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Q: How to prevent STD?

A: Monogomous relationship
Test taking strategies:
1. Process of elimination:
2 correct answers, 2 incorrect answers
Q: For 1st/2nd/3rd/4th degree burns, nursing priority?
A: #1 INFECTION
#2 Dependent on the type of burn
1st & 2nd degree = PAIN
3rd & 4th degree = FLUID & ELECTROLYTE

DEEPENING OF VOICE late to develop in men


Puberty start at age=9 for both
Q: Most appropriate food for a toddler (active, playful)
A: Spaghetti
X-hotdog, X-grapes = both have skin can cause CHOKING
X-milk = #1 cause of Iron deficiency

*Best/Most Important/Priority = IMMEDIATELY RELIEVE S/Sx


Airway
Breathing
Circulation
Safety
First/Initial Nursing Action:
Assess
Obtain base line data
Check
Q: Normal physical finding of thyroid gland (anterior of the neck,
only 1 gland with 2 lobes)
A: Nodular Consistency
X-palpable upon swallowing = if client has GOITER, and the only part
that can be palpated on the neck is the Thyroid cartilage (Adams apple)
= Men & women have Adams apple but men are more prominent
because of MORE FAT PADS, women has more fat pads on the BREAST
& HIPS
X-Tenderness, X-Marked asymmetry
THELARCHE breast enlargement 1st to develop in women
MENARCHE late to develop in women
ADRENARCHE pubic, auxillary hair development
TESTICULAR, PENILE ENLARGEMENT 1st to develop in men

NERVOUS SYSTEM
A. 3 DIVISIONS OF N/S
1. CNS
a. Brain
b. Spinal Cord H-shaped structure
2. Peripheral N/S (12 pairs of Cranial nerves)
I Olfactory
II Optic
III Occulomotor
IV Trochlear smallest CN
V Trigeminal largest CN
VI Abducen
VII Facial
VIII Acoustic
IX- Glossalpharyngeal
X Vagus longest CN
XI Spinal
XII Hypoglossal
3. Autonomic N/S
a. Symphatetic N/S
b. Parasymphatetic N/S
SYMPHATETIC (SNS)
FIGHT or Aggression Response
NOREPINEPHRINE @ Adrenal
Medulla
Adrenalins
VASOCONSTRICTOR
All bodily activities except
GIT - Constipation
ADRENERGIC or
Parasympatholytic response
When under STRESS,blood flows
to 3 important organs:

PARASYMPHATETIC (PNS)
FLIGHT or withdrawal response
ACETHYLCHOLINE
neurotransmitter
[ Acethylcholine = Bipolar
Disorder = Lithium
Acethylcholine = M.Gravies]
All bodily activities except
GIT - Diarrhea
CHOLINERGIC or Vagal or
Sympathetic response

#1 Brain - cerebration = to
think
#2 Heart propel blood to
systemic circulation
#3 Skeletal muscles
GIT = least important organ
blood flow
motility
CONSTIPATION
SYMPHATETIC (SNS)
Bodily
1. Eyes DILATES
Mydriasis aware of surroundings
2. Mouth DRY
salivation
3. Heart - HR BP
4. Lungs
BRONCHODILATION
- O2 because under stress
- RR
5. GIT CONSTIPATION
6. Urinary system
- URINARY RETENTION

PARASYMPHATETIC (PNS)
effects
- CONSTRICTS
Meiosis
- MOIST
salivation
- HR BP
- BRONCHOCONSTRICTION
- O2
- RR
- DIARRHEA
- URINARY FREQUENCY

Correlation to clinical nursing practice:


SYMPHATETIC (SNS)
PARASYMPHATETIC (PNS)
I. Adrenergic Agents
I. Cholinergic or Sympatholytic
a. Epinephrine, Adrenalins
Agents
SE: SNS All except GI
a. Beta-adrenergic blocking agents
or beta-blockers LOL
- can not prevent
- expectant effect of drug
PropranoLOL
AtenoLOL
- you can lessen/minimize
MetropoLOL
II. Antipsychotic Agents
a. Haloperidol
Effects:
b. Anti-depressants/Tricylic
> Bronchoconstiction/spasm
Mono Amine Oxidase Inhibitors
> Ellicits myocardial contraction
> 2-4 weeks effects
> Treats hypertension
ex. PARnate
> AV conductor slows down antiMARplan
arrythmic, mild arrhythmic
NARdil

c. Anti-anxiety Valium Diazepam

Indications: Angina pectoris/MI


to BP HR
SYMPHATETIC (SNS)

III. Anti-hypertension
1. Beta-blockers LOL
2. ACE Inhibitors PRIL ending ex: CaptoPRIL EnalaPRIL
3. Ca antagonist ex: Nifedipine
IV. Mestinon (Prostigmine)
nice to know:
COPD
1. Bronchitis
2. Asthma
3. Bronchiectasis
4. Emphysema

- Blue bloaters,
- Allergens, Hereditary
- Pink puffer, barrel chest

CENTRAL NERVOUS SYSTEM


A. Cells = Neurons = nerve impulse/conduction
Excitability affected to the external changes in the
environment
Conductivity transmits away of excitation to one cell to another
Permanent cells once destroyed, not capable of regeneration
Types of Cells:
According to regenerative cells:
1. LABILE
capable of regenerate
2. STABLE
3. PERMANENT

capable of regeneration
with limited survival time
period
once destroyed, can not
regenerate

Location
GUT, GIT, epidermal,
respiratory cells
Kidney, Liver, Pancreas,
Salivary gland-parotid
gland
Osteocytes, retina cells,
neurons, cardiac cells

nice to know:
For shallow wound, scar suggest to give Vitamin C precursor
collagen, aid in wound healing
For stab wound apply direct pressure to stabbed area using clean
cloth -> use CTT
For artificial eyes -> dry N/R: use eye drops q30mins

Parotid gland = located below and in front of ear


Medulla Oblongata = respiratory center
Frontal lobe = motor/speech head
Sceaman creases on foot normal
Artificial eyes = dry = use eye drops q 30 mins
when bladder constricts = individual urinates
plegia
hemiplegia
quadriplegia/tetraplegia
monoplegia
paraplegia

paralysis
L/R paralysis
4 limbs paralysis
1 limb paralysis
low extremities, with urinary & bowel
incontinence -> relaxed bladder ->atony
bladder -> urine retention N/R: assist in
catheterization
There is no upper extremities paralysis
B. Neuroglia = acts as support and protection of neurons
majority of brain tumors arises from Neuroglia
1. Types:
a. ASTROCYTES outer surface, 90% astrocytoma -> brain
tumor
o maintains the integrity of the blood brain barrier
o semi-permeable membrane
o selective toxic substances can enter:
1) Ammonia = cerebral toxin, 1st toxic substance in the
brain
Ammonia

hepatic encephalopathy (end stage)

liver cirrhosis (necrosis of the liver)


Primary cause: Malnutrition-Vit B1 Thiamine def.
Major cause: Alcoholism
Early sign of Hepatic encephalopathy:
1. Asterixis flapping hand tremors
Late signs:
1. Headache

4) Lead poisoning 4th toxic substance, Parkinsons


disease; Seizure activity. ANTIDOTE : Calcium EDTA

2. Confusion
3. Fetor hepaticus
4. LOC leads to hepatic coma

5) Ketone CNS depressant = by product of fat catabolism


Diabetic Ketoacidosis [DKA] DM I-IDDM early sign:

weight loss
fat catabolism
headache

free fatty acid

Cholesterol
Ketones

Atherosclerosis DKA -> Diabetic coma -> Death


HPN

Late sign: fruity


Kaussmauls respiration deep
Acetone
rapid, shallow, breathing pattern
Breath odor

Liver

converts ammonia

Urea

Urine
2) Bilirubin 2nd toxic substance yellow pigment irritant
to neurons
Bilirubin

Jaundice=icteric sclerae

Hyperbilirubenemia/Kernicterus

Irreversible Brain Damage


nice to know:
Biliverdin green pigment
Hemoglobin red pigment
Hemosiderin golden brown pigment
Sclerae white normal
Jaundice if yellow skin, discololoration & icteric sclerae
CAROTENEMIA = tumor in the pituitary gland if yellow skin but
NORMAL eyes
HEPATITIS B = from serum most dangerous, may lead to liver cancer,
liver cirrhosis, AIDS
HEPA I = from infectious hepa
HEPA A = from fecal-oral route
3) Carbon monoxide 3rd toxic substance, detaches hgb
from the oxygen; face = pinkish in color; Parkinsons
disease

b. MICROGLIA = stationary cells Phagocytosis cell eating;


engulfing of bacteria or cellular debris
nice to know:
ORGAN
BRAIN
BLOOD
KIDNEYS
LUNGS
SKIN subcutaneous tissues
c.

1.
2.
3.
4.
5.

MACROPHAGES
Microglia
Monocytes largest WBC
Kupffer macrophages
Alveolar macrophages
Histocytes

EPYNDEMAL CELLS secretes a glue-like substance that


concentrates bacteria = chemoattractants
Meninges
Microglia (2)
Epyndemal cells
(1)

defense of CNS

Bacteria

d. OLIGONDENDROCYTES produces myelin sheath covers


neurons/fibers; acts as insulator facilitates nerve
impulses/conduction
Pathognomonic Signs:
Asterixis flapping hand tremors
Pill rolling tremors
Intentional tremor
Low grade fever afternoon
Rusty sputum > needs penicillin
Barrel chest
Wheezing on expiration
Pseudo membrane
Koplick spots
Chills with step-ladder fever 38-39-40-41oC
Petechiae
Rose spots on abdomen
Rice-watery stool, diarrhea = BRAToast
Rebound tenderness (+), flex right leg,
palpate R iliac inguinal then remove
immediately
(+) Cullens sign bluish discoloration
umbilicus and (+) Gray-turner ecchymosis
of flank area
(+) Cullens sign and (+) Homans sign feet
dorsiflex with pain
(+) Kernigs - leg pain, and (+) Brudzenski
sign neck pain
(+) chevosteks sign face spastic; (+)
Trouseus sign carpopedal spasm
Lock -jaw, sardonic smile,
Exopthalmus
Butterfly rashes
Jaundice
Spider angiomas
Lions face
Chipmunk face, over eating, pinge & purge;
acid of stomach goes to mouth teeth
cavities

Disease:
Hepatic Encephalopathy
Parkinsons Disease
Multiple Sclerosis
PTB
Pneumonia
Emphysema
Asthma
Diphtheria
Measles
Malaria
Dengue
Typhoid fever
Cholera
Appendicitis
Pancreatitis
OB Ectopic pregnancy
Meningitis
Hypocalcemia
Tetany, tetanus
Hyperthyroidism
Hepatitis
Liver cirrhosis
Leprosy
Bulimia nervosa

Bronze like skin pigementation


Buffalo humps, moon faced
Red beefy tongue
Strawberry tongue
Protrusion of tongue; Sceaman creases on
palm
Machine-like murmur, acyanotic
Cyanotic, clubbing of fingrs
Hypoxemia with cyanosis
(+) Levines sign = Hand clutching of chest
emote
day light vision
hazy vision

Addisons disease
Cushing syndrome
Pernicious anemia
Kawasaki syndrome
Down syndrome
Patent ductus arteriosis
Tetralogy of Fallot
Tet spells
Angina pectoris
Retinal detachment
Glaucoma
Cataract

DEMYELINATING DISORDERS: Palliative for s/sx, can not cure


1. ALZHEIMERS DISEASE = atrophy (shrinkage of an organ) of
brain tissue
mnesia partial/total loss of memory
gnosia failure to familiarize
praxia failure to do the purpose of the object ex.combused to brush teeth
phasia expressive &/or receptive
RICEPT OR COGNEX given best @ bedtime
nice to know:
ANTEROGRADE
RETROGRADE
EXPRESSIVE APHASIA Broccas
RECEPTIVE APHASIA Wernickes

short memory loss


long term memory loss
inability to speak;
FRONTAL = motor speech center
inability to understand;
TEMPORAL = general
interpretative area

2. MULTIPLE SCLEROSIS = chronic intermittent disorder of the


CNS, characterized by: WHITE PATCHES of demyelinization in
the brain and spinal cord; remission & exacerbation
A. Incidence Rate: women 13-25 y.o.
B. Predisposing Factors:

1. Idopathic unknown cause


2. Viruses
3. Autoimmune self-killing immunity ex.
Glomerulonephritis, Systemic Lupus Erythematous =
connective tissue destruction; Pernicious Anemia
nice to know: WBC = LYMPHOCYTES & ANTIBODY
IgG > pass thru placental barrier = Passive (temporary, preventive
action, short acting) ex. IgG to fetus
> copies the genetic coding
IgA > present in bodily secretion: saliva; tears; sweat; colostrums
IgM > largest antibody; acute inflammation
IgE
> allergic reaction
IgD > chronic inflammation
C. S/SX of Multiple Sclerosis:
1. BLARING of vision visual disturbances
2. IMPAIRED SENSATION to touch, pain, pressure, heat & cold,
tingling sensation, numbness
3. MOOD SWINGS euphoria elated sense of well being
4. IMPAIRED MOTOR ACTIVITY
a) Weakness
b) Spascity
c) Paralysis
5. IMPAIRED CEREBELLAR FUNCTION
CHARCOTS TRIAD: INA
Intentional Tremors
Nystagmus abnormal rotation of eyes to head movement
Ataxia unsteady gait
6. Urinary retention/incontinence
7. Constipation
8. Decreased in sexual capacity
D. Diagnostic Procedures:
1. CSF Analysis = reveals IgG and Protein thru Lumbar
Tap/Spinal tap @ L3-L4 subarachnoid space because
spinal cord ends @ L1, L2. Aspirate CSF for microscopic
exam
nice to know:
DURA
Subdural
Subarachnoid
ARACHNOID

SUBARACHNOID

L3-L4 or L4-L5, no more spinal cord

2. Magnetic Resonance Imaging extent & site of


demyelinization with white patches = no nerve impulses; no
myelin sheath
E. Nursing management Palliative
1. Administer medication, for acute exacerbation ACTH
2. Provide relaxation techniques = deep breathing
3. Maintain side rails
4. Prevent complications of immobility: Adult Q2, Elderly Q1
5. Provide catheterization due to urinary incontinence/retention
6. Encourage increase Oral fluid Intake, Forced: 2-3L/day (for
constipation) and acid ash in the diet ->acidify urine

prune, grape, cranberry CGFNS


orange, pineapple, vitamin C local board
*avoid bacteria multiplication
7. Avoid heat application
nice to know: URINARY TRACT INFECTION
UTI female prone than male (20cm/8inches)
Risk factors:
1. Urethra 3-5cm or 1-1.5 inches
2. Poor perineal care/hygiene = back to front, dirtiest to cleanest
3. Vagina environment = moist, good source of bacterial growth
4. Sexual intercourse without urination after act, leads to urinary
retention
COMPOSITION OF BRAIN:
1. Brain mass = 80%
2. Blood = 10%
3. Cerebro Spinal Fluid = 10%
PARTS OF THE BRAIN:
I.
CEREBRUM
II.
DIENCEPHALON
III.
MIDBRAIN or MESENCEPHALON
IV.
BRAIN STEM
V.
CEREBELLUM

I.

CEREBRUM largest
a) 2 parts: Right and Left Cerebral hemisphere; CORPUS
COLLOSUM=bridge between two hemisphere
b) 3 functions: Sensory, Motor, Integrative
c) 6 LOBES:
1. FRONTAL lobe > motor activity, personality development,
controls higher cortical thinking of brain, Broccas area =
motor/speech center
2. TEMPORAL lobe > hearing, short term memory loss =
Anterograde, Wernickes area = Receptive
3. PARIETAL lobe > appreciation/discrimination of sensory
impulses: pain, touch, pressure, hot, cold -> check if with
numbness
4. OCCIPITAL lobe > vision, check if with blindness
5. INSULA or ISLET of REIM > above frontal lobe, controls visceral
function/activities of internal organs
6. LIMBIC SYSTEM > controls smell
RHINENCEPHALON ANOSMIA = absence of smell, sexual
e. Basal Ganglia > areas of Grey matter, located deep within each
cerebral hemisphere, produces dopamine = controls gross
voluntary movement

NEUROTRANSMITTER:
1. AcH
2. Dopamine

M.Gravies, Ptosis
Parkinson

Bipolar Disorder
Schizophrenia

II. DIENCEPHALON
a) HYPOTHALAMUS
> thermoregulator center
> controls BP
> controls fluids & electrolytes
> controls thirst
> controls appetite & satiety
> controls sleep & wakefulness
> controls emotional response
> controls some PITUITARY FUNCTION, ex. Adrenergic = Testoterone &
Progesterone
MENOPAUSE = 40 Female; ANDEPAUSE = Male

> FEAR = known cause, ANXIETY = unknown cause, impending doom ,


excitement; PHOBIA = extreme fear - desensitization
b) THALAMUS
> relay station for sensation
III. MIDBRAIN or MESENCEPHALON
relay station for sight and hearing
size of pupil Normal = 2-3mm
hearing acuity
ISOCORIA = equal size pupil
ANISOCORIA = unequal size pupil
(+) PERRLA = Normal = pupil equally round reactive to light and
accommodation; constricts
HEARING ACUITY = 30-40 decibels
IV. BRAIN STEM
MEDULLA OBLONGATA
Function:
respiration
heart rate
vomiting
hiccup = SINGULTUS
swallowing
vasomotor center
spinal deccussation
*most dangerous if affected

PONS
Pneumotaxic center
Depth of respiration

V. CEREBELLUM = smallest part of the brain


balance equilibrium
posture, gait coordination
a) Cerebellar Test or Rombergs Test = stand 5 to 10 minutes to:
Assume anatomical posture VS Assume normal anatomical posture

(+) Rombergs Test = ATAXIA: 2 nurses should support in both sides

b) Finger to Nose Test (FTNT)


Individual - faster
(+) FTNT = DYMETRIA = inability
to stop a movement @ a
desired point
Doctor and patient:

Alternate Supination Pronation


Normal:

Cerebrospinal Fluid
1. Normal Amount = 120-250ml/day
Head injury/trauma

Brain compression

Brain herniation

ICP
24-48H projectile vomiting; irregular RR/HR for monitoring
2. Site of CSF production: CHOROID PLEXUS
3. Composition = Clear, glucose, colorless, protein, WBC, no
RBC
4. CSF function = shock absorber, cushions
HYDROCEPHALUS = CSF = ICP
If postetriorly = theres early closure of posterior fontanelle
Blood
Stroke = partial/total brains blood supply
Circle of Willis = smallest part of artery
Collateral Circulation 24-48H Internal carotid and Middle Cererbral
Artery

ABNORMAL (+) Alternate Supination Pronation


*if hands do a Kung Fu style
Monroe Kellie Hypothesis:
Skull is a close container
ICP = 0-15mmHg
C1 = Atlas cervical enlargement, can palpate
C2 = Axis, with Foramen Magnum = hole, above Medulla Oblongata,
below C1

ICP = intracranial bulk brought about in 1 or the 3 major intracranial


components
A. Predisposing Factors:
1. Brain trauma/injury
2. Brain tumor
3. Localized abscess
4. Hydrocephalous
5. Meningitis
6. Cerebral edema
B. S/Sx:
1. Early Signs ICP:
a. Agitation
b. Change or LOC
c. Confusion -> restlessness -> agitation -> irritation
d. Disorientation -> Lethargy -> stupor -> coma

LOC: wakefulness = AWAKE


Level Of Orientation:
1. Conscious
1. Aware
2. Lethargy
2. Coherent
3. Stupor
3. Alert
4. Coma
Late signs ICP:
a. Changes in the vital signs:
> BP SBP, diastolic same
> Cheyne Stokes respiration = normal then with episodes of apnea
> HR
> Temperature, Temperature directly proportional BP
Example:
Patient has 120/80 Pulse pressure = 40mmHg
If ICP, BP 140/80, pulse pressure = 60mmHg -> widening of the pulse
pressure
Brain shock + Cardiac disorder = narrowing of pulse pressure
tissue perfusion

blood circulation
If with seizure = DO NOT restrain, may lead to fracture
CUSHINGs reflex = vital signs different that of ICP
b. Headache, papilledema, projectile vomiting
c. Abnormal posturing
d. Unilateral dilation of pupil UNCAL HERNIATION
e. Possible seizure

3)
4)
5)
6)
7)

Tachycardia
Bradycardia
Extreme restlessness
Dyspnea
Cyanosis

LATE

Hypoxia -> Cerebral Edema -> ICP


Powerful respiratory stimulant = CO2
b. Assist in mechanical ventilation
CO2

Negative Feedback @ Medulla Oblongata

Sends impulses

Lungs

Hyperventilation to remove

CO2

Oxygen = maintain homeostasis

C. Nursing Management ICP:


1. Maintain patent airway and adequate ventilation
a. Prevention of hypoxia and hypercabia

tissue oxygenation CO2 level

tissue perfusion
LATE sign of HYPOXIA: RAT-BED-C
1) Restlessness
2) Agitation
EARLY

MS 01-21-2006
Guillain Barre Syndrome (GBS) disorder of the CNS, characterized by
symmetrical, bi lateral olineuritis, leading to ascending paralysis
Polyneuritis>Inflammation of peripheral nerves
A.

Predisposing Factors
Idiopathic
Autoimmune
Antecedent viral infxn
Immunizations (best method URTI Annual flu vaccine) too
costly, not lifetime, yearly, USA 2 doses per year for freely given.
Pneumonia (rusty sputum) vaccine every 5 yrs - esp. 65 yrs old.
Pyloric stenosis olive shaped mass.

B.

Signs and Symptoms


Initial sign CLUMSINESS
Dysphagia can lead to aspiration shld be NGT feeding
Ascending muscle paralysis
Decreased Deep Tendon Reflex paralysis (patellar/plantar)
Alternate hypotension/hypertension irregular heart rate
complications- arrythmia
Autonomic changes increased sweating increased lacrimation
/ salivation constipation give anticholinergic agents (Atropine
Sulfate)

C. Diagnostic Procedures
CSF Analysis : elevated CHON and IgG, (+) Lermic sign (post
lumbar tap increased/ forced fluids) CSF opening pressure 50160mmHg. ICP =0-15mmHg
D.
1.
a.
b.

Nursing Mgmt
Maintain patent airway and ventilation
assist in mechanical ventilation
assess pulmonary function test spirometer vital lung capacity
Incentive spirometry
c. Maintain side rails due to paralysis
d. Prevent complications of immobility every 2 hours, elderly 1 hour
e. Institute NGT feeding
f. Administer medications as ordered
Anticholinergics- (Autoimmune) Give

Corticosteroids to suppress immune response BEST


GIVEN IN AM 2/3 dose, and PM 1/3
2.
Anti-arrhythmic agents
>> Lidocaine (Xylocaine) SE confusion
>> Bretyllim SE Blocks the release of norepinephrine vasodilation hypotension
>> Quinidines - anti-arrhythmic and malaria (king of
tropical diseases - QUEENS) agents Anophelus mosquito
female with antenna lay in the morning (female needs
blood for reproduction) NIGHT BITING [DAY BITING
Dengue Aedis Aegypti- 4 oclock habit-wash in the stagnant
water, lay in the afternoon or night, Complication:
hemorrhage, hypovolemic shocks INITIAL SIGN: COOL
MOIST SKIN RESTLESSNESS, LATE SIGN: ANURIA].
g. Assist in plasmapherresis removing autoimmune and returned
back to the client, other disease who undergoes the same: MG
h. Prevent complications. MOST FEARED: Anemia, respiratory
arrest prepare Trach set at bed side. CTT clamp- to prevent
air leakage prevent pneumothorax & air embolism and extra
bottle and petroleum gauze accidental removal of chest tube
to cover it. Liver cirrhosis complication esophageal varices veins of esophagus dilate - bleeding balde balde dugoprepare at bedside: Sengstaken Blakemore Tube to decompress
vein prevent bleeding may complain of difficulty of
breathing, prepare with scissor to cut the tube and deflate the
balloon. Hemodialysis Bulldog Clip to prevent embolism.
1.

