27157422 Medical Surgical Nursing Review

8/14/2019 27157422 Medical Surgical Nursing Review

1/110

MEDICAL-SURGICAL NURSINGNERVOUS SYSTEM Overview of structures and functions: Central Nervous System 11 Brain 12 Spinal Cord Peripheral Nervous System 13 Cranial Nerves 14 Spinal NervesAutonomic Nervous System 15 Sympathetic nervous system 16 Parasympathetic nervous system AUTONOMIC NERVOUS SYSTEM Sympathetic Nervous System (ADRENERGIC) - Involved in fight or aggression response. - Release of Norepinephrine (cathecolamines) from adrenal glands and causes vasoconstriction. - Increase all bodily activ

ity except GIT EFFECTS OF SNS - Dilation of pupils(mydriasis) in order to be aware. - Dry mouth (thickened saliva). - Increase BP and Heart Rate. - Bronchodilation, Increase RR - Constipation. - Urinary Retention. - Increase blood supply tobrain, heart and skeletal muscles. - SNS I. Adrenergic Agents - Give Epinephrine. Signs and Symptoms: - SNS Contraindication: - Contraindicated to patients suffering from COPD (Broncholitis, Bronchoectasis, Emphysema, Asthma). II. Beta-adrenergic Blocking Agents - Also called Beta-blockers. - All ending with lol Parasympathetic Nervous System (CHOLINERGIC, VAGAL, SYMPATHOLYTIC) - Involved in fight or withdrawal response. - Release of Acetylcholine. - Decreases all bodily activities except GIT. EFFECTS OF PNS - Constriction of pupils (meiosis). - Increase salivation. - Decrease BP and Heart Rate. - Bronchoconstriction, Decrease RR. - Diarrhea - Urinary frequency.

I. Cholinergic Agents - Mestinon, Neostigmine. Side Effects - PNS

II. Anti-cholinergic Agents - To counter cholinergic agents. - Atropine Sulfate


2/110

- Propranolol, Atenelol, Metoprolol. Effects of Beta-blockers B roncho spasm E licits a decrease in myocardial contraction. T reats hypertension. A V conduction slows down. q 1 Should be given to patients with Angina Pectoris, Myocardial Infarction, Hypertension. ANTI- HYPERTENSIVE AGENTS 1. Beta-blockers lol 2. Ace Inhibitors Angiotensin, pril (Captopril, Enalapril) 3. Calcium Antagonist Nifedipine (Calcibloc) q1 In chronic cases of arrhythmia give Lidocaine(Xylocaine)

Side Effects - SNS

CENTRAL NERVOUS SYSTEM 17 Brain and Spinal Cord. I. CELLS A. NEURONS 18 Basic cells for nerve impulse and conduction. PROPERTIES Excitability ability of neuron to be affected by changes in external environment. Conductivity ability of neuron to transmit a wave of excitation from one cell to another. Permanent Cell once destroyed not capable of regeneration. TYPES OF CELLS BASED ON REGENERATIVE CAPACITY 1. Labile 19 Capable of regeneration. 20 Epidermal cells, GIT cells,GUT cells, cells of lungs. 2. Stable 21 Capable of regeneration with limited time, survival period. 22 Kidney cells, Liver cells, Salivary cells, pancreas. 3.Permanent 23 Not capable of regeneration. 24 Myocardial cells, Neurons, Bone cel

ls, Osteocytes, Retinal Cells.


3/110

B. NEUROGLIA 25 Support and protection of neurons. TYPES 1. Astrocytes maintains blood brain barrier semi-permeable.

26 Majority of brain tumors (90%) arises from called astrocytoma.2. Oligodendria 3. Microglia 4. Epindymal SUBSTANCES THAT CAN PASS THE BLOOD-BRAIN BARRIER 1. Ammonia 27 Cerebral toxin 28 Hepatic Encephalopathy (Liver Cirrhosis) 29 Ascites 30 Esophageal Varices Early Signs of Hepatic Encephalopathy

31 asterixis (flapping hand tremors).Late Signs of Hepatic Encephalopathy 32 Headache 33 Dizziness 34 Confusion

35 Fetor hepaticus (ammonia like breath)36 Decrease LOC


4/110

PATHOGNOMONIC SIGNS 1. PTB low-grade afternoon fever. 2. PNEUMONIA rusty sputum. 3. ASTHMA wheezing on expiration. 4. EMPHYSEMA barrel chest. 5. KAWASAKI SYNDROME strawberry tongue. 6. PERNICIOUS ANEMIA red beefy tongue. 7. DOWNSYNDROME protruding tongue. 8. CHOLERA rice watery stool. 9. MALARIA stepladder like fever with chills. 10. TYPHOID rose spots in abdomen. 11. DIPTHERIA pseudo membrane formation 12. MEASLES kopliks spots. 13. SLE butterflyrashes. 14. LIVER CIRRHOSIS spider like varices. 15. LEPROSY lioning face. 1

6. BULIMIA chipmunk face. 17. APPENDICITIS rebound tenderness. 18. DENGUE petechiae or (+) Hermans sign. 19. MENINGITIS Kernigs sign (leg pain), Brudzinski sign (neck pain). 20. TETANY HYPOCALCEMIA (+) Trousseaus sign/carpopedal spasm; Chvostek sign (facial spasm). 21. TETANUS risus sardonicus. 22. PANCREATITIS Cullens sign (ecchymosis of umbilicus); (+) Grey turners spots. 23. PYLORIC STENOSIS olive like mass. 24. PDA machine like murmur. 25. ADDISONSDISEASE bronze like skin pigmentation. 26. CUSHINGS SYNDROME moon face appearance and buffalo hump. 27. HYPERTHYROIDISM/GRAVES DISEASE exopthalmus. 28.INTUSSUSCEPTION sausage shaped mass 2. Carbon Monoxide and Lead Poisoning

37 Can lead to Parkinsons Disease.38 Epilepsy

39 Treat with ANTIDOTE: Calcium EDTA.3. Type 1 DM (IDDM) 40 Causes diabetic ketoacidosis.


5/110

41 And increases breakdown of fats. 42 And free fatty acids

43 Resulting to cholesterol and (+) to Ketones (CNS depressant).44 Resulting to acetone breath odor/fruity odor.

45 KUSSMAULS respiration, a rapid shallow respiration.46 Which may lead to diabetic coma. 4. Hepatitis 47 Signs of jaundice (icteric s

clerae). 48 Caused by bilirubin (yellow pigment) 5. Bilirubin

49 Increase bilirubin in brain (Kernicterus).50 Causing irreversible brain damage.

DEMYELINATING DISORDERS1. ALZHEIMERS DISEASE 51 Atrophy of brain tissues. Sign and Symptoms 4 As of Alzheimer a. Amnesia loss of memory. b. Agnosia no recognition of inanimate objects. c. Apraxia no recognition of objects function. d. Aphasia no speech(nodding). *Expressive aphasia 52 motor speech center 53 Brocas Aphasia *Receptive aphasia 54 inability to understand spoken words. 55 Wernickes Aphasia 56General Knowing Gnostic Area or General Interpretative Area. DRUG OF CHOICE: ARI

CEPT (taken at bedtime) and COGNEX. 2. MULTIPLE SCLEROSIS 57 Chronic intermittent disorder of CNS characterized by white patches of demyelination in brain and spinal cord.


6/110

58 Characterized by remission and exacerbation. 59 Women ages 15-35 are prone 60Unknown Cause 61 Slow growing virus 62 Autoimmune disorders 63 Pernicious anemia 64 Myasthenia gravis 65 Lupus 66 Hypothyroidism 67 GBS Ig G only antibody that pass placental circulation causing passive immunity. - short term protection.- Immediate action. Ig A present in all bodily secretions (tears, saliva, colostrums). Ig M acute in inflammation. Ig E for allergic reaction. Ig D forchronic inflammation. * Give palliative or supportive care. Signs and Symptoms

1. Visual disturbances 68 blurring of vision (primary) 69 diplopia (double vision)

70 scotomas (blind spots)2. Impaired sensation 71 to touch, pain, pressure, heat and cold. 72 tingling sensation 73 paresthesia 74 numbness 3. Mood swings 75 euphoria (sense of well being) 4. Impaired motor function 76 weakness 77 spasticity 78 paralysis 5. Impaired cerebral function


7/110

79 scanning speech TRIAD SIGNS OF MS Ataxia (Unsteady gait, (+) Rombergs test)

Intentional tremors 6. Urinary retention/incontinence 7. Constipation 8. Decrease sexual capacity DIAGNOSTIC PROCEDURE

Nystagmus

80 CSF analysis (increase in IgG and Protein).81 MRI (reveals site and extent of demyelination).

82 (+) Lhermittes sign a continuous and increase contraction of spinal column.NURSING MANAGEMENT 1. Administer medications as ordered a. ACTH (Adreno Corticotropic Hormone)/ Steroids for acute exacerbation to reduce edema at site of demyelination to prevent paralysis. b. Baclofen (Dioresal)/ Dantrolene Sodium (Dantrene) muscle relaxants. c. Interferons alter immune response. d. Immunosupresants 2. Maintain side rails to prevent injury related to falls. 3. Institute stress management techniques. a. Deep breathing exercises b. Yoga 4. Increase fluidintake and increase fiber to prevent constipation. 5. Catheterization to preventretention. a. Diuretics


8/110

b. Bethanicol Chloride (Urecholine) Nursing Management 83 Only given subcutaneous. 84 Monitor side effects bronchospasm and wheezing. 85 Monitor breath sounds 1hour after subcutaneous administration. c. For Urinary Incontinence Anti spasmodic agent a. Prophantheline Bromide (Promanthene) 86 Acid ash diet like cranberry juice, plums, prunes, pineapple, vitamin C and orange. 87 To acidify urine andprevent bacterial multiplication. COMMON CAUSE OF UTI Female 88 short urethra (3-5 cm, 1-1 inches) 89 poor perineal hygiene 90 vaginal environment is moist N

ursing Management 91 avoid bubble bath (can alter Ph of vagina). 92 avoid use oftissue papers 93 avoid using talcum powder and perfume. Male 94 Urethra (20 cm,8 inches) 95 urinate after intercourse MICROGLIA 96 stationary cells that carryon phagocytosis (engulfing of bacteria or cellular debris, eating), pinocytosis(cell drinking). MACROPHAGE Microglia Monocytes Kupffers cells Histiocytes Alveolar Macrophage EPINDYMAL CELLS ORGAN Brain Blood Kidney Skin Lung

97 Secretes a glue called chemo attractants that concentrate the bacteria.


9/110

COMPOSITION OF BRAIN 98 80% brain mass 99 10% blood 100 10% CSF I. Brain Mass PARTS OF THE BRAIN 1. CEREBRUM 101 largest part 102 composed of the Right CerebralHemisphere and Left Cerebral Hemisphere enclosed in the Corpus Callosum. Functions of Cerebrum 103 integrative 104 sensory 105 motor Lobes of Cerebrum 1. Frontal 106 higher cortical thinking 107 controls personality 108 controls motor activity 109 Brocas Area (motor speech area) when damaged results to garbled speech. 2. Temporal 110 hearing 111 short term memory 3. Parietal 112 for appreciation

