Medical Surgical

MEDICAL-SURGICAL NURSING
NERVOUS SYSTEM
Overview of structures and functions:
Central Nervous System

 Brain
 Spinal Cord
Peripheral Nervous System
 Cranial Nerves
 Spinal Nerves
Autonomic Nervous System
 Sympathetic nervous system
 Parasympathetic nervous system
1. AUTONOMIC NERVOUS SYSTEMSympathetic Nervous

System(ADRENERGIC)
2. Parasympathetic Nervous System(CHOLINERGIC, VAGAL,

SYMPATHOLYTIC)-
Involved in fight or aggression response.- Release of Norepinephrine

(cathecolamines)from
adrenal glands
and causes
vasoconstriction.
- Increase all bodily activity except GIT
EFFECTS OF SNS
- Dilation of pupils(
mydriasis
) in order to be aware.- Dry mouth (thickened saliva).- Increase BP and Heart Rate.-
Bronchodilation, Increase RR- Constipation.- Urinary Retention.- Increase blood supply
to
brain
,
heart
and
skeletalmuscles
.- SNS
I. Adrenergic Agents
- Give
Epinephrine.Signs and Symptoms:
- SNS
Contraindication:
- Contraindicated to patients suffering from COPD(Broncholitis, Bronchoectasis,
Emphysema, Asthma).
II. Beta-adrenergic Blocking Agents
- Also called
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Beta-blockers
.- All ending with “
lol
”-
Propranolol
,
Atenelol
,
Metoprolol
.
Effects of Beta-blockers
B
– roncho spasm
E
– licits a decrease in myocardial contraction.
T
– reats hypertension.
A
– V conduction slows down.

Should be given to patients with
Angina Pectoris
,
Myocardial Infarction
,
Hypertension
.
ANTI- HYPERTENSIVE AGENTS
1. Beta-blockers – “lol”2. Ace Inhibitors – Angiotensin, “pril” (Captopril,Enalapril)3.
Calcium Antagonist – Nifedipine (Calcibloc)

In chronic cases of arrhythmia give
Lidocaine
(
Xylocaine
)
-
Involved in fight or withdrawal response.- Release of Acetylcholine.- Decreases all
bodily activities except GIT.
EFFECTS OF PNS
- Constriction of pupils (
meiosis
).- Increase salivation.- Decrease BP and Heart Rate.- Bronchoconstriction, Decrease
RR.- Diarrhea- Urinary frequency.
I. Cholinergic Agents
-
Mestinon
,
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Neostigmine
.
Side Effects
- PNS
II. Anti-cholinergic Agents-
To counter cholinergic agents.- Atropine Sulfate
Side Effects
- SNS
CENTRAL NERVOUS SYSTEM

Brain and Spinal Cord.
I. CELLSA. NEURONS

Basic cells for nerve impulse and conduction.
PROPERTIESExcitability
– ability of neuron to be affected by changes in external environment.
Conductivity
– ability of neuron to transmit a wave of excitation from one cell to another.
Permanent Cell
– once destroyed not capable of regeneration.
TYPES OF CELLS BASED ON REGENERATIVE CAPACITY1. Labile

Capable of regeneration.

Epidermal cells, GIT cells, GUT cells, cells of lungs.
2. Stable

Capable of regeneration with limited time, survival period.

Kidney cells, Liver cells, Salivary cells, pancreas.
3. Permanent

Not capable of regeneration.

Myocardial cells, Neurons, Bone cells, Osteocytes, Retinal Cells.
B. NEUROGLIA

Support and protection of neurons.
TYPES1. Astrocytes –
maintains blood brain barrier semi-permeable.

Majority of brain tumors (90%) arises from called
astrocytoma
.
2. Oligodendria3. Microglia4. EpindymalSUBSTANCES THAT CAN PASS THE BLOOD-
BRAIN BARRIER1. Ammonia

Cerebral toxin

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Hepatic Encephalopathy (Liver Cirrhosis)

Ascites

Esophageal Varices
Early Signs of Hepatic Encephalopathy

asterixis
(flapping hand tremors).
Late Signs of Hepatic Encephalopathy

Headache

Dizziness

Confusion

Fetor hepaticus
(ammonia like breath)

Decrease LOC
PATHOGNOMONIC SIGNS1. PTB –
low-grade afternoon fever.
2. PNEUMONIA –
rusty sputum.
3. ASTHMA –
wheezing on expiration.
4. EMPHYSEMA
– barrel chest.
5. KAWASAKI SYNDROME –
strawberry tongue.
6. PERNICIOUS ANEMIA –
red beefy tongue.
7. DOWN SYNDROME –
protruding tongue.
8. CHOLERA –
rice watery stool.
9. MALARIA –
stepladder like fever with chills.
10. TYPHOID –
rose spots in abdomen.
11. DIPTHERIA –
pseudo membrane formation
12. MEASLES –
koplik’s spots.
13. SLE –
butterfly rashes.
14. LIVER CIRRHOSIS –
spider like varices.
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15. LEPROSY –
lioning face.
16. BULIMIA –
chipmunk face.
17. APPENDICITIS –
rebound tenderness.
18. DENGUE –
petechiae or (+) Herman’s sign.
19. MENINGITIS –
Kernig’s sign (leg pain), Brudzinski sign (neck pain).
20. TETANY –
HYPOCALCEMIA (+)
Trousseau’s sign/carpopedal spasm; Chvostek sign
(facial spasm).
21. TETANUS –
risus sardonicus.
22. PANCREATITIS –
Cullen’s sign (ecchymosis of umbilicus); (+)
Grey turners spots
.
23. PYLORIC STENOSIS –
olive like mass.
24. PDA –
machine like murmur.
25. ADDISON’S DISEASE –
bronze like skin pigmentation.
26. CUSHING’S SYNDROME –
moon face appearance and buffalo hump.
27. HYPERTHYROIDISM/GRAVE’S DISEASE –
exopthalmus.
28. INTUSSUSCEPTION
–
sausage shaped mass
2. Carbon Monoxide and Lead Poisoning

Can lead to
Parkinson’s Disease.

Epilepsy

Treat with
ANTIDOTE
:
Calcium EDTA.3. Type 1 DM (IDDM)

Causes diabetic ketoacidosis.

And increases breakdown of fats.
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
And free fatty acids

Resulting to
cholesterol
and (+) to
Ketones
(CNS depressant).

Resulting to acetone breath odor/fruity odor.

KUSSMAUL’S respiration,
a rapid shallow respiration.

Which may lead to diabetic coma.
4. Hepatitis

Signs of jaundice (icteric sclerae).

Caused by bilirubin (yellow pigment)
5. Bilirubin

Increase bilirubin in brain (
Kernicterus
).

Causing irreversible brain damage.
Astrocites

Maintains integrity of blood brain barrier.
Oligodendria

Produces
myelin sheath
in CNS

Act as insulator and facilitates rapid nerve impulse transmission.
DEMYELINATING DISORDERS
1. ALZHEIMER’S DISEASE

Atrophy of brain tissues.
Sign and Symptoms
4 A’s of Alzheimer
a.
Amnesia
– loss of memory.b.
Agnosia
– no recognition of inanimate objects.c.
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Apraxia
– no recognition of objects function.d.
Aphasia
– no speech (nodding).
*Expressive aphasia

“motor speech center”

Broca’s Aphasia
*Receptive aphasia

inability to understand spoken words.

Wernicke’s Aphasia

General Knowing Gnostic Area or General Interpretative Area.
DRUG OF CHOICE: ARICEPT (
taken at bedtime
) and COGNEX.2. MULTIPLE SCLEROSIS

Chronic intermittent disorder of CNS characterized by white patches of
demyelination in brain andspinal cord.

Characterized by remission and exacerbation.

Women ages 15-35 are prone

Unknown Cause

Slow growing virus

Autoimmune disorders

Pernicious anemia

Myasthenia gravis

Lupus

Hypothyroidism

GBS
Ig G –
only antibody that pass placental circulation causing
passive immunity.-
short term protection.- Immediate action.
Ig A
– present in all bodily secretions (tears, saliva, colostrums).
Ig M
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– acute in inflammation.
Ig E
– for allergic reaction.
Ig D
– for chronic inflammation.
* Give palliative or supportive care.
Signs and Symptoms1. Visual disturbances

blurring of vision (primary)

diplopia (double vision)

scotomas
(blind spots)
2. Impaired sensation

to touch, pain, pressure, heat and cold.

tingling sensation

paresthesia

numbness
3. Mood swings

euphoria (sense of well being)
4. Impaired motor function


weakness

spasticity

paralysis
5. Impaired cerebral function

scanning speech
TRIAD SIGNS OF MS
Ataxia
(Unsteady gait,
(+) Romberg’s test
)
Intentional tremors
Nystagmus6. Urinary retention/incontinence7. Constipation8. Decrease sexual

capacityDIAGNOSTIC PROCEDURE

CSF analysis (increase in
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IgG
and
Protein
).

MRI (reveals site and extent of demyelination).

(+)
Lhermitte’s sign
a continuous and increase contraction of spinal column.
NURSING MANAGEMENT1.
Administer medications as ordereda.
ACTH (Adreno Corticotropic Hormone)/ Steroids
for acute exacerbation to reduce edema at siteof demyelination to prevent paralysis.b.
Baclofen (Dioresal)/ Dantrolene Sodium (Dantrene)
– muscle relaxants.c.
Interferons
– alter immune response.d.
Immunosupresants2.
Maintain side rails to prevent injury related to falls.
3.
Institute stress management techniques.a.
Deep breathing exercises
b.
Yoga4.
Increase fluid intake and increase fiber to prevent constipation.
5.
Catheterization to prevent retention.a.
Diuretics
b.
Bethanicol Chloride (Urecholine)Nursing Management

Only given subcutaneous.

Monitor side effects bronchospasm and wheezing.

Monitor breath sounds 1 hour after subcutaneous administration.c.
For Urinary IncontinenceAnti spasmodic agent
a.
Prophantheline Bromide (Promanthene)

Acid ash diet like cranberry juice, plums, prunes, pineapple, vitamin C and orange.

To acidify urine and prevent bacterial multiplication.
CHARCOTSTRIAD
IAN
COMMON CAUSE OF UTIFemale

short urethra (3-5 cm, 1-1 ½ inches)
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
poor perineal hygiene

vaginal environment is moist
Nursing Management

avoid bubble bath (can alter Ph of vagina).

avoid use of tissue papers

avoid using talcum powder and perfume.
Male

Urethra (20 cm, 8 inches)

urinate after intercourse
MICROGLIA

stationary cells that carry on phagocytosis (engulfing of bacteria or cellular
debris, eating),pinocytosis (cell drinking).
M A C R O P H A G E O R G A N MicrogliaMonocytesKupffers
cellsHistiocytesAlveolar MacrophageBrainBloodKidneySkinLungEPINDYMAL CELLS

Secretes a glue called
chemo attractants
that concentrate the bacteria.
COMPOSITION OF BRAIN

80% brain mass

10% blood

10% CSF
I. Brain MassPARTS OF THE BRAIN1. CEREBRUM

largest part

composed of the Right Cerebral Hemisphere and Left Cerebral Hemisphere enclosed in
theCorpus Callosum.
Functions of Cerebrum

integrative

sensory

motor
Lobes of Cerebrum1. Frontal

higher cortical thinking
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
controls personality

controls motor activity

Broca’s Area (motor speech area) when damaged results to garbled speech.
2. Temporal

hearing

short term memory
3. Parietal

for appreciation

discrimination of sensory impulses to pain, touch, pressure, heat, cold, numbness.
4. Occipital

for vision
Insula (Island of Reil)

visceral function activities of internal organ like gastric motility.
Limbic System (Rhinencephalon)

controls smell and if damaged results to
Anosmia
(absence of smell).

controls libido

controls long term memory
2. BASAL GAGLIA

areas of grey matter located deep within each cerebral hemisphere.

release dopamine (controls gross voluntary movement.
N E U R O
T R A N S M I T T E R D
E C R E A S E I N C R E
A S E A c e t h y l c h o l i n e M
y a s t h e n i a G r a v i s B i -
p o l a r
D i s o r d e r D o p a m i n e P
a r k i n s o n ’ s
D i s e a s e S c h i z o p h r
e n i a 3. MIDBRAIN/ MESENCEPHALON

acts as relay station for sight and hearing.

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size of pupil is
2 – 3 mm
.

equal size of pupil is
isocoria
.

unequal size of pupil is
anisocoria
.

hearing acuity is
30 – 40 dB
.

positive PERRLA
4. INTERBRAIN/ DIENCEPHALON
Parts of Diencephalon
A. Thalamus

acts as relay station for sensation.
B. Hypothalamus

controls temperature (thermoregulatory center).

controls blood pressure

controls thirst

appetite/satiety

sleep and wakefulness

controls some emotional responses like fear, anxiety and excitement.

controls pituitary functions

androgenic hormones
promotes secondary sex characteristics.

early sign for males are testicular and penile enlargement

late sign is deepening of voice.

early sign for females telarche and late sign is menarche.
5. BRAIN STEM

located at lowest part of brain
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Parts of Brain Stem
1. Pons

pneumotaxic center controls the rate, rhythm and depth of respiration.
2. Medulla Oblongata

controls respiration, heart rate, swallowing, vomiting, hiccup, vasomotor center (dilation
andconstriction of bronchioles).
3. Cerebellum

smallest part of the brain.

lesser brain.

controls balance, equilibrium, posture and gait.
INTRA CRANIAL PRESSURE
Monroe Kellie HypothesisSkull is a closed container Any alteration or increase in one of
the intracranial componentsIncrease intra-cranial pressure(
normal ICP is 0 – 15 mmHg
)
Cervical 1
– also known as ATLAS.
Cervical 2
– also known as AXIS.Foramen MagnumMedulla OblongataBrain HerniationIncrease
intra cranial pressure
* Alternate hot and cold compress to prevent HEMATOMA

CSF cushions brain (shock absorber)

Obstruction of flow of CSF will lead to enlargement of skull posteriorly called
hydrocephalus
.

Early closure of posterior fontanels causes posterior enlargement of skull in
hydrocephalus.
NEUROLOGIC DISORDERS
INCREASE INTRACRANIAL PRESSURE
– increase in intra-cranial bulk brought about by an increase in oneof the 3 major intra
cranial components.
Causes:

head trauma/injury

localized abscess

cerebral edema

hemorrhage

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inflammatory condition (stroke)

hydrocephalus

tumor (rarely)
Signs and Symptoms (Early)

decrease LOC

restlessness/agitation

irritability

lethargy/stupor

coma
Signs and Symptoms (Late)

changes in vital signs

blood pressure (
systolic blood pressure increases but diastolic remains the same
).

widening of pulse pressure is neurologic in nature (if narrow cardiac in nature).

heart rate decrease

respiratory rate decrease

temperature increase directly proportional to blood pressure.

projective vomiting

headache

papilledema
(edema of optic disc)

abnormal posturing

decorticate posturing
(damage to cortex and spinal cord).

decerebrate posturing
(damage to upper brain stem that includes pons, cerebellum and midbrain).

unilateral dilation of pupils
called
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uncal herniation

bilateral dilation of pupils
called
tentorial herniation

resulting to mild headache

possible seizure activity
Nursing Management
1. Maintain patent and adequate ventilation by:
a. Prevention of hypoxia and hypercarbiaEarly signs of hypoxia

restlessness

agitation

tachycardia
Late signs of hypoxia

B
radycardia

E
xtreme restlessness

D
yspnea

C
yanosis
HYPERCARBIA

Increase CO
2
(most powerful respiratory stimulant) retention.