CONVULSIVE DISORDERS disorder of the CNS characterized by


paroxysmal seizures, with or without loss of consciousness, abnormal
motor activity, alteration in sensation and perception, and changes in
behavior. Is Seizure (1st convulsive attack) and Epilepsy (2nd
convulsive attack). Febrile seizure - <5 yrs old normal, >5 yrs old
epilepsy

A. Predisposing factors
Head injury secondary to birth trauma
CO poisoning antidote: Hyperbaric oxygenation to remove
carbon dioxide and monoxide poisoning decrease Oxygen
carrying capacity of hemoglobin. (Lead poisoning Calcium
Edta)
Genetics

10

Brain tumor (Astrocytoma)


Nutritional and metabolic deficiencies
Sudden withdrawal of anti-convulsive agent NUMBER 1 CAUSE
of status epilepticus drug of choice diazepam, valium,
glucose continuous seizure increased firing in the brain
high metabolism glucose depletion may cause loss of oxygen
may lead to coma. Oxygen without 5 -10 mins irreversible brain
damage
B. Types of seizures
Generalized
a. Grand Mal (tonic clonic)
>> with or without AURA highly subjective - with blank
stare, flashes, hear voices, smell something, ants crawling in
the entire body initial size warning size pending seizure
AURA. Initial sign of AURA (epigastric pain accompanied by
visual, auditory, olfactory and tactile sensory experience)
>> Epileptic cry feeling of FALL, Loss of consciousness for
3-5mins.
>> Tonic clonic contractions. Tonic- direct symmetrical
extensions of extremities - naninigas, clonic contractions
>> post-ictal sleep un responsive sleep
b. Petitmal seizure (Absence Seizure) common pediatric
clients characterized by: s/sx:
>> blank stare
>> decreased blinking of the eyes
>> twitching of the mouth
>> loss of consciousness for 5-10 seconds
c. Partial Seizures
>> Jacksonian seizure (focal seizures) s/sx: jerky movement
of index finger and tongue that spreads to the shoulder and
to the other side of the body with jacksonian march
>> Psychomotor sezure ( focal- motor seizures) s/sx:
-Automatism -stereotype repetitive and non purposive
behavior.
- Clouding of consciousness - the client is not in contact with
his environment or reality
- Mild hallucinating sensory experience (3 types: Visualsevere alcoholism - Korsakoffs Psychosis, Auditory-Schizo-

Paranoid, Im Angry Are you angry?, Tactile hallucination


Substance abuse)
>> Status Epilepticus - continuous uninterrupted seizure
activity, can lead to coma, drug of choice diazepam,
valium, glucose
C. Diagnositc Procedures
1.
CT Scan reveals brain lesion
2.
EEG - reveals hyperactivity of brain waves.
D. Nursing Mgmt:
1. Maintain patent airway and promote safety before seizure activity.
a. Clear the site of sharps, blunt objects
b. Loosen clothing of the patient
c. Avoid use of restraints can lead to fracture
d. Maintain side rails
e. Turn clients head to side to prevent aspiration
f. Place tongue guard on the clients mouth, prevent biting of
the tongue, dont force anything during seizure, during
emergency can use of spoon, clean piece of towel
2. Avoid precipitating stimulus
bright/glaring lights
noise
3.
drafts
2. Administer medication as ordered:
a. Phenytoin (Dilantin) toxic level 20 normal 10-19
prevent alcoholism may lead to severe PNS
b. Diazepam (Valium)
c. Carbamazepine (Tegretol) > Treat trigeminal neuralgia
d. Phenobarbital (Luminal)
3. Institute seizure and safety precautions post seizure activity by:
a. administer O2 inhalation
b. provide suction apparatus
4. Monitor and document the following:
4.
Onset and duration
5.
Type of seizure
6.
Duration of post-ictal sleep, the loner post-ictal sleep
danger to lead to status epilepticus
5. Assist in surgical procedure, cortical resection cortical (pial)
incision for frontal lobectomy

11

Q: a one year old client is suffering from grandmal seizure. What is


the nursing priority? ABC-Safety/ Suffering
A. Place mouthpiece complete set of teeth at 2 -3 yrs old INCORRECT
B. Administer O2 inhalation
C. Give pillows CORRECT prevent banging of the head
D. Provide suction apparatus
Parkinson Stereotaxic thalamotomy
Huntingtons Chorea (pedia) & Parkinsons disease = decrease
dopamine
NEUROLOGICAL ASSESSMENT
A. Glasgow Coma
Scale: Components:
1. Motor Response 6
2. Verbal Response 5
3. Eye Opening 4
Findings 15
15-14 = Conscious/ Conscious - AWAKE
13-12 = Lethargy/Letahargic Drowsy, sleepy, obtunded
11-9 = Stupor/ Stuporous client is only awaken by vigorous
stimulation, client is (+) generalized body weakness, and decreased
bodily reflexes
7 Coma/ Comatose LIGHT COMA (+) all forms to painful
stimulation DEEP COMA (-) to all forms of painful stimulation

1. Deep Sternal
Pressure/ Stimulation
2. Orbital pressure

3. Pressure on Great
toes

LIGHT
close fist form a
knuckle, press the
sternum 3 strokes
with response
Tip of Thumbs press
orbital bones above
and below eyes, 3x,
with response
Press great toes 3x
with response

DEEP
without response
after 3 strokes
without response
after 3 storkes
without response

4. Corneal/ Blinking
Pass the cotton tip on Drop saline soln
Reflex Conscious
the eyes when
in the eyes it will
wisp of cotton hibla
looking straight to
blink even closed
dulo
the nurse, it will blink light coma,
Unconscious do not
if no response use cotton use one
deep
drop of saline solution
*PRECORDIAL TAP NEVER USED IN THE HOSPITAL causes:
fracture ribs, collapse lungs
*do not do CORNEAL PRESSURE may lead to corneal pressure,
cornea punit may lead to blindness
3 DEEP COMA
B. Comprehensive Neurological Exam
1. Survey of Mental Status and Speech
>> LOC
>> Test of memory
2. Levels of Orientation
3. Cranial Nerve Assessment
12 Vagus longest
Trigeminal largest
Trochlear - smalles
4. Motor Assessment
Movement of larger muscle
0 no movement plegia
1 smaller muscle
2
34
55. Sensory Assessment
6. Cerebellar Test Romberg Test Finger to nose Test (+)
Dymetria
7. DTRs
8. Autonomics
Test of memory
Short term memory what did you take this morning for breakfast
Anterograde TEMPORAL lobe affected

12

Long term memory when is your birthday? validate in the clients


data sheet
Retrograde Diencephalon or Limbic system damage
Levels of Orientation
Time Ask for the period of date Umaga or Hapon or Gabi?
Person Sino po ako?
Place Where po okay?
Cranial Nerves Assessment
I Olfactory - S
II- Optic -S
III- Oculomotor -M
IV Trochlear - M
V Trigeminal - SM
VI Abducen - M
VII Facial - SM
VIII Acoustic S
IX Glossopharyngeal -SM
X- Vagus- SM
XI Accessory -M
XII- Hypoglossal -M
NOTE: Some says marry money but my brother says bad business
marry money
CN I Olfactory nerve
Sensory smell
Materials used DO NOT USE ALCOHOL AMMONIA PERFUME
irritating to nasal mucosa highly diffusible easily to evaporate
USE COFFEE granules, VINEGAR, CIGARETTE TAR, BAR SOAP.
Procedure: CLOSE HIS EYES, TEST EACH NOSTRIL, BY
OCCULDING 1, ask what odor -symmetrical body to check
abnormalities
>> Hyposmia decrease sensitivity to smell (matagal vinegar
lumayo soy sauce)
>> Dysosmia - distorted sense of smell
>> Anosmia absence of smell might indicate:
1. HEAD INJURY
2. INFLAMMATION sinus SINUSITIS

CN II - OPTIC NERVE
>> Sensory Vision
>> Tests:
Test of Visual Acuity/Central or Distance Vision. Materials used:
Snellens Chart 1) Snellens Alphabet Chart used for literate client
who can read 2) Snellens E chart used for illiterate who can
not read 3) Snellens Animal Chart used for pediatric clients,
children have shorter attention span
1.
Findings: 20/20
2.
Numerator FIXED CONSTANT indicates distance of
the person to the snellens chart 20 feet or 6-7
meters
3.
Denominator indicates the distance by which the
person can normally see the letters in the chart
4.
OD oculodexter ; right OS oculosinister left OU both
eyes, small letters od once a day
5.
ABNORMAL FINDING: 20/200 indicates blindness can
not read the letter E
6.
NORMAL FINDINGS: 20/20 - can read at least 2 letters
above the shaded red lines
7.
If the clients can still read below the shaded red lines
perfect vision
Visual Fields/Peripheral vision
Where is the examiner when testing the peripheral vision of the
client?
1.
Superiorly sa forehead
2.
Bitemporally near ears
3.
Nasally - nose
4.
Inferiorly sa baba
Instruct client to stare at the nurses forehead, occlude right eye
instruct Roxanne to count the numbers of fingers wingling, tapat fingers
on areas above.
DAMAGE in peripheral vision Nystagmus
4 COMMON DISORDERS:
1. Glaucoma increased intraocular pressure Normal=12-21mmHg
causes:
1. 40 yrs old
2. Hypertension
3. Obesity

13

4. Trauma
s/sx:

1. LOSS of peripheral vision tunnel vision


2. Halos rainbow around lights
3. Steamy cornea cloudy
4. Ocular Pain eye pain
5. Headache
6. Nausea and Vomiting
*Can lead to blindness
Diagnostic Procedures:
1. Tonometry
2. Gonioscopy
3. Perimetry
Drug of choice:
1. MIOTICS constricts the pupil
Ex. Pilocarpine Sodium, Carbachol
2. Epinephrine eyedrops decrease aquaeous humor
3. Carbonic anhydrase inhibitor : Acetazolamide-Diamox promote
drainage
4. Timoptics Timolol Maleate
1. Trabeculectomy
2. Peripheral Iridectomy
BOTH-drainage of aquaeous humor
*It is preventable, but not curable, treatment is LIFETIME
2. Cataract opacity of the lens Degenerative/Senile Cataract
causes:
1. 65 yrs old and above
2. Congenital
3. DM
4. Prolong exposure to violent rays
s/sx:
1. Loss of central vision blaring or hazy vision
Lens- should be transparent, getting old turns to opaque
2. Milky white appearance at the center of the pupil.

3. Cataract has decreased perception to colors.


4.
Diagnostic: opthalmoscopic examination
drug of choice:
a. MYDRIATICS
ex. Mydriacyl, ATSO4 -dilates the pupil
b. Cyclopegics
ex. Cyclogyl paralyzes the ciliary muscle
Surgical procedure:
E xtra
C apsular
C atarat
L ens
E extraction
> partial removal
Intra Capsular Cataract Lens Extraction
Total Removal
Complication of lens extraction: RETINAL DETACHMENT
3. RETINAL DETACHMENT
means of separation of epithelial cells of the retina
CAUSE:
1. FOLLOWING LENS EXTRACTION
2. Myopia near sightedness Biconcave lens used as treatment
Emmetropia- normal eye
Hyperopia far sightedness Biconvex lens used as treatment
Astigmatism - Distorted vision Cylindrical lens used as treatment
Presbyopia- old sight loss of - bi-focal lens used as treatment
Pathognomonic signs:
s/sx:
1. Curtain-veil like vision
2. Floaters due to leakage of red blood cells

14

Surgical procedure:
1. Scleral Buckling
2. Cryosurgery cold application
3. Diathermy heat application

4. MACULAR DEGENERATION
> macula lutea yellowish spot at the center of the retina
- middle layer
Fovea centralis - site of perfect vision
Optic Disk covering of retina
Pathnognomonic signs:
Black spots

Q: A client is suffering Trigeminal Neuralgia, the nurse should


administer food products?
A. hot milk-X, wafer-ok, butter-ok
B. bread-ok, cereals-ok & cold drink-X
C. potato-OK, toast, gelatin-OK
D. gelatin-OK, salad-OK, potato-OK

CN III OCULOMOTOR 4 EOM


CONTROLS THE RAISING OF THE UPPER LID
ISOCORIA = Equal
PERRLA = PUPIL CONSTRICTS
CONTROLS THE SIZE OF THE PUPIL 2-3mm
CN IV TROCHLEAR SO
CN VI ABDUCENS Lateral Rectus
innervates movement of extrinsic ocular motor EOM= 6
Right eye
SR
SO
LR MR
IO
IR

n
o
s
e

Left eye
SO
SR
MR LR
IR
IO

Follow the direction of my pen according to 6 cardinal gaze


PER EYE
4- rectus
2 - oblique
3 cranial nerves
CN V Trigeminal
Ophthalmic branch
Maxillary branch
Mandibular branch
Sensory Motor
Largest CN

Sensory controls sensation of face and teeth (pain diffused),


mucous membrane and corneal reflex
Motor mastication or chewing
Damage to CN V Trigeminal Neuralgia difficulty in chewing
and swallowing

SALAD VS TOAST which is easy to chew


*AVOID EXTREME TEMPERATURES
Gelatin is CLEAR LIQUID DIET
Porridge is SOFT DIET
CN VII FACIAL NERVE
Sensory it controls taste anterior 2/3 of tongue. Cotton
applicator, pinch of sugar say ah place the sugar on the tip
of the clients tongue, dont allow to taste it- TIP OF THE
TONGUE SHOULD BE SWEET
Motor controls facial expression, instruct the client to smile to
frown or raise his eyebrows
Bells palsy facial nerve paralysis temporary 4 to 6 months
Q: What is
A.
B.
C.
D.

the most evident clinical sign of facial symmetry?


Lips remove due to cleft lip
Cheeks
Nasocranial bone remove due to cleft lip
Nasolabial folds smiling N= face pantay right and left
(+) Bells palsy = tabingi- no nasolabial folds

CN VIII Acoustic/Vestibulocochlear Nerve


inner ear
for balance Kinesthesia position sense movement and
orientation of the body in space.

15

Cochlear hearing, organ of corti= TRUE SENSE ORGAN OF


HEARING
Inner
Middle
Outer
cochlear
Hummer Anvil pinna
vestibule
Stirups external
Malleus I-?
Stapes
Eustachean
tube

Meiners
disease
sensory
hearing loss

otitis media
Conductive
hearing loss

impacted
cerumen
Conductive
hearing loss

Q: laws of physics:a client suffered from MSW multiple stab wound,


upon assessment, the client has difficulty of breathing, chest pain.
Movement of air in and out of the lungs is carried by what principles: law
of PARTIAL pressure of gases. Atmospheric pressure(+) OUTSIDE, lungs
= (-) atmospheric pressure NORMAL; (+) atmospheric pressure (higher
to lower) - DIFFUSION
A. Boyles
B. Archimedes
C. Daltons - CORRECT
D. Inertia
Q pregnant women on her 1st tri of pregnancy, visited a pre natal clinic
for check up, UTZ reveals fetus is suspended
LAW OF buoyancy Archimedes

likod ng tonge to initiate gag-reflex, vagal stimulation eyes


constricts, moist mouth, decrease RR, BP, diarrhea HYPOTENSION
Damage in cerebral hemisphere

CN XI SPINAL/ACCESSORY
CONTROLS two muscles of
Sternocleidomastoid (neck)
Trapezius (Shoulder)
Ask client to shrug, and apply pressure, if he can not hold the pressure
paresis, or paralysis
CN XII - HYPOGLOSSAL
controls the movement of the tongue
ask client to say AHH, to protrude the tongue, should be
straight, if it deviates to left and right, theres damage to
cerebral hemisphere. Ask the client to push tongue against
his/her check he/she might have short frenum/frenulum
linguae located at the back of the tongue litid tongue-tied
bulol
TSE: spontaneous answer, dont humm, dont be nervous, use
nouns, adjectives, connecting words

Q: A client suffered from vertigo dizziness due to fasting for 5 days.


INERTIA
Law of motion
CN IX - GLOSSOPHARYNGEAL
controls taste, posterior 1/3 of tongue
CN X VAGUS
Gag reflex
Tested both, say client to say ah, check the position of uvula,
should be at the center or midline, put the tongue depressor sa

16

ENDOCRINE SYSTEM
Pituitary gland main organ, (hypophysis cerebri) located at the
sella turcica at the base of the brain
master clock, master gland of the body because it secretes
hormones that controls or regulates all the metabolic fxn of the
body
thyroid
adrenal
gonads

2 DIVISIONS OF pituitary gland


1. Anterior pituitary (Adenohypophysis)
2. Posterior pituitary (neurohypophysis)
hormones:
1) Oxytocin promotes uterine contraction, thereby preventing
bleeding or hemorrhage when is the best time to give: after
placental delivery to prevent uterine atony that may lead to bleeding
and hemorrhage initiates milk let down reflex by the help of
prolactin
2) Antidiuretic Hormone ADH ADH replacement
>> Pitressin (vasopressin) prevents urination, conserving water
Diabetes Insipidus
1. Definition:
HYPOSECRETION of
ADH
2. Predisposing
Factors:
a. Pituitary surgery
b. Inflammation
c. Trauma
d. Tumor

Syndrome of
inappropriate ADH
HYPERSECRETION OF
ADH
2. Predisposing
Factors:
a. Head injury
b. Bronchogenic
cancer.(1.Lung cancer
initial: nonproductive
cough
2. Liver cancer 3.
Prostate cancer -40 4.
Testicular cancer 30,
BPH - 50)
C. Hyperplasia of

3. S/Sx:
Alcohol inhibits the
release of ADH A.
polyuria excessive
urination
B. Dehydration
- Thirst
- Agitation
-Poor skin turgor
-Dry mucous
membrane
C. weakness and
fatigue
D. Hypotension
E. Weight loss
if left untreated
F. hypovolemic shock
INITIAL: COOL
MOIST SKIN,
RESTLESSNESS LATE
SIGN: ANURIA
4. Diagnostic
procedures 1.010 to
1.030
a. Urine specific
gravity LOW
b. Serum Na 135145meq/L HIGH
5. Nursing Mgmt:
a. Forced fluids
b. Administer isotonic
soln as ordered
c. monitor VS and IO
d. Administer
medications as
ordered: Vassopressin

Pituitary gland
increased size of the
organ due to increased
number of cell
3. S/Sx:
a. Fluid retention
- Hypertension
- Weight gain
- edema
b. Water intoxication
may lead to cerebral
edema, lead to
increased ICP (N=015mmHg), may lead to
seizure activity

4. Diagnostic
Procedures:
a. Urine specific gravity
HIGH
b. Serum Na LOW
5. Nursing Mgmt.
a. Restrict fluid
b. Administer
medications as ordered
Diuretics both osmoticcerebral edema/loopedema GIVEN at AM,
10-15mins, max 6

17

IM
Petrissin
e. Prevent
complications:
Hypovolemic shock

hours effect, SD, fast


drip, c. 1st monitor VS
BP, then I& O
d. weight patient daily
and assess for edema
e. meticulous skin care

ANTERIOR PITUIATARY GLAND


1. Growth hormones/ somatotrophic hormones
> promotes elongation of your long bones
- DWARFISM
- GIGANTISM
- ACROMEGALY box/ squared face
distal ends epiphysis covered by epiphysial plate, shaft diaphysis
periosteum, center cavity medullary cavity covered by
endosteum
long bones contain bone marrow RED epyphysies RBC, WBC, and
platelets AND YELLOW medullary cavity - produces fat cells
Q: if theres a fracture- (loss or break of continuity) of femur, the
nurse would expect feared, complications: fat embolism
pulmonary embolism headache dizziness cerebral embolism;
second hemorrhage, and compartment syndrome
compression of the arteries and nerves assess neuro vascular
status
Puberty as early as 9 as late as 21 yrs old
@ age 21 epiphyseal plates closes
What to ask for person with Acromegally:
Q: what is the sizes of your recent shoes?
Drug of choice for Acromegally:
Ocreotide [Sandostatin]
2. ACTH Adenocorticotrophic Hormone promotes maturation and
development of adrenal cortex

Addison hyposecretion and Cushing diseases hypersecretion


3. PROLACTIN/Lactogenic Hormone initiates milk let down reflex
development or enlargement of breast
4. MELANOCYTE STIMULATING Hormone (MSH) fxn: for skin
pigmentation sufficient amount of melanin brown skin can
tolerate the heat of the sun
- Albinism - Hyposecretion of MSH, complications: blindness and
skin cancer
- Vitiligo - Hypersecretion of MSH Dalmatian spots seen in chest
5. LEUTENIZING HORMONE produces progesterone
6. FOLLICLE STIMULATING HORMONE (FSH) secretes estrogen
PINEAL GLAND secretes MELATONIN
inhibits leutenizing hormone secretion
controls circadian rhythm body clock
THYROID GLAND palpable only adams apple, if palpable you have
goiter
nodular consistency = NORMAL
1 thyroid gland continuous, left and right at the back
parathyroid, above-larynx
located anterior to the neck
3 hormones secreted
a. T3 triiodothyronine
b. T4 tetraiodothyronine or thyroxine
c. Thyrocalcitonin
1.
inhibits the action parathormone promotes calcium
resorption breaking down
2.
T3 and T4 metabolic or calorigenic hormone
Brain increase thinking
V/S high
Hypothyroidism ALL ARE DECREASED except weight and menstruation
a. Loss of appetite but theres weight gain
b. Menorrhagia excessive menstruation HIGH estrogen
promotes lipolysis- breakdown of lipids, dislodge to fats, can be

18

deposited to arteries, artherosclerosis, hypertension MI, stroke,


Increase serum cholesterol
Memory impairment
Forgetfulness
Constipation
Lethargy
Hypotension
Hypothermic
Low metabolism, no perspiration, skin dry, cold intolerance
Hyperthyroidism ALL ARE INCREASED except weight and menstruation
a. Hyperphagia increased appetite, weight loss- high metabolim ,
increased perspiration, heat intolerance
b. Amenorrhea absence of menstruation
CNS hyperactivity
Irritability
Tremors
hallucination
diarrhea
CRITICAL 16 section 3800 final coaching 3200, 340pax UE and ALIW,
Araneta PRC- St. Thomas Square Banco De Oro 2nd flr register
THYROID DISRODERS:
GOITER enlargement of the thyroid gland due to iodine deficiency
2. Predisposing Factors:
a. Goiter belt area
- places far from the sea walang seafoods no iodine
- mountainous regions- cordilleria and Baguio City increase of
goitrogenic foods
b. Goitrogenic foods contains pro-goitrin, anti-thyroid agent that has no
iodine
- metabolism low

ex. Cabbage, radish, singkamas turnips, all nuts, strawberries, sweet


potato, broccoli planted in mountainous area soil erosion, iodine is
washed away
c. Goitrogenic drugs
- Anti-thyroid agent (PTU) Prophyllthiuracil given to hyperthyroidism
Surgery:
Graves disease = removal thyroidectomy subtotal
Total thyroidectomy only to Thyroid Cancer
- Lithium toxic 2 N=.6-1.2, forced fluid, increase Na, to prevent
dehydration
3.
4.
5.
1.
2.
S/sx:
a.
b.
c.

