails (KOILONYCHIA)Dec O2hypoxiaatrophy oI epidermal cells
4. Atropic glossitis, dysphagia, stomatitis
5. Pica abnormal craving Ior non edible Iood (caused by hypoxiadec tissue perIusionpsychotic behavior)
Brittle hair, spoon shaped nail atrophy oI epidermal cells
N capillary reIill time 2 secs
N shape nails biconcave shape, 180
Atrophy oI cells 'Plummer Vinsons Syndrome due to cerebral hypoxia
1. Atropic glossiti inIlammation oI tongue due to atrophy oI pharyngeal and tongue cells
2. Stomatitis mouth sores
3. Dysphagia
Dx Proc:
1. RBC
2. Hgb
3. Reticulocyte
4. Hct
5. Iron
6. Ferritin
Nsg Mgt
1. Monitor signs oI bleeding oI all hema test including urine & stool
2. Complete bed rest don`t overtire pt weakness and Iatigueactivity intolerance
3. Encourage iron rich Iood
23. Raisins, legumes, egg yolk
4. Instruct the pt to avoid taking tea - impairs iron absorption
5. Administer meds
a.) Oral iron preparation
Ferrous SO4
Fe gluconate
Fe Fumarate
Nsg Mgt oral iron meds:
42
1. Administer with meals to lessen GIT irritation
2. II diluting in iron liquid prep adm with straw
Straw
1. Lugol`s
2. Tetracycline
3. Oral iron
4. Macrodantine
3. Give Orange juice Ior iron absorption
4. Monitor & inIorm pts S/E
a. Anorexia
b. n/v
c. Abdominal pain
d. Diarrhea or constipation
e. Melena
II pt can`t tolerate oral iron prep administer parenteral iron prep example:
1. Iron dextran (IV, IM)
2. Sorbitex (IM)
Nsg Mgt parenteral iron prep
1. Administer oI use Z tract method to prevent discomIort, discoloration leakage to tissues.
2. Don`t massage injection site. Ambulate to Iacilitate absorption.
3. Monitor S/E:
a.) Pain at injury site
b.) Localized abscess ('nana)
c.) Lymphadenopathy
d.) Fever/ chills
e.) Urticaria itchiness
I.) Hypotension anaphylactic shock
Anaphylactic shock give epinephrine
PERNICIOUS ANEMIA - megaloblastic, chronic anemia due to deIiciency oI intrinsic Iactor leading to
Hypochlorhydria decrease Hcl acid secretion. LiIetime B12 injections. With CNS involvement.
Predisposing Iactor
1. Subtotal gastrectomy removal stomach
2. Hereditary
3. InIl dse oI ileum
4. Autoimmune
5. Strict vegetable diet
STOMACH
Parietal or ergentaIIen Oxyntic cells
Fxn produce intrinsic Iactor Fxn secrets Hcl acid
For reabsorption oI B12 Fx aids in digestion
For maturation oI RBC
Diet high caloric or CHO to correct wt loss
S/Sx:
1. Headache dizziness, dyspnea, palpitations, cold sensitivity, gen body malaise, pallor
43
2. GIT changes
a. Red beeIy tongue PATHOGNOMONIC mouth sores
b. Dyspepsia indigestion
c. Wt loss
d. Jaundice
3. CNS
Most dangerous anemia: pernicious due to neuroglogic involvement.
a. Tingling sensation
b. Paresthesia
c. () Romberg`s test
Ataxia
d. Psychosis
Dx:- Shilling`s test
Nsg Mgt Pernicious anemia
1. EnIorce CBR
2. Administer B12 injections at monthly intervals Ior liIetime as ordered. IM- dorsogluteal or ventrogluteal. Not given oral
due pt might have tolerance to drug
3. Diet high calorie or CHO. Increase CHON, iron & Vit C
4. Avoid irritating mouthwashes. Use oI soIt bristled toothbrush is encouraged.
5. Avoid applying electric heating pads can lead to burns
APLASTIC ANEMIA stem cell disorder due to bone marrow depression leading to pancytopenia all RBC are decreased
Decrease RBC decrease WBC decrease platelets
Anemia leukopenia thrombocytopenia
Increase WBC leukocytocys
Increase RBC polycythemia vera complication stroke, CVA, thrombosis
Predisposing Iactors leading to Aplastic Anemia
1. Chemicals Banzene & its derivatives
2. radiation
3. Immunologic injury
4. Drugs cause bone marrow depression
a. Broad spectrum antibiotic - Chlorampenicol
- SulIonamides bactrim
b. Chemo therapeutic agents
Methotrexate alkylating agents
Nitrogen mustard anti metabolic
Vincristine plant alkaloid
S/Sx:
1. Anemia:
a. Weakness & Iatigue
b. Headache, dizziness, dyspnea
c. cold sensitivity, pallor
d. palpitations
2. Leucopenia increase susceptibility to inIection
3. Thrombocytopenia
a. Peticchiae
b. Oozing oIblood Irom venipuncture site
c. ecchymosis
Dx:
1. CBC pancytopenia
2. Bone marrow biopsy/ aspiration at post iliac crest reveals Iatty streaks in bone marrow
Nsg Mgt:
1. Removal oI underlying cause
2. Blood transIusion as ordered
44
3. Complete bed rest
4. O2 inhalation
5. Reverse isolation due leukopenia
6. Monitor signs oI inIection
7. Avoid SQ, IM or any venipuncture site HEPLOCK
8. Use electric razor when shaving to prevent bleeding
9. Administer meds
Immunosuppresants
Anti lymphocyte globulin (Alg) given via central venous catheter, 6 days 3 weeks to achieve max therapeutic eIIect oI
drug.
BLOOD TRANSFUSION:
Objectives:
1. To replace circulating blood volume
2. To increase O2 carrying capacity oI blood
3. To combat inIection iI there`s decrease WBC
4. To prevent bleeding iI there`s platelet deIiciency
Nsg Mgt & principles in Blood Transfusion
1. Proper reIrigeration
2. Proper typing & crossmatching
Type O universal donor
AB universal recipient
85 oI people is RH ()
3. Asceptically assemble all materials needed:
a.) Filter set
b.) Isotonic or PNSS or .9NaCl to prevent Hemolysis
Hypotonic sol swell or burst
Hypertonic sol will shrink or crenate
c.) Needle gauge 18 - 19 or large bore needle to prevent hemolysis.
d.) Instruct another RN to recheck the Iollowing .
Pts name, blood typing & cross typing expiration date, serial number.
e.) Check blood unit Ior presence oI bubbles, cloudiness, dark in color & sediments indicates bacterial contamination.
Don`t dispose. Return to blood bank.
I.) Never warm blood products may destroy vital Iactors in blood.
- Warming is done iI with warming device only in EMERGENCY! For multiple BT.
- Within 30 mins room temp only!
g.) Blood transIusion should be completed < 4hrs because blood that is exposed at room temp Ior ~ 2h causes blood
deterioration.
h.) Avoid mixing or administering drug at BT line leads to hemolysis
i.) Regulate BT 10 15 gtts/min KVO or 100cc/hr to prevent circulatory overload
j.) Monitor VS beIore, during & aIter BT especially q15 mins(local board) Ior 1st hour. NCLEX-q5min Ior 1
st
15min.
- Majority oI BT reaction occurs within 1h.
BT reactions S/Sx Hemolytic reaction:
H hemolytic Reaction 1. Headache, dizziness, dyspnea, palpitation, lumbar/ sterna/ Ilank pain,
A allergic Reaction hypotension, Ilushed skin , (red) port wine urine.
P pyrogenic Reaction
C circulatory overload
A air embolism
T - thrombocytopenia
C citrate intoxication expired blood hyperkalemia
H hyperkalemia
Nsg Mgt: Hemolytic Reaction:
1. Stop BT
45
2. NotiIy Doc
3. Flush with plain NSS
4. Administer isotonic Iluid sol to prevent acute tubular necrosis & conteract shock
5. Send blood unit to blood bank Ior reexamination
6. Obtain urine & blood samples oI pt & send to lab Ior reexamination
7. Monitor VS & Allergic Rxn
Allergic Reaction:
S/Sx
1. Fever/ chills
2. Urticaria/ pruritus
3. Dyspnea
4. Laryngospasm/ bronchospasm
5. Bronchial wheezing
Nsg Mgt:
1. Stop BT
2. NotiIy Doc
3. Flush with PNSS
4. Administer antihistamine diphenhydramine Hcl (Benadryl). Give bedtime.SE-Adult-drowsiness. Child-hyperactive
II () Hypotension anaphylactic shock administer epinephrine
5. Send blood unit to blood bank
6. Obtain urine & blood samples send to lab
7. Monitor VS & IO
8. Adm. Antihistamine as ordered Ior AllergicRxn, iI () to hypotension indicates anaphylactic shock
24. administer epinephrine
9. Adm antipyretic & antibiotic Ior pyrogenic Rxn & TSB
Pyrogenic Reaction:
S/Sx
a.) Fever/ chills d. tachycardia
b.) Headache e. palpitations
c.) Dyspnea I. diaphoresis
Nsg Mgt:
1. Stop BT
2. NotiIy Doc
3. Flush with PNSS
4. Administer antipyretics, antibiotics
5. Send blood unit to blood bank
6. Obtain urine & blood samples send to lab
7. Monitor VS & IO
8. Tepid sponge bath oIIer hypothermic blanket
Circulatory Overload:
Sx
a. Dyspnea
b. Orthopnea
c. Rales or crackles
d. Exertional discomIort
Nsg Mgt:
1. Stop BT
2. NotiIy Doc. Don`t Ilush due pt has circulatory overload.
3. Administer diuretics
Priority cases:
Hemolytic Rxn 1
st
due to hypotension 1
st
priority attend to destruction oI Hgb O2 brain damage
46
Allergic 3
rd
Pyrogenic 4
th
Circulatory 2
nd

Hemolytic 2
nd
Anaphylitic 1
st priority
DIC - DISSEMINATED INTRAVASCULAR COAGULATION
25. Acute hemorrhagic syndrome char by wide spread bleeding & thrombosis due to a deI oI clotting Iactors (Prothrombin &
Fibrinogen).
1. Rapid BT
2. Massive trauma
3. Massive burns
4. Septicemia
5. Hemolytic reaction
6. Anaphylaxis
7. Neoplasia growth oI new tissue
8. Pregnancy
S/Sx
1. Petechiae widespread & systemic (lungs, lower & upper trunk)
2. Ecchymosis widespread
3. Oozing oI blood Irom venipunctured site
4. Hemoptysis cough blood
5. Hemorrhage
6. Oliguria late sx
Dx Proc
1. CBC reveals decrease platelets
2. Stool Ior occult blood ()
Specimen stool
3. Opthalmoscopic exam sub retinal hemorrhage
4. ABG analysis metabolic acidosis
pH HCO3
R pH PCO2 respiratory alkalosis
O ph PCO2 respiratory acidosis
M ph HCO3 metabolic alkalosis
E ph HCO3 metabolic acidosis
Diarrhea met acidosis
Vomitting met alk
Pyloric stenosis met alkalosis vomiting
Ileostomy or intestinal tubing met acidosis
Cushing`s met alk
DM met acid
Chronic bronchitis resp acid with hypoxemia, cyanosis
Nsg Mgt DIC
1. Monitor signs oI bleeding hema test urine, stool, GIT
2. Administer isotonic Iluid solution to prevent shock.
3. Administer O2 inhalation
4. Administer meds
47
a. Vit K aquamephyton
b. Pitressin or vasopressin to conserve water.