In chronic respiratory distress syndrome
decrease O
2
stimulates respiration.
b. Before and after suctioning hyper oxygenate client 100% and done 10 – 15 seconds only.c.
Assist in mechanical ventilation
2. Elevate bed of client 30 – 35
o
angle with neck in neutral position unless contraindicated to promote venousdrainage.3.
Limit fluid intake to 1200 – 1500 ml/day (in force fluids 2000 – 3000 ml/day).4. Monitor
strictly input and output and neuro check5. Prevent complications of 6. Prevent further
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increase ICP by:a. provide an comfortable and quite environment.b. avoid use of
restraints.c. maintain side rails.d. instruct client to avoid forms of valsalva maneuver like:

straining stool

excessive vomiting (use anti emetics)

excessive coughing (use anti tussive like dextromethorphan)

avoid stooping/bending

avoid lifting heavy objectse. avoid clustering of nursing activity together.7. Administer
medications like:a.
Osmotic diuretic (Mannitol)

for cerebral diuresis
Nursing Management

monitor vital signs especially BP (hypotension).

monitor strictly input and output every 1 hour notify physician if output is less 30 cc/hr.

administered via side drip

regulated fast drip to prevent crystal formation.b.
Loop diuretic (Lasix, Furosemide)

Drug of choice for CHF (pulmonary edema)

Loop of Henle in kidneys.
Nursing Management

Monitor vital signs especially BP (hypotension).

monitor strictly input and output every 1 hour notify physician if output is less 30 cc/hr.

administered IV push or oral.

given early morning

immediate effect of 10 – 15 minutes
.

maximum effect of 6 hours.c.
Corticosteroids

Dexamethasone (Decadron)

Hydrocortisone
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
Prednisone (to reduce edema that may lead to increase ICP)

Mild Analgesics (Codeine Sulfate for respiratory depression)

Anti Convulsants (Dilantin, Phenytoin)
*CONGESTIVE HEART FAILURE
Signs and Symptoms

dyspnea

orthopnea

paroxysmal nocturnal dyspnea

productive cough

frothy salivation

cyanosis

rales/crackles

bronchial wheezing

pulsus alternans

anorexia and general body malaise

PMI (point of maximum impulse/apical pulse rate) is displaced laterally

S3 (ventricular gallop)

Predisposing Factors/Mitral Valve

RHD

Aging
TREATMENTM
orphine Sulfate
A
minophelline
D
igoxin
D
iuretics
O
xygen
G
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ases, blood monitor
RIGHT CONGESTIVE HEART FAILURE (Venous congestion)Signs and Symptoms

jugular vein distention (neck)

ascites

pitting edema

weight gain

hepatosplenomegaly

jaundice

pruritus

esophageal varices

anorexia and general body malaise
Signs and Symptoms of Lasix in terms of electrolyte imbalances
1. Hypokalemia

decrease
potassium level

normal value
is
3.4 – 5.5 meq/LSign and Symptoms

weakness and fatigue

constipation

positive U wave on ECG tracing
Nursing Management

administer potassium supplements as ordered (
Kalium Durule, Oral Potassium Chloride
)

increase intake of foods rich in potassium
F R U I T S V E G E T A B L E S A
pple
B
anana
C
antalope
O
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ranges
A
sparagus
B
rocolli
C
arrots
S
pinach
2. Hypocalcemia/ Tetany

decrease
calcium level

normal value
is
8.5 – 11 mg/100 mlSigns and Symptoms

tingling sensation

paresthesia

numbness

(+) Trousseau’s sign/ Carpopedal spasm

(+) Chvostek’s signComplications

Arrhythmia

Seizures
Nursing Management

Calcium Gluconate per IV slowly as ordered
* Calcium Gluconate toxicity – results to SEIZURE
Magnesium Sulfate
Magnesium Sulfate toxicity
S/S
B
P
U
rine output
DECREASER
espiratory rate
P
atellar relfex absent
3. Hyponatremia

decrease
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sodium level

normal value
is
135 – 145 meq/LSigns and Symptoms

hypotension

dehydration signs (Initial sign in adult is
THIRST
, in infant
TACHYCARDIA
)

agitation

dry mucous membrane

poor skin turgor

weakness and fatigue
Nursing Management

force fluids

administer
isotonic fluid solution
as ordered
4. Hyperglycemia

normal FBS
is
80 – 100 mg/dlSigns and Symptoms

polyuria

polydypsia

polyphagia
Nursing Management

monitor FBS
5. Hyperuricemia

increase uric acid (purine metabolism)

foods high in uric acid (sardines, organ meats and anchovies)

*Increase in tophi deposit leads to Gouty arthritis.Signs and Symptoms
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
joint pain (great toes)

swelling
Nursing Management

force fluids

administer medications as ordered
a. Allopurinol (Zyloprim)

Drug of choice for gout.

Mechanism of action : inhibits synthesis of uric acid
.
b. Colchecine

Acute gout

Mechanism of action
:
promotes excretion of uric acid
.
* KIDNEY STONESSigns and Symptoms

renal colic

Cool moist skin
Nursing Management

force fluids

administer medications as ordereda. Narcotic Analgesic

Morphine Sulfate

ANTIDOTE:
Naloxone (Narcan)
toxicity leads to tremors.b. Allopurinol (Zyloprim)
Side Effects

Respiratory depression (check for RR)
Multiple losscauses
PARKINSON’S DISEASE/ PARKINSONISM

Chronic progressive disorder of CNS characterized by degeneration of
dopamine producingcells
in the
SUBSTANCIA NIGRA
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of the
midbrain
and
basal ganglia
.
Predisposing Factors
1. Poisoning (lead and carbon monoxide)2. Arteriosclerosis3. Hypoxia4. Encephalitis5.
Increase dosage of the following drugs:a. Reserpine(Serpasil)b. Methyldopa(Aldomet)
AntihypertensiveS
c. Haloperidol(Haldol)d. Phenothiazine
AntipsychoticSSIDE EFFECTS RESERPINE

Major depression leading to

suicideAlonenessL o s s o f
s p o u s e L o s s
o f J o b

direct approach towards the client

close surveillance is a nursing priority

time to commit suicide is on weekends early morning
Signs and Symptoms for Parkinson’s

pill rolling tremors of extremities especially the hands.

bradykinesia (slowness of movement)

rigidity (cogwheel type)

stooped posture

shuffling and propulsive gait

over fatigue

mask like
facial expression with decrease blinking of the eyes.

difficulty rising from sitting position.

Monotone type speech

mood lability (in state of depression)

increase salivation (
drooling type
)
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
autonomic changesa. increase sweatingb. increase lacrimationc. seborrhead.
constipatione. decrease sexual capacity
Nursing Management1. Administer medications as orderedAnti Parkinsonian agents

Levodopa (L-dopa) short acting

Amantadine Hydrochloride (Symmetrel)

Carbidopa (Sinemet)
Mechanism of Action

increase level of dopamine
Side Effects

GIT irritation (should be taken with meals

orthostatic hypotension

arrhythmia

hallucinations
Contraindications

clients with narrow angle closure glaucoma

clients taking MAOI’s (no foods with triptophan and thiamine)

urine and stool may be darkened

no
Vitamin B6
(Pyridoxine) reverses the therapeutic effects of Levodopa
* Increase Vitamin B when taking INH (Isoniazid), Isonicotinic Acid HydrazideAnti
Cholinergic Agents (ARTANE and COGENTIN)
-
to relieve tremorsMechanism of Action

inhibits action of acethylcholine
Side Effects

SNS
Anti Histamine (Dipenhydramine Hydrochloride)Side Effects
Adult: drowsinessChildren: CNS excitement (hyperactivity) because blood brain barrier
is not yet fully developed.
Dopamine Agonist - relieves tremor rigidityBromocriptene Hydrochloride (Parlodel)Side
Effects

Respiratory depression
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2. Maintain side rails to prevent injury3. Prevent complications of immobility4. Decrease
protein in morning and increase protein in afternoon to induce sleep5. Encourage increase fluid
intake and fiber.6. Assist/supervise in ambulation7. Assist in Stereotaxic Thalamotomy
MAGIC 2’s IN DRUG MONITORING
D R U G N O R M A L
R A N G E T O X I C I T Y LEVELI N D I
C A T I O N C L A S S I F I C A T I O N Digoxin/ Lanoxin
(Increase force of cardiac output)
. 5 – 1 . 5
m e q / L 2 C H F C a r d i
a c G l y c o s i d e Lithium/
Lithane
(Decrease level of Ach/NE/Serotonin)
. 6 – 1 . 2
m e q / L 2 B i p o l a r A n t i
- M a n i c A g e n t s Aminophylline
(Dilates bronchial tree)
1 0 – 1 9 m g / 1 0 0
m l 2 0 C O P D B r o n c h o d i l
a t o r s D i l a n t i n / P h e n y t o i n
1 0 – 1 9 m g / 1 0 0
m l 2 0 S e i z u r e s A n t i -
C o n v u l s a n t A c e t a m i n o p h e n / T y l
e n o l 1 0 – 3 0 m g / 1 0 0
m l 2 0 0 O s t e o ArthritisNon-narcoticAnalgesic
1. Digitalis ToxicitySigns and Symptoms

nausea and vomiting

diarrhea

confusion

photophobia

changes in color perception (yellowish spots)
Antidote:
Digibind
2. Lithium ToxicitySigns and Symptoms

anorexia

nausea and vomiting

diarrhea

dehydration causing fine tremors

hypothyroidism
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Nursing Management

force fluids

increase sodium intake to 4 – 10 g% daily
3. Aminophylline ToxicitySigns and Symptoms

tachycardia

palpitations

CNS excitement (tremors, irritability, agitation and restlessness)
Nursing Management

only mixed with plain NSS or 0.9 NaCl to prevent development of crystals or precipitate.

administered sandwich method

avoid taking alcohol because it can lead to severe CNS depression

avoid caffeine
4. Dilantin ToxicitySigns and Symptoms

gingival hyperplasia (swollen gums)

hairy tongue

ataxia

nystagmusNursing Management

provide oral care

massage gums
5. Acetaminophen ToxicitySigns and Symptoms

hepatotoxicity (monitor for liver enzymes)

SGPT/ALT (Serum Glutamic Pyruvate Transaminace)

SGOT/AST (Serum Glutamic Oxalo-Acetil Transaminace)

nephrotoxicity monitor BUN (10 – 20) and Creatinine (.8 – 1)

hypoglycemia
T
remors, tachycardia
I
rritability
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R
estlessness
E
xtreme fatigue
D
iaphoresis, depression
Antidote:
Acetylcisteine (mucomyst) prepare suction apparatus as bedside.
MYASTHENIAGRAVIS

neuromuscular disorder characterized by a disturbance in the transmission of impulses
fromnerve to muscle cells at the neuromuscular junction leading to descending muscle
weakness.
Incidence rate:
women 20 – 40 years old
Predisposing factors

unknown

autoimmune: it involves release of cholinesterase an enzyme that destroys Ach.
Signs and Symptoms

initial sign is
ptosis
a clinical parameter to determine ptosis is palpebral fissure.

diplipia

mask like facial expression

dysphagia

hoarseness of voice

respiratory muscle weakness that may lead to respiratory arrest

extreme muscle weakness especially during exertion and morning
Diagnostic Procedure

Tensilon test
(Edrophonium Hydrochloride) provides temporary relief of signs and symptomsfor about
5 – 10 minutes
and a maximum of
15 minutes
.

if there is no effect there is damage to occipital lobe and midbrain and is negative for
M.G.
Nursing Management
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1. airway2. aspiration maintain patent airway and adequate ventilation3. mmobility*
assist in mechanical ventilation and monitor pulmonary function test* monitor strictly
vital signs, input and output and neuro check* monitor strength or motor grading scale4.
maintain side rails to prevent injury related to falls5. institute NGT feeding6. administer
medications as ordereda. Cholinergic (Mestinon)b. Anti Cholenisterase (Neostegmin)
Mechanism of Action

increase level of Ach
Side Effects

PNS

Cortocosteroids
suppress immune response

monitor for 2 types of crisis:
M Y A S T H E N I C
C R I S I S C H O L I N E R G
I C C R I S I S Causes:
- under medication- stress- infection
Signs and Symptoms
- The client is unable to see, swallow, speak,breathe
Treatment
- administer cholinergic agents as ordered
Cause:
- over medication
Signs and Symptoms
- PNS
Treatment
- Administer anti cholinergic agents(Atropine Sulfate)7 . A s s i s t i n s u rg i c a l
procedure known as thymectomy because it is believed that the
t h y m u s g l a n d i s responsible for M.G.8. Assist in plasma paresis and removing auto
immune anti bodies9. Prevent complications
INFLAMMATORYCONDITIONSOFTHEBRAIN
MENINGITIS
Meninges

3 fold membrane that covers brain and spinal cord.

for support and protection

for nourishment

blood supply
LAYERS OF THE MENINGES
1.
Dura matter
– outer layer 2.
Arachnoid
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– middle layer 3.
Pia matter
– inner layer

subdural space between the dura and arachnoid

subarachnoid space between the arachnoid and pia, CSF aspiration is done.
A. Etiology
1. Meningococcus – most dangerous2. Pneumococcus3. Streptococcus - causes adult
meningitis4. Hemophilus Influenzae – causes pediatric meningitis
B. Mode of transmission

airborne transmission (droplet nuclei)
C. Signs and Symptoms

headache

photophobia

projectile vomiting

fever, chills, anorexia, general body malaise and weight loss

Possible increase in ICP and seizure activity

Abnormal posturing (decorticate and decerebrate)

Signs of meningeal irritationa. Nuchal rigidity or stiff neckb. Opisthotonus (arching of
back)c. (+) Kernig’s sign (leg pain)d. (+) Brudzinski sign (neck pain)
D. Diagnostic Procedures

Lumbar puncture: a hollow spinal needle is inserted in the subarachnoid space between
theL3 – L4 to L5.
Nursing Management for LPBefore Lumbar Puncture
1. Secure informed consent and explain procedure.2. Empty bladder and bowel to
promote comfort.3. Encourage to arch back to clearly visualize L3-L4.
Post Lumbar Puncture
1. Place flat on bed 12 – 24
o
2. Force fluids3. Check punctured site for any discoloration, drainage and leakage to
tissues.4. Assess for movement and sensation of extremities.
CSF analysis reveals
1. Increase CHON and WBC2. Decrease glucose3. Increase CSF opening pressure
(normal pressure is 50 – 100 mmHg)4. (+) cultured microorganism (confirms meningitis)
CBC reveals
1. Increase wbc
E. Nursing Management
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1. Enforce complete bed rest2. Administer medications as ordereda. Broad spectrum
antibiotics (Penicillin, Tetracycline)b. Mild analgesicsc. Anti pyretics3. Institute strict
respiratory isolation 24 hours after initiation of anti biotic therapy4. Elevate head 30-45
o
5. Monitor strictly V/S, input and output and neuro check6. Institute measures to prevent
increase ICP and seizure.7. Provide a comfortable and darkened environment.8. Maintain
fluid and electrolyte balance.9. Provide client health care and discharge planning
concerning:a. Maintain good diet of increase CHO, CHON, calories with small frequent
feedings.b. Prevent complications

most
feared
is
hydrocephalus

hearing loss
/
nerve deafness
is second complication

consult
audiologist
c. Rehabilitation for neurological deficit

mental retardation

delayed psychomotor development
CVA (STROKE/BRAIN ATTACK/ ADOPLEXY/ CEREBRAL THROMBOSIS)

a partial or complete disruption in the brains blood supply.

2 most common cerebral artery affected by strokea. Mid Cerebral Arteryb. Internal
Cerebral Artery – the 2 largest artery
A. Incidence Rate

men are 2-3 times high risk
B. Predisposing Factors

thrombus (attached)

embolus (detached and most dangerous because it can go to
the
lungs
and cause
pulmonary embolism
or the
brain
and cause
cerebral embolism
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.
Signs and Symptoms of Pulmonary Embolism

Sudden sharp chest pain

Unexplained dyspnea

Tachycardia

Palpitations

Diaphoresis

Mild restlessness
Signs and Symptoms of Cerebral Embolism

Headache and dizziness

Confusion

Restlessness

Decrease LOC

Fat embolism is the most feared complications after femur fracture.

Yellow bone marrow are produced from the medullary cavity of the long bones and
produces fat cells.

If there is bone fracture there is hemorrhage and there would be escape of the fat cells in
the circulation.