113 discrimination of sensory impulses to pain, touch, pressure, heat, cold, numbness. 4. Occipital 114 for vision Insula (Island of Reil) 115 visceral function activities of internal organ like gastric motility. Limbic System (Rhinencephalon)

116controls smell and if damaged results to Anosmia (absence of smell).117 controls libido 118 controls long term memory


10/110

2. BASAL GAGLIA 119 areas of grey matter located deep within each cerebral hemisphere. 120 release dopamine (controls gross voluntary movement. NEURO TRANSMITTER Acethylcholine Dopamine DECREASE Myasthenia Gravis Parkinsons Disease INCREASE Bi-polar Disorder Schizophrenia

3. MIDBRAIN/ MESENCEPHALON 121 acts as relay station for sight and hearing.

122size of pupil is 2 3 mm. 123equal size of pupil is isocoria. 124unequal size of pupil is anisocoria. 125hearing acuity is 30 40 dB.126 positive PERRLA 4. INTERBRAIN/ DIENCEPHALON Parts of Diencephalon A. Thalamus 127 acts as relay station for sensation. B. Hypothalamus 128 controls temperature (thermoregulatory center). 129 controls blood pressure 130 controls thirst 131 appetite/satiety 132 sleep and wakefulness 133 controls some emotional responses like fear, anxiety and excitement. 134 controls pituitary functions

135androgenic hormones promotes secondary sex characteristics.136 early sign for males are testicular and penile enlargement 137 late sign isdeepening of voice. 138 early sign for females telarche and late sign is menarche. 5. BRAIN STEM 139 located at lowest part of brain Parts of Brain Stem 1. Pons


11/110

140 pneumotaxic center controls the rate, rhythm and depth of respiration. 2. Medulla Oblongata 141 controls respiration, heart rate, swallowing, vomiting, hiccup, vasomotor center (dilation and constriction of bronchioles).

3. Cerebellum 142 smallest part of the brain. 143 lesser brain. 144 controls balance, equilibrium, posture and gait. INTRA CRANIAL PRESSURE Monroe Kellie Hypothesis Skull is a closed container Any alteration or increase in one of the intrac

ranial components Increase intra-cranial pressure (normal ICP is 0 15 mmHg) Cervical 1 also known as ATLAS. Cervical 2 also known as AXIS. Foramen MagnumMedulla Oblongata Brain Herniation Increase intra cranial pressure * Alternate hot and cold compress to prevent HEMATOMA 145 CSF cushions brain (shock absorber)

146Obstruction of flow of CSF will lead to enlargement of skull posteriorly calledhydrocephalus. 147 Early closure of posterior fontanels causes posterior enlargement of skull in


12/110

hydrocephalus.

NEUROLOGIC DISORDERSINCREASE INTRACRANIAL PRESSURE increase in intra-cranial bulk brought about byan increase in one of the 3 major intra cranial components. Causes: q1 head trauma/injury 148 localized abscess 149 cerebral edema 150 hemorrhage 151 inflammatory condition (stroke) 152 hydrocephalus 153 tumor (rarely) Signs and Symptoms (

Early) 154 decrease LOC 155 restlessness/agitation 156 irritability 157 lethargy/stupor 158 coma Signs and Symptoms (Late) 159 changes in vital signs

160blood pressure (systolic blood pressure increases but diastolic remains thesame). 161 widening of pulse pressure is neurologic in nature (if narrow cardiacin nature). 162 heart rate decrease 163 respiratory rate decrease 164 temperature increase directly proportional to blood pressure. 165 projective vomiting 166headache

167papilledema (edema of optic disc)168 abnormal posturing

169decorticate posturing (damage to cortex and spinal cord). 170decerebrate posturing (damage to upper brain stem that includes pons,cerebellum and midbrain).

171unilateral dilation of pupils called uncal herniation 172bilateral dilation of pupils called tentorial herniation173 resulting to mild headache


13/110

174 possible seizure activity Nursing Management 1. Maintain patent and adequateventilation by: a. Prevention of hypoxia and hypercarbia Early signs of hypoxia175 restlessness 176 agitation 177 tachycardia Late signs of hypoxia

178Bradycardia 179Extreme restlessness 180Dyspnea 181CyanosisHYPERCARBIA

182Increase CO2 (most powerful respiratory stimulant) retention. 183In chronic respiratory distress syndrome decrease O2 stimulates respiration.b. Before and after suctioning hyper oxygenate client 100% and done 10 15 seconds only. c. Assist in mechanical ventilation 2. Elevate bed of client 30 35oangle with neck in neutral position unless contraindicated to promote venous drainage. 3. Limit fluid intake to 1200 1500 ml/day (in force fluids 2000 3000ml/day). 4. Monitor strictly input and output and neuro check 5. Prevent complications of 6. Prevent further increase ICP by: a. provide an comfortable and quite environment. b. avoid use of restraints. c. maintain side rails. d. instruct client to avoid forms of valsalva maneuver like: 184 straining stool 185 excessive vomiting (use anti emetics) 186 excessive coughing (use anti tussive like dextromethorphan) 187 avoid stooping/bending 188 avoid lifting heavy objects e. avoi

d clustering of nursing activity together.


14/110

7. Administer medications like: a. Osmotic diuretic (Mannitol) 189 for cerebraldiuresis Nursing Management 190 monitor vital signs especially BP (hypotension).191 monitor strictly input and output every 1 hour notify physician if output is less 30 cc/hr. 192 administered via side drip 193 regulated fast drip to prevent crystal formation. b. Loop diuretic (Lasix, Furosemide) 194 Drug of choice for CHF (pulmonary edema) 195 Loop of Henle in kidneys. Nursing Management 196 Monitor vital signs especially BP (hypotension). 197 monitor strictly input and out

put every 1 hour notify physician if output is less 30 cc/hr. 198 administered IV push or oral. 199 given early morning

200immediate effect of 10 15 minutes.201 maximum effect of 6 hours. c. Corticosteroids 202 Dexamethasone (Decadron) 203 Hydrocortisone 204 Prednisone (to reduce edema that may lead to increase ICP)205 Mild Analgesics (Codeine Sulfate for respiratory depression) 206 Anti Convulsants (Dilantin, Phenytoin) *CONGESTIVE HEART FAILURE Signs and Symptoms 207 dyspnea 208 orthopnea 209 paroxysmal nocturnal dyspnea 210 productive cough 211 frothy salivation 212 cyanosis 213 rales/crackles


15/110

214 bronchial wheezing 215 pulsus alternans 216 anorexia and general body malaise 217 PMI (point of maximum impulse/apical pulse rate) is displaced laterally 218 S3 (ventricular gallop) 219 Predisposing Factors/Mitral Valve RHD Aging TREATMENT Morphine Sulfate Aminophelline Digoxin Diuretics Oxygen Gases, blood monitor RIGHT CONGESTIVE HEART FAILURE (Venous congestion) Signs and Symptoms 220 jugular vein distention (neck) 221 ascites 222 pitting edema 223 weight gain 224hepatosplenomegaly 225 jaundice 226 pruritus 227 esophageal varices 228 anorexia

and general body malaise

Signs and Symptoms of Lasix in terms of electrolyte imbalances 1. Hypokalemia

229decrease potassium level 230normal value is 3.4 5.5 meq/LSign and Symptoms 231 weakness and fatigue 232 constipation


16/110

233 positive U wave on ECG tracing Nursing Management

234administer potassium supplements as ordered (Kalium Durule, Oral PotassiumChloride) 235 increase intake of foods rich in potassium FRUITS Apple Banana Cantalop e Oranges 2. Hypocalcemia/ Tetany VEGETABLES Asparagus Brocolli Carrots Spinach

236decrease calcium level 237normal value is 8.5 11 mg/100 mlSigns and Symptoms 238 tingling sensation 239 paresthesia 240 numbness 241 (+) Trousseaus sign/ Carpopedal spasm 242 (+) Chvosteks sign Complications Arrhythmia Seizures Calcium Gluconate per IV slowly as ordered

Nursing Managementq

* Calcium Gluconate toxicity results to SEIZURE Magnesium Sulfate Magnesium Sulfate toxicity S/S BP Urine output Respiratory rate Patellar relfex absent DECREASE


17/110

3. Hyponatremia

243decrease sodium level 244normal value is 135 145 meq/LSigns and Symptoms 245 hypotension

246dehydration signs (Initial sign in adult is THIRST, in infant TACHYCARDIA)247 agitation 248 dry mucous membrane 249 poor skin turgor 250 weakness and fati

gue Nursing Management 251 force fluids

252administer isotonic fluid solution as ordered4. Hyperglycemia

253normal FBS is 80 100 mg/dlSigns and Symptoms 254 polyuria 255 polydypsia 256 polyphagia Nursing Management257 monitor FBS 5. Hyperuricemia 258 increase uric acid (purine metabolism) 259foods high in uric acid (sardines, organ meats and anchovies) 260 *Increase intophi deposit leads to Gouty arthritis. Signs and Symptoms 261 joint pain (greattoes) 262 swelling Nursing Management 263 force fluids 264 administer medications as ordered a. Allopurinol (Zyloprim) 265 Drug of choice for gout.


18/110

266Mechanism of action: inhibits synthesis of uric acid.b. Colchecine 267 Acute gout

268Mechanism of action: promotes excretion of uric acid.* KIDNEY STONES Signs and Symptoms 269 renal colic 270 Cool moist skin Nursing Management 271 force fluids 272 administer medications as ordered a. Narcotic Analgesic 273 Morphine Sulfate

274ANTIDOTE: Naloxone (Narcan) toxicity leads to tremors.b. Allopurinol (Zyloprim) Side Effects 275 Respiratory depression (check for RR)

PARKINSONS DISEASE/ PARKINSONISM

276Chronic progressive disorder of CNS characterized by degeneration ofdopamine producing cells in the SUBSTANCIA NIGRA of the midbrain and basal ganglia. Predisposing Factors 1. Poisoning (lead and carbon monoxide) 2. Arteriosclerosis 3. Hypoxia 4. Encephalitis


19/110

5. Increase dosage of the following drugs: a. Reserpine(Serpasil) b. Methyldopa(Aldomet) c. Haloperidol(Haldol) d. Phenothiazine AntipsychoticS AntihypertensiveS

SIDE EFFECTS RESERPINE Major depression leading to suicide Aloneness

Loss of spouse 277 direct approach towards the client 278 close surveillance is

a nursing priority

Loss of Job

279 time to commit suicide is on weekends early morning Signs and Symptoms for Parkinsons 280 pill rolling tremors of extremities especially the hands. 281 bradykinesia (slowness of movement) 282 rigidity (cogwheel type) 283 stooped posture 284 shuffling and propulsive gait 285 over fatigue

286mask like facial expression with decrease blinking of the eyes.287 difficulty rising from sitting position. 288 Monotone type speech 289 mood lability (in state of depression)

290increase salivation (drooling type)291 autonomic changes a. increase sweating b. increase lacrimation c. seborrhea