5. NGT lavage
- Use iced saline lavage
6. Monitor NGT output
7. Provide heplock
8. Prevent complication: hypovolemic shock
Late signs oI hypovolemic shock : anuria
Oncologic Nsg:
Oncology study oI neoplasia new growth
Benign (tumor) Malignancy (cancer)
DiII - well diIIerentiated poorly or undiIIerentiated
Encapulation () (-)
Metastasis (-) ()
Prognosis good poor
Therapeutic modality surgery 1. Chemotherapy plenty S/E
2. Radiation
3. Surgery most preIerred treatment
4. Bone marrow transplant - Leukemia only
Predisposing factors: (carcinogenesis)
G genetic Iactors
I immunologic Iactors
V viral Iactors
a. Human papiloma virus causing warts
b. Epstein barr virus
E environmental Factors 90
a. Physical irradiation, UV rays, nuclear explosion, chronic irritation, direct trauma
b. Chemical Iactors
- Food additives (nitrates
- Hydrocarbon vesicants, alkalies
- Drugs (stillbestrol)
- Uraehane
- Hormones
- Smoking
Male
3.) Prostate cancer - common 40 & above (middle age & above)
BPH 50 & above
1.) Lung cancer
2.) Liver cancer
Female
1. Breast cancer 40 yrs old & up mammography 15 20 mins (SBE 7 days aIter mens)
2. Cervical cancer 90 multi sexual partners
5 early pregnancy
3. Ovarian cancer
Classes of cancer
Tissue typing
1. Carcinoma arises Irom surIace epithelium & glandular tissues
2. Sarcoma- Irom connective tissue or bones
3. Multiple myeloma Irom bone marrow
Pathological Iracture oI ribs & back pain
4. Lymphoma Irom lymph glands
5. Leukemia Irom blood
Warning / Danger Sx of CA
C change in bowel /bladder habits
48
A a sore that doesn`t heal
U unusual bleeding/ Discharge
T thickening oI lump breast or elsewhere
I indigestion? Dysphagia
O obvious change in wart/ mole
N nagging cough/ hoarseness
U unexplained anemia A - anemia
S sudden wt loss L loss oI wt
Therapeutic Modality:
1. Chemotherapy use various chemotherapeutic agents that kills cancer cells & kills normal rapidly producing cells GIT,
bone marrow, and hair Iollicle.
ClassiIication:
a.) Alkylating agents
b.) Plant alkaloids vincristine
c.) Anti metabolites nitrogen mustard
d.) Hormones DES
Steroids
e.) Antineoplastic antibiotics
S/E & mgt
GIT - -Nausea & vomiting
Nsg Mgt:
1. Administer anti emetic 4 6h beIore start oI chemo
Plasil
2. Withhold Iood/ Iluid beIore start oI chemo
3. Provide bland diet post chemo
26. Non irritating / non spicy
- Diarrhea
1. Administer anti diarrheal 4 6h beIore start oI chemo
2. Monitor urine, I&O qh
- Stomatitis/ mouth sores
1. Oral care oIIer ice chips/ popsickles
2. InIorm pt hair loss temporary alopecia
Hair will grow back aIter 4 6 months post chemo.
-Bone marrow depression anemia
1. EnIorce CBR
2. O2 inhalation
4. Monitor signs oI bleeding
Repro organ sterility
1. Do sperm banking beIore start oI chemo
Renal system increase uric acid
1. Administer allopurinol/ xyloprin (gout)
27. Inhibits uric acid
28. Acute gout colchicines
29. Increase secretion oI uric acid
Neurological changes peristalsis paralytic ileus
Most Ieared complication II any abdominal surgery
Vincristine plant alkaloid causes peripheral neuropathy
2. Radiation therapy involves use oI ionizing radiation that kills cancer cells & inhibit their growth & kill N rapidly producing
cells.
Types oI energy emitted
1. Alpha rays rarely used doesn`t penetrate skin tissues
2. Beta rays internal radiation more penetration
3. Gamma ray external radiation penetrates deeper underlying tissues
49
Methods oI delivery
1. External radiation- involves electro magnetic waves
Ex. cobalt therapy
2. Internal radiation injection/ implantation oI radioisotopes proximal to CA site Ior a speciIic period oI time.
2 types:
a.) Sealed implant radioisotope with a container & doesn`t contaminate body Iluid.
b.) Unsealed implant radioisotope without a container & contaminates body Iluid.
Ex. Phosphorus 32
3 Factors aIIecting exposure:
A.) HalI liIe time period required Ior halI oI radioisotopes to decay.
- At end oI halI liIe less exposure
B.) Distance the Iarther the distance lesser exposure
C. ) Time the shorter the time, the lesser exposure
D.) Shielding rays can be shielded or blocked by using rubber gloves " & ! gamma use thick lead on concrete.
S/E & Mgt:
a.) Skin errythema, redness, sloughing
1. Assist in battling pt
2. Force Iluid 2,000 3,000 ml/day
3. Avoid lotion or talcum powder skin irritation
4. Apply cornstarch or olive oil
b.) GIT nausea / vomiting -
1. Administer antiemetic 4 6h beIore start oI chemo - Plasil
2 Withhold Iood/ Iluid beIore start oI chemo
3. Provide bland diet post chemo
Non irritating / non spicy
Dysglusia decrease taste sensitivity
-When atrophy papilla (taste buds) 40 yo
Stomatitis
c.) Bone marrow depression
1. EnIorce CBR
2. O2 inhalation
4. Monitor signs oI bleeding
Overview of function & structure of the heart
HEART
- Muscular, pumping organ oI the body
- LeIt mediastinum
- Weigh 300 400 grams
- Resembles a closed Iist
- Covered by serous membrane pericardium
Pericardium
Parietal layer Pericardial Visceral layer
Fluid prevent
Friction rub
Layer
1. Epicardium outermost
2. Myocardium inner responsible Ior pumping action/ most dangerous layer - cardiogenic shock
3. Endocardium innermost layer
Chambers
1. Upper collecting/ receiving chamber - Atria
2. Lower pumping/ contracting chamber - Ventricles
Valves
1. Atrioventricular valves - Tricuspid & mitral valve
50
Closure oI AV valves gives rise to 1
st
heart sound or S1 or 'lub
2. Semi lunar valve
a.) Pulmonic
b.) Aortic
Closure oI semilunar valve gives rise to 2
nd
heart sound or S2 or 'dub
Extra heart Sound
S3 ventricular Gallop CHF
S4 atrial gallop MI, HPN
Heart conduction system
1. Sino atrial node (SA node) (or Keith-Flock node)
Loc junction oI SVC & Rt atrium
Fx- primary pace maker oI heart
-Initiates electric impulse oI 60 100 bpm
2. Atrioventicular node (AV node or Tawara node)
Loc inter atrial septum
Delay oI electric impulse to allow ventricular Iilling
3. Bundle oI His location interventricular septum
Rt main Bundle Branch
Lt main Bundle Branch
4. Purkenjie Fiber
Loc- walls oI ventricles-- Ventricular contractions
SA node

Purkenjie Fibers
Bundle oI His
Complete heart block insertion oI pacemaker at Bundle Branch
Metal Pace Maker change q3 5 yo

Prolonged PR atrial Iib T wave inversion MI
ST segment depression angina widening QRS arrhythmia
ST elev MI
CAD coronary artery dse or Ischemic Heart Dse (IHD)
Atherosclerosis Myocrdial injury
Angina Pectoris Myocardial ischemia
MI- myocardial necrosis
ATHEROSCLEROSIS ARTEROSCLEROSIS
- Hardening or artery due to Iat/ lipid deposits at tunica
intima.
- Narrowing or artery due to calcium & CHON deposits at tunica
media.
Artery tunica adventitia outer
- Tunica intima innermost
- Tunica media middle
ATHEROSCLEROSIS
Predisposing Factor
1. Sex male
2. Black race
51
AV
3. Hyperlipidemia
4. Smoking
5. HPN
6. DM
7. Oral contraceptive- prolonged use
9. Obesity
10. Hypothyroidism
Signs & Symptoms
1. Chest pain
2. Dyspnea
3. Tachycardia
4. Palpitations
5. Diaphoresis
Treatment
P percutaneous
T tansluminar
C coronary
A angioplasty
Obj:
1. To revascularize the myocardium
2. To prevent angina
3. Increase survival rate
PTCA done to pt with single occluded vessel .
Multiple occluded vessels
C coronary
A arterial
B bypass
A and
G graIt surgery
Nsg Mgt BeIore CABAG
1. Deep breathing cough exercises
2. Use oI incentive spirometer
3. Leg exercises
ANGINA PECTORIS- A clinical syndrome characterized by paroxysmal chest pain usually relieved by REST or NGT
nitroglycerin, resulting Ir temp myocardial ischemia.
1. sex male
2. black raise
3. hyperlipidemia
4. smoking
5. HPN
6. DM
7. oral contraceptive prolonged
8. sedentary liIestyle
9. obesity
10.hypothyroidism
Precipitating Iactors
4 E`s
1. Excessive physical exertion
2. Exposure to cold environment - Vasoconstriction
3. Extreme emotional response
4. Excessive intake oI Iood saturated Iats.
Signs & Symptoms
52
1. Initial symptoms Levine`s sign hand clutching oI chest
2. Chest pain sharp, stabbing excruciating pain. Location substernal
-radiates back, shoulders, axilla, arms & jaw muscles
-relieve by rest or NGT
3. Dyspnea
4. Tachycardia
5. Palpitation
6.diaphoresis
Diagnosis
1.History taking & PE
2. ECG ST segment depression
3. Stress test treadmill abnormal ECG
4. Serum cholesterol & uric acid - increase.
Nursing Management
1.) EnIorce CBR
2.) Administer meds
NTG small doses venodilator
Large dose vasodilator
1
st
dose NTG give 3 5 min
2
nd
dose NTG 3 5 min
3
rd
& last dose 3 5 min
Still painIul aIter 3
rd
dose notiIy doc. MI!
55 yrs old with chest pain:
1
st
question to ask pt: what did you do beIore you had chest pain.
2
nd
question: does pain radiate? II radiate heart in nature. II not radiate pulmonary origin
Venodilator veins oI lower ext increase venous pooling lead to decrease venous return.
Meds:
A. NTG- Nsg Mgt:
1. Keep in a dry place. Avoid moisture & heat, may inactivate the drug.
2. Monitor S/E:
orthostatic hypotension dec bp
transient headache
dizziness
3. Rise slowly Irom sitting position
4. Assist in ambulation.
5. II giving NTG via patch:
i. avoid placing it near hairy areas-will dec drug absorption
ii. avoid rotating transdermal patches- will dec drug absorption
iii. avoid placing near microwave oven or during deIibrillation-will burn pt due aluminum Ioil in patch
B. Beta blockers propanolol
C. ACE inhibitors captopril
D. Ca antagonist - neIedipine
3.) Administer O2 inhalation
4.) Semi-Iowler
5.) Diet- Decrease Na and saturated Iats
6.) Monitor VS, I&O, ECG
7.) HT: Discharge planning:
a. Avoid precipitating Iactors 4 E`s
b. Prevent complications MI
c. Take meds beIore physical exertion-to achieve maximum therapeutic eIIect oI drug
d. Importance oI Iollow-up care.
MI - MYOCARDIAL INFARCTION hear attack terminal stage oI CAD
- Characterized by necrosis & scarring due to permanent mal-occlusion
53
Types:
1. Trasmural MI most dangerous MI Mal-occlusion oI both R&L coronary artery
2. Sub-endocardial MI mal-occlusion oI either R & L coronary artery
Most critical period upon dx oI MI 48 to 72h
- Majority oI pt suIIers Irom PVC premature ventricular contraction.