Compartment syndrome (compression of arteries and nerves)
C. Risk Factors
1. Hypertension, Diabetes Mellitus, Myocardial Infarction, Atherosclerosis,
Valvular Heart Disease, PostCardiac Surgery (mitral valve replacement)2. Lifestyle
(smoking), sedentary lifestyle3. Obesity (increase 20% ideal body weight)4.
Hyperlipidemia more on genetics/genes that binds to cholesterol5. Type A personalitya.
deadline drivenb. can do multiple tasksc. usually fells guilty when not doing anything6.
Related to diet: increase intake of saturated fats like whole milk7. Related stress physical
and emotional8. Prolong use of oral contraceptives promotes lypolysis (breakdown of
lipids) leading to atherosclerosis thatwill lead to hypertension and eventually CVA.
D. Signs and Symptoms

dependent on stages of development
1. TIA

Initial sign of stroke or warning sign
Signs and Symptoms
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
headache and dizziness

tinnitus

visual and speech disturbances

paresis (plegia)

possible increase ICP
2. Stroke in evolution

progression of signs and symptoms of stroke
3. Complete stroke

resolution phase characterized by:
Signs and Symptoms

headache and dizziness

Cheyne Stokes Respiration

anorexia, nausea and vomiting

dysphagia

(+) Kernig’s sign and Brudzinski sign which may lead to hemorrhagic stroke

focal neurological deficitsa. phlegiab. aphasiac. dysarthria (inability to articulate words)d.
alexia (difficulty reading)e. agraphia (difficulty writing)f. homonymous hemianopsia
(loss of half of visual field)
E. Diagnostic Procedure
1.
CT Scan
– reveals brain lesions2.
Cerebral Arteriography

reveals the site and extent of malocclusion

uses dye for visualization

most of dye are iodine based

check for shellfish allergy

after diagnostic exam force fluids to release dye because it is nephro toxic

check for distal pulse (femoral)

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check for hematoma formation
F. Nursing Management
1. Maintain patent airway and adequate ventilation by:a. assist in mechanical
ventilationb. administrate O2 inhalation2. Restrict fluids to prevent cerebral edema that
might increase ICP3. Elevate head 30 – 45
o
4. Monitor strictly vitals signs, I & O and neuro check5. Prevent complications of
immobility by:a. turn client to sideb. provide egg crate mattresses or water bedc. provide
sand bag or food board.6. Assist in passive ROM exercise every 4 hours to promote
proper bodily alignment and prevent contractures7. Institute NGT feeding8. Provide
alternative means of communicationa. non verbal cuesb. magic slate9. If positive to
hemianopsia approach client on unaffected side10. Administer medications as ordereda.
Osmotic Diuretics (Mannitol)b. Loop Diuretics (Lasix, Furosemide)c. Cortecosteroidsd.
Mild Analgesicse. Thrombolytic/Fibrinolytic Agents – dissolves thrombus

Streptokinase

Side Effect: Allergic Reaction

Urokinase

Tissue Plasminogen Activating Factor

Side Effect: Chest Painf. Anti Coagulants

Heparin (short acting)

check for partial thromboplastin time if prolonged there is a risk for bleeding.

give Protamine Sulfate

Comadin/ Warfarin (long acting)

give simultaneously because Coumadin will take effect after 3 days

check for prothrombin time if prolonged there is a risk for bleeding

give Vit. K (Aqua Mephyton)g. Anti Platelet

PASA (Aspirin)

Contraindicated for dengue, ulcer and unknown cause of headache because it
maypotentiate bleeding11. Provide client health teachings and discharge planning
concerninga. avoidance of modifiable risk factors (diet, exercise, smoking)b. prevent
complication (subarachnoid hemorrhage is the most feared complication)c. dietary
modification (decrease salt, saturated fats and caffeine)d. importance of follow up care
GUILLAIN BARRE SYNDROME


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a disorder of the CNS characterized by bilateral symmetrical polyneuritis leading to
ascending muscleparalysis.
A. Predisposing Factors
1. Autoimmune2. Antecedent viral infections such as LRT infections
B. Signs and Symptoms
1.
Clumsiness (initial sign)
2. Dysphagia3. Ascending muscle weakness leading to paralysis4. Decreased of
diminished deep tendon reflex5. Alternate hypotension to hypertension
** ARRYTHMIA (most feared complication)
6. Autonomic symptoms that includesa. increase salivationb. increase sweatingc.
constipation
C. Diagnostic Procedures
1. CSF analysis reveals increase in IgG and protein
D. Nursing Management
1. Maintain patent airway and adequate ventilation by:a. assist in mechanical
ventilationb. monitor pulmonary function test2. Monitor strictly the followinga. vital
signsb. intake and outputc. neuro checkd. ECG3. Maintain side rails to prevent injury
related to fall4. Prevent complications of immobility by turning the client every 2 hours5.
Institute NGT feeding to prevent aspiration6. Assist in passive ROM exercise7.
Administer medications as ordereda. Corticosteroids – suppress immune responseb. Anti
Cholinergic Agents – Atrophine Sulfatec. Anti Arrythmic Agents

Lidocaine, Zylocaine

Bretylium – blocks release of norepinephrine to prevent increase of BP8. Assist in
plasma pharesis
(filtering of blood to remove autoimmune anti-bodies)9. Prevent complicationsa.
Arrythmiab. Paralysis or respiratory muscles/Respiratory arrest
* Sengstaken Blakemore Tube

for liver cirrhosis

to decompress bleeding esophageal verices (prepare scissor to cut tube incase of
difficulty inbreathing to release air in the balloon

for hemodialysis prepare bulldog clips to prevent air embolism.
CONVULSIVE DISORDER/ CONVULSION


disorder of CNS characterized by paroxysmal seizure with or without loss of
consciousnessabnormal motor activity alternation in sensation and perception and
changes in behavior.

Seizure
– first convulsive attack

Epilepsy
– second or series of attacks
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
Febrile seizure
– normal in children age below 5 years
1. Head injury due to birth trauma2. Genetics3. Presence of brain tumor 4. Toxicity froma.
leadb carbon monoxide5. Nutritional and Metabolic deficiencies6. Physical and
emotional stress7. Sudden withdrawal to anti convulsant drug is predisposing
factor for status epilepticus (drug of choice is Diazepam, Valium)

Dependent on stages of development or types of seizure
I. Generalized Seizure
1.
Grand mal Seizure
(tonic-clonic seizure)a. Signs or aura with auditory, olfactory, visual, tactile, sensory
experienceb. Epileptic cry – is characterized by fall and loss of consciousness for 3 – 5
minutesc. Tonic contractions - direct symmetrical extension of extremitiesClonic
contractions - contraction of extremitiesd. Post ictal sleep – unresponsive sleep2.
Petit mal Seizure
– absence of seizure common among pediatric clients characterized bya. blank stareb.
decrease blinking of eyesc. twitching of mouthd. loss of consciousness (5 – 10 seconds)
II. Partial or Localized Seizure
1.
Jacksonian Seizure
(focal seizure)

Characterized by tingling and jerky movement of index finger and thumb that
spreads to the shoulder and other side of the body.2.
Psychomotor Seizure
(focal motor seizure)a. automatism – stereotype repetitive and non propulsive behavior b.
clouding of consciousness – not in contact with environmentc. mild hallucinatory sensory
experience
III. Status Epilepticus

A continuous uninterrupted seizure activity, if left untreated can lead to hyperpyrexia and
leadto coma and eventually death.

Drug of choice
: Diazepam, Valium and Glucose
1. CT Scan – reveals brain lesions2. EEG – reveals hyper activity of electrical brain
waves
1. Maintain patent airway and promote safety before seizure activitya. clear the site of
blunt or sharp objectsb. loosen clothing of clientc. maintain side railsd. avoid use of
restrainse. turn clients head to side to prevent aspirationf. place mouth piece of tongue
guard to prevent biting or tongue2. Avoid precipitating stimulus such as bright/glaring
lights and noise3. Administer medications as ordereda. Anti convulsants (Dilantin,
Phenytoin)b. Diazepam, Valiumc. Carbamazepine (Tegretol) – Trigeminal neuralgiad.
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Phenobarbital, Luminal4. Institute seizure and safety precaution post seizure attacka.
administer O2 inhalationb. provide suction apparatus5. Document and monitor the
followinga. onset and durationb. types of seizuresc. duration of post ictal sleep may lead
to status epilepticusd. assist in surgical procedure cortical resection
COMPREHENSIVE NEURO EXAMGLASGOW COMA SCALE

objective measurement of LOC sometimes called as the quick neuro check
Components
1. Motor response2. Verbal response3. Eye opening

Survey of mental status and speecha. LOCb. Test of memory

Levels of orientation

Cranial nerve assessment

Sensory nerve assessment

Motor nerve assessment

Deep tendon reflex

Autonimics

Cerebellar testa, Romberg’s test – 2 nurses, positive for ataxiab. Finger to nose test –
positive result mean dimetria(inability of body to stop movement at desired point)c.
Alternate supination and pronation – positive result mean dimetriaConscious 15 –
14Lethargy 13 – 11Stupor 10 – 8Coma 7Deep Coma 3
I. LEVEL OF CONSCIOUSNESS
1. Conscious - awake2. Lethargy – lethargic (drowsy, sleepy, obtunded)3. Stupor

stuporous (awakened by vigorous stimulation)

generalized body weakness

decrease body reflex4. Coma

comatose

light coma (positive to all forms of painful stimulus)

deep coma (negative to all forms of painful stimulus)
DIFFERENT PAINFUL STIMULATION
1. Deep sternal stimulation/ deep sternal pressure2. Orbital pressure3. Pressure on great
toes4. Corneal or blinking reflex

Conscious client use a wisp of cotton

Unconscious client place 1 drop of saline solution
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II. TEST OF MEMORY
1. Short term memory

ask most recent activity

positive result mean anterograde amnesia and damage to temporal lobe2. Long term
memory

ask for birthday and validate on profile sheet

positive result mean retrograde amnesia and damage to limbic system

consider educational background
III. LEVELS OF ORIENTATION
1. Time – first asked2. Person – second asked3. Place – third asked
CRANIAL NERVESC R A N I A L
N E R V E S F U N C T I O N
I .
O L F A C T O R Y S
I I .
O P T I C S
I I I
O C C U L O M O T O R M I V .
T R O C H L E A R M (
Smallest
)V .
T R I G E M I N A L B (
Largest
)V I .
A B D U C E N S E M V I
I .
F A C I A L B V I
I I .
A C O U S T I C S IX.
GLOSSOPHARYNGEALBX .
V A G U S B
(
Longest
)X I . S P I N A L A C C E S S O R Y M X I I .
H Y P O G L O S S A L M
CRANIAL NERVE I: OLFACTORY

sensory function for smell
Material Used

don’t use alcohol, ammonia, perfume because it is irritating and highly diffusible.

use coffee granules, vinegar, bar of soap, cigarette
Procedure
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
test each nostril by occluding each nostril
Abnormal Findings
1. Hyposnia – decrease sensitivity to smell2. Dysosmia – distorted sense of smell3.
Anosmia – absence of smell
Indicative of
1. head injury damaging the
cribriform
plate of ethmoid bone where olfactory cells are located2. may indicate inflammatory
conditions (sinusitis)
CRANIAL NERVE II: OPTIC

sensory function for vision or sight
Functions
1. Test visual acuity or central vision or distance

use
Snellen’s Chart

Snellen’s Alphabet chart: for literate clients

Snellen’s E chart: for illiterate clients

Snellen’s Animal chart: for pediatric clients

normal visual acuity 20/20

numerator is constant, it is the distance of person from the chart (6 – 7 m, 20 feet)

denominator changes, indicates distance by which the person normally can see letter in
thechart.

- 20/200 indicates blindness

20/20 visual acuity if client is able to read letters above the red line.2. Test of visual field or
peripheral visiona. Superiorlyb. Bitemporalyc. Nasallyd. Inferiorly
COMMON VISUAL DISORDERS1. Glaucoma

increase IOP

normal IOP is
12 – 21 mmHg

preventable but not curable

Common among 40 years old and above

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Hereditary

Hypertension

Obesity
1. Loss of peripheral vision

pathognomonic sign is
tunnel vision
2. Headache, nausea, vomiting, eye pain (
halos around light
)

steamy cornea

may lead to blindness
1. Tonometry2. Perimetry3. Gonioscopy
D. Treatment
1.
Miotics
– constricts pupila.
Pilocarpine Sodium
,
Carbachol
2.
Epinephrine eyedrops
– decrease formation of aqueous humor 3.
Carbonic Anhydrase Inhibitors
a.
Acetazolamide (Diamox)
– promotes increase outflow of aqueous humor or drainage4.
Timoptics
(
Timolol Maleate
)
E. Surgical Procedures
1.
TRABECULECTOMY
(Peripheral Indectomy) – drain aqueous humor
2. Cataract

Decrease opacity of lens
A. Predisposing Factor
1. Aging 65 years and above2. Related to congenital3. Diabetes Mellitus4. Prolonged
exposure to UV rays
1. Loss of central vision
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C. Pathognomonic Signs
1. Blurring or hazy vision2. Milky white appearance at center of pupils3. Decrease
perception to colors

Complication is blindness
D. Diagnostic Procedure
1. Opthalmoscopic exam
E. Treatment
1.
Mydriatics (Mydriacyl)
– constricts pupils2.
Cyclopegics (Cyclogyl)
– paralyses cilliary muscle
F. Surgical ProcedureE
xtra
I
ntra
C
apsular
C
apsular
C
ataract
C
ataract
L
ens
L
ens
E
xtraction
E
xtraction- P a r t i a l r e m o v a l - T o t a l r e m o v a l o f
c a t a r a c t w i t h i t s s u r r o u n d i n g c a p s u l e s

Most feared complication post op is RETINAL DETACHMENT3. Retinal Detachment

Separation of epithelial surface of retina
1. Post Lens Extraction2. Myopia (near sightedness)
1. Curtain veil like vision2. Floaters
C. Surgical Procedures
1.
Scleral Buckling
2.
Cryosurgery
– cold application3.
Diathermy
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– heat application
4. Macular Degeneration

Degeneration of the
macula lutea
(yellowish spot at the center of retina)
A. Signs and Symptoms
1. Black Spots
CRANIAL NERVE III, IV, VI: OCULOMOTOR, TROCHLEAR, ABDUCENS

Controls or innervates the movement of extrinsic ocular muscle (EOM)

6 musclesS u p e r i o r R e c t u s S u p e r i o r
O b l i q u e L a t e r a l
R e c t u s M e d i a l
R e c t u s I n f e r i o r
O b l i q u e I n f e r i o r R e c t u s

trochlear controls superior oblique

abducens controls lateral rectus

oculomotor controls the 4 remaining EOM
Oculomotor

controls the size and response of pupil

normal pupil size is 2 – 3 mm

equal size of pupil: Isocoria

Unequal size of pupil: Anisocoria

Normal response: positive PERRLA
CRANIAL NERVE V: TRIGEMINAL

largest cranial nerve

consists of ophthalmic, maxillary, mandibular

sensory: controls sensation of face, mucous membrane, teeth, soft palate and corneal
reflex)

motor: controls the muscle of mastication or chewing

damage to CN V leads to trigeminal neuralgia/thickdolorum

medication: Carbamezapine(Tegretol)
CRANIAL NERVE VII: FACIAL
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
Sensory: controls taste, anterior 2/3 of tongue

pinch of sugar and cotton applicator placed on tip of tongue

Motor: controls muscle of facial expression

instruct client to smile, frown and if results are negative there is facial paralysis or Bell’s
Palsyand the primary cause is forcep delivery.
CRANIAL NERVE VIII: ACOUSTIC/VESTIBULOCOCHLEAR

Controls balance particularly
kinesthesia
o r p o s i t i o n s e n s e , r e f e r s t o m o v e m e n t a n d orientation of the body in
space.
Parts of the Ear
1.
Outer Ear