20/110

d. constipation e. decrease sexual capacity Nursing Management 1. Administer medications as ordered Anti Parkinsonian agents 292 Levodopa (L-dopa) short acting293 Amantadine Hydrochloride (Symmetrel) 294 Carbidopa (Sinemet) Mechanism of Action 295 increase level of dopamine Side Effects 296 GIT irritation (should be taken with meals 297 orthostatic hypotension 298 arrhythmia 299 hallucinations Contraindications 300 clients with narrow angle closure glaucoma 301 clients taking MAOIs (no foods with triptophan and thiamine) 302 urine and stool may be dark

ened

303no Vitamin B6 (Pyridoxine) reverses the therapeutic effects of Levodopa* Increase Vitamin B when taking INH (Isoniazid), Isonicotinic Acid Hydrazide Anti Cholinergic Agents (ARTANE and COGENTIN) - to relieve tremors Mechanism of Action 304 inhibits action of acethylcholine Side Effects 305 SNS Anti Histamine (Dipenhydramine Hydrochloride) Side Effects Adult: drowsiness Children: CNS excitement (hyperactivity) because blood brain barrier is not yet fully developed. Dopamine Agonist - relieves tremor rigidity Bromocriptene Hydrochloride (Parlodel)Side Effects 306 Respiratory depression


21/110

2. Maintain side rails to prevent injury 3. Prevent complications of immobility4. Decrease protein in morning and increase protein in afternoon to induce sleep5. Encourage increase fluid intake and fiber. 6. Assist/supervise in ambulation7. Assist in Stereotaxic Thalamotomy

MAGIC 2s IN DRUG MONITORINGDRUG Digoxin/ Lanoxin (Increase force of cardiac output) Lithium/ Lithane (Decre

ase level of Ach/NE/Serotonin) Aminophylline (Dilates bronchial tree) Dilantin/Phenytoin Acetaminophen/Tylenol NORMAL RANGE .5 1.5 meq/L .6 1.2 meq/L 10 19 mg/100 ml 10 19 mg/100 ml 10 30 mg/100 ml TOXICITY LEVEL 2 2 20 20 200 INDICATION CHF Bipolar COPD Seizures Osteo Arthritis CLASSIFICATION Cardiac Glycoside Anti-Manic Agents Bronchodilators Anti-Convulsant Non-narcotic Analgesic

1. Digitalis Toxicity Signs and Symptoms 307 nausea and vomiting 308 diarrhea 309 confusion 310 photophobia 311 changes in color perception (yellowish spots) Antidote: Digibind 2. Lithium Toxicity Signs and Symptoms 312 anorexia 313 nauseaand vomiting 314 diarrhea


22/110

315 dehydration causing fine tremors 316 hypothyroidism Nursing Management 317 force fluids 318 increase sodium intake to 4 10 g% daily 3. Aminophylline Toxicity Signs and Symptoms 319 tachycardia 320 palpitations 321 CNS excitement (tremors, irritability, agitation and restlessness) Nursing Management 322 only mixedwith plain NSS or 0.9 NaCl to prevent development of crystals or precipitate. 323 administered sandwich method 324 avoid taking alcohol because it can lead tosevere CNS depression 325 avoid caffeine 4. Dilantin Toxicity Signs and Symptoms

326 gingival hyperplasia (swollen gums) 327 hairy tongue 328 ataxia 329 nystagmus Nursing Management 330 provide oral care 331 massage gums 5. Acetaminophen Toxicity Signs and Symptoms 332 hepatotoxicity (monitor for liver enzymes) 333 SGPT/ALT (Serum Glutamic Pyruvate Transaminace) 334 SGOT/AST (Serum Glutamic Oxalo-Acetil Transaminace) 335 nephrotoxicity monitor BUN (10 20) and Creatinine (.8 1) 336 hypoglycemia Tremors, tachycardia Irritability


23/110

Restlessness Extreme fatigue Diaphoresis, depression Antidote: Acetylcisteine (mucomyst) prepare suction apparatus as bedside. MYASTHENIA GRAVIS 337 neuromuscular disorder characterized by a disturbance in the transmission of impulses fromnerve to muscle cells at the neuromuscular junction leading to descending muscleweakness. Incidence rate: women 20 40 years old Predisposing factors 338 unknown 339 autoimmune: it involves release of cholinesterase an enzyme that destroys Ach. Signs and Symptoms

340initial sign is ptosis a clinical parameter to determine ptosis is palpebralfissure.341 diplipia 342 mask like facial expression 343 dysphagia 344 hoarseness of voice 345 respiratory muscle weakness that may lead to respiratory arrest 346 extreme muscle weakness especially during exertion and morning Diagnostic Procedure

347Tensilon test (Edrophonium Hydrochloride) provides temporary relief of signsand symptoms for about 5 10 minutes and a maximum of 15 minutes.q

if there is no effect there is damage to occipital lobe and midbrain and is nega

tive for M.G.

Nursing Management 1. airway 2. aspiration 3. mmobility * assist in mechanical ventilation and monitor pulmonary function test * monitor strictly vital signs, input and output and neuro check * monitor strength or motor grading scale 4. maintain side rails to prevent injury related to falls 5. institute NGT feeding 6.administer medications as ordered a. Cholinergic (Mestinon) b. Anti Cholenisterase (Neostegmin) maintain patent airway and adequate ventilation


24/110

Mechanism of Actionq

increase level of Ach PNS Cortocosteroids suppress immune response monitor for 2types of crisis: CHOLINERGIC CRISIS Cause: - over medication Signs and Symptoms- PNS Treatment - Administer anti cholinergic agents (Atropine Sulfate)

Side Effectsq q q

MYASTHENIC CRISIS Causes: - under medication - stress - infection Signs and Symptoms - The client is unable to see, swallow, speak, breathe Treatment - administer cholinergic agents as ordered

7. Assist in surgical procedure known as thymectomy because it is believed thatthe thymus gland is responsible for M.G. 8. Assist in plasma paresis and removing auto immune anti bodies 9. Prevent complications

INFLAMMATORY CONDITIONS OF THE BRAIN

MENINGITIS Meningesq q q q

3 fold membrane that covers brain and spinal cord. for support and protection for nourishment blood supply

LAYERS OF THE MENINGES 1. Dura matter outer layer 2. Arachnoid middle layer3. Pia matter inner layerq q

subdural space between the dura and arachnoid subarachnoid space between the arachnoid and pia, CSF aspiration is done.


25/110

A. Etiology 1. Meningococcus most dangerous 2. Pneumococcus 3. Streptococcus -causes adult meningitis 4. Hemophilus Influenzae causes pediatric meningitisB. Mode of transmission 348 airborne transmission (droplet nuclei) C. Signs andSymptoms 349 headache 350 photophobia 351 projectile vomiting 352 fever, chills,anorexia, general body malaise and weight loss 353 Possible increase in ICP andseizure activity 354 Abnormal posturing (decorticate and decerebrate) 355 Signsof meningeal irritation a. Nuchal rigidity or stiff neck b. Opisthotonus (archi

ng of back) c. (+) Kernigs sign (leg pain) d. (+) Brudzinski sign (neck pain) D. Diagnostic Procedures 356 Lumbar puncture: a hollow spinal needle is insertedin the subarachnoid space between the L3 L4 to L5. Nursing Management for LP Before Lumbar Puncture 1. Secure informed consent and explain procedure. 2. Emptybladder and bowel to promote comfort. 3. Encourage to arch back to clearly visualize L3-L4. Post Lumbar Puncture 1. Place flat on bed 12 24 o 2. Force fluids3. Check punctured site for any discoloration, drainage and leakage to tissues.4. Assess for movement and sensation of extremities. CSF analysis reveals 1. Increase CHON and WBC 2. Decrease glucose 3. Increase CSF opening pressure (normalpressure is 50 100 mmHg) 4. (+) cultured microorganism (confirms meningitis)CBC reveals


26/110

1. Increase wbc E. Nursing Management 1. Enforce complete bed rest 2. Administermedications as ordered a. Broad spectrum antibiotics (Penicillin, Tetracycline)b. Mild analgesics c. Anti pyretics 3. Institute strict respiratory isolation 24 hours after initiation of anti biotic therapy 4. Elevate head 30-45o 5. Monitor strictly V/S, input and output and neuro check 6. Institute measures to prevent increase ICP and seizure. 7. Provide a comfortable and darkened environment. 8. Maintain fluid and electrolyte balance. 9. Provide client health care and disc

harge planning concerning: a. Maintain good diet of increase CHO, CHON, calorieswith small frequent feedings. b. Prevent complications

357most feared is hydrocephalus 358hearing loss/nerve deafness is second complication 359consult audiologistc. Rehabilitation for neurological deficit 360 mental retardation 361 delayed psychomotor development CVA (STROKE/BRAIN ATTACK/ ADOPLEXY/ CEREBRAL THROMBOSIS) 362 a partial or complete disruption in the brains blood supply. 363 2 most common cerebral artery affected by stroke a. Mid Cerebral Artery b. Internal CerebralArtery the 2 largest artery A. Incidence Rate 364 men are 2-3 times high riskB. Predisposing Factors 365 thrombus (attached)

366embolus (detached and most dangerous because it can go to the lungs andcause pulmonary embolism or the brain and cause cerebral embolism.


27/110

Signs and Symptoms of Pulmonary Embolism 367 Sudden sharp chest pain 368 Unexplained dyspnea 369 Tachycardia 370 Palpitations 371 Diaphoresis 372 Mild restlessness Signs and Symptoms of Cerebral Embolism 373 Headache and dizziness 374 Confusion 375 Restlessness 376 Decrease LOC Fat embolism is the most feared complications after femur fracture. Yellow bone marrow are produced from the medullary cavity of the long bones and produces fat cells. If there is bone fracture there is hemorrhage and there would be escape of the fat cells in the circulation

. Compartment syndrome (compression of arteries and nerves) C. Risk Factors 1.Hypertension, Diabetes Mellitus, Myocardial Infarction, Atherosclerosis, Valvular Disease, Post Cardiac Surgery (mitral valve replacement) 2. Lifestyle (smoking), sedentary lifestyle 3. Obesity (increase 20% ideal body weight) 4. Hyperlipidemia more on genetics/genes that binds to cholesterol 5. Type A personality a.deadline driven b. can do multiple tasks c. usually fells guilty when not doinganything 6. Related to diet: increase intake of saturated fats like whole milk 7. Related stress physical and emotional 8. Prolong use of oral contraceptives promotes lypolysis (breakdown of lipids) leading to atherosclerosis that will leadto hypertension and eventually CVA. D. Signs and Symptoms 377 dependent on stages of development Heart