Predisposing Iactors Signs & symptoms Diagnostic Exam
1. sex male
2. black raise
3. hyperlipidemia
4. smoking
5. HPN
6. DM
7. oral contraceptive
prolonged
8. sedentary liIestyle
9. obesity
10. hypothyroidism
1. chest pain excruciating, vice like, visceral pain
located substernal or precodial area (rare)
- radiates back, arm, shoulders, axilla, jaw & abd
muscles.
- not usually relived by rest r NTG
2. dyspnea
3. erthermia
4. initial increase in BP
5. mild restlessness & apprehensions
6. occasional Iindings
a.) split S1 & S2
b.) pericardial Iriction rub
c.) rales /crackles
d.) S4 (atrial gallop)
1. cardiac enzymes
a.) CPK MB Creatinine
Phosphokinase
b.) LDH lactic acid dehydrogenase
c.) SGPT (ALT) Serum Glutanic
Pyruvate Transaminase- increased
d.) SGOT (AST) Serum Glutamic Oxalo-
acetic - increased
2. Troponin test increase
3. ECG tracing ST segment increase,
widening or QRS complexes means
arrhythmia in MI indicating PVC
4. serum cholesterol & uric acid - increase
5. CBC increase WBC
Nursing Management
1. Narcotic analgesics Morphine SO4 to induce vasodilation & decrease levels oI anxiety.
2. Administer O2 inhalation low inIlow (CHF-increase inIlow)
3. EnIorce CBR without BP
a.) Bedside commode
4. Avoid valsalva maneuver
5. Semi Iowler
6. General liquid to soIt diet decrease Na, saturated Iat, caIIeine
7. Monitor VS, I&O & ECG tracings
8. Take 20 30 ml/week wine, brandy/whisky to induce vasodilation.
9. Assist in surgical; CABAG
10. Provide pt HT
a.) Avoid modiIiable risk Iactors
b.) Prevent complications:
1. Arrhythmias PVC
2. Shock cardiogenic shock. Late signs oI cardiogenic shock in MI oliguria
3. thrombophlebitis - deep vein
4. CHF leIt sided
5. Dressler`s syndrome post MI syndrome
-Resistant to medications
-Administer 150,000 450,000 units oI streptokinase
c.) Strict compliance to meds
- Vasodilators
1. NTG
2. Isordil
- Antiarrythmic
1. Lydocaine blocks release oI norepenephrine
2. Brithylium
- Beta-blockers 'lol
1. Propanolol (inderal)
- ACE inhibitors - pril
54
1. Captopril (enalapril)
- Ca antagonist
1. NiIedipine
- Thrombolitics or Iibrinolytics to dissolve clots/ thrombus
S/E allergic reactions/ uticaria
1. Streptokinase
2. Urokinase
3. Tissue plasminogen adjusting Iactor
Monitor Ior bleeding:
- Anticoagulants
1. Heparin 2. Caumadin delayed reaction 2 3 days
PTT PT
II prolonged bleeding prolonged bleeding
Antidote antidote Vit K
Protamine sulIate
- Anti platelet PASA (aspirin)
d.) Resume ADL sex/ activity 4 to 6 weeks
Post-cardiac rehab
1.)Sex as an appetizer rather then dessert
BeIore meals not aIter, due aIter meals increase metabolism heart is pumping hard aIter meals.
2.) Position non-weight bearing position.
When to resume sex/ act: When pt can already use staircase, then he can resume sex.
e.) Diet decrease Na, Saturated Iats, and caIIeine
I.) Follow up care.
CHF - CONGESTIVE HEART FAILURE - Inability oI heart to pump blood towards systemic circulation.
- BackIlow
1.) Left sided heart failure:
1.) 90 mitral valve stenosis due RHD, aging
RHD aIIects mitral valve streptococcal inIection
Dx: - Aso titer anti streptolysine O ~ 300 total units
- Steroids
- Penicillin
- Aspirin
Complication: RS-CHF
Aging degeneration / calciIication oI mitral valve
Ischemic heart disease
HPN, MI, Aortic stenosis
S/Sx
Pulmonary congestion/ Edema
1. Dyspnea
2. Orthopnea (DiII oI breathing sitting pos platypnea)
3. Paroxysmal nocturnal dysnea PNO- nalulunod
4. Productive cough with blood tinged sputum
5. Frothy salivation (Irom lungs)
6. Cyanosis
7. Rales/ crackles due to Iluid
55
9. PMI displaced lateral due cardiomegaly
10. Pulsus alternons weak-strong pulse
11. Anorexia & general body malaise
12. S3 ventricular gallop
Dx
1. CXR cardiomegaly
2. PAP Pulmonary Arterial Pressure
PCWP Pulmonary CapillaryWedge Pressure
PAP measures pressure oI R ventricle. Indicates cardiac status.
PCWP measures end systolic/ diastolic pressure
PAP & PCWP:
Swan ganz catheterization cardiac catheterization is done at bedside at ICU
(Trachesostomy bedside) - Done 5 20 mins scalpel & trachesostomy set
CVP indicates Iluid or hydration status
Increase CVP decrease Ilow rate oI IV
Decrease CVP increase Ilow rate oI IV
3. Echocardiography reveals enlarged heart chamber or cardiomayopathy
4. ABG PCO2 increase, PO2 decrease hypoxemia resp acidosis
2.) Right sided HF

Predisposing Iactor
1. 90 - tricuspid stenosis
2. COPD
3. Pulmonary embolism
4. Pulmonic stenosis
5. LeIt sided heart Iailure
S/Sx
Venous congestion
- Neck or jugular vein distension
- Pitting edema
- Ascites
- Wt gain
- Hepatomegalo/ splenomegaly
- Jaundice
- Pruritus
- Esophageal varies
- Anorexia, gen body malaise
Diagnosis:
1. CXR cardiomegaly
2. CVP measures the pressure at R atrium
Normal: 4 to 10 cm oI water
Increase CVP ~ 10 hypervolemia
Decrease CVP 4 hypovolemia
Flat on bed post oI pt when giving CVP
Position during CVP insertion Trendelenburg to prevent pulmonary embolism & promote ventricular
Iilling.
3. Echocardiography enlarged heart chamber / cardiomyopathy
4.Liver enzyme
SGPT ( ALT)
SGOT AST
56
Nsg mgt: Increase Iorce oI myocardial contraction increase CO
3 6L oI CO
1. Administer meds:
Tx Ior LSHF: M morphine SO4 to induce vasodilatation
A aminophylline & decrease anxiety
D digitalis (digoxin)
D - diuretics
O - oxygen
G - gases
a.) Cardiac glycosides
Increase myocardial increase CO
Digoxin (Lanoxin). Antidote: digivine
Digitoxin: metabolizes in liver not in kidneys not given iI with kidney Iailure.
b.) Loop diuretics: Lasix eIIect with in 10-15 min. Max 6 hrs
c.) Bronchodilators: Aminophillin (Theophyllin). Avoid giving caIIeine
d.) Narcotic analgesic: Morphine SO4 - induce vasodilaton & decrease anxiety
e.) Vasodilators NTG
I.) Anti-arrythmics Lidocaine
2. Administer O2 inhalation high! 3 -4L/min via nasal cannula
3. High Iowlers
4. Restrict Na!
5. Provide meticulous skin care
6. Weigh pt daily. Assess Ior pitting edema.
Measure abdominal girth daily & notiIy MD
7. Monitor V/S, I&O, breath sounds
8. Institute bloodless phlebotomy. Rotating tourniquet or BP cuII rotated clockwise q 15 mins to promote decrease venous
return
9. Diet decrease salt, Iats & caIIeine
10. HT:
a) Complications :shock
Arrhythmia
Thrombophlebitis
MI
Cor Pulmonale RT ventricular hypertrophy
b.) Dietary modiIications
c.) Adherence to meds
PERIPHERAL MUSCULAR DISEASE
Arterial ulcers venous ulcer
1. Thromboangiitis Obliterans male/ Ieet 1. Varicose veins
2. Reynauds Iemale/ hands 2. Thrombophlebitis
1.) Thromboangiitis obliterates/ BUERGER DISEASE- Acute inIlammatory disorder aIIecting small to medium sized
arteries & veins oI lower extremities. Male/ Ieet
- Male
- Smokers
57
S/Sx
1. Intermittent claudication leg pain upon walking - Relieved by rest
2. Cold sensitivity & skin color changes
White bluish red
Pallor cyanosis rubor
3. Decrease or diminished peripheral pulses - Post tibial, Dorsalis pedis
4. Tropic changes
5. Ulcerations
6. Gangrene Iormation
Dx:
1. Oscillometry decrease peripheral pulse volume.
2. Doppler UTZ decrease blood Ilow to aIIected extremities.
3. Angiography reveals site & extent oI mal-occulsion.
5.
Nsg Mgt:
1. Encourage a slow progression oI physical activity
a.) Walk 3 -4 x / day
b.) Out oI bed 2 3 x a / day
2. Meds
a.) Analgesic
b.) Vasodilator
c.) Anticoagulant
3. Foot care mgt like DM
a.) Avoid walking bareIoot
b.) Cut toe nails straight
c.) Apply lanolin lotion prevent skin breakdown
d.) Avoid wearing constrictive garments
4. Avoid smoking & exposure to cold environment
5. Surgery: BKA (Below the knee amputation)
2.)REYNAUD`S PHENOMENON acute episodes oI arterial spasm aIIecting digits oI hands & Iingers
1. Female, 40 yrs
2. Smoking
3. Collagen dse
a.) SLE pathognomonic sign butterIly rash on Iace
Chipmunk Iace bulimia nervosa
Cherry red skin carbon monoxide poisoning
Spider angioma liver cirrhosis
Caput medusae leg & trunk umbilicus- Liver cirrhosis
Lion Iace leprosy
b.) Rheumatoid arthritis
4. Direct hand trauma piano playing, excessive typing, operating chainsaw
S/Sx:
1. Intermittent claudication - leg pain upon walking - Relieved by rest
2. Cold sensitivity
Nsg Mgt:
58
a. Analgesics
b. Vasodilators
c. Encourage to wear gloves especially when opening a reIrigerator.
d. Avoid smoking & exposure to cold environment
VENOUS ULCERS
1. VARICOSITIES / Varicose veins - Abnormal dilation oI veins lower ext & trunk
- Due to:
a.) Incompetent valves leading to
b.) Increase venous pooling & stasis leading to
c.) Decrease venous return
a. Hereditary
b. Congenital weakness oI veins
c. Thrombophlebitis
d. Heart dse
e. Pregnancy
I. Obesity
g. Prolonged immobility - Prolonged standing
S/Sx:
1. Pain especially aIter prolonged standing
2. Dilated tortuous skin veins
3. Warm to touch
4. Heaviness in legs
Dx:
1. Venography
2. Trendelenberg`s test vein distend quickly 35 secs
Nsg Mgt:
1. Elevate legs above heart level to promote venous return 1 to 2 pillows
2. Measure circumIerence oI leg muscles to determine iI swollen.
3. Wear anti embolic or knee high stockings. Women panty hose
4. Meds: Analgesics
5. Surgery: vein sweeping & ligation
Sclerotherapy spider web varicosities
S/E thrombosis
THROMBOPHLEBITIS (deep vein thrombosis) - InIlammation oI veins with thrombus Iormation
1. Smoking
2. Obesity
2. Hyperlipedemia
4. Prolonged use oI oral contraceptives
5. Chronic anemia
6. DM
7. MI
8. CHF
9. Postop complications
10. Post cannulation insertion oI various cardiac catheters
S/Sx:
1. Pain at aIIected extremities
2. Cyanosis
3. () Homan`s sign - Pain at leg muscles upon dorsiIlexion oI Ioot.