Pinna

Eardrum2.
Middle Ear

H
ammer
M
alleus

A
nvil
I
ncus

S
tirrup
S
tapes3.
Inner Ear

Vestibule:
Meinere’s Disease

Cochlea

Mastoid Cells

Endolymph and Perilymph

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COCHLEA
: controls hearing, contains the
Organ of Corti
(the true organ of hearing)

Let client repeat words uttered
CRANIAL NERVE IX, X: GLOSOPHARYNGEAL, VAGUS NERVE

Glosopharyngeal: controls taste, posterior 1/3 of tongue

Vagus: controls gag reflex

Uvula should be midline and if not indicative of damage to cerebral hemisphere

Effects of vagal stimulation is PNS
CRANIAL NERVE XI: SPINALACCESSORY

Innervates with sternocleidomastoid (neck) and trapezius (shoulder)
CRANIAL NERVE XII: HYPOGLOSSAL

Controls the movement of tongue

Let client protrude tongue and it should be midline and if unable to do indicative of
damage tocerebral hemisphere and/or has short frenulum.
ENDOCRINE SYSTEMOverview of the structures and functions1. Pituitary Gland
(Hypophysis Cerebri)
o
Located at base of brain particularly at
sella turcica
o
Master gland or master clock
o
Controls all metabolic function of body
PARTS OF THE PITUITARY GLAND
1.
Anterior Pituitary Gland
o
called as adenohypophysis2.
Posterior Pituitary Gland
o
called as neurohypophysis
o
secretes hormones oxytocin -promotes uterine contractions preventing bleeding/
hemorrhage
o
administrate oxytocin immediately after delivery to prevent uterine atony.
o
initiates milk let down reflex with help of hormone prolactin
2. Antidiuretic Hormone
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o
Pitressin (Vasopressin)
o
Function: prevents urination thereby conserving water
o
Diabetes Insipidus/ Syndrome of Inappropriate Anti Diuretic Hormone
DIABETES INSIPIDUS
o
Decrease production of anti diuretic hormone
A. Predisposing Factor
o
Related to pituitary surgery
o
Trauma
o
Inflammation
o
Presence of tumor
1. Polyuria2. Signs of dehydrationa. Adult: thirstb. Agitationc. Poor Skin turgor d. Dry
mucous membrane3. Weakness and fatigue4. Hypotension5. Weight loss6. If left
untreated results to hypovolemic shock (sign is anuria)
1. Urine Specific Gravity
o
Normal value:
1.015 – 1.030
o
Ph 4 – 82. Serum Sodium
o
Increase resulting to hypernatremia
1. Force fluids2. Monitor strictly vital signs and intake and output3. Administer
medications as ordereda.
Pitressin (Vasopresin Tannate)
– administered IM Z-tract4. Prevent complilcations – HYPOVOLEMIC SHOCK is the
most feared complication
SIADH
o
hypersecretion of anti diuretic hormone
1. Head injury2. Related to presence of bronchogenic cancer
o
initial sign of lung cancer is non productive cough
o
non invasive procedure is chest x-ray3. Related to hyperplasia (increase size of
organ brought about by increase of number of cells) of pituitary gland.
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1. Fluid retentiona. Hypertensionb. Edemac. Weight gain2. Water intoxication may lead to
cerebral edema and lead to increase ICP – may lead to seizure activity
C. Diagnostic Procedure
1. Urine specific gravity is
increased
2. Serum Sodium is decreased
1. Restrict fluid2. Administer medications as ordereda. Loop diuretics (Lasix)b. Osmotic
diuretics (Mannitol)3. Monitor strictly vital signs, intake and output and neuro check4.
Weigh patient daily and assess for pitting edema5. Provide meticulous skin care6. Prevent
complications
ANTERIOR PITUITARY GLAND
o
also called
ADENOHYPOPHYSIS
secretes
1. Growth hormones (somatotropic hormone)
o
Promotes elongation of long bones
o
Hyposecretion
of GH among children results to
Dwarfism
o
Hypersecretion
of GH results to
Gigantism
o
Hypersecretion
of GH among adults results to
Acromegaly
(square face)
o
Drug of choice
:
Ocreotide (Sandostatin)2. Melanocyte Stimulating hormone
o
for skin pigmentation
o
Hyposecretion
of MSH results to
Albinism
o
Most feared complications of albinisma. Lead to
blindness
due to severe photophobiab. Prone to
skin cancer
o
Hypersecretion
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of MSH results to
Vitiligo3. Adrenochorticotropic hormone (ACTH)
o
promotes development of adrenal cortex4.
Lactogenic homone
(
Prolactin
)
o
promotes development of mammary gland
o
with help of oxytocin it initiates milk let down reflex5.
Leutinizing hormone
o
secretes estrogen6.
Follicle stimulating hormone
o
secretes progesterone
PINEAL GLAND
o
secretes
melatonin
o
inhibits LH secretion
o
it controls/regulates circadian rhythm (body clock)
THYROID GLAND
o
located anterior to the neck
3 Hormones secreted
1.
T3
(
Tri iodothyronine
)
- 3 molecules of iodine (more potent)2.

T4
(
tetra iodothyronine
,
Thyroxine)
o
T3 and T4 are metabolic or calorigenic hormone
o
promotes cerebration (thinking)3.
Thyrocalcitonin
– antagonizes the effects of parathormone to promote calcium resorption.
HYPOTHYROIDISM
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o
all are
decrease
except
weight
and
menstruation
o
memory impairment
Signs and Symptoms
o
there is loss of appetite but there is weight gain
o
menorrhagia
o
cold intolerance
o
constipation
HYPERTHYROIDISM
o
all are
increase
except
weight
and
menstruationSigns and Symptoms
o
increase appetite but there is weight loss
o
amenorrhea
o
exophthalmos
THYROID DISORDERSSIMPLE GOITER
o
enlargement of thyroid gland due to iodine deficiency
1. Goiter belt areaa. places far from seab. Mountainous regions2. Increase intake of
goitrogenic foods
o
contains pro-goitrin an anti thyroid agent that has no iodine.
o
cabbage, turnips, radish, strawberry, carrots, sweet potato, broccoli, all nuts
o
soil erosion washes away iodine
o
goitrogenic drugsa. Anti Thyroid Agent – Prophylthiuracil (PTU)b. Lithium Carbonate
c. PASA (Aspirin)d. Cobalte. Phenylbutazones (NSAIDs)- if goiter is caused by
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1. Enlarged thyroid gland2. Mild dysphagia3. Mild restlessness
1. Serum T3 and T4 – reveals normal or below normal2. Thyroid Scan – reveals enlarged
thyroid gland.3. Serum Thyroid Stimulating Hormone (TSH) – is increased (confirmatory
diagnostic test)
1. Enforce complete bed rest2. Administer medications as ordereda.
Lugol’s Solution/SSKI
( Saturated Solution of Potassium Iodine)
o
color purple or violet and administered via straw to prevent staining of teeth.
o
4 Medications to be taken via straw: Lugol’s, Iron, Tetracycline, Nitrofurantoin (drug of
choicefor pyelonephritis)b.
Thyroid Hormones
o
Levothyroxine (Synthroid)
o
Liothyronine (Cytomel)
o
Thyroid Extracts
Nursing Management when giving Thyroid Hormones
1. Instruct client to take in the morning to prevent insomnia2. Monitor vital signs
especially heart rate because drug causes tachycardia and palpitations3. Monitor side
effects
o
insomnia
o
tachycardia and palpitations
o
hypertension
o
heat intolerance4. Increase dietary intake of foods rich in iodine
o
seaweeds
o
seafood’s like oyster, crabs, clams and lobster but not shrimps because it
contains lesser amount of iodine.
o
iodized salt, best taken raw because it it is easily destroyed by heat5. Assist in surgical
procedure of
subtotal thyroidectomyHYPOTHYROIDISM
o
hyposecretion of thyroid hormone
o
adults
:
MYXEDEMA
non pitting edema
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o
children
:
CRETINISM
the only endocrine disorder that can lead to mental retardationA. Predisposing Factors
1.
Iatrogenic Cause
– disease caused by medical intervention such as surgery2. Related to atrophy of thyroid
gland due to
trauma
,
presence of tumor
,
inflammation
3. Iodine deficiency4. Autoimmune (
Hashimotos Disease
)
B. Signs and Symptoms(Early Signs)
1. Weakness and fatigue2. Loss of appetite but with weight gain which promotes lipolysis
leading to atherosclerosis and MI3. Dry skin4. Cold intolerance5. Constipation
(Late Signs)
1. Brittleness of hair and nails2. Non pitting edema (Myxedema)3. Hoarseness of voice4.
Decrease libido5. Decrease in all vital signs – hypotension, bradycardia, bradypnea,
hypothermia6. CNS changes
o
lethargy
o
memory impairment
o
psychosis
o
menorrhagia
1. Serum T3 and T4 is decreased2. Serum Cholesterol is increased3. RAIU (Radio Active
Iodine Uptake) is decreased
1. Monitor strictly vital signs and intake and output to determine presence of
o
Myxedema coma is a complication of hypothyroidism and an emergency case
o
a severe form of hypothyroidism is characterized by severe
h y p o t e n s i o n , b r a d y c a r d i a , bradypnea, hypoventilation, hyponatremia,
hypoglycemia, hypothermia leading to pregressivestupor and coma.
Nursing Management for Myxedema Coma

Assist in mechanical ventilation

Administer thyroid hormones as ordered
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
Force fluids2. Force fluids3. Administer isotonic fluid solution as ordered4. Administer
medications as orderedThyroid Hormonesa. Levothyroxineb. Leothyroninec. Thyroid
Extracts5. Provide dietary intake that is low in calories6. Provide comfortable and warm
environment7. Provide meticulous skin care8. Provide client health teaching and
discharge planning concerninga. Avoid precipitating factors leading to myxedema coma
o
stress
o
infection
o
cold intolerance
o
use of anesthetics, narcotics, and sedatives
o
prevent complications (myxedema coma, hypovolemic shock
o
hormonal replacement therapy for lifetime
o
importance of follow up care
HYPERTHYROIDISM
o
increase in T3 and T4
o
Grave’s Disease
or
Thyrotoxicosis
o
developed by
Robert GraveA. Predisposing Factors
1. Autoimmune – it involves release of long acting thyroid stimulator causing
exopthalmus
(protrusionof eyeballs)
enopthalmus
(late sign of dehydration among infants)2. Excessive iodine intake3. Related to
hyperplasia (increase size)
1. Increase appetite (hyperphagia) but there is weight loss2. Moist skin3. Heat
intolerance4. Diarrhea5. All vital signs are increased6. CNS involvementa. Irritability and
agitationb. Restlessnessc. Tremorsd. Insomniae. Hallucinations7. Goiter 8. Exopthalmus9.
Amenorrhea
1. Serum T3 and T4 is increased2. RAIU (Radio Active Iodine Uptake) is increased3.
Thyroid Scan- reveals an enlarged thyroid gland
1. Monitor strictly vital signs and intake and output2. Administer medications as
orderedAnti Thyroid Agenta. Prophythioracill (PTU)b. Methymazole (Tapazole)
Side Effects of Agranulocytosis
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o
increase lymphocytes and monocytes
o
fever and chills
o
sore throat (throat swab/culture)
o
leukocytosis (CBC)3. Provide dietary intake that is increased in
calories
.4. Provide meticulous skin care5. Comfortable and cold environment6. Maintain side
rails7. Provide bilateral eye patch to prevent drying of the eyes.8. Assist in surgical
procedures known as subtotal thyroidectomy**
Before thyroidectomy
administer Lugol’s Solution (SSKI) to decrease vascularity of the thyroidgland to prevent
bleeding and hemorrhage.
TRIAD SIGNS
POSTOPERATIVELY,1. Watch out for signs of thyroid storm/ thyrotoxicosis
AgitationH y p e r t h e r
m i a T a c h y c a
r d i a
o
administer medications as ordereda. Anti Pyreticsb. Beta-blockers
o
monitor strictly vital signs, input and output and neuro check.
o
maintain side rails
o
offer TSB
2. Watch out for accidental removal of parathyroid gland that may lead
toHypocalcemia (tetany)Signs and Symptoms
o
(+) trousseau’s sign
o
(+) chvostek sign
o
Watch out for arrhythmia, seizure give Calcium Gluconate IV slowly as ordered
3. Watch out for accidental Laryngeal damage which may lead to hoarseness of
voice
Nursing Management
o
encourage client to talk/speak immediately after operation and notify physician
4. Signs of bleeding (feeling of fullness at incisional site)
Nursing Management
o
Check the soiled dressings at the back or nape area.
5. Hormonal replacement therapy for lifetime6. Importance of follow up
carePARATHYROID GLAND
o
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A pair of small nodules behind the thyroid gland
o
Secretes parathormone
o
Promotes calcium reabsorption
o
Hypoparathyroidism
o
Hyperparathyroidism
HYPOPARATHYROIDISM
o
Decrease secretion of parathormone leading to
hypocalcemia
o
Resulting to hyperphospatemia
1. Following subtotal thyroidectomy2. Atrophy of parathyroid gland due to:
a. inflammationb. tumor c. trauma
1. Acute tetanya. tingling sensationb. paresthesiac. numbnessd. dysphagiae. positive
trousseu’s sign/carpopedal spasmf. positive chvostek signg.
laryngospasm/broncospasmh . s e i z u r e f e a r e d
c o m p l i c a t i o n s i. arrhythmia2. Chronic tetanya. photophobia and cataract
formationb. loss of tooth enamelc. anorexia, nausea and vomitingd. agitation and memory
impairment
1. Serum Calcium is decreased (normal value: 8.5 – 11 mg/100 ml)2. Serum Phosphate is
decreased (normal value: 2.5 – 4.5 mg/100 ml)3. X-ray of long bones reveals a decrease
in bone density4. CT Scan – reveals degeneration of basal ganglia
D. Nursing Management1. Administer medications as ordered such as:
a.
Acute Tetany

Calcium Gluconate IV slowlyb.
Chronic Tetany

Oral Calcium supplements

Calcium Gluconate

Calcium Lactate

Calcium Carbonatec. Vitamin D (Cholecalciferol) for absorption of calcium
CHOLECALCIFEROLARE DERIVED FROM
D r u g
D i e t (
Calcidiol
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)
S u n l i g h t
(
Calcitriol
)d. Phosphate binder

Aluminum Hydroxide Gel (
Ampogel
)

