MEDICAL SURGICAL 1.

orthostatic hpn
Overview of the Structures & Functions of Nervous System 1
Central NS PNS ANS 2. transient headache & dizziness.
Brain & spinal cord 31 spinal & cranial sympathetic NS -Mgt. Rise slowly. Assist in ambulation.
Parasypathatic NS CNS (brain & spinal cord)
Somatic NS I. Cells – A. neurons
C- 8 Properties and characteristics
T- 12 a. Excitability – ability of neuron to be affected in external environment.
L- 5 b. Conductivity – ability of neuron to transmit a wave of excitation from one cell to another
S- 5 c. Permanent cells – once destroyed, cant regenerate (ex. heart, retina, brain, osteocytes)
C- 1 Regenerative capacity
ANS (or adrenergic of parasympatholitic response) A. Labile – once destroyed cant regenerate
SNS involved in fight or aggression response Effects of SNS (anti-cholinergic/adrenergic) - Epidermal cells, GIT cells, resp (lung cells). GUT
1. Dilate pupil – to aware of surroundings B. Stable – capable of regeneration BUT limited time only ex salivary gland, pancreas cells cell of
Release of norepinephrine (adrenaline – cathecolamine) - medriasis liver, kidney cells
Adrenal medulla (potent vasoconstrictor) 2. Dry mouth C. Permanent cells – retina, brain, heart, osteocytes can’t regenerate.
Increases body activities VS = Increase 3. BP & HR= increased 3.) Neuroglia – attached to neurons. Supports neurons. Where brain tumors are found.
Except GIT – decrease GITmotility bronchioles dilated to take more oxygen Types:
4. RR increased 1. Astrocyte
* Why GIT is not increased = GIT is not important! 5. Constipation & urinary retention 2. Oligodendria
Increase blood flow to skeletal muscles, brain & heart. Astrocytoma – 90 – 95% brain tumor from astrocyte. Most brain tumors are found at astrocyte.
I. Adrenergic Agents – Epinephrine (adrenaline) Astrocyte – maintains integrity of blood brain barrier (BBB).
SE: SNS effect BBB – semi permeable / selective
II. PNS: Beta adrenergic blocking agents (opposite of adrenergic agents) (all end in –‘lol’) -Toxic substance that destroys astrocyte & destroy BBB.
- Blocks release of norepinephrine. Toxins that can pass in BBB:
- Decrease body activities except GIT (diarrhea) 1. Ammonia-liver cirrhosis.
Ex. Propanolol, Metopanolol 2. 2. Carbon Monoxide – seizure & parkinsons.
SE: 3. 3. Bilirubin- jaundice, hepatitis, kernicterus/hyperbilirubenia.
B – broncho spasm (bronchoconstriction) 4. 4. Ketones –DM.
E – elicits a decrease in myocardial contraction OLIGODENDRIA – Produces myelin sheath – wraps around a neuron – acts as insulator facilitates
T – treats HPN rapid nerve impulse transmission.
A – AV conduction slows down No myelin sheath – degenerates neurons
Given to angina & MI – beta-blockers to rest heart Damage to myelin sheath – demyellenating disorders
Anti HPN agents: DEMYELLENATING DSE
1. Beta blockers (-lol) 1.)ALZHEIMER’S DISEASE– atrophy of brain tissue due to a deficiency of acetylcholine.
2. Ace inhibitors (-pril) ex ENALAPRIL, CAPTOPRIL S&Sx:
3. Calcium antagonist A – amnesia – loss of memory
ex CALCIBLOC or NEFEDIPINE A – apraxia – unable to determine function & purpose of object
Peripheral nervous system: cholinergic/ vagal or sympatholitic response Effect of PNS: (cholinergic) A – agnosia – unable to recognize familiar object
- Involved in fly or withdrawal response 1. Meiosis – contraction of pupils A – aphasia –
- Release of acetylcholine (ACTH) 2. Increase salivation - Expressive – brocca’s aphasia – unable to speak
- Decrease all bodily activities except GIT (diarrhea) 3. BP & HR decreased - Receptive – wernickes aphasia – unable to understand spoken words
4. RR decrease – broncho constriction Common to Alzheimer – receptive aphasia
I Cholinergic agents 5. Diarrhea – increased GI motility Drug of choice – ARICEPT (taken at bedtime) & COGNEX.
ex 1. Mestinon 6. Urinary frequency Mgt: Supportive & palliative.
Antidote – anti cholinergic agents Atropine Sulfate – S/E – SNS Microglia – stationary cells, engulfs bacteria, engulfs cellular debris.
S/E- of anti-hpn drugs: II. Compositions of Cord & Spinal cord
80% - brain mass Isocoria – normal size (equal)
10% - CSF Anisocoria – uneven size – damage to mid brain
10% - blood PERRLA – normal reaction
MONROE KELLY HYPOTHESIS: The skull is a closed vault. Any increase in one component will DIENCEPHALON- between brain
increase ICP. Thalamus – acts as a relay station for sensation
Normal ICP: 0-15mmHg Hypothalamus – (thermoregulating center of temp, sleep & wakefulness, thirst, appetite/ satiety
Brain mass center, emotional responses,
2 controls pituitary function.
1. Cerebrum – largest - Connects R & L cerebral hemisphere BRAIN STEM- a. Pons – or pneumotaxic center – controls respiration
- Corpus collusum Cranial 5 – 8 CNS
Rt cerebral hemisphere, Lt cerebral hemisphere MEDULLA OBLONGATA- controls heart rate, respiratory rate, swallowing, vomiting, hiccups/ singutus
Function: Vasomotor center, spinal decuissation termination , CN 9, 10, 11, 12
1. Sensory CEREBELLUM – lesser brain
2. Motor - Controls posture, gait, balance, equilibrium
3. Integrative 3
Lobes Cerebellar Tests:
1.) Frontal a.) R – Romberg’s test- needs 2 RNs to assist
a. Controls motor activity - Normal anatomical position 5 – 10 min
b. Controls personality development (+) Romberg’s test – (+) ataxia or unsteady gait or drunken like movement with loss of balance.
c. Where primitive reflexes are inhibited b.) Finger to nose test –
d. Site of development of sense of umor (+) To FTNT – dymetria – inability to stop a movement at a desired point
e. Brocca’s area – speech center c.) Alternate pronation & supination
Damage - expressive aphasia Palm up & down . (+) To alternate pronation & supination or damage to cerebellum – dymentrium
2.) Temporal – Composition of brain - based on Monroe Kellie Hypothesis
a. Hearing - Skull is a closed container. Any alteration in 1 of 3 intracranial components = increase in ICP
b. Short term memory Normal ICP – 0 – 15 mmHg
c. Wernickes area – gen interpretative or knowing Gnostic area Foramen Magnum
Damage – receptive aphasia C1 – atlas
3.) Parietal lobe – appreciation & discrimation of sensory imp C2 – axis
- Pain, touch, pressure, heat & cold (+) Projectile vomiting = increase ICP
4.) Occipital - vision Observe for 24 - 48 hrs
5.) Insula/island of reil/ Central lobe- controls visceral fx CSF – cushions the brain, shock absorber
Function: - activities of internal organ Obstruction of flow of CSF = increase ICP
6.) Rhinencephalon/ Limbec Hydrocephalus – posteriorly due to closure of posterior fontanel
- Smell, libido, long-term memory CVA – partial/ total obstruction of blood supply
Basal Ganglia – areas of gray matte located deep within a cerebral hemisphere INCREASED ICP – increase ICP is due to increase in 1 of the Intra Cranial components.
- Extra pyramidal tract Predisposing factors:
- Releases dopamine- 1.) Head injury
- Controls gross voluntary unit 2.) Tumor
Decrease dopamine – (Parkinson’s) pin rolling of extremities & Huntington’s Dse. 3.) Localized abscess
Decrease acetylcholine – Myasthenia Gravis & Alzheimer’s 4.) Hemorrhage (stroke)
Increased neurotransmitter = psychiatric disorder Increase dopamine – schizo 5.) Cerebral edema
Increase acetylcholine – bipolar 6.) Hydrocephalus
MID BRAIN – relay station for sight & hearing 7.) Inflammatory conditions - Meningitis, encephalitis
Controls size & reaction of pupil 2 – 3 mm B. S&Sx change in VS = always late symptoms
Controls hearing acuity Earliest Sx:
CN 3 – 4 a.) Change or decrease LOC – Restlessness to confusion Wide pulse pressure: Increased ICP
- Disorientation to lethargy Narrow pp: Cardiac disorder, shock 5. Prevent complications of immobility
- Stupor to coma 6. Prevent increase ICP by:
Late sign – change in V/S a. Maintain quiet & comfy environment
1. BP increase (systolic increase, diastole- same) b. Avoid use of restraints – lead to fractures
2. Widening pulse pressure c. Siderails up
Normal adult BP 120/80 120 – 80 = 40 (normal pulse pressure) d. Instruct patient to avoid the ff:
Increase ICP = BP 140/80 = 140 – 80= 60 PP (wide) -Valsalva maneuver or bearing down, avoid straining of stool
3. RR is decreased (Cheyne-Stokes = bet period of apnea or hyperpnea with periods of apnea) (give laxatives/ stool softener Dulcolax/ Duphalac)
4. Temp increase - Excessive cough – antitussive
Increased ICP: Increase BP Shock – decrease BP – Dextrometorpham
Decrease HR Increase HR CUSHINGS EFFECT -Excessive vomiting – anti emetic (Plasil – Phil only)/ Phenergan
Decrease RR Increase RR - Lifting of heavy objects
Increase Temp Decrease temp - Bending & stooping
b.) Headache e. Avoid clustering of nursing activities
Projectile vomiting 7. Administer meds as ordered:
Papilledima (edema of optic disk – outer surface of retina) 1.) Osmotic diuretic – Mannitol./Osmitrol promotes cerebral diuresis by decompressing brain tissue
Decorticate (abnormal flexion) = Damage to cortico spinal tract / Nursing considerations: Mannitol
Decerebrate (abnormal extension) = Damage to upper brain stem-pons/ 1. Monitor BP – SE of hypotension
c.) Uncal herniation – unilateral dilation of pupil. (Bilateral dilation of pupil – tentorial herniation.) 2. Monitor I&O every hr. report if < 30cc out put
d.) Possible seizure. 3. Administer via side drip
4 4. Regulate fast drip – to prevent formation of crystals or precipitate
Nursing priority: 2.) Loop diuretic - Lasix (Furosemide)
1.) Maintain patent a/w & adequate ventilation Nursing Mgt: Lasix
a. Prevention of hypoxia – (decrease tissue oxygenation) & hypercarbia (increase in CO2 retention). Same as Mannitol except
Hypoxia – cerebral edema - increase ICP - Lasix is given via IV push (expect urine after 10-15mins) should be in the
Hypoxia – inadequate tissue oxygenation morning. If given at 7am. Pt will urinate at 7:15
Late symptoms of hypoxia – B – bradycardia Immediate effect of Lasix within 15 minutes. Max effect – 6 hrs due (7am – 1pm)
E – extreme restlessness 5
D – dyspnea S/E of Lasix
C – cyanosis Hypokalemia (normal K-3.5 – 5.5 meg/L)
Early symptoms – R – restlessness S&Sx
A – agitation 1. Weakness & fatigue
T – tachycardia 2. Constipation
Increase CO2 retention/ hypercarbia – cerebral vasodilatation = increase ICP 3. (+) “U” wave in ECG tracing
Most powerful respiratory stimulant increase in CO2 Nursing Mgt:
Hyperventilate decrease CO2 – excrete CO2 1.) Administer K supplements – ex Kalium Durule, K chloride
Respiratory Distress Syndrome (RDS) – decrease Oxygen Potassium Rich food:
Suctioning – 10-15 seconds, max 15 seconds. Suction upon removal of suction cap. ABC’s of K
Ambu bag – pump upon inspiration Vegetables Fruits
c. Assist in mechanical ventilation A - asparagus A – apple
1. Maintain patent a/w B – broccoli (highest) B – banana – green
2. Monitor VS & I&O C – carrots C – cantalope/ melon
3. Elevate head of bed 30 – 45 degrees angle neck in neutral position unless contra indicated to O – orange (highest) –for digitalis toxicity also.
promote venous Vit A – squash, carrots yellow vegetables & fruits, spinach, chesa
drainage Iron – raisins,
4. Limit fluid intake 1,200 – 1,500 ml/day Food appropriate for toddler – spaghetti! Not milk – increase bronchial secretions
(FORCE FLUID means:Increase fluid intake/day – 2,000 – 3,000 ml/day)- not for inc ICP. Don’t give grapes – may choke
S/E of Lasix: Antidote for morphine SO4 toxicity –Narcan (NALOXONE)
1.) Hypokalemia Naloxone toxicity – tremors
2.) Hypocalcemia (Normal level Ca = 8.5 – 11mg/100ml) or Tetany: Increase ICP meds:
S&Sx 3.) Corticosteroids - Dexamethsone – decrease cerebral edema (Decadrone)
weakness 4.) Mild analgesic – codeine SO4. For headache.
Paresthesia 5.) Anti consultants – Dilantin (Phenytoin)
(+) Trousseau sign – pathognomonic – or carpopedal spasm. Put bp cuff on arm=hand spasm. Question: Increase ICP what is the immediate nsg action?
(+) Chevostek’s sign a. Administer Mannitol as ordered
Arrhythmia b. Elevate head 30 – 45 degrees
Laryngospasm c. Restrict fluid
Administer – Ca gluconate – IV slowly d. Avoid use of restraints
Ca gluconate toxicity: Sx – seizure – administer Mg SO4 Nsg Priority – ABC & safety
Mg SO4 toxcicity– administer Ca gluconate Pt suffering from epiglotitis. What is nsg priority?
B – BP decrease a. Administer steroids – least priority
U – urine output decrease b. Assist in ET – temp, a/w
R – RR decrease c. Assist in tracheotomy – permanent (Answer)
P – patellar reflexes absent d. Apply warm moist pack? Least priority
3.) Hyponatremia – Normal Na level = 135 – 145 meg/L Rationale: Wont need to pass larynx due to larynx is inflamed. ET can’t pass. Need tracheostomy
S/Sx – Hypotension only-
Signs of Dehydration: dry skin, poor skin turgor, gen body malaise. Magic 2’s of drug monitoring
Early signs – Adult: thirst and agitation / Child: tachycardia Drug N range Toxicity Classification Indication
Mgt: force fluid D – digoxin .5 – 1.5 meq/L 2 cardiac glycosides CHF
Administer isotonic fluid sol L - lithium .6 – 1.2 meq/L 2 antimanic bipolar
4.) Hyperglycemia – increase blood sugar level A – aminophylline 10 – 19 mg/100ml 20 bronchodilator COPD
P – polyuria D – Dilantin 10 -19 mg/100 ml 20 anticonvulsant seizures
P – polyphagia A – acetaminophen 10 – 30 mg/100ml 200 narcotic analgesic osteoarthritis
P – polydipsia Digitalis – increase cardiac contraction = increase CO
Nsg Mgt: Nursing Mgt
a. Monitor FBS (N=80 – 120 mg/dl) 1. Check PR, HR (if HR below 60bpm, don’t giveDigoxin)
5.) Hyperurecemia – increase serum uric acid. Tophi- urate crystals in joint. Digitalis toxicity – antidote - Digivine
6 a. Anorexia -initial sx.
Gou ty arthritis kidney stones- renal colic (pain) b. n/v GIT
Cool moist skin c. Diarrhea
Sx joint pain & swelling usually at great toe. d. Confusion
Nsg Mgt of Gouty Arthritis 7
a.) Cheese (not sardines, anchovies, organ meat) e. Photophobia
(Not good if pt taking MAO) f. Changes in color perception – yellow spots
b.) Force fluid (Ok to give to pts with renal failure. Digoxin is metabolized in liver not in kidney.)
c.) Administer meds – Allopurinol/ Zyloprim – inhibits synthesis of uric acid – drug of choice for gout L – lithium (lithane) decrease levels of norepinephrine, serotonine, acetylcholine
Colchicene – excretes uric acid. Acute gout drug of choice. Antimanic agent
Kidney stones – renal colic (pain). Cool moist skin Lithium toxicity
Mgt: S/Sx -
1.) Force fluid a.) Anorexia
2.) Meds – narcotic analgesic b.) n/s
Morphine SO4 c.) Diarrhea
SE of Morphine SO4 toxicity d.) Dehydration – force fluid, maintain Na intake 4 – 10g daily
Respiratory depression (check RR 1st) e.) Hypothyroidism
(CRETINISM– the only endocrine disorder that can lead to mental retardation) Prepare suctioning apparatus.
A – aminophyline (theophylline) – dilates bronchioles. Question: The following are symptoms of hypoglycemia except:
Take bp before giving aminophylline. a. Nightmares
S/Sx : Aminophylline toxicity: b. Extreme thirst – hyperglycemia symptoms
1. Tachycardia c. Weakness d. Diaphoresis
2. Hyperactivity – restlessness, agitation, tremors PARKINSONS DSE (parkinsonism) - chronic, progressive disease of CNS char by degeneration of
Question: Avoid giving food with Aminophylline dopamine
a. Cheese/butter– food rich in tyramine, avoided only if pt is given MAOI producing cells in substancia nigra at mid brain & basal ganglia
b. Beer/ wine - - Palliative, Supportive
c. Hot chocolate & tea – caffeine – CNS stimulant tachycardia Function of dopamine: controls gross voluntary motors.
d. Organ meat/ box cereals – anti parkinsonian Predisposing Factors:
MAOI – antidepressant 1. Poisoning (lead & carbon monoxide). Antidote for lead = Calcium EDTA
m AR plan 2. Hypoxia
n AR dil can lead to CVA or hypertensive crisis 3. Arteriosclerosis
p AR nate 4. Encephalitis
3 – 4 weeks - before MAOI will take effect High doses of the ff:
Anti Parkinsonian agents – Vit B6 Pyridoxine reverses effect of Levodopa a. Reserpine (serpasil) anti HPN, SE – 1.) depression - suicidal 2.) breast cancer
D – dilatin (Phenytoin) – anti convulsant/seizure b. Methyldopa (aldomet) - promote safety
Nursing Mgt: c. Haloperidol (Haldol)- anti psychotic
1. Mixed with plain NSS or .9 NaCl to prevent formation of crystals or precipitate d. Phenothiazide - anti psychotic
- Do sandwich method SE of anti psychotic drugs – Extra Pyramidal Symptom
- Give NSS then Dilantin, then NSS! Over meds of anti psychotic drugs – neuroleptic malignant syndrome char by tremors (severe)
2. Instruct the pt to avoid alcohol – bec alcohol + dilantin can lead to severe CNS depression S/Sx: Parkinsonism –
Dilantin toxicity: 1. Pill rolling tremors of extremities – early sign
S/Sx: 2. Bradykinesia – slow movement
G – gingival hyperplasia – swollen gums 3. Over fatigue
i. Oral hygiene – soft toothbrush 4. Rigidity (cogwheel type)
ii. Massage gums a. Stooped posture
H – hairy tongue b. Shuffling – most common
A - ataxia c. Propulsive gait
N – nystagmus – abnormal movement of eyeballs 5. Mask like facial expression with decrease blinking eyes
A – acetaminophen/ Tylenol – non-opoid analgesic & antipyretic – febrile pts 6. Monotone speech
Acetaminophen toxicity : 7. Difficulty rising from sitting position
1. Hepato toxicity 8. Mood labilety – always depressed – suicide
2. Monitor liver enzymes Nsg priority: Promote safety
SGPT (ALT) – Serum Glutamic Piruvate Tyranase 9. Increase salivation – drooling type
SGOT- Serum Glutamic Acetate Tyranase 10. Autonomic signs:
3. Monitor BUN (10 – 20) - Increase sweating
Crea (.8-1) - Increase lacrimation
Acetaminophen toxicity can lead to hypoglycemia - Seborrhea (increase sebaceous gland)
8 - Constipation
T – tremors, Tachycardia - Decrease sexual activity
I – irritability Nsg Mgt
R – restlessness 1.) Anti parkinsonian agents
E – extreme fatigue - Levodopa (L-Dopa), Carbidopa (Sinemet), Amantadine Hcl (Symmetrel)
D – depression (nightmares) , Diaphoresis Mechanism of action
Antidote for acetaminophen toxicity – Acetylcesteine = causes outporing of secretions. Suction. Increase levels of dopa – relieving tremors & bradykinesia
S/E of anti parkinsonian Ig M – acute inflammation
- Anorexia Ig E – allergic reactions
- n/v IgD – chronic inflammation
- Confusion S & Sx of MS: (everything down)
- Orthostatic hypotension 1. Visual disturbances
9 a. Blurring of vision
- Hallucination b. Diplopia/ double vision
- Arrhythmia c. Scotomas (blind spots) – initial sx
Contraindication: 2. Impaired sensation to touch, pain, pressure, heat, cold
1. Narrow angled closure glaucoma a. Numbness
2. Pt taking MAOI (Parnate, Marplan, Nardil) b. Tingling
Nsg Mgt when giving anti-parkinsonian c. Paresthesia
1. Take with meals – to decrease GIT irritation 3. Mood swings – euphoria (sense of elation )
2. Inform pt – urine/ stool may be darkened 10
3. Instruct pt- don’t take food Vit B6 (Pyridoxine) cereals, organ meats, green leafy veg 4. Impaired motor function:
- Cause B6 reverses therapeutic effects of levodopa a. Weakness
Give INH (Isoniazide-Isonicotene acid hydrazide.) SE-Peripheral neuritis. b. Spasiticity –“ tigas”
2.) Anti cholinergic agents – relieves tremors c. Paralysis –major problem
Artane mech – inhibits acetylcholine 5. Impaired cerebellar function
Cogentin action , S/E - SNS Triad Sx of MS
3.) Antihistamine – Diphenhydramine Hcl (Benadryl) – take at bedtime I – intentional tremors
S/E: adult– drowsiness,– avoid driving & operating heavy equipt. Take at bedtime. N – nystagmus – abnormal rotation of eyes Charcots triad
Child – hyperactivity CNS excitement for kids. A – Ataxia
4.) Dopamine agonist & Scanning speech
Bromotriptine Hcl (Parlodel) – respiratory depression. Monitor RR. 6. Urinary retention or incontinence
Nsg Mgt – Parkinson 7. Constipation
1.) Maintain siderails 8. Decrease sexual ability
2.) Prevent complications of immobility Dx – MS
- Turn pt every 2h 1. CSF analysis thru lumbar puncture
Turn pt every 1 h – elderly - Reveals increase CHON & IgG
3.) Assist in passive ROM exercises to prevent contractures 2. MRI – reveals site & extent of demyelination
4.) Maintain good nutrition 3. Lhermitte’s response is (+). Introduce electricity at the back. Theres spasm & paralysis at spinal
CHON – in am cord.