59
Dx:
1. Angiography
2. Doppler UTZ
Nsg Mgt:
1. Elevate legs above heart level.
2. Apply warm, moist packs to decrease lymphatic congestion.
3. Measure circumIerence oI leg muscles to detect iI swollen.
4. Use anti embolic stockings.
5. Meds: Analgesics.
Anticoagulant: Heparin
6. Complication:
Pulmonary Embolism:
- Sudden sharp chest pain
- Dyspnea
- Tachycardia
- Palpitation
- Diaphoresis
- Mild restlessness
OVERVIEW OF RESPIRATORY SYSTEM:
I. Upper respiratory tract:
Fx:
1. Filtering oI air
2. Warming & moistening
3. HumidiIication
a. Nose cartilage
- Parts: Rt nostril separated by septum
Lt nostril
- Consists oI anastomosis oI capillaries
Kessel Bach Plexus site oI epistaxis
b. Pharynx (throat) muscular passageway Ior air& Iood
Branches:
1. Oropharynx
2. Nasopharynx
3. Layngopharynx
c. Larynx voice box
Fx:
1. For phonation
2. Cough reIlex
Glottis opening
Opens to allow passage oI air
Closes to allow passage oI Iood
II. Lower Rt Fx Ior gas exchange
a. Trachea windpipe
- has cartillagenous rings
- site Ior permanent/ artiIicial a/w tracheostomy
b. Bronchus R & L main bronchus
c. Lungs R 3 lobes 10 segments
L 2 lobes 8 segments
Post pneumonectomy - position aIIected side to promote expansion oI lungs
Post segmental lobectomy position unaIIected side to promote drainage
Lungs covered by pleural cavity, parietal lobe & visceral lobe
Alveoli acinar cells
- site oI gas exchange (O2 & CO2)
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- diIIusion: Daltons law oI partial pressure oI gases
Ventilation movement oI air in & out oI lungs
Respiration movement oI air into cells
Type II cells oI alveoli secrets surIactant
SurIactant - decrease surIace tension oI alveoli
Lecithin & spinogometer
L/S ratio 2:1 indicator oI lung maturity
II 1:2 adm O2 - 40 Concentration to prevent atelectasis & retinopathy or blindness.
I. PNEUMONIA inIlammation oI lung parenchyma leading to pulmonary consolidation as alveoli is Iilled with exudates.
Etiologic agents:
1. Streptococcus pneumoniae (pnemococcal pneumonia)
2. Hemophilus pneumoniae(Bronchopneumonia)
3. Escherichia coli
4. Klebsiella P.
5. Diplococcus P.
High risk elderly & children below 5 yo
1. Smoking
2. Air pollution
3. Immuno-compromised
a. AIDS PLP
b. Bronchogenic CA - Non-productive to productive cough
4. Prolonged immobility CVA- hypostatic pneumonia
5. Aspiration oI Iood
6. Over Iatigue
S/Sx:
1. Productive cough pathognomonic: greenish to rusty sputum
2. Dyspnea with prolonged respiratory grunt
3. Fever, chills, anorexia, gen body malaise
4. Wt loss
5. Pleuritic Iriction rub
6. Rales/ crackles
7. Cyanosis
8. Abdominal distension leading to paralytic ileus
Sputum exam could conIirm presence oI TB & pneumonia
Dx:
1. Sputum GSCS- gram staining & culture sensitivity - Reveals () cultured microorganism.
2. CXR pulmo consolidation
3. CBC increase WBC
Erythrocyte sedimentation rate
4. ABG PO2 decrease
61
Nsg Mgt:
1. EnIorce CBR
2. Strict respiratory isolation
3. Meds:
a.) Broad spectrum antibiotics
Penicillin or tetracycline
Macrolides ex azythromycin (zythromax)
b.) Anti pyretics
c.) Mucolytics or expectorants
4. Force Iluids 2 to 3 L/day
5. Institute pulmonary toilet-
a.) Deep breathing exercise
b.) Coughing exercise
c.) Chest physiotherapy cupping
d.) Turning & reposition - Promote expectoration oI secretions
6. Semi-Iowler
7. Nebulize & suction
8. ComIy & humid environment
9. Diet: increase CHO or calories, CHON & vit C
10. Postural drainage - To drain secretions using gravity
Mgt Ior postural drainage:
a.) Best done beIore meals or 2 4 hrs aIter meals to prevent Gastroesophageal ReIlux
b.) Monitor VS & breath sounds
Normal breath sound bronchovesicular
c.) Deep breathing exercises
d.) Adm bronchodilators 15 30 min beIore procedure
e.) Stop iI pt can`t tolerate procedure
I.) Provide oral care it may alter taste sensation
g.) C/I pt with unstable VS & hemoptysis, increase ICP, increase IOP (glaucoma)
Normal IOP 12 21 mmHg
11. HT:
a.) Avoidance oI precipitating Iactors
b.) Complication: Atelectacies & meningitis
c.) Compliance to meds
PULMONARY TUBERCULOSIS (KOCH DSE) - InIlammation oI lung tissue caused by invasion oI mycobacterium TB or
tubercle bacilli or acid Iast bacilli gram () aerobic, motile & easily destroyed by heat or sunlight.
1. Malnutrition
2. Overcrowding
3. Alcoholism
4. Ingestion oI inIected cattle (mycobacterium BOVIS)
5. Virulence
6. Over Iatigue
S/Sx:
1. Productive cough yellowish
2. Low Iever
3. Night sweats
4. Dyspnea
5. Anorexia, general body malaise, wt loss
6. Chest/ back pain
7. Hempotysis
Diagnosis:
1. Skin test mantoux test inIection oI PuriIied CHON Derivative PPD
DOH 8-10 mm induration
WHO 10-14 mm induration
Result within 48 72h
62
() Mantoux test previous exposure to tubercle bacilli
Mode oI transmission droplet inIection
2. Sputum AFB () to cultured microorganism
3. CXR pulmonary inIiltrate caseosis necrosis
4. CBC increase WBC
Nursing Mgt:
1. CBR
2. Strict resp isolation
3. O2 inhalation
4. Semi Iowler
5. Force Iluid to liqueIy secretions
6. DBCE
8. ComIy & humid environment
9. Diet increase CHO & calories, CHON, Vit, minerals
10. Short course chemotherapy
- Intensive phase
INH isoniazide - give beIore meals Ior absorption
RiIampicin - given within 4 months, given simultaneously to prevent resistance
-S/E: peripheral neutitis vit B6
RiIampicin -All body secretions turn to red orange color urine, stool, saliva, sweat & tears.
PZA Pyrazinamide given 2 mos/ aIter meals. S/E: allergic rxn, nephrotoxicity & hepatoxicity
Standard regimen
1. Injection oI streptomycin aminoglycoside
Ex. Kanamycin, gentamycin, neomycin
S/E:
a.) Ototoxicity damage CN # 8 tinnitus hearing loss
b.) Nephrotoxicicity monitor BUN & Crea
HT:
a.) Avoid pred Iactors
b.) Complications:
1.) Atelectasis
2.) Miliary TB spread oI Tb to other system
b.) Compliance to meds
- Religiously take meds
HISTOPLASMOSIS- acute Iungal inIection caused by inhalation oI contaminated dust with histoplasma capsulatum transmitted
to birds manure.
S/Sx: Same as pneumonia & PTB like
1. Productive cough
2. Dyspnea
3. Chest & joint pains
4. Cyanosis
5. Anorexia, gen body malaise, wt loss
6. Hemoptysis
Dx:
1. Histoplasmin skin test ()
2. ABG pO2 decrease
63
Nsg Mgt:
1. CBR
2. Meds:
a.) Anti Iungal agents
Amphotericin B (Fungizone)
S/E :
a.) Nephrotoxcicity check BUN
b.) Hypokalemia
b.)Corticosteroids
c.) Mucolytic/ or expectorants
3. O2 Iorce Iluids
4. Nebulize, suction
5. Complications:
a.) Atelectasis
b.) Bronchiectasis COPD
6. Prevent spread oI histoplasmosis:
a.) Spray breading places or kill the bird.
COPD - Chronic Obstructive Pulmonary Disease
1. Chronic bronchitis
2. Bronchial asthma
3. Bronchiectasis
4. Pulmonary emphysema terminal stage
CHRONIC BRONCHITIS - called BLUE BLOATERS inIlammation oI bronchus due to hypertrophy or hyperplasia oI goblet
mucus producing cells leading to narrowing oI smaller airways.
1. Smoking all COPD types
2. Air pollution
S/Sx:
1. Prod cough
2. Dyspnea on exertion
3. Prolonged expiratory grunt
4. Scattered rales/ rhonchi
5. Cyanosis
6. Pulmo HPN a.)Leading to peripheral edema
b.) Cor pulmonary respiratory in origin
7. Anorexia, gen body malaise
Dx:
1. ABG
PO2 PCO2 Resp acidosis
Hypoxemia causing cyanosis
Nsg Mgt:
(Same as emphysema)
2.) BRONCHIAL ASTHMA- reversible inIlammation lung condition due to hyerpsensitivity leading to narrowing oI smaller
airway.
1. Extrinsic Asthma called Atropic/ allergic asthma
a.) Pallor
b.) Dust
c.) Gases
d.) Smoke
64
e.) Dander
I.) Lints
2. Intrinsic Asthma-
Cause:
Herediatary
Drugs aspirin, penicillin, ! blockers
Food additives nitrites
Foods seaIood, chicken, eggs, chocolates, milk
Physical/ emotional stress
Sudden change oI temp, humidity &air pressure
3. mixed type: combi oI both ext & intr. Asthma
90 cause oI asthma
S/Sx:
1. C cough non productive to productive
2. D dyspnea
3. W wheezing on expiration
4. Cyanosis
5. Mild apprehension & restlessness
6. Tachycardia & palpitation
7. Diaphoresis
Dx:
1. Pulmo Iunction test decrease lung capacity
2. ABG PO2 decrease
Nsg Mgt:
1. CBR all COPD
2. Meds-
a.) Bronchodilator through inhalation or metered dose inhaled / pump. Give 1
st
beIore corticosteroids
b.) Corticosteroids due inIlammatory. Given 10 min aIter adm bronchodilator
c.) Mucolytic/ expectorant
d.) Mucomist at bedside put suction machine.
e.) Antihistamine
2. Force Iluid
3. O2 all COPD low inIlow to prevent resp distress
5. SemiIowler all COPD except emphysema due late stage
6. HT
a.) Avoid pred Iactors
b.) Complications:
- Status astmaticus- give epinephrine & bronchodilators
- Emphysema
c.) Adherence to med
BRONCHIECTASIS abnormal permanent dilation oI bronchus resulting to destruction oI muscular & elastic tissues oI alveoli.