Side effect: constipation
ANTACIDA . A .
C
M A D ▼
▼A l u m i n u m C o n t a i n i n g
M a g n e s i u m
C o n t a i n i n g A n t a c i d s
A n t a c i d s ▼ ▼ AluminumHydroxide
Gel ▼S i d e E f f e c t :
C o n s t i p a t i o n S i d e E f f e c t :
D i a r r h e a 2. Avoid precipitating stimulus such as glaring lights and noise3.
Encourage increase intake of foods rich in calcium
a. anchoviesb. salmonc. green turnips
4. Institute seizure and safety precaution5. Encourage client to breathe using paper bag to
produce mild respiratory acidosis result.6. Prepare trache set at bedside for presence of
laryngo spasm7. Prevent complications8. Hormonal replacement therapy for lifetime9.
Importance of follow up care.HYPERTHYROIDISM
o
Decrease parathormone
o
Hypercalcemia: bone demineralization leading to bone fracture (calcium is stored 99% in
bone and 1%blood)
o
Kidney stones
1. Hyperplasia of parathyroid gland2. Over compensation of parathyroid gland due to
vitamin D deficiencya. Children: Rickettsb. Adults: Osteomalacia
1. Bone pain especially at back (bone fracture)2. Kidney stonesa. renal cholicb. cool
moist skin3. Anorexia, nausea and vomiting4. Agitation and memory impairment
1. Serum Calcium is increased2. Serum Phosphate is decreased3. X-ray of long bones
reveals bone demineralization
1. Force fluids to prevent kidney stones2. Strain all the urine using gauze pad for stone
analysis3. Provide warm sitz bath4. Administer medications as ordereda. Morphine
Sulfate (Demerol)5. Encourage increase intake of foods rich in phosphate but decrease in
calcium6. Provide acid ash in the diet to acidify urine and prevent bacterial growth7.
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Assist/supervise in ambulation8. Maintain side rails9. Prevent complications (seizure and
arrhythmia)10. Assist in surgical procedure known as
parathyroidectomy
11. Hormonal replacement therapy for lifetime12. Importance of follow up care
ADRENAL GLAND
o
Located atop of each kidney
o
2 layers of adrenal glanda. Adrenal Cortex – outermostb. Adrenal Medulla – innermost
(secretes catecholamines a power hormone)
2 Types of Catecholamines
o
Epinephrine and Norepinephrine (vasoconstrictor)
o
Pheochromocytoma (adrenal medulla)
o
Increase secretion of norepinephrine
o
Leading to hypertension which is resistant to pharmacological agents leading to CVA
o
Use beta-blockers
ADRENAL CORTEX3 Zones/Layers1. Zona Fasciculata
- secretes glucocortocoids (cortisol)-
function
: controls glucose metabolism- Sugar
2. Zona Reticularis
- secretes traces of glucocorticoids and androgenic hormones-
function
: promotes secondary sex characteristics- Sex
3. Zona Glumerulosa
- secretes mineralocorticoids (aldosterone)-
function
: promotes sodium and water reabsorption and excretion of potassium- Salt
ADDISON’S DISEASE
o
Hyposecretion of adreno cortical hormone leading toa. metabolic disturbance – Sugar b.
fluid and electrolyte imbalance – Saltc. deficiency of neuromuscular function – Salt/Sex
1. Related to atrophy of adrenal glands2. Fungal infections
1.
Hypoglycemia
– TIRED2. Decrease tolerance to stress3.
Hyponatremia
- hypotension- signs of dehydration- weight loss4.
Hyperkalemia
- agitation- diarrhea- arrhythmia
5. Decrease libido6. Loss of pubic and axillary hair 7.
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Bronze like skin pigmentationC. Diagnostic Procedures
1. FBS is decreased (normal value: 80 – 100 mg/dl)2. Plasma Cortisol is decreased3.
Serum Sodium is decrease (normal value: 135 – 145 meq/L)4. Serum Potassium is
increased (normal value: 3.5 – 4.5 meq/L)
1. Monitor strictly vital signs, input and output to determine presence of
Addisonian crisis
(complication of addison’s disease)
o
Addisonian crisis
results from acute exacerbation of addison’s disease characterized bya. severe
hypotensionb. hypovolemic shockc. hyponatremia leading to progressive stupor and
coma
Nursing Management for Addisonian Crisis
1. Assist in mechanical ventilation,- administer steroids as ordered- force fluids2.
Administer
isotonic fluid solution
as ordered3. Force fluids4. Administer medications as orderedCorticosteroidsa.
Dexamethasone (Decadrone)b. Prednisonec. Hydrocortisone (Cortison)
Nursing Management when giving steroids
1. Instruct client to take 2/3 dose in the morning and 1/3 dose in the
afternoon to mimic the normal diurnal rhythm2. Taper dose (withdraw gradually
from drug)3. Monitor side effectsa. hypertensionb. edemac. hirsutismd. increase
susceptibility to infectione.
moon face appearance
4. Mineralocorticoids (Flourocortisone)5. Provide dietary intake, increase calories,
carbohydrates, protein but decrease in potassium6. Provide meticulous skin care7.
Provide client health teaching and discharge planning
a. avoid precipitating factor leading to addisonian crisis leading to
- stress- infection- sudden withdrawal to steroids
b. prevent complications
- addisonian crisis- hypovolemic shock
c. hormonal replacement for lifetimed. importance of follow up care
CUSHING SYNDROME
o
Hypersecretion of adenocortical hormones
1 Related to hyperplasia of adrenal gland2. Increase susceptibility to infections3.
Hypernatremiaa. hypertensionb. edemac. weight gaind.
moon face appearance and buffalo hump
e. obese trunkf. pendulous abdomeng. thin extremities4. Hypokalemiaa. weakness and
fatigueb. constipationc. U wave upon ECG (T wave hyperkalemia)5. Hirsutism6. Acne
and striae7. Easy bruising8.
Increase masculinity among femalesB. Diagnostic Procedures
1. FBS is increased2. Plasma Cortisol is increased3. Serum Sodium is increased4. Serum
Potassium is decreased
C. Nursing Management
1. Monitor strictly vital signs and intake and output2. Weigh patient daily and assess for
pitting edema3. Measure abdominal girth daily and notify physician4. Restrict sodium
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intake5. Provide meticulous skin care6. Administer medications as ordereda.
Spinarolactone – potassium sparring diuretics7. Prevent complications (DM)8. Assist in
surgical procedure (bilateral adrenoraphy)9. Hormonal replacement for lifetime10.
Importance of follow up care
PANCREAS
- Located behind the stomach- Mixed gland (exocrine and endocrine)- Consist of
acinar cells
which secretes pancreatic juices that aids in digestion thus it is an exocrine gland- Consist
of
islets of langerhans
- Has alpha cells that secretes glucagons (function: hyperglycemia)- Beta cells secretes
insulin (function: hypoglycemia)
- Delta cells secretes somatostatin (function: antagonizes the effects of growth hormones)
3 Main Disorders of Pancreas
1. Pancreatic Tumor/Cancer 2. Diabetes Mellitus3. Pancreatitis
DIABETES MELLITUS
- metabolic disorder characterized by non utilization of carbohydrates, protein and fat
metabolism
CLASSIFICATION OF DMType 1 (IDDM)
- Juvenile onset type-
Brittle diseaseA. Incidence Rate
- 10% general population has type 1 DM
1. Hereditary (total destruction of pancreatic cells)2. Related to viruses3. Drugsa. Lasixb.
Steroids4. Related to
carbon tetrachloride toxicityC. Signs and Symptoms
1. Polyuria2. Polydypsia3. Polyphagia4. Glucosuria5.
Weight loss
6. Anorexia, nausea and vomiting7. Blurring of vision8. Increase susceptibility to
infection9. Delayed/poor wound healing
D. Treatment
1. Insulin therapy2. Diet3. Exercise
E. Complication
1.
Diabetic KetoacidosisType 2 (NIDDM)
- Adult onset- Maturity onset type- Obese over 40 years old
A. Incidence Rate
- 90% of general population has type 2 DM
1 . O b e s i t y – b e c a u s e o b e s e p e r s o n s l a c k i n s u l i n receptor binding sites
1. Usually asymptomatic2. Polyuria3. Polydypsia4. Polyphagia5. Glucosuria6.
Weight gain
D. Treatment
1. Oral Hypoglycemic agents2. Diet3. Exercise
E. Complications
1.
H
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yper 2.
O
smolar 3.
N
on4.
K
etotic5.
C
oma
MAINFOODSTUFFA N A B O L I S M C A T A B O L I S M 1. Carbohydrates2.
Protein3. FatsGlucoseAmino AcidsFatty AcidsGlycogenNitrogenFree Fatty Acids-
Cholesterol- Ketones
HYPERGLYCEMIAIncrease osmotic
diuresisG l y c o s u r i
a P o l y u r i a
Cellular starvation – weight loss Cellular
dehydrationS t i m u l a t e s t h e a p p e t i t e / s a t i e t y
c e n t e r S t i m u l a t e s t h e t h i r s t
c e n t e r ( H y p o t h a l a m u s )
( H y p o t h a l a m u s )
P o l y p h a g i a
P o l y d y p s i a
* Liver has glycogen that undergo glycogenesis/ glycogenolysisGLUCONEOGENESIS
Formation of glucose from non-CHO sourcesIncrease protein formation▼Negative
Nitrogen balance▼Tissue wasting (
Cachexia
)▼
INCREASEFATCATABOLISM
▼Free fatty
acidsC h o l e s t e r o l
K e t o n e s ▼
▼A t h e r o s c l e r o s i s D i a b e t i c K e t o
A c i d o s i s ▼HypertensionA c e t o n e B r e a t h K u s s m a u l ’ s
R e s p i r a t i o n odor M I
C V A D e a
t h D i a b e t i c
C o m a
DIABETIC KETOACIDOSIS
- Acute complication of type 1 DM due to severe hyperglycemia leading to severe CNS
depression
1. Hyperglycemia2. Stress –
number one precipitating factor
3. Infection
1. Polyuria2. Polydypsia3. Polyphagia4. Glucosuria5. Weight loss6. Anorexia, nausea and
vomiting7. Blurring of vision8. Acetone breath odor 9.
Kussmaul’s Respiration
(rapid shallow breathing)10 CNS depression leading to coma
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1. FBS is increased2. BUN (normal value: 10 – 20)3. Creatinine (normal value: .8 – 1)4.
Hct (normal value: female 36 – 42, male 42 – 48) due to severe dehydration
1. Assist in mechanical ventilation2. Administer 0.9 NaCl followed by .45 NaCl
(hypotonic solutions) to counteract dehydration and shock3. Monitor strictly vital signs,
intake and output and blood sugar levels4. Administer medications as ordereda. Insulin
therapy (regular acting insulin/rapid acting insulin peak action of 2 – 4 hours)b. Sodium
Bicarbonate to counteract acidosisc. Antibiotics to prevent infection
HYPER OSMOLAR NON KETOTIC COMA
- Hyperosmolar: increase osmolarity (severe dehydration)- Non ketotic: absence of
lypolysis (no ketones)
A. Signs and Symptoms
1. Headache and dizziness2. Restlessness3. Seizure activity4. Decrease LOC – diabetic
coma
B. Nursing Management
1. Assist in mechanical ventilation2. Administer 0.9 NaCl followed by .45 NaCl
(hypotonic solutions) to counteract dehydration and shock3. Monitor strictly vital signs,
intake and output and blood sugar levels
4. Administer medications as ordereda. Insulin therapy (regular acting insulin peak action
of 2 – 4 hours)- for DKA use rapid acting insulinb. Antibiotics to prevent infection
INSULIN THERAPYA. Sources of Insulin1. Animal sources
- Rarely used because it can cause severe allergic reaction- Derived from beef and pork
2. Human Sources
- Frequently used type because it has less antigenicity property thus less allergic reaction
3. Artificially Compound InsulinB. Types of Insulin1. Rapid Acting Insulin (clear)
- Regular acting insulin (IV only)- Peak action is 2 – 4 hours
2. Intermediate Acting Insulin (cloudy)
- Non Protamine Hagedorn Insulin (NPH)- Peak action is 8 – 16 hours
3. Long Acting Insulin (cloudy)
- Ultra Lente- Peak action is 16 – 24 hours
C. Nursing Management for Insulin Injections
1. Administer at room temperature to prevent development of
l i p o d y s t r o p h y ( a t r o p h y, h y p e r t r o p h y o f subcutaneous tissues)2. Place in
refrigerator once opened3. Avoid shaking insulin vial vigorously instead gently roll vial
between palm to prevent formation of bubbles4. Use gauge 25 – 26 needle5. Administer
insulin either 45
o
– 90
o
depending on amount of clients tissue deposit6. No need to aspirate upon injection7.
Rotate insulin injection sites to prevent development of lipodystrophy8. Most accessible
route is abdomen9. When mixing 2 types of insulin aspirate first the clear
insulin before cloudy to prevent contaminating the clear insulin and promote
proper calibration.10. Monitor for signs of local complications such asa. Allergic
reactionsb. Lipodystrophyc.
Somogyis Phenomenon
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– rebound effect of insulin characterized by hypoglycemia
t o hyperglycemia
ORAL HYPOGLYCEMIC AGENTS
- Stimulates the pancreas to secrete insulin
A. Classsification1. First Generation Sulfonylureas
a. Chlorpropamide (Diabenase)b. Tolbutamide (Orinase)c. Tolamazide (Tolinase)
2. Second Generation Sulfonylureas
a. Glipzide (Glucotrol)b. Diabeta (Micronase)
Nursing Management when giving OHA
1. Instruct the client to take it with meals to lessen GIT irritation and prevent
hypoglycemia2. Instruct the client to avoid taking alcohol because it can lead to severe
hypoglycemia reaction or Disulfiram(Antabuse) toxicity symptoms
B. Diagnostic Procedures
1. FBS is increased (3 consecutive times with signs or polyuria, polydypsia,
polyphagia and glucosuriaconfirmatory for DM)2. Random Blood Sugar is
increased3. Oral glucose tolerance test is increased – most sensitive test4. Alpha
Glycosylated Hemoglobin is increased
1. Monitor for peak action of insulin and OHA and notify physician2. Administer insulin
and OHA therapy as ordered3. Monitor strictly vital signs, intake and output and blood
sugar levels4. Monitor for signs of hypoglycemia and hyperglycemia- administer simple
sugars- for hypoglycemia (cold and clammy skin) give simple sugars- for hyperglycemia
(dry and warm skin)5. Provide nutritional intake of diabetic diet that includes:
carbohydrates 50%, protein 30% and fats 20% or offer alternative food
substitutes6. Instruct client to exercise best after meals when blood glucose is rising7.
Monitor signs for complicationsa. Atherosclerosis (HPN, MI, CVA)b. Microangiopathy
(affects small minute blood vessels of eyes and kidneys)
E Y E S K
I D N E Y
-PREMATURECATARACT- Blindness-RECURRENT PYELONEPHRITIS- Renal failurec.
HPN and DM major cause of renal failured. Gangrene formatione. Shock due to
dehydration- peripheral neuropathy- diarrhea/constipation- sexual impotence8. Institute
foot care managementa. instruct client to avoid walking barefootedb. instruct client to cut
toenails straightc. instruct client to avoid wearing constrictive garmentsd. encourage
client to apply lanolin lotion to prevent skin breakdowne. assist in surgical wound
debriment (
give analgesics 15 – 30 mins prior)9. Instruct client to have an annual eye and kidney
exam10. Monitor for signs of DKA and HONKC11. Assist in surgical procedure
HEMATOLOGICAL SYSTEM
I . B l o o d I I . B l o o d
V e s s e l s I I I . B l o o d
F o r m i n g O r g a n s 1 .
A r t e r i e s 1 .
L i v e r 5 5 %
P l a s m a 4 5 % F o r m e d 2 .
V e i n s 3 . S p l e e n 4. Lymphoid
OrganS e r u m P l a s
