OUR LADY OF FATIMA UNIVERSITY

120 McArthur Highway Marulas, Valenzuela City

COLLEGE OF NURSING

NCM 104A: CARE OF CLIENTS WITH PROBLEMS IN INFLAMMATORY AND IMMUNOLOGIC RESPONSE, PERCEPTION AND COORINATION

ASSIGNMENT

Submitted by:

BALUNAN, MIKAELLA C.

BSN 3Y2-1

Submitted to:

MRS. P. A. MAROMA, PhD, RN

NOVEMBER 22, 2019

 MEDICAL NURSING MANAGEMENT
DISEASE DEFINITION ETIOLOGY SIGNS AND
SYMPTOMS MANAGEMENT
A. INCREASED A rise pressure around  Head injury o Pupils that do not o Administer osmotic  Maintain patent airway -
INTRACRANIAL your brain. It may be  Brain tumors respond to light in diuretic such as secretion obstructing the
PRESSURE (ICP) due to an increase in  Subarachnoid the usual way Mannitol the airway must be suctioned
the amount of fluid hemorrhage o Headache decrease cerebral with care. auscultating
surrounding your  Toxic and viral o Behavior changes edema lung fields
brain. encephalopathies o Reduced o Restricting fluids and  Monitor for respiratory
alertness draining CSF irregularities
o Sleepiness o Control fever  Monitoring PaCO2: ABG
o Muscle weakness o Maintain systemic BP (arterial blood gas) suction
o Speech or and oxygenation when needed suctioning
movement should not last longer than
difficulties 15 seconds
o Vomiting  Head of bed elevated 30 to
o Blurred vision 45 degree to improve
o Confusion venous drainage of the
brain to aid in clearing of
secretions
 Patients head is kept on
midline position
maintained with the use of
cervical collar
 Administer stool softener
as prescribed (soft bowels
prevent straining or
valsalva maneuver)
 Enemas and cathartics are
avoided if possible;
 maintain a calm
atmosphere
 Patient need careful oral
hygiene because mouth
dryness Oh cure with
dehydration
 Monitoring neurologic
functions and vital signs
B. VISUAL The sudden death of  Atherosclerosis, o Difficulty walking o Paletelet-inhibiting o Assess the level of
DISTURBANCES some brain cells due to where the arteries o Dizziness medications: Aspirin, consciousness and
lack of oxygen when become narrow o Loss of balance and dipyridamole, responsiveness as
CEREBROVASCULAR the blood flow to the  Thrombosis coordination clopidogrel and evidenced by movement
ACCIDENT (CVA) brain is impaired by  Embolic arterial blood o Difficulty speaking ticlopidine. Currently resistance to changes of
blockage or rupture of clot, which is a blood or understanding the most cost position and response to
an artery to the brain. clot in an artery of the others who are effective antiplatelet stimulation orientation to
A CVA is also referred brain speaking regimen is Aspirin. time place and person
to as a stroke.  Cerebral venous o Numbness or o Thrombolytic therapy o Presence or absence of
thrombosis, which is a paralysis in the o Carotid voluntary or involuntary
blood clot in a vein of face, leg, or arm, endarterectomy movements of the
the brain most likely on just o Craniotomy extremities muscle tone
 Age more than 65 one side of the body posture and position
years old body of the head
 More in men than o Blurred or o Stiffness or flaccidity of the
women darkened vision neck
 Modifiable risk oA sudden o Eye opening, comparative
factors: HPN, heart headache, size of pupils and pupillary
disease and smoking especially when reaction to light and ocular
accompanied by position
nausea, vomiting,
or dizziness
TRANSIENT ISCHEMIC A stroke that lasts only Transient ischemic attack o Weakness, o Antiplatelet drugs –  Monitoring neural
ATTACK (TIA) a few minutes. It may result from numbness or when blood vessels function, vital signs
happens when the atherothromboembolism paralysis in your are injured, sticky improving mobility and
blood supply to part of that originates from: face, arm or leg, platelets begin to joint deformities
the brain is briefly ulcerated extracranial typicaly on one form clots.  Correct positioning to
blocked. arteries, emboli of side of your body. o Ace Inhibitors prevent contractures
cardiac origin, occlusion o Slurred or garbled o Statins  Maintain body alignment
of small penetrating speech or o Thrombolytic agents -  Hand placed slight
articles that arise from difficulty it is used to treat an supination
large surface arteries of understanding ongoing stroke by  Position changes every 2
the Circle of Willis. others dissolving blood clots hours
o Blindness in one or that are blocking  Assisting in nutrition: NGT-
both eyes or blood flow to the elevate head of bed at
double vision brain least 30 degree. retained
o Dizziness or loss of residual feeding increase
balance or risk of aspiration.
coordination  Patient may be started on
o Sudden severe thick liquids because they
headache with no are easier to swallow than
known cause thin liquids
 Maintain skin integrity
 Improve communication
 Attaining bowel and
bladder control
 Assist in preparing for
ambulation
C. TRAUMATIC BRAIN - A non-  Usually results from a o Changes in o Anti hypertensives -  Place client semi-fowler’s
INJURY degenerative, non- violent blow or jolt did behavior such as to reduce blood position
congenital insult to the head or body irritability or pressure to prevent  Assess Glasgow Coma
the brain from an confusion exacerbation of Scale score
 external mechanical  An object that o Dilated intracerebral  Ventilatory support,
force, possibly penetrates brain tissue o Trouble walking or hemorrhage in seizure prevention,
leading to such as bullet or speaking hypertensive nutrition support
permanent or shattered piece of skull o Drainage of blood encephalophaty.  Treatment of Increased
temporary can also cause traumatic or clear fluids from o Diuretics – Mannitol ICP
impairment of brain injury ears and nose o Anti-convulsants –  Surgery evaluation of
cognitive, physical, o Vomiting reduce frequency of blood clot
and psychosocial o Seizures seizures and
functions, with an o Weakness or prophylaxis of
associated diminish numbness in the seizures
or altered state of arms or legs o Anti-pyretics –
consciousness. Relieve fever and pain
o Glucocorticoids may
help reduce the head
and neck ache caused
by Irritative effect of
subarachnoid blood.
D. SPINAL CORD INJURY  Damage to the spinal  Motor vehicular o Loss of muscle o Oxygenation  Immobilization
cord that causes accidents - most function o High dose of  Assess fluid volume
temporary or common cause o Pain corticosteroids  monitor for hypotension
permanent changes  Others: falls, violence, o Tenderness (Methylprednisolone) and bradycardia
in it’s function. sport injuries o Painful movement - Improves the  Continuous cardiac
 Spinal Cord Injury o Deformity prognosis and monitoring for
typically occurs from o Soft Tissue Injury decreases disability if dysrhythmia
indirect injury from in area of spine initiated within 8  Avoid changes in body
vertebral bones (bruise, laceration, hours of injury. temperature,
compressing cord etc.) patient receives a hypothermia can produce
 Spinal Cord Injury o Paralysis loading dose and brady-dysrhythmias and
frequently occur with o Paresthesias then a continuous sinus arrest
head injuries o Weakness drip.
 Cord injury may be o Spinal shock
caused by direct trauma
from knives bullets etc.
o High dose steroids,  Apply strategy to prevent
Mannitol, Dextran orthostatic hypotension as
o Neurological or reposition slowly, wear
orthopedic pressure stockings
management  Apply strategy to prevent
includes methods: A occurrence of Deep Vein
surgeon may use to Thrombosis (DVT) heparin
treat unstable Spinal
Cord Injuries:
Reduction, Fixation
and Fusion