Académique Documents
Professionnel Documents
Culture Documents
MEDICAL-SURGICAL NURSING
By: Anthony T. Villegas R.N.
period.
3.
NERVOUS SYSTEM
Permanent
or neurons
Retinal Cells.
Brain
B.
NEUROGLIA
TYPES
1.
Astrocytes
cord.
astrocytoma.
2.
Oligodendria
transmission.
3.
functioning.
drinking).
4.
CELLS
A.
Microglia
Epindymal
NEURONS
Axon
MACROPHAGE
Microglia
ORGAN
Brain
Monocytes
Blood
Kupffers
Kidney
Histiocytes
Skin
Alveolar Macrophage
Lung
Dendrites
Composition Of Brain
10% blood
10% CSF
Synapse
Neurotransmitter
Brain Mass
Parts Of The Brain
1.
Cerebrum
Myelin Sheath
impulse conduction.
o
o
by schwann cells
Functional Classification
1.
2.
3.
Lobes of Cerebrum
1.
Frontal Lobe
Properties
1.
external environment.
2.
3.
2.
3.
Pareital Lobe
for appreciation
Labile
Capable of regeneration.
Temporal Lobe
Stable
2
4.
Occipital Lobe
5.
for vision
Cerebellum
motility.
Limbic System (Rhinencephalon)
Spinal Cord
of smell).
controls libido
periphery
Corpus Callosum
Basal Ganglia
Gray Matter
1.
Anterior Horns
fibers
cerebral cortex
2.
Posterior Horns
2.
3.
Lateral Horns
White Matter
Diencephalon/interbrain
hemisphere.
1.
Posterior Column
Thalamus
b.
Spinocerebellar
c.
Lateral Spinothalamic
Anterior Spinothlamic
2.
characteristics.
the medulla)
enlargement
late sign is deepening of voice.
Hypothalamus
b.
Extrapyramidal
3.
4.
Mesencephalon/Midbrain
walking
Reflex Arc
positive PERRLA
a.
b.
c.
d.
e.
Pons
1.
Skull
Medulla Oblongata
controls respiration, heart rate, swallowing, vomiting,
hiccup, vasomotor center (dilation and constriction of
Supporting Structures
of respiration.
Effectors
cardiac functions.
Efferent Pathways
Interneurons
Receives/reacts to stimulus
Afferent Pathways
Sensory Receptors
Components
Brain Stem
2.
Spinal Column
bronchioles).
3
3.
Meninges
5.
Bilirubin
supply
Layers:
Dura Mater
Arachnoid Mater
4.
Spinal Nerves
Pia Mater
Ventricles
5.
2.
cavity
6.
Function
: CN I
Vascular Supply
sense of smell.
Optic
: CN II
Oculomotor
: CN III
posteriorly
4 out of 6 extraocular
movement.
Trochlear
of the brain
Trigeminal
: CN IV
: CN V
7.
Abducens
jugular veins
of eye
Blood-Brain-Barrier (BBB)
Facial
: CN VI
: CN VII
Movement.
Acoustic
: CN VIII
Amonia
Cerebral toxin
Ascites
Esophageal Varices
Glossopharyngeal
: CN IX
: CN X
2.
3.
Headache
Dizziness
Confusion
decrease LOC
Epilepsy
Type 1 DM (IDDM)
: CN XI
Motor: movement of
: CN XII
Component:
1.
Generally
accelerates
some
body
function
in
response to stress.
2.
depressant).
4.
Hepatitis
(Adrenergic) Effect
Sympatholytic
- Involved in flight or withdrawal
response.
response.
4
- Release of Norepinephrine
- Release of Acetylcholine.
except GIT.
decrease motility
increase motility
vasoconstriction.
Constrict sphincters
relaxed sphincters
except GIT
GI Tract
stimulate
EFFECTS OF PNS
secretions
EFFECTS OF SNS
- Increase salivation.
gallbladder&
ducts
order to be aware.
- Bronchoconstriction, Decrease
RR.
- Diarrhea
- Bronchodilation, Increase RR
- Urinary frequency.
no effect
Norepinephrine
- Constipation.
Urinary Tract
- Urinary Retention.
I. Cholinergic Agents
- Mestinon, Neostignin.
I. Adrenergic Agents
SE:
- Give Epinephrine.
- PNS effect
NEURO TRANSMITTER
Acethylcholine
Dopamine
Decrease
Myesthenia Gravis
Parkinsons Disease
Increase
Bi-polar Disorder
Schizophrenia
SE:
- SNS effect
Physical Examination
Contraindication:
- Contraindicated to patients
Neuro Check
1.
(Broncholitis, Bronchoectasis,
a.
Emphysema, Asthma).
- Atrophine Sulfate
b.
c.
d.
SE:
Agents
- SNS effect
stimulus
(ex.
Pressure
on
the
nailbeds,
- Propranolol, Atenelol,
Inappropriate: non-purposeful
Metoprolol.
e.
squeeze
Effect of Beta-blockers
response to stimulus)
B broncho spasm
E elicits a decrease in
myocardial contraction.
T treats hypertension.
cerebral hemisphere)
Infarction, Hypertension
midbrain, or pons)
2.
1. Beta-blockers lol
3. Calcium Antagonist
Nifedipine (Calcibloc)
Parasympathetic (Cholinergic)
Eye
Components
Effect
constrict
Gland of Head
no effect
stimulate secretions
Salivary
secretions
3.
Dry mouth
Heart
Eye opening
2.
Verbal response
3.
Motor response
pupil (miosis)
Lacrimal
1.
1.
Conscious
15 14
2.
Lethargy
13 11
3.
Stupor
10 8
4.
Coma
5.
Deep Coma
7
3
b.
c.
Blood Vessel
d.
no effect
bronchodilation
5.
Motor Function
a.
b.
Muscle strength
bronchoconstriction
5
a.
Cranial Nerves
c.
d.
1.
2.
3.
4.
Cranial Nerves
Olfactory
Optic
Oculomotor
Trochlear
Function
S
S
M
M
5.
6.
7.
8.
9.
10.
11.
12.
Trigeminal
Abducens
Facial
Acoustic
Glossopharengeal
Vagus
Spinal Accessory
Hypoglossal
(smallest)
B (largest)
M
B
S
B
B (longest)
M
M
Material Used
Neurologic Exam
1.
b.
LOC
c.
Intellectual
Procedure
Function:
memory
(recent
&
remote),
Abnormal Findings
1.
d.
Emotional status
2.
e.
Thought content
3.
f.
Language / speech
2.
plate of ethmoid bone where olfactory cells are located may indicate
3.
4.
a.
b.
Functions
1.
involuntary movements
Reflexes
a.
b.
Superficial
c.
2.
3.
Stupor
2.
Coma
Comatose
tracts
1.
4.
a.
Superiorly
b.
Bitemporaly
c.
Nasally
d.
Inferiorly
6 muscles:
2.
Orbital pressure
3.
4.
Superior Rectus
Superior Oblique
Lateral Rectus
Medial
Inferior Oblique
Inferior
Rectus
Test of Memory
1.
to temporal lobe
2.
limbic system
Level of Orientation
Oculomotor
1.
2.
3.
6
CRANIAL NERVE V: TRIGEMINAL
S/sx
4 As of Alzheimer
a.
b.
c.
objects.
d.
Douloureux
Brocas Aphasia
Common to Alzheimers
Wernikes Aphasia
is forcep delivery.
General
*Receptive aphasia
Knowing
Gnostic
Area
or
General
Interpretative Area.
CRANIAL NERVE VIII: ACOUSTIC, VESTIBULOCOCHLEAR
DOC
Cognex
Management
1.
cerebral hemisphere
(shoulder)
CRANIAL NERVE XII: HYPOGLOSSAL
Pathognomonic Signs:
1.
2.
3.
4.
5.
6.
7.
8.
9.
Ig M - acute in inflammation.
S/sx
1.
Visual disturbances
2.
Impaired sensation
pain).
20. TETANY hypocalcemia (+) trousseus sign or carpopedal
3.
4.
weakness
spasticity
paralysis
5.
scanning speech
ataxic gait
nystagmus
dysarthria
intentional tremor
6.
Bladder
DEMYELINATING DISORDERS
7.
Constipation
8.
Alzheimers disease
TRIAD SIGNS OF MS
acetylcholine.
Ataxia
CHARCOTS TRIAD
6
7
(unsteady gait,
a.
Nystagmus
Dx
CSF Analysis: increase in IgG and Protein.
2.
3.
4.
continuous
and
increase
b.
c.
Nursing Intervention
Assess the client for specific deficit related to location of
demyelination
2.
1.
Well-balance diet
Female
delayed
Lhermittes
1.
Positive
infection.
Intentional tremors
5.
Male
- urethra (20 cm, 8 inches)
- do not urinate after intercourse
b.
c.
necessary
3.
4.
5.
6.
7.
8.
9.
a.
b.
Yoga
Increase
fluid
intake
and
increase
fiber
to
Brain Herniation
prevent
constipation.
10. Maintain urinary elimination
1.
Urinary Retention
a.
b.
Nursing Management
2.
Urinary Incontinence
a.
b.
4.
CSF, Blood.
b.
c.
d.
nerve.
head trauma/injury
localized abscess
cerebral edema
hemorrhage
hydrocephalus
realistic goals.
tumor (rarely)
antibodies
13. Provide psychologic support to client/significant others.
b.
a.
banthine) if ordered
3.
S/sx
c.
d.
1.
(Early signs)
Decrease LOC
2.
Irritability / agitation
8
3.
(Late signs)
1.
e.
6.
7.
c.
a.
respiration)
Nursing Management
pressure.
Pupillary Changes
b.
c.
b.
d.
Motor Abnormalities
a.
c.
Nursing Management
b.
edema
herniation
abnormal posturing
cc/hr.
spinal cord).
d.
midbrain).
4.
Headache
5.
Projective Vomiting
6.
7.
c.
d.
Prevention
of
hypoxia
(decrease
O2)
and
e.
8.
Restlessness
Tachycardia
Agitation
Extreme restlessness
Bradycardia
Dyspnea
Cyanosis
measurement of ICP.
c.
a.
b.
c.
d.
b.
may be ordered
Hypercabia
stimulant) retention.
c.
b.
5.
4.
Nursing Intervention
3.
2.
1.
Avoid stooping/bending
b.
a.
3.
pressure)
d.
2.
client
c.
d.
e.
f.
9
10. Observe for hyperthermia secondary to hypothalamus
damage.