ASA SE: Thrombis, dyspepsia, heart burn CI: Dengue, ulcer antiplatelet
Phenylbutazone
Cobalt
Endemic Goiter caused by goiter belt area
Sporadic Goiter caused by 2 goitrogenic food and drugs
enlarged thyroid gland
mild dysphagia
mild restlessness

Diagnostic procedures
a. Serum T3 and T4 may reveal normal and below normal
b. Thyroid scan - Enlarge thyroid gland
c. Serum TSH is INCREASED confirms presence of goiter
6. Nursing Management:
1. Administer meds as ordered
a. Iodine solution
6.
Lugols solution saturated solution of Potassium
Iodide- purple or violet administer with straw to
prevent staining of the teeth. (Drugs given with
straw: Lugols soln, Iron Tetracycline,
Nitrofurantoin (Macrodantin) urinary antiseptic
drug of choice of pyelonephritis )
2. Thyroid agents of hormones

19

i. Levothryroxine (Synthroid)
ii. Liothyronine (Cytomel)
iii. Thyroid extracts
Nsg Mgmt:
1. best taken in AM to prevent INSOMNIA
2. Monitor heart rate, most SE: Tachycardia,
palpitation hypertension, heat intolerance (due to
metabolism) SE: HYPERTHYROIDISM
3. Encourage increased intake of foods rich in iodine.
a. seaweeds
b. seafoods oyster #1, clams, crab, lobster, mababa iodine content =
SHRIMP
c. Iodized salt too salty best taken at raw, because heat destroys it.
Too much iodized salt may lead to hyperthyroidism
4. Surgical procedure: partial thyroidectomy
MS 01/22/2006
Hypothyroidism
1. Def: hypo secretion of decreased to T3 and T4
7.
Myxedema adult
8.
Cretinism children, the only endocrine disorder can
lead to mental retardation
2. Predisposing Factors:
a. Iatrogenic cause disease caused by medical intervention
surgery
(Hospital acquired infection health related infection)
b. Atrophy of the Thyroid gland due to:
I rradiation
T umor
T rauma
I nflammation
c. Iodine deficiency
d. Autoimmune Hashimotos disease

3. S/Sx: low metabolism hoarseness of voice, anorexia, MI


Early signs:
a. Weakness and fatigue
b. loss of appetite but weight gain
c. Dry skin
d. Cold intolerance
e. Constipation
Late signs:
a. Brittleness of hair and nails
b. Non-pitting edema due to accumulation of mucopolysacchrides
in the subcutaneous tissue, hence to adult its Myxedema
c. Hoarseness of voice
d. Libido
e. VS Hypotension, Bradycardia, Bradypnea,
f. CNS Changes lethargy, memory impairment, psychosis
g. Menorrhagia estrogen
4.
a.
b.
c.
5.
a.

Diagnostic Procedures:
Serum T3 and T4 are normal or
Radioactive Iodine Uptake
Serum cholesterol due to weight gain
Nursing Mgmt:
Monitor VS and IO strictly
9.
Myxedema coma severe form of hypothyroidism,
characterized by:
severe hypotension
bradycardia
bradypnea
hypoventilation
hypoglycemia
hyponatremia *that may lead to progressive stupor and coma
COMA #
1. nsg management: - Assist in mechanical ventilation
2. Administer thyroid hormones
3. Forced fluids
b. Administer med as ordered
i. Levothryroxine (Synthroid)
ii. Liothyronine (Cytomel)

20

iii. Thyroid extracts


Nsg Mgmt:
1. best taken in AM to prevent INSOMNIA
2. Monitor heart rate, most SE: Tachycardia,
palpitation hypertension, heat intolerance (due to
metabolism) SE: HYPERTHYROIDISM
c. Provide dietary intake low in calories due to weight gain
d. Institute meticulous skin care due to dry skin
e. Provide comfortable and warm environment - due to cold intolerance
f. Forced fluids
g. Provide health teaching and discharge planning
> Avoidance of precipitating factors leading to myxedema coma
- Stress
- Infection
- Cold environment (do not put in air condition room)
- Anesthetics, sedatives, and narcotics (lead to respiratory depression)

Prevent complications: hypertension, MI, CHF, CVA, myxedema


coma, hypovolemic shock
Hormonal replacement therapy for lifetime
Importance of follow up

HYPERTHYROIDISM
- hyper secretion of T3 & T4
GRAVES DISEASE with Exopthalmus
- Thyrotoxicosis
Predisposing Factors:
a. Autoimmune - release of long-acting thyroid stimulator LATS
autoimmune antibodies responsible of occurrence of exopthalmus
b. Increased iodine intake
c. Hyperplasia (increase in the number of cells) of thyroid gland
Signs/Sympotms:
a. Hyperphagia increase in appetite
b. (+) weight loss T3 & T4 increase, metabolism increase
c. Moist skin
d. Diarrhea
e. Heat intolerance
f. VS -Hypertension, tachycardia, tachypnea, hyperthermia

g. CNS changes irritability, agitation, tremors, restlessness,


insomnia, hallucinations
h. Goiter
i. Exophtalmos protrusion of the eye
j. Amenorrhea
Diagnostic Procedure
a. T3 & T4
b. RAIU
c. Thyroid scan size of thyroid gland = goiter
d. TSH High confirms goiter
Nice to know: Enophtalmos- severe dehydration late sign among
children, depression in the eye
Nursing mgmt:
a. Monitor VS and IO strictly complication of Thyroid
storm
b. Administer med as ordered anti-thyroid agents
Prophethiuracil (PTU)
Methimazole (Tapozole)
Q: What is the most common SE of anti-thyroidism
A: SE: Agranulocytosis increase WBC
Agrunolocytes: Monocytes and Lymphocytes = theres infection
Fever, chills = CBC, sore throat throat swab/culture
c.
d.
e.
f.
g.

Increased caloric diet to correct the weight loss


Institute meticulous skin care due to moist skin
Provide comfortable and cool environment
Maintain side rails
Provide bilateral eye patch to prevent dryness of the eye
due to exophtalmos
h. Assist in surgical procedure subtotal thyroidectomy
Pre-op Nsg Mgmt: 1. Administer Lugols solution (SSKI) to
decrease vascularity of the thyroid gland to prevent bleeding
and hemorrhage
Post-Op Nsg Mgmt:
1. Watch out for signs of Thyroid storm TRIAD:
Hyperthermia, Tachycardia, Agitation
Nsg mgmt if theres thyroid storm:

21

1. Give medications: a. antipyretics, b. beta blockers


propanolol = SE: PNS
2. WOF: inadvertent or accidental removal of
parathyroid gland can lead to hypocalcemia or
tetany = trousseuas sign, chevosteks sign =
administer calcium gluconate IV slowly to prevent
cardiac arrest, antidote: magnesium sulfate =
toxicity BP low Urine output low RR low Patellar
reflex absent paralysis
2. WOF accidental laryngeal nerve damage instruct the client
to talk and speak after post op laryngeal nerve cut notify the
physician
3. WOF signs of bleeding post subtotal thyroidectomy =
feeling of fullness at the incisional site Nurse should check
soiled dressing at the back or nape area Notify the
physician
4. WOF signs of laryngeal spasm difficulty of breathing or
shortness of breath prepare at bedside trach set
5. Hormonal replacement therpy
6. Follow up care
Tonsillectomy general anesthesia keeps swallowing may have
bleeding offer ice chips, no straw may add tension to suture line, or
provide ice collar
PARATHYROID GLAND pair of small nodules located behind the
thyroid gland
1. Secretes parathormone promotes calcium reabsorption
antagonize Thyrocalcitonin calcium reabsorbtion
CALCIUM
HYPOPARATHYROIDISM
1. Definition: PARATHORMONE - calcium phosphate
hypocalcemia hyperphosphatemia
Complications: tetany
2. Predisposing Factors
a. Following subtotal throidectomy
b. Atrophy of parathyroid
Inflammation
Tumor
3. Signs/ SX

a.

Acute tetany
Tingling sensation
Paresthesia
Dysphagia Anorexia
Irritability
(+) laryngospasm bronchospasm prepare trach set
(+) Trousseus sing
(+) Chevosteks sign
Complications: Arrhythmia
And Seizures

b. CHRONIC TETANY
S/Sx:
Cataract and photophobia
Loss of tooth enamel
Anorexia and general body malaise
Irritability and memory impairment
4. Diagnostic Procedures
a. Serum Ca (N=8.5-11mg/100ml)
b. Serum phosphate (N=2.5-4.5mg/100ml)
c. X-ray of long bones will show bone density
d. CT scan reveals degeneration of Basal Ganglia
5. Nursing Management:
a. Administer med as ordered
1.
Ca Gluconate IV slowly- for acute
2.
Oral calcium supplement for chronic ex. Calcium
lactate, Calcium carbonate, Calcium Gluconate
(facilitate by vitamin)
3.
Vit D sources: (Cholecalciferol) drug, diet (Calcidiol)
, sunlight (Calcitriol) (ex. Eat Cheese 5am, 7am-9am
sunlight, direct to bones)
4.
Phosphate binders - If phosphate is ex. Aluminum
hydroxide gel (Ampho-gel) antacid SE: Constipationbinds phosphate in the intestines promoting its
excretion in the urine.
b. Avoid precipitating stimulus such as bright and glaring
lights, due to photophobia result to seizure

22

c.
d.
e.
f.
g.
h.
i.

Provide dietary intake Ca Phosphate diet of


osteoperosis #1 SALMON, #2 Turnips, #3 Anchovies
Institute seizure and safety precaustions
Prepare trache set at bedside - for possible laryngeal
spasm
Encourage the client to breath using paper bag.
Promotes mild respiratory acidosis, that can increased
ionized calcium levels
Prevent complications: Arrhythmias and Seizures
Hormonal replacement
Follow up care

Nice to know: Antacids 2 TYPES


A-A-C : Aluminum containing Antacids SE: Constipation
M-A-D : Magnesium containing Antacids (Milk of Magnesia) SE:
Diarrhea
Q: What is the most effective antacid with a fewer side effects: A:
MAALOX
HYPERPARATHYROIDISM
1. Definition:
Hypersecretion of parathormone - Calcium Phosphate
Hypercalcemia Ca in the blood
> lead to bone demineralization lead to bone fracture
>-lead to kidney stones
Calcium = 99%-bones, 1% blood
2. Predisposing factors
a. hyperplasia of parathyroid glands
b. over compensation of parathyroid gland d/t Vitamin D
deficiency
5.
Ricketts children
6.
Osteomalacia adult
3. S/sx:
a. Bone pain especially at the back and bone fracture
b. Kidney stones
renal colic pain
cool moist skin if with hypovolemic shock
c. Ulceration

d. Anorexia and general body malaise


e. Irritability and memory impairment
4.
a.
b.
c.

Diagnostic Procedure
Serum Ca
Serum Phosphate
Bone x-ray reveals bone demineralization

5. Nursing Management:
a. Forced fluids 2-3L due to kidney stones
b. Strain all the urine with gauze pad can filter the kidney stones
or precipitate for the laboratory for stone analysis: calcium,
uric acid
c. Provide warm sitz bath to promote comfort
d. Provide acid-ash diet cranberry, plums, grape juice, prunes,
Phils: orage-pineapple-ponkan-Vit C- acidify urine to prevent
bacterial multiplication
e. Administer med as ordered:
Narcotic analgesic respiratory depression
1.
Morphine Sulfate [antidote= Narcan, (Naloxol SE:
Tremors)]
2.
Demerol
f. Maintain side rails
g. Supervise/ Assist in ambulation
h. Diet: lean meat Phosphate Calcium
i. Assist in surgical procedure = Parathyroidectomy
j. Hormonal replacement for lifetime
k. Follow up care
l. Prevent complications: kidney stones ischemia death of
kidneys may lead to RENAL FAILURE
ADRENAL GLAND located on top of the kidney
Cortex outer part
Medulla inner part
Adrenal Medulla secretes catecholamines adrenalins
a. Epinephrine
b. Norepinephrine
Vasoconstriction SNS All bodily activities, except GI

23

Pheochromocytoma catecholamine producing tumor ->


- > Increased norepinephrine -> HPN (resistant to non-pharmacological
agents) -> Hypertensive crisis -> Stroke
- disease of adrenal medulla
Drug of choice: Beta blockers
Adrenal Cortex outermost
- consist of 3 zones or layers:
1. Zona Fasciculata SUGAR -> secretes GLUCOCORTICOIDS hormone ex.
Cortisol (steroid) fxn: it promotes glucose metabolism
2. Zona reticularis SEX -> secretes ANDROGENIC hormones ex. FEstrogen (FSH), Progesterone (LH); M-Testosteron fxn: promotes
secondary sexual characteristics
3. Zona glomerulosa SALT -> secretes Mineralocorticoids ex. Aldosterone
-> promotes Na and water reabsorption, while promoting excretion of K
( Na H2O K)
Addison HYPO - SSS
Cushing HYPER SSS
1. Def: hyposecretion of adrenocortical 1. Def: hypersecretion of
hormones leading to:
adrenocortical hormones
- metabolic disturbances SUGAR
- fluid & electrolyte imbalances SALT
- Deficiency of neuromuscular function
SUGAR & SEX
2. Predisposing Factors:
2. Predisposing Factors:
a. Atrophy of the Adrenal gland
a. Hyperplasia of Adrenal gland
b. Fungal infections
b. Tubular infection with TB
Q: WHAT do you call the
spread of tuberculi bacilli to
adjacent organ? A:MILLIARY
TUBERCULOSIS
3. S/Sx:
3. S/Sx:
a. Hypoglycemia (TIRED)
a. Hyperglycemia (PPP)
> Tremors
> Polyuria
> Irritability
> Polydipsia
> Extreme fatigue
> Polyphagia
> Diaphoresis & depression
Complications: DM
b. Decreased tolerance to stress ->
b. Increased susceptibility to
may lead to Addisonian crisis
infection

c. Hyponatremia
> hypotension no water absorption
low salt
> Signs of dehydration
> Weight loss no water
d. Hyperkalemia
> Irritability and agitation
> Diarrhea
> Arrhythmias peak T wave
e. Decreased libido
f. Loss of pubic and axillary hair
g. PS: Bronze-like skin pigmentation

c. Hypernatremia
> hypertension
> edema
> weight gain
> moonface appearance,
buffalo humps, obese trunk,
pendulous abdomen, thin
extremities
d. Hypokalemia
> Weakness and fatigue
> Constipation
> U wave on ECG tracing
e. Hirsutism
f. Acne and striae, easy
bruising
g. Increased masculinity in
females

4. Diagnostic Procedure
a. FBS low N=18-120mg/dl
B. Serum NA low
c. Serum K high
d. Plasma cortisol low
5. Nursing Mgmt:
a. Monitor strictly VS, IO and
Addisonian crisis characterized by:
> hyponatremia
> hypovolemia
> dehydration
> weight loss which may lead to
progressive stupor and coma
N/R in Addisonian crisis:
1. Assist in mechanical ventilation
2. Administer steroids
3. Forced fluids
b. Administer meds as ordered
> Corticosteroids ONE
- Hydrocortisone, Dexamethasone,
Prednisone
N/R:

4. Diagnostic Procedure
a. FBS high
b. Serum high
c. Serum K low
d. Plasma cortisol high
5. Nursing Mgmt:
a. Monitor IO and VS
b. Restrict Na and fluids
c. weight patient daily and
assess for edema
d. Measure abdominal girth
daily and notify physician
e. Diet low in carbohydrate,
high in K, high in protein
f. Administer meds as ordered:
Provide diuretics:
DO NOT GIVE LOOP
DIURETICS LASIX : HypoK,
HyperGlycemia
give only
K-sparing diuretics
Spironolactone (Aldactone)

24

1. Best taken 2/3 dose in AM, 1/3 dose


in PM, to mimic normal diurnal rhythm.
Cortisol immune response/ strong
immune system in AM.
2. Taper the dose instructs the client
to withdraw gradually from the drug. If
withhold immediately from drug
3. Monitor SE: a. Moon-faced
appearance, buffalo humps, HPN,
edema, hirusitism = increase
susceptible to infection = CUSHING
syndrome
> Mineralocoricoids
- Fluorocortisone
c. Forced fluids due to hyponatremia
d. maintain patent IV line
e. Diet in calories, protein
Carbohydrates, Na but K
ex. Ham Na; French fries saturated
fat
f. Meticulous skin care
g. Provide health teaching and
discharge planning
> Avoidance of precipitating factors
leading to Addisonian crisis
- Stress
- Infection
- Sudden withdrawal to steroids
> Prevent complications: Addisonian
crisis > dehydration > hypovolemic
crisis
> Hormonal replacement
> Importance of follow up care

promotes Na excretion, while


conserving K.
g. Prevent complications: DM
h. Assist in surgical procedurebilateral adrenalectomy
i. Hormonal replacement
j. Importance of follow up care

PANCREAS located behind the stomach endocrine/exocrine gland


Mixed gland:
Acinar Cells (exocrine gland) with ducts
secretes pancreatic juices goes through the pancreatic duct to
the stomach
aids in digestion

Islets of Langerhans (endocrine gland) ductless


alpha cells ->secretes glucagons -> hyperglycemia
beta cells -> secretes insulin -> hypoglycemia
delta cells -> somatostatin -> antagonizes production of GH

Disorders of the Pancreas


1. CANCER or TUMOR of Pancreas
2. Diabetes Mellitus
3. Pancreatitis autodigestion self digestion, self-eating - #1
cause = alcoholism, #2 obesity
NICE TO KNOW:
lipase and amylase toxic substance in the body
right pain gallstone
left pain - pancreatitis
GROIN pain inflammation of testicles (with fever), hernia, stones in
the ureters-immobility, limited intake of fluid, concentrated of urine
Pain in right iliac region appendicitis
Pain in gallbladder UTI
DM I (IDDM)
1.

2.

3.
a.
b.
c.
d.
4.
a.
b.
c.
d.
e.
f.
5.
a.
b.

Def:
Juvenile Onset/ Non-obese
Incidence Rate
Only 10% of general population
Predisposing Factors
Hereditary total destruction of pancreatic cells
Viruses
Toxicties (carbon tetrachloride CCl4)
Drugs, steroids, and loop diuretics (Lasix, and steroids)
Signs/Sx: PPP-G
Polyuria, polydipsia, polyphagia
Glucosuria
Weight loss, anorexia, nausea and vomiting
Blurring of vision
Increased susceptibility to infection
Poor/delayed wound healing
Treatment:
Insulin therapy
Exercise

25

c. Diet
6. Most feared complications: DKA give Na Bicarbonate
DM II (NIDDM)
1. Def:
Adult Onset/Obese (40 yrs old and above)
2. Incidence Rate
90% of the general population, started to increase in early 80s
3. Predisposing Factors:
a. Obesity Q:Why obese persons develop DM? A: Obese
individuals lack insulin receptor binding sites
4. Signs and Symptoms:
a. Usual asymptomatic
5. TREATMENT
1. Oral Hypoglycemic Agents (OHA)
2. Diet
3. Exercise
6. HyperOsmolarNonKitetotic Coma (HONK)

If glucose is low -> cell sends impulses to hypothalamus -> stimulate


liver to undergo:
a. Glycogenesis = synthesis of glycogen
b. Glycogenolysis = breakdown of glycogen
-> converts to glucose and undergo the normal function
c. Gluconeogenesis = formation of glucose from non-carbohydrate
sources: Proteins and Fats
DM: I no insulin
II low insulin
Increased glucose -> remains in the circulation hyperglycemia
(because of no or low insulin) -> theres an increased Osmotic diuresis > polyuria -> cellular dehydration -> stimulate the thirst center
(hypothalamus) Polydipsia
Osmotic diuresis -> Glycosuria -> cellular starvation -> stimulate
appetite center, sense of hunger Polyphagia
Cellular starvation -> weight loss

BASIC PATHOGENESIS
Main food stuff
Anabolism building up
Carbohydrates
(CHO)
Protein (CHON)
Fats

Glucose
Amino acids
Fatty Acids

Catabolism breaking
down
Glycogen
Nitrogen
Free fatty acids
cholesterol and ketones

Blood circulation contains nutrients CHO[ ->increase glucose in blood > stimulate pancreas to secrete insulin -> insulin transport glucose
inside the cell, but it needs a receptor] blood removed glucose hypoglycemia, CHON, Fats
Cell -> will undergo chemical reaction converts glucose to ATP= main
fuel of body
Some glucose are stored = glycogen, reserved glucose for future use in
skeletal muscle and liver

Gluconeogenesis
Liver -> release protein -> converted to glucose -> no insulin -> osmotic
diuresis
Increased CHON catabolism -> (-) nitrogen balance -> tissue
wasting/cachexia (client not taking insulin)
Increased fat catabolism -> free fatty acids by product -> release
cholesterol -> atherosclerosis -> HPN -> MI and Stroke -> Death
Free fatty acids -> Ketones -> DKA -> Acetone breath odor and
Kussmauls respiration -> Diabetic Coma -> Death
Q: What is the part of the brain controls thirst and hunger?
A: HYPOTHALAMUS
Liver largest gland
Pancreas produces insulin
DKA DIABETIC KETOACIDOSIS acute complication of Type I DM,
characterized by severe CNS depression due to hyperglycemia
1.
a.

Precipitating Factors:
Hyperglycemia

26

b.
c.

