FLUID AND ELECTROLYTES

Albumin protein that causes blood to stay inside the vessel. (Osmotic Pressure) Solutions: 1. Isotonic a. zero pressure solution b. for dehydrated patients c. Examples: i. Plain NSS / .9 NSS ii. Plain LR iii. Plain IMB iv. Plain solution 2. Hypertonic a. increased pressured (shrink/crenation) b. increased solute, decreased solvent c. Examples: i. D5 ii. D10 iii. D50 3. Hypotonic a. Decreased pressured (swelling) b. Decreased solute, increased solvent c. Examples: i. .30 ii. .35 iii. .45 iv. .80 Edema Formation hypertonic Hypertonic and diuretic go hand in hand! ***Electrolyte*** Sodium - sodium attracts water - water retention - Outside - Normal Value: 135-145 mmol/L or meq/L Potassium - Inside - Important for contraction - Normal Value: 3.5-5.0 meq/L Mineralocorticoid - sodium secretion - Example: aldosterone Glucocorticoid - glucose - Example: cortisol Fluid Disturbances: 1. Fluid Volume a. Deficit Decreased ECF i. Causes: 1. Inadequate intake/absorption of water

Increased renal losses (diurectic, Diabetes) Increased skins losses Increased gastrointestinal losses (vomiting, diarrhea) Third-spacing movement of fluid in the body where normally no fluid accumulates (ascitis) ii. Signs and Symptoms: 1. Thirst early manifestation 2. Weight loss acute; 2.2 lbs/day 3. Rough, dry tongue and it will shrink 4. Poor skin turgor ability of the skin to return to its normal appearance (abdominal area best site) 5. Oliguria urine output of >400 ml/24h 6. Hemoconcentration Test: Increased hematocrit 7. Fever (late manifestation) 8. Restlessness 9. Weakness 10. Decreased Level of Consciousness Lethargy: early manifestation in decreased LOC 11. Decreased CVP Normal: 4-6 mmHg (CVP is the pressure that monitors the Right Atrium) 12. Increased BUN due to hemoconcentration iii. Management: 1. Fluid replacement 2. Establish a patent line and start with isotonic solution 3. Treat the underlying cause b. Excess increased ECF i. Signs and Symptoms:

2. 3. 4. 5.

Edema Formation Systemi c Systemic Congestio n Pulmonar y Fluid migrates to pulmonary area

ii. Signs and Symptoms: (Systemic) 1. Acute weight gain 2. Hypertension (due to fluid overload) 3. Hepatosplenomegaly 4. Engorge tongue 5. Decreased hematocrit 6. Increased CVP (hypervolemia) 7. Distended neck vein/ neck vein engorgement elevate head of bed at 20 degrees angle; < 4cm distended neck vein fluid volume excess iii. Signs and Symptoms (Pulmonary) 1. Cough (cardinal sign of Respiratory Problem) 2. Dyspnea a. Exertional Dyspnea b. Orthopnea dyspnea c. Paroxysmal nocturnal dyspnea 3. Rales or crackles iv. Management:

1. Dietary modification (low sodium diet) 2. Fluid restrictions (1000 to 1300 ml/day) 3. Diuretic Therapy (most effective) v. Nursing Alerts 1. Diuretics a. Given in the morning b. Closely monitor for K and Na c. Not allowed to take food or beverages that increase diuretics 2. Fluid Volume Imbalances a. Daily weighing best way to assess fluid volume imbalances 2. Sodium Alterations a. Hyponatremia i. Decrease intake absorption of Na ii. Increase intake (fluid volume excess) iii. Signs and Symptoms 1. Nausea and vomiting 2. Headache 3. Muscle cramps 4. Restlessness 5. Weakness 6. Irritable 7. Decrease LOC iv. Management 1. Increase Na diet 2. Limit water intake v. Drugs 1. PNSS replace sodium 2. For severe Diuretic/Hypertonic b. Hypernatremia i. Life threatening condition cause intracranial bleeding ii. Signs and Symptoms 1. Thirst 2. Dry, sticky mucus membrance 3. Rough, dry tongue 4. Fever 5. Weakness 6. Cramps 7. Decrease LOC due to intracranial bleeding 8. Water retention iii. Management 1. Diet: Decrease Na 2. Fluid replacement 3. Potassium Alterations a. Potassium and Hydrogen are bestfriends b. Increase Potassium = Increase Hydrogen retention (decrease pH acidosis) c. Decrease Potassium = Hydrogen elimination (Increase pH alkalosis) d. Hypokalemia and Hyperkalemia will give weakness e. Hypokalemia potentiates the effect of digoxin i. A decrease in Potassium = Increase the effect of digoxin (leading to digitalis toxicity) f. Hyperkalemia increases the risk for cardiac arrest g. Potassium chloride must not be given in bolus or in high concentration. KCl will be incorporated with PNSS. KCl = 20 mg/dL (maximum that you can give)

h. Increase Potassium/hyperkalemia will increase sensitivity of insulin and glucose. i. HYPOKALEMIA i. Decrease potassium level ii. Causes: 1. Decrease intake/inadequate absorption of K 2. Increase renal losses 3. Increase gastrointestinal losses 4. Frequent gastric suctioning 5. Disorders (Cushings Syndrome) iii. Signs and Symptoms 1. Generalized weakness 2. Constipation 3. Paralytic Ileus 4. Fecal Impaction passing of a liquid stool 5. Dysrrhythmia/arrhythmia drug: Lidocaine, xylocaine 6. ECG changes prominent U wave 7. Muscle Cramps iv. Diet 1. Banana, dried food, meat, raisins, fruit juice (orange juice), green leafy vegetables (malunggay iron, Vitamin C, potassium) 2. 1 banana = 300 mg 3. Potassium supplement oral or parenteral j. HYPERKALEMIA i. Causes: 1. Increase intake/absorption of potassium 2. Renal failure Decrease potassium elimination Potassium retention Hyperkalemia 3. Release from intracellular to extracellular (e.g. burns, Frequent BT) ii. Signs and Symptoms 1. Weakness 2. Diarrhea 3. Irritability 4. Increased risk for cardiac arrest 5. Muscle cramps 6. Dysrrhythmia/arrhythmia 7. ECG changes Peaked T wave iii. Management: 1. Diet: Low potassium diet 2. Drugs: Diuretics/ OFI 3. Insulin and D50 water 4. Sodium polystyrene Sulfonate (kayexalate) PO or enema iv. Alert: Watch for hypernatremia 4. Calcium Alterations a. Calcium: Normal = 8.5 to 10.5 mg/dL i. Bone formation ii. Strengthen bone iii. Contraction iv. Clot formation b. HYPOCALCEMIA i. Decrease in calcium level ii. Causes: 1. Decrease intake/absorption of calcium 2. Increase renal losses 3. Decrease bone resorption iii. Signs and Symptoms 1. Neuromuscular Irritability

a. Chvosteks Sign i. Tap 2 to 3 cm anterior to the ear lobe, patient develops muscle twitching b. Trousseau sign/Carpapedal Spasm i. Get a BP cuff, inflate at the arms of the patient @ 100 mmHg. After 30 minutes, the patient fingers have spasms. c. Hyperreflexia i. Hyperactive reflexes 2. Weakness 3. Cramps 4. Dysrrhythmia/arrhythmia 5. Hypertension 6. Irritability iv. Management: 1. Diet: High calcium a. Diary products milk (1 glass of milk = 300 mg of Ca) b. Green leafy vegetables c. Vitamin D (Calciferon) enhances calcium d. Calcium-containing solutions i. Calcium gluconate ii. Calcium chloride iii. Calcium gluceptate

Ca Hypocalce mia Parathyroid gland is stimulated Parathormone: Ca absorption Promotes osteoclast activity (bone destroying) Calcium
c. HYPERCALCEMIA i. Too much calcium ii. Causes: 1. Increase intake/absorption of calcium 2. Increase bone resorption 3. Decrease renal losses iii. Signs and Symptoms 1. Hyporeflexia 2. Hypoactive bowel sound 3. Hypotension 4. Increase bone pain due to bone resorption 5. Flank pain due to kidney stone formation a. Most common form of kidney stone: Calcium Stones iv. Management: 1. Diet: Low calcium 2. Drugs: Diuretics, OFI, Calcitonin

3. Other Drugs: Biphosphonate, Plicamycin, Gallium Nitrate Ca Hypercalcemia Thyroid gland stimulated Calcitonin: Effects: Decrease Ca absorption Calcium deposition Calcium
5. Phosphate and Magnesium Alterations a. Phosphate For: b. Magnesium Electrical Transmission/Neuronal Transmission c. Normal Phosphate = 3.5 to 4.5 mg/dL d. Normal Magnesium = 2.7 mg/dL e. HYPOPHOPHATEMIA i. Causes: 1. Impaired renal function most common 2. Alcoholism - malnutrition ii. Signs and Symptoms 1. Seizures/convulsions 2. Disorientation 3. Weakness 4. Lethargy 5. Impaired WBC function 6. Platelet dysfunction 7. Anemia G6PD deficiencies (hemolytic anemia) Glucose-6 Phosphate Dehydrogenase Deficiency anemia iii. Management: 1. Diet: a. High phosphate diet b. Drink milk i. 1 glass = 250 mg c. Fish head d. Phosphate supplements: PO, Parenteral e. Phosphate is contraindicated in: i. Renal failure ii. Hypocalcemia (Why?)

Renal Failure

Phosphate Elimination

Phosphate retention

Hypocalcemia
f.

Ca absorption

Hyperphosphatemia

HYPERPHOSPHATEMIA

i. Increase phosphate in the blood ii. Causes: 1. Acute phosphate overload 2. Renal failure 3. Release from intracellular to extracellular iii. Signs and Symptoms: 1. Hyperphosphatemia will decrease Ca absorption leading to hypocalcemia 2. Signs and symptoms of hyperphosphatemia = hypocalcemia a. Neuromuscular Irritability i. Chvosteks Sign 1. Tap 2 to 3 cm anterior to the ear lobe, patient develops muscle twitching ii. Trousseau sign/Carpapedal Spasm 1. Get a BP cuff, inflate at the arms of the patient @ 100 mmHg. After 30 minutes, the patient fingers have spasms. iii. Hyperreflexia 1. Hyperactive reflexes b. Weakness c. Cramps d. Dysrrhythmia/arrhythmia e. Hypertension f. Irritability iv. Management: 1. Diet: Low phosphate diet, High Ca diet 2. Drugs: a. Diuretics/Increase O b. Ca supplements 3. Severe: Dialysis g. HYPOMAGNESEMIA i. Causes 1. Elimination of magnesium (ex. Diarrhea) 2. Decrease intake/absorption of magnesium ii. Signs and Symptoms 1. Hypertension 2. Seizures 3. Neuromuscular irritability 4. Weakness 5. Cramps/Paresthesia (numbness or tingling sensation) iii. Management: 1. Give Magnesium Sulfate a. Check DTR b. Check BP Magnesium c. Check RR Toxicity d. Check UO e. Magnesium sulfate toxicity/Hypermagnesemia h. HYPERMAGNESEMIA i. Causes 1. Decrease elimination 2. Acute magnesium overload ii. Signs and Symptoms 1. Diminished or absent reflexes (earliest manifestation) 2. Hypotension 3. Respiratory Depression 4. Oliguria 5. Patient develops irritability 6. Facial flushing

7. Risk for cardiac arrest iii. Management 1. Stop giving magnesium 2. Give calcium containing solution 3. Severe: Dialysis

ACID-BASE BALANCES
Normal ABG Results pH 7.35 to 7.45 PO2 80 to 100 mmHg PCO2 35 to 45 mmHg HCO3 22 to 26 mEq/L **HCO3 neutralizes acidity PO2 O2 CO2 Hypoxia Hypoxia Hypercap nia Hypocapn ia pH pH Results Alkalosis Acidosis Alkalosis Acidosis

HCO3 HCO3

CO2 Interpretation of Nursing Alerts 1. Respiratory and urinary systems are systems that will regulate acid-base. 2. Vasodilation is the common effect of acidosis. 3. Vasoconstriction is the common effect of alkalosis.

