Académique Documents
Professionnel Documents
Culture Documents
MEDICAL-SURGICAL NURSING
By: Anthony T. Villegas R.N.
• Spinal Cord – serves as a connecting link between the brain & the periphery.
Peripheral Nervous System
• Cranial Nerves –12 pairs; carry impulses to & from the brain.
• Sympathetic nervous system – generally accelerate some body functions in response to stress.
CELLS
A. NEURONS
• Primary component of nervous system
• Composed of cell body (gray matter), axon, and dendrites
• Basic cells for nerve impulse and conduction.
Axon
• Elongated process or fiber extending from the cell body
• Transmits impulses (messages) away from the cell body to dendrites or directly to the cell bodies of other neurons
Functional Classification
1. Afferent (sensory) neurons
• Transmit impulses from peripheral receptors to the CNS
2. Efferent (motor) neurons
• Conduct impulses from CNS to muscle and glands
3. Internuncial neurons (interneurons)
• Connecting links between afferent and efferent neurons
Properties
1. Excitability – ability of neuron to be affected by changes in external environment.
2. Conductility – ability of neuron to transmit a wave of excitetation from one cell to another.
3. Permanent Cell – once destroyed not capable of regeneration.
B. NEUROGLIA
• Support and protection of neurons.
TYPES
1. Astrocytes
• maintains blood brain barrier semi-permiable.
1
2
MACROPHAGE ORGAN
Microglia Brain
Monocytes Blood
Kupffers Kidney
Histiocytes Skin
Alveolar Macrophage Lung
Composition Of Brain
• 80% brain mass
• 10% blood
• 10% CSF
Brain Mass
Parts Of The Brain
1. Cerebrum
• largest part of the brain
• composed of two hemisphere the Right Cerebral Hemisphere and Left Cerebral Hemisphere enclosed in the Corpus Callosum.
• Each hemisphere divided into four lobes; many of the functional areas of the cerebrum have been located in these lobes:
Lobes of Cerebrum
1. Frontal Lobe
• controls personality, behavior
• higher cortical thinking, intellectual functioning
• Broca’s Area: specialized motor speech area - when damaged results to garbled speech.
2. Temporal Lobe
• hearing, taste, smell
• short term memory
• controls libido
• controls long term memory
Corpus Callosum
• large fiber tract that connects the two cerebral hemisphere
Basal Ganglia
• island of gray matter within white matter of cerebrum
• regulate & integrate motor activity originating in the cerebral cortex
• part of extrapyramidal system
• area of gray matter located deep within each cerebral hemisphere.
2. Diencephalon/interbrain
• Connecting part of the brain, between the cerebrum & the brain stem
• Contains several small structures: the thalamus & hypothalamus are most important
Thalamus
• acts as relay station for discrimination of sensory signals (ex. Pain, temperature, touch)
2
3
• plays a major role in regulation/controls of vital function: blood pressure, thirst, appetite, sleep & wakefulness, temperature
(thermoregulatory center)
• acts as controls center for pituitary gland and affects both divisions of the autonomic nervous system.
• controls some emotional responses like fear, anxiety and excitement.
3. Mesencephalon/Midbrain
• acts as relay station for sight and hearing.
• positive PERRLA
4. Brain Stem
• located at lowest part of brain.
• contains midbrain, pons, medulla oblongata.
• extends from the cerebral hemispheres to the foramen magnum at the base of the skull.
• contains nuclei of the cranial nerves and the long ascending and descending tracts connecting the cerebrum and the spinal cord.
• contains vital center of respiratory, vasomotor, and cardiac functions.
Pons
• pneumotaxic center controls the rate, rhythm and depth of respiration.
Medulla Oblongata
• controls respiration, heart rate, swallowing, vomiting, hiccup, vasomotor center (dilation and constriction of bronchioles).
5. Cerebellum
• smallest part of the brain, lesser brain.
• coordinates muscle tone and movements and maintains position in space (equilibrium)
• controls balance, equilibrium, posture and gait.
Spinal Cord
• serves as a connecting link between the brain and periphery
• extends from foramen magnum to second lumbar vertebra
• H-shaped gray matter in the center (cell bodies) surrounded by white matter (nerve tract and fibers)
Gray Matter
1. Anterior Horns
• Contains cell bodies giving rise to efferent (motor) fibers
2. Posterior Horns
• Contains cell bodies connecting with afferent (sensory) fibers from dorsal root ganglion
3. Lateral Horns
• In thoracic region, contain cells giving rise to autonomic fibers of sympathetic nervous system
White Matter
1. Ascending Tracts (sensory pathways)
a. Posterior Column
• Carry impulses concerned with touch, pressure, vibration, & position sense
b. Spinocerebellar
• Carry impulses concerned with muscle tension & position sense to cerebellum
c. Lateral Spinothalamic
• Carry impulses resulting in pain & temperature sensations
d. Anterior Spinothlamic
• Carry impulses concerned with crude touch & pressure
2. Descending Tracts (motor pathways)
a. Corticospinal (pyramidal, upper motor neurons)
• Conduct motor impulses from motor cortex to anterior horn cells (cross in the medulla)
b. Extrapyramidal
• Help to maintain muscle tone & to control body movement, especially gross automatic movements such as walking
Reflex Arc
• Reflex consists of an involuntary response to a stimulus occurring over a neural pathway called a reflex arc.
Components
a. Sensory Receptors
• Receives/reacts to stimulus
b. Afferent Pathways
• Transmits impulses to spinal cord
3
4
c. Interneurons
• Synapses with a motor neuron (anterior horn cell)
d. Efferent Pathways
• Transmits impulses from motor neuron to effector
e. Effectors
• Muscle or organ that responds to stimulus
Supporting Structures
1. Skull
• Rigid; numerous bones fused together
• Protects & support the brain
2. Spinal Column
• Consists of 7 cervical, 12 thoracic, & 5 lumbar vertebrae as well as sacrum & coccyx
• Supports the head & protect the spinal cord
3. Meninges
• Membranes between the skull & brain & the vertebral column & spinal cord
• 3 fold membrane that covers brain and spinal cord.
• For support and protection; for nourishment; blood supply
• Area between arachnoid & pia mater is called subarachnoid space: CSF aspiration is done
• Layers:
Dura Mater
• outermost layer, tough, leathery
Arachnoid Mater
• middle layer, weblike
Pia Mater
• innermost layer, delicate, clings to surface of brain
4. Ventricles
• Four fluid-filled cavities connecting with one another & spinal canal
• Produce & circulate cerebrospinal fluid
5. Cerebrospinal Fluid (CSF)
• Surrounds brain & spinal cord
• Allows fluid shifts from the cranial cavity to the spinal cavity
• These arteries communicate at the base of the brain through the circle of willis
• Anterior, middle, & posterior cerebral arteries are the main arteries for distributing blood to each hemisphere of the brain
• Brain stem & cerebellum are supplied by branches of the vertebral & basilar arteries
• Venous blood drains into dural sinuses & then into jugular veins
7. Blood-Brain-Barrier (BBB)
• Protective barrier preventing harmful agents from entering the capillaries of the CNS; protect brain & spinal cord
• Ascites
• Esophageal Varices
Early Signs of Hepatic Encephalopathy
• Asterexis (flapping hand tremors).
Late Signs of Hepatic Encephalopathy
• Headache
• Dizziness
• Confusion
• decrease LOC
2. Carbon Monoxide and Lead Poisoning
• Can lead to Parkinson’s Disease.
• Epilepsy
4
5
Spinal Nerves
31 pairs: carry impulses to & from spinal cord
Each segment of the spinal cord contains a pair of spinal nerves (one of each side of the body)
Cranial Nerves
12 pairs: carry impulses to & from the brain.
Include those peripheral nerves (both cranial & spinal) that regulates smooth muscles, cardiac muscles, & glands.
Component:
1. Sympathetic Nervous System
Generally accelerates some body function in response to stress.
2. Parasympathetic Nervous System
Controls normal body functioning
5
6
Gland of Head
Lacrimal no effect stimulate secretions
Salivary scanty thick, viscous secretions copious thin, watery secretions
Dry mouth
Physical Examination
Comprehensive Neuro Exam
Neuro Check
1. Level of Consciousness (LOC)
a. Orientation to time, place, person
b. Speech: clear, garbled, rambling
c. Ability to follow command
d. If does not respond to verbal stimuli, apply a painful stimulus (ex. Pressure on the nailbeds, squeeze trapezius muscle); note
response to pain
Appropriate: withdrawal, moaning
Inappropriate: non-purposeful
e. Abnormal posturing (may occur spontaneously or in response to stimulus)
6
7
Decorticate Posturing: extension of leg, internal rotation & abduction of arms with flexion of elbows, wrist, & finger: (damage to
corticospinal tract; cerebral hemisphere)
Decerebrate Posturing: back arched, rigid extension of all four extremities with hyperpronation of arms & plantar flexion of feet:
(damage to upper brain stem, midbrain, or pons)
Components
1. Eye opening
2. Verbal response
3. Motor response
Neurologic Exam
1. Mental status and speech (Cerebral Function)
a. General appearance & behavior
b. LOC
c. Intellectual Function: memory (recent & remote), attention span, cognitive skills
d. Emotional status
e. Thought content
f. Language / speech
2. Cranial nerve assessment
3. Cerebellar Function: posture, gait, balance, coordination
a. Romberg’s Test: 2 nurses, positive for ataxia
b. Finger to Nose Test: positive result mean dimetria (inability of body to stop movement at desired point)
4. Sensory Function: light touch, superficial pain, temperature, vibration & position sense
5. Motor Function: muscle size, tone, strength; abnormal or involuntary movements
6. Reflexes
a. Deep tendon reflex: grade from 0 (no response); to 4 (hyperactive); 2 (normal)
b. Superficial
c. Pathologic: babinski reflex (dorsiflexion of the great toe with fanning of toes): indicates damage to corticospinal tracts
7
8
Test of Memory
1. Short term memory
Ask most recent activity
Positive result mean anterograde amnesia and damage to temporal lobe
2. Long term memory
Ask for birthday and validate on profile sheet
Positive result mean retrograde amnesia and damage to limbic system
Consider educational background
Level of Orientation
1. Time: first asked
2. Person: second asked
3. Place: third asked
Cranial Nerves
Cranial Nerves Function
1. Olfactory S
2. Optic S
3. Oculomotor M
4. Trochlear M
(smallest)
5. Trigeminal B (largest)
6. Abducens M
7. Facial B
8. Acoustic S
9. Glossophareng B
eal
10. Vagus B (longest)
11. Spinal M
Accessory
12. Hypoglossal M
Numerator: is constant, it is the distance of person from the chart (6-7 m, 20 feet)
Denominator: changes, indicates distance by which the person normally can see letter in the chart.
20/200 indicates blindness
20/20 visual acuity if client is able to read letters above the red line.
2. Test of visual field or peripheral vision
a. Superiorly
b. Bitemporaly
c. Nasally
d. Inferiorly
8
9
Oculomotor
Controls the size and response of pupil
Normal pupil size is 2 – 3 mm
Sensory: controls sensation of face, mucous membrane, teeth, soft palate and corneal reflex
Instruct client to smile, frown and if results are negative there is facial paralysis or Bell’s Palsy and the primary cause is forcep delivery.
Let client protrude tongue and it should be midline and if unable to do indicative of damage to cerebral hemisphere and/or has short
frenulum.
Pathognomonic Signs:
9
10
DEMYELINATING DISORDERS
Alzheimer’s disease
Atrophy of brain tissue due to deficiency of acetylcholine.
S/sx
4 A’s of Alzheimer
a. Amnesia – loss of memory.
b. Agnosia – unable to recognized inanimate/familiar objects.
c. Apraxia – unable to determine purpose/ function of objects.
d. Aphasia – no speech (nodding).
*Expressive aphasia
“motor speech center” unable to speak
Broca’s Aphasia
*Receptive aphasia
inability to understand spoken words.
Common to Alzheimer’s
Wernike’s Aphasia
General Knowing Gnostic Area or General Interpretative Area.
DOC
Aricept (taken at bedtime)
Cognex
Management
1. Palliative & supportive
Incident: Affects women more than men ages 20-40 are prone & more frequent in cool or temperate climate.
Ig G - only antibody that pass placental circulation causing passive immunity, short term protection
Ig M - acute in inflammation.
S/sx
1. Visual disturbances
blurring of vision (primary)
TRIAD SIGNS OF MS
Ataxia
CHARCOTS
TRIAD 10
11
Dx
1. CSF Analysis: increase in IgG and Protein.
2. MRI: reveals site and extent of demyelination.
3. CT Scan: increase density of white matter.
4. Visual Evoked Response (VER) determine by EEG: maybe delayed
5. Positive Lhermittes Sign: a continuous and increase contraction of spinal column.
Nursing Intervention
1. Assess the client for specific deficit related to location of demyelination
2. Promote optimum mobility
a. Muscles stretching & strengthening exercises
b. Walking exercises to improve gait: use wide-base gait
c. Assistive devices: canes, walker, rails, wheelchair as necessary
3. Administer medications as ordered
a. ACTH (adreno chorticotropic hormone), Corticosteroids (prednisone) for acute exacerbations: to reduce edema at site of
demyelination to prevent paralysis.
b. Baclofen (Lioresal), Dantrolene (Dantrium), Diazepam (Valium) - muscle relaxants: for spacity
c. Beta Interferons - Immunosuppresants: alter immune response.
4. Encourage independence in self-care activities
5. Prevent complications of immobility
6. Institute bowel program
7. Maintain side rails to prevent injury related to falls.
8. Institute stress management techniques.
a. Deep breathing exercises
b. Yoga
9. Increase fluid intake and increase fiber to prevent constipation.
10. Maintain urinary elimination
1. Urinary Retention
a. perform intermittent catheterization as ordered: to prevent retention.
b. Bethanecol Chloride (Urecholine) as ordered
Nursing Management
only given subcutaneous.
monitor side effects bronchospasm and wheezing.
monitor breath sounds 1 hour after subcutaneous administration.
2. Urinary Incontinence
a. Establish voiding schedule
b. Anti spasmodic agent Prophantheline Bromide (Pro-banthine) if ordered
3. Force fluid to 3000 ml/day.
4. Promote use of acid ash diet like cranberry juice, plums, prunes, pineapple, vitamin C and orange: to acidify urine and prevent
bacterial multiplication.
11. Prevent injury related to sensory problems.
a. Test bath water with thermometer.
b. Avoid heating pads, hot water bottles.
c. Inspect body parts frequently for injury.
d. Make frequent position changes.
12. Prepare client for plasma exchange if indicated: to remove antibodies
13. Provide psychologic support to client/significant others.
a. Encourage positive attitude & assist client in setting realistic goals.
b. Provide compassion in helping client adapt to changes in body image & self-concept.
c. Do not encourage false hope during remission.
d. Refer to MS societies & community agencies.
14. Provide client teaching & discharge planning concerning:
a. General measures to ensure optimum health.
Balance between activity & rest
11
12
Foramen Magnum
Medulla Oblongata
Brain Herniation
Obstruction of flow of CSF will lead to enlargement of skull posteriorly called hydrocephalus.
DISORDERS
Increase Intracranial Pressure (IICP)
Increase in intracranial bulk brought due to an increase in any of the 3 major intracranial components: Brain Tissue, CSF, Blood.
Present life threatening situation because of pressure on vital structures in the brain stem, nerve tracts & cranial nerve.
Increase ICP may be caused:
head trauma/injury
localized abscess
cerebral edema
hemorrhage
tumor (rarely)
S/sx
(Early signs)
1. Decrease LOC
2. Irritability / agitation
3. Progresses from restlessness to confusion & disorientation to lethargy & coma
(Late signs)
1. Changes in Vital Signs (may be a late signs)
a. Systolic blood pressure increases while diastolic pressure remains the same (widening pulse pressure)
b. Pulse rate decrease
c. Abnormal respiratory patterns (cheyne-stokes respiration)
d. temperature increase directly proportional to blood pressure.
2. Pupillary Changes
a. Ipsilateral (same side) dilatation of pupil with sluggish reaction to light from compression of cranial nerve III
b. unilateral dilation of pupils called uncal herniation
c. bilateral dilation of pupils called tentorial herniation
d. Pupil eventually becomes fixed & dilated
3. Motor Abnormalities
a. Contralateral (opposite side) hemiparesis from compression of corticospinal tract
b. abnormal posturing
c. decorticate posturing (damage to cortex and spinal cord).
d. decerebrate posturing (damage to upper brain stem that includes pons, cerebellum and midbrain).
4. Headache
5. Projective Vomiting
6. Papilledema (edema of optic disc)
12
13
Nursing Intervention
1. Maintain patent airway and adequate ventilation by:
a. Prevention of hypoxia (decrease O2) and hypercarbia (increase CO2) important:
Hypoxia may cause brain swelling which increase ICP
Early signs of hypoxia:
Restlessness
Tachycardia
Agitation
Late signs of hypoxia:
Extreme restlessness
Bradycardia
Dyspnea
Cyanosis
Monitor strictly input and output every hour: (output should increase): notify physician if output is less 30 cc/hr.
Administered via side drip
Monitor strictly input and output every hour: (output should increase): notify physician if output is less 30 cc/hr.
Administered IV push or oral.
Given early morning
Immediate effect of 10-15 minutes.
Maximum effect of 6 hours.
c. Corticosteroids [Dexamethasone (Decadron)]: anti-inflammatory effect reduces cerebral edema
d. Analgesics for headache as needed:
Small dose of Codein SO4
Strong opiates may be contraindicated since they potentiate respiratory depression, alter LOC, & cause papillary changes.
e. Anti-convulsants [Phenytoin (Dilantin)]: to prevent seizures.
8. Assist with ICP monitoring when indicated:
a. ICP monitoring records the pressure exerted within the cranial cavity by the brain, cerebral blood, & CSF
b. Types of monitoring devices:
Intraventricular Catheter: inserted in lateral ventricle to give direct measurement of ICP; also allows for drainage of CSF if
needed.
Subarachnoid screw (bolt): inserted through the skull & dura matter into subarachnoid space.
Epidural Sensor: least invasive method; placed in space between skull & dura matter for indirect measurement of ICP.
c. Monitor ICP pressure readings frequently & prevent complications:
Normal ICP reading is 0-15 mmHg; a sustained increase above 15 mmHg is considered abnormal.
Use strict aseptic technique when handling any part of the monitoring system.
13
14
Assess system for CSF leakage, loose connections, air bubbles in he line, & occluded tubing.
9. Provide intensive nursing care for clients treated with barbiturates therapy or administration of paralyzing agents.
a. Intravenous administration of barbiturates may be ordered: to induce coma artificially in the client who has not responded to
conventional treatment.
b. Paralytic agents such as [vercuronium bromide (Norcuron)]: may be administered to paralyzed the client
c. Reduces metabolic demand that may protect the brain from further injury.
d. Constant monitoring of the client’s ICP, arterial blood gas, serum barbiturates level, & ECG is necessary.
e. EEG monitoring as necessary
f. Provide appropriate nursing care for the client on a ventilator
10. Observe for hyperthermia secondary to hypothalamus damage.
Treatment
Morphine Sulfate
Aminophelline
Digoxin
Diuretics
Oxygen
Gases, blood monitor
14
15
FRUITS VEGETABLE
S
Apple Asparagus
Banana Brocolli
Cantalop Carrots
e Spinach
Oranges
2. Hypocalcemia/Tetany
- decrease calcium level
- normal value is 8.5 – 11 mg/100 ml
Signs and Symptoms
- tingling sensation
- paresthesia
- numbness
- (+) Trousseus sign/Carpopedal spasm
- (+) Chvostek’s sign
Complications
- arrythmia
- seizures
Nursing Management
- Calcium Glutamate per IV slowly as ordered
* Calcium Glutamate toxicity – results to seizure
Magnesium Sulfate
3. Hyponatremia
- decrease sodium level
- normal value is 135 – 145 meq/L
Signs and Symptoms
- hypotension
- dehydration signs (initial sign in adult is thirst, in infant tachycardia)
- agitation
- dry mucous membrane
- poor skin turgor
- weakness and fatigue
Nursing Management
- force fluids
- administer isotonic fluid solution as ordered
4. Hyperglycemia
- normal FBS is 80 – 100 mg/dl
Signs and Symptoms
- polyuria
- polydypsia
- polyphagia
Nursing Management
- monitor FBS
5. Hyperuricemia
- increase uric acid (purine metabolism)
- foods high in uric acid (sardines, organ meats and anchovies)
Nursing Management
- force fluids
- administer medications as ordered
a. Allopurinol (Zylopril)
- drug of choice for gout.
- mechanism of action: inhibits synthesis of uric acid.
b. Colchesine
- acute gout
- mechanism of action: promotes excretion of uric acid.
* Kidney stones
Signs and Symptoms
- renal cholic
15
16
Cause Unknown: predominantly idiopathic, but sometimes disorder is postencephalitic, toxic, arteriosclerotic, traumatic, or drug induced
(reserpine, methyldopa (aldomet) haloperidol (haldol), phenothiazines).
Pathophysiology
Disorder causes degeneration of dopamine producing neurons in the substantia nigra in the midbrain
Predisposing Factors
1. Poisoning (lead and carbon monoxide)
2. Arteriosclerosis
3. Hypoxia
4. Encephalitis
5. Increase dosage of the following drugs:
a. Reserpine (Serpasil)
b. Methyldopa (Aldomet) Antihypertensive
c. Haloperidol (Haldol) _______
d. Phenothiazine ___________________ Antipsychotic
Multiple loss
causes
suicide
S/sx
1. Tremor: mainly of the upper limbs “pill rolling tremors” of extremities especially the hands; resting tremor: most common initial
symptoms
2. Bradykinesia: slowness of movement
3. Rigidity: cogwheel type
4. Stooped posture: shuffling, propulsive gait
5. Fatigue
6. Mask like facial expression with decrease blinking of the eyes.
7. Difficulty rising from sitting position.
8. Quite, monotone speech
9. Emotional lability: state of depression
10. Increase salivation: drooling type
11. Cramped, small handwriting
12. Autonomic Symptoms
a. excessive sweating
b. increase lacrimation
c. seborrhea
d. constipation
e. decrease sexual capacity
Nursing Intervention
1. Administer medications as ordered
Anti-Parkinson Drug
a. Levodopa (L-dopa) short acting
MOA: Increase level of dopamine in the brain; relieves tremors; rigidity; bradykinesia
16
17
SE: GIT irritation (should be taken with meal); anorexia; N/V; postural hypotension; mental changes: confusion, agitation,
hallucination; cardiac arrhythmias; dyskinesias.
CI: narrow-angled glaucoma; client taking MAOI inhibitor; reserpine; guanethidine; methyldopa; antipsychotic; acute psychoses
Avoid multi-vitamins preparation containing vitamin B6 & food rich in vitamin B6 (Pyridoxine): reverses the therapeutic effects of
Levodopa
Urine and stool may be darkened
Be aware of any worsening of symptoms with prolonged high-dose therapy: “on-off” syndrome.
b. Carbidopa-levodopa (Sinemet)
Prevents breakdown of dopamine in the periphery & causes fewer side effects.
c. Amantadine Hydrochloride (Symmetrel)
Used in mild cases or in combination with L-dopa to reduce rigidity, tremors, & bradykinesia
Anti-Cholinergic Drug
a. Benztropine Mesylate (Cogentin)
b. Procyclidine (Kemadrine)
c. Trihexyphenidyl (Artane)
MOA: inhinit the action of acetylcholine; used in mild cases or in combination with L-dopa; relived tremors & rigidity
SE: dry mouth; blurred vision; constipation; urinary retention; confusion; hallucination; tachycardia
Anti-Histamines Drug
a. Diphenhydramine (benadryl)
MOA: decrease tremors & anxiety
SE: Adult: drowsiness Children: CNS excitement (hyperactivity) because blood brain barrier is not yet fully developed.
b. Bromocriptine (Parlodel)
MOA: stimulate release of dopamine in the substantia nigra
Often employed when L-dopa loses effectiveness
MAOI Inhibitor
a. Eldepryl (Selegilene)
MOA: inhibit dopamine breakdown & slow progression of disease
Anti-Depressant Drug
a. Tricyclic
MOA: given to treat depression commonly seen in Parkinson’s disease
2. Provide safe environment
Side rails on bed
Rails & handlebars in the toilet, bathtub, & hallways
No scattered rugs
Hard-back or spring-loaded chair to make getting up easier
3. Provide measures to increase mobility
Physical Therapy: active & passive ROM exercise; stretching exercise; warm baths
Assistive devices
If client “freezes” suggest thinking of something to walk over
4. Encourage independence in self-care activities:
alter clothing for ease in dressing
use assistive device
do not rush the client
5. Improve communication abilities:
Instruct the client to practice reading a loud
Listen to own voice & enunciate each syllable clearly
6. Refer for speech therapy when indicated.
7. Maintain adequate nutrition.
Cut food into bite-size pieces
Provide small frequent feeding
Allow sufficient time for meals, use warming tray
8. Avoid constipation & maintain adequate bowel elimination
9. Provide significant support to client/ significant others:
Depression is common due to changes in body image & self-concept
10. Provide client teaching & discharge planning concerning:
a. Nature of the disease
b. Use prescribed medications & side effects
c. Importance of daily exercise as tolerated: balanced activity & rest
walking
swimming
gardening
d. Activities/ methods to limit postural deformities:
Firm mattress with small pillow
Keep head & neck as erected as possible
Use broad-based gait
Raise feet while walking
e. Promotion of active participation in self-care activities.