28/110

1. TIA 378 Initial sign of stroke or warning sign Signs and Symptoms 379 headache and dizziness 380 tinnitus 381 visual and speech disturbances 382 paresis (plegia) 383 possible increase ICP 2. Stroke in evolution 384 progression of signs and symptoms of stroke 3. Complete stroke 385 resolution phase characterized by:Signs and Symptoms 386 headache and dizziness 387 Cheyne Stokes Respiration 388anorexia, nausea and vomiting 389 dysphagia 390 (+) Kernigs sign and Brudzinskisign which may lead to hemorrhagic stroke 391 focal neurological deficits a. ph

legia b. aphasia c. dysarthria (inability to articulate words) d. alexia (difficulty reading) e. agraphia (difficulty writing) f. homonymous hemianopsia (loss of half of visual field) E. Diagnostic Procedure 1. CT Scan reveals brain lesions 2. Cerebral Arteriography 392 reveals the site and extent of malocclusion 393uses dye for visualization 394 most of dye are iodine based 395 check for shellfish allergy 396 after diagnostic exam force fluids to release dye because it isnephro toxic 397 check for distal pulse (femoral) 398 check for hematoma formation F. Nursing Management


29/110

1. Maintain patent airway and adequate ventilation by: a. assist in mechanical ventilation b. administrate O2 inhalation 2. Restrict fluids to prevent cerebraledema that might increase ICP 3. Elevate head 30 45o 4. Monitor strictly vitals signs, I & O and neuro check 5. Prevent complications of immobility by: a. turn client to side b. provide egg crate mattresses or water bed c. provide sand bag or food board. 6. Assist in passive ROM exercise every 4 hours to promote proper bodily alignment and prevent contractures 7. Institute NGT feeding 8. Provide

alternative means of communication a. non verbal cues b. magic slate 9. If positive to hemianopsia approach client on unaffected side 10. Administer medications as ordered a. Osmotic Diuretics (Mannitol) b. Loop Diuretics (Lasix, Furosemide) c. Cortecosteroids d. Mild Analgesics e. Thrombolytic/Fibrinolytic Agents dissolves thrombus 399 Streptokinase Side Effect: Allergic Reaction 400 Urokinase 401 Tissue Plasminogen Activating Factor 402 Side Effect: Chest Pain f. AntiCoagulants 403 Heparin (short acting) 404 check for partial thromboplastin timeif prolonged there is a risk for bleeding. 405 give Protamine Sulfate 406 Comadin/ Warfarin (long acting) 407 give simultaneously because Coumadin will take effect after 3 days 408 check for prothrombin time if prolonged there is a risk for


30/110

bleeding 409 give Vit. K (Aqua Mephyton) g. Anti Platelet 410 PASA (Aspirin) 411Contraindicated for dengue, ulcer and unknown cause of headache because it maypotentiate bleeding 11. Provide client health teachings and discharge planning concerning a. avoidance of modifiable risk factors (diet, exercise, smoking) b. prevent complication (subarachnoid hemorrhage is the most feared complication) c.dietary modification (decrease salt, saturated fats and caffeine) d. importanceof follow up care

GUILLAIN BARRE SYNDROME 412 a disorder of the CNS characterized by bilateral symmetrical polyneuritis leading to ascending muscle paralysis. A. Predisposing Factors 1. Autoimmune 2. Antecedent viral infections such as LRT infections B. Signs and Symptoms 1. Clumsiness (initial sign) 2. Dysphagia 3. Ascending muscle weakness leading to paralysis 4. Decreased of diminished deep tendon reflex 5. Alternate hypotension to hypertension ** ARRYTHMIA (most feared complication) 6. Autonomic symptoms that includes a. increase salivation b. increase sweating c. constipation


31/110

C. Diagnostic Procedures 1. CSF analysis reveals increase in IgG and protein D.Nursing Management 1. Maintain patent airway and adequate ventilation by: a. assist in mechanical ventilation b. monitor pulmonary function test 2. Monitor strictly the following a. vital signs b. intake and output c. neuro check d. ECG 3.Maintain side rails to prevent injury related to fall 4. Prevent complications of immobility by turning the client every 2 hours 5. Institute NGT feeding to prevent aspiration 6. Assist in passive ROM exercise 7. Administer medications as o

rdered a. Corticosteroids suppress immune response b. Anti Cholinergic Agents Atrophine Sulfate c. Anti Arrythmic Agents 413 Lidocaine, Zylocaine 414 Bretylium blocks release of norepinephrine to prevent increase of BP 8. Assist in plasma pharesis (filtering of blood to remove autoimmune anti-bodies) 9. Prevent complications a. Arrythmia b. Paralysis or respiratory muscles/Respiratory arrest* Sengstaken Blakemore Tube 415 for liver cirrhosis 416 to decompress bleedingesophageal verices (prepare scissor to cut tube incase of difficulty in breathing to release air in the balloon 417 for hemodialysis prepare bulldog clips to prevent air embolism.

CONVULSIVE DISORDER/ CONVULSION 418 disorder of CNS characterized by paroxysmalseizure with or without loss of


32/110

consciousness abnormal motor activity alternation in sensation and perception and changes in behavior.

419Seizure first convulsive attack 420Epilepsy second or series of attacks 421Febrile seizure normal in children age below 5 yearsA. Predisposing Factors 1. Head injury due to birth trauma 2. Genetics 3. Presence of brain tumor 4. Toxicity from a. lead b carbon monoxide 5. Nutritional and

Metabolic deficiencies 6. Physical and emotional stress 7. Sudden withdrawal toanti convulsant drug is predisposing factor for status epilepticus (drug of choice is Diazepam, Valium) B. Signs and Symptoms 422 Dependent on stages of development or types of seizure I. Generalized Seizure 1. Grand mal Seizure (tonic-clonic seizure) a. Signs or aura with auditory, olfactory, visual, tactile, sensoryexperience b. Epileptic cry is characterized by fall and loss of consciousnessfor 3 5 minutes c. Tonic contractions - direct symmetrical extension of extremities Clonic contractions - contraction of extremities d. Post ictal sleep unresponsive sleep 2. Petit mal Seizure absence of seizure common among pediatric clients characterized by a. blank stare b. decrease blinking of eyes c. twitching of mouth d. loss of consciousness (5 10 seconds) II. Partial or LocalizedSeizure 1. Jacksonian Seizure (focal seizure) 423 Characterized by tingling and

jerky movement of index finger and thumb that spreads to the shoulder and otherside of the body.


33/110

2. Psychomotor Seizure (focal motor seizure) a. automatism stereotype repetitive and non propulsive behavior b. clouding of consciousness not in contact with environment c. mild hallucinatory sensory experience III. Status Epilepticus 424 A continuous uninterrupted seizure activity, if left untreated can lead to hyperpyrexia and lead to coma and eventually death.

425Drug of choice: Diazepam, Valium and Glucose

C. Diagnostic Procedures 1. CT Scan reveals brain lesions 2. EEG reveals hyper activity of electrical brain waves

D. Nursing Management 1. Maintain patent airway and promote safety before seizure activity a. clear the site of blunt or sharp objects b. loosen clothing of client c. maintain side rails d. avoid use of restrains e. turn clients head to side to prevent aspiration f. place mouth piece of tongue guard to prevent biting or tongue 2. Avoid precipitating stimulus such as bright/glaring lights and noise3. Administer medications as ordered a. Anti convulsants (Dilantin, Phenytoin)b. Diazepam, Valium c. Carbamazepine (Tegretol) Trigeminal neuralgia d. Phenobarbital, Luminal 4. Institute seizure and safety precaution post seizure attacka. administer O2 inhalation b. provide suction apparatus 5. Document and monitor

the following a. onset and duration b. types of seizures c. duration of post ictal sleep may lead to status epilepticus d. assist in surgical procedure cortical resection


34/110

COMPREHENSIVE NEURO EXAM GLASGOW COMA SCALE 426 objective measurement of LOC sometimes called as the quick neuro check Components 1. Motor response 2. Verbal response 3. Eye opening

427 Survey of mental status and speech a. LOC b. Test of memory 428 Levels of orientation 429 Cranial nerve assessment 430 Sensory nerve assessment 431 Motor nerve assessment 432 Deep tendon reflex 433 Autonimics 434 Cerebellar test a, Romb

ergs test 2 nurses, positive for ataxia b. Finger to nose test positive result mean dimetria (inability of body to stop movement at desired point) c. Alternate supination and pronation positive result mean dimetria

I. LEVEL OF CONSCIOUSNESS 1. Conscious - awake 2. Lethargy lethargic (drowsy,sleepy, obtunded) 3. Stupor 435 stuporous (awakened by vigorous stimulation)


35/110

436 generalized body weakness 437 decrease body reflex 4. Coma 438 comatose 439light coma (positive to all forms of painful stimulus) 440 deep coma (negative to all forms of painful stimulus) DIFFERENT PAINFUL STIMULATION 1. Deep sternal stimulation/ deep sternal pressure 2. Orbital pressure 3. Pressure on great toes4. Corneal or blinking reflex 441 Conscious client use a wisp of cotton 442 Unconscious client place 1 drop of saline solution II. TEST OF MEMORY 1. Short termmemory 443 ask most recent activity 444 positive result mean anterograde amnesia

and damage to temporal lobe 2. Long term memory 445 ask for birthday and validate on profile sheet 446 positive result mean retrograde amnesia and damage to limbic system 447 consider educational background III. LEVELS OF ORIENTATION 1. Time first asked 2. Person second asked 3. Place third asked CRANIAL NERVESCRANIAL NERVES I. OLFACTORY II. OPTIC III OCCULOMOTOR IV. TROCHLEAR V. TRIGEMINAL FUNCTION S S M M (Smallest) B


36/110

VI. ABDUCENSE VII. FACIAL VIII. ACOUSTIC IX. GLOSSOPHARYNGEAL X. VAGUS

(Largest) M B S B B

(Longest) XI. SPINAL ACCESSORY M XII. HYPOGLOSSAL M CRANIAL NERVE I: OLFACTORY 448 sensory function for smell Material Used 449 dont use alcohol, ammonia, perfume because it is irritating and highly diffusible. 450 use coffee granules, vin

egar, bar of soap, cigarette Procedure 451 test each nostril by occluding each nostril Abnormal Findings 1. Hyposnia decrease sensitivity to smell 2. Dysosmia distorted sense of smell 3. Anosmia absence of smell Indicative of 1. headinjury damaging the cribriform plate of ethmoid bone where olfactory cells are located 2. may indicate inflammatory conditions (sinusitis) CRANIAL NERVE II: OPTIC 452 sensory function for vision or sight Functions 1. Test visual acuity or central vision or distance

453use Snellens Chart454 Snellens Alphabet chart: for literate clients 455 Snellens E chart: for illiterate clients 456 Snellens Animal chart: for pediatric clients 457 normal visual acuity 20/20 458 numerator is constant, it is the distance of person from t

he chart (6 7 m, 20 feet) 459 denominator changes, indicates distance by whichthe person normally can see letter in the chart. 460 - 20/200 indicates blindness 461 20/20 visual acuity if client is able to read letters above the red line.2. Test of visual field or peripheral vision


37/110

a. Superiorly b. Bitemporaly c. Nasally d. Inferiorly COMMON VISUAL DISORDERS 1.Glaucoma 462 increase IOP

463normal IOP is 12 21 mmHg464 preventable but not curable A. Predisposing Factors 465 Common among 40 years old and above 466 Hereditary 467 Hypertension 468 Obesity B. Signs and Symptoms 1. Loss of peripheral vision

469pathognomonic sign is tunnel vision2. Headache, nausea, vomiting, eye pain (halos around light) 470 steamy cornea 471 may lead to blindness