4. Hyperventilation leads to respiratory alkalosis.

Hyperventilation CO2 loss Hypocapnia pH (alkalosis) Respiratory 5. Hypoventilation leads to respiratory acidosis Hopoventilation CO2 loss Hypercapnia pH (acidosis) Respiratory 6. Vomiting and frequent gastric suctioning leads to metabolic alkalosis Vomiting and frequent gastric suctioning gastric acid loss pH (alkalosis) Metabolic 7. Diarrhea leads to metabolic acidosis Diarrhea fluid loss Hydrogen concentration pH (acidosis) Metabolic 8. Severe vomiting leads to metabolic acidosis Severe vomiting profound gastric acid loss Stimulates: Parietal cells to produce more HCl acid (compensation) pH (acidosis) Metabolic RESPIRATORY ALKALOSIS pH Uncompensated Partially compensated Fully compensated N PaCO 2 HCO3 N

Causes: 1. Hyperventilation a. Factors: i. Anxiety ii. Too much laughing iii. Fever iv. CNS infections

v. Ingestion of toxic substances/agent (Alkaseltzer) 2. Hypokalemia 3. Metabolic Acidosis

Signs and Symptoms 1. Seizures 2. Deep, rapid breathing 3. Hyperventilation 4. Confusion 5. Hypokalemia 6. Light headedness 7. Tingling of extremities Management 1. Breath in a cuphand or paper bag regardless of the color 2. Drugs: a. Sedative (to correct anxiety) b. Anxiolytic c. Narcotics d. Antipyretic 3. Treat infections RESPIRATORY ACIDOSIS pH Uncompensated Partially compensated Fully compensated N PaCO 2 HCO3 N

Causes: 1. Hypoventilation a. Factors: Damage: Medulla Oblongata (Center for Respiratory, BP, HR) Respiratory Disorders Chest trauma Neurologic problem (CVA, Seizures, Alzheimers) Neuromuscular problem (MS, MG) 2. Hyperkalemia 3. Suffocation 4. Metablic Alkalosis Signs and Symptoms 1. Hypoventilation 2. Rapid, shallow breathing 3. Increase BP 4. Dyspnea 5. Hyperkalemia 6. Disorganization 7. Increase cardiac output 8. Muscle weakness 9. Hypoxemia Management 1. Acute a. IV Sodium Barcarbonate (NaHCO3) less than 7.15 pH

b. Check for patent line because it can cause 3rd degree chemical burn
2. Chronic a. PO Sodium Bicarbonate (NaHCO3) 3. Hook patient to a mechanical ventilator to aide the patient to breath 3 Alarms in the mechanical ventilator: a. High Alarm obstruction Suction Auscultate if suctioning is effective b. Low Pressure Alarm leakage/loose connections correct the tubing c. Apnea Alarm Nobody is hooked at the ventilator d. If you cannot figure out what cause the alarm, do bagging manually. Give the patient oxygen vial bagging (Ambubag) METABOLIC ACIDOSIS pH Uncompensated Partially compensated Fully compensated N PaCO 2 N HCO3

Causes: 1. Diarrhea 2. Severe vomiting 3. Renal Failure Decrease hydrogen elimination Metabolic Acidosis 4. Increase fat metabolism (DM) Fats Fatty Acids Yields kenones DKA (form of metabolic acidosis) Penetrate blood brain barrier Diabetic Coma 5. Hyperkalemia 6. Respiratory Alkalosis Signs and Symptoms 1. Headache 2. Disorientation 3. Hyperkalemia 4. Muscle twitching 5. Changes in LOC 6. Kussmaul Respiration Management 1. Acute: IV NaHCO3 2. Severe: PO NaHCO3 3. Same management with Respiratory Acidosis METABOLIC ALKALOSIS pH Uncompensated Partially compensated Fully compensated N PaCO 2 N HCO3

Causes: 1. Vomiting 2. Frequent gastric suctioning 3. Acute HCO2 overload

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4. Hypokalemia 5. Respiratory Acidosis (Decrease pH) Signs and Symptoms 1. Restlessness followed by lethargy 2. Dysrrhythmia 3. Compensatory hypoventilation 4. Diarrhea 5. Confusion (decrease LOC) 6. Nausea and vomiting Management: 1. Mild: Na treatment 2. Vomiting a. Give antiemetic as ordered b. Give KCl + PNSS (to replace gastric losses) 3. Severe: Give IV ammonium chloride Nursing Alert a. Contraindicated to hepatic or renal disorders b. Must not be given I liter in 4 hours 4. Drugs: Acetazolamide (Diuretic) promote excretion/elimination of HCO3 and potassium BURNS - Refers to cell death or tissue death due to an extreme heat caused by chemical, geothermal, radiation, fire and electricity Classification: 1. First Degree Partial thickness burn 2. Second Degree 3. Third Degree Full thickness burn 4. Fourth Degree Classific ation First Second Third Fourth Healing Classific ation First Second Third LAYER Epidermis Epidemis + Dermis Skin + Subcutaenous Skin + Subcutaneous + Muscles + Bones Healing COMMON PRESENTATION Redness/Erythma Blisters/most painful Charcoal/Edema and Eschar Painless

3 to 7 days Average 21 days Skin grafting 3 types: *Autograft self *Xenograft/Heterograft animal cow/pig *Allograft cadaver Fourth Skin grafting and amputation Eschar tough coagulum of necrotic tissue (kugang) Compartment Syndrome 3rd degree burn Signs and Symptoms of Compartment Syndrome 1. Pain 2. Pallor

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3. Paralysis 4. Pulselessness 5. Paresthesia (numbness and tingling sensation) 6. Poikilothermia (coolness of the skin surface) 1st Nursing Action: 1. Elevate extremity for venous return 2. Report to doctor TBSA (Total Body Surface Area) - area of injury - Rule of Nines o Head (includes neck) 9% o Anterior Trunk 18% o Posterior Trunk 18% o Each arm 9% o Each leg 18% o Perineum 1% - Major Burn: More than 25% o Systemic complications arise if the patient sustained major burns o Systemic Complications of Burns: Hemodynamic instability (starts immediately) Talks about blood Begins almost immediately with injury to capillaries Problem with blood circulation; poor perfusion (secondary to fluid shifting secondary to increased permeability) Because of the burn, there is increased permeability. Leading to shifting of plasma to interstitial fluid. Respiratory dysfunction Common cause of death (carbon monoxide poisoning) Carbon monoxide has greater affinity to hemoglobin Carboxy hemoglobin hemoglobin filled with carbon; decreased oxygen carrying ability hypoxemia hypoxia Hemoglobin o Heme where oxygen binds o Globin where carbon dioxide binds Hypermetabolic Response Due to the injury sustained by the patient As a nurse, what is the implication if patient has hypermetabolic response: o Increased metabolism would lead to increased metabolic acid production metabolic acidosis o Increased calorie requirement 6,000 to 8,000 cal/day (Normal: 1200 to 2000 cal/day), therefore TPN is important. Diet of patient should be high calorie, high protein, high carbohydrates. Organ Dysfunction Due to shock, hemodynamic instability Sepsis and Immune dysfunction A small break in skin would lead to infection Patient is immunocompromised therefore put the patient in reverse isolation Doctors would prescribe antibiotic common drug given: Silvadene Not topical, IM but IVTT route Pain give analgesic (Morphine Sulfate 2 mg/hr until pain goes away)

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Morphine narcotic analgesic; can cause addiction. Watch for respiratory depression and drug addiction. Antidote: Naloxone (Narcan) Emotional trauma intervention: therapeutic communication (let the patient verbalize fear) Do not start the question with why In General, if patient got BURN ( more than 25% ), it would give 4 major problem: Cell lysis o Can cause release of potassium from intracellular to extracellular can cause hyperkalemia Increased heart rate decreased cardiac output decreased tissue perfusion organ dysfunctions Possible inhalation injury o Would lead to Carboxy hemoglobin decreased oxygen carrying ability Hypoxemia decreased tissue perfusion Break in the physical barrier o Lead to Increased infection and altered thermoregulation Increased permeability o Lead to fluid shifting (Effects) Hemoconcentration (increased in Hct) Hyponatremia o Burn Shock (An example of hypovolemic shock) o Burn shock requires massive stress response o MSR stimulates adrenal gland/ Release of Catecholamines o Simulation of adrenal gland would lead to following problems: Hyperglycemia Increased metabolism Would lead to metabolic acidosis Would increase calorie requirements Increased hydrochloric acid Curlings Ulcer Tissue Injury (due to catecholamines released; infection also would lead to tissue injury) Increased heart rate decreased cardiac output Stages of BURNS o Emergent Phase Occurs when? Actual exposure to extreme heat Shock Phase Occurs on the first 24-48 hours post burn (movement of fluid is from plasma to interstitial) Diuresis / Fluid Remobilization Phase Occurs 2 to 5 days post burn During this phase, movement of fluid is interstitial to plasma (there will be hemodilution), therefore, cge ihi (diuresis) to prevent congestion Priority: Prevention of congestion Rehabilitation Phase / Convalescent Phase / Recovery Phase Will only start if diuresis is completed Resuscitative Phase a combination of emergent and shock phase and Electrolyte Changes During Burns

o o Fluid

13

Emergent Phase/Shock/Resuscitative Phase Generalized dehydration (plasma to interstitial) Reduction of blood volume Decreased urine output Hyperkalemia (due to cell lysis) Hyponatremia (due to fluid shifting) Metabolic acidosis Hemoconcentration (elevated Hct) o Diuresis Phase Hemodilution (decreased Hct) Increased urine output compensation (because of hemodilution) Hyponatremia (due to dilution) Hypokalemia (early stage: Hyperkalemia, hyponatremia.. Later on: Hypokalemia, hyponatremia) Metabolic acidosis (due to the injury sustained by the patient) o Rehabilitation Phase No more imbalances Phases of Burn Care Priorities o Emergent/Shock Phase First aid safety; prevent added injury Rescue the patient/Remove the patient to a safe place Activate the alarm Confine or contain the fire How: close the door, lower the curtain, close the windows Extinguish the fire o Pull the safety pin o Aim the nozzle o Squeeze o Evacuate o Who to evacuate first? Well patient Prevention of shock/respiratory distress Detection and treatment of injuries Wound assessment and care evaluate the degree of damage; reassess the patient from time to time Diuretic Phase or Fluid Remobilization Phase Wound care and closure Prevention and treatment of complications Nutritional Support Rehabilitation Phase Prevention of scars and contractures How to prevent scars? o Let patient wear anti-scar stocking Best time to wear: must be worn a week after healing has completed For how long: 16 to 18 months, maximum of 2 years How often: wear 23 hours/day How to prevent contractures (happens because you fail to position the patient properly) o Position: Anatomical position (Extremities extended, digits abducted) Physical, occupational and vocational rehabilitation Start rehab upon admission When do rehab phase begin: when diuresis is completed

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Functional and cosmetic reconstruction Psychosocial counseling Treatment: o Soak burned area in cool water not more than 10 minutes. If more than 10 minutes, it would cause severe vasoconstriction and would impede normal flow of blood. o Prevent causal agent from producing further tissue damage FIRST ACTION o Emergency care includes: Resuscitation Stabilization with IV while maintaining cardiac and respiratory function o Hospital setting Fluid replacement Maintenance of nutritional demands (TPN) o Antibiotic Therapy o Maintenance of cardiac and respiratory function o Pain management o Emotional support o Prevention of complications o Skin grafting o Rehabilitation Common Complications o Respiratory Dysfunction o Infection o Fluids and electrolyte imbalances o Pain o DBT (Deep Vein Thrombosis) o DIC (Disseminated Intravascular Coagulation) or Blood coagulopathy o Body image disturbance o Compartment syndrome (Escharotomy; Escharectomy) can be performed on bedside without anesthesia Fasciotomy OR under general anesthesia

OXYGENATION - refers to perfusion of gases - not only oxygen, but also involves carbon dioxide - 3 systems involved: o Respiratory o Hemotopoesis o Cardiovascular RESPIRATORY SYSTEM Sneeze reflex that clears upper respiratory tract Vibriscae hair of the nose; filter the air coming in Epiglottis division of upper and lower respiratory system Cough reflex that clears lower respiratory tract Vocal cords - one injury: hoarseness of voice - both are injured: loss of voice - paralysis: Airway obstruction noisy breathing Complete airway obstruction loss of voice Globet cells produce mucus Carina anatomical landmark for the tip of endotracheal tube Hering-Breuer Reflex reflex that govern inflation or deflation process of alveoli

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Intrathoracic negative pressure Nursing Diagnosis: 1. Altered tissue perfusion a. Used if there is circulatory obstruction b. Dili pwede sa respiratory problems c. Example: MI, DVT, Pulmonary Embolism, Angina Pectoris 2. Impaired Gas Exchange a. Used if the patient is having alveolar problem or lung problem b. Example: Patient having emphysema - there is loss of lung elasticity; patient having or too much mucus production; 3. Ineffective Breathing Pattern a. Used if the patient has hypoventilation or hyperventilation 4. Ineffective Airway Clearance a. Used if patient has airway obstruction b. Example: Bronchitis, Asthma RESPIRATORY DISORDERS 1. Restrictive Lung Disease a. Are any process that limits lung expansion b. Limits movement of air into the lungs c. Inspiratory problem d. Example: Atelectasis, Infections (PTB, Pneumonia), Chest Trauma (Hemothorax, Tension Pneumothorax, Pneumothorax) 2. COPD/CAL (Chronic Airway Limitation) a. Any process that limits movement of air out from the lungs b. Expiratory problem c. Safest oxygen flow rate: 1 to 2 L/min ONLY d. 6 L/min the more it causes dyspnea; If oxygen increases, carbon dioxide decreases, so there is hypocapnea; kung walay carbon dioxide, walay stimulator, so it would lead to respiratory depression e. Most appropriate oxygen device: Venturi Mask (Because venturi mask is the only device that would give you the accurate oxygen concentration) Next: Nasal Cannula f. Croup Tent important nursing intervention: tuck the sides g. Most common cardiovascular for COPD: Cardiomegaly (right ventricular hypertrophy or cor pulmonale) h. Example: Emphysema, Bronchitis, Bronchiectasis, Asthma 3. Pulmonary Vascular Disorder a. Any problem affecting the vascular compartment of the pulmonary area b. Example: Cor Pulmonale, Pulmonary Embolism Restrictive Lung Disorders 1. Atelectasis a. Definition: Collapse of a previously inflated lung tissue b. 2 Major Types: i. Primary a type of atelectasis brought about by surfactant 1. common among premature babies (SIDS/ARDS) betamethasone promotes lung maturity ii. Secondary brought about by compression or obstruction 1. compression: hemothorax and pneumothorax 2. obstruction: aspiration c. Signs and Symptoms i. Dyspnea ii. Cough iii. Hypoxia iv. Chest pain v. Asymmetrical lung expansion vi. Decreased breath sound on the affected lung field

16

d. e.

f.