* Increase Vitamin B when taking INH (Isoniazid), Isonicotinic Acid Hydrazide
* Dopamine Agonist relieves tremor rigidity
17
18
LEVEL
Digoxin/Lanoxin .5 – 1.5 meq/L 2 CHF Cardiac
(increase force of Glycoside
cardiac output)
Lithium/Lithane .6 – 1.2 meq/L 2 Bipolar Anti-Manic
(decrease level of Agents
Ach/NE/Serotonin)
Aminophelline 10 – 19 mg/100 ml 20 COPD Bronchodilators
(dilates bronchial tree)
Dilantin/Phenytoin 10 – 19 mg/100 ml 20 Seizures Anti-Convulsant
Acetaminophen/Tylen 10 – 30 mg/100 ml 200 Osteo Non-narcotic
ol Arthritis Analgesic
1. Digitalis Toxicity
Signs and Symptoms
- nausea and vomiting
- diarrhea
- confusion
- photophobia
- changes in color perception (yellowish spots)
Antidote: Digibind
2. Lithium Toxicity
Signs and Symptoms
- anorexia
- nausea and vomiting
- diarrhea
- dehydration causing fine tremors
- hypothyroidism
Nursing Management
- force fluids
- increase sodium intake to 4 – 10 g% daily
3. Aminophelline Toxicity
Signs and Symptoms
- tachycardia
- palpitations
- CNS excitement (tremors, irritability, agitation and restlessness)
Nursing Management
- only mixed with plain NSS or 0.9 NaCl to prevent development of crystals of precipitate.
- administered sandwich method
- avoid taking alcohol because it can lead to severe CNS depression
- avoid caffeine
4. Dilantin Toxicity
Signs and Symptoms
- gingival hyperplasia (swollen gums)
- hairy tongue
- ataxia
- nystagmus
Nursing Management
- provide oral care
- massage gums
5. Acetaminophen Toxicity
Signs and Symptoms
- hepatotoxicity (monitor for liver enzymes)
- SGPT/ALT (Serum Glutamic Pyruvate Transaminace)
- SGOT/AST (Serum Glutamic Oxalo-Acetil Transaminace)
- nephrotoxicity monitor BUN (10 – 20) and Creatinine (.8 – 1)
- hypoglycemia
Tremors, tachycardia
Irritability
Restlessness
Extreme fatigue
Diaphoresis, depression
Antidote: Acetylceisteine (mucomyst) prepare suction apparatus as bedside.
Thought to be autoimmune disorder whereby antibodies destroy acetylcholine receptor sites on the postsynaptic membrane of the
neuromuscular junction.
Voluntary muscles are affected, especially those muscles innervated by the cranial nerve.
Pathophysiology
Autoimmune = Release of Cholinesterase Enzymes = Cholinesterase destroy Acetylcholine (ACH) = Decrease of Acetylcholine (ACH)
18
19
S/sx
1. Initial sign is ptosis a clinical parameter to determine ptosis is palpebral fissure: cracked or cleft in the lining or membrane of the eyelids
2. Diplopia
3. Dysphagia
4. Mask like facial expression
5. Hoarseness of voice, weakness of voice
6. Respiratory muscle weakness that may lead to respiratory arrest
7. Extreme muscle weakness especially during exertion and morning; increase activity & reduced with rest.
Dx
1. Tensilon Test (Edrophonium Hydrochloride): IV injection of tensilon provides temporary relief of S/sx for about 5-10 minutes and a
maximum of 15 minutes.
If there is no effect there is no damage to occipital lobe and midbrain and is negative for M.G.
2. Electromyography (EMG): amplitudes of evoked potentials decrease rapidly.
3. Presence of anti-acetlycholine receptors antibodies in the serum.
Medical Management
1. Drug Therapy
a. Anti-cholinesterase Drugs: [Ambenonium (Mytelase), Neostigmine (Prostigmin), Pyridostigmine (Mestinon)]
MOA: block the action of cholinesterase & increase the level of acetylcholine at the neuromuscular junction.
SE: excessive salivation & sweating, abdominal cramps, N/V, diarrhea, fasciculations (muscle twitching).
b. Corticosteroids: Prednisone
MOA: suppress autoimmune response
Used if other drugs are not effective
2. Surgery (Thymectomy)
a. Surgical removal of thymus gland: thought to be involve in the production of acetylcholine receptor antibodies.
b. May cause remission in some clients especially if performed early in the disease.
3. Plasma Exchange (Plasmapheresis)
a. Removes circulating acetylcholine receptor antibodies.
b. Use in clients who do not respond to other types of therapy.
Nursing Interventions
1. Administer anti-cholinesterase drugs as ordered:
a. Give medication exactly on time.
b. Give with milk & crackers to decrease GI upset
c. Monitor effectiveness of drugs: assess muscle strength & vital capacity before & after medication.
d. Avoid use of the ff drugs:
Morphine SO4 & Strong Sedatives: respiratory depressant effects
Quinine, Curare, Procainamide, Neomycin, Streptomycine, Kanamycine & other aminoglycosides: skeletal muscle blocking
effect
e. Observe for side effects
2. Promote optimal nutrition:
a. Mealtime should coincide with the peak effect of the drugs: give medication 30 minutes before meals.
b. Check gag reflex & swallowing ability before feeding.
c. Provide mechanical soft diet.
d. If the client has difficulty in chewing & swallowing, do not leave alone at mealtime; keep emergency airway & suctioning equipment
nearby.
3. Monitor respiratory status frequently: Rate, Depth, Vital Capacity; ability to deep breathe & cough
4. Assess muscle strength frequently; plan activity to take advantage of energy peaks & provide frequent rest periods.
5. Observe for signs of myasthenic or cholinergic crisis.
MYASTHENIC CRISIS CHOLINERGIC CRISIS
Abrupt onset of severe, generalized Symptoms similar to myasthenic crisis &
muscle weakness with inability to in addition the side effect of anti-
swallow, speak, or maintain respirations. cholinesterase drugs (excessive
Symptoms will improve temporarily with salivation & sweating, abdominal carmp,
tensilon test. N/V, diarrhea, fasciculation)
Symptoms worsen with tensilon test:
keep Atropine Sulfate & emergency
Causes: equipment on hand.
under medication Cause:
physical or emotional stress over medication with the cholinergic
infection drugs (anti-cholinesterase)
Signs and Symptoms
the client is unable to see, swallow, Signs and Symptoms
speak, breathe PNS
Treatment
administer cholinergic agents as ordered Treatment
administer anti-cholinergic agents
(Atrophine Sulfate)
19
20
Cholinergic Crisis: discontinue anti-cholinesterase drugs as ordered until the client recovers.
d. Established method of communication
e. Provide support & reassurance.
6. Provide nursing care for the client with thymectomy.
7. Provide client teaching & discharge planning concerning:
a. Nature of the disease
b. Use of prescribe medications their side effects & sign of toxicity
c. Importance of checking with physician before taking any new medication including OTC drugs
d. Importance of planning activities to take advantage of energy peaks & of scheduling frequent rest period
e. Need o avoid fatigue, stress, people with upper respiratory infection
f. Use of eye patch for diplopia (alternate eyes)
g. Need to wear medic-alert bracelet
h. Myasthenia Gravis foundation & other community agencies
Guillain-Barre Syndrome
a disorder of the CNS characterized by bilateral, symmetrical, peripheral polyneuritis characterized by ascending muscle paralysis.
Progression of disease is highly individual; 90% of clients stop progression in 4 weeks; recovery is usually from 3-6 months; may have
residual deficits.
Causes:
1. Unknown / idiopathic
2. May be autoimmune process
Predisposing Factors
1. Immunization
2. Antecedent viral infections such as LRT infections
S/sx
1. Mild Sensory Changes: in some clients severe misinterpretation of sensory stimuli resulting to extreme discomfort
2. Clumsiness (initial sign)
3. Progressive motor weakness in more than one limb (classically is ascending & symmetrical)
4. Dysphagia: cranial nerve involvement
5. Ascending muscle weakness leading to paralysis
6. Ventilatory insufficiency if paralysis ascends to respiratory muscles
7. Absence or decreased deep tendon reflex
8. Alternate hypotension to hypertension
9. Arrythmia (most feared complication)
10. Autonomic disfunction: symptoms that includes
a. increase salivation
b. increase sweating
c. constipation
Dx
1. CSF analysis: reveals increased in IgG and protein
2. EMG: slowed nerve conduction
Medical Management
1. Mechanical Ventilation: if respiratory problems present
2. Plasmapheresis: to reduce circulating antibodies
3. Continuous ECG monitoring to detect alteration in heart rate & rhythm
4. Propranolol: to prevent tachycardia
5. Atropine SO4: may be given to prevent episodes of bradycardia during endotracheal suctioning & physical therapy
Nursing Intervention
1. Maintain patent airway & adequate ventilation:
a. Monitor rate & depth of respiration; serial vital capacity
b. Observe for ventilatory insufficiency
c. Maintain mechanical ventilation as needed
d. Keep airway free of secretions & prevent pneumonia
2. Check individual muscle groups every 2 hrs in acute phase to check progression of muscle weakness
3. Assess cranial nerve function:
a. Check gag reflex
b. Swallowing ability
c. Ability to handle secretion
d. Voice
4. Monitor strictly the following:
a. Vital signs
b. Input and output
c. Neuro check
d. ECG: due to arrhythmia
e. Observe signs of autonomic dysfunction: acute period of hypertension fluctuating with hypotension
f. Tachycardia
g. Arrhythmias
20
21
Meningitis
Inflammation of the meninges of the brain & spinal cord.
Cause by bacteria, viruses, & other M.O.
Mode of transmission
1. Airborne transmission (droplet nuclei)
2. Via blood, CSF, lymph
3. By direct extension from adjacent cranial structures (nasal, sinuses, mastoid bone, ear, skull fracture)
4. By oral or nasopharyngeal route
Dx
1. Lumbar Puncture:
Measurement & analysis of CSF shows increased pressure, elevated WBC & CHON, decrease glucose & culture positive for specific
M.O.
A hollow spinal needle is inserted in the subarachnoid space between the L3-L4 or L4-L5.
21
22
CBC reveals
1. Increase WBC
Nursing Management
1. Administer large doses of antibiotic IV as ordered:
a. Broad spectrum antibiotics (Penicillin, Tetracycline)
b. Mild analgesics: for headaches
c. Antipyretics: for fever
2. Enforced strict respiratory isolation 24 hours after initiation of anti biotic therapy (for some type of meningitis)
3. Provide nursing care for increase ICP, seizure & hyperthermia if they occur
4. Provide nursing care for delirious or unconscious client as needed
5. Enforce complete bed rest
6. Keep room quiet & dark: if the client has headache & photophobia
7. Monitor strictly V/S, I & O & neuro check
8. Maintain fluid & electrolyte balance
9. Prevent complication of immobility
10. Provide client teaching & discharge planning concerning:
a. Importance of good diet: high CHON, high calories with small frequent feedings.
b. Rehabilitation program for residual deficit
mental retardation
delayed psychomotor development
c. Prevent complications
most feared is hydrocephalus
hearing loss/nerve deafness is second complication
consult audiologist
If there is bone fracture there is hemorrhage and there would be escape of the fat cells in the circulation.
Risk Factors
Disease:
1. Hypertension
2. Diabetes Mellitus
3. Atherosclerosis / Arteriosclerosis
4. Myocardial Infarction
5. Mitral valve replacement
6. Valvular Disease / replacement
7. Chronic atrial Fibrillation
22
23
Lifestyle:
1. Smoking
2. Sedentary lifestyle
3. Obesity (increase 20% ideal body weight)
4. Hyperlipidemia more on genetics/genes that binds to cholesterol
5. Type A personality
a. Deadline driven
b. Can do multiple tasks
c. Usually fells guilty when not doing anything
6. Related to diet: increase intake of saturated fats like whole milk
7. Related stress physical and emotional
8. Prolong use of oral contraceptives: promotes lypolysis (breakdown of lipids) leading to atherosclerosis that will lead to hypertension &
eventually CVA.
Pathophysiology
1. Interruption of cerebral blood flow for 5 min or more causes death of neurons in affected area with irreversible loss of function.
2. Modifying Factors:
a. Cerebral Edema:
Develops around affected area causing further impairment
b. Vasospasm:
Constriction of cerebral blood vessel may occur, causing further decrease in blood flow
c. Collateral Circulation:
May help to maintain cerebral blood flow when there is compromise of main blood supply
Stages of Development
1. Transient Ischemic Attack (TIA)
a. Initial / warning signs of impending CVA / stroke
b. Brief period of neurologic deficit:
Visual loss / Visual disturbance
Hemiparesis
Slurred Speech / Speech disturbance
Vertigo
Aphasia
S/sx
1. Headache
2. Generalized Signs:
Vomiting
Seizure
Confusion
Disorientation
Decrease LOC
Nuchal Rigidity
Fever
Hypertension
Slow Bounding Pulse
Cheyne-Strokes Respiration
Dx
1. CT & Brain Scan: reveals brain lesions
2. EEG: abnormal changes
3. Cerebral Arteriography: invasive procedure due to injection of dye (iodine based); Uses dye for visualization
May show occlusion or malformation of blood vessels
Reveals the site and extent of malocclusion
23
24
Corticosteroids (Dexamethazone)
b. Anti-convulsants: to prevent or treat seizures
c. Thrombolytic / Fibrinolytic Agents: given to dissolve clot (hemorrhage must be ruled out)
Tissue Plasminogen Activating Factor (tPA, Alteplase): SE: allergic Reaction
Check for Partial Thromboplastin Time (PTT): if prolonged there is a risk for bleeding
Give simultaneously with Heparin cause Warfarin (Coumadin) will take effect after 3 days
Check for Prothrombin Time (PT): if prolonged there is a risk for bleeding
PASA (Aspirin)
Contraindicated for dengue, ulcer and unknown cause of headache because it may potentiate bleeding
e. Antihypertensive: if indicated for elevated BP
f. Mild Analgesics: for pain
12. Provide client health teachings and discharge planning concerning
a. Avoid modifiable risk factors (diet, exercise, smoking)
b. Prevent complication (subarachnoid hemorrhage is the most feared complication)
c. Dietary modification (decrease salt, saturated fats and caffeine)
d. Importance of follow up care
24
25
CONVULSIVE DISORDER/CONVULSION
disorder of CNS characterized by paroxysmal seizure with or without loss of consciousness abnormal motor activity alternation in
sensation and perception and changes in behavior.
Seizure: first convulsive attack
Predisposing Factors
1. Head injury due to birth trauma
2. Genetics
3. Presence of brain tumor
4. Toxicity from the ff:
a. Lead
b. Carbon monoxide
5. Nutritional and Metabolic deficiencies
6. Physical and emotional stress
7. Sudden withdrawal to anti-convulsant drug: is predisposing factor for status epilepticus: DOC: Diazepam (Valium) & Glucose
S/sx
Dependent on stages of development or types of seizure
1. Generalized Seizure
Initial onset in both hemisphere, usually involves loss of consciousness & bilateral motor activity.
a. Major Motor Seizure (Grand mal Seizure): tonic-clonic seizure
Signs or aura with auditory, olfactory, visual, tactile, sensory experience
Epileptic cry: is characterized by fall and loss of consciousness for 3-5 minutes
Tonic Phase:
Limbs contract or stiffens
Pupils dilated & eye roll up to one side
25
26
Clonic Phase:
repetitive movement
increase mucus production
slowly tapers
3. Status Epilepticus
Usually refers to generalized grand mal seizure
Seizure is prolong (or there are repeated seizures without regaining consciousness) & unresponsive to treatment
Can result in decrease in O2 supply & possible cardiac arrest
A continuous uninterrupted seizure activity
If left untreated can lead to hyperpyrexia and lead to coma and eventually death.
C. Diagnostic Procedures
1. CT Scan – reveals brain lesions
2. EEG – reveals hyper activity of electrical brain waves
D. Nursing Management
1. Maintain patent airway and promote safety before seizure activity
a. clear the site of blunt or sharp objects
b. loosen clothing of client
c. maintain side rails
d. avoid use of restrains
e. turn clients head to side to prevent aspiration
f. place mouth piece of tongue guard to prevent biting or tongue
2. Avoid precipitating stimulus such as bright/glaring lights and noise
3. Administer medications as ordered
a. Anti convulsants (Dilantin, Phenytoin)
b. Diazepam, Valium
c. Carbamazepine (Tegnetol) – trigeminal neuralgia
d. Phenobarbital, Luminal
4. Institute seizure and safety precaution post seizure attack
a. administer O2 inhalation
b. provide suction apparatus
5. Document and monitor the following
a. onset and duration
b. types of seizures
c. duration of post ictal sleep may lead to status epilepticus
d. assist in surgical procedure cortical resection
Bulbar Conjunctiva: white with small blood vessels, covers anterior sclera
c. Lacrimal Apparatus (lacrimal gland & its ducts & passage): produces tears to lubricate the eye & moisten the cornea; tears drain into the
nasolacrimal duct, which empties into nasal cavity
26
27
Rods: more sensitive to light than cones, aid in peripheral vision; (night twilight vision)
b. Optic Disk: area in retina for entrance of optic nerve, has no photoreceptors
2 muscles of iris:
Circular smooth muscle fiber: Constricts the pupil
Radial smooth muscle fiber: Dilates the pupil
Physiology of vision
4 Physiological processes for vision to occur:
1. Refraction of light rays: bending of light rays
2. Accommodation of lens
3. Constriction & dilation of pupils
4. Convergence of eyes
Error of Refraction
1. Myopia: nearsightedness: Treatment: biconcave lens
2. Hyperopia: farsightedness: Treatment: biconvex lens
3. Astigmatisim: distorted vision: Treatment: cylindrical
4. Presbyopia: “old sight” inelasticity of lens due to aging: Treatment: bifocal lens or double vista
27
28
Predisposing Factors
1. Common among 40 years old and above
2. Hereditary
3. Hypertension
4. Obesity
5. History of previous eye surgery, trauma, inflammation
Types of Glaucoma:
1. Chronic (open-angle) Glaucoma:
Most common form
Due to obstruction of the outflow of aqueous humor, in trabecular meshwork or canal of schlemm
2. Acute (close-angle) Glaucoma:
Due to forward displacement of the iris against the cornea, obstructing the outflow of the aqueous humor
Occurs suddenly & is an emergency situation
If untreated it will result to blindness
3. Chronic (close-angle) Glaucoma:
similar to acute (close-angle) glaucoma, with the potential for an acute attack
S/sx
1. Chronic (open-angle) Glaucoma: symptoms develops slowly
Impaired peripheral vision (PS: tunnel vision)
Halos around light
Mild discomfort in the eye
Dx
1. Visual Acuity: reduced
2. Tonometry: reading of 24-32 mmHg suggest glaucoma; may be 50 mmHg of more in acute (close-angle) glaucoma
3. Ophthalmoscopic exam: reveals narrowing of small vessels of optic disk, cupping of optic disk
4. Perimetry: reveals defects in visual field
5. Gonioscopy: examine angle of anterior chamber
Medical Management
1. Chronic (open-angle) Glaucoma
a. Drug Therapy: one or a combination of the following
Miotics eye drops (Pilocarpine): to increase outflow of aqueous humor
Epinephrine eye drops: to decrease aqueous humor production & increase outflow
Timolol Maleate (Timoptic): topical beta-adrenergic blocker: to decrease intraocular pressure (IOP)
b. Surgery (if no improvement with drug)
Filtering procedure (Trabeculectomy / Trephining): to create artificial openings for the outflow of aqueous humor
Laser Trabeculoplasty: non-invasive procedure performed with argon laser that can be done on an out-client basis; procedure
similar result as trabeculectomy
2. Acute (close-angle) Glaucoma
a. Drug Therapy: before surgery
Miotics eye drops (Pilocarpine): to cause pupil to contract & draw iris away from cornea
Osmotic Agent (Glycerin oral, Mannitol IV): to decrease intraocular pressure (IOP)
Argon Laser Beam Surgery: non-invasive procedure using laser produces same effect as iridectomy; done in out-client basis
Iridectomy: usually performed on second eye later since a large number of client have an acute acute attack in the other eye
3. Chronic (close-angle) Glaucoma
a. Drug Therapy:
miotics (pilocarpine)
b. Surgery:
bilateral peripheral iridectomy: to prevent acute attacks
Nursing Intervention
28
29
Cataract
Decrease opacity of ocular lens
Incidence increases with age
Predisposing Factor
1. Aging 65 years and above
2. May caused by changes associated with aging (“senile” cataract)
3. Related to congenital
4. May develop secondary to trauma, radiation, infection, certain drugs (corticosteroids)
5. Diabetes Mellitus
6. Prolonged exposure to UV rays
S/sx
1. Loss of central vision
2. Blurring or hazy vision
3. Progressive decrease of vision
4. Glare in bright lights
5. Milky white appearance at center of pupils
6. Decrease perception to colors
Diagnostic Procedure
1. Ophthalmoscopic exam: confirms presence of cataract
Nursing Intervention
1. Prepare client for cataract surgery:
a. Performed when client can no longer remain independent because of reduced vision
b. Surgery performed on one eye at a time; usually in a same day surgery unit
c. Local anesthesia & intravenous sedation usually used
d. Types of cataract surgery:
Extracapsular Extraction: lens capsule is excised & the lens is expressed; posterior capsule is left in place (may be used to
support new artificial lens implant); partial removal of lens
Phacoemulsification: type of extracapsular extraction; a hollow needle capable of ultrasonic vibration is inserted into lens,
vibrations emulsify the lens, which is aspirated
Intracapsular Extraction: lens is totally removed within its capsules, may be delivered from eye by cryoextraction (lens is frozen
with metal probe & removed); total removal of lens & surrounding capsules
e. Peripheral Iridectomy: may be performed at the time of surgery; small hole cut in iris to prevent development of secondary glaucoma
f. Intraocular Lens Implant: often performed at the time of surgery
2. Nursing Intervention Pre-op
a. Assess vision in the unaffected eye since the affected eye will be patched post-op
b. Provide pre-op teaching regarding measures to prevent intraocular pressure (IOP) post-op
c. Administer medication as ordered:
Topical Mydriatics (Mydriacyl) & Cyclopegics (Cyclogyl): to dilate the pupil
Acetazolamide (Diamox) & osmotic agent (Oral Glycerin or Mannitol IV): to decrease intraocular pressure to provide soft eyeball
for surgery
3. Nursing Intervention Post-op
a. Reorient the client to surroundings
b. Provide safety measures:
Elevate side rails
Provide call bells
Assist with ambulation when fully recovered from anesthesia
c. Prevent intraocular pressure & stress on the suture line:
Elevate head of the bed 30-40 degree
Have the client lie on back or unaffected side
Avoid having the client cough, sneeze, bend over, or move head too rapidly
29
30
Retinal Detachment
Separation of epithelial surface of retina
Detachment or the sensory retina from the pigment epithelium of the retina
Predisposing Factors
1. Trauma
2. Aging process
3. Severe diabetic retinopathy
4. Post-cataract extraction
5. Severe myopia (near sightedness)
Pathophysiology
Tear in the retina allows vitreous humor to seep behind the sensory retina & separate it from the pigment epithelium
S/sx
1. Curtain veil like vision coming across field of vision
2. Flashes of light
3. Visual field loss
4. Floaters
5. Gradual decrease of central vision
Dx
1. Ophthalmoscopic exam: confirms diagnosis
Medical Management
1. Bed rest with eye patched & detached areas dependent to prevent further detachment
2. Surgery: necessary to repair detachment
a. Photocoagulation: light beam (argon laser) through dilated pupil creates an inflammatory reaction & scarring to heal the area
b. Cryosurgery or diathermy: application of extreme cold or heat to external globe; inflammatory reaction causes scarring & healing of
area
c. Scleral buckling: shortening of sclera to force pigment epithelium close to retina
30
31
Middle Ear
1. Ossicles
a. 3 small bones: malleus (Hammer) attached to tympanic membrane, incus (anvil), stapes (stirrup)
b. Ossicles are set in motion by sound waves from tympanic membrane
c. Sound waves are conducted by vibration to the footplate of the stapes in the oval widow (an opening between the middle ear & the
inner ear)
2. Eustachian Tube: connects nasopharynx & middle ear; bring air into middle ear, thus equalizing pressure on both sides of eardrum
Inner Ear
1. Cochlea
Controls hearing
Contains Organ of Corti (the true organ of hearing): the receptor end-organ for hearing
Transmit sound waves from the oval window & initiates nerve impulses carried by cranial nerve VIII (acoustic branch) to the brain
(temporal lobe of cerebrum)
2. Vestibular Apparatus
Organ of balance
Composed of three semicircular canals & the utricle
3. Endolymph & Perilymph
For static equilibrium
4. Mastoid air cells
Air filled spaces in temporal bone in skull
Predisposing Factor
1. Found more often in women
Cause
1. Unknown / idiopathic
2. There is familial tendency
3. Ear trauma & surgery
S/sx
1. Progressive hearing loss
2. Tinnitus
Dx
1. Audiometry: reveals conductive hearing loss
2. Weber’s & Rinne’s Test: show bone conduction is greater than air conduction
Medical Management
1. Stapedectomy: procedure of choice
Removal of diseased portion of stapes & replacement with prosthesis to conduct vibrations from the middle ear to inner ear
Usually performed under local anesthesia
Used to treat otoscrlerosis
31
32
Pain
Headaches
Vertigo
Unusual sensations in the ear
8. Provide client teaching & discharge planning concerning:
a. Warning against blowing nose or coughing; sneeze with mouth open
b. Need to keep ear dry in the shower; no shampooing until allowed
c. No flying for 6 mos. Especially if upper respiratory tract infection is present
d. Placement of cotton balls in auditory meatus after packing is removed; change twice daily
Meniere’s Disease
Disease of the inner ear resulting from dilatation of the endolymphatic system & increase volume of endolymph
Characterized by recurrent & usually progressive triad of symptoms: vertigo, tinnitus, hearing loss
Predisposing Factor
1. Incidence highest between ages 30 & 60
Cause
2. Unknown / idiopathic
3. Theories include the ff:
a. Allergy
b. Toxicity
c. Localized ischemia
d. Hemorrhage
e. Viral infection
f. Edema
S/sx
1. Sudden attacks of vertigo lasting hours or days; attacks occurs several times a year
2. N/V
3. Tinnitus
4. Progressive hearing loss
5. Nystagmus
Dx
1. Audiometry: reveals sensorineural hearing loss
2. Vestibular Test: reveals decrease function
Medical Management
1. Acute:
Atropine (decreases autonomic nervous system activity)
Diazepam (Valium)
Meclizine (antivert)
b. Diet:
Low sodium diet
Restricted fluid intake
Restrict caffeine & nicotine
3. Surgery:
a. Surgical destruction of labyrinth causing loss of vestibular & cochlear function (if disease is unilateral)
b. Intracranial division of vestibular portion of cranial nerve VIII
c. Endolymphatic sac decompression or shunt to equalize pressure in endolymphatic space
Nursing Intervention
1. Maintain bed rest in a quiet, darkened room in position of choice; elevate side rails as needed
2. Only move the client for essential care (bath may not be essential)
3. Provide emesis basin for vomiting
4. Monitor IV Therapy; maintain accurate I&O
5. Assist in ambulation when the attack is over
6. Administer medication as ordered
7. Prepare client for surgery as indicated (pot-op care includes using above measures)
8. Provide client care & discharge planning concerning:
a. Use of medication & side effects
b. Low sodium diet & decrease fluid intake
c. Importance of eliminating smoking
Endocrine System
32
33
Is composed of an interrelated complex of glands (Pituitary G, Adrenal G, Thyroid G, Parathyroid G, Islets of langerhans of the pancreas,
Ovaries & Testes) that secretes a variety of hormones directly into the bloodstream.