C. Diagnostic Procedures 1. Tonometry 2. Perimetry 3. Gonioscopy D. Treatment 1.Miotics constricts pupil a. Pilocarpine Sodium, Carbachol 2. Epinephrine eyedrops decrease formation of aqueous humor 3. Carbonic Anhydrase Inhibitors a. Acetazolamide (Diamox) promotes increase outflow of aqueous humor or drainage 4. Timoptics (Timolol Maleate) E. Surgical Procedures


38/110

1. TRABECULECTOMY (Peripheral Indectomy) drain aqueous humor

2. Cataract 472 Decrease opacity of lens A. Predisposing Factor 1. Aging 65 years and above 2. Related to congenital 3. Diabetes Mellitus 4. Prolonged exposureto UV rays B. Signs and Symptoms 1. Loss of central vision C. Pathognomonic Signs 1. Blurring or hazy vision 2. Milky white appearance at center of pupils 3. Decrease perception to colors 473 Complication is blindness D. Diagnostic Procedur

e 1. Opthalmoscopic exam E. Treatment 1. Mydriatics (Mydriacyl) constricts pupils 2. Cyclopegics (Cyclogyl) paralyses cilliary muscle F. Surgical ProcedureExtra Capsular Cataract Lens Extraction - Partial removal Intra Capsular Cataract Lens Extraction - Total removal of cataract with its surrounding capsules

474Most feared complication post op is RETINAL DETACHMENT


39/110

3. Retinal Detachment 475 Separation of epithelial surface of retina A. Predisposing Factors 1. Post Lens Extraction 2. Myopia (near sightedness) B. Signs and Symptoms 1. Curtain veil like vision 2. Floaters C. Surgical Procedures 1. Scleral Buckling 2. Cryosurgery cold application 3. Diathermy heat application 4.Macular Degeneration

476Degeneration of the macula lutea (yellowish spot at the center of retina)

A. Signs and Symptoms 1. Black Spots CRANIAL NERVE III, IV, VI: OCULOMOTOR, TROCHLEAR, ABDUCENS 477 Controls or innervates the movement of extrinsic ocular muscle (EOM) 478 6 muscles

Superior Rectus

Superior Oblique

Lateral Rectus

Medial Rectus


40/110

Inferior Oblique

Inferior Rectus

479 trochlear controls superior oblique 480 abducens controls lateral rectus 481oculomotor controls the 4 remaining EOM Oculomotor 482 controls the size and response of pupil 483 normal pupil size is 2 3 mm 484 equal size of pupil: Isoco

ria 485 Unequal size of pupil: Anisocoria 486 Normal response: positive PERRLA

CRANIAL NERVE V: TRIGEMINAL 487 largest cranial nerve 488 consists of ophthalmic, maxillary, mandibular 489 sensory: controls sensation of face, mucous membrane, teeth, soft palate and corneal reflex) 490 motor: controls the muscle of mastication or chewing 491 damage to CN V leads to trigeminal neuralgia/thickdolorum492 medication: Carbamezapine(Tegretol) CRANIAL NERVE VII: FACIAL 493 Sensory: controls taste, anterior 2/3 of tongue 494 pinch of sugar and cotton applicator placed on tip of tongue 495 Motor: controls muscle of facial expression 496 instruct client to smile, frown and if results are negative there is facial paralysisor Bells Palsy and the primary cause is forcep delivery. CRANIAL NERVE VIII: ACOUSTIC/VESTIBULOCOCHLEAR

497Controls balance particularly kinesthesia or position sense, refers to movementand orientation of the body in space.


41/110

Parts of the Ear 1. Outer Ear 498 Pinna 499 Eardrum 2. Middle Ear

500Hammer 501Anvil 502Stirrup3. Inner Ear

Malleus Incus Stapes

503Vestibule: Meineres Disease504 Cochlea 505 Mastoid Cells 506 Endolymph and Perilymph

507COCHLEA: controls hearing, contains the Organ of Corti(the true organ of hearing) 508 Let client repeat words uttered CRANIAL NERVE IX, X: GLOSOPHARYNGEAL, VAGUS NERVE 509 Glosopharyngeal: controls taste, posterior1/3 of tongue 510 Vagus: controls gag reflex 511 Uvula should be midline and ifnot indicative of damage to cerebral hemisphere 512 Effects of vagal stimulation is PNS CRANIAL NERVE XI: SPINAL ACCESSORY 513 Innervates with sternocleidomastoid (neck) and trapezius (shoulder) CRANIAL NERVE XII: HYPOGLOSSAL 514 Controlsthe movement of tongue 515 Let client protrude tongue and it should be midline and if unable to do indicative of damage to cerebral hemisphere and/or has short

frenulum.


42/110

ENDOCRINE SYSTEM Overview of the structures and functions 1. Pituitary Gland (Hypophysis Cerebri) o o o Located at base of brain particularly at sella turcica Master gland or master clock Controls all metabolic function of body

PARTS OF THE PITUITARY GLAND 1. Anterior Pituitary Gland o o o o o called as adenohypophysis called as neurohypophysis secretes hormones oxytocin -promotes uterine contractions preventing administrate oxytocin immediately after delivery to

prevent uterine atony. initiates milk let down reflex with help of hormone prolactin 2. Posterior Pituitary Gland

bleeding/ hemorrhage

2. Antidiuretic Hormone o o o Pitressin (Vasopressin) Function: prevents urination thereby conserving water Diabetes Insipidus/ Syndrome of Inappropriate Anti Diuretic Hormone

DIABETES INSIPIDUS o Decrease production of anti diuretic hormone

A. Predisposing Factor o o o o 1. Polyuria 2. Signs of dehydration a. Adult: thi

rst b. Agitation c. Poor Skin turgor d. Dry mucous membrane Related to pituitarysurgery Trauma Inflammation Presence of tumor

B. Signs and Symptoms


43/110

3. Weakness and fatigue 4. Hypotension 5. Weight loss 6. If left untreated results to hypovolemic shock (sign is anuria) C. Diagnostic Procedures 1. Urine Specific Gravity o o o 1. Force fluids 2. Monitor strictly vital signs and intake andoutput 3. Administer medications as ordered a. Pitressin (Vasopresin Tannate) administered IM Z-tract 4. Prevent complilcations HYPOVOLEMIC SHOCK is the most feared complication Normal value: 1.015 1.030 Ph 4 8 Increase resulting to hypernatremia

2. Serum Sodium D. Nursing Management

SIADH o hypersecretion of anti diuretic hormone

A. Predisposing Factors 1. Head injury 2. Related to presence of bronchogenic cancer o o pituitary gland. B. Signs and Symptoms 1. Fluid retention a. Hypertension b. Edema c. Weight gain 2. Water intoxication may lead to cerebral edema andlead to increase ICP may lead to seizure activity initial sign of lung canceris non productive cough non invasive procedure is chest x-ray

3. Related to hyperplasia (increase size of organ brought about by increase of n

umber of cells) of


44/110

C. Diagnostic Procedure 1. Urine specific gravity is increased 2. Serum Sodium is decreased D. Nursing Management 1. Restrict fluid 2. Administer medications asordered a. Loop diuretics (Lasix) b. Osmotic diuretics (Mannitol) 3. Monitor strictly vital signs, intake and output and neuro check 4. Weigh patient daily andassess for pitting edema 5. Provide meticulous skin care 6. Prevent complications ANTERIOR PITUITARY GLAND

516also called ADENOHYPOPHYSIS secretes1. Growth hormones (somatotropic hormone) 517 Promotes elongation of long bones

518Hyposecretion of GH among children results to Dwarfism 519Hypersecretion of GH results to Gigantism 520Hypersecretion of GH among adults results to Acromegaly (square face) 521Drug of choice: Ocreotide (Sandostatin)2. Melanocyte Stimulating hormone o o o for skin pigmentation Hyposecretion of MSH results to Albinism Most feared complications of albinism

a. Lead to blindness due to severe photophobia b. Prone to skin cancer o Hypersecretion of MSH results to Vitiligo

3. Adrenochorticotropic hormone (ACTH) o promotes development of adrenal cortex

4. Lactogenic homone (Prolactin)


45/110

o o o o

promotes development of mammary gland with help of oxytocin it initiates milk let down reflex secretes estrogen secretes progesterone

5. Leutinizing hormone 6. Follicle stimulating hormone

PINEAL GLAND o o o secretes melatonin inhibits LH secretion it controls/regulates circadian rhythm (body clock)

THYROID GLAND o located anterior to the neck 3 Hormones secreted 1. T3 (Tri iodothyronine) - 3 molecules of iodine (more potent) 2. T4 (tetra iodothyronine, Thyroxine) o o resorption. HYPOTHYROIDISM o o o o o o all are decrease except weight and menstruation memory impairment there is loss of appetite but there is weight gain menorrhagia cold intolerance constipation T3 and T4 are metabolic or calorigenic hormone promotes cerebration (thinking)

3. Thyrocalcitonin antagonizes the effects of parathormone to promote calcium

Signs and Symptoms

HYPERTHYROIDISM o o o all are increase except weight and menstruation increase appetite but there is weight loss amenorrhea Signs and Symptoms


46/110

o

exophthalmos

THYROID DISORDERS SIMPLE GOITER o enlargement of thyroid gland due to iodine deficiency

A. Predisposing Factors 1. Goiter belt area a. places far from sea b. Mountainous regions 2. Increase intake of goitrogenic foods o o o o contains pro-goitrin an anti thyroid agent that has no iodine. cabbage, turnips, radish, strawberry, carrots, sweet potato, broccoli, all nuts soil erosion washes away iodine goitrogenic drugs a. Anti Thyroid Agent Prophylthiuracil (PTU) b. Lithium Carbonate c. PASA (Aspirin) d. Cobalt e. Phenylbutazones (NSAIDs) - if goiter is caused byB. Signs and Symptoms 1. Enlarged thyroid gland 2. Mild dysphagia 3. Mild restlessness C. Diagnostic Procedures 1. Serum T3 and T4 reveals normal or below normal 2. Thyroid Scan reveals enlarged thyroid gland. 3. Serum Thyroid Stimulating Hormone (TSH) is increased (confirmatory diagnostic test) D. Nursing Management 1. Enforce complete bed rest 2. Administer medications as ordered a. Lugols Solution/SSKI ( Saturated Solution of Potassium Iodine) o color purple or viol

et and administered via straw to prevent staining of teeth.