2. Chest
a. b.

c.

vii. Restlessness viii. Cold, clammy skin Appropriate Nursing Diagnosis: i. Impaired Gas Exchange Diagnostic Test i. Chest X-ray confirms collapsed Lung ii. ABG 1. decreased PH 2. increased PCO2 3. decreased PO2 4. Reading: Respiratory acidosis, hypoxia Management i. Drugs: 1. Bronchodilator a. Ventolin, Aminophyline (given parenteral), Theophylline (given PO) 2. Anticholinergic Drug decreases spasm, decreases mucus production 3. Antibiotic 4. Anticholinergic ii. Specific Nursing Management: 1. Position: High Fowlers Position to promote lung expansion 2. Give oxygen supplement to correct hypoxia 3. Hook the patient in respiratory support 4. Treat the underlying cause/problem 5. Decrease environment and physical stimuli to decrease oxygen demand; limit visitors Trauma Common cause: accident Types: i. Blunt/Non-Penetrating Chest Trauma 1. Common problem is FLAIL CHEST arise from three or more fractured ribs adjacent to each other / multiple rib fracture. These fractured ribs become loose ribs, piercing own lung tissue during inspiration (Paradoxical Respiration). 2. Management: Hook the patient in mechanical ventilator, to facilitate healing of the fractured rib. ii. Penetrating Chest Trauma 1. Common problems: a. Hemothorax refers to blood in pleural space i. Accumulation of blood in the lower lobe b. Pneumothorax air i. Upper lobe c. HemoPneumothorax i. 1 tube in the lower lobe d. Tension Pneumothorax i. During inspiration, the hole opens allowing air to get inside. During expiration, it closes. So air is trapped inside the lungs. ii. Mediastinal shift common in pneumothorax, if not corrected would lead to cardiogenic shock or atelectasis 2. Thoracentesis 3. Thoracentesis i. A form of invasive procedure that involves insertion of needle in the pleural space to drain air or fluid for the purpose of diagnosis or treatment ii. Main Reason: to restore a negative pressured cavity

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iii. Nursing responsibilities before insertion: 1. Check Doctors order 2. Witness signing of consent 3. Check the vital signs of the patient pay attention on RR 4. Check chest x-ray result 5. Teach deep breathing exercises iv. Nursing responsibility during insertion 1. Best position: sitting position or high-fowlers position, leaning forward, arms supported on a high-chair or arms elevated. 2. What to instruct during insertion: Exhale and close your glottis / valsalvas maneuver higher intrathoracic pressure preventing entry of air into the lungs of the patient, prevents pneumothorax 3. Exact site: a. Drain air: insertion is on the 2nd or 3rd intercostal spaces b. Drain fluid: insertion is on 5th or 6th intercostal spaces v. Nursing responsibility after insertion: 1. Best position: Lying on the good side or unaffected side 2. Check the site of insertion 3. Check the vital signs of the patient particularly the RR of patient 4. Check tidaling or oscillation (fluctuation or the rise and fall of fluid in the tube during respiration) this is normal. If walay tidaling, the needle is out or there is obstruction in the tube. During inspiration, fluid rises. During expiration, fluid falls. vi. Nursing alerts: 1. Keep collecting bottle below the level of insertion 2. Do not clamp the tube for long period of time. Because it can cause tension pneumothorax. Clamp the tube not more than 30 minutes. 3. Clamp the tube as close to the patients body. 4. Do not milk the tube. Because it creates pressure inside, it causes suction and cause damage on the pleural tissue. vii. Interpretation: 1. Intermittent Bubbling a. Indicates that the lung had reexpanded 2. Continuous Bubbling a. Indicates leakage 3. No drainage coming out a. Indicates resolution viii. One-way bottle system ix. Two-way bottle system x. Three-way bottle system ** Immersed 2cm below COPD/CAL 1. Emphysema a. Loss of lung elasticity b. Irreversible c. Causes: i. Smoking ii. Deficiency in antitrypsin an enzyme that causes destruction of the alveolar wall iii. Chemical exposure asbestos d. Pathologic Changes i. Loss of lung elasticity ii. Formation of Bulla/Bullae

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iii. Hyperinflation of lung tissue - Common result of chest x-ray: Barrel chest (increased AP Diameter) Hyperresonant sound iv. Small air trapping or collapse e. Types i. Panlobular upper lobe ii. Centrolobular common in central aspect of lung tissue iii. Paraseptal Distal Acinar Emphysema distal part of lung tissue f. Diagnostic Test i. Chest x-ray barrel chest; increased AP diameter ii. Decreased PH, increased PCO2, decreased PO2 iii. Pulmonary function test 1. Incentive Spirometer Normal: increased in the residual volume and a decrease in the expiratory reserved volume iv. g. Pink Puffer i. Increased CO2 retention (pink) ii. No cyanosis iii. Purse lip breathing iv. Dyspnea v. Ineffective cough vi. Hyperresonance on percussion vii. Orthopneic viii. Barrel chest ix. Exertional dyspnea x. Prolonged expiratory time xi. Speaks in short jerky sentences xii. Anxious xiii. Use of accessory muscles to breathe xiv. Thin appearance h. Management: i. Drugs: 1. Bronchodilator 2. Antibiotic 3. Anticholinergic drug 4. Mucolytic expectorant ii. Nursing Management: 1. Cessation of smoking a. How to convince? Tell the patient on the consequences of his action. 2. Oxygen supplement 3. Diet of patient a. High calories b. High protein c. High fiber 4. Avoid pollutants or other irritating substances 5. Assist or prepare the patient for surgery a. Surgical procedures: i. Lobectomy part of a lung 1. Best position post lobectomy: lying on good side 2. Chest tube inserted in patients lung ii. Pneumonectomy entire lung 1. Best position post pneumonectomy: lying on the affected or bad side. New answer: lying high fowlers position 2. Bronchitis a. Refers to inflammation of the bronchial area due to inhalation of noxious fumes or irritating substances

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b. Smokers cough c. Common cause: Smoking (same with emphysema except decreased in antitrypsin) d. The problem is inflammation, too much mucus production which leads to obstruction e. Reversible problem f. Termed as blue bloaters i. Blue because there is cyanosis ii. Bloaters due to edema formation and clubbing of fingers (secondary to chronic hypoxia) iii. Edema Right ventricular hypertrophy CHF iv. Schamroth method method used to determine clubbing of fingers v. Normal degree angle of nail: 160 degrees 1. If > 160 but < 180 = early clubbing 2. IF > 180 = advanced clubbing/ digital clubbing vi. g. Nursing Diagnosis: Ineffective Airway Clearance h. Chronic Bronchitis Blue Bloaters i. Color dusky to cyanotic ii. Recurrent cough and increased sputum production iii. Hypoxia iv. Hypercapnia v. Acidosis vi. Edematous vii. Increased respiratory rate viii. Exertional dyspnea ix. Increased incidence in heavy cigarette smokers x. Digital clubbing i. Diagnostic Test i. X-ray constriction in the bronchial airway 1. increased mucus production 2. ABG same with emphysema, respiratory acidosis and hypoxia 3. Pulmonary function test same with emphysema j. Management: i. Most important management is cessation of smoking 1. Perception of owns behavior first question to be asked for patients under rehabilitation ii. Common drugs 1. Bronchodilator a. Closely monitor normal theophylline and aminophylline level which is 10 to 20 unit gram/dL b. If > 20: theophylline or aminophylline toxicity c. Indicators of aminophylline and theophylline toxicity i. Patient develops nausea and vomiting ii. Headache iii. Chest pain iv. Palpitations unpleasant awareness of heartbeat v. Tremors or shakiness d. Meter Dosed Inhaler i. Instruction: Simultaneously squeeze and inhale deeply to deliver the drug directly in the respiratory system 2. Corticosteroids a. Anti-inflammatory b. If patient is using corticosteroids, corticosteroids must not be taken for long periods of time because it

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causes immune suppression. So watch out for signs and symptoms of infections. c. It can also cause cushings syndrome or hypercorticolism. d. Do not stop corticosteroid abruptly, it must be gradual. e. Corticosteroids cause gynecomastia 3. Anticholinergic drug a. Decreases mucus production b. Example: atrophine sulfate c. Are also anti spasmodic 4. Beta blockers a. Help dilate bronchial area b. What is the most life-threatening side effect: BRONCHOSPASM. That is why it is contraindicated to asthmatic patient because the more it causes bronchospasm. c. Beta blocker may mask the signs and symptoms of shock and hypoglycemia. So closely monitor blood sugar level. d. What is the first drug given to patient? Bronchodilator. e. Corticosteroid first before beta blocker to subside inflammation first, so that beta blocker can get inside. 5. Antibiotic a. Prophylaxis against infection 6. Diuretic iii. Nursing Management 1. Oxygen supplement is important 2. Watch for water retention 3. High fowlers position to relieve dyspnea 4. Limit visitors, decrease environment and physical stimuli 5. Diet is similar with emphysema 3. Bronchiectasis a. Permanent dilation

Emphysema

Smoking and Increased CO2

Pink puffers - no cyanosis - hypercapnia Vasodilation

Blood congestion Pulmonary Vascular Disease 1. Cor Pulmonale a. Refers to enlargement of the right ventricle due to constriction on the pulmonary vessels secondary to respiratory disorders b. Management: treat respiratory disorder

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2. Pulmonary Embolism a. Narrowing or occlusion in one or more pulmonary vessel b. Causes: i. Clot ii. Cholesterol or fat or lipid iii. Amniotic fluid iv. Air embolism c. Common question i. What is the best position to patient suspected of pulmonary embolism? Trendelenberg position (because if head is higher, air will go to the head) ii. What position, right or left side lying position? Left side-lying position (if right lung is on top, air bubbles will get inside the right lung, then it will be absorbed by the pulmonary arteries correcting pulmonary embolism) d. Signs and symptoms i. Acute chest pain ii. Dyspnea iii. Cough iv. Nausea and vomiting v. Cold, clammy skin e. Signs and symptoms of shock i. Restlessness ii. Diaphoresis iii. Pleuritic pain there is pain when you inhale deeply f. Diagnostic test i. Confirmatory test: PULMONARY ANGIOGRAPHY 1. a procedure that will evaluate patency of blood vessel 2. doctors will make use of femoral line 3. In any form of angiography assess peripheral or distal pulses before and after procedure 4. If after angiography, no pulses, damaged ang artery. Therefore, inform the doctor immediately. 5. Post angriography, increase OFI to facilitate elimination of dye or contrasts. ii. g. Nursing Diagnosis: Altered Tissue Perfusion, Alteration in comfort h. Drugs: i. Anticoagulant prevents clot formation 1. example: Aspirin, Heparin, Warfarin, Coumadin 2. Best diagnostic test that would evaluate effectiveness of Heparin: Partial Thromboplastin Time (PTT) or Clotting time Antidote: Protamine Sulfate a. Can you give Heparin to pregnant mothers? YES because heparin cannot pass the placenta. b. Protamine Sulfate is still anticoagulant. But kung mag meet sila sa Heparin, mahimo siya coagulant. 3. Best diagnostic test that would evaluate effectiveness of Warfarin: PT Antidote: Vitamin K 4. Watch for bleeding! ii. Thrombolytic Drug 1. Streptokinase a. Dissolves the blood b. An enzyme that is from a bacteria. Thats why do not give to immunosuppressed. c. Delivered through IV pump d. *** Must be given within 6 hours. But better if given within 3 hours.

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i.

iii. Analgesic 1. Morphine Sulfate iv. Nursing Management i. Best position: High fowlers position to promote lung expansion except for air embolism ii. Oxygen supplement is important iii. If theres a need to hook the patient in respiratory support, do so. iv. Decrease environment and physical stimuli. v. Prepare the patient for surgery. Removal of clot (Embolectomy)

BLOOD - important for the following reasons: o transportation o protection o regulation - Pluripotent a cell that will subdivide into several types of cells o Myloid RBC, WBC, Platelet o Lymphoid B-Lymphocytes and T-Lymphocytes - RBC 4.8 to 5.4 m/mm3 - WBC 5000 to 10,000/mm3 - Platelet 150,000 to 450,000/mm3 o Thrombocytopenia less than normal platelet o Thrombocytosis too much platelet - Blood volume o Male - 5 to 6 liters o Female - 4 to 5 liters - Blood color o Oxygenated blood bright red o Deoxygenated blood dull red - Ph of blood o 7.35 to 7.45 o Slightly alkaline in nature - Normal Temperature = 38 degrees celsius - Taste: It has a metallic taste - Different Blood Types o Type A Can transfuse type A and O o Type B Type B and O o Type O Universal Donor Type O o Type AB Universal Recipient A, B, AB, O - Rh o Rh+ a blood with Rh antigen o Rh a blood without Rh antigen - O- - if you dont know the blood type, type O can be given. Negative because the safest blood is a blood that has no Rh antigen. o Ideally ang ihatag nimo nga blood for type O- nga patient, is blood type O. But in cases of emergency, pwede maghatag ug type 0+ provided that it is his FIRST transfusion. Ang succeeding na daun niya nga transfusion should be O- throughout his life. If maghatag ka ug 0+ the 2nd time around, idestroy na pud to niya ang daan nga antigen, resulting to hemolysis.