CHON – in pm – to induce sleep – due Tryptopan – Amino Acid Nsg Mgt MS
5.) Increase fluid in take, high fiber diet to prevent constipation - Supportive mgt
6.) Assist in surgery – Sterotaxic Thalamotomy 1.) Meds
Complications in sterotaxic thalmotomy- 1.) Subarachnoid hemorrhage 2.) aneurism 3.) encephalitis a. Acute exacerbation
MULTIPLE SCLEROSIS (MS) ACTH – adenocorticotopic
Chronic intermittent disorder of CNS – white patches of demyelenation in brain & spinal cord. Steroids – to reduce edema at the site of demyelination to prevent paralysis
- Remission & exacerbation Spinal Cord Injury
- Common – women, 15 – 35 yo cause – unknown Administer drug to prevent paralysis due to edema
Predisposing factor: a. Give ACTH – steroids
1. Slow growing virus b. Baclopen (Lioresol) or Dantrolene Na (Dantrene)
2. Autoimmune – (supportive & palliative treatment only) To decrease muscle spasticity
Normal Resident Antibodies: c. Interferone – to alter immune response
Ig G – can pass placenta – passive immunity. Short acting. d. Immunosuppresants
Ig A – body secretions – saliva, tears, colostrums, sweat 2. Maintain siderails
3. Assist passive ROMexercises – promote proper body alignment - Increase acetylcholine
4. Prevent complications of immobility s/e – PNS
5. Encourage fluid intake & increase fiber diet – to prevent constipation b.) Corticosteroids – to suppress immune resp
6. Provide catheterization die urinary retention Decadron (dexamethasone)
7. Give diuretics Monitor for 2 types of Crisis:
Urinary incontinence – give Prophantheline bromide (probanthene) Myastinic crisis Cholinergic crisis
Antispasmodic anti cholinergic A cause – 1. Under medication
8. Give stress reducing activity. Deep breathing exercises, biofeedback, yoga techniques. 2. Stress
9. Provide acid-ash diet – to acidify urine & prevent bacteria multiplication 3. Infection
Grape, Cranberry, Orange juice, Vit C B S&Sx 1. Unable to see – Ptosis &
MYASTHENIA GRAVIS (MG) – disturbance in transmission of impulses from nerve to muscle cell at diplopia
neuro muscular 2. Dysphagia- unable to swallow.
junction. 3. Unable to breath
Common in Women, 20 – 40 yo, unknown cause or idiopathic C Mgt – adm cholinergic agents
Autoimmune – release of cholenesterase – enzyme Cause: 1 over meds
Cholinesterase destroys ACH (acetylcholine) = Decrease acetylcholine S/Sx - PNS
Descending muscle weakness Mgt. adm anti-cholinergic
(Ascending muscle weakness – Guillain Barre Syndrome) - Atropine SO4
Nsg priority: - SNS – dry mouth
1) a/w 7. Assist in surgical proc – thymectomy. Removal of thymus gland. Thymus secretes auto immune
2) aspiration antibody.
3) immobility 8. Assist in plasmaparesis – filter blood
S/ Sx: 9. Prevent complication – respiratory arrest
1.) Ptosis – drooping of upper lid ( initial sign) Prepare tracheostomy set at bedside.
Check Palpebral fissure – opening of upper & lower lids = to know if (+) of MG. GBS – Guillain Barre Syndrome
2.) Diplopia – double vision - Disorder of CNS
11 - Bilateral symmetrical polyneuritis
3.) Mask like facial expression - Ascending paralysis
4.) Dysphagia – risk for aspiration! Cause – unknown, idiopathic
5.) Weakening of laryngeal muscles – hoarseness of voice - Auto immune
6.) Resp muscle weakness – lead respiratory arrest. Prepare at bedside tracheostomy set - r/t antecedent viral infection
7.) Extreme muscle weakness during activity especially in the morning. - Immunizations
Dx test S&Sx
1. Tensilon test (Edrophonium Hcl) – temporarily strengthens muscles for 5 – 10 mins. Short term- Initial :
cholinergic. PNS effect. 1. Clumsiness
Nsg Mgt 2. Ascending muscle weakness – lead to paralysis
1. Maintain patent a/w & adequate vent by: 3. Dysphagia
a.) Assist in mechanical vent – attach to ventilator 4. Decrease or diminished DTR (deep tendon reflexes)
b.) Monitor pulmonary function test. Decrease vital lung capacity. - Paralysis
2. Monitor VS, I&O neuro check, muscle strength or motor grading scale (4/5, 5/5, etc) 5. Alternate HPN to hypotension – lead to arrhythmia - complication
3. Siderails 6. Autonomic changes – increase sweating, increase salivation.
4. Prevent complications of immobility. Adult-every 2 hrs. Elderly- every 1 hr. Increase lacrimation
5. NGT feeding 12
Administer meds – Constipation
a.) Cholinergics or anticholinesterase agents Dx most important: CSF analysis thru lumbar puncture reveals increase in : IgG & CHON (same with
Mestinon (Pyridostigmine) MS)
Neostignine (prostigmin) – Long term Nsg Mgt
1. Maintain patent a/w & adequate vent Opisthotonus- rigid arching of back
a. Assist in mechanical vent Pathognomonic sign – (+) Kernig’s & Brudzinski sign
b. Monitor pulmonary function test 13
2. Monitor vs., I&O neuro check, ECG tracing due to arrhythmia Leg pain neck pain
3. Siderails Dx:
4. Prevent compl – immobility 1. Lumbar puncture – lumbar/ spinal tap – use of hallow spinal needle – sub arachnoid space L3 &
5. Assist in passive ROM exercises L4 or L4 & L5
6. Institute NGT feeding – due dysphagia Aspirate CSF for lumbar puncture.
7. Adm meds (GBS) as ordered: – 1. Anti cholinergic – atropine SO4 Nsg Mgt for lumbar puncture – invasive
2. Corticosteroids – to suppress immune response 1. Consent / explain procedure to pt
3. Anti arrhythmic agents - RN – dx procedure (lab)
a.) Lidocaine /Xylocaine –SE confusion = VTach - MD – operation procedure
b.) Bretyllium 2. Empty bladder, bowel – promote comfort
c.) Quinines/Quinidine – anti malarial agent. Give with meals. 3. Arch back – to clearly visualize L3, L4
- Toxic effect – cinchonism Nsg Ngt post lumbar
Quinidine toxicity 1. Flat on bed – 12 – 24 h to prevent spinal headache & leak of CSF
S/E – anorexia, n/v, headache, vertigo, visual disturbances 2. Force fluid
8. Assist in plasmaparesis (MG. GBS) 3. Check punctured site for drainage, discoloration & leakage to tissue
9. Prevent comp – arrhythmias, respiratory arrest 4. Assess for movement & sensation of extremeties
Prepare tracheostomy set at bedside. Result
INFL CONDITONS OF BRAIN 1. CSF analysis: a. increase CHON & WBC Content of CSF: Chon, wbc, glucose
Meninges – 3-fold membrane – cover brain & spinal cord b. Decrease glucose
Fx: Confirms meningitis c. increase CSF opening pressure
Protection & support N 50 – 160 mmHg
Nourishment d. (+) Culture microorganism
Blood supply 2. Complete blood count CBC – reveals increase WBC
3 layers Mgt:
1. Duramater sub dural space 1. Adm meds
2. Arachmoid matter a.) Broad-spectrum antibiotic penicillin
3. Pia matter sub arachnoid space where CSF flows L3 & L4. Site for lumbar puncture. S/E
MENINGITIS – inflammation of meningitis & spinal cord 1. GIT irritation – take with food
Etiology – Meningococcus 2. Hepatotoxicity, nephrotoxcicity
Pneumococcus 3. Allergic reaction
Hemophilous influenza – child 4. Super infection – alteration in normal bacterial flora
Streptococcus – adult meningitis - N flora throat – streptococcus
MOT – direct transmission via droplet nuclei - N flora intestine – e coli
S&Sx Sx of superinfection of penicillin = diarrhea
- Stiff neck or nuchal rigidity (initial sign) b.) Antipyretic
- Headache c.) Mild analgesic
- Projectile vomiting – due to increase ICP 2. Strict resp isolation 24h after start of antibiotic therapy
- Photophobia A – Cushing’s synd – reverse isolation - due to increased corticosteroid in body.
- Fever chills, anorexia B – Aplastic anemia – reverse isolation - due to bone marrow depression.
- Gen body malaise C – Cancer anytype – reverse isolation – immunocompromised.
- Wt loss D – Post liver transplant – reverse isolation – takes steroids lifetime.
- Decorticate/decerebration – abnormal posturing E – Prolonged use steroids – reverse isolation
- Possible seizure F – Meningitis – strict respiratory isolation – safe after 24h of antibiotic therapy
Sx of meningeal irritation – nuchal rigidity or stiffness G – Asthma – not to be isolated
3. Comfy & dark room – due to photophobia & seizure 6. Diet – increase saturated fats
4. Prevent complications of immobility 7. Emotional & physical stress
5. Maintain F & E balance 8. Obesity
6. Monitor vs, I&O , neuro check S & Sx
7. Provide client health teaching & discharge plan 1. TIA- warning signs of impending stroke attacks
a. Nutrition – increase cal & CHO, CHON-for tissue repair. Small freq feeding - Headache (initial sx), dizziness/ vertigo, numbness, tinnitus, visual & speech disturbances, paresis
b. Prevent complication hydrocephalus, hearing loss or nerve deafness. or plegia (monoplegia – 1
8. Prevent seizure. extreme)
14 Increase ICP
Where to bring 2 yo post meningitis 2. Stroke in evolution – progression of S & Sx of stroke
- Audiologist due to damage to hearing- post repair myelomeningocele 3. Complete stroke – resolution of stroke
- Urologist - Damage to sacral area – spina bifida – controls urination a.) Headache
9. Rehab for neurological deficit. Can lead to mental retardation or a delay in psychomotor b.) Cheyne-Stokes Resp
development. c.) Anorexia, n/v
CEREBRO VASCULAR ACCIDENT – stroke, brain attack or cerebral thrombosis, apoplexy d.) Dysphagia
- Partial or complete disruption in the brains blood supply 15
- 2 largest & common artery in stroke e.) Increase BP
Middle cerebral artery f.) (+) Kernig’s & Brudzinski – sx of hemorrhagic stroke
Internal carotid artery g.) Focal & neurological deficit
- Common to male – 2 – 3x high risk 1. Phlegia
Predisposing factor: 2. Dysarthria – inability to vocalize, articulate words
1. Thrombosis – clot (attached) 3. Aphasia
2. Embolism – dislodged clot – pulmo embolism 4. Agraphia diff writing
S/Sx: pulmo embolism 5. Alesia – diff reading
Sudden sharp chest pain 6. Homoninous hemianopsia – loss of half of field of vision
Unexplained dyspnea, SOB Left sided hemianopsia – approach Right side of pt – the unaffected side
Tachycardia, palpitations, diaphoresis & mild restlessness Dx
S/Sx: cerebral embolism 1. CT Scan – reveals brain lesion
Headache, disorientation, confusion & decrease in LOC 2. Cerebral arteriography – site & extent of mal occlusion
Femur fracture – complications: fat embolism – most feared complication w/in 24hrs - Invasive procedure due to inject dye
Yellow bone marrow – produces fat cells at meduallary cavity of long bone - Allergy test
Red bone marrow – provides WBC, platelets, RBC found at epiphisis All – graphy – invasive due to iodine dye
2.) Hemorrhage Post
3.) Compartment syndrome – compression of nerves/ arteries 1.) Force fluid – to excrete dye is nephrotoxic
Risk factors of CVA: HPN, DM, MI, artherosclerosis, valvular heart dse - Post heart surgery – mitral 2.) Check peripheral pulses - distal
valve replacement Nsg Mgt
Lifestyle: 1. Smoking – nicotine – potent vasoconstrictor 1. Maintain patent a/w & adequate vent
2. Sedentary lifestyle - Assist mechanical ventilation
3. Hyperlipidemia – genetic - Administer O2
4. Prolonged use of oral contraceptives 2. Restrict fluids – prevent cerebral edema
- Macro pill – has large amt estrogen 3. Elevate head of bed 30-45 degrees angle. Avoid valsalva maneuver.
- Mini pill – has large amt of progestin 4. Monitor vs., I&O, neuro check
- Promote lipolysis (breakdown of lipids/fats) – artherosclerosis – HPN - stroke 5. Prevent compl of immobility by:
5. Type A personality a. Turn client q2h
a. Deadline driven person Elderly q1h
b. 2 – 5 things at the same time - To prevent decubitus ulcer
c. Guilty when not dong anything - To prevent hypostatic pneumonia – after prolonged immobility.
b. Egg crate mattress or H2O bed Nutritional & metabolic deficit
c. Sand bag or foot board- prevent foot drop Physical stress
6. NGT feeding – if pt can’t swallow Sudden withdrawal to anticonvulsants will bring about status epilepticus
7. Passive ROM exercise q4h Status epilepticus – drug of choice: Diazepam & glucose
8. Alternative means of communication S & Sx
- Non-verbal cues I. Generalized Seizure –
- Magic slate. Not paper and pen. Tiring for pt. a.) Grand mal / tonic clonic seizures
- (+) To hemianopsia – approach on unaffected side With or without aura – warning symptoms of impending seizure attack- Epigastric pain- associated
9. Meds with
Osmotic diuretics – Mannitol olfactory, tactile, visual, auditory sensory experience
Loop diuretics – Lasix/ Furosemide - Epileptic cry – fall
Corticosteroids – dextamethazone - Loss of consciousness 3 – 5 min
Mild analgesic - Tonic clonic contractions
Thrombolytic/ fibrolitic agents – tunaw clot. SE-Urticaria, pruritus-caused by foreign subs. - Direct symmetrical extension of extremities-TONIC. Contractions-CLONIC
Streptokinase - Post ictal sleep -state of lethargy or drowsiness - unresponding sleep after tonic clonic
Urokinase b.) Petimal seizure – (same as daydreaming!) or absent seizure.
Tissue plasminogen activating - Blank stare
Monitor bleeding time - Decrease blinking eye
Anticoagulants – Heparin & Coumadin” sabay” - Twitching of mouth
Coumadin will take effect after 3 days - Loss of consciousness – 5 – 10 secs (quick & short)
Heparin – monitor PTT partial thromboplastin time if prolonged – bleeding give Protamine SO4- II. Localized/partial seizure
antidote. a.) Jacksonian seizure or focal seizure – tingling/jerky movement of index finger/thumb & spreads to
Coumadin –Long term. monitor PT prothrombin time if prolonged- bleeding give Vit K – shoulder &
Aquamephyton- antidote. 1 sideof the body with janksonian march
Antiplatelet – PASA – aspirin paraanemo aspirin, don’t give to dengue, ulcer, and unknown headache. b.) Psychomotor/ focal motor - seizure
Health Teaching -Automatism – stereotype repetitive & non-purposive behavior
1. Avoidance modifiable lifestyle - Clouding of consciousness – not in control with environment
- Diet, smoking - Mild hallucinatory sensory experience
2. Dietary modification HALLUCINATIONS
16 1. Auditory – schitzo – paranoid type
- Avoid caffeine, decrease Na & saturated fats 2. Visual – korsakoffs psychosis – chronic alcoholism
Complications: 3. Tactile – addict – substance abuse
Subarachnoid hemorrhage III. Status epilecticus – continuous, uninterrupted seizure activity, if untreated, lead to hyperprexia –
Rehab for focal neurological deficit – physical therapy coma – death
1. Mental retardation Seizure: inc electrical firing in brain=increased metabolic activity in brain=brain using glucose and
2. Delay in psychomotor development O2=dec glucose, dec O2.
CONVULSIVE Disorder (CONVULSIONS)- disorder of the CNS char. by paroxysmal seizures with or Tx:Diazepam (drug of choice), glucose
without loss of 17
consciousness, abnormal motor activity, alteration in sensation & perception & change in behavior. Dx-Convulsion- get health history!
Can you outgrow febrile seizure? Difference between: Seizure- 1st convulsive attack 1. CT scan – brain lesion
Febrile seizure Normal if < 5 yo Epilepsy – 2nd and with history of seizure 2. EEG electroencephalography
Pathologic if > 5 yo - Hyperactivity brain waves
Predisposing Factor Nsg Mgt
Head injury due birth trauma Priority – Airway & safety
Toxicity of carbon monoxide 1. Maintain patent a/w & promote safety
Brain tumor Before seizure:
Genetics 1. Remove blunt/sharp objects
2. Loosen clothing 18
3. Avoid restraints 2.) Levels of orientation
4. Maintain siderails 3.) CN assessment
5. Turn head to side to prevent aspiration 4.) Motor assessment
6. Tongue guard or mouth piece to prevent biting of tongue-BEFORE SEIZURE ONLY! Can use 5.) Sensory assessment
spoon at home. 6.) Cerebral test – Romhberg, finger to nose
7. Avoid precipitating stimulus – bright glaring lights & noises 7.) DTR
8. Administer meds 8.) Autonomics
a. Dilantin (Phenytoin) –( toxicity level – 20 ) Levels of consciousness (LOC) –
SE Ginguial hyperplasia 1. Conscious (conscious) – awake – levels of wakefulness
H-hairy tongue 2. Lethargy (lethargic) – drowsy, sleepy, obtunded
A-ataxia 3. Stupor (stuporous) – awakened by vigorous stimulation
N-nystagmus Pt has gen body weakness, decrease body reflex
A-acetaminophen- febrile pt 4. Coma (Comatose) light – (+) all forms of painful stimulations
Mix with NSS Deep – (-) to painful stimulation
- Don’t give alcohol – lead to CNS depression Question: Describe a conscious pt ?
b. (Tegretol) Carbamasene- given also to Trigeminal Neuralgia. SE: arrythmia a. Alert – not all pt are alert & oriented to time & place
c. Phenobarbital (Luminal)- SE: hallucinations b. Coherent
2. Institute seizure & safety precaution. Post seizure: Administer O2. Suction apparatus ready at c. Awake- answer
bedside d. Aware
3. Monitor onset & duration Different types of pain stimulation
- Type of seizure - Don’t prick
- Duration of post ictal sleep. The longer the duration of post ictal sleep, the higher chance of having 1. Deep sternal stimulation/ pressure 3x– fist knuckle
status With response – light coma
epilepticus! Without response – deep coma
4. Assist in surgical procedure. Cortical resection 2. Pressure on great toe – 3x
5. Complications: Subarachnoid hemorrhage and encephalitis 3. Orbital pressure – pressure on orbits only – below eye
Question: 1 yo grand mal – immediate nursing action = a/w & safety 4. Corneal reflex/ blinking reflex
a. Mouthpiece – 1 yr old – little teeth only Wisp of cotton – used to illicit blinking reflex among conscious patients
b. Adm o2 inhalation – post! Instill 1-drop saline solution – unconscious pt if (-) response pt is in deep coma
c. Give pillow – safety (answer) 5. Test of memory – considered educational background
d. Prepare suction a.) Short term memory –
Neurological assessment: - What did you eat for breakfast?
1. Comprehensive neuro exam Damage to temporal lobe – (+) antero grade amnesia
2. GCS - Glasgow coma scale – obj measurement of LOC or quick neuro check b.) Long term memory
3 components of ECS (+) Retrograde amnesia – damage to limbic system
M – motor 6 6. Levels of orientation
V – verbal resp 5 Time Place Person
E – eye opening 4 Graphesthesia- can identify numbers or letters written on palm with a blunt object.
15 Agraphesthesia – cant identify numbers or letters written on palm with a blunt object.
15 – 14 – conscious CN assessment:
13 – 11 – lethargy I – Olfactory s
10 – 8 – stupor II – Optic s
7 – coma III – Oculomotor m
3 – deep coma – lowest score IV – Trocheal m smallest CN
Survey of mental status & speech (Comprehensice Neuro Exam) V – Trigeminal b largest CN
1.) LOC & test of memory VI – Abducens m
VII – Facial b Oculomotor
VIII – Acustic/auditory s 1. Raising of eyelid – Ptosis
IX – Glassopharyngeal b 2. Controls pupil size 2 -3 cm or 1.5 – 2 mm
X – Vagus b longest CN V – Trigeminal – Largest – consists of - ophthalmic, maxillary, mandibular
XI– Spinal accessory m Sensory – controls sensation of the face, mucus membrane; teeth & cornea reflex
XII – Hypoglossal m Unconscious – instill drop of saline solution
I. Olfactory – don’t use ammonia, alcohol, cologne irritating to mucosa – use coffee, bar soap, Motor – controls muscles of chewing/ muscles of mastication
vinegar, cigarette tar Trigeminal neuralgia – diff chewing & swallowing – extreme food temp is not recommended
- Hyposmia – decrease sensitivity to smell Question: Trigeminal neuralgia, RN should give
- Diposmia – distorted sense of smell a. Hot milk, butter, raisins
19 b. Cereals
- Anosmia – absence of sense of smell c. Gelatin, toast, potato – all correct but
Either of 3 might indicate head injury – damage to cribriform plate of ethmoid bone where olfactory d. Potato, salad, gelatin – salad easier to chew
cells are located 20
or indicate inflammation condition – sinusitis VI Facial: Sensory – controls taste – ant 2/3 of tongue test cotton applicator put sugar.