47/110

o

4 Medications to be taken via straw: Lugols, Iron, Tetracycline, Nitrofurantoin(drug of choice for pyelonephritis)

b. Thyroid Hormones o o o Levothyroxine (Synthroid) Liothyronine (Cytomel) Thyroid Extracts

Nursing Management when giving Thyroid Hormones 1. Instruct client to take in the morning to prevent insomnia 2. Monitor vital signs especially heart rate because drug causes tachycardia and palpitations 3. Monitor side effects o o o o o oo insomnia tachycardia and palpitations hypertension heat intolerance seaweeds seafoods like oyster, crabs, clams and lobster but not shrimps because it contains lesser amount of iodine. iodized salt, best taken raw because it it is easilydestroyed by heat 5. Assist in surgical procedure of subtotal thyroidectomy HYPOTHYROIDISM o o o hyposecretion of thyroid hormone adults: MYXEDEMA non pittingedema children: CRETINISM the only endocrine disorder that can lead to mental retardation A. Predisposing Factors 1. Iatrogenic Cause disease caused by medical intervention such as surgery 2. Related to atrophy of thyroid gland due to tra

uma, presence of tumor, inflammation 3. Iodine deficiency 4. Autoimmune (Hashimotos Disease)

4. Increase dietary intake of foods rich in iodine

B. Signs and Symptoms


48/110

(Early Signs) 1. Weakness and fatigue 2. Loss of appetite but with weight gain which promotes lipolysis leading to atherosclerosis and MI 3. Dry skin 4. Cold intolerance 5. Constipation (Late Signs) 1. Brittleness of hair and nails 2. Non pitting edema (Myxedema) 3. Hoarseness of voice 4. Decrease libido 5. Decrease inall vital signs hypotension, bradycardia, bradypnea, hypothermia 6. CNS changes o o o o lethargy memory impairment psychosis menorrhagia

C. Diagnostic Procedures 1. Serum T3 and T4 is decreased 2. Serum Cholesterol isincreased 3. RAIU (Radio Active Iodine Uptake) is decreased D. Nursing Management 1. Monitor strictly vital signs and intake and output to determine presence of o o Myxedema coma is a complication of hypothyroidism and an emergency case asevere form of hypothyroidism is characterized by severe hypotension, bradycardia, bradypnea, hypoventilation, hyponatremia, hypoglycemia, hypothermia leading to pregressive stupor and coma. Nursing Management for Myxedema Coma 2. Force fluids 3. Administer isotonic fluid solution as ordered 4. Administer medications as ordered Assist in mechanical ventilation Administer thyroid hormones asordered Force fluids


49/110


50/110

c. Tremors d. Insomnia e. Hallucinations 7. Goiter 8. Exopthalmus 9. AmenorrheaC. Diagnostic Procedures 1. Serum T3 and T4 is increased 2. RAIU (Radio Active Iodine Uptake) is increased 3. Thyroid Scan- reveals an enlarged thyroid gland D.Nursing Management 1. Monitor strictly vital signs and intake and output 2. Administer medications as ordered Anti Thyroid Agent a. Prophythioracill (PTU) b. Methymazole (Tapazole) Side Effects of Agranulocytosis 522 increase lymphocytes and monocytes 523 fever and chills 524 sore throat (throat swab/culture) 525 leuk

ocytosis (CBC) 3. Provide dietary intake that is increased in calories. 4. Provide meticulous skin care 5. Comfortable and cold environment 6. Maintain side rails 7. Provide bilateral eye patch to prevent drying of the eyes. 8. Assist in surgical procedures known as subtotal thyroidectomy ** Before thyroidectomy administer Lugols Solution (SSKI) to decrease vascularity of the thyroid gland to prevent bleeding and hemorrhage.

POST OPERATIVELY, 1. Watch out for signs of thyroid storm/ thyrotoxicosis


51/110

Agitation

Hyperthermia 526 administer medications as ordered a. Anti Pyretics b. Beta-blockers 527 monitor strictly vital signs, input and output and neuro check. 528 maintain side rails 529 offer TSB

Tachycardia

2. Watch out for accidental removal of parathyroid gland that may lead to Hypocalcemia (tetany) Signs and Symptoms 530 (+) trousseaus sign 531 (+) chvostek sign 532 Watch out for arrhythmia, seizure give Calcium Gluconate IV slowly as ordered 3. Watch out for accidental Laryngeal damage which may lead to hoarseness ofvoice Nursing Management 533 encourage client to talk/speak immediately after operation and notify physician 4. Signs of bleeding (feeling of fullness at incisional site) Nursing Management 534 Check the soiled dressings at the back or nape area. 5. Hormonal replacement therapy for lifetime 6. Importance of follow upcare PARATHYROID GLAND 535 A pair of small nodules behind the thyroid gland 536Secretes parathormone


52/110

537 Promotes calcium reabsorption 538 Hypoparathyroidism 539 HyperparathyroidismHYPOPARATHYROIDISM

540Decrease secretion of parathormone leading to hypocalcemia541 Resulting to hyperphospatemia A. Predisposing Factors 1. Following subtotalthyroidectomy 2. Atrophy of parathyroid gland due to: a. inflammation b. tumor c. trauma B. Signs and Symptoms 1. Acute tetany a. tingling sensation b. paresthe

sia c. numbness d. dysphagia e. positive trousseus sign/carpopedal spasm f. positive chvostek sign g. laryngospasm/broncospasm h. seizure i. arrhythmia 2. Chronic tetany a. photophobia and cataract formation b. loss of tooth enamel c. anorexia, nausea and vomiting d. agitation and memory impairment C. Diagnostic Procedures 1. Serum Calcium is decreased (normal value: 8.5 11 mg/100 ml) 2. SerumPhosphate is decreased (normal value: 2.5 4.5 mg/100 ml) 3. X-ray of long bones reveals a decrease in bone density 4. CT Scan reveals degeneration of basalganglia feared complications


53/110

D. Nursing Management 1. Administer medications as ordered such as: a. Acute Tetany Calcium Gluconate IV slowly b. Chronic Tetany Oral Calcium supplements Calcium Gluconate Calcium Lactate Calcium Carbonate c. Vitamin D (Cholecalciferol) for absorption of calcium CHOLECALCIFEROL ARE DERIVED FROM Drug (Calcitriol) Diet (Calcidiol) Sunlight

d. Phosphate binder

542Aluminum Hydroxide Gel (Ampogel)543 Side effect: constipation ANTACID A.A.C Aluminum Containing Antacids Aluminum Hydroxide Gel Side Effect: Constipation MAD Magnesium Containing Antacids

Side Effect: Diarrhea

2. Avoid precipitating stimulus such as glaring lights and noise 3. Encourage increase intake of foods rich in calcium a. anchovies b. salmon c. green turnips


54/110

4. Institute seizure and safety precaution 5. Encourage client to breathe usingpaper bag to produce mild respiratory acidosis result. 6. Prepare trache set atbedside for presence of laryngo spasm 7. Prevent complications 8. Hormonal replacement therapy for lifetime 9. Importance of follow up care. HYPERTHYROIDISM 544Decrease parathormone 545 Hypercalcemia: bone demineralization leading to bonefracture (calcium is stored 99% in bone and 1% blood) 546 Kidney stones A. Predisposing Factors 1. Hyperplasia of parathyroid gland 2. Over compensation of para

thyroid gland due to vitamin D deficiency a. Children: Ricketts b. Adults: Osteomalacia B. Signs and Symptoms 1. Bone pain especially at back (bone fracture) 2.Kidney stones a. renal cholic b. cool moist skin 3. Anorexia, nausea and vomiting 4. Agitation and memory impairment C. Diagnostic Procedures 1. Serum Calciumis increased 2. Serum Phosphate is decreased 3. X-ray of long bones reveals bonedemineralization D. Nursing Management 1. Force fluids to prevent kidney stones2. Strain all the urine using gauze pad for stone analysis 3. Provide warm sitzbath 4. Administer medications as ordered a. Morphine Sulfate (Demerol) 5. Encourage increase intake of foods rich in phosphate but decrease in calcium


55/110

6. Provide acid ash in the diet to acidify urine and prevent bacterial growth 7.Assist/supervise in ambulation 8. Maintain side rails 9. Prevent complications(seizure and arrhythmia) 10. Assist in surgical procedure known as parathyroidectomy 11. Hormonal replacement therapy for lifetime 12. Importance of follow up care

ADRENAL GLAND 547 Located atop of each kidney 548 2 layers of adrenal gland a. A

drenal Cortex outermost b. Adrenal Medulla innermost (secretes catecholamines a power hormone) 2 Types of Catecholamines 549 Epinephrine and Norepinephrine(vasoconstrictor) 550 Pheochromocytoma (adrenal medulla) 551 Increase secretionof norepinephrine 552 Leading to hypertension which is resistant to pharmacological agents leading to CVA 553 Use beta-blockers ADRENAL CORTEX 3 Zones/Layers 1.Zona Fasciculata - secretes glucocortocoids (cortisol) - function: controls glucose metabolism - Sugar 2. Zona Reticularis - secretes traces of glucocorticoidsand androgenic hormones - function: promotes secondary sex characteristics - Sex 3. Zona Glumerulosa - secretes mineralocorticoids (aldosterone) - function: promotes sodium and water reabsorption and excretion of potassium


56/110


57/110

by a. severe hypotension b. hypovolemic shock c. hyponatremia leading to progressive stupor and coma Nursing Management for Addisonian Crisis 1. Assist in mechanical ventilation, - administer steroids as ordered - force fluids 2. Administerisotonic fluid solution as ordered 3. Force fluids 4. Administer medications asordered Corticosteroids a. Dexamethasone (Decadrone) b. Prednisone c. Hydrocortisone (Cortison) Nursing Management when giving steroids 1. Instruct client to take 2/3 dose in the morning and 1/3 dose in the afternoon to mimic the normal di

urnal rhythm 2. Taper dose (withdraw gradually from drug) 3. Monitor side effects a. hypertension b. edema c. hirsutism d. increase susceptibility to infectione. moon face appearance 4. Mineralocorticoids (Flourocortisone) 5. Provide dietary intake, increase calories, carbohydrates, protein but decrease in potassium 6. Provide meticulous skin care 7. Provide client health teaching and discharge planning a. avoid precipitating factor leading to addisonian crisis leading to -stress - infection - sudden withdrawal to steroids b. prevent complications - addisonian crisis - hypovolemic shock c. hormonal replacement for lifetime


58/110

d. importance of follow up care

CUSHING SYNDROME 556 Hypersecretion of adenocortical hormones A. Predisposing Factors 1 Related to hyperplasia of adrenal gland 2. Increase susceptibility to infections 3. Hypernatremia a. hypertension b. edema c. weight gain d. moon face appearance and buffalo hump e. obese trunk f. pendulous abdomen g. thin extremities 4. Hypokalemia a. weakness and fatigue b. constipation c. U wave upon ECG (T

wave hyperkalemia) 5. Hirsutism 6. Acne and striae 7. Easy bruising 8. Increasemasculinity among females B. Diagnostic Procedures 1. FBS is increased 2. PlasmaCortisol is increased 3. Serum Sodium is increased 4. Serum Potassium is decreased C. Nursing Management


59/110

1. Monitor strictly vital signs and intake and output 2. Weigh patient daily andassess for pitting edema 3. Measure abdominal girth daily and notify physician4. Restrict sodium intake 5. Provide meticulous skin care 6. Administer medications as ordered a. Spinarolactone potassium sparring diuretics 7. Prevent complications (DM) 8. Assist in surgical procedure (bilateral adrenoraphy) 9. Hormonal replacement for lifetime 10. Importance of follow up care PANCREAS - Located behind the stomach - Mixed gland (exocrine and endocrine) - Consist of acinar cel

ls which secretes pancreatic juices that aids in digestion thus it is an exocrine gland - Consist of islets of langerhans - Has alpha cells that secretes glucagons (function: hyperglycemia) - Beta cells secretes insulin (function: hypoglycemia) - Delta cells secretes somatostatin (function: antagonizes the effects of growth hormones)