Its major function, together with the nervous system: is to regulate body function
Hormones Regulation
1. Hormones: chemical substance that acts s messenger to specific cells & organs (target organs), stimulating & inhibiting various
processes
Two Major Categories
a. Local: hormones with specific effect in the area of secretion (ex. Secretin, cholecystokinin, panceozymin [CCK-PZ])
b. General: hormones transported in the blood to distant sites where they exert their effects (ex. Cortisol)
2. Negative Feedback Mechanisms: major means of regulating hormone levels
a. Decreased concentration of a circulating hormones triggers production of a stimulating hormones from pituitary gland; this hormones
in turn stimulates its target organ to produce hormones
b. Increased concentration of a hormones inhibits production of the stimulating hormone, resulting in decreased secretion of the target
organ hormone
3. Some hormones are controlled by changing blood levels of specific substances (ex. Calcium, glucose)
4. Certain hormones (ex. Cortisol or female reproductive hormones) follow rhythmic patterns of secretion
5. Autonomic & CNS control (pituitary-hypothalamic axis): hypothalamus controls release of the hormones of the anterior pituitary gland
through releasing & inhibiting factors that stimulate or inhibits hormone secretions
Hormone Function
Endocrine G Hormone Functions
Pituitary G
Anterior lobe : TSH : stimulate thyroid G to release thyroid hormones
: ACTH : stimulate adrenal cortex to produce & release adrenocoticoids
: FSH, LH : stimulate growth, maturation, & function of primary
& secondary sex organ
: GH, Somatotropin : stimulate growth of body tissues & bones
: Prolactin or LTH : stimulate development of mammary gland &
Lactation
Posterior lobe : ADH : regulates H2O metabolism; release during stress
Or in response to an increase in plasma osmolality
To stimulate reabsorption of H2O & decrease urine
Output
: Oxytocin : stimulate uterine contractions during delivery & the
Release of milk in lactation
Intermediate lobe : MSH : affects skin pigmentation
Adrenal G
Adrenal Cortex : Mineralocorticoid : regulate fluid & electrolyte balance; stimulate
(ex. Aldosterone) reabsoption of sodium, chloride, & H2O; stimulate
potassium excretion
: Glucocorticoids : increase blood glucose level by increasing rate of
(ex. Cortisol, glyconeogenesis; increase CHON catabolism; increase
corticosterone) mobilization of fatty acid; promote sodium & H2O
retention; anti-inflammatory effect; aid body in coping
with stress
: Sex Hormones : influence development of secondary sex
(androgens, estrogens characeristics
progesterones)
Adrenal Medulla : Epinephrine, : function in acute stress; increase HR, BP; dilates
Norepinephrine bronchioles; convert glycogen to glucose when
Needed by the muscles for energy
Pancreas (islets of
Langerhans)
Beta Cells : Insulin : allows glucose to diffuse across cell membrane;
Converts glucose to glycogen
Alpha Cells : Glucagon : increase blood glucose by causing glyconeogenisis
& glycogenolysis in the liver; secreted in response to
low blood sugar
33
34
Prolactin: promotes development of mammary gland; with help of oxytocin it initiates milk let down reflex
c. Regulated by hypothalamic releasing & inhibiting factors & by negative feedback system
2. Posterior Lobe PG (Neurohypophysis)
Does not produce hormones
Store & release anti-diuretic hormones (ADH) & oxytocin produced by hypothalamus
Adrenal Glands
Two small glands, one above each kidney; Located at top of each kidney
Zona Reticularis: secretes traces of glucocorticoids & androgenic hormones: promotes secondary sex characteristics: Sex
Zona Glumerulosa: secretes mineralocorticoids (aldosterone): promotes sodium and water reabsorption and excretion of
potassium: Salt
2. Adrenal Medulla (inner portion): produces epinephrine, norepinephrine (secretes catecholamines a power hormone): vasoconstrictor
2 Types of Catecholamines:
Epinephrine (vasoconstrictor)
Norepinephrine (vasoconstrictor)
o Pheochromocytoma (adrenal medulla): Increase secretion of norepinephrine: Leading to hypertension which is resistant to
pharmacological agents leading to CVA: Use beta-blockers
Thyroid Gland
Located in anterior portion of the neck
Consist of 2 lobes connected by a narrow isthmus
T3 and T4 are metabolic hormone: increase brain activity; promotes cerebration (thinking); increase V/S
Parathyroid Gland
4 small glands located in pairs behind the thyroid gland
Pancreas
Located behind the stomach
Consist of Acinar Cells (exocrine gland): which secretes pancreatic juices: that aids in digestion
34
35
Delta Cells: produce somatostatin: (function: antagonizes the effects of growth hormones)
Gonads
Ovaries: located in pelvic cavity; produce estrogen & progesterone
Pineal Gland
Secretes melatonin
Inhibits LH secretion
It controls & regulates circadian rhythm (body clock)
Predisposing Factor
1. Related to pituitary surgery
2. Trauma
3. Inflammation
4. Presence of tumor
S/sx
1. Severe polyuria with low specific gravity
2. Polydipsia (excessive thirst)
3. Fatigue
4. Muscle weakness
5. Irritability
6. Weight loss
7. Hypotension
8. Signs of dehydration
a. Adult: thirst; Children: tachycardia
b. Agitation
c. Poor Skin turgor
d. Dry mucous membrane
9. Tachycardia, eventually shock if fluids is not replaced
10. If left untreated results to hypovolemic shock (late sign anuria)
Dx
1. Urine Specific Gravity (NV: 1.015 – 1.030): less than 1.004
2. Serum Na: increase resulting to hypernatremia
3. H2O deprivation test: reveals inability to concentrate urine
Nursing Intervention
1. Maintain F&E balance / Force fluids 2000-3000 ml/day
a. Keep accurate I&O
b. Weigh daily
c. Administer IV/oral fluids as ordered to replace fluid loss
2. Monitor strictly V/S & observe for signs of dehydration & hypovolemia
3. Administer hormone replacement as ordered:
a. Vasopressin (Pitressin) & Vasopressin Tannate (Pitressin Tannate Oil): administered by IM injection
Warm to body temperature before giving
Shake tannate suspension to ensure uniform dispersion
b. Lypressin (Diapid): nasal spray
4. Prevent complications: hypovolemic shock is the most feared complication
5. Provide client teaching & discharge planning concerning:
a. Lifelong hormone replacement: Lypressin (Diapid) as needed to control polyuria & polydipsia
b. Need to wear medic-alert bracelet
Predisposing Factors
1. Head injury
2. Related to presence of bronchogenic cancer
Initial sign of lung cancer is non productive cough
35
36
S/sx
1. Person with SIADH cannot excrete a dilute urine
2. Fluid retention & Na deficiency
a. Hypertension
b. Edema
c. Weight gain
3. Water intoxication: may lead to cerebral edema: lead to increase ICP; may lead to seizure activity
Dx
1. Urine specific gravity: is increase
2. Serum Sodium: is decreased
Medical Management
1. Treat underlying cause if possible
2. Diuretics & fluid restriction
Nursing Intervention
1. Restrict fluid: to promote fluid loss & gradual increase in serum Na
2. Administer medications as ordered:
a. Loop diuretics (Lasix)
b. Osmotic diuretics (Mannitol)
3. Monitor strictly V/S, I&O & neuro check
4. Weigh patient daily and assess for pitting edema
5. Monitor serum electrolytes & blood chemistries carefully
6. Provide meticulous skin care
7. Prevent complications
HYPOTHYROIDISM
- all are decrease except weight and menstruation
- memory impairment
Signs and Symptoms
- there is loss of appetite but there is weight gain
- menorrhagia
- cold intolerance
- constipation
HYPERTHYROIDISM
- all are increase except weight and menstruation
Signs and Symptoms
- increase appetite but there is weight loss
- amenorrhea
- exophthalmos
Thyroid Disorder
Simple Goiter
Enlargement of thyroid gland due to iodine deficiency
Enlargement of the thyroid gland not caused by inflammation of neoplasm
Low level of thyroid hormones stimulate increased secretion of TSH by pituitary; under TSH stimulation the thyroid increases in size to
compensate & produce more thyroid hormone
Predisposing Factors
1. Endemic: caused by nutritional iodine deficiency, most common in the “goiter belt” area, areas where soil & H2O are deficient in iodine;
occurs most frequently during adolescence & pregnancy
Goiter belt area:
a. Midwest, northwest & great lakes region
b. Places far from sea
c. Mountainous regions
2. Sporadic: caused by
Increase intake of goitrogenic foods (contains agent that decrease the thyroxine production: pro-goitrin an anti-thyroid agent that
has no iodine). Ex. cabbage, turnips, radish, strawberry, carrots, sweet potato, rutabagas, peaches, peas, spinach, broccoli, all nuts
Soil erosion washes away iodine
Goitrogenic drugs:
a. Anti-Thyroid Agent: Propylthiouracil (PTU)
b. Large doses of iodine
c. Phenylbutazone
d. Para-amino salicylic acid
e. Lithium Carbonate
f. PASA (Aspirin)
g. Cobalt
3. Genetic defects that prevents synthesis of thyroid hormones
36
37
S/sx
1. Enlarged thyroid gland
2. Dysphagia
3. Respiratory distress
4. Mild restlessness
Dx
1. Serum T4: reveals normal or below normal
2. Thyroid Scan: reveals enlarged thyroid gland.
3. Serum Thyroid Stimulating Hormone (TSH): is increased (confirmatory diagnostic test)
4. RAIU (Radio Active Iodine Uptake): normal or increased
Medical Management
1. Drug Therapy:
Hormone replacement with levothyroxine (Synthroid) (T4), dessicated thyroid, or liothyronine (Cytomel) (T3)
Small dose of iodine (Lugol’s or potassium iodide solution): for goiter resulting from iodine deficiency
2. Avoidance of goitrogenic food or drugs in sporadic goiter
3. Surgery:
Subtotal thyroidectomy: (if goiter is large) to relieve pressure symptoms & for cosmetic reasons
Nursing Intervention
1. Administer Replacement therapy as ordered:
a. Lugol’s Solution / SSKI (Saturated Solution of Potassium Iodine)
Color purple or violet and administered via straw to prevent staining of teeth.
4 Medications to be taken via straw: Lugol’s, Iron, Tetracycline, Nitrofurantoin (DOC: for pyelonephritis)
b. Thyroid Hormones:
Levothyroxine (Synthroid)
Liothyronine (Cytomel)
Thyroid Extracts
Seafood’s like oyster, crabs, clams and lobster but not shrimps because it contains lesser amount of iodine.
Hypothyroidism (Myxedema)
Slowing of metabolic processes caused by hypofunction of the thyroid gland with decreased thyroid hormone secretion
Hyposecretion of thyroid hormone
Decrease in all V/S except wt & menses
Children: cretinism the only endocrine disorder that can lead to mental retardation
In severe or untreated cases myxedema coma may occur:
Characterized by intensification of S/sx of hypothyroidism & neurologic impairment leading to coma
Mortality rate high; prompt recognition & treatment essential
Precipitating factors: failure to take prescribed medications; infection; trauma; exposure to cold; use of sedatives, narcotics or
anesthetics
Predisposing Factors
1. Primary hypothyroidism: atrophy of the gland possibly caused by an autoimmune process
2. Secondary hypothyroidism: caused by decreased stimulation from pituitary TSH
3. Iatrogenic: surgical removal of the gland or over treatment of hyperthyroidism with drugs or radioactive iodine; disease caused by
medical intervention such as surgery
4. Related to atrophy of thyroid gland due to trauma, presence of tumor, inflammation
5. Iodine deficiency
6. Autoimmune (Hashimotos Disease)
7. Occurs more often to women ages 30 & 60
S/sx
1. Loss of appetite: but there is wt gain
2. Anorexia
3. Weight gain: which promotes lipolysis leading to atherosclerosis and MI
37
38
4. Constipation
5. Cold intolerance
6. Dry scaly skin
7. Spares hair
8. Brittleness of nails
9. Decrease in all V/S: except wt gain & menses
a. Hypotension
b. Bradycardia
c. Bradypnea
d. Hypothermia
10. Weakness and fatigue
11. Slowed mental processes
12. Dull look
13. Slow clumsy movement
14. Lethargy
15. Generalized interstitial non-pitting edema (Myxedema)
16. Hoarseness of voice
17. Decrease libido
18. Memory impairment
19. Psychosis
20. Menorrhagia
Dx
1. Serum T3 and T4: is decreased
2. Serum Cholesterol: is increased
3. RAIU (Radio Active Iodine Uptake): is decreased
Medical Management
1. Drug Therapy:
Levothyroxine (Synthroid)
Thyroglobulin (Proloid)
Dessicated thyroid
Liothyronine (Cytomel)
2. Myxedema coma is a medical emergency:
IV thyroid hormones
Correction of hypothermina
Maintenance of vital function
Treatment of precipitating cause
Nursing Intervention
1. Monitor strictly V/S & I&O, daily weights; observe for edema & signs of cardiovascular complication & to determine presence of
myxedema coma
2. Administer thyroid hormone replacement therapy as ordered & monitor effects:
a. Observe signs of thyrotoxicosis:
Tachycardia & palpitation
N/V
Diarrhea
Sweating
Tremors
Agitation
Dyspnea
b. Increase dosage gradually, especially in clients with cardiac complication
3. Provide comfortable and warm environment: due to cold intolerance
4. Provide a low calorie diet
5. Avoid the use of sedatives; reduce the dose of any sedatives, narcotics, or anesthetic agent by half as ordered
6. Provide meticulous skin care: to prevent skin breakdown
7. Increase fluid & food high in fiber: to prevent constipation; administer stool softener as ordered
8. Observe for signs of myxedema coma; provide appropriate nursing care
a. Administer medication as ordered
b. Maintain vital functions:
Correct hypothermia
Maintain adequate ventilation
9. Myxedema coma:
A complication of hypothyroidism & an emergency case
38
39
Hyperthyroidism
Secretion of excessive amounts of thyroid hormone in the blood causes an increase in metabolic process
Increase in T3 and T4
Grave’s Disease or Thyrotoxicosis
Increase in all V/S except wt & menses
Predisposing Factors
1. More often seen in women between ages 30 & 50
2. Autoimmune: involves release of long acting thyroid stimulator causing exopthalmus (protrusion of eyeballs) enopthalmus (late sign
of dehydration among infants)
3. Excessive iodine intake
4. Related to hyperplasia (increase size of TG)
S/sx
1. Increase appetite (hyperphagia): but there is weight loss
2. Heat intolerance
3. Weight loss
4. Diarrhea: increase motility
5. Increased in all V/S: except wt & menses
a. Tachycardia
b. Increase systolic BP
c. Palpitation
6. Warm smooth skin
7. Fine soft hair
8. Pliable nails
9. CNS involvement
a. Irritability & agitation
b. Restlessness
c. Tremors
d. Insomnia
e. Hallucinations
f. Sweating
g. Hyperactive movement
10. Goiter
11. PS: Exopthalmus (protrusion of eyeballs)
12. Amenorrhea
Dx
1. Serum T3 and T4: is increased
2. RAIU (Radio Active Iodine Uptake): is increased
3. Thyroid Scan: reveals an enlarged thyroid gland
Medical Management
1. Drug Therap:
a. Anti-thyroid drugs: Propylthiouracil (PTU) & methimazole (Tapazole): blocke synthesis of thyroid hormone; toxic effect include
agranulocytosis
b. Adrenergic Blocking Agent: Propranolol (Inderal): used to decrease sympathetic activity & alleviate symptoms such as
tachycardia
2. Radioactive Iodine Therapy
a. Radioactive isotope of iodine (ex. 131I): given to destroy the thyroid gland, thereby decreasing production of thyroid hormone
b. Used in middle-aged or older clients who are resistant to, or develop toxicity from drug therapy
c. Hypothyroidism is a potential complication
3. Surgery: Thyroidectomy performed in younger client for whom drug therapy has not been effective
Nursing Intervention
1. Monitor strictly V/s & I&O, daily weight
2. Administer anti-thyroid medications as ordered:
a. Propylthiouracil (PTU)
b. Methimazole (Tapazole)
3. Provide for period of uninterrupted rest:
a. Assign a private room away from excessive activity
b. Administer medication to promote sleep as ordered
4. Provide comfortable and cold environment
5. Minimized stress in the environment
6. Encourage quiet, relaxing diversional activities
39
40
7. Provide dietary intake that is high in CHO, CHON, calories, vitamin & minerals with supplemental feeding between meals & at
bedtime; omit stimulant
8. Observe for & prevent complication
a. Exophthalmos: protects eyes with dark glasses & artificial tears as ordered
b. Thyroid Storm
9. Provide meticulous skin care
10. Maintain side rails
11. Provide bilateral eye patch to prevent drying of the eyes
12. Assist in surgical procedures subtotal Thyroidectomy:
13. Provide client teaching & discharge planning concerning:
a. Need to recognized & report S/sx of agranulocytosis (fever, sore throat, skin rash): if taking anti-thyroid drugs
b. S/sx of hyperthyroidism & hypothyroidism
Thyroid Storm
Uncontrolled & potentially life-threatening hyperthyroidism caused by sudden & excessive release of thyroid hormone into the
bloodstream
Precipitating Factors
1. Stress
2. Infection
3. unprepared thyroid surgery
S/sx
1. Apprehension
2. Restlessness
3. Extremely high temp (up to 106 F / 40.7 C)
4. Tahchycardia
5. HF
6. Respiratory Distress
7. Delirium
8. Coma
Nursing Intervention
1. Maintain patent airway & adequate ventilation; administer O2 as ordered
2. Administer IV therapy as ordered
3. Administer medication as ordered:
a. Anti-thyroid drugs
b. Corticosteroids
c. Sedatives
d. Cardiac Drugs
Thyroidectomy
Partial or total removal of thyroid gland
Indication:
Agitation
TRIAD SIGNS
40
41
Hyperthermia Tachycardia
Administer medications as ordered:
Anti Pyretics
Beta-blockers
Monitor strictly vital signs, input and output and neuro check.