II optic- test of visual acuity – Snellens chart – central or distance vision -Put applicator with sugar to tip to tongue.
Snellens E chart – used for illiterate chart -Start of taste insensitivity: Age group – 40 yrs old
N 20/20 vision distance by w/c person can see letters- 20 ft Motor- controls muscles of facial expression, smile frown, raise eyebrow
Numerator – distance to snellens chart Damage – Bells palsy – facial paralysis
Denominator – distance the person can see the letters Cause – bells palsy pedia – R/T forcep delivery
OD – Rt eye 20/20 20/200 – blindness – cant read E – biggest Temporary only
OS – left eye 20/20 Most evident clinical sign of facial symmetry: Nasolabial folds
OU – both eye 20/20 VIII Acoustic/ vestibule cochlear (controls hearing) – controls balance (kenesthesia or position sense)
2. Test of peripheral vision/ visual field - Movement & orientation of body in space
a. Superiority - Organ of Corti – for hearing – true sense organ of hearing
b. Bitemporally Outer – tympanic membrane, pinna, oricle (impacted cerumen), cerumen
c. Inferiorly Middle – hammer, anvil, stirrup or melleus, incus, staples. Mid otitis media
d. Nasally - Eustachean ear
Common Disorders – see page 85-87 for more info on glaucoma, etc. Inner ear- meniere dse, sensory hearing loss (research parts! & dse)
1. Glaucoma – Normal 12 – 21 mmHg pressure Remove vestibule – meniere’s dse – disease inner ear
- Increase IOP - Loss of peripheral vision – “tunnel vision” Archimedes law – buoyancy (pregnancy – fetus)
2. Cataract – opacity of lens - Loss of central vision, “Blurring or hazy vision” Daltons law – partial pressure of gases
3. Retinal detachment – curtain veil – like vision & floaters Inertia – law of motion (dizziness, vertigo)
4. Macular degeneration – black spots 1.) Pt with multiple stab wound - chest
III, IV, VI – tested simultaneously - Movement of air in & out of lungs is carried by what principle?
- Innervates the movementt of extrinsic ocular muscle - Diffusion – Dalton’s law
6 cardinal gaze EOM 2.) Pregnant – check up – ultrasound reveals fetus is carried by amniotic fluid
Rt eye N left eye - Archimedes
IO SO O 3.) Severe vertigo due- Inertia
S Test for acoustic nerve:
LR MR E - Repeat words uttered
SR IX – Glossopharyngeal – controls taste – posterior 1/3 of tongue
3 – 4 EOM X – Vagus – controls gag reflex
IV – sup oblique Test 9 – 10
VI – lateral rectus Pt say ah – check uvula – should be midline
Normal response – PERRLA (isocoria – equal pupil) Damage cerebral hemisphere is L or R
Anisocoria – unequal pupil Gag reflex – place tongue depression post part of tongue
 Don’t touch uvula 3. Monitor VS, I&O
XI – Spinal Accessory - controls sternocleidomastoid (neck) & trapezius (shoulders and back) 4. Administer meds as ordered
- Shrug shoulders, put pressure. Pt should resist pressure. Paresis or phlegia a.) Pitresin (vasopressin) IM
XII – Hypoglossal – controls movement of tongue – say “ah”. Assess tongue position=midline 5. Prevent complications
L or R deviation Most feared complication – Hypovolemic shock
- Push tongue against cheek B.) SIADH - Syndrome of Inappropriate Anti-Diuretic Hormone
- Short frenulum lingue – - Increase ADH
Tongue tied – “bulol” - Idiopathic/ unknown
ENDOCRINE Predisposing factor
Fx of endocrine – ductless gland 1. Head injury
Main gland – Pituitary gland – located at base of brain of Stella Turcica 2. Related to Bronchogenic cancer or lung caner-
Master gland of body Early Sign of Lung Ca - Cough –1. non productive 2. productive
Master clock of body 3. Hyperplasia of Pit gland
21 Increase size of organ
Anterior pituitary gland – adenohypophysis 22
Posterior pituitary gland – neurohypophysis S&Sx
Posterior pituitary: 1. Fluid retention
1.) Oxytocin – a.) Promotes uterine contraction preventing bleeding/ hemorrhage. 2. Increase BP – HPN
- Give after placental delivery to prevent uterine atony. 3. Edema
b.) Milk letdown reflex with help of prolactin. 4. Wt gain
2.) ADH – antidiuretic hormone – (vasopressin) -Prevents urination – conserve H2O 5. Danger of H2O intoxication –Complications: 1. cerebral edema – increase ICP – 2. seizure
A. DIABETIS INSIPIDUS (DI- dalas ihi) – hyposecretion of ADH Dx Proc:
Cause: idiopathic/ unknown 1. Urine specific gravity increase – diluted urine
Predisposing factor: 2. Hyponatremia – Decreased Na
1. Pituitary surgery Nsg Mgt:
2. Trauma/ head injury 1. Restrict fluid
3. Tumor 2. Administer meds as ordered eg. Diuretics: Loop and Osmotic
4. Inflammation 3. Monitorstrictly V/S, I&O, neuro check – increase ICP
* alcohol inhibits release of ADH 4. Weigh daily
S & Sx: 5. Assess for presence edema
1. Polyuria 6. Provide meticulous skin care
2. Sx of dehydration (1st sx of dehydration in children-tachycardia) 7. Prevent complications – increase ICP & seizures activity
- Excessive thirst (adult) Anterior Pituitary Gland – adeno
- Agitation 1. Growth hormone (GH) (Somatotropic hormone)
- Poor skin turgor Fx: Elongation of long bones
- Dry mucus membrane Decrease GH – dwarfism children
3. Weakness & fatigue Increase GH – gigantism
4. Hypotension – if left untreated - Increase GH – acromegaly – adult
5. Hypovolemic shock Puberty 9 yo – 21 yo
Anuria – late sign hypovolemic shock Epiphyseal plate closes at 21 yo
Dx Proc: Square face
1. Decrease urine specific gravity- concentrated urine Square jaw
N= 1.015 – 1.035 Drug of choice in acromegaly: Ocreotide (Sandostatin) SE dizziness
2. Serum Na = increase (N=135 -145 meq/L) Hypernatremia - Somatostatin Hormone – antagonizes the release of of GH
Mgt: 2. Melanocytes stimulating hormone - MSH
1. Force fluid 2,000 – 3,000ml/day - Skin pigmentation
2. Administer IV fluid replacement as ordered 3. Prolactin/luteotrpic hormone/ lactogenic hormone - Promotes development of mammary gland
(Oxytocin-Initiates milk letdown reflex) a.) Iodine solution – Logol’s solution or saturated sol of K iodide SSKI
4. Adrenocorticotropic hormone – ACTH - Development & maturation of adrenal cortex Nsg Mgt Lugol’s sol – violet color
5. Luteinizing hormone – produces progesterone. 1. use straw – prevent staining teeth
6. FSH- produces estrogen 2. Prophylaxis 2 -3 drops Treatment – 5 to 6 drops
PINEAL GLAND Use straw – to prevernt staining of teeth
1. Secretes Melatonin – inhibits lutenizing hormone (LH) secretion 1. Lugol’s sol., 2. tetracycline 3. nitrofurantin (macrodantin)-urinary anticeptic-pyelonephritis. 4. Iron
THYROID GLAND (TG) solution.
Question: Normal physical finding on TG: B. Thyroid h / Agents
a. With tenderness – thyroid never tender 1. Levothyroxine (Synthroid)
b. With nodular consistency- answer 2. Liothyronine (cytomel)
c. Marked asymmetry – only 1 TG 3. Thyroid extract
d. Palpable upon swallowing - Normal TG never palpable unless with goiter Nsg Mgt: for TH/agents
TG hormones: 1. Monitor vs. – HR due tachycardia & palpitation
T3 T4 Thyrocalcitonin 2. Take it early AM – SE insomnia
- Triodothyronine -Tetraiodothyronine/ Tyroxine FX – antagonizes effects of parathormone 3. Monitor s/e
- 3 molecules of iodine - 4 molecules of iodine 24
23 Tachycardia, palpitations
Metabolic hormone Signs of insomnia
Increase metabolism brain –inc cerebration, inc v/s all v/s down, constipation Hyperthyroidism restlessness agitation
Hypo T3 T4 - lethargy & memory impairment – Heat intolerance
Hyper T3 T4 - agitation, restlessness, and hallucination HPN
7. Increase VS, increase motility 3. Encourage increase intake iodine – iodine is extracted from seaweeds (!)
HYPOTHYROIDISM – all decreased except wt & menstruation, loss of appetite but with wt gain Seafood- highest iodine content oysters, clams, crabs, lobster
menorrhagia – increase in mens Lowest iodine – shrimps
HYPERTHYROIDISM - Increase appetite – wt loss, amenorrhea Iodized salt –easily destroyed by heat take it raw not cooked
SIMPLE GOITER – enlarged thyroid gland - iodine deficiency 4. Assist surgery- Sub total thyroidectomy-
Predisposing factors Complication: 1. Tetany 2. laryngeal nerve damage 3.Hemorrhage-feeling of fullness at incision
1. Goiter belt area - Place far from sea – no iodine. Seafood’s rich in iodine site.Check nape for
2. Mountainous area – increase intake of goitrogenic foods (US: Midwest, NE, Salt Lake) wet blood. 4.Laryngeal spasm – DOB, SOB – trache set ready at bedside.
Cabbage – has progoitrin – an anti thyroid agent with no iodine 2.) HYPOTHYROIDISM – decrease secretion of T3, T4 – can lead to MI / Atherosclerosis
Example: Turnips (singkamas), radish, peas, strawberries, potato, beans, kamote, cassava (root Adult – myxedema
crops), all nuts. Child- cretinism – only endocrine dis lead to mental retardation
3. Goitrogenic drugs: Predisposing factor:
Anti thyroid agents :(PTU) prephyl thiupil 1. `Iatrogenic causes – caused by surgery
Lithium carbonate, Aspirin PASA 2. Atrophy of TG due to:
Cobalt, Phenyl butasone a. Irradiation
Endemic goiter – cause # 1 b. Trauma
Sporadic goiter – caused by #2 & 3 c. Tumor, inflammation
S & Sx – enlarged TG 3. Iodine def
Mild restlessness 4. Autoimmune – Hashimoto disease
Mild dysphagia S&Sx everything decreased except wt gain & mens increase)
Dx Proc. Early signs – weakness and fatigue
1. Thyroid scan – reveals enlarged TG Loss of appetite – increased lypolysis – breakdown of fats causing atherosclerosis = MI
2. Serum TSH – increase (confirmatory) Wt gain
3. Serum T3, T4 – N or below N Cold intolerance – myxedema - coma
Nsg Mgt: Constipation
1. Administer meds Late Sx – brittle hair/ nails
Non pitting edema due increase accumulation of mucopolysacharide in SQ tissue -Myxedema 2. Excessive iodine intake
Horseness voice 3. Hyperplasia of TG
Decrease libido S&Sx:
Decrease VS – hypotension bradycardia, bradypnea, and hypothermia 1. Increase in appetite – hyperphagia – wt loss due to increase metabolism
Lethargy 2. Skin is moist - perspiration
Memory impairment leading to psychosis-forgetfulness 3. Heat intolerance
Menorrhagia 4. Diarrhea – increase motility
Dx: 5. All VS increase = HPN, tachycardia, tachypnea, hyperthermia
1. Serum T3 T4 decrease 6. CNS changes
2. Serum cholesterol increase – can lead to MI 8. Irritability & agitation, restlessness, tremors, insomnia, hallucinations
3. RA IU – radio iodine uptake – decrease 7. Goiter
Nsg Mgt: 8. Exopthalmos – pathognomonic sx
1. Monitor strictly V/S. I&O – to determine presence of myxedema coma! 9. Amenorrhea
Myxedema Coma - Severe form of hypothyroidism Dx:
Hypotension, hypoventilation, bradycardia, bradypnea, hyponatremia, hypoglycemia, hypothermia 1. Serum T3 & T4 - increased
Might lead to progressive stupor & coma 2. Radio iodine uptake – increase
Impt mgt for Myxedema coma 3. Thyroid scan – reveals enlarged TG
1. Assist mech vent – priority a/w Nsg Mgt:
2. Adm thyroid hormone 1. Monitor VS & I & O – determine presence of thyroid storm or most feared complication:
3. Adm IVF replacement – force fluid Thyrotoxicosis
25 2. Administer meds
Mgt myxedema coma a. Antithyroid agents
1. Monitor VS, I&O 1. Prophylthiuracil (PTU)
2. Provide dietary intake low in calories – due to wt gain 2. Methymazole (Tapazole)
3. Skin care due to dry skin Most toxic s/e agranulocytosis- fever, sore throat, leukocytosis=inc wbc: check cbc and throat swab
4. Comfortable & warm environment due to cold intolerance culture
5. Administer IVF replacements Most feared complication : Thrombosis – stroke CVS
6. Force fluid 26
7. Administer meds – take AM – SE insomia. Monitor HR. 3. Diet – increase calorie – to correct wt loss
Thyroid hormones 4. Skin care –
Levothyroxine(Synthroid), Liothyronine (cytomel) 5. Comfy & cool environment
Thyroid extracts 6. Maintain siderails- due agitation/restlessness
8. Health teaching & discharge plan 7. Provide bilateral eye patch – to prevent drying of eyes- exopthalmos
a. Avoidance precipitating factors leading to myxedema coma: 8. Assist in surgery – subtotal thyroidectomy
1. Exposure to cold environment Nsg Mgt: pre-op
2. Stress 3. Infection Adm Lugol’s solution (SSKI) K iodide
4. Use of sedative, narcotics, anesthetics not allowed – CNS depressants V/S already down 9. To decrease vascularity of TG
Complications: 10. To prevent bleeding & hemorrhage
9. Hypovolemic shock, myxedema coma Mgt post op:
10. Hormonal replacement therapy - lifetime Complication: 1. Watch out for signs of thyroid storm or thyrotoxicosis
11. Importance of follow up care Triad signs of thyroidstorm;
HYPERTHYROIDISM - Graves dse or thyrotoxicosis ( everything up except wt and mens) a. Tachycardia /palpitation
-Increased T3 & T4 b. Hyperthermia
Predisposing factors: c. Agitation
1. Autoimmune disease – release of long acting thyroid stimulator (LATS) Nsg Mgt Thyroid Storm:
Exopthalmos 1. Monitor VS & neuro check
Enopthalmos – severe dehydration depressed eye Agitated might decrease LOC
2. Antipyretic – fever Pathognomonic Sign of tetany:
Tachycardia - b blockers (-lol) a. (+) Trousseau’s or carpopedial spasm
3. Siderails – agitated b. (+) Chvosteck’s sign
Comp 2. Watch for inadvertent (accidental) removal of parathyroid gland f. Seizure most feared complication
Secretes Para hormone g. Arrhythmia
If removed, hypocalcemia - classic sign tetany – 1. .(+) Trousseau sign/ 2. Chvosteck’s sign 2. Chronic tetany
Nsg Mgt: a. Loss of tooth enamel
Adm calcium gluconate slowly – to prevent arrhythmia b. Photophobia & cataract formation
Ca gluconate toxicity – antidote – MgSO4 c. GIT changes – anorexia, n/v, general body malaise
3.Laryngeal (voice box) nerve damage (accidental) d. CNS changes – memory impairment, irritability
Sx: hoarseness of voice Dx:
***Encourage pt to talk or speak post operatively asap to determine laryngeal nerve damage 1. Serum calcium – decrease (N 8.5 – 11 mg/100ml)
Notify physician! 2. Serum phosphate increase (N 2.5 – 4.5 mg/100ml)
4. Signs of bleeding post subtotal thyroidectomy 3. X-ray of long bone – decrease bone density
- “Feeling of fullness” at incision site 4. CT Scan – reveals degeneration of basal ganglia
Nsg mgt: Nsg Mgt:
Check soiled dressing at nape area 1. Administration of meds:
5. Signs of laryngeal spasm a.) Acute tetany –
a. DOB Ca gluconate – IV, slowly
b. SOB b.) Chronic tetany
Prepare at bedside tracheostomy 1. Oral Ca supplements
6. Hormonal replacement therapy - lifetime Ex. Ca gluconate
7. Importance of follow up care 28
(Liver cirrhosis – bedside scissor – if pt complaints of DOB) Ca carbonate
(Cut cystachean tube to deflate balloon) Ca lactate
Parathyroid gland – pair of small nodules located behind the TG Vit D (Cholecalceferol)
27 Drug diet sunlight
11. Secrets parathyroid hormone – promotes Ca reabsorption Cholecalceferol calcidiol calcitriol 7am – 9am
Thyrocalcitonin – antagonises secretion of parathyroid hormone 2. Phosphate binder
1. Hypoparthroidism – decrease of parathyroid hormone Alumminum DH gel (ampho gel)
2. Hyperparathroidsm SE constipation
HYPOPARATHYROIDISM – decreased parathormone Antacid
Hypocalcemia Hyperphosphatemia AAC MAD
(Or tetany) Aluminum containing acids Mg containing antacids
[If Ca decreases, phosphate increases] Ex. Milk or magnesia
A. Predisposing, factors: Aluminum OH gel Diarrhea
1. Following subtotal thyroidectomy Constipation Maalox – magnesium & aluminum - Less s/e
2. Atrophy of parathyroid gland due to 2. Avoid precipitating stimulus such as bright lights & noise: photophobia leading to seizure
a. Irradiation 3. Diet – increase Ca & decrease phosphorus
b. Trauma - Don’t give milk – due to increase phosphorus
S&Sx: Good = anchovies – increase Ca, decrease phosphorus + inc uric acid. Tuna & green turnips- Inc Ca.