Stress - #1
Infection

2. Signs and Symptoms:


a. Polyuria, Polydipsia, Polyphagia
b. Glycosuria
c. Weight loss *early sign
d. N/Vomiting
e. Weakness and fatigue * early sign
LATE SIGN:
a. acetone breath, fruity odor
b. Kussmauls rapid shallow breathing pattern
c. Decreased level of consciousness -> COMA
3. Diagnostic Procedures
a. FBS N=80-20 mg/dl
b. BUN N=10-20mg/dl due to severe dehydration, the body is
compensating
c. Creatinine N=.8-1
d. Hematocrit red cell percentage in whole blood
always 3x hemoglobin F=12-14gms% women menstruate
M=14-16gms%
Hct F=36-42%
M=42%-48% average = 42%
4. Nursing Mgmt:
a. #1 Airway Assist in mechanical ventilation
b. #2 Administer 0.9 NaCl, PNSS, isotonic, followed by 0.45 NaCl
hypotonic.
c. Monitor VS, IO and neuro check
d. Administer meds. As ordered
Insulin
Q: What is the type of insulin given to DKA
A: Rapid acting insulin Regular - the

Sodium bicarbonate
Antimicrobial

5. Complication: HONK
HO> increased osmolality -> severe dehydration

NK -> absence of lypolysis -> no ketosis


Coma s/sx: Headache, Confusion, Seizure, Decreased LOC
Treatment of HONK: the same DKA except NaBicarbonate
INSULIN THERAPY
1. Sources
Animal pork and beef, rarely given because it can cause severe
allergic reaction
Human Humulin it has less antigenecity property it can
cause less allergic reaction
2. Types of Insulin
Rapid (Short Acting Insulin)
the only clear insulin, peak: 2-4 hours
Intermediate AI
- NPH (Non-Protamine Hagedorn)
- cloudy, peak: 8-16 hours
> Long AI
- Ultra lente
- cloudy, peak 16-24 hours
*DO NOT MEMORIZE THE ONSET AND DURATION, only PEAK
HOURS = check for hypoglycemic reaction
ex. 5am = 250 mg/dl, give 6 units of Regular A-I due at peak: 79am = check for TIRED
CBG N = 80-120mg/dl
3. Nursing Mgmt:
a. Administer insulin at room temperature to prevent
lipodystrophy (atrophy and hypertrophy of SQ)
b. Insulin only refrigerated once opened
c. Avoid shaking insulin, roll between palms only
d. Accuracy of administration is important
e. No need to aspirate after insulin injection
f. Administer insulin injection @ 45 (thin individual)-90 (fat
individual) degree depending of the amount of tissue
deposit
g. Gently rotate insulin sites prevent lipodystrophy

27

h. Universal rule: when mixing 2 types of insulin aspirate


the clear before the cloudy to prevent the
contaminating the clear insulin and to promote accurate
calibration
4.
-

Complications:
Allergic reactions
Lipodystrophy
Somogyi Phenomenon> hyperglycemia followed by periods of
hypoglycemia

Nice to

know:
Horse anti tetanus
Goats brain anti rabies
Chicken anti-measles (most
expensive)

ORAL HYPOGLYCEMICS
for Type II
Mechanism of action: Stimulates the pancreas to secrete insulin
1. Classification of OHA ending NASE
First generation sulfonylureas ex. Chlorpropamide (Diabenase)
1.
Tolbutamide (Orinase)
2.
Tolazamide (Tolinase)
Second generation sulfonylureas

1.
Glipzide (glucotrol)
2.
Diabeta (Micronase)
3.
Nursing Mgmt in giving OHA:
1. Instruct the client to take it with meals, to lessen GIT irritation
and to prevent hypoglycemia
2. Instruct the client to avoid alcohol- because added OHA can
result to severe hypoglycemic reactions
Diagnostic Procedures for DM:
a. FBS if it is increased 3 consecutive times plus 3 Ps and 1 G, it
confir
Nice to know:
ms
Most accessible and most safe: ABDOMEN
prese
Q: What needle gauge? A: G25-26 small bore needle
nce of
DM,
Use Insulin syringe or tuberculin syringe
use
(1cc/ml=100units -0.5ml=50units -0.1ml=10units)
gluco
meter
1ml of tuberculin syringe = 100 units of insulin
, prick
index
*too much insulin -> leads to hypoglycemia -> insulin
finger
coma -> death

sides
only lesser nerve endings wipe it with saline solution-if no saline
soln use dry cotton, dont use alcohol (fermented sugar = ethyl it
can alter the result)
b. Random blood sugar RBS it is elevated
c. Oral Glucose Tolerance Test (OGTT) it is elevated, most sensitive
test
d. Alpha Glycosylated Hemoglobin
Nursing Management for DM:
1. Monitor for signs and symptoms of hypoglycemia (TIRED)-cold
and clammy to touch -> offer hard candies or 1 glass of orange
juice => needs simple sugar for easier digestion and easier
glucose formation (coke and chocolate =>complex sugar) and
hyperglycemia (PPP) warm and dry to touch -> administer
insulin

28

Q: A client has history of DM, one morning her body was found in
the floor, unconscious
A: The brain can tolerate an increase/excessive amount of glucose,
but the brain can never tolerate deficiency of glucose->offer simple
sugar
2. Monitor strictly VS, Blood sugar, and I/O
3. Diabetic diet CHO 50%, CHON 30%, Fats 20% or offer alternate
food products/beverages: glass of orange juice
4. Exercise after meals - to promote increase utilization of glucose
5. Monitor for complications:
atherosclerosis -> HPN -> MI or CVA (Stroke) Neuropathy
Microangiopathies: affects the small capilliaries and arteries of
the eyes: premature cataract -> retinopathy -> blindness
and
kidneys -> recurrent pyelonephritis (inflammation of the
renal pelvis) -> Nephropathy or Renal Failure
gangrene formation
Shock
Peripheral neuropathy -> diarrhea -> constipation ->
sterility/impotence
6. Institute foot care management
a. Instruct the client not to walk barefooted
b. Encourage client to apply lanolin lotion to prevent skin
breakdown
c. Instruct the client to cut toenails straight
7. Instruct the client to avoid wearing constrictive garments
8. Encourage annual eye and kidney exam prevent retinopathy
and nephropathy
9. Monitor for signs of DKA or HONK
10. Assist in surgical wound debridement
11. Assist in surgical procedure:
a. BKA - Right below the Knee Amputation Procedure
b. AKA above knee amputation

29

01/28/2006
Hematology
Hematologic System
Consists of 3 structures:
1. Blood forming organs: > produces blood cells
a. Liver largest gland right hypochondriac region
b. Thymus located near the sternum, removed Thymus
Myasthemia Gravies autoimmune antibodies
c. Spleen kills the RBC once it reaches 80-120 days old,
proximal to the liver, when hepatomegally occurs, there
will be spleenamegally
d. Bone marrow- red bone marrow epiphysis RBC WBC
platelets, yellow bone marrow long bones humerus,
femur, fats cells most feared complications of fracture
of femur: fat embolism dyspnea & chest pain,
hemorrhage, compartment syndrome
e. Lymph nodes
f. Lymphoid organ - Salmonella Typhi Payers patches
rose spots in the abdomen defense mechanism
between small and large intestines for Thypoid fever
g. Veins LARGEST: superior & inferior vena cava, jugular
veins - towards heart unoxygenated blood dark red superficial
h. Arteries LARGEST: aorta & carotid artery away the
heart, scarlet red oxygenated blood deep
i. Capilliaries NOTE: Alternate expansion and recoil of artery = PULSE
Varicosities venous ulcer elevate legs
Thrombophelbitis deep vein thrombosis- Homan sign - venous
Aneurysm Abnormal dilation of an artery lead to subarchnoid
hemorrhage - arterial
Reynauds disease arterial Female 40 yrs old and above hands or
digits bluish, have intermittent claudication pain upon walking or
excertion, gangrene formation - smoking
Buergers disease Thromboanginitis Obliterans arterial smoking,
Male 40 yrs old and above feet bluish, have intermittent claudication
pain upon walking or excertion, gangrene formation,
III. Blood

a. 55% Plasma color yellow pigment bilirubin

NOTE: red cell pigment hemoglobin, green biliverdin, golden brown


pigment hemostindirin

Serum
Plasma Proteins
a. Albumin
most abundant in plasma protein maintains osmotic pressure
thereby preventing EDEMA
b. Globulin
1.
Alpha transports hormones, steroids, and bilirubin
2.
Beta transports iron and copper
3.
Gamma transports antibodies, immunoglobulins 5:
G-chronic, maternal circulation A-sweat, tears M-acute
E-allergic
c. Prothrombin clotting factors lead to bleeding and
hemorrhage when lack of clotting factors
d. Fibrinogen clotting factors lack of c & d Disseminated
Intravascular Coagulation

Cellular components:
RBC
Normal value=erythrocytes 4-6M cubic mm
biconcave disks
NOTE: theres hemolytic anemia in which the RBC assumes an Sshape structure SICKLE CELL anemia immature RBC easily
destroyed by spleen hemolysis- low rbc, low oxygen.
Priority Nsg Mgmt:
1. Airway = avoid deoxygenating activities
Q: Sickle cell anemia patient what exercises to indulge:
a. Mountain climbing - x
b. Hiking - x
c. Bowling -
d. Ice Skiing x
Anti-sickling agent Hgb-S via IM can use before flying
2. Force fluids
3. Pain (Comfort) if too much vaso occlusion blood flow
decreased > ischemia -> hypoxia o2 low in tissue-> anerobic
metabolism -> lactic acid -> irritating to tissue, stimulates
mediators, release of prostaglandin->stimulate nociceptor->pain
sensation; Give: Mefenamic acid inhibits prostaglandin

30

decreased in RBC Anemia early sign: Weakness low hgb


low oxygen complete bed rest
increased in RBC Polycythemia early sign: Headache; late
sign: Pruritus/ Urticaria due to abnormal anti-histamine, can lead
to Thrombosis, HPN, CVA, Stroke TIA early sign: headache
A. RBC is anucleated
B. Molecules of Hgb (carries oxygen)

Hgb
F = 12-14gm %, lower blood volume due to women have monthly
menstruation
M = 14-16gm %, blood volume is higher
Child = higher blood volume compared to adults
C. HEMATOCRIT RBC percentage, 3x hemogblobin
Hct
F = 36-42%
M = 42-48%
Q: A client suffered a 3rd degree burns (Priority: Fluids & electrolytes),
the nurse will notice after 24-48 hours that the hct:
Pred factor: 3rd deg burn -> hypovolemia->ischemia->Hypoxia->major
stimulus for erythropoiesis-> stimulate kidneys->to secrete
erythropoietin -produced @ MACULA DENSA -> stimulate one marrow >increased RBC -> increased Hct
A: Elevated compensation
B: Decreased
C: The same
D: No change at all
Q: a pregnant woman on 1st trimester needs a larger amount of FOLIC
ACID to prevent neural tube defect SPINA BIFIDA/Myelo?-prone
position
3rd trimester needs IRON
WBC Basophil, Neutrophil, Eosinophil with granules granulocytes
In clients with DKA, Acute renal failure, 3rd degree burns Hct is
ALWAYS ELEVATED due to compensation
D. Substances needed for maturation of RBC
1.
folic acid
2.
iron
3.
vit B12 (Cyanocobalamin)
4.
vit C (Ascorbic Acid)

5.
vit B6 (Pyridoxine)
6.
intrinsic factor
E. Normal lifespan 80-120 days
F. Spleen graveyard of RBC at red pulp
WBC phagocytosis (Leukocytes)
Normal value = 5-10,000
Decreased WBC = Leukopnea increase susceptibility to infxn
Increased WBC = Leukocytosis (+) to infection
A. Granulocytes: (too check how long your infection, use the
differential count)
1. Polymorphonuclear Neutrophils > the most abundant of all
WBC, constitute 60-70% of WBC > involved in short term
phagocytosis-> acute inflammation because lifespan is only
good for 3-4Hrs (replaced by MOnocytes)
2. Polymorphonuclear Eosinophils > allergic rxn
3. Polymorphonuclear Basophils > involved in parasitic infxn >
involved in the release in chemical mediators for inflammation
(Prostaglandin, Histamine, Serotonin, Bradykinins) >
*RESPONSIBLE for dissolving or ingesting fat particles after
ingestion of high fat meal (presence of cholesterol if too much
fats and minimal basophils)
B. Monocytes the largest WBC (Macrophage) > fxn opposite of
neutrophils > long term > chronic inflammation > life span 8-12
months > non-granulocytes
C. Lymphocytes > non-granulocytes
B cells (arises from bone marrow)
T cells (arises from Thymus) > target site of HIV (incubation
period: 6mos to 5 yrs, window period: 6months-subjected to
ELISA-inaccurate-enzyme link immunosorbent assay,
confirmatory test = Western Blot) > non-granulocytes
NK (Natural killer cells) > have both anti-tumor, and anti-viral
property
III. Platelets (Thrombocytes)
Normal Values =
Promotes hemostatis prevention of blood loss
Immature/baby platelets Megakaryoctes, target site of virus =
Dengue Virus(Aedis Aegypti) increased capilliary fragility
Petechiae internal bleeding

31

Signs of Platelet dysfunction: low platelet


1. Petechiae
2. Ecchymoses (purpura-many ecchymoses)
3. Oozing of blood from venipunctured sites
Disorder: DIC (provide heplock because it is contraindicated to injection)
Hemophilia-pedia = both risk for HEMORRHAGE (Hypovolemic shock)
MOST DANGEROUS: Plasmodium Falciparium may lead to irreversible
brain damage, hemorrhage->hypovolemic shock (late sign: anuria)
NOTES: HIV complications:
4. Kaposis Sarcoma - skin
5. Pneumocystic carini pneumonia
6. Drug of choice: AZT(Zidovudine or Retrovir)
Platelets Normal lifespan: 9-12 days
7. Monocytes, Lymphocytes without granules non
granulocytes
Platelet namuo blood clot
Note:
What is the nsg dx decreased albumin & osmotic pressure? Impaired
SKIN INTEGRITY
PLASMA protein produce by liver
IRON DEFICIENCY ANEMIA
1. Incidence rate:
a. Common on developed countries: USA
#1 due to DIET Increase cereal intake milk products less iron
#2 Trauma, due to accident -> blood loss -> anemia
nice to know:
Teenagers
Children
Infant

Suicide
Poisoning-Aspirin
SIDS, suffocation

b. Common tropical areas: Philippines blood sucking parasites

b. Common tropical areas: Philippines


2. Causes:
c. inadequate absorption of iron due to:
- Chronic diarrhea
- r/t increased cereal intake with decreased animal CHON ingestion
- malabsorption syndrome
d. Inproper cooking of foods
Signs/Sx:
a. Usually asymptomatic
b. Headache
c.
Dizziness
d.
Palpitations - low o2, compensation increase pumping of blood
e.
Cold sensitivity
f.
Generalized body malaise
g.
Pallor
h.
Brittleness of hair
i.
Spoon shaped nails Koilonychia
j.
Atrophic glossitis inflammation of the tongue, Stomatitis
mouth sore, dysphagia = collectively known as PLUMMER
VINSONS SYNDROME
k.
Pica, abnormal appetite, craving for non-edible foods -> cerebral
hypoxia->psychosis-> neuronal impairment-> body will find an
immediate alternate source of nutrients (oxygen & glucose)
NOTES: Nails 180 degrees normal, form a diamond shape, thumb to
thumb
4. Diagnostic Procedure: ALL LOW
1.
RBC
2.
Hgb
3.
Hct
4.
Reticulocytes
5.
Iron
6.
Ferritin
RBC (80-120days) -> Spleen -> hgb disintegrate into ->>heme & ->>
globin ->back to spleen, while heme ->> ferrous & -> bilirubin & >biliverdin , ->>ferretin -> back to spleen

32

c. Women 15-35 yrs old-reproductive age


d. Common among the poor nutrition deficiency
Chronic

blood loss due to:


heavy trauma
menstruation
GIT bleeding
hematemesis = vomiting of blood
melena = passage of black tarry stool indicates upper GI
bleeding stomach, small intestines
hematochezia = fresh blood in stool indicates lower GI
bleeding large intestines
hemoptysis = coughing of blood

Bilirubin-> GIT (N flora) ->>Urine (urobilin), ->>stool (stercobilin)


If without bilirubin: urine tea colored, stool clay colored
Alicia Dionisio member Psychiatric nursing 200 items
Q: What is the most possible cause of death of count Dracula?
A. Eczema skin wounds
B. Halitosis bad breath
C. SLE butter fly rash
D. Porphyria increasing porphyrin (encircles ferritin) rings in the blood
severe photophobia, and psychotic behavior
5. Nursing Management:
a. Monitor for signs of bleeding of all hematest including
urine, stool and GIT
b. Enforce CBR, so as not to overtire the client
c. Encourage increased iron diet:
Iron - #1 California Raisins, egg yolk, organ: liver, meat,
legumes, green leafy vegetables, sweet potato
d. Avoid tannates-major substance mixed in coffee & teagives color brown (impairs iron absorption) in tea
e. Administer medications as ordered: oral iron
preparations: ferrous sulfate, Fe gluconate, Fe fumarate
300mg/OD- take it with meals, to lessen GIT irritation,
when diluting to liquid iron preparation: administer with
straw to prevent staining in the teeth

f.

Instruct with Vitamin C, orange juice to facilitate


absorption.
g. Monitor, and inform client of SE: all GIT
1.
Anorexia
2.
Nausea and vomiting
3.
Abdominal pain
4.
Diarrhea/constipation
5.
Melena
h. If the client can not tolerate iron preparation, theres poor
compliance to iron preparation administer parenteral iron
preparations Iron Dextran IM or IV, Sorbitex IM
Nsg Mgmt:
1. Administer z-track method to prevent discoloration,
discomfort, leakage to tissue
2. Avoid massaging the injection site, instead encourage
client to ambulate
3. Monitor and inform client of SE
6.
pain at injection site
7.
localized abscess
8.
Lymphadenopathy
9.
Fever and chills
10. Pruirtus and urticaria
11. Hypotension, if (+) Anaphylactic Shock = Epinephrine
SE: SNS, all increase except GIT
To use straw:
Tetracycline
Lugos
Iron
Nitrofurantoin macrolantin
Chinese: white : genetic, diet=tea
PERNICIOUS ANEMIA megaloblastic anemia, characterized by
macrocytic anemia due to deficiency of intrinsic factor leading to
hypochlorhydric (decreased to HCl acid secretion)
- most dangerous anemia because of neurological disturbances
Pathogenesis:
Stomach

33

Parietal cells/Oxyntic/Argentaffin

Secretes
Secretes
Intrinsic factor
hydrochloric acid
Fxn: promote

Reabsorption of
Aids in digestion VS Indigestion
Vitamin B12

Dyspepsia
promotes of maturation

of RBC
calories CHON
1. Predisposing Factors:
a. Subtotal gastrectomy
- Billroth I duodenostomy
- Billroth II Jejunostomy
b. Related to hereditary factors
c. Inflammatory disorders of the ileum
d. Autoimmune
e. Strictly vegetarian diet
2. S/SX:
12. headache
13. dizziness
14. dyspnea
15. palpitation
16. cold sensitivity
17. pallor
18. generalized body malaise
GIT changes:
19. mouth sores
20. red beefy tongue
21. Dyspepsia
22. Weight loss
23. Immature RBC jaundice
Neurologic changes:
24. Tingling sensation
25. Paresthesia
26. Ataxia
27. Psychosis

Vit B12 maintains myelin sheath, without it may lead to


neurologic impairment
3. Diagnostic Procedures
28. Schillings Test reveals inadequate absorption of Vit
B12
a. Injection of nonradioactive vit b12 given at IM Gluteus
maximus, or radioactive b12 ingested, Urine samples are
collected (water soluble vitamins, easily to excrete
through urine)- High vit B12
4. Nursing Management
a. Enforce complete bed rest
b. Administer Vit B12 injections at monthly intervals for
lifetime as ordered, should not be given orally- client
may develop resistance, NOT DAILY, major SE: NONE
c. Increase caloric intake, CHON, CHO, Fe, and Vit C
d. Encourage client to use soft bristled toothbrush and
avoid irritating mouthwashes due to mouth sore, red
beefy tongue
e. Avoid heat application- can lead to burns
Q: What are the sites of Vit B12 injections?
A: Ventrogluteal and dorsogluteal
APLASTIC ANEMIA
It is a stem cell disorder characterized by bone marrow depression ->
leading to Pancytopenia (All blood cells are decreased ->> decreased
RBC (Anemia) s:weakness, ->>decreased WBC (Leukopenia)s:increased
susceptibility to infection, ->> decreased platelets (thrombocytopenia)
1. Predisposing factors
a. Chemicals
29. Benzene and its derivatives
b. Irradiation
c. Immunologic injury
d. Drugs
30. Broad spectrum antibiotics
Chloramphenicol
Sulfonamides (Bactrin) co-trimoxazole (UTI)
31. Chemotherapeutic Agents
Nitrogen Mustard (anti-metabolite)
Vincristine (Plant Alkaloids)

34

Methotrexate (Alkylating agent)


Signs/Sx:
Anemia Headache
Dizziness
Dyspnea
Palpitations
Pallor
Cold sensitivity
Generalized body malaise
Leukopenia increased susceptibility
Thrombocytopenia PEO
32. Petechiae
33. Ecchymoses
34. Oozing blood
3. Diagnostics
35. CBC reveals Pancytopenia
36. Bone marrow biopsy or aspiration reveals fatty
streaks in the bone marrow
Q: Site of bone marrow aspiration
A: posterior iliac crest
2.
a.
b.
c.
d.
e.
f.
g.
h.
i.

4.
a.
b.
c.
d.
e.
f.
g.
h.

Nursing Management:
Removal of underlying cause
BT as ordered
Enforce complete BR
Administer O2 inhalation
Institute reverse isolation
Monitor for signs of infection: fever cough
Avoid IM, SQ or any venipuncture sites provide heparin lock
Administer medications as ordered:
37. Immunosuppressants: Anti-lymphocyte Globulin
given 6days to 3 weeks via central venous catheter to
achieve the maximum effect of the drug

DISSEMINATED INTRAVASCULAR COAGULATION an acute hemorrhagic


syndrome, characterized by wide spread & spontaneous bleeding &
thrombosis due to deficiency of prothrombin & fibrinogen -platelet
disorder
1. Predisposing Factors
a. Rapid BT

b.
c.
d.
e.
f.
g.
h.

Massive trauma
Massive Burns
Neoplasia -New growth of tissue or tumor
Anaphylaxis
Hemolytic Reactions
Pregnancy
Septicemia

2.
a.
b.
c.
d.
e.
f.

Signs and symptoms:


Petechiae whole body
Ecchymoses whole body
Oozing of blood
Hemoptysis scarlet red
Hemorrhage
Oliguria (late sign)

3. Diagnostic Procedure:
38. CBC reveals thrombocytopenia
39. Stool for occult blood (+)
40. Ophtalmoscopic exam
41. ABG analysis metabolic acidosis
Metabolic
acidosis
Chronic
Diarrhea
DM
Ileustomy

Metabolic
Alkalosis
Projective
Vomiting
Pyloric stenosis
Cushing

Respiratory
Acidosis
Emphysema

Respiratory
Alkalosis
Hyperventilation

Bronchitis

ROME respiratory
Before ABG, patient should be (+) Allens test: determines collateral
circulation, press radial & ulnar artery
ABG Normal Values
1.35-1.45
35-35
22-26
Polycytemia late sign- pruritus

35

Acidic hematemesis coffee ground, with HCl


4.
a.
b.
c.