m a C H O N 5 .
L y m p h
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N o d e s ( f o r m
e d i n
l i v e r ) 6 .
B o n e M a r r o w
1. Albumin2. Globulins3. Prothrombin and Fibrinogen
ALBUMIN
- Largest and numerous plasma CHON- Maintains osmotic pressure preventing edema
GLOBULINS
- Alpha globulins - transport steroids, bilirubin and hormones- Beta globulins – iron and
copper - Gamma globulinsa. anti-bodies and immunoglobulinsb. prothrombin and
fibrinogen clotting factors
FORMED ELEMENTS1. RBC (ERYTHROCYTES)
- normal value:
4 – 6 million/mm
3
-
only unnucleated cell
- biconcave discs- consist of molecules of hgb (red pigment) bilirubin (yellow pigment)
biliverdin (green pigment) hemosiderin(golden brown pigment)- transports and carries
oxygen to tissues-
hemoglobin
: normal value
female 12 – 14 gms% male 14 – 16 gms%
-
hematocrit
red cell percentage in wholeblood- normal value:
female 36 – 42% male 42 – 48%
- substances needed for maturation of RBCa. folic acidb. ironc. vitamin cd. vitamin b
12
(cyanocobalamin)e. vitamin b
6
(pyridoxine)f. intrinsic factor -
Normal life span of RBC is 80 – 120 days and is killed in red pulp of spleen2. WBC
(LEUKOCYTES)
- normal value:
5000 – 10000/mm
3
A.
Granulocytes
1.
Polymorpho Neutrophils
- 60 – 70% of WBC- involved in short term phagocytosis for acute inflammation2.
Polymorphonuclear Basophils
- for parasite infections- responsible for the release of chemical mediation for
inflammation3.
Polymorphonuclear Eosinophils
- for allergic reaction
B.
Non Granulocytes
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1.
Monocytes
- macrophage in blood- largest WBC- involved in long term phagocytosis for chronic
inflammation2.
Lymphocytes B-cell
T - c e l l N a t u r a l
k i l l e r c e l l
- b o n e m a r r o w - t h y m u s -
a n t i v i r a l a n d a n t i
t u m o r p r o p e r t y
for immunityHIV
- 6 months – 5 years incubation period- 6 months window period- western blot
opportunistic- ELISA- drug of choice AZT (
Zidon Retrovir
)
2 Common fungal opportunistic infection in AIDS
1. Kaposi’s Sarcoma2. Pneumocystis Carinii Pneumonia
3.
Platelets (THROMBOCYTES)
- Normal value:
150,000 – 450,000/mm
3
- Promotes
hemostasis
(prevention of blood loss)- Consist of immature or baby platelets or megakaryocytes
which is the target of dengue virus-
Normal life span of platelet is 9 – 12 daysSigns of Platelet Dysfunction
1. Petechiae2. Echhymosis3. Oozing of blood from venipunctured site
BLOOD DISORDERS
Iron Deficiency Anemia
- A chronic microcytic anemia resulting from inadequate absorption of iron leading to
hypoxemic tissue injury
A. Incidence Rate
1. Common among developed countries2. Common among tropical zones3. Common
among women 15 – 35 years old4. Related to poor nutrition
1. Chronic blood loss due to traumaa. Heavy menstruationb. Related to GIT bleeding
resulting to
hematemesis
and
melena
(sign for upper GIT bleeding)c. fresh blood per rectum is called
hematochezia
2. Inadequate intake of iron due toa. Chronic diarrheab. Related to malabsorption
syndromec. High cereal intake with low animal protein digestiond. Subtotal
gastrectomy4. Related to improper cooking of foods
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1. Usually asymptomatic2. Weakness and fatigue (initial signs)3. Headache and
dizziness4. Pallor and cold sensitivity5. Dyspnea6. Palpitations7. Brittleness of hair and
spoon shape nails (
koilonychias
)
8. Atropic Glossitis (inflammation of tongue)- Stomatitis
PLUMBER VINSON’S SYNDROME
- Dysphagia9. PICA (abnormal appetite or craving for non edible foods
D. Diagnostic Procedures
1. RBC is decreased2. Hgb is decreased3. Hct is deceased4. Iron is decreased5.
Reticulocyte is decreased6. Ferritin is decreased
1. Monitor for signs of bleeding of all hema test including urinw, stool and GIT2. Enforce
CBR so as not to over tire client3. Instruct client to take foods rich in irona. Organ meatb.
Egg (yolk)c. Raisind. Sweet potatoese. Dried fruitsf. Legumesg. Nuts4. Instruct the client
to avoid taking tea and coffee because it contains
tannates
which impairs iron absorption5. Administer medications as ordered
Oral Iron Preparations
a. Ferrous Sulfateb. Ferrous Fumaratec. Ferrous Gluconate- 300 mg/day
Nursing Management when taking oral iron preparations
1. Instruct client to take with meals to lessen GIT irritation2. When diluting it in liquid
iron preparations administer with straw to prevent staining of teeth
Medications administered via straw
- Lugol’s solution- Iron- Tetracycline- Nitrofurantoin (Macrodentin)3. Administer with
Vitamin C or orange juice for absorption4. Monitor and inform client of side effectsa.
Anorexiab. Nausea and vomitingc. Abdominal paind. Diarrhea/constipatione. Melena5. If
client cant tolerate/no compliance administer parenteral iron preparationa. Iron Dextran
(IM, IV)b. Sorbitex (IM)
Nursing Management when giving parenteral iron preparations
1. Administer Z tract technique to prevent discomfort, discoloration and leakage to
tissues2. Avoid massaging the injection site instead encourage to ambulate to facilitate
absorption3. Monitor side effectsa. Pain at injection siteb. Localized abscessc.
Lymphadenopathyd. Fever and chillse. Skin rashes
f. Pruritus/orticariag. Hypotension (anaphylactic shock)
PERNICIOUS ANEMIA
- Chronic anemia characterized by a deficiency of intrinsic factor leading to
hypochlorhydria (decreasehydrochloric acid secretion)
1. Subtotal gastrectomy2. Hereditary factors3. Inflammatory disorders of the ileum4.
Autoimmune5. Strictly vegetarian diet
STOMACH▼Pareital cells/ Argentaffin or Oxyntic cells
P r o d u c e s i n t r i n s i c f a c t o r s S e c r e t e s
h y d r o c h l o r i c a c i d
▼▼
Promotes reabsorption of Vit B
12
Aids in digestion
▼
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Promotes maturation of RBC
1. Weakness and fatigue2. Headache and dizziness3. Pallor and cold sensitivity4.
Dyspnea and palpitations as part of compensation5. GIT changes that includesa. mouth
soreb.
red beefy tongue
c. indigestion/dyspepsiad. weight losse. jaundice6. CNS changesa. tingling sensationb.
numbnessc. paresthesiad. positive to Romberg’s test – damage to cerebellum resulting to
ataxiae. result to psychosis
C. Diagnostic ProcedureSchilling’s Test
– reveals inadequate/decrease absorption of Vitamin B
12
1. Enforce CBR2. Administer Vitamin B
12
injections at monthly intervals for lifetime as ordered- Never given orally because there is
possibility of developing tolerance- Site of injection for Vitamin B
12
is dorsogluteal and ventrogluteal-
No side effects
3. Provide a dietary intake that is high in carbohydrates, protein, vitamin c and iron4.
Instruct client to avoid irritating mouth washes instead use soft bristled toothbrush
5. Avoid heat application to prevent burns
APLASTIC ANEMIA
- Stem cell disorder leading to bone marrow depression leading to
pancytopeniaPANCYTOPENIA
D e c r e a s e R B C
D e c r e a s e W B C
D e c r e a s e
P l a t e l e t ( a n e m
i a )
( l e u c o p e n i a )
( t h r o m b o c y t o
p e n i a )
1. Chemicals (Benzine and its derivatives)2. Related to irradiation/exposure to x-ray3.
Immunologic injury4. Drugs
Broad Spectrum Antibiotics
a. Chloramphenicol (Sulfonamides)
Chemotherapeutic Agents
a. Methotrexate (Alkylating Agent)b. Vincristine (Plant Alkaloid)c. Nitrogen Mustard
(Antimetabolite)
Phenylbutazones
(NSAIDS)
1. Anemiaa. Weakness and fatigueb. Headache and dizzinessc. Pallor and cold sensitivityd.
Dyspnea and palpitations2. Leukopeniaa. Increase susceptibility to infection3.
Thrombocytopeniaa. Petechiae (multiple petechiae is called purpura)b. Ecchymosisc.
Oozing of blood from venipunctured sites
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1. CBC reveals pancytopenia2. Bone marrow biopsy/aspiration (site is the posterior iliac
crest) – reveals fat necrosis in bone marrow
1. Removal of underlying cause2. Institute BT as ordered3. Administer oxygen
inhalation4. Enforce CBR5. Institute reverse isolation6. Monitor for signs of infectiona.
fever b. cough7. Avoid IM, subcutaneous, venipunctured sites8 Instead provide heparin
lock9. Instruct client to use electric razor when shaving
10. Administer medications as ordereda. Corticosteroids – caused by immunologic
injuryb. ImmunosuppressantsAnti Lymphocyte Globulin
▼
Given via central venous catheter
▼
Given 6 days to 3 weeks to achieveMaximum therapeutic effect of drug
DISSEMINATED INTRAVASCULAR COAGULATION
Acute hemorrhagic syndrome characterized by wide spread bleeding and
thrombosis due to a deficiency of prothrombin and fibrinogen
1. Related to rapid blood transfusion2. Massive burns3. Massive trauma4. Anaphylaxis5.
Septecemia6. Neoplasia (new growth of tissue)7. Pregnancy
1. Petechiae (widespread and systemic) eye, lungs and lower extremities2. Ecchymosis3.
Oozing of blood from punctured sites4. Hemoptysis6. Oliguria (late sign)
1. CBC reveals decreased platelets2. Stool occult blood positive3. ABG analysis reveals
metabolic acidosis4. Opthamoscopic exam reveals sub retinal hemorrhages
1. Monitor for signs of bleeding of all hema test including stool and GIT2. Administer
isotonic fluid solution as ordered3. Administer oxygen inhalation4. Force fluids5.
Administer medications as ordereda. Vitamin Kb. Pitressin/ Vasopresin to conserve fluidsc.
Heparin/Coumadin is ineffective6. Provide heparin lock7. Institute NGT decompression
by performing gastric lavage by using ice or cold saline solution of 500 – 1000ml8.
Monitor NGT output9. Prevent complicationa. Hypovolemic shockb. Anuria – late sign
BLOOD TRANSFUSIONGoals/Objectives
1. Replace circulating blood volume2. Increase the oxygen carrying capacity of blood3.
Prevent infection in there is a decrease in WBC4. Prevent bleeding if there is platelet
deficiency
Principles of blood transfusion1. Proper refrigeration
-
Expiration of packed RBC is 3 – 6 days
-
Expiration of platelet is 3 – 5 days2. Proper typing and cross matching
a. Type O – universal donor b. Type AB – universal recipientc. 85% of population is RH
positive
3. Aseptically assemble all materials needed for BT
a. Filter setb. Gauge 18 – 19 needlec. Isotonic solution (0.9 NaCl/plain NSS) to prevent
hemolysis
4. Instruct another RN to re check the following
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a. Client nameb. Blood typing and cross matchingc. Expiration dated. Serial number
5. Check the blood unit for bubbles cloudiness, sediments and darkness in color
because it indicatesbacterial contamination
- Never warm blood as it may destroy vital factors in blood.- Warming is only done
during emergency situation and if you have the warming device- Emergency rapid BT is
given after 30 minutes and let natural room temperature warm the blood.
6. BT should be completed less than 4 hours because blood that is exposed at room temperature
morethan 2 hours causes blood deterioration that can lead to BACTERIAL
CONTAMINATION7. Avoid mixing or administering drugs at BT line to prevent
HEMOLYSIS8. Regulate BT 10 – 15 gtts/min or KVO rate or equivalent to 100 cc/hr
to prevent circulatory overload9. Monitor strictly vital signs before, during and
after BT especially every 15 minutes for first hour because majority of transfusion
reaction occurs during this period
a. Hemolytic reactionb. Allergic reactionc. Pyrogenic reactiond. Circulatory overloade.
Air embolismf. Thrombocytopeniag. Cytrate intoxication
h. Hyperkalemia (caused by expired blood)
Signs and Symptoms of Hemolytic reaction
1. Headache and dizziness2. Dyspnea3. Diarrhea/Constipation4. Hypotension5. Flushed
skin6. Lumbasternal/ Flank pain7. Urine is color red/
portwine urineNursing Management
1. Stop BT2. Notify physician3. Flush with plain NSS4. Administer isotonic fluid
solution to prevent shock and acute tubular necrosis5. Send the blood unit to blood bank
for re examination6. Obtain urine and blood sample and send to laboratory for re
examination7. Monitor vital signs and intake and output
SIGNS AND SYMPTOMS OF ALLERGIC REACTION
1. Fever 2. Dyspnea3. Broncial wheezing4. Skin rashes5. Urticaria6. Laryngospasm and
Broncospasm
Nursing Management
1. Stop BT2. Notify physician3. Flush with plain NSS4. Administer medications as
ordereda. Anti Histamine (Benadryl) - if positive to hypotension, anaphylactic shock treat
with
Epinephrine
5. Send the blood unit to blood bank for re examination6. Obtain urine and blood sample
and send to laboratory for re examination7. Monitor vital signs and intake and output
SIGNS AND SYMPTOMS PYROGENIC REACTIONS
1. Fever and chills2. Headache3. Tachycardia4. Palpitations5. Diaphoresis6. Dyspnea
Nursing Management
1. Stop BT2. Notify physician3. Flush with plain NSS4. Administer medications as
ordereda. Antipyreticb. Antibiotic5. Send the blood unit to blood bank for re examination
6. Obtain urine and blood sample and send to laboratory for re examination7. Monitor
vital signs and intake and output8. Render TSB
SIGNS AND SYMPTOMS OF CIRCULATORY REACTION
1. Orthopnea2. Dyspnea3. Rales/Crackles upon auscultation4. Exertional discomfort
Nursing Management
1. Stop BT2. Notify physician3. Administer medications as ordereda. Loop diuretic
(Lasix)
CARDIOVASCULAR SYSTEMOVERVIEW OF THE STRUCTURE AND FUNCTIONS
OF THE HEARTHEART
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- Muscular pumping organ of the body.- Located on the left mediastinum- Resemble like
a close fist- Weighs approximately 300 – 400 grams- Covered by a serous membrane
called the pericardium
2 layers of pericardium
a. Parietal – outer layer b. Visceral – inner layer - In between is the
pericardial fluid
which is
10 – 20 cc
- Prevent pericardial friction rub- Common among MI, pericarditis, Cardiac tamponade
A.
Layers of Heart
1.
Epicardium
– outer layer 2.
Myocardium
– middle layer 3.
Endocardium
– inner layer - Myocarditis can lead to
cardiogenic shock
and
rheumatic heart diseaseB. Chambers of the Heart1. Upper Chamber (connecting or receiving)
a.
Atria2. Lower Chamber (contracting or pumping)
a.
Ventricles
- Left ventricle has increased pressure which is 120 – 180 mmHg- In order to propel
blood to the systemic circulation- Right atrium has decreased pressure which is 60 – 80
mmHg
C. Valves
- To promote unidimensional flow or prevent backflow
1. Atrioventricular Valves
– guards opening betweena. tricuspid valveb. mitral valve
- Closure of AV valves give rise to first heart sound (S
1
“lub”)
2. Semi – lunar Valves
SA NODEAV NODEBUNDLE OF HIS
a. pulmonicb. aortic
- Closure of SV valve give rise to second heart sound (S
2
“dub”)
Extra Heart Sounds
1.
S
3
– ventricular gallop usually seen in