1. Acute tetany 4. Bedside – tracheostomy set –due to laryngospasm
a. Tingling sensation 5. Encourage to breath with paper bag in order to produce mild respiratory acidosis – to promote
b. Paresthesia increase ionized Ca levels
c. Dysphagia 6. Most feared complication : Seizure & arrhythmia
d. Laryngospasm 7. Hormonal replacement therapy - lifetime
e. Bronchospasm 8. Important fallow up care
HYPERPARATHYROIDISM - increase parathormone. Complication: Renal failure 12. Impt ff up care
Hypercalcemia can lead to Hypophosphatemia 13. Hormonal replacement- lifetime
Bone dse - kidney stones ADRENAL GLAND
Mineralization 12. Atop of @ kidney
Leading to bone fracture 13. 2 parts
Ca – 99% bones Adrenal cortex – outermost layer
1% serum blood Adrenal medulla - innermost layer
Predisposing Factors: 14. Secrets cathecolamines
1. Hyperplasia parathyroid gland (PTG) a.) Epinephrine / Norephinephrine – potent vasoconstrictor – adrenaline=Increase BP
2. Over compensation of PTG due to Vit D deficiency Adrenal Medulla’s only disease:
Children – Rickets Vit D PHEOCHROMOCYTOMA- presence of tumor at adrenal medulla
Adults – Osteomalacia deficiency -increase nor/epinephrine
Sippy’s diet – Vit D diet – not good for pt with ulcer -with HPN and resistant to drugs
2 -4 cups of milk & butter -drug of choice: beta blockers
Karrel’s diet – Vit D diet – not good for pt with ulcer -complication: HPN crisis = lead to stroke
6 cups of milk & whole cream -no valsalva maneuver
Food rich in CHON – eggnog – combination of egg & milk Adrenal Cortex –
S/Sx: 1. Zona fasiculata – secrets glucocorticoids
Bone fracture Ex. Cortisol - Controls glucose metabolism (SUGAR)
1. Bone pain (especially at back), bone fracture 2. Zona reticularis – secrets traces of glucocorticoids & androgenic hormones
29 M – testosterone
2. Kidney stone – F – estrogen & progesterone
a. Renal colic 30
b. Cool moist skin Fx – promotes development of secondary sexual characteristics
3. GIT changes – anorexia, n/v, ulcerations 3. Zona glomerulosa - secretes mineralcortisone
4. CNS involvement– irritability, memory impairment Ex. Aldosterone
Dx Proc: Fx: promotes Na & H2O reabsorption & excretion of potassium (SALT)
1. Serum Ca increase ADDISON’S DISEASE – Steroids-lifetime
2. Serum phosphorus decreases Decreased adrenocortical hormones leading to:
3. X-ray long bones – reveals bone demineralization a.) Metabolic disturbances (sugar)
Nsg Mgt: Kidney Stone b.) F&E imbalances- Na, H2O, K
1. Force fluids – 2,000 – 3,000/day or 2-3L/day c.) Deficiency of neuromuscular function (salt & sex)
2. Isotonic solution Predisposing Factors:
3. Warm sitz bath – for comfort 1. Atrophy of adrenal gland
4. Strain all urine with gauze pad 2. Fungal infections
5. Acid ash diet – cranberry, plum, grapefruit, vit C, calamansi – to acidify urine 3. Tubercular infections
6. Adm meds S/Sx:
a. Narcotic analgesic – Morphine SO4, Demerol (Meperidine Hcl) 1. Decrease sugar – Hypoglycemia – Decreased glucocorticoids - cortisol
S/E – resp depression. Monitor RR) T – tremors, tachycardia
Narcan/ Naloxone – antidote I - irritability
Naloxone toxicity – tremors R - restlessness
7. Siderails E – extreme fatigue
8. Assist in ambulation D – diaphoresis, depression
9. Diet – low in Ca, increase phosphorus lean meat 2. Decrease plasma cortisol
10. Prevent complication Decrease tolerance to stress – lead to Addisonian’s crisis
Most feared – renal failure 3. Decrease salt – Hyponatermia – Decreased mineralocorticoids - Aldosterone
11. Assist surgical procedure – parathyroidectomy Hypovolemia
a.) Hypotension 6. Meticulous skin care – due to bronze like
b.) Signs of dehydration – extreme thirst, agitation 7. HT & discharge planning
c.) Wt loss a) Avoid precipitating factors leading to Addisonian crisis
4. Hyperkalemia 1. Sudden withdrawal crisis
a.) Irritability 2. Stress
b.) Diarrhea 3. Infection
c.) Arrhythmia b) Prevent complications
5. Decrease sexual urge or libido- Decreased Androgen Addisonian crisis & Hypovolemic shock
6. Loss of pubic and axillary hair 8. Hormonal replacement therapy – lifetime
To Prevent STD Local – practice monogamous relationship 9. Important: follow up care
CGFNS/NCLEX – condom CUSHING’S SYNDROME – increase secretion of adrenocortical hormone
7. Pathognomonic sign– bronze like skin pigmentation due to decrease cortisol will stimulate pituitary Predisposing Factors:
gland to release 1. Hyperplasia of adrenal gland
melanocyte stimulating hormone. 2. Tubercular infection – milliary TB
Dx Proc: S/Sx
1. FBS – decrease FBS (N 80 – 120 mg/dL) 1. Increase sugar – Hyperglycemia
2. Plasma cortisol – decreased 3 P’s
Serum Na – decreased (N 135 – 145 meg/L) 1. Polyuria
3. Serum K – increased (N 3.5 – 5.5 meg/L) 2. Polydipsia – increase thirst
Nsg Mgt: 3. Polyphagia – increase appetite
1. Monitor VS, I&O – to determine presence of Addisonian crisis Classic Sx of DM – 3 P’s & glycosuria + wt loss
15. Complication of Addison’s dse : Addisonian crisis 2. Increase susceptibility to infection – due to increased corticosteroid
16. Results the acute exacerbation of Addison’s dse characterized by : 3. Hypernatrermia
Hypotension, hypovolemia, hyponatremia, wt loss, arrhythmia a. HPN
31 b. Edema
17. Lead to progressive stupor & coma c. Wt gain
Nsg Mgt Addisonian Crisis (Coma) d. Moon face
1. Assist in mechanical ventilation Buffalo hump
2. Adm steroids 32
3. Force fluids Obese trunk classic signs
2. Administer meds Pendulous abdomen
a.) Corticosteroids - (Decadron) or Dexamethazone Thin extremities
- Hydrocortisone (cortisone)- Prednisone 4. Hypokalemia
Nsg Mgt with Steroids a. Weakness & fatigue
1. Adm 2/3 dose in AM & 1/3 dose in PM in order to mimic the normal diurnal rhythm. b. Constipation
2. Taper the dose (w/draw, gradually from drug) – sudden withdrawal can lead to addisonian crisis c. ECG – (+) “U” wave
3. Monitor S/E (Cushing’s syndrome S/Sx) 5. Hirsutism – increase sex
a.) HPN 6. Acne & striae
b.) Hirsutism 7. Increase muscularity of female
c.) Edema Dx:
d.) Moon face & buffalo hump 1. FBS – increase↑ (N: 80-120mg/dL)
e.) Increase susceptibility to infection sue to steroids- reverse isolation 2. Plasma cortisol increase
b.) Mineralocorticoids ex. Flourocortisone 3. Na – increase (135-145 meq/L)
3. Diet – increase calorie or CHO 4. K- decrease (3.5-5.5 meq/L)
Increase Na, Increase CHON, Decrease K Nsg Mgt:
4. Force fluid 1. Monitor VS, I&O
5. Administer isotonic fluid as ordered 2. Administer meds
a. K- sparing diuretics (Aldactone) Spironolactone 6. Hyperthyroidism
- promotes excretion of NA while conserving potassium 7. High intake of fatty food – saturated fats
Not lasix due to S/E hypoK & Hyperglycemia! DIABETES MELLITUS - metabolic disorder characterized by non utilization of CHO, CHON,& fat
3. Restrict Na metabolism
4. Provide Dietary intake – low in CHO, low in Na & fats Classification:
High in CHON & K I. Type I DM (IDDM) – “Juvenile “ onset, common in children, non-obese “brittle dse”
5. Weigh pt daily & assess presence of edema- measure abdominal girth- notify doc. -Insulin dependent diabetes mellitus
6. Reverse isolation Incidence rate
7. Skin care – due acne & striae 1.) 10% of population with DM have Type I
8. Prevent complication Predisposing Factor:
- Most feared – arrhythmia & DM 1. 90% hereditary – total destruction of pancreatic dells
(Endocrine disorder lead to MI – Hypothyroidism & DM) 2. Virus
9. Surgical bilateral Adrenolectomy 3. Toxicity to carbon tetrachloride
10. Hormonal replacement therapy – lifetime due to adrenal gland removal- no more corticosteroid! 4. Drugs – Steroids both cause hyperglycemia
PANCREAS – behind the stomach, mixed gland – both endocrine and exocrine gland Lasix - loop diuretics
Acinar cells (exocrine gland) Islets of Langerhans (endocrine gland ductless) S/Sx:
Secrete pancreatic juices at pancreatic ducts. a cells 3 P’S + G
Aids in digestion (in stomach) secrets glucagon 1.) Polyuria
Fxn: hyperglycemia (high glucose) 2.) Poydipsia
b Cells 3.) Polyphagia
Secrets insulin 4.) Glycosuria
Fxn: hypoglycemia 5.) Weight loss
Delta Cells 34
33 6.) Anorexia
Secrets somatostatin 7.) N/V
Fxn: antagonizes growth hormone 8.) Blurring of vision
3 disorders of the Pancreas 9.) Increase susceptibility to infection
1. DM 10.) Delayed/ poor wound healing
2. Pancreatic Cancer Mgt:
3. Pancreatitis 1. Insulin Therapy
Overview only: Diet
PANCREATITIS (check page 72)– acute inflammation of pancreas leading to pancreatic edema, Exercise
hemorrhage & necrosis due to Complications – Diabetic Ketoacidosis (DKA)
Autodigestion – self-digestion Diabetic Ketoacidosis (DKA) – due to increase fat catabolism or breakdown of fats
Cause: unknown/idiopathic DKA –(+) fruity or acetone breath odor
18. Or alcoholism Kassmaul’s respiration – rapid, shallow breathing
Pathognomonic sign- (+) Cullen’s sign - Ecchymosis of umbilicus (bluish color)- pasa Diabetic coma (needs oxygen)
(+) Grey turner’s sign – ecchymosis of flank area II. Type II DM – (NIDDM)
Both sx means hemorrhage Adult/ maturity onset type – age 40 & above, obese
CHRONIC HEMORRHAGIC PANCREATITIS- “bangugot” Incidence Rate
Predisposing factors - unknown 1. 90% of pop with DM have Type II
Risk factor: Mid 1980’s marked increase in type II because of increase proliferation of fast food chains!
1. History of hepatobiliary disorder Predisposing Factor:
2. Alcohol 1. Obesity – obese people lack insulin receptors binding site
3. Drugs – thiazide diuretics, oral contraceptives, aspirin, penthan 2. Hereditary
4. Obesity S/Sx:
5. Hyperlipidemia 1. Asymptomatic
2. 3 P’s and 1G Polydipsia
Tx: Increased CHON catabolism
1. Oral Hypoglycemic Agents (OHA) Lead to (-) nitrogen balance
2. Diet Tissue wasting (cachexia)
3. Exercise Increase fat catabolism
Complication: HONKC Free fatty acids
H – hyper Cholesterol ketones DKA
O – osmolar Atherosclerosis coma
N – non HPN death
K – ketotic MI stroke
C – coma DIABETIC KETOACIDOSIS (DKA)
III. GESTATIONAL DM – occurs during pregnancy & terminates upon delivery of child - Acute complication of Type I DM due to severe hyperglycemia leading to CNS depression & Coma.
Predisposing Factors: - Ketones- a CNS depressant
1. Unknown/ idiopathic Predisposing factor:
2. Influence of maternal hormones 36
S/Sx : 1. Stress – between stress and infection, stress causes DKA more.
Same as type II – 2. Hyperglycemia
1. Asymptomatic 3. Infection
2. 3 P’s & 1G S/Sx: 3 P’s & 1G
Type of delivery – CS – due to large baby 1. Polyuria
Sx of hypoglycemia on infant 2. Polydipsia
1. High pitched shrill cry 3. Polyphagia
35 4. Glycosuria
2. Poor sucking reflex 5. Wt loss
IV. DM ASSOCIATED WITH OTHER DISORDER 6. Anorexia, N/V
a.) Pancreatic tumor 7. (+) Acetone breath odor- fruity odor pathognomonic DKA
b.) Cancer 8. Kussmaul's resp-rapid shallow respiration
c.) Cushing’s syndrome 9. CNS depression
3 MAIN FOOD GROUPS 10. Coma
Anabolism Catabolism Dx Proc:
1. CHON glucose glycogen 1. FBS increase, Hct – increase (compensate due to dehydration)
2. CHON amino acids nitrogen N =BUN – 10 -20 mg/100ml --increased due to severe dehydration
3. Fats fatty acids free fatty acids (FFA) – Cholesterol & Ketones Crea - .8 – 1 mg/100ml
Pancreas → glucose → ATP (Main fuel/energy of cell ) Hct 42% (should be 3x high)-nto hgb
Reserve glucose – glycogen Nsg Mgt:
Liver will undergo – glucogenesis – synthesis of glucagons 1. Can lead to coma – assist mechanical ventilation
& Glycogenolysis – breakdown of glucagons 2. Administer .9NaCl – isotonic solution
& Gluconeogenesis – formation of glucose form CHO sources – CHON & fats Followed by .45NaCl hypotonic solution
Hyperglycemia – pancreas will not release insulin. Glucose can’t go to cell, stays at circulation To counteract dehydration.
causing hyperglycemia. 3. Monitor VS, I&O, blood sugar levels
increase osmotic diuresis – glycosuria 4. Administer meds as ordered:
Lead to cellular starvation a.) Insulin therapy – IV push
Lead to wt loss stimulates the appetite/ satiety center polyuria Regular Acting Insulin – clear (2-4hrs, peak action)
(Hypothalamus) b.) To counteract acidosis – Na HCO3
Cellular dehydration c.) Antibiotic to prevent infection
Polyphagia Insulin Therapy
Stimulates thirst center (hypothalamus) A. Sources:
1. Animal source – beef/ pork-rarely used. Causes severe allergic reaction. 2. Administer .9NaCl – isotonic solution
2. Human – has less antigenecity property Followed by .45NaCl hypotonic solution
Cause less allergic reaction. Humulin To counteract dehydration.
If kid is allergic to chicken – don’t give measles vaccine due it comes from chicken embryo. 3.Monitor VS, I&O, blood sugar levels
3. Artificially compound 4.Administer meds
B. Types of Insulin a.) Insulin therapy – IV
1. Rapid Acting Insulin - Ex. Regular acting I b.) Antibiotic to prevent infection
2. Intermediate acting I - Ex. NPH (non-protamine Hagedorn I) Tx:
3. Long acting I - Ex. Ultra lente O ral
Types of Insulin color & consistency onset peak duration H ypoglycemic
1. Rapid clear - 2-4h - A gents
2. Intermediate cloudy - 6-12h - 19. Stimulates pancreas to secrete insulin
3. Long acting cloudy - 12-24h - Classifications of OHA
Ex. 5am Hemoglucose test (HGT) 1. First generation Sulfonylurear
250 mg/dl a. Chlorpropamide (diabenase)
Adm 5 units of RA I b. Tolbutamide (orinase)
37 c. Tolazamide (tolinase)
Peak 7-9am – monitor hypoglycemic reaction at this time- TIRED 38
Nsg Mgt: upon injection of insulin: 2. 2nd generation sulfonylurear
1.Administer insulin at room temp! – To prevent lipodystrophy = atrophy/ hypertrophy of SQ tissues a. Diabeta (Micronase)
2. Insulin is only refrigerated once opened! b. Glipside (Glucotrol)
3. Gently roll vial bet palms. Avoid shaking to prevent formation of bubbles. Nsg Mgt or OHA
4. Use gauge 25 – 26needle – tuberculin syringe 1. Administer with meals – to lessen GIT irritation & prevent hypoglycemia
5. Administer insulin at either 45(for skinny pt) or 90° (taba pt)depending on the client tissue deposit. 2. Avoid alcohol (alcohol + OHA = severe hypoglycemic reaction=CNS depression=coma) Antabuse-
6. Don’t aspirate after injection Disufram
7. Rotate injection site to prevent lipodystrophy Dx for DM
8. Most accessible site – abdomen 1. FBS – N 80 – 120 mg/dl = Increased for 3 consecutive times =confirms DM!!
9. When mixing 2 types of insulin, aspirate + 3 P’s & 1G
1st regular/ clear – before cloudy to prevent contaminating clear insulin & to promote accurate 2. Oral glucose tolerance (OGTT) - Most sensitive test
calibration. 3. Random blood sugar – increased
10. Monitor signs of complications: 4. Alpha Glucosylated Hgb – elevated
a. Allergic reactions – lipodystrophy Nsg Mgt;
b. Somogyi’s phenomenon – hypoglycemia followed by periods of hyperglycemia or rebound effect of 1. Monitor for PEAK action of OHA & insulin
insulin. Notify Doc
11. 1ml or cc of tuberculin = 100 units of insulin 2. Monitor VS, I&O, neurocheck, blood sugar levels.
- - 1 cc = 100 units 3. Administer insulin & OHA therapy as ordered.
- - .5cc = 50 units 4. Monitor signs of hyper & hypoglycemia.
- - .1 cc = 10 units Pt DM –“ hinimatay”
6 units RA 20. You don’t know if hypo or hyperglycemia.
Most Feared Complication of Type II DM Give simple sugar
Hyper ↑ osmolarity = severe dehydration (Brain can tolerate high sugar, but brain can’t tolerate low sugar!)
Osmolar Cold, clammy skin – hypo – Orange Juice or simple sugar / warm to touch – hyper – adm insulin
Non - absence of lipolysis 5. Provide nutritional intake of diabetic diet:
Ketotic - no ketone formation CHO – 50%
Coma – S/Sx: headache, restlessness, seizure, decrease LOC = coma CHON – 30%
Nsg Mgt; - same as DKA except don’t give NaHCO3! Fats – 20%
1.Can lead to coma – assist mechanical ventilation -Or offer alternative food products or beverage.
-Glass of orange juice. b - Transports iron & copper
6. Exercise – after meals when blood glucose is rising. Gamma – transport immunoglobulins or antibodies
7. Monitor complications of DM 3. Prothrombin – fibrinogen – clotting factor to prevent bleeding
a. Atherosclerosis – HPN, MI, CVA Formed Elements:
b. Microangiopathy – small blood vessels 1. RBC (erythrocytes) Spleen life span = 120 days
Eyes – diabetic retinopathy , premature cataract & blindness (N) 3 – 6 M/mm3
Kidneys – recurrent pyelonephritis & Renal Failure - Anucleated
(2 common causes of Renal Failure : DM & HPN) - Biconcave discs
c. Gangrene formation - Has molecules of Hgb (red cell pigment)
d. Peripheral neuropathy Transports & carries O2
1. Diarrhea/ constipation SICKLE CELL ANEMIA –sickle shaped RBC. Should be round. Impaired circulation of RBC.
2. Sexual impotence -immature cells=hemolysis of RBC=decreased hgb
e. Shock due to cellular dehydration 3 Nsg priority
8. Foot care mgt 1. a/w – avoid deoxygenating activities
a. Avoid waking barefooted - High altitude is bad
b. Cut toe nails straight 2. Fluid deficit – promote hydration
c. Apply lanolin lotion – prevent skin breakdown 3. Pain & comfort
d. Avoid wearing constrictive garments Hgb ( hemoglobin)
9. Annual eye & kidney exam F= 12 – 14 gms %
10. Monitor urinalysis for presence of ketones M = 14-16 gms %
Blood or serum – more accurate Hct – 3x hgb 12 x 3 = 36
11. Assist in surgical wound debridement (hamatocrit) F 36 – 42% 14 x 3 = 42
12. Monitor signs or DKA & HONKC M 42 – 48%
13. Assist surgical procedure Average 42%
39 - Red cell percentage in whole red
BKA or above knee amputation 40
Overview: HEMATOLOGICAL SYSTEMS Substances needed for maturation of RBC
I Blood a.) Folic acid
II Blood vessels b.) Iron
III Blood forming organs c.) Vit C
1. Thymus – removed myasthenia gravis d.) Vit B12 (cyanocobalamin)
2. Liver – largest gland e.) Vit B6 (Pyridoxine)
3. Lymph nodes f.) Intrinsic factor
4. Lymphoid organs – payers patch Pregnant: 1st trimester- Folic acid – prevent neural tube deficit
5. Bone marrow 3rd tri – iron
6. Spleen – destroys RBC Life span of rbc – 80 – 120 days. Destroyed at spleen.
Blood vessels WBC – leucocytes 5,000 – 10,000/mm3
1. Veins –SVC, IVC, Jugular vein – blood towards the heart GRANULOCYTES
2. Artery – carries blood away from the 1. Polymorphonuclearneutrophils
21. Aorta, carotid Most abundant 60-70% WBC
3. Capillaries - fx – short term phagocytosis
Blood 45% formed elements – 55% plasma – fluid portion of vlood. Yellow color. For acute inflammation
Serum Plasma CHON’s (Produced in Liver) 2. PM Basophils
1. Albumin- largest, most abundant plasma -Involved in Parasitic infection
Maintains osmotic pressure preventing edema - Release of chem. Mediator for inflammation
FXN: promotes skin integrity Serotonin, histamine, prostaglandin,
2. Globulins – alpha – transports steroids Hormones & bilirubin bradykinins
3. PM eosinophils 22. Common in tropical zone – Phil due blood sucks
- Allergic reactions Predisposing factor:
NON-GRANULOCYTES 1. Chronic blood loss
1. Monocytes (macrophage) - largest WBC a. Trauma
- involved in long term phagocytes b. Mens
- For chronic inflammation c. GIT bleeding:
- Other name macrophage i. Hematemesisii.
Macrophage in CNS- microglia Melena – upper GIT – duodenal cancer
Macrophage in skin – Histiocytes iii. Hematochezia – lower GIT – large intestine – fresh blood from rectum
Macrophage in lungs – alveolar macrophage 2. Inadequate intake of food rich in iron
Macrophage in Kidneys – Kupffer cells 3. Inadequate absorption of iron – due to :
2. Lymphocytes a. Chronic diarrhea
B Cell – L – bone marrow or bursa dependent b. Malabsorption syndrome –celiac disease-gluten free diet. Food for celiac pts- sardines
T cell – dev’t of immunity- target site for HIV c. High cereal intake with low animal CHON ingestion
NK cell – natural killer cell d. Subtotal gastrectomy
Have both antiviral & anti-tumor properties 4. Improper cooking of food
3.Platelets (thrombocytes) S/Sx:
N- 150,000 – 450, 000/ mm3 1. Asymptomatic
it promotes hemostasis – prevention of blood loss by activating clotting 2. Headache, dizziness, dyspnea, palpitations, cold sensitivity, gen body malaise, pallor
- Consists of immature or baby platelets known as megakaryocytes – target of virus – 3. Brittle hair, spoon shaped nails (KOILONYCHIA)=Dec O2=hypoxia=atrophy of epidermal cells
dengue 4. Atropic glossitis, dysphagia, stomatitis
- Normal lifespan 9 – 12 days 5. Pica – abnormal craving for non edible food (caused by hypoxia=dec tissue perfusion=psychotic
Drug of choice for HIV Zidovudine (AZT or Retrovir) behavior)
Standard precaution for HIV gloves, gown, goggles & mask Brittle hair, spoon shaped nail – atrophy of epidermal cells
Malaria – night biting mosquito N = capillary refill time < 2 secs
Dengue – day biting mosquito N = shape nails – biconcave shape, 180°
Signs of platelet dis function: Atrophy of cells “Plummer Vinsons Syndrome” due to cerebral hypoxia
a.) Petecchiae 1. Atropic glossiti – inflammation of tongue due to atrophy of pharyngeal and tongue cells
b.) Ecchemosis/ bruises 2. Stomatitis – mouth sores
c.) Oozing or blood from venipuncture site 3. Dysphagia
ANEMIA Dx Proc:
Iron deficiency Anemia – chronic normocytic, hypocromic (pale), microcytic anemia due to inadequate 1. RBC
absorption of iron leading to 2. Hgb
hypoxemic injury. 3. Reticulocyte
Incidence rate: 4. Hct
1. Common – developed country – due to high cereal intake 5. Iron
Due to accidents – common on adults 6. Ferritin
2. Common – tropical countries – blood sucking parasites Nsg Mgt
3. Women – 15 – 35yo – reproductive yrs 1. Monitor signs of bleeding of all hema test including urine & stool
4. Common among the poor – poor nutritional intake 2. Complete bed rest – don’t overtire pt =weakness and fatigue=activity intolerance
41 3. Encourage – iron rich food
Suicide - common in teenager 23. Raisins, legumes, egg yolk
Poisoning – common in children (aspirin) 4. Instruct the pt to avoid taking tea - impairs iron absorption
Aspiration – common in infant 5. Administer meds
Accidents – common in adults a.) Oral iron preparation
Choking – common in toddler Ferrous SO4
SIDS – common in infant in US Fe gluconate
Fe Fumarate 43
Nsg Mgt oral iron meds: 2. GIT changes
42 a. Red – beefy tongue – PATHOGNOMONIC – mouth sores
1. Administer with meals – to lessen GIT irritation b. Dyspepsia – indigestion
2. If diluting in iron liquid prep –adm with straw c. Wt loss
Straw d. Jaundice
1. Lugol’s 3. CNS –
2. Tetracycline Most dangerous anemia: pernicious due to neuroglogic involvement.
3. Oral iron a. Tingling sensation
4. Macrodantine b. Paresthesia
3. Give Orange juice – for iron absorption c. (+) Romberg’s test
4. Monitor & inform pts S/E Ataxia
a. Anorexia d. Psychosis
b. n/v Dx:- Shilling’s test
c. Abdominal pain Nsg Mgt – Pernicious anemia
d. Diarrhea or constipation 1. Enforce CBR
e. Melena 2. Administer B12 injections at monthly intervals for lifetime as ordered. IM- dorsogluteal or
If pt can’t tolerate oral iron prep – administer parenteral iron prep example: ventrogluteal. Not given oral –
1. Iron dextran (IV, IM) due pt might have tolerance to drug
2. Sorbitex (IM) 3. Diet – high calorie or CHO. Increase CHON, iron & Vit C
Nsg Mgt parenteral iron prep 4. Avoid irritating mouthwashes. Use of soft bristled toothbrush is encouraged.