Spinach
Oranges
2. Hypocalcemia/Tetany
- decrease calcium level
- normal value is 8.5 11 mg/100 ml
- tingling sensation
dyspnea
- paresthesia
orthopnea
- numbness
productive cough
frothy salivation
Complications
cyanosis
- arrythmia
rales/crackles
- seizures
bronchial wheezing
Nursing Management
pulsus alternans
S3 (ventricular gallop)
RHD
Aging
Treatment
Morphine Sulfate
Aminophelline
Digoxin
Diuretics
Oxygen
Gases, blood monitor
RIGHT CONGESTIVE HEART FAILURE (venous congestion)
Signs and Symptoms
- jugular vein distention (neck)
- ascites
- pitting edema
- weight gain
- hepatosplenomegaly
- jaundice
Magnesium Sulfate
Magnesium Sulfate toxicity
S/S
BP
Urine output
DECREASE
Respiratory rate
Patellar relfex absent
3. Hyponatremia
- decrease sodium level
- normal value is 135 145 meq/L
Signs and Symptoms
- hypotension
- dehydration signs (initial sign in adult is thirst, in infant
tachycardia)
- agitation
- dry mucous membrane
- poor skin turgor
- weakness and fatigue
Nursing Management
- force fluids
- administer isotonic fluid solution as ordered
- pruritus
- esophageal varices
- anorexia and general body malaise
4. Hyperglycemia
- normal FBS is 80 100 mg/dl
Signs and Symptoms
- polyuria
- polydypsia
- polyphagia
Nursing Management
- monitor FBS
5. Hyperuricemia
- increase uric acid (purine metabolism)
- foods high in uric acid (sardines, organ meats and anchovies)
*Increase in tophi deposit leads to gouty arthritis.
Signs and Symptoms
FRUITS
VEGETABLE
Apple
S
Asparagus
Banana
Brocolli
Cantalop
Carrots
a. Narcotic Analgesic
Nursing Management
- force fluids
10
- Morphine Sulfate
a.
b. Allopurinol (Zylopril)
Side Effects
arrhythmias; dyskinesias.
muscular function
b.
Carbidopa-levodopa (Sinemet)
Pathophysiology
Anti-Cholinergic Drug
a.
ganglia
b.
Procyclidine (Kemadrine)
c.
Trihexyphenidyl (Artane)
Predisposing Factors
1.
2.
Arteriosclerosis
& rigidity
3.
Hypoxia
4.
Encephalitis
5.
Anti-Histamines Drug
a. Reserpine (Serpasil)
a.
b. Methyldopa (Aldomet)
Antihypertensive
c. Haloperidol (Haldol)
_______
Diphenhydramine (benadryl)
b.
Aloneness
Bromocriptine (Parlodel)
MOA:
stimulate
release
of
dopamine
in
the
substantia nigra
MAOI Inhibitor
Multiple loss
causes
suicide
a.
Eldepryl (Selegilene)
Loss of spouse
Loss
MOA:
inhibit
dopamine
breakdown
&
slow
progression of disease
of Job
Nursing Intervention for Suicide
Anti-Depressant Drug
a.
Tricyclic
2.
S/sx
1.
No scattered rugs
3.
4.
5.
Fatigue
6.
easier
3.
8.
9.
eyes.
7.
Assistive devices
4.
a.
excessive sweating
b.
increase lacrimation
c.
seborrhea
d.
constipation
6.
e.
7.
Nursing Intervention
1.
8.
10
11
9.
- hypoglycemia
self-concept
Tremors, tachycardia
Irritability
a.
Restlessness
b.
Extreme fatigue
c.
Diaphoresis, depression
d.
e.
walking
swimming
gardening
bedside.
MYASTHENIA GRAVIS (MG)
weakness.
Incidence rate:
for men.
Hydrazide
NORMAL RANGE
TOXICITY
INDICATION
Digoxin/Lanoxin
.5 1.5 meq/L
LEVEL
2
CHF
Cause:
Unknown/ idiopathic
(increase force of
cardiac output)
Lithium/Lithane
.6 1.2 meq/L
Bipolar
(decrease level of
Pathophysiology
Ach/NE/Serotonin)
Aminophelline
10 19 mg/100 ml
20
COPD
10 19 mg/100 ml
10 30 mg/100 ml
20
200
Seizures
Osteo
ol
Arthritis
1. Digitalis Toxicity
S/sx
1.
- confusion
- photophobia
2.
Diplopia
Antidote: Digibind
3.
Dysphagia
2. Lithium Toxicity
4.
5.
- anorexia
6.
arrest
7.
- hypothyroidism
Dx
Nursing Management
1.
- force fluids
3. Aminophelline Toxicity
- palpitations
- CNS excitement (tremors, irritability, agitation and restlessness)
3.
Nursing Management
serum.
Medical Management
crystals of precipitate.
1.
Drug Therapy
a.
- avoid caffeine
4. Dilantin Toxicity
junction.
- hairy tongue
- ataxia
twitching).
- nystagmus
b.
Corticosteroids: Prednisone
Nursing Management
- massage gums
2.
5. Acetaminophen Toxicity
Surgery (Thymectomy)
a.
b.
3.
11
12
a.
b.
therapy.
Nursing Interventions
1.
a.
b.
Causes:
c.
1.
Unknown / idiopathic
2.
d.
Predisposing Factors
depressant effects
1.
Immunization
2.
3.
S/sx
1.
a.
discomfort
2.
b.
3.
c.
d.
4.
5.
6.
muscles
7.
8.
9.
5.
MYASTHENIC CRISIS
Abrupt onset of severe, generalized
4.
Causes:
under medication
infection
Cause:
Medical Management
& rhythm
Signs and Symptoms
4.
PNS
5.
speak, breathe
Treatment
Treatment
therapy
Nursing Intervention
1.
a.
a.
b.
c.
b.
d.
c.
2.
3.
a.
b.
Swallowing ability
recovers.
c.
d.
Voice
d.
e.
4.
6.
a.
Vital signs
7.
b.
a.
c.
Neuro check
b.
d.
toxicity
e.
c.
d.
e.
f.
Tachycardia
g.
Arrhythmias
5.
6.
respiratory infection
2 hrs
f.
7.
g.
8.
h.
changes):
agencies
a.
Foot cradle
b.
Sheepskin
c.
Guided imagery
Guillain-Barre Syndrome
12
13
d.
9.
Relaxation techniques
3.
leakage to tissues.
a.
b.
c.
4.
b.
c.
prevent aspiration
1.
2.
Decrease glucose
3.
Atrophine Sulfate
4.
Lidocaine (Xylocaine)
CBC reveals
1.
Increase WBC
prevent increase of BP
Nursing Management
autoimmune anti-bodies)
a.
Arrythmia
b.
c.
2.
significant others
14. Refer for rehabilitation to regain strength & treat any
3.
Provide
nursing
care
for
increase
ICP,
seizure
4.
Meningitis
1.
2.
Pneumococcus
3.
6.
Keep room quiet & dark: if the client has headache &
photophobia
7.
8.
9.
b.
Mode of transmission
c.
mental retardation
Prevent complications
1.
2.
3.
&
residual deficits.
4.
consult audiologist
2.
Attack/Apoplexy/Cerebral Thrombosis)
3.
4.
5.
6.
7.
a.
8.
b.
a.
b.
Incidence Rate:
a.
d.
Causes:
a.
Thrombosis (attached)
b.
PS: Brudzinski sign (neck pain): flexion at the hip & knee
Dx
1.
Affects men more than women; Men are 2-3 times high
Hemorrhage
d.
Lumbar Puncture:
1.
2.
Unexplained dyspnea
3.
SOB
4.
Tachycardia
5.
Palpitations
6.
Diaphoresis
1.
7.
Mild restlessness
2.
3.
Headache
2.
disorientation
1.
3.
Confusion
2.
Force fluids
4.
Decrease LOC
13
14
1.
Vomiting
Seizure
Confusion
Disorientation
Decrease LOC
fat cells.
Nuchal Rigidity
Fever
Hypertension
Cheyne-Strokes Respiration
Risk Factors
Disease:
1.
Hypertension
2.
Diabetes Mellitus
3.
Atherosclerosis / Arteriosclerosis
4.
stroke
3.
Hemiplegia
Myocardial Infarction
5.
Sensory loss
6.
Aphasia
7.
8.
Lifestyle:
1.
Smoking
2.
Sedentary lifestyle
1.
3.
2.
4.
3.
5.
6.
Dx
cholesterol
Type A personality
a.
Deadline driven
b.
c.
milk
7.
8.
1.
1.
2.
Modifying Factors:
a.
Cerebral Edema:
2.
5.
b.
c.
2.
3.
c.
b.
Hemiparesis
a.
b.
Vertigo
c.
Aphasia
Dizziness
Tinnitus
7.
8.
b.
May last less than 30 sec, but no more than 24 hrs with
9.
b.
c.
Complete Stroke
Stroke in Evolution
b.
c.
affected side)
Stages of Development
a.
a.
1.
4.
Collateral Circulation:
Administer O2 inhalation
b.
3.
Vasospasm:
a.
impairment
b.
S/sx
1.
Headache
2.
Generalized Signs:
b.
Corticosteroids (Dexamethazone)
14
15
c.
attempts to speak
d.
7.
a.
b.
c.
8.
movement of washing)
treating TIAs
b.
PASA (Aspirin)
9.
f.
bleeding
Antihypertensive: if indicated for elevated BP
modifiable
risk
factors
(diet,
b.
exercise,
smoking)
b.
concerning
Avoid
Left Hemiplegia
Right Hemiplegia
d.
CONVULSIVE DISORDER/CONVULSION
a.
b.
c.
2.
3.
4.
Predisposing Factors
1.
2.
Genetics
3.
4.
d.
a.
Lead
e.
b.
Carbon monoxide
Susceptibility to hazard
5.
a.
6.
b.
7.
c.
b.
S/sx
c.
d.
e.
f.
1.
Generalized Seizure
a.
visual field
seizure
a.
b.
c.
sensory experience
6.
Tonic Phase:
May be incontinent
c.
b.
b.
a.
Expressive Aphasia
Clonic Phase:
repetitive movement
slowly tapers
15
16
a.
b.
Conjunctiva:
drowsiness
b.
2.
Blank stare
Twitching of mouth
nasal cavity
d.
a.
Outer Layer
a.
b.
2.
Middle Layer
a.
b.
c.
d.
propulsive behavior
environment
20-40 sec
eyelids
Inner Layer
a.
3.
Status Epilepticus
treatment
B.
C. Diagnostic Procedures
pressure
2.
Visual Pathways
a.
b.
tongue
2. Avoid precipitating stimulus such as bright/glaring lights and
c.
noise
d. Phenobarbital, Luminal
2 muscles of iris:
b. types of seizures
Physiology of vision
4 Physiological processes for vision to occur:
1.
2.
Accommodation of lens
3.
16
17
4.
Convergence of eyes
Dx
1.
2.
3.
Error of Refraction
1.
2.
3.
4.
4.
5.
1.
accommodation
Error:
b.
1.
2.
Esophoria:
corrected by
4.
humor
b.
Hereditary
3.
Hypertension
4.