Left Congestive Heart Failure
2.
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S
4
– atrial gallop usually seen in

Myocardial Infarction
and
HypertensionD.
Coronary Arteries
- Arises from base of the aorta
Types of Coronary Arteries
1. Right Main Coronary Artery2. Left Main Coronary Artery- Supplies the myocardium
E. Cardiac Conduction System1. Sino – Atrial Node (SA or Keith Flack Node)
- Located at the junction of superior vena cava and right atrium- Acts as primary
pacemaker of the heart- Initiates electrical impulse of 60 – 100 bpm
2. Atrio – Ventricular Node (AV or Tawara Node)
- Located at the inter atrial septum- Delay of electrical impulse for about .08 milliseconds
to allow ventricular filling
3. Bundle of His
- Right Main Bundle of His- Left Main Bundle of His- Located at the interventricular
septum
4. Purkinje Fibers
- Located at the walls of the ventricles for ventricular contractionPURKINJE FIBERS-
PWAVE
(atrial depolarization) contraction-
QRSWAVE
(ventricular depolarization)-
TWAVE
(ventricular repolarization)

Insert pacemaker if there is complete heart block

Most common pacemaker is the metal pacemaker and lasts up to 2 – 5 years
ABNORMAL ECG TRACING
1. Positive U wave - Hypokalemia2. Peak T wave – Hyperkalemia3. ST segment
depression – Angina Pectoris4. ST segment elevation – Myocardial Infarction5. T wave
inversion – Myocardial Infarction6. Widening of QRS complexes – Arrythmia
CARDIAC DISORDERS
Coronary Arterial Disease/ Ischemic Heart DiseaseStages of Development of
Coronary Artery Disease
1. Myocardial Injury - Atherosclerosis2. Myocardial Ischemia – Angina Pectoris3.
Myocardial Necrosis – Myocardial Infarction
ATHEROSCLEROSISA T H E R O S C L E R
O S I S A R T E R I O S C L E
R O S I S
- narrowing of artery- lipid or fat deposits-
tunica intima
- hardening of artery- calcium and protein deposits-
tunica mediaA. Predisposing Factors
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1. Sex – male2. Race – black3. Smoking4. Obesity5. Hyperlipidemia6. sedentary
lifestyle7. Diabetes Mellitus8. Hypothyroidism9. Diet – increased saturated fats10. Type A
personality
1. Chest pain2. Dyspnea3. Tachycardia4. Palpitations5. Duaphoresis
C. TreatmentP
ercutaneous
T
ransluminal
C
oronary
A
ngioplasty
Objectives of PTCA
1. Revascularize myocardium2. To prevent angina3. Increase survival rate- Done to single
occluded vessels- If there is 2 or more occluded blood vessels CABG is done
C
oronary
A
rterial
B
ypass
A
nd
G
raft
S
urgery
3 Complications of CABG
1. Pneumonia – encourage to perform deep breathing, coughing exercise and use of
incentive spirometer
2. Shock3. Thrombophlebitis
ANGINA PECTORIS (SYNDROME)
Clinical syndrome characterized by paroxysmal chest pain that is usually relieved by rest
or nitroglycerine dueto temporary myocardial ischemia
personality
B. Precipitating Factors4 E’s of Angina Pectoris
1. Excessive physical exertion – heavy exercises2. Exposure to cold environment3.
Extreme emotional response – fear, anxiety, excitement4. Excessive intake of foods rich in
saturated fats – skimmed milk
1.
Levine’s Sign
– initial sign that shows the hand clutching the chest2. Chest pain characterized by sharp
stabbing pain located at sub sterna usually radiates from back, shoulder,arms, axilla and
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jaw muscles, usually relieved by rest or taking nitroglycerine3. Dyspnea4. Tachycardia5.
Palpitations6. Diaphoresis
1. History taking and physical exam2. ECG tracing reveals ST segment depression3.
Stress test – treadmill test, reveal abnormal ECG4. Serum cholesterol and uric acid is
increased
1. Enforce complete bed rest2. Administer medications as ordereda.
Nitroglycerine (NTG)
– when given in
small doses
will act as
venodilator
, but in
large doses
willact as
vasodilator
- Give first dose of NTG (sublingual) 3 – 5 minutes- Give second dose of NTG if pain
persist after giving first dose with interval of 3 - 5 minutes- Give third and last dose of
NTG if pain still persist at 3 – 5 minutes interval
Nursing Management when giving NTG
-
Keep the drug in a dry place, avoid moisture and exposure to sunlight as it may inactivate
the drug
-
Monitor side effects
o
Orthostatic hypotension
o
Transient headache and dizziness
-
Instruct the client to rise slowly from sitting position
-
Assist or supervise in ambulation
-
When giving
nitrol
or
transdermal patch
o
Avoid placing near hairy areas as it may decrease drug absorption
o
Avoid rotating transdermal patches as it may decrease drug absorption
o
Avoid placing near microwave ovens or duting defibrillation as it may lead to burns (
mostimportant thing to remember
)b.
Beta-blockers
- Propanolol - side effects PNS- Not given to
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COPD cases
because it causes
bronchospasm
c.
ACE Inhibitors
- Enalaprild.
Calcium Antagonist
- NIfedipine3. Administer oxygen inhalation4. Place client on semi fowlers position5.
Monitor strictly vital signs, intake and output and ECG tracing6. Provide decrease
saturated fats sodium and caffeine7. Provide client health teachings and discharge
planninga. Avoidance of 4 E’sb. Prevent complication (myocardial infarction)c. Instruct
client to take medication before indulging into physical exertion to achieve
the maximumtherapeutic effect of drugd. The importance of follow up care
MYOCARDIAL INFARCTION
Heart attackTerminal stage of coronary artery disease characterized by malocclusion,
necrosis and scarring.
A. Types1. Transmural Myocardial Infarction
– most dangerous type characterized by occlusion of both right and leftcoronary artery
2. Subendocardial Myocardial Infarction
– characterized by occlusion of either right or left coronary artery
B. The Most Critical Period Following Diagnosis of Myocardial Infarction
** 6 – 8 hours because majority of death occurs due to arrhythmia leading to
PVC’sC. Predisposing Factors
personality
D. Signs and Symptoms
1. Chest pain- Excruciating visceral, viselike pain
located at substernal
and rarely in precordial- Usually radiates from back, shoulder, arms, axilla, jaw and
abdominal muscles (abdominal ischemia)- Not usually relieved by rest or by
nitroglycerine2. Dyspnea3. Increase in blood pressure (initial sign)4. Hyperthermia5.
Ashen skin6. Mild restlessness and apprehension7. Occasional findingsa. Pericardial
friction rubb. Split S
1
and S
2
c. Rales/Crackles upon auscultationd. S
4
or atrial gallop
E. Diagnostic Procedure1. Cardiac Enzymes
a.
CPK – MB
- Creatinine phosphokinase is
increased
- Heart only, 12 – 24 hoursb.
LDH
– Lactic acid dehydroginase is
increased
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c.
SGPT
– Serum glutamic pyruvate transaminase is
increased
d.
SGOT
– Serum glutamic oxal-acetic transaminase is
increased2. Troponin Test
– is increased
3. ECG tracing
revealsa. ST segment elevationb. T wave inversionc. Widening of QRS complexes
indicates that there is arrhythmia in MI
4. Serum Cholesterol
and
uric acid
are both
increased5. CBC
– increased WBC
F. Nursing ManagementGoal:
Decrease myocardial oxygen demand1. Decrease myocardial workload (rest heart)-
Administer narcotic analgesic/morphine sulfate-
Side Effects:
respiratory depression-
Antidote:
Narcan/Naloxone-
Side Effects of Naloxone Toxicity
is tremors2. Administer oxygen low inflow to prevent respiratory arrest at 2 – 3 L/min3.
Enforce CBR without bathroom privilegesa. Using bedside commode4. Instruct client to
avoid forms of valsalva maneuver 5. Place client on semi fowlers position6. Monitor
strictly vital signs, intake and output and ECG tracing7. Provide a general liquid to soft
diet
that is
low in saturated fats, sodium and caffeine
8. Encourage client to
take 20 – 30 cc/week of wine, whisky and brandy
to induce vasodilation9. Administer medication as ordereda.
Vasodilators
- Nitroglycerine- ISD (Isosorbide Dinitrate, Isodil) sublingualb.
Anti Arrythmic Agents
- Lidocaine (Xylocane-
Side Effects:
confusion and dizziness- Brutyliumc.
Beta-blockers
d.
ACE Inhibitors
e.
Calcium Antagonist
f.
Thrombolytics/ Fibrinolytic Agents
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- Streptokinase-
Side Effects:
allergic reaction, pruritus- Urokinase- TIPAF (tissue plasminogen activating factor)-
Side Effects:
chest pain- Monitor for bleeding timeg.
Anti Coagulant
- Heparin (check for partial thrombin time)-
Antidote:
protamine sulfate- Coumadin/ Warfarin Sodium (check for prothrombin time)-
Antidote:
Vitamin Kh.
Anti Platelet
- PASA (Aspirin)- Anti thrombotic effect-
Side Effects of Aspirin

Tinnitus

Heartburn

Indigestion/Dyspepsia-
Contraindication

Dengue

Peptic Ulcer Disease

Unknown cause of headache10. Provide client health teaching and discharge planning
concerninga. Avoidance of modifiable risk factors- arrhythmia (caused by premature
ventricular contraction)b. Cardiogenic shock-
late sign is oliguria
c. Left Congestive Heart Failured. Thrombophlebitis-
homan’s sign
e. Stroke/CVAf. Post MI Syndrome/
Dressler’s Syndrome
- client is resistant to pharmacological agents, administer 150,000 –
4 5 0 , 0 0 0 u n i t s o f streptokinase as orderedg. Resumption of ADL particularly sexual
intercourse is
4 – 6 weeks
post cardiac rehab, post CABGand instruct to
- make sex as an appetizer rather than dessert- instruct client to assume a non weight
bearing position- client can resume sexual intercourse if can
climb staircase
- dietary modificationh. Strict compliance to mediation and importance of follow up care
CONGESTIVE HEART FAILURE
Inability of the heart to pump blood towards systemic circulation
Types of Heart Failure1. LEFT SIDED HEART FAILUREA. Predisposing Factors
1. 90% is mitral valve stenosis due toa. RHD – inflammation of mitral valve due to
invasion of Grp. A beta-hemolytic streptococcus- Formation of
aschoff bodies
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in the
mitral valve
- Common among children- ASO Titer (Anti streptolysin O titer)- Penicillin- Aspirinb.
Aging2. Myocardial Infarction3. Ischemic heart disease4. Hypertension5. Aortic valve
stenosis
1. Dyspnea2. Paroxysmal nocturnal dyspnea – client is awakened at night due to
difficulty of breathing3. Orthopnea – use 2 – 3 pillows when sleeping or place in high
fowlers4. Productive cough with blood tinged sputum5. Frothy salivation6. Cyanosis7.
Rales/Crackles8. Bronchial wheezing9.
Pulsus Alternans
– weak pulse followed by strong bounding pulse10. PMI is displaced laterally due to
cardiomegaly11. There is anorexia and generalized body malaise12. S
3
– ventricular gallop
1. Chest x-ray – reveals cardiomegaly2. PAP (pulmonary arterial pressure) – measures
pressure in right ventricle or cardiac statusPCWP (pulmonary capillary wedge pressure) –
measures end systolic and dyastolic pressure
-
both are increased
-
done by cardiac catheterization (insertion of
swan ganz catheter
)3. Ecocardiography –
enlarged heart chamber
(cardiomyopathy), dependent on extent of heart failure4. ABG – reveals PO
2
is decreased (hypoxemia), PCO
2
is increased (respiratory acidosis)
2. RIGHT SIDED HEART FAILUREA. Predisposing Factors
1. Tricuspid valve stenosis2. Pulmonary embolism3. Related to COPD4. Pulmonic valve
stenosis
5. Left sided heart failure
B. Signs and Symptoms (venous congestion)
1. Neck/jugular vein distension2. Pitting edema3. Ascites4. Weight gain5.
Hepatosplenomegaly6. Jaundice7. Pruritus8. Anorexia9. Esophageal varices
1. Chest x-ray – reveals cardiomegaly2. Central venous pressure (CVP)- Measure
pressure in right atrium (4 – 10 cm of water)- CVP fluid status measure- If CVP is less
than 4 cm of water hypovolemic shock- Do the fluid challenge (increase IV flow rate)- If
CVP is more than 10 cm of water hypervolemic shock- Administer loop diuretics as
ordered- When reading CVP patient should be flat on bed- Upon insertion place
client in trendelendberg position to promote ventricular filling and
preventpulmonary embolism3. Ecocardiography – reveals enlarged heart chambers
(cardiomyopathy4. Liver enzymes – SGPT and SGOT is increased
D. Nursing ManagementGoal:
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increase cardiac contractility thereby increasing cardiac output (3 – 6 L/min)1. Enforce
CBR2. Administer medications as ordereda.
Cardiac glycosides
- Digoxin (Lanoxin)- Increase force of cardiac contraction- If heart rate is decreased do
not giveb.
Loop Diuretics
- Lasix (Furosemide)c.
Bronchodilators
d.
Narcotic analgesics
- Morphine Sulfatee.
Vasodilators
- Nitroglycerinef.
Anti Arrhythmic
- Lidocaine (Xylocane)3. Administer oxygen inhalation with high inflow, 3 – 4 L/min,
delivered via nasal cannula4. High fowlers position5. Monitor strictly vital signs, intake
and output and ECG tracing6. Measure abdominal girth daily and notify physician7.
Provide a dietary intake of
low sodium, cholesterol and caffeine
8. Provide meticulous skin care
9. Assist in bloodless phlebotomy – rotating tourniquet, rotated clockwise
every 15 minutes to promotedecrease venous return10. Provide client health teaching
and discharge planninga. Prevent complications- Arrythmia- Shock- Right ventricular
hypertrophy- MI- Thrombophlebitisb. Dietary modificationc. Strict compliance to
medications
PERIPHERAL VASCULAR DISORDERArterial Ulcer I. Thrombo Angitis Obliterans

Burger’s Disease

Reynaud’s Disease
Venous Ulcer
1. Varicose Veins2. Thrombophlebitis (deep vein thrombosis)
THROMBOANGITIS OBLITERANS
A c u t e i n f l a m m a t o r y d i s o r d e r u s u a l l y a ff e c t i n g t h e s m a l l m e d i u m
s i z e d a r t e r i e s a n d v e i n s o f t h e l o w e r extremities
1. High risk groups – men 30 years old and above2. Smoking
1. Intermittent claudication – leg pain upon walking2. Cold sensitivity and changes in
skin color (pallor, cyanosis then rubor)3. Decreased peripheral pulses4. Trophic
changes5. Ulceration6. Gangrene formation
1.
Oscillometry
– decrease in peripheral pulses2.
Doppler UTZ
– decrease blood flow to the affected extremity3.
Angiography
– reveals site and extent of malocclusion
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1. Encourage a slow progressive physical activitya. walking 3 – 4 times a dayb. out of
bed 3 – 4 times a day2. Administer medications as ordereda. Analgesicsb. Vasodilatorsc.
Anti coagulants3. Institute foot care management4. Instruct client to avoid smoking and
exposure to cold environment
5. Assist in surgical procedure – bellow knee amputation
REYNAUD’S DISEASE
Disorder characterized by acute episodes of arterial spasm involving the fingers or digits
of the hands
1. High risk group – female 40 years old and above2. Smoking3. Collagen diseasesa. SLE
(butterfly rash)b. Rheumatoid Arthritis4. Direct hand traumaa. Piano playingb. Excessive
typingc. Operating chainsaw
1. Intermittent claudication – leg pain upon walking2. Cold sensitivity and changes in
skin color (pallor, cyanosis then rubor)3. Trophic changes4. Ulceration5. Gangrene
formation
1.
Doppler UTZ
– decrease blood flow to the affected extremity2.
Angiography
– reveals site and extent of malocclusion
1. Administer medications as ordereda. Analgesicsb. Vasodilators2. Encourage to wear
gloves3. Instruct client on importance of cessation of smoking and exposure to cold
environment
VARICOSITIES
Abnormal dilation of veins of lower extremities and trunks due to
Incompetent valve
resulting to
Increased venous pooling
resulting to
Venous stasis
causing
Decrease venous returnA. Predisposing Factors
1. Hereditary2. Congenital weakness of veins3. Thrombophlebitis4. Cardiac disorder 5.
Pregnancy6. Obesity7. Prolonged standing or sitting
1. Pain after prolonged standing2. Dilated tortuous skin veins3. Warm to touch4. Heaviness
in legs
1. Venography2. Trendelenburg’s Test - veins distends quickly in less than 35 seconds
1. Elevate legs above heart level to promote increased venous return by placing 2 – 3
pillows under the legs2. Measure the circumference of leg muscle to determine if
swollen3. Wear anti embolic stockings4. Administer medications as ordereda.
Analgesics5. Assist in surgical procedurea. Vein stripping and ligation (most effective)b.
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Sclerotherapy – can recur and only done in spider web varicosities and danger of
thrombosis (2 – 3years for embolism)
THROMBOPHLEBITIS
Deep vein thrombosisInflammation of the veins with thrombus formation
1. Obesity2. Smoking3. Related to pregnancy4. Chronic anemia5. Prolong use of oral
contraceptives – promotes lipolysis6. Diabetes mellitus7. Congestive heart failure8.
Myocardial infarction9. Post op complication10. Post cannulation – insertion of various
cardiac catheter 11. Increase in saturated fats in the diet.
1. Pain at affected extremity2. Warm to touch3. Dilated tortuous skin veins4. Positive
Hpman’s Signs – pain at the calf or leg muscle upon dorsi flexion of the foot
1. Venography2. Angiography
1. Elevate legs above heart level to promote increase venous return2. Apply warm moist
pack – to reduce lymphatic congestion3. Measure circumference of leg muscle to
determine if swollen4. Encourage to wear anti embolic stockings or knee elastic
stockings
5. Administer medications as ordereda. Analgesicsb. Anti Coagulant- Heparin6. Monitor