Maintain side rails
Offer TSB
8. Administer IV fluids as ordered: until the client is tolerating fluids by mouth
9. Administer analgesics as ordered: for incisional pain
10. Relieve discomfort from sore throat:
a. Cool mist humidifier to thin secretions
b. Administer analgesic throat lozenges before meals prn as ordered
11. Encourage coughing & deep breathing every hour
12. Assist the client with ambulation: instruct the client to place the hands behind the neck: to decrease stress on suture line if added
support is necessary
13. Hormonal replacement therapy for lifetime
14. Watch out for accidental laryngeal damage which may lead to hoarseness of voice: encourage client to talk/speak immediately after
operation and notify physician
15. Provide client teaching& discharge planning concerning:
a. S/sx of hyperthyroidism & hypothyroidism
b. Self administration of thyroid hormone: if total thyroidectomy is performed
c. Application of lubricant to the incision once suture is removed
d. Perform ROM neck exercise 3-4 times a day
e. Importance of follow up care with periodic serum calcium level
Hypoparathyroidism
Disorder characterized by hypocalcemia resulting from a deficiency of parathormone (PTH) production
Predisposing Factors
1. May be hereditary
2. Idiopathic
3. Caused by accidental damage to or removal of parathyroid gland during thyroidectomy surgery
4. Atrophy of parathyroid gland due to: inflammation, tumor, trauma
S/sx
1. Acute hypocalcemia (tetany)
a. Paresthesia: tingling sensation of finger & around lip
b. Muscle spasm
c. laryngospasm/broncospasm
d. Dysphagia
e. Seizure: feared complications
f. Cardiac arrhythmia: feared complications
g. Numbness
h. Positive trousseu’s sign: carpopedal spasm
i. Positive chvostek sign
2. Chronic hypocalcemia (tetany)
a. Fatigue
b. Weakness
c. Muscle cramps
d. Personality changes
e. Irritability
f. Memory impairment
g. Agitation
h. Dry scaly skin
i. Hair loss
j. Loss of tooth enamel
k. Tremors
l. Cardiac arrhythmias
m. Cataract formation
n. Photophobia
o. Anorexia
p. N/V
Diagnostic Procedures
1. Serum Calcium level: decreased (normal value: 8.5 – 11 mg/100 ml)
2. Serum Phosphate level: increased (normal value: 2.5 – 4.5 mg/100 ml)
3. Skeletal X-ray of long bones: reveals a increased in bone density
4. CT Scan: reveals degeneration of basal ganglia
41
42
Nursing Management
1. Administer medications as ordered such as:
a. Acute Tetany: Calcium Gluconate slow IV drip as ordered
b. Chronic Tetany:
Oral calcium preparation: Calcium Gluconate, Calcium Lactate, Calcium Carbonate (Os-Cal)
Phosphate Binder: Aluminum Hydroxide Gel (Amphogel) or aluminum carbonate gel, basic (basaljel): to decrease phosphate
levels
ANTACID
A.A.C MAD
Aluminum
Hydroxide
Gel
Hyperparathyroidism
Increase secretion of PTH that results in an altered state of calcium, phosphate & bone metabolism
Decrease parathormone
Hypercalcemia: bone demineralization leading to bone fracture (calcium is stored 99% in bone and 1% blood)
Kidney stones
Predisposing Factors
1. Most commonly affects women between ages 35 & 65
2. Primary Hyperparathyroidism: caused by tumor & hyperplasia of parathyroid gland
3. Secondary Hyperparathyroidism: cause by compensatory over secretion of PTH in response to hypocalcemia from:
a. Children: Ricketts
b. Adults: Osteomalacia
c. Chronic renal disease
d. Malabsorption syndrome
S/sx
1. Bone pain (especially at back); Bone demineralization; Pathologic fracture
2. Kidney stones; Renal colic; Polyuria; Polydipsia; Cool moist skin
3. Anorexia; N/V; Gastric Ulcer; Constipation
4. Muscle weakness; Fatigue
5. Irritability / Agitation; Personality changes; Depression; Memory impairment
6. Cardiac arrhythmias; HPN
Dx
1. Serum Calcium: is increased
2. Serum Phosphate: is decreased
3. Skeletal X-ray of long bones: reveals bone demineralization
Nursing Intervention
1. Administer IV infusions of normal saline solution & give diuretics as ordered:
2. Monitor I&O & observe fluid overload & electrolytes imbalance
3. Assist client with self care: Provide careful handling, Moving, Ambulation: to prevent pathologic fracture
4. Monitor V/S: report irregularities
42
43
Addison’s Disease
Primary adrenocortical insufficiency; hypofunction of the adrenal cortex causes decrease secretion of the mineralcorticoids,
glucocorticoids, & sex hormones
Hyposecretion of adrenocortical hormone leading to:
Predisposing Factors
1. Relatively rare disease caused by:
Idiopathic atrophy of the adrenal cortex: due to an autoimmune process
Destruction of the gland secondary to TB or fungal infections
S/sx
1. Fatigue, Muscle weakness
2. Anorexia, N/V, abdominal pain, weight loss
3. History of hypoglycemic reaction / Hypoglycemia: tremors, tachycardia, irritability, restlessness, extreme fatigue, diaphoresis,
depression
4. Hyponatremia: hypotension, signs of dehydration, weight loss, weak pulse
5. Decrease tolerance to stress
6. Hyperkalemia: agitation, diarrhea, arrhythmia
7. Decrease libido
8. Loss of pubic and axillary hair
9. Bronze like skin pigmentation
Dx
1. FBS: is decreased (normal value: 80 – 100 mg/dl)
2. Plasma Cortisol: is decreased
3. Serum Sodium: is decrease (normal value: 135 – 145 meq/L)
4. Serum Potassium: is increased (normal value: 3.5 – 4.5 meq/L)
Nursing Intervention
1. Administer hormone replacement therapy as ordered:
a. Glucocorticoids: stimulate diurnal rhythm of cortisol release, give 2/3 of dose in early morning & 1/3 of dose in afternoon
Corticosteroids: Dexamethasone (Decadrone)
43
44
Addisonian Crisis
Severe exacerbation of addison’s diseasecaused by acute adrenal insufficiency
Predisposing Factors
1. Strenuous activity
2. Stress
3. Trauma
4. Infection
5. Failure to take prescribe medicine
6. Iatrogenic:
Surgery of pituitary gland or adrenal gland
Rapid withdrawal of exogenous steroids in a client on long-term steroid therapy
S/sx
1. Generalized muscle weakness
2. Severe hypotension
3. Hypovolemic shock: vascular collapse
4. Hyponatremia: leading to progressive stupor and coma
Nursing Intervention
1. Assist in mechanical ventilation
2. Administer IV fluids (5% dextrose in saline, plasma) as ordered: to treat vascular collapse
3. Administer IV glucocorticoids: Hydrocortisone (Solu-Cortef) & vasopressors as ordered
4. Force fluids
5. If crisis precipitate by infection: administer antibiotics as ordered
6. Maintain strict bed rest & eliminate all forms of stressful stimuli
7. Monitor V/S, I&O & daily weight
8. Protect client from infection
9. Provide client teaching & discharge planning concerning: same as addison’s disease
Cushing Syndrome
Condition resulting from excessive secretion of corticosteroids, particularly glucocorticoid cortisol
Hypersecretion of adrenocortical hormones
Predisposing Factors
1. Primary Cushing’s Syndrome: caused by adrenocortical tumors or hyperplasia
2. Secondary Cushing’s Syndrome (also called Cushing’s disease): caused by functioning pituitary or nonpituitary neoplasm secreting
ACTH, causing increase secretion of glucocorticoids
3. Iatrogenic: cause by prolonged use of corticosteroids
4. Related to hyperplasia of adrenal gland
5. Increase susceptibility to infections
S/sx
1. Muscle weakness
2. Fatigue
3. Obese trunk with thin arms & legs
4. Muscle wasting
5. Irritability
6. Depression
7. Frequent mood swings
8. Moon face
9. Buffalo hump
10. Pendulous abdomen
11. Purple striae on trunk
12. Acne
13. Thin skin
14. Signs of masculinization in women: menstrual dysfunction, decrease libido
15. Osteoporosis
16. Decrease resistance to infection
17. Hypertension
18. Edema
19. Hypernatremia
44
45
Dx
1. FBS: is increased
2. Plasma Cortisol: is increased
3. Serum Sodium: is increased
4. Serum Potassium: is decreased
Nursing Intervention
1. Maintain muscle tone
a. Provide ROM exercise
b. Assist in ambulation
2. Prevent accidents fall & provide adequate rest
3. Protect client from exposure to infection
4. Maintain skin integrity
a. Provide meticulous skin care
b. Prevent tearing of the skin: use paper tape if necessary
5. Minimize stress in the environment
6. Monitor V/S: observe for hypertension & edema
7. Monitor I&O & daily weight: assess for pitting edema: Measure abdominal girth: notify physician
8. Provide diet low in Calorie & Na & high in CHON, K, Ca, Vitamin D
9. Monitor urine: for glucose & acetone; administer insulin as ordered
10. Provide psychological support & acceptance
11. Prepare client for hypophysectomy or radiation: if condition is caused by a pituitary tumor
12. Prepare client for Adrenalectomy: if condition is caused by an adrenal tumor or hyperplasia
13. Restrict sodium intake
14. Administer medications as ordered: Spironolactone (Aldactone): potassium sparring diuretics
15. Provide client teaching & discharge planning concerning:
a. Diet modification
b. Importance of adequate rest
c. Need to avoid stress & infection
d. Change in medication regimen (alternate day therapy or reduce dosage): if caused of condition is prolonged corticosteroid
therapy
e. Prevent complications (DM)
f. Hormonal replacement for lifetime: lifetime due to adrenal gland removal: no more corticosteroid!
g. Importance of follow up care
Hyperglycemia: due to total or partial insulin deficiency or insensitivity of the cells to insulin
Characterized by disorder in the metabolism of CHO, fats, CHON, as well as changes in the structure & function of blood vessels
Metabolic disorder characterized by non utilization of carbohydrates, protein and fat metabolism
Pathophysiology
Lack of insulin causes hyperglycemia (insulin is necessary for the transport of glucose across the cell membrane) = Hyperglycemia leads to
osmitic diuresis as large amounts of glucose pass through the kidney result polyuria & glycosuria = Diuresis leads to cellular dehydration & F & E
depletion causing polydipsia (excessive thirst) = Polyphagia (hunger & increase appetite) result from cellular starvation = The body turns to fat
& CHON for energy but in the absence of glucose in the cell fat cannot be completely metabolized & ketones (intermediate products of fat
metabolism) are produced = This leads to ketonemia, ketonuria (contributes to osmotic diuresis) & metabolic acidosis (ketones are acid bodies)
= Ketone sacts as CNS depressants & can cause coma = Excess loss of F & E leads to hypovolemia, hypotension, renal failure & decease blood
flow to the brain resulting in coma & death unless treated.
HYPERGLYCEMIA
Increase osmotic diuresis
Glycosuria Polyuria
Polyphagia Polydypsia
* liver has glycogen that undergo glycogenesis/glycogenolysis
45
46
GLUCONEOGENESIS
Formation of glucose from non-CHO sources
Cholesterol Ketones
Hypertension
Acetone Breath Kussmaul’s Respiration
odor
MI CVA
Classification Of DM
1. Type I Insulin-dependent Diabetes Mellitus (IDDM)
Secondary to destruction of beta cells in the islets of langerhans in the pancreas resulting in little of no insulin production
Non-obese adults
Requires insulin injection
Incidence Rate
1. 10% general population has Type I DM
Predisposing Factors
1. Autoimmune response
2. Genetics / Hereditary (total destruction of pancreatic cells)
3. Related to viruses
4. Drugs: diuretics (Lasix), Steroids, oral contraceptives
5. Related to carbon tetrachloride toxicity
S/sx
1. Polyuria
2. Polydipsia
3. Polyphagia
4. Glucosuria
5. Weight loss
6. Fatigue
7. Anorexia
8. N/V
9. Blurring of vision
10. Increase susceptibility to infection
11. Delayed / poor wound healing
Dx
1. FBS:
a. A level of 140 mg/dl of greater on at two occasions confirms DM
b. May be normal in Type II DM
2. Postprandial Blood Sugar: elevated
3. Oral Glucose Tolerance Test (most sensitve test): elevated
4. Glycosolated Hemoglobin (hemoglobin A1c): elevated
Medical Management
1. Insulin therapy
2. Exercise
3. Diet:
a. Consistency is imperative to avoid hypoglycemia
b. High-fiber, low-fat diet also recommended
4. Drug therapy:
a. Insulin:
Short Acting: used in treating ketoacidosis; during surgery, infection, trauma; management of poorly controlled diabetes; to
supplement long-acting insulins
Intermediate: used for maintenance therapy
Long Acting: used for maintenance therapy in clients who experience hyperglycemia during the night with intermediate-
acting insulin
b. Insulin preparation can consist of mixture of pure pork, pure beef, or human insulin. Human insulin is the purest insulin & has the
lowest antigenic effect
46
47
c. Human Insulin: is recommended for all newly diagnosed Type I & Type II DM who need short-term insulin therapy; the pregnant
client & diabetic client with insulin allergy or severe insulin resistance
d. Insulin Pumps: externally worn device that closely mimic normal pancreatic functioning
5. Exercise: helpful adjunct to therapy as exercise decrease the body’s need for insulin
Insulin, Zinc Semilente Ins Cloudy ½-1 4-6 12-16 Lente prep
suspension,
prompt
Intermediate Acting
Isophane Ins NPH Ins Cloudy 1-1 ½ 8-12 18-24 Regular Ins
injection injection
Insulin Zinc Lente Ins Cloudy 1-1 ½ 8-12 18-24 Regular Ins &
Suspension semilente prep
Long Acting
Insulin Zinc Ultralente Ins Cloudy 4-8 16-20 30-36 Regular Ins &
suspension, semilente prep
extended
Complication
1. Diabetic Ketoacidosis (DKA)
Incidence Rate
1. 90% of general population has Type II DM
Predisposing Factors
1. Genetics
2. Obesity: because obese persons lack insulin receptor binding sites
S/sx
1. Usually asymptomatic
2. Polyuria
3. Polydypsia
4. Polyphagia
5. Glycosuria
6. Weight gain / Obesity
7. Fatigue
8. Blurred Vision
9. Increase susceptibility to infection
10. Delayed / poor wound healing
Dx
5. FBS:
c. A level of 140 mg/dl of greater on at two occasions confirms DM
d. May be normal in Type II DM
6. Postprandial Blood Sugar: elevated
7. Oral Glucose Tolerance Test (most sensitve test): elevated
8. Glycosolated Hemoglobin (hemoglobin A1c): elevated
Medical Management
1. Ideally manage by diet & exercise
2. Oral Hypoglycemic agents or occasionally insulin: if diet & exercise are not effective in controlling hyperglycemia
3. Insulin is needed in acute stress: ex. Surgery, infection
4. Diet: CHO 50%, CHON 30% & Fats 20%
a. Weight loss is important since it decreases insulin resistance
b. High-fiber, low-fat diet also recommended
5. Drug therapy:
a. Occasional use of insulin
b. Oral hypoglycemic agent:
Used by client who are not controlled by diet & exercise
Increase the ability of islet cells of the pancreas to secret insulin; may have some effect on cell receptors to decrease
resistance to insulin
6. Exercise: helpful adjunct to therapy as exercise decrease the body’s need for insulin
47
48
Oral Biguanides
Metformin (Glucophage) 2-2.5 10-16 :Decrease glucose
production in liver
:Decrease intestinal
absorption of glucose &
improves insulin sensitivity
Complications
1. Hyper Osmolar Non-Ketotic Coma (HONKC)
Nursing Intervention
1. Administer insulin or oral hypoglycemic agent as ordered: monitor hypoglycemia especially during period of drug peak action
2. Provide special diet as ordered:
a. Ensure that the client is eating all meals
b. If all food is not ingested: provide appropriate substitute according to the exchange list or give measured amount of orange juice
to substitute for leftover food; provide snack later in the day
3. Monitor urine sugar & acetone (freshly voided specimen)
4. Perform finger sticks to monitor blood glucose level as ordered (more accurate than urine test)
5. Observe signs of hypo/hyperglycemia
6. Provide meticulous skin care & prevent injury
7. Maintain I&O; weight daily
8. Provide emotional support: assist client in adapting change in lifestyle & body image
9. Observe for chronic complications & plan of care accordingly:
a. Atherosclerosis: leads to CAD, MI, CVA & Peripheral Vascular Disease
b. Microangiopathy: most commonly affects eyes & kidneys
c. Kidney Disease
Recurrent Pyelonephritis
Diabetic Nephropathy
d. Ocular Disorder
Premature Cataracts
Diabetic Retinopathy
e. Peripheral Neuropathy
Affects PNS & ANS
Cause diarrhea, constipation, neurogenic bladder, impotence, decrease sweating
10. Provide client teaching & discharge planning concerning:
a. Disease process
b. Diet
Client should be able to plan a meal using exchange lists before discharge
Insert needle at a 45 (skinny clients) or 90 (fat or obese clients) degree angle depending on amount of adipose tissue
May store current vial of insulin at room temperature; refrigerate extra supplies
Avoid alcohol intake while on medication: it can lead to severe hypoglycemia reaction
Instruct the client to take it with meals: to lessen GIT irritation & prevent hypoglycemia
e. Urine testing (not very accurate reflection of blood glucose level)
48
49
May be satisfactory for Type II diabetics since they are more stable
Use clinitest, tes-tape, diastix, for glucose testing
Perform test before meals & at bedtime
Use freshly voided specimen
Be consistent in brand of urine test used
Report results in percentage
Report result to physician if results are greater that 1%, especially if experiencing symptoms of hyperglycemia
Urine testing for ketones should be done by Type I diabetic clients when there is persistent glycosuria, increase blood glucose
level or if the client is not feeling well (acetest, ketostix)
f. Blood glucose monitoring
Use for Type I diabetic client: since it gives exact blood glucose level & also detects hypoglycemia
Instruct client in finger stick technique: use of monitor device (if used), & recording & utilization of test results
g. General care
Perform good oral hygiene & have regular dental exam
Have regular eye exam
Do not omit insulin or oral hypoglycemic agent: since infection causes increase blood sugar
Notify physician
Monitor urine or blood glucose level & urine ketones frequently
Inspect foot daily & notify physician: if cut, blister, or break in skin occurs
i. Exercise
Undertake regular exercise; avoid sporadic, vigorous exercise
Food intake may need to be increased before exercising
Exercise is best performed after meals when the blood sugar is rising
j. Complication
Learn to recognized S/sx of hypo/hyperglycemia: for hypoglycemia (cold and clammy skin), for hyperglycemia (dry and warm
skin): administer simple sugars
Eat candy or drink orange juice with sugar added for insulin reaction (hypoglycemia)
Monitor signs of DKA & HONKC
k. Need to wear a Medic-Alert bracelet
Acute complication of Type I DM: due to severe hyperglycemia leading to severe CNS depression
Occurs in insulin-dependent diabetic clients
Predisposing Factors
1. Undiagnosed DM
2. Neglect to treatment
3. Infection
4. cardiovascular disorder
5. Hyperglycemia
6. Physical & Emotional Stress: number one precipitating factor
S/sx
1. Polyuria
2. Polydipsia
3. Polyphagia
4. Glucosuria
5. Weight loss
6. Anorexia
7. N/V
8. Abdominal pain
9. Skin warm, dry & flushed
10. Dry mucous membrane; soft eyeballs
11. Blurring of vision
12. PS: Acetone breath odor
13. PS: Kussmaul’s Respiration (rapid shallow breathing) or tachypnea
14. Alteration in LOC
15. Hypotension
16. Tachycardia
17. CNS depression leading to coma
49
50
Dx
1. FBS: is increased
2. Serum glucose & ketones level: elevated
3. BUN (normal value: 10 – 20): elevated: due to dehydration
4. Creatinine (normal value: .8 – 1): elevated: due to dehydration
5. Hct (normal value: female 36 – 42, male 42 – 48): elevated: due to dehydration
6. Serum Na: decrease
7. Serum K: maybe normal or elevated at first
8. ABG: metabolic acidosis with compensatory respiratory alkalosis
Nursing Intervention
1. Maintain patent airway
2. Assist in mechanical ventilation
3. Maintain F&E balance:
a. Administer IV therapy as ordered:
Normal saline (0.9% NaCl), followed by hypotonic solutions (.45% NaCl) sodium chloride: to counteract dehydration & shock
Predisposing Factors
1. Undiagnosed diabetes
2. Infection or other stress
3. Certain medications (ex. dilantin, thiazide, diuretics)
4. Dialysis
5. Hyperalimentation
6. Major burns
7. Pancreatic disease
S/sx
1. Polyuria
2. Polydipsia
3. Polyphagia
4. Glucosuria
5. Weight loss
6. Anorexia
7. N/V
8. Abdominal pain
9. Skin warm, dry & flushed
10. Dry mucous membrane; soft eyeballs
11. Blurring of vision
12. Hypotension
13. Tachycardia
14. Headache and dizziness
15. Restlessness
16. Seizure activity
17. Alteration / Decrease LOC: diabetic coma
Dx
1. Blood glucose level: extremely elevated
2. BUN: elevated: due to dehydration
3. Creatinine: elevted: due to dehydration
4. Hct: elevated: due to dehydration
5. Urine: (+) for glucose
Nursing Intervention
1. Maintain patent airway
2. Assist in mechanical ventilation
50
51
The structure of the hematological of hematopoietic system includes the blood, blood vessels, & blood forming organs (bone marrow,
spleen, liver, lymph nodes, & thymus gland).
The major function of blood: is to carry necessary materials (O2, nutrients) to cells & remove CO2 & metabolic waste products.
The hematologic system also plays an important role in hormone transport, the inflammatory & immune responses, temperature
regulation, F&E balance & acid-base balance.
HEMATOLOGICAL SYSTEM
1. Arteries 1. Liver
55% Plasma 45% Formed 2. Veins 2. Thymus
(Fluid) cellular elements 3. Capillaries 3. Spleen
4. Lymphoid Organ
Serum Plasma CHON 5. Lymph Nodes
(formed in liver) 6. Bone Marrow
1. Albumin
2. Globulins
3. Prothrombin and Fibrinogen
Bone Marrow
Contained inside all bones, occupies interior of spongy bones & center of long bones; collectively one of the largest organs in the body
(4-5% of total body weight)
Primary function is Hematopoiesis: the formation of blood cells
All blood cells start as stem cells in the bone marrow; these mature into different, specific types of cells, collectively referred to as
Formed Elements of Blood or Blood Components:
1. Erythrocytes
2. Leukocytes
3. Thrombocytes
Two kinds of Bone Marrow:
1. Red Marrow
Carries out hematopoiesis; production site of erythroid, myeloid, & thrombocytic component of blood; one source of lymphocytes
& macrophages
Found in the ribs, vertebral column, other flat bones
2. Yellow Marrow
Red marrow that has changed to fats; found in long bone; does not contribute to hematopoiesis
Blood
Composed of plasma (55%) & cellular components (45%)
Hematocrit
1. Reflects portion of blood composed of red blood cells
2. Centrifugation of blood results in separation into top layer of plasma, middle layer of leukocytes & platelets, & bottom layer of
erythrocytes
3. Majority of formed elements is erythrocytes; volume of leukocytes & platelets is negligible
Distribution
1. 1300 ml in pulmonary circulation
a. 400 ml arterial
b. 60 ml capillary
c. 840 ml venous
2. 3000 ml in systemic circulation
a. 550 ml arterial
b. 300 ml capillary
c. 2150 ml venous
Plasma
Liquid part of the blood; yellow in color because of pigments
51
52
Normal blood contains 12-18 g Hgb/100 ml blood; higher (14-18 g) in men than in women (12-14 g)
e. Production
Start in bone marrow as stem cells, release as reticulocytes (immature cells), mature into erythrocytes
Erythropoietin stimulates differentiation; produced by kidneys & stimulated by hypoxia
Iron, vitamin B12, folic acid, pyridoxine vitamin B6, & other factors required for erythropoiesis
f. Hemolysis (Destruction)
Normal life span of RBC is 80 – 120 days and is killed in red pulp of spleen
Immature RBCs destroyed in either bone marrow or other reticuloendothelial organs (blood, connective tissue, spleen, liver,
lungs and lymph nodes)
Mature cells remove chiefly by liver and spleen
Bilirubin (yellow pigment): by product of Hgb (red pigment) released when RBCs destroyed, excreted in bile
Iron: feed from Hgb during bilirubin formation; transported to bone marrow via transferring and and reclaimed for new Hgb
production
Premature destruction: may be caused by RBC membrane abnormalities, Hgb abnormalities, extrinsic physical factors (such as
the enzyme defects found in G6PD)
Normal age RBCs may be destroyed by gross damage as in trauma or extravascular hemolysis (in spleen, liver, bone marrow)
g. Hemoglobin: normal value female 12 – 14 gms% male 14 – 16 gms%
h. Hematocrit red cell percentage in wholeblood (normal value: female 36 – 42% male 42 – 48%)
i. Substances needed for maturation of RBC:
a. Folic acid
b. Iron
c. Vitamin c
d. Vitamin b12 (Cyanocobalamin)
e. Vitamin b6 (Pyridoxine)
f. Intrinsic factor
2. Leukocytes (WBC)
a. Normal value: 5000 – 10000/mm3
b. Granulocytes and mononuclear cells: involved in the protection from bacteria and other foreign substances
c. Granulocytes:
• Polymorphonuclear Neutrophils
- 60 – 70% of WBC
- Involved in short term phagocytosis for acute inflammation
- Mature neutrophils: polymorphonuclear leukocytes
- Immature neutrophils: band cells (bacterial infection usually produces increased numbers of band cells)
• Polymorphonuclear Basophils
- For parasite infections
- Responsible for the release of chemical mediation for inflammation
- Involved in prevention of clotting in microcirculation and allergic reactions
• Polymorphonuclear Eosinophils
- Involved in phagocytosis and allergic reaction
• Eosinophils & Basophils: are reservoirs of histamine, serotonin & heparin
d. Non Granulocytes
• Mononuclear cells: large nucleated cells
a. Monocytes:
Involved in long-term phagocytosis for chronic inflammation
Play a role in immune response
Macrophage in blood
Largest WBC
Produced by bone marrow: give rise to histiocytes (kupffer cells of liver), macrophages & other components of
reticuloendothelial system
52
53
b. Lymphocytes: immune cells; produce substances against foreign cells; produced primarily in lymph tissue (B cells) & thymus
(T cells)
Lymphocytes
HIV
c. Thrombocytes (Platelets)
• Normal value: 150,000 – 450,000/mm3
• Consist of immature or baby platelets or megakaryocytes which is the target of dengue virus
Blood Groups
Erythrocytes carry antigens, which determine the different blood group
Blood-typing system are based on the many possible antigens, but the most important are the antigens of the ABO & Rh blood groups
because they are most likely to be involved in transfusion reactions
1. ABO Typing
a. Antigens of systems are labeled A & B
b. Absence of both antigens results in type O blood
c. Presence of both antigen is type AB
d. Presence of either type A or B results in type A & type B, respectively
e. Type O: universal donor
f. Antibodies are automatically formed against ABO antigens not on persons own RBC
2. Rh Typing
a. Identifies presence or absence of Rh antigens (Rh + or Rh -)
b. Anti-Rh antibodies not automatically formed in Rh (-) persons, but if Rh (+) blood is given, antibody formation starts & second
exposure to Rh antigen will trigger a transfusion reaction
c. Important for Rh (-) woman carrying Rh (+) baby; 1st pregnancy not affected, but subsequent pregnancy with an Rh (+) baby,
mother’s antibodies attack baby’s RBC
53
54
Blood Coagulation
Conversion of fluid blood into a solid clot to reduce blood loss when blood vessels are ruptured
Clot Resolution: takes place via fibrinolytic system by plasmin & proteolytic enzymes; clots dissolves as tissue repairs.