Obesity
5.
Surgery
2.
Predisposing Factors
Common among 40 years old and above
40 is recommended
1.
Types of Glaucoma:
1.
3.
a.
b.
3.
Nursing Intervention
1.
2.
3.
4.
5.
6.
S/sx
1.
2.
3.
miotics (pilocarpine)
Surgery:
Drug Therapy:
a.
b.
d.
e.
N/V
Steamy cornea
Cataract
Predisposing Factor
1.
2.
3.
Related to congenital
17
18
4.
5.
Diabetes Mellitus
6.
6.
b.
c.
1.
a.
2.
b.
3.
c.
4.
d.
5.
to physician:
6.
Decrease vision
Diagnostic Procedure
Excessive drainage
Swelling of eyelid
1.
e.
Nursing Intervention
1.
d.
becomes familiar
Retinal Detachment
f.
2.
Predisposing Factors
1.
Trauma
2.
Aging process
3.
4.
Post-cataract extraction
5.
b.
Pathophysiology
S/sx
1.
2.
Flashes of light
3.
4.
Floaters
5.
b.
Dx
1.
1.
2.
c.
prevent vomiting
4.
anesthesia
c.
c.
c.
Restlessness
Increased pulse
b.
c.
2.
3.
4.
5.
18
19
Nursing Intervention Post-op
1.
Dx
a.
1.
b.
2.
dependent position
2.
3.
Topical mydriatics
b.
Analgesic as needed
Medical Management
1.
b.
c.
weeks
d.
e.
May watch TV
f.
g.
2.
External Ear
1.
2.
middle ear
Middle Ear
Ossicles
a.
6.
2.
Analgesic
Antibiotics
Anti-emetics
tympanic membrane
c.
(Bonamine)
1.
to tympanic membrane
3.
detachment
2.
a.
1.
7.
Wrinkle forehead
Close eyelids
sides of eardrum
Pain
Inner Ear
Headaches
1.
Vertigo
Cochlea
Controls hearing
8.
concerning:
a.
3.
Organ of balance
d.
4.
c.
Vestibular Apparatus
cerebrum)
2.
Menieres Disease
1.
inner ear
Cause
1.
Predisposing Factor
2.
Unknown / idiopathic
3.
Allergy
Cause
b.
Toxicity
1.
Unknown / idiopathic
c.
Localized ischemia
2.
d.
Hemorrhage
3.
e.
Viral infection
f.
Edema
S/sx
1.
2.
Tinnitus
S/sx
19
20
1.
2.
N/V
b.
3.
Tinnitus
4.
5.
Nystagmus
3.
Dx
4.
1.
2.
5.
1.
Medical Management
Acute:
2.
Hormone Function
Diazepam (Valium)
Endocrine G
Pituitary G
Chronic:
a.
Hormone
Anterior lobe
Functions
: TSH
: stimulate
Drug Therapy:
: ACTH
: stimulate adrenal
Diuretics
release
adrenocoticoids
(Valium)
b.
3.
Meclizine (antivert)
Diet:
: FSH, LH
maturation, & function of primary
unilateral)
b.
Lactation
Posterior lobe
: ADH
Or in response to an
increase in plasma
osmolality
To stimulate
reabsorption of H2O &
Nursing Intervention
1.
decrease urine
Output
Only move the client for essential care (bath may not be
essential)
3.
4.
5.
6.
7.
8.
b.
c.
: Oxytocin
1.
Release of milk in
lactation
Intermediate lobe
Adrenal Cortex
2.
: Mineralocorticoid
reabsoption
: increase
glyconeogenesis;
mobilization of fatty
: influence
Adrenal Medulla
: Epinephrine,
: function in acute
bronchioles;
: affects skin
Adrenal G
: MSH
pigmentation
: stimulate uterine
: regulates H2O
c.
: stimulate
: stimulate growth of
Surgery:
a.
: stimulate growth,
Needed by the
muscles for energy
Thyroid G
: T3, T4
: regulate metabolic
aid
in
20
21
Growth
&
1.
lowers
2.
development
: Thyrocalcitonin
: PTH
regulates
serum
Pancreas (islets of
Langerhans)
1.
Beta Cells
: Insulin
: allows glucose to
Converts glucose to
3 Zones/Layers
glycogen
Alpha Cells
: Glucagon
: increase blood
characteristics: Sex
: Estrogen, Progesterone
Female,
hormone): vasoconstrictor
maturation
2 Types of Catecholamines:
Epinephrine (vasoconstrictor)
Norepinephrine (vasoconstrictor)
pregnancy
: Testosterone
response to
2.
Testes
& glycogenolysis in
Ovaries
development
of
Male maturation of
beta-blockers
Thyroid Gland
thyrocalcitonin
b.
3.
Intermediate Lobe PG
Parathyroid Gland
Pancreas
Gonads
V/S
down reflex
c.
3 Hormones Secreted:
Pineal Gland
Secretes melatonin
Inhibits LH secretion
DI: dalas-ihi
21
22
Hyposecretion of ADH
3.
in deficiency of ADH
1.
2.
1.
2.
Predisposing Factor
1.
2.
Trauma
3.
Inflammation
4.
Presence of tumor
1.
S/sx
1.
2.
3.
Fatigue
4.
Muscle weakness
5.
Irritability
6.
Weight loss
7.
Hypotension
8.
Signs of dehydration
9.
a.
b.
Agitation
c.
d.
2.
b.
3.
4.
5.
6.
7.
Prevent complications
HYPOTHYROIDISM
- all are decrease except weight and menstruation
- memory impairment
Signs and Symptoms
- there is loss of appetite but there is weight gain
- menorrhagia
- cold intolerance
anuria)
- constipation
Dx
1.
2.
3.
HYPERTHYROIDISM
- all are increase except weight and menstruation
Signs and Symptoms
- increase appetite but there is weight loss
Nursing Intervention
1.
2.
3.
b.
Weigh daily
c.
Thyroid Disorder
Simple Goiter
b.
inflammation of neoplasm
dispersion
hormone
5.
- exophthalmos
hypovolemia
a.
4.
- amenorrhea
1.
common in the goiter belt area, areas where soil & H2O
a.
b.
b.
c.
Mountainous regions
2.
Sporadic: caused by
Predisposing Factors
1.
Head injury
2.
3.
Goitrogenic drugs:
a.
b.
S/sx
c.
Phenylbutazone
1.
d.
2.
e.
Lithium Carbonate
a.
Hypertension
f.
PASA (Aspirin)
b.
Edema
g.
Cobalt
c.
Weight gain
3.
22
23
S/sx
1.
2.
Dysphagia
3.
Respiratory distress
4.
Mild restlessness
Predisposing Factors
1.
Dx
2.
1.
2.
3.
surgery
4.
4.
Medical Management
1.
Drug Therapy:
3.
5.
Iodine deficiency
6.
7.
1.
Surgery:
2.
Anorexia
3.
atherosclerosis and MI
1.
4.
Constipation
Nursing Intervention
5.
Cold intolerance
6.
a.
7.
Spares hair
Iodine)
8.
Brittleness of nails
9.
b.
a.
Hypotension
b.
Bradycardia
c.
Bradypnea
d.
Hypothermia
Thyroid Hormones:
Levothyroxine (Synthroid)
Liothyronine (Cytomel)
Thyroid Extracts
2.
3.
2.
Insomnia
Hypertension
Heat intolerance
Seaweeds
14. Lethargy
15. Generalized interstitial non-pitting edema (Myxedema)
16. Hoarseness of voice
17. Decrease libido
18. Memory impairment
19. Psychosis
20. Menorrhagia
Dx
1.
2.
3.
1.
3.
4.
2.
Hypothyroidism (Myxedema)
Drug Therapy:
Levothyroxine (Synthroid)
Thyroglobulin (Proloid)
Dessicated thyroid
Liothyronine (Cytomel)
IV thyroid hormones
Correction of hypothermina
Nursing Intervention
1.
2.
to mental retardation
N/V
Diarrhea
Sweating
Tremors
Agitation
Dyspnea
23
24
3.
f.
Sweating
g.
Hyperactive movement
4.
10. Goiter
5.
12. Amenorrhea
ordered
6.
7.
8.
Dx
breakdown
1.
2.
3.
9.
a.
b.
Medical Management
1.
a.
Correct hypothermia
Myxedema coma:
Drug Therap:
case
Severe hypotension
Bradycardia
Bradypnea
Hypoventilation
Hyponatremia
Hypoglycemia
Hypothermia
b.
c.
3.
1.
1.
2.
2.
3.
3.
a.
Propylthiouracil (PTU)
b.
Methimazole (Tapazole)
b.
a.
4.
b.
5.
c.
6.
d.
7.
e.
f.
g.
8.
Hyperthyroidism
b.
Thyroid Storm
9.
Increase in T3 and T4
concerning:
a.
Predisposing Factors
1.
2.
drugs
b.
4.
Thyroid Storm
S/sx
1.
2.
Heat intolerance
3.
Weight loss
1.
Stress
4.
2.
Infection
5.
3.
Precipitating Factors
a.
Tachycardia
b.
Increase systolic BP
c.
Palpitation
1.
Apprehension
6.
2.
Restlessness
7.
3.
8.
Pliable nails
4.
Tahchycardia
9.
CNS involvement
5.
HF
a.
6.
Respiratory Distress
b.
Restlessness
7.
Delirium
c.
Tremors
8.
Coma
d.
Insomnia
e.
Hallucinations
S/sx
Nursing Intervention
24
25
1.
administer O2 as ordered
2.
3.
a.
Anti-thyroid drugs
b.
Corticosteroids
c.
Sedatives
d.
Cardiac Drugs
physician
15. Provide client teaching& discharge planning concerning:
Thyroidectomy
Indication:
Subtotal Thyroidectomy: hyperthyroidism
d.
e.
b.
Hypoparathyroidism
storm
3.
b.
c.
2.
1.
a.
Predisposing Factors
1.
May be hereditary
2.
Idiopathic
3.
pillow
4.
4.
S/sx
1.
a.
b.
Muscle spasm
c.
laryngospasm/broncospasm
d.
Dysphagia
e.
f.
g.
Numbness
h.
i.
6.
a.
b.
7.
TRIAD SIGNS
Fatigue
b.
Weakness
c.
Muscle cramps
d.
Personality changes
e.
Irritability
f.
Memory impairment
g.
Agitation
h.
i.
Hair loss
j.
k.
Tremors
l.
Cardiac arrhythmias
m. Cataract formation
Hyperthermia
Tachycardia
Photophobia
o.
Anorexia
p.
N/V
Anti Pyretics
Beta-blockers
8.
n.
Offer TSB
Diagnostic Procedures
1.
2.
3.
4.
b.
Nursing Management
1.
b.
Chronic Tetany:
25
26
1.
Pathologic fracture
2.
3.
4.
5.