1. Administer of use Z tract method to prevent discomfort, discoloration leakage to tissues. 5. Avoid applying electric heating pads – can lead to burns
2. Don’t massage injection site. Ambulate to facilitate absorption. APLASTIC ANEMIA – stem cell disorder due to bone marrow depression leading to pancytopenia –
3. Monitor S/E: all RBC are decreased
a.) Pain at injury site Decrease RBC decrease WBC decrease platelets
b.) Localized abscess (“nana”) Anemia leukopenia thrombocytopenia
c.) Lymphadenopathy Increase WBC leukocytocys
d.) Fever/ chills Increase RBC polycythemia vera – complication stroke, CVA, thrombosis
e.) Urticaria – itchiness Predisposing factors leading to Aplastic Anemia
f.) Hypotension – anaphylactic shock 1. Chemicals – Banzene & its derivatives
Anaphylactic shock – give epinephrine 2. radiation
PERNICIOUS ANEMIA - megaloblastic, chronic anemia due to deficiency of intrinsic factor leading to 3. Immunologic injury
Hypochlorhydria – decrease Hcl acid secretion. Lifetime B12 injections. With CNS involvement. 4. Drugs – cause bone marrow depression
Predisposing factor a. Broad spectrum antibiotic - Chlorampenicol
1. Subtotal gastrectomy – removal stomach - Sulfonamides – bactrim
2. Hereditary b. Chemo therapeutic agents
3. Infl dse of ileum Methotrexate – alkylating agents
4. Autoimmune Nitrogen mustard – anti metabolic
5. Strict vegetable diet Vincristine – plant alkaloid
STOMACH S/Sx:
Parietal or ergentaffen Oxyntic cells 1. Anemia:
Fxn – produce intrinsic factor Fxn – secrets Hcl acid a. Weakness & fatigue
For reabsorption of B12 Fx aids in digestion b. Headache, dizziness, dyspnea
For maturation of RBC c. cold sensitivity, pallor
Diet high caloric or CHO to correct wt loss d. palpitations
S/Sx: 2. Leucopenia – increase susceptibility to infection
1. Headache dizziness, dyspnea, palpitations, cold sensitivity, gen body malaise, pallor 3. Thrombocytopenia –
a. Peticchiae g.) Blood transfusion should be completed < 4hrs because blood that is exposed at room temp for >
b. Oozing ofblood from venipuncture site 2h causes blood
c. ecchymosis deterioration.
Dx: h.) Avoid mixing or administering drug at BT line – leads to hemolysis
1. CBC – pancytopenia i.) Regulate BT 10 – 15 gtts/min KVO or 100cc/hr to prevent circulatory overload
2. Bone marrow biopsy/ aspiration at post iliac crest – reveals fatty streaks in bone marrow j.) Monitor VS before, during & after BT especially q15 mins(local board) for 1st hour. NCLEX-q5min
Nsg Mgt: for 1st 15min.
1. Removal of underlying cause - Majority of BT reaction occurs within 1h.
2. Blood transfusion as ordered BT reactions S/Sx Hemolytic reaction:
44 H – hemolytic Reaction 1. Headache, dizziness, dyspnea, palpitation, lumbar/ sterna/ flank pain,
3. Complete bed rest A – allergic Reaction hypotension, flushed skin , (red) port wine urine.
4. O2 inhalation P – pyrogenic Reaction
5. Reverse isolation due leukopenia C – circulatory overload
6. Monitor signs of infection A – air embolism
7. Avoid SQ, IM or any venipuncture site = HEPLOCK T - thrombocytopenia
8. Use electric razor when shaving to prevent bleeding C – citrate intoxication – expired blood =hyperkalemia
9. Administer meds H – hyperkalemia
Immunosuppresants Nsg Mgt: Hemolytic Reaction:
Anti lymphocyte globulin (Alg) given via central venous catheter, 6 days – 3 weeks to achieve max 1. Stop BT
therapeutic effect of 45
drug. 2. Notify Doc
BLOOD TRANSFUSION: 3. Flush with plain NSS
Objectives: 4. Administer isotonic fluid sol – to prevent acute tubular necrosis & conteract shock
1. To replace circulating blood volume 5. Send blood unit to blood bank for reexamination
2. To increase O2 carrying capacity of blood 6. Obtain urine & blood samples of pt & send to lab for reexamination
3. To combat infection if there’s decrease WBC 7. Monitor VS & Allergic Rxn
4. To prevent bleeding if there’s platelet deficiency Allergic Reaction:
Nsg Mgt & principles in Blood Transfusion S/Sx
1. Proper refrigeration 1. Fever/ chills
2. Proper typing & crossmatching 2. Urticaria/ pruritus
Type O – universal donor 3. Dyspnea
AB – universal recipient 4. Laryngospasm/ bronchospasm
85% of people is RH (+) 5. Bronchial wheezing
3. Asceptically assemble all materials needed: Nsg Mgt:
a.) Filter set 1. Stop BT
b.) Isotonic or PNSS or .9NaCl to prevent Hemolysis 2. Notify Doc
Hypotonic sol – swell or burst 3. Flush with PNSS
Hypertonic sol – will shrink or crenate 4. Administer antihistamine – diphenhydramine Hcl (Benadryl). Give bedtime.SE-Adult-drowsiness.
c.) Needle gauge 18 - 19 or large bore needle to prevent hemolysis. Child-hyperactive
d.) Instruct another RN to recheck the following . If (+) Hypotension – anaphylactic shock administer – epinephrine
Pts name, blood typing & cross typing expiration date, serial number. 5. Send blood unit to blood bank
e.) Check blood unit for presence of bubbles, cloudiness, dark in color & sediments – indicates 6. Obtain urine & blood samples – send to lab
bacterial contamination. 7. Monitor VS & IO
Don’t dispose. Return to blood bank. 8. Adm. Antihistamine as ordered for AllergicRxn, if (+) to hypotension – indicates anaphylactic shock
f.) Never warm blood products – may destroy vital factors in blood. 24. administer epinephrine
- Warming is done if with warming device – only in EMERGENCY! For multiple BT. 9. Adm antipyretic & antibiotic for pyrogenic Rxn & TSB
- Within 30 mins room temp only! Pyrogenic Reaction:
S/Sx 2. Ecchymosis – widespread
a.) Fever/ chills d. tachycardia 3. Oozing of blood from venipunctured site
b.) Headache e. palpitations 4. Hemoptysis – cough blood
c.) Dyspnea f. diaphoresis 5. Hemorrhage
Nsg Mgt: 6. Oliguria – late sx
1. Stop BT Dx Proc–
2. Notify Doc 1. CBC – reveals decrease platelets
3. Flush with PNSS 2. Stool for occult blood (+)
4. Administer antipyretics, antibiotics Specimen – stool
5. Send blood unit to blood bank 3. Opthalmoscopic exam – sub retinal hemorrhage
6. Obtain urine & blood samples – send to lab 4. ABG analysis – metabolic acidosis
7. Monitor VS & IO pH HCO3
8. Tepid sponge bath – offer hypothermic blanket R pH PCO2 respiratory alkalosis
Circulatory Overload: O ph PCO2 respiratory acidosis
Sx M ph HCO3 metabolic alkalosis
a. Dyspnea E ph HCO3 metabolic acidosis
b. Orthopnea Diarrhea – met acidosis
c. Rales or crackles Vomitting – met alk
d. Exertional discomfort Pyloric stenosis – met alkalosis – vomiting
Nsg Mgt: Ileostomy or intestinal tubing – met acidosis
1. Stop BT Cushing’s – met alk
2. Notify Doc. Don’t flush due pt has circulatory overload. DM met acid
3. Administer diuretics Chronic bronchitis – resp acid – with hypoxemia, cyanosis
Priority cases: Nsg Mgt DIC
Hemolytic Rxn – 1st due to hypotension – 1st priority – attend to destruction of Hgb – O2 brain 1. Monitor signs of bleeding – hema test + urine, stool, GIT
damage 2. Administer isotonic fluid solution to prevent shock.
46 3. Administer O2 inhalation
Allergic 3rd 4. Administer meds
Pyrogenic 4th 47
Circulatory 2nd a. Vit K aquamephyton
Hemolytic 2nd b. Pitressin or vasopressin – to conserve water.
Anaphylitic 1st priority 5. NGT – lavage
DIC – DISSEMINATED INTRAVASCULAR COAGULATION - Use iced saline lavage
25. Acute hemorrhagic syndrome char by wide spread bleeding & thrombosis due to a def of clotting 6. Monitor NGT output
factors (Prothrombin & 7. Provide heplock
Fibrinogen). 8. Prevent complication: hypovolemic shock
Predisposing factor: Late signs of hypovolemic shock : anuria
1. Rapid BT Oncologic Nsg:
2. Massive trauma Oncology – study of neoplasia –new growth
3. Massive burns Benign (tumor) Malignancy (cancer)
4. Septicemia Diff - well differentiated poorly or undifferentiated
5. Hemolytic reaction Encapulation – (+) (-)
6. Anaphylaxis Metastasis – (-) (+)
7. Neoplasia – growth of new tissue Prognosis – good poor
8. Pregnancy Therapeutic modality surgery 1. Chemotherapy plenty S/E
S/Sx 2. Radiation
1. Petechiae – widespread & systemic (lungs, lower & upper trunk) 3. Surgery most preferred treatment
4. Bone marrow transplant - Leukemia only 1. Chemotherapy – use various chemotherapeutic agents that kills cancer cells & kills normal rapidly
Predisposing factors: (carcinogenesis) producing cells – GIT,
G – genetic factors bone marrow, and hair follicle.
I – immunologic factors Classification:
V – viral factors a.) Alkylating agents –
a. Human papiloma virus – causing warts b.) Plant alkaloids – vincristine
b. Epstein barr virus c.) Anti metabolites – nitrogen mustard
E – environmental Factors 90% d.) Hormones – DES
a. Physical – irradiation, UV rays, nuclear explosion, chronic irritation, direct trauma Steroids
b. Chemical factors – e.) Antineoplastic antibiotics
- Food additives (nitrates S/E & mgt
- Hydrocarbon vesicants, alkalies GIT - -Nausea & vomiting
- Drugs (stillbestrol) Nsg Mgt:
- Uraehane 1. Administer anti emetic 4 – 6h before start of chemo
- Hormones Plasil
- Smoking 2. Withhold food/ fluid before start of chemo
Male 3. Provide bland diet post chemo
3.) Prostate cancer - common 40 & above (middle age & above) 26. Non irritating / non spicy
BPH – 50 & above - Diarrhea
1.) Lung cancer 1. Administer anti diarrheal 4 – 6h before start of chemo
2.) Liver cancer 2. Monitor urine, I&O qh
Female - Stomatitis/ mouth sores
1. Breast cancer – 40 yrs old & up – mammography 15 – 20 mins (SBE – 7 days after mens) 1. Oral care – offer ice chips/ popsickles
2. Cervical cancer – 90% multi sexual partners 2. Inform pt – hair loss – temporary alopecia
5% early pregnancy Hair will grow back after 4 – 6 months post chemo.
3. Ovarian cancer -Bone marrow depression – anemia
Classes of cancer 1. Enforce CBR
Tissue typing 2. O2 inhalation
1. Carcinoma – arises from surface epithelium & glandular tissues 3. Reverse isolation
2. Sarcoma- from connective tissue or bones 4. Monitor signs of bleeding
3. Multiple myeloma – from bone marrow Repro organ – sterility
Pathological fracture of ribs & back pain 1. Do sperm banking before start of chemo
4. Lymphoma – from lymph glands Renal system – increase uric acid
5. Leukemia – from blood 1. Administer allopurinol/ xyloprin (gout)
Warning / Danger Sx of CA 27. Inhibits uric acid
C – change in bowel /bladder habits 28. Acute gout – colchicines
48 29. Increase secretion of uric acid
A – a sore that doesn’t heal Neurological changes – peristalsis – paralytic ileus
U – unusual bleeding/ Discharge Most feared complication ff any abdominal surgery
T – thickening of lump – breast or elsewhere Vincristine – plant alkaloid causes peripheral neuropathy
I – indigestion? Dysphagia 2. Radiation therapy – involves use of ionizing radiation that kills cancer cells & inhibit their growth &
O – obvious change in wart/ mole kill N rapidly producing
N – nagging cough/ hoarseness cells.
U – unexplained anemia A - anemia Types of energy emitted
S – sudden wt loss L – loss of wt 1. Alpha rays – rarely used – doesn’t penetrate skin tissues
Therapeutic Modality: 2. Beta rays – internal radiation – more penetration
3. Gamma ray – external radiation – penetrates deeper underlying tissues
49 Layer
Methods of delivery 1. Epicardium – outermost
1. External radiation- involves electro magnetic waves 2. Myocardium – inner – responsible for pumping action/ most dangerous layer - cardiogenic shock
Ex. cobalt therapy 3. Endocardium – innermost layer
2. Internal radiation – injection/ implantation of radioisotopes proximal to CA site for a specific period Chambers
of time. 1. Upper – collecting/ receiving chamber - Atria
2 types: 2. Lower – pumping/ contracting chamber - Ventricles
a.) Sealed implant – radioisotope with a container & doesn’t contaminate body fluid. Valves
b.) Unsealed implant – radioisotope without a container & contaminates body fluid. 1. Atrioventricular valves - Tricuspid & mitral valve
Ex. Phosphorus 32 50
3 Factors affecting exposure: Closure of AV valves – gives rise to 1st heart sound or S1 or “lub”
A.) Half life – time period required for half of radioisotopes to decay. 2. Semi lunar valve
- At end of half life – less exposure a.) Pulmonic
B.) Distance – the farther the distance – lesser exposure b.) Aortic
C. ) Time – the shorter the time, the lesser exposure Closure of semilunar valve – gives rise to 2nd heart sound or S2 or “dub”
D.) Shielding – rays can be shielded or blocked by using rubber gloves – a & b gamma – use thick Extra heart Sound
lead on concrete. S3 – ventricular Gallop – CHF
S/E & Mgt: S4 – atrial gallop – MI, HPN
a.) Skin errythema, redness, sloughing Heart conduction system
1. Assist in battling pt 1. Sino atrial node (SA node) (or Keith-Flock node)
2. Force fluid – 2,000 – 3,000 ml/day Loc – junction of SVC & Rt atrium
3. Avoid lotion or talcum powder – skin irritation Fx- primary pace maker of heart
4. Apply cornstarch or olive oil -Initiates electric impulse of 60 – 100 bpm
b.) GIT –nausea / vomiting - 2. Atrioventicular node (AV node or Tawara node)
1. Administer antiemetic 4 – 6h before start of chemo - Plasil Loc – inter atrial septum
2 Withhold food/ fluid before start of chemo Delay of electric impulse to allow ventricular filling
3. Provide bland diet post chemo 3. Bundle of His – location interventricular septum
Non irritating / non spicy Rt main Bundle Branch
Dysglusia – decrease taste sensitivity Lt main Bundle Branch
-When atrophy papilla (taste buds) – 40 yo 4. Purkenjie Fiber
Stomatitis Loc- walls of ventricles-- Ventricular contractions
c.) Bone marrow depression SA node
1. Enforce CBR Purkenjie Fibers
2. O2 inhalation Bundle of His
3. Reverse isolation Complete heart block – insertion of pacemaker at Bundle Branch
4. Monitor signs of bleeding Metal – Pace Maker – change q3 – 5 yo
Overview of function & structure of the heart Prolonged PR – atrial fib T wave inversion – MI
HEART ST segment depression – angina widening QRS – arrhythmia
- Muscular, pumping organ of the body ST – elev – MI
- Left mediastinum CAD – coronary artery dse or Ischemic Heart Dse (IHD)
- Weigh 300 – 400 grams Atherosclerosis – Myocrdial injury
- Resembles a closed fist Angina Pectoris – Myocardial ischemia
- Covered by serous membrane – pericardium MI- myocardial necrosis
Pericardium ATHEROSCLEROSIS ARTEROSCLEROSIS
Parietal layer Pericardial Visceral layer - Hardening or artery due to fat/ lipid deposits at tunica
Fluid – prevent intima.
Friction rub - Narrowing or artery due to calcium & CHON deposits at tunica
media. Predisposing Factor:
Artery – tunica adventitia – outer 1. sex – male
- Tunica intima – innermost 2. black raise
- Tunica media – middle 3. hyperlipidemia
ATHEROSCLEROSIS 4. smoking
Predisposing Factor 5. HPN
1. Sex – male 6. DM
2. Black race 7. oral contraceptive prolonged
51 8. sedentary lifestyle
AV 9. obesity
3. Hyperlipidemia 10.hypothyroidism
4. Smoking Precipitating factors
5. HPN 4 E’s
6. DM 1. Excessive physical exertion
7. Oral contraceptive- prolonged use 2. Exposure to cold environment - Vasoconstriction
8. Sedentary lifestyle 3. Extreme emotional response
9. Obesity 4. Excessive intake of food – saturated fats.
10. Hypothyroidism Signs & Symptoms
Signs & Symptoms 52
1. Chest pain 1. Initial symptoms – Levine’s sign – hand clutching of chest
2. Dyspnea 2. Chest pain – sharp, stabbing excruciating pain. Location – substernal
3. Tachycardia -radiates back, shoulders, axilla, arms & jaw muscles
4. Palpitations -relieve by rest or NGT
5. Diaphoresis 3. Dyspnea
Treatment 4. Tachycardia
P – percutaneous 5. Palpitation
T – tansluminar 6.diaphoresis
C – coronary Diagnosis
A – angioplasty 1.History taking & PE
Obj: 2. ECG – ST segment depression
1. To revascularize the myocardium 3. Stress test – treadmill = abnormal ECG
2. To prevent angina 4. Serum cholesterol & uric acid - increase.
3. Increase survival rate Nursing Management
PTCA – done to pt with single occluded vessel . 1.) Enforce CBR
Multiple occluded vessels 2.) Administer meds
C – coronary NTG – small doses – venodilator
A – arterial Large dose – vasodilator
B – bypass 1st dose NTG – give 3 – 5 min
A –and 2nd dose NTG – 3 – 5 min
G – graft surgery 3rd & last dose – 3 – 5 min
Nsg Mgt Before CABAG Still painful after 3rd dose – notify doc. MI!
1. Deep breathing cough exercises 55 yrs old with chest pain:
2. Use of incentive spirometer 1st question to ask pt: what did you do before you had chest pain.
3. Leg exercises 2nd question: does pain radiate? If radiate – heart in nature. If not radiate – pulmonary origin
ANGINA PECTORIS- A clinical syndrome characterized by paroxysmal chest pain usually relieved by Venodilator – veins of lower ext – increase venous pooling lead to decrease venous return.
REST or NGT Meds:
nitroglycerin, resulting fr temp myocardial ischemia. A. NTG- Nsg Mgt:
1. Keep in a dry place. Avoid moisture & heat, may inactivate the drug. - not usually relived by rest r NTG
2. Monitor S/E: 2. dyspnea
orthostatic hypotension – dec bp 3. erthermia
transient headache 4. initial increase in BP
dizziness 5. mild restlessness & apprehensions
3. Rise slowly from sitting position 6. occasional findings
4. Assist in ambulation. a.) split S1 & S2
5. If giving NTG via patch: b.) pericardial friction rub
i. avoid placing it near hairy areas-will dec drug absorption c.) rales /crackles
ii. avoid rotating transdermal patches- will dec drug absorption d.) S4 (atrial gallop)
iii. avoid placing near microwave oven or during defibrillation-will burn pt due aluminum foil in patch 1. cardiac enzymes
B. Beta blockers – propanolol a.) CPK – MB – Creatinine
C. ACE inhibitors – captopril Phosphokinase
D. Ca antagonist - nefedipine b.) LDH – lactic acid dehydrogenase
3.) Administer O2 inhalation c.) SGPT – (ALT) – Serum Glutanic
4.) Semi-fowler Pyruvate Transaminase- increased
5.) Diet- Decrease Na and saturated fats d.) SGOT (AST) – Serum Glutamic Oxaloacetic
6.) Monitor VS, I&O, ECG - increased
7.) HT: Discharge planning: 2. Troponin test – increase
a. Avoid precipitating factors – 4 E’s 3. ECG tracing – ST segment increase,
b. Prevent complications – MI widening or QRS complexes – means
c. Take meds before physical exertion-to achieve maximum therapeutic effect of drug arrhythmia in MI indicating PVC
d. Importance of follow-up care. 4. serum cholesterol & uric acid - increase
MI – MYOCARDIAL INFARCTION – hear attack – terminal stage of CAD 5. CBC – increase WBC
- Characterized by necrosis & scarring due to permanent mal-occlusion Nursing Management
53 1. Narcotic analgesics – Morphine SO4 – to induce vasodilation & decrease levels of anxiety.
Types: 2. Administer O2 inhalation – low inflow (CHF-increase inflow)
1. Trasmural MI – most dangerous MI – Mal-occlusion of both R&L coronary artery 3. Enforce CBR without BP
2. Sub-endocardial MI – mal-occlusion of either R & L coronary artery a.) Bedside commode
Most critical period upon dx of MI – 48 to 72h 4. Avoid valsalva maneuver
- Majority of pt suffers from PVC premature ventricular contraction. 5. Semi fowler
Predisposing factors Signs & symptoms Diagnostic Exam 6. General liquid to soft diet – decrease Na, saturated fat, caffeine
1. sex – male 7. Monitor VS, I&O & ECG tracings
2. black raise 8. Take 20 – 30 ml/week – wine, brandy/whisky to induce vasodilation.