Spleen
Largest Lymphatic Organ: functions as blood filtration system & reservoir
Vascular bean shape; lies beneath the diaphragm, behind & to the left of the stomach; composed of fibrous tissue capsule surrounding a
network of fiber
Contains two types of pulp:
a. Red Pulp: located between the fibrous strands, composed of RBC, WBC & macrophages
b. White Pulp: scattered throughout the red pulp, produces lymphocytes & sequesters lymphocytes, macrophages, & antigens
1%-2% of red cell mass or 200 ml blood/minute stored in the spleen; blood comes via splenic artery to the pulp for cleansing, then
passes into splenic venules that are lined with phagocytic cells & finally to the splenic vein to the liver.
Important hematopoietic site in fetus; postnatally procedures lymphocytes & monocytes
Important in phagocytosis; removes misshapen erythrocytes, unwanted parts of erythrocytes
Also involved in antibody production by plasma cells & iron metabolism (iron released from Hgb portion of destroyed erythrocytes
returned to bone marrow)
In the adult functions of the spleen can be taken over by the reticuloendothelial system.
Liver
54
55
Involved in bile production (via erythrocyte destruction & bilirubin production) & erythropoeisis (during fetal life & when bone marrow
production is insufficient).
Kupffer cells of liver have reticuloendothelial function as histiocytes; phagocytic activity & iron storage.
Liver also involved in synthesis of clotting factors, synthesis of antithrombins.
Blood Tranfusion
Purpose
1. RBC: Improve O2 transport
2. Whole Blood, Plasma, Albumin: volume expansion
3. Fresh Frozen Plasma, Albumin, Plasma Protein Fraction: provision of proteins
4. Cryoprecipitate, Fresh Frozen Plasma, Fresh Whole Blood: provision of coagulation factors
5. Platelet Concentration, Fresh Whole Blood: provision of platelets
Goals / Objectives
1. Replace circulating blood volume
2. Increase the O2 carrying capacity of blood
3. Prevent infection: if there is a decrease in WBC
4. Prevent bleeding: if there is platelet deficiency
55
56
a. Hemolytic reaction
b. Allergic reaction
c. Pyrogenic reaction
d. Circulatory overload
e. Air embolism
f. Thrombocytopenia
g. Cytrate intoxication
h. Hyperkalemia (caused by expired blood)
Nursing Management
1. Stop BT
2. Notify physician
3. Flush with plain NSS
4. Administer isotonic fluid solution: to prevent shock and acute tubular necrosis
5. Send the blood unit to blood bank for re-examination
6. Obtain urine & blood sample & send to laboratory for re-examination
7. Monitor vital signs & I&O
Nursing Management
1. Stop BT
2. Notify physician
3. Flush with plain NSS
4. Administer medications as ordered
a. Anti Histamine (Benadryl): if positive to hypotension, anaphylactic shock: treat with Epinephrine
5. Send the blood unit to blood bank for re examination
6. Obtain urine & blood sample & send to laboratory for re-examination
7. Monitor vital signs and intake and output
Nursing Management
1. Stop BT
2. Notify physician
3. Flush with plain NSS
4. Administer medications as ordered
a. Antipyretic
b. Antibiotic
5. Send the blood unit to blood bank for re examination
6. Obtain urine & blood sample & send to laboratory for re-examination
7. Monitor vital signs & I&O
8. Render TSB
Nursing Management
1. Stop BT
2. Notify physician
3. Administer medications as ordered
a. Loop diuretic (Lasix)
56
57
Nursing Care
1. Assess client for history of previous blood transfusions & any adverse reaction
2. Ensure that the adult client has an 18-19 gauge IV catheter in place
3. Use 0.9% sodium chloride
4. At least two nurse should verify the ABO group, RH type, client & blood numbers & expiration date
5. Take baseline V/S before initiating transfusion
6. Start transfusion slowly (2 ml/min)
7. Stay with the client during the first 15 min of the transfusion & take V/S frequently
8. Maintain the prescribed transfusion rate:
a. Whole Blood: approximately 3-4 hr
b. RBC: approximately 2-4 hr
c. Fresh Frozen Plasma: as quickly as possible
d. Platelet: as quickly as possible
e. Cryoprecipitate: rapid infusion
f. Granulocytes: usually over 2 hr
g. Volume Expander: volume-dependent rate
9. Monitor for adverse reaction
10. Document the following:
a. Blood component unit number (apply sticker if available)
b. Date of infusion starts & end
c. Type of component & amount transfused
d. Client reaction & vital signs
e. Signature of transfusionist
HIV
- 6 months – 5 years incubation period
- 6 months window period
- western blot opportunistic
- ELISA
- drug of choice AZT (Zidon Retrovir)
Blood Disorder
Acute or chronic bleeding principal cause in adults (chiefly from trauma, dysfunctional uterine bleeding & GI bleeding)
May also be caused by inadequate intake of iron-rich foods or by inadequate absorption of iron
In iron-deficiency states, iron stores are depleted first, followed by a reduction in Hgb formation
Incidence Rate
1. Common among developed countries & tropical zones (blood-sucking parasites)
2. Common among women 15 & 45 years old & children affected more frequently, as are the poor
3. Related to poor nutrition
Predisposing Factors
1. Chronic blood loss due to:
a. Trauma
b. Heavy menstruation
c. Related to GIT bleeding resulting to hematemasis and melena (sign for upper GIT bleeding)
d. Fresh blood per rectum is called hematochezia
2. Inadequate intake or absorption of iron due to:
a. Chronic diarrhea
b. Related to malabsorption syndrome
c. High cereal intake with low animal CHON digestion
d. Partial or complete gastrectomy
e. Pica
3. Related to improper cooking of foods
S/sx
1. Usually asymptomatic (mild cases)
2. Weakness & fatigue (initial signs)
3. Headache & dizziness
4. Pallor & cold sensitivity
5. Dyspnea
6. Palpitations
7. Brittleness of hair & nails, spoon shape nails (koilonychias)
8. Atrophic Glossitis (inflammation of tongue)
a. Stomatitis PLUMBER VINSON’S SYNDROME
b. Dysphagia
9. PICA: abnormal appetite or craving for non edible foods
57
58
Dx
1. RBC: small (microcytic) & pale (hypochromic)
2. RBC: is decreased
3. Hgb: decreased
4. Hct: moderately decreased
5. Serum iron: decreased
6. Reticulocyte count: is decreased
7. Serum ferritin: is decreased
8. Hemosiderin: absent from bone marrow
Nursing Intervention
1. Monitor for s/sx of bleeding through hematest of all elimination including urine, stool & gastrict content
2. Enforce CBR / Provide adequate rest: plan activities so as not to over tire the client
3. Provide thorough explanation of all diagnostic exam used to determine sources of possible bleeding: help allay anxiety & ensure
cooperation
4. Instruct client to take foods rich in iron
a. Organ meat
b. Egg yolk
c. Raisin
d. Sweet potatoes
e. Dried fruits
f. Legumes
g. Nuts
5. Instruct the client to avoid taking tea and coffee: because it contains tannates which impairs iron absorption
6. Administer iron preparation as ordered:
a. Oral Iron Preparations: route of choice
Ferrous Sulfate
Ferrous Fumarate
Ferrous Gluconate
b. Parenteral: used in clients intolerant to oral preparations, who are noncompliant with therapy or who have continuing blood
losses
58
59
Pernicious Anemia
Chronic progressive, macrocytic anemia caused by a deficiency of intrinsic factor; the result is abnormally large erythrocytes &
hypochlorhydria (a deficiency of hydrochloric acid in gastric secretion)
Chronic anemia characterized by a deficiency of intrinsic factor leading to hypochlorhydria (decrease hydrochloric acid secretion)
Characterized by neurologic & GI symptoms; death usually resuls if untreated
Lack of intrinsic factor is caused by gastric mucosal atrophy (possibly due to heredity, prolonged iron deficiency, or an autoimmune
disorder); can also results in clients who have had a total gastrctomy if vitamin B12 is not administer
Pathophysiology
1. Intrinsic factor is necessary for the absorbtion of vitamin B12 into small intestines
2. B12 deficiency diminished DNA synthesis, which results in defective maturation of cell (particularly rapidly dividing cells such as blood
cells & GI tract cells)
3. B12 deficiency can alter structure & function of peripheral nerves, spinal cord, & the brain
STOMACH
Predisposing Factors
1. Usually occurs in men & women over age of 50 with an increase in blue-eyed person of Scandinavian decent
2. Subtotal gastrectomy
3. Hereditary factors
4. Inflammatory disorders of the ileum
5. Autoimmune
6. Strictly vegetarian diet
S/sx
1. Anemia
2. Weakness & fatigue
3. Headache and dizziness
4. Pallor & cold sensitivity
5. Dyspnea & palpitations: as part of compensation
6. GIT S/sx:
a. Mouth sore
b. PS: Red beefy tongue
c. Indigestion / dyspepsia
d. Weight loss
e. Constipation / diarrhea
f. Jaundice
7. CNS S/sx:
a. Tingling sensation
b. Numbness
c. Paresthesias of hands & feet
d. Paralysis
e. Depression
f. Psychosis
g. Positive to Romberg’s test: damage to cerebellum resulting to ataxia
Dx
1. Erythrocytes count: decrease
2. Blood Smear: oval, macrocytic erythrocytes with a proportionate amount of Hgb
3. Bilirubin (indirect): elevated unconjugated fraction
4. Serum LDH: elevated
5. Bone Marrow:
a. Increased megaloblasts (abnormal erythrocytes)
b. Few normoblasts or maturing erythrocytes
c. Defective leukocytes maturation
6. Positive Schilling’s Test: reveals inadequate / decrease absorption of Vitamin B12
a. Measures absorption of radioactive vitamin B12 bothe before & after parenteral administration of intrinsic factor
b. Definitive test for pernicious anemia
c. Used to detect lack of intrinsic factor
d. Fasting client is given radioactive vitamin B12 by mouth & non-radioactive vitamin B12 IM to permit some excretion of radioactive
vitamin B12 in the urine if it os absorbed
e. 24-48 hour urine collection is obtained: client is encourage to drink fluids
f. If indicated, second stage schilling test performed 1 week after first stage. Fasting client is given radioactive vitamin B12
combined with human intrinsic factor & test is repeated
7. Gastric Analysis: decrease free hydrochloric acid
8. Large number of reticulocytes in the blood following parenteral vitamin B12 administration
Medical Management
1. Drug Therapy:
a. Vitamin B12 injection: monthly maintenance
59
60
b. Iron preparation: (if Hgb level inadequate to meet increase numbers of erythrocytes)
c. Folic Acid
Controversial
Reverses anemia & GI symptoms but may intensify neurologic symptoms
May be safe if given in small amounts in addition to vitamin B12
2. Transfusion Therapy
Nursing Intervention
1. Enforce CBR: necessary if anemia is severe
2. Adminster Vitamin B12 injections at monthly intervals for lifetime as ordered
Never given orally because there is possibility of developing tolerance
Site of injection for Vitamin B12 is dorsogluteal and ventrogluteal
No side effects
3. Provide a dietary intake that is high in CHON, vitamin c and iron (fish, meat, milk / milk product & eggs)
4. Avoid highly seasoned, coursed, or very hot foods: if client has mouth sore
5. Provide safety when ambulating (especially when carrying hot item)
6. Instruct client to avoid irritating mouth washes instead use soft bristled toothbrush
7. Avoid heat application to prevent burns
8. Provide client teaching & discharge planning concerning:
a. Dietery instruction
b. Importance of lifelong vitamin B12 therapy
c. Rehabilitation & physical therapy for neurologic deficit, as well as instruction regarding safety
Aplastic Anemia
Stem cell disorder leading to bone marrow depression leading to pancytopenia
Pancytopenia or depression of granulocytes, platelets & erythrocytes production: due to fatty replacement of the bone marrow
Bone marrow destruction may be idiopathic or secondary
PANCYTOPENIA
Predisposing Factors
1. Chemicals (Benzene and its derivatives)
2. Related to radiation / exposure to x-ray
3. Immunologic injury
4. Drugs:
a. Broad Spectrum Antibiotics: Chloramphenicol (Sulfonamides)
b. Cytotoxic agent / Chemotherapeutic Agents:
Methotrexate (Alkylating Agent)
Vincristine (Plant Alkaloid)
Nitrogen Mustard (Antimetabolite)
Phenylbutazones (NSAIDS)
S/sx
1. Anemia
a. Weakness & fatigue
b. Headache & dizziness
c. Pallor & cold sensitivity
d. Dyspnea & palpitations
2. Leukopenia
a. Increase susceptibility to infection
3. Thrombocytopenia
a. Petechiae (multiple petechiae is called purpura)
b. Ecchymosis
c. Oozing of blood from venipunctured sites
Dx
1. CBC: reveals pancytopenia
2. Normocytic anemia, granulocytopenia, thrombocytopenia
3. Bone marrow biopsy: aspiration (site is the posterior iliac crest): marrow is fatty & contain very few developing cells; reveals fat
necrosis in bone marrow
Medical Management
1. Blood transfusion: key to therapy until client’s own marrow begins to produce blood cells
2. Aggressive treatment of infection
3. Bone marrow transplantation
4. Drug Therapy:
a. Corticosteroids & / or androgens: to stimulate bone marrow function & to increase capillary resistance (effective in children but
usually not in adults)
b. Estrogen & / or progesterone: to prevent amenorrhea in female clients
5. Identification & withdrawal of offending agent or drug
Nursing Intervention
1. Removal of underlying cause
2. Administer Blood Transfusion as ordered
3. Administer O2 inhalation
60
61
4. Enforce CBR
5. Institute reverse isolation
6. Provide nursing care for client with bone marrow transplant
7. Administer medications as ordered:
a. Corticosteroids: caused by immunologic injury
b. Immunosuppressants: Anti Lymphocyte Globulin
Pathophysiology
1. Underlying disease (ex. toxemia of pregnancy, cancer) cause release of thromboplastic substance that promote the deposition of
fibrin throughout the microcirculation
2. Microthrombi form in many organs, causing microinfarcts & tissue necrosis
3. RBC are trapped in fibrin strands & are hemolysed
4. Platelets, prothrombin & other clotting factors are destroyed, leading to bleeding
5. Excessive clotting activates the fibrinolytic system, which inhibits platelet function, causing futher bleeding.
Predisposing Factors
1. Related to rapid blood transfusion
2. Massive burns
3. Massive trauma
4. Anaphylaxis
5. Septecemia
6. Neoplasia (new growth of tissue)
7. Pregnancy
S/sx
1. Petechiae & Ecchymosis on the skin, mucous membrane, heart, eyes, lungs & other organs (widespread and systemic)
2. Prolonged bleeding from breaks in the skin: oozing of blood from punctured sites
3. Severe & uncontrollable hemorrhage during childbirth or surgical procedure
4. Hemoptysis
5. Oliguria & acute renal failure (late sign)
6. Convulsion, coma, death
Dx
1. PT: prolonged
2. PTT: usually prolonged
3. Thrombin Time: usually prolonged
4. Fibrinogen level: usually depressed
5. Fibrin splits products: elevated
6. Protamine Sulfate Test: strongly positive
7. Factor assay (II, V, VII): depressed
8. CBC: reveals decreased platelets
9. Stool occult blood: positive
10. ABG analysis: reveals metabolic acidosis
11. Opthamoscopic exam: reveals sub retinal hemorrhages
Medical Management
1. Identification & control the underlying disease is key
2. Blood Tranfusions: include whole blood, packed RBC, platelets, plasma, cryoprecipitites & volume expanders
3. Heparin administration
a. Somewhat controversial
61
62
b. Inhibits thrombin thus preventing further clot formation, allowing coagulation factors to accumulate
Nursing Intervention
1. Monitor blood loss & attemp to quantify
2. Monitor for signs of additional bleeding or thrombus formation
3. Monitor all hema test / laboratory data including stool and GIT
4. Prevent further injury
a. Avoid IM injection
b. Apply pressure to bleeding site
c. Turn & position the client frequently & gently
d. Provide frequent nontraumatic mouth care (ex. soft toothbrush or gauze sponge)
5. Administer isotonic fluid solution as ordered: to prevent shock
6. Administer oxygen inhalation
7. Force fluids
8. Administer medications as ordered:
a. Vitamin K
b. Pitressin / Vasopresin: to conserve fluids
c. Heparin / Comadin is ineffective
9. Provide heparin lock
10. Institute NGT decompression by performing gastric lavage: by using ice or cold saline solution of 500-1000 ml
11. Monitor NGT output
12. Prevent complication
a. Hypovolemic shock: Anuria (late sign of hypovolemic shock)
13. Provide emotional support to client & significant other
14. Teach client the importance of avoiding aspirin or aspirin-containing compounds
• Cardiovascular system consists of the heart, arteries, veins & capillaries. The major function are circulation of blood, delivery of O2 &
other nutrients to the tissues of the body & removal of CO2 & other cellular products metabolism
Heart
• Muscular pumping organ that propel blood into the arerial system & receive blood from the venous system of the body.
• Located on the left mediastinum
• Resemble like a close fist
• Weighs approximately 300 – 400 grams
• Covered by a serous membrane called the pericardium
• In between is the pericardial fluid which is 10 – 20 cc: Prevent pericardial friction rub
• 2 layers of pericardium
• Right Atrium: receives systemic venous blood through the superior vena cava, inferior vena cava & coronary sinus
• Left Atrium: receives oxygenated blood returning to the heart from the lungs trough the pulmonary veins
Ventricles
• 2 thick-walled chambers; major responsibility for forcing blood out of the heart; lie below the atria
• Right Ventricle: contracts & propels deoxygenated blood into pulmonary circulation via the aorta during ventricular systole; Right
atrium has decreased pressure which is 60 – 80 mmHg
• Left Ventricle: propels blood into the systemic circulation via aortaduring ventricular systole; Left ventricle has increased pressure
which is 120 – 180 mmHg in order to propel blood to the systemic circulation
Valves
62
63
• Mitral Valve: located between the left atrium & left ventricle; contains 2 leaflets attached to the chordae tandinae
• Tricuspid Valve: located between the right atrium & right ventricle; contains 3 leaflets attached to the chordae tandinae
Functions
• Permit unidirectional flow of blood from specific atrium to specific ventricle during ventricular diastole
• Prevent reflux flow during ventricular systole
• Valve leaflets open during ventricular diastole; Closure of AV valves give rise to first heart sound (S1 “lub”)
Semi-lunar Valve
• Pulmonary Valve
• Valve open when ventricle contract & close during ventricular diastole; Closure of SV valve produces second heart sound (S2 “dub”)
Coronary Circulation
Coronary Arteries
• Branch off at the base of the aorta & supply blood to the myocardium & the conduction system
• Arises from base of the aorta
• Types of Coronary Arteries
• Right Main Coronary Artery
• Left Main Coronary Artery
Coronary Veins
• Return blood from the myocardium back to the right atrium via the coronary sinus
Conduction System
Sinoatrial Node (SA node or Keith Flack Node)
• Located at the junction of superior vena cava and right atrium
• Acts as primary pacemaker of the heart
• Initiates the cardiac impulse which spreads across the atria & into AV node
• Initiates electrical impulse of 60-100 bpm
Bundle of His
• Arises from the AV node & conduct impulse to the bundle branch system
• Located at the interventricular septum
• Right Bundle Branch: divided into anterior lateral & posterior; transmits impulses down the right side of the interventricular
myocardium
• Left Bundle Branch: divided into anterior & posterior
• Anterior Portion: transmits impulses to the anterior endocardial surface of the left ventricle
• Posterior Portion: transmits impulse over the posterior & inferior endocardial surface of the left ventricle
Purkinje Fibers
• Transmit impulses to the ventricle & provide for depolarization after ventricular contraction
• Located at the walls of the ventricles for ventricular contraction
SA NODE
AV NODE
BUNDLE OF HIS
PURKINJE FIBERS
63
64
Electrical activity of heart can be visualize by attaching electrodes to the skin & recording activity by ECG
Electrocadiography (ECG) Tracing
• P wave (atrail depolarization) contraction
Vascular System
• Major function of the blood vessels isto supply the tissue with blood, remove wastes, & carry unoxygenated blood back to the heart
Cardiac Disorders
Coronary Arterial Disease / Ischemic Heart Disease
ATHEROSCLEROSIS
ATHEROSCLEROSIS ARTERIOSCLEROSIS
• Narrowing of artery • Hardening of artery
• Lipid or fat deposits • Calcium and protein deposits
• Tunica intima • Tunica media
Predisposing Factors
1. Sex: male
2. Race: black
3. Smoking
4. Obesity
5. Hyperlipidemia
6. Sedentary lifestyle
7. Diabetes Mellitus
8. Hypothyroidism
9. Diet: increased saturated fats
10. Type A personality
S/sx
1. Chest pain
2. Dyspnea
3. Tachycardia
4. Palpitations
5. Diaphoresis
Treatment
P - Percutaneous
T - Transluminal
C - Coronary
64
65
A – Angioplasty
C - Coronary
A - Arterial
B - Bypass
A - And
G - Graft
S - Surgery
Objectives
1. Revascularize myocardium
2. To prevent angina
3. Increase survival rate
4. Done to single occluded vessels
5. If there is 2 or more occluded blood vessels CABG is done
3 Complications of CABG
1. Pneumonia: encourage to perform deep breathing, coughing exercise and use of incentive spirometer
2. Shock
3. Thrombophlebitis
Angina Pectoris
• Transient paroxysmal chest pain produced by insufficient blood flow to the myocardium resulting to myocardial ischemia
• Clinical syndrome characterized by paroxysmal chest pain that is usually relieved by rest or nitroglycerine due to temporary myocardial
ischemia
Predisposing Factors
1. Sex: male
2. Race: black
3. Smoking
4. Obesity
5. Hyperlipidemia
6. Sedentary lifestyle
7. Diabetes Mellitus
8. Hypertension
9. CAD: Atherosclerosis
10. Thromboangiitis Obliterans
11. Severe Anemia
12. Aortic Insufficiency: heart valve that fails to open & close efficiently
13. Hypothyroidism
14. Diet: increased saturated fats
15. Type A personality
Precipitating Factors
4 E’s of Angina Pectoris
1. Excessive physical exertion: heavy exercises, sexual activity
2. Exposure to cold environment: vasoconstriction
3. Extreme emotional response: fear, anxiety, excitement, strong emotions
4. Excessive intake of foods or heavy meal
S/sx
1. Levine’s Sign: initial sign that shows the hand clutching the chest
2. Chest pain: characterized by sharp stabbing pain located at sub sterna usually radiates from neck, back, arms, shoulder and jaw muscles
usually relieved by rest or taking nitroglycerine (NTG)
3. Dyspnea
4. Tachycardia
5. Palpitations
6. Diaphoresis
Dx
1. History taking and physical exam
2. ECG: may reveals ST segment depression & T wave inversion during chest pain
3. Stress test / treadmill test: reveal abnormal ECG during exercise
4. Increase serum lipid levels
5. Serum cholesterol & uric acid is increased
Medical Management
1. Drug Therapy: if cholesterol is elevated
• Nitrates: Nitroglycerine (NTG)
65
66
Nursing Intervention
1. Enforce complete bed rest
2. Give prompt pain relievers with nitrates or narcotic analgesic as ordered
3. Administer medications as ordered:
a. Nitroglycerine (NTG): when given in small doses will act as venodilator, but in large doses will act as vasodilator
• Give 1st dose of NTG: sublingual 3-5 minutes
• Give 2nd dose of NTG: if pain persist after giving 1st dose with interval of 3-5 minutes
• Give 3rd & last dose of NTG: if pain still persist at 3-5 minutes interval
• Orthostatic hypotension
• Avoid placing near microwave ovens or during defibrillation as it may lead to burns (most important thing to remember)
b. Beta-blockers
• Propanolol: side effects PNS
Myocardial Infarction
• Death of myocardial cells from inadequate oxygenation, often caused by sudden complete blockage of a coronary artery
• Characterized by localized formation of necrosis (tissue destruction) with subsequent healing by scar formation & fibrosis
• Heart attack
• Terminal stage of coronary artery disease characterized by malocclusion, necrosis & scarring.