Diet (Calcidiol)
6.
Sunlight (Calcitriol)
absorption of calcium
Drug
1.
2.
3.
ANTACID
Nursing Intervention
A.A.C
1.
MAD
2.
Aluminum
Magnesium
Containing
3.
Containing
Antacids
Antacids
4.
5.
6.
Aluminum
Hydroxide
7.
Gel
8.
9.
(Demerol)
2.
3.
4.
5.
6.
noise
concerning:
a.
b.
c.
of laryngospasm
d.
e.
f.
9.
Addisons Disease
b.
c.
1.
d.
Prevent complications
e.
Predisposing Factors
autoimmune process
Hyperparathyroidism
Kidney stones
Predisposing Factors
1.
2.
3.
Children: Ricketts
b.
Adults: Osteomalacia
c.
d.
Malabsorption syndrome
S/sx
1.
2.
3.
4.
5.
6.
7.
Decrease libido
8.
9.
1.
2.
Dx
S/sx
26
27
3.
k.
meq/L)
4.
1.
Addisonian Crisis
b.
Predisposing Factors
1.
Strenuous activity
2.
Stress
3.
Trauma
4.
Infection
5.
6.
Iatrogenic:
Mineralocorticoids:
diurnal rhythm
2.
3.
S/sx
Hypertension
1.
Edema
2.
Severe hypotension
Hirsutism
3.
4.
coma
2.
Monitor V/S
3.
4.
5.
6.
Weight daily
7.
Nursing Intervention
&
discharge
a.
b.
d.
e.
Diet modification
f.
i.
j.
7.
8.
9.
Cushing Syndrome
sweating
h.
5.
need to be adjusted
g.
Force fluids
stressful stimuli
planning
concerning:
c.
4.
6.
antibiotics as ordered
10. Provide
2.
3.
9.
1.
2.
periods
weather
glucocorticoids
3.
4.
steroids
5.
hypovolemic shock
1.
Muscle weakness
2.
Fatigue
3.
15. Osteoporosis
4.
Muscle wasting
5.
Irritability
17. Hypertension
6.
Depression
18. Edema
7.
19. Hypernatremia
8.
Moon face
9.
Buffalo hump
21. Hypokalemia
22. Constipation
12. Acne
24. Hirsutis
Dx
Nursing Intervention
1.
FBS: is increased
1.
2.
a.
3.
b.
Assist in ambulation
4.
2.
27
28
3.
4.
HYPERGLYCEMIA
b.
necessary
5.
6.
7.
Glycosuria
Polyuria
Cellular starvation: weight loss
dehydration
Vitamin D
9.
Cellular
as ordered
10. Provide psychological support & acceptance
(Hypothalamus)
Polydypsia
concerning:
a.
Diet modification
b.
c.
d.
f.
Cholesterol
Hypertension
Acetone
Diabetic
Keto Acidosis
characterized by hyperglycemia
Atherosclerosis
Breath
Kussmauls Respiration
odor
MI
CVA
blood vessels
Death
Diabetic Coma
Pathophysiology
Classification Of DM
1.
production
Non-obese adults
Incidence Rate
1.
CNS depressants & can cause coma = Excess loss of F & E leads to
hypovolemia, hypotension, renal failure & decease blood flow to the
brain resulting in coma & death unless treated.
Predisposing Factors
1.
Autoimmune response
2.
MAIN FOODSTUFF
1. CHO
ANABOLISM
Glucose
CATABOLISM
Glycogen
3.
Related to viruses
2. CHON
Amino Acids
Nitrogen
4.
3. Fats
Fatty Acids
5.
: cholesterol
S/sx
: ketones
1.
Polyuria
7.
Anorexia
2.
Polydipsia
8.
N/V
3.
Polyphagia
9.
Blurring of vision
4.
Glucosuria
5.
Weight loss
6.
Fatigue
b.
Dx
1.
FBS:
a.
2.
3.
elevated
4.
28
29
S/sx
1.
Usually asymptomatic
1.
Insulin therapy
Medical Management
2.
Polyuria
2.
Exercise
3.
Polydypsia
3.
Diet:
4.
Polyphagia
a.
5.
Glycosuria
b.
6.
Drug therapy:
7.
Fatigue
a.
8.
Blurred Vision
9.
4.
Insulin:
long-acting insulins
5.
FBS:
c.
confirms DM
6.
7.
8.
1.
2.
3.
4.
resistance
Synonym
Duration
Appearance
Onset
b.
Peak
5.
Compatible Mixed
Rapid Acting
Insulin Injection Regular Ins
Clear
-1
2-4
6-8
Drug therapy:
a.
b.
except lente
Insulin, Zinc
Semilente Ins
16
Lente prep
Cloudy
-1
4-6
126.
suspension,
prompt
Intermediate Acting
Isophane Ins
NPH Ins
24
Regular Ins
Cloudy
1-1
8-12
Onset
Oral Sulfonylureas
Acetohexamide (Dymelor)
Chlorpropamide (Diabinase)
24
4-6
12-
24
injection
Lente Ins
Duration
Comments
18-
injection
Insulin Zinc
Peak
Cloudy
1-1
8-12
18-
4-6
40-60
2-8
10-24
Oral Biguanides
Suspension
Metformin (Glucophage)
semilente prep
16
2-2.5
10-
:Decrease glucose
Long Acting
Insulin Zinc
Ultralente Ins
36
Cloudy
4-8
16-20
30-
production in liver
:Decrease intestinal
suspension,
semilente prep
extended
Complication
1.
2.
Acarbose (Precose)
Unknown
Unknown
Incidence Rate
1.
Miglitol (Glyset)
Troglitazone (Rezulin)
2-3
Rapid
2-3
Unknown
Genetics
2.
insulin
:Potetiates action of insulin
in skeletal muscle &
29
30
decrease glucose
production in liver
Complications
1.
Nursing Intervention
1.
b.
specimen)
4.
f.
6.
7.
8.
General care
c.
d.
e.
accordingly:
b.
kidneys
Kidney Disease
sugar
Recurrent Pyelonephritis
Notify physician
Diabetic Nephropathy
Ocular Disorder
Premature Cataracts
Diabetic Retinopathy
h.
Peripheral Neuropathy
Foot care
Wash foot with mild soap & water & pat dry
concerning:
a.
Disease process
b.
Diet
shoes in gradually
Never go barefoot
i.
Insulin
Exercise
vigorous exercise
Complication
tissue)
simple sugars
Injection technique
k.
demonstration
d.
acidosis
30
31
Predisposing Factors
5.
Hyperglycemia
6.
1.
Undiagnosed DM
2.
Neglect to treatment
3.
Infection
4.
cardiovascular disorder
1.
Polyuria
2.
Polydipsia
3.
Polyphagia
4.
Glucosuria
5.
Weight loss
6.
Anorexia
7.
N/V
15. Hypotension
8.
Abdominal pain
16. Tachycardia
9.
factor
S/sx
tachypnea
b.
Dx
1.
FBS: is increased
2.
3.
a.
dehydration
b.
4.
c.
5.
6.
dehydration
7.
8.
9.
6.
7.
8.
5.
alkalosis
Nursing Intervention
1.
2.
3.
a.
1.
Undiagnosed diabetes
2.
5% dextrose to IV
3.
4.
Dialysis
is adequate
5.
Hyperalimentation
6.
Major burns
7.
Pancreatic disease
b.
4.
Predisposing Factors
S/sx
1.
Polyuria
2.
Polydipsia
3.
Polyphagia
12. Hypotension
4.
Glucosuria
13. Tachycardia
5.
Weight loss
6.
Anorexia
15. Restlessness
7.
N/V
8.
Abdominal pain
9.
1.
2.
3.
4.
5.
b.
c.
5.
Nursing Intervention
6.
1.
7.
2.
8.
3.
9.
a.
b.
31
32
a.
hormones
products.
b.
c.
HEMATOLOGICAL SYSTEM
1.
I. Blood
III. Blood Forming Organs
Liver
55% Plasma
Thymus
(Fluid)
Spleen
45% Formed
cellular elements
1. Arteries
1.
2. Veins
2.
3. Capillaries
3.
Erythrocytes (RBC)
a.
b.
c.
d.
portion is CHON
4.
Lymphoid Organ
Serum
Lymph Nodes
Plasma CHON
5.
(formed in liver)
6.
e.
Production
1. Albumin
2. Globulins
3. Prothrombin and Fibrinogen
erythrocytes
f.
Hemolysis (Destruction)
cells
All blood cells start as stem cells in the bone marrow; these
Components:
1.
Erythrocytes
2.
Leukocytes
3.
Thrombocytes
in bile
1.
Red Marrow
2.
Yellow Marrow
Blood
Hematocrit
1.
2.
Bone Marrow
Bone Marrow
i.
a.
Folic acid
b.
Iron
Distribution
c.
Vitamin c
1.
d.
a.
400 ml arterial
e.
Vitamin b6 (Pyridoxine)
b.
60 ml capillary
f.
Intrinsic factor
c.
840 ml venous
2.
2.
Leukocytes (WBC)
a.
550 ml arterial
a.
b.
300 ml capillary
b.
c.
2150 ml venous
Plasma
Granulocytes:
Polymorphonuclear Neutrophils
60 70% of WBC
inflammation
-
neutrophils:
polymorphonuclear
leukocytes
Albumin
-
Immature
neutrophils:
band
cells
(bacterial
volume
band cells)
2.
Mature
Serum Globulins
Polymorphonuclear Basophils
-
32
33
-
Responsible
for
the
release
of
chemical
c.
Involved
in
prevention
of
clotting
in
Polymorphonuclear Eosinophils
Type
Causes
Mechanism
Occurrence
Antibodies in
Acute:
S/sx
Intervention
d.
Hemolytic
Non Granulocytes
Headache,
Macrophage in blood
Largest WBC
lumbar or
continue saline IV
Rh
react w/ antigen
completion
sternal pain,
first 5 min
after
of transfusion
diarrhea, fever,
client blood
Use of dextrose
Agglutinated cell
solutions;
reticuloendothelial system
b.
Stop transfusion.
Monocytes:
ABO
Wide temp
blood flow to
restlessness,
hemoglobinuria.
fluctuation
organs.
anemia, jaundice,
cells)
Watch for
days to 2
weeks after
Treat or prevent
Hemolysis (Hgb
Lymphocytes
dyspnea, signs
B-cell
T-cell
- bone marrow
- thymus
and anti-tumor property
for immunity
shock, renal
of
renal shutdown
urine)
shutdown, DIC
HIV
c.
Thrombocytes (Platelets)
Type
Causes
Occurrence
Immune
Within 30 min
S/sx
Intervention
Allergic
Transfer of an
Uticaria, larygeal
antigen &
edema, wheezing
Stop transfusion.
sensitivity to
start of
Administer
antihistamine &
donor to
CHON
transfusion
bronchospasm, or epinephrine.