Nursing Management
Monitor for signs of bleeding of all hema tests
Administer IV fluid replacement as ordered isotonic
Administer oxygen inhalation as ordered
42. Vitamin K (Aquamephyton)
43. Heparin short acting
44. Vasopressin, Pitrissin to prevent urination,
conserving water
d. Provide heplock, avoid IM SQ or any venipuctured sites
e. Institute NGT decompression gastric lavage
45. iced saline solution
46. cold saline solution
f. Prevent complications: Hypovolemic SHOCK, late sign = anuria
NOTES:
NGT tube kink closed for feeding gavage
NGT tube open drain sa bed side bottles lavage remove gastric
contents decompression
Give ice or cold water saline solution instill 1 litter, then decompress
BLOOD TRANSFUSIONS
1. FOUR objectives:
1.) To replace circulating blood volume
2.) To increase the oxygen carrying capacity of the blood
3.) To combat infection if decreased WBCs
4.) Prevent bleeding if decreased PLT
2. Nursing Management:
47. proper refrigeration
48. proper blood typing and cross-matching
O - universal donor
AB universal recipient
85% of general population is Rh (+)
49. Aseptically assemble all materials needed for BT:
Filter set (BT set)
PNSS isotonic to prevent hemolysis
Needle gauge 18-19 large bore needle
50. Instruct another RN to re-check the following
Name of patient

BT and crossmatching
Expiration date
Serial number
51. check blood unit for presence of bubbles, cloudiness,
sediments and dark color signs of contamination DO NOT DISPOSE, RETURN TO THE BLOOD BANK, for
re-exam
52. NEVER WARM BLOOD PRODUCT, it may destroy vital
components in the blood, wait for 30 minutes, let room
temperature warm the blood product, NEVER WRAP IT
53. WARMING of blood, used only through warming
DEVICE, emergency-RAPID BLOOD TRANSFUSION
54. Transfusion should be completed in 4 hours, blood that
is exposed more than 2 hours causes blood
deterioration, can result to bacterial contamination
55. Avoid mixing or administering drug at BT line may
cause to hemolysis
56. Regulate at KVO (Macro- 10-12gtts/min) at 100cc/hr
to prevent circulatory overload
57. Monitor VS BEFORE, DURING & AFTER transfusion,
especially every 15 minutes (majority of transfusion
rxn occurs in this period) for the first hour.
3. Signs of BT reaction - HAPCATCH
Hemolytic Reaction
Signs/sx:
58. dizziness
59. headache
60. dyspnea
61. hypotension
62. flush skin
63. lumbar, flank, sternal pain
64. red colored urine (portwine urine)
Nsg. Mgmt:
1. Stop the blood transfusion
2. Notify the physician
3. Flush it with PNSS, to prevent hemolysis
4. Administer isotonic fluid solution as ordered to counteract shock &
prevent acute tubular necrosis (leads to renal failure)
5. Return the blood unit to the blood bank for re-examination
6. Obtain urine & blood samples to laboratory for re-examination
7. Monitor vital signs

36

Allergic Reaction:
s/sx:
65. fever, chills
66. dyspnea
67. laryngospasm
68. bronchial wheezing
69. urticaria, pruritus
Nursing Mgmt:
1. to 3 same
4. Administer anti-histamines as ordered Diphenhydramide Hcl
(Benadryl) drowsiness, avoid driving and operating machineries
5. If (+) hypotension due to anaphylactic reaction
6. Return blood to blood bank (same)
Pyrogenic Reaction
s/sx:
-fever and chills
- headache
- dyspnea
- tachycardia and palpitations
- diaphoresis
Nursing Mgmt:
1. to 3 same
4. Administer anti-pyretics & antibiotics as ordered
5 to 7th same
8. Provide TSB
Circulatory Overload
S/Sx:
70. dyspnea
71. rales/crackles
72. orthopnea
Nsg Mgmt:
1 to 2 same
3. Administer loop diuretics as ordered: Lasix 10-15mins 6 H, given AM
Air embolism
Thrombocytopenia

Citrate intoxication hypocalcemia, tetany, trousseous sign


Hyperkalemia indicates that blood is already expired lead to
arrythmia
Q: You have 4 patients, who will the nurse help in emergency case?
A: Hemolytic reactions
B: Allergic
C: Pyrogenic
D: Circulatory
Next is Anaphylactic reaction
Verbal order during emergency only, let another doctor to sign it for
the other doctors order
Administer KCl 11.5 meq/L- (should be given 3.5-5.5meq/L) to be given
via IV bolus now (may lead to cardiac arrest, should be given IV drip)
Hypotonic solution: what happened to the cell? SWELL
Hypertonic solution: SHRINK
Insulin G25-26
RBC 1 unit/pack = 3-6 days refrigeration = 250cc
Platelet bag expiration = 3-5 days refrigeration = 110cc
Whole blood with plasma= 2-3 months = 500cc
Oncology Nursing
Differences
Differentiation
Encapsulation
Metastasis
Prognosis
Tx modality

Benign (Tumor)
well differentiated
with capsule
(-)
Good
Surgery-most chosen
treatment

Malignant (Cancer)
poorly differentiated
without capsule
(+)
Poor
Chemotherapy
Radiation many side
effects
Surgery
Bone marrow
Transplantation
Normal growth of cell: by straight line, with structure, pantay
Cancer cells: They pile each other, forming mass

37

Oldest type of cancer BREAST CANCER


1. Predisposing Factors (Carcinogenesis)
GIVE
73. Genetic history (smoking, drinking, staying late at
night=immunocompromised) with oncogenes
74. Immunologic factors:
75. Viral factors: Epstein barr virus infectious
mononucleuosis KISSING DISEASE (dysphagia,
retinopathy, fever & chills, sore throat, spleenic
rupture->immediate death); Human papelloma Virus
wart-pre-carcinogenic (same as moles) (if it spreads,
tender,
76. Environmental factors
Physical factors
Radiation
UV rays
Nuclear explosion
Chronic irritation
Direct trauma: cervical cancer
(multiple sexual partners or birth)
Chemical factors
Urethrane/hydrocarbons
Food additives (nitrates/nitrites) tocino
tapa-salitre
Drugs (stilbestrol, diethylstilbestrol,
DES)
Smoking
Hormones
2. Classification (based on tissue type)
77. Carcinoma -epithelial tissue and surface of the granular
tissue
78. Sarcoma connective tissue
79. Multiple Myeloma arises from bone marrow & plasma
cells, hypocalcemia, early sign: back pain especially in
AM
80. Lymphoma arises from lymph glands
81. Leukemia arises from blood cells, CODE: ANT
Anemia

Neutropenia
Thrombocytopenia
3. Warning danger signal signs: CAUTION
82. Change in bowel or bladder movements
83. A sore that doesnt heal
84. Unusual bleeding or discharges
85. Thickening of a lump in breast or elsewhere
86. Indigestion or dysphagia
87. Obvious change in a wart or mole
88. Nagging cough or hoarness
89. Unexplained anemia
90. Sudden weight loss
91. Anemia
92. Loss of weight
NOTE: 3 to 4 (+) signs, consult a doctor
4. Therapeutic Modalities
1. Chemo-utilization of various chemotherapeutic
agents that kills the cancer cells, and also kills
normal rapidly producing cells-GIT, hair follicles,
bone marrow.
Antimetabolites
Alkylating agents
Plant alkaloids
Hormones and steroids
Antineoplastic antibiotics
5. Side effect and nursing Management
a. Hair follicles alopecia
93. Encourage use wigs turban/bandana
94. Inform client that hair loss is temporary, hair will grow
back in 4-6months after chemotheraphy
b. GIT - Nausea and vomiting:
95. NPO before procedure
96. Administer anti-emetics (Metoclopramide) Plasil 4-6
hours before chemotheraphy
97. Bland diet post-chemo
98. Diarrhea :Administer anti-diarrhea agents 4-6hrs
before chemotherapy
99. Stomatitis: provide oral care, offer popsicles
100. Dysgeusia (altered taste sensitivity):

38

c. Bone Marrow Depression Anemia:


101. CBR
102. Provide O2 inhalation
103. Leukopenia: reverse isolation
104. Thrombocytopenia: encourage client to use electric
razor when shaving
d. Reproductive organs
105. Sterility: encourage client to sperm banking before the
start of chemotherapy
106. Genetic counseling
e. Renal System
107. Lead to increasd serum uric acid
- Allopurinol
- Colchicine
f. Neurologic Disturbance
- Peripheral neuropathy
- Paralytic ileus> absence of peristalsis, the only chemotherapeutic
agent: Vincristin -plant alkaloid
II. Radiation therapy- utilization of electro-magnetic waves that kills the
cancer cells and inhibit their growth and also kills the normal rapid
producing cells
a. Types of energy emitted
108. Alpha does not penetrate skin tissues
109. Beta internal radiation; more penetrating
110. Gamma rays external radiation; penetrates deeper
underlying tissues (ex. cobalt)

117. Distance the farther the distance, the lesser the


exposure
118. Shielding alpha and beta rays can be blocked by
rubber gloves; gamma rays can be blocked by thick
lead and concrete
d. Major SE and nursing management:
119. Skin erythema/redness and sloughing of tissues
Assist in bathing
Force fluids, to flush the radioisotopes, flush water
(-) talcum powder, lotion may lead to skin irritation &
breakdown, use olive oil (NCLEX) or cornstarch (local exam)
1.
GIT N/V, diarrhea, stomatitis
2.
Bone marrow anemia, leucopenia, thrombocytopenia
Same intervention
NOTE:
Atrophy of taste buds (decreased taste sensitivity) 40 yrs old
Phils: 95% Filipino males who have cancer are aged
European: dominant gene
Q: what should be avoided post chemo?
A. custard
B. milk
C. Pork (beef)
D. Banana

b. Methods of delivery
111. External utilizes electromagnetic waves
112. Internal involves injection or implantation /
transplantation or injection radioisotopes proximal to
the cancer site
113. Sealed implant radioisotope within a container and
does not contaminate body fluids ex. Phosphorus 32
114. Unsealed implant radioisotope without a container
and contaminates body fluids
c. Factors affecting Exposure
115. Half life time required for half of the radioisotope to
decay
116. Time shorter time lesser exposure

39

01/29/06
CARDIOVASCULAR SYSTEM
Heart muscular pumping organ of the body
A. the only organ located in the midastinum Left
B. it resembles like a closed fist
C. Weighs 300-400 grams
D. This is covered by a continuous sheet serous membrane
pericardium
3.
Parietal outside
4.
Visceral middle
Pericardial fluid approx 10-20cc in the middle
of parietal & visceral, to prevent pericardial
friction
E. Layers
Epicardium
Mayocardium
Endocardium
III. Chambers
a. Atria collecting or receiving chamber
b. Ventricles pumping or the contracting medium, left ventricleHIGHEST PRESSURE: 180-250mmHg needs pressure to force the
blood going to the aorta, going to the systemic circulation
TO PREVENT backflow,
IV.
a.

b.
1.
2.

Valves
atrioventricular valves
Tricuspid
Mitral
closure of the AV valves gives rise to: 1st heartsound S1 LAB
Semilunar valves
Pulmonic
Aortic
closure of the semilunar valves gives rise to: 2nd heart sound S2
DAB
Extra heart sound
1.
S3 ventricular gallop CHF LEFT
2.
S4 atrial gallop MI HPN
IV Coronary Arteries both supply the myocardium with blood
a. Arises from the base of the aorta
b. Right main coronary artery RMCA

c. Left MCA
If one of the coronary arteries is blocked, myocardial ischemia -> angina
pectoris -> if prolonged myocardial necrosis -> MI (heart attack)
V. Cardiac conduction sytem
a. SA node pacemaker, (Keith Flock node)
located at the junction of superior vena cava and right atrium
3.fxn: primary pacemaker of the heart, it is the one that initiates an
electrical impulse of 60-100bpm
4.if heart rate is below 60 brady, above 100 tachycardia -> arrythmias
b. AV node (Tawara node)
- located at the inter-atrial septum
- theres a delay of electrical impulse NORMAL= 0.08 milliseconds to
allow ventricular filling
- secondary pacemaker, can initiate electrical impulse only for about 4060bpm
c. Bundle of His
- R and L main bundle branch
- located in the interventricular septum
d. Purkinje fibers
- located at the walls of the ventricles
- leading to ventricular contractions (1 heartbeat)
Q: complete heart block = L R bundle of HIS are damaged
N/R: needs an artificial pacemaker made of metal, every 5 years has
to be changed
Q: sign of malfunction pacemaker= HICCUPS
Coronary Artery Disease Ischemic Heart Disease
Stages:
1. Myocardial injury Artherosclerosis = presence of lipid deposits
2. Myocardial Ischemia Angina Pectoris =lead to decreased blood
flow
3. Myocardial Necrosis Myocardial infarction, unpredictable disease
Atherosclerosis
narrowing of artery
lipid and fat deposits
Tunica intima

Arteriosclerosis
hardening of an artery
CHON protein and Ca deposits
Tunica media

40

Layers of the artery :


Tunica adventitia/externa- external
Tunica media middle
Tunica intima - innermost
Coronary Artery Disease Ischemic Heart Disease
1. Predisposing Factors
5. Sex: male
6. Race: Black
7. Smoking nicotine vasoconstrictor
8. Hyperlipidemia genetic
9. Obesity - >20%
Overweight >10%
prolonged use of oral contraceptives
Sedentary lifestyle
Diet high in saturated fats WHOLE MILK
DM
Hypothyroidism
S/sx:
Chest pain
Tachycardia
Palpitations
Diaphoresis
3. Treatment
- Percutaneous Transluminal Coronary Angioplasty (PTCA)
Objectives:
> Revascularized myocardium
> prevent angina
> increase survival rate
10.
11.
12.
13.
14.
2.

deflate balloon, put KY, pasok sa femoral artery, inject dye (pre-op:
check for allergies-seafoods-shellfish dyes are iodine base), to clearly
visualize where to place the catheter, x-ray is used,if near atheroma,
syringe 10 cc insert air to inflate balloon to compress the atheroma
PTCA done to single occluded vessel
(post-op: force fluids, flush the dye, dyes are nephrotoxic agents it can
destroy the kidneys and dyes are osmotic diuretics-> leads to severe
DHN)

If 2 or more blood vessel or artery are occluded -> perform Coronary


Arterial Bypass and Graft Surgery (CABG)
1ST GRAFT give doctor 2-3 hours, get artery in the femur, placed in ice
or cold solution, open heart, xyphoid process to umbilicus, open ribs, put
valve, coronary artery cut, harvested femoral connected through
cauterized
CABG respiratory complications coughing
4. Same diagnostic/nursing management with Angina pectoris
ANGINA PECTORIS
1. Definition: a clinical syndrome characterized by paroxysmal chest
pain resulting from temporary myocardial ischemia, relieved by rest
or by taking nitroglycerine
2. Predisposing Factors: same as atherosclerosis
3. Precipitating Factors: 4E
Excessive strenuous physical exertion
Extreme emotional response
Exposure to cold environment
Excessive intake of foods rich in saturated fats
4. Signs/Symptoms:
> Initial sign: Levins sign hand clutching of the chest
> Chest pain sharp, stabbing, excruciating, crushing substernal pain
> Usually radiates from back, shoulder, arms, axilla and jaw muscles
> Usually relieved by rest or by taking NTG
> Dyspnea
> Tachycardia
> Palpitations
> Diaphoresis
5. Diagnostic Procedure
ECG -reveals ST segment depression
ST elevation MI
Stress test trendmill abnormal
Serum uric acid and cholesterol HIGH
6. Nursing Management
Nsg goal: decrease myocardial demand or workload REST the
heart
a. Enforce CBR
b. Administer medications as ordered

41

Nitroglycerin (NTG)
1.
Small doses dilates lower extremities, venous pulling
-> venous stasis -> leg retained can not return to
heart -> heart lesser pumping
2.
Large doses vaso dilator dilates all
Nursing Mgmt: (NTG)
1st dose of NTG = 3-5 mins
2nd dose of NTG = 3-5 mins
3rd & last dose of NTG = 3-5 mins
STOP giving the dose, notify the physician
Given only 3x at 3-5 mins interval, if not relieved by NTG = it is MI
1. Place the drug in a dry - AVOID heat & moisture as it may
inactivate the drug
2. Monitor side effects low BP -> Orthastatic hypotension,
transient headache, and dizziness
3. Instruct patient to rise slowly from sitting position
4. If giving transdermal patch, avoid placing near hairy areas as it
may decrease drug absorption, if hairy-shave it when giving
NGT, if auscultating put water (+) hairy chest water is good
conductor for sound waves
5. Avoid rotating transdermal patches decrease drug absorption,
avoid placing near microwave ovens during defibrillation-may
lead to burns-it contains aluminum foil in the package
6. Beta-blockers propanolol
7. ACE inhibitors captopril
8. Ca channel blockers nifedipine
9. Administer O2 inhalation low in flow 2-3LPM

4-5lpm WILL LEAD TO RESPIRATORY ARREST


10. Place client on semi-fowlers position (lung expansion)
11. Monitor strictly VS, IO and ECG tracing
12. Diet- low in saturated fats, low in sodium, low in caffeine, avoid
gas forming foods (prevent valsalva maneuver)
13. Provide health teaching and discharge planning concerning:
- Avoidance of precipitating factors: 4Es
- Prevent complications: MI
- Take medications before activity/exercise
Instruct client to take medication before indulging in physical
exertion- to achieve maximum therapeutic effect of the drug
- Importance of follow up care

MYOCARDIAL INFARCTION (MI) HEART ATTACK


1. Definition: terminal stage of CAD characterized by permanent
malocculusion leading to necrosis and scarring
2. Types: (depending on location)
3. Transmural the most dangerous of all types of MI,
characterized by occlusion (blocked) of both R and L coronary
arteries
4. Subendocardial occlusion either the L or R coronary artery
3. Critical period
6-8 hours after MI, majority of arrhythmia occurs during this
period, most common or #1 cause of death PVC premature
ventricular contraction, if PVCs and conscious assist in the
defibrillation but positive to PVC and unconscious assist in
cardioversion
Ventricular tachycardia -2nd most common cause of death,
ventricles are pumping ?180bpm -> lead to arrest N/R:
Administer Lidocaine, Xylocaine SE: Confusion
Ventricular Fibrillation NR: Administer epinephrine, assist in
defibrillation, perform advance cardiac life support or CPR
4. Predisposing Factors: same as atherosclerosis
5. Signs and symptoms:
Chest pain excruciating, visceral pain, substernal, rarely
precordial
Radiates from back, shoulder, arms, axilla, jaws and abdominal
muscles indigestion bloated may signify myocardial
infarction, dont do valsalva maneuver - may have abdominal
ischemia
Not relieved by NTG
dyspnea
hyperthermia high metabolism
initial rise in BP
cool, moist, ashen skin
mild apprehension, restlessness
occasional findings:
1.
split S1 and S2
2.
pericardial friction rub
3.
rales/crackles
4.
S4- atrial gallop
S3 CHF Left side
6. Diagnostics
Cardiac Enzymes

42

CPK MB Creatinine Phosphokinase Serum Increased


12-24H most important
2.
LDH lactic Acid Dehydrogenase Increased
3.
SGPT (ALT) serum glutamic pyruvate transaminase
can be found in liver
4.
SGOT (AST) Serum oxaloacetic pyruvate transaminase
- can be found in liver
5.
Troponin Test Increased (+) MI, result released
within 1-2hours only
6.
ECG reveals ST segment elevation and widening of
QRS complexes indicative of arrhythmia
If theres a pathologic Q wave (depressed)
indicates infarction
Peak T waves
7.
Serum uric acid increased
8.
CBC increased WBC
7. Nursing Management:
Goal: decrease myocardial workload
a. Administer medications as ordere:
>First give Morphine sulfate induces vasodilation respiratory
depression antidote- narcan naloxon and relieve anxiety
>Administer O2 inhalation, low flow at 2-3 LPM
>enforce CBR without BP (not universal abbreviation) use bedside
commode
b. instruct client to avoid activities of valsalva maneuver
c. place client on semi-fowlers position
d. Diet provide general liquid to soft diet avoid saturated fats, sodium,
caffeine, and gas forming foods
e. monitor VS, IO, ECG strictly ST elevation QRS widening
f. administer medications as ordered:
- Vasodilators for high BP
- NTG
- ISDN Isorsorbide dinitrate - Isordil via SL
- Anti arrhythmic agents lidocaine
- beta blockers
- ACE inhibitors
g. Administer medications as ordered
- Thrombolytic/Fibrinolytic agents (should be administerd within 12 hours
post MI)
> Streptokinase SE: allergic rxn
> Urokinase
1.

> Tissue Plasminogen activating factor SE: chest pain


monitor for bleeding time
g. administer medications as ordered
9.
anticoagulants
heparin
coumadin
10. antiplatelets PASA aspirin due to anti-thrombotic
CI: Dengue, ulcer, un known cause of headache
h. encourage patient to take 20-30 cc/week of whiskey or brandy
to induce vasodilation red wine- prevent clot of fat
i. assist in surgical procedure CABG
j. PROVIDE HEALTH teaching and d/c planning
11. avoidance of precipitating factors
12. prevent complications
arrythmias
cardiogenic shock late sign MI: OLIGURIA
L CHF
Thrombophlebitis hOmans sign
DRESSLERS SYNDROME or post MI syndrome
the client is non-resistant to pharmacological
agents
Administer 15-400T units of
streptokinase as ordered
13. regular adherence to medications
14. resumption of ADLs especially sexual activity (4-6
weeks post-cardiac rehabilitation CABG) and instruct
patient to have sex as appetizer rather than a dessert > have sex before meals, not after meals
assume non-weight bearing position
missionary normal, 69, 88
CPK MM for brain
Q: What is the initial question- angina pectoris?
A: What did you do prior to having the chest pain?
Q: What is the second question to ask?
A: is the chest pain radiates? problem is cardiac in nature
If it does not radiate respiratory in origin Pneumonia,
Emphysema, PTB, Pleural effusion
NTG is given sublingually prick it gel
Universal RULE: when given small doses renal dilator

43

02/04/06
PSYCHIATRIC NSG:
Thoughts -> Feelings
I am not prepared -> nervous -> restless
This is not right! -> angry -> frown
At last, after 48 years -> excited -> open eyes
Im on a diet -> hungry
I lack sleep -> sleepy -> closed eyes, open mouth, drooling
Somebody kissed me -> loved -> happy
No txt, no luv -> unloved -> sad
I am the queen of the world -> self-esteem -> flamboyant heavy make
up
Life is empty -> sad -> withdrawn suicide
The FBI is out to get me! -> sad scared -> withdrawn violent
I am fat. Fat is beautiful -> self-esteem
I am fat, Fat is ugly -> self-esteem -> diet, diet, diet
Belief determines your feelings
Feelings determines your behavior
Grandma slouching, sad, low self-esteem, withdrawn -> talk to her
NOTE: 1. Whatever you see, what you say
You seemed sad/happy today. -> the person seemed interest, the
person thinks he/she is important
NOTE: 2. Restating:
You are so sad today?
You dont want to eat?
*Listening to the client, whatever client she/he says is important
NOTE: 3. Recognition
You have done something right. You have combed hair, arranged the
bed.
NOTE: 4. Present reality
You are a monster. -> Good morning, mam. Im not a monster, I am
wilen. I will be your nurse for today.
Why are they dysfunctional? Why they are not normal? Why are they
different from us?

we are the result of whatever happened to us when we were


kids
Structure of Personality
ID
EGO
SUPEREGO
Impulsive
Delays gratification
I want to impronto
Should not
Pain avoidance
Executive decision
Small voice of God
Pleasure Principle
Reality Principle
Conscience
MAN
Schizophrenia
OA
Manic
Impaired reality
Obsessive Compulsive
Anti-social
perception- ego
Anorexia Nervosa
Narcissistic
disintegration

The Factory = Earth & Factory worker Mother


Libido sexual energy responsible for survival
It began when we were born
0-18 months survival
want to eat, sleep, urinate, defecate
ID developed CRY-> mother gives breast nipple SUCK ->
MOUTH = ORAL STAGE
When the child cries ->>Feed the infant -> important -> happy
-> successful
When the child cries ->>If ignore the infant -> not important ->
NARCISSISTIC = to meet their needs for the entire lifetime
FIXATION= when a person is stuck in a certain developmental
stage
Mouth smoking, eat, talk, bite, suck, drink, gossip, lick, kiss,
chew REGRESSION return to an earlier developmental stage
EGO 6 MONTHS
18months 3 years old ANAL STAGE
You should NOT
Toilet Training
SUPEREGO is developed
Ambivalence = Pulled to 2 forces to stay or not to stay
TT ->>Good mother -> Successful SuperEgo
TT->> Bad mother ->> Clean, organized, obedient, OBSESSIVECOMPULSIVE = Strong Superego = Anal Retentive

Sigmund Freud father of psychoanalysis

44

TT-> Bad mother ->> Dirty, disorganized, disobedient ANTISOCIAL = Weak Superego and ID = Anal Expulsive

Q: But whos anal retentive and anal expulsive?