1. Recurrent upper & lower RI
2. Congenital anomalies
3. Tumors
4. Trauma
S/Sx:
1. Productive cough
2. Dyspnea
3. Anorexia, gen body malaise- all energy are used to increase respiration.
4. Cyanosis
5. Hemoptisis
65
Dx:
1. ABG PO2 decrease
2. Bronchoscopy direct visualization oI bronchus using Iiberscope.
Nsg Mgt: beIore bronchoscopy
1. Consent, explain procedure MD/ lab explain RN
2. NPO
3. Monitor VS
Nsg Mgt after bronchoscopy
1. Feeding aIter return oI gag reIlex
2. Instruct client to avoid talking, smoking or coughing
3. Monitor signs oI Irank or gross bleeding
4. Monitor oI laryngeal spasm
- DOB
- Prepare at bedside tracheostomy set
Mgt: same as emphysema except Surgery
Pneumonectomy removal oI aIIected lung
Segmental lobectomy position oI pt unaIIected side
PULMONARY EMPHYSEMA irreversible terminal stage oI COPD
- Characterized by inelasticity oI alveolar wall leading to air trapping, leading to maldistribution oI gases.
- Body will compensate over distension oI thoracic cavity
- Barrel chest
1. Smoking
2. Allergy
3. Air pollution
4. High risk elderly
5. Hereditary - " 1 anti trypsin to release elastase Ior recoil oI alveoli.
S/Sx:
1. Productive cough
2. Dyspnea at rest due terminal
3. Anorexia & gen body malaise
4. Rales/ rhonchi
6. Decrease tactile Iremitus (should have vibration) palpation '99. Decreased - with air or Iluid
7. Resonance to hyperresonance percussion
8. Decreased or diminished breath sounds
9. Pathognomonic: barrel chest increase post/ anterior diameter oI chest
10. Purse lip breathing to eliminated PCO2
11. Flaring oI alai nares
Diagnosis:
1. Pulmonary Iunction test decrease vital lung capacity
2. ABG
a.) Panlobular / centrolobular emphysema
pCO2 increase
pO2 decrease hypoxema resp acidosis Blue bloaters
b.) Panacinar/ Centracinar
pCO2 decrease
pO2 increase hyperaxemia resp alkalosis Pink puIIers
Nursing Mgt:
1. CBR
2. Meds
a.) Bronchodilators
66
b.) Corticosteroids
c.) Antimicrobial agents
d.) Mucolytics/ expectorants
3. O2 Low inIlow
4. Force Iluids
5. High Iowlers
6. Neb & suction
7. Institute
P posture
E end
E expiratory to prevent collapse oI alveoli
P pressure
8. HT
a.) Avoid smoking
b.) Prevent complications
1.) Cor pulmonary R ventricular hypertrophy
2.) CO2 narcosis lead to coma
3.) Atelectasis
4.) Pneumothorax air in pleural space
9. Adherence to meds
RESTRICTIVE LUNG DISORDER
PNEUMOTHORAX partial / or complete collapse oI lungs due to entry or air in pleural space.
Types:
1. Spontaneous pneumothorax entry oI air in pleural space without obvious cause.
Eg. rupture oI bleb (alveoli Iilled sacs) in pt with inIlammed lung conditions
Eg. open pneumothorax air enters pleural space through an opening in chest wall
-Stab/ gun shot wound
2. Tension Pneumothorax air enters plural space with inspiration & can`t escape leading to over distension oI thoracic
cavity resulting to shiIting oI mediastinum content to unaIIected side.
Eg. Ilail chest 'paradoxical breathing
1.Chest trauma
2.InIlammatory lung conditions
3.Tumor
S/Sx:
1. Sudden sharp chest pain
2. Dyspnea
3. Cyanosis
4. Diminished breath sound oI aIIected lung
5. Cool moist skin
6. Mild restlessness/ apprehension
7. Resonance to hyper resonance
Diagnosis:
1. ABG pO2 decrease
2. CXR conIirms pneumothorax
Nursing Mgt:
1. Endotracheal intubation
2. Thoracenthesis
3. Meds Morphine SO4
- Anti microbial agents
4. Assist in test tube thoracotomy
Nursing Mgt iI pt is on CPT attached to H2O drainage
1. Maintain strict aseptic technique
2. DBE
3. At bedside
67
a.) Petroleum gauze pad iI dislodged Hemostan
b.) II with air leakage clamp
c.) Extra bottle
4. Meds Morphine SO4
Antimicrobial
5. Monitor & assess Ior oscillation Iluctuations or bubbling
a.) II () to intermittent bubbling means normal or intact
- H2O rises upon inspiration
- H2o goes down upon expiration
b.) II () to continuous, remittent bubbling
1. Check Ior air leakage
2. Clamp towards chest tube
3. NotiIy MD
c.) II (-) to bubbling
1. Check Ior loop, clots, and kink
2. Milk towards H2O seal
3. Indicates re-expansion oI lungs
When will MD remove chest tube:
1. II (-) Iluctuations
2. () Breath sounds
3. CXR Iull expansion oI lungs
Nursing Mgt oI removal oI chest tube
1. DBE
2. Instruct to perIorm Valsalva maneuver Ior easy removal, to prevent entry oI air in pleural space.
3. Apply vaselinated air occlusive dressing
- Maintain dressing dry & intact
GIT
I. Upper alimentary canal - Iunction Ior digestion
a. Mouth
b. Pharynx (throat)
c. Esophagus
d. Stomach
e. 1
st
halI oI duodenum
II. Middle Alimentary canal Function: Ior absorption
- Complete absorption large intestine
a. 2
nd
halI oI duodenum
b. Jejunum
c. Ileum
d. 1
st
halI oI ascending colon
III. Lower Alimentary Canal Function: elimination
a. 2
nd
halI oI ascending colon
b. Transverse
c. Descending colon
d. Sigmoid
e. Rectum
IV. Accessory Organ
a. Salivary gland
b. VerniIorm appendix
c. Liver
d. Pancreas auto digestion
e. Gallbladder storage oI bile
I. Salivary Glands
1. Parotid below & Iront oI ear
2. Sublingual
3. Submaxillary
- Produces saliva Ior mechanical digestion
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- 1200 -1500 ml/day - saliva produced
PAROTITIS 'mumps inIlammation oI parotid gland
-Paramyxo virus
S/Sx:
1. Fever, chills anorexia, gen body malaise
2. Swelling oI parotid gland
3. Dysphagia
4. Ear ache otalgia
Mode oI transmission: Direct transmission & droplet nuclei
Incubation period: 14 21 days
Period oI communicability 1 week beIore swelling & immediately when swelling begins.
Nursing Mgt:
1. CBR
2. Strict isolation
3. Meds: analgesic
Antipyretic
Antibiotics to prevent 2 complications
4. Alternate warm & cold compress at aIIected part
5. Gen liquid to soIt diet
6. Complications
Women cervicitis, vaginitis, oophoritis
Both sexes meningitis & encephalitis/ reason why antibiotics is needed
Men orchitis might lead to sterility iI it occur during / aIter puberty.
VERNIFORM APPENDIX Rt iliac or Rt inguinal area
- Function lymphatic organ produces WBC during Ietal liIe - ceases to Iunction upon birth oI baby
APENDICITIS inIlamation oI verniIorm appendix
1. Microbial inIection
2. Feacalith undigested Iood particles tomato seeds, guava seeds
3. Intestinal obstruction
S/Sx:
1. Pathognomonic sign: () rebound tenderness
2. Low grade Iever, anorexia, n/v
3. Diarrhea / & or constipation
4. Pain at Rt iliac region
5. Late sign due pain tachycardia
Diagnosis:
1. CBC mild leukocytosis increase WBC
2. PE () rebound tenderness (Ilex Rt leg, palpate Rt iliac area rebound)
3. Urinalysis
Treatment: - appendectomy 24 45
Nursing Mgt:
1. Consent
2. Routinary nursing measures:
a.) Skin prep
b.) NPO
c.) Avoid enema lead to rupture oI appendix
3. Meds:
Antipyretic
69
Antibiotics
*Don`t give analgesic will mask pain
- Presence oI pain means appendix has not ruptured.
4. Avoid heat application will rupture appendix.
5. Monitor VS, I&O bowel sound
Nursing Mgt: post op
1. II () to Pendrose drain indicates rupture oI appendix
Position- aIIected side to drain
2. Meds: analgesic due post op pain
Antibiotics, Antipyretics PRN
3. Monitor VS, I&O, bowel sound
4. Maintain patent IV line
5. Complications- peritonitis, septicemia
Liver largest gland
- Occupies most oI right hypochondriac region
- Color: scarlet red
- Covered by a Iibrous capsule Glisson`s capsule
- Functional unit liver lobules
Function:
1. Produces bile
Bile emulsiIies Iats
- Composed oI H2O & bile salts
-Gives color to urine urobilin
Stool stircobilin
2. DetoxiIies drugs
3. Promotes synthesis oI vit A, D, E, K - Iat soluble vitamins
Hypevitaminosis vit D & K
Vit A retinol
DeI Vit A night blindness
Vit D cholecalciIeron
- Helps calcium
- Rickets, osteoarthritis
4. It destroys excess estrogen hormone
5. For metabolism
A. CHO
1. Glycogenesis synthesis oI glycogens
2. Glycogenolysis breakdown oI glycogen
3. Gluconeogenesis Iormation oI glucose Irom CHO sources
B. CHON-
1. Promotes synthesis oI albumin & globulin
Cirrhosis decrease albumin
Albumin maintains osmotic pressure, prevents edema
2. Promotes synthesis oI prothrombin & Iibrinogen
3. Promotes conversion oI ammonia to urea.
Ammonia like breath Ietor hepaticus
C. FATS promotes synthesis oI cholesterol to neutral Iats called triglycerides
LIVER CIRRHOSIS - lost oI architectural design oI liver leading to Iat necrosis & scarring
Early sign hepatic encephalopathy
1. Asterixis Ilapping hand tremors
Late signs headache, restlessness, disorientation, decrease LOC hepatic coma.
Nursing priority assist in mechanical ventilation
70
Decrease Laennac`s cirrhosis caused by alcoholism
1. Chronic alcoholism
2. Malnutrition decreaseVit B, thiamin - main cause
3. Virus
4. Toxicity- eg. Carbon tetrachloride
5. Use oI hepatotoxic agents
S/Sx:
Early signs:
a.) Weakness, Iatigue
b.) Anorexia, n/v
c.) Stomatitis
d.) Urine tea color
Stool clay color
e.) Amenorrhea
I.) Decrease sexual urge
g.) Loss oI pubic, axilla hair
h.) Hepatomegaly
i.) Jaundice
j.) Pruritus or urticaria
2. Late signs
a.) Hematological changes all blood cells decrease
Leukopenia- decrease
Thrombocytopenia- decrease
Anemia- decrease
b.) Endocrine changes
Spider angiomas, Gynecomastia
Caput medusate, Palmar errythema
c.) GIT changes
Ascitis, bleeding esophageal varices due to portal HPN
d.) Neurological changes:

Hepatic encephalopathy - ammonia (cerebral toxin)
Late signs: Early signs:
Headache asterexis
Fetor hepaticus (Ilapping hand tremors)
ConIusion
Restlessness
Decrease LOC
Hepatic coma
Diagnosis:
1. Liver enzymes- increase
SGPT (ALT)
SGOT (AST)
2. Serum cholesterol & ammonia increase
3. Indirect bilirubin increase
4. CBC - pancytopenia
5. PTT prolonged
6. Hepatic ultrasonogram Iat necrosis oI liver lobules
Nursing Mgt
1. CBR
2. Restrict Na!
3. Monitor VS, I&O
4. With pt daily & assess pitting edema
5. Measure abdominal girth daily notiIy MD
6. Meticulous skin care
71
7. Diet increase CHO, vit & minerals. Moderate Iats. Decrease CHON
Well balanced diet
8. Complications:
a.) Ascites Iluid in peritoneal cavity
Nursing Mgt:
1. Meds: Loop diuretics 10 15 min eIIect
2. Assist in abdominal paracentesis - aspiration oI Iluid
- Void beIore paracentesis to prevent accidental puncture oI bladder as trochar is inserted
b.) Bleeding esophageal varices
- Dilation oI esophageal veins
1. Meds: Vit K
Pitrisin or Vasopresin (IM)
2. NGT decompression- lavage
- Give beIore lavage ice or cold saline solution
- Monitor NGT output
3. Assist in mechanical decompression
- Insertion oI sengstaken-blackemore tube
- 3 lumen typed catheter
- Scissors at bedside to deIlate balloon.
c.) Hepatic encephalopathy
1. Assist in mechanical ventilation due coma
2. Monitor VS, neuro check
3. Siderails due restless
4. Meds Laxatives to excrete ammonia
HEPATITIS- jaundice (icteric sclera)
Bilirubin
Kernicterus/ hyperbilirubinia
Irreversible brain damage
Pancreas mixed gland (exocrine & endocrine gland)
PANCREATITIS acute or chronic inIlammation oI pancreas leading to pancreatic edema, hemorrhage & necrosis due to auto
digestion.