Mechanism
recipient;
headache,
dengue virus
Treat
Allergic donor
anaphylaxis
life-threatening
Petechiae
2.
Echhymosis
3.
Blood Groups
reaction
_____________________________________________________________________
__________________
Pyrogenic
Fever, chills,
flushing,
palpitation,
agglutination
bacterial
min
after
initiation
of
Transfuse with
directed against
tachycardia,
Within 15-90
Treat temp.
antibodies
Leukocytes
Stop transfusion.
possesses
Recipient
organism
transfusion
leukocytes-poor
WBC; bacterial
1.
ABO Typing
occasional
b.
c.
Multitransfused
d.
Administer
respectively
client;
e.
antibiotics prn
f.
multiparous
contamination;
lumbar pain
blood of washed
a.
RBC.
client
Rh Typing
_____________________________________________________________________
a.
__________________
Rh -)
Circulatory
b.
Too rapid
Dyspnea,
Overload
transfusion
Fluid volume
overload
increase BP,
Susceptible
tachycardia,
instead of whole
33
34
Client
orthopnea,
blood.
cyanosis, anxiety
1.
2.
hro
3.
ug
4.
Monitor CVP
t
ha
separate line.
_____________________________________________________________________
__________________
Air Embolism
Blood given
Dyspnea,
Bolus of air
Anytime
Spleen
Clamp tubing.
under air
blocks pulmonary
artery outflow
left side
following severe
pain, decrease BP,
blood loss
apprehension
_____________________________________________________________________
__________________ThromboWhen large
cytopenia
Used of large
Abnormal
amount of
bleeding
b.
Platelets
deteriorate
& antigens
amount
of
blood
given
over
blood
precautions.
_____________________________________________________________________
__________________
Large amount
Citrate binds
After large
Neuromascular Monitor/treat
of citrated blood
irritability
Intoxication
rapidly in stored
Initiate bleeding
Citrate
of bleeding.
banked blood
24 hr
ionic calcium
amount of
hypocalcemia.
in client with
Bleeding due to
banked
blood
Avoid large
Liver
decrease liver
decrease calcium
amounts of
function
citrated blood.
_____________________________________________________________________
__________________
Hyperkalemia
Blood Tranfusion
Nausea, colic,
Purpose
Administer blood
increase in
diarrhea, muscle
stored blood
spasm, ECG
In client with
1.
2.
3.
plasma with
insufficiency
provision of proteins
4.
with impaired
5.
peaked T-waves,
potassium
Blood & Blood Products
short Q-T
excretion
1.
seg
ments)
Blood Coagulation
a.
2.
b.
b.
Extrinsic System:
a.
c.
protein)
3.
34
35
a.
g.
Cytrate intoxication
b.
h.
minutes to thaw
c.
5.
Platelets
1.
2.
Dyspnea
3.
Diarrhea / Constipation
a.
b.
4.
Hypotension
c.
5.
Flushed skin
6.
7.
6.
Nursing Management
Granulocytes
1.
Stop BT
a.
2.
Notify physician
3.
4.
b.
acetaminophen
c.
5.
6.
Obtain urine & blood sample & send to laboratory for re-
examination
7.
Fever
2.
Dyspnea
3.
Broncial wheezing
4.
Skin rashes
5.
Urticaria
6.
Goals / Objectives
1.
2.
3.
1.
Stop BT
4.
2.
Notify physician
3.
4.
2.
3.
4.
5.
Nursing Management
Proper refrigeration
a.
a.
b.
Epinephrine
5.
a.
6.
Obtain urine & blood sample & send to laboratory for re-
b.
c.
examination
7.
Filter set
b.
1.
c.
2.
Headache
hemolysis
3.
Tachycardia
4.
Palpitations
a.
Client name
5.
Diaphoresis
b.
6.
Dyspnea
c.
Expiration date
d.
Serial number
Nursing Management
1.
Stop BT
2.
Notify physician
contamination
3.
a.
4.
b.
c.
a.
Antipyretic
b.
Antibiotic
5.
6.
Obtain urine & blood sample & send to laboratory for re-
examination
7.
8.
Render TSB
prevent hemolysis
1.
Orthopnea
2.
Dyspnea
3.
4.
Exertional discomfort
Nursing Management
a.
Hemolytic reaction
1.
Stop BT
b.
Allergic reaction
2.
Notify physician
c.
Pyrogenic reaction
3.
d.
Circulatory overload
e.
Air embolism
f.
Thrombocytopenia
a.
Nursing Care
35
36
1.
3.
4.
5.
Dyspnea
catheter in place
6.
Palpitations
3.
7.
4.
2.
6.
7.
8.
9.
(koilonychias)
8.
Stomatitis
PLUMBER
VINSONS SYNDROME
b.
9.
Dysphagia
b.
1.
c.
2.
RBC: is decreased
d.
3.
Hgb: decreased
e.
4.
f.
5.
g.
6.
7.
8.
Dx
b.
c.
d.
e.
Signature of transfusionist
Nursing Intervention
1.
2.
3.
HIV
4.
a.
Organ meat
- ELISA
b.
Egg yolk
c.
Raisin
d.
Sweet potatoes
e.
Dried fruits
1. Kaposis Sarcoma
f.
Legumes
g.
Nuts
5.
Blood Disorder
6.
Ferrous Sulfate
Ferrous Fumarate
Ferrous Gluconate
Incidence Rate
1.
2.
3.
(blood-sucking parasites)
absorption
cause constipation
Predisposing Factors
1.
Trauma
b.
Heavy menstruation
c.
b.
3.
iron preparation
a.
Chronic diarrhea
b.
c.
d.
e.
Pica
S/sx
1.
2.
36
37
3.
4.
Lymphadenitis
5.
6.
GIT S/sx:
Headache
Urticaria
Pruritus
Hypotension
Skin rashes
Anaphylactic shock
7.
Mouth sore
b.
c.
Indigestion / dyspepsia
d.
Weight loss
e.
Constipation / diarrhea
f.
Jaundice
CNS S/sx:
a.
Tingling sensation
b.
Numbness
Lugols Solution
c.
Iron
d.
Paralysis
Tetracycline
e.
Depression
Nitrofurantoin (Macrodentin)
f.
Psychosis
g.
7.
8.
9.
a.
resulting to ataxia
a.
Anorexia
b.
N/V
c.
Abdominal pain
1.
d.
Diarrhea / constipation
2.
e.
Melena
Dx
3.
4.
a.
5.
Bone Marrow:
b.
Sorbitex (IM)
a.
b.
c.
6.
taken
Pernicious Anemia
intrinsic factor
b.
c.
d.
acid secretion)
urine if it os absorbed
e.
resuls if untreated
f.
Pathophysiology
1.
7.
8.
3.
Medical Management
1.
Drug Therapy:
a.
b.
STOMACH
Pareital cells/Argentaffin or Oxyntic cells
Folic Acid
Controversial
2.
3.
Hereditary factors
4.
5.
Autoimmune
6.
1.
Anemia
2.
2.
Transfusion Therapy
Nursing Intervention
Predisposing Factors
1.
3.
No side effects
4.
5.
37
38
6.
7.
a.
7.
b.
8.
concerning:
a.
Dietery instruction
b.
c.
risk:
b.
9.
bone marrow
a.
d.
Fever
e.
Cough
a.
PANCYTOPENIA
Decrease RBC
Decrease Platelet
(anemia)
c.
b.
Decrease WBC
(leukopenia)
c.
d.
(thrombocytopenia)
ecchymoses
10. Provide client teaching & discharge planning
Predisposing Factors
concerning:
1.
a.
Self-care regimen
2.
b.
3.
Immunologic injury
4.
Drugs:
a.
b.
Phenylbutazones (NSAIDS)
and fibrinogen
S/sx
1.
2.
Anemia
a.
b.
c.
d.
Leukopenia
a.
3.
Thrombocytopenia
Pathophysiology
1.
a.
b.
Ecchymosis
c.
2.
Dx
1.
3.
2.
4.
thrombocytopenia
3.
1.
2.
Massive burns
3.
Massive trauma
2.
4.
Anaphylaxis
3.
5.
Septecemia
4.
Drug Therapy:
6.
a.
7.
Pregnancy
1.
b.
S/sx
1.
Nursing Intervention
1.
2.
3.
Administer O2 inhalation
4.
Hemoptysis
4.
Enforce CBR
5.
5.
6.
6.
3.
Dx
38
39
1.
PT: prolonged
2.
3.
4.
5.
6.
7.
8.
9.
2.
3.
Epicardium
Somewhat controversial
b.
Outer layer
Myocardium
Endocardium
Inner layer
Papillary Muscle
Heparin administration
a.
Chordae Tendinae
2.
3.
4.
Atria
and GIT
sinus
a.
Avoid IM injection
b.
c.
d.
6.
7.
Force fluids
8.
9.
a.
Vitamin K
b.
c.
Ventricles
Valves
Atrioventricular Valve
hypovolemic shock)
tandinae
aspirin-containing compounds
Heart
Semi-lunar Valve
Function
Pemit unidirectional flow of the blood from specific ventricle
to arterial vessel during ventricular diastole
from friction
Aortic Valve
Pulmonary Valve
2 layers of pericardium
39
40
Hypertension
Coronary Circulation
Coronary Arteries
Branch off at the base of the aorta & supply blood to the
myocardium & the conduction system
Coronary Veins
Vascular System
Arteries
Conduction System
Arterioles
atrium
Capilliaries
The following exchanges occurs in the capilliaries
Delays the impulse from the atria while the ventricles fill
Venules
O2 & CO2
Bundle of His
branch system
heart.
interventricular myocardium
Purkinje Fibers
Cardiac Disorders
Coronary Arterial Disease / Ischemic Heart Disease
Stages of Development of Coronary Artery Disease
1.
2.
3.
ATHEROSCLEROSIS
ATHEROSCLEROSIS
Narrowing of artery
ARTERIOSCLEROSIS
Hardening of artery
contraction
Tunica intima
deposits
Tunica media
Predisposing Factors
SA NODE
AV NODE
BUNDLE OF HIS
JLJLJLJJLJLJL
PURKINJE FIBERS
1.
Sex: male
2.
Race: black
3.
Smoking
4.
Obesity
5.
Hyperlipidemia
6.
Sedentary lifestyle
7.
Diabetes Mellitus
8.
Hypothyroidism
9.
S/sx
1.
Chest pain
2.
Dyspnea
3.
Tachycardia
4.
Palpitations
5.
Diaphoresis
Treatment
P - Percutaneous
T - Transluminal
C - Coronary
A Angioplasty
40
41
1.
C - Coronary
A - Arterial
B - Bypass
A - And
G - Graft
S - Surgery
Objectives
1.
Revascularize myocardium
2.
To prevent angina
3.
4.
5.
2.
3.
4.