3. hyperlipidemia 9. Assist in surgical; CABAG
4. smoking 10. Provide pt HT
5. HPN a.) Avoid modifiable risk factors
6. DM b.) Prevent complications:
7. oral contraceptive 1. Arrhythmias – PVC
prolonged 2. Shock – cardiogenic shock. Late signs of cardiogenic shock in MI – oliguria
8. sedentary lifestyle 3. thrombophlebitis - deep vein
9. obesity 4. CHF – left sided
10. hypothyroidism 5. Dressler’s syndrome – post MI syndrome
1. chest pain – excruciating, vice like, visceral pain -Resistant to medications
located substernal or precodial area (rare) -Administer 150,000 – 450,000 units of streptokinase
- radiates back, arm, shoulders, axilla, jaw & abd c.) Strict compliance to meds
muscles. - Vasodilators
1. NTG HPN, MI, Aortic stenosis
2. Isordil S/Sx
- Antiarrythmic Pulmonary congestion/ Edema
1. Lydocaine blocks release of norepenephrine 1. Dyspnea
2. Brithylium 2. Orthopnea (Diff of breathing sitting pos – platypnea)
- Beta-blockers – “lol” 3. Paroxysmal nocturnal dysnea – PNO- nalulunod
1. Propanolol (inderal) 4. Productive cough with blood tinged sputum
- ACE inhibitors - pril 5. Frothy salivation (from lungs)
54 6. Cyanosis
1. Captopril – (enalapril) 7. Rales/ crackles – due to fluid
- Ca – antagonist 8. Bronchial wheezing
1. Nifedipine 55
- Thrombolitics or fibrinolytics– to dissolve clots/ thrombus 9. PMI – displaced lateral – due cardiomegaly
S/E allergic reactions/ uticaria 10. Pulsus alternons – weak-strong pulse
1. Streptokinase 11. Anorexia & general body malaise
2. Urokinase 12. S3 – ventricular gallop
3. Tissue plasminogen adjusting factor Dx
Monitor for bleeding: 1. CXR – cardiomegaly
- Anticoagulants 2. PAP – Pulmonary Arterial Pressure
1. Heparin 2. Caumadin – delayed reaction 2 – 3 days PCWP – Pulmonary CapillaryWedge Pressure
PTT PT PAP – measures pressure of R ventricle. Indicates cardiac status.
If prolonged bleeding prolonged bleeding PCWP – measures end systolic/ diastolic pressure
Antidote antidote Vit K PAP & PCWP:
Protamine sulfate Swan – ganz catheterization – cardiac catheterization is done at bedside at ICU
- Anti platelet PASA (aspirin) (Trachesostomy – bedside) - Done 5 – 20 mins – scalpel & trachesostomy set
d.) Resume ADL – sex/ activity – 4 to 6 weeks CVP – indicates fluid or hydration status
Post-cardiac rehab Increase CVP – decrease flow rate of IV
1.)Sex as an appetizer rather then dessert – Decrease CVP – increase flow rate of IV
Before meals not after, due after meals increase metabolism – heart is pumping hard after meals. 3. Echocardiography – reveals enlarged heart chamber or cardiomayopathy
2.) Position – non-weight bearing position. 4. ABG – PCO2 increase, PO2 decrease = = hypoxemia = resp acidosis
When to resume sex/ act: When pt can already use staircase, then he can resume sex. 2.) Right sided HF
e.) Diet – decrease Na, Saturated fats, and caffeine Predisposing factor
f.) Follow up care. 1. 90% - tricuspid stenosis
CHF – CONGESTIVE HEART FAILURE - Inability of heart to pump blood towards systemic 2. COPD
circulation. 3. Pulmonary embolism
- Backflow 4. Pulmonic stenosis
1.) Left sided heart failure: 5. Left sided heart failure
Predisposing factors: S/Sx
1.) 90% mitral valve stenosis – due RHD, aging Venous congestion
RHD affects mitral valve – streptococcal infection - Neck or jugular vein distension
Dx: - Aso titer – anti streptolysine O > 300 total units - Pitting edema
- Steroids - Ascites
- Penicillin - Wt gain
- Aspirin - Hepatomegalo/ splenomegaly
Complication: RS-CHF - Jaundice
Aging – degeneration / calcification of mitral valve - Pruritus
Ischemic heart disease - Esophageal varies
- Anorexia, gen body malaise Thrombophlebitis
Diagnosis: MI
1. CXR – cardiomegaly Cor Pulmonale – RT ventricular hypertrophy
2. CVP – measures the pressure at R atrium b.) Dietary modifications
Normal: 4 to 10 cm of water c.) Adherence to meds
Increase CVP > 10 – hypervolemia PERIPHERAL MUSCULAR DISEASE
Decrease CVP < 4 – hypovolemia Arterial ulcers venous ulcer
Flat on bed – post of pt when giving CVP 1. Thromboangiitis Obliterans – male/ feet 1. Varicose veins
Position during CVP insertion – Trendelenburg to prevent pulmonary embolism & promote ventricular 2. Reynauds – female/ hands 2. Thrombophlebitis
filling. 1.) Thromboangiitis obliterates/ BUERGER DISEASE- Acute inflammatory disorder affecting small
3. Echocardiography – enlarged heart chamber / cardiomyopathy to medium sized
4.Liver enzyme arteries & veins of lower extremities. Male/ feet
SGPT ( ALT) Predisposing factors:
SGOT AST - Male
56 - Smokers
Nsg mgt: Increase force of myocardial contraction = increase CO 57
3 – 6L of CO S/Sx
1. Administer meds: 1. Intermittent claudication – leg pain upon walking - Relieved by rest
Tx for LSHF: M – morphine SO4 to induce vasodilatation 2. Cold sensitivity & skin color changes
A – aminophylline & decrease anxiety White bluish red
D – digitalis (digoxin) Pallor cyanosis rubor
D - diuretics 3. Decrease or diminished peripheral pulses - Post tibial, Dorsalis pedis
O - oxygen 4. Tropic changes
G - gases 5. Ulcerations
a.) Cardiac glycosides 6. Gangrene formation
Increase myocardial = increase CO Dx:
Digoxin (Lanoxin). Antidote: digivine 1. Oscillometry – decrease peripheral pulse volume.
Digitoxin: metabolizes in liver not in kidneys not given if with kidney failure. 2. Doppler UTZ – decrease blood flow to affected extremities.
b.) Loop diuretics: Lasix – effect with in 10-15 min. Max = 6 hrs 3. Angiography – reveals site & extent of mal-occulsion.
c.) Bronchodilators: Aminophillin (Theophyllin). Avoid giving caffeine 5.
d.) Narcotic analgesic: Morphine SO4 - induce vasodilaton & decrease anxiety Nsg Mgt:
e.) Vasodilators – NTG 1. Encourage a slow progression of physical activity
f.) Anti-arrythmics – Lidocaine a.) Walk 3 -4 x / day
2. Administer O2 inhalation – high! @ 3 -4L/min via nasal cannula b.) Out of bed 2 – 3 x a / day
3. High fowlers 2. Meds
4. Restrict Na! a.) Analgesic
5. Provide meticulous skin care b.) Vasodilator
6. Weigh pt daily. Assess for pitting edema. c.) Anticoagulant
Measure abdominal girth daily & notify MD 3. Foot care mgt like DM –
7. Monitor V/S, I&O, breath sounds a.) Avoid walking barefoot
8. Institute bloodless phlebotomy. Rotating tourniquet or BP cuff rotated clockwise q 15 mins = to b.) Cut toe nails straight
promote decrease venous c.) Apply lanolin lotion – prevent skin breakdown
return d.) Avoid wearing constrictive garments
9. Diet – decrease salt, fats & caffeine 4. Avoid smoking & exposure to cold environment
10. HT: 5. Surgery: BKA (Below the knee amputation)
a) Complications :shock 2.)REYNAUD’S PHENOMENON – acute episodes of arterial spasm affecting digits of hands & fingers
Arrhythmia Predisposing factors:
1. Female, 40 yrs 5. Surgery: vein sweeping & ligation
2. Smoking Sclerotherapy – spider web varicosities
3. Collagen dse S/E thrombosis
a.) SLE – pathognomonic sign – butterfly rash on face THROMBOPHLEBITIS (deep vein thrombosis) - Inflammation of veins with thrombus formation
Chipmunk face – bulimia nervosa Predisposing factors:
Cherry red skin – carbon monoxide poisoning 1. Smoking
Spider angioma – liver cirrhosis 2. Obesity
Caput medusae – leg & trunk umbilicus- Liver cirrhosis 2. Hyperlipedemia
Lion face – leprosy 4. Prolonged use of oral contraceptives
b.) Rheumatoid arthritis – 5. Chronic anemia
4. Direct hand trauma – piano playing, excessive typing, operating chainsaw 6. DM
S/Sx: 7. MI
1. Intermittent claudication - leg pain upon walking - Relieved by rest 8. CHF
2. Cold sensitivity 9. Postop complications
Nsg Mgt: 10. Post cannulation – insertion of various cardiac catheters
58 S/Sx:
a. Analgesics 1. Pain at affected extremities
b. Vasodilators 2. Cyanosis
c. Encourage to wear gloves especially when opening a refrigerator. 3. (+) Homan’s sign - Pain at leg muscles upon dorsiflexion of foot.
d. Avoid smoking & exposure to cold environment 59
VENOUS ULCERS Dx:
1. VARICOSITIES / Varicose veins - Abnormal dilation of veins – lower ext & trunk 1. Angiography
- Due to: 2. Doppler UTZ
a.) Incompetent valves leading to Nsg Mgt:
b.) Increase venous pooling & stasis leading to 1. Elevate legs above heart level.
c.) Decrease venous return 2. Apply warm, moist packs to decrease lymphatic congestion.
Predisposing factors: 3. Measure circumference of leg muscles to detect if swollen.
a. Hereditary 4. Use anti embolic stockings.
b. Congenital weakness of veins 5. Meds: Analgesics.
c. Thrombophlebitis Anticoagulant: Heparin
d. Heart dse 6. Complication:
e. Pregnancy Pulmonary Embolism:
f. Obesity - Sudden sharp chest pain
g. Prolonged immobility - Prolonged standing - Dyspnea
S/Sx: - Tachycardia
1. Pain especially after prolonged standing - Palpitation
2. Dilated tortuous skin veins - Diaphoresis
3. Warm to touch - Mild restlessness
4. Heaviness in legs OVERVIEW OF RESPIRATORY SYSTEM:
Dx: I. Upper respiratory tract:
1. Venography Fx:
2. Trendelenberg’s test – vein distend quickly < 35 secs 1. Filtering of air
Nsg Mgt: 2. Warming & moistening
1. Elevate legs above heart level – to promote venous return – 1 to 2 pillows 3. Humidification
2. Measure circumference of leg muscles to determine if swollen. a. Nose – cartilage
3. Wear anti embolic or knee high stockings. Women – panty hose - Parts: Rt nostril separated by septum
4. Meds: Analgesics Lt nostril
- Consists of anastomosis of capillaries – 3. Immuno-compromised
Kessel – Bach Plexus – site of epistaxis a. AIDS – PLP
b. Pharynx (throat) – muscular passageway for air& food b. Bronchogenic CA - Non-productive to productive cough
Branches: 4. Prolonged immobility – CVA- hypostatic pneumonia
1. Oropharynx 5. Aspiration of food
2. Nasopharynx 6. Over fatigue
3. Layngopharynx S/Sx:
c. Larynx – voice box 1. Productive cough – pathognomonic: greenish to rusty sputum
Fx: 2. Dyspnea with prolonged respiratory grunt
1. For phonation 3. Fever, chills, anorexia, gen body malaise
2. Cough reflex 4. Wt loss
Glottis – opening 5. Pleuritic friction rub
Opens to allow passage of air 6. Rales/ crackles
Closes to allow passage of food 7. Cyanosis
II. Lower Rt – Fx for gas exchange 8. Abdominal distension leading to paralytic ileus
a. Trachea – windpipe Sputum exam – could confirm presence of TB & pneumonia
- has cartillagenous rings Dx:
- site for permanent/ artificial a/w – tracheostomy 1. Sputum GSCS- gram staining & culture sensitivity - Reveals (+) cultured microorganism.
b. Bronchus – R & L main bronchus 2. CXR – pulmo consolidation
c. Lungs – R – 3 lobes = 10 segments 3. CBC – increase WBC
L – 2 lobes – 8 segments Erythrocyte sedimentation rate
Post pneumonectomy - position affected side to promote expansion of lungs 4. ABG – PO2 decrease
Post segmental lobectomy – position unaffected side to promote drainage 61
Lungs – covered by pleural cavity, parietal lobe & visceral lobe Nsg Mgt:
Alveoli – acinar cells 1. Enforce CBR
- site of gas exchange (O2 & CO2) 2. Strict respiratory isolation
60 3. Meds:
- diffusion: Daltons law of partial pressure of gases a.) Broad spectrum antibiotics
Ventilation – movement of air in & out of lungs Penicillin or tetracycline
Respiration – movement of air into cells Macrolides – ex azythromycin (zythromax)
Type II cells of alveoli – secrets surfactant b.) Anti pyretics
Surfactant - decrease surface tension of alveoli c.) Mucolytics or expectorants
Lecithin & spinogometer 4. Force fluids – 2 to 3 L/day
L/S ratio 2:1 – indicator of lung maturity 5. Institute pulmonary toileta.)
If 1:2 – adm O2 - < 40% Concentration to prevent atelectasis & retinopathy or blindness. Deep breathing exercise
I. PNEUMONIA – inflammation of lung parenchyma leading to pulmonary consolidation as alveoli is b.) Coughing exercise
filled with exudates. c.) Chest physiotherapy – cupping
Etiologic agents: d.) Turning & reposition - Promote expectoration of secretions
1. Streptococcus pneumoniae (pnemococcal pneumonia) 6. Semi-fowler
2. Hemophilus pneumoniae(Bronchopneumonia) 7. Nebulize & suction
3. Escherichia coli 8. Comfy & humid environment
4. Klebsiella P. 9. Diet: increase CHO or calories, CHON & vit C
5. Diplococcus P. 10. Postural drainage - To drain secretions using gravity
High risk elderly & children below 5 yo Mgt for postural drainage:
Predisposing factors: a.) Best done before meals or 2 – 4 hrs after meals to prevent Gastroesophageal Reflux
1. Smoking b.) Monitor VS & breath sounds
2. Air pollution Normal breath sound – bronchovesicular
c.) Deep breathing exercises 8. Comfy & humid environment
d.) Adm bronchodilators 15 – 30 min before procedure 9. Diet – increase CHO & calories, CHON, Vit, minerals
e.) Stop if pt can’t tolerate procedure 10. Short course chemotherapy
f.) Provide oral care – it may alter taste sensation - Intensive phase
g.) C/I – pt with unstable VS & hemoptysis, increase ICP, increase IOP (glaucoma) INH – isoniazide - give before meals for absorption
Normal IOP – 12 – 21 mmHg Rifampicin - given within 4 months, given simultaneously to prevent resistance
11. HT: -S/E: peripheral neutitis – vit B6
a.) Avoidance of precipitating factors Rifampicin -All body secretions turn to red orange color urine, stool, saliva, sweat & tears.
b.) Complication: Atelectacies & meningitis PZA – Pyrazinamide – given 2 mos/ after meals. S/E: allergic rxn, nephrotoxicity & hepatoxicity
c.) Compliance to meds Standard regimen
PULMONARY TUBERCULOSIS (KOCH DSE) - Inflammation of lung tissue caused by invasion of 1. Injection of streptomycin – aminoglycoside
mycobacterium TB or Ex. Kanamycin, gentamycin, neomycin
tubercle bacilli or acid fast bacilli – gram (+) aerobic, motile & easily destroyed by heat or sunlight. S/E:
Predisposing factors: a.) Ototoxicity – damage CN # 8 – tinnitus – hearing loss
1. Malnutrition b.) Nephrotoxicicity – monitor BUN & Crea
2. Overcrowding HT:
3. Alcoholism a.) Avoid pred factors
4. Ingestion of infected cattle (mycobacterium BOVIS) b.) Complications:
5. Virulence 1.) Atelectasis
6. Over fatigue 2.) Miliary TB – spread of Tb to other system
S/Sx: b.) Compliance to meds
1. Productive cough – yellowish - Religiously take meds
2. Low fever HISTOPLASMOSIS- acute fungal infection caused by inhalation of contaminated dust with
3. Night sweats histoplasma capsulatum transmitted
4. Dyspnea to birds manure.
5. Anorexia, general body malaise, wt loss S/Sx: Same as pneumonia & PTB – like
6. Chest/ back pain 1. Productive cough
7. Hempotysis 2. Dyspnea
Diagnosis: 3. Chest & joint pains
1. Skin test – mantoux test – infection of Purified CHON Derivative PPD 4. Cyanosis
DOH – 8-10 mm induration 5. Anorexia, gen body malaise, wt loss
WHO – 10-14 mm induration 6. Hemoptysis
Result within 48 – 72h Dx:
62 1. Histoplasmin skin test = (+)
(+) Mantoux test – previous exposure to tubercle bacilli 2. ABG – pO2 decrease
Mode of transmission – droplet infection 63
2. Sputum AFB – (+) to cultured microorganism Nsg Mgt:
3. CXR – pulmonary infiltrate caseosis necrosis 1. CBR
4. CBC – increase WBC 2. Meds:
Nursing Mgt: a.) Anti fungal agents
1. CBR Amphotericin B (Fungizone)
2. Strict resp isolation S/E :
3. O2 inhalation a.) Nephrotoxcicity check BUN
4. Semi fowler b.) Hypokalemia
5. Force fluid to liquefy secretions b.)Corticosteroids
6. DBCE c.) Mucolytic/ or expectorants
7. Nebulize & suction 3. O2 – force fluids
4. Nebulize, suction Drugs – aspirin, penicillin, b blockers
5. Complications: Food additives – nitrites
a.) Atelectasis Foods – seafood, chicken, eggs, chocolates, milk
b.) Bronchiectasis COPD Physical/ emotional stress
6. Prevent spread of histoplasmosis: Sudden change of temp, humidity &air pressure
a.) Spray breading places or kill the bird. 3. mixed type: combi of both ext & intr. Asthma
COPD – Chronic Obstructive Pulmonary Disease 90% cause of asthma
1. Chronic bronchitis S/Sx:
2. Bronchial asthma 1. C – cough – non productive to productive
3. Bronchiectasis 2. D – dyspnea
4. Pulmonary emphysema – terminal stage 3. W – wheezing on expiration
CHRONIC BRONCHITIS - called BLUE BLOATERS inflammation of bronchus due to hypertrophy or 4. Cyanosis
hyperplasia of goblet 5. Mild apprehension & restlessness
mucus producing cells leading to narrowing of smaller airways. 6. Tachycardia & palpitation
Predisposing factors: 7. Diaphoresis
1. Smoking – all COPD types Dx:
2. Air pollution 1. Pulmo function test – decrease lung capacity
S/Sx: 2. ABG – PO2 decrease
1. Prod cough Nsg Mgt:
2. Dyspnea on exertion 1. CBR – all COPD
3. Prolonged expiratory grunt 2. Medsa.)
4. Scattered rales/ rhonchi Bronchodilator through inhalation or metered dose inhaled / pump. Give 1 s t before corticosteroids
5. Cyanosis b.) Corticosteroids – due inflammatory. Given 10 min after adm bronchodilator
6. Pulmo HPN – a.)Leading to peripheral edema c.) Mucolytic/ expectorant
b.) Cor pulmonary – respiratory in origin d.) Mucomist – at bedside put suction machine.
7. Anorexia, gen body malaise e.) Antihistamine
Dx: 2. Force fluid
1. ABG 3. O2 – all COPD low inflow to prevent resp distress
PO2 PCO2 Resp acidosis 4. Nebulize & suction
Hypoxemia – causing cyanosis 5. Semifowler – all COPD except emphysema due late stage
Nsg Mgt: 6. HT
(Same as emphysema) a.) Avoid pred factors
2.) BRONCHIAL ASTHMA- reversible inflammation lung condition due to hyerpsensitivity leading to b.) Complications:
narrowing of smaller - Status astmaticus- give epinephrine & bronchodilators
airway. - Emphysema
Predisposing factor: c.) Adherence to med
1. Extrinsic Asthma – called Atropic/ allergic asthma BRONCHIECTASIS – abnormal permanent dilation of bronchus resulting to destruction of muscular &
a.) Pallor elastic tissues of alveoli.
b.) Dust Predisposing factors:
c.) Gases 1. Recurrent upper & lower RI
d.) Smoke 2. Congenital anomalies
64 3. Tumors
e.) Dander 4. Trauma
f.) Lints S/Sx:
2. Intrinsic Asthma- 1. Productive cough
Cause: 2. Dyspnea
Herediatary 3. Anorexia, gen body malaise- all energy are used to increase respiration.
4. Cyanosis pCO2 increase
5. Hemoptisis pO2 decrease – hypoxema resp acidosis Blue bloaters
65 b.) Panacinar/ Centracinar
Dx: pCO2 decrease
1. ABG – PO2 decrease pO2 increase – hyperaxemia resp alkalosis Pink puffers
2. Bronchoscopy – direct visualization of bronchus using fiberscope. Nursing Mgt:
Nsg Mgt: before bronchoscopy 1. CBR
1. Consent, explain procedure – MD/ lab explain RN 2. Meds –
2. NPO a.) Bronchodilators
3. Monitor VS 66
Nsg Mgt after bronchoscopy b.) Corticosteroids
1. Feeding after return of gag reflex c.) Antimicrobial agents
2. Instruct client to avoid talking, smoking or coughing d.) Mucolytics/ expectorants
3. Monitor signs of frank or gross bleeding 3. O2 – Low inflow
4. Monitor of laryngeal spasm 4. Force fluids
- DOB 5. High fowlers
- Prepare at bedside tracheostomy set 6. Neb & suction
Mgt: same as emphysema except Surgery 7. Institute
Pneumonectomy – removal of affected lung P – posture
Segmental lobectomy – position of pt – unaffected side E – end
PULMONARY EMPHYSEMA – irreversible terminal stage of COPD E – expiratory to prevent collapse of alveoli
- Characterized by inelasticity of alveolar wall leading to air trapping, leading to maldistribution of P – pressure
gases. 8. HT
- Body will compensate over distension of thoracic cavity a.) Avoid smoking
- Barrel chest b.) Prevent complications
Predisposing factor: 1.) Cor pulmonary – R ventricular hypertrophy
1. Smoking 2.) CO2 narcosis – lead to coma
2. Allergy 3.) Atelectasis
3. Air pollution 4.) Pneumothorax – air in pleural space
4. High risk – elderly 9. Adherence to meds
5. Hereditary - a 1 anti trypsin to release elastase for recoil of alveoli. RESTRICTIVE LUNG DISORDER
S/Sx: PNEUMOTHORAX – partial / or complete collapse of lungs due to entry or air in pleural space.