A: Anal expulsive Anti-Social
A: Anal retentive Obsessive Compulsive

3-6 years old


PHALLIC STAGE
Preschooler
Penis
Vagina
Parents
Will have a relationship with the opposite sex parent
Oedipus Complex - Boy loves mommy, IDENTIFICATION =
imitates daddy, afraid of removing his testis Fear of Castration
Electra Complex - Girl loves daddy, IDENTIFICATION = imitates
mommy, Penis envy thinking of somebody cut off your penis,
wants to have it

Dr. Karen Horney disagrees with Dr. S.Freuds concept of Penis Envy
SUPPRESSION = conscious forgetting of an anxiety provoking
concept
Conscious = theres a level of awareness
Preconscious= tip of the tongue
Unconscious = unconscious forgetting of an anxiety provoking
concept/idea = REPRESSION= ex. birth traumatic experience =is to
be forgotten, not worth recalling, stored place

6-12 years old


School LATENCY dormant, submissive, TULOG
School phobia = Separation anxiety
Reading, WRiting, ARithmetic
SUBLIMATION = Placing sexual energies toward more
productive endeavors
12 ABOVE = GENITAL STAGE Gising
most important, responsible of sexual intercourse, continuation
of human species

PHARMA MOMENTS:

ANTI-ANXIETY
V alium
L ibrium Liberty
A- tivan Ate guy
S erax Sira ulo
T ranxene LR -Transit
M iltown meal town down town
E quanil aqua/tubig
V istaril larVabista
A tarax Ang dami rocks
I nderal hINDE RALph
B uspar Bus pa taRa na
Ex. Childhood Kurt Cobain 27 years old, when he was 4-8 years old
Thanksgiving he performed, bullied, nobody wants to keep me=
became a successful Nirvana vocalist but killed himself, feeling of
emptiness
Erik Erikson theres more to life than just sex,
hence, the psychosocial theory of development
Stage
+
Factor
0-18
TRUST
MISTRUST
Feeding
months
18mos -3
AUTONOMY
SHAME/
Toilet training
y/o
- stand on his
DOUBT
own
3 6 y/o
INITIATIVE
GUILT
Independence
- imitates
-anger turned
parents
inwards
- initial steps
6-12 y/o
INDUSTRY
INFERIORITY INDUStry
- many steps
in da skul - SCHOOL
12-20 y/o
IDENTITY
ROLE
PEERS
The garden of
CONFUSION
Belief#1 Education is
life:
valuable
Belief #2 Success can
Who am I?
be achieved by
perseverance
Belief#3 I have the
capability to effect
changes in the society

45

20-25 y/o
25-45 y/o

45 &
above

INTIMACY
GENERATIVITY
grab
opportunity,
learning
EGO
INTEGRITY
- aging
- examine life,
replay events
- embrace all
experiences
because it
contributed to
their
development

ISOLATION
STAGNATION

LOVE
PARENTING

DESPAIR

REFLECTION

Abraham Maslows Hierarchy of Needs


SelfActualization
Self-Esteem
Love & Belongingness
Safety and Security
Basic Needs: air, food, shelter, clothing, sex
Psychiatric Nursing goals:
1. Love & belongingness
2. Self Esteem
3. Self Actualization
As a nurse, the role is to:
Acknowledge whatever the client has done
- to improve the clients condition until the client reaches selfactualization
Behavioral Models:
Ivan Pavlovs Classical Conditioning
all behavior is learned
1939, laboratory experiment, food = stimulus, has been shown
to a dog, dog salivates, he used a bell, followed by the food

BF Skinner Operant Conditioning


behavior can be repeated
positive reinforcement = reward = result to repetition of
behavior
negative reinforcement = punishment = behavior is
stopped/extinct
Frontal Lobe
Language
Learning
Personality
Judgment

Occipital Lobe
Vision - eyes

Temporal Lobe
Hear
Smell

Parietal Lobe
Touch
Taste

CN
Olfactory
Optic
Oculomotor

ACTION
smell of food
open eyes - sight
move up light brighten up eyes constrict,
movement of pupil
Trochlear
look down food thrown at the floor
Trigeminal
pray 3, chewing
Abducens
look at the sides
Facial
taste, facial expression
Vestibulocochlear balance, hear
Glossopharyngeal throat, swallow
Vagal/vagus
bagal-parasympathetic
Accessory
move shoulders-happy
Hypoglossal
movement of tongue-Belat
How do you interact with your environment? SIM
SENSORY
Eyes
Nose
Ears
Tongue
INTEGRATION
MOTOR->> Voluntary = Voluntary Nervous System = SOMATIC
NERVOUS SYSTEM begins from the brain ->Spinal Cord -> Motor
Nerve [Synapse-neurotransmitter: ACETYLCHOLINE = chemical
responsible for movement ON]->Muscle Fiber
->>Involuntary = AUTOMATIC AUTONOMIC NERVOUS SYSTEM

46

ANS
----------------------------------------------
Sympathetic-Anticholinergic
Parasympathetic-Cholinergic

heart rate
heart rate
RR
RR
GI Constipation,Dry Mouth
Diarrhea, Moist Mouth
GU Retention
Urinary frequency
Dilate pupils DILAT-ALERT
Constrict
Mydriasis
Miotic
Vaso constrictor
Vaso dilation
BP
BP
Neurotransmitter:
Epinephrine
Norepinephrine
Acetycholine
Q: The following are anticholinergic side effects of antidepressants
exept:
a. urinary retention
b. Dry mouth
c. Constipation
Q: The following are anticholinergic side effects of antipsychotic agents
except
a. Tachyardia
b. Urinary retention
c. Diarrhea correct
MONOAMINE OXIDASE INHIBITORS - PANAMA
M
PLAN
N AR DIL
P
NATE
Therapeutic Communication Techniques:
If a person is withdrawn, will you ignore the person?
Offer self: I will be here with you. I will sit with you. I will go with you.
Lets so there. Lets sit down.
Silence: You want the client to think of any topic, and let the client to
talk and talk

Making Observations: You seem sad. You have made your bed
today.
Active Listening:
What if you want a person to continue speaking?
- nodding
- eye contact
- lean forward
Broad opening:
How are you today?
How are things going today?
How are you?
Tell us about yourself?
Who are you?
How do you make it verbal?
General Leads: Go on, Im listening. And then. What else?
Exploring: Who, What, When
Restating: Im sad. Youre sad?
Im happy. youre happy?
Refocusing: Dave, Im not asking what you do, who you are?
Deltner/Videbeek/Shives Psychiatric Nursing
Reflect VS Restate
Youre hungry? VS You want cheeseburger?
Non-Therapeutic :
False reassurance: Everythings going to be fine
Changing topic/subject
Ignore the client
Value based judgement: Avoid using ADJECTIVE
Nice weather were having today
You have the most wonderful bed in the ward
Why? = putting the client in defensive position
Flattery
You should do this now = Advising = Commanding

47

In my opinion
Arguing = No, you are wrong
Mind visualize things to happen
Fantasy > mental
Reality
You have to know where to go
You must know what you really want to have in life
STRESS use DEFENSE MECHANISM:
1. Displacement transfer of feelings to a lesser threatening objects,
than the one who provoked it.
2. Denial failure to acknowledge an unacceptable trait or situation
3. Dissociation - Pschological Flight From Self = amnesia - Raped
traumatic experience = Sino ka? Sino ako? = wants to forget
4. Regression return to an earlier developmental stage fetal position
5. Repression unconscious forgetting of an anxiety provoking concept
6. Rationalization illogical reasoning for a socially unacceptable trait.
Ex. I drink because I socialize and I socialize everyday
7. Reaction Formation done the opposite of your intention. Ex. Gusto
mo sakalin pero niyakap mo. Plastik, Tupperware, Orocan, Kyowa
8. Undoing do the opposite of what you have done/action. Ex. You
shown your true feelings, frown then other smile. Felt guilty, next
time you smiled
9. Identification assume trait for personal, social, occupational role.
Ex. I want to be like my father = Personal goal. I want to be the
president = Social role. Occupational role I want to be an
architect.
10. Projection attribute to others ones unacceptable trait. PASA LOAD
ex. My friends are alcoholic. Not me, but them.
11. Introjection assume another persons trait as your own, not just,
me too! Ako din.
12. Suppression conscious forgetting of an anxiety provoking concept.
13. Sublimation destructive energies/ sexual energies/ hostile energies
put towards more productive endeavors:music, poetry, writing lyrics,
dance, art, handicraft.
14. Conversion
15. Compensation overachievement in one area to cover a defective
part

No, I did not feel angry

Anger is repressed

Conversion

Converted to physical symptoms

Nervous system
-----------------------------
Sensory
Motor
Numbness
Paralysis
16. Substitution replace difficult goals with more accessible one
SNS

Stop GABA Gamma Amino Butyric Acid


slow down
go Epinephrine/Norepinephrine

Anxiety
SNS E/NE axn: bring the GABA - Anti-Anxiety Agents

Anticholinergic

Constipation
within 1 week

Urinary ret
Seizures

Rebound Phenomenon

Abrupt

Withdrawal
---------------------Anti-anxiety------------------------------------- Dependence

drowsy

can not drink alcohol

can not drink coffee


Gradual

Dev.Orthostatic Hypotension
Tapered dose
Relaxed
Anxiety - RR

48

pH 7.35-45
CO2 35-45
HCO3 22-26

Metabolic
acidosis
pH
CO2
HCO3

Respiratory
acidosis
pH
CO2
HCO3

Respiratory
Alkalosis
pH
CO2
HCO3

Metabolic
Alkalosis
pH
CO2
HCO3

My thoughts wont shut off. Theyre constantly running, making


me worry
If a loved one is ten minutes late, the person with generalized
anxiety fears the very worst

Principles:
1.
2.
3.
4.

CO2 is opposite pH =
HCO3 is same Ph
Compensation: same direction for CO2 HCO3
CO2 HCO3 pH Normal = Fully, Abnormal = Partially

Interpretation:
1. ph acidosis alkalosis
2. CO2 opposite: RESPIRATORY
3. HCO3 same direction with the Ph: METABOLIC

PANIC
MILD

MODERATE

+1
Widened perceptual
field
Restless
Enhanced learning
capacity

+2
Pacing
Prn Meds
Valium
Librium

NR:
1. Sit
2. Dangle
3. Stand gradually
Anticholinergic SE in taking Antianxiety:
1. Constipation
2. Urinary retention
3. dry mouth
4. blurred
02/05/06
Fear something that protects us
Trade off/Price of gift of fear anxiety
Anxiety vague sense of impending doom
Doom - Parasympathetic SNS
Assess Level of Anxiety
Subjective Data:
I just dread being alone at night. I dont know why, but I do

Simple words are enough


You seem restless

SEVERE

+4
Suicide
+3
Safety
Dont know
Dont touch
what to do/
the client!
say
Respiratory
Directive:
Alkalosis
Lets go to the Breathe into
room.
bag!
Enter the room Sympathetic
Stop. Come
.here.
Anxiety

SNS

RR

CO2

pH

Respiratory Alkalosis

Nx Dx: Ineffective Individual Coping


Subjective: Hey, I can not handle things anymore.
Nx Dx: Powerlessness
Subjective: I have lost control over my life
Nx. Dx: Impaired Skin Integrity
Objective: keeps of cleaning hands

49

Planning/Implementation:
1. Decreased Level of Anxiety
2. Decreased Environmental Stimuli
3. Relaxation Technique
Manipulating the environment
Evaluation:Effective Individual Coping
6 months excessive worrying
Generalized Anxiety Disorder:GAD
Restless
Concentration difficulty
Sleep problems
Palpitations
Edge of the seat
Easy fatigability
if your worrying affects or interferes with ADLs
may lead to harm to self & others escape panic
attack
Panic attack may happen anytime
SNS activation but goes down, difficult to manage
15 to 30 minutes escalation of SNS
Agoraphobia fear of open spaces, they can not go outside
1. can still communicate with other people
Social Phobia fear of public/ other people
Victims - trauma, disaster, accident, rape, earthquake

Survivor victims who were able to cope and emerged as

new people
Flashbacks- haunted by the past

Nightmares disorder happens > 1 month

Post Traumatic Stress Disorder - PTSD


6 yrs old

Assignments
Homeworks

No assignment
No homework

You think,
Teacher may get
angry!

Anxiety

Psychosomatic
I am sick

Malingering
Somatoform
pretending to be
sick-conscious

Absent

Escape
from
teacher

Primary Anxiety
Gain

Somatoform
no pretension
unconscious
no organic basis

Nervous system
Conversion disorder
La belle indifference
No reaction to the
s/sx happening

Mama
care

Attention Secondary
Gain
-result of malingering
where attention increases
Illusion of structural defect
Body Dysmorphic disorder

Minor discomfort
Interpreted as major illness
Hypochondriasis

Favorite pastime: Symptom: Doctor Hopping


Nursing Focus: focus on clients feelings

50

Mind Psychophysiologic/Psychosomatic
Real pains/illness/ Real Symptoms
Body

SNS
PNS

Vasoconstriction
Bronchoconstriction

Cerebral
Left
Asthma
Artery
Gastric
Spasm
Artery

Migraine
O2

Mucosal lining

Stress Ulcer
* no causative agent
Duodenal ulcer Etiologic Agent: H-pylori
Thought-> Feelings->
Open
Anxiety

Burglar
Obsession-> Anxiety->

Behavior
-action
- return house
Compulsion->Anxiety

P/I: THOUGHT STOPPING RELAXATION


*explore feelings
TECHNIQUES

*gloves
*substitute
*schedule
*gradual withdrawal

Obsessive-Compulsive Disorder
fear of dirt or contamination
concern with order, symmetry, and exactness

constantly thinking about certain sounds, images,


words, or numbers
fear of harming a family member or friend
fear of thinking evil or sinful
COMPULSIONS
excessive hand washing
repeatedly checking that doors are locked and
appliances are turned off
arranging items in a precise order
repeatedly counting to the same number
touching certain objects a precise number of times
High Obsession High Compulsion
PHOBIA
irrational fear
immediate nursing intervention: REMOVAL of the
object
stimulus -> anxiety
root of the clients phobia is the stimulus
Aiming for behavioral change: SYSTEMATIC
DESENSITIZATION = gradual EXPOSURE to the
feared object. Ex: fear of snake- show black & white
picture, then colored picture, then show dead snake,
let client touch, then show alive snake, let the client
touch it. Brain/Mind is conditioned, theres a change
of perception, a new response.
Etiology of Phobia:
1. Knowledge
2. Experience

51

Psychotherapy:
1. Free Association - Free to talk any ideas
2. Catharsis allowed to express feelings
3. Transference client to therapist ex. Client thinks of
the healthcare personnel as his father
4. Countertransference therapist to client

A need for detoxification:


Detoxification withdrawal with MD supervision
Withdrawal - Stop taking a drug
1. Alcohol
2. Mouthwash
3. Elixir alcohol based

ANTI-PARKINSON AGENTS - CAPABLES


C ongentin Cogie Domingo
B enadryl
A rtane arte
L arodopa laro dapa
P arlodel ayos sa parlor
E ldeprl elderly
A kineton akin eto
S ymmetrel palit SIM

1st subdivision of Anti-parkinson CAPABLES:

ALCOHOL
1ST Generation with history of alcoholism
1. can be passed on from generations
2. genetic make up
3. environmental
Intergenerational transmission
Alcohol

Blackout
Risk for injury
awake but Memory gap
unaware

Confabulation
Inventing stories to increase self esteem

Denial
Dependence -> Tolerance substance to maintain desired
euphoria

Enabling Significant other tolerates abuser

Anticholinergics-ABC
Artane
Akineton
Bendaryl
Cogentin

Dopaminergics-PLEASE
Parlodel
Larodopa
Symmetrel
Eldeprl

THERAPY:
Avoid alcohol therapy
Never Drink Alcohol
Aversion Therapy
12-hour interval
Alcoholics Anonymous
or else, nausea, vomiting and
Antabuse-Disulfiram
hypotension

B1 vitamin deficiency

Wernickes encephalopathy VahComplications:


motor

Korsakoffs psychosis-memory
Delirium Tremens nurse I dont know my name?
-like anxiety/panic attack
-illusion, hallucination

Formication bugs crawling under the skin


Family therapy
Ask the client:
When was your last dose of alcohol?
52

The client must not take Antabuse if the client has just taken
alcohol, because there might be effects.
12 HOURS interval needed before giving antabuse
4-6 hours will experience withdrawal symptoms
24-72 hours will experience delirium tremens
Echolalia - repeats whatever people say, talk to them slowly,
they live in their own world = Autism
Autistic Savant gifted child, can concentrate
Nobody Nowhere Somebody, Somewhere by Donna Williams
Assess: ABC
Appearance Flat Affect no eye/poor eye contact
Consistent movement
no emotion, clean OCD
Behavior Repetitive
Ritualistic
keep on rocking relaxes them, love bicycles
Communication Echolalia
Incomprehensible
Nx Dx:

Impaired Verbal Communication


Impaired Social Interaction
Self mutilation hurt oneself internal factors
Risk for injury external factors
Planning/Implementation:
Maslows Hierarchy of Needs: Language-important
1. Use Expressive Therapy art, music, song, poetry
2. Provide constant environment
Evaluation:
Enhanced communication
Improved Social Interaction
Safety

ANTI-PSYCHOTIC AGENTS
S telazin Stella Sin
P rolixin
S erentil serena til midnight
T horazine tora
T rilafon - tri band phone
C lozaril close na reel
M ellaril milya milya reel
H aldol hahaha
ADHD Attention Deficit Hyperactivity Disorder
If eight or more of the following statements accurately
describe your child or yourself as a child, particularly before
age 7 (ONSET), there may be reason to suspect ADHD. A
definitive diagnosis requires further examination.
1. often fidgets or squirms in seat.
2. has difficulty remaining seated
3. is easily distracted
4. has difficulty awaiting turn in groups
5. often blurts out answers to questions
6. has difficulty following instructions
7. has difficulty sustaining attention to tasks
8. Often shifts from one uncompleted activity to another
9. has difficulty playing quietly
10. often talks excessively
11. often interrupts or intrudes on others
12. often does not seem to listen
13. often loses things necessary for tasks
14. often engages in physically dangerous activities
without considering consequences.
can not control impulses ID is the dominant part,
always impulsive
7 yrs old and below

53

ADHD
Onset: 7 yrs old and below
Duration: 6 months and above
Settings: 2
Assess: ABC
Appearance:
Dirty
Behavior:
Clumsy, Hyperactive, Impatient
Communication:
Talkative, blurts out in class
Nx Dx: Risk for Injury High
Impaired Social Interaction
ID impulsive - Will not follow the mother, teacher, principal,
society-> Antisocial disorder: anger may build up = future
criminals
Planning/Implementation:
S tructure
S chedule time for everything
S et limits providing ample time, extent of what u can do
S afety
Evaluation:
Minimize Risk for injury
Improved social Interaction
Safety

18 months 3 yrs 6yrs old -> Class Valedictorian

Model Student
Toilet training
Social life inactive

Clean obedient organized One night, a dream


Eating Disorders
Anorexia
Diet, diet, diet
<85% of expected weight
Amenorrhea 3 months
Sad
Both are manipulative
If they want to go to the
Bathroom, accompany them

Bulimia
Eat, eat, vomit
Normal weight
Irregular
Feel guilty when
Eating - PINGE
HCl dental carries,
Metabolic alkalosis hand
biting - wounds
Laxative Diarrhea
HCO3 same ph
Metabolic Acidosis

CAT Scan --------------- glucose


Frontal

glucose
Ritalin after breakfast

-give after meals: prevent loss of appetite


Judgement - stimulant

- be given 6 hours before bedtime


ADHD

54

FVD

BP

CO

O2

Heart
Brain

Arrhythmias

BIPOLAR DISORDER 1 MANIA


Profile: Female, 20 yrs old & above, stress, obese

Excited

Relaxed
Self Actualization
Caregiver role
Self Esteem
strain
Safety
Impaired Social Interaction
Safety

NR:

Risk for injury/other-directed violence


1.
2.
3.
4.

Restore fluid and electrolyte balance


Collaborate regarding menu contract
Target weight gain
After meals, stay for 30 mins-1 hour

eating

sleep

Hyperactive

Finger food Private room

Sex
Anxiety

MANIA high neurotransmitter NE


Lithium vs Norepinephrine
Check for kidney Renal Function Test
L evel 0.6-1.2 mEq/L
I ncrease urination polyuria
T remors, fine hand
H ydration 3L/day to be hydrated
I ncrease
U u diarrhea
M outh, dry

Sexual urge promiscuous = confront behavior = aware but


not in control you should not do it here

1st 3 signs of Lithium toxicity: Nausea, vomiting, diarrhea


Na+ needed

self-esteem -> inc compensation -> up interferes ADLs


harm of others

Wait for 2-4 weeks of Lithium Therapy to end


Patient teaching: #1 Drug compliance
#1 defense mechanism by manic patient: COMPENSATION
flamboyant
queen of the world, heavy make up, loud voice,
overachievement in one area to cover a defective part

55

up self esteem -> dec compensation -> down interferes


ADLs harm of others
How do you increase the self esteem of client?
T-A-S-K
No basketball, volleyball
No pingpong no to competition
Yes - Gross motor skills: sweeps the floor, wiping the dining
table, watering the plant, Escorted walk outdoors
= SUBLIMATION = put energies toward more productive
endeavors & DISPLACEMENT punching bag
No - Cross stitch Fine motor skills
SCHIZOPHRENIA
ego disintegration
impaired reality perception
twin if one suffer, theres a possibility that other
genetic vulnerability
stress diathesis model -> stress factor
Biological theory : Dopamine level, exact cause is
unknown
PROCESS:
Assess: Affect external patient feeling inside & emotion
Mood internal subjective
Affect:
1.
2.
3.
4.

Inappropriate
Appropriate
Flat
Blunt

SYMPTOMS
NEGATIVE
Hypoactive
Withdrawn
Apathy

POSITVE
Hyperactive
Sociable
Flight of ideas
Talkative

Assess:
Content of thought
Nx Dx:
Disturbed Thought Process
Planning/Implementation: Present Reality
Provide Safety
Evaluation: Improved Thought Process
Assess:
Nx Dx:
P/I:
E:
violence
Assess:
Nx Dx:
P/I:
Evaluation:

Suspicious
Risk for other directed violence
Present Reality, Provide Safety
Eliminate/minimize risk for other directed

Assess:
Nx. Dx:
Planning/I:
Evaluation:
violence

Suicidal
Risk for self-directed violence
Present Reality, Provide safety
Eliminate/minimize risk for self-directed

Hallucinations/Illusions
Disturbed Sensory Perception
Present reality, Provide safety
Improved Sensory perception

Ambivalence caught to 2 choices


Autism trap in one world
Associative Looseness
56

I am going to the mall. The


mall is big. Big is the tree.
Tree is tall.

I am going to the mall.


Where is the light? Go here,
mineral water. Hurray!

Looseness of Association =
two words with association,
with common words

Flight of ideas = no common


words

Magical Thinking = I can turn you into a frog.


Ambivalence = 2 opposing thoughts
Echolalia = repeat what you say
Echopraxia = repeat what you do
Word salad = Just words, no rhyme life, like, lice
Clang Association= Clang Poet with rhyme life, wife, knife
Neologisms = Plungplang, priskip, sertugil =
CLARIFICATION= What do you mean by thisplungplang?