Nursing Intervention
1.
2.
3.
3 Complications of CABG
1.
2.
Shock
3.
Thrombophlebitis
Give 3rd & last dose of NTG: if pain still persist at 3-5
minutes interval
Angina Pectoris
1.
ischemia
Predisposing Factors
Orthostatic hypotension
1.
Sex: male
2.
Race: black
3.
Smoking
4.
Obesity
5.
Hyperlipidemia
6.
Sedentary lifestyle
7.
Diabetes Mellitus
8.
Hypertension
9.
CAD: Atherosclerosis
effect
2.
12. Aortic Insufficiency: heart valve that fails to open & close
efficiently
b.
13. Hypothyroidism
14. Diet: increased saturated fats
15. Type A personality
c.
Beta-blockers
ACE Inhibitors
Precipitating Factors
d.
4 Es of Angina Pectoris
Enalapril
Calcium Antagonist
Nefedipine
1.
2.
4.
3.
5.
strong emotions
6.
4.
S/sx
1.
2.
8.
Levines Sign: initial sign that shows the hand clutching the
Avoidance of 4 Es
chest
effect of drug
nitroglycerine (NTG)
3.
Dyspnea
4.
Tachycardia
5.
Palpitations
6.
Diaphoresis
imagery
Dx
1.
2.
9.
4.
5.
Myocardial Infarction
Medical Management
41
42
1.
fibrosis
Heart attack
Types
1.
artery
2.
2.
3.
workload
4.
5.
(PVC)
6.
Predisposing Factors
7.
1.
Sex: male
8.
2.
Race: black
3.
Smoking
4.
Obesity
5.
CAD: Atherosclerotic
6.
Thrombus Formation
7.
Genetic Predisposition
8.
Hyperlipidemia
9.
Sedentary lifestyle
b.
S/sx
1.
Chest pain
c.
d.
e.
f.
crushing
2.
N/V
3.
Dyspnea
4.
g.
Anti Coagulant
Heparin
5.
6.
7.
Antidote: Vitamin K
8.
Occasional findings:
Split S1 & S2
S4 or atrial gallop
Caumadin (Warfarin)
Time (PT)
h.
Dx
1.
Cardiac Enzymes
CPK-MB: elevated
b.
c.
of caffeine
d.
2.
3.
e.
f.
Prevent Complication
ST segment elevation
T wave inversion
arrhythmia in MI
contraction
4.
Stroke / CVA
5.
Nursing Intervention
42
43
g.
h.
6.
program
failure
7.
Dyspnea
Weakness
Fatigue
Persistent palpitation
Light headedness
Predisposing Factors
1.
2.
3.
4.
Pulmonary embolism
5.
Related to COPD
j.
6.
k.
7.
up care
S/sx
Congestive Heart Failure
1.
Anorexia
2.
Nausea
3.
Weight gain
4.
circulation
5.
Pitting edema
6.
Bounding pulse
7.
Hepatomegaly / Slenomegaly
8.
Cool extremities
2.
9.
Ascites
3.
High-Output Failure
10. Jaundice
11. Pruritus
12. Esophageal varices
Dx
1.
2.
streptococcus
2.
Myocardial Infarction
3.
4.
Hypertension
5.
Nursing Intervention:
S/sx
1.
Dyspnea
2.
3.
4.
Tiredness
5.
Muscle Weakness
6.
7.
Tachycardia
8.
Frothy salivation
9.
Cyanosis
10. Pallor
11. Rales / Crackles
3.
4.
5.
Medical Management
1.
2.
3.
4.
5.
M Morphine SO4
A Aminophylline
D Digitalis
D Diuretics
O O2
G Gases
Dx
1.
Nursing Intervention
2.
3.
4.
5.
1.
status
a.
b.
c.
Monitor ABG
43
44
d.
2.
3.
a.
b.
1.
c.
2.
d.
4.
Trophic changes
5.
c.
Monitor V/S
Dx
volume
2.
b.
Daily weight
c.
d.
e.
f.
g.
h.
i.
3.
Medical Management
1.
Drug Therapy
a.
Papaverine
Cyclandelate (Cyclospasmol)
Failure only
a.
b.
c.
2.
Bronchodilators: Aminophylline IV
b.
Endarterectomy
c.
d.
e.
2.
Analgesics
Vasodilators
Anti-coagulants
3.
d.
e.
Prevent complications
f.
Surgery
c.
c.
Bypass Grafting
b.
a.
a.
b.
7.
b.
d.
3.
6.
S/sx
give
5.
a.
4.
2.
Arrythmia
Shock
MI
Thrombophlebitis
4.
5.
6.
7.
Raynauds Phenomenon
1.
High risk group: female between the teenage years & age
40 years old & above
Arterial Ulcer
1.
2.
Raynauds Phenomenon
Venous Ulcer
2.
Smoking
3.
Collagen diseases
4.
a.
b.
Rheumatoid Arthritis
1.
Varicose Veins
a.
Piano playing
2.
b.
Excessive typing
c.
Operating chainsaw
Predisposing Factors
1.
S/sx
1.
Coldness
2.
Numbness
3.
4.
5.
44
45
6.
1.
2.
7.
Dx
Thrombophlebitis (Deep vein thrombosis)
Medical Management
1.
b.
Reserpine
popliteal
Vasodilators
Nursing Intervention
Predisposing Factors
1.
1.
Obesity
2.
2.
Smoking
3.
3.
Related to pregnancy
4.
Severe anemia
5.
6.
Prolonged immobility
7.
Trauma
Varicose Veins
8.
Dehydration
9.
Sepsis
return
S/sx
Predisposing Factors
1.
2.
1.
Hereditary
2.
3.
Thrombophlebitis
4.
Cardiac disorder
Swelling
5.
Pregnancy
6.
Obesity
7.
S/sx
1.
2.
3.
Warm to touch
4.
Heaviness in legs
Dx
1.
Venography
2.
1.
3.
seconds
Doppler Ultrasound: decreased or no blood flow heard after
Medical Management
1.
Anti-coagulant therapy
a.
Heparin
Spontaneous bleeding
Ecchymoses
Cyanosis
Thrombocytopenia
2.
3.
4.
5.
6.
Side effects:
Nursing Intervention
1.
Cyanosis
Dx
2.
3.
Deep vein:
b.
Warfarin (Coumadin)
Side effects:
GI:
a.
b.
Anorexia
N/V
Diarrhea
Stomatitis
Hypersensitivity:
Dermatitis
Urticaria
Pruritus
45
46
2.
Other:
Unexplained dyspnea
Tachycardia
Palpitations
Bleeding complication
Diaphoresis
Restlessness
Fever
Surgery
a.
b.
iliofemoral region
c.
Nursing Intervention
1.
Nose
2.
3.
a.
1.
Heparin
2.
3.
filtering air.
4.
Pharynx
1.
2.
3.
iliac crest
2.
contains the palatine tonsils; air & food enter the body
through oropharynx
3.
Warfarin (Coumadin)
Larynx
1.
airways
2.
3.
4.
4.
5.
6.
7.
b.
c.
d.
5.
Glottis
1.
Opening of larynx
2.
3.
4.
Trachea
AKA Windpipe
Air move from the pharynx to larynx to trachea (length 1113 cm, diameter 1.5-2.5 cm in adult)
feet
drug-drug interaction)
INR of 2
e.
Drug regimen
f.
rings
lying down
Site of tracheostomy
g.
h.
Pulmonary Embolism
Bronchi
46
47
Pulmonary Circulation
alveolar air
Pneumonia
Lungs
Right lung (consist of 3 lobes, 10 segments)
Etiologic Agents
1.
3.
Diplococcus Pneumoniae
4.
Klebsella Pneumoniae
5.
Escherichia Pneumoniae
6.
Pseudomonas
Pleura
Parietal Pleura
1.
the parietal pleura & visceral pleura) this fluid holds the
2.
Elderly
Predisposing Factors
1. Smoking
2. Air pollution
Chest Wall
3. Immuno compromised
S/sx
Diaphragm
Alveoli
3.
Nasal flaring
4.
5.
6.
7.
8.
9.
alveolar epithelium
12. Anorexia
Surfactant
2.
11. Chills
10. Fever
directly from alveolar ducts & are responsible for about 35%
1.
peristalsis)
Dx
1.
Alveolar Ducts
2.
Alveolar Sac
3.
4.
Secretes surfactant
Nursing Intervention
1.
47
48
Histoplasmosis
2.
Monitor ABG
General hydration
birds manure
expectoration
S/sx
promote expectoration
3.
4.
5.
6.
7.
8.
1.
2.
Productive cough
3.
4.
5.
Dyspnea
6.
Cyanosis
7.
Hemoptysis
8.
Sometimes asymptomatic
1.
2.
3.
Dx
Medical Management
1.
Penicillin
Tetracycline
Microlides (Zethromax)
Nursing Intervention
staphylococcal pneumonia
1.
2.
Enforce CBR
Monitor temperature A
3.
4.
a.
prophylactically
a.
esophageal reflux
Creatinine, Hypokalemia
b.
5.
c.
6.
d.
7.
procedure
8.
e.
f.
g.
Contraindicated with
Unstable V/S
Hemoptysis
places
Chronic Obstructive Pulmonary Disease (COPD)
Chronic Bronchitis
Increase ICP
IOP 12 21 mmHg)
9.
a.
b.
c.
Availability of vaccines
e.
Chills
Increased pain
Difficulty in breathing
Weight loss
Persistent fatigue
f.
Avoid smoking
g.
Prevent complications
h.
Atelectasis
Meningitis
Predisposing Factors
1.
Smoking
2.
Air pollution
S/sx
1.
2.
Dyspnea on exertion
3.
4.
5.
6.
Slight Cyanosis
7.
8.
Ankle edema
9.
48
49
11. Pulmonary hypertension
a.
b.
6.
7.
Dx
a.
b.
Prevent complications
Emphysema
Bronchial Asthma
DOC: Epinephrine
Steroids
Bronchodilators
c.
d.
Bronchiectasis
Causes
Pollen
Dust
Fumes
1.
Smoke
2.
Gases
3.
Chest trauma
Danders
4.
Furs
5.
Lints
6.
1.
Predisposing Factors
Sx
Causes
Hereditary
2.
Dyspnea in exertion
3.
Cyanosis
4.
5.
6.
Wheezing
7.
Weight loss
1.
2.
3.
humidity
3.
S/sx
1.
2.
Dyspnea
3.
Wheezing on expiration
4.
Cyanosis
5.
6.
Tachycardia, palpitations
7.
Diaphoresis
Dx
1.
2.
3.
Dx
2.
3.
1.
2.
3.
4.
Medical Management
1.
Surgery
Medical Management
1.
2.
affected side
Drug Therapy
a.
bronchodilator
c.
Emphysema
d.
Mucolytics / expectorants
e.