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Blood Disorders 1. ANEMIA it is not a disease but a condition where there is a decrease in RBC # and a decrease in hemoglobin mass a. Common denominator among Anemias: Decreased oxygen carrying ability b. Common Signs and Symptoms i. Pallor ii. Weakness iii. Headache iv. Dizziness v. **Easy fatigability or easy exhaustion is very common among Iron-Deficiency anemia. vi. Patient develops pica cause of pica is unknown; common among iron-deficiency anemia vii. Neurologic Deficits common among patients with pernicious anemia; priority is safety of patient viii. Beefy red tongue or sore in the tongue common to patients with pernicious anemia 1. **Strawberry tongue Kawasaki 2. **Red or white strawberry tongue Scarlet fever c. Chronic manifestations of late anemia i. Koilonychia spoon-like nail because of hypoxia ii. Angular Chelliosis ulcer formation on the side of the mouth; an indication of chronic anemia iii. Hyperthyroidism common to patient with iron-deficiency anemia because iron is important to the synthesis of T3 and T4 iv. Chronic infection v. Cardiomegaly vi. Heart failure vii. Generalized edema d. Classifications of Anemia i. Anemia secondary to blood loss anemia results from bleeding 1. Acute Anemia a. Sudden b. Conditions: Hemorrhage 2. Chronic Anemia a. Occurs gradually b. Conditions: Peptic Ulcer Disease, Ulcerative Colitis, Bleeding hemorrhoids c. Management: i. Blood Transfusion ii. Correct underlying cause ii. Anemia secondary to nutritional deficiencies most common anemia in the Philippines due to poverty 1. Iron-Deficiency Anemia a. Patient must have iron supplement b. Food rich in iron: i. Green leafy vegetables ii. c. Nursing Alerts for Iron i. Iron is best absorbed in an empty stomach ii. Iron is gastric irritant iii. Iron must be taken 30 minutes before meal or an hour after meal iv. Iron must be taken together with vitamin C vitamin c enhances iron absorption. 70 cc is enough to enhance iron absorption. v. Pediatric with Iron Deficiency Anemia. The best indicator that iron supplement is effective: A change in the stool

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characteristics. What is that change? It becomes a black tarry stool or green stool. d. Drug of choice against iron toxicity: 1gm DEFEROXAMINE (Destferal) 1gm can neutralize 75 mg of iron e. Antidote of iron hypersensitivity: EPINEPHRINE f. Iron preparations i. Tablet ii. Liquid** - if taken in liquid form, do not forget to use straw or medicine dropper because it can cause permanent discoloration of the teeth, which is brown to black in color. 1. The most important nursing action after giving iron in liquid form is Oral Care. iii. Parenteral 1. Example: Dextran Forte 2. Do not forget, you have to give deep IM Z-track technique. 2. Megaloblastic Anemia a. Folate/Folic Acid Anemia i. Folic Acid is important for DNA and RNA synthesis of RBC. Also important to prevent neural tube defects. ii. As a result, the bone marrow of the patient will compensate. That compensation is that the bone marrow produces large cells. iii. Implication: iv. Folic Acid dosage: 1mg/day b. Pernicious Anemia i. The problem is that you have a deficiency in Vitamin B12 ii. Either there is no parietal cells or no intrinsic factor. iii. Without intrinsic factor, you cannot absorb vitamin B12 iv. B12 is absorbed in the Ileum part of the small intestine. So maski naay intrinsic factor, but wala na ang Ileum, naa japun ka pernicious anemia. v. HALLMARK: Beefy red tongue or red beefy tongue or sore in the tongue vi. Confirmatory Test: Schillings Test 1. Hatagan ug 2 ka klase nga B12 ang patient, that is Radioactive B12 (PO) and Non-radioactive (IM) 2. 6 to 9% of the radioactive substances will be eliminated through urine within 24 hours. Therefore the most important nursing action during Schillings test, is 24-hour urine collection. 3. If may radioactive substances ang urine, negative for pernicious anemia. 4. If there is no radioactive substance, there is pernicious anemia. 5. Ang non-radioactive pang buffer lang. vii. Lifelong administration of B12 1. Dosage: 1000 units of Vitamin B12

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2. Frequency: every month 3. Route: IM, vastus lateralis 3. G6PD Deficiency Anemia a. Glucose 6 Phosphate Dehydrogenase Deficiency b. G6PD is important for glucose metabolism. c. There is hemolysis because of too much glucose, because there is no metabolism of glucose due to the deficiency in G6PD d. Added Manifestations i. Weakness ii. Petichae iii. Hepatosplenomegaly iv. Hemoglobinuria v. Bloody urine vi. Renal shut down e. Management: i. Diet: high phosphate diet ii. Blood transfusion iii. BMT Bone Marrow Transplant (3 types) 1. Antologous a. The donor will be the patient himself b. When do doctors harvest bone marrow of the patient? During period of Remission. Remission is a time when no laboratory tests can identify presence of cancer cells or abnormal cells. 2. Allogeneic a. The donors are the siblings or brothers or sisters. It must be compatible. 3. Syngeneic a. Donor is the identical twin. iii. Anemia secondary to Impaired RBC Production the problem here is the bone marrow of the patient. It is not producing sufficient or mature blood cells. 1. Aplastic Anemia a. A rare blood disorder characterized by a decrease in the bone marrow elements of unknown reason. b. A precursor for leukemia. c. Decreased bone marrow elements, so decreased RBC, WBC (pancytopenia) and platelet. d. Aplastic anemia and pancytopenia are the same. e. Patients are immunocompromised so important ang reverse isolation. Observe strict aseptic technique. f. Platelet is decreased so bleeding is common. So no invasive procedures and no aspirin. g. Drug of choice: Bone Marrow Suppressant METHOTREXATE or Cytosan i. I-suppress ang bone marrow para magstop siya ug produce ug immature blood cells. ii. Antibiotic iii. BT iv. BMT 2. Sickle Cell Anemia a. A blood disorder characterized by production of a defective hemoglobin S b. Hemoglobin S sickling

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2.

c. Sickle Cell Crisis or vaso occlusive crisis common cause: hypoxia d. ***Oxygen supplement to prevent hypoxia e. ***Hydrate, hydrate, hydrate the patient to prevent clot formation f. Infarction g. Effects of Sickling i. Spleen primary site of sickling 1. So there is infarction decreased spleen activity increased risk for infection ii. CNS infarction neurologic deficits (CVA) iii. Lungs infarction increased pulmonary pressure pulmonary hypertension iv. Liver jaundice/biliribinemia/pruritus/bleeding tendencies v. Kidneys infarction glomerular damage vi. Bones hypoxia increase bone marrow activity bone pain vii. Skin/Vascular obstruction ulcer formation pain viii. Penis obstruction priapism necrosis pain h. Management: i. Drugs 1. methotrexate 2. antibiotics 3. thrombolitics 4. anticoagulant 5. analgesic ii. nursing Management: 1. oxygen supplement 2. hydration 3. bone marrow transplant iv. Anemia secondary to Renal Failure 1. Kidneys will produce or release erythropoietin (a hormone that stimulates bone marrow activity. Leading to increased RBC production. 2. Management: a. Drugs i. Iron supplement ii. Erythropoietin (Eprex) iii. Blood transfusion iv. Kidney transplant Polycythema Vera a. A chronic myeloproliferative disorder, involving all bone marrow elements. There is proliferation in myeloid cell. Increased RBC, WBC and platelet. b. Common among women compared to men. c. Cause is unknown d. Signs and Symptoms: i. Increased RBC, WBC, platelet ii. Plethoric appearance (rody appearance) iii. Hypertension (because of increase in blood volume) iv. Hemoconcentration v. Pain on the digits because of increase in blood volume vi. Hepatsplenomegaly

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e.

f.

vii. Cardiomegaly viii. Increased clot formation * - the most common cause of death amont polycythema vera **Avoid high altitude places because a high altitude area has a decrease oxygen concentration. In the environment, the normal oxygen saturation is >21%. In the body, oxygen saturation is 95 to 100%. Once there is less oxygen saturation, it would stimulate the kidneys of the patient, releasing erythropoietin, causing an increase in RBC production. Management: i. Medication: 1. Immune bone marrow suppressant METHOTREXATE 2. Vasodilators 3. Anticoagulant 4. Antihypertensive drugs ii. Nursing Management: Nursing Diagnosis: Risk for altered tissue perfusion because of circulatory obstruction 1. Deliver oxygen 2. Hydrate patient to prevent clot formation 3. Bone marrow transplant 4. Phlebotomy about 500 to 2000 ml / week a. Cannot be transfused, because the blood is considered to be defective.

3. Thrombocytopenia a. A decrease in platelet count b. Causes: i. Drugs Alcohol, Aspirin, Chloramphenicol (drug of choice for typhoid fever), chemotherapy drug, radiation exposure, anticoagulants, thrombolytics, quinolones, Phenobarbital ii. Infection viral infection (tanan naay thrombocytopenia), Ebola Viral Infection (most feared viral infection). Ebola and dengue viral infection pareho naay fever and thrombocytopenia. But Ebola liquefaction of internal organ. iii. Disorder leukemia c. Management: i. Platelet concentrate transfusion d. Nursing Alerts i. No invasive procedures ii. No dark-colored foods iii. No strenuous activities iv. Avoid aspirin v. Patient with bleeding tendencies, best exercise: Swimming (less physical contact) vi. For pediatric patients, common presentation of bleeding: hemarthrosis (bleeding in the joints). Early indication of hemarthrosis is reluctance to move a body part. **Nursing Actions: Pad the joint or extremities vii. Ensure safe administration of blood product CARDIOVASCULAR SYSTEM 2 Valves 1. AV Valve a. Tricuspid Valve b. Mitral Valve 2. Semilunar Valve a. Pulmonary b. Aortic

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Heart sound is due to the closure of the valve. S1 closure of AV valve. S2 closure of the Semilunar valve. Abnormal heart sounds murmurs; S3 and S4 S3 heard after S2; common cause is heart failure S4 heard before S1; common cause is hypertension ECG = EKG 1. P wave atrial depolarization (depolarization is contraction/stimulation) 2. QRS complex a. Atrial repolarization (repolarization is resting/relaxation) b. Ventricular depolarization 3. T wave ventricular repolarization 12 Leads of ECG - are the different angles or view of the heart 1. Chest Leads a. V1 right side b. V2 right side c. V3 septum d. V4 septum e. V5 left side f. V6 left side 2. Limb Leads a. I b. II c. III d. IV e. AVR f. AVL g. AVF Normal Rate: 60 to 100 bpm Normal P-R: 0.12 to 0.20 seconds Normal QRS: 0.08 to 0.12 seconds 1 small box = 0.04 seconds 1 big box (5X5) = 0.20 seconds 350, 150, 100, 75, 60, 50 ECG INTERPRETATION 1. Ischemia Inverted T wave 2. Injury ST segment elevated 3. Infarction a. Old pathological Q wave b. New ST segment elevation 4. Hypokalemia prominent U wave 5. Hyperkalemia peak T wave CORONARY ARTERY DISORDERS - refers to perfusion alteration - coronary arteries is not allowing blood to flow freely in the heart, most probably because of obstruction - the goal is to improve perfusion by all means 1. Atherosclerosis a. An abnormal accumulation of lipid, or fatty, substances and fibrous tissues in the vessel wall b. Cholesterol i. LDL bad

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1. as early as 7 years old, there is already fat deposition 2. WBC and macrophages modify the LDL 3. during modification, there is injury in the vessel ii. HDL good iii. Triglycerides increased risk for CAD c. 2. Arteriosclerosis a. Refers to hardening of the vessel walls b. Ischemia disrupted blood flow Risk Factors: 1. Modifiable a. High Blood Pressure b. Cigarette Smoking c. High Blood Cholesterol Levels d. Diabetes Mellitus accelerates atherosclerosis e. Lack of estrogen in women f. Physical inactivity g. Obesity paired with hypertension 2. Non Modifiable a. Family History of CAD b. Increasing age (55 years old and above) c. Gender common among Males, type A personality d. Race African-American Normal Total Serum Cholesterol = 150 to 240 mg/dl HDL = 29 to 77 mg/dl LDL 60 to 160 mg/dl Triglycerides = 10 to 190 mg/dl Desired LD levels: 1. 1 risk factor or no risk factor = < 160 2. 2 or more risk factors = < 130 3. Diagnosed with CAD = < 100 ANGINA PECTORIS - refers to chest pain or chest discomfort - choked chest - Angina is due to myocardial ischemia (inability of the coronary arteries to supply blood adequately) - Specific causes: o Atherosclerosis o Arteriosclerosis o Vasospasm common early in morning o Vasocompression brought about by inflammatory processes o Drugs Decongestants all lead to myocardial ischemia Adrenergic drugs - Types: o Stable A type of angina pectoris if patient is under stress or physical exertion. You know when the attack will occur. Arteriosclerosis o Unstable Even at rest may occur You need to closely monitor patient, because may progress to myocardial infarction Also known as Preinfarction Angina