The nurses are talking about me


People are looking at me
Concrete Association pilosopo
saan ka pupunta? Eh di sa pupuntahan.
Give a proverb & have it explained
Thought blocking interruption in the thought/ stream of
thought
Hallucinations
Absent
X
X
X

Illusions
Present

Stimulus
Visual
Auditory
Tactile
Hallucinations
Acknowledgment:I know the voices are real to you.
Reality: But I dont hear them
Diversion: Lets go to the garden.
But what if nothing in the preceding interventions are seen?
Is it appropriate to assess what the voices are saying?
Command hallucinations assess what the voices are saying
to know if the client will commit suicide, or harm others

Delusion persecutory
The FBI is out to get me.
Delusion religious
I am Jesus Christ, the savior
Delusion grandeur
I am the Queen of world
Delusion Ideas of reference
57

02/11/06

Antipsychotic
D High Dopamine = Schizophrenia

TYPES
DISORGANIZED
-sad but smiles
Inappropriate affect
-no reaction
Flat affect

CATATONIC
Ambivalence

PARANOID

No
-flight of ideas
Disorganized speech

Negativism

-giggling
Hebephrenic
Positive/Negative S/S

RESIDUAL
No more positive
Just withdrawn

UNclassified
UNdifferentiated
Mixed classification
Cant be classified

AcH

Suspicious

Waxy Flexibility

Violent
Keep
Door
Open
Near
the
door
Dont
Touch
Eye
Contact
1 arm
away
Call
Reinforcement

ON= Extrapyramidal Effects

AcH
D
AKATHISIA- Restless, Inability to sit
AKINESIA Muscle Rigidity
DYSTONIA
Torticollis- wryneck
Oculogyric Crisis fixed stare
Opisthotonos Arched back

MISTRUST->SCARED->WITHDRAWN
TRUST 1 TO 1
SHORT INTERACTION
FREQUENT
FOODS IN SEALED CONTAINER
MEDS WRAPPED

AcH- Acetycholine ON switch of muscle


D- Dopamine OFF switch of muscle
ParkinsON disease Dopamine goes , Acetycholine

Tardive Dyskinesia
Lips Smacking
Tongue Protruding
Cheeks puffing
Irreversible
Neuroleptic Malignant Syndrome fever
ON = glucose = ATP used = heat
Other Side Effects:
1. photosensitivity:
a. use sunscreen
b. wear shades
c. wide brimmed hat
2. Agranulocytosis: Lymphocytes, Monocytes
neutrophils , Eosinophils, Basophils -> sore throat

58

Anticholinergic - minimize side effects of extrapyramidal effects -> Ach


Dopaminergic both are used to keep balance, used as partners-> D
Anti-psychotic -> EPSE
Anti-parkinson -> EPSE

Given to restore balance

Antianxiety - > GABA drowsy

ANTIDEPRESSANT:
A sendin to go up
N orpramin knorr para mainit
T ofranil lagyan ng tofu
S inequan sine Kuan
A nafranil Ana franing
A ventil aven til midnight
V ivactil- bye back til next week
E lavil e lab mo ba ako?
P rozac - pero zaka na tayo magpakasal
P axil isa kang taksil
Z oloft -mag SOLO ka
Task - esteem of the manic patient

Personality Disorders
1. SCHIZOID I avoid people. Theres no enjoyment
no reaction/flat affect, mechanical, they like computer hacking, cross
stitching, they avoid sex, do not engage in play, school activities, dont
have best friends-maybe have pets, no plan of marrying, not dated at all,
dont want people loving other people, people who can live by
themselves
2. AVOIDANT - I avoid people. Im afraid of criticisms longs for
people around them, to care for them
3. ANTI-SOCIAL used to steal, liars, violating the rules, engage in
bank robbery, drug trafficking, easily irritated, drug abuser,
dangerous sex, break the law, anti-social, good speakers, serial
killers
4. BORDERLINE my life is an empty glass (+) Fill Friends, usually
feel discontented, likes SPLITTING friends, SPLIT affect happy vs
sad LABILE affect (-) will commit suicide
5. DEPENDENT I cant live if living is without you.

6. HISTRIONIC - wants to be center of attention, manipulative, excited,


dramatic wants to be seen by everyone
7. NARCISSISTIC I love myself, wants to be center of attention,
blessed and cursed only wants the best for him
8. OBSESSIVE COMPULSIVE I am so organized consistency
9. PARANOID I am suspicious leads to domestic violence
Sensory Frontal lobe chemical manipulated in the film
Integration
Motor
Serotonin

Serotonin -> SAD

Antidepressants

Safest
Selective
Side effects low
Serotonin
Reuptake
I to 4 weeks
Inhibitor

SSRI
serotonin

Two-four weeks
Two neurotransmitters
Tri
Cyclic
Antidepressant

Mono

Higher Incidence of
side effects

Inhibitors

TCA
serotonin
norepinephrine

Amine
Oxidase

Avoid tyramine-rich
foods, or else therell
be Hypertensive Crisis
2-6 weeks
Avocado
Fermented
Aged cheese foods
Beer
Pickles
Chocolate
Preserved
Soy sauce
food

MonoAmine Oxidase KILLS Serotonin


MAO -> Serotonin -> SAD

59

How do you bring MonoAmine Oxidase DOWN?


MonoAmine Oxidase INHIBITORS or MAOIS
MAO -> Serotonin ->

Anti-depressants Side effects: Male Erectile Dysfunction - IMPOTENT


VLASTMEVAIB
Anxiety
E/NE

Antianxiety

GABA

Anticholinergic

SEIZURE
Rebound
Abrupt

S/E
Constipation
Retention
Dry Mouth
Blurred Vision
WITHDRAWAL

D
E
P
E
N
D
E
N
C
E

Drowsy
Do not Drink Alcohol
Do not drink Coffee
Do not drive Equipment
Develop O.H.
GRADUAL

Antipsychotic
Anticholinergic
D

60

DOWNERS
ABON Much to take IN
A lcohol
Morph
B arbituates Code INE
O piates
Hero
N arcotic
M arijuana - ambivalent
ASSESS: S/S: Overdose
bradycardia
bradypnea
moist mouth
pupils constrict
constipation
retention
hypotension
coma, lethargy
asleep
weight gain

UPPERS
CHA CHA
C ocaine
H allucinogens
A mphetamines - shabu

S/S: Overdose
Tachycardia
tachypnea
dry mouth
pupils dilate
hypertension
seizures
alertness
awake
weight loss

Psychological well being of a client - EUPHORIA


NARCAN (Naloxone HCl) Narcotics Antagonist drug of
choice narcotics overdose
Alcohol Overdose
HR

RR

LOC COMA
BP

Cocaine withdrawal Crash Syndrome from elation to


euphoria, then goes down when withdrawing - may commit
suicide
Black crisis
Blue return to original stage
White pure optimist, gotten through troubles in life
Gold ambitious
Black suffering depression
DEPRESSION
1. ASSESS
Are there things that got LOST?
STAGE OF GRIEF PROCESS
DENIAL No, this cant be! 1ST
ANGER Why me? Why this? Why now? Why God?
BARGAINING if something happens, then Ill give
something back
DEPRESSION Im down 2 weeks or more s/s = Major
Clinical Depression
ACCEPTANCE Client acts according to situation
MELATONIN - HYPERSOMNIA responsible for sleep,
secreted by pineal gland
When aged pineal gland calcified - INSOMNIA

Self-Actualization

Withdrawal opposite of intoxication

SEIZURE

Note: Overdose/Intoxication inversely proportional withdrawal


METHADONE - drug of choice narcotics detoxification
Detoxification is withdrawal with MD Supervision

SELF ESTEEM

T-A-S-K

WITHDRAWN

STAY

RISK FOR SELF-DIRECTED VIOLENCE


EAT

SLEEP

HYPOACTIVE

SEX

SENSITIVITY TO CLIENTS NEEDS

61

SUICIDE -> VERBAL I wont be a problem anymore


This is my last day on earth
Ill soon be gone.
NON VERBAL
Give away valuables
Sudden change in mood be suspicious
When the client is suicidal, what will the nurse do?
4.
helpless, hopeless
the nurse must
D irect discuss, Do you plan to commit suicide?
I rregular
Interval unpredictable when checking client
E ndorsement Period Early A.M.
SAFETY - Avoid giving knife, no jigsaw, give simple task.

62

03/04/06
Fundamentals of Nursing
Nursing Process > the nursing process provides the framework
in which nurses their knowledge and skills to express human
caring and to help clients meet their health needs
1. Assessment
2. Diagnosis
3. Planning
4. Implementation
5. Evaluation
Characteristics of the nursing process
1. It is cyclic and dynamic rather than static
2. It is client-centered nurse organizes plan of care
according to client problems rather than nursing goals.
3. It is interpersonal and collaborative depends on open and
meaningful communication between client and the nurse.
4. It is universally applicable can be used with clients of any
age at any point of wellness-illness continuum; useful in a
variety of settings.
5. It is an adaptation of problem-solving techniques and
systems theory-based on the scientific method
6. It can be viewed as parallel to but separate from the
medical process = focuses on resolving the disease of the
patient; Health/nursing problems human response to
the existing to the health condition disease or
wellness state
The nursing process diagram in each phase (see handout)
Quality assurance = safety in caring out nursing intervention =
standards of nursing care
Q: volunteer, nursing graduate, what type of nursing care:
A: interventions should live up to the standards of nursing
profession, even if you are just a volunteer.
Evidence based nursing = Research findings
Rectal temperature taking = 3-5mins
Oral temperature taking = 2-3mins

NGT = testing if the end of tubing submerge in a basin of waterbubbles lungs; distention in stomach = gas; should always be
updated
Data gathering: 2 sources of data:
Primary
Secondary
client himself/herself
significant others
chart
doctors
members of the health team
other related literature
Methods used in data gathering:
Observation using senses
Interviewing nursing history, therapeutic communication skills
Examining physical examination
Nursing history:
using subjective data
Data base is more often based on
Gordons Typology of 11 Functional Patterns
Health-perception-health management pattern
2. Describes clients perceived pattern of health and wellbeing and how health is managed
Nutritional-metabolic pattern describes pattern of
food and fluid consumption relative to metabolic need
and pattern indicators of local nutrient supply
Elimination pattern describes patterns of excretory
function (bowel, bladder, and skin)
Activity-exercise pattern describes pattern of
exercise, activity, leisure and recreation
ADLs healthy lifestyle household chores
Regular -> 3x/week -> 5-10mins warm up; 20-30mins cardiophase; 5-10mins cool down
Cognitive-perceptual pattern describes sensoryperceptual and cognitive pattern
Sleep-rest pattern describes pattern of sleep, rest and
relaxation

63

Self-perception-self-concept pattern psychosocial


interventions; describes self-concept pattern and
perceptions of self (e.g. body comfort, body image, feeling
state)
Role-relationship pattern describes pattern of role
engagements and relationships
Sexuality reproductive pattern describes clients patterns
of satisfaction and dissatisfaction with sexuality; describes
reproductive patterns
Coping stress tolerance pattern describes general
coping pattern and effectiveness of the pattern in terms of
stress tolerance
Value belief pattern describes patterns of values beliefs,
including spiritual; or goals that guide choices or
decisions.
Sign
Sx
Treatment
Medcl Dx
Nsg Dx
Restlessness Thirst
Passive
HyperRisk for
ROM
tension
latex
Hematuria
Pain
exercise
allergy
violent
3x/day
Acute
behavior
Reported prevent
myocardial Nonweight
atrophy,
infarction
compPain rating
loss of
contractures
liance
scale
20
promote
Hyper0-no pain
pounds
circulation
thyroidism
Impaired
1-2 mild
in 3 mos
mobility
3-4 moderate
Shampoo at Depression
5-6 severe
Nausea
bedtime
Impaired
7-8 very
Schizotissue
severe
Cholecystec- phrenia
perfusion
9-10 worst
tomy
ABG
possible pain
Oxygen

palpation on
painful site =
(+)
tenderness
elevated

Self care
deficit
Anxiety
complicated

Pco3 on
ABG

behavior

Vomiting

Impaired
parenting

Temperature
38.5 pyrexic,
febrile, fever

Decreased
cardiac
output

diaphoresis
Hemoptysis
Phase II NURSING DIAGNOSIS
clinical judgment about individual, family or community
responses to actual and potential health problems/life
processes; provides a basis for the selection of nursing
interventions to achieve outcomes for the which the nurse
is accountable.
This means that:
1. Professional nurses are responsible for making nursing
diagnosis
2. Nursing diagnosis describe a continuum of health states

Actual
Health
Problems

Potential
Health
Problems

Nursing Diagnosis
Focus on identifying human
responses to health and illness
Describe problems treated by
nurses within the scope of
independent nursing practice
Changes from day to day as
client responses change

Healthy
Responses

Medical Diagnosis
Identifies disease
Describe problems for which
the physician directs the
primary treatment
Remains the same for as long
as the disease is present

64

Types of Nursing Diagnosis


1. Actual Diagnosis judgment about a clients response to
a health problem at the time of assessment and is
signified by the presence of associated signs and
symptoms
Formats:
1 part statement problem format
2 part (problem related to etiology)
3 part (PES format) Problem related to etiology as manifested
by s/sx

Effective breastfeeding
Anticipatory grieving

2. Risk Nursing Diagnosis a clinical judgment that a client


is more vulnerable to develop the problem than others in
the same situation
Format: 2 part statement diagnostic label R/T risk factors
Ex. 1: Risk for disuse syndrome R/T immobility
Ex. 2: High risk for infection R/T compromised immune system

ALFAROs RULE FOR A COLLABORATIVE PROBLEM


To write a diagnostic statement for a collaborative problem, focus
on POTENTIAL COMPLICATIONS (PC) of the problem

3. Possible Nursing Diagnosis evidence about a certain


health problem is unclear or the causative factors are
unknown; needs collection of more data either to support
or refute it; not a real type of nursing diagnosis

Common Errors in Writing Nursing Diagnoses and


Recommendations
Error
Example
Correction
Example
Writing the
Needs
Write the
Self care
diagnosis in
assistance with diagnosis in deficit: bathing
terms of needs bathing related terms of
related to
and not
to bed rest
response
immobility
response
rather than
need
Making legally Noncompliance Use related Non
inadvisable
due to hostility to rather
compliance
statements
toward nursing than due to related to
staff (the words or caused
hostility toward
due to imply a
by to link
nursing staff
direct cause
the etiology (denotes a
and effect
to the
relation
relationship)
problem
between the
statement
problem and
etiology but not
necessarily a
causal

Format 2 part statement


Ex: possible social isolation R/T unknown etiology
4. Wellness Diagnosis is a clinical judgement about an
individual, family or community in transition from a specific
level of wellness to a higher level of wellness
Format: NANDA has specified that wellness diagnosis should be
developed as a one-part statement with: Potential + desired
higher level of wellness; readiness for (+) desired higher level of
wellness (LeFevre, 2004)
Ex.
Potential for enhanced parenting
Health seeking behaviors
Family coping
Potential for growth
Enhanced Parenting

5. Syndrome Diagnosis comprises of a cluster of problems


Format: one part statement
Ex.
Rape trauma syndrome
Post trauma response
Defensive coping

PC+:+complication+related to + etiology
Ex. Potential complication: pneumothorax related to fracture ribs

65

Spouse abuse
related to
husbands
immaturity and
violent temper

Impaired skin
integrity related
to clients lying
on back all
night

Identifying as a
problem a
client respond
that is not
necessarily
unhealthy

Mild anxiety
related to
impending
surgery

Identifying as a
problem signs
and symptoms
of illness

Cough related
to long history
of smoking

Identifying as a

Alterations in

> more alert,


normal,
motivate to
understand

Write
diagnosis in
legally
advisable
terms:
statements
that may be
interpreted
as libel OR
that imply
nursing
negligence
are legally
hazardous
to all nurses
caring for
the patient
Include in
the problem
statement
of the
nursing
diagnosis
only client
responses
that are
unhealthy
or that the
client wants
to change
Avoid
including
signs and
symptoms
of illness
Express the

relationship)
High risk for
violence:
spouse abuse
related to
husbands
reported
inability to
control
behavior.
Impaired skin
integrity related
to immobility

No need for
nursing
diagnosis; mild
anxiety before
surgery is a
healthy
response that
motivates preoperative self
care behavior

Ineffective
airway
clearance
related to 20
year history of
smoking
Self care

client problem
or etiology
what cannot be
changed

Bowel
Elimination:
Permanent
colostomy
related to
cancer of the
bowel
Grieving
related to
death of
spouse

>grieving is a
normal
response to
death
> if
dysfunctional
grieving 1
year can not
accept death
Problem +
Etiology
Suggest
suggest that
objective/Goals intervention;
eliminate
etiology will
eventually
eliminate
problem

Identifying
environmental
factors rather
than client
factors as a
problem
Reversing

client
statement
and
etiologic
factors in
terms that
can be
changed;
otherwise,
nursing
energies
are being
directed to
a hopeless
task

Cluttered home
related to
inability to
discard
anything
Knowledge

Avoid

deficit: care of
colostomy,
related to
severe anxiety
about cancer
and feelings of
powerlessness
> do not put the
medical
diagnosis as
the etiologic
statement but
put the human
responses only

Inability to
accept the
death of the
spouse.
provide
psychological
support/
emotional
support to
client
High risk for
injury related to
cluttered home
(inability to
discard
anything)
Altered

66

clauses

Having both
clauses say
the same thing

Including value
judgments in
the nursing
diagnosis

Including the
medical
diagnosis in
the diagnostic
statement

deficit related
to alteration in
parenting

Alteration in
comfort related
to pain (pain is
the comfort
alteration
what is
contributing to
the pain?)
> describe,
location, type
of pain
Poor home
maintenance
management
related to
laziness

Impaired home
maintenance
management
related to
arthritis

reversing
the problem
statement
and
etiologic
statement

Be sure that
the two
parts of the
diagnosis
do not
mean the
same thing

Write the
diagnosis
without
value
judgments;
avoid words
such as
poor,
inadequate,
abnormal
unhealthy
as much as
possible

parenting
related to
knowledge
deficit: OR
LACK OF
INFORMATION
ABOUT child
growth and
developmental
discipline
Unrelieved
incisional pain
related to fear
of addiction

Impaired home
maintenance
management
related to low
value ascribed
to home safety
and cleanliness

Impaired home
maintenance
management
related to
mobility,

endurance and
comfort
alterations
RIGHT
Alteration in oral mucous
membranes related to the
effects of chemotherapy
stomatitis Oral care
Increase fluid
Risk for injury related to
disorientation and impaired
judgment
> can intervene
Self-feeding deficit (Level III)
related to joint pain/swelling
Impaired physical mobility :
level III related to general
muscle weakness and spasm
in the legs
Ineffective airway clearance
related to accumulation of
tenacious secretions in the
airway
Hyperthermia
Infection
Non compliance with renal diet
related to the clients
perception of its therapeutic
ineffectiveness

WRONG
Risk for injury related to
frequent falls

Dysfunctional grieving related


to death of spouse

Self-feeding deficit (Level III)


related to arthritis
Patient difficult to get along with
related to his frustrations at
being in the hospital.
Alteration in bowel elimination:
stool incontinence related to
involuntary passage of stool
Elevation in temperature
caused by infection
Alteration in level of
consciousness due to grandmal
seizures
self-care deficit: bathing related
to inability to bathe self
Nausea and vomiting related to
cancer of the pancreas
Poor hygiene related to
laziness
Alteration in comfort related to
chest pain

67

Alteration in nutritional intake:


less than body requirements
related to as manifested by
nausea and vomiting
Impaired skin integrity

Ineffective management of
therapeutic regimen: families
related to economic difficulties
> may intervene because you
can refer

Nausea and vomiting related to


alteration in nutritional intake

Loss of skin integrity related to


prolonged bed rest and
infrequent position changes
Anger related to knowledge of
the diagnosis of cancer

FIRST
Ineffective airway
clearance related to
accumulation of
viscous secretions

MEDIUM
Anxiety related to
difficulty in
breathing
> because you can
resolve it if the 1st
priority

LOW
Sleep pattern
disturbance
Self care deficit
Altered family
processes

Fluid volume deficit:


intake insufficient to
replace fluid loss
related to
diaphoresis

Impaired memory related to


observed experiences of
forgetting
Airway, Breathing, Circulation first priority
Three helpful guides suggested by Atkinson and Murray (1990)
for prioritizing client problems are:
Maslows hierarchy of Human Needs:
Physiologic needs safety needs love and belonging needs
self actualization needs.
Prioritizing nursing Diangnoses:
Priority setting process of establishing a preferential order for
nursing strategies
FIRST PRIORITY is any threat to the vital functions of
breathing, heartbeat, and blood pressure
MEDIUM PRIORITY health threatening problems that
may result in delayed development or cause destructive
physical or emotional changes
LOW PRIORITY problems that arise from normal
developmental needs or those that require minimal
nursing support

Goal versus Objective versus Expected Outcome:


Goals are broad statements about the effects of nursing
intervention
Ex. The clients nutritional status will improve
Objectives are more specific statements about the effects of the
nursing intervention
Ex. The client will gain weight after two weeks.
Criteria/Characteristics of objectives:
SMART- specific, measurable->observable, attainable,
realistic, time-bound
Client centered
Statement of a single human response-> human condition
or behavior -> performance of a procedure taught
Expected Outcomes are the more specific, measurable criteria,
used to evaluate whether the goal has been met.
Ex. The client will have a weight gain of 5 lbs by October 28
SMART
After 2 weeks, the client will be
able to ambulate in the hall
3x/day.

NOT SMART
After 2 weeks, the nurse will
assist the client to ambulate in
the hall 3x a day.

68

After nursing intervention, the


clients lungs will be clear to
auscultation.
After nursing intervention the
clients RR will be normal by
afternoon of March 4, 2006
After 30 minutes of health
teaching, the significant others
will explain, verbalizes, discuss,
enumerate, identify the ways
on how to prevent bedsores in
the client.
if psychomotor = demonstrate,
perform, show

After nursing intervention, the


clients lungs will be clear to
auscultation and the RR will be
normal.
> should be of single human
response
After nursing intervention, the
significant others will know how
to prevent bedsores in the
client actions are not the same
as knowing, you will not know
unless the client speaks or
answer the exam
knowing is not
measurable
will know how is
cognitive ask
questions

Types of nursing Interventions:


1. Independent interventions those activities that nurses
are licensed to initiate on the basis of their knowledge and
skills
Ex. Physical care, ongoing assessment, health teachings,
emotional support, and comfort

Vital signs
wound care
Massage
assisting to
ambulate
perineal care
position client in
bed

administration of
medication
IV therapy

NGT feeding
Passive ROM
crutch walking

Writing the Evaluation statement


Conclusion + Supporting Data
Conclusion:
Goal Met
Goal Partially Met
Goal Not met
ND: Ineffective airway clearance related to viscous secretions
and shallow chest expansion
Expected Outcome: Demonstrates adequate air exchange as
evidenced by:
1. absence of pallor and
2. absence of cyanosis (skin and mucous
membranes)
Evaluation:

2. Dependent Interventions activities carried out under the


physicians orders or supervision or according to
specified routines;
Ex. Medication, diagnostic tests, diet, treatment,
activity
3. Collaborative interventions actions nurse carries out in
collaboration with other health team members such as
physical therapists, social workers, dieticians and
physicians
INDEPENDENT

DEPENDENT

COLLOBORATIVE

69

March 11, 2006


LEGAL DOCTRINES IN NURSING
Professional Negligence
Definition: failure to do something which are reasonable and
prudent nurse should have done something under a particular
situation. (e.g. failure to raise side rails when the patient is
unconscious)
3 Elements:
1. duty
2. failure to do said duty
3. injury, harm, death important in negligence, not
in malpractice
Ms. Ara Mae Quinto, an OR nurse in a government hospital has
prior knowledge regarding some defective OR table. It is unsafe
to use for heavy patients. Due to some reason she still allows
patients to undergo surgery using said defective OR TABLE. One
day, a 40 year old obese female patient, will undergo
appendectomy, fell and suffered fracture.
The case of Humpee Dumpee
-drug rehabilitation clinic, he was having withdrawal syndrome,
p[sychiatrist provide a safe and calm environment for Humpee. In
a room with an open window. One night, while Gloria was about
to give medication, Humpee thought that Gloria was a dragon.
The patient jumped the window and died. Will the nurse be liable
for negligence?