for signs of complications
Embolism
a.
Pulmonary
- Sudden sharp chest pain- Unexplained dyspnea- Tachycardia- Palpitations- Diaphoresis-
Restlessnessb.
Cerebral
- Headache- Dizziness- Decrease LOC
•
MURPHY’S SIGN is seen in clients with cholelithiasis, cholecystitis characterized
by pain at theright upper quadrant with tendernessRESPIRATORY SYSTEMOVERVIEW
OF THE STRUCTURES AND FUCNTIONS OF THE RESPIRATORY SYSTEMI. Upper
Respiratory System
1. Filtering of air 2. Warming and moistening of air 3. Humidification
A. Nose
- Cartillage- Right nostril- Left nostril- Separated by septum- Consist of anastomosis of
capillaries known as
Keissel Rach Plexus
(the site of nose bleeding)
B. Pharynx/Throat
- Serves as a muscular passageway for both food and air
C. Larynx
- For phonation (voice production)- For cough reflex
Glottis
- Opening of larynx- Opens to allow passage of air - Closes to allow passage of food
going to the esophagus- The initial sign of complete airway obstruction is the inability to
cough
II. Lower Respiratory System
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- For gas exchange
A. Trachea/Windpipe
- Consist of cartilaginous rings- Serves as passageway of air going to the lungs- Site of
tracheostomy
B. Bronchus
- Right main bronchus- Left main bronchus
C. Lungs
- Right lung (consist of 3 lobes, 10 segments)- Left lung (consist of 2 lobes, 8 segments)-
Serous membranes
Pleural Cavity
a . P a r e i t a l b.Pleural fluidc . V i s c e r a l
With Pleuritic Friction Rub
a. Pneumoniab. Pleural effusionc. Hydrothorax (air and blood in pleural space
Alveoli
- Site of gas exchange (CO
2
and O
2
)- Diffusion (Dalton’s law of partial pressure of gases)
Respiratory Distress Syndrome
- Decrease oxygen stimulates breathing- Increase carbon dioxide is a powerful stimulant
for breathing
Type II Cells of Alveoli
- Secretes surfactant- Decrease surface tension- Prevent collapse of alveoli- Composed of
lecithin and spingomyelin- L/S ratio to determine lung maturity- Normal L/S ratio is 2:1-
In premature infants 1:2- Give oxygen of less 40% in premature to prevent atelectasis and
retrolental fibroplasias- retinopathy/blindness in prematurity
Disorders of Respiratory System
1. PTB/Pulmonary Tuberculosis (Koch’s Disease)
- Infection of lung tissue caused by invasion of mycobacterium tuberculosis or tubercle
bacilli- An acid fast, gram negative, aerobic and easily destroyed by heat or sunlight
A. Precipitating Factors
1. Malnutrition2. Overcrowded places3. Alcoholism4. Over fatigue5. Ingestion of an
infected cattle with mycobacterium bovis6. Virulence (degree of pathogenecity) of
microorganism
B. Mode of Transmission
1. Airborne transmission via droplet nuclei
1. Low grade afternoon fever, night sweats2. Productive cough (yellowish sputum)3.
Anorexia, generalized body malaise4. Weight loss5. Dyspnea6. Chest pain
7. Hemoptysis (chronic)
1.
Mantoux Test (skin test)
- Purified protein derivative- DOH 8 – 10 mm induration, 48 – 72 hours- WHO 10 – 14
mm induration, 48 – 72 hours- Positive Mantoux test (previous exposure to tubercle
bacilli but without active TB)2.
Sputum Acid Fast Bacillus
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- Positive to cultured microorganism3.
Chest X-ray
- Reveals pulmonary infiltrates4.
CBC
- Reveals increase WBC
1. Enforce CBR2. Institute strict respiratory isolation3. Administer oxygen inhalation4.
Force fluids to liquefy secretions5. Place client on semi fowlers position to promote
expansion of lungs6. Encourage deep breathing and coughing exercise7. Nebulize and
suction when needed8. Comfortable and humid environment9. Institute short course
chemotherapya.
Intensive phase
- INH (Isonicotinic Acid Hydrazide)- Rifampicin (Rifampin)- PZA (Pyrazinamide)- Given
everyday simultaneously to prevent resistance- INH and Rifampicin is given for 4
months, taken before meals to facilitate absorption- PZA is given for 2 months, taken
after meals to facilitate absorption-
Side Effect INH:
peripheral neuritis/neuropathy (increase intake of Vitamin B
6
/Pyridoxine)-
Side Effect Rifampicin:
all bodily secretions turn to red orange color -
Side Effect PZA:
allergic reaction, hepatotoxicity, nephrotoxicity- PZA can be replaced by Ethambutol-
Side Effect Ethambutol:
optic neuritisb.
Standard phase
- Injection of streptomycin (aminoglycoside)- Kanamycin- Amikacin- Neomycin-
Gentamycin-
Side Effect:
-
Ototoxicity
damage to the 8
th
cranial nerve resulting to tinnitus leading to hearing loss-
Nephrotoxicity
check for BUN and Creatinine- Give aspirin if there is fever
-
Side Effect:
tinnitus, dyspepsia, heartburn10. Provide increase carbohydrates, protein, vitamin C and
calories11. Provide client health teaching and discharge planninga. Avoidance of
precipitating factorsb. Prevent complications (atelectasis, military tuberculosis)
PTB
- Bones (potts)- Meninges- Eyes- Skin- Adrenal glandc. Strict compliance to
medicationsd. Importance of follow up care
PNEUMONIA
Inflammation of the lung parenchyma leading to pulmonary consolidation as the alveoli
is filled with exudates
A. Etiologic Agents
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1.
Streptococcus Pneumonae
– causing pneumococal pneumonia2.
Hemophylus Influenzae
– causing broncho pneumonia3.
Diplococcus Pneumoniae
4.
Klebsella Pneumoniae
5.
Escherichia Pneumoniae
6.
PseudomonasB. High Risk Groups
1. Children below 5 years old2. Elderly
C. Predisposing Factors
1. Smoking2. Air pollution3. Immuno compromiseda.
AIDS
- Pneumocystic carini pneumonia- Drug of choice is
Retrovir
b.
Bronchogenic Cancer
- Initial sign is non productive cough- Chest x-ray confirms lung cancer 4. Related to
prolonged immobility (CVA clients), causing
hypostatic pneumonia
5. Aspiration of food causing
aspiration pneumoniaD. Signs and Symptoms
1. Productive cough with greenish to rusty sputum2. Dyspnea with prolong expiratory
grunt3. Fever, chills, anorexia and general body malaise4. Weight loss5. Rales/crackles6.
Bronchial wheezing7. Cyanosis8. Pleuritic friction rub9. Chest pain10. Abdominal
distention leading to paralytic ileus (absence of peristalsis)
E. Diagnostic Procedure
1. Sputum Gram Staining and Culture Sensitivity – positive to cultured microorganisms2.
Chest x-ray – reveals pulmonary consolidation3. ABG analysis – reveals decrease PO
2
4. CBC – reveals increase WBC, erythrocyte sedimentation rate is increased
F. Nursing Management
1. Enforce CBR2. Administer oxygen inhalation low inflow3. Administer medications as
ordered
Broad Spectrum Antibiotic
a . P e n i c i l l i n b . T e t r a c y c l i n e c.Microlides (Zethromax)
-
Azethromycin (
Side Effect:
Ototoxicity)
-
Antipyretics
-
Mucolytics/Expectorants
-
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Analgesics4. Force fluid5. Place on semi fowlers position6. Institute pulmonary toilet
(tends to promote expectoration)- Deep breathing exercises- Coughing exercises- Chest
physiotherapy- Turning and reposition7. Nebulize and suction as needed8. Assist in
postural drainage- Drain uppermost area of lungs- Placed on various position
Nursing Management for Postural Drainage
a. Best done before meals or 2 – 3 hours to prevent gastro esophageal refluxb. Monitor
vital signsc. Encourage client deep breathing exercisesd. Administer bronchodilators 15 –
30 minutes before proceduree. Stop if client cannot tolerate proceduref. Provide oral care
after procedureg. Contraindicated with- Unstable vital signs- Hemoptysis- Clients with
increase intra ocular pressure (Normal IOP 12 – 21 mmHg)- Increase ICP9. Provide
increase carbohydrates, calories, protein and vitamin C10. Health teaching and discharge
planninga. Avoid smokingb. Prevent complications- Atelectasis- Meningitis (nerve
deafness, hydrocephalus)c. Regular adherence to medicationsd. Importance of follow up
care
HISTOPLASMOSIS
Acute fungal infection caused by inhalation of contaminated dust or particles
with histoplasma capsulatumderived from birds manure
A. Signs and SymptomsPTB or Pneumonia like
1. Productive cough2. Dyspnea3. Fever, chills, anorexia, general body malaise4.
Cyanosis5. Hemoptysis6. Chest and joint pains
B. Diagnostic Procedures
1. Histoplasmin Skin Test – positive2. ABG analysis PO
2
decrease
1. Enforce CBR2. Administer oxygen inhalation3. Administer medications as ordereda.
Antifungal- Amphotericin B- Fungizone (Nephrotoxicity, check for BUN and Creatinine,
Hypokalemia)b. Steroidsc. Mucolyticsd. Antipyretics4. Force fluids to liquefy
secretions5. Nebulize and suction as needed6. Prevent complications – bronchiectasis7.
Prevent the spread of infection by spraying of breeding places
COPD (Chronic Obstructive Pulmonary/Lung Disease)Chronic Bronchitis
Inflammation of bronchus resulting to hypertrophy or hyperplasia of goblet mucous
producing cells leading tonarrowing of smaller airways
1. Smoking2. Air pollution
1. Productive cough (consistent to all COPD)2. Dyspnea on exertion3. Prolonged
expiratory grunt4. Anorexia and generalized body malaise5. Scattered rales/ronchi6.
Cyanosis7. Pulmonary hypertensiona. Peripheral edema
b.
Cor Pulmonale
(right ventricular hypertrophy)
C. Diagnostic ProcedureABG analysis
– reveals PO
2
decrease (hypoxemia), PCO
2
increase, pH decrease
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Bronchial Asthma
Reversible inflammatory lung condition due to hypersensitivity to allergens
leading to narrowing of smaller airways
A. Predisposing Factors (Depending on Types)1. Extrinsic Asthma ( Atopic/ Allergic )Causes
a. Pollenb. Dustc. Fumesd. Smokee. Gasesf. Dandersg. Fursh. Lints
2. Intrinsic Asthma (Non atopic/Non allergic)Causes
a. Hereditaryb. Drugs (aspirin, penicillin, beta blocker)c. Foods (seafoods, eggs, milk,
chocolates, chickend. Food additives (nitrates)e. Sudden change in temperature, air
pressure and humidityf. Physical and emotional stress
3. Mixed Type

90 – 95%
1. Cough that is non productive2. Dyspnea3. Wheezing on expiration4. Cyanosis5. Mild
Stress/apprehension6. Tachycardia, palpitations7. Diaphoresis
1. Pulmonary Function Test- Incentive spirometer reveals decrease vital lung capacity2. ABG
analysis – PO
2
decrease- Before ABG test for positive Allens Test, apply direct pressure to
ulnar and radial artery to determine presence of collateral circulation
1. Enforce CBR2. Oxygen inhalation, with low inflow of 2 – 3 L/min3. Administer
medications as ordereda. Bronchodilators – given via inhalation or metered dose inhalaer
or MDI for 5 minutesb. Steroids – decrease inflammation
c. Mucomysts (acetylceisteine)d. Mucolytics/expectorantse. Anti histamine4. Force

fluids5. Semi fowlers position6. Nebulize and suction when needed7. Provide client
health teachings and discharge planning concerninga. Avoidance of precipitating factor b.
Prevent complications- Emphysema- Status Asthmaticus (give drug of choice)-
Epinephrine- Steroids- Bronchodilatorsc. Regular adherence to medications to prevent
development of status asthmaticusd. Importance of follow up care
BRONCHIECTASIS
Abnormal permanent dilation of bronchus leading to destruction of muscular and elastic
tissues of alveoli
1. Recurrent lower respiratory tract infections2. Chest trauma3. Congenital defects4.
Related to presence of tumor
1. Productive cough2. Dyspnea3. Cyanosis4. Anorexia and generalized body malaise5.
Hemoptysis (only COPD with sign)
1. ABG – PO
2
decrease2. Bronchoscopy – direct visualization of bronchus using fiberscope
Nursing Management PRE Bronchoscopy
1. Secure inform consent and explain procedure to client2. Maintain NPO 6 – 8 hours
prior to procedure3. Monitor vital signs and breath sound
POST Bronchoscopy
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1. Feeding initiated upon return of gag reflex2. Avoid talking, coughing and smoking,
may cause irritation3. Monitor for signs of gross4. Monitor for signs of laryngeal spasm –
prepare tracheostomy set
D. Treatment
1. Surgery (pneumonectomy , 1 lung is removed and position on affected side)2.
Segmental Wedge Lobectomy (promote re expansion of lungs)- Unaffected lobectomy
facilitate drainage
EMPHYSEMA
Irreversible terminal stage of COPD characterized bya. Inelasticity of alveolib. Air
trappingc. Maldistribution of gasesd. Over distention of thoracic cavity (barrel chest)
1. Smoking2. Air pollution3. Allergy4. High risk: elderly5. Hereditary – it involves
deficiency of
ALPHA-1 ANTI TRYPSIN
(needed to form Elastase, for recoil of alveoli)
1. Productive cough2. Dyspnea at rest3. Prolong expiratory grunt4. Anorexia and
generalized body malaise5. Resonance to hyperresonance6. Decrease tactile fremitus7.
Decrease or diminished breath sounds8. Rales or ronchi9. Bronchial wheezing10. Barrel
chest11. Flaring of alai nares12. Purse lip breathing to eliminates excess CO
2
(compensatory mechanism)
1. Pulmonary Function Test – reveals decrease vital lung capacity2. ABG analysis
revealsa. Panlobular/ centrilobular - Decrease PO
2
(hypoxemia leading to chronic bronchitis, “
Blue Bloaters
”)- Decrease ph- Increase PCO
2
- Respiratory acidosisb. Panacinar/ centriacinar - Increase PO
2
(hyperaxemia, “
Pink Puffers
”)- Decrease PCO
2
- Increase ph- Respiratory alkalosis
1. Enforce CBR2. Administer oxygen inhalation via low inflow3. Administer medications
as ordereda. Bronchodilatorsb. Steroids
c. Antibioticsd. Mucolytics/expectorants4. High fowlers position5. Force fluids6. Institute

pulmonary toilet7. Nebulize and suction when needed8. Institute PEEP (positive end
expiratory pressure) in mechanical ventilation promotes maximum alveolar
lungexpansion9. Provide comfortable and humid environment10. Provide high
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carbohydrates, protein, calories, vitamins and minerals11. Health teachings and discharge
planning concerninga. Avoid smokingb. Prevent complications- Atelectasis- Cor
Pulmonale- CO
2
narcosis may lead to coma- Pneumothoraxc. Strict compliance to medicationd.
Importance of follow up care
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MEDICAL-SURGICAL NURSING

Overview of structures and functions:

Central Nervous System

1. AUTONOMIC NERVOUS SYSTEMSympathetic Nervous

2. Parasympathetic Nervous System(CHOLINERGIC, VAGAL,

Involved in fight or aggression response.- Release of Norepinephrine

4. Impaired motor function

Nystagmus6. Urinary retention/incontinence7. Constipation8. Decrease sexual

Major depression leading to

GUILLAIN BARRE SYNDROME

CONVULSIVE DISORDER/ CONVULSION

- 3 molecules of iodine (more potent)2.

– ventricular gallop usually seen in

– atrial gallop usually seen in

5. Administer medications as ordereda. Analgesicsb. Anti Coagulant- Heparin6. Monitor

c. Mucomysts (acetylceisteine)d. Mucolytics/expectorantse. Anti histamine4. Force

c. Antibioticsd. Mucolytics/expectorants4. High fowlers position5. Force fluids6. Institute

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