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Most common cause: Atherosclerosis Silent No signs and symptoms (asymptomatic) o Variant Nocturnal angina pectoris Pwede mugawas early in the morning AKA Prinzmetal Angina Most common cause: Vasospasm o Intractable/Refractory The patient will not respond to common medications, that is why patient complains of severe pain. o Ludwigs Angina Brought about by drugs. Drug-induced angina Signs and Symptoms o Chest pain (precipitated by the following) Emotion Eating Environment (cold) Exertion Exercise ** can be relieved by rest and or nitroglycerin ** chest pain is usually less than 20 minutes ** (+) Levine sign grasping anterior chest because of pain ** The major difference of chest pain experienced by patient with angina and MI: Characteristic of pain o Chest discomfort o Chest tightness Common Diagnostic Test o ECG inverted T wave o Blood analysis Lipid profile Cardiac enzymes (CPK-MB, Trop-T, LDH) o Thalium Scan an invasive procedure Identify what part of the heart with hypoxia o Coronary Angiography All assess for distal and peripheral pulses Management o Drugs Vasodilator Nitroglycerin Nursing Alerts: Nitroglycerin is a vasodilator Nitroglycerin comes in different preparations o tablet, spray take sublingually; store in a dark dry tightly capped container because it is photosensitive. Burning or tingling sensation when taking the drug best indicator that nitroglycerin is effective or still fresh Lightheadedness is a normal side effect of nitroglycerin Discard nitroglycerin after 6 months nitroglycerin starts to decline its potency on the 4th month Nitroglycerin must be taken 1 tab at a time or one spray at a time, 5 minutes interval, maximum of 3 tablets or 3 sprays o

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Patch do not touch the medicated surface place on anterior chest do not place on a hairy site shave site along the direction of hair growth to decrease the risk for skin breakdown To prevent nitroglycerin tolerance, the nursing action is to establish a 12-bour no nitroglycerin per day

After 3 days, if pain is still present, consult doctor.

Anticoagulant Analgesic if severe pain occurs Beta blockers to decrease myocardial oxygen demand Nursing Management: First nursing action if patient in your unit complains of chest pain: Give oxygen supplement 1 to 2 L/minute Position the patient in a Semi-Fowlers position to promote good lung expansion Modify the diet of the patient: Low sodium, low fat, high protein, high potassium, high fiber diet (to prevent constipation) Decrease environment and physical stimuli to decrease the workload of the heart Prepare the patient for surgery PTCA (Percutaneous Transluminal Coronary Angioplasty) o Before and after, assess for peripheral and distal pulses CABG (Coronary Artery Bypass Grafting) ultimate choice If not corrected, angina may progress to MI

MYOCARDIAL INFARCTION - caused by coronary occlusion - causes are same with angina - Patient may present with the following: o Dyspnea o Anxiety dyspnea, diaphoresis and nausea and vomiting are related to anxiety o Nausea and vomiting o Chest pain / crushing substernal pain not all patients with MI have chest pain, not common among women. Not also common to patient with diabetes mellitus, because they have diabetic neuropathy, so sira ang nerve, so walay pain. Chest pain is more than 20 minutes Cannot be relived by rest or nitroglycerin (+) for Levine sign Chest pain may radiate back, down the neck, shoulder and on the left arm. Pwede sa right but most common sa left arm. Why it radiates on the left arm? Because the nerve that supplies the heart and the nerve that supplies the left arm originated in the same branch. Aura - Epigastric Pain. Ngano naa epigastric pain? Patient thought it was an epigastric pain, but instead, it is part of chest pain. o Elevated temperature

Why elevated? Pag may occlusion, there is no oxygen supply on the cells, so they will pursue an anaerobic circulation. Anaerobic circulation increases the release of lactic acid, these acid causes

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o o

Palor

injury to the vessels. Due to injury. Injury triggers release of cardiac enzymes, and these enzymes activate pyrogens which causes and elevated temperature. CPK-MB Normal CPK o Male 5 to 35 o Female 5 to 25 CPK rises 4 to 8 hours Peak of CPK is to 1 days CPK normalizes 3 to 4 days after the attack LDH Normal: 100 to 190 IU/L Rises 12 to 24 hours after the attack Peak is 2 to 6 days after Trop-T Normal: Negative Kelan lumalabas: immediately Peak is 4 to 24 hours Trop-T normalizes 1 to 3 weeks after the attack Most reliable enzyme

Due to a decrease in cardiac output decrease tissue perfusion Arrhythmia Or dysrrhythmia a life-threatening complication of MI. If not correct, not prevented, it will lead to cardiac arrest. (Lidocaine) **Watch for PVC (characteristics) Widening of QRS complex 6 PVC in 1 minute is considered life threatening ** Watch out for Ventricular Tachycardia a life threatening arrhythmia or dysrrhythmia First drug given to patient Vasopressin Next is give Lidocaine After Lidocaine, defibrillation (Max Joules: 300 J) Next, cardiac compression o Diaphoresis When is MI attack common? In the morning during when taking a bath because ga startle man. Diagnostic Test o Ischemia inverted T wave o Old infarction pathological Q wave o New infarction inverted ST segment o Blood analysis Lipid profile Cardiac enzymes Liver enzymes BUN and Creatinine o Thalium scan and coronary angiography Management: o Morphine Sulfate narcotic analgesic, may cause respiratory depression o Oxygen o Aspirin o Nitrates a vasodilator o Streptokinase a thrombolytic drug o Surgery PTCA and CABG Nursing Diagnosis: Alteration in Comfort: Pain

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Nursing Alerts: o Diet: low sodium, low fat, high protein, high fiber o Position: Semi Fowlers o Avoid constipation o Decrease environment and physical stimuli o Resumption of physical activity 4 to 6 weeks after the attack or if not, patient can resume sexual activity if patient can climb stairs more than 10 steps without chest pain o When is the best time to do sexual activity??? Early in the morning because the heart has well rested o Approach: Use passive approach o Where is the best place to do sexual activity?? In a familiar environment to decrease anxiety

CONGESTIVE HEART FAILURE - inability of the heart to pump properly - Two types o Right-Sided CHF Systemic manifestation Fatigue Increased peripheral venous pressure Ascites Enlarged liver and spleen Distended jugular vein Anorexia and complaints of GI distress Swelling in hands and finger Dependent edema o Left-Sided CHF Pulmonary manifestation Paroxysmal nocturnal dyspnea Elevated pulmonary capillary wedge pressure Cough Crackles Wheezes Blood tinged sputum Restlessness Confusion Orthopnea Tachycardia Exertional dyspnea Cyanosis - Goal in management: increase the force of contraction without increasing heart rate - Approach in managing CHF: o Upright position to prevent pulmonary congestion o Nitrates nitrates are vasodilator, to promote blood flow o Lasix a form of diuretic; to get rid of too much fluid inside the body; best given in morning and watch out for hypokalemia. Hypokalemia increases the risk of digitalis toxicity. o Oxygen o Aminophylline a bronchodilator; dilates the bronchial area to relieve dyspnea o Digoxin drug of choice for CHF. Why? Because the action of digoxin is the goal of the digoxin and that is to increase the force of contraction.

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o o

o o

Before giving digoxin : check heart rate and blood pressure, because these are indications of digitalis toxicity or overdosage of digoxin What is the normal digoxin level? 0.5 to 2.0 microgram/dL If more than 2, digitalis toxicity. (signs) Bradycardia Hypotension Tremors Diarrhea Nausea and vomiting Yellow to yellow-green halos around the light Risk for cardiac arrest Antidote: Digibind or Digoxin Immune Fab or DigiFab Fluid restriction 1000 to 1300 ml/day or 1 to 1.3 L/day After load decrease How to decrease afterload? Bed rest Giving drugs o Beta blockers o ACE inhibitor drugs ending in pril; common side effect is COUGH Rotating tourniquet do not remove all tourniquets at the same time Sodium restriction because sodium attracts water Test for potassium and ABG because hypokalemia potentiates the effect of ABG

RHEUMATIC HEART DISEASE - is a sequalae or a complication of frequent or untreated GABS (Group A Betahemolytic Streptococcus) infection - Major Manifestations: o Pancarditis inflammation on the three layers of the heart o Valvular defect/s must be prevented or corrected because this is irreversible. Mitral Valve commonly affected valve o Subcutaneous nodules ** Would resolve even without medication It does not require treatment o Chorea St. Vitus Dance; abnormal jerky movement; common in upper extremities and jaw of patient; it is self-limiting lasting for 3 months; aggravated by loud music - Minor Manifestations: o Chest pain o Frequent sore throat o Fever o Weakness o Myalgia muscle pain o Elevated ASO titer Anti Streptolysin O (an antibody specific for Streptolysin O) - Diagnostic Test o No specific test o Diagnosing is based on assessment by Jones Criteria 2 major manifestations, 1 minor manifestation 1 major manifestation, 2 minor manifestations o Other tests

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 Throat culture X-ray Blood analysis - Management: o Drug Penicillin drug of choice Given 6 to 8 years during active infection stress the importance of compliance or Erythromycin Aspirin Corticosteroids - Nursing Alerts: o Stress the importance of good oral hygiene o Inform the doctor or dentist prior to dental work-up or any invasive procedures o Stress the importance of compliance o Have yearly or annual physical examination, specially 2D-echo to evaluate cardiac abnormalities ALTERATION IN HORMONAL REGULATION Hormonal Regulation: Hypothalamus

Pituitary Gland (hypophysis)

Hormone

Target Cell/Organ

Effect Pituitary Gland 1. Anterior a. Growth Hormone b. Prolactin c. Melanocyte Stimulating Hormone d. Follicle Stimulating Hormone e. Leutinizing Hormone f. ACTH g. Thyroid Stimulating Hormone 2. Posterior a. Anti Diuretic Hormone / Vasopressin b. Oxytocin ADRENOCORTICOTROPIC HORMONE - target cell or organ: Adrenal Gland (located above the kidney) or Supra Renal Gland - Effect:

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o o

Stimulate the adrenal gland to produce its own hormone Adrenal Cortex (4 hormones) Cortisol (most abundant hormone produced) Glucocorticoid - because it has a direct effect on glucose anti-inflammatory Aldosterone Mineralocorticoid - because it has a direct effect on mineral Promotes water retention Androgen Development of secondary male characteristics Adrenal Estrogen Insignificant Adrenal Medulla (2 hormones) Epinephrine (Adrenalin) For sympathetic reactions Norepinephrine -same-

THYROID STIMULATING HORMONE - Stimulates thyroid gland to produce its own hormone - 3 hormones produced: o T3 Triiodothyronine Derived from iodine Important to increase the basal metabolic rate o T4 Tetraiodothyronine or Thyroxine Derived from iodine Important to increase the basal metabolic rate o Calcitonin Decreases calcium level ANTIDIURETIC HORMONE (Vasopressin) - target cell or organ: KIDNEY - Prevents formation of large volume of urine Anterior Pituitary Gland (7 hormones) 1. Growth Hormone a. Hypersecretion i. Pedia giantism/gigantism ii. Adult - Acromegaly b. Hyposecretion i. Dwarfism 2. Melanocyte Stimulating Hormone a. Hypersecretion darkens the skin b. Hyposecretion - Albino 3. Prolactin a. Hypersecretion lactation or milk production b. Hyposecretion no lactation 4. FSH a. Menstrual Disorders 5. LH a. Menstrual Disorders 6. ACTH

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a. Hypersecretion Cushings Syndrome b. Hyposecretion Addisons Disease 7. TSH a. Hypersecretion Hyperthyroidism/Thyrotoxicosis (Example: Graves Disease) b. Hyposecretion Hypothyroidism i. Pedia Cretinism ii. Adult - Myxedema Posterior Pituitary Gland 1. ADH a. Hyper SIADH b. Hypo Diabetes Insipidus 2. Oxytocin a. Hyper contraction or Let-down reflex or Milk Ejection b. Hypo muscle atony Tumor the most common cause Management: Surgery removal of the tumor Hypophysectomy removal of pituitary gland; a form of craniotomy Common Problem post-op: Increased ICP elevate head of bed (30 to 45 degrees) to promote venous return. Midline position neutral position to prevent compression Craniotomy - 3 approaches o Supratentorial Above the hair line Best position: Elevate head of bed / High Fowlers Position / Lying on his back with head of bed elevated / Head of bed elevated, lying on the side of the unaffected side o Infratentorial Below Best position: Side lying position, head of bed elevated depending on patients preference kung left or right o Transsphenoidal Most common approach for hypophysectomy Incision: beneath the upper lip of the patient to gain access on the nasal cavity Best position post-op: High Fowlers position / Lying on his back - Nursing Alerts o Avoid blowing the nose o Maintain nasal packing o Avoid brushing the teeth and do not gargle because the more it increases ICP and bleeding episodes. Use padded tongue depressor 6 to 10 days post-operatively. o Watch for Rhinorrhea CSF leakage sa nose. First nursing action if you suspect Rhinorrhea: Check for the glucose content because CSF contains glucose 50 to 80 mg/dL. How? Get a specimen and send to lab for analysis. Or get a white clean clothe or gauze, wipe the fluid and let it dry. If it leaves a yellow mark, then it is CSF. DISTURBANCES AFFECTING ACTH 1. Addisons Disease a. Decreased adrenal hormones b. Manifestation:

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i. Decreased glucocorticoid hypoglycemia ii. Decreased mineralocorticoid hyponatremia/hyperkalemia iii. Decreased androgen abnormal hair distribution c. Pathognomonic Sign: Bronze pigmentation of the skin or tanning of the skin d. Other signs and symptoms i. Weakness ii. Postural hypotension or orthostatic hypotension 1. *** Avoid sitting or standing quickly, it must be gradual iii. Abnormal distribution of body hair e. Nursing Diagnosis: Fluid Volume Deficit i. **Dehydration is the most common cause of Adrenal Crisis or Addisonian Crisis ii. Adrenal Crisis or Addisonian Crisis refers to critical deficiency of the adrenal hormones iii. Most common cause: Dehydration iv. Nursing Implication: How to prevent adrenal crisis? Hydrate the patient v. Signs and Symptoms of Adrenal Crisis 1. Dehydration 2. Hyponatremia 3. Hyperkalemia 4. Vascular collapse a. ***It is the most common cause of death b. Vascular collapse is due to fluid volume deficit 5. Renal shut down vi. Drug of choice: Hydrocortisone f. Diet of the patient: i. Before steroids 1. High carbohydrates 2. High Na 3. Low K 4. High protein 5. High calorie ii. During steroids steroids promote water retention 1. Low Na 2. High K g. Drug that replaces glucocorticoid Hydrocortisone h. Drug that replaces mineralocorticoid Fludocortisone i. Wath for: Cushings Syndrome 2. Cushings Sydnrome a. Refers to excessive adrenal hormone production b. Increase in adrenal hormone (cortex Cortisol) c. AKA Hypercorticolism d. Manifestation i. Increased glucocorticoid hyperglycemia ii. Increased mineralocorticoid hypernatremia / hypokalemia iii. Increased androgen Hirsutism (applicable to females) e. Nursing Diagnosis: Fluid Volume Excess f. Pathognomonic Sign: i. Moon face due to edema ii. Buffalo hump or fat deposition on the back due to edema and fat deposition iii. Truncal Obesity due to fat deposition iv. Weight gain classic sign *** g. Other signs and symptoms i. Poor wound healing ii. Infection or chronic infection admit under reverse isolation iii. Fragile skin

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iv. Acne v. Amenorrhea vi. Ecchymosis vii. Decreased libido viii. Enlarged clitoris ix. Hypertension x. Mood swings irritable h. Diet: i. Low carbohydrates ii. Low sodium iii. High potassium iv. High protein v. Low calorie i. Drugs i. Drug of choice: Metyrapone (adrenal suppressant) ii. Diuretic iii. Insulin anti diabetic agent iv. K supplement j. Surgery i. Adrenalectomy removal of adrenal gland TSH DISTURBANCES 1. Hyperthyroidism / Thyrotoxicosis a. Example: Graves Disease common if you failed to eat iodine-rich food (ex: seafoods) b. 3 common features: i. Increased T3 and T4 1. Increased basal metabolic rate a. Tachycardia b. Palpitation c. Weight loss d. Diarrhea e. Fine silky straight hair f. Diaphoresis g. Hypertension h. Increased systolic blood pressure i. Hyperactive j. Amenorrhea k. Fine hand tremors l. Muscle wasting m. Hyperactivity provide restful environment 2. Increased heat production a. Heat intolerance 3. Increased calorie requirement a. Polyphagia 4. Diet: Increased calorie, increase carbohydrates, increase protein ii. Exopthalmia bulging of eyeballs; Dalyrimple Sign or thyroid stare iii. Goiter enlargement of thyroidism 1. May be present also in hypothyroidism 2. Cause: hyperplasia 3. Assess for bruit or thrill over the thyroid c. Best Diagnostic Test: TSH d. Drugs: i. Antithyroid agent 1. PTU Propylthiurazil; inhibits thyroid hormone synthesis 2. Lugols Solution also known as SSKI (Strong Saturated Potassium Iodide) a. Action: Decrease vascularity of thyroid gland

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Watch for: Hypothyroidism! ii. Corticosteroids help inhibit thyroid hormone synthesis iii. Beta blockers (-olol drugs) iv. Digoxin v. Iodine preparation (Iodotope) e. Surgery: i. Thyroidectomy ii. Nursing Alert: 1. Best position post-thyroidectomy Fowlers position 2. Keep tracheostomy tray on the bed side, specially on the first 24 hours post-op because respiratory distress is common on the first 24 hours a. Causes of respiratory distress: i. Tracheal collapse due to surgery ii. Trachea mucus accumulation iii. Laryngeal edema iv. Vocal cord paralysis can cause airway obstruction v. Hypocalcemia accident removal of parathyroid gland. Drug of choice: Calcium Gluconate 3. Hoarseness and a weak voice are normal and temporary conditions 4. How to assess for laryngeal nerve function: ability to swallow or ability to talk or speak 5. Watch for bleeding: Check for blood in the nape of the patient 6. Watch for thyroid storm a sudden increase in the T3 and T4 due to stimulation upon surgery. Signs of thyroid storm: a. Tachycardia b. Vomiting c. Fever d. Hypertension e. Hyperkinesis 2. Hypothyroidism a. There is a decrease in T3 and T4 b. Common to women than in men c. Most common cause: Hashimotos Disease i. An autoimmune problem ii. Our immune system will destroy our own thyroid gland d. 3 problems i. Decreased BMR 1. Constipation 2. Amenorrhea 3. Hair loss 4. Brittle nails and hair 5. Coarse, Scaly, dry skin 6. Lethargy 7. Anorexia 8. Fatigue ii. Decreased heat production 1. Cold intolerance iii. Decreased calorie requirements iv. Goiter due to hypertrophy e. For pedia Cretinism i. Mentally retarded ii. Dwarfism f. Adult Myxedema i. Edema formation

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ii. Depression g. Myxedema Coma i. A critical deficiency in T3 and T4, leading to severe depression ii. Most common cause: STRESS iii. Signs and symptoms: 1. Hypothermia 2. Bradycardia 3. Lethargy progressing to Coma 4. Cardiopulmonary arrest iv. ***Priority: Airway of Patient h. DIET i. Low calorie ii. High protein iii. High fiber i. DRUGS i. Liothyronine (Cytomel) replaces T3 ii. Levothyroxine (Synthroid) replaces T4 Nursing Alert: 1. When is the best time to give Cytomel and Synthroid: In the morning. Not at night because it can cause insomnia. 2. Watch for over dosage or over medication. Signs of over medication: a. Tachycardia b. Restlessness c. Nervousness d. Insomnia iii. Stool Softeners: DOCUSATE SODIUM (Colace) j. Nursing Alert: i. Avoid sedative, narcotics and other CNS depressants the more it causes depression ii. Assess fluid volume because there is edema iii. Provide a warm environment because there is cold intolerance iv. Provide frequent rest period DISTURBANCES CAUSES ADH (ANTIDIURETIC HORMONE) 1. Syndrome of Inappropriate AntiDiuretic Hormone a. Increased ADH b. Fluid volume excess because there is retention c. Signs and symptoms: i. Decrease Hct (Hemodilution) ii. Increase Urine Specific Gravity urine is concentrated; Normal: 1.010 to 1.025 1. ***Best Test to evaluate ADH abnormalities d. Drugs i. Diuretics 2. Diabetes Insipidus a. Decrease in ADH b. Cause: Ideopathic / Unknown c. Closely related to patient who underwent brain surgery d. Nursing Diagnosis: Fluid Volume Deficit e. Signs and Symptoms i. Polydypsia 4 to 40 L per day ii. Polyuria - > 5 L/day iii. Dehydration iv. Increased Hct v. Decreased Urine specific gravity f. Diet: i. Regular diet but avoid food that exert diuretic effect

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g. Drugs: i. Vasopressin route: nasal spray or parenteral 1. Desmopressin 2. Desmoressin 3. Pitressin 4. Lypressin 3. Diabetes Mellitus a. Siphoning of the blood because of too much sugar b. A form of a metabolic disorder characterized by an elevation in blood sugar (hyperglycemia), resulting from a defect in insulin production, action or both action and production c. The problem is the pancreas i. Alpha Cells secrete glucagons (increase glucose in the blood) ii. Beta Cells insulin (decrease glucose) d. Test to evaluate function of Pancreas: Fasting Blood Sugar e. Types i. Type 1 1. Also called Juvenile Diabetes, Juvenile-onset Diabetes, Ketosis-prone Diabetes, Brittle Diabetes 2. approximately 5 to 10% of people with diabetes 3. acute onset, usually before age 30 4. requires injection of insulin to control their blood glucose level 5. Normal glucose: 80 to 120 6. Not enough production of insulin 7. DKA ii. Type 2 1. Adult-onset Diabetes, Maturity-onset Diabetes, KetosisResistant Diabetes, Stable Diabetes 2. Hyperglycemic, Hyperosmolar, Non Ketosis (HHNK) 3. 90 to 95% of people with diabetes 4. onset is common to people older than 30 years and obese 5. Not necessarily mag insulin 6. the problem is the action of insulin 7. f. 5 Ps i. Polydypsia excessive thirst ii. Polyuria excessive urination iii. Polyphagia excessive hunger iv. Poor wound healing v. Profound weight loss g. Signs of hyperglycemia i. Polydipsia ii. Polyuria iii. Polyphagia iv. Fever v. Warm skin to touch vi. Fruity breath h. Signs of Hypoglycemia i. Shakiness or tremors ii. Headache iii. Nausea iv. Cold, clammy skin v. Diaphoresis vi. Irritability i. ** If the skin is warm to touch, insulin is rush j. ** If the skin is cold and clammy, give candy k. Life-saving carbohydrates

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i. Fruit juice cup mas okay sa hard candy because fruit juice is
already in liquid form ii. Hard candy iii. 4 tsp of sugar iv. 1 tbsp honey or syrup v. 8 ounces low fat milk or skim milk vi. 3 graham crackers Management: i. Nutritional Management 1. the basic foundation for diabetes control 2. Factors: a. Nutrition b. Diet c. Weight reduction 3. Caloric requirement: 1800 to 2400 per day a. Carbo 50 to 60% b. Fats 20 to 30% c. Protein 10% d. *** Diabetic diet is a well-balanced diet ii. Exercise 1. Benefits: a. Help decrease blood sugar level How? By increasing sensitivity of insulin receptors b. Helps decrease risk for cardiac abnormality 2. General Precaution: a. Use proper foot wear during exercise b. Inspect feet daily after exercise c. Avoid exercise during extreme temperature d. Avoid exercise during periods of poor metabolic control iii. Monitoring 1. essential to evaluate whether blood sugar is well regulated 2. FBS (Things to remember) a. Place the patient on NPO 8 to 12 hours 3. HGT a. Where to prick? Side less nerve endings, so less pain 4. Glycosylated Hemoglobin Test the best to evaluate glucose in the blood for the past 2 to 3 months. That is the best test to evaluate effectiveness of treatment. Normal: < 7.5% iv. Pharmacologic therapy 1. Things to remember about insulin: a. Insulin is a fat-soluble hormone b. Insulin must be given subcutaneously do not massage site, do not apply warm compress c. Insulin must be stored in a cool environment ref: 3 months, room temp: 1 month d. Breastfeeding will decrease insulin dosage requirement breastfeeding has an antidiabegenic effect e. Infection or illness will not affect insulin administration f. When monitoring for hypoglycemia, check for the peak g. When monitoring for the time, when you will see a decrease in the blood sugar, monitor for the onset or check for the onset h. Regular insulin is short-acting insulin regular insulin can be given subcu and IV

l.

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i.

NPH (neutral protamine hagedorn) intermediate acting insulin; cloudy insulin j. NPH must be given at 10 pm to prevent dawn phenomenon k. When mixing insulin, aspirate air first. Regular insulin should be aspirated first. l. Watch for complications. i. Acute hypoglycemia ii. Somogyi effect rebound hyperglycemia iii. Lipodystrophy hardening of the fats due to frequent site of administration. 1. abdomen pinaka mabilis mag absorb nang insulin 2. arms 3. thigh iv. Dawn phenomenon a condition in which the patient requires high dose of insulin in the morning due to an effect of growth hormone and adrenal hormone m. Types of Insulin i. Rapid Acting 1. Agent Lispro (Humalog); Aspart (Novolog) 2. Onset: 10 to 15 minutes 3. Peak: 1 hour 4. Duration: 3 hours ii. Short-Acting 1. Agent: Regular Insulin; Humalog R; Novolin R; Iletin II Regular 2. Onset: to 1 hour 3. Peak: 2 to 3 hours 4. Duration: 4 to 6 hours iii. Intermediate-acting 1. Agent: NPH; Humulin N; Iletin II Lente; Iletin II NPH; Novolin (Lente); Novolin N 2. Onset: 2 to 4 hours 3. Peak: 6 to 12 hours 4. Duration: 16 to 20 hours 5. Note: Given at 10 pm to prevent Dawn Phenomenon . 3 am is the best time to check sugar level for Dawn Phenomenon. iv. Long-Acting Insulin 1. Agent: Ultralente (UL) 2. Onset: 6 to 8 hours 3. Peak: 12 to 16 hours 4. Duration: 20 to 30 hours v. Very Long-Acting 1. Agent: Glargine (Lantus) 2. Onset: 1 hour 3. Peak: Continous 4. Duration: 24 hours v. Education 1. Proper feet care Reminders: a. Keep your feet dry at all times b. You may apply moisturizer on the feet, except on the toes or between the toes. A moist area attracts microorganism.