1. Productive cough Types:
2. Dyspnea at rest – due terminal 1. Spontaneous pneumothorax – entry of air in pleural space without obvious cause.
3. Anorexia & gen body malaise Eg. rupture of bleb (alveoli filled sacs) in pt with inflammed lung conditions
4. Rales/ rhonchi Eg. open pneumothorax – air enters pleural space through an opening in chest wall
5. Bronchial wheezing -Stab/ gun shot wound
6. Decrease tactile fremitus (should have vibration)– palpation – “99”. Decreased - with air or fluid 2. Tension Pneumothorax – air enters plural space with @ inspiration & can’t escape leading to over
7. Resonance to hyperresonance – percussion distension of thoracic
8. Decreased or diminished breath sounds cavity resulting to shifting of mediastinum content to unaffected side.
9. Pathognomonic: barrel chest – increase post/ anterior diameter of chest Eg. flail chest – “paradoxical breathing”
10. Purse lip breathing – to eliminated PCO2 Predisposing factors:
11. Flaring of alai nares 1.Chest trauma
Diagnosis: 2.Inflammatory lung conditions
1. Pulmonary function test – decrease vital lung capacity 3.Tumor
2. ABG – S/Sx:
a.) Panlobular / centrolobular emphysema 1. Sudden sharp chest pain
2. Dyspnea I. Upper alimentary canal - function for digestion
3. Cyanosis a. Mouth
4. Diminished breath sound of affected lung b. Pharynx (throat)
5. Cool moist skin c. Esophagus
6. Mild restlessness/ apprehension d. Stomach
7. Resonance to hyper resonance e. 1st half of duodenum
Diagnosis: II. Middle Alimentary canal – Function: for absorption
1. ABG – pO2 decrease – - Complete absorption – large intestine
2. CXR – confirms pneumothorax a. 2nd half of duodenum
Nursing Mgt: b. Jejunum
1. Endotracheal intubation c. Ileum
2. Thoracenthesis d. 1st half of ascending colon
3. Meds – Morphine SO4 III. Lower Alimentary Canal – Function: elimination
- Anti microbial agents a. 2nd half of ascending colon
4. Assist in test tube thoracotomy b. Transverse
Nursing Mgt if pt is on CPT attached to H2O drainage c. Descending colon
1. Maintain strict aseptic technique d. Sigmoid
2. DBE e. Rectum
3. At bedside IV. Accessory Organ
67 a. Salivary gland
a.) Petroleum gauze pad if dislodged Hemostan b. Verniform appendix
b.) If with air leakage – clamp c. Liver
c.) Extra bottle d. Pancreas – auto digestion
4. Meds – Morphine SO4 e. Gallbladder – storage of bile
Antimicrobial I. Salivary Glands
5. Monitor & assess for oscillation fluctuations or bubbling 1. Parotid – below & front of ear
a.) If (+) to intermittent bubbling means normal or intact 2. Sublingual
- H2O rises upon inspiration 3. Submaxillary
- H2o goes down upon expiration - Produces saliva – for mechanical digestion
b.) If (+) to continuous, remittent bubbling 68
1. Check for air leakage - 1200 -1500 ml/day - saliva produced
2. Clamp towards chest tube PAROTITIS – “mumps” – inflammation of parotid gland
3. Notify MD -Paramyxo virus
c.) If (-) to bubbling S/Sx:
1. Check for loop, clots, and kink 1. Fever, chills anorexia, gen body malaise
2. Milk towards H2O seal 2. Swelling of parotid gland
3. Indicates re-expansion of lungs 3. Dysphagia
When will MD remove chest tube: 4. Ear ache – otalgia
1. If (-) fluctuations Mode of transmission: Direct transmission & droplet nuclei
2. (+) Breath sounds Incubation period: 14 – 21 days
3. CXR – full expansion of lungs Period of communicability – 1 week before swelling & immediately when swelling begins.
Nursing Mgt of removal of chest tube Nursing Mgt:
1. DBE 1. CBR
2. Instruct to perform Valsalva maneuver for easy removal, to prevent entry of air in pleural space. 2. Strict isolation
3. Apply vaselinated air occlusive dressing 3. Meds: analgesic
- Maintain dressing dry & intact Antipyretic
GIT Antibiotics – to prevent 2° complications
4. Alternate warm & cold compress at affected part - Occupies most of right hypochondriac region
5. Gen liquid to soft diet - Color: scarlet red
6. Complications - Covered by a fibrous capsule – Glisson’s capsule
Women – cervicitis, vaginitis, oophoritis - Functional unit – liver lobules
Both sexes – meningitis & encephalitis/ reason why antibiotics is needed Function:
Men – orchitis might lead to sterility if it occur during / after puberty. 1. Produces bile
VERNIFORM APPENDIX – Rt iliac or Rt inguinal area Bile – emulsifies fats
- Function – lymphatic organ – produces WBC during fetal life - ceases to function upon birth of baby - Composed of H2O & bile salts
APENDICITIS – inflamation of verniform appendix -Gives color to urine – urobilin
Predisposing factor: Stool – stircobilin
1. Microbial infection 2. Detoxifies drugs
2. Feacalith – undigested food particles – tomato seeds, guava seeds 3. Promotes synthesis of vit A, D, E, K - fat soluble vitamins
3. Intestinal obstruction Hypevitaminosis – vit D & K
S/Sx: Vit A – retinol
1. Pathognomonic sign: (+) rebound tenderness Def Vit A – night blindness
2. Low grade fever, anorexia, n/v Vit D – cholecalciferon
3. Diarrhea / & or constipation - Helps calcium
4. Pain at Rt iliac region - Rickets, osteoarthritis
5. Late sign due pain – tachycardia 4. It destroys excess estrogen hormone
Diagnosis: 5. For metabolism
1. CBC – mild leukocytosis – increase WBC A. CHO –
2. PE – (+) rebound tenderness (flex Rt leg, palpate Rt iliac area – rebound) 1. Glycogenesis – synthesis of glycogens
3. Urinalysis 2. Glycogenolysis – breakdown of glycogen
Treatment: - appendectomy 24 – 45° 3. Gluconeogenesis – formation of glucose from CHO sources
Nursing Mgt: B. CHON-
1. Consent 1. Promotes synthesis of albumin & globulin
2. Routinary nursing measures: Cirrhosis – decrease albumin
a.) Skin prep Albumin – maintains osmotic pressure, prevents edema
b.) NPO 2. Promotes synthesis of prothrombin & fibrinogen
c.) Avoid enema – lead to rupture of appendix 3. Promotes conversion of ammonia to urea.
3. Meds: Ammonia like breath – fetor hepaticus
Antipyretic C. FATS – promotes synthesis of cholesterol to neutral fats – called triglycerides
69 LIVER CIRRHOSIS - lost of architectural design of liver leading to fat necrosis & scarring
Antibiotics Early sign – hepatic encephalopathy
*Don’t give analgesic – will mask pain 1. Asterixis – flapping hand tremors
- Presence of pain means appendix has not ruptured. Late signs – headache, restlessness, disorientation, decrease LOC – hepatic coma.
4. Avoid heat application – will rupture appendix. Nursing priority – assist in mechanical ventilation
5. Monitor VS, I&O bowel sound Predisposing factor:
Nursing Mgt: post op 70
1. If (+) to Pendrose drain – indicates rupture of appendix Decrease Laennac’s cirrhosis – caused by alcoholism
Position- affected side to drain 1. Chronic alcoholism
2. Meds: analgesic due post op pain 2. Malnutrition – decreaseVit B, thiamin - main cause
Antibiotics, Antipyretics PRN 3. Virus –
3. Monitor VS, I&O, bowel sound 4. Toxicity- eg. Carbon tetrachloride
4. Maintain patent IV line 5. Use of hepatotoxic agents
5. Complications- peritonitis, septicemia S/Sx:
Liver – largest gland Early signs:
a.) Weakness, fatigue 7. Diet – increase CHO, vit & minerals. Moderate fats. Decrease CHON
b.) Anorexia, n/v Well balanced diet
c.) Stomatitis 8. Complications:
d.) Urine – tea color a.) Ascites – fluid in peritoneal cavity
Stool – clay color Nursing Mgt:
e.) Amenorrhea 1. Meds: Loop diuretics – 10 – 15 min effect
f.) Decrease sexual urge 2. Assist in abdominal paracentesis - aspiration of fluid
g.) Loss of pubic, axilla hair - Void before paracentesis to prevent accidental puncture of bladder as trochar is inserted
h.) Hepatomegaly b.) Bleeding esophageal varices
i.) Jaundice - Dilation of esophageal veins
j.) Pruritus or urticaria 1. Meds: Vit K
2. Late signs Pitrisin or Vasopresin (IM)
a.) Hematological changes – all blood cells decrease 2. NGT decompression- lavage
Leukopenia- decrease - Give before lavage – ice or cold saline solution
Thrombocytopenia- decrease - Monitor NGT output
Anemia- decrease 3. Assist in mechanical decompression
b.) Endocrine changes - Insertion of sengstaken-blackemore tube
Spider angiomas, Gynecomastia - 3 lumen typed catheter
Caput medusate, Palmar errythema - Scissors at bedside to deflate balloon.
c.) GIT changes c.) Hepatic encephalopathy –
Ascitis, bleeding esophageal varices – due to portal HPN 1. Assist in mechanical ventilation – due coma
d.) Neurological changes: 2. Monitor VS, neuro check
Hepatic encephalopathy - ammonia (cerebral toxin) 3. Siderails – due restless
Late signs: Early signs: 4. Meds – Laxatives – to excrete ammonia
Headache asterexis HEPATITIS- jaundice (icteric sclera)
Fetor hepaticus (flapping hand tremors) Bilirubin
Confusion Kernicterus/ hyperbilirubinia
Restlessness Irreversible brain damage
Decrease LOC Pancreas – mixed gland (exocrine & endocrine gland)
Hepatic coma PANCREATITIS – acute or chronic inflammation of pancreas leading to pancreatic edema,
Diagnosis: hemorrhage & necrosis due to auto
1. Liver enzymes- increase digestion.
SGPT (ALT) Bleeding of pancreas - Cullen’s sign at umbilicus
SGOT (AST) Predisposing factors:
2. Serum cholesterol & ammonia increase 1. Chronic alcoholism
3. Indirect bilirubin increase 2. Hepatobilary disease
4. CBC - pancytopenia 3. Obesity
5. PTT – prolonged 4. Hyperlipidemia
6. Hepatic ultrasonogram – fat necrosis of liver lobules 5. Hyperparathyroidism
Nursing Mgt 6. Drugs – Thiazide diuretics, pills Pentamidine HCL (Pentam)
1. CBR 7. Diet – increase saturated fats
2. Restrict Na! S/Sx:
3. Monitor VS, I&O 1. Severe Lt epigastric pain – radiates from back &flank area
4. With pt daily & assess pitting edema - Aggravated by eating, with DOB
5. Measure abdominal girth daily – notify MD 2. N/V
6. Meticulous skin care 3. Tachycardia
71 4. Palpitation due to pain
5. Dyspepsia – indigestion 5. Pruritus
6. Decrease bowel sounds 6. Easy bruising
72 7. Tea colored urine
7. (+) Cullen’s sign - ecchymosis of umbilicus hemorrhage 8. Steatorrhea
8. (+) Grey Turner’s spots – ecchymosis of flank area Diagnosis:
9. Hypocalcemia 1. Oral cholecystogram (or gallbladder series)- confirms presence of stones
Diagnosis: Nursing Mgt:
1. Serum amylase & lipase – increase 1. Meds – a.) Narcotic analgesic - Meperdipine Hcl – Demerol
2. Urine lipase – increase b.) Anti cholinergic - Atropine SO4
3. Serum Ca – decrease c.) Anti emetic
Nursing Mgt: Phenergan – Phenothiazide with anti emetic properties
1. Meds 73
a.) Narcotic analgesic - Meperidine Hcl (Demerol) 2. Diet – increase CHO, moderate CHON, decrease fats
Don’t give Morphine SO4 –will cause spasm of sphincter. 3. Meticulous skin care
b.) Smooth muscle relaxant/ anti cholinergic 4. Surgery: Cholecystectomy
- Ex. Papavarine Hcl Nursing Mgt post cholecystectomy
Prophantheline Bromide (Profanthene) -Maintain patency of T-tube intact & prevent infection
c.) Vasodilator – NTG Stomach – widest section of alimentary canal
d.) Antacid – Maalox - J shaped structures
e.) H2 receptor antagonist - Ranitidin (Zantac) to decrease pancreatic stimulation 1. Anthrum
f.) Ca – gluconate 2. Pylorus
2. Withold food & fluid – aggravates pain 3. Fundus
3. Assist in Total Parenteral Nutrition (TPN) or hyperalimentation Valves
Complications of TPN 1. 1.cardiac sphincter
1. Infection 2. Pyloric sphincter
2. Embolism Cells
3. Hyperglycemia 1. Chief/ Zymogenic cells – secrets
4. Institute stress mgt tech a.) Gastric amylase - digest CHO
a.) DBE b.) Gastric lipase – digest fats
b.) Biofeedback c.) Pepsin – CHON
5. Comfy position - Knee chest or fetal like position d.) Rennin – digests milk products
6. If pt can tolerate food, give increase CHO, decrease fats, and increase CHON 2. Parietal / Argentaffin / oxyntic cells
7. Complications: Chronic hemorrhagic pancreatitis Function:
GALLBLADDER – storage of bile – made up of cholesterol. a.) Produces intrinsic factor – promotes reabsorption of vit B12 cyanocobalamin – promotes
CHOLECYSTITIS/ CHOLELITHIASIS – inflammation of gallbladder with gallstone formation. maturation of RBC
Predisposing factor: b.) Secrets Hcl acid – aids in digestion
1. High risk – women 40 years old 3. Endocrine cells - Secrets gastrin – increase Hcl acid secretion
2. Post menopausal women – undergoing estrogen therapy Function of the stomach
3. Obesity 1.Mechanical
4. Sedentary lifestyle 2.Chem. Digestion
5. Hyperlipidemia 3.Storage of food
6. Neoplasm -CHO, CHON- stored 1 -2 hrs. Fats – stored 2 – 3 hrs
S/Sx: PEPTIC ULCER DISEASE – (PUD) – excoriation / erosion of submucosa & mucosal lining due to:
1. Severe Right abdominal pain (after eating fatty food). Occurring especially at night a.) Hypercecretion of acid – pepsin
2. Fatty intolerance b.) Decrease resistance to mucosal barrier
3. Anorexia, n/v Incidence Rate:
4. Jaundice 1. Men – 40 – 55 yrs old
2. Aggressive persons HEMORRHAGE hematemeis Melena
Predisposing factors: WT Wt loss Wt gain
1. Hereditary COMPLICATIONS a. stomach cause
2. Emotional b. hemorrhage
3. Smoking – vasoconstriction – GIT ischemia a. perforation
4. Alcoholism – stimulates release of histamine = Parietal cell release Hcl acid = ulceration HIGH RISK 60 years old 20 years old
5. Caffeine – tea, soda, chocolate Diagnosis:
6. Irregular diet 1. Endoscopic exam
7. Rapid eating 2. Stool from occult blood
8. Ulcerogenic drugs – NSAIDS, aspirin, steroids, indomethacin, ibuprofen 3. Gastric analysis – N – gastric
Indomethacin - S/E corneal cloudiness. Needs annual eye check up. Increase – duodenal
9. Gastrin producing tumor or gastrinoma – Zollinger Ellisons sign 4. GI series – confirms presence of ulceration
10. Microbial invasion – helicobacter pylori. Metromidazole (Flagyl) Nursing Mgt:
Types of ulcers 1. Diet – bland, non irritating, non spicy
Ascending to severity 2. Avoid caffeine & milk/ milk products
1. Acute – affects submucosal lining Increase gastric acid secretion
2. Chronic – affects underlying tissue – heals & forms a scar 3. Administer meds
74 75
According to location a.) Antacids
1. Stress ulcer AAC
2. Gastric ulcer Aluminum containing antacids Magnesium containing antacids
3. Duodenal ulcer – most common Ex. aluminum OH gel ex. milk of magnesia
Stress ulcers – common among eritically ill clients (Ampho-gel) S/E diarrhea
2 types S/E constipation
1.Curing’s ulcer – cause: trauma & birth Maalox (fever S/E)
hypovolemia b.) H2 receptor antagonist
GIT schemia Ex
Decrease resistance of mucosal barriers to Hcl acid 1. Ranitidine (Zantac)
Ulcerations 2. Cimetidine (Tagamet)
2.Cushing’s ulcer – cause – stroke/CVA/ head injury 3. Tamotidine (Pepcid)
Increase vagal stimulation - Avoid smoking – decrease effectiveness of drug
Hyperacidity Nursing Mgt:
Ulcerations 1. Administer antacid & H2 receptor antagonist – 1hr apart
GASTRIC ULCER DUODENAL ULCER -Cemetidine decrease antacid absorption & vise versa
SITE Intrum or lesser curvature Duodenal bulb c.) Cytoprotective agents
PAIN -30 min – 1 hr after eating Ex
- epigastrium 1. Sucralfate (Carafate) - Provides a paste like subs that coats mucosal lining of stomach
- gaseous & burning 2. Cytotec
- not usually relieved by food & d.) Sedatives/ Tranquilizers - Valium, lithium
antacid e.)Anticholinergics
-2-3 hrs after eating 1. Atropine SO4
- mid epigastrium 2. Prophantheline Bromide (Profanthene)
- cramping & burning (Pt has history of hpn crisis With peptic ulcer disease. Rn should not administer alka seltzer- has large
- usually relieved by food & antacid amount of Na.
- 12 MN – 3am pain 4. Surgery: subtotal gastrectomy - Partial removal of stomach
HYPERSECRETION Normal gastric acid secretion Increased gastric acid secretion Billroth I (Gastroduodenostomy)
VOMITING common Not common -Removal of ½ of stomach & anastomoses of gastric stump
to the duodenum. Stages:
Billroth II (Gastrojejunostomy) 1. Emergent phase – Removal of pt from cause of burn. Determine source or loc or burn
- removal of ½ -3/4 of stomach & duodenal bulb & anastomostoses of 2. Shock phase – 48 - 72°. Characterized by shifting of fluids from intravascular to interstitial space
gastric stump to jejunum. =Hypovolemia
Before surgery for BI or BII - Do vagotomy (severing of vagus nerve) & pyloroplasty (drainage) first. S/Sx:
Nursing Mgt: - BP decrease
1. Monitor NGT output - Urine output
a.) Immediately post op should be bright red - HR increase
b.) Within 36- 42h – output is yellow green - Hct increase
c.) After 42h – output is dark red - Serum Na decrease
2. Administer meds: - Serum K increase
a.) Analgesic - Met acidosis
b.) Antibiotic 3. Diuretic/ Fluid remobilization phase - 3 to 5 days. Return of fluid from interstitial to intravascular
c.) Antiemetics space
3. Maintain patent IV line 4. Recovery/ convalescent phase – complete diuresis. Wound healing starts immediately after tissue
4. VS, I&O & bowel sounds injury.
5. Complications: Class:
a.) Hemorrhage – hypovolemic shock I. Partial Burn
Late signs – anuria 1. 1 s t degree – superficial burns
b.) Peritonitis - Affects epidermis
c.) Paralytic ileus – most feared - Cause: thermal burn
d.) Hypokalemia - Painful
e.) Thromobphlebitis - Redness (erythema) & blanching upon pressure with no fluid filled vesicles
f.) Pernicious anemia 2. 2 nd degree – deep burns
76 - Affects epidermis & dermis
7.)Dumping syndrome – common complication – rapid gastric emptying of hypertonic food solutions - Cause –chem. burns
– CHYME leading to - very painful
hypovolemia. - Erythema & fluid filled vesicles (blisters)
Sx of Dumping syndrome: II Full thickness Burns
1. Dizziness 1. Third & 4 th degrees burn
2. Diaphoresis - Affects all layers of skin, muscles, bones
3. Diarrhea - Cause – electrical
4. Palpitations - Less painful
Nursing mgt: - Dry, thick, leathery wound surface – known as ESCHAR – devitalized or necrotic tissue.