Anti histamine
2.
Physical Therapy
3.
Hyposensitization
4.
Execise
Nursing Intervention
1.
Enforce CBR
Inelasticity of alveoli
2.
Air trapping
distress
Maldistribution of gases
3.
4.
5.
49
50
Predisposing Factors
6.
1.
Smoking
2.
expansion
3.
7.
4.
8.
5.
minerals
9.
S/sx
1.
Productive cough
2.
Sputum production
3.
4.
Weight loss
5.
6.
7.
Dyspnea at rest
8.
9.
immediately
b.
Control of environment
prevent bronchospasm
c.
d.
mechanism)
Dx
1.
2.
capacity
breathing
Panlobular/centrilobular
Prevent complications
Decrease ph
Atelectasis
Increase PCO2
Respiratory acidosis
Panacinar/centriacinar
f.
Decrease PCO2
g.
Increase ph
Respiratory alkalosis
Oncology Nursing
Pathophysiology & Etiology of Cancer
Nursing Intervention
1.
Enforce CBR
2.
3.
a.
b.
Aminophylline
Isoproterenol (Isuprel)
Terbutalin (Brethine)
Metaproterenol (Alupent)
Theophylline
Isoetharine (Bronkosol)
d.
4.
5.
Prednisone
Tetracycline
Ampicilline
cancer process.
b.
c.
d.
Mucolytics / expectorants
a.
Corticosteroids:
c.
Improve ventilation
a.
b.
c.
& growth.
e.
Rate of Growth
50
51
8.
P.E. with lab work up: every 3 years ages 20-40; yearly
for age 40 & over
Pre-disposing Factors
Testicular Cancer
i.
G Genetics
Painless swelling
ii.
Feeling of heaviness
iii.
iv.
v.
V Viral
o
Viruses
HTLV-I,
Epstein
Barr
Virus,
vii.
Enlargement
or
tenderness
the
environmental carcinogens
Types:
I: indigestion or dysphagia
of
breasts
E Environmental
o
vi.
Human
i.
I Immunologic
Physical
Treatment of Cancer
Therapeutic Modality
Chemical
dyes,
alkylating
Chemotherapy
agents
Drugs:
arsenicals,
stilbestol,
urethane
Cigarette smoke
hormones
Classification of Cancer
Tissue Typing:
Ability of the drug to kill cancer cells; normal cells may also
2.
1.
Antimetabolites
o
2.
Alkylating Agent
o
3.
Plant Alkaloids
A. Staging System:
4.
Antitumor Antibiotics
o
extent of tumors
o
5.
Stages
A. GI System
1.
2.
Normal
Administer antidiarrheals.
Definitely cancer
Client Factors
1.
2.
3.
4.
Hazards of smoking
5.
6.
7.
Diarrhea
51
52
o
o
after meal.
effects.
cracked lips.
breakdown products.
provide moisture.
Types of Energy Emitted
B. Hematologic System
Beta
Thrombocytopenia
particle
cannot
passed
through
skin,
more
or X-ray)
Methods of Delivery
Leukopenia
time.
o
1000/mm
o
Administer O2 if needed
Alopecia
o
treatment
D. Renal System
2.
agent
Advice client to obtain wig before initiating
1.
decreases.
Anemia
C. Integumentary System
Wash affected areas with plain H2O & pat dry; avoid soap.
allopurinol
E. Reproductive System
chemotherapy
F. Neurologic System
Avoid injury.
Radiation Therapy
C. Diarrhea
It not only injured cell membrane but destroy & alter DNA so
that the cell cannot reproduce.
52
53
Burns
Functions of Muscles
Maintain posture
Type:
1.
Thermal
2.
Smoke Inhalation
3.
Chemical
4.
Electrical
Types of Muscles
Classification
Partial Thickness
1.
Sensation: painful
1.
Cartilage
pressure, no vesicles
2.
2.
3.
4.
Functions
hard
1.
2.
ligaments, bursae
Bones
jaw.
Function of Bones
(hematopoiesis)
1.
Types of Bones
1.
2.
3.
Genetic factors
4.
Long Bones
Predisposing factors
1.
Short Bones
2.
Fatigue
3.
Cold
4.
Emotional stress
5.
Infection
Flat Bones
S/sx
Irregular Bones
Joints
1.
Fatigue
2.
3.
Weight loss
4.
5.
movements
Classification
6.
7.
8.
1.
2.
problems.
3.
Muscles
Dx
1.
2.
3.
ESR: elevated
4.
5.
6.
53
54
Medical Management
1.
Drug therapy
a.
a.
b.
b.
independence
c.
c.
prostaglandins.
d.
Ibuprofen (Motrin)
e.
Indomethacin (Indocin)
f.
Fenoprofen (Nalfon)
g.
h.
Phenylbutazone (Butazolidin)
i.
Piroxicam (Feldene)
Naproxen (Naprosyn)
Sulindac (Clinoril)
Osteoarthritis
Aurothioglucose (Solganal)
1.
2.
Incident Rate
Proteinuria
Mouth ulcers
Skin rash
Aplastic anemia.
Predisposing Factors
1.
on joints)
Obesity
3.
Joint trauma
S/sx
Auranofin (Ridaura)
1.
monitored.
2.
Diarrhea
3.
Corticosteroids
2.
d.
e.
Dx
1.
2.
Cytoxan
2.
3.
Nursing Interventions
1.
2.
2.
3.
4.
6.
c.
d.
e.
b.
c.
b.
c.
Rest & support inflamed joints: if splints used: remove 12 times/day for gentle ROM exercises.
5.
b.
a.
lying.
4.
standing.
a.
b.
c.
d.
e.
f.
b.
5.
6.
a.
b.
c.
d.
e.
f.
7.
a.
b.
Gout
acute episodes.
8.
9.
joints
strengths.
54
55
Incident Rate
2.
Fever
1.
3.
Anorexia
2.
Familial tendency
4.
Weight loss
5.
Malaise
6.
S/sx
1.
Joint pain
7.
Joint pain
2.
Redness
8.
Morning stiffness
3.
Heat
9.
Skin lesions
4.
Swelling
5.
6.
Headache
7.
Malaise
8.
Anorexia
11. Alopecia
9.
Tachycardia
10. Fever
Proteinuria
11. Tophi in outer ear, hands & feet (chronic tophaceous stage)
Hematuria
Renal failure
Dx
1.
Medical Management
1.
Drug therapy
a.
b.
Acute attack:
Naproxen (Naprosyn)
Phenylbutazone (Butazolidin)
Prevention of attacks
Probenecid (Benemid)
Sulfinpyrazone (Anturanel)
2.
3.
4.
Peripheral neuritis
Seizures
Psychosis
Pericarditis
Pleurisy
ESR: elevated
2.
3.
4.
5.
Anti-DNA: positive
6.
Medical Management
1.
Nursing Interventions
Drug therapy
a.
1.
2.
3.
4.
5.
conservative therapy
6.
Azathioprine (Imuran)
7.
Cyclophosphamide (Cytoxan)
8.
b.
c.
d.
e.
f.
& arthritis
b.
2.
3.
2.
Immune
3.
2.
3.
4.
5.
6.
b.
c.
d.
e.
f.
g.
Pathophysiology
1.
1.
Predisposing Factors
Cause unknown
Nursing Interventions
1.
of circulating antibodies.
Incident Rate
1.
h.
i.
j.
Fatigue
S/sx
1.
Osteomyelitis
55
56
destruction.
S/sx
1.
Malaise
2.
Fever
3.
4.
5.
6.
duodenum
1.
2.
3.
2.
3.
5.
Fundus
Body
Antrum
Gastric Secretions:
Pepsinogen: secreted by the chief cells located in the
fundus aid in CHON digestion
Nursing Interventions
Administer analgesics & antibiotics as ordered.
1.
Dx
7.
digestion
cartilage
Leg amputation
Small Intestines
FRACTURES
A.
General information
1.
Structural Features:
B. Medical management
C. Assessment findings
D. Nursing interventions
Large Intestine
Esophagus
Rectum
Anus
Stomach
Feces (solid waste): leave the body via rectum & anus
Stores & mixes food with gastric juices & mucus producing
a.
b.
Transverse
c.
Descending colon
d.
Sigmoid
e.
Rectum
nd
56
57
Accessory Organ
Liver
pancreatic enzymes
Salivary Glands
hepatic cells
2. Sublingual
3. Submaxillary
Function:
Production of bile
hormones
Doudenal Ulcer
Salivary gland
Verniform appendix
Liver
Pancreas: auto digestion
Gallbladder: storage of bile
Predisposing factor
Biliary System
ducts)
Emotional Stress
Drugs:
Salicylates (Aspirin)
Steroids
intestines
Butazolidin
S/sx
Gastric Ulcer
Duodenal Ulcer
Site
Pancreas
Pain
Antrum or lesser
Left
Gaseous &
Not usually
Hypersecretion
Initiate in the mouth where the food mixes with saliva &
Vomiting
Hemorrhage
Weight
Complications
relieved by
relieved by
food &
Normal gastric
12 MN 3am
pain
Increased
secretion
Not common
Melena
Weight gain
Perforation
Hemorrhage
60 years old
20 years old
High Risk
Common
Hematemeis
Weight loss
Stomach
gastric acid
cause
Usually
antacid
Cramping &
burning
acid secretion
Mid
epigastrium
burning
epigastrium
after eating
which extends along the gland & enters the duodenum via
curvature
30 min-1 hr
Duodenal bulb
Dx
gastric cancer
Medical Management
1.
Supportive:
Rest
Bland diet
Stress management
Drug Therapy:
57
58
1.
2.
3.
secretion
4.
Magnesium
containing Antacids
Ex. Aluminum OH gel (Amphojel)
SE: Constipation
SE: Diarrhea
b.
SE: fever
Histamines (H2) receptor antagonist: inhibits gastric
Ranitidine (Zantac): has some antibacterial action
against H. pylori
Cimetidine (Tagamet)
Famotidine (Pepcid)
c.
Proper Diet
Eat slowly
Relaxation techniques
Exercise
Biofeedback
Dumping syndrome
Appears 15-20 min after meal & last for 20-60 min
ulcer
Weakness
Helicobacter Pylori
2.
Faintness
Surgery:
3.
Feeling of fullness
Gastric Resection
4.
Dizziness
5.
Diaphoresis
6.
Diarrhea
7.
Palpitations
Billroth I
(Gastroduodenostomy)
Billroth II (Gastrojejunostomy)
Removal of -3/4 of
Nursing Intervention
1.
2.
3.
4.
Removal of of
stomach &
& anastomostoses of
anastomoses of gastric
Cholecystitis / Cholelithiasis
stump to the
duodenum.
Nursing Intervention Post op
2.
1.
3.
Anticholinergic:
for antacids
Maalox
Medical Regimen
Administer medication
Analgesic
Antibiotic
Antiemetics
3.