X
Negligence

Malpractice

Ex. Prescribing nurse has already memorized all the contents of


her drug handbook. She has a prescription pad bearing her
name, hospital that she is employed, license number and contact
number. She gives it for free for all her indigent patients.

The X stitch
An OB Gyn is too tired after having 10 CS operation for the past
10 hours. It is a practice of said physician to delegate the suturing
of the last layer of the patients abdominal cavity to her OR nurse.
Nurse Kristeta being young and aggressive accepted the task
and does it well.
Normal spontaneous delivery with specific training on suturing of
perineal cavity episiorrhapy ALLOWED
Allowed to do the IE during normal spontaneous delivery, prior to
complete delivery: in the absence of maternal fetal
aberration/abnormalities: abrupt placenta placenta previa
abortion, H-mole and absence of full delivery = DOCTOR
Crime Affecting Nurses:
1. Manner of Commission
3. DOLO > crimes committed with deceit (sinadya mo ang
crime), real criminal intention
4. CULPA > unintentional, product of negligence (hindi mo
sinadya)
2. Stages of Execution
5. CONSUMMATED > when the crime was totally,
absolutely commited or perfected
6. FRUSTRATED > when the offender performs everything
to consummate the crime but it did not happen
7. ATTEMPTED > no crime done, overt acts = merely
showing the intention to commit the crime
Degree of Participation
1. Principal very, very important, indispensable, primary
author of the crime
2. Accomplice dispensable, before & during
3. Accessory after the crime has been committed
benefiting itself from the product of the crime
Q: Referral by a nurse to an abortionist, the nurse is considered
to accomplice to an Abortionist, before the committing the act

70

RA 7877 Anti-Sexual Harassment Act


Conditions:
1. Any person who exercises authority ex. Doctor-nurse;
Head nurse-nurse, Teacher-student
2. Who is asking for sexual favors, in exchange for another
favor

mandatory report within 30 days before the Local Civil Registrars


Office with penalty if beyond 30 days)

Rape crisis situation


1. Ordinary Rape a forcible penetration of an organ for
copulation to another organ for copulation, Victim is
women only
2. Sexual Assault anything forcible penetration to any body
orifice with sexual malice ex. Victims can be male or
female

1) ACT 2808 (1919) 1ST TRUE NURSING LAW


under doctor
removed from the jurisdiction of the doctor and formed
Board of Nursing
Board of Nursing appointed 3 man team
a) 1 chairman
b) 2 members
c) ALL nurses

Intervention:
SAFETY physical, emotional
REPORT 48h at barangay - accessibility
REFERRAL DWSD
Abortion expulsion/termination of the product of conception
before the age of viability 12-24 weeks or 3-6months AOG
Infanticide crime if you killed a person/infant less than 3 days
or 72 hours of life
Parricide killing another person, whom you have a relationship
Homicide killed another person without any relationship, no
intention to kill, product of negligence ex. Somera case, wrong
drug administration
Murder with an intention to kill another person
Simulation of Birth committed by any person who shall
substitute 1 child to another child or alter his identities for the
purpose of losing his civil status. (e.g. failure to report the birth of
the baby PD 651 Birth Registration Act = requires all person
who shall assist in giving birth, OB, midwife, hilot, nurse, to

Pink baby girl

Blue baby boy

LAWS AFFECTING NURSES

1920 - 1st nursing licensure examination


TRAIDS
Iloilo mission hospital (1906) -1st nursing school
PGH School of Nursing (1907)
St. Lukes School of Nursing (1907)
Mary Johnston School of Nursing (1907)
St. Paul-Iloilo (1907)
San Juan De Dios (1907)
University of the Philippines - 1st college in the Philippines, 4 yrs
Bucaullereate degree - Dean Julieta Sotejo
2) RA 7164 (1991)
BON = MAFSON PTC
M Man
A Accredited Nursing Organization
F Five Man Team = 1 chairman, 4 members, all NURSES
S Sixty Five y.o.
O One year Interim period
N not convicted of any crime
P Pecuniary Interest (Absence) monetary consideration
T Ten Years nursing practice
C Citizen of R.P.

71

3) RA 9173 (OCT 21, 2002)


Board of Nursing MASIN PTC
M MAN
A Accredited Nursing Organization
S Seven man team
I Immediately resigned upon appointment
N Not convicted of any crime
P Pecuniary Interest (Absence)
T Ten years Nursing Practice but the last five years must be
in the Philippines
C Citizen and resident of the Philippines
POWERS AND FUNCTIONS OF BON
L icensure Exam- formulates examination, not the PRC
I ssue Certificate Of Registration = it is a privilege, not a
right, PRC issues of nurse license = it is a privilege = with
all the qualification and not disqualification
M onitor standards of Nursing Practice- BON only have the
power to inspect or recommend, only the CHED is authorized
to open or close the school 30% passing rate consistent for 5
consecutive years
E ducation
C ode of Ethics (2003)
H ear and decides cases of negligence/malpractice
A ccredits different Organizations, training center
G uides Nursing Practice in the Philippines ex. ICU 1:1,
Ward 1:8
Dean
1.
RN
2.
MAN
3.
5 years of nursing experience
CI - AMOR
A ccredited member organization
M ay have MAN or any Other Allied Health courses
O ne year experience
R-N
Nursing Administrator

SM BANT
Supervisor/Manager/Head
Nurse per ward, per shift,
per department
B BSN RN
A Accredited Organization
N Nine units MAN
T Two years general staff
nursing experience
C/D Chief/Director the
whole hospital
RN+MAN+
5 years Supervisory
Experience
(except: N.B. IF primary
hospital = 50 Bed capacity)

COMMUNITY

MILITARY
HOSPITAL

ADD ONLY
MASTERS IN
PHN OR CHN
5 years
supervisory in
the Community

MAN + General
Staffing Course

Nurse Licensure Examinees


Optional and Mandatory
1. Certificate of Good Moral Character (optional)
2. Proofs of Valid Holder of Filipino Citizenship given Birth
Certificate (Mandatory)
3. Proofs of Valid Holder of A BSN degree only from Schools
whose curriculum is approved by the CHED
a. TOR with scanned photo
b. RLE, MAN, licensure number, Chief Nurse, PNA number,
notarized at the back of completion form; only 2
operations are allowed to have the same procedure, filing
of PRC deadline May 22
Other Related Laws:
1. PD 223 PRC Act
2. RA 1080 Civil Service Act, if you pass Civil Service,
PRC, Magna Cum Laude, Summa Cum Laude, Cum
Laude = civil service eligible
3. RA 6425 Dangerous Drugs Act 2 types of chemical
substances:

72

a) Prohibited absolutely, totally, can not be consumed by


cannabis, shabu, hallucinogen, cocaine, LSD, opium
can not use it even if theres physician order
b) Regulated can use the drug, prescription, with
appropriate license from BFAD and Dangerous Drugs
Board ex. Antipsychotic drugs
4. RA 7600 - Baby Friendly Hospital, early bonding
between mother and child Sen. Flavier
a) Rooming in
b) Breastfeeding Galing Sa Ina Sustansya

- Registration and Oath


Q: What are the grounds for a nurse not to be registered?
D dishonorable conduct
U unsound mind
M moral turpitude
I indecent, immoral conduct

Q: how can you promote bonding father and newborn?


A: cuddling, and embracing
5. E.O. Milk Code avoid manufactured or formulated
milk, use breast milk
HOW TO BE AN RN UNDER RA 9173?
1. Have all qualifications
2. Take the Exam June 11
3. Acquire the Required Ratings
In order to pass the exam, an examinee must obtain a general
average of at least seventy five percent with a rating of not below
sixty percent in any subject. An examinee who obtains an
average rating of seventy-five percent or higher but gets a rating
below sixty percent in any subject must take the examination
again but only in the subject or subjects where he/she is rated
below sixty percent exam, an examinee must obtain a rating of at
least seventy-five percent in the subject or subjects repeated.
- absolutely, totally, unconditionally pass = 60, 100, 100,
100, 100 because General Ave 75 higher, with no <60
- conditionally passed = 59, 100, 100, 100, 100 General
ave = 75 higher, with <60, repeat exam = 60, failed it
should be 75, may retake exam 2x in a year
6. RA 8391 - PRC modernization act at least 5000
examinees, after 5 days the result will be released or
check www.prc.gov.ph prc rating florante, Jude Thaddeus
C

73

COMMUNITY HEALTH NURSING


03-17-2006

pour flush

PRIMARY LEVEL DISEASE PREVENTION


Through environmental control
I. Safe Water = tasteless, odorless, colorless, slightly basic ph
- hard and soft water- rain water, can easily have bubbles
but hard to rinse
- biological: e-coli present in feces excreted
a.) HH: Boiling 5 minutes high fire then low fire
b.) Filtration solid carbon blocks
c.) Sedimentation let water stand for 1 hour
COMMUNITY
1.
Chlorination/Iodination
2.
Macrofiltration
3.
Microfiltration
Aeration
Flocculation pure water tanks = high concentration of
chlorine
II. Food Hygiene
Safety:
1. Sources of raw food check food for pesticides
(biocides), soak with water with vinegar 1:1 portion, to
neutralize chemicals; check for slaughter houses double
dead issue, 1st to absorb bacteria are clams, oysters,
mussel all shellfish, then squids = deep sea fish blue
marlin, salmon = no bulges and dents on canned
goods = source of lead poisoning grayish color
Chinese
2. Food handlers - carrier of typhoid 40s female food
handler
3. Environmental sanitation
Goal: preventing food intoxication ingestion of poison =
sudden effects, food infection ingestion of pathogens

No Transport
automatic flush or
pour flush

III. Safe excreta disposal


Water
Transport
Cistern flush, with
automatic flush or
sewerage system

No Water
pail system
(bucket latrine),

Cistern flush with


septic tank, best
method, aneorobic
type
Japan: Vault Type
carthage sipsip

arinola
- flying saucer
(ballot system)
1. pit privy (not
water sealed
maamoy
- Antipolo
- bored hole
- Ventilated
Improved Pit (VIP)
- Reed odorless
Earth Closet
- twin pit/ compose
2. Over hung
Latrine

N/R: Respect of culture and way of life of people. DOH


Sanitation Program example in Samar, mid 70s Halahala
Rizal socialization process = pag gabi all community
members have the same time to do bowel elimination in the
rice field - participatory
Best method squatting Credes = for bowel elimination
Negros: Hacindero versus Sacada workers, Europe =
Loo, or water closet
IV. Proper Refuse Management:
Refuse = solid, and semi-solid wastes excluding
human excreta
Garbage = biodegradable and Rubbish = recycling
scrap iron, carton, paper, plastic, broken glasses, tin
cans
Method of Refuse Mgmt except: X A. open burning
Clean Air Act X B. Open Dumping = best reservoir
for infection, fire, causes floods, methane gas in
74

smokey mountain = spontaneous smoke C. Burial D.


Composting
V. Safe Home Environment
Proper ventilation, adequate space, adequate lighting
VI. Safe Workplace
Health education very essential appreciate to prevent
diseases, and to manipulate their environment
Secondary Level Disease Prevention = Asymptomatic,
subclinical test
Mass screening = the more people we screen, the
better, simple & inexpensive and not complicated =
ex. Bantay presyon = hypertensive and high risk;
Operasyon Timbang FNPI International Standard
Case-finding positive diseases in the leading
causes of morbidity ex. TB TOP 10, Ideal Standard =
culture and sensitivity, Sputum Smear microscopy=
for community screening; tuberculin test children;
chest x-ray can be under or over read
Contact-tracing through the case, we can trace
other contact/s, ex. Leprosy = respiratory infection
droplet ex. Nasal discharge
Multi-phasic screening
Surveillance tantamount to research, RA7573 to
report cases ex. Scabies, sore eyes
HIV ANTIBODY TESTING
RNA count USA, RNA virus no capacity to replicate,
too expensive
Philippines setting:
Cell mediated
Humoral Response both produces antibodies

used as evidence if the client who has HIV infection,


Check presence of HIV antibody
Pre-test Counseling
a. Risk Appraisal try to approximate of the individuals
risk, extent of exposure of an individual or the
presence of risk behavior or risk situation=SEX
which can contribute to the development of the
disease, consider individuals uniqueness
Risk factors may act synergistically, potentiate action
HIV+ source, medium with adequate infectious load (32
liters of saliva), mode of transmission HIV to enter hosts
body, test after 6months of sexual intercourse= window
period time for the body to produce HIV antibodies, 1012 yrs incubation period
b. ELISA 1 results can be (-), and (+)/indiscriminate =
assume the worst than better
c. If negative, Post-Test Counseling Behavior change
d. If (+) ELISA 1, do ELISA 2 results can be (-) and
(+)/indiscriminate. If (-) go to C
e. If (+) ELISA 2, do Western Blot results can be (-)
go to C
f. If positive in Western Blot HIV/Aids registry, then
go to C
* Theres difference between exposed and infected.
Not all exposed are infected, but all infected are
exposed.
Intention: identify (+) cases provide prompt treatment,
prevent spread, shorten the disease process, and
enable client to perform the usual roles and functions as
soon as possible.
Serum (blood) once only
75

Health Education can also be given in the secondary


level, people will learn what are notifiable diseases.
Tertiary Level Disease Prevention symptomatic or
clinical, client knows he is sick, seeks services of health
provider
Diagnosis assess, to have a correct diagnosis
Treatment
Management
Rehabilitation upon approach of the client rehab
starts
Health education can be applied, much easier, theres a
captive audience, will cooperate in the management., to
prevent occurrence of the diseases again.
Community participation to self reliance
COMMUNITY ORGANIZING ensuring peoples
participation in health stayed in 6 months, and created
an organization, but the students functions were to
support other sector, or facilitate community
a continuous and sustained process of:
COPAR Awareness-raising conscientization,
Paolo Fraile in order people to learn increase the
level of awareness. Education is liberating from
oppression and ignorance
Organizing
Mobilizing of responsible action
Levels of Awareness
How the community members relate to existing problems
in the community?

POLITICAL SOCIALIZATION
POLITICAL COMMUNICATION
INTEREST AGGREGATION
INTEREST ARTICULATION
SILENCE AND PASSIVITY

POLITICAL COMMUNICATION
Facilitate PEOPLES ORGANIZATION, to have a venue
for political consensus, in UNITY, theres STRENGTH
POLITICAL SOCIALIZATION
mobilization through activities to serve the people for
responsible action
Radical

Ultra

Leftist
Agaw Lalaki-AL
Liberal

Rightist
Single but
Satisfied-SISA
Conservative

Centralist
Neutral
Opportunists
Waitress: naghihintay/nanabik

Basic Concepts and principles in Community Organizing:


Based on concrete analysis of actual situation
scientific method
Basic trust on the people
By, for, of, with and among the people
Any one is capable of change
Self willed changes over imposed changes
Fear-tactic will not learn
Context of Community Organizing:
1. Current Situation:
76

Rich
Extravagant
Oppressors

Poor
Deprived
Bias
Oppressed
- no access to social
services, more problem,
more vulnerable

Goal of Community Organizing: Community Development


COMMUNITY DEVELOPMENT
A commitment towards the creation of a society that
provides each and every individual member the equal
access to all benefits and opportunities the society can offer
CO in H:
1. Health Sector Organizing
2. Establishing Community based health
programs
2 types:
1. Organized (Peoples Organization)
> Support Program done by nurses
2. Unorganized (Virgin) entry point for organizing
Approach:
Primary Health Care: essential care based on scientifically
sound and socially- acceptable methods and technology
made universally available to individuals, families and
communities at a cost that they can afford at any given
stage of their development through their full participation
towards self-reliance and self-determination
-1978 Alma Alta
Multi-sectoral Approach
Intra-sectoral Linkages
- Tertiary
- Secondary
- Primary

Inter-sectoral Linkages
Agricultural
Social welfare
Education
Population control
Public works
Private sector

Community Participation
active and full participation of the people in decisionmaking process:
- Assessment
- Planning
- Implementation
- Monitoring and evaluation
Levels of Participation:
Genuine Participation
- Delegated power 0:100
people/citizen control/people
empowerment starts 40:60
- Partnership shared leadership
minimum level of participation
50:50, shared majority
Token Participation
- Placation palliative
- Consultation problem identification,
democratic process
- Information decision has been made
Non-participation
- Therapy
- Manipulation
77

Nurses: Social apathy apolitical, apathetic


Community Organizing in Health
Social Investigation
- Preliminary before entry, baseline info
* 2ndary data sourcesUtilize findings of their studies and
data
- Deepening SI upon entry continuous, assessment
of community situation.
Entry
- best method for entry : LOW-KEY/ LOW PROFILE,
so as not to expect too much.
- Start:
1. DSI
2. Social Preparation
3. Community Integration
Social Preparation tempering the grounds for
setting up the health program/health situation, target:
community leaders courtesy calls meetings, 1st
establish rapport, establish trust, clarify expectation,
objectives
Community Integration - Imbibing community life,
house to house, places & events, production process
- Do spot mapping distribution of household, Cluster
8-15 HH, management of unit
Small group formation, election of community
health workers ano ang mga katangain kailangan
community health leader? 1st set of elected officers
(at least 5), not appointed
- decision making
- delivery of care
Election of Community Health Workers
Launching, community mass, induction, formally
launch table of organization
* Starts at entry, end at the launching of the organization

Community Diagnosis get the priority health


problem of the different units (small group)
Training and Services at least a year, not
continuous, staggered during weekends
Core-group formation extra special training,
program management, leadership skills, teaching
learning skills, advance accounting skills, these
leaders are committed, reliable, and dedicated
Phase Out for people to exercise self-reliance
3 to 6 months from Community to Phase out organized
community
3 years Entry to Phase out Virgin community
Appropriate Technology
Available
Acceptable
Affordable
Simple
Safe
Feasible doable
Acupuncture acus = needle to prick, in order to diagnose,
and treat
Acupressure acus = needle, Finger-pressure
Qi chi or te chi
Meridians - system that is hiwalay sa circulation &
lymphatic system 40
Yin-Yang 2 opposing forces, theres should be a balance,
if theres imbalance disease formation develops
Tsun natural boundaries of the body through body
measurement body itch
Ahshi points tender points indicating vital organs being
supplied by the meridian
2-3 cycles/second (1-5 minutes/point)
78

premature contraction can be used in abortion


Moxibustion Heat content is medicinal plant dahong
Maria, for dysmenorrhea, cough & colds

Elixir internal use 1:10 alcohol ginger chopped 1


tbsp:10 tbsp gin stay for 1 week = elixir, tbsp
dry cough related to TB.
BREAK (low battery)

Herbal medicines:
1. Mayana pigsa, lavender, pink, red, yellow, orange
2. Chichirika white, violet flowers alkaloid vincristine
oncovin = gamut sa cancer 1 vial injection
3. Oregano cough & colds, boiled, adobo
4. Akapulko anti-fungal, scabies
5. Sambong cough & colds, renal stones, stomach ache
6. Malunggay - scabies
7. Tanglad for fever, cough & colds
8. Mangga cough & colds, high fever
Aromatic Medicinal plants:
Volatile oils used for fever, cough & colds, itchiness, gas
pain
1. Sampalok 2 saklot ng leaves boil
2. Luya boil, decoction , 1 glass for am, noon,
night add half glass sugar, dissolve to thin the
consistency syrup can last 3-5 days = SLK
3. Kalamansi use 7 pcs to add flavor to SLK.
Infants, lowers fever, boil leaves of kalamansi
4. Sambong cough & colds
5. Oregano cough & colds
6. Yerba-buena cough & colds, itchiness,
arthritis, tooth ache with swollen gums.
7. Alagaw
8. Tanglad
9. Mangga
10. Damong Marya
11. Bawang- high blood, with antiseptic properties
12. Sibuyas
Tincture-external use 1:5 alcohol maputi, aceuate reddish

Goal of Family Planning Program


Maternal and child health through:
Proper timing of pregnancy
- Ideal age: 20-30
Ideal space: 3yrs No.3
- below 20 to 18
with risk
q 2 years
4
- below 30 to 35
- below 18
high risk
q year
>4
- above 35
Major Program Policies
- Improvement of family welfare with main focus on
womens health, safe motherhood, and child survival
- Freedom of choice = informed choice
- Promotion of family solidarity and responsible
parenthood
FAMILY PLANNING METHODS
1. Spacing Methods
- Hormones (pills, injectibles) with systemic effects
- Barrier methods: Intrauterine Device (Arabs), 70s
plastic, polyutherane looks like bituka ng manok
- Condoms (male, female)- contraindicated to use oilbased ex. baby oil to prevent tearing of condom,
cervical cap(Leahs shield); diaphragm; sponge;
spermicides = toxic shock syndrome TSS
- Scientific, Natural (Cervical Mucus, Basal Body
Temp., Sympto-Thermal, Lactational Amenorrhea
Method-exclusive 6 months breastfeeding)-High
literacy/education, Standard days Method, white
bead = fertile; brown bead = non-fertile
2. Permanent Methods
79

Tubal Ligation
Vasectomy ejaculate 25-40x to check sterility after
procedure

Expanded Program on Immunization


Goal EPI: morbidity and mortality reduction of immunizable
disease (p.14)
Types and Schedule of Vaccines
At birth
BCG anti-TB 0.05ml ID (infant) 0.1ml ID (school entrant)
Prevent leprosy
1 month
DPT1
05ml IM
HEP B1
TT
OPV1 trivalent 3 class poliomyelitis virus 1,2,3
2 mos.
DPT2
OPV2
HEP2
3 mo
DPT3
OPV3
HEP3
9-12mo
Measles 0.5ml SQ
Side effects: BCG
2-3 weeks abscess will ulcerate then heals leaving a scar
(approx 12 weeks from vaccination)

Kochs Phenomenon normal inflammation of the site after 2-4


days.
NR: warm compression
Deep Abscess at site not normal.
NR:incision and drainage; powdered INH, do use alcohol it will kill
the vaccine.
Indolent Ulceration ulcer after 12 weeks
NR: incision and drainage; INH powder
Glandular Enlargement not normal, treat as abscess
Side effects: DPT
Fever for a day usually
Soreness at site within 3-4 days normal, warm compress
Abscess after a week or more incision and drainage,
use local antiseptic: Betadine solution, or alcohol
Convulsions do not give next dose and refer for next
check up
Side Effects: Measles
Fever after 5-7 days usually 1-3 days
Mild rashes
Cold Chain
Vaccines destroyed by heat
Viral: BCG, DPT, OPV, TT, MEASLES, HEP B viral
Most sensitive to heat: OPV, measles
Destroyed by freezing: DPT, TT, HEP B

Control of Diarrheal Diseases:


Control of dehydration,
Q: what is the reason to deaths due to diarrhea?
A: Dehydration
Classification of Dehydration VS Diarrhea
MILD
MODERATE
SEVERE
5-10 bouts of
10-15 bouts/day
>15 bouts/day
watery stool/day
- sunken fontanels -lethargic, normal - comatose,
80

and eyeballs
- dry lips, child is
irritable but
conscious
- (-) skin fold test

blood pressure
- (+) skin fold test

almost (-) urine


output
- dry tear ducts
- (++) skin fold test

> Give ORS for 46 hours treatment


Less than 2 years
glass
ORS/bout or
- cup rice
water/bout
If 2 yrs & above
- 1 glass ORS or
- 1 cup of rice
water
- Reassess after
4-6 hours

Intravenous Fluid

Available

YES NO

Assess if child can drink

yes
no -> NGT

ors
yes
no

REFER
via NGT
REFER
REFER IVF

Supplementary? Give to ensure proper nutrition to avoid


malnutrition
Weight loss
Mild
<1 yr
5% of total BW

>1 YR
3%

Moderate

10%

6%

Severe

15%

9%

81