Bleeding oI pancreas - Cullen`s sign at umbilicus
1. Chronic alcoholism
2. Hepatobilary disease
3. Obesity
4. Hyperlipidemia
5. Hyperparathyroidism
6. Drugs Thiazide diuretics, pills Pentamidine HCL (Pentam)
7. Diet increase saturated Iats
S/Sx:
1. Severe Lt epigastric pain radiates Irom back &Ilank area
- Aggravated by eating, with DOB
2. N/V
3. Tachycardia
4. Palpitation due to pain
5. Dyspepsia indigestion
6. Decrease bowel sounds
72
7. () Cullen`s sign - ecchymosis oI umbilicus hemorrhage
8. () Grey Turner`s spots ecchymosis oI Ilank area
9. Hypocalcemia
Diagnosis:
1. Serum amylase & lipase increase
2. Urine lipase increase
3. Serum Ca decrease
Nursing Mgt:
1. Meds
a.) Narcotic analgesic - Meperidine Hcl (Demerol)
Don`t give Morphine SO4 will cause spasm oI sphincter.
b.) Smooth muscle relaxant/ anti cholinergic
- Ex. Papavarine Hcl
Prophantheline Bromide (ProIanthene)
c.) Vasodilator NTG
d.) Antacid Maalox
e.) H2 receptor antagonist - Ranitidin (Zantac) to decrease pancreatic stimulation
I.) Ca gluconate
2. Withold Iood & Iluid aggravates pain
3. Assist in Total Parenteral Nutrition (TPN) or hyperalimentation
Complications oI TPN
1. InIection
2. Embolism
3. Hyperglycemia
4. Institute stress mgt tech
a.) DBE
b.) BioIeedback
5. ComIy position - Knee chest or Ietal like position
6. II pt can tolerate Iood, give increase CHO, decrease Iats, and increase CHON
7. Complications: Chronic hemorrhagic pancreatitis
GALLBLADDER storage oI bile made up oI cholesterol.
CHOLECYSTITIS/ CHOLELITHIASIS inIlammation oI gallbladder with gallstone Iormation.
1. High risk women 40 years old
2. Post menopausal women undergoing estrogen therapy
3. Obesity
5. Hyperlipidemia
6. Neoplasm
S/Sx:
1. Severe Right abdominal pain (aIter eating Iatty Iood). Occurring especially at night
2. Fatty intolerance
3. Anorexia, n/v
4. Jaundice
5. Pruritus
6. Easy bruising
7. Tea colored urine
8. Steatorrhea
Diagnosis:
1. Oral cholecystogram (or gallbladder series)- conIirms presence oI stones
Nursing Mgt:
1. Meds a.) Narcotic analgesic - Meperdipine Hcl Demerol
b.) Anti cholinergic - Atropine SO4
c.) Anti emetic
Phenergan Phenothiazide with anti emetic properties
73
2. Diet increase CHO, moderate CHON, decrease Iats
3. Meticulous skin care
4. Surgery: Cholecystectomy
Nursing Mgt post cholecystectomy
-Maintain patency oI T-tube intact & prevent inIection
Stomach widest section oI alimentary canal
- J shaped structures
1. Anthrum
2. Pylorus
3. Fundus
Valves
1. 1.cardiac sphincter
2. Pyloric sphincter
Cells
1. ChieI/ Zymogenic cells secrets
a.) Gastric amylase - digest CHO
b.) Gastric lipase digest Iats
c.) Pepsin CHON
d.) Rennin digests milk products
2. Parietal / ArgentaIIin / oxyntic cells
Function:
a.) Produces intrinsic Iactor promotes reabsorption oI vit B12 cyanocobalamin promotes maturation oI RBC
b.) Secrets Hcl acid aids in digestion
3. Endocrine cells - Secrets gastrin increase Hcl acid secretion
Function oI the stomach
1.Mechanical
2.Chem. Digestion
3.Storage oI Iood
-CHO, CHON- stored 1 -2 hrs. Fats stored 2 3 hrs
PEPTIC ULCER DISEASE - (PUD) excoriation / erosion oI submucosa & mucosal lining due to:
a.) Hypercecretion oI acid pepsin
b.) Decrease resistance to mucosal barrier
Incidence Rate:
1. Men 40 55 yrs old
2. Aggressive persons
1. Hereditary
2. Emotional
3. Smoking vasoconstriction GIT ischemia
4. Alcoholism stimulates release oI histamine Parietal cell release Hcl acid ulceration
5. CaIIeine tea, soda, chocolate
6. Irregular diet
7. Rapid eating
8. Ulcerogenic drugs NSAIDS, aspirin, steroids, indomethacin, ibuproIen
Indomethacin - S/E corneal cloudiness. Needs annual eye check up.
9. Gastrin producing tumor or gastrinoma Zollinger Ellisons sign
10. Microbial invasion helicobacter pylori. Metromidazole (Flagyl)
Types oI ulcers
Ascending to severity
1. Acute aIIects submucosal lining
2. Chronic aIIects underlying tissue heals & Iorms a scar
74
According to location
1. Stress ulcer
2. Gastric ulcer
3. Duodenal ulcer most common
Stress ulcers common among eritically ill clients
2 types
1.Curing`s ulcer cause: trauma & birth
hypovolemia
GIT schemia
Decrease resistance oI mucosal barriers to Hcl acid
Ulcerations
2.Cushing`s ulcer cause stroke/CVA/ head injury
Increase vagal stimulation
Hyperacidity
Ulcerations

GASTRIC ULCER DUODENAL ULCER
SITE Intrum or lesser curvature Duodenal bulb
PAIN -30 min 1 hr aIter eating
- epigastrium
- gaseous & burning
- not usually relieved by Iood &
antacid
-2-3 hrs aIter eating
- mid epigastrium
- cramping & burning
- usually relieved by Iood & antacid
- 12 MN 3am pain
HYPERSECRETION Normal gastric acid secretion Increased gastric acid secretion
VOMITING common Not common
HEMORRHAGE hematemeis Melena
WT Wt loss Wt gain
COMPLICATIONS a. stomach cause
b. hemorrhage
a. perIoration
HIGH RISK 60 years old 20 years old
Diagnosis:
1. Endoscopic exam
2. Stool Irom occult blood
3. Gastric analysis N gastric
Increase duodenal
4. GI series conIirms presence oI ulceration
Nursing Mgt:
1. Diet bland, non irritating, non spicy
2. Avoid caIIeine & milk/ milk products
Increase gastric acid secretion
3. Administer meds
75
a.) Antacids
AAC
Aluminum containing antacids Magnesium containing antacids
Ex. aluminum OH gel ex. milk oI magnesia
(Ampho-gel) S/E diarrhea
S/E constipation
Maalox (Iever S/E)
b.) H2 receptor antagonist
Ex
1. Ranitidine (Zantac)
2. Cimetidine (Tagamet)
3. Tamotidine (Pepcid)
- Avoid smoking decrease eIIectiveness oI drug
Nursing Mgt:
1. Administer antacid & H2 receptor antagonist 1hr apart
-Cemetidine decrease antacid absorption & vise versa
c.) Cytoprotective agents
Ex
1. SucralIate (CaraIate) - Provides a paste like subs that coats mucosal lining oI stomach
2. Cytotec
d.) Sedatives/ Tranquilizers - Valium, lithium
e.)Anticholinergics
1. Atropine SO4
2. Prophantheline Bromide (ProIanthene)

(Pt has history oI hpn crisis With peptic ulcer disease. Rn should not administer alka seltzer- has large amount oI Na.
4. Surgery: subtotal gastrectomy - Partial removal oI stomach
Billroth I (Gastroduodenostomy)
-Removal oI oI stomach & anastomoses oI gastric stump
to the duodenum.
Billroth II (Gastrojejunostomy)
- removal oI -3/4 oI stomach & duodenal bulb & anastomostoses oI
gastric stump to jejunum.
BeIore surgery Ior BI or BII - Do vagotomy (severing oI vagus nerve) & pyloroplasty (drainage) Iirst.
Nursing Mgt:
1. Monitor NGT output
a.) Immediately post op should be bright red
b.) Within 36- 42h output is yellow green
c.) AIter 42h output is dark red
2. Administer meds:
a.) Analgesic
b.) Antibiotic
c.) Antiemetics
3. Maintain patent IV line
4. VS, I&O & bowel sounds
5. Complications:
a.) Hemorrhage hypovolemic shock
Late signs anuria
b.) Peritonitis
c.) Paralytic ileus most Ieared
d.) Hypokalemia
e.) Thromobphlebitis
I.) Pernicious anemia
76
7.)Dumping syndrome common complication rapid gastric emptying oI hypertonic Iood solutions CHYME leading to
hypovolemia.
Sx oI Dumping syndrome:
1. Dizziness
2. Diaphoresis
3. Diarrhea
4. Palpitations
Nursing mgt:
1. Avoid Iluids in chilled solutions
2. Small Irequent Ieeding s-6 equally divided Ieedings
3. Diet decrease CHO, moderate Iats & CHON
4. Flat on bed 15 -30 minutes aIter q Ieeding
BURNS direct tissue injury caused by thermal, electric, chemical & smoke inhaled (TECS)
Nursing Priority inIection (all kinds oI burns)
Head burn-priority- a/w
2
nd
priority Ior 1
st
& 2
nd
- pain
2
nd
priority Ior 3
rd
- F&E
Thermal- direct contact Ilames, hot grease, sunburn.
Electric, wires
Chem. direct contact corrosive materials acids
Smoke gas / Iume inhalation
Stages:
1. Emergent phase Removal oI pt Irom cause oI burn. Determine source or loc or burn
2. Shock phase 48 - 72. Characterized by shiIting oI Iluids Irom intravascular to interstitial space
Hypovolemia
S/Sx:
- BP decrease
- Urine output
- HR increase
- Hct increase
- Serum Na decrease
- Serum K increase
- Met acidosis
3. Diuretic/ Fluid remobilization phase - 3 to 5 days. Return oI Iluid Irom interstitial to intravascular space
4. Recovery/ convalescent phase complete diuresis. Wound healing starts immediately aIter tissue injury.
Class:
I. Partial Burn
1. 1
st
degree superIicial burns
- AIIects epidermis
- Cause: thermal burn
- PainIul
- Redness (erythema) & blanching upon pressure with no Iluid Iilled vesicles
2. 2
nd
degree deep burns
- AIIects epidermis & dermis
- Cause chem. burns
- very painIul
- Erythema & Iluid Iilled vesicles (blisters)
II Full thickness Burns
1. Third & 4
th
degrees burn
- AIIects all layers oI skin, muscles, bones
- Cause electrical
- Less painIul
- Dry, thick, leathery wound surIace known as ESCHAR devitalized or necrotic tissue.