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c. Pat when drying the feet. d. Trim your own nails. trim straight across; do not let a Podiatrist or manicurist trim your nails e. Do not soak your feet on extreme temperature f. Do not walk barefooted g. Regularly change your socks. Best sock a cotton fiber sock because it is absorbent. h. Use a well-fitted footwear. Not too tight, not too loose. Best shoes walking on the beach: a canvass shoes. DKA Common to Type 1 There is slight elevation in the blood sugar level Acidosis Hyperventilation or Cosmos Respiration There is ketone breath Normal or slightly elevated blood osmolality (normal blood osmolality 260 to 290) Hypernatremia and hypokalemia Due to increase fat metabolism Diagnostic Test: ABG Management: 1. First anticipated action is fluid replacement. The first solution to be used is Isotonic Solution. To be followed by Hypotonic Solution. Never use Hypertonic. 2. Give insulin 3. Give potassium supplement 4. Give sodium bicarbonate HHNK Common to Type 2 Blood sugar is highly elevated (700mg/dL) No acidosis No hyperventilation or cosmos respiration No ketone breath Hyper osmolar blood (333 osmolality) Hypernatremia and hypokalemia Due to hyperglycemia and fluid loss, leading to dehydration, hypernatremia and hypokalemia Management: 1. Give potassium supplement 2.

Sodium Hypochlorite - Active component of Dakins Solution MUSCULOSKELETAL DISORDERS 1. Arthritis a. Inflammation of joint b. Joint refers to connection of two bones for mobility c. 3 Major Types: i. Rheumatoid Arthritis ii. Osteoarthritis iii. Gouty Arthritis ARTHRITIS Description RHEUMATOID Systemic (all joints) * Synovial OSTEOARTHRITIS Non-systemic (specific for weight bearing joint and joint in the interphalangeal area) Most common form of arthritis. Cause: Idiopathic, but said to be GOUTY Not systemic or not non-systemic, it is a purine metabolism disorder. Common joint affected: Big toe/ankles Cause: - Familial Increase uric acid level

Cause

Idiopathic: But said to be auto-immune Closely related to 3 factors:

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Infection Hormonal Lifestyle changes

degenerative type Related to 3 Factors: - Aging - Trauma - Obesity Both sexes

Common Common Signs and Symptoms Sign and Symptoms

Women (35 to 50 yo) Inflammation *Nursing Action: Apply cold compress Pain aspirin Stiffness in the joint *Nursing action: Take a warm shower bath Increase synovial fluid Node formation: - Heberdens Leading to structural Node seen on damage distal joints (most common) Leading to physical - Bouchards deformities Node seen on proximal joints Management: Arthrocentesis removal of sinovial fluid

Men

Urate crystal deposition, referred to as Tophi

d. Diagnostic Tests i. Xray ii. CBC (anemia) - common to rheumatoid arthritis because it is an autoimmune disease iii. Increased ESR indicates chronic or systemic inflammation iv. (+) Rheumatoid Factor v. Increased serum uric acid level vi. IF negative sa rheumatoid factor and normal uric acid level, tapos naay inflammation diagnosis: Osteoarthritis e. Nursing Alerts: i. If inflammation occurs, apply cold compress. ii. If stiffness occurs, apply warm compress or take warm shower bath. iii. Supply light-weight cups, utensils, easy to open beverages or cartons. 1. type of utensil to offer: a plastic spoon and fork 2. Fracture a. Refers to a break in the continuity of the bone b. Most common cause: Trauma c. 2 Major Types: i. Open/Compound a break in the bone and the bone is exposed to the environment ii. Closed/Simple A break in the bone, but the skin is intact 1. Comminuted Fracture fragmented 2. Transverse break is transversely done 3. Oblique slanted break 4. Spiral 5. Greenstick common to pediatric; common site: ulna and radius 6. Depressed common in skull 7. Compressed common in extremities d. Signs and symptoms i. Pain aggravated by movement 1. First nursing action: immobilize ii. Develops inflammation*

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iii. Edema formation* 1. inflammation and edema increase the risk for compartment syndrome iv. Asymmetry v. Hematoma or discoloration vi. Complaints of pain vii. *Patient with long bone fracture or multiple fracture is at risk to develop fat embolism. fat embolism is common on the first 24 to 48 hours. And the most common presentation: Respiratory difficulty. viii. *If the patient sustained anterior cranial fracture, patient develops rhinorrhea and raccoons eye (discoloration of the periorbital area or periorbital hematoma). ix. If the patient sustained basilar fracture, common presentation is otorrhea and Battles sign. e. Diagnostic Test i. X-ray f. Management: i. The first nursing action is to immobilize the patient. Advantages: 1. Promote bone healing 2. Decreases bleeding episodes 3. Decreases paint 4. Decreases risk for further injury Methods of Immobilization: 1. Splint application 2. Cast application 3. Traction application ii. Surgery 1. reduction realignment of the bone 1. open 2. closed 2. amputation iii. Using of assistive device for walking 1. crutches 2. walker 3. cane CASTS 2 Types: 1. Plaster of Paris Nursing Alert a. 24 to 72 hours to dry b. Avoid water c. Dry the cast but turning the patient every 2 hours to promote drying of the cast. Wrap the cast on a cotton fiber to promote dryness. d. Electric fan in drying Plaster of Paris. e. When caring for the cast, use your palm, not your fingertips. f. Signs of a dry cast white, hard, shiny and resistant g. Support the cast on a plastic, protected by pillow or rubber underneath. h. Do not cover the cast until it is dry. 2. Synthetic Cast (Fiberglass) Nursing Alert a. Perform neurovascular status of the patient i. Neuro warm, hot, sharp ii. Vascular check the capillary refill time < 3 seconds b. Watch out for Compartment Syndrome i. Elevate the extremity ii. Report to the physician iii. Prepare the patient for removal of cast

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c. It is normal for the patient to feel heat sensation. When it dries, heat must subside. d. Maintain good skin integrity instruct patient to do isometric exercises i. Isotonic movement contraction and degree of flexion ii. Isometric movement contraction e. Check for hot spots i. Hot spots indicate inflammation under the cast f. Note any odor from the cast infection g. Do not insert anything under the cast h. If itchy i. Scratch the opposite side ii. Get straw and blow iii. Pour alcohol iv. Apply cold compress on top of the cast v. Tap the cast on top vi. Drink anti-histamine as ordered vii. Prepare to remove the cast TRACTION 2 Types 1. Skin traction a. Pulling only the skin b. Short-term/Intermittent traction c. Pedia d. 5 to 8 pounds (2.5 to 3.5 kg) e. Types of Skin Traction i. Bucks Traction 1. Patient with fracture hip 2. Exerts pull in the extremities 3. Priority: Prevention of foot drop. Put some foot plate but never allow to rest the foot on the board 4. Shock block will prevent the client from falling the bed and provides counter traction 5. How to Turn to side? a. Client may turn towards the unaffected side b. Place pillow between the legs and client can turn towards the unaffected side ii. Russells Traction 1. Used to patient with fractured femoral shaft 2. Knee bent, suspended in a sling, attach to rope and pulling on a Balkan Frame 3. Priority: Prevention of skin breakdown in the popliteal area. 4. How to turn the patient? a. Patient can turn slightly from side to side without turning the body below the waist iii. Cervical Traction 1. Used by patient who develops spinal cord injury, specifically cervical injury 2. First priority: Maintain head, neck, spin alignment 3. Second priority: Pad the chin, protect the ears. 4. Do not turn the patient. If it is a must to turn the patient, use log rolling technique. iv. Pelvic Traction 1. Used when the patient develops low back pain 2. Best position: Semi-fowlers position with knee bent 3. Priority: To prevent skin breakdown on the lumbo-sacral area

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4. Turn to side? NO, instead tell the patient to hold the trapeze, then pull the body v. Bryants Traction 1. Common to pedia 2. Used to patient with hip dislocation and fracture in the lower extremities 3. Both lower extremities are raise up/above the mattress 4. Priority: Maintain leg at 90 degree angle and elevate the buttock above the mattress at 3 inches 2. Skeletal Traction a. Doctors insert tongs, pin b. Nursing Priority: Prevention of Infection Infection Osteomyelitis CA: Staphylococcus Aureus c. Signs and Symptoms i. Inflammation ii. Redness iii. Tenderness iv. Pain on the site v. Foul smelling vi. Discharges coming from the site vii. Fever d. Nursing Actions i. Observe for proper pin care surgical asepsis ii. How often is the pin care? Every 8 hours e. Nursing Alert i. Perform neurovascular check ii. Watch out for compartment syndrome iii. Instruct the patient to wiggle toes or fingers to promote good circulation iv. Instruct the patient to do plantar/dorsiflexion v. Ropes must be align and weights must be hang freely vi. The line of traction must be alone the long axis of the bone vii. There should be no PAIN while on traction pain means not in proper position; best nursing action is to reposition the patient NEURO Cerebral Cortex decorticate Broca motor speech formation; speech aphasia Wernicke sensory speech understanding; receptive aphasia Hypothalamus thirst, limbs Covering/Protection of the Brain 1. Scalp 2. Skull 3. Maninges Signs of Meningeal Irritation a. Nuchal rigidity (stiff neck) b. Brudzinskis Sign c. Kernigs Sign d. Opisthotonos 4. CSF a. Produced by the choroids plexus b. Absorbed by arachnoid villi c. Normal volume: 150 mL d. Normal characteristics: i. Color: clear and colorless cloudy CSF means infection ii. Protein in CSF normal: 15 to 45 mg/dL

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Increase protein in CSF bacterial infection, demyelination iii. Glucose in CSF Normal: 50 to 80 mg/dL Increase glucose hyperglycemia; promotes infection Decrease glucose - hypoglycemia iv. Gama Globulin in CSF 3 to 12 % 1. Increased Gama Globulin infection 2. Increased IgG demyelination (MS, GBS) 3. Increased IgG MS 4. Increased IgG, Increase CHON GBS v. WBC in the CSF 0 to 5 mm3 1. Increased WBC infection vi. RBC in the CSF negative e. Lumbar Tap i. Side-lying, knee chest position, fetal position, shrimp position, C position to widen vertebral disk ii. L3 and L4 iii. Void before procedure because distended bladder cause headache iv. Post procedure 1. Flat on bed 8 to 12 hours to prevent leakage 2. Prone 2 to 3 hours 3. Post procedure headache increased OFI v. Contraindication 1. Increased ICP sudden release of pressure cerebral herniation; Normal pressure is 5 to 15 mmHg vi. 3 Factors 1. CSF Volume 150 mL 2. Blood Volume 150 mL 3. Brain Volume 1,400 mL **IF increased, it can cause increased ICP Signs and Symptoms of Increased ICP (Adult) 1. Headache 2. Vomiting 3. Decrease sensory and motor function 4. Impaired eye movement 5. Unequal size of pupils 6. Cushing triad increase systolic (widening pulse pressure); decrease diastolic; decrease pulse rate 7. Seizure 8. Respiratory depression Signs and Symptoms Increased ICP (Pedia) 1. High pitch cry 2. Increase head circumference 3. Bulging of fontanels 4. Cranial suture separation Management: 5. Drugs: a. Mannitol - osmotic diuretic b. Corticosteroid decrease inflammation c. Anticonvulsant: Phenytoin (Dilantin) cause gingival hyperplasia provide oral care and use a soft bristle tooth bruth give in small amount because it can cause vasoconstriction and vascular collapse d. Acetazolamide decrease CSF 6. Nursing Management a. Position patient: head of the bed elevated and in neutral position