Types
1. Transmural Myocardial Infarction: most dangerous type characterized by occlusion of both right and left coronary artery
2. Subendocardial Myocardial Infarction: characterized by occlusion of either right or left coronary artery
Predisposing Factors
1. Sex: male
2. Race: black
3. Smoking
4. Obesity
5. CAD: Atherosclerotic
6. Thrombus Formation
7. Genetic Predisposition
8. Hyperlipidemia
9. Sedentary lifestyle
10. Diabetes Mellitus
11. Hypothyroidism
66
67
S/sx
1. Chest pain
• Excruciating visceral, viselike pain with sudden onset located at substernal & rarely in precordial
• Usually radiates from neck, back, shoulder, arms, jaw & abdominal muscles (abdominal ischemia): severe crushing
• Split S1 & S2
• S4 or atrial gallop
Dx
1. Cardiac Enzymes
• CPK-MB: elevated
Nursing Intervention
• Goal: Decrease myocardial oxygen demand
• Administer narcotic analgesic as ordered: Morphine Sulfate IV: provide pain relief (given IV because after an infarction there is poor
peripheral perfusion & because serum enzyme would be affected by IM injection as ordered)
• Side Effects: Respiratory Depression
2. Administer oxygen low flow 2-3 L / min: to prevent respiratory arrest or dyspnea & prevent arrhythmias
3. Enforce CBR in semi-fowlers position without bathroom privileges (use bedside commode): to decrease cardiac workload
4. Instruct client to avoid forms of valsalva maneuver
5. Place client on semi fowlers position
6. Monitor strictly V/S, I&O, ECG tracing & hemodynamic procedures
7. Perform complete lung / cardiovascular assessment
8. Monitor urinary output & report output of less than 30 ml / hr: indicates decrease cardiac output
9. Provide a full liquid diet with gradual increase to soft diet: low in saturated fats, Na & caffeine
10. Maintain quiet environment
11. Administer stool softeners as ordered: to facilitate bowel evacuation & prevent straining
12. Relieve anxiety associated with coronary care unit (CCU) environment
13. Administer medication as ordered:
a. Vasodilators: Nitroglycirine (NTG), Isosorbide Dinitrate, Isodil (ISD): sublingual
b. Anti Arrythmic Agents: Lidocaine (Xylocane), Brithylium
• Side Effects: confusion and dizziness
67
68
• Caumadin (Warfarin)
• Antidote: Vitamin K
• Stroke / CVA
• Dressler’s Syndrome (Post MI Syndrome): client is resistant to pharmacological agents: administer 150,000-450,000 units of
streptokinase as ordered
g. Importance of participation in a progressive activity program
h. Resumption of ADL particularly sexual intercourse: is 4-6 weeks post cardiac rehab, post CABG & instruct to:
• Make sex as an appetizer rather than dessert
• Instruct client to assume a non weight bearing position
• Client can resume sexual intercourse: if can climb or use the staircase
i. Need to report the ff s/sx:
• Increased persistent chest pain
• Dyspnea
• Weakness
• Fatigue
• Persistent palpitation
• Light headedness
j. Enrollment of client in a cardiac rehabilitation program
k. Strict compliance to mediation & importance of follow up care
Predisposing Factors
1. 90% is mitral valve stenosis due to RHD: inflammation of mitral valve due to invasion of Group A beta-hemolytic streptococcus
2. Myocardial Infarction
3. Ischemic heart disease
4. Hypertension
5. Aortic valve stenosis
S/sx
1. Dyspnea
2. Paroxysmal nocturnal dyspnea (PND): client is awakened at night due to difficulty of breathing
3. Orthopnea: use 2-3 pillows when sleeping or place in high fowlers
4. Tiredness
5. Muscle Weakness
6. Productive cough with blood tinged sputum
7. Tachycardia
8. Frothy salivation
9. Cyanosis
10. Pallor
11. Rales / Crackles
12. Bronchial wheezing
13. Pulsus Alternans: weak pulse followed by strong bounding pulse
14. PMI is displaced laterally: due to cardiomegaly
15. Possible S3: ventricular gallop
Dx
1. Chest X-ray (CXR): reveals cardiomegaly
68
69
2. Pulmonary Arterial Pressure (PAP): measures pressure in right ventricle or cardiac status: increased
3. Pulmonary Capillary Wedge Pressure (PCWP): measures end systolic and dyastolic pressure: increased
4. Central Venous Pressure (CVP): indicates fluid or hydration status
• Increase CVP: decreased flow rate of IV
Predisposing Factors
1. Right ventricular infarction
2. Atherosclerotic heart disease
3. Tricuspid valve stenosis
4. Pulmonary embolism
5. Related to COPD
6. Pulmonic valve stenosis
7. Left sided heart failure
S/sx
1. Anorexia
2. Nausea
3. Weight gain
4. Neck / jugular vein distension
5. Pitting edema
6. Bounding pulse
7. Hepatomegaly / Slenomegaly
8. Cool extremities
9. Ascites
10. Jaundice
11. Pruritus
12. Esophageal varices
Dx
1. Chest X-ray (CXR): reveals cardiomegaly
2. Central Venous Pressure (CVP): measure fluid status: elevated
• Measure pressure in right atrium: 4-10 cm of water
• If CVP is more than 10 cm of water: Hypervolemic shock: Administer loop diuretics as ordered
• Nursing Intervention:
• When reading CVP patient should be flat on bed
• Upon insertion place client in trendelendberg position: to promote ventricular filling and prevent pulmonary embolism
Medical Management
1. Determination & elimination / control of underlying cause
2. Drug therapy: digitalis preparations, diuretics, vasodilators
3. Sodium-restricted diet: to decrease fluid retention
4. If medical therapies unsuccessful: mechanical assist devices (intra-aortic balloon pump), cardiac transplantation, or mechanical heart
may be employed
5. Treatment for Left Sided Heart Failure Only:
M – Morphine SO4
A – Aminophylline
D – Digitalis
D – Diuretics
O – O2
G – Gases
Nursing Intervention
Goal: Increase cardiac contractility thereby increasing cardiac output of 3-6 L / min
1. Monitor respiratory status & provide adequate ventilation (when HF progress to pulmonary edema)
a. Administer O2 therapy: high inflow 3-4 L / min delivered via nasal cannula
b. Maintain client in semi or high fowlers position: maximize oxygenation by promoting lung expansion
c. Monitor ABG
d. Assess for breath sounds: noting any changes
2. Provide physical & emotional rest
a. Constantly assess level of anxiety
b. Maintain bed rest with limited activity
c. Maintain quiet & relaxed environment
d. Organized nursing care around rest periods
69
70
• Action: relieve bronchospasm, increase urinary output & increase cardiac output
c. Administer Anti-arrythmic as ordered
• Anti-arrythmic: Lidocaine (Xylocane)
6. Assist in bloodless phlebotomy: rotating tourniquet, rotated clockwise every 15 minutes: to promote decrease venous return or reducing
preload
7. Provide client teaching & discharge planning concerning:
a. Need to monitor self daily for S/sx of Heart Failure (pedal edema, weight gain, of 1-2 kg in a 2 day period, dyspnea, loss of appetite,
cough)
b. Medication regimen including name, purpose, dosage, frequency & side effects (digitalis, diuretics)
c. Prescribe diet plan (low Na, cholesterol, caffeine: small frequent meals)
d. Need to avoid fatigue & plan for rest periods
e. Prevent complications
• Arrythmia
• Shock
• Right ventricular hypertrophy
• MI
• Thrombophlebitis
f. Importance of follow-up care
Arterial Ulcer
1. Thromboangiitis Obliterans (Buerger’s Disease)
2. Raynaud’s Phenomenon
Venous Ulcer
1. Varicose Veins
2. Thrombophlebitis (deep vein thrombosis)
Predisposing Factors
1. High risk groups - men 25-40 years old
2. High incident among smokers
S/sx
1. Intermittent claudication: leg pain upon walking
2. Cold sensitivity & changes in skin color 1st white (pallor) changing to blue (cyanosis) then red (rubor)
3. Decreased or absent peripheral pulses (posterior tibial & dorsalis pedis)
4. Trophic changes
5. Ulceration & Gangrene formation (advanced)
Dx
1. Oscillometry: may reveal decrease in peripheral pulse volume
2. Doppler (UTZ): reveals decrease blood flow to the affected extremity
3. Angiography: reveals location & extent of obstructive process
70
71
Medical Management
1. Drug Therapy
a. Vasodilators: to improve arterial circulation (effectiveness ?)
• Papaverine
• Cyclandelate (Cyclospasmol)
Nursing Intervention
1. Encourage a slow progressive physical activity
• Walking at least 2 times / day
• Out of bed at least 3-4 times / day
2. Administer medications as ordered
• Analgesics
• Vasodilators
• Anti-coagulants
3. Foot care management:
• Need to avoid trauma to the affected extreminty
4. Importance of stop smoking
5. Need to maintain warmth especially in cold weather
6. Prepare client for surgery: below knee amputation (BKA)
7. Importance of follow-up care
Raynaud’s Phenomenon
Intermittent episodes of arterial spasm most frequently involving the fingers or digits of the hands
Predisposing Factors
1. High risk group: female between the teenage years & age 40 years old & above
2. Smoking
3. Collagen diseases
a. Systemic Lupus Erythematosus (SLE): butterfly rash
b. Rheumatoid Arthritis
4. Direct hand trauma
a. Piano playing
b. Excessive typing
c. Operating chainsaw
S/sx
1. Coldness
2. Numbness
3. Tingling in one or more digits
4. Pain: usually precipitated by exposure to cold, Emotional upset & Tobacco use
5. Intermittent color changes: pallor (white), cyanosis (blue), rubor (red)
6. Small ulceration & gangrene a tips of digits (advance)
Dx
1. Doppler UTZ: decrease blood flow to the affected extremity
2. Angiography: reveals site & extent of malocclusion
Medical Management
1. Administer medications as ordered
a. Catecholamine-depliting antihypertinsive drugs:
• Reserpine
• Guanethidine Monosulfate (Ismelin)
b. Vasodilators
Nursing Intervention
1. Importance of stop smoking
2. Need to maintain warmth especially in cold weather
3. Need to wear gloves when handling cold object / opening a freezer or refrigerator door
Varicose Veins
71
72
• Dilated veins that occurs most often in the lower extremities & trunk. As the vessel dilates the valves become stretched & incompetent
with result venous pooling / edema
• Abnormal dilation of veins of lower extremities and trunks due to incompetent valve resulting to increased venous pooling resulting to
venous stasis causing decrease venous return
Predisposing Factors
1. Hereditary
2. Congenital weakness of the veins
3. Thrombophlebitis
4. Cardiac disorder
5. Pregnancy
6. Obesity
7. Prolonged standing or sitting
S/sx
1. Pain after prolonged standing: relieved by elevation
2. Swollen dilated tortuous skin veins
3. Warm to touch
4. Heaviness in legs
Dx
1. Venography
2. Trendelenburg Test: veins distends quickly in less than 35 seconds
3. Doppler Ultrasound: decreased or no blood flow heard after calf or thigh compression
Medical Management
1. Vein Ligation: involves ligating the saphenous vein where it joins the femoral vein & stripping the saphenous vein system fro groin to
ankles
2. Sclerotherapy: can recur & only done in spider web varicosities & danger of thrombosis (2-3 years for embolism)
Nursing Intervention
1. Elevate legs above heart level: to promote increased venous return by placing 2-3 pillows under the legs
2. Measure the circumference of ankle & calf muscle daily: to determine if swollen
3. Apply anti-embolic / knee-length stockings
4. Provide adequate rest
5. Administer medications as ordered
a. Analgesics: for pain
6. Prepare client for vein ligation if necessary
a. Provide routine pre-op care: usually OPD
b. In addition to routine post-op care:
• Keep affected extremity elevated above the level of the heart: to prevent edema
• Apply elastic bandage & stockings which should be removed every 8 hours for short periods & reapplied
• Assist out of bed within 24 hours ensuring the elastic stockings is applied
• Assess for increase of bleeding particularly in groin area
7. Provide client teaching & discharge planning
Predisposing Factors
1. Obesity
2. Smoking
3. Related to pregnancy
4. Severe anemia
5. Prolong use of oral contraceptives: promotes lipolysis
6. Prolonged immobility
7. Trauma
8. Dehydration
9. Sepsis
10. Congestive heart failure
11. Myocardial infarction
12. Post-op complication: surgery
13. Venous cannulation: insertion of various cardiac catheter
14. Increase in saturated fats in the diet.
S/sx
1. Pain in the affected extremity
2. Superficial vein: Tenderness, redness induration along course of the vein
3. Deep vein:
• Swelling
• Venous distention of limb
• Tenderness over involved vein
72
73
• Positive homan’s sign: pain at the calf or leg muscle upon dorsi flexion of the foot
• Cyanosis
Dx
1. Venography (Phlebography): increased uptake of radioactive material
2. Doppler ultrasonography: impairment of blood flow ahead of thrombus
3. Venous pressure measurement: high in affected limb until collateral circulation is developed
Medical Management
1. Anti-coagulant therapy
a. Heparin
• Action: block conversion of prothrombin to thrombin & reduces formation or extension of thrombus
• Side effects:
• Spontaneous bleeding
• Injection site reaction
• Ecchymoses
• Tissue irritation & sloughing
• Reversible transient alopecia
• Cyanosis
• Pan in the arms or legs
• Thrombocytopenia
b. Warfarin (Coumadin)
• Action: block prothrombin synthesis by interfering with vit. K synthesis
• Side effects:
• GI:
• Anorexia
• N/V
• Diarrhea
• Stomatitis
• Hypersensitivity:
• Dermatitis
• Urticaria
• Pruritus
• Fever
• Other:
Nursing Intervention
1. Elevate legs above heart level: to promote increase venous return & decreased edema
2. Apply warm moist pack: to reduce lymphatic congestion
3. Administer anti-coagulant as ordered:
a. Heparin
• Monitor PTT: dosage should be adjusted to keep PTT between 1.5-2.5 times normal control level
• Assess for increased bleeding tendencies (hematuria, hematemesis, bleeding gums, petechiae of soft palate, conjunctiva retina,
ecchymoses, epistaxis, bloody spumtum, melena) & instruct the client to observe for & report these
• Have antidote (Protamine Sulfate) available
• Instruct the client to avoid aspirin, antihistamines 7 cough preparations containing glyceryl guaiacolate & obtain MD permission
before using other OTC drugs
b. Warfarin (Coumadin)
• Assess PT daily: dosage should be adjusted to maintain PT at 1.5-2.5 times normal control level; INR of 2
• Alert client to factors that may affect the anticoagulant response (high-fat diet or sudden increased in vit. K-rich food)
73
74
Nose
1. External nose is a frame work of bone & cartilage , internally divided into two passages or nares (nasal cavity) by the septum: air enters
the system through the nares
2. The septum is covered with mucous membrane, where the olfactory receptors are located. Turbinates, located internally, assist in
warming & moistening the air
3. The major function of the nose are warming, moistening & filtering air.
4. Consist of anastomosis of capillaries known as Keissel Rach Plexus: the site of nose bleeding
Pharynx
1. A muscular passageway commonly called the throat
2. Air passes through the nose to the pharynx
3. Serves as a muscular passageway for both food and air
Larynx
1. Sometimes called “voice Box” connects upper & lower airways
2. Framework is formed by the hyoid bone, epiglotitis & thyroid, cricoid & arytenoids cartilages
3. Larynx opens to allow respiration & closes to prevent aspiration when food passes through the pharynx
4. Vocal cords of larynx permit speech & are involved in the cough reflex
5. For phonation (voice production)
Glottis
1. Opening of larynx
2. Opens to allow passage of air
3. Closes to allow passage of food going to the esophagus
4. The initial sign of complete airway obstruction is the inability to cough
Trachea
AKA “Windpipe”
Air move from the pharynx to larynx to trachea (length 11-13 cm, diameter 1.5-2.5 cm in adult)
Extend from the larynx to the second costal cartilage, where it bifurcates & is supported by 16-20 C-shaped cartilage rings
The area where the trachea divides into two branches is called the carina
Consist of cartilaginous rings
Serves as passageway of air going to the lungs
Site of tracheostomy
Bronchi
Right main bronchus
Larger & straighter than the left
Divided into three lobar branches (upper, middle & lower bronchi) to supply the three lobes of right lung
Left main bronchus
Divides into the upper & lower lobar bronchi to supply the left lobes
74
75
Bronchioles
In the bronchioles, airway patency is primarily dependent upon elastic recoil formed by network of smooth muscles
The tracheobronchial tree ends at the terminal bronchials. Distal to the terminal bronchioles the major function is no longer air
conduction but gas exchange between blood & alveolar air
The respiratory bronchioles serves as the transition to the alveolar epithelium
Lungs
Right lung (consist of 3 lobes, 10 segments)
Broad area of lungs resting on diaphragm is called the base & the narrow superior portion called the apex
Pleura
Serous membranes covering the lungs, continuous with the parietal pleura that lines the chest wall
Parietal Pleura
Lines the chest walls & secretes small amounts of lubricating fluid into the intrapleural space (space between the parietal pleura &
visceral pleura) this fluid holds the lungs & chest wall together as a single unit while allowing them to move separately
Chest Wall
Includes the ribs cage, intercostal muscles & diaphragm
Chest is a C shaped & supported by 12 pairs of ribs & costal cartilages, the ribs have several attached muscles
Contraction of the external intercostal muscles raises the ribs cage during inspiration & helps increase the size of the thoracic cavity
The internal intercoastal muscles tends to pull ribs down & in & play a role in forced expiration
Diaphragm
A major muscle of ventilation (the exchange of air between the atmosphere & the alveoli).
Alveoli
Are functional cellular unit of the lungs; about half arise directly from alveolar ducts & are responsible for about 35% of alveolar gas
exchange
Produces surfactants
Surfactant
A phospholipids substance found in the fluid lining the alveolar epithelium
Reduces surface tension & increase stability of the alveoli & prevents their collapse
Alveolar Ducts
Arises from the respiratory bronchioles & lead to the alveoli
Alveolar Sac
Form the last part of the airway
Functionally the same as the alveolar ducts they are surrounded by alveoli & are responsible for the 65% of the alveolar gas exchange
Type II Cells of Alveoli
Secretes surfactant
Decrease surface tension
Prevent collapse of alveoli
Composed of lecithin and spingomyelin
Lecitin / Spingomyelin ratio: to determine lung maturity
Normal Lecitin / Spingomyelin ratio: is 2:1
In premature infants: 1:2
Give oxygen of less 40% in premature: to prevent atelectasis and retrolental fibroplasias
Retinopathy & blindness: in premature
Pulmonary Circulation
Provides for reoxygenation of blood & release of CO2
Gas transfers occurs in the pulmonary capillary bed
Pneumonia
Inflammation of the alveolar spaces of the lungs, resulting in consolidation of lung tissue as the alveoli fill with exudates
Inflammation of the lung parenchyma leading to pulmonary consolidation as the alveoli is filled with exudates
Etiologic Agents
1. Streptococcus Pneumonae: causing pneumococal pneumonia
2. Hemophylus Influenzae: causing broncho pneumonia
3. Diplococcus Pneumoniae
4. Klebsella Pneumoniae
75
76
5. Escherichia Pneumoniae
6. Pseudomonas
Predisposing Factors
1. Smoking
2. Air pollution
3. Immuno compromised
4. Related to prolonged immobility (CVA clients): causing hypostatic pneumonia
5. Aspiration of food: causing aspiration pneumonia
S/sx
1. Productive cough with greenish to rusty sputum
2. Rapid shallow respiration with expiratory grunt
3. Nasal flaring
4. Intercostal rib retraction
5. Use of accessory muscles of respiration
6. Dullness to flatness upon auscultation
7. Possible pleural friction rub
8. High-pitched bronchial breath sound
9. Rales / crackles (early) progressing to coarse (later)
10. Fever
11. Chills
12. Anorexia
13. General body malaise
14. Weight loss
15. Bronchial wheezing
16. Cyanosis
17. Chest pain
18. Abdominal distention leading to paralytic ileus (absence of peristalsis)
Dx
1. Sputum Gram Staining & Culture Sensitivity: positive to cultured microorganisms
2. Chest x-ray: reveals pulmonary consolidation over affected area
3. ABG analysis: reveals decrease PO2
4. CBC: reveals increase WBC, erythrocyte sedimentation rate is increased
Nursing Intervention
1. Facilitate adequate ventilation
Administer O2 as needed & assess its effectiveness: low inflow
Place client semi fowlers position
Turn & reposition frequently client who are immobilized
Administer analgesic as ordered: DOC: codeine: to relieve pain associated with breathing
Auscultate breath sound every 2-4 hour
Monitor ABG
2. Facilitate removal of secretions
General hydration
Microlides (Zethromax)
76
77
Histoplasmosis
Systemic fungal disease caused by inhalation of dust contaminated by histoplasma capsulatum which is transmitted to bird manure
Acute fungal infection caused by inhalation of contaminated dust or particles with histoplasma capsulatum derived from birds manure
S/sx
1. Similar to PTB or Pneumonia
2. Productive cough
3. Fever, chills, anorexia, general body malaise
4. Chest and joint pains
5. Dyspnea
6. Cyanosis
7. Hemoptysis
8. Sometimes asymptomatic
Dx
1. Chest X-ray: often appears similar to PTB
2. Histoplasmin Skin Test: positive
3. ABG analysis: PO2 decrease
Medical Management
1. Anti-fungal Agent: Amphotericin B (Fungizone)
Very toxic: toxicity includes anorexia, chills, fever, headaches & renal failure
Nursing Intervention
1. Monitor respiratory status
2. Enforce CBR
3. Administer oxygen inhalation
4. Administer medications as ordered
a. Antifungal: Amphotericin B (Fungizone)
Observe severe side effects:
Abnormal renal function with hypokalemia & azotemia: Nephrotoxicity, check for BUN and Creatinine, Hypokalemia
5. Force fluids to liquefy secretions
6. Nebulize & suction as needed
7. Prevent complications: bronchiectasis
8. Prevent the spread of infection by spraying of breeding places
Chronic Bronchitis
77
78
Predisposing Factors
1. Smoking
2. Air pollution
S/sx
1. Productive copious cough (consistent to all COPD)
2. Dyspnea on exertion
3. Use of accessory muscle of respiration
4. Scattered rales / rhonchi
5. Feeling of gastric fullness
6. Slight Cyanosis
7. Distended neck veins
8. Ankle edema
9. Prolonged expiratory grunt
10. Anorexia and generalized body malaise
11. Pulmonary hypertension
a. Leading to peripheral edema
b. Cor Pulmonale (right ventricular hypertrophy)
Dx
1. ABG analysis: reveals PO2 decrease (hypoxemia): causing cyanosis, PCO2 increase
Bronchial Asthma
Immunologic / allergic reaction results in histamine release which produces three mainairway response: Edema of mucus membrane,
Spasm of the smooth muscle of bronchi & bronchioles, Accumulation of tenacious secretions
Reversible inflammatory lung condition due to hypersensitivity to allergens leading to narrowing of smaller airways
S/sx
1. Cough that is non productive
2. Dyspnea
3. Wheezing on expiration
4. Cyanosis
5. Mild Stress or apprehension
6. Tachycardia, palpitations
7. Diaphoresis
Dx
1. Pulmonary Function Test Incentive spirometer: reveals decrease vital lung capacity
2. ABG analysis: PO2 decrease
3. Before ABG test for positive Allens Test, apply direct pressure to ulnar & radial artery to determine presence of collateral circulation
Medical Management
1. Drug Therapy
a. Bronchodilators: given via inhalation or metered dose inhaler or MDI for 5 minutes
b. Steroids: decrease inflammation: given 10 min after bronchodilator
c. Mucomysts (acetylceisteine): at bed side put suction machine
78
79
d. Mucolytics / expectorants
e. Anti histamine
2. Physical Therapy
3. Hyposensitization
4. Execise
Nursing Intervention
1. Enforce CBR
2. O2 inhalation: low flow 2-3 L/min: to prevent respiratory distress
3. Administer medications as ordered
4. Force fluids 2-3 L/day
5. Semi fowlers position: to promote lung expansion
6. Nebulize & suction when needed
7. Provide client health teachings and discharge planning concerning
a. Avoidance of precipitating factor
b. Prevent complications
Emphysema
Status Asthmaticus: severe attack of asthma which cause poor controlled asthma
DOC: Epinephrine
Steroids
Bronchodilators
c. Regular adherence to medications: to prevent development of status asthmaticus
d. Importance of follow up care
Bronchiectasis
Permanent abnormal dilation of the bronchi with destruction of muscular & elastic structure of the bronchial wall
Abnormal permanent dilation of bronchus leading to destruction of muscular and elastic tissues of alveoli
Predisposing Factors
1. Caused by bacterial infection
2. Recurrent lower respiratory tract infections
3. Chest trauma
4. Congenital defects (altered bronchial structure)
5. Related to presence of tumor (lung tumor)
6. Thick tenacious secretion
Sx
1. Productive cough with mucopurulent sputum
2. Dyspnea in exertion
3. Cyanosis
4. Anorexia & generalized body malaise
5. Hemoptysis (only COPD with sign)
6. Wheezing
7. Weight loss
Dx
1. CBC: elevation in WBC
2. ABG: PO2 decrease
3. Bronchoscopy: reveals sources & sites of secretion: direct visualization of bronchus using fiberscope
Post Bronchoscopy
1. Feeding initiated upon return of gag reflex
2. Avoid talking, coughing and smoking, may cause irritation
3. Monitor for signs of gross
4. Monitor for signs of laryngeal spasm: prepare tracheostomy set
Medical Management
1. Surgery
Pneumonectomy: 1 lung is removed & position on affected side
Emphysema
Enlargement & destruction of the alveolar, bronchial & bronchiolar tissue with resultant loss of recoil, air tapping, thoracic
overdistension, sputum accumulation & loss of diaphragmatic muscle tone
These changes cause a state of CO2 retention, hypoxia & respiratory acidosis
Irreversible terminal stage of COPD characterized by
Inelasticity of alveoli
Air trapping
Maldistribution of gases
79
80
Predisposing Factors
1. Smoking
2. Inhaled irritants: air pollution
3. Allergy or allergic factor
4. High risk: elderly
5. Hereditary: it involves deficiency of Alpha 1 anti-trypsin: to release elastase for recoil of alveoli
S/sx
1. Productive cough
2. Sputum production
3. Anorexia & generalized body malaise
4. Weight loss
5. Flaring of nostrils (alai nares)
6. Use of accessory muscles
7. Dyspnea at rest
8. Increased rate & depth of breathing
9. Decrease respiratory excursion
10. Resonance to hyper resonance
11. Decrease or diminished breath sounds with prolong expiration
12. Decrease tactile fremitus
13. Prolong expiratory grunt
14. Rales or rhonchi
15. Bronchial wheezing
16. Barrel chest
17. Purse lip breathing: to eliminates excess CO2 (compensatory mechanism)
Dx
1. Pulmonary Function Test: reveals decrease vital lung capacity
2. ABG analysis: reveals
Panlobular/centrilobular
Nursing Intervention
1. Enforce CBR
2. Administer oxygen inhalation via low inflow
3. Administer medications as ordered
a. Bronchodilators: used to treat bronchospam
Aminophylline
Isoproterenol (Isuprel)
Terbutalin (Brethine)
Metaproterenol (Alupent)
Theophylline
Isoetharine (Bronkosol)
b. Corticosteroids:
Prednisone
c. Anti-microbial / Antibiotics: to treat bacterial infection
Tetracycline
Ampicilline
d. Mucolytics / expectorants
4. Facilitate removal of secretions:
a. Force fluids at least 3 L/day
b. Provide chest physiotherapy, coughing & deep breathing
c. Nebulize & suction when needed
d. Provide oral hygiene after expectoration of sputum
5. Improve ventilation
a. Position client to semi or high fowlers
b. Instruct the client diaphragmatic muscles to breathe
c. Encourage productive cough after all treatment (splint abdomen to help produce more expulsive cough)
d. Employ pursed-lip breathing techniques (prolonged slow relaxed expiration against pursed lips)
e. Institute pulmonary toilet
6. Institute PEEP (positive end expiratory pressure) in mechanical ventilation promotes maximum alveolar lung expansion
7. Provide comfortable & humid environment
8. Provide high carbohydrates, protein, calories, vitamins and minerals
9. Provide client teachings and discharge planning concerning
a. Prevention of recurrent infection
Avoid crowds & individual with known infection
Adhere to high CHON, CHO & increased vit C diet
80
81
Oncology Nursing
Pathophysiology & Etiology of Cancer
Rate of Growth
• Cancer cells have uncontrolled growth or cell division
• Rate at which a tumor grows involves both increased cell division & increased survival time of cells.