77
Assessment Iindings
Rule oI nines
Head & neck 9
Ant chest 18
Post chest 18
Arm 99 18
leg 1818 18
Genitalia/ perineum 1
Total 100
Nursing Mgt
1. Meds
a.) Tetanus toxoid- burn surIace area is source oI anaerobic growth Claustridium tetany
Tetany
Tetanolysin tetanospasmin
Hemolysis muscle spasm
b.) Morphine SO4
c.) Systemic antibiotics
1. Ampicillin
2. Cephalosporin
3. Tetracyclin
4. Topical antibiotic :
1. Silver SulIadiazene (silvadene)
2. SulIamylon
3. Silver nitrate
4. Povidone iodine (betadine)
2. Administer isotonic Iluid sol & CHON replacements
3. Strict aseptic technique
4. Diet increase CHO, increase CHON, increase Vit C, and increase K- orange
5. II () to burns on head, neck, Iace - Assist in intubation
6. Assist in hydrotherapy
7. Assist in surgical wound debridement. Administer analgesic 15 30 minutes beIore debridement
8. Complications:
a.) InIection
b.) Shock
c.) Paralytic ileus - due to hypovolemia & hypokalemia
d.) Curling`s ulcer H2 receptor antagonist
e.) Septicemia blood poisoning
I.) Surgery: skin graIting
GUT genito-urinary tract
Function:
1. Promote excretion oI nitrogenous waste products
2. Maintain F&E & acid base balance
1. Kidneys pair oI bean shaped organ
- Retro peritonially (back oI peritoneum) on either side oI vertebral column. Encased in Bowmans`s capsule.
Parts:
1. Renal pelvis pyenophritis inIl
2. Cortex
3. Medulla
Nephrones basic living unit
Glomerulus Iilters blood going to kidneys
78
Function oI kidneys:
1. Urine Iormation
2. Regulation oI BP
Urine Iormation 25 oI total CO (Cardiac Output) is received by kidneys
1. Filtration
2. Tubular Reabsorption
3. Tubular Secretion
Filtration Normal GFR/ min is 125 ml oI blood
Tubular reabsorption 124ml oI ultra inIiltrates (H2O & electrolytes is Ior reabsorption)
Tubular secretion 1 ml is excreted in urine
Regulation oI BP:
Ex CS hypovolemia decrease BP going to kidneys
Activation oI RAAS
Release oI Renin (hydrolytic enzyme) at juxtaglomerular apparatus
Angiotensin I mild vasoconstrictor
Angiotensin II vasoconstrictor
Adrenal cortex increase CO increase PR
Aldosterone
Increase BP
Increase Na &
H2O reabsorption
Hypervolemia
Ureters 25 35 cm long, passageway oI urine to bladder
Bladder loc behind symphisis pubis. Muscular & elastic tissue that is distensible
- Function reservoir or urine
1200 1800 ml Normal adult can hold
200 500 ml needed to initiate micturition reIlex
Color amber
Odor aromatic
Consistency clear or slightly turbid
pH 4.5 8
SpeciIic gravity 1.015 1.030
WBC/ RBC (-)
Albumin (-)
E coli (-)
Mucus thread Iew
Amorphous urate (-)
Urethra extends to external surIace oI body. Passage oI urine, seminal & vaginal Iluids.
- Women 3 5 cm or 1 to 1 '
- Male 20cm or 8
UTI
CYSTITIS inIlammation oI bladder
1. Microbial invasion E. coli
79
2. High risk women
3. Obstruction
4. Urinary retention
5. Increase estrogen levels
6. Sexual intercourse
S/Sx:
1. Pain Ilank area
2. Urinary Irequency & urgency
3. Burning upon urination
4. Dysuria & hematuria
5. Fever, chills, anorexia, gen body malaise
Diagnosis:
1. Urine culture & sensitivity - () to E. coli
Nursing Mgt:
1. Force Iluid 2000 ml
2. Warm sitz bath to promote comIort
3. Monitor & assess Ior gross hematuria
4. Acid ash diet cranberry, vit C -OJ to acidiIy urine & prevent bacterial multiplication
5. Meds: systemic antibiotics
Ampicillin
Cephalosporin
SulIonamides cotrimaxazole (Bactrim)
- Gantrism (ganthanol)
Urinary antiseptics Mitropurantoin (Macrodantin)
Urinary analgesic- Pyridum
6. Ht
a.) Importance oI Hydration
b.) Void aIter sex
c.) Female avoids cleaning back & Iront
Bubble bath, Tissue paper, Powder, perIume
d.) Complications:
Pyelonephritis
PYELONEPHRITIS acute/ chronic inIl oI 1 or 2 renal pelvis oI kidneys leading to tubular destruction, interstitial abscess
Iormation.
- Lead to Renal Failure
1. Microbial invasion
a.) E. Coli
b.) Streptococcus
2. Urinary retention /obstruction
3. Pregnancy
4. DM
5. Exposure to renal toxins
S/Sx:
Acute pyelonephritis
a.) Costovertibral angle pain, tenderness
b.) Fever, anorexia, gen body malaise
c.) Urinary Irequency, urgency
d.) Nocturia, dsyuria, hematuria
e.) Burning on urination
Chronic Pyelonephritis
a.) Fatigue, wt loss
b.) Polyuuria, polydypsia
c.) HPN
80
Diagnosis:
1. Urine culture & sensitivity () E. coli & streptococcus
2. Urinalysis
Increase WBC, CHON & pus cells
3. Cystoscopic exam urinary obstruction
Nursing Mgt:
1. Provide CBR acute phase
2. Force Iluid
3. Acid ash diet
4. Meds:
a.) Urinary antiseptic nitroIurantoin (macrodantin)
SE: peripheral neuropathy
GI irritation
Hemolytic anemia
Staining oI teeth
b.) Urinary analgesic Peridium
2. Complication- Renal Failure
NEPHROLITHIASIS/ UROLITHIASIS- Iormation oI stones at urinary tract
- calcium , oxalate, uric acid
milk cabbage anchovies
cranberries organ meat
nuts tea nuts
chocolates sardines
1. Diet increase Ca & oxalate
2. Hereditary gout
3. Obesity
5. Hyperparathyroidism
S/Sx:
1. Renal colic
2. Cool moist skin (shock)
3. Burning upon urination
4. Hematuria
5. Anorexia, n/v
Diagnosis:
1. IVP intravenous pyelography. Reveals location oI stone
2. KUB reveals location oI stone
3. Cytoscopic exam- urinary obstruction
4. Stone analysis composition & type oI stone
5. Urinalysis increase EBC, increase CHON
Nursing Mgt:
1.Force Iluid
2.Strain urine using gauze pad
3.Warm sitz bath Ior comIort
4.Alternate warm compress at Ilank area
5. a.) Narcotic analgesic- Morphine SO4
b.) Allopurinol (Zyeoprim)
c.) Patent IV line
d.) Diet iI Ca stones acid ash diet
II oxalate stone alkaline ash diet - (Ex milk/ milk products)
II uric acid stones decrease organ meat / anchovies sardines
6. Surgery
a.) Nephectomy removal oI aIIected kidney
Litholapoxy removal oI 1/3 oI stones- Stones will recur. Not advised Ior pt with big stones
b.) Extracorporeal shock wave lithotripsy
81
- Non - invasive
- Dissolve stones by shock wave
7. Complications: Renal Failure
BENIGN PROSTATIC HYPERTROPHY - enlarged prostate gland leading to
a.) Hydro ureters dilation oI ureters
b.) Hydronephrosis dilation oI renal pelvis
c.) Kidney stones
d.) Renal Iailure
1. High risk 50 years old & above
60 70 (3 to 4 x at risk)
2. InIluence oI male hormone
S/Sx:
1.Decrease Iorce oI urinary stream
2.Dysuria
3.Hematuria
4.Burning upon urination
5.Terminal bubbling
6.Backache
7.Sciatica
Diagnosis:
1. Digital rectal exam enlarged prostate gland
2. KUB urinary obstruction
3. Cystoscopic exam obstruction
4. Urinalysis increase WBC, CHON
Nursing Mgt:
1. Prostatic message promotes evacuation oI prostatic Iluid
2. Limit Iluid intake
3. Provide catheterization
4. Meds:
a. Terazozine (hytrin) - Relaxes bladder sphincter
b. Fenasteride (Proscar) - Atrophy oI Prostate Gland
5. Surgery: Prostatectomy TURP- Transurethral resection oI Prostate- No incision
-Assist in cystoclysis or continuous bladder irrigation.
Nursing mgt:
c. Monitor symptoms oI inIection
d. Monitor symptoms gross/ Ilank bleeding. Normal bleeding within 24h.
3. Maintain irrigation or tube patent to Ilush out clots - to prevent bladder spasm & distention
ACUTE RENAL FAILURE sudden immobility oI kidneys to excrete nitrogenous waste products & maintain F&E balance
due to a decrease in GFR. (N 125 ml/min)
Pre renal cause- decrease blood Ilow
Causes:
1. Septic shock
2. Hypovolemia
3. Hypotension decrease Ilow to kidneys
4. CHF
5. Hemorrhage
6. Dehydration
Intra-renal cause involves renal pathology kidney problem
1. Acute tubular necrosis-
82
2. Pyelonephritis
3. HPN
4. Acute GN
Post renal cause involves mechanical obstruction
1. Stricture
2. Urolithiasis
3. BPH
CHRONIC RF irreversible loss oI kidney Iunction
1. DM
2. HPN
3. Recurrent UTI/ nephritis
4. Exposure to renal toxins
Stages oI CRF
1. Diminished Reserve Volume asymptomatic
Normal BUN & Crea, GFR 10 30
2. Renal InsuIIiciency
3. End Stage Renal disease
S/Sx:
1.) Urinary System
a.) polyuria
b.) nocturia
c.) hematuria
d.) Dysuria
e.) oliguria
2.) Metabolic disturbances
a.) azotemia (increase BUN & Crea)
b.) hyperglycemia
c.) hyperinulinemia
3.) CNS
a.) headache
b.) lethargy
c.) disorientation
d.) restlessness
e.) memory impairment
4.) GIT
a.) n/v
b.) stomatitis
c.) uremic breath
d.) diarrhea/ constipation
5.) Respiratory
a.) Kassmaul`s resp
b.) decrease cough
reIlex
6.) hematological
a.) Normocytic anemia
bleeding tendencies
7.) Fluid & Electrolytes
a.) hyperkalemia
b.) hypernatermia
c.) hypermagnesemia
d.) hyperposphatemia
e.) hypocalcemia
I.) met acidosis
8.) Integumentary
a.) itchiness/ pruritus
b.) uremic Irost
Nursing Mgt:
1. EnIorce CBR
2. Monitor VS, I&O
3. Meticulous skin care. Uremic Irost assist in bathing pt
4. Meds:
a.) Na HCO3 due Hyperkalemia
b.) Kagexelate enema
c.) Anti HPN hydralazine
d.) Vit & minerals
e.) Phosphate binder
(Amphogel) Al OH gel - S/E constipation
I.) Decrease Ca Ca gluconate
5. Assist in hemodialysis
1.) Consent/ explain procedure
83
2.) Obtain baseline data & monitor VS, I&O, wt, blood exam
3.) Strict aseptic technique
4.) Monitor Ior signs oI complications:
B bleeding
E embolism
D disequilibrium syndrome
S septicemia
S shock decrease in tissue perIusion
Disequilibrium syndrome Irom rapid removal oI urea & nitrogenous waste prod leading to:
a.) n/v
b.) HPN
c.) Leg cramps
d.) Disorientation
e.) Paresthesia
2. Avoid BP taking, blood extraction, IV, at side oI shunt or Iistula. Can lead to compression oI Iistula.
3. Maintain patency oI shunt by:
i. Palpate Ior thrills & auscultate Ior bruits iI () patent shunt!
ii. Bedside- bulldog clip
- II with accidental removal oI Iistula to prevent embolism.