1. Avoid fluids in chilled solutions 77
2. Small frequent feeding s-6 equally divided feedings Assessment findings
3. Diet – decrease CHO, moderate fats & CHON Rule of nines
4. Flat on bed 15 -30 minutes after q feeding Head & neck = 9%
BURNS – direct tissue injury caused by thermal, electric, chemical & smoke inhaled (TECS) Ant chest = 18%
Nursing Priority – infection (all kinds of burns) Post chest = 18%
Head burn-priority- a/w @ Arm 9+9 = 18%
2nd priority for 1st & 2nd ° - pain @ leg 18+18 = 18%
2nd priority for 3rd ° - F&E Genitalia/ perineum= 1%
Thermal- direct contact – flames, hot grease, sunburn. Total 100%
Electric, – wires Nursing Mgt
Chem. – direct contact – corrosive materials acids 1. Meds
Smoke – gas / fume inhalation a.) Tetanus toxoid- burn surface area is source of anaerobic growth – Claustridium tetany
Tetany Filtration – Normal GFR/ min is 125 ml of blood
Tetanolysin tetanospasmin Tubular reabsorption – 124ml of ultra infiltrates (H2O & electrolytes is for reabsorption)
Hemolysis muscle spasm Tubular secretion – 1 ml is excreted in urine
b.) Morphine SO4 Regulation of BP:
c.) Systemic antibiotics Predisposing factor:
1. Ampicillin Ex CS – hypovolemia – decrease BP going to kidneys
2. Cephalosporin Activation of RAAS
3. Tetracyclin Release of Renin (hydrolytic enzyme) at juxtaglomerular apparatus
4. Topical antibiotic : Angiotensin I mild vasoconstrictor
1. Silver Sulfadiazene (silvadene) Angiotensin II vasoconstrictor
2. Sulfamylon Adrenal cortex increase CO increase PR
3. Silver nitrate Aldosterone
4. Povidone iodine (betadine) Increase BP
2. Administer isotonic fluid sol & CHON replacements Increase Na &
3. Strict aseptic technique H2O reabsorption
4. Diet – increase CHO, increase CHON, increase Vit C, and increase K- orange Hypervolemia
5. If (+) to burns on head, neck, face - Assist in intubation Ureters – 25 – 35 cm long, passageway of urine to bladder
6. Assist in hydrotherapy Bladder – loc behind symphisis pubis. Muscular & elastic tissue that is distensible
7. Assist in surgical wound debridement. Administer analgesic 15 – 30 minutes before debridement - Function – reservoir or urine
8. Complications: 1200 – 1800 ml – Normal adult can hold
a.) Infection 200 – 500 ml – needed to initiate micturition reflex
b.) Shock Color – amber
c.) Paralytic ileus - due to hypovolemia & hypokalemia Odor – aromatic
d.) Curling’s ulcer – H2 receptor antagonist Consistency – clear or slightly turbid
e.) Septicemia blood poisoning pH – 4.5 – 8
f.) Surgery: skin grafting Specific gravity – 1.015 – 1.030
GUT – genito-urinary tract WBC/ RBC – (-)
Function: Albumin – (-)
1. Promote excretion of nitrogenous waste products E coli – (-)
2. Maintain F&E & acid base balance Mucus thread – few
1. Kidneys – pair of bean shaped organ Amorphous urate (-)
- Retro peritonially (back of peritoneum) on either side of vertebral column. Encased in Bowmans’s Urethra – extends to external surface of body. Passage of urine, seminal & vaginal fluids.
capsule. - Women 3 – 5 cm or 1 to 1 ½ “
Parts: - Male – 20cm or 8”
1. Renal pelvis – pyenophritis – infl UTI
2. Cortex CYSTITIS – inflammation of bladder
3. Medulla Predisposing factors:
Nephrones – basic living unit 1. Microbial invasion – E. coli
Glomerulus – filters blood going to kidneys 79
78 2. High risk – women
Function of kidneys: 3. Obstruction
1. Urine formation 4. Urinary retention
2. Regulation of BP 5. Increase estrogen levels
Urine formation – 25% of total CO (Cardiac Output) is received by kidneys 6. Sexual intercourse
1. Filtration S/Sx:
2. Tubular Reabsorption 1. Pain – flank area
3. Tubular Secretion 2. Urinary frequency & urgency
3. Burning upon urination 80
4. Dysuria & hematuria Diagnosis:
5. Fever, chills, anorexia, gen body malaise 1. Urine culture & sensitivity – (+) E. coli & streptococcus
Diagnosis: 2. Urinalysis
1. Urine culture & sensitivity - (+) to E. coli Increase WBC, CHON & pus cells
Nursing Mgt: 3. Cystoscopic exam – urinary obstruction
1. Force fluid – 2000 ml Nursing Mgt:
2. Warm sitz bath – to promote comfort 1. Provide CBR – acute phase
3. Monitor & assess for gross hematuria 2. Force fluid
4. Acid ash diet – cranberry, vit C -OJ to acidify urine & prevent bacterial multiplication 3. Acid ash diet
5. Meds: systemic antibiotics 4. Meds:
Ampicillin a.) Urinary antiseptic – nitrofurantoin (macrodantin)
Cephalosporin SE: peripheral neuropathy
Sulfonamides – cotrimaxazole (Bactrim) GI irritation
- Gantrism (ganthanol) Hemolytic anemia
Urinary antiseptics – Mitropurantoin (Macrodantin) Staining of teeth
Urinary analgesic- Pyridum b.) Urinary analgesic – Peridium
6. Ht 2. Complication- Renal Failure
a.) Importance of Hydration NEPHROLITHIASIS/ UROLITHIASIS- formation of stones at urinary tract
b.) Void after sex - calcium , oxalate, uric acid
c.) Female – avoids cleaning back & front milk cabbage anchovies
Bubble bath, Tissue paper, Powder, perfume cranberries organ meat
d.) Complications: nuts tea nuts
Pyelonephritis chocolates sardines
PYELONEPHRITIS – acute/ chronic infl of 1 or 2 renal pelvis of kidneys leading to tubular destruction, Predisposing factors:
interstitial abscess 1. Diet – increase Ca & oxalate
formation. 2. Hereditary – gout
- Lead to Renal Failure 3. Obesity
Predisposing factor: 4. Sedentary lifestyle
1. Microbial invasion 5. Hyperparathyroidism
a.) E. Coli S/Sx:
b.) Streptococcus 1. Renal colic
2. Urinary retention /obstruction 2. Cool moist skin (shock)
3. Pregnancy 3. Burning upon urination
4. DM 4. Hematuria
5. Exposure to renal toxins 5. Anorexia, n/v
S/Sx: Diagnosis:
Acute pyelonephritis 1. IVP – intravenous pyelography. Reveals location of stone
a.) Costovertibral angle pain, tenderness 2. KUB – reveals location of stone
b.) Fever, anorexia, gen body malaise 3. Cytoscopic exam- urinary obstruction
c.) Urinary frequency, urgency 4. Stone analysis – composition & type of stone
d.) Nocturia, dsyuria, hematuria 5. Urinalysis – increase EBC, increase CHON
e.) Burning on urination Nursing Mgt:
Chronic Pyelonephritis 1.Force fluid
a.) Fatigue, wt loss 2.Strain urine using gauze pad
b.) Polyuuria, polydypsia 3.Warm sitz bath – for comfort
c.) HPN 4.Alternate warm compress at flank area
5. a.) Narcotic analgesic- Morphine SO4 d. Monitor symptoms gross/ flank bleeding. Normal bleeding within 24h.
b.) Allopurinol (Zyeoprim) 3. Maintain irrigation or tube patent to flush out clots - to prevent bladder spasm & distention
c.) Patent IV line ACUTE RENAL FAILURE – sudden immobility of kidneys to excrete nitrogenous waste products &
d.) Diet – if + Ca stones – acid ash diet maintain F&E balance
If + oxalate stone – alkaline ash diet - (Ex milk/ milk products) due to a decrease in GFR. (N 125 ml/min)
If + uric acid stones – decrease organ meat / anchovies sardines Predisposing factor:
6. Surgery Pre renal cause- decrease blood flow
a.) Nephectomy – removal of affected kidney Causes:
Litholapoxy – removal of 1/3 of stones- Stones will recur. Not advised for pt with big stones 1. Septic shock
b.) Extracorporeal shock wave lithotripsy 2. Hypovolemia
81 3. Hypotension decrease flow to kidneys
- Non - invasive 4. CHF
- Dissolve stones by shock wave 5. Hemorrhage
7. Complications: Renal Failure 6. Dehydration
BENIGN PROSTATIC HYPERTROPHY - enlarged prostate gland leading to Intra-renal cause – involves renal pathology= kidney problem
a.) Hydro ureters – dilation of ureters 1. Acute tubular necrosis-
b.) Hydronephrosis – dilation of renal pelvis 82
c.) Kidney stones 2. Pyelonephritis
d.) Renal failure 3. HPN
Predisposing factor: 4. Acute GN
1. High risk – 50 years old & above Post renal cause – involves mechanical obstruction
60 – 70 – (3 to 4 x at risk) 1. Stricture
2. Influence of male hormone 2. Urolithiasis
S/Sx: 3. BPH
1.Decrease force of urinary stream CHRONIC RF – irreversible loss of kidney function
2.Dysuria Predisposing factors:
3.Hematuria 1. DM
4.Burning upon urination 2. HPN
5.Terminal bubbling 3. Recurrent UTI/ nephritis
6.Backache 4. Exposure to renal toxins
7.Sciatica Stages of CRF
Diagnosis: 1. Diminished Reserve Volume – asymptomatic
1. Digital rectal exam – enlarged prostate gland Normal BUN & Crea, GFR < 10 – 30%
2. KUB – urinary obstruction 2. Renal Insufficiency
3. Cystoscopic exam – obstruction 3. End Stage Renal disease
4. Urinalysis – increase WBC, CHON S/Sx:
Nursing Mgt: 1.) Urinary System
1. Prostatic message – promotes evacuation of prostatic fluid a.) polyuria
2. Limit fluid intake b.) nocturia
3. Provide catheterization c.) hematuria
4. Meds: d.) Dysuria
a. Terazozine (hytrin) - Relaxes bladder sphincter e.) oliguria
b. Fenasteride (Proscar) - Atrophy of Prostate Gland 2.) Metabolic disturbances
5. Surgery: Prostatectomy – TURP- Transurethral resection of Prostate- No incision a.) azotemia (increase BUN & Crea)
-Assist in cystoclysis or continuous bladder irrigation. b.) hyperglycemia
Nursing mgt: c.) hyperinulinemia
c. Monitor symptoms of infection 3.) CNS
a.) headache D – disequilibrium syndrome
b.) lethargy S – septicemia
c.) disorientation S – shock – decrease in tissue perfusion
d.) restlessness Disequilibrium syndrome – from rapid removal of urea & nitrogenous waste prod leading to:
e.) memory impairment a.) n/v
4.) GIT b.) HPN
a.) n/v c.) Leg cramps
b.) stomatitis d.) Disorientation
c.) uremic breath e.) Paresthesia
d.) diarrhea/ constipation 2. Avoid BP taking, blood extraction, IV, at side of shunt or fistula. Can lead to compression of fistula.
5.) Respiratory 3. Maintain patency of shunt by:
a.) Kassmaul’s resp i. Palpate for thrills & auscultate for bruits if (+) patent shunt!
b.) decrease cough ii. Bedside- bulldog clip
reflex - If with accidental removal of fistula to prevent embolism.
6.) hematological - Infersole (diastole) – common dialisate used
a.) Normocytic anemia 7. Complication
bleeding tendencies - Peritonitis
7.) Fluid & Electrolytes - Shock
a.) hyperkalemia 8. Assist in surgery:
b.) hypernatermia Renal transplantation : Complication – rejection. Reverse isolation
c.) hypermagnesemia EYES
d.) hyperposphatemia External parts
e.) hypocalcemia 1. Orbital cavity – made up of connective tissue protects eye form trauma.
f.) met acidosis 2. EOM – extrinsic ocular muscles – involuntary muscles of eye needed for gazing movement.
8.) Integumentary 3. Eyelashes/ eyebrows – esthetic purposes
a.) itchiness/ pruritus 4. Eyelids – palpebral fissure – opening upper & lower lid. Protects eye from direct sunlight
b.) uremic frost Meibomean gland – secrets a lubricating fluid inside eyelid
Nursing Mgt: b.) Stye/ sty or Hordeolum- inflamed Meibomean gland
1. Enforce CBR 5. Conjunctiva
2. Monitor VS, I&O 6. Lacrimal apparatus – tears
3. Meticulous skin care. Uremic frost – assist in bathing pt Process of grieving
4. Meds: a. Denial
a.) Na HCO3 – due Hyperkalemia b. Anger
b.) Kagexelate enema c. Bargaining
c.) Anti HPN – hydralazine d. Depression
d.) Vit & minerals e. Acceptance
e.) Phosphate binder 2. Intrinsic coat
(Amphogel) Al OH gel - S/E constipation I. sclerotic coat – outer most
f.) Decrease Ca – Ca gluconate a.) Sclera – white. Occupies ¾ post of eye. Refracts light rays
5. Assist in hemodialysis b.) Canal of schlera – site of aqueous humor drainage
1.) Consent/ explain procedure c.) Cornea – transparent structure of eye
83 II/ Uveal tract – nutritive care
2.) Obtain baseline data & monitor VS, I&O, wt, blood exam 84
3.) Strict aseptic technique Uveitis – infl of uveal tract
4.) Monitor for signs of complications: Consist of:
B – bleeding a.) Iris – colored muscular ring of eye
E – embolism 2 muscles of iris:
1. Circular smooth muscle fiber - Constricts the pupil 1. Chronic – (open angle G.) – most common type
2.radial smooth muscle fiber - Dilates the pupil Obstruct in flow of aqueous humor at trabecular meshwork of canal of schlema
2 chambers of the eye 2. Acute (close angle G.) – Most dangerous type
1. Anterior Forward displacement of iris to cornea leading to blindness.
a.) Vitereous Humor – maintains spherical shape of the eye 3. Chronic (closed – angle) - Precipitated by acute attack
b.) Aqueous Humor – maintains intrinsic ocular pressure S/Sx:
Normal IOP= 12-21 mmHg 1. Loss of peripheral vision – tunnel vision
II. Retina (innermost layer) 2. Halos around lights
i. Optic discs or blind spot – nerve fibers only 3. Headache
No auto receptors 4. n/v
cones (daylight/ colored vision) rods – night twilight vision 5. Steamy cornea
phototopic vision “scotopic vision” = vit A deficiency – rods insufficient 6. Eye discomfort
ii. Maculla lutea – yellow spot center of retina 7. If untreated – gradual loss of central vision – blindness
iii. Fovea centralis – area with highest visual acuity oracute vision Diagnosis:
Physiology of vision 1. Tonometry – increase IOP >12- 21 mmHg
4 Physiological processes for vision to occur: 2. Perimetry – decrease peripheral vision
1. Refraction of light rays – bending of light rays 3. Gonioscopy – abstruction in anterior chamber
2. Accommodation of lens Nursing mgt:
3. Constriction & dilation of pupils 1. Enforce CBR
4. Convergence of eyes 2. Maintain siderails
Unit of measurements of refraction – diopters 3. Administer meds
Normal eye refraction – emmetropia a.) Miotics – lifetime - contracts ciliary muscles & constricts pupil. Ex Pilocarpine Na (Carbachol)
ERROR of refraction b.) Epinephrine eye drops – decrease secretion of aqueous humor
1. Myopia – near sightedness – Treatment: biconcave lens c.) Carbonic anhydrase inhibitors. Ex. acetapolamide (Diamox)
2. Hyperopia/ or farsightedness – Treatment: biconvex lens - Promotes increase out flow of aquaeous humor
3. Astigmatisim – distorted vision – Treatment: cylindrical d.) Temoptics (Timolol maleate)- Increase outflow of aquaous humor
4. Prebyopia – “old slight” – inelasticity of lens due to aging – Treatment: bifocal lens or double vista 2. Surgery:
Accommodation of lenses – based on thelmholtz theory of accommodation Invasive:
Near vision = far vision= a.) Trabeculectomy – eyetrephining – removal of trabelar meshwork of canal or schlera to drain
Ciliary muscle contracts= ciliary muscle dilates / relaxes= aqueous humor
Lens bulges lens is flat b.) Peripheral Iridectomy – portion of iris is excised to drain aqueous humor
Convergence of the eye: Non-invasive:
Error: Trabeculoctomy (eye laser surgery)
1. Exotropia – 1 eye normal Nursing Mgt pre op- all types surgery
2. Esophoria – corrected by corrective eye surgery 1. Apply eye patch on unaffected eye to force weaker eye to become stronger.
3. Strabismus- squint eye Nursing Mgt post op – all types of surgery
4. Amblyopia – prolong squinting 1. Position unaffected/ unoperated side - to prevent tension on suture line.
GLAUCOMA – increase IOP – if untreated, atrophy of optic nerve disc – blindness 2. Avoid valsalva maneuver
Predisposing factors: 3. Monitor symptoms of IOP
1. High risk group – 40 & above a.) Headache
2. HPN b.) n/v
3. DM c.) Eye discomfort
85 d.) Tachycardia
4. Hereditary 2. Eye patch – both eyes - post op
5. Obesity CATARACT – partial/ complete opacity of lens
6. Recent eye trauma, infl, surgery Predisposing factor:
Type: 86
1. 90-95% - aging (degenerative/ senile cataract) 4. Gradual decrease in central vision
2. Congenital 5. Headache
3. Prolonged exposure to UV rays 87
4. DMS/ Diagnosis- opthaloscopic exam
Sx: Nursing Mgt:
1. Loss of central vision - “Hazy or blurring of vision” 1. Siderails (all visual disease)
2. Painless 2. Surgery:
3. Milky white appearance at center of pupil a.) Cryosurgery
4. Decrease perception of colors b.) Scleral buckling
Diagnosis: Opthalmoscopic exam – (+) opacity of lens EAR –
Nsg Mgt: 1. Hearing
1. Reorient pt to environment – due opacity 2. Balance (Kinesthesia or position sense)
2. Siderails Parts:
3. Meds – a.) Mydriatics – dilate pupil – not lifetime 1. Outera.)
Ex. Mydriacyl Pinna/ auricle – protects ear from direct trauma
c.) Cyslopegics – paralyzes ciliary muscle. Ex. Cyclogye b.) Ext. auditory meatus – has ceruminous gland. Cerumen
4. Surgery c.) Tympanic membrane – transmits sound waves to middle ear
E – extra Disorders of outer ear
C - capsular Entry of insects – put flashlight to give route of exit
C – cataract partial removal of lens Foreign objects – beans (bring to MD)
L - lens H2O - drain
E – extraction 2. Middle ear
I - intra a.) Ear osssicle
C - capsular 1. Hammer -malleus
C – cataract total removal of lens & surrounding capsules 2. Anvil -Incus for bone conduction disorder conductive hearing loss
L - lens 3. Stirrups -stapes
E – extraction b. Eustachian tube - Opens to allow equalization of pressure on both ears
Nursing Mgt: - Yawn, chew, and swallow
1.Position unaffected/ unoperated side - to prevent tension on suture line. Children – straight, wide, short
2.Avoid valsalva maneuver c.) Otitis media
3.Monitor symptoms of IOP Adult – long, narrow & slanted
a.) Headache c. Muscles
b.) n/v 1. Stapedius
c.) Eye discomfort 2. Tensor tympani
d.) Tachycardia 3. Inner ear
4.Eye patch – both eyes - post op a. Bony labyrinth – for balance, vestibule
RETINAL DETACHMENT- separation of 2 layers of retina Utricle & succule
Predisposing factors: Otolithe or ear stone – has Ca carbonate
1. Severe myopia – nearsightedness Movement of head = Righting reflex = Kinesthesia
2. Diabetic Retinopathy b. Membranous Labyrinth
3. Trauma 1. Cochlea – ( function for hearing) has organ of corti
4. Following lens extraction 2. Endolymph & perilymph – for static equilibrium
5. HPN 3. Mastoid air cells – air filled spaces in temporal bone in skull
S/Sx: Complications of Mastoditis – meningitis
1. “Curtain –veil” like vision Types of hearing loss:
2. Flashes of lights 1. Conductive hearing loss – transmission hearing loss
3. Floaters Causes:
a.) Impacted cerumen – tinnitus & conduction hearing loss- assist in ear irrigaton a.) Tinnitus
b.) Immobility of stapes – OTOSCLEROSIS b.) Vertigo
d.) Middle ear disease char by formation of spongy bone in the inner ear causing fixation or immobility c.) Sensory neural hearing loss
of stapes 89
e.) Stapes can’t transmit sound waves 2. Nystagmus
88 3. n/v
Surgery 4. Mild apprehension, anxiety
Stapedectomy – removal of stapes, spongy bone & implantation of graft/ ear prosthesis 5. Tachycardia
Predisposing factor: 6. Palpitations
1. Familiar tendency 7. Diaphoresis
2. Ear trauma & surgery Diagnosis:
S/Sx: 1. Audiometry – (+) sensory hearing loss
1. Tinnitus Nursing mgt:
2. Conductive hearing loss 1. Comfy & darkened environment
Diagnosis: 2. Siderails
1. Audiometry – various sound stimulates (+) conductive hearing loss 3. Emetic basin
2. Weber’s test – Normal AC> BC 4. Meds:
result BC > AC a.) Diuretics –to remove endolymph
Stapedectomy b.) Vasodilator
Nursing Mgt post op c.) Antihistamine
1. Position pt unaffected side d.) Antiemetic
2. DBE e.) Antimotion sickness agent
No coughing & blowing of nose f.) Sedatives/ tranquilizers
- Night lead to removal of graft 5. Restrict Na
3. Meds: 6. Limit fluid intake
a.) Analgesic 7. Avoid smoking
b.) Antiemetic 8. Surgery – endolymphatic sac decompression- Shunt
c.) Antimotion sickness agent. Ex. meclesine Hcl (Bonamine) 90
4. Assess – motor function – facial nerve - (Smile, frown, raise eyebrow)
5. Avoid shampoo hair for 1 to 2 weeks. Use shower cap
SENSORY NEURAL HEARING LOSS/ NERVE DEAFNESS
Cause:
1. Tumor on cocheal
2. Loud noises (gun shot)
3. Presbycusis – bilateral progressive hearing loss especially at high frequencies – elderly
Face elderly to promote lip reading
4. Meniere’s disease – endolymphatic hydrops
f.) Inner ear disease char by dilation of endo – lympathic system leading to increase volume of endolin
Predisposing factor of MENIERE’S DISEASE
Smoking
Hyperlipidemia
30 years old
Obesity – (+) chosesteatoma
Allergy
Ear trauma & infection
S/Sx:
1. TRIAD symptoms of Meniere’s disease