• Malignant cells do not form orderly layers, but pile on top of each other to eventually form tumors.
Pre-disposing Factors
• G – Genetics
81
82
• Stages 0 – IV: all cancers divided into five stages incorporating size, nodal involvement & spread
Treatment of Cancer
Therapeutic Modality
Chemotherapy
• Ability of the drug to kill cancer cells; normal cells may also be damaged, producing side effects.
• Different drug act on tumor cell in different stages of the cell growth cycle.
1. Antimetabolites
o Foster cancer cell death by interfering with cellular metabolic process.
2. Alkylating Agent
o act with DNA to hinder cell growth & division.
3. Plant Alkaloids
o obtained from periwinkle plant.
o makes the host’s body a less favorable environment for the growth of cancer cells.
4. Antitumor Antibiotics
o affect RNA to make environment less favorable for cancer growth.
5. Steroids & Sex Hormones
o alter the endocrine environment to make it less conducive to growth of cancer cells.
82
83
A. GI System
• Diarrhea
o Administer antidiarrheals.
o Maintain good perineal care.
o Give clear liquids as tolerated.
o Monitor K, Na, Cl levels.
B. Hematologic System
• Thrombocytopenia
o Avoid bumping or bruising the skin.
o Protect client from physical injury.
o Avoid aspirin or aspirin products.
o Avoid giving IM injections.
o Monitor blood counts carefully.
o Assess for signs of increase bleeding tendencies (epistaxis, petechiae, ecchymoses)
• Leukopenia
o Use careful handwashing technique.
o Maintain reverse isolation if WBC count drops below 1000/mm
o Assess for signs of respiratory infection
o Avoid crowds/persons with known infection
• Anemia
o Provide adequate rest period
o Monitor hemoglobin & hematocrit
o Protect client from injury
o Administer O2 if needed
C. Integumentary System
• Alopecia
o Explain that hair loss is not permanent
o Offer support & encouragement
o Scalp tourniquets or scalp hypothermia via ice pack may be ordered to minimize hair loss with some agent
o Advice client to obtain wig before initiating treatment
D. Renal System
• Encourage fluid & frequent voiding to prevent accumulation of metabolites in bladder; R: may cause direct damage to kidney by
excretion of metabolites.
• Increased excretion of uric acid may damage kidney
• Administer allopurinol (Zyloprim) as ordered; R: to prevent uric acid formation; encourage fluids when administering allopurinol
E. Reproductive System
• Damage may occur to both men & women resulting infertility &/or mutagenic damage to chromosomes
• Banking sperm often recommended for men before chemotherapy
• Clients & partners advised to use reliable methods of contraception during chemotherapy
F. Neurologic System
Radiation Therapy
• Uses ionizing radiation to kill or limit the growth of cancer cells, maybe internal or external.
• It not only injured cell membrane but destroy & alter DNA so that the cell cannot reproduce.
• Effects cannot be limited to cancer cells only; all exposed cells including normal cells will be injured causing side effects.
• Localized effects are related to the area of the body being treated; generalized effects maybe related to cellular breakdown products.
83
84
• Beta – particle cannot passed through skin, more penetrating than alpha, generally emitted from radioactive isotopes, used for internal
source.
• Gamma – penetrate more deeper areas of the body, most common form of external radiotherapy (ex. Electromagnetic or X-ray)
Methods of Delivery
• External Radiation Therapy – beams high energy rays directly to the affected area. Ex. Cobalt therapy
• Internal Radiation Therapy – radioactive material is injected or implanted in the client’s body for designated period of time.
o Sealed Implants – a radioisotope enclosed in a container so it does not circulate in the body; client’s body fluids should not be
contaminated.
o Unsealed source – a radioisotope that is not encased in a container & does circulate in the body & contaminate body fluids.
• Distance – the greater the distance from the radiation source the less the exposure.
• Shielding – all radiation can be blocked; rubber gloves for alpha & usually beta rays; thick lead or concrete stop gamma rays.
• Wash affected areas with plain H2O & pat dry; avoid soap.
Burns
• direct tissue injury caused by thermal, electric, chemical & smoke inhaled (TECS)
Type:
1. Thermal
2. Smoke Inhalation
3. Chemical
4. Electrical
Classification
• Partial Thickness
1. Superficial partial thickness (1st degree)
Depth: epidermis only
Causes: sunburn, splashes of hot liquid
Sensation: painful
Characteristics: erythema, blanching on pressure, no vesicles
2. Deep Partial Thickness (2nd degree)
Depth: epidermis & dermis
Causes: flash, scalding, or flame burn
Sensation: very painful
Characteristics: fluid filled vesicles; red, shinny, wet after vesicles ruptures
• Full Thickness (3rd & 4th degree)
1. Depth: all skin layers & nerve endings; may involve muscles, tendons & bones
84
85
Bones
• Function of Bones
• Provide support to skeletal framework
• Assist in movement by acting as levers for muscles
• Protect vital organ & soft tissue
• Central shaft (diaphysis) made of compact bone & two end (epiphyses) composed of cancellous bones (ex. Femur & humerus)
• Short Bones
• Cancellous bones covered by thin layer of compact bone (ex. Carpals & tarsals)
• Flat Bones
• Two layers of compact bone separated by a layer of cancellous bone (ex. Skull & ribs)
• Irregular Bones
Joints
• Articulation of bones occurs at joints
• Movable joints provide stabilization and permit a variety of movements
Classification
1. Synarthroses: immovable joints
2. Amphiarthroses: partially movable joints
3. Diarthroses (synovial): freely movable joints
• Have a joint cavity (synovial cavity) between the articulating bone surfaces
• Have properties of contraction and extension, as well as elasticity, to permit isotonic (shortening and thickening of the muscle)
and isometric (increased muscle tension) movement.
• Contraction is innervated by nerve stimulation.
Cartilage
• A form of connective tissue
• Major functions are to cushion bony prominences and offer protection where resiliency is required
• Joint distribution is symmetric (bilateral): most commonly affects smaller peripheral joints of hands & also commonly involves wrists,
elbows, shoulders, knees, hips, ankles and jaw.
• If unarrested, affected joints progress through four stages of deterioration: synovitis, pannus formation, fibrous ankylosis, and bony
ankylosis.
Cause
85
86
Predisposing factors
1. Occurs in women more often than men (3:1) between the ages 35-45.
2. Fatigue
3. Cold
4. Emotional stress
5. Infection
S/sx
1. Fatigue
2. Anorexia & body malaise
3. Weight loss
4. Slight elevation in temperature
5. Joints are painful: warm, swollen, limited in motion, stiff in morning & after a period of inactivity & may show crippling deformity in long-
standing disease.
6. Muscle weakness secondary to inactivity
7. History of remissions and exacerbations
8. Some clients have additional extra-articular manifestations: subcutaneous nodules; eye, vascular, lung, or cardiac problems.
Dx
1. X-rays: shows various stages of joint disease
2. CBC: anemia is common
3. ESR: elevated
4. Rheumatoid factor positive
5. ANA: may be positive
6. C-reactive protein: elevated
Medical Management
1. Drug therapy
a. Aspirin: mainstay of treatment: has both analgesic and anti-inflammatory effect.
b. Nonsteroidal anti-inflammatory drugs (NSAIDs): relieve pain and inflammation by inhibiting the synthesis of prostaglandins.
• Ibuprofen (Motrin)
• Indomethacin (Indocin)
• Fenoprofen (Nalfon)
• Phenylbutazone (Butazolidin)
• Piroxicam (Feldene)
• Naproxen (Naprosyn)
• Sulindac (Clinoril)
• Aurothioglucose (Solganal)
• Proteinuria
• Mouth ulcers
• Skin rash
• Aplastic anemia.
• Oral form: smaller doses are effective; take 3-6 months to become effective
• Auranofin (Ridaura)
• Diarrhea
d. Corticosteroids
• Intra-articular injections: temporarily suppress inflammation in specific joints.
• Systemic administration: used only when client does not respond to less potent anti-inflammatory drugs.
Nursing Interventions
1. Assess joints for pain, swelling, tenderness & limitation of motion.
2. Promote maintenance of joint mobility and muscle strength.
a. Perform ROM exercises several times a day: use of heat prior to exercise may decrease discomfort; stop exercise at the point of pain.
b. Use isometric or other exercise to strengthen muscles.
3. Change position frequently: alternate sitting, standing & lying.
4. Promote comfort & relief / control of pain.
86
87
Osteoarthritis
Chronic non-systemic disorder of joints characterized by degeneration of articular cartilage
Weight-bearing joints (spine, knees and hips) & terminal interphalangeal joints of fingers most commonly affected
Incident Rate
1. Women & men affected equally
2. Incidence increases with age
Predisposing Factors
1. Most important factor in development is aging (wear & tear on joints)
2. Obesity
3. Joint trauma
S/sx
1. Pain: (aggravated by use & relieved by rest) & stiffness of joints
2. Heberden’s nodes: bony overgrowths at terminal interphalangeal joints
3. Decreased ROM with possible crepitation (grating sound when moving joints)
Dx
1. X-rays: show joint deformity as disease progresses
2. ESR: may be slightly elevated when disease is inflammatory
Nursing Interventions
1. Assess joints for pain & ROM.
2. Relieve strain & prevent further trauma to joints.
a. Encourage rest periods throughout day.
b. Use cane or walker when indicated.
c. Ensure proper posture & body mechanics.
d. Promote weight reduction: if obese
e. Avoid excessive weight-bearing activities & continuous standing.
3. Maintain joint mobility and muscle strength.
a. Provide ROM & isometric exercises.
b. Ensure proper body alignment.
c. Change client’s position frequently.
4. Promote comfort / relief of pain.
a. Administer medications as ordered:
Aspirin & NSAID: most commonly used
Corticosteroids (Intra-articular injections): to relieve pain & improve mobility.
b. Apply heat or ice as ordered (e.g. warm baths, compresses, hot packs): to reduce pain.
5. Prepare client for joint replacement surgery if necessary.
6. Provide client teaching and discharge planning concerning
a. Used of prescribed medications and side effects
b. Importance of rest periods
c. Measures to relieve strain on joints
d. ROM and isometric exercises
e. Maintenance of a well-balanced diet
f. Use of heat/ice as ordered.
Gout
87
88
A disorder of purine metabolism; causes high levels of uric acid in the blood & the precipitation of urate crystals in the joints
Inflammation of the joints caused by deposition of urate crystals in articular tissue
Incident Rate
1. Occurs most often in males
2. Familial tendency
S/sx
1. Joint pain
2. Redness
3. Heat
4. Swelling
5. Joints of foot (especially great toe) & ankle most commonly affected (acute gouty arthritis stage)
6. Headache
7. Malaise
8. Anorexia
9. Tachycardia
10. Fever
11. Tophi in outer ear, hands & feet (chronic tophaceous stage)
Dx
1. CBC: uric acid elevated
Medical Management
1. Drug therapy
a. Acute attack:
Colchicine IV or PO: discontinue if diarrhea occurs
NSAID: Indomethacin (Indocin)
Naproxen (Naprosyn)
Phenylbutazone (Butazolidin)
b. Prevention of attacks
Uricosuric agents: increase renal excretion of uric acid
Probenecid (Benemid)
Sulfinpyrazone (Anturanel)
Allopurinal (Zyloprim): inhibits uric acid formation
2. Low-purine diet may be recommended
3. Joint rest & protection
4. Heat or cold therapy
Nursing Interventions
1. Assess joints for pain, motion & appearance.
2. Provide bed rest & joint immobilization as ordered.
3. Administer anti-gout medications as ordered.
4. Administer analgesics as ordered: for pain
5. Increased fluid intake to 2000-3000 ml/day: to prevent formation of renal calculi.
6. Apply local heat or cold as ordered: to reduce pain
7. Apply bed cradle: to keep pressure of sheets off joints.
8. Provide client teaching and discharge planning concerning
a. Medications & their side effects
b. Modifications for low-purine diet: avoidance of shellfish, liver, kidney, brains, sweetbreads, sardines, anchovies
c. Limitation of alcohol use
d. Increased in fluid intake
e. Weight reduction if necessary
f. Importance of regular exercise
Incident Rate
1. Occurs most frequently in young women
Predisposing Factors
1. Cause unknown
2. Immune
3. Genetic & viral factors have all been suggested
Pathophysiology
1. A defect in body’s immunologic mechanisms produces autoantibodies in the serum directed against components of the client’s own cell
nuclei.
2. Affects cells throughout the body resulting in involvement of many organs, including joints, skin, kidney, CNS & cardiopulmonary system.
S/sx
1. Fatigue
2. Fever
3. Anorexia
4. Weight loss
5. Malaise
88
89
Dx
1. ESR: elevated
2. CBC: RBC anemia, WBC & platelet counts decreased
3. Anti-nuclear antibody test (ANA): positive
4. Lupus Erythematosus (LE prep): positive
5. Anti-DNA: positive
6. Chronic false-positive test for syphilis
Medical Management
1. Drug therapy
a. Aspirin & NSAID: to relieve mild symptoms such as fever & arthritis
b. Corticosteroids: to suppress the inflammatory response in acute exacerbations or severe disease
c. Immunosuppressive agents: to suppress the immune response when client unresponsive to more conservative therapy
Azathioprine (Imuran)
Cyclophosphamide (Cytoxan)
2. Plasma exchange: to provide temporary reduction in amount of circulating antibodies.
3. Supportive therapy: as organ systems become involved.
Nursing Interventions
1. Assess symptoms to determine systems involved.
2. Monitor vital signs, I&O, daily weights.
3. Administer medications as ordered.
4. Institute seizure precautions & safety measures: with CNS involvement.
5. Provide psychologic support to client / significant others.
6. Provide client teaching & discharge planning concerning
a. Disease process & relationship to symptoms
b. Medication regimen & side effects.
c. Importance of adequate rest.
d. Use of daily heat & exercises as prescribed: for arthritis.
e. Need to avoid physical or emotional stress
f. Maintenance of a well-balanced diet
g. Need to avoid direct exposure to sunlight: wear hat & other protective clothing
h. Need to avoid exposure to persons with infections
i. Importance of regular medical follow-up
j. Availability of community agencies
Osteomyelitis
Infection of the bone and surrounding soft tissues, most commonly caused by S. aureus.
Infection may reach bone through open wound (compound fracture or surgery), through the bloodstream, or by direct extension from
infected adjacent structures.
Infections can be acute or chronic; both cause bone destruction.
S/sx
1. Malaise
2. Fever
3. Pain & tenderness of bone
4. Redness & swelling over bone
5. Difficulty with weight-bearing
6. Drainage from wound site may be present.
Dx
89
90
Nursing Interventions
1. Administer analgesics & antibiotics as ordered.
2. Use sterile techniques during dressing changes.
3. Maintain proper body alignment & change position frequently: to prevent deformities.
4. Provide immobilization of affected part as ordered.
5. Provide psychologic support & diversional activities (depression may result from prolonged hospitalization)
6. Prepare client for surgery if indicated.
Incision & drainage: of bone abscess
Importance of recognizing & reporting signs & complications (deformity, fracture) or recurrence
FRACTURES
A. General information
1.
B. Medical management
C. Assessment findings
D. Nursing interventions
• Oral Cavity: contains the teeth used for mastication & the tongue which assists in deglutition & the taste sensation & mastication
• Salivary gland: located in the mouth produce secretion containing pyalin for starch digestion & mucus for lubrication
• Pharynx: aids in swallowing & functions in ingestion by providing a route for food to pass from the mouth to the esophagus
Esophagus
• Muscular tube that receives foods from the pharynx & propels it into the stomach by peristalsis
Stomach
• Located on the left side of the abdominal cavity occupying the hypochondriac, epigastric & umbilical regions
• Stores & mixes food with gastric juices & mucus producing chemical & mechanical changes in the bolus of food
• The secretion of digestive juice is stimulated by smelling, tasting & chewing food which is known as cephalic phase of digestion
• The gastric phase is stimulated by the presence of food in the stomach & regulated by neural stimulation via PNS & hormonal
stimulation through secretion of gastrin by the gastric mucosa
• After processing in the stomach the food bolus called chyme is released into the small intestine through the duodenum
• Cardiac Sphincter: located at the opening between the esophagus & stomach
• Pepsinogen: secreted by the chief cells located in the fundus aid in CHON digestion
• Hydrocholoric Acid: secreted by parietal cells, function in CHON digestion & released in response to gastrin
Middle Alimentary canal: Function for absorption; Complete absorption: large intestine
Small Intestines
• Composed of the duodenum, jejunum & ileum
• Extends from the pylorus to the ileocecal valve which regulates flow into the large intestines to prevent reflux to the into the small
intestine
• Major function: digestion & absorption of the end product of digestion
• Structural Features:
• Villi (functional unit of the small intestines): finger like projections located in the mucous membrane; containing goblet cells that
secrets mucus & absorptive cells that absorb digested food stuff
90
91
• Rectum
• Anus
• Serves as a reservoir for fecal material until defecation occurs
• MO present in the large intestine: are responsible for small amount of further breakdown & also make some vitamins
• Amino Acids: deaminated by bacteria resulting in ammonia which is converted to urea in the liver
• Bacteria in the large intestine: aid in the synthesis of vitamin K & some of the vitamin B groups
• Feces (solid waste): leave the body via rectum & anus
• Anus: contains internal sphincter (under involuntary control) & external sphincter (voluntary control)
• Fecal matter: usually 75% water & 25% solid wastes (roughage, dead bacteria, fats, CHON, inorganic matter)
Accessory Organ
Liver
• Largest internal organ: located in the right hypochondriac & epigastric regions of the abdomen
• Hepatic Sinusoids (capillaries): are lined with kupffer cells which carry out the process of phagocytosis
• Portal circulation brings blood to the liver from the stomach, spleen, pancreas & intestines
• Function:
• Metabolism of fats, CHO & CHON: oxidizes these nutrient for energy & produces compounds that can be stored
• Production of bile
• Conjugation & excretion (in the form of glycogen, fatty acids, minerals, fat-soluble & water-soluble vitamins) of bilirubin
Salivary gland
Verniform appendix
Liver
Pancreas: auto digestion
Gallbladder: storage of bile
Biliary System
• Consist of the gallbladder & associated ductal system (bile ducts)
• Hepatic Duct: joins with the cystic duct (which drains the gallbladder) to form the common bile duct
• If the sphincter of oddi is relaxed: bile enters the duodenum, if contracted: bile is stored in gallbladder
Pancreas
• Positioned transversely in the upper abdominal cavity
• Consist of head, body & tail along with a pancreatic duct which extends along the gland & enters the duodenum via the common bile
duct
• Has both exocrine & endocrine function
91
92
• Initiate in the mouth where the food mixes with saliva & starch is broken down
• Food then passes into the esophagus where it is propelled into the stomach
• In the stomach food is processed by gastric secretions into a substance called chyme
• In the small intestines CHO are hydrolyzed to monosaccharides, fats to glycerol & fatty acid & CHON to amino acid to complete the
digestive process
• When chymes enters the duodenum, mucus is secreted to neutralized hydrocholoric acid, in response to release secretin,
pancreas releases bicarbonate to neutralized acid chyme
• Cholecystokinin & Pancreozymin (CCKPZ)
• Stimulate contraction of the gallbladder along with relaxation of the sphincter of oddi (to allow bile flow from common bile
duct into the duodenum) & stimulate release of the pancreatic enzymes
Salivary Glands
1. Parotid – below & front of ear
2. Sublingual
3. Submaxillary
Doudenal Ulcer
• Most commonly found in the first 2 cm of the duodenum
• Characterized by gastric hyperacidity & a significant rate of gastric emptying
Predisposing factor
• Smoking: vasoconstriction: effect GIT ischemia
• Alcohol Abuse: stimulates release of histamine: Parietal cell release Hcl acid = Ulceration
• Emotional Stress
• Drugs:
• Salicylates (Aspirin)
• Steroids
• Butazolidin
S/sx
Gastric Ulcer Duodenal Ulcer
Site Antrum or lesser curvature Duodenal bulb
• Pain • 30 min-1 hr after eating • 2-3 hrs after eating
• Left epigastrium • Mid epigastrium
• Gaseous & burning • Cramping & burning
• Not usually relieved by food & • Usually relieved by food &
antacid antacid
• 12 MN – 3am pain
• Hypersecreti • Normal gastric acid secretion • Increased gastric acid
on secretion
• Vomiting • Common • Not common
• Hemorrhage • Hematemeis • Melena
• Weight • Weight loss • Weight gain
• Complication • Stomach cause • Perforation
s • Hemorrhage
• High Risk • 60 years old • 20 years old
Dx
• Hgb & Hct: decrease (if anemic)
Medical Management
1. Supportive:
• Rest
• Bland diet
• Stress management
2. Drug Therapy:
• Antacids: neutralizes gastric acid
• Aluminum hydroxide: binds phosphate in the GIT & neutralized gastric acid & inactivates pepsin
92
93
• Magnesium & aluminum salt: neutralized gastric acid & inactivate pepsin if pH is raised to >=4
Maalox
SE: fever
• Histamines (H2) receptor antagonist: inhibits gastric acid secretion of parietal cells
• Cimetidine (Tagamet)
• Famotidine (Pepcid)
• Anticholinergic:
• Atropine SO4: inhibit the action of acetylcholine at post ganglionic site (secretory glands) results decreases GI secretions
• Proton Pump Inhibitor: inhibit gastric acid secretion regardless of acetylcholine or histamine release
• Omeprazole (Prilosec): diminished the accumulation of acid in the gastric lumen & healing of duodenal ulcer
• Pepsin Inhibitor: reacts with acid to form a paste that binds to ulcerated tissue to prevent further destruction by digestive enzyme
pepsin
• Sucralfate (Carafate): provides a paste like subs that coats mucosal lining of stomach
• Peritonitis
• Hypokalemia
• Thromobphlebitis
• Pernicious anemia
Nursing Intervention
1. Administer medication as ordered
2. Diet: bland, non irritating, non spicy
3. Avoid caffeine & milk / milk products: Increase gastric acid secretion
4. Provide client teaching & discharge planning
a. Medical Regimen
• Take medication at prescribe time
• Have antacid available at all times
• Recognized situation that would increase the need for antacids
93
94
Dumping syndrome
• Abrupt emptying of stomach content into the intestine
• Rapid gastric emptying of hypertonic food solutions
• Common complication of gastric surgery
• Appears 15-20 min after meal & last for 20-60 min
• Associated with hyperosmolar CHYME in the jejunum which draws fluid by osmosis from the extracellular fluid into the bowel. Decreased
plasma volume & distension of the bowel stimulates increased intestinal motility
S/sx
1. Weakness
2. Faintness
3. Feeling of fullness
4. Dizziness
5. Diaphoresis
6. Diarrhea
7. Palpitations
Nursing Intervention
1. Avoid fluids in chilled solutions
2. Small frequent feeding: six equally divided feedings
3. Diet: decrease CHO, moderate fats & CHON
4. Flat on bed 15-30 min after q feeding
Predisposing Factor:
1. High risk: women 40 years old
2. Post menopausal women: undergoing estrogen therapy
3. Obesity
4. Sedentary lifestyle
5. Hyperlipidemia
6. Neoplasm
S/sx:
1. Severe Right abdominal pain (after eating fatty food): Occurring especially at night
2. Intolerance of fatty food
3. Anorexia
4. N/V
5. Jaundice
6. Pruritus
7. Easy bruising
8. Tea colored urine
9. Steatorrhea
Dx
1. Direct Bilirubin Transaminase: increase
2. Alkaline Phosphatase: increase
3. WBC: increase
4. Amylase: increase
5. Lipase: increase
6. Oral cholecystogram (or gallbladder series): confirms presence of stones
Medical Management
1. Supportive Treatment: NPO with NGT & IV fluids
2. Diet modification with administration of fat soluble vitamins
3. Drug Therapy
• Narcotic analgesic: DOC: Meperdipine Hcl (Demerol): for pain
94
95
Nursing Intervention
1. Administer pain medication as ordered & monitor effects
2. Administer IV fluids as ordered
3. Diet: increase CHO, moderate CHON, decrease fats
4. Meticulous skin care: to relieved priritus
• Proteolytic & lipolytic pancreatic enzymes are activated in the pancreas rather than in the duodenum resulting in tissue damage & auto
digestion of pancreas
• Acute or chronic inflammation of pancreas leading to pancreatic edema, hemorrhage & necrosis due to auto digestion
Predisposing factors:
1. Chronic alcoholism
2. Hepatobilary disease
3. Trauma
4. Viral infection
5. Penetrating duodenal ulcer
6. Abscesses
7. Obesity
8. Hyperlipidemia
9. Hyperparathyroidism
10. Drugs: Thiazide, steroids, diuretics, oral contraceptives
S/Sx:
1. Severe left upper epigastric pain radiates from back & flank area: aggravated by eating with DOB
2. N/V
3. Tachycardia
4. Palpitation: due to pain
5. Dyspepsia: indigestion
6. Decrease bowel sounds
7. (+) Cullen’s sign: ecchymosis of umbilicus Hemorrhage
8. (+) Grey Turner’s spots: ecchymosis of flank area
9. Hypocalcemia
Dx
1. Serum amylase & lipase: increase
2. Urinary amylase: increase
3. Blood Sugar: increase
4. Lipids Level: increase
5. Serum Ca: decrease
6. CT Scan: shows enlargement of the pancreas
Medical Management
1. Drug Therapy
• Narcotic Analgesic: for pain
• Papaverine Hcl
• Atrophine SO4
• Propantheline Bromide (Profanthene)
• Maalox
• Ranitidin (Zantac)
• Nitroglycerine (NTG)
Nursing Intervention
1. Administer medication as ordered
2. Withhold food & fluid & eliminate odor: to decrease pancreatic stimulation / aggravates pain
95
96
Apendicitis
• Inflammation of the appendix that prevents mucus from passing into the cecum
• Inflammation of verniform appendix
• If untreated: ischemia, gangrene, rupture & peritonitis
• May cause by mechanical obstruction (fecalith, intestinal parasites) or anatomic defect
• May be related to decrease fiber in the diet
Predisposing factor:
1. Microbial infection
2. Feacalith: undigested food particles like tomato seeds, guava seeds etc.
3. Intestinal obstruction
S/Sx:
1. Pathognomonic sign: (+) rebound tenderness
2. Low grade fever
3. N/V
4. Decrease bowel sound
5. Diffuse pain at lower Right iliac region
6. Late sign: tachycardia: due to pain
Dx
1. CBC: mild leukocytosis: increase WBC
2. PE: (+) rebound tenderness (flex Right leg, palpate Right iliac area: rebound)
3. Urinalysis: elevated acetone in urine
Medical Management
• Surgery: Appendectomy 24-45 hrs
Nursing Intervention
1. Administer antibiotics / antipyretic as ordered
2. Routinary pre-op nursing measures:
• Skin prep
• NPO
96
97
Liver Cirrhosis
Chronic progressive disease characterized by inflammation, fibrosis & degeneration of the liver parenchymal cell
Destroyed liver cell are replaced by scar tissue, resulting in architectural changes & malfunction of the liver
Lost of architectural design of liver leading to fat necrosis & scarring
Types
Laennec’s Cirrhosis:
Associated with alcohol abuse & malnutrition
Characterized by an accumulation of fat in the liver cell progressing to widespread scar formation
Postnecrotic Cirrhosis
Result in severe inflammation with massive necrosis as a complication of viral hepatitis
Cardiac Cirrhosis
Occurs as a consequence of right sided heart failure
Manifested by hepatomegaly with some fibrosis
Biliary Cirrhosis
Associated with biliary obstruction usually in the common bile duct
Results in chronic impairment of bile excretion
S/sx
Fatigue
Anorexia
N/V
Dyspepsia: Indigestion
Weight loss
Flatulence
Change (Irregular) bowel habit
Ascites
Peripheral edema
Hepatomegaly: pain located in the right upper quadrant
Atrophy of the liver
Fetor hepaticus: fruity, musty odor of chronic liver disease
Aterixis: flapping of hands & tremores
Hard nodular liver upon palpation
Increased abdominal girth
Changes in moods
Alertness & mental ability
Sensory deficits
Gynecomastia
Decrease of pubic & axilla hair in males
Amenorrhea in female
Jaundice
Pruritus or urticaria
Easy bruising
Spider angiomas on nose, cheeks, upper thorax & shoulder
Palmar erythema
Muscle atrophy
Dx
Liver enzymes: increase
SGPT (ALT)
SGOT (AST)
LDH Alkaline Phosphate
Serum cholesterol & ammonia: increase
Indirect bilirubin: increase
CBC: pancytopenia
PT: prolonged
Hepatic Ultrasonogram: fat necrosis of liver lobules
Nursing Intervention
CBR with bathroom privileges
Encourage gradual, progressive, increasing activity with planned rest period
Institute measure to relieve pruritus
Do not use soap & detergent
Bathe with tepid water followed by application of emollient lotion
Provide cool, light, non-constrictive clothing
Keep nail short: to avoid skin excoriation from scratching
Apply cool, moist compresses to pruritic area
Monitor VS, I & O
Prevent Infection
Prevent skin breakdown: by turning & skin care
Provide reverse isolation for client with severe leukopenia: handwashing technique
Monitor WBC
Diet:
Small frequent meals
Restrict Na!
High calorie, low to moderate CHON, high CHO, low fats with supplemental Vit A, B-complex, C, D, K & folic acid
Monitor / prevent bleeding
Measure abdominal girth daily: notify MD
With pt daily & assess pitting edema
97
98
Nursing Intervention
Meds: Loop diuretics: 10-15 min effect
Assist in abdominal paracentesis: aspiration of fluid
Void before paracentesis: to prevent accidental puncture of bladder as trochar is inserted
Nursing Intervention
Administer meds:
Vit K
Pitrisin or Vasopresin (IM)
NGT decompression: lavage
Give before lavage: ice or cold saline solution
Monitor NGT output
Assist in mechanical decompression
Insertion of sengstaken-blackemore tube
3 lumen typed catheter
Scissors at bedside to deflate balloon.
Hepatic encephalopathy
Nursing Intervention
Assist in mechanical ventilation: due coma
Monitor VS, neuro check
Siderails: due restless
Administer meds
Laxatives: to excrete ammonia
Kidneys
Two of bean shaped organ that lie in the retroperitonial space on either side of the vertebral column
Retroperitonially (back of peritoneum) on either side of vertebral column
Adrenal gland is on top of each kidneys
Encased in Bowmans’s capsule
Renal Parenchyma
Cortex
Outermost layer
Site of glomeruli & proximal & distal tubules of nephron
Medulla
Middle layer
Formed by collecting tubules & ducts
Nephron
Functional unit of the kidney
Basic living unit
98
99
Ureters
Two tubes approximately 25-35 cm long
Extend from the renal pelvis to the pelvic cavity where they enter the bladder, convey urine from the kidney to the bladder
Passageway of urine to bladder
Ureterovesical valve: prevent backflow of urine into ureters
Bladder
Located behind the symphisis pubis
Composed of muscular elastic tissue that makes it distensible
Serve s as reservoir of urine (capable of holding 1000-1800 ml & 500 ml moderately full)
Internal & external urethral sphincter controls the flow of urine
Urge to void stimulated by passage of urine past the internal sphincter (involuntary) to the upper urethra
Relaxation of external sphincter (voluntary) produces emptying of the bladder (voiding)
Urethra
Small tube that extends from the bladder to the exterior of the body
Passage of urine, seminal & vaginal fluids.
Females: located behind the symphisis pubis & anterior vagina & approximately 3-5 cm
Males: extend the entire length of the penis & approximately 20 cm
Function of kidneys
Kidneys remove nitrogenous waste & regulates F & E balance & acid base balance
Urine is the end product
Tubular Function
Tubules & collecting ducts carry out the function of reabsorption, secretion & excretion
Reabsorption of H2O & electrolytes is controlled by anitdiuretics hormones (ADH) released by the pituitary & aldosterone secreted by
the adrenal glands
Proximal Convoluted Tubule
Reabsorb the ff:
80% of F & E
H2O
Glucose
Amino acids
Bicarbonate
Secretes the ff:
Organic substance
Waste
Loop of Henli
Reabsorb the ff:
Na & Chloride in the ascending limb
H2O in the descending limb
Concentrate / dilutes urine
Distal Convoluted Tubule
Secretes the ff:
Potassium
Hydrogen ions
Ammonia
Reabsorb the ff:
H2O
Bicarbonate
Regulate the ff:
Ca
Phosphate concentration
Collecting Ducts
Received urine from distal convoluted tubules & reabsorb H2O (regulated by ADH)
Regulation of BP
Through maintenance of volume (formation / excretion of urine)
Rennin-angiotensin system is the kidneys controlled mechanism that can contribute to rise the BP
99
100
When the BP drops the cells of the glomerulus release rennin which then activates angiotensin to cause vasoconstriction.
Regulation of BP:
Predisposing factor:
Ex CS – hypovolemia – decrease BP going to kidneys
Activation of RAAS
Angiotensin II vasoconstrictor
Aldosterone
Increase BP
Increase Na &
H2O reabsorption
Hypervolemia
Color – amber
Odor – aromatic
Consistency – clear or slightly turbid
pH – 4.5 – 8
Specific gravity – 1.015 – 1.030
WBC/ RBC – (-)
Albumin – (-)
E coli – (-)
Mucus thread – few
Amorphous urate (-)
UTI
CYSTITIS
Inflammation of bladder due to bacterial infection
Predisposing factors:
Microbial invasion: E. coli
High risk: women
Obstruction
Urinary retention
Increase estrogen levels
Sexual intercourse
S/Sx:
Pain: flank area
Urinary frequency & urgency
Burning pain upon urination
Dysuria
Hematuria
Nocturia
Fever
Chills
Anorexia
Gen body malaise
Dx
Urine culture & sensitivity: (+) to E. coli
Nursing Intervention
Force fluid: 3000 ml
Warm sitz bath: to promote comfort
Monitor & assess urine for gross odor, hematuria & sediments
Acid Ash Diet: cranberry, vit C: OJ: to acidify urine & prevent bacterial multiplication
Administer Medication as ordered:
Systemic Antibiotics
100
101
Ampicillin
Cephalosporin
Aminoglycosides
Sulfonamides
Co-trimaxazole (Bactrim)
Gantrism (Gantanol)
Antibacterial
Nitrofurantoin (Macrodantin)
Methenamine Mandelate (Mandelamine)
Nalixidic Acid (NegGram)
Urinary Tract Anagesic
Urinary antiseptics: Mitropurantoin (Macrodantin)
Urinary analgesic: Pyridium
Provide client teachings & discharge planning
Importance of Hydration
Void after sex: to avoid stagnation
Female: avoids cleaning back & front (should be front to back)
Bubble bath, Tissue paper, Powder, perfume
Complications: Pyelonephritis
Pyelonephritis
Acute / chronic inflammation of 1 or 2 renal pelvis of kidneys leading to tubular destruction & interstitial abscess formation
Acute: infection usually ascends from lower urinary tract
Chronic: a combination of structural alteration along with infection major cause is ureterovesical reflux with infected urine backing up
into ureters & renal pelvis
Recurrent infection will lead to renal parenchymal deterioration & Renal Failure
Predisposing factor:
Microbial invasion
E. Coli
Streptococcus
Urinary retention /obstruction
Pregnancy
DM
Exposure to renal toxins
S/sx:
Acute Pyelonephritis
Severe flank pain or dull ache
Costovertibral angle pain / tenderness
Fever
Chills
N/V
Anorexia
Gen body malaise
Urinary frequency & urgency
Nocturia
Dsyuria
Hematuria
Burning sensation on urination
Medical Management
Urinary analgesic: Peridium
Acute
Antibiotics
Antispasmodic
Surgery: removal of any obstruction
Chronic
Antibiotics
Urinary Antiseptics
Nitrofurantoin (macrodantin)
SE: peripheral neuropathy
GI irritation
Hemolytic anemia
Staining of teeth
Surgery: correction of structural abnormality if possible
Dx
Urine culture & sensitivity: (+) E. coli & streptococcus
101
102
Nursing Intervention
Provide CBR: acute phase
Monitor I & O
Force fluid
Acid ash diet
Administer medication as ordered
Chronic: possibility of dialysis & transplant if has renal deterioration
Complication: Renal Failure
Nephrolithiasis / Urolithiasis
Presence of stone anywhere in the urinary tract
Formation of stones at urinary tract
Frequent composition of stones
Calcium
Oxalate
Uric acid
Predisposing factors:
Diet: increase Ca & oxalate
Increase uric acid level
Hereditary: gout or calculi
Immobility
Sedentary lifestyle
Hyperparathyroidism
S/sx
Abdominal or flank pain
Renal colic
Cool moist skin (shock)
Burning sensation upon urination
Hematuria
Anorexia
N/V
Dx
Intravenous Pyelography (IVP): identifies site of obstruction & presence of non-radiopaque stones
KUB: reveals location, number & size of stone
Cytoscopic Exam: urinary obstruction
Stone Analysis: composition & type of stone
Urinalysis: indicates presence of bacteria, increase WBC, RBC & CHON
Medical Management
Surgery
Percutaneous Nephrostomy:
Tube is inserted through skin & underlying tissue into renal pelvis to remove calculi
Percutaneous Nephrostolithotomy
Delivers ultrasound wave through a probe placed on the calculus
Extracorporeal Shockwave Lithotripsy:
Non-invasive
Delivers shockwaves from outside of the body to the stone causing pulverization
Pain management & diet modification
Nursing Intervention
Force fluid: 3000-4000 ml / day
Strain urine using gauze pad: to detect stones & crush all cloths
Encourage ambulation: to prevent stasis
Warm sitz bath: for comfort
Administer narcotic analgesic as ordered: Morphine SO4: to relieve pain
Application warm compress at flank area: to relieve pain
Monitor I & O
Provide modified diet depending upon the stone consistency
Calcium Stones
Limit milk & dairy products
Provide acid ash diet (cranberry or prune juice, meat, fish, eggs, poultry, grapes, whole grains): to acidify urine
Take vitamin C
Oxalate Stone
Avoid excess intake of food / fluids high in oxalate (tea, chocolate, rhubarb, spinach)
Maintain alkaline-ash diet (milk, vegetable, fruits except cranberry, plums & prune): to alkalinize urine
Uric Acid Stone
102
103
Reduce food high in purine (liver, brain, kidney, venison, shellfish, meat soup, gravies, legumes)
Maintain alkaline urine
Administer Allopurinol (Zyloprim) as ordered: to decrease uric acid production: push fluids when giving allopurinol
Provide client teaching & discharge planning
Prevention of urinary stasis: increase fluid intake especially during hot weather & illness
Mobility
Voiding whenever the urge is felt & at least twice during night
Adherence to prescribe diet
Complications: Renal Failure
Predisposing factor:
High risk: 50 years old & above & 60-70 (3-4x at risk)
Influence of male hormone
S/sx
Urgency, frequency & hesitancy
Nocturia
Enlargement of prostate gland upon palpation by digital rectal exam
Decrease force & amount of urinary stream
Dysuria
Hematuria
Burning sensation upon urination
Terminal bubbling
Backache
Sciatica: severe pain in the lower back & down the back of thigh & leg
Dx
Digital rectal exam: enlarged prostate gland
KUB: urinary obstruction
Cystoscopic Exam: reveals enlargement of prostate gland & obstruction of urine flow
Urinalysis: alkalinity increase
Specific Gravity: normal or elevated
BUN & Creatinine: elevated (if longstanding BPH)
Prostate-specific Antigen: elevated (normal is < 4 ng /ml)
Nursing Intervention
Prostate message: promotes evacuation of prostatic fluid
Force fluid intake: 2000-3000 ml unless contraindicated
Provide catheterization
Administer medication as ordered:
Terazosine (Hytrin): relaxes bladder sphincter & make it easier to urinate
Finasteride (Proscar): shrink enlarge prostate gland
Surgery: Prostatectomy
Transurethral Resection of Prostate (TURP): insertion of a resectoscope into urethra to excise prostatic tissue
Assist in cystoclysis or continuous bladder irrigation.
Nursing Intervention
Monitor symptoms of infection
Monitor symptoms gross / flank bleeding. Normal bleeding within 24h
Maintain irrigation or tube patent to flush out clots: to prevent bladder spasm & distention
Causes
Pre-renal cause: interfering with perfusion & resulting in decreased blood flow & glomerular filtrate
Inter-renal cause: condiion that cause damage to the nephrons
Post-renal cause: mechanical obstruction anywhere from the tubules to the urethra
103
104
Dehydration
S/sx
Oliguric Phase: caused by reduction in glomerular filtration rate
Urine output less than 400 ml / 24 hrs; duration 1-2 weeks
S/sx
Hypernatremia
Hyperkalemia
Hyperphosphotemia
Hypermagnesemia
Hypocalcemia
Metabolic acidosis
Dx
BUN & Creatinine: elevated
Diuretic Phase: slow gradual increase in daily urine output
Diuresis may occur (output 3-5 L / day): due to partially regenerated tubules inability to concentrate urine
Duration: 2-3 weeks
S/sx
Hyponatremia
Hypokalemia
Hypovolemia
Dx
BUN & Creatinine: elevated
Recovery or Covalescent Phase: renal function stabilized with gradual improvement over next 3-12 mos
Nursing Intervention
Monitor / maintain F&E balance
Obtain baseline data on usual appearance & amount of client’s urine
Measure I&O every hour: note excessive losses
Administer IV F&E supplements as ordered
Weight daily
Monitor lab values: assess / treat F&E & acid base imbalance as needed
Monitor alteration in fluid volume
Monitor V/S. PAP, PCWP, CVP as needed
Monitor I&O strictly
Assess every hour fro hypervolemia
Maintain ventilation
Decrease fluid intake as ordered
Administer diuretics, cardiac glycosides & hypertensive agent as ordered
Assess every hour for hypovolemia: replace fluid as ordered
Monitor ECG
Check urine serum osmolality / osmolarity & urine specific gravity as ordered
Promote optimal nutrition
Administer TPN as ordered
Restrict CHON intake
Prevent complication from impaired mobility
Pulmonary Embolism
Skin breakdown
Contractures
Atelectesis
Prevent infection / fever
Assess sign of infection
Use strict aseptic technique for wound & catheter care
Take temperature via rectal
Administer antipyretics as ordered & cooling blankets
Support clients / significant others: reduce level of anxiety
Provide care for client receiving dialysis
Provide client teaching & discharge planning
Adherence to prescribed dietary regime
104
105
Predisposing factors:
DM
HPN
Recurrent UTI/ nephritis
Urinary Tract obstruction
Exposure to renal toxins
Stages of CRF
Diminished Reserve Volume – asymptomatic
Normal BUN & Crea, GFR < 10 – 30%
2. Renal Insufficiency
3. End Stage Renal disease
S/Sx:
N/V
Diarrhea / constipation
Decreased urinary output
Dyspnea
Stomatitis
Hypotension (early)
Hypertension (late)
Lethargy
Convulsion
Memory impairment
Pericardial Friction Rub
HF
Dx
Urinalysis: CHON, Na & WBC: elevated
Specific gravity: decrease
Platelets: decrease
Ca: decrease
Medical Management
Diet restriction
Multivitamins
Hematinics
Aluminum Hydroxide Gels
Antihypertensive
105
106
Nursing Intervention
Prevent neurologic complication
Monitor for signs of uremia
Fatigue
Loss of appetite
Decreased urine output
Apathy
Confusion
Elevated BP
Edema of face & feet
Itchy skin
Restlessness
Seizures
Monitor for changes in mental functioning
Orient confused client to time, place, date & person
Institute safety measures to protect the client from falling out of bed
Monitor serum electrolytes, BUN & creatinine as ordered
Promote optimal GI function
Provide care for stomatitis
Monitor N/V & anorexia: administer antiemetics as ordered
Monitor signs of GI bleeding
Monitor & prevent alteration in F&E balance
Monitor for hyperphosphatemia: administer aluminum hydroxides gel (amphojel, alternagel) as ordered
Paresthesias
Muscle cramps
Seizures
Abnormal reflex
Maintenance of skin integrity
Provide care for pruritus
Monitor uremic frost (urea crystallization on the skin): bathe in plain water
Monitor for bleeding complication & prevent injury to client
Monitor Hgb, Hct, platelets, RBC
Hematest all secretions
Administer hematinics as ordered
Avoid IM injections
Maintain maximal cardiovascular function
Monitor BP
Auscultate for pericardial friction rub
Perform circulation check routinely
Administer diuretics as ordered & monitor I&O
Modify digitalis dose as ordered (digitalis is excreted in kidneys)
Provide care for client receiving dialysis
Disequilibrium syndrome: from rapid removal of urea & nitrogenous waste prod leading to:
N/V
HPN
Leg cramps
Disorientation
Paresthes
Enforce CBR
Monitor VS, I&O
Meticulous skin care. Uremic frost – assist in bathing pt
4. Meds:
a.) Na HCO3 – due Hyperkalemia
b.) Kagexelate enema
c.) Anti HPN – hydralazine
d.) Vit & minerals
e.) Phosphate binder
(Amphogel) Al OH gel - S/E constipation
f.) Decrease Ca – Ca gluconate
5. Assist in hemodialysis
Consent/ explain procedure
Obtain baseline data & monitor VS, I&O, wt, blood exam
Strict aseptic technique
Monitor for signs of complications:
B – bleeding
E – embolism
D – disequilibrium syndrome
S – septicemia
S – shock – decrease in tissue perfusion
Disequilibrium syndrome – from rapid removal of urea & nitrogenous waste prod leading to:
n/v
HPN
Leg cramps
Disorientation
Paresthesia
Avoid BP taking, blood extraction, IV, at side of shunt or fistula. Can lead to compression of fistula.
Maintain patency of shunt by:
Palpate for thrills & auscultate for bruits if (+) patent shunt!
106
107
8. Assist in surgery:
Renal transplantation : Complication – rejection. Reverse isolation
107