- InIersole (diastole) common dialisate used
7. Complication
- Peritonitis
- Shock
8. Assist in surgery:
Renal transplantation : Complication rejection. Reverse isolation
EYES
External parts
1. Orbital cavity made up oI connective tissue protects eye Iorm trauma.
2. EOM extrinsic ocular muscles involuntary muscles oI eye needed Ior gazing movement.
3. Eyelashes/ eyebrows esthetic purposes
4. Eyelids palpebral Iissure opening upper & lower lid. Protects eye Irom direct sunlight
Meibomean gland secrets a lubricating Iluid inside eyelid
b.) Stye/ sty or Hordeolum- inIlamed Meibomean gland
5. Conjunctiva
6. Lacrimal apparatus tears

Process of grieving
a. Denial
b. Anger
c. Bargaining
d. Depression
e. Acceptance
2. Intrinsic coat
I. sclerotic coat outer most
a.) Sclera white. Occupies post oI eye. ReIracts light rays
b.) Canal oI schlera site oI aqueous humor drainage
c.) Cornea transparent structure oI eye
II/ Uveal tract nutritive care
84
Uveitis inIl oI uveal tract
Consist oI:
a.) Iris colored muscular ring oI eye
2 muscles oI iris:
1. Circular smooth muscle Iiber - Constricts the pupil
2.radial smooth muscle Iiber - Dilates the pupil
2 chambers oI the eye
1. Anterior
a.) Vitereous Humor maintains spherical shape oI the eye
b.) Aqueous Humor maintains intrinsic ocular pressure
Normal IOP 12-21 mmHg
II. Retina (innermost layer)
i. Optic discs or blind spot nerve Iibers only
No auto receptors
cones (daylight/ colored vision) rods night twilight vision
phototopic vision 'scotopic vision vit A deIiciency rods insuIIicient
ii. Maculla lutea yellow spot center oI retina
iii. Fovea centralis area with highest visual acuity oracute vision
Physiology oI vision
4 Physiological processes Ior vision to occur:
1. ReIraction oI light rays bending oI light rays
2. Accommodation oI lens
3. Constriction & dilation oI pupils
4. Convergence oI eyes
Unit oI measurements oI reIraction diopters
Normal eye reIraction emmetropia
ERROR oI reIraction
1. Myopia near sightedness Treatment: biconcave lens
2. Hyperopia/ or Iarsightedness Treatment: biconvex lens
3. Astigmatisim distorted vision Treatment: cylindrical
4. Prebyopia 'old slight inelasticity oI lens due to aging Treatment: biIocal lens or double vista
Accommodation oI lenses based on thelmholtz theory oI accommodation
Near vision Iar vision
Ciliary muscle contracts ciliary muscle dilates / relaxes
Lens bulges lens is Ilat
Convergence oI the eye:
Error:
1. Exotropia 1 eye normal
2. Esophoria corrected by corrective eye surgery
3. Strabismus- squint eye
4. Amblyopia prolong squinting
GLAUCOMA increase IOP iI untreated, atrophy oI optic nerve disc blindness
1. High risk group 40 & above
2. HPN
3. DM
85
4. Hereditary
5. Obesity
6. Recent eye trauma, inIl, surgery
Type:
1. Chronic (open angle G.) most common type
Obstruct in Ilow oI aqueous humor at trabecular meshwork oI canal oI schlema
2. Acute (close angle G.) Most dangerous type
Forward displacement oI iris to cornea leading to blindness.
3. Chronic (closed angle) - Precipitated by acute attack
S/Sx:
1. Loss oI peripheral vision tunnel vision
2. Halos around lights
3. Headache
4. n/v
5. Steamy cornea
6. Eye discomIort
7. II untreated gradual loss oI central vision blindness
Diagnosis:
1. Tonometry increase IOP ~12- 21 mmHg
2. Perimetry decrease peripheral vision
3. Gonioscopy abstruction in anterior chamber
Nursing mgt:
1. EnIorce CBR
3. Administer meds
a.) Miotics liIetime - contracts ciliary muscles & constricts pupil. Ex Pilocarpine Na (Carbachol)
b.) Epinephrine eye drops decrease secretion oI aqueous humor
c.) Carbonic anhydrase inhibitors. Ex. acetapolamide (Diamox)
- Promotes increase out Ilow oI aquaeous humor
d.) Temoptics (Timolol maleate)- Increase outIlow oI aquaous humor
2. Surgery:
Invasive:
a.) Trabeculectomy eyetrephining removal oI trabelar meshwork oI canal or schlera to drain aqueous humor
b.) Peripheral Iridectomy portion oI iris is excised to drain aqueous humor
Non-invasive:
Trabeculoctomy (eye laser surgery)
Nursing Mgt pre op- all types surgery
1. Apply eye patch on unaIIected eye to Iorce weaker eye to become stronger.
Nursing Mgt post op all types oI surgery
1. Position unaIIected/ unoperated side - to prevent tension on suture line.
2. Avoid valsalva maneuver
3. Monitor symptoms of IOP
a.) Headache
b.) n/v
c.) Eye discomIort
d.) Tachycardia
2. Eye patch both eyes - post op
CATARACT partial/ complete opacity oI lens
86
1. 90-95 - aging (degenerative/ senile cataract)
2. Congenital
3. Prolonged exposure to UV rays
4. DM-
S/Sx:
1. Loss oI central vision - 'Hazy or blurring oI vision
2. Painless
3. Milky white appearance at center oI pupil
4. Decrease perception oI colors
Diagnosis: Opthalmoscopic exam () opacity oI lens
Nsg Mgt:
1. Reorient pt to environment due opacity
2. Siderails
3. Meds a.) Mydriatics dilate pupil not liIetime
Ex. Mydriacyl
c.) Cyslopegics paralyzes ciliary muscle. Ex. Cyclogye
4. Surgery
E extra
C - capsular
C cataract partial removal oI lens
L - lens
E extraction
I - intra
C - capsular
C cataract total removal oI lens & surrounding capsules
L - lens
E extraction
Nursing Mgt:
1.Position unaIIected/ unoperated side - to prevent tension on suture line.
2.Avoid valsalva maneuver
3.Monitor symptoms of IOP
a.) Headache
b.) n/v
c.) Eye discomIort
d.) Tachycardia
4.Eye patch both eyes - post op
RETINAL DETACHMENT- separation oI 2 layers oI retina
1. Severe myopia nearsightedness
2. Diabetic Retinopathy
3. Trauma
4. Following lens extraction
5. HPN
S/Sx:
1. 'Curtain veil like vision
2. Flashes oI lights
3. Floaters
4. Gradual decrease in central vision
5. Headache
87
Diagnosis- opthaloscopic exam
Nursing Mgt:
1. Siderails (all visual disease)
2. Surgery:
a.) Cryosurgery
b.) Scleral buckling
EAR
1. Hearing
2. Balance (Kinesthesia or position sense)
Parts:
1. Outer-
a.) Pinna/ auricle protects ear Irom direct trauma
b.) Ext. auditory meatus has ceruminous gland. Cerumen
c.) Tympanic membrane transmits sound waves to middle ear
Disorders of outer ear
Entry oI insects put Ilashlight to give route oI exit
Foreign objects beans (bring to MD)
H2O - drain
2. Middle ear
a.) Ear osssicle
1. Hammer -malleus
2. Anvil -Incus Ior bone conduction disorder conductive hearing loss
3. Stirrups -stapes
b. Eustachian tube - Opens to allow equalization oI pressure on both ears
- Yawn, chew, and swallow
Children straight, wide, short
c.) Otitis media
Adult long, narrow & slanted
c. Muscles
1. Stapedius
2. Tensor tympani
3. Inner ear
a. Bony labyrinth Ior balance, vestibule
Utricle & succule
Otolithe or ear stone has Ca carbonate
Movement oI head Righting reIlex Kinesthesia
b. Membranous Labyrinth
1. Cochlea ( Iunction Ior hearing) has organ oI corti
2. Endolymph & perilymph Ior static equilibrium
3. Mastoid air cells air Iilled spaces in temporal bone in skull
Complications oI Mastoditis meningitis
Types oI hearing loss:
1. Conductive hearing loss transmission hearing loss
Causes:
a.) Impacted cerumen tinnitus & conduction hearing loss- assist in ear irrigaton
b.) Immobility oI stapes OTOSCLEROSIS
d.) Middle ear disease char by Iormation oI spongy bone in the inner ear causing Iixation or immobility oI stapes
e.) Stapes can`t transmit sound waves
88
Surgery
Stapedectomy removal oI stapes, spongy bone & implantation oI graIt/ ear prosthesis
1. Familiar tendency
2. Ear trauma & surgery
S/Sx:
1. Tinnitus
2. Conductive hearing loss
Diagnosis:
1. Audiometry various sound stimulates () conductive hearing loss
2. Weber`s test Normal AC~ BC
result BC ~ AC
Stapedectomy
Nursing Mgt post op
1. Position pt unaIIected side
2. DBE
No coughing & blowing oI nose
- Night lead to removal oI graIt
3. Meds:
a.) Analgesic
b.) Antiemetic
c.) Antimotion sickness agent. Ex. meclesine Hcl (Bonamine)
4. Assess motor Iunction Iacial nerve - (Smile, Irown, raise eyebrow)
5. Avoid shampoo hair Ior 1 to 2 weeks. Use shower cap
SENSORY NEURAL HEARING LOSS/ NERVE DEAFNESS
Cause:
1. Tumor on cocheal
2. Loud noises (gun shot)
3. Presbycusis bilateral progressive hearing loss especially at high Irequencies elderly
Face elderly to promote lip reading
4. Meniere`s disease endolymphatic hydrops
I.) Inner ear disease char by dilation oI endo lympathic system leading to increase volume oI endolin
Predisposing Iactor oI MENIERE`S DISEASE
Smoking
Hyperlipidemia
30 years old
Obesity () chosesteatoma
Allergy
Ear trauma & inIection
S/Sx:
1. TRIAD symptoms oI Meniere`s disease
a.) Tinnitus
b.) Vertigo
c.) Sensory neural hearing loss
89
2. Nystagmus
3. n/v
4. Mild apprehension, anxiety
5. Tachycardia
6. Palpitations
7. Diaphoresis
Diagnosis:
1. Audiometry () sensory hearing loss
Nursing mgt:
1. ComIy & darkened environment
2. Siderails
3. Emetic basin
4. Meds:
a.) Diuretics to remove endolymph
b.) Vasodilator
c.) Antihistamine
d.) Antiemetic
e.) Antimotion sickness agent
I.) Sedatives/ tranquilizers
5. Restrict Na
6. Limit Iluid intake
7. Avoid smoking
8. Surgery endolymphatic sac decompression- Shunt
90

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MEDICAL SURGICAL

Overview oI the Structures & Functions oI Nervous System

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