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b. Diet: Low Na, Fluid restricted diet, High fiver to prevent constipation c. Avoid coughing, sneezing, bending body below the waist, combing the hair, brushing the teeth vigorously CEREBROVASCULAR ACCIDENT - a disruption in the normal flow of blood going to the brain - Type o Ischemic/Thromboembolic Clot formation Atrial flutter, atrial fibrillation will lead to clot formation Increased ICP Gradual TIA abrupt neurologic deficit lasting less than 1 hour but not exceeding 24 hours o Hemorrhagic Bleeding 3 problems: Bleeding Increase ICP Nasospasm Sudden TIA CM 1. Visual Field a. Homonymous hemi i. Blindness or visual fluid deficit of either right or left visual field of both eyes ii. Horners Syndrome iii. Priority: 1. Safety of the patient 2. Walk on the side of the patient that is blind 3. Stay with the unaffected visual field b. Loss of peripheral vision Tunnel Vision i. Nursing Implication: Scan the loss visual field c. Diplopia i. Double vision ii. Nursing Implication 1. Cover each eye alternately each day 2. Place things of the patient on its proper place and do not forget to tell the quantity of the object 2. Motor Deficits a. Hemiparesis weakness b. Hemiplagia paralysis i. Turn patient to side every 2 hours ii. Affected side 20 minutes iii. Right side on the headboard things will be placed if right hemispheric stroke iv. Right hemispheric stroke Ambulate? Left side approach v. Immobility? Passive ROM c. Ataxia raise side rails d. Dysarthria difficulty in forming words; use other forms; Drug: Piracetam e. Dysphagia difficulty swallowing i. Nursing alert: Avoid thin liquid increase risk of aspiration elevate head of bed 3. Sensory Deficits a. Paresthesia tingling sensation, funny feeling

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4. Visual Deficits a. Expressive Aphasia b. Receptive Aphasia c. Global Aphasia 5. Cognitive Deficits a. Memory loss b. Decrease attention span c. Altered judgment 6. Emotional Deficits a. Depression motivation: Positive Reinforcement let the patient feel little success b. Withdrawal c. Decrease tolerance to stressful situation i. Formulate short term goal ii. Adhere to the plan, inform the patient of the plan of care 7. Diagnostic Test a. CT Scan non contrast type b. MRI no metals allowed c. EKG/ECG dysrhthmia/arrhythmia d. Cerebral Angiography assess for peripheral distal 8. Management: a. Thromboembolic/Ischemic Stroke i. Goal: Salvage brain function ii. Drugs: 1. Thrombolyic Drugs 2. Anticoagulant 3. Piracetam iii. Measure to decrease ICP iv. Surgery v. Best indication for ambulation: Decrease in ICP b. Hemorrhagic Stroke i. Goal: 1. To control bleeding 2. To prevent rebleeding common on the 1st 2 weeks after intial bleeding 3. Correct or prevent complication a. Re-bleeding (common) b. Cerebral vasospasm anti cholinergic Atropine sulfate c. Acute hydrocephalus d. Seizure/convulsions/epilepsy 4. Specific Management: a. Complete bed rest with sedation b. Drugs: Anti cholinergic dug Piracetam c. Measures to decrease ICP d. Surgery e. Best indication for ambulation: No signs of active bleeding SEIZURES - Abnormal sensory, motor, autonomic psychic functions due to excessive firing of neurons - Causes: o Idiopathic Genetic Developmental defect on the first trimester o Acquired Allergic reaction Metatoxic, metabolic toxic conditions

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Hypertension Brain tumor/injury CNS infections Fever Febrile seizure is 3 months to 7 years old

2 Types o Partial excessive firing of neurons is generated by part of the brain Simple Partial conscious, repetitive distal to proximal Complex Partial unconscious, repetitive distal to proximal Secondary Generalized Partial unconscious o Generalized excessive firing of the neurons is generated by the entire brain Tonic Clonic (Grand-Mal) Combined with tonic and clonic seizure Tonic is a purposeful body movement/rigidity lasting for 10 to 20 seconds Clonic is a period of contraction, relaxation Absence Seizure (Petit Mal) Characterized by blank stares Common to children Lasting for less than 20 seconds Akinetic/Atonic (Drop Attack) Characterized by sudden loss of muscle tone Diagnostic Test o EEG Test that records electrical activity of the brain Last for 45 to 60 minutes Nursing action: Increase chance of seizure While on EEG Deprive patient if enough rest a night prior test Management o Drugs Anticonvulsant Phenytoin (Dilantin) Clonazepam Phenobarbital Lamotrigine Valproic Acid (Depakene) o Nursing Management: Nurses major role before and during seizure Observe and record the event Duration of seizure Type of movement Circumstance just before the seizure The first thing the patient does before the seizure Epileptic cry first sound heard just before the seizure Occurrence of aura common aura: epigastric pain Nursing care during seizure Provide privacy Priority: safety Ease the patient to the floor If in bed, raise the side rails, remove the pillows and remove the blanket to prevent suffocation Protect the head with a pad Push aside any furniture Best time to insert oral airway: During aura

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Best position: Side lying position Do not attempt to restrain the patient during seizure Nurses major role after seizure Best position: Side lying position with head flexed forward to facilitate drainage of secretion Re-orient the patient Allow the patient to take the rest. Best approach if the patient is agitated or anxious after seizure is to use a calm persuasion and a gentle restrain.

PARKINSONS DISEASE - a slowly progressive neurologic movement disorder - decrease dopamine (inhibitory) - Triad Symptoms o Resting tremors Head of the patient and hand of the patient Head side to side Hand pill rolling o Bradykinesia Slow movement Decrease blinking reflex, loss of facial expression (muscle-face) Loss of normal arm swing while walking o Muscle Rigidity Increase resistance to passive movement - Other signs and symptoms o Paroxysmal flushing o Gastric and urinary retention o Shuffle gait o Stoop posture o Sexual dysfunction - Diagnostic Test o No specific test o PET Scan (Position Emission Tomography) Invasive procedure Structure and cellular activity - Drugs o Levodopa Anti-Parkinsonian Precursor for dopamine Decrease vitamin B6 because it can inhibit absorption of Levodopa o Anti-histamine o MAOI o Dopamin Agonist o Anti-Viral - Surgery o Sterotactic Surgery it will limit the syndrome (triad) o Thalamotomy incision of thalamus o Pallidotomy incision of pallidum - Nursing Alert o Safety is the primary concern o Best chair? Rocking chair o Hungry and wants to eat utensils? Provide steel spoon and fork o Raise the bedside commode or chair of the patient o Install hand rails in the CR SPINAL CORD INJURY

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Common sites: C5, C6, C7, T12 and L1 Signs and Symptoms o C1 C8 (atlas and axis) Develops quadriplegia Respiratory Failure Bladder, bowel dysfunction o T1 L4 Paraplegia Bladder and bowel dysfunction o Spinal Cord Injury above T6, Increases the risk of Autonomic Dysreflexia (autonomic hyperreflexia) Signs and Symptoms Motor deficits of the upper extremities UE Bowel/bladder dysfunction Loss of pain, touch, temperature sensation, + motor deficits LE Ipsilateral Paralysis Diagnostic Test o X-ray o CT Scan o MRI careful for patients with claustrophobia Drug o Corticosteroid to decrease inflammation Specific Management o Immobilize the patient o Priority? Maintain neck and spine alignment o Using of devices: Traction and Halo vest driving is contraindicated o Surgery Nursing Alert o Maintain good skin integrity o Maintain urinary elimination Urinary elimination distended urinary bladder autonomic dysreflexia o Promote adequate breathing and airway clearance o Monitor for complications Orthostatic hypotension/postural hypotension DVT Causes Virchows Triad o Venous Stasis o Hypercoagulopathy Increase platelet Burns o Blood vessel wall injury brns Signs and Symptoms Positive Homans Sign Pain or tenderness on the site common: lower pelvis or calf Distention of superficial veins Warm skin to touch Management Warfarin Bed rest minimum of 3 days Improve venous return

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Affected Limb do not massage, no passive ROM, do not apply compression, no exercise, do not put pillow under the knee o Unaffected limbs promote passive ROM o Anti-emboli stocking best time is early in the morning before raising up from bed o Warm compress warm compress site? Lower part of the abdomen Autonomic Dysreflexia Abnormal sympathetic reaction that arises after spinal shock Common to SCI above T6 Spinal Shock an abrupt loss in spinal cord function Causes o Distended visceral organ urinary bladder o Physical stimuli constipation o Signs and Symptoms o Severe headache o Severe hypertension Most common cause of death Head of the bed elevated o Facial flushing o Diaphoresis forehead of the patient o Pallor below the lesion Management o First Nursing Action: Promote urinary elimination If catheter is attached, check for obstruction o Decrease physical stimuli Drug of Choice o Apressolin (Hydralazine) o Other hypertensive drugs

MYASTHENIA GRAVIS - Autoimmune problem affecting myoneural junction causing varying degree of weakness of the face, throat and other voluntary muscles due to production of antibodies specific for acetylcholine - Common: Women (20 to 40 years old) Men (60 to 70 years old) - Idiopathic - Signs and Symptoms o Ptosis and Diplopia early manifestation o Generalized weakness Generalized weakness respiratory failure death o Nasal Smile - Hallmark - Diagnostic Test o Tensilon Test Anti-cholinesterase test Tensilon Edrophonium HCl; inhibits Ach breakdown 2 mg @ a time = 10 mg 30 seconds post administration Negative weakness/ptosis for 3 to 5 minutes positive tensilon test 10 mg given @ chetine Cholinergic Crisis

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Cholinergic Crisis Signs and Symptoms Bradycardia Sweating Cramping and Weakness Antidote: Atropine Sulfate 0.4 mg Management Mestinon (Prydostimine Bromide) and Prostigmine (Neostigmine Bromide) o Must be given before meal to improve motor activity Plasmapheresis o Cleansing of the blood to remove circulatory antibodies Surgery o Removal of thymus Thymectomy o 3 Common Problems Myasthenia crisis Weakness respiratory failure Cholinergic Crisis overdose Test to differentiate Tensilon Test Brittle crisis **Myasthenic positive slight increase muscle strength **Cholinergic exacerbate weakness o Management: Myasthenia Crisis give Tensilon Cholinergic Crisis stop Tensilon and give atropine sulfate Brittle crisis - plasmapheresis MI pain radiates @ left arm Spleen pain radiates @ left shoulder Gallbladder pain radiates @ right shoulder Urinary bladder pain radiates on shoulders right and left GENITO-URINARY Renal 1. 2. 3. Calculi Kidney stones, urolithiasis Most common cause of upper urinary tract infection Stones a. Calcium Stones due to hypercalcemia b. Urate Stones due to increase uric acid level (Purine metabolism disorder) c. Cystine Stones rare (Amino acid metabolism disorder) d. Magnessium Ammonium Phosphate Stone staghorn/struvite (UTI) 4. Signs and Symptoms a. Pain classic symptom of Renal Calculi (costovertebral angle) i. Renal colic brought about by over stretching of the ureter or other collecting system; deep dull ache and exaggerated by drinking large volume of liquid ii. Non colicky Pain due to pressure on the renal pelvis; hydronephrosis increase in pressure causes pain 5. Diagnostic Test a. Urinarlysis i. Hematuria, UTI, crystals formation ii. Most important nursing action: Strain the urine of the patient using several layer of gauze.

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iii. Send to laboratory for analysis b. Radiograph i. Xray ii. Ultrasound iii. Bladder is full prior to the test c. Blood analysis i. Increase WBC UTI ii. Increase uric acid iii. Increase calcium 6. Management a. Drugs i. Analgesic ii. Diuretic iii. Antibiotic iv. Anti-gout v. Anti-inflammatory vi. Alpha-blockers block alpha receptors to relax smooth muscle vii. Doxazosin, Teraxosin viii. Calcitonin for hypercalcemia b. Dietary Modification c. Surgery i. Percutaneous Nephrolithotomy ii. Lithotripsy 1. Nursing alert: Post lithotripsy Increase OFI to flush stones d. Specific Management i. Calcium Stones 1. Increase OFI 2. Diuretics 3. Low calcium diet 4. Calcitonin ii. Urate Stones 1. Increase OFI (2 to 3 L/day) 2. Decrease purine diet 3. Drugs Allopurinol, Colchicine 4. Alkalanization of urine alkaline-ash diet; drink milk and citrus juice iii. Cystine Stones 1. Increase OFI 2. Diuretic 3. Alkalinization of urine iv. Magnesium Ammonium Phosphate Stone 1. Increase OFI 2. Drugs: Ciprofloxacin 500 mg TID x 7 days Rocephin 1 gm IM single dose Doxycycline 1000mg BID x 7 days 3. Acidify the urine acid-ash diet; drink cranberry juice BENIGN PROSTATIC HYPERTROPHY/HYPERPLASIA - Enlargement of the prostate narrowing of ureter - Cause o Uknown o Related: Aging above 60 years old and Androgen hormone imbalance - Signs and Symptoms o Urinary frequency o Dribbling urine o Hematuria o Urinary stasis o Obstructive voiding syndrome Difficulty starting urination

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Urinary hesitancy Decrease urine stream force Feeling of incomplete voiding Diagnostic Test o Most definitive test: Cystouretheroscopy o Urinalysis o DRE (Digital Rectal Exam) evaluate the size of the prostate Prostate soft BPH Prostate firm prostate CA o Blood analysis BUN/Creatinine (RF) PSA Level Normal: 4 to 10 mg/mL) Management: o Drugs Alpha blockers Diuretic Antibiotic Androgen hormone inhibitor Example: Proscar o Catheterization o Surgery Most effective: Prostatectomy removal of the prostate Approaches Suprapubic/intravesical Retropubic Perineal o Lead to impotence Transurethral (TURP) o Post procedure continuous bladder irrigation (cystoclysis/murphys drip/CBI) o o Nursing Alert

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