3 Main Disorders of Pancreas 1. Pancreatic Tumor/Cancer 2. Diabetes Mellitus 3.Pancreatitis DIABETES MELLITUS - metabolic disorder characterized by non utilization of carbohydrates, protein and fat metabolism CLASSIFICATION OF DM Type 1 (IDDM) - Juvenile onset type - Brittle disease Type 2 (NIDDM) - Adult onset - Maturity onset type - Obese over 40 years old


60/110

A. Incidence Rate - 10% general population has type 1 DM B. Predisposing Factors1. Hereditary (total destruction of pancreatic cells) 2. Related to viruses 3.Drugs a. Lasix b. Steroids 4. Related to carbon tetrachloride toxicity C. Signsand Symptoms 1. Polyuria 2. Polydypsia 3. Polyphagia 4. Glucosuria 5. Weight loss 6. Anorexia, nausea and vomiting 7. Blurring of vision 8. Increase susceptibility to infection 9. Delayed/poor wound healing D. Treatment 1. Insulin therapy 2. Diet 3. Exercise E. Complication 1. Diabetic Ketoacidosis

A. Incidence Rate - 90% of general population has type 2 DM B. Predisposing Factors 1. Obesity because obese persons lack insulin receptor binding sites

C. Signs and Symptoms 1. Usually asymptomatic 2. Polyuria 3. Polydypsia 4. Polyphagia 5. Glucosuria 6. Weight gain

D. Treatment 1. Oral Hypoglycemic agents 2. Diet 3. Exercise E. Complications 1.Hyper 2. Osmolar 3. Non 4. Ketotic 5. Coma


61/110

MAIN FOODSTUFF 1. Carbohydrates 2. Protein 3. Fats

ANABOLISM

CATABOLISM

Glucose Amino Acids Fatty Acids

Glycogen Nitrogen Free Fatty Acids - Cholesterol - Ketones

HYPERGLYCEMIA Increase osmotic diuresis Glycosuria Cellular starvation weightloss Stimulates the appetite/satiety center (Hypothalamus) Polyphagia Polyuria Cellular dehydration Stimulates the thirst center (Hypothalamus) Polydypsia

* Liver has glycogen that undergo glycogenesis/ glycogenolysis GLUCONEOGENESIS Formation of glucose from non-CHO sources Increase protein formation Negative Nitrogen balance Tissue wasting (Cachexia) INCREASE FAT CATABOLISM Free fatty acids Cholesterol Ketones


62/110

Atherosclerosis Hypertension Respiration odor MI CVA

Diabetic Keto Acidosis Acetone Breath Kussmauls

Death

Diabetic Coma

DIABETIC KETOACIDOSIS - Acute complication of type 1 DM due to severe hyperglycemia leading to severe CNS depression A. Predisposing Factors 1. Hyperglycemia 2.Stress number one precipitating factor 3. Infection B. Signs and Symptoms 1.Polyuria 2. Polydypsia 3. Polyphagia 4. Glucosuria 5. Weight loss 6. Anorexia, nausea and vomiting 7. Blurring of vision 8. Acetone breath odor


63/110

9. Kussmauls Respiration (rapid shallow breathing) 10 CNS depression leading tocoma C. Diagnostic Procedures 1. FBS is increased 2. BUN (normal value: 10 20) 3. Creatinine (normal value: .8 1) 4. Hct (normal value: female 36 42, male 42 48) due to severe dehydration D. Nursing Management 1. Assist in mechanical ventilation 2. Administer 0.9 NaCl followed by .45 NaCl (hypotonic solutions)to counteract dehydration and shock 3. Monitor strictly vital signs, intake andoutput and blood sugar levels 4. Administer medications as ordered a. Insulin t

herapy (regular acting insulin/rapid acting insulin peak action of 2 4 hours)b. Sodium Bicarbonate to counteract acidosis c. Antibiotics to prevent infectionHYPER OSMOLAR NON KETOTIC COMA - Hyperosmolar: increase osmolarity (severe dehydration) - Non ketotic: absence of lypolysis (no ketones) A. Signs and Symptoms1. Headache and dizziness 2. Restlessness 3. Seizure activity 4. Decrease LOC diabetic coma B. Nursing Management 1. Assist in mechanical ventilation 2. Administer 0.9 NaCl followed by .45 NaCl (hypotonic solutions) to counteract dehydration and shock 3. Monitor strictly vital signs, intake and output and blood sugarlevels 4. Administer medications as ordered a. Insulin therapy (regular actinginsulin peak action of 2 4 hours) - for DKA use rapid acting insulin


64/110

b. Antibiotics to prevent infection INSULIN THERAPY A. Sources of Insulin 1. Animal sources - Rarely used because it can cause severe allergic reaction - Derived from beef and pork 2. Human Sources - Frequently used type because it has lessantigenicity property thus less allergic reaction 3. Artificially Compound Insulin B. Types of Insulin 1. Rapid Acting Insulin (clear) - Regular acting insulin(IV only) - Peak action is 2 4 hours 2. Intermediate Acting Insulin (cloudy)- Non Protamine Hagedorn Insulin (NPH) - Peak action is 8 16 hours 3. Long Act

ing Insulin (cloudy) - Ultra Lente - Peak action is 16 24 hours C. Nursing Management for Insulin Injections 1. Administer at room temperature to prevent development of lipodystrophy (atrophy, hypertrophy of subcutaneous tissues) 2. Placein refrigerator once opened 3. Avoid shaking insulin vial vigorously instead gently roll vial between palm to prevent formation of bubbles 4. Use gauge 25 26needle 5. Administer insulin either 45o 90o depending on amount of clients tissue deposit 6. No need to aspirate upon injection 7. Rotate insulin injection sites to prevent development of lipodystrophy 8. Most accessible route is abdomen9. When mixing 2 types of insulin aspirate first the clear insulin before cloudy to prevent contaminating the clear insulin and promote proper calibration. 10.Monitor for signs of local complications such as a. Allergic reactions


65/110

b. Lipodystrophy c. Somogyis Phenomenon rebound effect of insulin characterized by hypoglycemia to hyperglycemia ORAL HYPOGLYCEMIC AGENTS - Stimulates the pancreas to secrete insulin A. Classsification 1. First Generation Sulfonylureas a.Chlorpropamide (Diabenase) b. Tolbutamide (Orinase) c. Tolamazide (Tolinase) 2.Second Generation Sulfonylureas a. Glipzide (Glucotrol) b. Diabeta (Micronase)Nursing Management when giving OHA 1. Instruct the client to take it with mealsto lessen GIT irritation and prevent hypoglycemia 2. Instruct the client to avoi

d taking alcohol because it can lead to severe hypoglycemia reaction or Disulfiram (Antabuse) toxicity symptoms B. Diagnostic Procedures 1. FBS is increased (3consecutive times with signs or polyuria, polydypsia, polyphagia and glucosuriaconfirmatory for DM) 2. Random Blood Sugar is increased 3. Oral glucose tolerance test is increased most sensitive test 4. Alpha Glycosylated Hemoglobin is increased C. Nursing Management 1. Monitor for peak action of insulin and OHA andnotify physician 2. Administer insulin and OHA therapy as ordered 3. Monitor strictly vital signs, intake and output and blood sugar levels 4. Monitor for signsof hypoglycemia and hyperglycemia - administer simple sugars - for hypoglycemia(cold and clammy skin) give simple sugars - for hyperglycemia (dry and warm skin) 5. Provide nutritional intake of diabetic diet that includes: carbohydrates 50%, protein 30% and fats 20% or offer alternative food substitutes 6. Instruct c

lient to exercise best after meals when blood glucose is rising


66/110

7. Monitor signs for complications a. Atherosclerosis (HPN, MI, CVA) b. Microangiopathy (affects small minute blood vessels of eyes and kidneys) EYES -PREMATURECATARACT - Blindness KIDNEY -RECURRENT PYELONEPHRITIS - Renal failure

c. HPN and DM major cause of renal failure d. Gangrene formation e. Shock due todehydration - peripheral neuropathy - diarrhea/constipation - sexual impotence8. Institute foot care management a. instruct client to avoid walking barefooted

b. instruct client to cut toenails straight c. instruct client to avoid wearingconstrictive garments d. encourage client to apply lanolin lotion to prevent skin breakdown e. assist in surgical wound debriment (give analgesics 15 30 minsprior) 9. Instruct client to have an annual eye and kidney exam 10. Monitor forsigns of DKA and HONKC 11. Assist in surgical procedure HEMATOLOGICAL SYSTEM

I. Blood Organs 55% Plasma Serum 45% Formed

II. Blood Vessels 1. Arteries 2. Veins

III.

Blood

Forming

Plasma CHON (formed in liver) 1. Albumin 2. Globulins 3. Prothrombin and Fibrinogen

1. Liver 3. Spleen 4. Lymphoid Organ 5. Lymph Nodes 6. Bone Marrow

ALBUMIN - Largest and numerous plasma CHON - Maintains osmotic pressure preventing edema


67/110

GLOBULINS - Alpha globulins - transport steroids, bilirubin and hormones - Betaglobulins iron and copper - Gamma globulins a. anti-bodies and immunoglobulinsb. prothrombin and fibrinogen clotting factors FORMED ELEMENTS 1. RBC (ERYTHROCYTES) - normal value: 4 6 million/mm3 - only unnucleated cell - biconcave discs - consist of molecules of hgb (red pigment) bilirubin (yellow pigment) biliverdin (green pigment) hemosiderin (golden brown pigment) - transports and carriesoxygen to tissues - hemoglobin: normal value female 12 14 gms% male 14 16 gm

s% - hematocrit red cell percentage in wholeblood - normal value: female 36 42% male 42 48% - substances needed for maturation of RBC a. folic acid b. ironc. vitamin c d. vitamin b12 (cyanocobalamin) e. vitamin b6 (pyridoxine) f. intrinsic factor - Normal life span of RBC is 80 120 days and is killed in red pulpof spleen 2. WBC (LEUKOCYTES) - normal value: 5000 10000/mm3 A. Granulocytes1. Polymorpho Neutrophils - 60 70% of WBC - involved in short term phagocytosis for acute inflammation 2. Polymorphonuclear Basophils - for parasite infections - responsible for the release of chemical mediation for inflammation


68/110

3. Polymorphonuclear Eosinophils - for allergic reaction B. Non Granulocytes 1.Monocytes - macrophage in blood - largest WBC - involved in long term phagocytosis for chronic inflammation 2. Lymphocytes

B-cell T-cell - bone marrow - thymus for immunity

Natural killer cell - anti viral and anti tumor property

HIV - 6 months 5 years incubation period - 6 months window period - western blot opportunistic - ELISA - drug of choice AZT (Zidon Retrovir) 2 Common fungal opportunistic infection in AIDS 1. Kaposis Sarcoma 2. Pneumocystis Carinii Pneumonia 3. Platelets (THROMBOCYTES) - Normal value: 150,000 450,000/mm3 - Promotes hemostasis (prevention of blood loss) - Consist of immature or baby plateletsor megakaryocytes which is the target of dengue virus - Normal life span of platelet is 9 12 days Signs of Platelet Dysfunction 1. Petechiae 2. Echhymosis 3.Oozing of blood from venipunctured site