4.
5.
Complications:
Peritonitis
Hypokalemia
Thromobphlebitis
Pernicious anemia
Cholecystitis:
Cholelithiasis:
Predisposing Factor:
1.
2.
3.
Obesity
4.
Sedentary lifestyle
5.
Hyperlipidemia
6.
Neoplasm
S/sx:
1.
Nursing Intervention
2.
58
59
3.
Anorexia
3.
4.
N/V
4.
5.
Jaundice
5.
6.
Pruritus
6.
7.
Easy bruising
8.
9.
Steatorrhea
Medical Management
1.
Drug Therapy
Dx
1.
2.
3.
WBC: increase
4.
Amylase: increase
5.
Lipase: increase
6.
2.
3.
Drug Therapy
Papaverine Hcl
Atrophine SO4
pain
Medical Management
Supportive Treatment: NPO with NGT & IV fluids
Sphincter of Oddi
presence of stones
1.
Nitroglycerine (NTG)
2.
Diet Modification
3.
NPO (usually)
4.
Peritoneal Lavage
5.
Dialysis
emetic properties
4.
Nursing Intervention
1.
2.
3.
4.
Nursing Intervention
1.
2.
3.
Complication of TPN
Infection
Pancreatitis
Embolism
Hyperglycemia
4.
like position
5.
digestion
Predisposing factors:
1.
Chronic alcoholism
2.
Hepatobilary disease
3.
Trauma
4.
Viral infection
5.
Continued N/V
6.
Abscesses
7.
Obesity
8.
Hyperlipidemia
9.
Hyperparathyroidism
temperature (2 day)
S/Sx:
1.
Severe left upper epigastric pain radiates from back & flank
area: aggravated by eating with DOB
2.
N/V
3.
Tachycardia
4.
5.
Dyspepsia: indigestion
6.
7.
8.
Apendicitis
9.
Hypocalcemia
1.
Microbial infection
2.
Dx
2.
3.
Intestinal obstruction
59
60
S/Sx:
1.
2.
disease
3.
N/V
4.
5.
Changes in moods
6.
Dx
Gynecomastia
1.
2.
Amenorrhea in female
Jaundice
Pruritus or urticaria
3.
Easy bruising
Medical Management
Palmar erythema
Muscle atrophy
Nursing Intervention
1.
2.
3.
Skin prep
NPO
4.
5.
2.
3.
Administer Meds:
Dx
Liver enzymes: increase
SGPT (ALT)
SGOT (AST)
LDH Alkaline Phosphate
Serum cholesterol & ammonia: increase
Indirect bilirubin: increase
CBC: pancytopenia
PT: prolonged
Hepatic Ultrasonogram: fat necrosis of liver lobules
Nursing Intervention
CBR with bathroom privileges
Encourage gradual, progressive, increasing activity with
planned rest period
Institute measure to relieve pruritus
Do not use soap & detergent
Bathe with tepid water followed by application of emollient
lotion
Provide cool, light, non-constrictive clothing
4.
5.
6.
Liver Cirrhosis
Chronic progressive disease characterized by inflammation,
fibrosis & degeneration of the liver parenchymal cell
Destroyed liver cell are replaced by scar tissue, resulting in
architectural changes & malfunction of the liver
Lost of architectural design of liver leading to fat necrosis &
scarring
Types
Biliary Cirrhosis
Associated with biliary obstruction usually in the common bile
duct
Results in chronic impairment of bile excretion
S/sx
Nursing Intervention
N/V
Dyspepsia: Indigestion
Weight loss
Flatulence
Peripheral edema
Hepatomegaly: pain located in the right upper quadrant
Atrophy of the liver
Nursing Intervention
Administer meds:
60
61
Vit K
Nursing Intervention
the body
20 cm
Function of kidneys
Kidneys remove nitrogenous waste & regulates F & E
GUT includes the kidneys, ureters, urinary bladder, urethra & the
Glomerular Filtration
Kidneys
Renal Parenchyma
Cortex
Outermost layer
Tubular Function
Middle layer
Papillae
glands
pyramids
Calices
80% of F & E
H2O
Glucose
Amino acids
Nephron
Bicarbonate
Organic substance
Waste
Loop of Henli
Reabsorb the ff:
Renal Tubule
Divided into proximal convoluted tubule, descending
Hydrogen ions
Ammonia
H2O
Bicarbonate
Ureters
Ca
Phosphate concentration
Collecting Ducts
Received urine from distal convoluted tubules & reabsorb H2O
(regulated by ADH)
61
62
Regulation of BP
Nursing Intervention
Monitor & assess urine for gross odor, hematuria & sediments
Acid Ash Diet: cranberry, vit C: OJ: to acidify urine & prevent
bacterial multiplication
Administer Medication as ordered:
Systemic Antibiotics
Ampicillin
Cephalosporin
is for reabsorption)
Aminoglycosides
Sulfonamides
Co-trimaxazole (Bactrim)
Regulation of BP:
Gantrism (Gantanol)
Antibacterial
Predisposing factor:
Nitrofurantoin (Macrodantin)
Activation of RAAS
juxtaglomerular apparatus
Importance of Hydration
Void after sex: to avoid stagnation
Angiotensin II vasoconstrictor
Adrenal cortex
increase CO
increase PR
Aldosterone
Complications: Pyelonephritis
Pyelonephritis
Increase BP
Increase Na &
H2O reabsorption
abscess formation
Acute: infection usually ascends from lower urinary tract
Hypervolemia
Color
amber
Odor
aromatic
Consistency
pH
4.5 8
Predisposing factor:
Microbial invasion
E. Coli
Streptococcus
(-)
Albumin
(-)
E coli
Pregnancy
(-)
DM
CYSTITIS
Fever
Chills
Predisposing factors:
N/V
Anorexia
Obstruction
Urinary retention
Nocturia
Dsyuria
Sexual intercourse
Hematuria
Burning sensation on urination
S/Sx:
Pain: flank area
disease
Bladder irritability
Dysuria
Hematuria
Chronic Fatigue
Nocturia
Weight loss
Fever
Polyuria
Chills
Polydypsia
Anorexia
HPN
Dx
Medical Management
Urine culture & sensitivity: (+) to E. coli
62
63
Antibiotics
Antispasmodic
pulverization
Chronic
Antibiotics
Nursing Intervention
Urinary Antiseptics
Nitrofurantoin (macrodantin)
Strain urine using gauze pad: to detect stones & crush all cloths
GI irritation
Hemolytic anemia
Staining of teeth
relieve pain
Dx
Calcium Stones
Nursing Intervention
Take vitamin C
Oxalate Stone
Monitor I & O
Force fluid
urine
deterioration
Nephrolithiasis / Urolithiasis
Calcium
Oxalate
Uric acid
Mobility
Voiding whenever the urge is felt & at least twice during night
Calcium
Oxalate
Uric Acid
Milk
Cabbage
Anchovies
Cranberries
Organ meat
Nuts tea
Nuts
Chocolates
Sardines
Predisposing factors:
urinary retention
Immobility
Kidney stones
Sedentary lifestyle
Renal failure
Hyperparathyroidism
Predisposing factor:
S/sx
High risk: 50 years old & above & 60-70 (3-4x at risk)
Renal colic
Cool moist skin (shock)
S/sx
Hematuria
Nocturia
Anorexia
N/V
rectal exam
Decrease force & amount of urinary stream
Dx
Dysuria
Intravenous Pyelography (IVP): identifies site of obstruction &
Hematuria
Terminal bubbling
Backache
Sciatica: severe pain in the lower back & down the back
CHON
Dx
Medical Management
Surgery
Percutaneous Nephrostomy:
Tube is inserted through skin & underlying tissue into renal
pelvis to remove calculi
Percutaneous Nephrostolithotomy
calculus
Nursing Intervention
63
64
Prostate message: promotes evacuation of prostatic
fluid
Provide catheterization
S/sx
easier to urinate
Hyponatremia
Hypokalemia
Hypovolemia
Dx
Nursing Intervention
Nursing Intervention
clients urine
Measure I&O every hour: note excessive losses
Administer IV F&E supplements as ordered
Weight daily
imbalance as needed
(N 125 ml/min)
Causes
ordered
Monitor ECG
Check urine serum osmolality / osmolarity & urine
Cardiogenic shock
Acute vasoconstriction
Septicemia
Hypovolemia
flow to kidneys
Pulmonary Embolism
Skin breakdown
Hypotension
Contractures
CHF
Atelectesis
Hemorrhage
Dehydration
Endocarditis
DM
Tumors
Pyelonephritis
Malignant HPN
Acute Glomerulonephritis
Hypercalemia
Tumors
Stricture
Blood cloths
Urolithiasis
Predisposing factors:
BPH
DM
Anatomic malformation
HPN
Recurrent UTI/ nephritis
S/sx
Stages of CRF
Hypernatremia
Hyperkalemia
Hyperphosphotemia
2. Renal Insufficiency
Hypermagnesemia
Hypocalcemia
Metabolic acidosis
Dx
S/Sx:
64
65
N/V
Diarrhea / constipation
Paresthesias
Dyspnea
Muscle cramps
Stomatitis
Seizures
Hypotension (early)
Abnormal reflex
Hypertension (late)
Lethargy
Convulsion
Memory impairment
in plain water
HF
Urinary System
Polyuria
Avoid IM injections
Metabolic Disturbance
Nocturia
Monitor BP
& Creatinine)
Hematuria
Hyperglycemia
Dysuria
Hyperinsulinemia
Oliguria
CNS
GIT
Headache
N/V
Lethargy
Stomatitis
Disorientation
Uremic breath
Restlessness
Diarrhea /
Memory impairment
Respiratory
kidneys)
Kassmauls resp
Normocytic anemia
Decrease cough
Bleeding tendencies
reflex
Fluid & Electrolytes
constipation
Hematological
N/V
HPN
Leg cramps
Disorientation
Paresthes
Integumentary
Hyperkalemia
Enforce CBR
Itchiness /
Hypernatermia
pruritus
Hypermagnese
Uremic frost
mia
4. Meds:
Hyperposphate
mia
Hypocalcemia
Metabolic
acidosis
5. Assist in hemodialysis
Platelets: decrease
Ca: decrease
blood exam
Strict aseptic technique
Medical Management
Diet restriction
B bleeding
Multivitamins
E embolism
Hematinics
D disequilibrium syndrome
S septicemia
Antihypertensive
Nursing Intervention
Prevent neurologic complication
Monitor for signs of uremia
Fatigue
Loss of appetite
Disorientation
Paresthesia
Apathy
Confusion
Elevated BP
Edema of face & feet
Itchy skin
Restlessness
patent shunt!
Seizures
embolism.
7. Complication
- Peritonitis
- Shock
8. Assist in surgery:
Renal transplantation : Complication rejection.
Reverse isolation
65
66
66