BLOOD DISORDERSIron Deficiency Anemia


69/110

- A chronic microcytic anemia resulting from inadequate absorption of iron leading to hypoxemic tissue injury A. Incidence Rate 1. Common among developed countries 2. Common among tropical zones 3. Common among women 15 35 years old 4. Related to poor nutrition B. Predisposing Factors 1. Chronic blood loss due to trauma a. Heavy menstruation b. Related to GIT bleeding resulting to hematemesis and melena (sign for upper GIT bleeding) c. fresh blood per rectum is called hematochezia 2. Inadequate intake of iron due to a. Chronic diarrhea b. Related to ma

labsorption syndrome c. High cereal intake with low animal protein digestion d.Subtotal gastrectomy 4. Related to improper cooking of foods C. Signs and Symptoms 1. Usually asymptomatic 2. Weakness and fatigue (initial signs) 3. Headache and dizziness 4. Pallor and cold sensitivity 5. Dyspnea 6. Palpitations 7. Brittleness of hair and spoon shape nails (koilonychias) 8. Atropic Glossitis (inflammation of tongue) - Stomatitis - Dysphagia 9. PICA (abnormal appetite or cravingfor non edible foods D. Diagnostic Procedures 1. RBC is decreased 2. Hgb is decreased 3. Hct is deceased 4. Iron is decreased 5. Reticulocyte is decreased PLUMBER VINSONS SYNDROME


70/110

6. Ferritin is decreased E. Nursing Management 1. Monitor for signs of bleedingof all hema test including urinw, stool and GIT 2. Enforce CBR so as not to overtire client 3. Instruct client to take foods rich in iron a. Organ meat b. Egg(yolk) c. Raisin d. Sweet potatoes e. Dried fruits f. Legumes g. Nuts 4. Instruct the client to avoid taking tea and coffee because it contains tannates which impairs iron absorption 5. Administer medications as ordered Oral Iron Preparations a. Ferrous Sulfate b. Ferrous Fumarate c. Ferrous Gluconate - 300 mg/day Nurs

ing Management when taking oral iron preparations 1. Instruct client to take with meals to lessen GIT irritation 2. When diluting it in liquid iron preparationsadminister with straw to prevent staining of teeth Medications administered viastraw - Lugols solution - Iron - Tetracycline - Nitrofurantoin (Macrodentin) 3. Administer with Vitamin C or orange juice for absorption 4. Monitor and informclient of side effects a. Anorexia b. Nausea and vomiting c. Abdominal pain d.Diarrhea/constipation e. Melena 5. If client cant tolerate/no compliance administer parenteral iron preparation a. Iron Dextran (IM, IV) b. Sorbitex (IM) Nursing Management when giving parenteral iron preparations


71/110

1. Administer Z tract technique to prevent discomfort, discoloration and leakageto tissues 2. Avoid massaging the injection site instead encourage to ambulateto facilitate absorption 3. Monitor side effects a. Pain at injection site b. Localized abscess c. Lymphadenopathy d. Fever and chills e. Skin rashes f. Pruritus/orticaria g. Hypotension (anaphylactic shock)

PERNICIOUS ANEMIA - Chronic anemia characterized by a deficiency of intrinsic fa

ctor leading to hypochlorhydria (decrease hydrochloric acid secretion) A. Predisposing Factors 1. Subtotal gastrectomy 2. Hereditary factors 3. Inflammatory disorders of the ileum 4. Autoimmune 5. Strictly vegetarian diet

STOMACH Pareital cells/ Argentaffin or Oxyntic cells Produces intrinsic factors acid Promotes reabsorption of Vit B12 Promotes maturation of RBC B. Signsand Symptoms 1. Weakness and fatigue 2. Headache and dizziness Aids in digestion Secretes hydrochloric


72/110

3. Pallor and cold sensitivity 4. Dyspnea and palpitations as part of compensation 5. GIT changes that includes a. mouth sore b. red beefy tongue c. indigestion/dyspepsia d. weight loss e. jaundice 6. CNS changes a. tingling sensation b. numbness c. paresthesia d. positive to Rombergs test damage to cerebellum resulting to ataxia e. result to psychosis C. Diagnostic Procedure Schillings Test reveals inadequate/decrease absorption of Vitamin B12 D. Nursing Management 1.Enforce CBR 2. Administer Vitamin B12 injections at monthly intervals for lifeti

me as ordered - Never given orally because there is possibility of developing tolerance - Site of injection for Vitamin B12 is dorsogluteal and ventrogluteal -No side effects 3. Provide a dietary intake that is high in carbohydrates, protein, vitamin c and iron 4. Instruct client to avoid irritating mouth washes instead use soft bristled toothbrush 5. Avoid heat application to prevent burns

APLASTIC ANEMIA - Stem cell disorder leading to bone marrow depression leading to pancytopenia PANCYTOPENIA Decrease RBC Platelet Decrease WBC Decrease


73/110

(anemia) (thrombocytopenia) A. Predisposing Factors 1. Chemicals (Benzine and its derivatives) 2. Related to irradiation/exposure to x-ray 3. Immunologic injury4. Drugs Broad Spectrum Antibiotics a. Chloramphenicol (Sulfonamides) Chemotherapeutic Agents a. Methotrexate (Alkylating Agent) b. Vincristine (Plant Alkaloid) c. Nitrogen Mustard (Antimetabolite) Phenylbutazones (NSAIDS) B. Signs and Symptoms 1. Anemia a. Weakness and fatigue b. Headache and dizziness c. Pallor andcold sensitivity d. Dyspnea and palpitations 2. Leukopenia a. Increase susceptib

ility to infection 3. Thrombocytopenia

(leucopenia)

a. Petechiae (multiple petechiae is called purpura) b. Ecchymosis c. Oozing of blood from venipunctured sites C. Diagnostic Procedures 1. CBC reveals pancytopenia 2. Bone marrow biopsy/aspiration (site is the posterior iliac crest) reveals fat necrosis in bone marrow D. Nursing Management 1. Removal of underlying cause 2. Institute BT as ordered


74/110

3. Administer oxygen inhalation 4. Enforce CBR 5. Institute reverse isolation 6.Monitor for signs of infection a. fever b. cough 7. Avoid IM, subcutaneous, venipunctured sites 8 Instead provide heparin lock 9. Instruct client to use electric razor when shaving 10. Administer medications as ordered a. Corticosteroids caused by immunologic injury b. Immunosuppressants Anti Lymphocyte Globulin Given via central venous catheter Given 6 days to 3 weeks to achieve Maximum therapeutic effect of drug DISSEMINATED INTRAVASCULAR COAGULATION Acute hemorrhagi

c syndrome characterized by wide spread bleeding and thrombosis due to a deficiency of prothrombin and fibrinogen A. Predisposing Factors 1. Related to rapid blood transfusion 2. Massive burns 3. Massive trauma 4. Anaphylaxis 5. Septecemia6. Neoplasia (new growth of tissue) 7. Pregnancy B. Signs and Symptoms 1. Petechiae (widespread and systemic) eye, lungs and lower extremities 2. Ecchymosis 3.Oozing of blood from punctured sites 4. Hemoptysis 6. Oliguria (late sign)


75/110

C. Diagnostic Procedures 1. CBC reveals decreased platelets 2. Stool occult blood positive 3. ABG analysis reveals metabolic acidosis 4. Opthamoscopic exam reveals sub retinal hemorrhages D. Nursing Management 1. Monitor for signs of bleeding of all hema test including stool and GIT 2. Administer isotonic fluid solution as ordered 3. Administer oxygen inhalation 4. Force fluids 5. Administer medications as ordered a. Vitamin K b. Pitressin/ Vasopresin to conserve fluids c. Heparin/Coumadin is ineffective 6. Provide heparin lock 7. Institute NGT decompres

sion by performing gastric lavage by using ice or cold saline solution of 500 1000 ml 8. Monitor NGT output 9. Prevent complication a. Hypovolemic shock b. Anuria late sign

BLOOD TRANSFUSION Goals/Objectives 1. Replace circulating blood volume 2. Increase the oxygen carrying capacity of blood 3. Prevent infection in there is a decrease in WBC 4. Prevent bleeding if there is platelet deficiency Principles of blood transfusion


76/110

1. Proper refrigeration - Expiration of packed RBC is 3 6 days - Expiration ofplatelet is 3 5 days 2. Proper typing and cross matching a. Type O universal donor b. Type AB universal recipient c. 85% of population is RH positive 3.Aseptically assemble all materials needed for BT a. Filter set b. Gauge 18 19needle c. Isotonic solution (0.9 NaCl/plain NSS) to prevent hemolysis 4. Instruct another RN to re check the following a. Client name b. Blood typing and crossmatching c. Expiration date d. Serial number 5. Check the blood unit for bubbles

cloudiness, sediments and darkness in color because it indicates bacterial contamination - Never warm blood as it may destroy vital factors in blood. - Warmingis only done during emergency situation and if you have the warming device - Emergency rapid BT is given after 30 minutes and let natural room temperature warmthe blood. 6. BT should be completed less than 4 hours because blood that is exposed at room temperature more than 2 hours causes blood deterioration that canlead to BACTERIAL CONTAMINATION 7. Avoid mixing or administering drugs at BT line to prevent HEMOLYSIS 8. Regulate BT 10 15 gtts/min or KVO rate or equivalentto 100 cc/hr to prevent circulatory overload 9. Monitor strictly vital signs before, during and after BT especially every 15 minutes for first hour because majority of transfusion reaction occurs during this period a. Hemolytic reaction b.Allergic reaction c. Pyrogenic reaction d. Circulatory overload e. Air embolism

f. Thrombocytopenia


77/110

g. Cytrate intoxication h. Hyperkalemia (caused by expired blood)

Signs and Symptoms of Hemolytic reaction 1. Headache and dizziness 2. Dyspnea 3.Diarrhea/Constipation 4. Hypotension 5. Flushed skin 6. Lumbasternal/ Flank pain 7. Urine is color red/ portwine urine Nursing Management 1. Stop BT 2. Notifyphysician 3. Flush with plain NSS 4. Administer isotonic fluid solution to prevent shock and acute tubular necrosis 5. Send the blood unit to blood bank for re

examination 6. Obtain urine and blood sample and send to laboratory for re examination 7. Monitor vital signs and intake and output SIGNS AND SYMPTOMS OF ALLERGIC REACTION 1. Fever 2. Dyspnea 3. Broncial wheezing 4. Skin rashes 5. Urticaria6. Laryngospasm and Broncospasm Nursing Management


78/110


79/110

3. Administer medications as ordered a. Loop diuretic (Lasix) CARDIOVASCULAR SYSTEM OVERVIEW OF THE STRUCTURE AND FUNCTIONS OF THE HEART HEART - Muscular pumping organ of the

27157422 Medical Surgical Nursing Review

Documents